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Issue: 2021, June, Volume 15, No 2
issue id: 2021_6_15_2
article id: 2021_6_15_2_20

Original Research



Experiences of Nurses about Traditional Practices Encountered in Women and Newborns

Hemşirelerin, Kadınlarda ve Yenidoğanlarda Karşılaştıkları Geleneksel Uygulamalara İlişkin Deneyimleri

Nazan Çakırer Çalbayram*1, İlknur Münevver Gönenç2, Sebahat Altundağ3



Abstract
Objectives: This study was conducted to determine the experiences of nurses working in the obstetric and neonatal fields regarding the traditional practices and their results they encounter. Method: The phenomenological research design, one of the qualitative research methods, was used in the study, and the data were collected by focus group interview method. Four focus group interviews, each of which consisted of about 6-8 participants, a moderator, and an assistant, were held. The data obtained from the interviews were first analyzed in terms of content, and then themes have emerged. Results: In the interviews, it was determined that nurses experienced many traditional practices for women and newborns. The findings of the study are grouped under three themes and 14 categories. These themes; 'traditional practices and consequences encountered in woman health', 'traditional practices for newborn health and the consequences', and 'the motivations for the implementation of traditional methods'. Conclusion: Nurses observed many traditional practices. They have experienced that these traditional practices often have harmful effects on women's and newborn health.
Key words: Traditional practice, women, newborn, nurse

Özet
Amaç: Bu çalışma obstetrik ve yenidoğan alanlarında çalışan hemşirelerin bu alanlarda karşılaştıkları geleneksel uygulamalar ve sonuçlarına ilişkin deneyimlerini belirlemek amacıyla yapılmıştır. Yöntem: Çalışmada niteliksel araştırma yöntemlerinden fenomolojik araştırma deseni kullanılmış, veriler odak grup görüşme yöntemi ile toplanmıştır. Araştırmada, her biri 6-8’er katılımcıdan, bir moderatör ve bir yardımcıdan oluşan dört odak grup görüşmesi yapılmıştır. Görüşmelerden elde edilen veriler önce içerik bakımından analiz edilmiş ve daha sonra kodlanmıştır. Bulgular: Yapılan görüşmelerde hemşirelerin kadınlara ve yenidoğanlara yönelik birçok geleneksel uygulama deneyimledikleri belirlenmiştir. Araştırmanın bulguları üç tema, 14 kategori altında toplanmıştır. Temalar; “kadın sağlığında karşılaşılan geleneksel uygulamalar ve sonuçları”, “yenidoğan sağlığında karşılaşılan geleneksel uygulamalar ve sonuçları” ve “geleneksel yöntemlerin uygulanmasına yönelik motivasyonlar”. Sonuç: Hemşirelerin deneyimledikleri birçok geleneksel uygulama vardır. Hemşireler karşılaştıkları bu geleneksel uygulamaların genellikle kadın ve yenidoğan sağlığını olumsuz etkileri olduğunu deneyimlemişlerdir.
Anahtar kelimeler: Geleneksel uygulamalar, kadın, yenidoğan, hemşire

This study was presented at the 8th International Conference on Nursing & Midwifery (ICNM) in Rome, Italy,10-11 June 2017.

Received / Geliş tarihi: 25.09.2021
Accepted / Kabul tarihi: 18.03.2021

1 Çanakkale Onsekiz Mart Üniversitesi Sağlık Bilimleri Fakültesi Hemşirelik Bölümü, Çanakkale-TÜRKİYE.
2 Ankara Üniversitesi Hemşirelik Fakültesi Ebelik Bölümü, Ankara-TÜRKİYE.
3 Pamukkale Üniversitesi Sağlık Bilimleri Fakültesi Hemşirelik Bölümü, Denizli-TÜRKİYE.

* Address for Correspondence / Yazışma Adresi: Nazan Çakırer Çalbayram, Çocuk Sağlığı ve Hastalıkları Hemşireliği, Çanakkale Onsekiz Mart Üniversitesi Sağlık Bilimleri Fakültesi Hemşirelik Bölümü, Çanakkale-TÜRKİYE.
E-mail: nazancalbayram@comu.edu.tr

Çakırer Çalbayram N, Gönenç İM, Altundağ S. Experiences of Nurses about Traditional Practices Encountered in Women and Newborns. TJFMPC, 2021;15(2): 357-365.

