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\def\RunningAuthor{Lipilekha Patnaik}
\firstPage{5134}
\articleType{Original Article}
\receivedDate{31 May 2020}
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\title{\textbf{Assessment of Knowledge, Attitude and Practices towards menopause among postmenopausal women - A Cross-sectional study in an urban slum of Eastern India}}
\author{Saswatika~Beura\textsuperscript{1},  
            Lipilekha~Patnaik\textsuperscript{*}\textsuperscript{1},  
            Manisha~Sahoo\textsuperscript{2},  
            Sumitra~Pattanaik\textsuperscript{1}, 
            Trilochan~Sahu\textsuperscript{1}~\\[5pt]{\textsuperscript{1}Department of Community Medicine, Institute of Medical Sciences \& SUM Hospital Siksha `O' Anusandhan deemed to be University, Bhubaneswar, Khordha, Odisha - 751003, India}~\\{\textsuperscript{2}Department of Obstetrics and Gynaecology, Institute of Medical Sciences \& SUM Hospital, Siksha `O' Anusandhan deemed to be University, Bhubaneswar, Khordha, Odisha - 751003, India}}

\begin{abstract}
Majority women attain menopause without having adequate knowledge and approaches to cope with the menopausal changes. So, they face many physical and psychological disorders during their menopause. Awareness, positive attitude and healthy practice towards menopause can help women to reduce their menopausal symptoms. Women who are had menopause more than 12 months were included in the study. In this study, 80.8\% women had poor knowledge and 73.1\% women having positive attitude towards menopause. But none of the participants reported healthy practices in their menopause. 44.2\% women had knowledge that postmenopausal bleeding was abnormal, 36.5\% women said that menopause is associated with many chronic diseases and 32.7\% said that menstruation does not stop suddenly at the time of menopause. In our study 90.4\% of participants positively accepted their menopause. Knowledge score was significantly associated with age and education. The perceived poor knowledge and practice towards menopause require more efforts for creating mass awareness about this issue.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}KAP study,\newline Menopausal symptoms,\newline Climacteric stage
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Lipilekha~Patnaik~\\ Phone:\ ~\\  Email:\ drlipilekha@yahoo.co.in
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
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\section{Introduction}
Menopause is permanent stop of regular menstruation and an end of a woman's reproductive life. Menopausal period is divided into three phases like Pre, peri and post menopause. This is also known as the climacteric stage of women's life\textbf{\space }\unskip~\citep{849453:19982022}. According to World Health Organization (WHO), the ratio of postmenopausal women in industrialized and developing countries will be 24\% and 76\%, respectively and by 2030 the total number of postmenopausal women will reach 1.2 billion \unskip~\citep{849453:19982037}.

Each and every women's experience towards menopause are different and many of them are unaware about the menopausal symptoms and health complications related to menopausal symptoms\unskip~\citep{849453:19982020}. Physical, psychological, vasomotor and sexual dysfunction are the major symptoms in this stage \unskip~\citep{849453:19982031}. Majority women attain menopause without having adequate knowledge and approaches to cope with the menopausal changes\unskip~\citep{849453:19982036}. Menopausal women can take appropriate steps by early identification of menopausal symptoms, which will enhance their postmenopausal quality of life \unskip~\citep{849453:19982025}.\ensuremath{^{\textbf{\space }}}Findings of numerous studies said that awareness, positive attitude and healthy practices towards menopause can help women to reduce their menopausal symptoms\unskip~\citep{849453:19982039},\unskip~\citep{849453:19982023}. In India the population of menopausal women are increasing \unskip~\citep{849453:19982021}, but there is no current health policy regarding menopausal health \unskip~\citep{849453:19982028}.

Due to lack awareness about menopause among slum women, they ignore menopausal symptoms and suffer silently. Studies suggest that awareness among menopausal women, will reduce their discomfort and fear of menopausal problems \unskip~\citep{849453:19982021}.\ensuremath{^{\textbf{\space }}}With this background information, this study was done to assess the knowledge, attitude and practice among postmenopausal women in an urban slum of Bhubaneswar city of Odisha. 
    
