Quantitative Research
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Quantitative Study Appraisal Reference:
Critiquing Theoretical and Conceptual Frameworks and Ethical Aspects in a Research Study
Student Answers (enter date of posting and your name). Provide a rationale for your answer.
1. What theory or model or conceptual framework was stated? Why was the theory, model, or framework appropriate for the research problem and/or hypothesis and/or purpose?
2. Did the researcher discuss the study findings in relation to the theory, model, or framework? Support your answer based on the study content.
3. What IRB or similar approved the study?
4. What was the harm or risk to the participants?
5. If present, what type of coercion, undue influence, or deception was used to recruit or consent?
6. Through what modality was informed consent obtained? Support your answer.
7. What was the population and did it represent a research vulnerable population(s)?
8. If population groups were omitted from the study, did the authors address a justifiable rationale for lack of inclusion of women. minors, older adults?
Critiquing a Quantitative Study, Design and Validity
1. What quantitative research design is used in this study?
2. For an intervention or experimental study is the intervention described? Is there a control? Is the control described? What is the type of comparison specified such as pre-post in one group, or between groups?
3. If the design is quasi-experimental, is there justification for not conducting as experimental research? Provide support from the study content. If not, then state your personal assessment of why not
4. If the intervention study involves more than one group, does the researcher address the likeness of the groups? Is there adequate statistical power?
5. If an intervention study, what are the measurement instruments? Is reliability and validity stated for each instrument?
6. If the design was non-experimental, is a retrospective or prospective design used?
7. In the chosen research study, to what extent does the study design minimize threats to internal validity?
8.In the chosen research study, what are possible threats to the construct validity of the study? (Think about conceptualization to measurement to results, setting, etc.) Provide support from the study content. Cent Eur J Nurs Midw 2020;11(2):7884
doi: 10.15452/CEJNM.2020.11.0014
2020 Central European Journal of Nursing and Midwifery 78
ORIGINAL PAPER
BASIC HUMAN NEEDS IN PATIENTS WITH MULTIPLE SCLEROSIS: INTIMACY AND
SEXUALITY
Dijana Tesla1, 2, Ruica Mrkonji 1, 2 Tatjana Badrov1
1Department of Nursing, University of Applied Sciences, Bjelovar, Croatia
2Clinic for Surgery, University Hospital Dubrava, Zagreb, Croatia
Received December 22, 2019; Accepted May 13, 2020. Copyright: This is an open access article under the CC BY-NC-4.0 license.
Abstract
Aim: To analyse the occurrence of sexual dysfunction in patients with multiple sclerosis. Design: A quantitative cross-sectional
study. Methods: The study was conducted in cooperation with the Croatian Association of Patients with Multiple Sclerosis,
in the form of a questionnaire. A total of 106 patients responded: 24 (23%) male and 82 (77%) female. All subjects were in the
age group 2163 years. Data were analysed using descriptive statistics and the Mann-Whitney test, Kruskal-Wallis test,
ANOVA test, and Spearmans rank correlation coefficient. Results: Primary sexual dysfunction (lack of sexual interest and
desire), Secondary sexual dysfunction (the occurrence of bladder or urinary symptoms), and Tertiary dysfunction (caused by
emotional aspects of MS) were present in most patients. There were no statistically significant differences between subjects
within individual categories. Conclusion: Sexual dysfunction is very common among patients suffering from multiple
sclerosis, significantly impairing quality of life since sexual and intimate expression are basic human needs which persist
in spite of disability or illness. However, patients are reluctant to talk about this highly sensitive issue.
Keywords: basic human needs, communication intimacy, multiple sclerosis, sexuality.
Introduction
Multiple Sclerosis (MS) predominantly affects young
people, and in most patients, the symptoms occur
between the ages of 20 and 45, and only rarely before
the age of 15 and after the age of 55. Women are
affected twice as often as men. The disease has
a highly variable course, characterized by frequent
deteriorations in the clinical picture of varying
degrees, interchanged with sudden improvements.
Clinical signs and symptoms that appear in patients
include visual disorders, sensory disorders, motion
and balance disorders, urinary and defecation
disorders, intellectual function disorders, and sexual
function disorders (Topi et al., 2004).
Sexual dysfunction (SD) symptoms are common
in multiple sclerosis patients. Men experience
impotence, loss of desire, genital sensory disturbance,
ejaculation disorder, and inability to achieve or
maintain erections. Women experience genital
stiffness, decreased intensity of orgasm, decreased
libido, unpleasant sensations during intercourse, and
reduced vaginal secretion.