DOI: 10.21763/tjfmpc.800019





INTRODUCTION
Culture is defined as values, beliefs, attitudes and behaviors, customs, and traditions learned, shared, and transferred from generation to generation by a group of people. Culture is the texture of life, and every human being belongs to a specific culture.1 Belief and practices about health and diseases are parts of the culture of the society. These are called traditional practices and are carried out to overcome physical and mental health problems, and they are transferred from generation to generation.2 Traditional methods are practiced almost everywhere globally, although they can vary from region to region, from family to family, and even from person to person.3

For years, people who have been trying to preserve certain cultural values have also reflected their efforts on their health behaviors and seeking solutions to their health problems in their cultural life.4 For this reason, cultural data collection is important to healthcare professionals. Thus, they will be able to understand better the attitudes of individuals towards coping with illness as well as promoting and protecting their health.5

The impact of traditional practices on health can be positive. However, they can sometimes lead to life-threatening outcomes.6 Harmful health practices prolong the healing period, hinder effective treatment, and even result in death.7 The cultural aspects of society affect individuals' health and disease conditions, especially for mothers and children. Maternal and child health services, which cover medical care during pregnancy, delivery, and the post-natal period, have special significance in terms of traditional practices.4
Inadequate post-natal care leads individuals to rely mostly on traditional practices during this period. In addition, unless an emergency occurs, mothers often do not seek professional health care. Contributing factors include the pressure from the family elders, perceiving the post-natal health problems as a regular occurrence, the status of women in the society, economic inadequacies, distant health centers, religious beliefs, lack of trust in health personnel, and lack of health insurance.4,8 Harmful traditional practices are likely to extend the treatment process and may cause both the mother and the infant to lose their health and subject to late effects in their future life.7

Although they can cause critical health problems, traditional practices are still widely used in infant care9-13 and women's health.7,8,14,15 Therefore, to provide better healthcare, it is necessary to understand people receiving care without making any judgments about how they perceive and react to disease and health issues.16 Healthcare workers, especially nurses, should know the traditional health-related methods used in their countries and make use of them in their practice.17

This study was conducted to determine the experiences of nurses working in the obstetric and neonatal fields regarding the traditional practices they encounter in these areas and their results.

METHODS

Study Design
This qualitative study was carried out in a phenomenological research design.
Phenomenology 'defines the common significance of a few people's experiences of a phenomenon or concept' and 'intends to reduce individual experiences about a phenomenon to a description of a universal nature.'18-19 In this study, 'Traditional Practices' defined as a phenomenon, and the experiences of nurses working in the field of obstetrics and neonatology were examined.

Setting
The data were collected through focus group interviews. The focus group technique is essential in determining specific behaviors of the phenomenon. This method enables a better understanding of the characteristics of the population who will receive nursing services, and service planning can be done according to the obtained data.1 There were four focus group interviews, each consisting of 6-8 participants, a moderator, and an assistant. The data were transcribed with the help of the moderator and the assistant reporter. Each interview lasted about 80 or 90 minutes. The question-answer technique was used in the interviews. The study data were collected from 30 nurses working in a hospital in Ankara between 20th March and 3rd April 2017. Participants were selected among the volunteered nurses working in the obstetrics and neonatology clinics for at least five years. Maximum sampling diversity was ensured by considering age, education status, and work experience.

Data Collection
Before the interviews began, the researchers introduced themselves to the group. They provided information about the purpose of the study and, how long the interview would take, and how it would be carried out. Participants were also told that the researchers would transcribe the interviews anonymously. Each participant was given one minute to introduce him/herself.

In the focus group discussions, the following three questions were asked to determine the areas of debate.

'Could you share your experiences with traditional practices you have encountered in the field of obstetrics and neonatology during the last five years?'

'Could you tell us about your experiences regarding the effects of traditional practices you have encountered in the field of obstetrics and neonatology on women's and newborn's health?'

'Can you share your experiences on the reasons why individuals apply traditional methods of women's and newborn's health?'

The participants were given the right to speak in turn. At the end of the interview, they were asked if they wanted to add anything.

The researchers transferred the interview recordings to the computer system and transcribed them verbatim. Content analysis technique was used. The main themes associated with the traditional practices and outcomes were coded. Then, categories were formed and analyzed. These procedures helped to determine the conceptual structure of the study. Direct quotations from the participants about the related topic were used to support the data.

