Abstract
Background:
Despite the increasing burden of chronic kidney disease (CKD) and its associated challenges, there is limited understanding of the lived experiences, awareness, and treatment perspectives of patients in Bangladesh.
Objective:
We aimed to explore the experiences of patients with CKD undergoing maintenance hemodialysis in Bangladesh, identifying key challenges and areas for improvement.
Design:
Descriptive qualitative study.
Setting:
Khulna, Bangladesh.
Participants:
Individuals with CKD undergoing maintenance hemodialysis.
Methods:
We recruited people with CKD undergoing maintenance hemodialysis from two tertiary hospitals in Khulna, Bangladesh, using purposive sampling. Semi-structured interviews were conducted, and the data were analyzed using Braun and Clarke’s inductive thematic analysis approach.
Results:
We interviewed 16 participants with CKD. Our findings revealed that most participants had limited knowledge about chronic kidney disease and experienced delays in diagnosis. While maintenance hemodialysis provided temporary relief, it also resulted in considerable physical and emotional distress. Financial strain was a major concern, with many participants struggling to afford treatment. Accessibility issues, such as long waiting times and transportation challenges, were common. Participants expressed a strong desire for better service delivery and reduced treatment costs.
Limitations:
All participants were recruited from two tertiary care hospitals in Khulna, an urban setting, which may limit the applicability of the findings to other regions of Bangladesh.
Conclusion:
Our study underscores the need for improved financial support, enhanced mental health services, greater patient awareness, and healthcare policy reforms to alleviate the burden on patients with chronic kidney disease and improve their overall quality of life.
Introduction
Chronic kidney disease (CKD) is a major global public health challenge, affecting over 800 million people worldwide. 1 The increasing prevalence of diabetes and hypertension largely drives the growing burden of CKD.2,3 The World Health Organization has identified CKD as the 12th and 17th leading cause of death and disability worldwide, respectively. 4 In Bangladesh, CKD accounts for 1.54% of disability-adjusted life years. 5 Approximately 20 million people are affected by CKD, and an estimated 35 000 to 40 000 individuals progress to kidney failure each year in the country.6,7 The major causes of CKD in Bangladesh include glomerulonephritis (40%), diabetes mellitus (24%), and hypertension (15%).8,9
While all three recognized kidney replacement therapies—hemodialysis (HD), peritoneal dialysis, and kidney transplantation—are available for treating patients with CKD in Bangladesh, access remains limited. HD is the most widely used modality in public and private facilities. Peritoneal dialysis is far less common due to the high cost of peritoneal fluid, concerns about maintaining hygiene, the risk of peritonitis, and limited availability of trained nursing staff. Kidney transplantation is performed in only a small number of centers, and the scarcity of eligible donors further restricts access. For these reasons, we focused our study on patients receiving maintenance HD, who represent most individuals undergoing kidney replacement therapy in Bangladesh. Only 25% of patients with kidney failure can avail themselves of these therapies due to inadequate facilities and the high cost of healthcare, 10 with two-thirds of healthcare expenses being paid out-of-pocket. A significant portion of patients begin dialysis but are forced to discontinue after three to six months due to financial constraints. 9 Furthermore, only a few centers in the country regularly perform kidney transplantation. 6 The availability of dialysis services is also limited, with approximately 84 dialysis centers nationwide, half of which are in the capital city. 9 Other centers are spread over the six large cities of the country, including Khulna. More than two-thirds of the centers are profit-oriented, leaving only a tiny proportion of public and nonprofit, nongovernment organizations. 11
The consequences of CKD extend beyond the direct impact on health, contributing to reduced quality of life and substantial economic burdens, 12 particularly in low- and middle-income countries (LMIC). 13 Individuals with CKD who receive proper information and knowledge about CKD and its risk factors are more likely to engage in health-promoting behavior and lifestyle changes. 14 Despite the growing burden of CKD and its associated challenges, there is limited understanding of the lived experiences, awareness, and treatment perspectives of patients in Bangladesh. Addressing this gap could provide valuable insights for redesigning HD services and improving patient outcomes. Therefore, we aimed to explore the experiences of patients with CKD undergoing maintenance HD to derive recommendations for practice and policy. Our objectives were to (1) understand patients’ experiences and perspectives on HD, (2) explore their challenges in accessing HD, and (3) identify areas for future service improvement.
