Psychometric Properties of the SOC-13 Scale in Colombian Adults
The aim of this study was to determine the psychometric properties of the Spanish version of the SOC-13 in Colombian adults. The SOC-13 questionnaire was administered to 489 individuals aged ≥18 years who were in lockdown from March to July 2020 in Nariño County, Colombia. Psychometric properties of...
- Autores:
-
Mafla Chamorro, Ana Cristina
Herrera López, Mauricio
España Fuelagan, Karen
Ramírez Solarte, Ivan
Gallardo Pino, Carmen
Schwendicke, Falk
- Tipo de recurso:
- Article of investigation
- Fecha de publicación:
- 2021
- Institución:
- Universidad Cooperativa de Colombia
- Repositorio:
- Repositorio UCC
- Idioma:
- OAI Identifier:
- oai:repository.ucc.edu.co:20.500.12494/46656
- Palabra clave:
- sentido de coherencia
SOC-13
validación cruzada
análisis factorial
análisis multi-grupo
sense of coherence
SOC-13
cross-validation
factor analysis
multi-group analysis
- Rights
- openAccess
- License
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oai:repository.ucc.edu.co:20.500.12494/46656 |
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Repositorio UCC |
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|
dc.title.spa.fl_str_mv |
Psychometric Properties of the SOC-13 Scale in Colombian Adults |
title |
Psychometric Properties of the SOC-13 Scale in Colombian Adults |
spellingShingle |
Psychometric Properties of the SOC-13 Scale in Colombian Adults sentido de coherencia SOC-13 validación cruzada análisis factorial análisis multi-grupo sense of coherence SOC-13 cross-validation factor analysis multi-group analysis |
title_short |
Psychometric Properties of the SOC-13 Scale in Colombian Adults |
title_full |
Psychometric Properties of the SOC-13 Scale in Colombian Adults |
title_fullStr |
Psychometric Properties of the SOC-13 Scale in Colombian Adults |
title_full_unstemmed |
Psychometric Properties of the SOC-13 Scale in Colombian Adults |
title_sort |
Psychometric Properties of the SOC-13 Scale in Colombian Adults |
dc.creator.fl_str_mv |
Mafla Chamorro, Ana Cristina Herrera López, Mauricio España Fuelagan, Karen Ramírez Solarte, Ivan Gallardo Pino, Carmen Schwendicke, Falk |
dc.contributor.author.none.fl_str_mv |
Mafla Chamorro, Ana Cristina Herrera López, Mauricio España Fuelagan, Karen Ramírez Solarte, Ivan Gallardo Pino, Carmen Schwendicke, Falk |
dc.subject.spa.fl_str_mv |
sentido de coherencia SOC-13 validación cruzada análisis factorial análisis multi-grupo |
topic |
sentido de coherencia SOC-13 validación cruzada análisis factorial análisis multi-grupo sense of coherence SOC-13 cross-validation factor analysis multi-group analysis |
dc.subject.other.spa.fl_str_mv |
sense of coherence SOC-13 cross-validation factor analysis multi-group analysis |
description |
The aim of this study was to determine the psychometric properties of the Spanish version of the SOC-13 in Colombian adults. The SOC-13 questionnaire was administered to 489 individuals aged ≥18 years who were in lockdown from March to July 2020 in Nariño County, Colombia. Psychometric properties of the scale were examined using a cross-validation method via exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Additionally, configural and metric invariance were tested. To determine the internal consistency of the questionnaire, McDonald’s omega (ω), Cronbach’s alpha (α), and composite reliability (CR) coefficients were estimated. The EFA determined that a three-factor structure best fit the data (comprehensibility, manageability, and meaningfulness) and CFA confirmed this three-factor model structure showing a good fit (χ2 S-B = 188.530, χ2 S-B/(62) = 3.615, p = 0.001; NNFI = 0.959; CFI = 0.968; RMSEA = 0.052 (90% CI [0.041–0.063]) and SRMR = 0.052). The invariance analysis indicated the same underlying theoretical structure between genders. Additionally, (ω), (α), and (CR) coefficients confirmed a high internal consistency of the instrument. The SOC-13 scale, reflecting comprehensibility, manageability, and meaningfulness, is a reliable and valid tool for assessing the sense of coherence in Colombian populations. |
