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Abstract

Abortion is an essential social and public health issue. The diverse opinions about abortion originate from several factors that affect attitudes toward abortion. Using the world-value survey (2010-2014), this study sought to understand if Ghanaians and Nigerians justify abortion and the factors that inform why they justify abortion. Various sociodemographic variables (religion, religious attendance, gender, and the number of children born) were used to understand their association with justification for abortion. The results here replicate what other studies have found, with emphasis on the relationship that exists between sex and justification of abortion. The study revealed the influence of religion and religious attendance on justifying abortion cut across Ghana and Nigeria. The findings carry implications as to how the debate on abortion can be undertaken in West Africa.

Keywords

abortion justification sociodemographic Ghana Nigeria world values survey

Introduction

Whether safe or unsafe abortion, legal or illegal or induced abortion, whatever the concepts are depending on the geographical context, is a general phenomenon that has existed throughout human history (Joffe, 2009). When confronted with an unplanned pregnancy, women seek an abortion and self-induce it or find abortion providers, irrespective of the law. Nevertheless, the issue of abortion continues to be one of the most delicate and contentious problems in reproductive health. The World Health Organization (WHO) defines unsafe abortion as a procedure for terminating an unintended pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both (WHO, 1992). This means that abortion is said to be safe when it is performed by persons with necessary skills in an environment that conforms to minimal medical standards. Estimates indicate that at least each year, 44 million abortions take place throughout the world, nearly half of them safely and the rest unsafely (Sedgh, 2012). Irrespective of the advance in the health care profession and the availability of safe and effective technologies and skills for abortion, deaths and disabilities resulting from abortion continue to occur (WHO, 2012). This challenge is very acute in lower and middle-income countries particularly Nigeria and Ghana where abortion remains restricted.

For instance, although Nigeria has 2% of the world’s population, it accounts for about 10% of global maternal mortalities. Evidence suggests that with a maternal mortality ratio of 814 per 100,000 live births in Nigeria (World Bank Data, 2015), unsafe abortion is a significant contributor to the country’s high levels of maternal mortality (Federal Ministry of Health, 2007; Guttmacher Institute, 2015). About one fourth of Nigeria’s 9.2 million pregnancies were unintended (Guttmacher Institute, 2015). Previous studies in North Central Nigeria on factors contributing to maternal mortality revealed that problems due to unsafe abortion contributed to 9.4% of all maternal deaths (Diop et al., 2006). Other studies have shown that the contribution of abortion to maternal mortality varies widely in Nigeria with as many as 30% to 40% reported (Abdul, Shittu, Ameh, & Khan, 2006; Okonofua, Shittu, Oronsaye, Ogunsakin, & Ogbomwan, 2005). Although postabortion complications have been reported in many studies in Nigeria, evidence suggests that abortion is still restricted in the legal environment reinforcing the use of unsafe methods to induce abortion (Adinma et al., 2011).

In Ghana, unsafe abortion is a major social and public health problem. Notwithstanding the liberalization of the law on abortion within the last 20 years; many women in Ghana still obtain unsafe abortions due to lack of knowledge among the public and provider levels (Ahiadeke, 2001; Lithur, 2004; Morhee & Morhee, 2006). About 17% of pregnancies in Ghana are unwanted (Gyesi, 2018), and evidence suggests that induced abortion is the second largest direct cause of maternal mortality in Ghana—second only to hemorrhage (Ghana Statistical Service, Ghana Health Service, & Macro International, 2009). Although many studies have been conducted in Ghana and Nigeria on abortion, studies that attempt to examine the issue of justification of abortion are still lacking.

Generally, previous studies on abortion in sub-Saharan Africa have examined the sociodemographic profile of women having abortions (Adanu, Ntumy, & Tweneboah, 2005; Klutsey & Ankomah, 2014). However, many of these country-specific studies in Africa are limited in geographical scope, often focusing on a specific city, region/province, urban/rural area (Biney, 2011; Payne et al., 2013) or a specific subgroup of women, such as young, unmarried, or university students (Patel & Myeni, 2008; Wheeler, Zullig, Reeve, Buga, & Morroni, 2012). Also, previous efforts have been made through academic research and policy domains to understand peoples’ position in the issue of justification of abortion, but most of these studies are found in the United States and Canada (Cook, Jelen, & Wilcox, 1992; Dillon, 1996; Emerson, 1996; Jelen & Wilcox, 2003), in India (Agrawal, 2012; Gurung, 2004; Mallik, 2002; Rao, 2002), and in the Middle East and North Africa (Alkuraya & Kilani, 2002). Thus, using the world value survey (2010-2014), this study examines the subject matter from a comparative perspective, in the context of Ghana and Nigeria. This study seeks to examine the factors that inform people’s view on abortion in Nigerian and Ghana.

