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Comparison of the Professionalism Behaviours of Medical Students from Four GCC Universities with Single-gender and Co-educational Learning Climates
Abstract
Background:
Medical professionalism is a multi-dimensional construct that is viewed differently across institutions. Such variations might be related to diverse cultural and societal characteristics of learners and faculty.
Objectives:
This study determined whether differences exist between proposed sanctions for a one-time academic integrity infraction associated with unprofessional behaviors. We selected four medical schools with either single-gender or co-educational learning environments in the Gulf Cooperation Council (GCC) countries.
Methods:
The 34-statement Dundee Polyprofessionalism Inventory I was disseminated to all medical students across years in selected institutions. Descriptive and inferential statistical analyses were conducted, and median scores were used to determine the respondents’ proposed sanctions.
Results:
Of the 1941 invitees, 1313 students responded (response rate of 68%). Significant similarity, as recorded by median sanction scores was recorded for 21 (62%) of the 34 inventory items from two medical schools. However, significant differences of one level of difference between all the median sanction scores for single-gender and co-educational students were found for 32% of inventory items. In co-educational schools, males were stricter than females for 9% and seniors were stricter than juniors for 12% of the inventory items. In contrast, in single-gender schools, females were stricter than males for only 6% of the inventory and seniors were more lenient than juniors for another 6% of the inventory.
Conclusions:
This study reports significant congruence and some differences in medical students’ perceptions of unprofessional behaviors. Educators are urged to develop a unified framework for enforcing sanctions to unprofessional behaviors.
1. INTRODUCTION
Academic integrity is a comprehensive concept that incorporates many fundamental values, such as scientific honesty, originality, accountability, responsibility, respect, trust, fairness, and acknowledgement of the ideas of others.Academic integrity and scientific honesty are the basis of the quality of education and research [1]. Various researchers in different contexts have defined the term “medical professionalism” differently. Such variation might be related to the various types and nature of organizations that researchers are from as well as their due to cultural and societal characteristics [2]. According to the Accreditation Council for Graduate Medical Education (ACGME 2004), professionalism is related to the “commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population” [3]. The main components of medical professionalism include integrity, honesty, the ability to work in a team, and effective communication skills between doctors and their patients [4, 5]. Additionally, altruism is a key component of professionalism that refers to selflessness and commitment to duty over self-care [6].
Medical polyprofessionalism refers to working together with a variety of healthcare specialists to deliver high quality, evidence-based patient care [7]. Worldwide, evaluation of the offenses that violate professional and academic codes of ethics are often subjective and varies among institutions according to cultural and social factors. Within the Gulf Cooperation Council (GCC) countries, a call for the integration of professionalism into medical schools’ national curricula has been well received [8]. Therefore, a national competency framework for doctors was developed in the Kingdom of Saudi Arabia (KSA) that contains 6 of 30 elements related to professionalism [9]. In the United Arab Emirates (UAE), a study was performed by Abdel-Raziq et al. to reach a consensus on the characteristics of medical professionalism as viewed by a professional team [8]. The study results identified nine characteristics: communication, integrity, education, compassion and empathy, respect, commitment to advocacy, responsibility, adherence to ethical practice, and lifelong learning. Of these, compassion and empathy are noteworthy as they reflect the degree of professional attachment of the physicians with their patients.
As shown in the literature, many studies have been performed to investigate students' insights for appropriate penalties for infractions based on hypothetical events related to professional problems [10]. Nevertheless, it has been argued that it is difficult to reach a consensus or produce consistent results regarding the proper responses from a professional team through studies based on hypothetical events [11]. Roff and her colleagues carried out a series of studies to generate a list of agreed-upon levels of sanctions for unprofessional actions related to academic integrity, which ultimately led to the development of the Dundee Polyprofessionalism Inventory [12]. This inventory is an accessible, validated tool to evaluate academic integrity worldwide. The inventory investigates the attitudes of respondents regarding the most critical issues related to the quality of academic and professional practice to meet ethical codes by the General Medical Council (GMC) in the United Kingdom (UK). In 2011, an attempt was made to reach a consensus among medical teachers and students in the UK regarding lapses in academic integrity and professionalism. The study reported that there was a broad range of consensus among the two groups [12]. Since then, the inventory has been utilized at national and international levels. For example, the inventory has been utilized to identify the perceptions of medical students from one medical school regarding the recommended sanctions for unprofessional behaviors related to academic integrity [13]; to explore perceptions of the severity of lapses in professionalism among medical students at two medical schools at a national level [14] and among medical students in two different cultural contexts; to determine the degree of consensus regarding recommended sanctions between faculty and students in one medical school environment [12]; to compare the views of students and faculty regarding recommended sanctions at two different medical schools at a national level [15] and at two different medical schools in 2 different cultural contexts (international level) [5]; to map medical students professionalism in three different countries within the Arab Gulf region [16]; and to map norms of professionalism among medical students and faculty cohorts in multiple settings both within the UK and internationally, mainly in the KSA, Pakistan, and Egypt [17]. Regrettably, there is a scarcity of data that can shed light on the role of gender in shaping and explaining participants’ views about unprofessional behaviors.
