https://doi.org/10.35845/kmuj.2024.23472 ORIGINAL ARTICLE
Prevalence and factors
associated with anxiety and depression among undergraduate students amid COVID-19:
a mixed-method study
Nadia Noreen 1 
, Rozina
Karamaliani 1, Lubna Ghazal
1,2, Fauzia Basaria Hasnani 1, Syeda Humera 1,
Muhammad Abdullah 1
|
1: School of Nursing and Midwifery, Aga Khan
University, Karachi, Pakistan
2: School of Nursing and Rehabilitation, Shandong
University, China and Director outreach program, Aga Khan University,
Karachi, Pakistan
Email
: nadia.noreen@scholar.aku.edu
Contact #: +92-343-5188124
Date Submitted: September 07, 2023
Date Revised: January 10, 2024
Date Accepted: January 27, 2024
|
|
THIS ARTICLE MAY BE CITED AS: Noreen N,
Karamaliani R, Ghazal L, Hasnani FB, Humera S, Abdullah M. Prevalence
and factors associated with anxiety and depression among undergraduate
nursing students amid COVID-19: a mixed-method study. Khyber Med Univ J
2024;16(1):52-60. https://doi.org/10.35845/kmuj.2024.23472
|
ABSTRACT
OBJECTIVES: To
investigate the prevalence of anxiety and
depression among undergraduate nursing students during the COVID-19 pandemic
and identify associated factors.
METHODS: This study employed a
concurrent mixed methodology, comprising a quantitative analytical
cross-sectional web-based survey and a qualitative descriptive exploratory
study using focus group discussions. The study was conducted at two
university-based schools of nursing, one public and one private, in Karachi,
Pakistan, from May to September 2021, during the third wave of the COVID-19
pandemic. Two questionnaires were employed: The Aga Khan University Anxiety and
Depression Scale and COVID-19 related stressors.
RESULTS: Among the study participants (n=300) 74%,
were female. The 76.3% individuals’ age between 20 to 29 years and 97.3% were
single. The study reported 51% prevalence of anxiety and depression in COVID-19
were associated with females (OR=2.56, 95%CI:1.34-4.88), hostel residents
(OR=1.9, 95%CI:1.02-3.52), final year students (OR=1.36, 95% CI:1.002-1.870),
e-learning (OR=1.74, 95%CI: 1.28-2.37), and those who had COVID-19 academic
apprehensions and transition as future nurses (OR=1.13, 95%CI: 1.0-1.29). The
qualitative analysis highlighted the theme, the realities of students'
academic life amid COVID-19. This theme was emerged from three
categories, lack of preparedness, range of emotions and humble
submissions.
CONCLUSION:
This study revealed a high prevalence (51%) of anxiety and depression among
nursing students during the COVID-19 pandemic, particularly among females,
hostel residents, and final-year students. Qualitative analysis highlighted
challenges in academic adaptation amid COVID-19, revealing themes of lack of
preparedness, a range of emotions, and humble submissions, stressing the need
for targeted interventions and support systems.
KEYWORDS: COVID-19
(MeSH); Anxiety (MeSH); Depression (MeSH); Students, Nursing (MeSH); Pakistan (MeSH).
INTRODUCTION
The global
health crisis sparked by the COVID-19 pandemic has exacerbated existing
challenges in mental health, particularly among vulnerable populations such as
university students. The World Health Organization (WHO) has underscored the
severity of mental health conditions, with an estimated 264 million individuals
affected worldwide, including anxiety and depression.1 The pandemic,
declared by the WHO in March 2020, has intensified these concerns, compelling
individuals into social isolation and triggering a cascade of adverse effects
on psychological, physical, financial, academic, and work-related aspects.2
Research suggests that the pandemic and social distancing significantly
worsened global mental health, leading to increased anxiety and depression
across various pandemic waves.3
University
students, particularly young adults, are highly vulnerable to mental health
issues.4 This vulnerability is attributed to the transitional phase
they undergo, marked by uncertainty and challenges in transitioning to
adulthood and adult learning. A longitudinal study in the USA found that 53% of
undergraduates experienced depression and 49% reported anxiety during the
COVID-19 pandemic.5
Globally,
medical and nursing students have a higher prevalence of anxiety and
depression, with about one in three medical students experiencing these issues.
