Sample Master Education Literature Review

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Analyse and Explore Contemporary Research Literature to Identify Areas for Service Improvement

Introduction

Background

Tuberculosis (TB) was declared a global health emergency by the World Health Organization (WHO) in 1993. Despite this, it remains a significant cause of mortality and morbidity throughout the world. Tomas et al. (2013) find that tuberculosis has been gradually declining since the 1990s and 2000s, with an estimated nine million incidences of tuberculosis in 2010.

TB is caused by mycobacterium tuberculosis which is an air-borne disease and transmitted when an individual with the active form of the disease sneezes, coughs, spits, or speaks (Bender, Andrews, & Peter, 2010; Bodenmann et al., 2009; Kan, Kalin, & Bruchfeld, 2013; Nuzzo, Golub, Chaulk, & Shah, 2013).

It is estimated that one-third of the global population is infected with tuberculosis, but not all infected people can develop it. The disease can remain latent, asymptomatic, and non-infectious for many years (van der Werf & Zellweger, 2016). However, in about 10% of cases, the infection can reactivate at any time (Werf & Kramarz, 2016a).

The reemergence of tuberculosis in low-prevalence industrialized countries in the West and Australia has become a public health challenge. A part of the disease’s reemergence is attributed to multiple antibiotic resistance and its interaction with AIDS/HIV (Tomás et al., 2013). According to Panchal et al. (2013),

TB is strongly connected with poverty; in developed and less developed countries, 95% of the deaths linked to TB occur in places of poverty and marginalization in developed countries. According to the WHO (2016), population groups who are vulnerable to tuberculosis includes prisoners, injecting drug users, the homeless, ethnic minorities, and migrants – documented or undocumented, refugees, economic and labour migrants, asylum seekers – are those who experience access to health services is complicated by factors of social discrimination, poverty, and isolation.

Various political and socio-economic factors have recently surged the human migration rate, contributing to changes in different patterns of tuberculosis infection (Werf & Kramarz, 2016a). Many Western countries and Australia has seen an increase in TB infection with the influx of migrants and refugees (Rogo et al., 2017).

According to Tomas et al. (2013), in North America, Europe, and Australia, TB disproportionally impacts foreign-born populations that have migrated from Africa, Asia, and/or Latin America because TB infection rates in this area are much higher. In countries with low incidence, the infection rate among foreign-born migrants is ten to twenty times that of the autochthonous population (Tomás et al., 2013).

However, some studies indicate low infection rates in non-immigrant populations (Barniol et al., 2009). Still, the risk of transmission within the immigrant communities in the host country is very high.

Reactivation of latent TB infection is common among immigrant populations. It is considered the main reason behind many TB cases that occur even many years after the arrival of migrants into the host country. Current measures and interventions are not enough to detect latent TB and call for more active surveillance (Moore-Gillon, Davies, & Ormerod, 2010).

Notwithstanding the high proportion of TB cases among immigrants in low-incidence countries, there is an ensuing debate about the screening and educational programs and their public health impact. Research notes that TB control and treatment services in low-incidence countries that house a large population of immigrants face many challenges from the changing patterns of TB. The primary research question the current study looks to answer is;

How is latent tuberculosis tackled among immigrant populations in low-incidence Western countries and Australia regarding screening, educating, and adhering to patients’ treatments?

The current report looks to access and analyze relevant research literature to answer the research question. Understanding these factors plays an imperative role in evaluating and adapting the current programs and processes in place.

Research Aims & Objectives

The general aim of this literature review is to explore screening processes for immigrants, their perceptions and knowledge of TB in addition to educational programs catered for them, and immigrant patient adherence to TB treatment. Using the developed research question and the study’s primary aim, the research objectives have been devised.

1. Use current peer-reviewed academic papers and articles to examine the latent TB screening process/programs and patient education programs for immigrant populations in developed countries of the West and Australia.
2. Use current peer-reviewed academic papers and articles to examine how well immigrant populations with latent TB adhere to their treatment programs.
3. Implement the literature critique model by Caldwell et al. (2005) when analyzing the literature review results.

Three primary themes are being used to organize and analyze the literature review;

1. Screening of immigrant populations with latent tuberculosis.
2. Education/awareness of latent tuberculosis in immigrant populations.
3. Immigrant populations with latent tuberculosis adhering to treatment plans and medication.