\section{Materials and Methods}
This cross-sectional study was conducted among 104 postmenopausal women during September and October 2019. A pretested, semi-structured questionnaire was used to assess the sociodemographic profile, reproductive and menstrual history including age of menarche, age at marriage, number of children, age of menopause and types of menopause etc. For assessing the socioeconomic status of postmenopausal women, BG Prasad scale for urban areas was used \unskip~\citep{849453:19982017}. For assessing knowledge, attitude and practice, a questionnaire consisting of total 33 items in Odia language was developed. It was initially pretested on 5 menopausal women to identify any difficulty in understanding and modified accordingly. Knowledge part consisted 15 questions and correct answer was given 1 score and wrong answer 0 score. In attitude part, there were 7 questions and positive attitude was given 1 score and negative attitude 0 score. In the practice portion, there were 11 questions and each healthy practice scored 1 and those who were not adopting healthy practices they were given 0 score.\unskip~\citep{849453:19982020} The answer of the questions were designed as yes, no and don't know form. According to people's knowledge was classified into three categories: poor (0-5 score), moderate (6-10 score), good (11-15 score) knowledge. In attitude, the participants were placed in two groups with negative attitude (0-3 score) and positive attitude (4-7 score). In the practice section, there were three categories: poor (0-3 score), moderate (4-7 score), good (8-11 score) practice. Women who were having menopause more than one year, aged less than 60 years were included in the study. Sick and terminally ill women were excluded from the study. The data collected were analyzed with the help of SPSS version 20. Mann Whitney U~test and Kruskal Wallis H test were used for statistical analysis. \ensuremath{\leq } 0.05 was considered as significant association. 
    
\section{Results }
In this study, total 104 postmenopausal women participated. Mean age of the participants was 50.92 \ensuremath{\pm} 3.2 years, and maximum number of postmenopausal women (53.8\%) were in the age group of 45-50 years. Among them all were Hindu, 75\% belonged to general caste and 50\% had nuclear family. Majority of the participants were married (78.8\%) and 21.2\% were widowed. We found that among them around 23.1\% were illiterate, 51.9\% had primary education and only four were graduate in the study population. Most of the women (73.1\%) were homemaker, 15.4\% were waged earner and 9.6\% of women had other occupation like tailoring, tutoring small kids, business, etc. The economic status was categorized based on per capita monthly income as per modified BG Prasad socioeconomic classification scale \unskip~\citep{849453:19982017}. In this study 11.5\% of the subjects belonged to upper class, 63.5\% to upper-middle class, 23.1\% to middle and 1.9\% to lower-middle socioeconomic background.

Among those interviewed 76.9\% had menarche between 12{\textendash}14 years of age and the mean age of menarche was 13.2 \ensuremath{\pm} 1.3 years. The age of marriage for 63.46\% women was in between 16{\textendash}18 years and the mean age of marriage was 17.1 \ensuremath{\pm} 2.3 years. The age of 1\ensuremath{^{st}} pregnancy for majority of the participants (42.3\%) was 18-19 years. In this study 88.5\% participants had regular menstrual cycle and 28.8\% of women had some problems like abdomen pain (26.9\%). Most of the respondents said that they did not experience any complication during their pregnancy (88.5\%) and child delivery (80.8\%). The mean age of menopause was 47.29 \ensuremath{\pm} 2.98 years and the age of menopause for maximum women (61.6\%) was between the age of 45-49 years. Most of the women (71.2\%) of postmenopausal women had menopause naturally.