publishDate |
2021 |
dc.date.issued.none.fl_str_mv |
2021-12-10 |
dc.date.accessioned.none.fl_str_mv |
2022-10-08T16:25:24Z |
dc.date.available.none.fl_str_mv |
2022-10-08T16:25:24Z 2023-12-10 |
dc.type.none.fl_str_mv |
Artículos Científicos |
dc.type.coar.none.fl_str_mv |
http://purl.org/coar/resource_type/c_2df8fbb1 |
dc.type.coarversion.none.fl_str_mv |
http://purl.org/coar/version/c_970fb48d4fbd8a85 |
dc.type.driver.none.fl_str_mv |
info:eu-repo/semantics/article |
dc.type.version.none.fl_str_mv |
info:eu-repo/semantics/publishedVersion |
format |
http://purl.org/coar/resource_type/c_2df8fbb1 |
status_str |
publishedVersion |
dc.identifier.issn.spa.fl_str_mv |
ISSN (online): 1660-4601 | ISSN (print): 1661-7827 |
dc.identifier.uri.spa.fl_str_mv |
http://doi.org/10.3390/ijerph182413017 |
dc.identifier.uri.none.fl_str_mv |
https://hdl.handle.net/20.500.12494/46656 |
dc.identifier.bibliographicCitation.spa.fl_str_mv |
Mafla AC, Herrera-López M, España-Fuelagan K, Ramírez-Solarte I, Gallardo Pino C, Schwendicke F. (2021) Psychometric Properties of the SOC-13 Scale in Colombian Adults. Int J Environ Res Public Health. 2021;18(24):13017.https://repository.ucc.edu.co/handle/20.500.12494/46656 |
identifier_str_mv |
ISSN (online): 1660-4601 | ISSN (print): 1661-7827 Mafla AC, Herrera-López M, España-Fuelagan K, Ramírez-Solarte I, Gallardo Pino C, Schwendicke F. (2021) Psychometric Properties of the SOC-13 Scale in Colombian Adults. Int J Environ Res Public Health. 2021;18(24):13017.https://repository.ucc.edu.co/handle/20.500.12494/46656 |
url |
http://doi.org/10.3390/ijerph182413017 https://hdl.handle.net/20.500.12494/46656 |
dc.relation.isversionof.spa.fl_str_mv |
https://www.mdpi.com/1660-4601/18/24/13017 |
dc.relation.ispartofjournal.spa.fl_str_mv |
International Journal of Environmental Research and Public Health |
dc.relation.references.spa.fl_str_mv |
1. Eriksson, M.; Lindström, B. Antonovsky’s sense of coherence scale and the relation with health: A systematic review. J. Epidemiol. Community Health 2006, 60, 376–381. 2. Eriksson, M. The Sense of Coherence in the Salutogenic Model of Health. In The Handbook of Salutogenesis; Mittelmark, M.B., Sagy, S., Eriksson, M., Bauer, G.F., Pelikan, J.M., Lindström, B., Espnes, G.A., Eds.; Springer: Cham, Switzerland, 2017; pp. 91–96. 3. Kekäläinen, T.; Kokko, K.; Sipilä, S.;Walker, S. Effects of a 9-month resistance training intervention on quality of life, sense of coherence, and depressive symptoms in older adults: Randomized controlled trial. Qual. Life Res. 2018, 27, 455–465. 4. Antonovsky, A. Unraveling the Mystery of Health. How People Manage Stress and Stay Well; Jossey-Bass Inc.: San Francisco, CA, USA, 1987. 5. Galletta, M.; Cherchi, M.; Cocco, A.; Lai, G.; Manca, V.; Pau, M.; Tatti, F.; Zambon, G.; Deidda, S.; Origa, P.; et al. Sense of coherence and physical health-related quality of life in Italian chronic patients: The mediating role of the mental component. BMJ Open 2019, 9, e030001. 6. Kristofferzon, M.-L.; Engström, M.; Nilsson, A. Coping mediates the relationship between sense of coherence and mental quality of life in patients with chronic illness: A cross-sectional study. Qual. Life Res. 2018, 27, 1855–1863. 