Abstract
The study seeks to evaluate psychometric properties of Attitudes toward Cross Border Reproductive Care (ATCBRC) Inventory in terms of reliability and validity among Greek healthcare professionals. A total suitable sample of 315 doctors, 302 dentists, 356 nurses and 312 midwives were recruited to complete ATCBRC Inventory. To examine the applicability of the ATCBRC Inventory in different groups, its invariance was evaluated. The results certified the internal consistency, as measured by Cronbach alpha coefficient, test–retest reliability, composite reliability and AVE, convergent and construct validity of ATCBRC Inventory. The results revealed the internal consistency and reliability, convergent and construct validity of the ATCBRC Inventory for the group of doctors, dentists, nurses, and midwives. Furthermore, the four-factor structure of the ATCBRC Inventory was confirmed. Structural Equation Model (SEM) verified the model’s good fit and its invariance. Until now the there was any Inventory that evaluates Attitudes toward Cross Border Reproductive Care. A valid and reliable Inventory will enable researchers, doctors, healthcare marketers to capture attitudes toward CBRC and develop healthcare strategies and policies.
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1 Introduction
The issue of Cross Border Reproductive Care is more relevant than ever. Millions of dollars are spent each year by would-be parents who travel abroad to other countries in the hope of either being able to access Reproductive Care services that are not available in their home countries, or in other countries where these services are incredibly cheaper or to look for surrogacy services for which the procedures are not completely transparent and legal. The legal dilemmas and ethical concerns, the economic consequences are many as are the human rights and social justice issues regarding human assisted reproduction and surrogacy. It is very important to research people’s attitudes, opinions and beliefs towards Cross Border Reproductive Care. However, there is no Inventory so far that measures people’s attitudes towards Cross Border Reproductive Care involving surrogacy. This gap is to be covered by the present research, a fact which also proves the originality of the present research. Attitudes toward Cross Border Reproductive Care (ATCBRC) Inventory is proposed and evaluated, in terms of reliability and validity. A reliable and valid assessment tool Attitudes towards Cross Border Reproductive Care will enable very important research in the field of Cross Border Reproductive Care to assess the legal, economic, ethical and human rights issues.
2 Literature Review
Today very low infertility rates have led to the search for modern techniques of assisted reproduction known as ART [1]. Cross-border reproductive care (CBRC) is a growing phenomenon in which national borders are crossed as people seek reproductive treatment [2]. CBRC is division of the spreading globalization and commercialization of health care [3] and access to it is differentiated based on the cost and quality of ART. The social, economic, educational level as well as the logistical means to access CBRC services differentiate the possibility of this form of medical care [4]. The legal, social, religious, political and cultural institutional framework of a country favors or not CBRC [5] as in other countries surrogate motherhood, the donation of hours and sperm, the transfer of embryos, pre-implantation genetics are legalized e-check etc. Internet continuously produces a coefficient competitive market globally [6]. CBRC services and the relatives’ entrepreneurs used communication tools in order people aware of their services [7]. Internet access allow doctors to have some benefit from medical marketing as well as patients seeking for specific services [8].
By passing mostly legal restrictions of ART in a country and more cost-effective services are some of the main reasons why people choose CBRC [9] that become a huge industry. Particular concerns with legal, ethical and economic ramifications concern the case of surrogacy. Saxena et al. [1] distinguish between commercial and altruistic surrogacy. In the first case there is the financial transaction. McLean et al. [10] report in their research that patients who resort to CBRC indicate economic and legal components as factors for choosing CBRC. The cost and legality of ART in countries are decisive factors for the country of choice for the provision of these services. On the other hand, health providers listen to the code of risk regarding the safety of non-patients. McLean et al. [10]) in their research noted that according to clinicians competent and necessary global legislation regarding CBRC to remove the exploitation of economically and socially vulnerable social groups, the instrumentalization of the surrogate mother and the removal of her freedom and autonomy, etc.
The study of attitudes of social subjects of various professional, social, religious groups regarding CBRC is extremely timely because thousands of childless couples, same-sex couples, elderly women without a spouse, men without a spouse or a relationship with a woman, etc. seek fertility treatments in countries other than the country of residence [11]. In Greece today it is a country of choice for the CBRC. There are no surveys documenting attitudes to CBRC as Greece as a country destination. Also, there is no tool that will record these attitudes. The gap comes to be answered by the present research as Psychometric Testing Procedures Reproductive Tourism and Cross Border Reproductive Care (ATCBRC) Inventory Validity, Reliability evaluation are carried out.
3 Methodology
3.1 Sample-Statistical Methodology
To test the study hypotheses, a survey was conducted using 315 doctors, 302 dentists, 356 nurses and 312 midwives were recruited to complete CBRC Inventory. In addition, the sample consists of 748 females and 537 males aged 25–68 years old (M = 34.357, SD = 8.0726).