Methods
Study Design and Setting
The qualitative study was conducted at two tertiary care hospitals in Khulna, Bangladesh: Shaheed Sheikh Abu Naser Specialized Hospital (SSANSH) and Gazi Medical College Hospital (GMCH). SSANSH, a publicly funded hospital, provided HD services to approximately 110 patients annually. GMCH, a private hospital, offered yearly HD services to around 24 patients. Kidney failure is primarily diagnosed and managed by nephrologists, although their numbers remain insufficient to meet the growing demand for care in the country. Diagnosis typically involves clinical evaluation supported by laboratory testing, including measurement of estimated glomerular filtration rate, which enables CKD staging in accordance with standard clinical guidelines. 15 Maintenance HD services are delivered by teams of nephrologists, dialysis nurses, and technicians, though the availability of specialized staff varies across centers. In both study sites, maintenance HD is provided in outpatient units, with each session lasting approximately four hours. At the public hospital (SSANSH), patients usually pay around USD 4 per session due to government subsidies; however, high patient volumes and limited dialysis machines often result in long waiting times, with appointments allocated based on availability and clinical urgency. At the private hospital (GMCH), the structure of care is similar, but each maintenance HD session costs approximately USD 24, and access to services is more readily available for patients who are financially solvent.
Study Participants
We used purposive sampling to include participants with relevant experience of maintenance HD while also ensuring a diverse participant pool by incorporating variation in characteristics such as age, sex, occupation, and type of center (public vs private), thereby capturing a broad range of perspectives. Inclusion criteria were adults aged 18 years or above who had been receiving hemodialysis for at least three months and were able to provide informed consent. Exclusion criteria were an unstable clinical condition or communication difficulties that prevented participation in the interview. Eligible participants with CKD undergoing HD at SSANSH and GMCH were approached and recruited during their maintenance dialysis sessions at each center. Data collection and analysis were conducted iteratively, with the research team reviewing preliminary codes after every few interviews to assess whether new insights were still emerging. Recruitment continued until no additional information relevant to the study objectives was identified, at which point data saturation was considered to have been reached. 16
Data Collection
We trained 2 interviewers who were not directly involved in patient care. This approach encouraged participants to share their experiences openly, as participants might otherwise be hesitant to discuss negative aspects of the service with their doctors. To ensure quality and consistency in data collection, MAUA and GMMH (the authors) regularly engaged with the interviewers to guide the practical aspects of conducting the interviews. Although interviews were conducted iteratively, the core interview guide (see Supplemental Appendix 1) was not altered during data collection to ensure consistency across participants. As patterns in participant narratives became clearer, the interviewers refined their use of probing questions to explore these areas in greater depth, while keeping the guide unchanged. This approach allowed the interviews to remain flexible and responsive while maintaining a stable structure across all participants. Face-to-face interviews were conducted during participants’ hospital visits for maintenance HD sessions, and all conversations were audio-recorded. Interviews were conducted in a private area of the HD unit, away from other patients and staff. Only the participant and interviewer were present, and all audio recordings and transcripts were anonymised to protect confidentiality. Each interview lasted approximately 45 minutes. Data collection took place between 15th April to 23rd August 2024. Written informed consent was obtained from all study participants before data collection.
Data Analysis
We applied Braun and Clarke’s six-phase approach to conduct an inductive thematic analysis of the interview data. 17 MAUA transcribed all interviews verbatim in the original language (Bengali), ensuring that the nuances and full meaning of participants’ accounts were preserved. Coding was also carried out in Bengali to maintain the richness of the data. Transcripts and codes were then translated into English for sharing with English-speaking collaborators and for inclusion in publications. Data analysis was conducted iteratively by MAUA, with ongoing input from the other study authors. To minimize semantic drift during translation from Bengali to English, 10% of the transcripts were independently back-translated into Bengali by another author (GMMH), who is bilingual and familiar with both the clinical and cultural context of the study. The back-translated versions were compared with the original transcripts, and any discrepancies were discussed and resolved to preserve intended meaning and nuance. To enhance the credibility and dependability of the analysis, 20% of the transcripts were independently coded by GMMH. Coding differences were discussed until consensus was reached, reducing the potential for individual thematic bias.