Statistical Analysis
As a result of the content analysis, three themes and 14 categories were created. Themes are 'Traditional practices and consequences encountered in woman health,' 'Traditional practices for newborn health and the consequences,' and 'The motivations for the implementation of traditional methods' (Figure 1).

For the validity of the study, Lincoln and Guba's Evaluative Criteria were utilized. 21 To do this, the following procedures were conducted:
Two researchers (an interviewer and an observer) joined the interviews to increase the conformity of the study. The researcher took notes about the interviews. The researchers were given weekly feedback. The findings of the study were shared directly with no comments. An analysis was also carried out for the relationships between themes and categories and between each theme and the rest to ensure the integrity of the study. The study participants were made sure that the interview data would only be used for scientific purposes, kept confidential, which helped collect reliable data. Procedures carried out during this study were explained in detail to increase the transferability of the study. Moreover, the content was read to a participant and asked whether the statements accurately reflected the findings, which increased the study's credibility.

Ethical Considerations
Necessary institutional approvals and ethical permissions were obtained in order to conduct the study (20.03.2017-5.97). The study was conducted in full accordance with the Declaration of Helsinki (2013).

RESULTS
The mean age of the nurses who participated in the study was 44.5 (min: 30 - max: 51). The educational level of 13.3% of the participants was high school, 33.3% college, 46.7% undergraduate, and 6.7% postgraduate. Mean work experience was 16.2 years (min 7 - max 40).

It was determined that the participants witnessed many traditional practices regarding woman and newborn health. Three themes were derived from the qualitative data. These were; 1. Traditional practices and their consequences encountered in woman health, 2. Traditional practices and their consequences encountered in newborn health, and 3. The motivations for the implementation of traditional methods.

Traditional practices and their consequences encountered in woman health
Traditional practices observed by nurses in woman health could be grouped under four categories. They were practices to terminate the pregnancy, practices related to pregnancy, practices used in natal and post-natal periods, and practices to handle sexual and gynecological problems. Our participants observed various methods for terminating the pregnancy and the harm of these practices on women's health.

'Women place a soap into their womb to induce a miscarriage. They hope that this will open cervix, and end the pregnancy. It starts bleeding and harms the woman so much.' (age, 51; high school graduate; work experience, 29 years).

'They dust off the heavy carpets or jump off a high place to induce a miscarriage. Another frequent practice nowadays is taking aspirin to induce a miscarriage. They come to the hospital with a hemorrhage complaint.' (age, 36; undergraduate; work experience, 13 years).

There were also some false beliefs relating to sexual matters, and some traditional practices were exercised in line with these beliefs.

'Before the first coitus, the woman bathes her genitals with sugared water or honey. The husband does not know about this. Women do this to make their husbands loyal. They come to the hospital with cystitis. They develop infection' (age, 49; college; work experience, 30 years).

'We found a hard lid in the vagina during the examination of a woman coming for delivery. We asked her why did she do this. She said she had done it to prevent the baby from getting messed with the sperm of her husband. It had caused pain and discomfort. We found out that she usually placed the lid before the coitus and took it out afterward, but she had forgotten it this time.' (age, 43; college, work experience, 22 years).

'They frequently have vaginal douche, especially pregnant women. They think that the sperms of the man will reach the fetus. They are especially disturbed more if the baby is a girl. They usually develop a vaginal infection.' (age, 40; graduate; work experience, 23 years).

'They place it before sexual intercourse. They place a piece of cotton soaked in lemon and vinegar at the cervix. They do it to prevent pregnancy, as a birth control method. A woman came to the hospital with an infection.' (age, 50; college, work experience, 30 years).
A participant reported about the traditional practices relating to pregnancy and the natal and post-natal period,.

'They turn the womb backward to get pregnant. They do it with soap. It's interesting, but they really get pregnant. In another case I met, the woman had been hung herself to the ceiling from her feet. After that, she got pregnant. '

'Women consume pears daily because pear increases the amnion fluid. Because carrot juice and grape molasses prevent the anemia, pregnant women consume them regularly.' (age, 34; undergraduate; work experience, 12 years).

'Some women wash their vagina with carbonates to have a boy and with vanilla to have a girl. They develop an infection, and then they come to the hospital.' (age, 42; undergraduate; work experience, 24 years).