Method

Participants and Procedure

This study employed the World Values Survey conducted in Ghana and Nigeria in January/February, 2012. The survey is based on a nationally representative sample, which represented a cross-section of adult Ghanaians and Nigerians. The estimated margin of error for the survey was ± 2.5 (Ghana) and ± 2.4 (for Nigeria). The sample size in Ghana and Nigeria were 1,552 and 1,759, respectively. The questionnaire was administered to an eligible adult member of the household randomly selected for the study. The survey collected information on sociocultural values and political sentiments, from which the analysis for this article was done.

Measures

The outcome variable of this study is justification for abortion. The variable was as a count variable as respondents were asked to indicate their justification for abortion on a scale of 0 (never justified) to 10 (always justified). For the independent variables, socioeconomic and demographic variables were used to investigate the predictors of justification for abortion. Socioeconomic variables include employment status (unemployed = 1, self-employed = 2, employed = 3), employment sector (unemployed = 1, government-employed = 2, privately employed = 3, private NGO = 4), and educational attainment (no/informal school = 1, primary education = 2, technical education = 3, secondary education = 4, university education = 5). The demographic variables include sex (female = 1, male = 2), marital status (single = 1, married = 2, separated/divorced/widowed = 3), religion (Christian = 1, Muslim = 2, other religion = 3, no religion = 4), and frequency of religious attendance (rarely/never = 1, sometimes = 2, always = 3). Age and number of children were measured at the interval-ratio level.

Data Analysis

Percentage distribution was used in describing the independent and dependent variables for the univariate analysis. The negative binomial regression model (NBRM) was applied to the bivariate and multivariate analyses. This form of analysis is suitable for count variables as respondents were asked to indicate their justification of abortion on a scale of 0 (no justification) to 10 (always justified; Long & Freese, 2014). The NBRM was applied given that the outcome variable was overdispersed (Figures 1 and 2), as the conditional variance exceeded the conditional mean. The NBRM provides extra parameters to capture the overdispersed version of the outcome variable (Cameron & Trivedi, 1998). Incident rates were generated for the NBRM. The independent variables associated with the justification for abortion at the bivariate level were used to develop a parsimonious multivariate model. Two multivariate models were created for Ghana and Nigeria. Personal weights were applied for all personal-level estimates, and sampling weights were employed for the regression analysis. Stata Version 15 was used in analyzing this study.

Figure 1.

Justification of abortion among the respondents in Nigeria.

Figure 2.

Justification of abortion among the respondents in Ghana.

Results

Univariate Analysis

Table 1 presents the frequency distribution of the various independent and outcome variables of the study. In Ghana, 50.5% and 49.5% of the respondents were male and female, respectively. Most of the respondents were single (40.9%) or married (52%). For employment status, 36% of the respondents were unemployed, 38.8% were self-employed, and 24.8% were employed. Regarding educational attainment, most of the respondents had primary education (44.3%) or technical education (26.7%). About 10.3% of the respondents had no formal education. Up to 80.3% of the respondents were Christians, and 11.3% were Muslims. About 12.2% of the respondents rarely or never attended a religious place of worship, 9.6% of the respondents sometimes attended, whereas 78.2% always attended. The mean age was 32.3 years.

Table 1.

Frequency Distribution of Independent and Dependent Variables.