This is due to the demanding nature of health sciences courses and the high
expectations placed on students for patient care.6 The COVID-19
pandemic has significantly impacted undergraduate health sciences programs,
leading many universities to transition to online learning. However, this shift
was particularly challenging for nursing students, as the curriculum heavily
relies on hands-on experience for developing psycho-motor skills to develop
psycho-motor skills, which online learning cannot adequately provide.6-8
Prior to the
COVID-19 pandemic, studies have reported mental health related issues in
nursing students.9,10 The pandemic has further exacerbated stress
levels among healthcare workers, particularly nurses.11 This period
has also brought to light significant concerns regarding the prevalence and
impact of anxiety and depression among nursing students. Multiple studies have
shed light on these mental health issues, revealing variable findings regarding
their prevalence among nursing students during the pandemic. B,et al.,7
found that 42.8% of nursing students experienced moderate anxiety during the
pandemic. M, et al., documented that 30.5% of nursing students experienced
anxiety symptoms, while 31.1% exhibited depressive symptoms.12 R, et
al., reported a prevalence of 25.7% for depression among healthcare workers
during the pandemic.13 MP, et al., reported higher rates among
nursing students specifically during the COVID-19 lockdown, with 56.4%
experiencing anxiety symptoms and 38.2% showing depressive symptoms.14
In Pakistan,
40% of nursing students were reported to experience anxiety and depression
before the pandemic. 15 However, there has been no research
addressing the prevalence of anxiety and depression among undergraduate nursing
students during the pandemic. It is hypothesized that in developing countries
like Pakistan, nursing students may face an increased risk of anxiety and
depression amid COVID-19 due to cultural, economic, geographical, and
resource-related factors. Furthermore, individuals with these mental disorders
are at a heightened risk of suicide, emphasizing the importance of timely
screening and effective treatment.8 The literature also identified
various stressors experienced by undergraduate nursing students during
e-teaching and learning amid COVID-19, including challenges related to
resources such as the unavailability of personal computers, internet
connectivity issues, and electricity problems.8,15 Additionally,
students faced personal and family-related stressors, such as fear of
contracting COVID-19, social isolation, and economic difficulties.8 Therefore,
nursing students have encountered challenges in virtual learning during the
pandemic, alongside other difficulties. Now that they have returned to
traditional learning after passing through the e-learning phase of the
pandemic, it is crucial to understand the factors contributing to anxiety and
depression among undergraduate nursing students in the local context. This
study aimed to recommend activities and strategies for future pandemics to
promote mental well-being. Thus, the research was designed to determine the
prevalence and factors associated with anxiety and depression among
undergraduate nursing students in public and private nursing schools in
Karachi, Pakistan amid COVID-19.
METHODS
This study employed a concurrent
mixed methodology, comprising a quantitative analytical cross-sectional
web-based survey and a qualitative descriptive exploratory study using Focus
Group Discussions (FGDs). This approach was deemed appropriate for
comprehensively addressing the complexities of the phenomenon under investigation.16
The study was conducted
from May 2021 to September 2021,
in two university-based schools
of nursing, one public and one private in Karachi, Pakistan. Ethical
approval was obtained from the Ethics Review Committees, with reference numbers
2021-5998-17603/AKU and IRB-1971/DUHS at the selected study settings.
The
study population comprised 797 Bachelor of Science in Nursing (BSN) students. Sample
size calculation using OpenEpi indicated that 286 participants, with a 10%
attrition rate, would be sufficient at a 95% confidence level. Using
consecutive sampling, 300 volunteers were enrolled in the study. Proportionate
sampling was employed to recruit undergraduate nursing students, with 197 from
the private university and 103 from the public university, resulting in a total
of 300 participants for the quantitative part of the study. For the qualitative
component, purposive sampling was utilized to recruit 38 participants for four FGDs.
Initially, two virtual FGDs were conducted (one in each public and private
institute), each involving nine participants (n=18), due to limited data
exploration caused by the third wave of COVID-19. Subsequently, two
face-to-face FGDs were conducted (one in each public and private institute),
each involving ten participants (n=20).
Inclusion Criteria
·
All undergraduate nursing students (BScN)
enrolled during the pandemic period who were willing to participate in
the study.
·
Both hostel ites and day scholars were eligible.
Exclusion Criterion
·
Visiting students
(students from other
institutes, not affiliated with the selected study setting).
·
Students enrolled
in diploma in nursing and Post Registered Nursing (PRN) program.
