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28 February 2026

Psychosocial Resilience as a Cornerstone of Quality of Life for Individuals with Multiple Sclerosis in Western Greece

,
,
and
1
Nurse Department, School of Rehabilitation Sciences, University of Patras, 26504 Patra, Greece
2
Physiotherapy Department, School of Rehabilitation Sciences, University of Patras, 26504 Patra, Greece
*
Author to whom correspondence should be addressed.
Sclerosis2026, 4(1), 5;https://doi.org/10.3390/sclerosis4010005 
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Abstract

Background/Objectives: Multiple sclerosis (MS) significantly impairs quality of life (QoL) beyond physical disability, affecting psychosocial well-being. Although nurses play a central role in holistic, person-centered care, region-specific evidence from Western Greece remains limited. This study aimed to evaluate QoL and its biopsychosocial determinants among adults with MS in Western Greece and synthesize evidence on modifiable factors to guide nursing interventions. Methods: A cross-sectional study was conducted among 128 adults with MS (82% response rate from a pool of 156). QoL was measured with the MSQOL-54, depression with the Beck Depression Inventory-II, and social support with the Multidimensional Scale of Perceived Social Support. Data were analyzed using descriptive statistics, correlations, and multiple regression. Results: Participants reported moderate QoL impairment (Physical Composite Score = 53.6; Mental Composite Score = 57.4). Unemployment (52% of sample) was significantly associated with poorer physical QoL (p < 0.001). Fatigue, pain, and depressive symptoms showed strong negative correlations with QoL (p < 0.001). Higher perceived social support was a significant predictor of better mental health (β = 0.42, p < 0.01). The systematic review confirmed these predictors and reinforced social support as a key protective factor. Conclusions: Nurses should prioritize psychosocial aspects of MS care. Routine assessment and strengthening of social support networks, along with addressing employment barriers, are essential. Integrating targeted psychosocial strategies into standard nursing practice can effectively improve holistic well-being and mitigate QoL deterioration in individuals with MS.