\begin{table*}[!htbp]
\caption{\boldmath {Item-wise Analysis} }
\label{tw-0b445f663b5c}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.070200000000000005\linewidth-2\tabcolsep}p{\dimexpr.54449999999999996\linewidth-2\tabcolsep}p{\dimexpr.19830000000000005\linewidth-2\tabcolsep}p{\dimexpr.18700000000000003\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor} & Knowledge  & Correct  & Incorrect \\
\tblmidrule 
1 &
  Do you have knowledge of menopausal symptoms?  &
  18(17.3\%) &
  86(82.7\%)\\
2 &
  Do you know in which age menopause occurs? &
  32(30.8\%) &
  72(69.2\%)\\
3 &
  Does menstruation stop suddenly at the time of menopause?  &
  34(32.7\%) &
  70(67.3\%)\\
4 &
  Hereditary background affect the age of menopause?  &
  0 (0\%) &
  104(100\%)\\
5 &
  Post- menopausal bleeding is abnormal?  &
  46(44.2\%) &
  58(55.8\%)\\
6 &
  Menopause affect your sexual life?  &
  8(7.7\%) &
  96(92.3\%)\\
7 &
  Thin people become menopause sooner?  &
  24(23.1\%) &
  80(76.9\%)\\
8 &
  Menopause increases weight \& obesity in women?  &
  8(7.7\%) &
  96(92.3\%)\\
9 &
  Menopause increases stress in women?  &
  22(21.2\%) &
  82(78.8\%)\\
10 &
  Menopause associated with many chronic diseases?  &
  38(36.5\%) &
  66(63.5\%)\\
11 &
  Menopausal women should consult with a physician?  &
  22(21.2\%) &
  82(78.8\%)\\
12 &
  Practising healthy life styles are beneficial in menopause?  &
  4(3.8\%) &
  100(96.2\%)\\
13 &
  Menopausal symptoms are preventable \& curable?  &
  2(1.9\%) &
  102(98.1\%)\\
14 &
  Intake of specific types of food beneficial during menopause?  &
  2(1.9\%) &
  102(98.1\%)\\
15 &
  Are you aware of Hormone Replacement Therapy (HRT)?  &
  0 (0\%) &
  104(100\%)\\
 &
  Attitude  &
  Positive  &
  Negative \\
16 &
  Do you perceive menopause as loss of youth?  &
  58(55.8\%) &
  46(44.2\%)\\
17 &
  Do you think menopausal psychological symptoms affect QOL?  &
  62(59.6\%) &
  42(40.4\%)\\
18 &
  Do you think menopause means ends of sexual life?  &
  58(55.8\%) &
  46(44.2\%)\\
19 &
  Do you think menopausal women should give more time on spirituality?  &
  80(76.9\%) &
  24(23.1\%)\\
20 &
  Do you think menopause is associated with maturity \& experience?  &
  74(71.2\%) &
  30(28.8\%)\\
21 &
  Do you think menopause is a relief from menstruation?  &
  66(57.7\%) &
  44(42.3\%)\\
22 &
  Physical changes in menopause are inevitable \& hence acceptable?   &
  94(90.4\%) &
  10(9.6\%)\\
 &
  Practice  &
  Yes  &
  No \\
23 &
  Did you discuss menopausal symptoms with others?  &
  10(9.6\%) &
  94(90.4\%)\\
24 &
  Did you consult a physician at the onset of menopause?  &
  2(1.9\%) &
  102(98.1\%)\\
25 &
  Have you taken any medical treatment for menopausal symptoms?  &
  0(0\%) &
  104(100\%)\\
26 &
  Are you giving emphasis on personal hygiene at menopause?  &
  32(30.8\%) &
  72(69.2\%)\\
27 &
  Are you doing any exercise to get relief from these symptoms?  &
  2(1.9\%) &
  102(98.1\%)\\
28 &
  Are you doing Yoga to get relief from menopausal symptoms?  &
  0 (0\%) &
  104(100\%)\\
29 &
  Are you doing spiritual activity to get relief?  &
  0 (0\%) &
  104(100\%)\\
30 &
  Are you taking any special food to get rid from symptoms?  &
  0 (0\%) &
  104(100\%)\\
31 &
  Do you take healthy diet for better menopausal health?  &
  0 (0\%) &
  104(100\%)\\
32 &
  Are you giving importance to improve your inter-personal relationship?  &
  0 (0\%) &
  104(100\%)\\
33 &
  Are you doing any activity to release your stress?   &
  0 (0\%) &
  104(100\%)\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
In our study, knowledge of postmenopausal bleeding got the highest correct answer (44.2\%). Only 36.5\% women said that menopause is associated with many chronic diseases and 32.7\% said that menstruation does not stop suddenly at the time of menopause. In our study 90.4\% of participants positively accepted their menopause. 76.9\% of participants thought that women should give more time on spirituality after menopause in a positive way. A very few participants (30.8\%) were giving importance on their menopausal hygiene and others were not practicing any healthy activities after menopause Table~\ref{tw-0b445f663b5c}. 


