Exploring the Efficacy of Spiritually Integrated Psychological Sessions in Managing Internet Addiction and Other Comorbid Symptoms

Abstract

Background

In this fast-paced world, the use of the internet has become very fundamental to both professional and personal existence, ultimately influencing human cognition. This has grown as a global concern for every age group, particularly among young adults. There have been many psychological therapies to effectively deal with internet addiction, and one such intervention can be through enhancing the spirituality component within individuals. Therefore, spiritually integrated psychological sessions (SIPS) within counselling settings can serve as a significant framework in managing internet addiction, particularly related to spending excessive time on social media platforms.

Purpose

(a) The purpose of this study is to assess the effectiveness of spirituality-based counselling sessions on reducing internet addiction (time spent ≥8 h/day on social media platforms), depression, anxiety and stress. (b) To enhance emotional and spiritual intelligence within the participants.

Methods

The present study used a single-case experimental design (SCED) using a phased intervention model inspired by non-concurrent multiple baseline design (NCMBD) to assess the effectiveness of the well-structured SIPS on reducing internet addiction, while enhancing emotional and spiritual intelligence as well as managing other comorbid symptoms reported by the participants, which are depression, anxiety and stress. A total of three participants (age between 15 and 18 years) were selected through purposive sampling with criterion-based selection. The methodology strictly followed the SCRIBE guidelines across the implementation of the sessions.

Results

The results obtained showed consistent patterns of stability in managing the usage of the internet, significant reduction in the reported symptoms of depression, anxiety and stress. There was also an enhancement in the emotional and spiritual intelligence among the participants.

Conclusion

The present research indicates that SIPS is an effective framework in reducing internet addiction (time spent ≥8 h/day on social media platforms like Instagram, WhatsApp, Facebook and Snapchat) and other symptoms of depression, anxiety and stress. The activities as well as techniques involved in SIPS have also been found to be effective in regulating both emotional and spiritual intelligence among adolescents while managing and improving their behavioural patterns.

Keywords

Spiritually integrated psychological sessions internet addiction emotional intelligence spiritual intelligence adolescents depression anxiety and stress

Introduction

In this new media age, the internet has significantly shaped adolescents’ lifestyles and become a central part of their lives, thanks to the convenience of portable devices, making it an everyday necessity.^{1, 2} The use of these devices and the easy accessibility of the internet have been proven to be highly beneficial for educational purposes, social interactions and entertainment.^{1, 3} This has consequently led to the ubiquitous use of the internet, contributing to its addiction.^{1, 4} Factors such as the type of activity, the user’s gender and the geographical region of the adolescents are linked with the prevalence of internet addiction (IA).^5–7 IA among adolescents is linked to many behavioural patterns with negative outcomes like aggression, frustration, self-harm, emotional burnout, social isolation, unrealistic perceptions, irrationality, cyberbullying, as well as indulgence in many risky behaviours.^6–9 There are other psychological comorbidities existing, like a depressive state of mind, anxiousness and sleep-related issues.^10–13 There are many factors that contribute to problematic use of the internet, which vary from dysfunctional family systems, lack of parental monitoring, conflicts arising in families on an everyday basis, low academic achievements, to adolescents who are living primarily apart from their parents or guardians.^{8, 14–16} According to extensive research, excessive internet use has led to numerous behavioural and social issues, raising serious concerns that necessitate immediate attention.¹⁷ Despite global concern, this condition is not specifically included in any of the authorised diagnostic manuals, such as the International Classification of Diseases (ICD-11), the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the World Health Organization’s (WHO) classification. However, the first media-related disorder identified in the diagnostic manuals is the ‘internet gaming disorder’.^{17, 18} Hence, the excessive use of the internet requires the role of well-planned psychological interventions in addressing the negative behavioural patterns of adolescents and promoting social adjustment, as well as fostering positive emotions.^{16, 19, 20}

IA gives a sense of alienation and detachment from the inner self, leading to a feeling of loss and identity crisis.²¹ Research indicates that spirituality enhances one’s stimulating and adaptive powers^21–24 and can be utilised to address feelings of crisis and alienation through psychological interventions. A deeper sense of contemplation is necessary to foster a feeling of relatedness, which can be achieved through spiritual intelligence (SI). Similar to spiritual quotient, another essential component that helps to manage IA is emotional intelligence (EI). According to past literature, high EI is linked with lower IA, as IA impacts one’s ability to manage emotions and maintain healthy interactions with others.²⁵ In such cases, therapies focusing on the enhancement of EI can help people to overcome addiction and maintain a healthy lifestyle.^26–29

