Examining Factors Contributing to Mortality in Saudi Arabia: Proposing Effective Healthcare Management Approaches: A Descriptive Study

doi:10.21203/rs.3.rs-3781822/v1

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Research Article

Examining Factors Contributing to Mortality in Saudi Arabia: Proposing Effective Healthcare Management Approaches: A Descriptive Study

https://doi.org/10.21203/rs.3.rs-3781822/v1

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Background

Non-communicable diseases (NCDs) are a leading cause of death worldwide, and their prevalence is increasing in Saudi Arabia due to unhealthy lifestyles and longer life expectancy. This research aims to investigate the primary causes of mortality in Saudi Arabia and develop healthcare management strategies to improve mortality outcomes, reduce preventable deaths, and enhance the delivery of healthcare services.

Methods

Secondary quantitative data from local statistics perdu GASTAT and WHO is utilized to analyze mortality rates and non-communicable diseases in Saudi Arabia from 2017 to 2021. The study includes the entire Saudi Arabian population, and statistical analysis is performed using IBM SPSS Statistics version 27 and Microsoft Excel.

Results

The analysis of mortality rates in Saudi Arabia over five years reveals non-communicable diseases as the primary contributors to increased mortality. Variations in mortality rates are observed between adult females and males, with standard deviations (SD) of 3.69 for females and 3.53 for males. Ischemic Heart Disease demonstrates a higher mean mortality rate among males (133.25) compared to females (87.84), followed by Stroke, Neoplasms, Kidney diseases, and Diabetes Mellitus. The regression model highlights the significant impact of different causes of death on mortality rates, offering a robust framework for predicting these rates (p < 0.001).

Conclusion

To effectively address the leading causes of mortality, Saudi Arabia requires comprehensive policy measures to manage healthcare. These measures include public health campaigns, wellness programs, early detection initiatives, government investment in medical research, regulatory measures, and policies promoting healthy lifestyles.

Mortality

NCD

death

health strategies

health policy

Non-communicable diseases (NCDs) are the leading cause of death worldwide. It is accountable for 74% of deaths globally [1]. In Saudi Arabia, 73% of Mortalities are due to NCDs. Most deaths are caused by cardiovascular diseases 37%, followed by Cancers 10% Chronic respiratory diseases 3% and Diabetes 3% also 20% for other NCDs. Other causes of death are 16% from Injuries and 11% from Communicable, maternal, perinatal, and nutritional conditions [2].

The growing frequency of NCDs in Saudi Arabia can be attributed to two key factors. In the first place, there has been a rising tendency toward unhealthy lifestyles and ill health behaviors, which may account for the transition in disease trends from primarily communicable diseases to noncommunicable diseases. Second, the lifespan of the Saudi Arabian population has increased, with life expectancy rising from 64 years in the 1980s to 74 years in the 2000s. The prevalence of NCDs, which grows with age, has increased concurrently with this increase in life expectancy [3]. Also, behavioral risk factors such as tobacco use, poor diet, physical inactivity, and alcohol consumption, and biological risk factors such as high blood glucose, increased blood pressure, obesity, and abnormal blood lipids contribute to NCD mortality and morbidity rates [4]. Through effective control measures, the effects of this global epidemic can be diminished. Reducing chronic disease risk factors is necessary to avoid premature death, disease, and disability [5]. If risk factors remain unchanged it is expected that by the year 2050, the DALYs (disability-adjusted life years) per 100,000 for women will increase from 3,550 in 2020 to 8,628 in 2050, and for men from 5,073 in 2020 to 12,198 in 2050 [6]. Making alterations in these risk factors such as smoking cessation, healthy diet and exercising would have an enormous potential to reduce the DALY burden of NCDs in Saudi Arabia by 4.9% in the year 2050 [6].

Effective national NCD policies and initiatives have been shown to decrease the burden of NCDs, even though the prevalence and impact of NCDs continue to rise, posing a challenge to every health system [5]. The Ministry of Health (MOH) in Saudi Arabia has launched several policies and programs to improve NCDs' early detection and treatment [5]. The national health policies include Nutrition policy, Physical activity policies, and Tobacco policies. The national programs include the establishment of an NCD control program, monitoring, and evaluation, multisectoral collaboration, and the chronic care model [5].

