From Interactive Regulation to the Development of Self Regulatory Processes in Pre-term Infants:
A Preliminary Report1
Grazyna Kmita, PhD Faculty of Psychology, University of Warsaw, Poland
Eliza Kiepura, MA Institute of Mother and Child, Warsaw, Poland
1This study was partly financed by a statutory research fund BST 1134/30 and BST 1250/8 of the Faculty of Psychology, University of Warsaw.
The aim of this study was to describe the development of self-regulatory processes in high-risk and low-risk pre-term infants and to analyse the dynamic, reciprocal relationship between patterns of dyadic regulation in mother-child interactions and the child's self-regulatory competence. The subjects were 24 mother - child dyads. The study design was longitudinal in nature with assessments at 5(±1), 11(±1) and 24(±1) months corrected age. At 5 and 11 months the study procedure lasted 12 minutes and comprised the following episodes: 1) free dyadic play, 2) triadic interaction with mother, child and a "stranger", 3) mother-child- "new object" play. A special method of data analysis at both macro and micro levels was developed to allow for the empirical identification of patterns of interactive regulation as well as self-regulatory strategies. Results show that mid-range interactive regulation seemed to enhance successful interactions for children with low self-regulatory competence, while "co-regulation" was only observed in dyads with children with at least medium levels of self-regulatory competence. These results suggest that there is a reciprocal, bi-directional relationship between these two processes.
Key words: self-regulation, interactive regulation, prematurity, mother-infant interaction
Self-regulation is defined by Raffaelli, Crocket and Shen (2005) as the internally- directed capacity to modulate affect, attention and behaviour to respond effectively to both internal and environmental demands. Self-regulation can be understood in terms of many interrelated processes that enable the psyche to exert control (both consciously and unconsciously) over its functions, states and processes (Baumeister, Vohr, 2004). In fact, it can be regarded as a key factor in the process of self organization and is often assumed to be responsible for competent functioning throughout the life span (Derryberry & Tucker, 2006). According to Calkins and Fox (2002), self-regulatory processes can be observed on multiple levels, including the physiological, attentional, emotional, cognitive, and interpersonal domains of functioning, and these multiple levels are hierarchically organized (Derryberry & Tucker, 2006).
In fact, self-regulation is not an end in itself but rather a set of meta-processes that enable a person to complete goal-directed activity. In a sense, these processes constitute the "how" of the motivational system. In other words, self regulatory processes are shaped by the innate motives underlying perception and action that are operating even in the early infancy such as the three groups of motives described by Trevarthen (1998) as "basic, innate motives for self, objects and others". Regulation refers here to child as a person who from the first moments of life is endowed with some rudiments of subjectivity and intentionality. What's more, it is the child who at the same time "regulates" and "is being regulated" (voluntarily and involuntarily). In light of this approach to self-regulatory processes, a child takes an active role in interactions with the environment and all his/ her behaviors are an expression of what Daniel Stern (1985) calls the developing sense of self. Therefore self-regulatory processes cannot be conceptualized as exclusively automatic or biologically rooted phenomena or simply reduced to the mechanisms by which homeostasis is maintained (Kmita, 2007).
The key assumption here is that although regulatory processes are rooted in neurobiological factors, they develop through interactions of the child with significant others in the context of the caregiver-child relationship (with mutual, reciprocal relations between the two) (Crockenberg et al., 2004). One can say that there are two interrelated types of regulatory processes: self-regulation and interactive regulation (Gianino & Tronick, 1988; Sander, 1977; Thomas & Malone, 1979; cited after Beebe, 2006). The first refers to the ability of the self to modulate, control and adjust one's own processes to internal as well as external demands. The second one refers to moment-by-moment adjustments of socially directed behaviors of the partners, enabling the smooth interactive flow and effective management of interactive repair. It's not just the sum of what Sameroff and Fiese (2000) call "self- and other- regulation", although the regulatory competence of the adult partner seems to be of crucial importance, especially in infancy. Interactive regulation should rather be regarded as a dyadic process, co-constructed by both partners, with the active participation even of a very young infant who at this early stage of development is equipped with powerful tools to focus as well as avert his or her attention (Beebe, 2006). If this is true then how should Sroufe's (1995) notion of self-regulation as an interactive process be understood? In our opinion, even if the child plays an active role in his or her interactions with others, it is the adult who "sets the stage", so to speak, in terms of the "physical framework" of the interaction,, the culturally specific expectations regarding parenting and care giving, and so on. At a more direct level, interactive regulation makes use of the child's self-regulatory competence while simultaneously providing the scaffolding (to use Bruner's term) for its further development. Therefore, in our view self-regulation should only be studied with reference to or in the context of interactive regulation.