Justification of Research

Many immigrant populations migrating to developed countries of the West and Australia are at higher risk of reactivating the latent TB disease. In many low-incidence industrialized countries with the high flux of immigration from less-developed countries, the general tuberculosis control strategies minimize transmission through identifying and curing a high portion of cases.

This strategy’s main components include early detection of TB, adequate treatment adherence for active infections, and detection and prophylactic treatment of latent infections, in some cases (Tomás et al., 2013). However, there is a notable difference between countries regarding screening and education programs for immigrants, such as screening/education locations, the programs’ administrative and financial costs, and legalities for providing care (Werf & Kramarz, 2016b; Wieland et al., 2012).

Often a migrant’s legal, economic and social circumstances can have detrimental impacts on the disease’s progression, diagnosis, treatment, and adherence to the scheme. Not only does this put immigrants at risk, but it also places a large risk to non-immigrant populations.

Immigrants face an array of issues in the process of migration which includes challenges like communication problems, adapting to new surroundings, loss of social support, acculturation, and discrimination which can be further aggravated by fear of TB, the stigmas associated with its diagnosis, fear of deportation, and changes that may need to be made when undergoing TB treatment.

Results from the current research can provide medical professionals insight into the macro-and micro-level impacts of TB on immigrant populations. Understanding these factors may lead to public health policy changes that are more lenient on immigrants and aid the wider community. Nurses can gain practical insight and knowledge from patient care results in immigrant populations with latent TB. The current study can also contribute to the existing literature to improve care and public health policies.

Methodology

Systematic Literature Review

The current study uses a systematic literature review of qualitative, quantitative, and mixed methods studies. The literature review uses rigid methods and analysis to identify, evaluate and synthesize scientific evidence from primary studies on latent tuberculosis among immigrant populations.

According to Boland et al. (2013), a systematic literature review is designed to “locate, appraise, and synthesize” the best available evidence related to a specific research question to provide informed, evidence-based answers. In evidence-based nursing, a systematic literature review aids nurses in deciding whether the evidence is relevant to a particular patient.

It provides balanced clinical expertise pointing out the risks and benefits of specific procedures, treatments, and processes (Bettany-Saltikov, 2012). This study’s approach is relevant to tackling latent tuberculosis in immigrants allowing professionals insight into the screening process, adherence to treatment, views, and attitudes towards tuberculosis.

Search Strategy

The current study’s Searches were carried out in the following databases: NCBI/PubMed, PLOS one, Embase, and Springer. These databases are used because of the number of articles they house and provide access to relevant topics to study.

Search topics in these databases included terms like “tuberculosis,” “immigrants,” “screening,” “adherence to treatment,” and “education” in combination with search terms and MeSH descriptions. The concept of “immigrant” in the current study uses a broad interpretation that includes asylum-seekers, economic refugees, and international migrants.

Refinement of search terms is essential to ensure that time is spent narrowing down appropriate literature (Holly, Salmond, & Saimbert, 2011). A second stage manual search was conducted on the selected articles’ bibliographies to identify the maximum possible relevant articles. A final internet search using Google Scholar was used to minimize the possibility of losing relevant sources.

Inclusion & Exclusion Criteria

Both qualitative and quantitative studies were included in the systematic literature review. The search was limited to studies that were published in English. It was also necessary that publication remain recent, making it essential to limit the publication date from 2009-2017.

However, the study’s place was partially restricted in the search only to include industrialized Western countries and Australia. Studies that were literature reviews of any kind were excluded from the study.

Also, studies that had conducted any randomized control trial were excluded from this literature review. Such studies were excluded because they could not provide relevant data regarding the selected themes used to analyze the literature.

Study Selection

The initial results using the databased highlighted above identified a total of 3,223 articles. This was reduced to 2,394 articles when removing duplicates/overlapping articles from each database (829 duplicates). Afterward, titles and abstracts were reviewed, removing 2,041 articles since they were irrelevant to the research topic.

The 353 remaining articles were then read, both abstracts and full-text versions, resulting in 22 articles that were selected as meeting the inclusion criteria set above. Each of the articles’ bibliographies was then searched in addition to searches on Google Scholar, which further identified 6 articles that met the inclusion criteria. A total of 28 articles were finalized for inclusion in the literature review.