To the best of the authors’ knowledge, no formal study has examined the variations in the recommended sanctions for academic integrity infractions among medical students enrolled in medical schools with either single-gender or co-educational learning environments within GCC countries. The purpose of the current study is to compare the two medical schools’ learning environments regarding the similarities and differences in students’ recommended sanctions for unprofessional behaviors. The study aims to determine whether significant differences exist in the proposed sanctions of students from four medical schools with either single-gender or co-educational learning environments in GCC countries.
2. METHODS
2.1. Study Settings
The current study was performed in four medical schools in GCC countries: one in the KSA (single-gender learning environment), one in Bahrain (BAH) (co-educational learning environment), one in the UAE in Al Ain (UAE-Al Ain) (single-gender learning environment), and one in the UAE in Sharjah (UAE-Sharjah) (co-educational learning environment).
2.2. Study Design
A cross-sectional study was performed from 1st April to the end of October 2016.
2.3. Study Population Sample Size and Sampling Technique
This study recruited all undergraduate medical students in their first, second, third, fourth, and fifth years studying at the four target medical schools in the KSA, BAH, the UAE-Al Ain, and the UAE-Sharjah.
2.4. Data Collection Tools
The questionnaire was administered on paper and online through SurveyMonkey® to all participants studying years one through five in the KSA, BAH, the UAE-Ain, and the UAE-Sharjah. The objective of the study was clarified on the cover page of the questionnaire, and the anonymous and voluntary basis of participation and confidentiality was explained. A participant’s completion of the survey was considered his or her provision of informed consent.
2.5. Instrument
We used the Dundee Polyprofessionalism Inventory I: Academic Integrity9 to investigate students' opinions about the proper sanctions for unprofessional behaviors related to academic integrity. The inventory includes 34 unprofessional behavior items (Appendix 1) for which students were asked to propose a sanction for a one-time lapse in each behavior with no mitigating situations. The sanction scores range from one to ten as shown below;
- 1= Ignore
- 2= Reprimand (verbal warning)
- 3= Reprimand (written warning)
- 4= Reprimand, plus mandatory counseling
- 5= Reprimand, counseling, extra work assignment
- 6 =Failure of specific class/remedial work to gain credit
- 7= Failure of specific year (repetition allowed)
- 8= Expulsion from college (readmission after one year possible)
- 9= Expulsion from college (no chance for readmission)
- 10= Report to regulatory body
Additionally, sociodemographic data, including variables such as gender, age nationality, and year of study, were included.
| Features | Single-gender | Co-educational | Total |
|---|---|---|---|
| Age (Years) | 21.07±1.37 | 21.24±1.36 | |
| No (%) | No (%) | No (%) | |
| 17-19 | 71 (8.6) | 57 (11.8) | 128 (9.7) |
| 20-24 | 745 (90.0) | 385 (79.4) | 1130 (86.1) |
| 25 or more | 12 (1.4) | 43 (8.9) | 55 (4.2) |
| Gender | |||
| Male | 181 (13.7) | 232 (17.6) | 404 (30.7) |
| Female | 291 (22.1) | 618 (47) | 909 (69.3) |
| Level of study | |||
| Junior | 266 (20.2) | 421 (32) | 687 (52.3) |
| Senior | 219 (16.6) | 407 (30.9) | 626 (47.7) |
2.6. Statistical Analysis
The Statistical Package for Social Sciences, version 19 (SPSS, IBM, Chicago, Illinois, USA) was utilized to analyze the data. Descriptive statistics were calculated, with categorical data reported as frequencies and percentages and continuous data reported as medians, means, and standard deviations. According to the results of the normality test, non-parametric tests were utilized. Comparison analyses of the participants' median sanction scores based on their demographic characteristics were performed using the Mann-Whitney U test and Kruskal-Wallis tests (for two groups and for more than 2 groups, respectively). A significance level of 0.05 was considered the cut-off point for statistical significance.