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\centering \makeatletter\IfFileExists{images/ea939c7d-c144-495f-9994-b12020bdf426-upicture1.png}{\includegraphics{images/ea939c7d-c144-495f-9994-b12020bdf426-upicture1.png}}{}
\makeatother 
\caption{\boldmath {Level of Knowledge, Attitude and Practice on Menopause}}
\label{f-5c72ec546126}
\end{figure}
\egroup
In the current study 80.8\% women had poor knowledge and 73.1\% women having positive attitude towards menopause. But none of the participants reported healthy practices in their menopause Figure~\ref{f-5c72ec546126}.

The median and IQR of knowledge score was 0.50 (0.00-5.00), attitude score 4.50 (3.00-6.00) and practice score was 0.00 (0.00-1.00) Table~\ref{tw-05a43668e067}.


\begin{table*}[!htbp]
\caption{\boldmath {Knowledge, attitude and practice scores of postmenopausal women} }
\label{tw-05a43668e067}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1677\linewidth-2\tabcolsep}p{\dimexpr.1585\linewidth-2\tabcolsep}p{\dimexpr.28459999999999997\linewidth-2\tabcolsep}p{\dimexpr.1892\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor} & Median & IQR (25th-75th percentile) & Minimum & \\
\tblmidrule 
Knowledge &
  0.50 &
  0.00-5.00 &
  0 &
  10\\
Attitude &
  4.50 &
  3.00-6.00 &
  0 &
  7\\
Practice &
  0.00 &
  0.00-1.00 &
  0 &
  3\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
Data presented in Table~\ref{tw-9b3f86a40dc8}  showed the association of knowledge scores with demographic variables. The knowledge scores were significantly associated with age and education.
\begin{table*}[!htbp]
\caption{\boldmath {Factors associated with Knowledge score regardingmenopause} }
\label{tw-9b3f86a40dc8}
\centering 
\begin{threeparttable}