The selected articles were then compiled into a matrix to synthesize them based on the devised themes for analysis. The themes included are screening immigrants, education/knowledge of immigrants on latent tuberculosis, and adherence to immigrants’ treatments. The matrix of studies can be found in appendix A.

Framework for Analysing Research Articles

Baker (2014) asserted the necessity for becoming familiar with the work being analyzed to examine its relevance, strengths, and limitations to the research question when critiquing a piece of literature. Hence, the literature review uses the model developed by Caldwell et al. (2005) in critiquing literature (see fig.2) as the standard.

Figure 2- Research Critique Framework (Caldwell et al., 2005)

The model proposed by Caldwell et al. (2005) has a basic framework that breaks down the process of critiquing into four main questions that need to be answered.

This includes; ensuring that the literature review is current and comprehensive; if the sample is adequately described and reflective of the population for quantitative studies; if the selection criteria for recruiting patients is described and if a sampling method is identified for qualitative studies; and if the conclusion of the study is comprehensive (Caldwell et al., 2005).

Literature Review

Results and Findings

A total of 28 articles were reviewed for the current literature review, with all the articles summaries and implications provided in Appendix A of this report. Complete analysis in this chapter of each piece of literature was not possible due to the current report’s word limit’s constrictions. Each of the articles presented one or more of the themes designated for analysis.

Each article is organized based on the themes they held and analyzed based on the Caldwell et al. (2005) model discussed earlier. The purpose of the investigation was to identify trends in the literature that may lead to contradictions or gaps/weaknesses that need to be filled.

Each piece of literature has been organized based on the themes being discussed and chronologically, based on the publication date from oldest to newest.

Screening

Panchal et al. (2013) study the potential impact on prospective TB incidence of implementing a strategy of targeted LTBI screening when immigrant registers with primary care. The study finds that LTBI screening at primary care registration provides an effective strategy for potentially identifying immigrants at high risk for developing TB (Panchal et al., 2013).

However, the study includes missing data into its statistical analysis, making it extremely probable for the study to have an extreme bias. The missing data is associated with the study’s cohorts’ attrition with internal migration away from the region during the observation period and the possibility of under ascertaining TB cases before 2006 (Panchal et al., 2013).

Schepisi et al. (2013) assessed adherence to and yield of TB screening programs based on symptom screening conducted at primary care centres for regular and irregular refugees/asylum seekers and immigrants in Rome, Italy. Evidence found that verbal symptom screening for TB of migrants in primary healthcare centres had yielded a higher percentage of migrants visiting specified TB clinics (Schepisi et al., 2013).

The study reports 254 individuals that provided at least one symptom of active TB during screening. Of these patients referred to a TB clinic, about half of them were present for further diagnosis and eventual treatment. A drawback to the study was the lack of detail on the screening model used.

The study does not outline TB symptoms used to determine a migrant’s eligibility to be recommended to TB clinics. It was found that 30 percent of migrants were not referred for further diagnostic evaluation (Schepisi et al., 2013), which ultimately questions the entire results.

Bennett et al. (2014) used TBHI screening results to analyze the prevalence of LTBI among the refugee population in San Diego, California, from January 2010 and October 2012. Based on the study, the screening initiative indicated 43 percent of cases with LTBI come from Sub-Saharan Africa (Bennett, Brodine, Waalen, Moser, & Rodwell, 2014).

The study found that these patients were less likely to initiate treatment than refugees from the Middle East. Bennett et al. (2014) also found that refugees with post-secondary education at minimum were more likely to participate in screening, understanding the disease, and then initiating treatment.

One of the study’s drawbacks is its methodology, which heavily relied on self-report data on factors such as smoking, diabetes, malignancy, ESRD, and education (Bennett et al., 2014). Therefore, there is an excellent chance of information bias which may have limited the variables’ accuracy or underreported because of perceived stigma.

Heuvelings et al. (2016) focus on screening techniques in European countries and Canada for LTBI. The study focuses the screening efforts placed on a category of the “vulnerable” population, including migrants, those of foreign birth, homeless people, drug/alcohol abusers, prisoners, and people with HIV in big cities (Heuvelings et al., 2016).

