Determinants of periodontal health in pregnant women and association with infants’ anthropometric status: a prospective cohort study from Eastern Uganda

BMC Pregnancy and Childbirth, Volume 12, Year 2012

Interprétation

Background: Preterm-low birth weight delivery is a major cause of infant morbidity and mortality in sub Saharan Africa and has been linked to poor periodontal health during pregnancy. This study investigated predisposing and enabling factors as determinants of oral health indicators in pregnancy as well as the association between periodontal problems at 7 months gestational age and the infants’ anthropometric status.Method: A community -based prospective cohort study was conducted in Mbale, Eastern Uganda between 2006 and 2008. Upon recruitment, 713 pregnant women completed interviews and a full mouth oral clinical examination using the CPITN (Community Periodontal Index of Treatment Need) and OHI-S (Simplified Oral Hygiene) indices. A total of 593 women were followed up with anthropometric assessments of their infants 3 weeks after delivery. Multiple logistic regression analyses were used to identify independent determinants of periodontal problems and use of dental services during pregnancy. Analysis of covariance (ANCOVA) was used to investigate the relationship between periodontal problems and the child’s anthropometric status in terms of wasting, underweight and stunting.Results: A total of 67.0% women presented with periodontal problems, 12.1% with poor oral hygiene, 29.8% with recent dental visit and 65.0% with periodontal symptoms. Of the infants, 2.0% were wasted, 6.9% were underweight and 10.0% were stunted. The odds ratio of having CPI > 0 increased with increased maternal age and single marital status, and was lower in primiparous women and those who used mosquito bed nets. Mean wasting scores discriminated between mothers with CPI = 0 and CPI > 0 as well as between mothers with good and poor OHI-S scores.Conclusions: Socio-demographic factors and information about oral health were associated with oral health indicators in pregnant women. Second, the height- for- age status at 3 weeks postpartum was worse in infants of mothers having periodontal problems and poor oral hygiene during pregnancy. Efforts to prevent oral diseases during pregnancy should be part of the local state and national health policy agenda in Uganda. © 2012 Wandera et al.; licensee BioMed Central Ltd. Participating women were members of a multi-center cluster-randomized behavioral intervention trial: Safety and Efficacy of Exclusive Breast feeding Promotion in the era of HIV in Sub Saharan Africa –PROMISE EBF (Id {“type”:”clinical-trial”,”attrs”:{“text”:”NCT00397150″,”term_id”:”NCT00397150″}}NCT00397150 at http://clinicaltrials.gov) conducted in Uganda, Burkina Faso, Zambia and South Africa. The aim of PROMISE EBF was to develop and test an intervention to promote exclusive breastfeeding, to assess its impact on infants in African contexts and to strengthen the evidence base regarding optimal duration of exclusive breastfeeding [28]. In Uganda, the Mbale district was purposively selected as the intervention site. The units for randomization were clusters made up of 1–2 villages with an average of 1000 inhabitants (35 infants per year given a birth rate of 3.5%). All pregnant women in 24 clusters (18 rural and 6 urban), were eligible for the study. Clusters were selected according to accessibility in terms of being on a main road with reasonable standard especially during the rainy season, access to church, school, trading center and water from the village well. The women were recruited into the PROMISE EBF study between January 2006 and June 2008. There were a total of 6 interviews and 1 oral examination scheduled for each participant: a recruitment interview and a clinical oral examination at 7 months of gestational age, followed by interviews of mothers and anthropometric measurement of infants at 3-, 6-, 12-, and 24 weeks post- partum. Women who did not intend to breastfeed and infants born with serious diseases or deformities that prevented breastfeeding were excluded from participation. A total of 886 pregnant women were eligible for the study and information was obtained from 877 of the participants (participation rate 98.9%) (mean age 25.6, SD 6.4). Of these, 713 women participated in the oral interview and clinical oral examination conducted between 2006 and 2008. The number of participants satisfied a sample size of 800 pregnant women calculated for the oral sub study, assuming a prevalence of tooth loss (i.e. at least one tooth lost) of 50%, a precision of 0.05 and a design effect of 2. At three weeks post- partum, 635 mothers were re-interviewed in their homes and 593 of their infants were assessed for anthropometric status. The procedures of recruitment and participation are detailed in the PROMISE EBF study profile [18,29-31]. Ethical Clearance was obtained from the Ethical Review Board, Faculty of Medicine, Makerere University. Written consent was obtained from all participants in the study and prior to each examination and interview a verbal consent was obtained. Structured interviews, designed on a desk- top PC using Epi-Handy and then down loaded to handheld computers, were conducted in face- to- face settings with participating women at household level. The interview schedules were developed in English and translated into the local language of Lumasaba. Oral health professionals reviewed the interview schedule for semantic, experiential and conceptual equivalence. Sensitivity to culture was considered and words selected appropriately. The interview schedules were piloted before administration. Gilbert [32] has described a model that explicitly conceptualizes the relationship of oral health conditions with predisposing and enabling immutable and mutable factors, such as socio-demographics, parity (predisposing factors) and exposure to oral health