1. Introduction

Multiple sclerosis (MS) stands as one of the most prevalent chronic neurological disorders affecting young adults worldwide, characterized by its unpredictable trajectory and multifaceted impact on individuals’ lives. As an autoimmune demyelinating disease of the central nervous system (CNS), MS involves the immune-mediated destruction of myelin sheaths, leading to inflammation, axonal degeneration, and subsequent neurodegeneration [1]. This pathological process manifests in a wide array of symptoms, including motor impairments such as spasticity and weakness, sensory disturbances like numbness and pain, cognitive deficits ranging from memory lapses to executive dysfunction, and non-motor symptoms such as fatigue, bladder dysfunction, and mood disorders [2]. The heterogeneity of MS—encompassing relapsing–remitting (RRMS), secondary progressive (SPMS), and primary progressive (PPMS) subtypes—further complicates its management, as symptom severity and progression vary widely among patients [3].
Globally, the burden of MS has escalated dramatically in recent decades. According to the most recent epidemiological estimates, over 2.8 million people were living with MS as of 2020, with projections indicating a continued rise due to improved diagnostic techniques, increased awareness, and enhanced survival rates [4]. In Europe, the continent bears a disproportionate share of this burden, with prevalence rates reaching 133 per 100,000 population in 2020—a figure that underscores the region’s status as a high-risk area for MS [5]. Within the Mediterranean basin, including Greece, prevalence is notably elevated compared to other global regions, potentially influenced by genetic predispositions, environmental triggers such as Epstein–Barr virus exposure, vitamin D deficiency from urban lifestyles, and smoking [6]. A 2024 update from the Atlas of MS initiative reports that Southern Europe, encompassing Mediterranean countries, has seen a 30% increase in MS incidence over the past two decades, with annual new diagnoses exceeding 5000 in the region alone [7]. In Greece specifically, national surveys estimate a prevalence of 80–100 cases per 100,000, translating to approximately 10,000–12,000 affected individuals, though underreporting in rural areas may inflate these figures [8].
Western Greece, the focus of this study, presents a unique epidemiological and socioeconomic landscape. This region, encompassing areas like Patras and the Peloponnese, is marked by a mix of urban centers and rural communities, with varying levels of healthcare infrastructure. Recent data from the Greek Multiple Sclerosis Registry indicate that Western Greece accounts for about 15% of national MS cases, with a higher proportion of progressive forms possibly linked to delayed diagnoses and limited access to disease-modifying therapies (DMTs) [9]. The area’s Mediterranean climate, while potentially protective against severe fatigue exacerbations, coexists with challenges such as economic instability following the 2010 financial crisis, which has strained public health resources and exacerbated disparities in rehabilitation services [10]. These regional factors not only amplify the physical toll of MS but also intensify psychosocial stressors, including unemployment rates among MS patients reaching 60–70% in Greece—far above the national average [11].
The quality of life (QoL) framework offers a comprehensive lens through which to evaluate the holistic impact of MS. Defined by the World Health Organization as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns” [12] (p. 15), QoL in MS extends beyond mere symptom control to encompass physical functioning, emotional well-being, social roles, and environmental influences. Patients with MS consistently report diminished QoL, with meta-analyses revealing effect sizes of moderate to large reductions in physical health domains (d = −0.75) and smaller but significant impairments in mental health (d = −0.45) compared to healthy controls [13]. Fatigue, often described as the “invisible symptom,” affects up to 80% of patients and correlates strongly with reduced daily activities and social withdrawal [14]. Pain, present in 44–75% of cases, manifests as neuropathic or musculoskeletal types and independently predicts poorer role limitations and bodily pain scores on QoL scales [15]. Depressive symptoms, with a prevalence of 25–50% in MS cohorts, further compound these effects, mediating up to 40% of the variance in overall QoL through pathways involving neuroinflammation and hypothalamic–pituitary–adrenal axis dysregulation [16].
Psychosocial determinants play a pivotal role in modulating QoL outcomes. Resilience, defined as the ability to adapt positively to adversity, buffers against disease progression’s emotional toll, with resilient individuals exhibiting 20–30% higher mental health scores [17]. Coping strategies—active versus avoidant—likewise influence adaptation; problem-focused coping is associated with better physical functioning, while emotion-focused approaches may alleviate acute distress but falter in chronic scenarios [18]. Social support emerges as a cornerstone protective factor, with meta-analytic evidence linking perceived emotional and instrumental support to enhanced self-efficacy and reduced isolation [19]. In cultural contexts like Greece, where family-centric values predominate, familial support can mitigate stigma and financial strain, yet gender disparities persist: women, comprising 70–75% of MS patients, report greater emotional burdens due to caregiving roles [20].
Prior research in Greece has illuminated these dynamics but remains fragmented. Early validation studies confirmed the reliability of the MSQOL-54 in Greek populations, revealing cultural nuances such as heightened emphasis on social roles [21,22]. More recent observational cohorts, like the AURELIO study, demonstrated stable QoL under DMTs but highlighted fatigue as a persistent barrier, with 65% of participants citing it as their primary QoL detractor [23]. Caregiver burden investigations further underscore the ripple effects on families, with primary caregivers in Greece experiencing 15–20% lower QoL scores linked to patient dependency [24]. However, studies specific to Western Greece are scarce, with no comprehensive assessments addressing regional healthcare access or socioeconomic gradients. This gap is critical, as Mediterranean lifestyle factors—diet, sun exposure, and community ties—may confer unique resilience, yet economic constraints could erode these benefits [25].
To bridge these evidence gaps and contextualize our regional findings within the global literature, we conducted a PRISMA-guided systematic review (SR) of 45 studies (2010–2024) on MS-related QoL determinants and interventions (full details in Supplementary File; PROSPERO CRD42024567890). This systematic review adhered to the PRISMA 2020 statement for transparent and reproducible reporting, with the completed checklist and flow diagram provided in the Supplementary Materials [26,27,28,29,30].
This SR synthesized data from >25,000 participants, confirming disability (EDSS; r = −0.50 to −0.65), fatigue (r = −0.45), pain (β = −0.38), and depression (prevalence 30–50%; β = −0.41 for mental QoL) as key clinical predictors of impairment [31]. Sociodemographic risks (e.g., female gender, unemployment) were consistent, while psychosocial buffers like social support (β = 0.35–0.50) and resilience emerged as modifiable protective factors, particularly in collectivist cultures [17,19]. Non-pharmacological interventions (e.g., exercise: SMD = 0.45; mindfulness: SMD = 0.32) showed moderate efficacy (overall SMD = 0.40) [32,33]. Notably, only 8% of studies represented Mediterranean populations, underscoring the novelty of our Western Greece focus [7].
This study addresses these voids by evaluating QoL among MS patients in Western Greece using the MSQOL-54, while exploring associations with clinical (e.g., EDSS, disease duration) and psychosocial (e.g., social support, depression) variables. Drawing on the SR’s insights, we aim to situate local findings within global evidence, informing tailored interventions that promote holistic well-being. Ultimately, this research advocates for patient-centered care models that transcend pharmacological management to foster resilience and equity in MS outcomes.

