Parenting Programme Review: Structure, Barriers & Enablers

International Journal of

Environmental Research

and Public Health

Review

Parenting Programme Structure, Potential Barriers, and

Facilitators: A Scoping Review

Ana Ramos 1, * , Filomena Matos 2 and H é lia Soares 3

1 Instituto Polit é cnico de Set ú bal, Escola Superior de Sa ú de. NURSE’IN-UIESI, Campus do IPS, Estefanilha,

2910-761 Set ú bal, Portugal

2 University of Algarve, Health School. UICISA: E. NURSE’IN-UIESI, University of Algarve,

Campus de Gambelas, 8005-139 Faro, Portugal

3 University of Azores, Health School. NURSE’IN-UIESI, University of Azores,

9700-042 Angra do Hero í smo, Portugal

* Correspondence: ana.ramos@ess.ips.pt

Abstract: Becoming a parent is a challenging transition, and stress factors may arise. This scoping

review aims to map, from the literature, the structure, potential barriers, and facilitators to be consid-

ered when conducting a parenting programme for parents of children up to 3 years old. It followed

the JBI methodology and included studies with parents of children up to 3 years old (Participants),

studies about parenting programme structure, its potential barriers, and facilitators (Concept) in

the healthcare or community setting (Context). Qualitative and/or quantitative study designs and

grey literature publications between 2016 and 2021 were eligible. The search was performed in three

stages in CINAHL Plus with Full Text, MEDLINE with Full Text, and PubMed databases. It was

also conducted in OpenGrey, ProQuest, Portuguese Open Access Scientific Repository, and Google

Scholar. Fourteen articles were selected. The following aspects were identified regarding parenting programmes: benefits; structuring elements to be considered; facilitating factors and possible barriers to its development, and measurement instruments to assess the programme.

Parenting programmes are important ways to contribute to a healthy, sustainable, and resilient society. It should be adapted

to individuals, groups, and communities. They add value to parents, children, and society and should

be carefully adapted to the group’s needs.

Citation: Ramos, A.; Matos, F.;

Soares, H. Parenting Programme

to individuals, groups, and communities. They add value to parents, children, and society and should

Structure, Potential Barriers, and

be carefully adapted to the group’s needs.

Facilitators: A Scoping Review. Int. J.

Environ. Res. Public Health 2022 , 19 ,

Keywords: parental stress; parenting education; child development; family health; parenting;

13655. https://doi.org/10.3390/

scoping review

ijerph192013655

Academic Editor: Dylan P. Cliff

1. Introduction

Healthy development during childhood promotes vigorous adulthood, contributing

to a productive and sustainable society. A family household is where children establish first

Publisher’s Note: MDPI stays neutral relationships, attachment, and continuous interaction, learn to trust and become acquainted

with regard to jurisdictional claims in with basic social rules [ 1 ]. However, it is also where most child abuse occurs, often caused

published maps and institutional affil-

by a parent [ 2 – 6 ]. This toxic stress impact on the early years triggers adverse adulthood

iations.

outcomes and shortens life expectancy [7–10].

Different kinds of stress can be induced: positive, tolerable, and toxic. The first is a

normal part of healthy functioning; the second is more intense and long-lasting but can

Licensee MDPI, Basel, Switzerland. toxic stress arises from prolonged adverse childhood experiences (ACEs) such as reiterated

Parents and family are those closest to the child and are expected to be the best

conditions of the Creative Commons

Attribution (CC BY) license (https:// caregivers [ 11 ]. However, cumulative toxic stress can occur without appropriate parental

creativecommons.org/licenses/by/

support, which may cause development disruption [ 12 ] and promote morbidity before

4.0/).

adulthood and early death [8,12].

Int. J. Environ. Res. Public Health 2022 , 19 , 13655. https://doi.org/10.3390/ijerph192013655

The COVID-19 pandemic has put children and caregivers at even higher risk by

promoting inequalities with long-term impacts [ 12 , 13 ]. Studies show that this abrupt

change in daily life harms the individual’s mental health and increases depression and

anxiety [ 13 ]. Chronic stress, due to adversity, lays a foundation for adverse outcomes in

both physical and mental health since it generates an inadequate response of inflammation

from the nervous system that affects the metabolic and immune systems deeply [ 7 , 8 , 12 ]

without proper backing.

