|Ahead of print publication
Psychosocial well-being and quality of life in women with breast cancer in foothills of North India
Rajesh Kumar1, Rajesh Pasricha2, Manoj Kumar Gupta2, Bina Ravi3
1 Department of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Radiation Oncology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
3 Department of Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
|Date of Submission||25-Apr-2021|
|Date of Acceptance||29-Oct-2021|
|Date of Web Publication||03-May-2022|
College of Nursing, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
Source of Support: None, Conflict of Interest: None
Introduction: Breast cancer remains a leading cause of unintended death among Indian women. Cancer treatment-induced pain, fatigue, nausea/vomiting, body image, and sexual problems could affect the patient psychosocial well-being and quality of life (QOL). The study aims to determine the QOL and psychosocial well-being among women with breast cancer.
Materials and Methods: A cross-sectional survey completed by 244 women with breast cancer at a tertiary level teaching hospital. The European Organisation for Research and Treatment of Cancer QOL Questionnaire C30, the Breast Module (QLQ-BR23), and the Hospital Anxiety and Depression Scale (HADS) is used to measure the QOL, and psychological well-being, respectively. Appropriate descriptive and inferential statistics are applied to compute the results.
Results: The total number of women with breast cancer interviewed was 244, with a mean age of 45.06 (standard deviation ± 11.17) years. The mean global health score was 70.97 ± 15.63. As per the QLQ-C30 scale, “physical functioning” scored the highest (70.54 ± 22.00), and “role functioning” reported the lowest (49.45 ± 36.15) mean score. Further, on the QLQ-C30 symptoms scale, “appetite loss” (45.09 ± 35.09) was the worst reported symptom, followed by “nausea and vomiting” (34.97 ± 38.39). On the BR-23 scale, body image said (68.42 ± 22.28) higher score than other domains and experience of arm-related problems (43.80 ± 26.06) were more frequently reported symptom in women. As per the HADS scale, 24.6% and 36.1% of women were in moderate anxiety and depression, respectively. The mean HADS score was 14.39 ± 5.82. Findings on predictors for the individual patient remained the same as that earlier published literature.
Conclusions and Recommendations: Women with breast cancer have an overall good QOL and poor psychosocial well-being. However, using a holistic approach, including identifying psychological problems and their time management, signifies the need for the studied population.
Keywords: Anxiety, breast, cancer, depression, psychosocial well-being, quality of life
| > Introduction|| |
Breast cancer is reported as one of the most prevalent cancers in women. The rising new cases of breast cancer are alarming worldwide. In cancer statistics 2020, 7738 new breast cancer cases were reported with a prevalence of 57–135/10,000 and mortality of 4–5 lakh/year. Breast cancer cases need different treatment approaches based on the stage, tumor size, and other features of cancer. Chemotherapy, radiotherapy, and primary or end surgery are common treatment styles recommended for a breast cancer patient. However, chemotherapy is one of the commonly practiced treatment modalities to prevent reoccurrence after primary surgery. Apart from different treatment modalities, patients with breast cancer experience multiple stressors. Being diagnosed with breast cancer is one of the most traumatic and distressful moments for a patient. Further, the long-term impact of chemotherapy equally makes life miserable. Chemotherapy is not limited to drug administration only. Still, it is accompanied by repeated hospitalization and an endless number of side effects including weakness, nausea, vomiting, and alopecia (chemotherapy-induced hair loss).
Chemotherapy-induced alopecia can be incredibly distressing to patients, with an adverse impression on physical, psychological, emotional, and global life quality., Similarly, patients with breast cancer undergoing radiotherapy, palliative treatment, and irrepressible pain reported a higher episode of psychiatric illness, adjustment disorders, anxiety, and depression.,,,
Quality of life (QOL) is very frequently and important research component in health care, especially oncological research. It is subjective and multidimensional concept focus on evaluation of life as a whole including appraisal and satisfaction status of the patients. QOL construct encompassing perception of both positive and negative aspects related to physical, social, emotional, and cognitive functions of an individual. Cancer has detrimental effects on different aspects of QOL and as a whole and at present time, cancer problems are in alarming in India and around the globe.