The study finds that screening uptake improves after vulnerable populations are specifically accommodated based on their unique needs (Heuvelings et al., 2016). The study is lacking in differentiating between populations and their correlations with screening. The study’s major research gap clans the screening effects into one broad category labelled “vulnerable population. Therefore, the study results are difficult to comprehend as generalizations are made to son in the study.

Pareek et al. (2016) examine the significance of LTBI on high-income countries with foreign-born patients to determine the best possible screening processes to lower the disproportionate burden of TB on these countries. The study focuses on multiple countries by reviewing their screening strategies in terms of yield and cost-effectiveness.

The study finds that common screening methods used for LTBI include tuberculin skin tests and interferon-gamma release assay, which is conducted post-arrival to the host countries (Pareek et al., 2016). The study finds that most high-income countries do not practice screening for LTBI. Do so post-arrival However, those who do, Pareek et al. (2016) see this method to be programmatically challenging to implement with the number of immigrants accepting and completing treatment to be suboptimal.

Zenner et al. (2017) examined the screening program Blackburn TST-based LTBI screening between 1989 and 2001 and further studied the treatment program between 2009 and 2013 that had used QuantiFERON (QFT) testing. According to the study, screening programs were aimed at recent migrants from high incidence TB areas identified through registrations with primary care physicians or a referral from the port of arrival (Zenner et al., 2017).

The comparative study of the two screening methods shows that there was a better predictive value of QFT than compared to TST. Zenner et al. (2017) also observe a greater reactivation rate of LTBI in the immigrant population, particularly immigrants from Southeast Asia, primarily from Pakistan and India.

However, there is a significant research gap found in Zenner et al.’s (2017) study, which is the length of the follow-up timing with participants being far-ranging and, in some cases, unknown. There are also cases in the study with participants that had entered the UK, resided, and then exited the UK (with the date of exit unknown), only to reenter again.

Education

Tardin et al. (2009) aimed to analyze TB in a low-incidence area (i.e., area in Geneva) using a computerized database that had identified an unusually high proportion of patients coming from a specific country between 2004 and 2006. Aside from its primary aim, the study also conducted a cultural evaluation to examine the social stigma of TB in the community, especially for contact tracing methods.

The study was primarily quantitative, focusing on 13 patients diagnosed with TB and using RFLP (restriction fragment length polymorphism) analysis. Tardin et al. (2009) were able to identify all the possible ethical issues in the study. To maintain ethical credibility, Tardin et al. (2009) addressed these issues and maintained its integrity and participants.

The study’s main findings are the revelation that the community has the low acceptance of the diagnosis of TB as it’s considered a ‘dirty and sinful” disease that only impacts people of low status or living deprived life (Tardin et al., 2009). The study provided a cultural evaluation that allowed several strategies to use community characteristics to facilitate contact tracing by enhancing TB testing and portraying it as a desirable social behaviour.

Wieland et al. (2012) examine the use of English as a second language program at a community centre as the backdrop setting of understanding perceptions about TB among foreign-born persons. The study was qualitative in that it used focus groups as a means for data collection among 83 participants. The study found a plethora of misconceptions about the transmission of TB and nearly no knowledge of latent TB.

The hindrance to obtaining TB-related knowledge was practical consideration for the foreign-born participants, like transportation costs and conflicts with their work schedule.

Butcher et al. (2013) examined 52 participants who were refugees and undergoing Isoniazid treatment for LTBI. The questionnaire distributed to participants focused on total knowledge and total side effects scores.

The study found a range of misconceptions about how TB was spread via water, dust, wind, or pollution (Butcher et al., 2013). These misconceptions impacted the patient’s willingness to take medication and comply with the treatment standards.

Colson et al. (2014) examine the TB knowledge, attitudes, and beliefs of foreign-born people in the US and Canada. The study finds that most participants had correctly answered their knowledge-based question son TB, while a majority also answered the perceived questions in the affirmative (Colson et al., 2014). Participants from Mexico and Latin America had a higher model adjusted knowledge score than immigrants from other world regions.

Gao et al. (2015) studied the knowledge and perceptions of LTBI among Chinese immigrants in Canada. The study is brilliantly executed by honing a specific immigrant population in a high-income low incidence country.

The study uses a mixed-methods methodology different from other studies discussed under this theme that used quantitative research approaches. Gao et al. first used a cross-section patient survey with focus group discussions with Chinese immigrants to understand the cultural perception of LTBI (2015).