Corresponding author: Ruica Mrkonji, Clinic for Surgery,
University Hospital Dubrava, Av. G. Suska 6, Zagreb, Croatia;
email: [emailprotected]
Foley divide sexual dysfunction in MS patients into
three categories: primary, secondary, and tertiary
(Kalb, 2018). Primary sexual dysfunction in patients
is caused by nerve damage, due to which brain
signals can no longer travel to parts of the body
that are involved in sexual activity. A classic example
of primary dysfunction is genital insensitivity.
Examples of difficulties that lead to secondary
dysfunction are urinary incontinence, diarrhea,
constipation, spasticity, hand tremor: i.e. everything
that indirectly complicates intimacy. Tertiary
dysfunction is caused by emotional aspects of MS:
i.e., psychosocial or cultural issues related to
sexuality and intimacy that may have an impact
on the feelings of a patient.
Sexuality is a set of feelings, behaviors, attitudes and
values that are linked to sexual desire and identity.
In other words, every human being is defined by their
sex, gender and sexuality. As an integral part
of human development throughout all stages of life,
sexuality includes physical, psychological, and social
components. An intimate relationship is a particularly
close form of interpersonal relationship and can be
defined by the following characteristics: recurring
interaction, emotional attachment, and fulfilment
of needs (Brehm et al., 2007; Stangor et al., 2014).
Sexuality is dynamic and changes over time,
sometimes as a response to life experiences.
https://orcid.org/0000-0002-4454-7708
https://orcid.org/0000-0002-9918-7818
Tesla, D., et al. Cent Eur J Nurs Midw 2020;11(2):7884
2020 Central European Journal of Nursing and Midwifery 79
Sexuality is a personal journey through life, and no
matter how it changes, it is important for health and
personal satisfaction. The World Health Organization
states: A central aspect of being human throughout
life encompasses sex, gender identities and roles,
sexual orientation, eroticism, pleasure, intimacy and
reproduction. Sexuality is influenced by the
interaction of biological, psychological, social,
economic, political, cultural, legal, historical,
religious, and spiritual factors (WHO, 2002).
For most people, sexuality and sexual expression are
natural and very important components of self-image,
emotional well-being, and, above all, good quality
of life.
Aim
The objective of the study was to make
an epidemiological analysis of the occurrence
of certain forms of sexual dysfunction in patients
diagnosed with multiple sclerosis.
Patients were interviewed, with the additional aim
of analyzing whether there was a difference in the
occurrence of certain forms of sexual dysfunction
in terms of age, sex of subjects, and the total
duration of the disease.
Methods
Design
A quantitative cross-sectional study.
Sample
The survey was conducted in cooperation with
the Croatian Association of Multiple Sclerosis
Patients in the form of a questionnaire The Multiple
Sclerosis Intimacy and Sexuality Questionnaire-19
(MSISQ-19) (Sanders et al., 2000) translated into
Croatian. The questionnaire was sent to 500 members
of the association by e-mail.
Data collection
The questionnaire was composed of 19 questions to
identify difficulties that directly or indirectly
interfered with respondents sexual satisfaction or
activity over the six months prior to the survey.
Subjects were asked to express their agreement with
the 19 questions/assertions, using a Likert scale from
15.
The occurrence of primary sexual dysfunction was
determined through responses to subscale items about
the existence of desire for/interest in sexual
intercourse, intensity of and time needed to achieve
orgasm, problems with lubrication (women), and
problems with erections and maintaining erections
(men) i.e., questions 12, 16, 17, 18 and 19.
Subscale items indicating secondary sexual
dysfunction were questions 1, 2, 3, 4, 5, 6, 8, 10 and
11.
Subscale items indicating tertiary sexual dysfunction
were questions 7, 9, 13, 14 and 15.
Data analysis
All data were explained descriptively and in tabular
form. Nominal features were displayed in numbers
and percentages. With respect to the small number
of subjects, the Shapiro-Wilk test was used to test the
distribution of the analyzed features. If features did
not indicate normal distribution, they were compared
with the non-parametric Mann-Whitney test and the
Kruskal-Wallis test. One-way analysis of variance
(ANOVA) was used for features for which normal
distribution was recorded. Correlations between
continuous features were determined by computing
Spearmans rank correlation coefficient.
