key: cord-0319313-2dh1k4xv authors: Abdou, M. S.; Kheirallah, K. A.; Aly, M. O.; Ramadan, A. M.; Elhadi, Y. A. M.; Elbarazi, I.; Deghidy, E.; El Saeh, H. M.; Salem, K. M.; Ghazy, R. M. title: Psychological antecedents towards COVID-19 vaccination using the Arabic 5C validated tool: An online study in 13 Arab countries date: 2021-09-02 journal: nan DOI: 10.1101/2021.08.31.21262917 sha: 29faca4bc23c26c22894491e5c47c5673383085c doc_id: 319313 cord_uid: 2dh1k4xv Background and aim: Following emergency approval of vaccines, the amount of scientific literature investigating population hesitancy towards vaccination against the novel coronavirus disease (COVID-19) has increased exponentially. Nevertheless, the associated psychological behaviors with this phenomenon are still not clearly understood. This study aims to assess the psychological antecedents of the Arab population toward COVID-19 vaccines. Methods: A cross-sectional, online study using a validated Arabic version of the 5C questionnaire was conducted through different media platforms in different Arabic-speaking countries. The questionnaire included three sections: socio-demographics, COVID-19 related questions, and the 5C scale of vaccine psychological antecedents, namely confidence, complacency, constraints, calculation, and collective responsibility. Results: A total of 4,474 participants, 40.8% males from 13 Arab countries were included in the study. About 26.7% of participants had confidence in COVID-19 vaccination, 10.7% had complacency, 96.5% had no constraints, 48.8% had calculation and 40.4% had collective responsibility. The 5C antecedents showed variation among countries with confidence and collective responsibility being higher in the United Arab Emirates (UAE) (59% and 58%, respectively), complacency and constraints were higher in Morocco (21% and 7%, respectively) and calculation was higher in Sudan (60%). Regression analysis revealed that sex, age, educational degrees, being a health care professional, getting a COVID-19 infection, having a relative infected or died from COVID-19 can affect the 5C psychological antecedents by different degrees. Conclusion and recommendations: Wide variations of psychological antecedents between Arab countries exist. Different determinants can affect vaccine psychological antecedents. Coronavirus disease (COVID- 19) was initially identified in China in December 2019. Since then, infection with the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has swamped the globe. (1) The global threat of the pandemic is still on the rise with more than 200 million cases and more than 4 million deaths. (2) The situational report of the World Health Organization (WHO) showed that the Eastern Mediterranean Region (EMR) ranks fourth in the number of COVID-19 cases, totaling more than 12 million cases and nearly 240 thousand deaths. (3) (4) (5) Among the Arab world, as of 27 July 2021, Iraq had disclosed the highest number of cases followed by Jordan, the United Arab Emirates (UAE), Morocco, and Tunisia. Associated deaths were highest in Tunisia, Iraq, and Egypt. (5) The new variant strains, like the delta strain, are posing another threat to these countries and call for immediate action in terms of precautionary measures including vaccination. (6) As the Non-Pharmaceutical Intervention (NPI) measures against COVID-19, such as social distancing and curfew, were not enough to mitigate the spread of the virus, vaccination became the vital measure against the threats associated with COVID-19. (7) There is a global consensus supporting the notion that COVID-19 vaccines are likely the most effective approach to control the pandemic. (8) The unprecedented research efforts, and global coordination, have resulted in the rapid development and administration of vaccines likely to control COVID-19. (9) Since the emergence of COVID- 19 , there has been a surge in vaccines development. By 24 September 2020, a staggering number of vaccines had been under pre-clinical development, of All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted September 2, 2021. ; https://doi.org/10.1101/2021.08.31.21262917 doi: medRxiv preprint which 43 had entered clinical trials, including some approaches that have not previously been licensed for human vaccines. (10) Strenuous scientific efforts against the pandemic have led to the utilization of different modalities and novel techniques as vaccine platforms. COVID-19 vaccines are either mRNA (manufactured by Moderna and BioNTech/Pfizer), inactivated virus (Sinovac, Sinopharm), viral vector (Oxford/AstraZeneca, Gamaleya, Janssen/Johnson & Johnson, CanSino), or protein subunit (Novavax). The vaccine produced by BioNTech/Pfizer has been deployed to the public as the first-ever licensed COVID-19 vaccine. (11) More countries are entering the race of vaccine development such as Cuba, Brazil, and others. (12) People all over the globe have developed concerns regarding the COVID-19 authorized vaccines due to many reasons. (10) Some of these reasons include the quick development and release of the vaccines, the conspiracy theory including the origin of the vaccine, and possibly due to other factors to be explored. Vaccine Hesitancy (VH) existed before the COVID-19 emergence which augmented people's doubts and pushed people to become against vaccination. (13) One of the major obstacles against the success of the vaccination programs is VH, which can affect both the individual, by having a greater risk to get infected, and the community, by easily transmitting the pathogen. (14) As such, VH is among nine other health challenges considered as global health threats by the World Health Organization (WHO) in 2019. (15) VH is defined as a behavior associated with delay in acceptance or refusal of vaccines despite available services. It is a complex and context-specific behavior that varies across time, place, and disease but is still influenced by factors such as complacency, convenience, and confidence. (16) 6 The Five psychological antecedents of the vaccination tool (5C model) were developed by Betsch and colleagues. (17) The 5C model identifies psychological antecedents for everyone that may indicate whether an individual will vaccinate or not. These five antecedents are confidence, complacency, constraints, calculation, and collective responsibility. The 5C scale is used to assess these 5 psychological antecedents of vaccination and to provide insights into how the individual may think, feel, and behave regarding vaccination. These antecedents impact the vaccination behavior to varying degrees and assess the mental portrayals, attitudinal and behavioral propensities that result from the environment and context the individual lives in. (17) (18) (19) These antecedents are used nowadays as a framework to assess VH in the high-income countries to find whether people will or will not take the COVID-19 vaccine. (20) The COVID-19 VH rate was reported to be significantly different by socio-demographic characteristics, seasonal flu vaccination status, COVID-19 risk perception, and perceived benefits and clinical barriers of the COVID-19 vaccine. (21) In Hong Kong, 63% of nursing staff were likely to take the COVID-19 vaccine when available. (22) In low-and middle-income countries, the vaccine acceptance rate ranged from 66.5% in Burkina Faso to 96.6% in Nepal with an overall acceptance rate of 80.3%. (23) At this stage of the pandemic, especially as vaccine compliance remains variable and inconsistent, public health officers and policymakers, especially in developing countries where healthcare resources are limited, need to understand the reasons and factors associated with VH. To investigate the associated physiological behaviors with this phenomenon, this study has been conceived, the present study aimed to investigate the psychological antecedents of the Arab population towards COVID-19 vaccination. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. A cross-sectional, web-based, anonymous survey using the Arabic-validated version of the 5C questionnaire (24) was conducted between December 2020 and February 2021. The research team used social media platforms such as Facebook, Twitter, and WhatsApp, to recruit potential participants. The survey consists of the following sections: The first section includes the complacency, constraints, calculation, and collective responsibility were 5.7, 4.7, 6.0, 6.3, and 6.2, respectively. (25) The collected data was wrangled, coded, and analyzed using Python 3.9.2 software. The quantitative variables were expressed using mean ± SD, whereas counts (percentages) were utilized to describe the categorical variables. The Chi-square test was used to estimate pairwise correlations between categorical variables. Finally, respondents were categorized (Yes/No) based All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted September 2, 2021. ; https://doi.org/10.1101/2021.08.31.21262917 doi: medRxiv preprint on their mean 5C scores with reference to the cutoff points determined before. Further, five stepwise binary logistic regression models were performed to estimate significant predictors for confidence, complacency, calculation, constraints, and collective responsibility. Coefficients and correlations with P-value <0.05 were considered statistically