The study results are significant as they suggest a significant concern in receiving the complex healthcare system. This took away the immigrant group’s want for testing and treatment.

Gao et al.’s (2017) focused on studying education material for immigrants regarding tuberculosis and LTBI. The study used a video that was a culturally tailored, multi-lingual, 4.5-minute health promotional video focused on LTBI with Canadian immigrants (Gao et al., 2017). Gao et al. (2017) found that 84 percent of viewers had found the video helpful while viewing the video caused a 21 percent increase in knowledge about LTBI.

This includes a significant increase in basic knowledge of LBTI transmission, symptoms, and treatments. However, the study did not focus on the video’s potential adverse effects, such as exaggerated fear, which can be considered an ethical ramification of conducting the study (Gao et al., 2017).

The study also lacked a long-term follow-up to determine if the knowledge that was gained was sustained. A major gap is the lack of clinical evidence that correlates knowledge acquisition to greater treatment or seeking screening.

Adherence to Treatment

Trauer and Krause’s (2011) study focused on newly arrived refugees from February 2006 to January 2009, studying the prevalence of latent TB and their adherence to treatments. The study found that older male patients from the Eastern Mediterranean region were associated with increased latent TB.

However, the results found that only 44 percent of refugees had completed treatment (Trauer & Krause, 2011). The common reason for discontinuation or non-adherence to treatments was gastrointestinal side effects and their loss to follow-up. There were no cultural obstacles to the acceptance of treatment or stigmas that hindered treatment regimes.

Nuzzo et al. (2013) looked to determine the proportion of refugee patients at the Baltimore City Health Department TB program completing their LTBI treatment compared to other referral groups. Examine 841 patients, and it was concluded that 81 percent of refugees had completed their LTBI treatments compared to 50 percent of non-refugee patients and 35 percent of US-born patients (Nuzzo et al., 2013).

The findings are not presented because the research approach mainly focused on quantitative research, which does not examine participant opinions or perspectives, keeping strictly to empirical analysis measures. This lack of analysis in the study prevents it from reaching its full potential and brings to question the conclusions drawn in the study.

The lack of explanation is a major research gap that needs to be filled to understand more refugees’ phenomena adhering to treatment than native-born patients.

Kan et al. (2013) aimed at studying treatment completion in refugees to identify factors associated with failure to complete preventive treatments. The study had found that younger patients from Somalia and asylum seekers were more likely not to complete their preventative treatments.

However, the trend of medication completers has increased by 16 percent, most like caused by a skewness from an influx of European immigrants (Kan et al., 2013). The skewed data used for comparison purposes in the study makes it more challenging to provide accurate conclusions to question the entire study.

Peluso et al. (2014) focused on analysing a student-run free clinic for LTBI patients in a predominately Hispanic immigrant community. The study found that their foundation, which focused on cultural case management, improved adherence to LTBI treatments. The free clinic model used matching patients and providers based on language competence and social or cultural affiliations (Peluso et al., 2014).

There was improved communication between patient and provider through shared language, direct phone call access, and patient-centred interviews (Peluso et al., 2014). The drawback to the study is that it used a relatively small sample size, making it difficult to draw definitive conclusions from the statistical comparison of factors linked to treatment outcome and adherence to treatment.

Subedi et al. (2015) examined the evaluation and treatment of LTBI in refugees at various member clinics of Philadelphia Refugee Health Collaborative (PRHC) vs. non-PRHC clinics. Subedi et al. (2015) examine a specific model implemented in PRHC practices hiring a bilingual refugee health service coordinator.

This resulted in refugees being screened in great proportion, attending follow-up appointments, and completing the course of treatment. The model studied bases its success on a multidisciplinary approach whereby doctors, nurses, social workers, and caseworkers manage refugees’ screening, evaluation, and treatment follow-up.

From the sample, 89 refugees completed follow-up appointments and 34 completed treatments in PRHC clinics compared to only 31 completing follow-ups and 9 completing treatments in non-PRHC clinics (Subedi et al., 2015).

Rogo et al. (2017), in their quantitative study, studied 120 patients with LTBI in Rhode Island. The study followed these participants over their 9-month course of Isoniazid, all of them being children. The study compared refugee patients with those who were not refugees to develop a basis for their conclusions.