Looking at development in terms of regulatory processes has a long tradition in the field of Psychology (Sameroff & Fiese, 2000, Trevarthen et al., 2006), but surprisingly, relatively little is known about self-regulatory processes in infancy and toddlerhood (Raikes et al., 2007) especially in the case of the preterm infant. . Moreover, this is the very domain, where the development of preterm children can be compromised due to: 1) specific biological risk factors and immaturity, 2) the quality of early experience, and 3) challenges to the parent-child relationship. The question arises as to the advantages of studying self-regulatory processes specifically in children born pre-term. First of all, there are many studies pointing to the increased risk of emotional disorders, ADHD and ADD in preterm infants (Kmita, 2002, Winders Davis & Burns, 2001). One of the postulated mechanisms here is some dysfunction or dysfunctions of regulatory processes may underlie the above mentioned disorders (Derryberry & Tucker, 2006). A closer look at these mechanisms may contribute to the unraveling of the complex paths that lead to a disorder as well as to possible ways of treatment and early intervention. The second advantage is related to the fact that preterm birth constitutes a kind of a natural experiment enabling us to observe these levels of self-regulation which are more challenging for a preterm baby as opposed to a full term baby. This may enable us to learn more about the structure and organization of the infant's self-regulatory processes. Last but not least, comparing a group of high-risk preterm infants with a sample of low-risk preterm infants, in addition to comparing the behavior of infants whose mothers were relatively more available to those whose mothers were less available during the time of child's hospitalization, may shed some light on how biological and psychosocial factors work together in the process of self-regulation development.
The aim of the study
The aim of our study was to describe the development of self-regulatory processes in both pre-term infants of high and low biological risk and to analyse the dynamic, reciprocal relationship between patterns of interactive regulation in mother-child dyads and child's self regulatory competence. The project was an attempt to look for sources of regulatory competence of preterm infants and interpersonal interaction patterns that may support the development of these "emerging" competencies. This is in line with the idea of Winders Davis and Burns (2001), who point to self-regulation as a new framework that can enable us to understand both the developmental problems and the developmental competencies of low birth weight infants. Our view is that it can be also regarded as a window into the mechanisms of resilience in this group of children and can be used as a "guidebook" for early psychological intervention.
In this brief report we will focus on the questions addressed in the first phase of the project, and namely:
- What patterns of interactive regulation are characteristic of the mother-infant dyads at 5 months corrected age?
- What patterns of self-regulatory competence can be described in prematurely born infants at 5 months corrected age?
- Is there any relationship between:
- patterns of interactive regulation and "biological risk"?
- patterns of interactive regulation and "mother's availability" during hospitalization?
- patterns of regulatory competence and "biological risk"?
- patterns of regulatory competence and "mother's availability" during hospitalization?
- patterns of interactive regulation and child's regulatory competence?
Thirty-six premature infants with an expected date of birth between November 2005 and November 2006 and their families were invited to take part in the study. Three families refused to participate, while two families did not attend the scheduled meeting despite the initial agreement. In the case of 4 children, although the parents agreed to participate, they later decided not to take part due to child's medical problems (mainly upper and lower respiratory tract infections; in one case requiring hospitalization). Finally, three children had to be excluded in light of inclusion or exclusion criteria. As a result the sample consisted of 24 preterm children and their mothers. The inclusion criteria included: parental written consent, child's gestational age below 37 weeks, mother's age above 18 years, and a place of residence within the municipal area of Warsaw. The exclusion criteria were: multiple birth, genetic/ metabolic disorders affecting mental development, and a severe impairment of vision or hearing. The children had been recruited from the NICU and follow-up clinic of the Institute of Mother and Child in Warsaw in the first four months of life, on the basis of two dichotomized variables: biological risk and mother's availability during child's hospitalization. Children were assigned to either high or low biological risk group on the basis of the analysis of their medical records by a neonatologist, with special attention to following risk factors: intraventricular hemorrhage (IVH) grade III and higher, periventricular leukomalacia (PVL), gestational age below 28 weeks, intrauterine growth retardation, retinopathy of prematurity (ROP) grade III and higher, chronic lung disease (CLD), mechanical ventilation for more than 14 days, sepsis, necrotizing enterocolitis (NEC), etc. Mean biological age, birth weight and number of days of hospitalization in the high versus low risk group were respectively: 26.2 ±2.8 vs.30.8±2.5 weeks, 842.2±205 vs. 1546.5±485 g, 99±37 vs. 41±14 days (table 1).