7. Márquez-Palacios, J.H.; Yanez-Peñúñuri, L.Y.; Salazar-Estrada, J.G. Relationship between sense of coherence and diabetes mellitus: A systematic review. Relación entre sentido de coherencia y diabetes mellitus: Una revisión sistemática. Ciênc. Saúde Coletiva 2020, 25, 3955–3967. 8. Tóth, Á.; Soós, R.; Szovák, E.; Najbauer, N.M.; Tényi, D.; Csábí, G.;Wilhelm, M. Energy Drink Consumption, Depression, and Salutogenic Sense of Coherence Among Adolescents and Young Adults. Int. J. Environ Res. Public Health 2020, 17, 1290. 9. Kobayashi, T. [Effects of sense of coherence on depressive symptoms after employment in the Japan Self-Defense Force among male young adults]. Nihon Koshu Eisei Zasshi 2017, 64, 150–155. 10. Bonzanini, L.I.L.; Soldera, E.B.; Ortigara, G.B.; Schulz, R.E.; Knorst, J.K.; Ardenghi, T.M.; Ferrazzo, K.L. Effect of the sense of coherence and associated factors in the quality of life of head and neck cancer patients. Braz. Oral Res. 2020, 34, e009. 11. Silarova, B.; Nagyova, I.; Rosenberger, J.; van Dijk, J.P.; Reijneveld, S.A. Sense of coherence as a mediator between hostility and health-related quality of life among coronary heart disease patients. Heart Lung 2016, 45, 126–131. 12. Lage, C.F.; Fulgencio, L.B.; Corrêa-Faria, P.; Serra-Negra, J.M.; Paiva, S.M.; Pordeus, I.A. Association between dental caries experience and sense of coherence among adolescents and mothers. Int. J. Paediatr. Dent. 2017, 27, 412–419. 13. Da Silva, A.N.; Vettore, M.V. Sense of coherence modifies the association between untreated dental caries and dental pain in low-social status women. Community Dent. Health 2016, 33, 54–59. 14. da Rosa Possebon, A.P.; Martins, A.P.P.; Danigno, J.F.; de Oliveira Langlois Langlois, C.; Silva, A.E.R. Sense of coherence and oral health in older adults in Southern Brazil. Gerodontology 2017, 34, 377–381. 15. Eriksson, M.; Mittelmark, M.B. The Sense of Coherence and Its Measurement. In The Handbook of Salutogenesis; Mittelmark, M.B., Sagy, S., Eriksson, M., Bauer, G.F., Pelikan, J.M., Lindström, B., Espnes, G.A., Eds.; Springer: Cham, Switzerland, 2017; pp. 97–106. 16. Getnet, B.; Alem, A. Construct validity and factor structure of sense of coherence (SoC-13) scale as a measure of resilience in Eritrean refugees living in Ethiopia. Confl. Health 2019, 13, 3. 17. Rajesh, G.; Eriksson, M.; Pai, K.; Seemanthini, S.; Naik, D.G.; Rao, A. The validity and reliability of the Sense of Coherence scale among Indian university students. Glob. Health Promot. 2016, 23, 16–26. 18. Stern, B.; Socan, G.; Rener-Sitar, K.; Kukec, A.; Zaletel-Kragelj, L. Validation of the Slovenian Version of Short Sense of Coherence Questionnaire (SOC-13) in Multiple Sclerosis Patients. Zdr. Varst. 2019, 58, 31–39. 19. Naaldenberg, J.; Tobi, H.; van den Esker, F.; Vaandrager, L. Psychometric properties of the OLQ-13 scale to measure Sense of Coherence in a community-dwelling older population. Health Qual. Life Outcomes 2011, 9, 37. 20. Antonovsky, A. The structure and properties of the sense of coherence scale. Soc. Sci. Med. 1993, 36, 725–733. 21. Virués-Ortega, J.; Martínez-Martín, P.; del Barrio, J.L.; Lozano, L.M.; Grupo Español sobre Envejecimiento. Validación transcultural de la Escala de Sentido de Coherencia de Antonovsky (OLQ-13) en ancianos mayores de 70 años. Med. Clin. 2007, 128, 486–492. 22. Sartorius, N.; Kuyken, W. Translation of Health Status Instruments. In Quality of Life Assessment: International Perspectives; Orley, J., Kuyken,W., Eds.; Springer: Berlin/Heidelberg, Germany, 1994; pp. 3–18. 23. World Health Organization. Gender and Health. Available online: https://www.who.int/es/news-room/fact-sheets/detail/ gender (accessed on 5 April 2020). 