The study has found a greater completion rate among refugee populations as they had adhered better to treatment regimes, especially among female patients. The refugee population also attended more scheduled visits compared to non-refugee patients in the study.

Service Improvement

The literature review provides insight into the clinical issues related to screening, education, and adherence to treatment among immigrant populations with latent TB. Older studies in the current literature review, those pre-dating 2010, have shown that there is generally a low level of knowledge about latent TB and widespread misconceptions about the disease, especially regarding its transmission.

Some of the respondents in the studies did not have basic knowledge about the nature of bacteria and infection related to airborne transmission (Colson, Franks, Sondengam, Hirsch-Moverman, & El-Sadr, 2010; Nkulu, Hurtig, Ahlm, & Krantz, 2010; Wieland et al., 2012) but participants in other studies had attributed the disease to its correct facts (Colson et al., 2014; Gao et al., 2017; Rogo et al., 2017).

The attitudes and perceptions differed in each study based on its research location and the immigrant’s ethnicity group being studied. For example, in Gao et al. (2015), Chinese immigrants viewed the disease as irresponsible lifestyles or caused by living conditions, while the study conducted by Kan et al. (2013) found that Somali refugees considered TB to be a form of divine punishment for those that practiced a form of witchcraft or were dishonest.

When only focusing on immigrants’ education, the results provide insight into how the other three themes are impacted. With lack of education, more immigrants are likely not to adhere to preventive treatments, active treatments, and participate in screenings which were evident from the results obtained from studies like Bodenmann et al. (2009); Kulanes et al. (2010); Minodier et al. (2010); and Rogo et al. (2017).

Therefore, healthcare organizations and policy-making bodies need to widen their reach in immigrant populations to educate them on TB and latent TB. A greater awareness in the population will result in immigrants participating in a great deal more in screening and treatment. Heuvelings et al. (2016) found in their study that mobile screening units in Canada had increased the percentage of screenings in the country’s immigrant population.

Keeping in line with this service, it is recommended that low-incidence but high-income countries with large immigrant populations should invest in mobile health units dedicated to preventive diseases, like latent TB, to become available to their immigrant communities. A similar case was studied by Ospina et al. (2012), which found that community health workers improved screening and contact tracing among immigrants with TB in Barcelona.

Using a group of volunteer nurses, a mobile health unit’s strategy designated to specific areas that hold large populations of immigrants can help bring the incidence rate down. None of the literature reviewed in the current study has examined this particular strategy, most probably because it is non-existent.

However, this strategy’sactual implementation may be led to research in this area that focuses on mobile health units’ impact on screening, education, and adherence to treatment for latent TB.

Conclusion

The current study aimed to study how latent TB was tackled in the immigrant populations of low-incidence and high-income countries of the West and Australia. The literature review answered the research question to the fullest extent based on the available data. The current report uses 28 articles that were selected using the procedure of the systematic literature review.

Each of the articles was then analyzed using Caldwell et al. (2005) to critique academic literature. Based on the review, it is found that immigrant populations have a great lack of education in the topic of latent TB, often associated with their cultural misconceptions.

Articles published before 2010 found greater misinformation among immigrant populations, while more recent articles, particularly those published in 2017, saw a greater amount of awareness amongst them. The study has found various ways in which latent TB screening occurs, each differing based on the host country conducting the screening process.

However, most countries screen latent TB before the arrival of the host country. Studies have found that this allows for a greater chance of reactivation of latent TB among the immigrant population. There is no universal form of screening, causing disparities of TB incidences in each host country.

One of the most critical findings of the study was refugees’ great participation in adherence to TB and latent TB treatments compared to other forms of immigration and even native-born patients. Unfortunately, the studies analyzed could not provide the underlying cause for this phenomenon, proving a wide research gap in the literature.

Based on the literature review findings, a service improvement recommendation was made to improve the status of TB among immigrant populations in low-incidence, high-income countries.

The recommendation is made to healthcare organizations of such countries and policymakers – a greater effort in education and awareness programs targeted to immigrant communities in host countries. It was recommended that government and healthcare providers invest in mobile units dedicated to educating, screening, and providing treatment to immigrant communities for preventable diseases.

This recommendation’s justification comes from the literature review, which links a lack of education and knowledge to a lack of screening and non-adherence to treatments. This conclusion is based on correlation and not causation, as all the literature studied did not explain the relationship between these factors.

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