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Open Access J Pak Med Assoc
320
KAP STUDY
Sports-related concussion history, reporting behaviours, knowledge, and
attitudes in Pakistani university student-athletes
Masood Mahfooz, Young-Eun Noh, Eng Wah Teo, Zubia Savila
Abstract
Objective: To assess student-athletes’ knowledge and attitudes towards sport-related concussions and to
investigate concussion history and reporting behaviours.
Method: The cross-sectional, survey-based study was conducted from September 2020 to June 2021 after approval
from the research ethics committee of Universiti Malaya, Malaysia, and comprised student-athletes of either gender
aged 18 years or above at various universities across Pakistan and who played contact or collision sports for their
universities. Data was collected using the Urdu version of the Rosenbaum Concussion Knowledge and Attitudes
Survey-Student Version. Data was also gathered about the participants’ self-reported exposure to formal concussion
education, previous sport-related concussion history, and reporting behaviours, where applicable. Data was
analysed using SPSS 23.
Results: Of the 369 participants, 224(60.7%) were males and 145(39.3%) were females. The overall mean age was
19.95±1.75 years. Among the participants, 327(88.6%) had not received formal concussion education. The mean
knowledge score was 12.76±2.73 out of a possible 25 points, and the mean attitude score was 38.63±10.30 out of
75 points. Knowledge had a weak positive correlation with attitude towards sport-related concussions SRC (p<0.05).
Females displayed better attitudes towards sport-related concussions than their male counterparts (p<0.05).
Overall, 126(34%) participants had experienced sport-related concussion symptoms following a blow to the head in
the preceding 12 months, and 81(64.3%) of them had continued playing while being symptomatic.
Conclusion: Pakistani university student-athletes lacked adequate concussion knowledge and held poor attitudes
towards sport-related concussions.
Key Words: Brain concussions, Brain injuries, Traumatic, Athletes, Incidence.
(JPMA 74: 320; 2024) DOI: https://doi.org/10.47391/JPMA.9343
Introduction
Sports-related concussions (SRCs) are among the most
frequent sports-related injuries and have been
recognised as a significant public health concern.1,2 Each
year, up to 3.8 million SRCs occur in the United States
alone.3 Collision or contact sports expose athletes to
situations where they may sustain an SRC. Although most
athletes fully recover within 7-10 days of experiencing an
SRC, some experience adverse neurological effects that
remain throughout their lifespans.3 A return to play (RTP)
while experiencing SRC symptoms increases the risk of
additional complications.1,4 A second impact while being
symptomatic can result in exacerbated neurological
effects, intracerebral haemorrhage, cerebral oedema, or
even death.5 Multiple individual SRCs may result in
chronic traumatic encephalopathy (CTE).1,3 CTE has long-
term repercussions on cognitive functions, including
decreased attention span, memory and focus, potentially
leading to confusion, disorientation, and, in some cases,
suicidal tendencies. SRCs have also been linked to health-
related quality of life (HRQOL) impairments, dementia,
and depression.6
Several sports have modified their safety rules to help
keep athletes safe from the negative impacts of SRCs.2,7
However, preventing SRCs in contact or collision sports is
not easy.3 Hence, timely identification and appropriate
medical attention are crucial. Current recommendations
from organisations, such as the Concussion in Sport
Group, are to immediately remove a player who has
sustained a potentially concussive impact and only allow
them RTP after proper medical evaluation.1-3 However,
SRC is often considered an “invisible injury”. Although a
few of its symptoms, such as loss of consciousness and
vomiting, are easily noticeable, several others, such as
headaches or dizziness, are challenging to observe.
Hence, many concussions go unnoticed, and medical
professionals rely on the athletes to report potential
symptoms.1
University Malaya, Kuala Lumpur, Malaysia.
Correspondence: Young-Eun Noh. Email: youngeun@um.edu.my
ORCID ID. 0000-0002-6266-8554
Submission complete: 10-03-2023 Review began: 28-04-2023
Acceptance: 27-09-2023 Review end: 23-09-2023
For athletes to report a concussion, they must be able to
recognise a potential concussion and believe that
reporting is in their best interests.2,8 Educating athletes
about concussions is now considered a priority.2 In the US,
all states have passed legislation aimed at educating
athletes about concussions and their complications.