A few instruments are specifically developed to measure the concept of QOL in patients with breast cancer. These include the Functional Assessment of Cancer Therapy-B Questionnaire, The Breast Cancer Chemotherapy Questionnaire, and the European Organization for Research and Treatment of cancer core Questionnaire and breast module (EORTC-BR 3). The European Organization for Research and Treatment of cancer core Questionnaire and breast module is validated and translated in multiple language to use around the globe and most preferred questionnaire. This questionnaire could be used at different stages and in patients on different treatment modalities.
Psychosocial well-being is a broad term cover negative reflections of the QOL related to psychological morbidity such as anxiety, depression, life satisfaction, self-esteem, morale, emotional distress, and sense of coherence. Previous studies used different types of questionnaires to measure psychosocial well-being including, Hospital Anxiety and Depression Scale (HADS), the Center for Epidemiology Studies Depression Scale, State Trait Anxiety Inventory.
Further, it has been noticed that psychosocial disturbances and QOL run parallel to each other's in cancer patients. Some studies reported that cancer at a young age is more distressing and leads to poor global QOL, higher anxiety, and depression leads to a higher suicide rate., Similarly, it has been reported that young age cancer diagnosis has a detrimental impact on life, financial affairs, bodily pain, and worse sexual life.
Cancer-induced stress intensifies the feelings of nausea, vomiting, poor sleep, and pain and adversely impacts the global QOL.,, Despite advancements in screening and cancer treatment modalities in breast cancer, it remains a disease linked to fear, helplessness, anxiety, pain, and higher death events.,,,
Therefore, we planned this study to measure the QOL and psychosocial well-being among women with breast cancer visiting tertiary care teaching hospitals in the foothills of North India.
| > Materials and Methods|| |
A cross-sectional survey was planned and completed between March 2018 and December 2019 at one of the Apex Tertiary Public Health Care Centre, North India. A purposive consecutive sampling technique was adopted for recruiting women with breast cancer at the radiotherapy outpatient department. Patients with breast cancer between 18 and 65 years and able to communicate in the Hindi language were included in the study. Women with existing comorbid conditions, i.e., heart disease, liver problems, substance abuse, history of psychosis, dementia, history of diagnosis and had treatment for suicide, or any other treatment for chronic illness such as tuberculosis, psychiatric disease, any other cancer, for a minimum of 6 months, and refuse to provide consent for participation, were excluded from the study. Information on the interest of variables was sought using a structured sociodemographic and clinical datasheet, the HADS, the European Organisation for Research and Treatment of Cancer QOL Questionnaire (EORTC-QLQ-C30), and the Breast Module (EORTC-QLO-BR23) for psychosocial well-being and QOL in breast cancer, respectively. This survey was restricted to a single and baseline observation of the QOL and psychosocial well-being in the population.
Institutional Ethical Committee approved the study (07/IEC/IM/NF/2018). Women were informed about the study objectives and duration of involvement at the time of data collection.
Sampling and recruitment
This is a descriptive cross-sectional study. Based on the population attending the outpatient department of radiation oncology, 500 women with breast cancer were included in the study. However, only 244 women with breast cancer responded (response rate = 48.8%) to questionnaires during follow-up and provided consent to participate in the study. A convenience sampling was used to administered questionnaires to the women after obtaining their approval in writing.
Sociodemographic and clinical profile sheet
It includes information on age, occupation, marital status, family monthly income (INR), habitat, menopause, types, duration, and forms of tobacco use, night sweat, family history of carcinoma, history of hypertension, diabetes mellitus, the extent of disease, therapy-related adverse effects, carcinoma histopathology, and financial problems, social problems, and psychological counseling after a cancer diagnosis. The structured information sheet sought validation of experts in radiotherapy, nursing, and psychology.