All statistical tests were performed at the level
of statistical relevance of p < 0.05 with the use of the statistical software, Statsoft.Statistica (version 13.3). Results A total of 106 patients (21%) of the 500 subjects to whom the questionnaire was sent provided a response. Of the 106 subjects, 24 (23%) were male and 82 (77%) female. The age of subjects ranged from 20 to 63 years. The majority of subjects, i.e., 70 (70%), were in the age group from 31 to 50 years. There were 15 (15%) subjects under the age of 30, and 14 subjects (15%) over the age of 50. The duration of the disease for subjects ranged from one to 32 years, with 62 subjects (62%) suffering from MS less than ten years, 24 subjects (24%) 11 to 20 years, and 13 subjects (13%) more than 20 years. Out of the 106 returned questionnaires, some questions in the questionnaire were not scored, but the rest of the questionnaire entered the analysis, 99 in total. Results of subjects responses regarding symptoms of sexual dysfunction that directly or indirectly interfered with sexual satisfaction or activity over the six months prior to the survey are shown in Table 1. The results of comparison of the occurrence of particular categories of sexual dysfunction in subjects are presented in Table 2. There was no statistically significant difference in the occurrence of particular categories of sexual dysfunction in the study sample. The three categories of sexual dysfunction were represented evenly among all subjects. Tesla, D., et al. Cent Eur J Nurs Midw 2020;11(2):7884 2020 Central European Journal of Nursing and Midwifery 80 Table 1 Overview of sexual dysfunction symptoms experienced by MS patients MSISQ 19 (Sanders et al., 2000) % of subjects Over the last 6 months, the following symptoms have interfered with my sexual activity or satisfaction: never rarely occasionally almost always always 1. muscle tightness or spasms in arms, legs, or body 16 20 35 21 7 2. bladder or urinary symptoms 15 16 24 33 11 3. bowel symptoms 25 23 24 22 5 4. feelings of dependency because of ms 30 18 27 17 7 5. tremors or shaking in arms or body 18 25 27 21 8 6. pain, burning, or discomfort in body 23 21 18 19 8 7. feeling that own body is less attractive 32 17 23 14 13 8. problems moving body during sexual activity 17 13 28 23 18 9. feeling less masculine or feminine due to ms 34 16 24 14 11 10. problems with concentration, memory, or thinking 7 14 28 32 18 11. exacerbation or significant worsening of ms 26 31 20 18 4 12. less feeling or numbness in genitals 26 27 22 20 4 13. fear of being rejected sexually because of ms 36 16 20 11 16 14. worries about sexually satisfying to partner 26 19 23 12 19 15. feeling less confident about sexuality due to ms 23 22 12 28 14 16. lack of sexual interest or desire 20 16 28 21 14 17. less intense or pleasurable orgasms or climaxes 27 16 31 16 9 18. takes too long to orgasm or climax 15 21 23 18 20 19. inadequate vaginal wetness or lubrication (women)/difficulty getting or keeping a satisfactory erection (men) 20 20 29 16 14 Table 2 Comparison of the occurrence of a particular categories of sexual dysfunction in all subjects Category of sexual dysfunction primary secondary tertiary primary 0.59 0.5 secondary 0.59 0.53 tertiary 0.5 0.53 Due to abnormalities in the distribution in these three variables, Spearmans rank correlation coefficient was used. Table 3 The comparison of differences between men and women in the occurrence of a particular categories of sexual dysfunction Category of sexual dysfunction RS W RS M U Z p primary 3,882 1,068 792 0.68 0.5 secondary 4,047.5 902.5 626.5 2.05 0.04* tertiary 3,722.5 1,227.5 796.5 -0.64 0.52 RS rank sum; W woman; M men; U U score; Z Z score; p p-value; *statistically significant difference established. Normal distribution was tested
by the Shapiro-Wilk test and it was established that the data are not normally distributed. Therefore, the Mann-Whitney test was used.
Analysis of the differences in the occurrence
of particular categories of dysfunction between male
and female subjects is presented in Table 3.
There was a statistically significant difference
between men and women in secondary sexual
dysfunction, with women achieving significantly
higher values (p = 0.04). There were no statistically
significant differences between men and women in
primary and tertiary sexual dysfunctions (p > 0.05).
Subjects who stated their age (n = 99) were divided
into three age categories: A = up to 30 years; B = 31
to 50 years; C > 50 years. The results of comparison
of the occurrence of particular categories of sexual
dysfunction in the three age categories are presented
in Table 4.