The Nutrition Policy

Excessive salt and sugar intake, trans fat intake, and a lack of fruit and vegetable consumption are among the most common examples of nutritional risk factors [7]. In Saudi Arabia, 94% of the population consumes inadequate quantities of fruit and vegetables regularly according to World Health Survey Saudi Arabia 2019 [8]. Saudi Arabia has implemented some of the WHO's Global Action Plans for The Prevention and Control of NCDs 2013–2020, such as monitoring salt intake in society, banning the use of trans fat in food content, and applying taxation on sweetened beverages [7, 9–11].

The Physical activity policy

In Saudi Arabia, lack of physical activity is a major problem. A systematic analysis found that Saudi Arabian children, adolescents, and adults do not reach the recommended levels of physical exercise suggested by WHO, with women being especially sedentary [12]. Saudi Arabia made efforts to enhance public awareness of physical activity such as doing campaigns and educating the population about the importance of physical activity [13].

The Tobacco policy

In Saudi Arabia, the use of Tobacco is quite common, according to the 2019 Global Adults Tobacco Survey 19.8% of the population are using Tobacco products [7]. In 2019 MOH implemented Anti-smoking laws which included prohibiting the manufacturing of tobacco products, preventing advertisement of tobacco, forbidding smoking in many public places, warning labels on tobacco packages, and tax increases on tobacco products [14, 15].

Non-communicable Diseases Control Program

Numerous initiatives were created by MOH to specifically lower the prevalence of NCDs and enhance people's quality of life. These programs, which concentrate on cardiovascular diseases, cancer, diabetes, respiratory disorders, and obesity are used in all primary healthcare facilities. The programs include a national program for diabetes and prevention control, a national program for cardiovascular diseases, a national program for cancer prevention, and a national program for obesity. The program strategies concentrate on primary prevention, Secondary prevention, Quality health services, Monitoring, evaluation, and Research [5].

Monitoring and Evaluation

The MOH conducts surveys in the country regularly to monitor and assess the effectiveness of the implemented policies and procedures for controlling the NCDs [7].

Multisectoral Collaboration

The Public Health Authority oversees encouraging cross-sector cooperation and has created and supported several intersectoral programs such as the collaboration between MOH and the Ministry of Education in the RASHAKA program and The Healthy Schools program [7].

Chronic Care Model

The Chronic Care Model (CCM) is a team-centered care approach that aims to connect evidence-based chronic illness care and real care delivery by promoting efficient communication between primary care teams and patients. To provide patients with NCDs with high-quality care, the CCM includes six clinical practice components: decision support, delivery system design, clinical information systems, self-management support, community resource use, and enhanced healthcare organization. Clinical outcomes and care processes for patients with NCDs have been proven to benefit from interventions that incorporate one or more of the CCM's major components [16].

The Saudi Arabian government has implemented many strategies to decrease mortality rates in the country by making policies regarding the leading cause of death which is NCDs. This research aims to investigate the leading causes of death in Saudi Arabia and develop healthcare management strategies that can be implemented to improve mortality outcomes, reduce preventable deaths, and enhance healthcare service delivery.

Data

The data used for this study was secondary quantitative data derived from The General Authority for Statistics (GASTAT), and The World Health Organization (WHO). The data sets span a period of 5 years, from 2017 to 2021, and include comprehensive information about mortality rates in Saudi Arabia for both genders. Also, the other set of data includes information about several non-communicable diseases as a cause of death for males and females during the period from 2015 to 2019. These data sources are exceptionally reliable and have been used for many healthcare-related studies.

The study population includes the entire Saudi Arabian population, including the residents and the Saudi nationals. The results of this research are meant to apply to the whole Saudi Arabian population given that these data are indicative of the entire nation.

Variables

The main variables included in this study are: causes of death they are categorized into most leading causes of death in Saudi Arabia, number of deaths represents the number of deaths related to each cause for each year and gender, the year variable specifies the year for each cause of death for both genders and gender is categorized as Male and Female. This variable enables analysis of mortality rates according to gender.

Analytical approach

The data were analyzed and presented using descriptive statistics. The statistical analysis is conducted using IBM SPSS Statistics version 27, and data visualization is performed using Microsoft Excel.

The main analytical Methods employed are as follows:

Calculating mortality rates per 1,000 adults for both genders in each year from 2017 to 2021.