Another participant reported a traditional practice for removing the chloasma formed during pregnancy: 'They believe that they will remove pregnancy blotches by wiping their face with their sweaty hair at birth.' (age, 39; undergraduate; work experience, 20 years).

'Before coming, they drink herbal tea to facilitate the delivery. It relaxes the muscles. They believe the flower of Maryam (Anastatica hierochuntica) facilitates birth. They soak the herb in water and await it to open. They believe the uterus will open as soon as the herb opens.' (age, 49; college; work experience, 30 years).

In interviews with nurses revealed that women employed several traditional practices for their gynecological problems. One of the participants described this situation as follows.

'Women place an apple in their vagina to prevent prolapsus, to push up the bladder. A woman applied to the hospital with an infection developed due to this practice. Another case I encountered was that a woman who came to the hospital with vaginal infection had washed her vagina with vinegar-added water.' (age, 44; undergraduate; work experience, 26 years).

'Which one should I start with? Women with vaginal prolapsus get pregnant to get rid of this problem, even if their complaints were relatively new. But they come to the hospital with more complaints after pregnancy.' (age, 41; postgraduate; work experience, 20 years).

Traditional practices for newborn health and their consequences
The traditional practices that nurses encountered in newborn health were classified into two categories: 1. traditional practices related to newborns' physical and social development, and 2. Traditional practices regarding finding solutions to the common disorders in the newborn.

Nurses reported that there were many traditional practices employed relating to the physical and social development of newborns. Some practices employed unwisely to accelerate the baby's development were found to affect the newborn health negatively. The participants described this situation as follows;

'They shaved the child's hair, cut a scar on the head with a knife, and then rubbed it with garlic to help the child to gain weight. The child developed an infection. In another case, they poured lead into the water to remove the evil eye. They spilled the lead on the baby accidentally and burned him.' (age, 42; undergraduate; work experience, 22 years).

'They put on mascara on the newborn's eyes and eyebrows, to make its eyes look more beautiful. They end up with an eye infection.' (age, 44; college; work experience, 11 years).

'A mother searched on the Internet and said that the child does not respond after vaccination, and she diagnosed autism in her 4-year-old child. Then she started leech therapy for the baby. She believes that the leeches will absorb the dirty blood and treat the disease. The baby was brought to the hospital with severe bleeding in the neck.' (age, 35; undergraduate; work experience, 10 years).

'In order to stop breastfeeding and make the baby feel sickened, they wrapped hair or black tape around the nipple. I think this is traumatic for the baby. But I think we have not been able to provide them adequate information. We tell them how to breastfeed their babies, but we do not tell them how to stop it. They put quince seeds in water to form a gel and wipe the chapped nipples with this gel. Interestingly, I have witnessed that it works. Another interesting event I encountered was that the mother-in-law breastfed the baby to prevent the mother from opening her breast in the crowd. A situation I encountered at the hospital.' (age, 44; undergraduate; work experience, 26 years).

'They put Turkish delight in the pacifier and give it to the baby. It makes him/her feel full. Then s/he does not want to suck the breast milk because the milk is tasteless (after the Turkish delight). Because of this, babies can not suck breast milk.' (age, 36; college; work experience, 17 years).

Nurses stated that parents apply many traditional methods to treat common disorders seen in newborns and that these practices harm the infant. 'The mother rubs the male newborn's breast due to the swelling of the breast. They came to the hospital with a breast infection. The baby was put in the intensive care unit due to sepsis.' (age, 44; college; work experience, 11 years).

Nasal congestion is a common problem in newborns. One of the participants said;

'The baby has nasal congestion, so the mother mixes some breast milk with olive oil and drips it to baby's nose. They came to the hospital with aspiration pneumonia.' (age, 44; college; work experience, 11).

Another participant reported a traditional method related to the infant's sleep problem as follows;

'The baby can't sleep, so they give it poppy oil. The baby can't wake up, so they bath him. Then they bring the baby to the hospital because the baby can't wake up. The infant develops hypoglycemia.'(age, 55; high school; work experience, 40 years).