Table 1. High and low biological risk groups characteristics.
|Birth weight (g)
|Biological age (weeks)
24 preterm children and their mothers. The inclusion criteria included: parental written consent, child's gestational age below 37 weeks, mother's age above 18 years, and a place of residence within the municipal area of Warsaw. The exclusion criteria were: multiple birth, genetic/ metabolic disorders affecting mental development, and a severe impairment of vision or hearing. The children had been recruited from the NICU and follow-up clinic of the Institute of Mother and Child in Warsaw in the first four months of life, on the basis of two dichotomized variables: biological risk and mother's availability during child's hospitalization. Children were assigned to either high or low biological risk group on the basis of the analysis of their medical records by a neonatologist, with special attention to following risk factors: intraventricular hemorrhage (IVH) grade III and higher, periventricular leukomalacia (PVL), gestational age below 28 weeks, intrauterine growth retardation, retinopathy of prematurity (ROP) grade III and higher, chronic lung disease (CLD), mechanical ventilation for more than 14 days, sepsis, necrotizing enterocolitis (NEC), etc. Mean biological age, birth weight and number of days of hospitalization in the high versus low risk group were respectively: 26.2 ±2.8 vs.30.8±2.5 weeks, 842.2±205 vs. 1546.5±485 g, 99±37 vs. 41±14 days (table 1).
Mother's availability was determined by means of a short questionnaire regarding the timing of visits in NICU, hours spent daily with the child in subsequent weeks of hospitalization and mother's ease with taking care of her child (kangaroo care, changing diapers, holding, etc.). Spending less than 4 hours daily with the child in the last two weeks of hospitalization or having difficulties in caring for the child were treated as indices of relatively "low availability". As a result the group comprised four subgroups (table 2).
Table 2. Number of subjects in the subgroups2.
2We intended to include an equal number of dyads in each of the subgroups but the analysis of medical records revealed that one of the children who initially was evaluated as "high biological risk" should in fact be included in the "low biological risk" group.
At the beginning of the study all children were brought up in two-parent families. 50% of the children had older siblings. Mother's ages were between 23 and 37 years of age (M=29.9, SD=3.55), were Caucasian and had an education level between 10 and 17 completed years of schooling (median = 14.0).
The study design was longitudinal with assessments conducted at 5(±1), 11(±1) and 24(±1) months corrected age. At 5 and 11 months the study procedure lasted 12 minutes and comprised the following episodes: 1) dyadic free-play, 2) triadic interaction of mother, child and a "stranger", 3) mother-child- "new object" play. At 11 months a short episode of mother-child separation and reunion was added. As for the last assessment, the procedure had been modified to include triadic interactions with both parents in free play episode as well as engagement in a task. The interactions were recorded with two digital camcorders. The recordings took place in a specially prepared playroom at the Therapeutic Centre for Children and Youth of the Department of Psychology, University of Warsaw. After the procedure each family was interviewed by the first author and a child was observed for about an hour in a free play situation. After each assessment the children were given a gift - an age appropriate toy not exceeding 50 PLN (approximately 10-12 EURO). For purposes of this brief report, only the data obtained in the first assessment will be presented.