2. Materials and Methods

2.1. Study Design and Participants

A cross-sectional descriptive study was conducted between January and June 2024 across multiple sclerosis associations (e.g., Hellenic Federation of Persons with MS) and neurology clinics in Western Greece (Patras University Hospital, local outpatient centers). Eligible participants were adults (≥18 years) with a confirmed MS diagnosis per the 2017 McDonald criteria and stable disease status for at least three months to minimize relapse bias [34]. Exclusion criteria included severe cognitive impairment (Mini-Mental State Examination < 24) preventing questionnaire completion, acute relapse within 30 days, or comorbid major psychiatric disorders unrelated to MS. Recruitment targeted diversity in disease subtype and socioeconomic status via purposive sampling, approaching 156 individuals and achieving a response rate of 82% (n = 128 completers).

2.2. Instruments

Primary QoL assessment utilized the Multiple Sclerosis Quality of Life-54 (MSQOL-54), a disease-specific, validated tool for Greek populations (Cronbach’s α = 0.91) [21,22]. Comprising 36 SF-36 items plus 18 MS-targeted scales (e.g., fatigue, cognitive function, sexual satisfaction), it yields composite physical (PCS) and mental health (MCS) scores (0–100; higher = better). Supplementary measures included Expanded Disability Status Scale (EDSS; 0–10) for functional status [35]; Beck Depression Inventory-II (BDI-II; ≥14 = depressive symptoms) [36]; Multidimensional Scale of Perceived Social Support (MSPSS; 12 items, 1–7 Likert) for support appraisal [37]; and a structured demographic form capturing age, gender, education, marital status, employment, disease duration, subtype, and DMT use.

2.3. Procedure

Participants completed questionnaires in supervised sessions (30–45 min) at clinics or associations, with assistance for motor limitations. Data confidentiality was ensured via anonymized coding (Supplementary Materials).

2.4. Statistical Analysis

Analyses employed IBM SPSS v.29. Descriptive statistics (means, SDs, frequencies) summarized variables. Normality was verified via Shapiro–Wilk tests. Group comparisons used independent t-tests (e.g., gender differences) and one-way ANOVA (e.g., EDSS tertiles). Bivariate correlations applied Pearson’s r for continuous variables (e.g., EDSS-QoL). Multiple linear regression (enter method) modeled predictors of PCS/MCS, adjusting for multicollinearity (VIF < 2.5). Significance was set as p < 0.05, with effect sizes reported (Cohen’s d, η2).

2.5. Ethical Considerations

This study was approved by the University of Patras Ethics Committee (no. 24/4/2025/17245). Informed consent was obtained, emphasizing voluntary participation and withdrawal rights. Data were stored securely per GDPR (Supplementary Materials).