The hospital anxiety and depression scale
The self-administered Hindi version of the HADS questionnaire is used to screen out women with breast cancer for anxiety and depression. The 14-item scale measures anxiety and depression, with seven items each. Women were asked to rate each item on a four-point rating scale (not at all to most of the time ). Each subscale's total score was calculated by summing responses at the end, with higher scores indicating higher anxiety or depression and vice-versa. The overall score is categorized into three categories: noncase (0–7), mild (8–10), moderate (15–21), and severe (11–21). The scale demonstrated higher specificity and sensitivity (0.75 and 0.89) to the anxiety subscale and 0.88 and 0.80 to the depression subscale, respectively. The scale showed excellent reliability in women with breast cancer and was widely used for a similar patient in earlier studies., The The use of Hindi version of this questionnaire has been validated for use in hospitalized patients.
The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 and the Breast Module (QLQ-BR23)
The EORTC QLQ-C30 and the Breast Module for Breast Cancer patients have been widely used to assess the QOL, symptoms, and psychosocial well-being. The EORTC QLQ-C30 is a self-administered questionnaire developed to cover the multidimensional concept of health-related QOL in cancer patients. It is a 30-item questionnaire, which aggregates five functional scales (emotional, physical, role, social, and cognitive functioning), three symptoms scales (pain, nausea/vomiting, and fatigue), and one global health/QL scale, and six single items to measure financial impacts and other related symptoms of cancer. An individual has to respond to each item on a four-point rating scale: 1 (not at all) to 4 (very much) and two items for global health and QOL on a 7-point rating scale; 1 (very poor) to 7 (excellent). QLQ-C30 manual scoring system was used to transform raw scores into a 0–100 scale. A high score on the symptoms scale indicates worse symptoms and vice versa. A high score on the global health/QL scale suggests a high level of QOL.
QLQ-BR23 is a 23-item questionnaire that includes four functional scales (future prospects, sexual function, sexual enjoyment, and body image disturbances) and four symptoms scale (of the affected breast and arm, adverse effects of systematic therapies, and alopecia). An individual has to respond for each item on a four-point rating scale; 1 (not at all) to 4 (very much). A high score on the functional scale indicates better functioning, and a higher score on the symptoms scale indicates worsening of the symptoms. So far, the EORTC-QLQ-C30 and BR23 have been translated and available to use in more than sixty languages and show excellent validity and reliability for a similar population. The translated version, including the Hindi version, has been validated.
All statistical analyses were carried out using IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp. The data distribution was analyzed, and appropriate statistical tests were applied. General and clinical characteristics were described using frequency and percentage and descriptive statistics. The mean and standard deviation were computed for EORTC-QLQ-C30 and QLQ-BR-23 as appropriate to the data distribution. The influence of sociodemographic and clinical characteristics on QOL was calculated using stepwise selection linear regression analysis. Two-tailed significance tests were used, and P < 0.05 was considered for all statistical significance.
| > Results|| |
Two hundred and forty-four women completed the questionnaires with a response rate of 48.8%. Of the study women, 99.2% were married and never attended (39.3%) school for formal education, followed by a handful of women (8.2%) who had a college education. Regarding occupation and monthly income of study women, 97.5% of women were living with family, homemakers (78.7%), and reported monthly income of <10,000 INR (73%). The findings are summarized in [Table 1].
|Table 1: Sociodemographic and clinical profile of women with breast cancer (n=244)|
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In terms of the medical history of the women, around half (46.7%) reached menopause, currently using tobacco (10.7%), and had a history of using smokeless tobacco products (97.5%). Surprisingly, a significant number of women (50%) reported a family history of carcinoma, followed by diabetes mellitus (10.7%) and hypertension (10.7%) at the time of breast carcinoma diagnosis. However, there is no treatment history revealed for diabetes and hypertension in women.
Findings on clinical indicators revealed that 91% of women had ductal carcinoma with a tumor size of ≤2 cm (71.3%). Of the women, 50% were in the local stage of cancer development, whereas 34.4% were in the regional stage, and the remaining 15.6% were in the distal stage. About the surgical intervention, 74.6% of women had undergone mastectomy and lumpectomy (18.9%). A large number of women were exclusively on cancer treatment (96.7%), and the remaining 3.3% were taking alternative medicine along with cancer treatment. With symptoms and side effects of cancer treatment, 74.6% of women had reported cancer therapy-related adverse effects; 27.9% of women had complained of night sweet, and 54.9% had numbness. Only a handful of women (2.45%) attended psychological counseling after the diagnosis of cancer. The percentage of women who faced financial difficulties was 66.4%. Social problem was encountered in 13.1% of the women.