Following
institutional and ERC approval, both quantitative and qualitative data were
collected simultaneously. A Google Docs link containing the consent form and
study questionnaire was distributed to students via email or WhatsApp accounts.
Data collection took place during the third wave of COVID-19, necessitating the
use of an online self-administered questionnaire accessible to volunteer
students.
For
the qualitative component, purposive sampling was employed for the FGDs, and
the date and time were scheduled based on mutual consensus. Regarding the
quantitative aspect, the self-reported questionnaire covered socio-demographic
data (19 items) and stressors related to COVID-19 (12 items), including General Apprehension (GA, 5 items) and Academic Apprehension
(AA, 4 items). Responses were evaluated on a Likert scale ranging from 1 to 5.17 The higher scoring revealed
higher apprehension levels. The Content Validity index of
this tool was 1, the S.CVI 0.8,
and the Cronbach's alpha was 0.89. In addition, anxiety and depression were assessed through another self-reported Aga
Khan University Anxiety Depression Scale (AKUADS) included somatic symptoms
(13items) and psychiatric symptoms (12 items) with a score range of 0 to 3 (never
happens, sometimes, often,
and always happens).
Furthermore, at a cut-
off score of AKUADS >19, the literature verified a sensitivity of
74%, a specificity of 81% and a Cronbach alpha of 0.88.18 The
literature has demonstrated that these two self-reported questionnaires are
valid and reliable tools for the initial screening of anxiety and depression.
Additionally, they are culturally valid for the regional population.17,18
Moreover, a pilot test was done on 10% of the study population. Similarly, for
the qualitative arm, a semi-structured interview guide containing six broad
questions with probes was used for the FGDs also the pilot test conducted. Following
Guba and Lincoln's criteria,16 the researcher assumed the primary
responsibility within the research team for maintaining and ensuring the
study's findings and rigor.
The
data was analyzed in SPSS version 25.0 for continuous variables. Mean and
standard deviation were calculated while frequency and percentages were
recorded for the categorical variables. The confidence interval (CI 95%) and
non-adjusted and adjusted odds ratio (OR) were reported by using univariate and
multivariate logistic regression respectively. Meanwhile, for qualitative data
via the Creswell approach, the content analysis
and coding of the data were done to define the
data. The second-order analysis was done by
constructive reduction of the data in the form of subcategories, and
categories, and the recurrent theme was consolidated.19 Finally, the
concurrent triangulation strategy was used to analyze the study results of both
arms and conclude the findings.
RESULTS
Quantitative Result
As
illustrated in Table I, the majority of participants (n=300) were females
(74%); 76.3% of participants were aged between 20 to 29 years, and 97.3% of the
participants were single. Moreover, 9% reported having suicidal thoughts
sometimes, 2.3% reported
often, and 0.35 % reported
always (finding taken from AKUADS). Of the participants tested for
COVID-19 64.7%; among them, 5.7% screened positive. A small number of students
were tested for COVID-19 because at the time of data collection students were
attending their classes virtually due to unavailability of the vaccination.
Table
I: Sociodemographic and COVID-19 variable of study participants (n=300)
|
Variables
|
Frequency
|
Percentages
|
|
Gender
|
Female
|
222
|
74%
|
|
Male
|
78
|
26%
|
|
Age (years)
|
≤19
|
71
|
23.7%
|
|
20 to 29
|
229
|
76.3%
|
|
Marital Status
|
Single
|
292
|
97.3%
|
|
Married
|
8
|
2.7%
|
|
Geographical Area
|
Sindh
|
153
|
51%
|
|
Gilgit-Baltistan
|
113
|
37.7%
|
|
Khyber Pakhtunkhwa
|
26
|
8.7%
|
|
Punjab
|
8
|
2.7%
|
|
Earning Members
in Family
|
1
|
161
|
53.7%
|
|
2222
|
85
|
28.3%
|
|
≥ 3
|
54
|
18%
|
|
Study Program
|
Bachelor of Science in Nursing
|
300
|
100%
|
|
Nature of Institute
|
Private
|
197
|
65.7%
|
|