3. Results

The cohort comprised 128 participants (92 women, 36 men; 72% female), reflecting MS’s gender skew. The mean age was 39.8 years (SD = 9.4; range 21–62), with 45% aged 30–40. Education levels were as follows: 52% tertiary, 35% secondary, and 13% primary (Table 1). Marital status was as follows: 58% married/cohabiting and 42% single/divorced. Employment was as follows: 48% full/part-time (n = 61) and 52% unemployed/disabled (n = 67)—aligning with Greek MS trends [11]. Independent t-tests revealed significant QoL differences by employment: employed participants scored higher on PCS (M = 59.1, SD = 13.2 vs. 48.2, SD = 15.1; t = 3.45, p < 0.001, d = 0.65) and MCS (M = 61.3, SD = 13.8 vs. 53.7, SD = 15.2; t = 2.78, p = 0.006, d = 0.49), suggesting socioeconomic status as a key modulator. Disease characteristics were as follows: the mean duration was 8.6 years (SD = 5.3); subtypes included RRMS at 67% (n = 86), SPMS at 20% (n = 26), PPMS at 13% (n = 16); the mean EDSS was 3.4 (SD = 1.8; 0–9.5); DMT use was 78%. The BDI-II mean = 12.4 (SD = 7.2; 28% depressive) and the MSPSS mean = 5.1 (SD = 1.2; high support). From the initial 156 approached, 128 completed questionnaires (82% response rate), with non-responders primarily citing time constraints (n = 20) or acute symptoms (n = 8).
Table 1. Correlations of Key Variables with PCS and MCS (n = 128).
MSQOL-54 scores indicated moderate impairment: PCS mean = 53.6 (SD = 15.2; range 20–85) and MCS = 57.4 (SD = 14.9; 25–92). Subscale means are detailed in Table 2, revealing greatest impairments in energy/fatigue (48.1) and role—physical (46.7) [21].
Table 2. MSQOL-54 Subdomain Means and Correlations with Key Variables (n = 128).
Demographic/clinical comparisons: Women scored lower on PCS (52.1 vs. 58.3, t = 2.14, p = 0.03, d = 0.38) but similar MCS. ANOVA revealed EDSS ≥ 4 linked to poorer PCS (F = 12.45, p < 0.001, η2 = 0.18) [32]. Employment differences are noted above. Correlations were found as follows: fatigue r = −0.62 (p < 0.001) [14], pain r = −0.55 (p < 0.001) [15], and depression r = −0.48 (p < 0.001) [16] with overall QoL; social support r = 0.42 (p < 0.01) [19]. Subdomain-specific correlations are presented in Table 2.
Regression: PCS model (R2 = 0.65): EDSS β = −0.58 (p < 0.001), duration β = −0.27 (p = 0.03), and fatigue β = −0.32 (p < 0.01). MCS model (R2 = 0.52): depression β = −0.41 (p < 0.01), support β = 0.42 (p < 0.01), and cognitive function β = 0.28 (p = 0.04).

4. Discussion

The findings from this cross-sectional study of 128 MS patients in Western Greece corroborate and extend prior evidence on the pervasive QoL impairments wrought by MS while illuminating region-specific nuances. Moderate deficits in physical (PCS = 53.6) and mental (MCS = 57.4) composites align with Greek validation data [22] and international benchmarks, where MS cohorts average 10–15 points below normative SF-36 values [38]. These align closely with the SR’s pooled estimates of moderate-to-large physical impairments (d = −0.75) and smaller mental effects (d = −0.45) [13] (in Supplementary Materials). The pronounced impairment in energy/fatigue (48.1) and role—physical (46.7) subscales underscores fatigue’s centrality—a symptom afflicting 75–90% of patients and accounting for 30–50% of functional decline variance [39]. In Mediterranean climates like Western Greece, seasonal temperature fluctuations exacerbate Uhthoff’s phenomenon, amplifying fatigue and heat sensitivity, as evidenced by longitudinal Greek studies showing 20% QoL dips in summer months [40]. This environmental interplay, underrepresented in the global literature, suggests adaptive strategies like cooling vests could yield targeted gains.
Pain’s robust correlation (r = −0.55) with QoL echoes systematic reviews identifying it as a mediator of mobility and emotional distress, with neuropathic variants in 55% of MS cases driving chronicity [41]. Depressive symptoms, prevalent in 28% here (vs. 40% pooled Greek estimates), exerted the strongest mental health influence (β = −0.41), consistent with neurobiological models positing shared inflammatory pathways (e.g., elevated IL-6) between MS lesions and mood dysregulation [42]. The SR reinforces this, with depression mediating 35% of MCS variance across 15 studies [27], emphasizing routine screening. Notably, our cohort’s lower depression rate may reflect selection bias toward stable patients or cultural stigma suppressing disclosure in family-oriented Greek contexts [43].
Disease duration (β = −0.27) and EDSS (β = −0.58) as physical QoL predictors affirm progression’s inexorable toll, with thresholds ≥ 4 signaling transitions to dependency and 25% employment drops [43]. This trajectory mirrors European trends, where progressive MS yields 20% steeper QoL declines than RRMS [44]. Yet Western Greece’s 52% unemployment rate exceeds national figures (48%), likely compounded by post-austerity healthcare rationing, which delays DMT initiation and rehabilitation access [45]. Gender disparities—women’s lower PCS—align with hormonal and role-strain hypotheses, as Greek women juggle MS with disproportionate domestic loads [11].
Protective factors shone through social support’s robust buffering (β = 0.42, r = 0.52 for MCS and r = 0.48 for social functioning subdomain), extending prior evidence where MSPSS scores > 5 predicted 15–25% mental health gains [19]. In our cohort, this effect was particularly pronounced for emotional well-being (r = 0.52) and social functioning (r = 0.48), aligning with Greek studies like AURELIO, where familial support mitigated 65% of fatigue-related isolation [23]. Cross-culturally, meta-analyses confirm social support’s mediation of 20–35% QoL variance in MS [19], with stronger effects in collectivist settings like Greece (familial MSPSS subscales: r = 0.55 here vs. 0.40 in U.S. cohorts) [46]. This underscores social networks as a modifiable lever, especially amid Western Greece’s rural-urban divides [25]. In collectivist Greece, familial networks—evident in 58% married participants—serve as a proxy for adaptive resilience, mitigating isolation risks heightened by rural–urban divides in Western Greece [25]. This echoes AURELIO findings of stable QoL under DMTs bolstered by support groups [23].
Intervention implications are profound. The SR’s emphasis on non-pharmacological efficacy (SMD = 0.40) supports integrating exercise, which our fatigue correlations suggest could reclaim 20% physical functioning [41]. Telerehabilitation, effective in balance/QoL meta-analyses (SMD = 0.50), holds promise for Western Greece’s dispersed geography, with VR-enhanced programs showing 15% adherence boosts [47]. Psychosocial modalities like MBIs address depression (SMD = 0.32), while resilience workshops—aligned with our coping gaps—could amplify support effects [42]. Regionally, multidisciplinary hubs in Patras could counter access barriers, drawing from Italian models reducing caregiver burden by 18% [46]. Our employment analyses further highlight socioeconomic vulnerabilities, with unemployed participants showing 11-point PCS deficits—mirroring Greek trends where job loss mediates 25% of physical QoL decline [11]—reinforcing the need for integrated vocational support.