Trustworthiness in the Findings
We remained aware of the potential influence of our personal experiences and contextual factors on participants' responses. MAUA, an experienced nephrologist, and GMMH, an experienced clinician-researcher in Khulna, Bangladesh, led the analysis and took deliberate steps to minimize interpretive bias. To enhance trustworthiness,18,19 GMMH independently coded 20% of the transcripts and reviewed the preliminary coding framework developed by the lead analyst (MAUA); any differences were discussed until consensus was reached, ensuring that interpretations reflected participants’ accounts. Data analysis was conducted iteratively, allowing for continuous refinement of themes and interpretations. The involvement of a multidisciplinary team of authors contributed to a more nuanced understanding of the findings. We maintained an audit trail documenting coding decisions and theme development. Member checking was undertaken with a subset of participants, who confirmed that the preliminary findings resonated with their experiences and did not suggest changes to the content or structure of the themes, thereby reinforcing the credibility of the analysis. Triangulation was achieved by involving multiple researchers in the review and interpretation of the data, thereby strengthening the credibility, dependability, and confirmability of the analysis. 18
Ethics Approval
Before commencing the study, we obtained ethical approval for it from the Institutional Review Board of Gazi Medical College, Khulna (reference number GMC/IERB/2024/05).
Results
We interviewed 16 participants with CKD undergoing maintenance HD at two tertiary care hospitals. Participants aged 26 to 58 represented diverse occupations. Their characteristics are summarized in Table 1. Of the 16 participants, 12 received maintenance HD services at the public hospital (SSANSH) and four at the private hospital (GMCH). This distribution reflected the markedly higher patient volume at the public facility, where subsidized treatment drew a larger number of patients, compared with the smaller and more financially solvent population that attended the private center. The findings from participant interviews are presented across five themes.
Characteristics of Interview Participants.
Note. NGO = nongovernment organization; M = male; F = female.
Theme 1: Understanding of CKD
Many participants found it difficult to comprehend the causes and progression of their illness. They were often unaware of the early symptoms, and by the time a diagnosis was made, their kidney function had deteriorated significantly. Consequently, they frequently struggled to implement preventive measures.
I don’t know how it (CKD) happened, . . . I never smoked a single stick of cigarette or have any other addiction that may damage my kidney. [HD 4; Ex-Rickshaw puller]
Some participants associated their condition with environmental factors, such as extended exposure to saline areas or employment in hazardous environments, while a few recognized the impact of pre-existing conditions like diabetes and hypertension on the progression of their kidney disease.
Satkhira, specifically Kaligonj, is the most saline region in our country due to its proximity to the Bay of Bengal. During my time working there for a few years, unfortunately, my kidneys were damaged . . . [HD 2; Ex-Construction contractor]
Theme 2: Perceived Relief and Stress of Hemodialysis
Many participants reported experiencing immediate relief after maintenance HD sessions, but the effects were often short-lived, lasting only a few days before they felt fatigued or unwell again. A few participants experienced discomfort during or after the sessions, sometimes disrupting their daily activities. For many, undergoing maintenance HD was regarded as a necessary yet unpleasant reality, providing little improvement to their overall quality of life in the long term.
After my dialysis, I feel better for a few days until the next session. However, my family is facing significant challenges in terms of finances, assets, dynamics, and our future. I'm uncertain about how my family will manage in the coming days. Ultimately, I worry that I will leave them with nothing when I pass away. [HD 8; Ex-Farmer]
Psychological distress was common for many, arising from both the illness itself and the ongoing burden of HD. Feelings of frustration, anxiety, and helplessness were often reported, particularly due to the uncertainty surrounding the long-term outcome of the treatment. For numerous individuals, the routine of attending dialysis sessions served as a constant reminder of their reliance on the treatment, which exacerbated their emotional strain.
Frustration is an inevitable part of life, impossible to ignore. Until death, one must visit the haemodialysis centre twice a week—there is no alternative. It feels as if it stretches on endlessly until the end. [HD 5; Ex-Grocery shop owner]
However, some participants developed effective coping strategies to manage their stress. A few found ways to engage with their communities, participate in social activities, or focus on maintaining a sense of normalcy. These coping mechanisms helped alleviate some of the psychological burden, although the majority continued to struggle with the emotional challenges of living with CKD.