Psychological interventions have been one of the fundamental approaches to handling issues such as impulsiveness, maladaptive cognition, depression or anxiousness. Cognitive Behavioural Therapy, Naikan therapy, mindfulness, reality therapy and sports-based interventions are known best for the treatment of IA in the last decade.^{20, 30–35} However, these therapies are proven to be good for digital detox only for a short duration of time. There is a need for more effective and sustained interventions, considering the severity and prevalence of the condition, which can be achieved through spiritually integrated interventions.^36–38

Case Presentation

Case A: ‘A’ is a 17 years old Male Higher secondary school-going student who reported constant irregularities in sleep. He had complaints of hypertension with emotional irregularities for the past 6 months. The client also complains of excessive self-doubt, inappropriate ways of expression and constant irritability. One week ago, the client reported heightened aggression, which resulted in a heated argument among family members and peers. He also reported maladjustment in various social gatherings with mood irritability. No other organic cause is present.

Case B: ‘B’ is an 18 years old Female Higher secondary school-going student who reported constant mood swings. She reported constant fatigue, high caffeine intake and sleep disturbances. She also reported the feeling of lightheadedness and hot flashes in her entire body. She complained of high frustration levels in her day-to-day activities, with a decrease in concentration. The informant also reported high mood dysregulation, and for the past 2 weeks, the client has poor social interaction and has refused to participate in any social event. There was also a series of self-criticising statements by the client during case history intake.

Case C: ‘C’ is a 17 years old Male Higher secondary school-going student who reported constant mood swings and extremity of fatigue. He also reported lack of sleep and hopelessness. He also reported the feeling of isolation and social disconnectedness. He complained of intense levels of impulse and frustration in his day-to-day activities, with a decrease in concentration and memory. The client also reported emotional dysregulation from the past 4 weeks, withdrawal from social interaction and refused to participate in any social gathering.

Objective

The purpose of this study is to assess the effectiveness of spirituality-based counselling sessions on reducing IA (time spent ≥8 h/day on social media platforms) depression, anxiety and stress (DAS).

To enhance emotional and SI within the participants.

Method

The present study used a single-case experimental design (SCED) using a phased intervention model inspired with non-concurrent multiple baseline design (NCMBD) to assess the effectiveness of the well-structured spiritually integrated psychological sessions (SIPS) on reducing IA and other comorbid symptoms reported by the participants. The design was opted for due to its relevance and applicability for understanding the functionality of the SIPS on different psychological variables reported by the participants.^{39, 40} As per the ethical standards in psychological counselling, unlike the NCMBD approach, the therapeutic support was provided to the candidates from the start till the end, which did not allow staggering in the baselines or any discrimination while dealing with the enrolled clients. However, the differences in the varied time periods were to emphasise the rigour of the SIPS and not the absence of the sessions. Therefore, all the participants received a total number of 15 sessions without any discrimination. The objective of the present study was to explore the significance and efficacy of a SIPS, which was carefully designed to enhance SI and EI and to lower the symptoms of DAS among adolescents aged between 15 and 18 years screened with IA, particularly excessive use of social media platforms like Instagram, WhatsApp, Facebook and Snapchat. The candidates who spent ≥8 h/day on social media platforms, as well as those diagnosed with IA by Dr Kimberly S. Young’s Internet Addiction Test,³⁷ were only selected for the study. The existing research indicates that there are limited interventions specifically designed to address IA, inspired by the lens of spirituality, which have been proven to be more effective.³⁸ Before starting the sessions, participants were pre-assessed on psychological variables, that is, on DAS levels using DASS-21 developed by Lovibond & Lovibond.^{12, 13} The participants were also evaluated on their EI using a scale developed by Nicolas Schutte.^{28, 29} Since the interventions were designed with a spiritual framework in particular, participants were also assessed on their SI using a scale developed by K.S. Mishra. The participants who were diagnosed previously with any other chronic mental or physical condition were excluded. Candidates seeking any other help to deal with their IA were also excluded. The research employed a purposive sampling with criterion-based selection method to select participants. The inclusion criteria included age of the participants, which was between 15 and 18 years only, were well proficient in both Hindi and English language and homogeneity based on socio-economic status was also maintained. Apart from these candidates who agreed to take offline therapy and continue for all 15 sessions were only included in this research. Another aspect, which was well kept in consideration about the inclusion criteria, was that participants and their respective guardians who had given their consent for undergoing spiritually integrated psychological counselling sessions were only involved in the study. Finally, only three adolescents were selected for this intervention-based study in dealing with IA and related comorbid symptoms. Participants also reported other comorbid symptoms like guilt, frustration and aggression. They were also targeted during the session as they were part of the reported symptoms. However, no separate standardised measure was opted to check pre-and-post scores of guilt, frustration and aggression as they were not directly part of the study. Consequently, a total of 15 sessions were given to the participants (n = 3) once a week, which lasted between 60 and 75 min each.⁴¹ The intervention was divided into three phases.