2.7. Ethical Considerations
The current study obtained ethical approval from the institutional review board (IRB-2016-03-022) of the target medical school in the KSA, the Research Ethics Committee of the target medical school in the UAE-Sharjah (REC-18- 10-09-01) and agreements with the targeted medical schools in BAH and the UAE-Al Ain.
3. RESULTS
Of 1941 distributed questionnaires, 1313 complete responses were received (response rate of 68%). Table 1 shows that the majority of the students in the two types of medical schools (90%, single-gender; 79%, co-educational) belonged to the 20-24 year age group. Most students were females at both single-gender and co-educational medical schools; 909 (69.3%) females and 404 (30.7%) males. Similarly, other demographics are outlined in Table 1.
3.1. Comparison of the Students Proposed Sanctions for Unprofessional Behaviors
We found high similarity, as measured by the median sanction scores, for 21 (62%) of the 34 items in the inventory as proposed by the two groups of medical schools (Table 2).
Table 3 shows that for 11 (32.4%) of the 34 items in the inventory, there were significant differences of one level of difference between all the median sanction scores provided by the students of single-gender and co-educational medical schools.
As many as 10 of the 34 items in the inventory showed significant similarity between all the median sanction scores provided by male and female students at single-gender or co-educational medical schools (Table 4).
| Statement | Single-gender Medical Schools | Co-educational Medical Schools |
|---|---|---|
| S1 | 2 | 2 |
| S2 | 4 | 4 |
| S5 | 5 | 5 |
| S6 | 5 | 5 |
| S7 | 5 | 5 |
| S8 | 4 | 4 |
| S11 | 5 | 5 |
| S12 | 3 | 3 |
| S14 | 8 | 8 |
| S15 | 5 | 5 |
| S16 | 2 | 2 |
| S17 | 8 | 8 |
| S18 | 4 | 4 |
| S19 | 3 | 3 |
| S20 | 6 | 6 |
| S22 | 9 | 9 |
| S24 | 5 | 5 |
| S25 | 6 | 6 |
| S29 | 10 | 10 |
| S31 | 4 | 4 |
| S32 | 4 | 4 |
| Statement | Single-gender | Co-educational | p-Value |
|---|---|---|---|
| S3 | 2 | 3 | 0.000 |
| S4 | 1 | 2 | 0.000 |
| S9 | 4 | 5 | 0.000 |
| S10 | 7 | 6 | 0.000 |
| S13 | 7 | 6 | 0.000 |
| S21 | 4 | 5 | 0.000 |
| S23 | 5 | 4 | 0.002 |
| S28 | 5 | 6 | 0.004 |
| S30 | 3 | 4 | 0.000 |
| S33 | 6 | 5 | 0.000 |
| S34 | 8 | 7 | 0.000 |
| Gender | Age Group | |||||||
|---|---|---|---|---|---|---|---|---|
| Statement | Segregation Status | Male | Female | p-value | 17-19 | 20-24 | ≥ 25 | p-value |
| S6 | Single-gender | 5 | 5 | 0.000 | 5 | 5 | 5 | 0.888 |
| Co-educational | 4.50 | 5 | 0.555 | 4 | 5 | 4 | 0.608 | |
| S7 | Single-gender | 5 | 5 | 0.009 | 6 | 5 | 6 | 0.696 |
| Co-educational | 5 | 5 | 0.614 | 5 | 5 | 5 | 0.517 | |
| S8 | Single-gender | 4 | 4 | 0.000 | 4 | 4 | 3.50 | 0.809 |
| Co-educational | 4 | 4 | 0.820 | 4 | 4 | 4 | 0.763 | |
| S11 | Single-gender | 5 | 5 | 0.001 | 5 | 5 | 8.50 | 0.333 |
| Co-educational | 5 | 5 | 0.909 | 5 | 5 | 5 | 0.749 | |
| S17 | Single-gender | 6 | 8 | 0.000 | 8 | 8 | 10 | 0.726 |
| Co-educational | 7 | 8 | 0.382 | 9 | 7 | 8 | 0.028 | |
| S18 | Single-gender | 3 | 5 | 0.000 | 5 | 4 | 3.50 | 0.112 |
| Co-educational | 4 | 3 | 0.958 | 2 | 4 | 4 | 0.000 | |
| S23 | Single-gender | 4 | 5 | 0.055 | 5 | 5 | 3 | 0.233 |
| Co-educational | 4 | 4 | 0.302 | 3 | 4 | 4 | 0.055 | |
| S24 | Single-gender | 5 | 5 | 0.031 | 5 | 5 | 3.50 | 0.010 |
| Co-educational | 5 | 5 | 0.239 | 5 | 5 | 5 | 0.256 | |
| S25 | Single-gender | 6 | 6 | 0.000 | 6 | 6 | 6 | 0.586 |
| Co-educational | 6 | 6 | 0.092 | 6 | 6 | 7 | 0.007 | |
| S27 | Single-gender | 4 | 3 | 0.000 | 3 | 3 | 4 | 0.967 |
| Co-educational | 4 | 3 | 0.054 | 3 | 4 | 4 | 0.004 | |
| Co-educational | 4 | 4 | 0.004 | 5 | 4 | 5 | 0.000 | |
Table 4 displays a comparison of the gender differences in the median sanction scores within each type of medical school. For the co-educational medical schools, there were significant differences between one or more levels in the median sanction scores provided by female and male students regarding 3 items (S3, S16, and S26). Male students were significantly stricter (p < 0.05) for these items than their female counterparts. For single-gender medical schools, there were significant differences (p < 0.000) of one or more levels in the median sanction scores provided by female and male students regarding 3 items (S17, S18, and S27). Females were significantly stricter for S17 and S18, while males were significantly stricter for S27.