I keep myself busy with friends, chatting, playing indoor games, and watching movies—doing my best to fill my days with joy and entertainment. I try to live alongside my illness. [HD 16; Ex-School teacher]
Theme 3: Financial Burden of Hemodialysis
The financial burden of maintenance HD was a significant concern for many participants. Numerous individuals struggled to manage treatment costs alongside other household expenses, leading to considerable financial strain. Some participants were particularly anxious about the long-term sustainability of their treatment, as funds were often diverted from essential needs, such as their children's education or future welfare, to cover dialysis expenses.
I often think about my children's future, but all available resources are currently focused on addressing kidney-related issues, which leaves my children's needs unaddressed [HD 4; Ex-Rickshaw puller]
Furthermore, the illness prompted many participants to cease working, resulting in a loss of income. Consequently, most families had to adapt their financial circumstances, with some even selling assets or depending on extended family for support. Several participants expressed profound concern about the future, not only for themselves but also for their families, fearing the long-term financial impact the illness would impose.
I previously held a managerial position at an NGO with a generous salary, but circumstances forced me to resign. My wife and I run a small grocery store, but our monthly income is insufficient to meet my family's needs. [HD 1; Ex-NGO manager]
I have exhausted my finances and am now forced to sell my land. The only option remaining is to rely on family members’ assistance or to beg. [HD 7; Ex-Agriculture worker]
Although the study was not designed to formally compare experiences across subgroups, some patterns were observed. Female participants, who were fewer in number and often financially dependent on spouses or adult children, appeared to experience additional challenges related to transportation, maintaining regular dialysis attendance, and securing adequate food. These observations suggest that financial dependence may compound the burden of hemodialysis for some women, although further research would be needed to explore this in depth.
Theme 4: Challenges in Accessing Services and Suggestions for Improvement
The majority of participants reported encountering challenges related to service delivery. Prolonged waiting times at HD centers were a prevalent issue, which often worsened participants' health and contributed to the discomfort experienced during treatment. Many participants also voiced dissatisfaction with the facilities, observing that although the service environment was functional, it lacked amenities that could enhance their overall experience. Some participants faced logistical difficulties, such as insufficient transportation options, leading to increased travel times and additional costs for attending their sessions.
I face difficulties with traveling. After arriving here, I have to wait for a serial number. If the queue isn’t managed in a timely manner, it causes delays and I end up returning home late at night. Sometimes I have to bring my mother as an accompanying person. She is able to travel, but it’s difficult for her. [HD 7; Ex-Agriculture worker]
While some participants expressed satisfaction with the care provided by health professionals, many suggested improvements to service delivery. Recommendations included increasing the number of HD centers to lessen long travel distances and offering affordable accommodation options for patients coming from remote areas. A few participants also proposed lowering treatment costs to make it more accessible for low-income families.
The ideal option is a free service, which may not be feasible for the Government. Nevertheless, efforts could be undertaken to reduce the cost of the service at the very least. [HD 14; Housewife]
Theme 5: Future Perspectives Beyond Hemodialysis
Most participants conveyed a blend of hope and anxiety regarding their future. While some remained optimistic about potential advancements in kidney disease treatment, especially new therapies or nondialysis options, many were uncertain about long-term alternatives to maintenance HD. Although many recognized the possibility of kidney transplantation, most were disheartened by the high costs, limited donor availability, and regulatory hurdles. At the same time, a few were unaware that it was even an option, perceiving maintenance HD as the final stage of kidney treatment.
I understand the concept of transplantation, but I'm curious about how many more days I can expect to live with this new kidney and what the overall benefit will be. [HD 5; Ex-Grocery shop owner] I am familiar with transplantation; however, it requires substantial financial resources. Furthermore, in our country, kidney donors are restricted to immediate family, which may not always be practical. [HD 8; Ex-Farmer]
However, some were keen to learn more about organ donation, particularly deceased kidney donation, and suggested that awareness programs, especially those utilizing social media and public platforms, could help inform people about its benefits and encourage more donations.
Discussions on television, posts on Facebook, and lectures during Friday prayers at the mosque can also play a significant role in raising awareness about organ donation. [HD 16; Ex-School teacher]
Discussion
Summary of Findings
We interviewed 16 participants with CKD undergoing maintenance HD in two tertiary care hospitals. Most patients had a limited understanding of CKD, often diagnosed at an advanced stage. While maintenance HD provided temporary relief, it caused physical discomfort and emotional distress. Financially, many participants struggled to afford treatment, often at the expense of household needs. Difficulties accessing HD services, including long wait times and transportation issues, were common, with participants suggesting improvements. Most expressed uncertainty about long-term options, such as transplantation, due to high costs and limited donor availability.