The first phase included five sessions that were dedicated to ‘inner connection’, which focused on rapport building as well as basic somatic awareness and mindful breathing as a meditative anchor, while establishing attentional anchoring.⁴² In the last two sessions of the ‘initial phase’ (Session 4 and Session 5), auto-suggestion-based breathing was introduced.⁴³

The second phase of the intervention included the next five sessions, which primarily focused on ‘identity formation and meaningful life’.⁴⁴ The first session emphasised on ‘identity exploration’ by recognising meaning in life. The clients were asked to set long-term and short-term goals and finally set the priorities. The narrative therapy was used with a spiritual lens, thereafter personal values were explored while addressing the existential questions like ‘Who am I? Why am I here? What gives life meaning?’⁴⁵ The second session emphasised on developing ‘coping skills’, and the third session focused on ‘relationship building’.⁴⁶ The fourth session mainly worked on ‘developing inner strengths’. The techniques included in this session were about reflection on spiritual stories and parables, leading to the formation of spiritual anchors and connection to inner strengths.^{47, 48} Apart from this, guided meditation,⁴³ creative expressions,⁴⁹ personalised affirmations ritual and strength mapping were also involved to understand their unique strengths. The fifth session included ‘shadow work by integrating inner dialogue’. The participants were encouraged ‘safe circle dialogues on their digital triggers’, ‘symbolic drawings’, ‘trigger mapping exercise’, ‘engaging in sacred substitutions’ and ‘creating commitment cards’.^{50, 51}

The last phase: It has another five sessions in which the first session focused on ‘Maintenance/Integration of past learnings’. In this session, participants were asked to share a reflection of his/her learning based on the previous sessions, thereafter they were encouraged to create a map of all the strengths, values and spiritual practices (three pillar journaling) developed by them.⁵² Further participants were asked to reframe a learning and connection through any spiritual story and their culturally relevant parable. The client was encouraged to map their own therapeutic journey about their confusions, clarity obtained and wisdom gained.⁵³ In the second session, emphasis was placed on ‘future prospects and identity’. In this sitting, the participants were given guided visualisation of meeting their future self and creating the ‘future self-portrait’. Thereafter, the participants were asked to identify one role model and recognise any three traits which they should imbibe in themselves. Further in the session, the client was asked to create a future compass with the three recognised qualities by identifying the paths for future trajectories.^{54, 55} Finally, the participants were given the task of planting one sapling in a pot and decorating the pot with colours of their choice and placing pebbles. The clients were told during the session that the growth of these saplings is symbolic of their growth and development. Further, the clients were asked to carry it as well as and were further motivated to take care and give attention to these saplings and have also been told they have to take care of themselves as well and be mindful about their actions and patterns in order to grow and inculcate strengths and values within themselves.⁵⁶ The third session was about ‘coping and relapse prevention’ in future. This session mainly focused on preparing a ‘coping toolbox’, which included creating an affirmations web, a booklet for journaling about their triggering emotions and subsequent reflections, a list of exercises/practices in which they can engage whenever their internet usage time increases, reflective reading as well as preparing their sacred substitutions.⁵³ Participants were given the guided visualisation for their ‘safe inner space’ and set spiritual anchors.^{54, 55} In the fourth session, participants were encouraged to create a gratitude circle, create their artistic expressions, perform candle gazing activity (Taraka kriya) and mindful object observation.⁵⁷ Clients were asked to re-evaluate their journey so far and discuss future prospects as well as the challenges they are still experiencing. In the last sitting, the ‘closure session’ was emphasised, in which ‘mindful digital pausing of technology’ was the focus, which tends to develop mindful awareness about controlling impulsiveness among the clients.⁵⁸ The last session again included guided meditation which emphasised upon the relaxation and releasing of all the previous negative thought patterns like guilt, frustrations or aggressions.⁵⁸ This helped clients for emotional release and set new patterns of transformations. Participants were finally asked to do cognitive reframing with creative engagements to carry as their future goals.⁴⁹ Clients were then re-assessed on the IA scale, EI, depression, stress and anxiety (DAS) as well as SI.