Calculating mortality rates per 1,000 adults for all age groups in each year from 2018 to 2022.

Calculating the Number of deaths for each cause of death per 100,000 population for both genders in each year from 2015 to 2019.

Frequency distributions and proportions are used to examine the primary cause of death.

Correlation and regression analysis are used to find the relationship between causes of death and mortality rates.

In Fig. 1. It appears that the mortality rates in Saudi Arabia from 2018 to 2022 vary across different age groups. Among the observed trends, the 5–9 age group consistently exhibits the lowest mortality rates, experiencing a notable decline from 2018 to 2019. On the other hand, the 65 + age group demonstrates the highest mortality rates, reaching a peak in 2021 before a subsequent decrease in 2022. Noteworthy fluctuations are observed in the 35–39 and 55–59 age groups, with mortality rates peaking in 2021 and 2019, respectively. The 50–54 age group also experience a substantial increase in mortality rates in 2021. Overall, these trends underscore the importance of age-specific considerations in understanding mortality patterns and informing targeted healthcare interventions.

Table 1

Demographic Table for Mortality Rates by Gender Per 1000 Adults (2017–2021).
Year	Female Mortality Rate per 1000 (n)	n (%)	Male Mortality Rate per 1000 (n)	n (%)
2017	79.41	7.94%	100.02	10%
2018	79.49	7.94%	101.80	10.18%
2019	81.36	8.13%	100.89	10.08%
2020	88.31	8.83%	108.38	10.83%
2021	80.84	8.08%	99.91	10%
Mean	81.88		102.20
Std Deviation	3.69		3.53

The data in Table 1. Reveals distinct patterns in mortality rates among adult females and males per 1000 population over the five-year period. The mortality rate for adult females exhibited a stable trend, from 2017 to 2019, followed by an increase in 2020. In contrast, adult males experienced a higher mortality rate across the years, with a similar pattern of initial increase and decrease.

The standard deviation for both groups remained within a narrow range with a SD = 3.69 for females and a SD = 3.53 for males, indicating that the data points were closely distributed around the respective means. These findings underscore the differences in mortality rates between adult females and males.

Table 2

Leading Causes of Death in Saudi Arabia for Females and Males Per 100,000 population (2015–2019).
Cause of Death	%	Mean	Std Deviation
Ischemic heart disease
Female	0.08%	87.84	0.3
Male	0.13%	133.25	0.42
Stroke
Female	0.05%	50.38	0.51
Male	0.04%	49.54	0.78
Neoplasm
Female	0.03%	37.48	0.84
Male	0.03%	33.55	1.18
Kidney Disease
Female	0.02%	27.24	0.53
Male	0.02%	25.63	0.23
Diabetes Mellitus
Female	0.009%	9.86	0.15
Male	0.01%	11.84	0.35

Descriptive statistics for the leading causes of death in Saudi Arabia for Females and Males between the years 2015 and 2019 are shown in Table 2. In summary, the mean of the causes of death are calculated for the 5 years span. The table shows that the leading cause of increased mortality rates are due to non-communicable diseases (NCDs), The data reveals variations in mortality rates between adult females and males across different causes of death. Notably, ischemic heart disease shows a higher mean mortality rate among adult males (133.25) compared to females (87.84), with low standard deviations, indicating a more consistent pattern in both genders. In contrast, stroke mortality rates are quite similar between females (50.38) and males (49.54), though the standard deviation for males is slightly higher. Neoplasm-related mortality rates, while lower, show a similar pattern with males having a slightly lower mean (33.55) compared to females (37.48). For kidney disease and diabetes mellitus, males exhibit higher mean mortality rates compared to females, but the standard deviations for both genders are low, suggesting less variability in mortality rates for these causes.

Note

H = Ischemic Heart Disease, S = Stroke, N = Neoplasm, K = Kidney Disease, DM = Diabetes Mellitus.

Figure 2. shows that according to WHO, the primary causes of death in Saudi Arabia from the year 2015 to 2019 are ischemic heart disease, stroke, neoplasms, kidney disease, and diabetes mellitus. The graph shows that ischemic heart disease is the leading cause with (220) deaths per 100,000. It is followed by stroke (100), neoplasms (70), kidney disease (52), and diabetes mellitus with (21) deaths per 100,000 population.