	Ghana (n = 1,552)		Nigeria (n = 1,759)
Variables	Frequency	Percentage	Frequency	Percentage
Sex
Male	783	50.5	904	51.4
Female	769	49.5	855	48.6
Marital status
Single	635	40.9	740	42.0
Married	807	52.0	958	54.5
Separated/divorced/widowed	110	7.1	61	3.5
Employment status
Unemployed	565	36.4	724	41.2
Self-employed	602	38.8	746	42.4
Employed	385	24.8	289	16.4
Employment sector
Unemployed	376	24.2	592	33.7
Government	124	8.0	170	9.7
Private	953	61.4	814	46.3
Private NGO	99	6.4	182	10.3
Educational attainment
None	159	10.3	217	12.3
Primary	688	44.3	220	12.5
Technical	415	26.7	807	45.9
Secondary	161	10.4	293	16.7
University	129	8.3	222	12.6
Religion
Muslim	176	11.3	757	43.0
Christian	1,246	80.3	803	45.7
Others/no religion	130	8.4	198	11.3
Frequency of religious attendance
Rarely/never	189	12.2	124	7.1
Sometimes	150	9.6	101	5.7
Always	1,214	78.2	1,534	87.2
Mean number of children	1.85 (2.1)		1.8 (2.3)
Mean age	32.3 (13.4)		31.5 (11.8)
Justified abortion	1.6 (1.42)		2.1 (1.85)

Note. Standard deviation values are in parentheses. NGO = nongovernmental organizations.

In Nigeria, 51.4% and 48.6% of the respondents were male and female, respectively. Most of the respondents were single (42%) or married (54.5%). Of the respondents, 41% were unemployed, 42% were self-employed, and 16.4% were employed. Regarding educational attainment, most of the respondents had a technical education (45.9%) or secondary education (16.7%). About 12.3% of the respondents had no formal education. Up to 45.7% of the respondents were Christians, and 43% were Muslims. Up to 7.1% of the respondents rarely or never attended a religious place of worship, 5.7% of the respondents sometimes attended, whereas 87.2% always attended. The mean age was 31.5 years.

Bivariate Analysis

Table 2 revealed the bivariate association between the independent and dependent variables. For the categorical variables, the conditional variance was higher than the conditional mean for Ghana (variance = 2.37, M = 1.71) and Nigeria (variance = 3.60, M = 2.13), which implies that NBRM was the appropriate analysis for this study. In addition, Figures 1 and 2 reveal the overdispersion of justification for abortion in both countries. In Ghana, among the independent variables, variables such as employment sector, religion, religious attendance, and the number of children given birth to were associated with justification for abortion. In Nigeria, among the independent variables, variables such as gender, marital status, religion, educational attainment, and the number of children given birth to were associated with justification for abortion. Variables found to be associated with justification for abortion at the bivariate level were employed in building a parsimonious multivariate regression model for Ghana and Nigeria.

Table 2.

Bivariate NBRM Analysis Predicting Justification for Abortion in Ghana and Nigeria.

	Ghana	Nigeria
Variables	Coefficient (CI)	Coefficient (CI)
Gender: Male (RC)
Female	0.98 [0.89, 1.08]	1.15** [1.04, 1.27]
Educational attainment: No education (RC)
Primary	0.94 [0.76, 1.16]	1.23 [0.99, 1.52]
Technical	0.97 [0.78, 1.21]	1.20* [1.03, 1.41]
Secondary	1.01 [0.80, 1.27]	1.26* [1.05, 1.51]
University	0.94 [0.74, 1.19]	1.38** [1.15, 1.66]
Employment status: Not employed (RC)
Self-employed	0.89 [0.79, 1.00]	0.99 [0.88, 1.10]
Employed	1.00 [0.89, 1.12]	1.16* [1.01, 1.34]
Employment sector: Not employed (RC)
Government	1.00 [0.83, 1.22]	0.99 [0.83, 1.17]
Private	0.84* [0.74, 0.94]	0.93 [0.83, 1.05]
Private NGO	0.87 [0.69, 1.09]	1.12 [0.94, 1.34]
Marital status: Single (RC)
Married	0.91 [0.83, 1.01]	0.91 [0.82, 1.00]
Divorced/widowed	0.93 [0.78, 1.12]	0.75 [0.56, 1.01]
Age	1.00 [0.99, 1.00]	0.99* [0.99, 1.00]
Religion: Muslim (RC)
Christian	0.74** [0.62, 0.89]	1.26*** [1.13, 1.41]
Others/no religion	0.70** [0.57, 0.88]	1.25*** [1.08, 1.46]
Religious attendance: Rarely/never (RC)
Sometimes	0.69** [0.56, 0.86]	0.71 [0.56, 0.90]
Always	0.68*** [0.57, 0.80]	0.97 [0.81, 1.16]
Number of children	0.97** [0.95, 0.99]	0.95 [0.93, 0.97]

Note. NBRM = negative binomial regression model; NGO = nongovernmental organizations; RC = reference category.

p < .05. *p < .01. **p < .001.