Quality of life in women with breast cancer
[Figure 1] represents a 95% confidence interval and means score for the QLQ-C30 and QLQ-BR23. It presents the proportion of women with breast cancer who scored <33.3% and more than 66.7%. A score below and above the given range represent the poor and good QOL, respectively. However, this interpretation of the score is reverse for symptoms in the patient. The global QOL score on QLQ-C30 was 70.97 ± 15.63 [Table 2]. However, none of the women scored <33.3%, which indicates a good QOL on QLQ-C30. Moreover, 46.7% reported a mean score of global QOL on QLQ-C30 was more than 66.7% [Table 3].
|Figure 1: Ninety five percent confidence interval for the mean of quality of life measures|
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|Table 3: Descriptive statistics on Quality of life Questionnaire-C30 and Breast Module-23 scales (n=244)|
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On the functional subscale, women reported the highest mean scores on “physical functioning” (70.54 ± 22.0) and the lowest mean scores on “role functioning” (49.45 ± 36.15). On QLQ-BR23, “sexual functioning” reported worst (60.37 ± 24.22) affected domain of functional scale, followed by “future prospects” (65.29 ± 28.49) and sexual enjoyment (66.93 ± 24.75). However, women's perception of “body image” was healthier (68.42 ± 22.28) than the subscales of the functional scale. Further, on the symptoms scale of QLQ-C30, “appetite loss” (45.09 ± 35.09) reported the highest mean score, whereas “diarrhea” was the lowest reported symptoms among breast cancer patients (10.65 ± 21.91) [Table 2].
Analysis of the QLQ-C30 by clinical variables of women revealed that there is a statistically significant difference in physical functioning (P = 0.007) and emotional functioning (P = 0.008) between women who undergo lumpectomy than those who experienced a total mastectomy. Similarly, it has been seen that women who underwent a mastectomy reported significantly more pain (P = 0.001), insomnia (P = 0.006), constipation (P = 0.004), and diarrhea (P = 0.012) than those patients who undergone lumpectomy [Supplementary Table 1].
Further, findings revealed that there was a statistically significant difference in the emotional functioning (P = 0.012) and social functioning (P = 0.001) in the women diagnosed for the regional stage of cancer and in those who were in the local stage. Further analyses of the QLQ-C30 showed significantly more pain in women who were in the regional stage on fatigue (P ≤ 0.021), pain (P = 0.021) and dyspnea (P = 0.006) than those who were in the local stage of cancer [Supplementary Table 2].
In terms of the size of the tumor, there is significantly less problem of insomnia (P < 0.001) in women who had tumor size >2 cm than those who had tumor size <2 cm [Supplementary Table 3]. Further, analysis shows statistically fewer problems in women who had attended psychological counseling after cancer diagnosis on managing diarrhoeal symptoms (P = 0.010) and financial difficulties (P = 0.017) than those who had not. Similarly, there was a statistically better global health score (P = 0.001) in patients who had attended psychological counseling after cancer diagnosis and those who had not [Supplementary Table 4]. These findings have a positive effect on psychological counseling in women with breast cancer in our study.
Psychosocial well-being status
The mean score for the HADS scale was 14.39 ± 5.82 in our population. Of the women, 39.3% and 15.6% had mild symptoms of depression and anxiety, respectively. Further, 36.1% and 24.6% of women have reported moderate depression and anxiety symptoms, respectively. However, none of the women had symptoms of severe depression, while only 0.8% had symptoms of severe anxiety [Table 4]. Coefficient correlation is used to see the effect of symptoms on the psychosocial status. Findings revealed a significant relationship of the HADS score with role functioning (P = 0.001), social functioning (P = 0.020), emotional functioning (P = 0.003), and appetite loss (P = 0.001) domains of the QLQ-C30 scale in this population [Supplementary Table 2]b. However, there is no significant relationship observed between HADS and domains of the QLQ-BR23 scale.