Table 3

Correlations for Study Variables.
Correlations
			Cause of Death	Mortality
Spearman's rho	Death Cause	Correlation Coefficient	1.000	− .981^**
		Sig. (2-tailed)	.	.000
		N	25	25
	Mortality	Correlation Coefficient	− .981^**	1.000
		Sig. (2-tailed)	.000	.
		N	25	25
Note: **. Correlation is significant at the 0.01 level (2-tailed).

Table 3. presents the results of Spearman's rank correlation analysis between two variables, "Death Cause" and "Mortality," using a dataset of 25 data points. The analysis aimed to assess the relationship between causes of death and mortality rates within the dataset. The Spearman's rho coefficient of approximately − 0.981 suggests a strong negative correlation between "Death Cause" and "Mortality," indicating that as the values of "Death Cause" change, the corresponding values of "Mortality" tend to change in the opposite direction. This suggests that certain causes of death are associated with higher mortality rates, while others are associated with lower mortality rates.

The highly statistically significant p-value (0.000) indicates that the observed correlation is not due to random chance, indicating that the negative correlation is real and not a result of random fluctuations. This negative correlation could have important implications for understanding the relationship between specific causes of death and mortality rates, suggesting that certain causes of death may be associated with higher mortality rates, while others may be associated with lower mortality rates.

Table 4

Regression analysis for Study Variables.
Model Summary
Model	R	R Square	Adjusted R Square	Std. Error of the Estimate
1	− .917^a	.841	.834	28.49313
Coefficients^b
Model	B	Std. Error	Beta	t	Sig.
(constant)	226.788	13.364		16.969	.000
Cause of Death	-44.510	4.030	− .917	-11.046	.000
a. Note: Predictors: (Constant), Cause of Death b. Dependent Variable: Mortality

In Table 4. The regression analysis (Model 1) explores the relationship between the independent variable "Cause of Death" and the dependent variable "Mortality Rate." The negative correlation coefficient (-.917) indicates a strong inverse relationship between the cause of death and mortality rate. The coefficient of determination (R Square) suggests that approximately 84.1% of the variability in mortality rates can be explained by the cause of death. The adjusted R Square, accounting for model complexity, remains high at .834. The standard error of the estimate is 28.49313, reflecting the average deviation of observed values from predicted values. The model includes a constant term and emphasizes the significance of the cause of death as a predictor. Overall, the analysis provides valuable insights into the impact of the cause of death on mortality rates.

The Coefficients Table outlines the relationships and significance of the variables in the regression model. The constant term (intercept) has a coefficient of 226.788, with a standard error of 13.364 and a highly significant t-value of 16.969 (p < 0.001), indicating that it contributes significantly to the model. The coefficient for "Death Cause" is -44.510, suggesting that for each unit change in the cause of death, there is an associated decrease in mortality rates. This relationship is supported by a substantial standardized coefficient (Beta) of -0.917 and a highly significant t-value of -11.046 (p < 0.001). These results underscore the robust and negative association between the cause of death and mortality rates. In practical terms, this means that different causes of death have a considerable impact on mortality, and the model provides a strong basis for predicting mortality rates based on the cause of death.

This study aims to examine the primary factors contributing to mortality in Saudi Arabia and propose effective healthcare management approaches that may reduce mortality outcomes, diminish avoidable deaths, and optimize the delivery of healthcare services.

The overall results show that the age group consisting of adults aged 65 years and older exhibits the highest mortality rates in Saudi Arabia. This tendency can be attributed to the high prevalence of chronic diseases within this group [17].

The findings collectively indicate that the primary contributors to mortality rates in Saudi Arabia are sequenced as follows: foremost is ischemic heart disease, succeeded by Stroke, Neoplasms, Kidney Diseases, and Diabetes Mellitus, respectively. This discernment underscores the predominant prevalence of non-communicable diseases (NCDs) as the leading cause of mortality within the Saudi Arabian population.

The study findings indicated a negative correlation between non-communicable diseases (NCDs) and increased death rates in Saudi Arabia. This phenomenon can be attributed to progress in reducing risk factors and efficiently controlling non-communicable diseases among the population. Research has shown that public health interventions can reduce mortality rates associated with diseases such as cancer, diabetes, and cardiovascular disease. However, the results can differ based on the circumstances and the type of programs [18]. For instance, the outcomes of different methods for cancer prevention and screening varied significantly, depending on the specific kind of cancer [19]. Nevertheless, programs can potentially enhance results and reduce medical expenses by motivating individuals with chronic illnesses to adhere to their outpatient treatment and attend scheduled sessions [20].