Multivariate Analysis

Table 3 presents the multinomial regression analysis of the independent variables and justification for abortion for Ghana (Model 1) and Nigeria (Model 2). Model 1 is statistically significant (p < .001). Sector of occupation, religion, and religious attendance were associated with justification for abortion. In Ghana, respondents who worked in private organizations were less likely to believe that abortion is justifiable than unemployed individuals. Christians were less likely to believe that abortion is justified than Muslims. Respondents who always or sometimes attended religious services were less likely to believe that abortion is justified than respondents who rarely or never attended religious services.

Table 3.

Multivariate NBRM analysis predicting justification for abortion in Ghana and Nigeria.

	Ghana	Nigeria
Variables	Coefficient	Coefficient
Educational attainment: No education (RC)
Primary	—	1.14 [0.93, 1.41]
Technical	—	1.02 [0.86, 1.21]
Secondary	—	1.05 [0.86, 1.29]
University	—	1.12 [0.90, 1.37]
Employment status: Not employed (RC)
Self-employed	1.04 [0.90, 1.20]	1.02 [1.00, 1.46]
Employed	1.14 [0.97, 1.32]	1.42** [1.13, 1.78]
Employment sector: Not employed (RC)
Government	0.99 [0.78, 1.25]	0.74* [0.55, 0.99]
Private	0.85* [0.72, 0.99]	0.79* [0.64, 0.97]
Private NGO	0.85 [0.68, 1.07]	0.94 [0.76, 1.17]
Gender: Male (RC)
Female	—	1.17** [1.05, 1.30]
Marital status: Single(RC)
Married	—	1.05 [0.90, 1.22]
Divorced/widowed	—	0.88 [0.65, 1.21]
Age	—	1.00 [0.99, 1.01]
Religion: Muslim (RC)
Christian	0.79** [0.67, 0.93]	1.17** [1.04, 1.31]
Others/no religion	0.68** [0.55, 0.85]	1.16 [1.00, 1.36]
Religious attendance: Rarely/never (RC)
Sometimes	0.69*** [0.56, 0.85]	0.70** [0.56, 0.88]
Always	0.68*** [0.58, 0.79]	0.93 [0.78, 1.12]
Number of children	0.98 [0.96, 1.00]	0.96*** [0.93, 0.99]
Constant	3.08*** [2.45, 3.89]	1.87*** [1.42, 2.45]
Wald χ²(5)	59.17	79.09
Probability > χ²	0.0000	0.0000
R²/adjusted R²	0.0183	0.0168
Observations	1,552	1,759

Note. Confidence intervals are within square brackets. The Em dash implies that the variable was not associated with the justification of abortion at the bivariate in the country in which the dotted line is. NBRM = negative binomial regression model; NGO = nongovernmental organizations; RC = reference category.

p < .05. **p < .01. ***p < .001.

Model 2 is also statistically significant (p < .001). In Nigeria, gender, the sector of employment, employment status, religion, religious attendance, and the number of children had were associated with the justification for abortion. Female respondents were more likely to believe that abortion is justified than male respondents. Respondents who worked in government and private organizations were less likely to believe that abortion is justifiable than unemployed individuals. Christians were more likely to believe that abortion is justified than Muslims. Respondents who attended religious services were less likely to justify abortion than those who rarely or never did. Finally, the number of children a respondent has was negatively associated with the justification of abortion, that is, the number of children one has, the less likely they believed that abortion is justified. Using the beta value, the model reveals that the most critical factor in predicting the justification of abortion is the number of children born to the respondent.

Discussion

Induced abortion has long been a source of considerable debate particularly in most African countries where abortion is illegal unless the life of the mother is in danger. Issues of health, moral, religious, legal, and biological concerns have long been considered in the argument for or against induced abortions. In both public and private debates, arguments for or against abortion access focuses on either the moral acceptability of induced abortion or the justification of laws permitting or restricting abortion (Courtney, 2010). Previous efforts have been made to understand people’s opinion on the issue of legalized abortion in Africa and the individuals’ basis for their conclusions. In this study, we examined the issue of justification of abortion in Ghana and Nigeria concerning variables such as employment status, employment sector, marital status, religion, religious attendance, educational attainment, and the number of children respondents have.