Method of data analysis
A special method of data analysis at macro and micro levels was developed to allow for the empirical identification of patterns of interactive regulation as well as self-regulatory strategies. The method was inspired by earlier works of Shugar (1981), Trevarthen and Marwick (1982), Beebe (2006) as well as Als (1999), Papousek (Papousek et al., 2008), and Brazelton and Nugent (1995) in terms of self-regulatory competence. The first step in the analysis was to identify socially directed behaviors in both partners (i.e. behaviors that are directed to and potentially perceivable by the other person). This served as a basis for distinguishing the periods of time in the procedure when the partners were in interaction as opposed time spent in interactive breaks. Interaction was understood in terms of coordination of socially directed behaviors in time and within a shared focus of attention (Bokus, 1984). It's important to note, that shared focus of attention should not be confounded with the same focus of attention as only the former is a necessary prerequisite for social interaction (Bokus, 1984). Interactive episodes were operationally defined as the smallest units of interaction comprising, at the minimum, two turns of socially directed behaviors: an initiation and a response of the partner (and optionally a confirmation by the first partner). Special attention was paid to instances of the child's "looking away" behavior (i.e. breaking of the interactive flow by changing the focus of attention to something other than himself/ herself, the mother or the experimental toy). Attention was also paid to the mother's respective responses (in terms of either waiting for the child, following and naming what the child was looking at, or else intensifying the stimulation, trying to make the baby immediately available for the interaction or focusing on what the mother thought was appropriate at that moment).
Apart from that, the coding system comprised a functional macro-analysis of interactive behaviors partly based on Trevarthen and Marwick's work (1982) with an evaluation of the following domains: behavioral states of a baby (according to Peter H. Wolff), forms of interpersonal engagement, affect, vocal expression, focusing attention on person, focusing attention away from the partner, forms of sharing attention, imitation and mirroring, forms of cooperation in a task (new object play).
Interactive regulation was evaluated macro-analytically with reference to four dimensions: 1) quality of coordination of interactive behaviors, 2) reciprocity, 3) facility to achieve or "restore" shared focus of attention and 4) emotional attunement. This was done by dividing the whole recording into 60s. segments and giving scores on a 5 point Likert-type scale for each minute and each dimension separately and then computing the mean for a given dyad. Each point of the scale was given an exact definition. Cluster analysis by k-means method on cases was done to empirically derive patterns of interactive regulation defined by the four dimensions and as distinct from each other as possible.
Self-regulatory competence was estimated on the level of regulation of autonomic/ physiological processes, behavioral states, motor tone and functions, attention and emotions. Indices of self- regulatory competence vs. vulnerability pertinent to each particular level at the ages under study were elaborated based on work by Als (1999), Brazelton and Nugent (1995), Calkins and Fox (2002), Papousek et al.(2008) and earlier research by Kmita (2002, 2007). Again, 60s. segments of recordings were analyzed with special attention paid to the child's behavior during "challenging events", such as meeting "a stranger", presentation of a novel object, the first minute of each new episode of the procedure, and in the case of older children episodes of separation as well as during the tasks. For each 60s. time segment, signs of competence/ vulnerability were coded. This served as a basis for analyzing an overall level of the child's self-regulatory competence. As a result five empirically derived categories of self- regulatory competence were described (see the results).
The analysis was done by the first author and then two independent coders were asked to rate randomly selected recordings (25% of all recordings were rated with respect to interactive episodes identification and "looking away" behavior plus mothers' responses; three randomly selected recordings - were rated with respect to all other categories). Inter-rater reliability ranged from 0.71 to 0.80. Dubious cases were discussed in a group until the
consensus was reached. The coding system should be treated as a "working" one and still requires some modification. Further work on improving the system's reliability is needed.
Figure A: Number of children with low, medium and high self-regulatory competence in dyads of unilateral and middle range interactive regulation as well as co-regulation.
|At 5 months corrected age, three groups of dyads were identified on the basis of macro-analytic measures of interactive regulation (INT_REG) and three groups of children were identified based on measures of self-regulatory competence (S_R COMP) (figure A).
As to interactive regulation, each of the patterns was characterized by a different configuration of a dyad's scores on the four dimensions described above. Unilateral regulation was characterized by relatively low contingency, low level of reciprocity and mutuality, difficulties in returning to a shared focus of attention (at least a number of attempts to achieve it by one of the partners) and poorly emotionally attuned responses, in the case of middle range regulation - medium levels of contingency and reciprocity, no major problems with repairing interaction and relatively well attuned responses were observed, whereas "co-regulation" - meant high scores on each of the four dimensions.