The correlation test results imply that causes of death correlate with elevated mortality rates, while others exhibit associations with lower mortality rates. The high mortality rates observed in cardiovascular disease raise significant concerns. The prevalence of cardiovascular disease (CVD) risk factors is significant in the Saudi population. This includes approximately two-thirds of the population having poor levels of physical activity, half of the population being obese, one-third consuming an unhealthy diet, one-third having dyslipidemia, one-third having hypertension, and one-quarter having diabetes [21].

To examine the prevalence of specific risk factors related to non-communicable diseases in Saudi Arabia, a study employed the World Health Organization's STEPwise strategy for monitoring such health issues. The results revealed a notable occurrence of physical inactivity, obesity, hypercholesterolemia, hypertension, diabetes, and current daily smoking within the population under investigation [22].

Due to the significantly high occurrence of cardiovascular disease (CVD) risk factors, patients in Saudi Arabia experience acute coronary syndromes and acute heart failure at an age almost ten years younger than the norm in industrialized nations. Consequently, they face an increased risk of cardiovascular complications and mortality [23–25].

Patients with diabetes have a 2 to 4 times higher risk of developing cardiovascular disease (CVD) compared to the general population [26]. Saudi Arabia ranks in the top 10 nations in terms of diabetes prevalence, as reported by the International Diabetes Federation Diabetes Atlas (8th edition) [27].

A study found that the total occurrence of obesity was extremely high in Saudi Arabia [28]. Highlighting the ineffectiveness of obesity prevention measures in the monarchy. Furthermore, certain risk factors have been associated with the rising incidence of obesity in the nation, such as a sedentary lifestyle and a growing tendency to calorie consumption [21].

The government's acknowledgment of the significance of primary prevention in treating cardiovascular illnesses (CVD) The Saudi government has implemented significant reforms in its healthcare system as part of the Saudi Vision 2030, intending to achieve high-quality treatment and efficient service delivery [21]. These changes are being carried out through the National Transformation Program. Furthermore, the government has acknowledged the significance of primary prevention in fighting cardiovascular diseases (CVD) and has introduced significant initiatives to enhance lifestyles such as Saudi Guideline for Tobacco [29], Obesity Control & Prevention Strategy 2030 [30], RASHAKA Program [31], Saudi Hypertension Guideline [32], KSA National Strategy for Diet and Physical Activity [33], and City humanization and walkability [34].

In addition, The World Heart Federation has launched an attempt to create a set of "roadmaps" aimed at decreasing premature mortality caused by cardiovascular disease (CVD) by a minimum of 25% by the year 2025. These roadmaps serve as a guide for countries aiming to establish or revise their national programs for the prevention and control of non-communicable diseases [35].

In Saudi Arabia, non-communicable diseases presently constitute the predominant burden of disease [36]. The annual economic burden due to non-communicable diseases in Saudi Arabia is quantified at US$24.4 billion, with direct charges constituting 45% of this financial burden [37].

The strategic prioritization of healthcare expenditure in Saudi Arabia (KSA) towards augmenting primary and preventive care is underscored by the pursuit of optimal efficiency and value for money. A critical imperative in this context is the comprehensive evaluation of the national readiness of Primary Health Care Centers (PHCs) to effectively implement the proposed reforms, particularly considering their commitment to prioritizing the new model of care [38].

Primary healthcare centers (PHCs) play a crucial role in assessing, managing, and treating non-communicable diseases (NCDs). The Saudi Ministry of Health (MOH) is currently conducting a plan to decrease the occurrence of chronic diseases. This plan involves the creation of specialized clinics for chronic disease care within Primary Health Care centers (PHCs). In 2019, Electronic Health Records (EHRs) were introduced in all Primary Health Centers (PHCs) to enhance their efficiency in handling chronic diseases and decrease the number of hospital admissions. While physicians acknowledge the good influence of EHRs, the system has not yet reached its maximum potential. The existing Electronic Health Record (EHR) system cannot grant patients complete access to their health information, hence limiting its potential to effectively assist in the management of chronic diseases. Furthermore, there is a requirement for enhanced capability to assist patients in terms of nutrition and physical activity [39].