Early childhood development (ECD) science explains that the factors that influence

health outcomes and the achievement of development potential depend not only on biolog-

ical or behavioural characteristics but also on the experience and environment in which the

child develops [14–16].

Additionally, the 4.2 Goal Target of the United Nations Sustainable Development Goal

is “to ensure that all girls and boys have access to quality early childhood development,

care, and pre-primary education” [ 17 ]. However, the current policy landscape has not

yet resulted in the implementation of large-scale national parenting programmes. Thus,

more scientific research is needed to adapt and deliver parenting programmes in diverse

local contexts, coordinate within existing systems and services, fund programmes to be

cost-effective and sustainable, and scale-up parenting programmes while maintaining

quality and effectiveness [18].

Effective parenting is critical in fostering healthy child development [19] and respon-

sive care, which is the caregiver’s ability to understand the child’s needs and respond

appropriately, promoting growth and buffering stress response. However, for some par-

ents, a social support network, parental education and support programmes are essential.

Thus, parental education and support programmes that strengthen informal social support

networks are needed [20].

This study supports its framework in three theoretical models, which are complemen-

tary and interconnected: the child-centred care model, the family-centred care model and

the nurturing care framework.

The child-centred care model places the children and their interests as the care fo-

cus [ 21 ]. The parenting programmes to be developed must have this purpose, considering

they seek to support the family in promoting the child’s well-being.

Naturally, that parenting programmes aimed at parents of children up to 3 years old

need to be based on a family-centred care philosophy approach that respects the specificity

of each family, informs them, increases their literacy, and helps to support the decisions

that best suit their needs and contexts [22].

The Nurturing Care Framework “provides strategic directions for supporting the

holistic development of children from pregnancy up to age 3” [ 15 ].

The brain is particularly receptive to experience during the early development phase.

Investing in this period is one of the best ways to eliminate inequality, boost shared prosperity and create human capital for economic growth [15,23].

This article is focused on parenting programmes for parents of children up to three

years old. The choice of the age group up to 3 years is related to early childhood develop-

ment and the opportunity that the first years of life must influence the child’s growth and

development. On the other hand, it corresponds to the period in which children spend

more time with their families, highlighting the importance of this interaction.

A preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews, JBI

Evidence Synthesis, PubMed, and PROSPERO, was conducted. No current systematic or

scoping reviews on all the specific questions were identified.

Thus, this scoping review aimed to map in the literature the aspects to be considered when

structuring a parenting programme for parents of children up to 3 years of age. The review

question was: What information is available in the literature about parenting programme

structure, potential barriers, and facilitators for parents of children up to 3 years old in a

healthcare setting or community?

More specifically, this scoping review aims to answer the following questions:

- What are the benefits of parenting programmes?

- What aspects should be considered in structuring a parenting programme for parents of

children up to 3 years?

- What facilitating aspects were found in the literature?

- What are the potential barriers that were found in the literature?

- What measurement tools and indicators can be monitored to evaluate parenting programmes?

2. Materials and Methods

Using the participants, concept, and context (PCC) framework [ 24 ], the scoping review

included studies that: (a) participants were parents of children up to 3 years old ; (b) focused

on the concept of parenting programme structure, its potential barriers, and facilitators;

(c) occurred in the context of healthcare setting or community.

The inclusion criteria were: (1) studies in English and Portuguese, with full text

available, (2) studies published between 2016 and 2021, (3) studies with qualitative and/or

quantitative methodology and grey literature, (4) studies with parents of children up to

3 years old, (5) completed studies with results.

The time limit is aimed at collecting the most current evidence, given the dynamics

of contemporary society and parenthood. Studies with parents of children up to 3 years

were included, not excluding studies with a different age range, provided that children

up to 3 years of age were integrated. This option aims to gather more information about

the existing programmes in the literature and allows integration of our study’s target

population: the parents of children up to 3 years old.

The exclusion criteria were: (1) study protocols, (2) studies on educational interven-

tions for infants in neonatal intensive care units with children with specific disorders,

diseases, or conditions; (3) studies about programmes aimed at adolescent parents and

parents in situations of psychosocial vulnerability.

This review aims to identify the aspects to be considered in a universal parenting

programme. Programmes aimed at parents in specific situations were excluded because

those families’ needs may differ from those of other families.