A cross-sectional research design was used in order the data to be collected. Explanatory Factor Analysis (ΕFA) and more precisely Principal Components Analysis (PCA) was used to examine the instrument’ validity. Confirmatory Factor Analysis (CFA) and SEM of the ADF method was used to evaluate the structure of ATCBRC Inventory. Instrument validity was evaluated by factor loadings, %Variance, and AVE coefficients. The measurement model fits were evaluated × 2/df, CFI, GFI, AGFI, TLI, RMSR, RMSEA, IFI and CD indexes. ATCBRC Inventory’ reliability was measured by Cronbach alpha (α), Test–retest reliability, CR and AVE coefficients.
3.2 Research Instrument
Attitudes toward Cross Border Reproductive Care (ATCBRC) Inventory of four conceptual constructs or latent variables named Legal, Economic, Ethical, and Social Justice. More especially, Legal conceptual construct consists of 8 items (e.g. Leg1: There are risks linked to issues of citizenship and nationality in case of a transnational surrogacy, Leg2: The citizenship and legal status of children resulting from surrogacy arrangements can be problematic, Leg3: There are important issues of children’s right to nationality, especially in cases where the surrogate mother does not share her nationality with the intended parents, Leg4: In commercial surrogacy, the rights of the child are often neglected as the baby becomes a mere commodity in a financial transaction of a good and a service, Leg5: The intended parents should be legally bound to accept custody of the child/children regardless of any abnormality in the child/children, Leg6: It is possible to be a difference between the laws regulating surrogacy in a certain state and how they are actually enforced, Leg7: There is no transparency in the whole system and the possibility of getting involved in legal problems exists due to unpredictable regulations governing surrogacy in different countries, Leg8: Cross-border surrogacy leads to problems of citizenship, nationality, maternity, origin and rights of a child.
Economic conceptual construct consists of 10 items (e.g. Eco1:The cost of infertility treatment is one of the most basic reasons for me in order to seek an assisted reproduction service outside the borders of my country of origin and residence, Eco2: In the case of Cross-Border Reproductive Care, known as CBRC, costs are shifted from the private sector and private clinics to the public health system, Eco3: Those interested who choose CBRC belong to high economic strata and can comfortably but have access to every possibility of assisted reproduction, transparent and opaque, Eco4: Sperm, gamete, egg donors, surrogates belong to low economic, social and educational strata and it is easy for the CBRC industry to exploit them, Eco5: The choice of the surrogate mother does not come from altruistic motives but from extremely economic ones, Eco6: The cost of infertility treatment is one of the main reasons for those interested to seek assisted reproduction services outside the borders of their country of origin and residence, Eco7: A very important economic issue in the CBRC is that the prospective parents involved spend their income, which they earn in the country of residence/origin, in a different country thereby boosting the GDP of the country of destination, Eco8: The cost of care during pregnancy and the cost of birth and care of a newborn is transferred to the country of origin, which is considered a very large financial burden on the public insurance system of the country of origin by the country where the assisted reproduction takes place, Eco9: Countries of origin in the CBRC may refuse to cover such an expense from their insurance funds when the extracorporeal treatment takes place in a foreign state, Eco10: Interested potential parents choose destination countries where ART (Assisted Reproductive Technology) is more affordable, usually third countries, without considering success rates).
Ethical conceptual construct consists of 15 items (Eth1: The ability of a surrogate mother to manage her own body is nullified, Eth2: Τhere is a potential violation of the surrogate mother’s dignity in case she develops feelings for the life she carries, while, simultaneously, not being able to have any rights over it, Eth3: There is a potential postpartum depression that can have great consequences for the surrogate mother, Eth4: There is a potential minimization of fundamental freedoms like autonomy, Eth5: There is a potential minimization of fundamental freedoms like privacy, Eth6: There is a potential minimization of fundamental freedoms like self-determination, Eth7: There is a potential minimization of informed consent of any medical action regarding the surrogate mother, Eth8: Surrogate mothers from countries with a low income easily become victims of instrumentalization, Eth9: Commercial surrogacy commoditizes women’s bodies in a manner akin to prostitution, Eth10: there is a possible violation of the surrogate mother’s dignity, as surrogate mothers are forced to consent to predictive diagnostic tests, Eth11: There is a possible violation of the surrogate mother’s dignity, in case she wants to terminate the pregnancy, as she would do, if she became pregnant by her own choice, Eth12: In case of surrogate mother’s pregnancy termination there are ethical issues related to embryo health, Eth13: In case of a genetic disorder of embryo occurring in a predictive diagnostic tests, pregnancy termination arise ethical issues related to embryo’s life dignity, Eth14: Τhe application of NIPT otherwise non-invasive pre-genetic testing offers the possibility of carrying out diagnostic tests on the fetus from the first stages of its development and at the same time offers the path of DNA analysis where intervention can be done on its genetic material, which causes ethical issues, Eth15: Basic is the ethical dilemma that refers to the selection of suitable eggs or even suitable sperm with the aim of creating embryos during assisted reproduction).