\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1893\linewidth-2\tabcolsep}p{\dimexpr.3107\linewidth-2\tabcolsep}p{\dimexpr.268\linewidth-2\tabcolsep}p{\dimexpr.232\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Factors & Total Participants & Median (IQR) & P Value \\
\tblmidrule 
\multicolumn{4}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{Age (in years)}\\
45-50   &
  56 (53.8\%) &
  0.00 (0.00 {\textendash} 2.75)  &
  \multicolumn{1}{p{\dimexpr(.232\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{0.003}}\\
50-55   &
  36 (34.6\%) &
  4.00 (0.00 {\textendash} 6.00)  &
  \\
55-60   &
  12 (11.6\%)  &
  3.50 (0.00 {\textendash} 6.00) &
  \\
\multicolumn{4}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{Caste}\\
General &
  78 (75\%) &
  0.00 (0.00 {\textendash} 5.00) &
  \multicolumn{1}{p{\dimexpr(.232\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{0.240}}\\
SC  &
  26 (25\%) &
  2.00 (0.00 {\textendash} 6.50) &
  \\
\multicolumn{4}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{Marital status}\\
Married &
  82 (78.8\%) &
  0.00 (0.00 {\textendash} 5.00) &
  \multicolumn{1}{p{\dimexpr(.232\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{0.506}}\\
Widow &
  22 (21.2\%) &
  2.00 (0.00 {\textendash} 6.00) &
  \\
\multicolumn{4}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{Family Type}\\
Joint &
  52 (50\%) &
  1.50 (0.00 {\textendash} 5.00) &
  \multicolumn{1}{p{\dimexpr(.232\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{0.856}}\\
Nuclear &
  52 (50\%) &
  0.00 (0.00 {\textendash} 5.00) &
  \\
\multicolumn{4}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{Education}\\
Illiterate &
  24 (23.1\%) &
  0.00 (0.00 {\textendash} 1.75) &
  \multicolumn{1}{p{\dimexpr(.232\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{0.006}}\\
Literate &
  80 (76.9\%) &
  2.00 (0.00 {\textendash} 5.75) &
  \\
\multicolumn{4}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{Occupation}\\
Housewife &
  76 (73.1\%) &
  2.00 (0.00 {\textendash} 5.00) &
  \multicolumn{1}{p{\dimexpr(.232\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{0.480}}\\
Others &
  28 (26.9\%) &
  0.00 (0.00 {\textendash} 4.00) &
  \\
\multicolumn{4}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{Socio-Economic Status }\\
Upper Class  &
  10 (9.6\%) &
  0.00 (0.00 {\textendash} 1.25) &
  \multicolumn{1}{p{\dimexpr(.232\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{0.065}}\\
Middle Class  &
  94 (90.4\%) &
  0.00 (0.00 {\textendash} 5.00) &
  \\
\multicolumn{4}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{Age of attaining menopause }\\
40-45  &
  18 (17.2\%) &
  0.00 (0.00 {\textendash} 2.50) &
  \multicolumn{1}{p{\dimexpr(.232\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{0.348}}\\
45-50  &
  64 (61.6\%) &
  0.00 (0.00 {\textendash} 5.00) &
  \\
50-55  &
  22 (21.2\%) &
  0.00 (0.00 {\textendash} 6.00) &
  \\
\multicolumn{4}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{Types of Menopause }\\
Natural &
  74 (71.2\%) &
  2.00 (0.00 {\textendash} 5.00) &
  \multicolumn{1}{p{\dimexpr(.232\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{0.325}}\\
Surgical &
  30 (28.8\%) &
  0.00 (0.00 {\textendash} 3.00) &
  \\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{Mann Whitney U~testand Kruskal Wallis H test}
\end{tablenotes}
\end{threeparttable}

\end{table*}

    
\section{Discussion}
In this study maximum (61.6\%) of participants were attained their menopause in the age between 45-50 years, which was similar to a study conducted by Nahid Yasmin et al. that majority of the respondents (63.5\%) were the age between 45-50 years \unskip~\citep{849453:19982018}. Majority (76.9\%) were literate in the present study in contrast to another study \unskip~\citep{849453:19982020}, where, 55.45\% of participants were illiterate. Most of the participants (90.4\%) belonged to middle class socioeconomic background. In a study by Malik HS, 75.5\% belonged to poor socioeconomic class\unskip~\citep{849453:19982032}.