significant. The study was approved by the Ethics Committee of the Faculty of Medicine, Alexandria University, Egypt (IRB No: 00012098). The researchers complied with the International Guidelines for Research Ethics. (26) Participants were informed that their participation was voluntary, and consent was obtained before administering the survey. A total of 4,474 participants from 13 Arabic countries were included in the current analysis, of which, 40.8% were males. The mean (SD) age was 32.48 ±10.76 years. The majority were either married (50.7%) or single (44.4%). About half of participants had a university degree (50.3%), the majority reported no chronic illnesses (82.7%), about two-fifth (40%) were health care professionals (HCPs), more than one-quarter (27.9%) reported being vaccinated against COVID-19 infection, nearly half (47.5%) had at least one person who got infected with COVID-19, about one third (33.6%) reported at least one relative died from COVID-19, and only 21.5% knew that there are different types of COVID-19 vaccines (Table 1) . All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. As shown in (Figure 2 ), confidence and collective responsibility were higher among the UAE population (59% and 58%, respectively), complacency and constraints were higher among the Morocco population (21% and 7%, respectively), while calculation was higher among Sudanese (60%). On the other hand, Egypt had the lowest confidence (15%), Lebanon had the lowest complacency (7.5%), Sudan had the lowest constraint (1.2%), Iraq had the lowest calculation (36%) and Morocco had the lowest collective responsibility (25%) Table 2 shows the distribution of each of the 5C domains by independent variables at the bivariate levels. The following variables significantly affected confidence domain: male sex (p<0.001), (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted September 2, 2021. The COVID-19 related constraint was significantly affected by being HCP (p= 0.004), previously infected with COVID-19 (p= 0.001), and knowing about different types of vaccines (p< 0.001). The calculation domain was significantly affected by sex (p= 0.007), marital status (p= 0.011), educational level (p< 0.001), being HCP (p< 0.001), having at least one relative died due to COVID-19 (p= 0.002), knowing about the different available types of vaccine (p< 0.001), and believing that there was a risk to get COVID-19 even after vaccination (p= 0.008). All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Educational level (p< 0.001), working as HCP (p< 0.001), previously infected with COVID-19 (p< 0.001), receiving Influenza vaccine yearly (p= 0.049), knowing about the different types of COVID-19 vaccine (p< 0.001), following COVID-19 protective measures (p< 0.001), and availability of vaccine for free (p= 0.003) affected the collective responsibility domain. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. To understand the reasons behind poor vaccination uptake and low acceptance, tools such as the 5C aim to determine individuals' psychological antecedents towards vaccination and to design interventions and develop appropriate actions. (17) This study was able to determine psychological antecedents of vaccine acceptance and determinants of hesitancy within a large number of Arab countries. This large multinational study aimed to assess COVID-19 vaccines psychological antecedent using an online disseminated validated Arabic version of the 5C scale. (2021) were able to demonstrate that it has discriminatory satisfactory power to predict the psychological antecedents of COVID-19 vaccine acceptance and were able to create a cut-off score used in this study. (25) In this study, it was found that the highest confidence was among the population from UAE, Saudi Arabia, and Kuwait, while the lowest confidence was among the population from Egypt. This finding is supported by the fact that most of the population in UAE and Saudi Arabia had been vaccinated with at least one dose of COVID-19 vaccination, while on the other hand, Egypt's data regarding vaccination of population is still unclear but in general, less than 4% of the population had been vaccinated. Four vaccines were approved to be used in All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted September 2, 2021. (2021) showed that Health care workers in Kuwait showed a high intention rate to receive vaccination and that may be again due to the high number of cases in the population, availability of vaccines, and educational efforts, and policies imposed by authorities. (29) The similarity in Poland and Canada HCPs demonstrated a high acceptance rate. (30, 