Public
|
103
|
34.3%
|
|
Study Year
|
1st year student
|
108
|
36%
|
|
2nd year student
|
99
|
33%
|
|
3rd year student
|
52
|
17.3%
|
|
4th year student
|
41
|
13.7%
|
|
Satisfaction from Studies
|
Satisfied
|
192
|
64%
|
|
Neutral
|
72
|
24%
|
|
Not satisfied
|
36
|
12%
|
|
Family History of
Mental Illness
|
No
|
288
|
96%
|
|
Yes
|
12
|
4%
|
|
Family Suicidal
History
|
No
|
291
|
97%
|
|
Yes
|
9
|
3%
|
|
Last Six Month Major Life Stressors
|
No
|
217
|
72.3%
|
|
Yes
|
74
|
24.7%
|
|
Self-Past Mental
Illness History
|
No
|
293
|
97.7%
|
|
Yes
|
7
|
2.3%
|
|
Sleeping Habits
|
1-3 Hours
|
06
|
2%
|
|
4-6 Hours
|
104
|
34.6%
|
|
>06 Hours
|
190
|
63.3%
|
|
Current Residency
|
Home with parents
|
160
|
53.3%
|
|
Living with relative
|
81
|
27%
|
|
Living in apartment alone
|
43
|
14.3%
|
|
Living in hostels
|
16
|
5.3%
|
|
Financial Assistance System for Study
|
Parents
|
209
|
69.7%
|
|
University FA
|
73
|
24.3%
|
|
Others (relative)
|
18
|
6%
|
|
Leisure Time
Activities
|
Music
|
144
|
48%
|
|
Watching Television
|
58
|
19.3%
|
|
Sleeping
|
60
|
20%
|
|
Playing sports
|
38
|
12.7%
|
|
Smoking Status
|
Yes
|
6
|
2%
|
|
No
|
294
|
98%
|
activities even if we get
100% … we are unsatisfied with our clinical
learning." (University A,
p. 12).
Additionally,
53.6% of the participants had severe anxiety about COVID-19 affecting their
grades in the examination. Likewise, the students reported fear of failing the
virtual assessment. "In online quizzes…. if a student attempted few
questions and his internet connection is lost, it means he fails in that
quiz." (University A, p. 9)
Range of emotions: Most participants felt
mental stress, anxiety, fear, and helplessness when they had to go through
e-learning amid COVID-19. All these
led to students' dissatisfaction with the current studies
(p = 0.04), which is also supported by the quantitative results.
"It
was good that the holidays started …. As online classes started, I was unable
to understand the lectures [helplessness]
anxious about my future, what will happen [fear of incompetency on clinicals]. Repeated
thoughts of uncertainties [delayed graduation] came to
my mind frequently". (University B, p. 7)
Anxiety, fear, and helplessness: In
quantitative data, 51.7% of the students had severe anxiety about their future
nursing profession. Similarly, students reported that during e-learning the lack of valid assessments obstructed their future
practice life. "We
were assessed for only
theoretical component whereas most of us got 4.0 GPA; however, in clinical we
do not know basic nursing skills like we don't know how to insert a cannula how
we will do exemplary patient care" (University B, p. 15).
Moreover,
in quantitative data, 53.7% of the participants had only one earning member in their family. Similarly, in qualitative data "During corona,
my father lost his job… to
purchase data packages for my study…was difficult." (University B, p. 15)
&
The feeling of ambivalence: When e-education was started, most of the students felt happy
at the closure of the university, however, due to scarce resources, students
were not able to understand the e-lectures and they felt frustrated. "In
the beginning, we were excited to continue online education
from home; however,
as time passed due to scarce resources
we got frustrated." (University A, p. 7)
The feeling of inadequacy: Most of the
participants articulated the inadequacy of in-depth learning during
e-learning because they did not get an opportunity to integrate the theoretical
concept into clinical. "I did not want to ke classes, then I left classes;
because a nursing degree needs practical work; online courses are not enough
" (University B, p. 21)
Humble submissions: Students suggested
e-learning system improvement in institution facilities, like physical classes
for theory and practical for their in-depth learning and integration into practice. "Injecting to a patient
is not possible in an online class." (University A, p. 11) Students requested the provision of
e-mental health facilities as well as capacity building for both teachers and
students.