Strengths and Limitations
Our study provides valuable insights into the lived experiences of participants with CKD undergoing maintenance HD in Bangladesh. Purposive sampling was used to capture a range of perspectives within the constraints of available resources, ensuring variation in age, gender and occupational background. The use of semi-structured interviews allowed participants to share their views openly in alignment with the study objectives, while inductive thematic analysis facilitated the identification of nuanced themes and practical recommendations for service improvement.
In line with the principles of qualitative research, the aim of this study was not to achieve statistical generalizability but rather to generate rich, contextualized insights that may support transferability to similar settings. All participants were recruited from 2 tertiary hospitals in Khulna, an urban setting, which may limit the applicability of the findings to other regions of Bangladesh. Differences in healthcare infrastructure, access to services and socio-economic conditions, particularly in rural areas, may influence patient experiences in ways not captured here. Nonetheless, the structural constraints, financial challenges, and care delivery experiences described by participants may resonate with patients in comparable low-resource contexts. These contextual factors should be considered when interpreting the results and applying them beyond the study setting.
Discussion in Relation to Published Research
Patient understanding and awareness
Our study revealed that many participants with CKD undergoing maintenance HD struggled to understand the causes and progression of their disease, which aligns with findings in other settings. 20 Many participants believed that factors such as smoking, unhealthy lifestyles, drug addiction, working in salty environments, diabetes, and high blood pressure could lead to kidney disease and eventually require maintenance HD. Muhammad et al investigated the high prevalence of kidney failure requiring HD among ethnic groups characterized by widespread misconceptions regarding CKD, 21 while a study in Nigeria described beliefs linking kidney failure to personal wrongdoing, spiritual causes, and counterfeit drugs. 22 Such patterns likely reflect limited public health literacy and a lack of structured education on CKD in resource-constrained settings. Our findings highlight the need for patient education to be offered much earlier in the care pathway, ideally during routine primary care visits and at the point of CKD diagnosis. Providing information before symptoms become severe may support earlier detection, improve understanding of disease progression, and help patients make more informed treatment decisions. Strengthening community-based screening and integrating CKD education into general outpatient services could therefore play an important role in preventing late presentation and reducing avoidable complications.
Psychological distress
The psychological distress experienced by participants undergoing maintenance HD in our study mirrors findings from other studies that highlight the mental health challenges associated with chronic illness and ongoing treatment. 23 Many participants reported feelings of frustration, anxiety, and helplessness stemming from both the chronic nature of CKD and the burdensome demands of HD. However, some participants demonstrated resilience through coping strategies such as social engagement and maintaining a sense of normalcy. Other literature has noted these strategies as important mechanisms for managing the emotional strain of chronic illness. 24 However, the intensity of financial anxiety appeared particularly pronounced in our study, likely influenced by Bangladesh’s predominantly out-of-pocket healthcare financing, which exacerbates the emotional strain associated with long-term treatment.
Financial burden
A major concern for participants in our study was the financial strain caused by HD. Many participants reported redirecting funds from essential needs, including children's education, to cover dialysis costs. This is consistent with findings from similar studies where the financial burden of CKD forced families to make difficult economic choices. 25 The combined impact of treatment costs and reduced earning ability due to illness further intensified financial vulnerability, echoing findings that CKD can have catastrophic economic consequences for households. 26 The pronounced financial strain in our study may reflect the limited subsidy systems and lack of insurance coverage available in Bangladesh.