Similarly, all major sporting organisations have protocols
to educate athletes about SRCs.7 Researchers have also
advocated that concussion education programmes
should use existing psychosocial theories of health
behaviour to influence athletes’ reporting behaviours.8-10
SRCs are common sport injuries that affect more than
10% of athletes participating in collision or contact sports
each season worldwide, and their incidence is on the
rise.1,11 In Pakistan, contact or collision sports with high
rates of concussions, such as football (soccer) and field
hockey, are popular among youth.12 A high incidence of
concussions has also been reported for kabaddi,13 a
traditional subcontinental sport. Rugby, a sport with the
highest rate of SRCs,14 is also gaining popularity in
Pakistan. Cricket, the most popular sport in Pakistan, has
also been linked to SRC cases.15 Voss et al.16 reported that
the SRC rate in Pakistan is low, but studies of neurotrauma
in Pakistan have identified numerous SRC cases.17,18
Researchers have suggested that the actual number of
SRCs may be higher in Pakistan, but underreporting by
athletes is high.12,19 Underreporting could arise due to a
lack of knowledge among athletes about the potential
consequences of head injury and failure to recognise
concussion signs and symptoms or poor reporting
behaviours.1,19
Investigating athletes’ knowledge and attitudes about
concussions — particularly at the university level — is
critical because the risk of SRCs has been reported to be
higher at university or collegiate levels compared to lower
levels of competition.4,20 Moreover, researchers have
claimed that university student-athletes are less likely to
disclose concussion symptoms than athletes at other
levels.8,21,22 Another element of interest is the gender
difference in athletes' attitude towards SRC and reporting
behaviours.23 Additionally, exploring the correlation
between SRC knowledge and attitudes is crucial for
designing effective interventions.9,22
Despite a thorough literature review, no study could be
found on SRC knowledge and attitudes — or incidence of
SRCs — among athletes in Pakistan. The current study
was planned to fill the gap by investigating SRC-related
knowledge, attitudes, and reporting behaviours among
university student-athletes in Pakistan.
Subjects and Methods
The cross-sectional, survey-based study was conducted
from September 2020 to June 2021 after approval from
the research ethics committee of Universiti Malaya,
Malaysia, and comprised student-athletes of either
gender aged 18 years or above at various universities
across Pakistan and who played contact or collision sports
for their universities. Student-athletes under the age of
18, as well as those involved in non-contact or non-
collision sports, or who did not agree to participate in the
study, were excluded. Participants were recruited using
purposive sampling strategies. The sample size was
calculated using an online calculator,24 with 1.96 million
university students in Pakistan,25 at 95% confidence
interval (CI), and 5% margin of error.
Data was collected after obtaining informed consent from
the participants, permission from the relevant officials at
each university, and permission from the authors of the
data-collection tools.9,26 The athletes were approached
during visits to their respective universities.
The Rosenbaum Concussion Knowledge and Attitudes
Survey–Student Version (RoCKAS-ST)26 has undergone
extensive psychometric evaluation and has been
recognised as a valid and reliable tool. It consists of 55
items divided into three subscales: Concussion
Knowledge Index (CKI), Concussion Attitude Index (CAI),
and the Validity Index (VI). The CKI, which measures
concussion knowledge, comprises three subsections with
a total of 25 dichotomous (True/False) items.
Dichotomous items are commonly used in knowledge
quizzes to assess existing knowledge or knowledge gaps
because they help reduce respondents' boredom and
fatigue. However, they are also known for certain
drawbacks, such as oversimplification of complex
concepts and the possibility of respondents guessing the
correct answer. Nevertheless, researchers frequently
employ them as they are user-friendly and time-efficient.
Each correct response to a CKI item is scored as 1,
resulting in a maximum score of 25 points, with higher
scores reflecting greater concussion knowledge. The CAI,
which measures attitudes towards concussion, consists of
15 questions answered on a 5-point Likert scale ranging
from strongly agree to strongly disagree. Answers
reflecting safer attitudes towards concussions are scored
as 4-5 points, while unsafe responses receive 1-2 points,
resulting in a maximum score of 75 points, with a higher
score reflecting safer attitudes towards concussions.
Likert scales are widely employed in survey research due
to their ease of construction, administration, and analysis.