Therefore, in the present study, the sessions were planned according to spiritually oriented interventions to reduce compulsive thoughts of using the internet, inculcate relatedness with others, identify the purpose or meaningfulness, minimise the symptoms of depressive thoughts, anxiety as well as stress, and develop SI and EI.

All the participants (n = 3) were enrolled in the intervention-based study at different time periods, which did not vary in the duration of the sessions. As the design was inspired by NCMBD, in order to assess the impact of the sessions, the candidates were evaluated on their reported symptoms before beginning the initial phase A₁. The pre-assessment scores and observations were collected for the next participant, that is, Case B, once the initial phase A₁ was completed and assessed for Case A on the targeted variables. Similarly, the pre-assessment scores and observations were collected for Case C after phase B was completed for Case A and the initial phase A₁ was completed for Case B. This did not present any staggered baselines for the participants across all the sessions. Due to the nature of the design, there is no reversal or randomisation in the study, but the internal validity is strengthened without staggering through the replication of the same kind of activities across all the sessions. The replication of the intervention for all the participants served as the fundamental indicator of experimental control in order to ensure reliability as well as accuracy. The replication also establishes the generalisability and the credibility of the SIPS. Therefore, all the participants (n = 3) have undergone the sequential steps of the ABA design, where A is the initial phase, B is middle phase, and A is the last phase.

Table 1 showing the description of the cases with total session and counseling activities.

Table 1.

The Description of the Cases with Total Session and Counselling Activities.

Case(s)	Total Sessions	Counselling Activities	Phase Pattern	Design Label
Cases 1–3	15	Identical across sessions	A₁–B–A₂	Concurrent single-case design

Table 2 presents comprehensive overview of the division of the phases, sessions range, nature of counselling and purpose of the study to evaluate the effectiveness of the SIPS.

Table 2.

Comprehensive Overview of the Division of the Phases, Sessions Range, Nature of Counselling and Purpose of the Study.

Phases	Session Range	Nature of Counselling	Purpose
Phase A₁ (Initial Phase)	Sessions 1–5	Inner connection	Rapport building/basic somatic awareness to mindful breathing
Phase B (Second Phase)	Sessions 6–12	Identity formation and meaningful life	Setting spiritual anchors and connect to inner strengths
Phase A₂ (Last Phase)	Sessions 13–15	Integration of past learnings	Maintenance and consolidation/preventing relapse

The obtained data were further analysed using visual inspection methods, which are found consistent with SCED and SCRIBE guidelines, which include the variability, stability and trend analysis.^{59, 60}

Results

Case A

Table 3 represents the scores of Case A in IA, EI, SI as well as DAS.

Table 3.

Scores of Case A in IA, EI, SI as well as DAS.

Phase	IA	EI	SI	DAS
A₁ (Initial Phase)	65	85	50	18
B (Second Phase)	40	110	75	10
A₂ (Last Phase)	42	108	74	11

Note: DAS: Depression, anxiety and stress; EI: Emotional intelligence; IA: Internet addiction; SI: Spiritual intelligence.

Figure 1 represents the obtained scores calculated in order to check the effectiveness of the SIPS in reducing IA, enhancing EI and SI as well as decreasing DAS across A₁ (Initial Phase), B (Second Phase) and A₂ (Last Phase). Table 3 and Figure 1 clearly present the consistent pattern of stability across all the variables selected. The scores obtained on IA in A₁ (Initial Phase) are 65, whereas in B (Second Phase) they are 40 and in A₂ (Last Phase) they are 42. The scores indicate a substantial improvement in IA from A₁ to B but a very minimal and slight increase from B phase to A₂ phase is very substantial and is negligible therefore, it can be said that spiritually integrated sessions were effective for Case A. Thereafter, scores observed in EI in A₁ (Initial Phase) was 85 whereas, in B (Second Phase) was 110 and in A₂ (Last Phase) was 108. In another selected variable, SI, the scores obtained during various phases were 50 in A₁ (Initial Phase), whereas the score was 75 score in B (Second Phase), and the score was 74 in A₂ (Last Phase). The obtained scores in both EI and SI show very minor fluctuations, which are suggestive of high effectiveness of the SIPS in enhancing EI as well as SI within Case A. Subsequently, the DAS was also measured which the consolidated score of 18 in A₁ (Initial Phase), 10 in B (Second Phase) and 11 in A₂ (Last Phase) was obtained. The scores clearly indicate the improvement in trend within the participants’ DAS levels.