From the bivariate and multivariate NBRM, we found that variables, such as employment sector, religious affiliation, religious attendance, and the number of children had, were associated with justifying abortion. In this study, gender was not a significant predictor of justification of abortion in Ghana, however, in Nigeria, we found out that females were more likely to justify abortion. It must be noted that previous findings of whether gender affects abortion attitudes are inconsistent and yield different results. A previous study had found that gender was associated with abortion attitudes, with men tending to have more liberal attitudes toward abortion than women (Rogers, 1987). However, other researchers have found very weak or no associations with gender and the justification of abortion. Finlay (1981) was one of the many researchers whose studies reached the same conclusion. Similarly, Basow and Esposito (1995) found no statistically significant sex differences as well. Thus, in this study, women were more likely to believe that abortion is justified than men. It is possible to argue that women’s prochoice nature stems from the fact that they would have to bear the burden of childbirth. Also, it is also possible to argue that childbirth can restrict women’s life chances and economic viability. It has been argued that motherhood is one of the primary reasons for the wage gap between men and women (Grimshaw & Rubery, 2015; Miller, 2017; Strimpel, 2017).

Of all the social predictors of abortion attitudes, religious attendance is generally considered to be a significant predictor of justifying abortion (Jelen & Wilcox, 2003), especially in Ghana. The influence of religious attendance cuts across Ghana and Nigeria. Religious membership, beliefs, and practices appear to make independent contributions to the justification of abortion. This is not surprising as religious groups in Africa tend to take strong positions against abortion. In this study, we found a statistically positive relationship between religion and the justification of abortion in Ghana and Nigeria. For instance, in Ghana, we observed that respondents who sometimes and always attended religious services were less likely to believe that abortion is always justified than respondents who rarely or never attended religious services. This relationship between religious characteristics and the justification of abortion aligns with previous studies (see Cook et al., 1992; Dillon, 1996; Emerson, 1996). These studies have consistently shown that frequent church attendance is associated with more significant opposition to abortion, even when denominational affiliation and doctrinal beliefs have been controlled. This suggests that frequent church attendees tend to be indiscriminately prolife, regardless of the position taken by their denomination on the abortion issues.

One striking observation from this study is that in Nigeria, Muslims were less likely to believe that abortion is sometimes and always justified than Christians. This finding differs from earlier studies from Saudi Arabia and Lebanon. In a study among people in Saudi Arabia of attitudes toward abortion in cases of sickle cell anemia and thalassemia, most participants were unaware of the increased risk with consanguinity and did not know about the Saudi Arabian fatwa justifying abortion in cases of fetal impairment. Close to half of the participants, who had initially rejected the idea of pregnancy termination, changed their minds when informed of the fatwa (Alkuraya & Kilani, 2002). Similar findings concerning the justification of abortion in Lebanon have been reported (IPPF, 2004). In Ghana, we observed Muslims were more likely to believe that abortion is always justified than Christians. This finding may be attributed to the demographic patterns of both countries. It must be noted that Nigeria’s population is equally Muslims and Christian, whereas Ghana is mostly a Christian-dominated country.

The study also revealed that across Ghana and Nigeria, the sector of employment was associated with the tendency to see abortion as unjustifiable. This is somewhat different from the findings of Jelen, Damore, and Lamatsch (2002) who found that working women and homemakers tend to be similar in their attitudes toward abortion. However, recent studies by Biggs, Gould, and Foster (2013), Chae, Desai, Crowell, and Sedgh (2017) shared a different perspective on the sector of employment and employment status on the justification of abortion. Their study showed that as homemaker women tend to be more “pro-life” than working women, they were less likely to see abortion as justifiable. Finally, we found that the number of children born is negatively associated with the justification of abortion, thus, the number of children one has, the less likely they believed that abortion is always justified. However, previous studies have found the direct opposite. Previous studies in India have shown that women desire to limit their family size was positively and significantly correlated with the justification of abortion (Agrawal, 2012). Other studies have also found that the pressure to reduce family size and ensure the birth of desired children was positively correlated with the justification of abortion (Gurung, 2004; Mallik, 2002; Rao, 2002).