However, they are prone to response bias and social
desirability. Despite these limitations, researchers
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Sports-related concussion history, reporting behaviours, knowledge... 321
commonly use Likert scales as reliable tools to assess
levels of agreement or feelings towards a particular
subject. The VI consists of 3 questions to confirm internal
validity: fewer than two correct responses result in
disqualification.
The current study used the reliable and validated Urdu
version of RoCKAS-ST.27Also used was a tool developed
by Kroshus et al.9 The participants reported (yes/no) if
they ever received a knock to the head, face or neck while
playing their sport. In addition, the participants indicated
(yes/no) if they experienced any sensory, somatic or
cognitive symptom(s) of SRC following an impact within
the preceding 12 months. Participants’ history of
reporting SRCs was assessed using two dichotomised
items, asking if they reported the symptoms to a coach or
medical professional immediately or the next day. These
items were scored as 0 or 1, with 1 indicating that the SRC
was reported. Participants also provided their
demographic variables (age, gender), main sport, current
competition level, years playing their main sport, and
previous exposure to concussion education (yes/no).
Data was analysed using SPSS 23. Athletes’ knowledge
and attitude scores were analysed using descriptive
statistics, such as mean ± standard deviations or
frequencies and percentages. Correlations between the
CKI and CAI total scores were assessed using Spearman’s
rank correlation due to data non-normality. Mann-
Whitney U test was used to assess differences in attitude
scores between male and female participants. Chi-square
test of independence was used to examine gender
differences in reporting past SRCs. P<0.05 was considered
statistically significant.
Results
Out of 450 individuals approached, 400(88.8%) returned
the questionnaires, but 31(7.75%) questionnaires were
excluded as they had not been filled completely. The final
sample, as such, had 369(92.2%) participants; 224(60.7%)
males and 145(39.3%) females. The overall mean age was
19.95±1.75 years, and the mean playing experience was
5.11±2.30 years. Among the participants, 327(88.6%) had
not received formal concussion education. Football was
the most common sport played by 156(42.3%) subjects,
and 7(1.9%) subjects had international exposure (Table 1).
Overall, 222(60.2%) participants reported having received
a knock to the head, face or neck, while 126(34.1%)
reported experiencing at least one concussion symptom
after receiving a knock in the preceding 12 months.
Participants who reported a knock in the preceding 12
months experienced an average of 3.14±1.49 SRC
symptoms. Among the possible SRC symptoms,
93(73.8%) subjects reported dizziness, and 83(65.9%)
reported headaches after a knock. Other symptoms, such
as bell rung, amnesia, concentration problems, nausea,
and seeing stars, were reported by 48(38.1%), 46(36.5%),
41(32.5%), 35(27.8%) and 33(26.2%) participants,
respectively. Only 15(11.9%) participants reported loss of
consciousness. Of these 126(34.1%) participants,
81(64.3%) did not report the symptoms and continued
playing, while 88(70.4%) continued experiencing
symptoms the next day but did not report them to their
coaches or medical staff.
The mean knowledge score was 12.76±2.73 (range: 6-20;
95% CI: 12.49-13.05) (Table 2).
The mean attitude score was 38.63±10.30 (range: 19-66;
95% CI: 37.58-39.69). Overall, 229(62.1%) participants said
it is players’ responsibility to return to a game even if they
are still experiencing SRC symptoms, and 298(81.6%) felt
that players should return to an important game even if
they had concussion symptoms (Table 3).
There was a weak but significant positive correlation
between CKI and CAI scores, indicating that an increase in
knowledge is likely to positively affect safer attitudes
towards SRCs (Table 4).
Female participants had a significantly better attitude
towards SRCs (p<0.05), but previous SRC reporting
patterns did not differ significantly between the genders
(Table 5).
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M Mahfooz, Y-E Noh, E W Teo, et al
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Table-1: Main sports by gender and current participation level (n = 369).