Individuals having chronic diseases and experiencing financial strain may encounter difficulties adhering to their prescribed drug regimen [40, 41]. In numerous other countries, legislation protects those with chronic diseases from taking on an excessive financial load. As an illustration, France implemented a reduction in copayments for persons with chronic diseases, whereas Germany limits cost sharing to 1% of income instead of 2% for the entire population [42]. Saudi Arabia is a high-income country. A considerable proportion of this income has been distributed to the Saudi population through the provision of complimentary healthcare services to those who can verify their legal stay in the country status, regardless of their nationality [43].

Study Limitations

As of the year 2020 and subsequent years, the World Health Organization (WHO) lacks comprehensive data regarding the predominant causes of mortality in Saudi Arabia, rendering recent and updated information on this matter currently unavailable.

Recommendation

Further studies should be conducted from most recent data from the year 2023 to further investigate the relationship between non-communicable diseases and the Mortality rates in Saudi Arabia.

In conclusion, a range of policy recommendations can be instituted to effectively manage healthcare and address the predominant causes of mortality in Saudi Arabia. Firstly, healthcare promotion and preventive measures stand as crucial strategies in mitigating the leading causes of death in the country. Comprehensive public health campaigns and programs aimed at cultivating a healthy lifestyle, with a focus on aspects such as diet, exercise, and tobacco cessation, should be prioritized. Furthermore, the implementation of health and wellness initiatives within educational institutions and workplaces is imperative. Secondly, early detection and screening programs, particularly for prevalent diseases like chronic illnesses, need to be established. Diseases such as diabetes should undergo early screening for timely intervention and treatment. Encouraging individuals at elevated risk of diseases to undergo regular health check-ups and screenings is essential. Thirdly, substantial governmental investment in medical research and innovation is essential to comprehend the patterns, trends, prevention, and treatment modalities of diseases. Increased allocation of resources to healthcare is imperative for an in-depth understanding of the causes of diseases and the development of effective prevention measures. Embracing technology for studying disease patterns and facilitating early detection is crucial. Lastly, regulatory measures should be implemented to oversee the quality of foods available in the market. These regulations should ensure that only healthful foods are sold, promoting public access to safe dietary options. Policies advocating for healthy lifestyle choices, such as imposing high taxes on cigarettes and placing restrictions on the marketing of unhealthy foods, play a pivotal role in alleviating the burden of diseases in the population.

NCD: Non-communicable disease; GASTAT: The General Authority for Statistics; WHO: The World Health Organization; DALY: Disability-adjusted life years; CCM: Chronic Care Model; CVD: Cardiovascular disease; PHC: Primary healthcare center; MOH: Ministry of Health; EHR: Electronic Health Record.

Ethical approval

The study involves the analysis of secondary data collected from open resources for administrative and public health purposes. During this research, there was no direct contact with human individuals or sensitive data. This secondary data analysis does not require ethical approval.

Consent for publication

Not applicable.

Availability of data and materials

The datasets analyzed during the current study are available in The General Authority of Statistics. Mortality Rates in Saudi Arabia. Saudi Arabia Statistics. https://database.stats.gov.sa/home/indicator/544 , and The World Health Organization. (Global Health Observatory Data: Leading Causes of Death. World Health Organization. https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading-causes-of-death.

Competing interests

The authors declare that they have no competing interests.

Funding

Not applicable.

Authors' contributions

SJ conceptualized the study, designed the analytic plan, conducted statistical analysis, drafted sections of the manuscript, conducted the policy analysis, drafted study tables, critically reviewed the manuscript and approved the final manuscript as submitted. WO reviewed and revised the study protocol, critically reviewed the manuscript, and approved the final manuscript as submitted.

Acknowledgements

Not applicable.

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No competing interests reported.

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Examining Factors Contributing to Mortality in Saudi Arabia: Proposing Effective Healthcare Management Approaches: A Descriptive Study

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Abstract

Background

Methods

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Introduction

The Nutrition Policy

The Physical activity policy

The Tobacco policy

Non-communicable Diseases Control Program

Monitoring and Evaluation

Multisectoral Collaboration

Chronic Care Model

Methods

Data

Variables

Analytical approach

Results

Discussion

Study Limitations

Recommendation

Conclusion

Abbreviations

Declarations

Acknowledgements

References

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