Figure 1.

Graphical Representation of the Scores Obtained in the Pattern of Phases for Case A.

Case 2

Table 4 represents the scores of Case B in IA, EI, SI as well as DAS.

Table 4.

Scores of Case B in IA, EI, SI as well as DAS.

Phase	IA	EI	SI	DAS
A₁ (Initial Phase)	70	80	48	22
B (Second Phase)	45	105	72	18
A₂ (Last Phase)	47	103	74	13

Note: DAS: Depression, anxiety and stress; EI: Emotional intelligence; IA: Internet addiction; SI: Spiritual intelligence.

Figure 2 showcases the calculated scores of IA, EI, SI as well as DAS across all the phases A₁ (Initial Phase), B (Second Phase) and A₂ (Last Phase) while giving SIPS to the participants. Table 4 and Figure 2 show the consistency in the pattern of stability across all the variables, namely EI, SI and DAS. The participants scored on IA in A₁ (Initial Phase) as 70, whereas in B (Second Phase) it was 45 and in A₂ (Last Phase) it was 47. However, there was a meaningful improvement in internet use from A₁ phase to B phase, but there was a very insignificant increase observed in scores from B phase to A₂ phase. This slight increase in score does not indicate the instability of the sessions. Therefore, there was no lapse observed in the usefulness of the SIPS. Thereafter, the scores in EI and SI were observed during different phases while SIPS was given to the candidate. In A₁ (Initial Phase), the score in EI was 80 and SI was 48; whereas, in B (Second Phase), the EI was 105 and SI was 57, and finally, the scores during A₂ (Last Phase) in EI were 103, and SI were 74. The obtained scores indicate an inconsiderable fluctuation, which propounds the high effectiveness of the SIPS in increasing and strengthening the level of EI as well as SI within the candidate. Likewise, other selected variables, which were DAS, were also measured across all the phases, and the scores obtained were during A₁ (Initial Phase) were 22, in B (Second Phase) were 18 and score of 13 during A₂ (Last Phase). The obtained scores are indicative of substantial changes within the participants’ DAS levels.

Figure 2.

Graphical Representation of the Scores Obtained in the Pattern of Phases Case B.

Case C

Table 5 represents the scores of Case C in IA, EI, SI as well as DAS.

Table 5.

Scores of Case C in IA, EI, SI as well as DAS.

Phase	IA	EI	SI	DAS
A₁ (Initial Phase)	60	86	48	16
B (Second Phase)	35	110	78	12
A₂ (Last Phase)	33	105	77	9

Note: DAS: Depression, anxiety and stress; EI: Emotional intelligence; IA: Internet addiction; SI: Spiritual intelligence.

Figure 3 shows the obtained scores for Case 3 on different phases of the SIPS effectiveness on IA, EI, SI as well as DAS across A₁ (Initial Phase), B (Second Phase) and A₂ (Last Phase). Table 5 and Figure 3 clearly highlight the stable patterns of stability across all selected variables. The scores obtained on IA in A₁ (Initial Phase) are 60, whereas in B (Second Phase) they are 35 and in A₂ (Last Phase) they are 33. Although there was a substantial improvement in IA from phase A₁ to phase B, there was a very negligible increase in scores from B phase to A₂ phase, which indicates that there is no decline in the effectiveness of the sessions. Thereafter, the scores of EI in A₁ (Initial Phase) is 86 whereas, in B (Second Phase) is 110 and in A₂ (Last Phase) is 105 whereas in SI scores are in A₁ (Initial Phase) is 48 whereas, in B (Second Phase) is 78 and in A₂ (Last Phase) is 77. The obtained scores elicit very inconsequential fluctuations, which suggests a high effectiveness of the SIPS in enhancing EI as well as SI within the participants during the sessions. Subsequently, the DAS was measured through using DASS-21 inventory which gives the consolidated score of DAS as 16 in A₁ (Initial Phase), 12 in B (Second Phase) and 9 in A₂ (Last Phase). The obtained scores are clearly indicative of sustained improvement in trend within the participants’ DAS levels.