24. Metodología de Estratificación Socio-Económica Urbana y Rural para Servicios Públicos Domiciliarios. DANE. Available online: https://www.dane.gov.co/files/geoestadistica/estratificacion/ManualdeActualizacion.pdf (accessed on 5 April 2020). 25. Brown, T.A. Confirmatory Factor Analysis for Applied Research; Guilford Press: New York, NY, USA, 2006. 26. Lloret-Segura, S.; Ferreres-Traver, A.; Hernández-Baeza, A.; Tomás-Marco, I. El análisis factorial exploratorio de los ítems: Una guía práctica, revisada y actualizada. Anal. Psicol. 2014, 30, 1151–1169. 27. Lorenzo-Seva, U.; Ferrando, P.J. FACTOR: A computer program to fit the exploratory factor analysis model. Behav. Res. Methods Instrum. Comput. 2006, 38, 88–91. 28. Bryant, F.B.; Satorra, A. Principles and practice of scaled difference Chi-Square testing. Struct. Equ. Model. Multidiscip. J. 2012, 19, 372–398. 29. De los Ángeles Morata-Ramírez, M.; Holgado-Tello, F.P. Construct validity of likert scales through confirmatory factor analysis: A simulation study comparing different methods of estimation based on pearson and polychoric correlations. Int. J. Soc. Sci. Stud. 2013, 1, 54–61. 30. Satorra, A.; Bentler, P.M. A scaled difference chi-square test statistic for moment structure analysis. Psychometrika 2001, 66, 507–514. 31. Byrne, B.M. Structural Equation Modeling with Lisrel, Prelis, and Simplis: Basic Concepts, Applications, and Programming, 2nd ed.; Psychology Press: New York, NY, USA, 2013. 32. Bentler, R.M.;Wu, E.J. EQS 6.2 for Windows [Statistical Program]; Multivariate Software: Encino, CA, USA, 2012. 33. Dimitrov, D.M. Testing for Factorial Invariance in the Context of Construct Validation. Meas. Eval. Couns. Dev. 2010, 43, 121–149. 34. Bollen, K.A. Structural Equations with Latent Variables; John Wiley & Sons: New York, NY, USA, 1989. 35. Satorra, A.; Bentler, P.M. Ensuring Positiveness of the Scaled Difference Chi-square Test Statistic. Psychometrika 2010, 75, 243–248. 36. Elosua-Oliden, P.; Zumbo, B.D. Coeficientes de fiabilidad para escalas de respuesta categórica ordenada. Psicothema 2008, 20, 896–901. 37. Albino, J.; Shapiro, A.L.B.; Henderson, W.G.; Tiwari, T.; Brega, A.G.; Thomas, J.F.; Bryant, L.L.; Braun, P.A.; Quissell, D.O. Validation of the Sense of Coherence Scale in an American Indian population. Psychol. Assess. 2016, 28, 386–393. 38. Eriksson, M.; Lindström, B. Validity of Antonovsky’s sense of coherence scale: A systematic review. J. Epidemiol. Community Health 2005, 59, 460–466. 39. Del Carmen Vega Martínez, M.; Osuna, A.F.; del Pino Casado, R. Validez y confiabilidad de la escala de sentido de coherencia en estudiantes de grado de enfermería de una universidad española. Gac. Sanit. 2019, 33, 310–316. 40. DeVellis, R.F.; Robert, F. Scale Development: Theory and Applications, 3rd ed.; Sage Publications Inc.: Thousand Oaks, CA, USA, 2012. |
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Universidad Cooperativa de Colombia, Facultad de Ciencias de la Salud, Odontología, Pasto Prof. Dr. Karl Goodkin (Section Mental Health) |
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Odontología |
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Universidad Cooperativa de Colombia |