DISCUSSION
An
undergraduate degree in nursing is regarded as one of the most rigorous
programs.20 The current study revealed a high prevalence of anxiety
and depression (51%) among undergraduate nursing students during the COVID-19
pandemic. A study conducted by Rehmani,
N, et al., at a private university (in a similar
setting) before the pandemic, using the AKUADS reported a 40% prevalence
of anxiety and depression among undergraduate nursing students.15
However, the current study, conducted during the third wave of COVID-19, reported a higher prevalence using the
same scale. While during the pandemic a study conducted in Lahore Pakistan
among undergraduate students reported a prevalence of anxiety of (35%) and
depression (45%).21 The population of this study was non-nursing
students, so their psychomotor curriculum is less than the nursing curriculum.
Hence, the prevalence is comparatively lower than the current study results
Another study conducted among Indian medical
undergraduate students reported the prevalence of depression at
35.5% and 33.2% anxiety amid COVID-19; however, this study reported otherwise
when compared to other regional studies because
the nursing degree has a curriculum that contains 60% hands-on experience while medical student’s curriculum contains 45-50%. During
e-learning it was difficult for nursing students to go for direct patient care.17
It is anticipated that 1.5% of mortality is due to suicide
among young adults, the fourth leading cause of death.19 Similarly, the current study reported that 11.6% of undergraduate
nursing students had suicidal
ideation history. This finding is aligned with the study which reported 1.57 OR
of suicidal thoughts among undergraduate students.22 Therefore, it
is proposed to introduce e- mental health services along with physical services
as mandatory because nursing school platforms were not prepared for e-mental
health services during this pandemic. As per the demand of the digital era and
to overcome the huge prevalence of mental health issues at the nursing
institutional level, mental health services are an obligatory part of the
system. Moreover, further studies are recommended after the implementation of
the current study findings, and future researchers could use a tool that can measure
anxiety and depression as an independent domain.
In
the current study, 40.7% of female and 10.3% of male students were screened
positive for anxiety and depression amid COVID-19. Consistent results are found in local and international studies.4,7,21,23
The researcher believes that significantly high odds of anxiety and depression among females possibly can
be the stereotypical belief that females are more negative emotional
respondents towards unpleasant experiences compared to males.24 While minimal prefrontal action in
stressful conditions enables greater efficiency in regulating negative emotions
in males.24
A less reported and novel associated factor in this study is that the final year was
significantly associated with anxiety and depression among undergraduate
nursing students. These results are contrary to some studies.17,23
The qualitative analysis revealed that final- year students felt their capstone
theoretical and clinical courses were not well covered while e-learning amid COVID-19.
Hence, they develop feelings of fear to become incompetent professionals. While
junior-year students were less anxious about their studies and becoming
incompetent professionals because they have time in academia to compensate for
their theoretical and clinical loss.
It
was found that hostel resident students were significantly associated with
anxiety and depression; these results were consistent with other studies.20,25
The association between hostel residence and anxiety as well as depression can be explained by several factors.
During the first year of study, adjusting to residence away from home, it was
difficult for the freshmen to interact with the new environment and people;
socializing and homesickness were the other factors. Moreover, during the pandemic, the unemployment of
family breadwinners also contributes to hostel residents' mental well-being.
Pandemic
COVID-19 and its unprecedented measures, like the rapid transition from
traditional face-to-face to e-learning, increased students' apprehensions as
evidenced by the high prevalence in the current study. The students were not satisfied with e-learning because
of the lack of preparedness of parents,
teachers, students, and institutions.
The family
plays a vital role in mental wellbeing, if the parenting
role is flawed,
then it negatively impacts adult mental health.26 In this regard a novel finding highlighted
by participants about the issue of authoritarian parenting
style, parents felt that
during e-learning students stick to
their laptops and phones which is highly discouraged and disliked by Pakistani
families; therefore, awareness-raising sessions are proposed to enhance
understanding of parents about e-learning support at home.