The search strategy followed that advocated by the Joanna Briggs Institute [ 24 ] and

Pollock et al. [ 26 ]. It included published and unpublished studies and was conducted in

three stages: (1) Limited initial search in MEDLINE with Full Text (via EBSCO), CINAHL

Plus with Full Text (via EBSCO), and PubMed databases, followed by an identification

of text words in the title and abstract of retrieved papers, and of the index terms used to

describe the articles; (2) Second search using the search terms identified, in all databases

included (Table 1); (3) the third search conducted in the references of all articles and reports

identified from the initial search.

A broad search strategy was used to cover the issues in the review mentioned above.

As advocated by the Joanna Briggs Institute [ 24 ], data were extracted from papers

included in the scoping review by two independent reviewers. Data were extracted into a

table created by the authors, adapted from Pollock et al. [ 26 ], including the author(s), year

of publication, origin/country of origin, population, context, concept, methodology, and

outcomes. If necessary, a third reviewer was ready to resolve reviewer disagreements [ 24 ].

There were no conflicts between the evaluators when selecting and extracting the data.

Figure 1 illustrates the selection process, according to the Preferred Reporting Items

for Systematic and Meta-Analyses (PRISMA), adapted for scoping review, Flow Diagram.

Records identified through database searching

CINAHL Plus with Full Text (n = 758)

MEDLINE with Full Text (n = 776)

PubMed (n = 3 67 )

Identification

Additional records identified through other sources

OpenGrey.eu (n = 0)

ProQuest (n = 197)

Google Scholar (n = 331 )

Thesis repository - RCAAP (n = 35 )

Number of duplicates removed

Records screened (title and

abstract)

Screening

(n = 2330)

Studies included assessed for

eligibility (full text)

(n = 67)

Eligibility

Studies included in review

(n = 14)

Included

(n = 134)

Records excluded on the basis of

title and abstract

(n = 2263)

Records excluded, with reasons

Different child age (n = 9 )

Unspecific methodology (n = 1)

Different context (n = 12 )

Different population (n = 5 )

Not related to objective (n = 2 6 )

Figure 1. Preferred Reporting Items for Systematic and Meta-Analyses (PRISMA), adapted for

scoping review, Flow Diagram.

Fig. 1. Preferred Reporting Items for Systematic and Meta - Analyses (PRISMA), adapted for scoping

review, Flow Diagram

Table 1. Search terms identified in all databases included.

Database

Search Terms

Limiters

(MM “Parenting Education”)

(MM “Parenting Education”) AND (MM “Program

CINAHL Plus with Full Text (via

Evaluation”)

EBSCOhost Research Databases)

parent* AND program

Subject Age: infant, newborn:

birth to 1 month old; all children

(MM “Education, Nonprofessional”) AND (MM

Language: English, Portuguese

“Parenting”)

MEDLINE with Full Text (via

(MM “Program Evaluation”) AND (MM “Education,

EBSCOhost Research Databases)

Nonprofessional”) AND (MM “Parenting”)

parent* AND program

(“Education, Nonprofessional” [Mesh]) AND

“Parenting” [Mesh]

Subject Age: all children

((“Education, Nonprofessional” [Mesh]) AND

PubMed

Language: English, Portuguese

“Parenting” [Mesh]) AND “Program Evaluation” [Mesh]

parent* AND program

OpenGrey.eu; ProQuest; RCAAP;

parent* AND program

Google Scholar

Language: English, Portuguese

Programa parental (parental programme, in Portuguese)

As can be seen, 2330 scientific articles were identified after removing those duplicates.

Of these, 2263 were excluded after reading the title and abstract and applying the inclusion

and exclusion criteria, leaving 67 articles eligible for a full reading.

After full reading, 14 articles were included in this scoping review after independent

analysis by two reviewers. The reasons for exclusion are explained in Figure 1. There were

no conflicts in data selection and extraction, so there was no need for a third reviewer.

3. Results

The origins of the 14 studies were diverse, although studies from Australia (n = 4), the

United States of America (n = 3), and China (n = 3) predominated.

The design of the included studies was a randomised controlled trial (n = 6), mixed

method (n = 5), qualitative (n = 2), and quantitative (n = 1).

Although the Critical Appraisal and quality of the articles are not mandatory in

scoping reviews, according to the JBI, this aspect was considered. For this purpose, the

research databases were carefully selected. The articles included in the scoping review

are integrated, according to SCImago, in the first quartile (eleven studies), second quartile

(two studies) and third quartile (one study) journals, which corroborates the rigour in the

selection of studies. In addition, the selected articles were analysed considering the critical

appraisal tools made available by the JBI. Only the studies with more than 75% of positive

items were included.