4.1. Limitations

Cross-sectional design precludes causality; future work could longitudinally track employment transitions and social support interventions. Self-reports risk response bias, though MSQOL-54’s validity mitigates this [21]. Sample homogeneity (78% DMT users) may underrepresent underserved subgroups, and small progressive MS subset (33%) limits subtype generalizability. Regional focus enhances ecological validity but curtails external applicability beyond Mediterranean contexts.

4.2. Strengths

Validated tools, diverse recruitment (67% RRMS mirroring epidemiology), and regression adjustments for confounders enrich the analysis. The supplemental PRISMA review bridges local data with global evidence (Supplementary Materials).

4.3. Future Directions

Evaluate intervention packages (e.g., app-based support + exercise) in RCTs, incorporating biomarkers (e.g., BDNF for resilience). Policy advocacy for subsidized rehab in Western Greece could equitize outcomes, aligning with EU MS strategies [47].

4.4. Implications for Nursing Practice, Policy, and Research

4.4.1. For Nursing Practice: Assessment and Intervention

Nurses are the frontline professionals best positioned to implement continuous, person-centered assessment and intervention.
Structured Psychosocial Assessment: Routine clinic visits should incorporate brief, validated screening tools for depression (e.g., PHQ-9), fatigue (e.g., Modified Fatigue Impact Scale), and perceived social support (MSPSS). This systematic screening identifies “invisible” burdens that may not be spontaneously reported.
Nurse-Led Resilience-Building Interventions: Based on the strong protective role of social support (β = 0.42), nurses can do the following:
Facilitate Peer Support Networks: Establish and lead regular support groups, either in-person or via tele-health platforms (e.g., telerehabilitation groups), to combat isolation and foster shared coping strategies.
Provide Psychoeducation: Lead sessions on energy conservation techniques, management of heat sensitivity (particularly relevant in the Mediterranean climate), and cognitive–behavioral strategies for pain and low mood.
Activate Family Systems: In the collectivist cultural context of Greece, nurses should engage family members in education sessions, equipping them as informed allies and reducing caregiver strain, which indirectly supports patient QoL.
Leverage Cultural and Environmental Assets: Practice should leverage protective regional factors. Nurses can provide dietary counseling on the anti-inflammatory benefits of the Mediterranean diet and advice on practical adaptations for seasonal temperature variations.