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Mafla Chamorro, Ana CristinaHerrera López, MauricioEspaña Fuelagan, KarenRamírez Solarte, IvanGallardo Pino, CarmenSchwendicke, Falk182022-10-08T16:25:24Z2023-12-102022-10-08T16:25:24Z2021-12-10ISSN (online): 1660-4601 | ISSN (print): 1661-7827http://doi.org/10.3390/ijerph182413017https://hdl.handle.net/20.500.12494/46656Mafla AC, Herrera-López M, España-Fuelagan K, Ramírez-Solarte I, Gallardo Pino C, Schwendicke F. (2021) Psychometric Properties of the SOC-13 Scale in Colombian Adults. Int J Environ Res Public Health. 2021;18(24):13017.https://repository.ucc.edu.co/handle/20.500.12494/46656The aim of this study was to determine the psychometric properties of the Spanish version of the SOC-13 in Colombian adults. The SOC-13 questionnaire was administered to 489 individuals aged ≥18 years who were in lockdown from March to July 2020 in Nariño County, Colombia. Psychometric properties of the scale were examined using a cross-validation method via exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Additionally, configural and metric invariance were tested. To determine the internal consistency of the questionnaire, McDonald’s omega (ω), Cronbach’s alpha (α), and composite reliability (CR) coefficients were estimated. The EFA determined that a three-factor structure best fit the data (comprehensibility, manageability, and meaningfulness) and CFA confirmed this three-factor model structure showing a good fit (χ2 S-B = 188.530, χ2 S-B/(62) = 3.615, p = 0.001; NNFI = 0.959; CFI = 0.968; RMSEA = 0.052 (90% CI [0.041–0.063]) and SRMR = 0.052). The invariance analysis indicated the same underlying theoretical structure between genders. Additionally, (ω), (α), and (CR) coefficients confirmed a high internal consistency of the instrument. The SOC-13 scale, reflecting comprehensibility, manageability, and meaningfulness, is a reliable and valid tool for assessing the sense of coherence in Colombian populations.1. Introduction. -- 2. Materials and Methods. 2.1 Study, Participants and Settings. -- 2.2 Instrument. -- 2.3 Procedures. -- 2.4 Statistical Approach. -- 3. Results. -- 3.1 Sociodemographic Characteristics. -- 3.2 Psychometric Properties of the SOC-13 Scale. -- 4. Discussion. -- 5. Conclussions.https://scienti.minciencias.gov.co/cvlac/visualizador/generarCurriculoCv.do?cod_rh=0000676616https://orcid.org/0000-0002-2805-7901https://scienti.minciencias.gov.co/gruplac/jsp/visualiza/visualizagr.jsp?nro=00000000002911ana.mafla@campusucc.edu.cohttps://scholar.google.com/citations?user=MSFc5YoAAAAJ&hl=es13017Universidad Cooperativa de Colombia, Facultad de Ciencias de la Salud, Odontología, PastoProf. Dr. Karl Goodkin (Section Mental Health)OdontologíaPastohttps://www.mdpi.com/1660-4601/18/24/13017International Journal of Environmental Research and Public Health1. Eriksson, M.; Lindström, B. Antonovsky’s sense of coherence scale and the relation with health: A systematic review. J. Epidemiol. Community Health 2006, 60, 376–381.2. Eriksson, M. The Sense of Coherence in the Salutogenic Model of Health. In The Handbook of Salutogenesis; Mittelmark, M.B., Sagy, S., Eriksson, M., Bauer, G.F., Pelikan, J.M., Lindström, B., Espnes, G.A., Eds.; Springer: Cham, Switzerland, 2017; pp. 91–96.3. Kekäläinen, T.; Kokko, K.; Sipilä, S.;Walker, S. Effects of a 9-month resistance training intervention on quality of life, sense of coherence, and depressive symptoms in older adults: Randomized controlled trial. Qual. Life Res. 2018, 27, 455–465.4. Antonovsky, A. Unraveling the Mystery of Health. How People Manage Stress and Stay Well; Jossey-Bass Inc.: San Francisco, CA, USA, 1987.5. Galletta, M.; Cherchi, M.; Cocco, A.; Lai, G.; Manca, V.; Pau, M.; Tatti, F.; Zambon, G.; Deidda, S.; Origa, P.; et al. Sense of coherence and physical health-related quality of life in Italian chronic patients: The mediating role of the mental component. BMJ Open 2019, 9, e030001.6. Kristofferzon, M.