The data extracted are presented in Table 2.

Table 2. Characteristics of the included studies.

Study

Reference, Country

Population

Context

Community

Parents who were primary

Family-organisations such

caregivers of an infant

[27], Australia

as libraries and playgroups

or toddler

aged under two years old in Perth, Western Australia

English-speaking mothers

Community

[28], USA

with infants 3–12 months

The rural area of the

of age

Pacific Northwest

Community

Parents of children aged

Playgroup Queensland

[29], Australia

0–5 years

(PGQ), a not-for-profit

organisation

155 parents (M = 33 years,

[ 30 ], Australia and USA

SD = 7.5) with a 2- to

Community

12-year-old child

22 groups of 10–14 parents

Community

with a child 2–12 years old.

[31], Spain

health strategy “Health in

216 participants who

the Neighbourhoods”

completed the intervention

Concept

Methodology

Outcomes

Benefits:

• Increase in parent competence and refocus on

Respectful approach

Quasi-experimental

relationship with children;

intervention

mixed-method study

• Reduce stress, depression; the sense of

performance pressure.

Benefits:

• Increase knowledge of temperament and

New brief temperament

related concepts; representations of children’s

guidance programme for

Mixed method study

attributes; sensitive interactions with

parents of infants

their children.

Facilitators:

• Practical strategies to apply the knowledge;

• Peer support group.

Community playgroups

Qualitative study

Barriers:

• Tiredness or lack of time to participate.

Facilitators:

• Programme’s reward system;

• Social network.

Triple P Online Community

Barriers:

Mixed method study

Programme

• Time;

• Technical problems;

• Content not adjusted to the child’s age.

Mixed method study:

Quasi-experimental study Benefits:

Parenting Skills Programme design with pre (T0), post • Improve parenting skills, children’s behaviours,

(T1), a follow-up (T2), and

parental stress, and social support immediately

for families (PSP)

no control group,

and six months after participation.

complemented by a

qualitative study

Table 2. Cont.

Study

Reference, Country

Population

Context

[32], USA

99 mothers

Community

Parents of infants aged

Community-based

[33], Australia

6–12 months and parents of

parenting programme

toddlers aged 12–36 months

819 infants and their

caregivers in 50 rural

Community

[34], China

villages in

north-western China

133 new mothers were

referred by their birthing

[35], Australia

hospital for their initial

Community

postnatal health check

by nurses

Two hundred thirteen

primary caregivers of

[36], USA

Community

children ages

0–4 participated.

44 first-time primiparous

women 18 years old or

above were admitted to

[37], China

Community

maternity wards of two

public tertiary hospitals

in China

Concept

Methodology

Outcomes

Facilitators:

Mom Power Programme

Mixed method study

• Motivational interview.

Facilitator factors:

Programme and community

contextual factors on parent Two parallel randomised • A structured curriculum;

controlled trial

• Home coaching.

engagement

Facilitator factor:

• Social interactions.

Community-based ECD

Quantitative study

Barrier:

programme

• Geographic distance.

Benefits:

Online group–based

Block randomised

nurse-led intervention

controlled trial.

programme

Benefits:

Active Parenting First Five

An inclusive randomised • Increase: responsive parenting, developmental

knowledge, parent self-efficacy, mindfulness.

Years (FFY) programme

controlled trial

• Decrease: parenting stress.

Benefits:

Internet-based support

Multicentre, single-blinded, • Increase: maternal self-efficacy and social

support;

programme

randomised controlled trial.

• Decrease postpartum depression symptoms.

Table 2. Cont.

Study

Reference, Country

Population

Context

Four PDEP facilitators and

seven parents (one male

Community-primary

[38], Canada

and six female) completed

the programme

[35], Denmark

112 families with new-borns

Community

[39], China

149 parent–child dyads

Community

Concept

Methodology

Outcomes

Benefits:

• Created learn new ways of thinking

about parenting;

• Contributed to changes in the

parenting approach.

Facilitator factors:

Positive Discipline in

Qualitative study

• Coherence and continuity among

Everyday Parenting (PDEP)

programme modules;

• Concrete examples to demonstrate concepts;

• Supportive facilitators and fellow

group members;

• Childcare provision.

Incredible Years Parents and

A two-arm parallel

No effects were found.