31) Complacency was higher among the Moroccan and Jordan populations, while the lowest was among the population from Lebanon. Complacent people see that the vaccination is not important as their immune system can protect them from being infected with COVID-19. Chinese people saw themselves as having good health which in turn affects their intention to be vaccinated. (32) Similarly for constraints which were higher among Moroccan and Iraqi population. They had their own psychological barriers to avoid taking the vaccine although Morocco had vaccinated nearly 10 million of their population and 12% of them were fully vaccinated, and Morocco ranked the first country in Africa vaccinating its population as it received more vaccination doses than any other African country and designed a large number of vaccination centers and mobile vaccination teams for vaccinating its population. (33, 34) Since the vaccination All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted September 2, 2021. ; https://doi.org/10.1101/2021.08.31.21262917 doi: medRxiv preprint against COVID-19 started, Morocco's government launched communication campaigns to offer information, reassurance and raise the courage of people to be vaccinated. (34) The main barrier of Moroccan people is the European refusal of Sinopharm and Sputnik V vaccines which restrict their travel to Europe. (35) The highest calculation score was among Sudanese and Egyptians. Weighing between benefits and risks of being vaccinated before taking the decision. Both Sudan and Egypt did not The Emiratis had a higher collective responsibility regarding the COVID-19 vaccine. They are willing to protect themselves and others from being infected with the COVID-19 virus. Emirati population as well residents are among the highest populations in the Arab world to encourage social responsibility and collective responsibility. For the last few years, the UAE has been embedding these concepts through educational and social programs. The UAE national charter envisioned the importance of social commitment and responsibility through its mission and vision. (37) The UAE 2030 agenda for Sustainable Development Goals (SDGs) incorporated its goal to improve solidarity and unity as well as social responsibility. (38) Predictors affecting the five psychological antecedents vary between these antecedents, however, they are mainly related to being male, of advanced age, education, being a HCP, getting COVID-19, or having a relative infected or died from COVID-19. A similar study All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted September 2, 2021. ; https://doi.org/10.1101/2021.08.31.21262917 doi: medRxiv preprint 0 conducted among Arab countries found that gender, academic background, attitude towards flu vaccine, infection with COVID-19, and knowledge regarding the type of vaccine had a correlation with vaccine acceptance. (39) The results from Turkey and United Kingdom (UK) say that male, high education degree, and having children affect vaccine acceptance. (40) Also, results from low-and middle-income countries showed the willingness of persons to be protected from COVID-19 was the main reason for their acceptance to be vaccinated, while the fear from side effects was the main cause of VH. (23) Sallam et al (2021) (41) found an acceptance rate of COVID-19 vaccine of only 29% of their participants which showed a low acceptance rate worldwide compared to acceptance rate ranged from 55% to 90% in other countries. (42) (43) (44) American Study concluded that their high VH contributed to the beliefs that political and social factors and pressures were behind the accelerated approval of COVID-19 vaccines before complete testing of their efficacy and safety. (45) At the same time, a systematic review found variability of COVID-19 vaccination acceptance between countries with a large number having an acceptance rate of less than 60% which reflects the challenge in controlling the COVID-19 pandemic. The lower rate was reported mainly from Middle East, Russia, and Eastern Europe, while higher rates were reported from East and Southeast Asia. It concluded that COVID-19 VH has a major role in controlling the pandemic which in turn needs a collaborative response from governments, policymakers, and media. (46) Another meta-analysis found a VH of 17% and a pooled vaccine acceptance of 75%. It reported two reasons determining vaccine acceptance which are case fatality and the number of COVID-19 cases, while the most powerful cause affecting intention to be vaccinated was the people's trust in the safety of vaccines provided by their countries. (47) All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted September 2, 2021. ; https://doi.org/10.1101/2021.08.31.21262917 doi: medRxiv preprint 1 Soares et al (2021) studied the determinants of vaccine hesitancy and found that young age, loss of income during the pandemic, no intention of taking the flu vaccine, low confidence in health care systems during the pandemic, perception of adequacy measures taken by the governments, inadequate information announced by health authorities and low confidence in COVID-19 vaccine safety and efficacy were the factors affecting the refusal or delay of taking COVID-19 vaccine. (48) Studies around the world have identified reasons and prevalence of COVID-19 VH. In the Arab world, few studies were conducted and pointed out COVID-19 VH. In a recent pre -COVID-19 study conducted in the UAE, 12% of parents were vaccine-hesitant with concerns related to side effects, safety, and multiple injection sites. (49) In another qualitative study, health care professionals in the UAE showed some hesitancy and training needs on vaccine hesitancy. (50) Many recent studies have investigated COVID-19 vaccines acceptance around the world. (13, 49, 50) In Kuwait, a large number of HCPs had a satisfied acceptance of the COVID-19 vaccine with VH concentrated more among female HCPs, nurses, and HCPs working in private facilities, (29) while in Egypt, the level of VH among medical students was reported at 46% with the main concerns were side effects and ineffectiveness of COVID-19 vaccine. (51) In Jordan, willingness to take the COVID-19 vaccine (acceptance rates) with a significant portion of the population being indecisive. Participants were reported to be equally distributed between being willing, unwilling, and indecisive to take the COVID-19 vaccine. Participants reported more COVID-19 acceptance for the elderly than themselves. Vaccine development and availability are necessary but not sufficient to achieve immunity against a disease such as COVID-19. Reducing the incidence and prevalence of COVID-19, therefore, necessitates high acceptance and coverage rates to ensure high rates of the population will receive the vaccine. (52) (53) (54) (55) All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted September 2, 2021. ; https://doi.org/10.1101/2021.08.31.21262917 doi: medRxiv preprint One of the major strengths of the present study is the large sample size, in addition, the survey population is diverse with representation from different countries, age groups, ethnic and cultural backgrounds. However, the use of convenience sampling, online distribution of the study tool, and sample size determination which did not follow the standard procedure would limit the generalization of the study results to the region of interest. furthermore, there is a risk of selection bias favoring only individuals with access to the internet. A self-reported questionnaire was used to collect the data; hence our findings may be affected by social desirability bias. Despite the stated limitations, the study findings are not inconsistent with previous studies that reported the behavioral factors associated with COVID-19 vaccination hesitancy. More importantly, the study was able to shed light on the overlooked psychological antecedents of COVID-19 vaccination behavior in Arab countries for better policies and actions. The study found wide variations in the psychological antecedents of COVID-19 vaccination between the studied countries. Confidence and collective responsibility were higher in countries with high vaccination rates and lower in countries with low vaccination rates. However, other psychological parameters (complacency, constraints, and calculation) differed across countries with varying vaccination rates. Gender, education, getting infected, or having a relative infected or died were the predictors affecting the five psychological antecedents of vaccination. Governments' decisions and policies, media, and health care authorities must have a role in changing the behavior of the population toward COVID-19 vaccines to insure optimal vaccine acceptance in the region. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted September 2, 2021. ; https://doi.org/10.1101/2021.08.31.21262917 doi: medRxiv preprint Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): The epidemic and the challenges Five million COVID-19 cases reported in WHO's Eastern Mediterranean Region 2021 COVID-19 weekly epidemiological update 2021 World Health Organization Regional office of Eastern Mediterranean World Health Organization Regional office of Eastern Mediterranean Acceptance and preference for COVID-19 vaccination in health-care workers (HCWs) Vaccine development for emerging infectious diseases Vaccines for COVID-19: The current state of play COVID-19 vaccines: comparison of biological, pharmacological characteristics and adverse effects of Pfizer/BioNTech and Moderna Vaccines. European review for medical and pharmacological sciences COVID-19 Vaccines: Current Status and Implication for Use in Indonesia COVID-19 vaccine manufacturing 2021 COVID-19 vaccine rumors and conspiracy theories: The need for cognitive inoculation against misinformation to improve vaccine adherence COVID-19 vaccine hesitancy in the UK: the Oxford coronavirus explanations, attitudes, and narratives survey (Oceans) II Ten threats to global health in Vaccine hesitancy: Definition, scope and determinants Beyond confidence: Development of a measure assessing the 5C psychological antecedents of vaccination Using Behavioral Insights to Increase Vaccination Policy Effectiveness The 5As: A practical taxonomy for the determinants of vaccine uptake Understanding COVID-19 vaccine hesitancy Determinants of the willingness of the general population to get vaccinated against COVID-19 in a developing country Editor's Choice: Influenza vaccine uptake, COVID-19 vaccination intention and vaccine hesitancy among nurses: A survey COVID-19 vaccine acceptance and hesitancy in low-and middle-income countries Arabic validation and cross-cultural adaptation of the 5C scale for assessment of COVID-19 vaccines psychological antecedents Determining the cutoff points of the 5C scale for assessment of COVID-19 vaccines psychological antecedents among the Arab population: a multinational study Sample study protocol for adapting and translating the 5C scale to assess the psychological antecedents of vaccination Psychological Determinants of COVID-19 Vaccine Acceptance among Healthcare Workers in Kuwait: A Cross-Sectional Study Using the 5C and Vaccine Conspiracy Beliefs Scales Covid-19 vaccine acceptance, hesitancy, and refusal among Canadian healthcare workers: A multicenter survey Attitude and Behaviors towards SARS-CoV-2 Vaccination among Healthcare Workers: A Cross-Sectional Study from Poland Understanding COVID-19 vaccine demand and hesitancy: A nationwide online survey in China Morocco achieves the highest COVID-19 vaccine rates in Africa in the first phase: what are reasons for its success Moroccans lament as Sinopharm's vaccines run up against EU barriers. Africannews. 2021. 36. Amnesty International. Egypt: Haphazard and flawed Covid-19 vaccine rollout fails to prioritize most at-risk 2021 National Committee on Sustainable Development Goals. UAE and the 2030 agenda for sustainable development; Excellence in implementation COVID-19 vaccine hesitancy is associated with beliefs on the origin of the novel coronavirus in the UK and Turkey High Rates of COVID-19 Vaccine Hesitancy and Its Association with Conspiracy Beliefs: A Study in Jordan and Kuwait among Other Arab Countries Attitudes Toward a Potential SARS-CoV-2 Vaccine : A Survey of U.S. Adults. Annals of internal medicine A global survey of potential acceptance of a COVID-19 vaccine Influences on Attitudes Regarding Potential COVID-19 Vaccination in the United States. Vaccines (Basel) Vaccination Hesitancy in the United States: A Rapid National Assessment COVID-19 Vaccine Hesitancy Worldwide: A Concise Systematic Review of Vaccine Acceptance Rates Systematic Review and Meta-analysis on COVID-19 Vaccine Hesitancy Factors Associated with COVID-19 Vaccine Hesitancy Vaccine hesitancy and its determinants among Arab parents: a cross-sectional survey in the United Arab Emirates Exploring vaccine hesitancy among healthcare providers in the United Arab Emirates: a qualitative study Vaccine hesitancy: Beliefs and barriers associated with COVID-19 vaccination among Egyptian medical students Vaccine hesitancy: an overview When a COVID-19 vaccine is ready, will we all be ready for it? Herd Immunity": A Rough Guide Mandatory vaccination: suited to enhance vaccination coverage in Europe? Euro surveillance : bulletin Europeen sur les maladies transmissibles Conceptualization of research idea, data collection, and writing the manuscript Assisted in data collection, writing, and revising the manuscript Assisted in data collection, writing, and revising the manuscript Performed the statistical analysis, data interpretation, and visualization, and revising the manuscript Assisted in data collection, writing, and revising the manuscript Assisted in data collection and revising the manuscript • Haider M. El Saeh: Assisted in data collection, writing, and revising the manuscript Assisted in data collection, writing, and revising the manuscript