In the interviews, it was found that traditional methods were also practiced for jaundice in newborns. One of the participants reported the following;

'One common practice in newborn jaundice among people is to wrap the baby with yellow cheesecloth. In one case, the infant develops kernicterus. The mother delays visiting the doctor, hoping that it would recover. They put gold on the baby’s chest and believe that the baby will not develop jaundice, but they all end up coming to the hospital with quite high bilirubin levels.'(age, 34; postgraduate; work experience, 7 years).

The motivations for the implementation of traditional methods
Participants' thoughts about the motivations for implementing traditional methods were classified under eight categories, including the pressure of the elders, lack of education, beliefs, lack of money, helplessness, culture, commitment to traditions, and fear. The participants explained this situation as follows:

'They practiced traditional methods and benefited from some of them. Due to their financial situation, they would prefer these methods rather than go to the doctor. Also, they do not have adequate information.' (age, 55; high school; work experience, 40 years).

'They have learned these practices from their families, and they say that these methods must be true as the elders have been applying them. They never think why.' (age, 39; undergraduate; work experience, 20 years).

'Lack of information. They do not know where to find out the truth. They do not spare any thoughts for the reasons. They will change if they receive training, but the training is inadequate.'(age, 44; undergraduate; work experience, 26 years).

'There are habitual practices coming from the past. They believe that these methods are useful. Some of them apply the methods because they can't resist their elders. Some women say their mothers-in-law do not give up these practices. In fact, they are helpless, too.' (age, 25; undergraduate; work experience, 10 years).

'They keep doing it because of despair and faith. When people are desperate, they resort to anything. You say they can apply a method if it isn't harmful. But these women find everything useful. On the other hand, they say 'it’s the destiny’ when it’s harmful.' (age, 43; college; work experience, 22 years).

DISCUSSION
It was determined that the women are practicing some traditional methods to terminate unwanted pregnancies, deal with problems encountered during birth and the post-natal period, and solve sexual and gynecological issues. It seems that there is considerable inaccurate knowledge and beliefs about sex. According to the participants' statements, it was determined that pregnant women were fearful of contaminating the baby with the male’s sperms; thus, they practiced methods that can harm their own body and the fetus. Similarly, a participant in another study said that she thought parents should abstain from coitus as of the fourth month of pregnancy since the fetus can get messed with the father’s sperms. Nearly half of the participants reported they refrained from coitus due to such reasons as ‘fear of damage to the hymen of the female fetus, and possible consequences on the fetus such as blindness and suffocation.’

Furthermore, another participant reported that 'having sexual intercourse after the first three months may cause the sperms to reach the eyes of the fetus and lead to the loss of sight.'22 According to the statements of the participants, women usually performed vaginal showers after sexual intercourse. Another common practice, especially among Afro-American and Muslim women, was jetting liquid solution in the vagina for maintaining cleanliness, odor control, or relieving the vaginal itching and irritation.23 A study found that more than half of the women had vaginal cleaning and that it was usually performed following the coitus (49.7%).14 Similarly, Çalışkan et al. found that 50.2% of the women were carrying out vaginal douching.15 According to their study, women believed the benefits of this practice because they thought it provided cleanliness, prevented infections and pregnancy, got rid of sperms, eliminated symptoms like discharge and unwanted odor, and was an Islamic practice.

According to studies conducted so far, women were found to apply several methods to determine the gender of their babies.23-25 For example, they washed their vagina with carbonate and vanilla to determine the gender of the baby. However, these practices hadn’t been encountered in the studies reviewed.

In this study, the participants stated that women used 'the flower of Maryam' to facilitate birth. Similarly, Yalçın (2012) found that 77.9% of the women in their study used the flower of Maryam’ to facilitate the delivery. 13 In this study, nurses’ experiences revealed another method used to promoting delivery was sexual intercourse which was also found to be effective by the participants. A possible alternative for relieving pain during delivery is orgasm and sexual intercourse. This was thought to be a physiological effect due to hormones and genitosensory nerves.26

One of our participants stated that the breast of the male baby was infected due to rubbing; this suggested that the educational need of new mothers. When a baby has just been born, the breast may swell due to hormones passing from the mother.27 Rubbing or squeezing the breast to reduce the swelling can cause irritation or even infection. If the swelling is left untouched, it will great possibly disappear in a few days.7

Additionally, the participants in the study stated that mothers gave the baby poppy oil to handle the sleep problem. Herbal products are widely used in adults and children, and their use is growing. Although there are numerous concerns about their possible harmful effects, they are widely used to treat diseases and improve overall health.28 There is a widespread false belief among people that if something is natural, it is harmless. However, unexpected side effects may develop due to hundreds of components that plants contain.29 This becomes even riskier, especially in newborns and children.