Table 4 also displays the significant differences in the median scores for the statements based on age group across the two types of medical schools. For the co-educational medical schools, notably, students belonging to the older age group (i.e., ≥ 25 years old) were stricter than other age groups in their recommended sanctions for seven statements. On the other hand, the younger students (20-24 years old) were more lenient than the other age groups in their recommended sanction for S17, “providing illegal drugs to fellow students”. For the single-gender medical schools, older students (≥ 25-year-old) were more lenient than the other age groups in their recommended sanctions for S19, “examining patients without knowledge or consent of supervising clinician”, and S24, “plagiarizing work from a fellow student or publications/ internet”. This study also showed that for the co-educational medical schools, senior students were stricter than the junior students in their recommended sanctions for S18, S27, S31, and S32. For the single-gender medical schools, senior students were more lenient than junior students in their proposed sanctions for S4, S12, S17, S19, and S23, while they were stricter for S9, “threatening or verbally abusing a university or college employee or fellow student”.
4. DISCUSSION
This research has highlighted some congruence and some variations in perceptions of the 34 identified unprofessional behaviors among medical students from four universities in GCC countries. There were significant similarities for 21 (62%) of the 34 items in the inventory, as measured by the median sanction scores. In sharp contrast, we found significant variations of one level of difference between all median sanction scores provided by the students from single-gender and co-educational medical schools for 11 (32.4%) of 34 items in the inventory. Such findings indicate a lack of standardized policy regarding sanctions and a lack of general consensus regarding the proper way to address unprofessional behaviors in medical schools.
Our study showed that 27 (79%) of the students from single-gender medical schools and 19 (56%) of the students from co-educational medical schools, including both male and female students, exhibited significant similarity for all their median sanction scores. This finding suggests some similarities in the study cohort’s understandings of professional attitudes and their suggested sanctions. Interestingly, in the study by Shukr and Roff [14], 1%-64% of Pakistani medical students admitted having committed 44 of 47 lapses in academic integrity, whereas, in our study, 34% of the respondents indicated that they had either witnessed or committed unprofessional acts. This wide range of variation has been linked to cultural and regional differences in various studies [18]. In one study, Ho et al. gathered Taiwanese students’ responses to ethical scenarios in five medical practice vignettes. The participants were presented with ethical dilemmas from North America, and then the collected data were compared with the data from the Canadian medical students. Although the Canadian framework was generally acceptable to the Taiwanese students, there were some different principles that were predominantly influenced by cultural virtues. In another study, Chandratilake et al. [19] identified 46 professional characteristics through a rigorous literature review and then surveyed 584 medical practitioners from the UK, Europe, North America and Asia. The researchers then measured the ‘essentialness’ of each attribute framed around different geographic perspectives using the content validity index. This study identified 29 attributes as ‘essential’, thereby indicating the universality of the defined professional attributes; however, six attributes were considered non-essential.