Access to hemodialysis services
Most participants in our study expressed frustration with the accessibility and quality of maintenance HD services. Long waiting times, inadequate transportation options, and limited healthcare facilities were common issues. These challenges reflect findings from similar studies that report difficulties accessing dialysis services, especially in regions with limited healthcare infrastructure.27,28 However, our findings also highlight a notable contrast between public and private hospitals. Participants at public facilities described considerable overcrowding and unpredictability, whereas those at private centers experienced more reliable scheduling. This discrepancy likely reflects broader structural imbalances in Bangladesh’s health system, where private facilities serve smaller, more financially solvent populations. 29
Treatment options and future perspectives
Most participants in our study expressed hope and uncertainty regarding their future treatment options. Although some participants were optimistic about potential advancements in CKD treatment, including nondialysis therapies, many were concerned about the high costs and limited availability of kidney transplantation. This is consistent with literature highlighting the financial and logistical barriers to kidney transplantation in many countries, especially those with underdeveloped organ donation systems. 30 A few participants in our study expressed interest in learning more about organ donation and its potential benefits, reinforcing recommendations from other studies emphasizing the importance of public education and awareness raising to improve transplant rates. 31
Novel Contributions of Our Study
Beyond similarities with findings from other low-resource settings, our study provides several context-specific contributions to the evidence base. This is among the first qualitative studies to examine the lived experiences of patients with maintenance hemodialysis across public and private hospitals in Bangladesh, providing insight into how differing service models influence financial hardship, transportation challenges, and continuity of care. The study also highlights a substantial gap in awareness and understanding of kidney transplantation and variability in counseling, areas that remain underexplored in the Bangladeshi context. In addition, the narratives of female participants underscore how financial dependence and mobility constraints may intensify the burden of hemodialysis, a dimension seldom discussed in prior research. These findings offer novel, contextually grounded evidence that can inform patient-centered service improvements and policy development within Bangladesh and similar low-resource settings.
Implications for Clinical Practice and Research
Our findings underscore the necessity for enhanced patient education on CKD, particularly concerning early detection and risk factors, as many participants were unaware of their condition until it had progressed. Healthcare providers should integrate educational programs and mental health support, such as counseling and support groups, to address psychological distress and enhance patient well-being. Financial challenges also necessitate policy changes, including subsidized treatment, financial assistance, and improved transportation options, especially for patients from rural areas. Future research should encompass a wider range of patients with CKD from diverse regions to gain a better understanding of their unique challenges. Furthermore, exploring strategies to mitigate the financial impact of CKD, such as insurance models or government support, could assist in alleviating the burden on patients and families.
Conclusion
Our study reveals that the exorbitant cost of treatment and loss of income impose a significant financial burden on CKD patients. Simultaneously, the ongoing nature of maintenance HD contributes to anxiety, frustration, and uncertainty. These findings underscore the necessity for improved financial support, enhanced mental health services, and reforms in healthcare policy to alleviate the burden on patients and improve their overall quality of life.
Supplemental Material
sj-docx-1-cjk-10.1177_20543581261429257 – Supplemental material for Experiences of Patients With Chronic Kidney Disease Undergoing Hemodialysis: A Qualitative Study in Bangladesh
Supplemental material, sj-docx-1-cjk-10.1177_20543581261429257 for Experiences of Patients With Chronic Kidney Disease Undergoing Hemodialysis: A Qualitative Study in Bangladesh by Muhammed Arshad Ul Azim, Md Enamul Kabir, Md Obaidul Haque, Md Afzalul Bashar, Zannatul Ferdous, Banga Kamal Basu, Moyeenuddin Amin, Asma Begum, Kazi Maria Haque Semme, Syed Abdullah Jami, Nazim Uzzaman and GM Monsur Habib in Canadian Journal of Kidney Health and Disease
Supplemental Material
sj-docx-2-cjk-10.1177_20543581261429257 – Supplemental material for Experiences of Patients With Chronic Kidney Disease Undergoing Hemodialysis: A Qualitative Study in Bangladesh
Supplemental material, sj-docx-2-cjk-10.1177_20543581261429257 for Experiences of Patients With Chronic Kidney Disease Undergoing Hemodialysis: A Qualitative Study in Bangladesh by Muhammed Arshad Ul Azim, Md Enamul Kabir, Md Obaidul Haque, Md Afzalul Bashar, Zannatul Ferdous, Banga Kamal Basu, Moyeenuddin Amin, Asma Begum, Kazi Maria Haque Semme, Syed Abdullah Jami, Nazim Uzzaman and GM Monsur Habib in Canadian Journal of Kidney Health and Disease
Footnotes
Acknowledgements
We sincerely thank the study participants and dedicated staff members of SSANSH and GMCH for their invaluable support in completing this study. We also thank Sumaiya Akhter and Keya Biswas for their help during transcription.
Authors’ Contributions
MAUA conceptualized the study, while GMMH provided support for its design and execution. MAUA analyzed the data and prepared the initial version of the manuscript with assistance from GMMH and NU. All authors have critically reviewed and approved the final manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Supplemental Material
Supplemental material for this article is available online.
References
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