Babies (IYPB) programme randomised controlled trial

Benefits:

Parent and Child

Enhancement (PACE)

Randomised controlled trial • Decrease: child behaviour problems and

parental stress.

3.1. Benefits of Parenting Programmes

According to the studies included in this scoping review, the benefits of parenting

programmes are evident for parents, the parent and child relationship, and society as

a whole.

Parenting programmes can increase parenting competence, skills and practices [27,31,38] ,

self-efficacy [ 37 ] and parents’ knowledge about children’s temperament and developmental

stages [ 28 , 38 ]. It also enabled the strengthening of social support [ 31 , 37 ] and the way to solve

children’s conduct problems [ 36 , 38 ]. The demonstration of various feelings of stress and

frustration concerning day-to-day parenting was also reported as one of the benefits of the

parental programme [29].

Moreover, the results report that parenting programmes can reduce stress [ 27 , 39 ] and

depression [27,37].

Parents reported that the parenting programme relieved societal pressure on parents,

allowing them to focus on their relationships with their children. Parents also referred

that parenting programmes made it easier for them to understand their children as indi-

viduals with their interests and feelings [ 27 ] and contributed to child–parent behavioural

changes [28].

The results suggest that parenting programmes can have benefits that transcend the

family nucleus. Parents shared concepts, strategies, and attitudes among themselves, family

members, friends, teachers, and day-care providers [ 30 ]. The results of this scoping review

indicate other benefits of parenting programmes, such as the better utilisation of child health

care resources [19] and a reduction in unplanned consultations and readmissions [40].

3.2. Structure of a Parenting Programme for Parents of Children up to 3 Years of Age

The studies suggest that motivational interviewing may be essential in promoting par-

ticipants’ engagement efforts in parenting interventions [ 32 ] and the coherence between the

contents and methodology toward target parents’ needs and conditions [ 33 ]. A structured

curriculum in a programme geared towards providing play and social opportunities was

associated with better enrolment than the more typical structured parent group [33].

Factors that contributed to positive experiences included: access for future refer-

ence and content more specific to the child’s age and more sortable [ 30 ], consistency and

continuity between programme modules, using concrete examples to demonstrate con-

cepts, supportive facilitators and group companions, providing childcare, using concrete

examples to illustrate parenting concepts, and flexibility in programme delivery [38].

3.3. Facilitators of Parenting Programmes

Including children in the sessions was mentioned in the studies as a facilitating

aspect [ 27 ]. Another facilitating aspect reported by parents was the existence of weekly

challenges set, adapted to each one’s reality, to practice the strategies learned [27].

The use of digital technologies and information in digital format was another aspect that

parents considered facilitating the parenting programme [ 27 , 30 ]. Accessible content using

pictures to promote understanding of the content by less literate mothers [ 28 ] and focused

on strategies that parents can experiment [29] were also identified as facilitator factors.

Parents reported that the reward system integrated into the programme was an es-

sential motivator for participation [ 30 ]. Studies indicate that providing an in-home coach

could help vulnerable parents identify and overcome practical barriers [ 33 ]. The existence

of group facilitators [ 33 ] and peer support groups [ 29 ] contributed to supporting parents’

active participation.

3.4. Potential Barriers to a Parenting Programme

Two main themes emerged concerning barriers to autonomy-supporting parenting

practices: (1) lack of empowerment to influence children’s preferences; and (2) stress,

fatigue, or lack of time can make parenting challenging. Parents indicated that they had

difficulty applying this knowledge. They wanted guidance on translating their knowledge

into effective strategies [29].

Time lost was the most common barrier [ 30 ]. Parents stated that the many demands

placed on them throughout the day made it difficult to “cope” or handle challenges as

they arose, particularly at the end of the day. Parents also expressed not having enough

time or being too tired to use supportive parenting practices [29]. Suppose the parenting

programme is planned to be face-to-face. In that case, the distance between families and

parenting centres is essential to be aware of because geographical distance remains a

significant barrier to participation in the programme [34].

Technical problems hindering participation have also been reported, such as the

requirement of work email addresses during registration, and insufficient internet

network, among others [30].

3.5. Measurement Tools and Indicators to Monitor and Evaluate Parenting Programme

According to the studies in the scoping review, several dimensions can be evaluated According to the studies in the scoping review, several dimensions can be evaluated

in a parenting programme. in a parenting programme. In addition to assessing satisfaction with the programme, other In addition to assessing satisfaction with the programme,

other indicators can be considered, such as parenting skills, parental stress, social support, indicators can be considered, such as parenting skills, parental stress, social support,

depression, parenting sense of competence, and self-efficacy. depression, parenting sense of competence, and self-efficacy.