In the current study, in the co-educational medical schools, the senior students (i.e., ≥ 25-year-old) were stricter than the junior students in their recommended sanctions for S3, S12, S15, S16, S18, S21, and S25. Most of these unprofessional attributes are related to drug abuse and the provision of drugs to fellow students. Since all participants in this study belonged to the Muslim community, their strictness regarding these unprofessional acts reaffirms a general consensus about drug abuse and its legal and religious implications. In sharp contrast, from the single-gender medical schools, older students (≥ 25 years old) were more lenient than the younger students in their recommended sanctions for S19, “examining patients without knowledge or consent of supervising clinician”, and S24, “plagiarizing work from a fellow student or publications/ internet”. Worldwide, there has been a staggering rise in the incidence of the plagiarism of scientific literature [20]. Poor writing skills, a lack of knowledge about plagiarism, the pressure to publish mantra and academic and financial perks have been identified as key confounding factors contributing to plagiarism. In our study, other unprofessional behaviors had nonsignificant variations in the recommended sanctions, indicating major areas of consensus about professionalism. This study reports a consensus by the majority of the students from all four medical schools in the recommendation of high sanctions for cheating on examinations. Cheating involves the use of crib notes that are illegally brought into examination rooms and the use of silent cell phones to carry subject notes in students’ inbox and outbox folders. In collaborative cheating, candidates exchange special examination papers to help each other. We also observed that the students from single-gender medical schools were stricter than the students from co-educational medical schools for S9, “threatening or verbally abusing a university or college employee or fellow student” [21]. This strictness coincides with the degree of harassment that university students experience, particularly in countries with single-gender institutions [22].
Our study showed that in co-educational medical schools, greater sanctions were recommended by male than female students for 9% of the inventory items, whereas in single-gender learning environments, females were stricter than males in their proposed sanctions for only 6% of the inventory. While no logical insight can be derived from this finding, one can conclude that gender variations do exist among medical students regardless of the educational climate. However, generally, female students recommend strict behavior towards students making personal insults and derogatory remarks, while male students are stricter towards plagiarism and cheating [23]. In a comparative study of cheaters and non-cheaters, Jordan [24] argued that cheaters had different perspectives in terms of their knowledge of institutional policy and social norms about cheating. The study concluded that cheaters possessed lower mastery motivation and higher extrinsic motivation. These findings suggest the need to foster students’ awareness of unprofessional attitudes, including cheating and academic misconduct [25].
Understanding professionalism and its key elements hold a vital place for international medical graduates (IMGs), who are qualified in other countries but serve in the UK [26]. IMGs account for 37% of the registered physicians within the GMC. IMGs working in the Great Britain are reported to have been subjected to proportionally more investigations by the GMC regarding complaints about poor clinical skills, insufficient professional knowledge about legislative codes [27]. A body of literature has signaled that the majority of IMGs are not prepared to work in the UK due to difficulties in understanding the legal framework and cultural expectations of patients [28]. Poor communication skills, unawareness of cultural norms, individual autonomy, probity, confidentiality, and informed consent to treatment, which are required within the National Health Services (NHS), are major hurdles to the trainees. This dilemma, if not appropriately handled, can potentially lead to serious consequences, such as threats to patient safety, more complaints against practicing doctors, escalating compensation claims, and poor impressions of the NHS [29]. Another study concluded that Australian IMGs also showed significant variations in cultural attitudes, professional behaviors, and clinical acumen, as they felt culturally disconnected and isolated [30-31]. Educators have argued that better IMGs can be produced by applying a unified code of professional conduct that can cater to the culture-oriented professional character- istics of medical students worldwide [32]. This strategy will not only promote doctors’ confidence and professional performance but also lead to more highly skilled doctors working across countries. The current analysis reiterates the need to develop a standard code for professional values that can be conveniently applied across several regions of the world.