No statistically significant differences among the
three age categories were found in any of the
categories (primary, secondary, or tertiary
dysfunction). During analysis of the occurrence
of primary dysfunction, the highest values were
recorded in age category B (31 to 50 years), although
without statistical significance (p = 0.24). Age group
A (up to 30 years) recorded the highest values for
occurrence of secondary and tertiary dysfunctions.
All subjects who stated the duration of disease were
divided into three groups: Group 1 = up to 10 years;
Group 2 = 11 to 20 years; Group 3 > 20 years.
The results of the comparison by disease duration are
presented in Table 5.
Tesla, D., et al. Cent Eur J Nurs Midw 2020;11(2):7884
2020 Central European Journal of Nursing and Midwifery 81
Table 4 Differences between 3 age categories in the occurrence of particular categories of sexual dysfunction
Category of sexual dysfunction A AS SD B AS SD C AS SD F p
primary 13.27 5.5 14.41 4.92 12.07 4.48 1.45 0.24
A B C H p
secondary 54.3 50.46 43.1 1.16 0.56
tertiary 56.93 50.83 38.43 3.22 0.2
A up to 30 years; B 31 to 50 years; C > 50 years; SD standard deviation; AS the mean sum of squares; F F score; H H score p p-value;
middle value of ranks in the sample; Normal data distribution was recorded in the primary sexual dysfunction category, therefore the one-way variance
analysis was used (ANOVA). There was an abnormal distribution of the data in the secondary and tertiary sexual dysfunction components. Therefore, the
Kruskal-Wallis test was used.
Table 5 The occurrence of a particular categories of dysfunction by disease duration
Category of exual dysfunction 1 AS SD 2 AS SD 3 AS SD F p
secondary 26.06 7.63 24.16 6.71 25.23 8.37 0.56 0.57
1 2 3 H p
primary 52.22 43.88 50.73 1.48 0.48
tertiary 51.37 43.9 53 1.46 0.48
1 up to 10 years, 2 11 to 20 years, 3 > 20 years; AS the mean sum of squares; F F score; H H score; p p-value;
middle value of ranks in the sample. Normal data distribution was recorded in the secondary sexual dysfunction category, therefore the one-way
variance analysis was used (ANOVA). There was an abnormal distribution of data in the primary and tertiary sexual dysfunction components. Therefore, the
Kruskal-Wallis test was used.
No statistically significant differences were found
among these three groups in any of the categories
(primary, secondary, or tertiary dysfunction). In the
primary and secondary categories, the highest values
were recorded in Group 1 (up to 10 years), whereas
in the tertiary category, the highest value was
recorded in Group 3 (> 20 years).
Discussion
In addition to the other problems related to the
underlying disease that multiple sclerosis patients
encounter daily, sexuality and intimacy are a special
challenge, both for patients and for the healthcare
system. Despite increases in therapeutic options,
many patients with MS do not seek treatment for
their SD complaints (Orasanu et al., 2013). In
a project conducted by Orasanu et al. (2013) to
determine the prevalence of various SD symptoms
among MS sufferers, 17,883 surveys were sent to
patients and 9,861 (55.1%) were returned, only 6,739
(68.3%) of which included responses to questions
regarding sexuality, suggesting that patients are
reluctant to talk openly about issues such as sexuality
and intimacy.
To analyze the occurrence of sexual dysfunction
in MS patients in Croatia, a questionnaire was sent to
500 members of the Croatian Multiple Sclerosis
Association, only 106 (21%) of whom completed the
questionnaire. The participation of such a small
number of subjects in the study could mean that only
a small number of MS patients, or only a small
number of the members of the Association had
sexual/intimate difficulties, or that the majority of the
patients (79%) did not wish to share their
sexual/intimate difficulties (in support of this, it
should be pointed out that this type of research had
not been carried out in Croatia before).
The MSISQ-19 was used for the study. The value
of the MSISQ-19 questionnaire has been verified
in numerous studies. A study conducted in Iran
representing a sample of 226 women (Mohammadi et
al., 2013), and a US study conducted on a larger
sample of 6,300 subjects of both sexes (Foley et al.,
2013) demonstrated that the MSISQ-19 questionnaire
was a reliable and valid indicator for sexual
dysfunction measurement in all three dimensions,
both in female and male respondents.
Sexual dysfunction symptoms are common in MS
patients. Although research in this area is still
limited, studies indicate a sexual dysfunction
prevalence rate of 40 to 80% in women, and 50 to
90% in men (Zorzon et al., 2001). From the
respondents answers it can be concluded that sexual
dysfunction is present in the majority. A very small
number of respondents claimed not to have
experienced any sexual problems, 21% claimed not
to have had any problems indicating the existence of
primary sexual dysfunction, 19% claimed not to have
had problems regarding secondary dysfunction, and
28% claimed not to have had difficulties regarding
tertiary sexual dysfunction. All other subjects had
experienced some degree of sexual dysfunction.