Demographics Total Male Female
n % n % n %
Sports Played
Football 156 42.3 97 62.2 59 37.8
Hockey 49 13.3 17 34.7 32 65.3
Boxing 12 3.3 9 75.0 3 25.0
Martial Arts 36 9.8 10 27.8 26 72.2
Kabaddi 24 6.5 24 100 Nil Nil
Basketball 38 10.3 13 34.2 25 65.8
Rugby 31 8.4 31 100 Nil Nil
Handball 23 6.2 23 100 Nil Nil
Total 369 224 60.7 145 39.3
Level of Participation
International Level 7 1.9 3 42.9 4 57.1
National Level 29 7.9 18 62.1 11 37.9
Department Level 35 9.5 13 37.1 22 62.9
University Level 237 64.2 159 67.1 78 32.1
Club Level 61 16.5 31 50.8 30 42.9
Total 369 224 60.7 145 39.3
Discussion
The current study investigated SRC-related knowledge
and attitudes of university student-athletes in Pakistan.
Previous studies have found the risk of SRCs to be higher
at the post-secondary level.4,20 Thus, it is imperative that
university student-athletes are aware of concussion
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Sports-related concussion history, reporting behaviours, knowledge... 323
Table-2: Concussion knowledge scores.
Concussion Knowledge Index Correct Answered %
Response Correctly
Section 1
1.There is a possible risk of death if a second concussion occurs before the first one has healed. True 150 40.7
2.People who have had one concussion are more likely to have another concussion. True 208 56.4
3.In order to be diagnosed with a concussion, you have to be knocked out. False 117 31.7
4.A concussion can only occur if there is a direct hit to the head. False 153 41.5
5.Being knocked unconscious always causes permanent damage to the brain. False 213 57.7
6.Symptoms of a concussion can last for several weeks. True 248 67.2
7.Sometimes a second concussion can help a person remember things that were forgotten after the first concussion. False 94 25.5
8.After a concussion occurs, brain imaging (e.g., CAT Scan, MRI, X-Ray, etc.) typically shows visible physical damage (e.g., bruise, blood clot) to the brain. False 80 21.7
9.If you receive one concussion and you have never had a concussion before, you will become less intelligent. False 220 59.6
10.After 10 days, symptoms of a concussion are usually completely gone. True 229 62.1
11.After a concussion, people can forget who they are and not recognize others but be perfect in every other way. False 218 59.1
12.Concussions can sometimes lead to emotional disruptions. True 251 68.0
13.An athlete who gets knocked out after getting a concussion is experiencing a coma . True 220 59.6
14.There is rarely a risk to long-term health and well-being from multiple concussions. False 148 40.1
Section 2
15.It is likely that Player Q’s concussion will affect his long-term health and well-being. False 198 53.7
16.It is likely that Player X’s concussion will affect his long-term health and well-being. True 149 40.4
17.Even though Player F is still experiencing the effects of the concussion, her performance will be the same as it would be had she not suffered a concussion. False 232 62.9
Table-3: Concussion attitude scores.
Concussion Attitude Index Safer Correct %
Response Responses
Personal Return to Play Attitudes
1.I would continue playing a sport while also having a headache that resulted from a minor concussion . SD/D 106 28.7
2.I feel that an athlete has a responsibility to return to a game even if it means playing while still experiencing symptoms of a concussion. SD/D 108 29.3
3.I feel that Athlete M should have returned to play during the first game of the season. SD/D 95 25.7
4.I feel that Athlete O should have returned to play during the semifinal playoff game . SD/D 61 16.6
Views about Others’ Return to Play Attitudes
1.Most athletes would feel that Coach A made the right decision to keep Player R out of the game. SA/A 68 18.4
2.Most athletes would feel that athlete M should have returned to play during the first game of the season. SD/D 62 16.8
3.Most athletes feel that Athlete O should have returned to play during the semifinal playoff game. SD/D 48 13.0
4.Most athletes would feel that Athlete H should tell his coach about the symptoms. SA/A 65 17.7
Views about Coaches’ Concussion Management & Precautions
1.I feel that an athlete who is knocked unconscious should be taken to the emergency room. SA/A 236 64.0
2.I feel that coaches need to be extremely cautious when determining whether an athlete should return to play. SA/A 253 68.6
3.I feel that Coach A made the right decision to keep Player R out of the game. SA/A 236 64.0
Views about Physiotherapists’ Concussion Management
1.I feel that the physiotherapist, rather than Athlete R, should make the decision about returning Athlete R to play. SA/A 117 31.7
2.Most athletes would feel that the physiotherapist, rather than Athlete R, should make the decision about returning Athlete R to play. SA/A 68 18.4
General Attitude Towards Concussion
1.I feel that concussions are less important than other injuries. SD/D 181 49.0
2.I feel that Athlete H should tell his coach about the symptoms. SA/A 90 24.3
SA/A: Strongly agree/agree, SD/D: Strongly disagree/disagree.