Five levels or categories of self-regulatory competence were empirically identified:
- Very Low Competence
- significant difficulties (as compared to age expected) for most of the time of the procedure (at least half of the time of each episode)
- significant difficulties (as compared to age expected), increasing as the procedure progresses
- Low Competence
- significant difficulties appear in more challenging parts of the procedure - the first minute of the first episode, when a stranger enters and then engages mother's attention, etc.; problems are less prominent at other times
- at first significant difficulties but with time a child copes better with regulatory tasks
- Medium Competence
- there are difficulties but typical for child's age and do not disturb the child's overall functioning
- difficulties described in points 2a or 2b are present but the child takes efforts to actively regulate attention/ emotions
- High Competence
- the child is able to effectively self-regulate for most of the time; if any minor difficulty occurs it is only in the most challenging parts of the procedure
- Very High Competence
- a. a child self-regulates exceptionally well and shows competence above the level typical for his/ her age (e.g. in the case of attention regulation - evidence of coordinated joint visual attention in the case of a child younger than nine months).
Data reduction assigned the children to three groups: "low" (1a, 1b, 2a, 2b), "medium" (3a, 3b) and "high" competence (4, 5). Eleven children were categorized "low competence" at 5 months of whom only 6 remained in this group at the age of 11 months, including 4 children of dyads with unilateral and 2 children of dyads with mid-range pattern of interactive regulation.
There was a statistically significant association between the dichotomized variables: interactive regulation (INT_REG) (unilateral- UNI vs. mid-range & co-regulation ÐM-R & CO-REG) and self regulatory competence (S_R COMP) (low vs. medium & high) (Fisher's exact test, p=0.00343). We could not reject the hypothesis of that there was no relationship between any of the two variables (INT_REG or S_R COMP) and mother's availability in the NICU or biological risk index.
As could be expected, dyads with unilateral patterns of interactive regulation spent less time in interaction than "mid-range" and "co-regulation" dyads, both in free play episodes as well as in object play (for free play episode- time in interaction/T_I_1: t(22)=6.183, p<0.001; for novel object play- time in interaction/T_I_3: t(22)=2.168, p<0.05). Interestingly, only the differences between mean time in free play episode turned out to be statistically significant for children of low vs. medium & high level of self-regulatory competence (t(22)=3.147, p<0.01). As shown in figure B, in dyads with unilateral patterns of interactive regulation, children of low self regulatory competence spent significantly less time in interaction with their mothers in comparison to dyads categorized as " mid-range and co-regulation", but this difference was more pronounced for free play episodes and not so distinct in the case of object play. No differences were found in the mean time in interaction in free vs. object play in the case of children with medium and high level of self-regulatory competence.
Figure B: Mean time in interaction in free play (T_I_1) and object play (T_I_3) for children of low vs. medium & high self regulatory competence (SELF_REG_COMP) in dyads of unilateral interactive regulation (UNI) versus mid-range & co-regulation (M-R & CO_REG).
|Instances of breaking interactive turn-taking by the child's looking away (LA) differentiated both dyads with unilateral vs. other patterns of interactive regulation (t(22)=-2.155, p<0.05) as well as children with low vs. medium and high self-regulatory competence (t(22)=-2.495, p<0.05), with higher mean number of LA in children with low competence and especially in dyads with pattern UNI (figure C).
Figure C: Figure C: Number of looking away (LA) behavior in children with low vs. medium & high self regulatory competence during free play in dyads of unilateral versus two other patterns of interactive regulation. Mothers' responses to child's LA behavior categorized as either: "increasing stimulation" (LA/I) or "decreasing stimulation" (LA/D) are also provided.
|An interesting difference was observed in mothers' responses to the child's looking away in dyads with unilateral vs. other patterns of interactive regulation, with a prevalence of increasing stimulation (calling the child, trying to immediately make him/her available and focused on what the mother likes) in the case of the former ones and waiting/ decreasing stimulation (looking, waiting, naming the child's new focus of interest) in the latter dyads (figure C).
Finally, k-means clustering on cases was performed using STATISTICA PL. Three clusters had been identified on the basis of qualitative analysis of the data (figure D). Cluster 1 was quite different from the other two and it was the one with a relatively low biological risk index, the shortest effective time in interaction both in free play as well as a task, high prevalence of looking away and of mothers responding to this by increasing the stimulation. What's more, the number of dyads with unilateral patterns of interactive regulation was the highest in this cluster and so was the number of children with low self regulatory competence. This may be a little surprising considering the fact of low biological risk. Cluster 2 was similar to Cluster 1 in terms of biological risk, but completely different with reference to all the other variables. Interesting differences and similarities occurred between cluster 2 and 3.