While a small number of respondents had
experienced temporary difficulties, a large number
had experienced prevalent problems, requiring
medical attention.
Tesla, D., et al. Cent Eur J Nurs Midw 2020;11(2):7884
2020 Central European Journal of Nursing and Midwifery 82
MS symptoms can begin at any age between 10 and
80 years, although they usually start between 20 and
40 years, with a mean age of 32 years (Lew-
Starowicz & Gianotten, 2015). The youngest subject
to complete the questionnaire in our study was 20
years old, the oldest was 63 years old, and the
majority of patients were in the age group between
3150 years old.
Globally, multiple sclerosis is more prevalent
in women than in men. Of the 106 participants in our
survey, 77% were female. There are no known data
on the proportion of women in the total population
of MS patients in Croatia. Therefore, it is debatable
whether these results can be interpreted as a greater
readiness in women to talk about sexual difficulties
(as in a study in Iran: Mohammadi et al., 2013) or
whether this reflects the likely proportion of women
to men with MS in Croatia.
Multiple sclerosis can affect sexuality in many ways.
Dysfunction is not only related
to brain or spinal cord lesions within areas directly
involved in sexual response but also to limited
mobility, spasticity, fatigue, pain, bowel and bladder
dysfunction, and psychological disturbances,
cognitive dysfunction, and depression. It is hard to
find definite correlations
between brain and spinal cord lesions and particular
sexual dysfunctions that will explain the problem
in the majority of patients. This may also be due to
the multifactorial nature of the sexual response (Lew-
Starowicz & Gianotten, 2015). In sexual dysfunction,
organic and nonorganic factors may coexist.
No differences were found in the interviewed sample
duringn the analysis of the occurrence of particular
categories of sexual dysfunction. Difficulties arising
from nerve path disruptions due to nerve damage
caused by pathophysiological processes, difficulties
related to the urinary system, spasticity, hand tremor,
and anything else that can indirectly complicate the
intimate and emotional life of patients (perception
of ones own body, mood swings, self-esteem) were
equally present (p = 0.72).
The results of studies on differences between men
and women in primary, secondary, and tertiary
categories of sexual dysfunction are highly
controversial. Zorzon et al. (1999) found sexual
dysfunction in 73% of patients, with difficulties
in the primary category of sexual dysfunction being
most common for both men and women, with similar
results reported by Demirkiran et al. (2006).
In contrast, elik et al. (2013) found that secondary
sexual dysfunction was most common for both men
and women, although women had more difficulties
in this category. Our study indicated similar results,
with a significant difference between male and
female subjects in the secondary sexual dysfunction
category, for which female respondents recorded
significantly higher scores. There were no
statistically significant differences in the primary and
tertiary categories.
When primary, secondary, and tertiary sexual
dysfunction were analyzed in relation to age, no
significant differences were found between the three
age categories for any of the dysfunction categories.
In the primary sexual dysfunction category, the
highest values were recorded in the 31 to 50 years
age group, whereas the highest values in the
secondary and tertiary categories were observed
in subjects up to 30 years of age.
A number of studies have found sexual dysfunction
in MS patients to be associated with duration
of disease (Demirkian et al., 2006; Khan et al.,
2011). However, it is not known whether the picture
for each category of dysfunction changes over time.
In our study, no significant difference was found
between categories of sexual dysfunction with
respect to the duration of MS. In the primary and
secondary categories, the highest values were
recorded in subjects with disease duration of up to ten
years, while in the tertiary category the highest values
were recorded in subjects with disease duration
of more than 20 years.
Nowadays, a considerable amount of information is
readily available regarding sex and sexuality, which
might seem to imply that the topic is easy for all to
discuss, and that sex is practiced by everyone without
any difficulties or feelings of shame or guilt.
Changes induced by MS may affect sexual response
by making sexual activity physically and emotionally
more difficult. Common MS issues, such as fatigue,
changes in muscle tone, lack of coordination and/or
pain, can result in frustration related to sexual
expression and lack of desire. Incontinence disorders,
both urinary and bowel, can cause inhibitions and
a sense of shame.
Of all the symptoms occurring in MS, cognitive
changes are potentially among the most damaging to
relationships and intimacy with others, as they may
distort perceptions of the sufferers personality.