Figure 3.

Graphical Representation of the Scores Obtained in the Pattern of Phases Case C.

Across all three cases, the pattern of the observed scores indicates a consistent decline in internet usage and in establishing healthy digital habits through SIPS, which is also consistent with past research as well.⁶⁰ It clearly shows that SIPS are helpful in mitigating the problematic use of the internet among adolescents, which is a global concern.⁶¹ This model framework also helps in the regulation of EI, SI as well as managing other psychological variables like DAS-related symptoms.^{62, 63} Therefore, the findings align well with the reduction of internet usage tendencies and the production of multi-dimensional benefits, which not only addresses the behavioural issues of the participants but also work on existential vulnerabilities. For instance, in Case A, the participant experienced hypertension with emotional irregularities, excessive self-doubt constant irritability, which are indicative of anxiety and stress.⁶⁴ While Case B reported the feeling of lightheadedness and hot flashes in her entire body, constant fatigue, high caffeine intake and sleep disturbances. There was poor social interaction and social withdrawal reported, which indicated symptoms of anxiety, stress and the presence of low emotional regulation.⁶⁴ Similarly, in Case C, the participant’s constant mood swings and extremity of fatigue were reported. There was a lack of sleep and hopelessness, a feeling of isolation and social disconnectedness. Apart from these intense levels of impulse and frustration in his day-to-day activities, there was a decrease in concentration and memory.⁶⁴ Participants reported a constant decline in the symptoms across all the phases when SIPS was given to them. However, there are other types of spiritually integrated psychotherapies, like acceptance commitment therapy and integrated CBT (SI-CBT), which have shown promising results in the past for treating depression as well as anxiety symptoms,^{65, 66} which ultimately contribute to the authenticity of spirituality-based counselling sessions. These therapies must be customised to clients’ religious and spiritual inclinations to provide value-driven therapy in enhancing emotional and spiritual wellbeing while alleviating the comorbid symptoms of DAS within the participants.^{60, 65, 67}

Conclusion

The present research is based on a single case-experimental design (SCED), which highlights the importance and effectiveness of the SIPS in managing IA, symptoms of DAS while enhancing emotional and SI. Since spirituality increases the deeper sense of self-contemplation within an individual, leading to better adaptability in life and managing their existential vulnerabilities. Therefore, this research incorporates a spiritually integrated framework that provides preliminary evidence that SIPS is beneficial in managing as well as reducing the IA where participants spend their ≥8 h/day on social media platforms. The parallel improvements in the symptoms of DAS indicate that such sessions contribute to an integrative process of change among the participants. The deeper sense of self is also enhanced by regulating the emotional and SI, which lowers the feeling of identity crisis and maladaptive behaviour that often contributes to addictive behavioural patterns.^{68, 69} Similar findings in the past research also advocate the idea of incorporating the EI and spirituality components in the counselling sessions for dealing with compulsive patterns of internet usage among young adults.^70–72

Limitations of Study

The efficacy of SIPS can also be tested through the experimental design, in which a broader perspective, along with causal implications, can be obtained. Apart from IA related to excessive indulgence in social media platforms, the applicability of SIPS under counselling settings must be considered for gaming addiction, cybersex addiction, compulsive online shopping and online trading. The role of SIPS can also be explored in other variables like guilt, frustration and aggression, which were reported as comorbid symptoms by the participants during their diagnostic interviews. Since these symptoms were not actively assessed in the present study, they can be considered for future research.

Footnotes

Acknowledgements

The authors would like to thank all three participants and their parents/guardians who have participated in this research-based counselling session and have continued through all 15 sessions.

Authors’ Contribution

The conceptualization was done by Dr Pandey and Dr Rastogi. The literature and drafting of the manuscript were conducted by Dr Pandey, Ms. Sharma and Dr Rastogi. Dr Srivastava and Dr. Gupta assisted in data analysis, visualization, and formatting of the manuscript. The final proof-read and supervision were performed by Dr Gupta, Ms. Pal, and Prof Zaidi. All authors have read and agreed to the final version of the manuscript.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Statement of Ethics

The approval was taken from the Ethical Board Committee. The participants were also properly informed about the study, and they have given the written consent to participate in the study.

ORCID iDs

Madhu Pandey

Suvarna Sharma

Chhaya Gupta

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