In the current study, 44.2\% of women considered postmenopausal bleeding as abnormal, but in the study by Pathak et al, 16.3\% women considered postmenopausal bleeding as abnormal \unskip~\citep{849453:19982020}. Other studies reported that majority participants had knowledge about that menopause is associated with many chronic diseases like cancer, osteoporosis etc., \unskip~\citep{849453:19982020}\unskip~\citep{849453:19982034}.\ensuremath{^{}} In our study we also found that 36.5\% respondents were aware about it. In the present study 21.2\% of women thought that menopausal women should consult a physician. Likewise, in a study conducted by Loutfy et al. 12.2\% of women were aware that menopausal women should consult a doctor \unskip~\citep{849453:19982035}. In our study no one had knowledge about the hormone therapy. In similarly studies \unskip~\cite{849453:19982020},\unskip~\citep{849453:19982035} 4.5\% and 9.3\% women had knowledge about the hormone replacement therapy. In our study, 90.4\% women thought that physical changes of menopause are inevitable and hence acceptable, which was contrast to a study by \unskip~\citep{849453:19982040}, where 83\% of the respondents considered menopause as an unpleasant experience. In the present study 55.8\% women perceived menopause as loss of youth, which was almost similar another study \unskip~\citep{849453:19982020}.  Majority 55.8\% of women in our study considered menopause as an end of sexual life. On contrary to a study \unskip~\citep{849453:19982029}, 60\% women had their regular sex life after menopause. In a study \unskip~\citep{849453:19982035}, 69.8\% of women had discussed menopausal symptoms with others which may be due to the education status (mostly illiterate) or close social relationships of the participants,. But our result showed that only 9.6\% of respondents had discussed the menopausal symptoms with others. Only 1.9\% of women in our study have consulted a physician at the onset of their menopause. In a study \unskip~\citep{849453:19982035}, 11.1\% of women had consulted a physician regarding their menopausal problems. In a similar study\unskip~\citep{849453:19982033}, only 31.86\% of women had sought advice from a doctor. In the same way, a study by Thomas SE\textbf{\ensuremath{^{14}}}, 52\% of women had neither visited to a doctor nor taken any prescribed treatment. This variation may be due to study area and sociodemographic differences. As per the present study 30.8\% of women had given emphasis on their personal hygiene and only 1.9\% women were doing exercise to get rid from menopausal symptoms. Apart from these practices no one had adopted any other healthy activities to reduce the menopausal symptoms, whereas some other studies\unskip~\citep{849453:19982020}, \unskip~\citep{849453:19982035} had adopted healthy practices like doing mild to moderate physical activities in their postmenopausal years.

The level of knowledge towards menopause was poor among majority of participants (80.8\%) in this study. Many studies conducted in other developing countries were consistent with the results of our study. They also found inadequate knowledge of women about menopausal issues \unskip~\citep{849453:19982030}, \unskip~\citep{849453:19982024}, \unskip~\citep{849453:19982027}. The results of assessing women's attitude in our study indicated that mostly (73.1\%) participant had positive attitude towards menopause, which was quite similar to a study by Noroozi et al where 85.1\% women had positive attitude \unskip~\citep{849453:19982019}.\ensuremath{^{\textbf{\space }}} We found that none of the participants were doing healthy practices during their menopausal period which is similar to the study \unskip~\citep{849453:19982026}, practice of the respondents towards menopause was not satisfactory. In a study\unskip~\citep{849453:19982038} they found significant difference between the knowledge score on menopause and socio-demographic variables like religion, occupation and types of family of the participants. In our study, there was difference between knowledge on menopause and age and education of the respondents were statistically significant.
    
\section{Conclusion}
Knowledge of menopausal women was inadequate and practice to reduce menopausal symptoms was not satisfactory with they had remarkably positive attitude. These results suggest that education and intervention programs to increase awareness on menopause is necessary to for enhancing their knowledge and practice which in turn help them to lead a healthy life during their menopausal period. Interventions programmes should include health promotion and lifestyle modification activities for improving menopausal health. 
    
\section{Acknowledgments}
We gratefully acknowledge the support extended by Siksha `O' Anusandhan deemed to be University for giving us an opportunity to undertake the study. We also like to thank our study participants for their co-operation during this study. 

\textbf{Funding Support}

The authors declare that they have no funding support for this study.

\textbf{Conflict of Interest}

The authors declare that they have no conflict of interest for this study.
    

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