Many of the symptoms of MS are not visible, while
others are painfully present. All have a strong
influence on quality of life and self-esteem. In a
study of the impact of sexual dysfunction on the
overall quality of life of a sample of 6,183 patients
with multiple sclerosis, the authors concluded that
sexual dysfunction, in comparison to physical
dysfunction, has a much greater detrimental effect on
the mental state of patients (Sanders et al., 2000).
Tesla, D., et al. Cent Eur J Nurs Midw 2020;11(2):7884
2020 Central European Journal of Nursing and Midwifery 83
For most people, sexuality and sexual expression are
natural and very important components of self-image,
emotional well-being, and, above all, good quality of
life. Some individuals and couples affected by MS
give little or no priority to intimacy and sexuality,
since they are preoccupied by other issues related to
the underlying disease. Regardless of whether
a patient is in an intimate relationship or not, it is
a great challenge to maintain their sexual identity and
to take care of their sexual self-esteem while having
to face a chronic disease like MS.
Today, numerous medications and aids are available
to help MS patients overcome difficulties in the
sphere of sexual function. Discussing intimacy and
sexuality is very important, but can often be difficult
for both MS patients and healthcare professionals.
Often, conversations about this subject are avoided
by healthcare professionals due to personal
discomfort, lack of professional education on the
subject of sexuality and intimacy, or fear of invading
the privacy of the patient. On the other hand,
intimacy and sexuality are also a difficult topic for
MS patients, either due to a lack of information
on problems related to the disease which might affect
intimacy and sexuality, or due to discomfort, fear
of condemnation, or cultural inhibitions.
Health and illness should not be seen in absolute
terms: How can we claim to provide holistic care
if we are not assessing aspects of sexuality and
intimacy? (Maslow, 1954). If a person has multiple
sclerosis, this does not mean that other needs,
especially basic human needs such as sexuality,
should be neglected.
Conclusion
The study indicated that all patients with MS
experience sexual dysfunction to a certain degree,
and that there is no difference between incidence
of primary, secondary, and tertiary sexual
dysfunction. Patients with MS find it very difficult to
talk about intimacy and sexuality. Healthcare
professionals should give every patient the
opportunity to discuss their problems whenever they
feel the need to talk about them.
Overcoming barriers successfully requires creativity,
communication and patience. Healthcare
professionals can assist MS patients in several ways:
– by initiating conversation on sensitive subjects;
– by explaining that sexuality and intimacy are
part of everyday life;
– by informing them about useful sources
of information;
– by assuring patients that they can contact
a professional without hesitation whenever they
feel the need to;
– by informing patients about medication and their
possible impacts on intimate intercourse;
– by informing patients about aids that can help
them during intimacy (sensory body maps,
mechanical aids, visual stimulation, medication,
lubricants, etc.);
– by recommending communication between the
patient and their partner.
Multiple sclerosis patients should not have to suffer
in silence. Healthcare professionals must listen to
them without prejudice, with an open ear and mind,
and create a secure and comfortable environment in
which they will be able to discuss sensitive issues
at their ease. If MS patients feel uncomfortable with
suchaconversation, they should be given the option
of expressing their fears, questions, and experiences
in writing and they should receive a written response.
An intimate relationship consists of much more than
the simple interaction of body parts, and intimacy is
far more than the sexual act itself. The foundation
must be good communication, and trust in both
healthcare professionals and their partner.
Ethical aspects and conflict of interest
The study was approved by the institutional review
board of the University of Applied Science, Bjelovar
(IRB 2103/01-21-01-17-01).
The survey was conducted in cooperation with the
Croatian Association of Multiple Sclerosis Patients,
and The City of Zagreb Multiple Sclerosis Society
in the form of a questionnaire.
Consent for the survey was obtained from the
president of the Society. Participants in the survey
completed a questionnaire sent by email. Completion
of the questionnaire was regarded as agreement to
participate in the research, with the right to terminate
further participation at any time.
Acknowledgments
The authors gratefully wish to thank the members of
Croatian Association of Multiple Sclerosis Patients
for their cooperation.
Author contributions
The concept and study design (DT, RM), data
analysis and interpretations (DT, TB, RM),
processing the draft of the manuscript (RM), critical
revision of the manuscript (RM), article finalisation
(DT, RM).
Tesla, D., et al. Cent Eur J Nurs Midw 2020;11(2):7884
2020 Central European Journal of Nursing and Midwifery 84
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