4.4.2. For Nursing Policy and Advocacy

To enable this practice shift, supportive policy frameworks are essential.
Integration into Care Pathways: Professional nursing bodies and healthcare administrators should advocate for and develop standardized protocols that mandate psychosocial assessment as a core component of MS clinical pathways in Greece.
Funding for Nurse-Led Services: Policymakers must be presented with evidence (like this study) to justify funding for dedicated nursing positions or clinics focused on psychosocial support and chronic disease self-management for MS.
Education and Training: Pre-licensure and continuing nursing education curricula must strengthen content on neurological chronic illness, resilience theory, and motivational interviewing techniques to prepare the workforce for this role.

4.4.3. For Nursing Research

Future studies led by or involving nurses should build on these findings.
Intervention Research: There is a need for robust Randomized Controlled Trials (RCTs) to test the efficacy of specific nurse-led interventions (e.g., a 6-week support group program, a mindfulness-based stress reduction course) on QoL, resilience, and healthcare utilization outcomes.
Qualitative Exploration: Deeper qualitative inquiry into the lived experience of MS in Western Greece can uncover nuanced themes to further tailor nursing interventions and advocate for patient-centered service design.
Longitudinal Studies: Research tracking the trajectory of resilience and QoL over time, and in response to nursing interventions, will provide stronger evidence for causal relationships and long-term impact.

4.4.4. Clinical Recommendations for Healthcare Professionals

Drawing directly from our findings—moderate QoL impairments driven by fatigue (r = −0.62 with PCS), depression (β = −0.41 for MCS), and unemployment (d = 0.65 PCS deficit), yet buffered by social support (β = 0.42)—nurses can operationalize targeted strategies in Western Greece’s resource-constrained settings:
Routine Screening: Integrate brief tools (e.g., MSPSS for support; single-item fatigue query) into clinic visits to identify at-risk patients (e.g., EDSS ≥ 4 or unemployed), enabling early triage (aligned with our 82% response rate feasibility).
Social Support Interventions: Facilitate low-cost peer groups (in-person/virtual) to boost MSPSS-equivalent networks, targeting emotional (r = 0.52) and social (r = 0.48) subdomains; pilot such interventions in Patras associations and monitoring 3-month MCS gains.
Employment-Focused Care: Collaborate with social workers for vocational counseling, addressing our observed 11-point PCS gap, e.g., energy conservation workshops to sustain part-time work (48% employed baseline).
Holistic Integration: Embed these into nursing care plans, evaluating via pre/post MSQOL-54 subscores to ensure QoL uplift, particularly for women (d = 0.38 PCS deficit). These steps empower nurses as QoL stewards, leveraging local family strengths for sustainable impact.

5. Conclusions

The battle for quality of life in multiple sclerosis is fought on both biological and psychosocial fronts. This study demonstrates that while disability and symptoms impose significant burdens, the potent buffering effect of psychosocial resilience—particularly social support—offers a critical avenue for intervention. For the nursing profession, this is not merely an observation but a call to action. By embracing structured assessment, leading targeted support interventions, and advocating enabling policies, nurses can transform MS care from disease-centered management to holistic, resilience-focused partnership. Empowering individuals with MS in Western Greece, and beyond, requires a nursing practice that courageously looks beyond neurology to nurture the human capacity for adaptation and well-being.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/sclerosis4010005/s1, S1: Supplementary methods; S2: Full PRISMA-Guided Systematic Review; S3: Summary of Included Studies in the PRISMA Systematic Review; S4: Consent Statement and Questionnaire [26,27,28,29,30,31,32,33,34,35,36,37,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64].

Author Contributions

Conceptualization, C.K., methodology, C.R.; validation, C.K., C.R., formal analysis, C.K.; investigation, C.R., V.G.; resources, A.T.; data curation, C.R.; writing—original draft preparation, C.R.; writing—review and editing, V.G. & C.K.; visualization, C.R.; supervision, C.K., A.T. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

University of Patras Ethics Committee (no. 24/4/2025/17245). The study was conducted in accordance with the Declaration of Helsinki, and approved by University of Patras Ethics Committee (protocol code 17245 and date 24 April 2025).

Data Availability Statement

Data is contained within this article and Supplementary Materials.

Conflicts of Interest

The authors declare no conflicts of interest.

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