The biggest difference was in low vs. high biological risk and that there were relatively more children with lower self-regulatory competence in cluster 3 as compared to cluster 2. At the same time no differences were observed in terms of effectively engaging in dyadic interaction both in free play and object play setting. This may lead us to a conclusion that biological factors are not enough to explain children's self-regulatory competence and that the quality of dyadic processes can be crucial especially in the case of infants whose self-regulatory skills are, due to various reasons, compromised.
Figure D: Figure C: Results of k-means clustering on cases. Variables: MRI - biological/ medical risk index, T_I_1 - effective time in interaction during free play; T_I_3 - as T_I_1 but during a task (object play); LA - number of times in free play episode when child looks away; LA/ I - number of times in free play situation when child looks away and mother's response is to increase stimulation; INT_REG - interactive regulation; S_R COMP - self regulatory competence. N - number of children/ dyads in each cluster.
Our results on the regulatory use of visual attention are in line with previous work conducted by Beatrice Beebe (2006) and Crown and colleagues (2002), who emphasize the self-regulatory function of "looking away" in the case of young infants and point out to the important role of mother's ability to decrease stimulation when responding to her baby's averting his or her gaze. It is worth noticing however that the number of events coded as "LA" on its own may be quite misleading. First of all, it does not inform us about the duration of the "looking away" episodes, which may be worth considering in further analyses. Secondly, the small number as well as the short duration of such episodes or events may not necessarily imply competence. This was actually the case with two girls of our sample, who evidently exhibited low self-regulatory competence and yet hardly ever averted their gaze, which was actually related to their inability to withdraw attention in the face of overstimulation. The costs of not being able to use a "distraction strategy" resulted in difficulties to state-regulation, , physiological imbalance, etc.. Apart from that, the phenomenon of gaze orientation and "looking away" is quite complex because there are diverse functions involved is beyond the scope of this paper (Butterworth, 2006; Reddy, 2006, Morales et al., 2005).
The question arises as to the differences in interactive behavior of mothers who tend to use LA/D versus LA/I strategy. This issue was addressed in qualitative analyses made by Eliza Kiepura and Aleksandra Budniak on a subgroup of 6 mothers, for Master's thesis projects under the supervision of the first author. Their results showed that mothers who tended to use LA/D rather than LA/I were also more likely to use more declarative & phatic messages and less imperative ones when talking to their children. This held true for both free and object play and could be regarded as an effective strategy to support and repair interactive flow as reflected in longer mean time of the interactive episode and relatively more child - initiated interactive episodes (Budniak, 2008; Kiepura, 2007). A vital part of this strategy was the very subtle use of space and gesture by a mother, which was especially important for interactions with 5 month olds and at the age of 11 months when it was associated with frequent episodes of coordinated joint attention, which can be regarded as a highly effective strategy of self-regulation at the level of attention and emotions.
In our study, differences in patterns of interactive regulation as well as children's self- regulatory competence were related to factors other than biological risk. At the same time mother's availability for the child during hospitalization seemed not to be of crucial importance. This does not imply that presence of parents in NICUs and their participation in the care for their children is not important. In fact, it is just the opposite. It may well be that the way the construct of availability was measured for purposes of this study captured the physical rather than emotional presence of a mother. Another possibility is that even relatively low maternal emotional availability in the first weeks of child's life in a medical setting of neonatal intensive care does not imply low sensitivity and responsiveness in later parenting. On the basis of our pilot analysis of mothers' narrations, we can hypothesize that processes related to coping with the trauma of experiencing a preterm birth might be worth considering in this context.
- The results presented in this brief report were based on the data collected in the first part of the project with all limitations it may imply.
- Mid-range interactive regulation seemed to enhance successful interactions for children with low self-regulatory competence and "co-regulation" was only observed in dyads with children of at least medium level of self-regulatory competence. This reflects a reciprocal, bi-directional relationship between the two variables or processes.
- In this study, differences in patterns of interactive regulation as well as children's self- regulatory competence were related to factors other than biological risk. This may have far reaching implications for activities in the field of early intervention directed to preterm children and their parents.
The authors would like to thank Krystyna Polak, Ewa Skladanek, Anna Zak and all families who participated in the study for their contribution and commitment. Special thanks go to Aleksandra Budniak for her innovative approach and participation in the process of data collection and analysis.
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