In
addition, internet connection unavailability
in remote areas of Pakistan, internet instability in the
urban areas, hurdles in handling electronic gadgets, an amorphous environment
at home, electricity, and the financial burden to buy data and internet
services were challenging.27 Moreover, jobs loss of earning members
in the family and students paying their
institutional hostel fees, and transport fees even though they were living in
the home during the pandemic
lockdown were some issues. All these were major challenges for nursing students
during e-learning.4,5
Furthermore,
amid COVID-19, e-learning had a limitation on student-centered learning,
because of lack of supervision of teachers, lack of entertainment of questions,
and lack of valid assessments, compared to traditional teaching. Because of
these challenges, students preferred face-to-face learning instead of
e-learning. Similarly, analysis of student transcripts showed that during
the pandemic, their sleep time further increased because they did not need to wake up to travel to the university;
they could take classes while in bed; and
they could even sleep during class because there was a no monitoring system and
lack of active involvement of the students in the studies.28
Likewise,
the e-learning was quite tedious that it had a lot of physical health issues
such as headaches, eyesight, and hearing issues due to increased screen time
and headphones.4,29,30 To replace
real-time skill-based and clinical learning during the pandemic
educators use different virtual activities such as cyber patient, online
simulation, videos, and multiple assignments. However, these
all strategies were found not alternatives to hands-on experience at a clinical
site in real-life settings.27 Therefore, it is proposed that the existing
educational policies need to be reviewed to overcome the feeling of inadequacy in education. There could be a hybrid education system at the national level and accessibility of the internet and electricity to move toward
the digital world. The nursing institute could struggle for gradual improvement
of infrastructure, and capacity-building training for teachers and students for
e-learning. Moreover, the institutes could use them as alternatives for
clinical during the pandemic, but the hands-on experience can be encouraged by
the utilization of a maximum skill lab and small groups at a clinical site with
proper SOPs.
The
lack of teacher preparation to handle e-learning was a major contributor to
students being dissatisfied with their studies. Moreover, the students thought
that teacher facilitation and supervision were necessary for their active
learning.4,29 Students at the undergraduate level have not developed
enough adult learning skills; they still need to be observed during class for
their learning. These findings are in contrast with Saraswathi study.17,30
However, the possible explanation for the variation of anxiety and depression
related to academic apprehension amid COVID-19; are differences in the level of
development of virtual education systems,
economic constraints, and differences in terms of accessibility and availability of
resources.
In
the national context, it was the first time that online teaching and learning
was being conducted, the Higher Education Commission approved the guidelines
for the online system. However, the nursing institutes in the national context
had deficiencies in planning and teaching psychomotor skills and e-assessments
through virtual mode. Educational policymakers can make necessary changes to
develop efficient e-platform at nursing educational institutes. Furthermore, the institutions lacked
COVID-19 screening planning;
if one student became positive for COVID-19, the whole class was
supposed to go for screening; which also increased the economic burden and
contribute to students' stressors.
There is a need for a strategic plan for screening
to overcome the financial burden at the institutional level. Especially as the
e- learning capacity building in nursing institutes where's 60% curriculum
based on psychomotor skills. Instead
of online skills
learning, there can be the use of proper SOPs in a clinical setting for the adequacy of
learning in future pandemics.
CONCLUSION
The
current study reported a high prevalence of anxiety and depression among
undergraduate nursing students; with
significant factors including being female, in the final year of study, and
residing in hostels. The rapid shift from traditional teaching to e-learning
and transition as future nurses with
limited hands on practice due to the COVID-19 pandemic was also identified as a
contributing factor to increased psychological distress. To overcome
these issues in future pandemics, there is a need to develop strategies to
overcome these at institutional, teacher, parent,
and student levels.
The study reported
only 2.3% of the students sought mental rehabilitation
services. This has significant implications for mental health promotion and
mental health issue prevention among undergraduate nursing students.
STRENGTHS AND LIMITATIONS
The researcher was involved in
all FGDs to explore and understand the student stressors amid COVID-19. The researcher's observation and participant's participation were limited to
online FGDs; then, physical FGDs were conducted.
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AUTHORS' CONTRIBUTIONS
Following
author have made substantial contributions to the manuscript as under:
NN, RK & MA: Concept and study design, acquisition of
data, drafting the manuscript, critical review, approval of the final version
to be published
LG, FBH & SH: Acquisition, analysis and interpretation
of data, drafting the manuscript, approval of the final version to be
published
Author
agree to be accountable for all aspects of the work in ensuring that
questions related to the accuracy or integrity of any part of the work are
appropriately investigated and resolved.
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CONFLICT OF INTEREST
Authors declared no conflict of interest, whether
financial or otherwise, that could influence the integrity, objectivity, or
validity of their research work.
GRANT SUPPORT AND FINANCIAL DISCLOSURE
Authors declared no specific grant for this research
from any funding agency in the public, commercial or non-profit sectors
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DATA SHARING STATEMENT
The data that support
the findings of this study are available from the corresponding author upon
reasonable request
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 This is an Open Access article distributed under the
terms of the Creative Commons Attribution-Non-Commercial 2.0 Generic License.
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