One of the nurses in this study stated that mothers employed traumatic methods to stop breastfeeding and that the health personnel did not provide them with enough information. Dinç et al. (2013) reported that mothers used several ways to stop breastfeeding their babies, such as sticking wool, chicken feather, or hair around the nipple, applying tomato paste, lipstick, vaseline, salt or red pepper on the breast, telling the child that the breast is a poo to disgust the baby, giving supplemental food with feeding bottle, fooling the baby with water or fruit juice, sending the baby to a separate home, and sticking parcel band on the breast or staining the nipple with something black.30

According to the participants' statements, one of the traditional practices frequently encountered in newborns was to put on mascara on the baby’s eyes. It was stated that this caused an eye infection in the newborn as a result. Several studies have reported that mothers apply kajal to newborns’ eyes.31-33 This ancient traditional application is believed to ward off evil in addition to its cosmetic benefits but may cause conjunctivitis and dacryocystitis.34 Long term users are likely to end up with excessive lead storage in their body, which leads to convulsions and anemia.35

One participant in the study talked about some commonly practiced methods used for infant jaundice. She mentioned some methods such as dressing the baby in yellow cheesecloth and putting a golden accessory in the chest. She also reported that mothers were usually applying late to the hospital for treatment. Similarly, Yalçın (2012) determined that to treat jaundice, mothers wrapped the baby in yellow swaddling clothes or yellow scarf, had the baby wear golden accessories and yellow garments, and gave the baby sugared water.12 Nethra and Udgiri (2018) found that mothers exposed the infant to sunlight when the baby had yellow skin, thinking that the sunlight would help recover. Also, mothers thought giving sugared water to their infant would be a treatment for jaundice.33

Many traditional practices encountered by participants in the study were found to have harmful effects on women, such as bleeding, infection, pain, and discomfort. On the other hand, methods applied to newborns seemed to cause serious health problems such as infection, hypoglycemia, bleeding, aspiration, and hyperbilirubinemia. Similar to the results of this study, some studies reported that harmful traditional methods applied to mothers and babies could lead to the development of disorders, cause the development of infection, dehydration, hypothermia, hypoglycemia, anemia, prolong treatment periods, or cause them to have late effects in their future life.7,16 According to studies, some of the traditional methods practiced in infants increase the risk of morbidity and mortality.36

According to the participants, the individuals applied traditional methods due to the pressure of the elders, lack of education, beliefs, lack of money, helplessness, culture, loyalty to traditions, and fear. Similarly, in a study of Le et al. (2014), regarding traditional beliefs and practices related to newborn care, individuals resorted to traditional methods due to the reasons such as costs, distance to care, bad weather, poor perception of healthcare, the baby is too young to be taken outside, and lack of transportation.37 Sivri and Karataş (2015) stated that individuals did not choose to go to a health institution due to such reasons as the pressure of family elders, economic inadequacies, or religious beliefs unless they were obliged to; instead, they tried to solve their health problems using traditional methods.7

It is crucial to know the traditional beliefs and methods used by societies, reveal the harmful ones, eliminate them, preserve the convenient ones, and maintain cultural values and traditions.8

CONCLUSION and RECOMMENDATIONS
As a result of the content analysis, three themes and 14 categories were created. Themes are 'Traditional practices and consequences encountered in woman health,' 'Traditional practices for newborn health and the consequences,' and 'the motivations for the implementation of traditional methods.' Participants stated that they experienced many harmful effects of traditional practices on women and newborn health. They also stated that as a result of these practices, women and newborns went to the hospital late, and the healing process is prolonged, and some procedures cause side effects and complications. The nurses in the study stated that individuals practiced these methods due to ignorance, helplessness, belief, poverty, and cultural reasons. It is essential for nurses and all health professionals to identify and recognize the cultural characteristics underlying individuals' health and sickness-related behaviors. It is recommended to include these practices in the nursing education curriculum to reduce the effects of traditional practices on women and newborns.

Funding
No external or intramural funding was received.

Conflict of interest
None of the authors received any financial support that could be considered a potential conflict of interest regarding the manuscript or its submission.



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