In addition to the narrative description, a visual summary of the results is presented In addition to the narrative description, a visual summary of the results is presented in

Figure 2. Figure 2.

Figure 2. Figure 2. Key findings: benefits, structure, facilitator factors, potential barriers, measurement tools, Key findings: benefits, structure, facilitator factors, potential barriers, measurement tools,

and indicators of Parenting Programmes .

and indicators of Parenting Programmes.

4. Discussion 4. Discussion

This scoping review aimed to map in the literature the benefits of a parenting pro- This scoping review aimed to map in the literature the benefits of a parenting

gramme and the aspects to be considered when structuring a parenting programme for programme and the aspects to be considered when structuring a parenting programme

parents of children up to 3 years of age. for parents of children up to 3 years of age.

Several parenting programmes were found in the literature that have been imple- Several parenting programmes were found in the literature that have been

mented worldwide. implemented worldwide.

This article brings together in a single document the aspects that professionals should This article brings together in a single document the aspects that professionals should

consider when implementing a successful parenting programme. consider when implementing a successful parenting programme.

The evaluation of previous experiences will allow a better adjustment to the real needs

of the populations and how these parenting programmes can help families to develop their

role better, promoting their well-being, as well as the well-being of children, with positive

repercussions for society.

Promoting tailored early guidance programmes to families’ strengths and needs [ 41 ]

improves effective engagement and outcomes for families by increasing parenting qual-

ity [ 42 , 43 ]. A couple-centred psycho-educational programme can successfully promote

father involvement in parenting [44].

Studies mention virtual delivery as a facilitating factor for parenting programmes,

reaching more parents and expanding their networks. Other studies referred to facilitating

elements that corroborate the results of this scoping review: a structure according to

each family’s needs [ 45 ], considering parents’ disposition [ 42 ] and reducing distances and

costs [46].

Cultural barriers cannot also be forgotten [ 45 ]; thus, any materials produced should

be culturally relevant and meet the real needs of families.

This analysis agrees with the systematic review [ 18 ] results which state that programme duration, delivery mode, and location should be determined based on existing resources and systems, community needs, population risk profiles, and cultural context.

In summary, the present scoping review gives important clues in structuring parenting

programmes related to the content, means to be used, and duration. Several models of

structure may be used, but the literature is clear that these decisions affect the involvement

and motivation of parents’ adhesion to the programme.

This study provides an overview of parenting programmes, and the results guide several recommendations for the future.

The results of this article may help public health professionals to plan evidence-based parenting programmes with better outcomes for families, children, and society.

Considering the various benefits, such as increased parent competence, self-efficacy, lower parental stress, lower depression symptoms, and child behaviour problems, implementing parental programmes is an added value for parents, children, and society.

Parenting programmes are important ways to contribute to a healthy, sustainable,

and resilient society. They benefit parents by reducing signs of stress and depression

and increasing their self-efficacy and social behaviour, which leads to positive changes

in childcare. In addition, they bring benefits to the parent–child relationship by relieving

social pressure from parents, allowing a focus on the relationship with the child as an

individual. Finally, parenting programmes also positively affect society through knowledge

sharing, networking, and support so that children can grow up in healthy environments

and maximise their full potential.

Author Contributions: A.R.: Conceptualisation, Methodology, Validation, Investigation, Writing— original draft, Writing—review and editing, Visualisation, Supervision; F.M.: Conceptualisation,

Methodology, Validation, Investigation, Writing—original draft, Writing—review and editing, Visu- alization; H.S.: Conceptualisation, Methodology, Validation, Investigation, Writing—original draft, Writing—review and editing, Visualisation. All authors have read and agreed to the published

version of the manuscript.

Funding: The publication of this article was supported by Instituto Polit é cnico de Set ú bal.

Institutional Review Board Statement: Not applicable.

Informed Consent Statement: Not applicable.

Data Availability Statement: Dataset is available upon request to the authors.

Acknowledgments: We thank Ruth Paterson (School of Health and Social Care—Edinburgh Napier

University) for her collaboration on the linguistic revision of the article.

Conflicts of Interest: The authors declare no conflict of interest.