Table-4: Correlation between concussion knowledge and attitude.
Attitude Knowledge 95% confidence interval P
p < .05 0.109 0.01-.22 0.03*
symptoms and complications. However, the current
sample’s average concussion knowledge was inadequate,
and many misunderstandings were observed. Specifically,
more than half of the participants believed that an athlete
must lose consciousness to be diagnosed with an SRC.
Furthermore, over half of the participants assumed that
SRC could occur only after a direct hit to the head. More
than 55% of the participants were unaware that an
additional SRC could cause death. Athletes must be aware
of SRC symptoms so they may identify and inform
medical professionals.2,8 However, only headache was
successfully identified as a valid concussion symptom by
majority of the current participants. The fact that 88.6% of
participants reported no formal concussion education
might explain the low concussion knowledge scores.
Besides awareness of concussion symptoms, athletes
should believe that reporting SRC symptoms and
following the RTP protocols are in their own best
interest.9,23 The participants generally showed unsafe
attitudes towards concussion symptom disclosure and
RTP, with 65.1% indicating that they would continue
playing despite having a headache from a concussion and
73.7% saying that players should hide their concussion
symptoms if they thought that the coach might exclude
them from the match.
Individual attitudes play a significant role in shaping a
specific behaviour. Previous studies on SRC nondisclosure
in other countries have suggested that personal attitudes,
like the desire to succeed, the significance of the match,
not wanting to leave a game, and not wanting to let
teammates down, play a significant role in SRC reporting
behaviours.23,28 Additionally, factors such as athletic
identity, sports culture, coaches’ attitudes towards injury
reporting, and insufficient knowledge can also impact
SRC reporting behaviours.10,23 However, no published
studies could be found that explored the factors
influencing the attitudes and reporting behaviours of
Pakistani athletes regarding SRCs. Therefore, it is
recommended that qualitative research be conducted to
explore the underlying causes of poor attitudes towards
SRC reporting among Pakistani student-athletes.
The current participants’ beliefs about other athletes’
attitudes towards concussion management and RTP were
particularly alarming. The vast majority (81.6%) of the
participants stated that most athletes would feel that a
player who experiences SRC symptoms should return to
an important match. Furthermore, 79.9% subjects
believed other athletes would hide their symptoms from
coaches to play a game. Researchers have suggested that
social norms and perceived team reporting norms
influence athletes’ SRC reporting behaviours.21,23 Thus,
concussion education interventions should include
teammates and role models, and focus on cultivating
intra-team communication about concussion safety.
Views about physiotherapists’ concussion management
were also concerning. Most participants indicated that
athletes, not physiotherapists, should decide about RTP
after a concussion. The unavailability of medical
assistance in Pakistani sports fields12 may explain these
views. Encouragingly, the participants reported positive
attitudes towards coaches’ concussion management,
with 68.6% believing that a coach needs to be extremely
careful when determining an athlete’s RTP, and 64%
agreeing with a coach’s decision to remove an athlete
from a game after a concussion. Despite agreeing that
playing with a concussion would negatively affect
performance, 75.6% subjects felt that athletes should not
report symptoms to their coaches to avoid being
sidelined. The desire to avoid “letting the team down” or
“losing the spot on the team” may help explain this
finding.23,28 Thus, concussion education programmes
may highlight the impact of playing while being
symptomatic on individual and team performance to
improve SRC reporting.
Overall, female participants showed significantly better
attitudes towards reporting SRCs than males in the
current study. Past studies have suggested that female
athletes tend to have better intentions towards SRC
reporting than male athletes.23 Interestingly, no
difference was observed between male and female
participants’ previous reporting of SRC symptoms.
Researchers have proposed that male and female athletes
conform to traditional masculine norms of risk-taking,
avoiding help-seeking, and winning at all costs.8 Thus,
concussion interventions are encouraged to focus on
improving sports ethos rather than gender differences.
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Table-5: SRC reporting pattern and its correlation with gender.