This study can inform the debate of abortion practice in West Africa. Given the fact that abortion is illegal in Nigeria and Ghana, except in special circumstances, this study points to the relatively low level of justification for abortion. It is possible that the illegal nature of abortion informs the low levels of justification. It is also tenable that people’s conservative or religious views on the conception of life may be contrary to the idea of abortion (Dim, 2018). However, this does not address the fact that a large number of Nigerian and Ghanaian women carry unintended pregnancies and the children born from such pregnancies may not get the appropriate care, time, and upbringing they need, given the impoverished nature of the average Nigerian and Ghanaian (Central Intelligence Agency, 2013; Golubski, 2017; World Poverty Index, 2018). Thus, this study provides an avenue in which the debates on abortion can be generated, and workable compromises can be created to address women’s reproductive health needs and the sociocultural beliefs of Nigerians and Ghanaians.

The findings of this study also imply the possible role of religious institutions on the debate on abortion. The imperative of providing better knowledge on abortion practice can incorporate religious leaders. The findings of this study show the possibilities among Christian religious leaders in contributing effectively to the debate on abortion. The study’s findings also have implications for policies on birth control and the manner in which couples can be informed on family planning. The association between women and the justification of abortion points to the persuasive role women can play in motivating effective family planning, especially in Nigeria, which adopts an antinatalist policy (National Population Commission, 2006) meant to reduce the fertility rate for its ever-growing population (Population Reference Bureau, 2016). This aligns with the association between the number of children born and justification of abortion. It is possible to say that the emotional attachment parents have with their children makes abortion less acceptable. Thus, contraceptive use can be promoted among couples with children to enable them to avoid unwanted pregnancies.

Conclusion

Abortion is a prominent social issue in Africa. The mixed beliefs over abortion originate from numerous factors that affect attitudes toward abortion in Africa. Many efforts have been made through academic research and policy domains to understand people’s perception of and attitudes toward justifying abortion in Africa and on what grounds they come to their conclusions. This current study is one of the efforts that will help policy makers understand the issue of justification of abortion in Africa specifically Ghana and Nigeria. Using the world-value survey (2010-2014), this study showed that Ghanaians and Nigerians tend not to find abortion justifiable. Various sociodemographic variables (religion, level of education, marital status, number of children) were shown to be associated with the respondents’ justification for abortion. One of the limitations of this study is the limited sample size of the world value survey from which the analyzed data were gathered. Also, the lack of other important variables such as income, place of residence, and a region of residence, among others, limited the range of analysis that could be conducted and controlled. More research can be undertaken on a larger population, including the collection of broader levels of variables to understand the dynamics of attitudes toward abortion. Also, qualitative studies should be undertaken to understand the contextual and in-depth interplay of various variables found to be associated with the justification of abortion in this study.

Footnotes

Declaration of Conflicting Interests

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

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Eugene Emeka Dim

Author Biographies

Isaac Adisah-Atta holds a master’s degree in political science from the Department of Political Studies, University of Saskatchewan, Canada. He is a versatile researcher that publishes extensively in the specialized fields of health and social policy. His area of specialization focuses on women’s health, health care financing, health care information dissemination in rural communities, aging, and quality of life and pension reforms in Africa. His research has appeared in peer-reviewed journals such as Journal of Health and Medical Informatics, International Journal of Women’s Health and Wellness, Journal of Public Policy and Administration Research, among other journals.

Eugene Emeka Dim is a PhD student in the Department of Sociology at the University of Toronto. His core research focuses on political sociology, democratic consolidation in Africa, gender issues, intimate partner violence, and sociology of the family. His research has appeared in peer-reviewed journals such as Trauma, Violence, and Abuse, Journal of Interpersonal Violence, Journal of Aggression Maltreatment and Trauma, African Population Studies, and Journal of Peacebuilding & Development. He is also a peer-reviewer for Victims and Violence.

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Justification of Abortion in West Africa and Interplay of Sociodemographic Predictors: A Comparative Study of Ghana and Nigeria

Abstract

Keywords

Introduction

Method

Participants and Procedure

Measures

Data Analysis

Results

Univariate Analysis

Bivariate Analysis

Multivariate Analysis

Discussion

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iD

Author Biographies

References