-L.; Engström, M.; Nilsson, A. Coping mediates the relationship between sense of coherence and mental quality of life in patients with chronic illness: A cross-sectional study. Qual. Life Res. 2018, 27, 1855–1863.7. Márquez-Palacios, J.H.; Yanez-Peñúñuri, L.Y.; Salazar-Estrada, J.G. Relationship between sense of coherence and diabetes mellitus: A systematic review. Relación entre sentido de coherencia y diabetes mellitus: Una revisión sistemática. Ciênc. Saúde Coletiva 2020, 25, 3955–3967.8. Tóth, Á.; Soós, R.; Szovák, E.; Najbauer, N.M.; Tényi, D.; Csábí, G.;Wilhelm, M. Energy Drink Consumption, Depression, and Salutogenic Sense of Coherence Among Adolescents and Young Adults. Int. J. Environ Res. Public Health 2020, 17, 1290.9. Kobayashi, T. [Effects of sense of coherence on depressive symptoms after employment in the Japan Self-Defense Force among male young adults]. Nihon Koshu Eisei Zasshi 2017, 64, 150–155.10. Bonzanini, L.I.L.; Soldera, E.B.; Ortigara, G.B.; Schulz, R.E.; Knorst, J.K.; Ardenghi, T.M.; Ferrazzo, K.L. Effect of the sense of coherence and associated factors in the quality of life of head and neck cancer patients. Braz. Oral Res. 2020, 34, e009.11. Silarova, B.; Nagyova, I.; Rosenberger, J.; van Dijk, J.P.; Reijneveld, S.A. Sense of coherence as a mediator between hostility and health-related quality of life among coronary heart disease patients. Heart Lung 2016, 45, 126–131.12. Lage, C.F.; Fulgencio, L.B.; Corrêa-Faria, P.; Serra-Negra, J.M.; Paiva, S.M.; Pordeus, I.A. Association between dental caries experience and sense of coherence among adolescents and mothers. Int. J. Paediatr. Dent. 2017, 27, 412–419.13. Da Silva, A.N.; Vettore, M.V. Sense of coherence modifies the association between untreated dental caries and dental pain in low-social status women. Community Dent. Health 2016, 33, 54–59.14. da Rosa Possebon, A.P.; Martins, A.P.P.; Danigno, J.F.; de Oliveira Langlois Langlois, C.; Silva, A.E.R. Sense of coherence and oral health in older adults in Southern Brazil. Gerodontology 2017, 34, 377–381.15. Eriksson, M.; Mittelmark, M.B. The Sense of Coherence and Its Measurement. In The Handbook of Salutogenesis; Mittelmark, M.B., Sagy, S., Eriksson, M., Bauer, G.F., Pelikan, J.M., Lindström, B., Espnes, G.A., Eds.; Springer: Cham, Switzerland, 2017; pp. 97–106.16. Getnet, B.; Alem, A. Construct validity and factor structure of sense of coherence (SoC-13) scale as a measure of resilience in Eritrean refugees living in Ethiopia. Confl. Health 2019, 13, 3.17. Rajesh, G.; Eriksson, M.; Pai, K.; Seemanthini, S.; Naik, D.G.; Rao, A. The validity and reliability of the Sense of Coherence scale among Indian university students. Glob. Health Promot. 2016, 23, 16–26.18. Stern, B.; Socan, G.; Rener-Sitar, K.; Kukec, A.; Zaletel-Kragelj, L. Validation of the Slovenian Version of Short Sense of Coherence Questionnaire (SOC-13) in Multiple Sclerosis Patients. Zdr. Varst. 2019, 58, 31–39.19. Naaldenberg, J.; Tobi, H.; van den Esker, F.; Vaandrager, L. Psychometric properties of the OLQ-13 scale to measure Sense of Coherence in a community-dwelling older population. Health Qual. Life Outcomes 2011, 9, 37.20. Antonovsky, A. The structure and properties of the sense of coherence scale. Soc. Sci. Med. 1993, 36, 725–733.21. Virués-Ortega, J.; Martínez-Martín, P.; del Barrio, J.L.; Lozano, L.M.; Grupo Español sobre Envejecimiento. Validación transcultural de la Escala de Sentido de Coherencia de Antonovsky (OLQ-13) en ancianos mayores de 70 años. Med. Clin. 2007, 128, 486–492.22. Sartorius, N.; Kuyken, W. Translation of Health Status Instruments. In Quality of Life Assessment: International Perspectives; Orley, J., Kuyken,W., Eds.; Springer: Berlin/Heidelberg, Germany, 1994; pp. 3–18.23. World Health Organization. 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