Total Male (n = 224) Female (n = 145)
Mean SD Mean SD U Z/X2 p
Attitudes 369 36.98 9.78 41.19 10.59 12638.50 -3.60‡ 0.000*
SRC Reporting 126 – – – – – 2.79† 0.09
SRC: Sport-related concussion. * Significant, ‡Mann-Whitney U test, †Chi-square test.
Voss et al.16 reported low SRC rates in Pakistan. However,
126(34.1%) participants reported experiencing at least
one SRC symptom after receiving a knock to the head,
face or neck in the preceding 12 months in the current
study. The findings are congruent with Pakistani
neurotrauma studies, which recorded multiple SRCs
nationally.17 Notably, 64.3% of the concussed athletes in
the current study did not report their symptoms to their
coaches, which is consistent with the claims that most
SRCs are not reported in Pakistan.12,19
Prior studies have found that athletes who received
formal concussion education reported a better
understanding of and attitudes towards concussions.1
However, 88.6% of the current participants had not
undergone any formal concussion education. Therefore,
the government, educational institutions, and sporting
bodies should mandate and organise formal concussion
education programmes for athletes.
The coaches’ role becomes critical in identifying and
managing concussive events, given that medical
assistance is not readily available on playing fields in
Pakistan.12 Furthermore, coaches’ positive attitudes
towards injury reporting influence athletes’ attitudes
towards concussion reporting.8,10,23 Indeed, the current
participants demonstrated positive attitudes towards
concussion management by coaches. Therefore,
university coaches should be included in concussion
education programmes. Similarly, match officials at
university sporting events should be educated on SRCs to
ensure timely identification of concussive incidents and
withdrawal of concussed athletes from play.
Studies have also called for SRC education to focus on
changing behaviours regarding SRC reporting.10 Some
researchers have claimed that personal attitudes and
social norms drive SRC reporting behaviours more than
SRC knowledge.10,23 In the current study, concussion
knowledge was weakly correlated with attitudes towards
concussions. Thus, delivering concussion education
without targeting the factors associated with concussion
reporting is not recommended. Instead, theory-based
concussion education programmes targeting behavioural
constructs are recommended.8,9,23
The current study contributes significantly to the under-
researched field of SRCs in Pakistan by identifying the
knowledge gaps among athletes. Considering the
popularity of contact and collision sports in Pakistan,
along with the cultural norms that encourage pain
tolerance, the findings provide valuable insights into
athletes’ SRC reporting and RTP attitudes. Additionally,
the study sheds light on athletes’ views concerning
influential individuals, such as teammates, coaches and
physiotherapists, who may influence SRC reporting.
Understanding these dynamics will aid in the
development of effective implementation strategies for
future SRC interventions and national policies. Future
studies should focus on exploring barriers and facilitators
to reporting SRCs, with the aim of incorporating these
factors into contextually appropriate SRC awareness
programmes.
The current study, however, has some limitations. First, in
Islamic countries, like Pakistan, sports participation
among females is generally lower than among males;
thus, 60.7% of the study participants were males, skewing
the data. Second, previous concussion incidents,
symptoms and reporting history were self-reported by
the participants based on memory recall. As such, the
accuracy of the data cannot be validated. Future studies
could triangulate memory recall and injury surveillance to
address this limitation.
Conclusion
Pakistani university student-athletes were found to have
received no formal SRC education and, as such, lacked
adequate concussion knowledge. They held poor
attitudes towards SRCs. The tendency to play while
symptomatic and failure to report symptoms are of
considerable concern. There is an urgent need for
targetted programmes to enhance SRC knowledge and
improve reporting behaviours. Evidence-based
concussion awareness interventions grounded in
behavioural change theories should be initiated to
promote understanding, reporting, and appropriate
management of SRCs.
Disclaimer: The text is based on a thesis done as part of a
PhD programme at Universiti Malaya, Malaysia.
Conflict of Interest: None.
Source of Funding: None.
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Author’s Contributions
MM: Conceived the idea, writing, collecting and analyzing the
data
YN: Conceived the idea, verified the results, and edited the
manuscript.
ET: Supervised the project and helped write, edit, revise and
verify the results.
ZS: Helped with revising, proofreading, data collection and
analysis.
All authors consulted for collecting and analysing the data,
contributed to the article and approved the final version.