CONCLUSION
Using the Dundee Polyprofessionalism Inventory I: Academic Integrity, this study shows some regional similarities and some variations in understandings of the sanctions to unprofessional behaviors. Cultural and religious backgrounds essentially drive these differences. Nevertheless, we have identified a considerable number of areas that are universally agreed upon. This research emphasizes the need for more cross-cultural in providing a unique roadmap for reaching a consensus for recommended sanctions of unprofessional behaviors for the first time offense with no mitigating circumstances.
| # | Unprofessional Behavior | Sanction Level |
|---|---|---|
| 1 | Getting or giving help for coursework against a teacher's rules (e.g. lending work to another student to look at) | - |
| 2 | Removing an assigned reference from a shelf in the library in order to prevent other students from gaining access to the information therein. | - |
| 3 | Signing attendance sheets for absent friends or asking classmates to sign attendance sheets for you in clinic or lectures | - |
| 4 | Exchanging information about an exam before it has been taken (e.g. OSCE) | - |
| 5 | Forging a clinical tutor's signature on a piece of work, patient chart, grade sheet or attendance form | - |
| 6 | Claiming collaborative work as one's individual effort | - |
| 7 | Altering or manipulating data or findings (e.g. to obtain a significant result or disguise mistakes) | - |
| 8 | Failure to follow proper infection control procedures | - |
| 9 | Threatening or verbally abusing a university or college employee or fellow student | - |
| 10 | Attempting to use personal relationships, bribes or threats to gain academic advantages (e.g. by getting advance copies of exam papers or passing the exam) | - |
| 11 | Engaging in substance misuse (e.g. drugs) | - |
| 12 | Completing work for another student | - |
| 13 | Intentionally falsifying test results or treatment records in order to disguise mistakes | - |
| 14 | Physically assaulting a university or college employee or student | - |
| 15 | Purchasing work from a fellow student or internet supplier, etc. | - |
| 16 | Lack of punctuality for classes or clinics | - |
| 17 | Providing illegal drugs to fellow students | - |
| 18 | Not doing the part assigned in group work | - |
| 19 | Examining patients without knowledge or consent of supervising clinician | - |
| 20 | Sabotaging another student's work | - |
| 21 | Inventing extraneous circumstances to delay sitting an exam | - |
| 22 | Sexually harassing a university employee or fellow student | - |
| 23 | Resubmitting work previously submitted for a separate assignment or earlier degree | - |
| 24 | Plagiarizing work from a fellow student or publications/ internet | - |
| 25 | Cheating in an exam by e.g. copying form neighbor, taking in crib material or using mobile phone or getting someone else to sit for you | - |
| 26 | Cutting and pasting or paraphrasing material without acknowledging the source | - |
| 27 | Damaging public property (e.g. scribbling on desks or chairs | - |
| 28 | Falsifying references or grades on a curriculum vitae or altering grades in the official record | - |
| 29 | Involvement in paedophilic activities - possession/viewing of child pornography images or molesting children | - |
| 30 | Photographing dissection or prosection or cadaver materials | - |
| 31 | Joking or speaking disrespectfully about bodies/body parts | - |
| 32 | Inappropriate involvement in social media by posting photos/videos/texts about class or clinic activities | - |
| 33 | Posting inappropriate material bout fellow students, teachers or patients on social media | - |
| 34 | Drinking alcohol over lunch and interviewing a patient in the afternoon | - |
STUDY LIMITATIONS
The findings of this study reflect a selected cohort of medical students from four institutions in the GCC region. This may have some selection bias and more evidence-based research is needed to validate our findings.
ETHICS APPROVAL AND CONSENT TO PARTICIPATE
The current study obtained ethical approval from the institutional review board (IRB-2016-03-022) of the target medical school in the KSA, the Research Ethics Committee of the target medical school in the UAE-Sharjah (REC-18- 10-09-01) and agreements with the targeted medical schools in BAH and the UAE-Al Ain.
HUMAN AND ANIMAL RIGHTS
No animals/humans were used for studies that are the basis of this research.
CONSENT FOR PUBLICATION
Informed consent was obtained from all participants.
STANDARD OF REPORTING
STROBE Guideline and methodology were followed.
AVAILABILITY OF DATA AND MATERIALS
The data was collected from institutions involved in the study and then we did statistical analysis and incorporated in the article. The data is not stored in a URL or repository.
FUNDING
None.
CONFLICT OF INTEREST
The author declares no conflict of interest, financial or otherwise.
ACKNOWLEDGEMENTS
Declared none.