Social Justice consists of 7 items (e.g. SoJ1: surrogate mothers from low and economic backgrounds do not have the possibility of legal support, SoJ2: only wealthy people can possibly hire surrogate mothers, fact that can arise issues regarding social justice, SoJ3: The financial transaction in the case of surrogacy alone entails risks of uncontrolled ethical challenges and protection of human rights of economically and socially vulnerable women, SoJ4: The financial transaction in the case of surrogacy grossly invalidates issues of women’s autonomy and reproductive rights, SoJ5: Intended parents are subject to the same human rights laws and responsibilities as those that bind a biological or adoptive parent, SoJ6: In the case of surrogacy, fundamental rights of children are violated, SoJ7: The financial transaction in the case of surrogacy only entails risks of uncontrollable moral challenges such as in the case of same-sex couples being awarded the right to have a child who may have gender identification problems in the future.
4 Results
ATCBRC Inventory reliability was assessed by the very well coefficient named Cronbach alpha (α). In addition, ATCBRC Inventory reliability was valued by Test–retest reliability coefficient alongside with Composite reliability and AVE coefficients. Coefficient α for ATCBRC Inventory equals to 0.921 that confirms reliability [12,13,14]. Coefficient α for ATCBRC Inventory’ conceptual constructs named Legal, Economic, Ethical, and Social Justice counts for 0.728, 0.847, 0.793 and 0.724 respectively. Composite Reliability or CR for Legal, Economic, Ethical, and Social Justice counts for 0.869, 0.907, 0.883 and 0.853 respectively. The above coefficients values are above the threefold of 0.7 suggesting internal consistency [15]. Average Variance Extracted or ΑVΕ for Legal, Economic, Ethical, and Social Justice counts for 0.488, 0.404, 0.431 and 0.430 correspondingly. The above values are above the threefold of 0.4 suggesting the ATCBRC Inventory reliability. Overall ATCBRC Inventory reliability is confirmed [16]. In addition, the ATCBRC Inventory validity is also confirmed. Eigenvalue, %Variance, Loadings and Communalities are used for validity evaluation. These indices are acceptable and disclosed convergent and construct validity of ATCBRC Inventory [17,18,19,20,21]. CFA and SEM were used to evaluate the structure of ATCBRC Inventory. Nine common model-fit measures were employed to measure the model’ overall fit [22, 23]. The coefficients of the proposed model fit, the model described by ATCBRC Inventory’ conceptual constructs supported the model confirmation (×2/df = 1.76, CFI = 0.96, GFI = 0.94, AGFI = 0.95, TLI = 0.94, SRMR = 0.034, RMSEA = 0.035, IFI = 0.96 and CD = 0.976) [24,25,26]. All the fit indices of the model show a good fit. In particular, for X2, which shows the validity of the model, the observed level of significance is p = 0.07 > 0.05, which means that we have a good fit. The indexes: X2/df < 2 CFI index = 0.96 > 0.95, RMSEA index = 0.035 < 0.05, GFI = 0.94 > 0.90, AGFI index = 0.94 > 0.90, TLI = 0.95 > 0.90, SRMR = 0.034 < 0.05, RMSEA = 0.035 < 0.05 IFI = 0.96 > 0.90 support good fit. The CD = 0.976 > 0.95 index not only supports a good fit but also tends to approach the value 1 which indicates that it tends to approach the ideal fit. Consequently, the measurement model fits well the observed data [27].
5 Discussion and Conclusions
The current study asks for psychometric properties of ATCBRC Inventory in terms of reliability and validity among Greek healthcare professionals association. ΕFA and more precisely PCA, Confirmatory Factor Analysis (CFA) and SEM were used to evaluate the structure of ATCBRC Inventory. SEM validated the model of four conceptual constructs structured of ATCBRC Inventory. Consequently, the ATCBRC Inventory is a conceptualized model structured by four laten variables named Legal, Economic, Ethical, and Social Justice. Test–retest reliability coefficient alongside with Composite reliability and AVE coefficients confirmed ATCBRC Inventory’ reliability. × 2/df, CFI, GFI, AGFI, TLI, SRMR, RMSEA, IFI, CD confirmed ATCBRC Inventory’ validity. Along these lines, ATCBRC Inventory’ is a four structured reliable and valid conceptual model defined by named Legal, Economic, Ethical, and Social Justice conceptual constructs. Besides there was not any statistical difference between males and females regarding Attitudes toward Reproductive Tourism and Cross Border Reproductive Care. In addition, respondents’ specialty did not statistically differentiate Attitudes toward Cross Border Reproductive Care. Still, further research based on Big Data, AI, Cloud Computing and Cloud Analytics regarding Attitudes toward Cross Border Reproductive Care [28,29,30,31]. A picture of Big Data regarding Attitudes toward Cross Border Reproductive Care can be of major importance [32,33,34].
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Anastasiadou, S. (2024). Psychometric Testing Procedures for Attitudes Toward Reproductive Tourism and Cross Border Reproductive Care (ATCBRC). In: Kavoura, A., Borges-Tiago, T., Tiago, F. (eds) Strategic Innovative Marketing and Tourism. ICSIMAT 2023. Springer Proceedings in Business and Economics. Springer, Cham. https://doi.org/10.1007/978-3-031-51038-0_14
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