|Table 4: Descriptive statistics of hospital anxiety-depression scale (n=244)|
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Predictors of the quality of life scores
The stepwise selection method was applied to find the predictors of the QOL scores with alpha-to-enter of 0.05 and alpha-to-remove of 0.1. [Table 5] shows the findings on symptoms score of the QLQ-BR23. Results on the predictors to global and functional scores are shown in [Table 6] and [Table 7]. Four predictors were selected for global health scores using the stepwise method: counseling after the cancer diagnosis, current tobacco use, financial difficulties, and the HADS scores. These predictors together explain about 12% of the variance in global health (R2 = 0.116). Similarly, it has been noticed that the HADS score was a significant predictor for body image, sexual functioning, sexual enjoyment, systematic therapy side effects, and upset by hair loss domains of the QLQ-BR23 symptoms scale. Other predictors of QLQ-BR23 are summarized in [Table 5].
|Table 5: The estimated regression coefficient for Quality of life Questionnaire-Breast Module 23 Scores* (n=244)|
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|Table 6: The estimated regression coefficients for global and functional of Quality of life Questionnaire-C30 Scores* (n=244)|
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|Table 7: The estimated regression coefficient for symptoms of Quality of life Questionnaire-C30 Scores* (n=244)|
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| > Discussion|| |
This study was conducted to measure the QOL and psychosocial well-being in women with breast cancer. All of the women in the study reported a good QOL. The score on global QOL was found in concurrence with the existing studies conducted on Bahrain and German women with breast cancer., Conversely, literature from Arb, Denmark, and the UK and sister study or two sister study reported a lower score on the global QOL scale. The higher QOL may be because of access to psychosocial support programs and psychological screening and consultations for patients diagnosed with breast cancer. However, variations in women's QOL with breast cancer in different countries warrant further investigations.
Role functioning was reported as the lowest score on the functional domain of QLQ-C30. Surprisingly, none of the women reported any problem in role functioning. This score is steady with the earlier work conducted on breast cancer patients in Bahrain and Kuwait. However, this score was slightly higher in German women with breast cancer and the United Kingdom Start trial. The physical functioning score was slightly higher than the Jordan study and slightly lower than the Bahrain study. Variations in the findings need further research to reach a specific conclusion for QOL in North Indian women with breast cancer.
The mean age of women with breast cancer was 45.06 ± 11.17. This reflects breast cancer cases in a younger population in contrast to studies conducted in Jordan and Bahrain women with breast cancer. Cancer is alarming at a young age and needs to devise a specific preventive strategy to curb the problem in the initial stage.
Further, the fatigue score was worst on the QLQ-C30 scale, with 6.6% of women falling in the category of more than 66.67% and 54.1% were below 33.3%. This score was closely similar to pain (8.2%) and constipation (13.9%) in the population. These findings are in uniformity with the studies conducted on breast cancer patients in Bahrain, Jordan, and in the United Kingdom. Furthermore, fatigue found an accurate predictor of psychological impairments, enhancing depression and anxiety., Similarly, in a systematic review, fatigue is pointed out as a significant risk factor (6/9 studies, 67%) for distress among women with breast carcinoma. Similar findings are also reported in an earlier work reported fatigue as a most frequent reported predictor for depression. Earlier studies on breast cancer found that up to 99% of women suffer some sort of fatigue during cancer treatment and more than 60% experienced severe fatigue and reported one of the predictors for psychological well-being.,
The psychological effect of chemotherapy-related alopecia on body image is well documented in the literature. On the QLQ-BR23 symptoms scale, disturbance in body image was less reported than sexual dysfunction, sexual enjoyment, and future perspective. Similarly, this score is found better in previously conducted work on women with breast cancer., In Indian culture, a joint family structure and a secure social network could be a possible reason behind decent body image perception. However, it is also a matter of research to explore the impact of family and social support or psychological counseling on the perception of body image among women with breast cancer.
Systematic side effects show the lowest score on the QLQ-BR23 scale, with 78% of women falling below 33.3% and 6.6% were above 66.67%. Earlier studies from Bahrein, Malaysia, and the United Kingdom on patients with breast cancer found in agreement for the systematic side effects of the cancer treatment and its subsequent impact on the QOL and psychosocial well-being.
Other findings in predictors of individual scores remain the same as earlier published literature such as current tobacco use, employment status, education level, financial difficulties, type of surgery, and disease extent.,,,
The present study reported 24.6% of patients' in moderate anxiety, whereas 0.8% reported severe anxiety. Similarly, 39.3% and 36.1% had symptoms of mild and moderate symptoms of depression, respectively. A study on breast cancer in Jordan reported that 53% of women had mild to severe anxiety, and 14% had severe anxiety, whereas 45% of patients had mild-to-moderate depression and severe depression (18%) in a similar population. Similarly, findings reported from earlier work reported mild depression (19.9%), and 29.1% had mild anxiety. A similar close finding reported in earlier work reported moderate-to-severe depression (22%) and reduced QOL in women with breast cancer. An earlier study also reported similar findings for higher stress in breast cancer patients. However, it is surprising to note that most women were unaware of their anxiety and depression status. This may be presumed because of a lack of established screening services for psychological problems and psychological support programs to protect the mental health of cancer patients. These findings reflect the need for psychological counseling and psychoeducation programs for women with breast cancer.
Regarding the impact of symptoms, as identified by QLQ-C30 and BR-23, body image, sexual dysfunction, upset by hair loss, cognitive functions, pain, sleep problems, and role functioning score predicted psychological well-being in cancer patients. It can be interpreted that these factors play a direct role in influencing the QOL and psychosocial well-being among patients with breast cancer. Unmanaged distress has been negatively related to compromised QOL and cancer-related morbidity and mortality and needs attention for distress screening in the initial days of treatment and potential necessary treatment.
Further, findings represent pain as an accurate predictor for psychological well-being in breast cancer patients. Earlier work also reported pain as a predictor for psychosocial well-being in women with breast cancer., Similar findings for a predictor of anxiety and depression were also reported in work., Clinicians should take a message from these findings to control the pain by appropriate drug prescriptions in cancer patients to improvise the QOL.
About psychological counseling after a cancer diagnosis, only 2.45% of women with breast cancer attended psychological counseling, faced social problems (13.1%), and had income <10,000 rupees/month (73%). Further, findings reported that 39.3% of women had informal education, and only 2.5% had regular income sources. Consistent results reported for monthly family income and facing social embarrassment in dealing with the odds related to disease in a similar population. A similar trend for availing counseling services in patients with breast cancer is observed in existing literature where only a small proportion (12.3%) of the women attended services Conversely, the use of rehabilitation services (57%) and access to psychological support services (24%) were more in a similar population. These findings reflect a lack of established counseling services and psychoeducation about mental health to the vulnerable group and draw the attention of policymakers to develop rehabilitation and psychological support services in the country. Lack of formal existence of these services may be considered a cause of poor psychosocial well-being in women with breast cancer compared to developed countries.
| > Conclusions|| |
The study findings highlighted a good QOL in women with breast cancer as compared to those existing studies. However, more than half of the patients reported mild-to-moderate anxiety and depression, indicating a need for urgent psychological help or support. The study recommends a severe need for counseling or support services for breast cancer patients. A liaison with psychiatric services signifies holistic care for breast cancer patients for early screening, diagnosis, and management of the psychological problem and better QOL.
The present study should be appraised under many limitations. First, the study is a one-time cross-sectional in nature and, therefore, failed to get information on patients' follow-ups. Second, the sample is the women who attended OPD for chemotherapy and radiotherapy services, which may not be the dedicated representative of all breast cancer patients. Third, the lack of established psychological counseling services for the cancer population in the Indian health-care system may infuse bias in the study findings and advise to use findings cautiously in another setting. Fourth, the authors used a time-bound approach to recruit samples without sample size analysis, which may restrict the generalizability of the findings. Still, findings give vital insight to oncologists and other health-care professionals treating women with breast cancer to refer them for psychological management. However, others should be cautious while interpreting the findings of this study.
Authors would like to acknowledge Mr. Arun Varghese and Ms. Neetu Kataria for helping in the initial data collection and analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]