counseling during pregnancy (enabling factors). This model was used to guide the identification of exploratory variables utilized in this study. The following self-reported outcome variables were assessed: Use of dental care was assessed by asking “When was your last dental visit “and recorded as (0) never attended and (1) within the recent 6 months or more seldom. Periodontal symptoms were measured by five items in terms of “During the previous 3 months have you experienced: bleeding gums when brushing/eating, spontaneous bleeding from gums, pain in gums, changed gum color, swollen gums?” Each item was recorded as (0) no and (1) yes. A sum score was constructed by adding the items and dichotomizing based on a median split into (0) mild symptoms, (1) severe symptoms. Predisposing explanatory variables were identified as place of residence, age, educational level, marital status, parity and previous birth outcome experience. Enabling explanatory variables related to information received about own teeth/child’s teeth were assessed by 6 items in terms of “have you ever received information regarding how to take care of own teeth from health worker, dentist, radio, MCH clinic, newspapers and other sources?”. Each item was recorded as (0) no and (1) yes. A sum score was constructed and dichotomized into (0) never received information and (1) received information from one or more sources. A similar score was computed for information received about children’s teeth. Attendance at antenatal care and use of bed nets were each recorded as (0) no and (1) yes. The predictor variables employed and their coding are depicted in Table Table11. Frequency distribution of self-reported and clinically assessed exploratory variables at 3 weeks post- partum (total n = 877) The total number of the various categories does not add to 877 due to missing values. A trained and calibrated dentist (MW) carried out oral examinations under field conditions based on the WHO criteria [16]. An assistant recorded the data on a prepared record sheet. All fully erupted permanent teeth were scored excluding third molars. All examinations were performed at household level with subjects seated on the left hand side of the examiner who used a headlamp as source of illumination. No radiographic examination or drying of teeth was performed. The periodontal status was assessed using a plane –faced dental mirror and a specially designed lightweight CPITN probe with a 0,5 mm ball tip. Using the epidemiological part of the CPITN, the Community Periodontal Index (CPI) [15] with 10 index teeth (17,16,11,26,27,47,46,31,36 and 37) and 6 sextants per individual, four indicators of periodontal status were applied. Periodontal pockets were measured from the edge of the free gingiva to the bottom of the pocket. The criteria used were; healthy (code 0), bleeding on probing observed (code 1), calculus detected during probing (code 2), pocket 4–5 mm (code 3) and pocket >5 mm (code 4). Each index tooth was scored on two sites (buccal and lingual) and each sextant was scored according to its highest CPI score. In accordance with the hierarchical assumption, teeth with score 3 were assumed positive with respect to bleeding and calculus whereas teeth with score 2 were assumed positive with respect to bleeding [33]. Prevalence of healthy-, bleeding-, calculus and pocket sextants was assessed as the percentage of subjects affected (having at least one sextant affected). Severity of periodontal condition was assessed by the mean number of sextants having CPI code 0–3 and by the mean number of sextants in affected persons. The CPI recordings, total CPI, were also presented as the percentage distribution of dentate subjects according to the highest score in the mouth. Oral hygiene status was measured using the Oral Hygiene Index- Simplified (OHI-S) by Greene and Vermillion [34]. The index has two components (debris index- simplified (DI-S) and calculus index – simplified (CI-S). Debris and calculus were graded on a numeric scale from 0 to 3, divided by number of sites recorded and categorized in terms of low debris/calculus (0) (score 0.0-0.67) and fair debris/calculus score (1) (score 0.69-1.67). A total of 593 infants were examined regarding their weight and recumbent length in accordance with the WHO recommendations [35]. Standardized 25 kg portable Salter Spring scales measuring to the nearest 0.1 kg were used to determine weight. Recumbent length was measured to the nearest 0.1 cm with specially designed length boards. Using the WHO Child Growth Standards [35], anthropometric indices were constructed on the basis of weight, length, age and sex. Wasting was defined as weight-for-height z-scores (WHZ) < −2 SD, stunting as height-for-age z-scores (HAZ) < −2 SD and underweight as weight-for-age z-scores (WAZ) < −2 SD [35]. Predisposing and enabling variables used as explanatory variables in the analyses as well as the outcome variables and the numbers of subjects (%) according to categories are depicted in Table Table11. Duplicate clinical examinations were carried out with 50 mothers considered to be representative of the study participants after a period of one month. Kappa values for indicators of periodontal condition ranged from 0.48 (CPI index tooth 11) to 0.85 (CPI index tooth 31). The figures indicate moderate to good intra examiner reliability [36]. Data was entered into the Epi-Handy program on the handheld computers and analyzed using SPSS version 19.0 (Chicago, IL, USA). Cross tabulation, chi square statistics and ANOVA were used to assess bivariate relationships. Multiple variable logistic regression analyses were conducted with maternal oral health indicators as dependent variables using the logit model and 95% confidence intervals (CI) for the odds ratios. ANCOVA was used to assess the relationship between children’s anthropometric status and mothers’ periodontal status during pregnancy.

Résumé de l’IA

Study Justification:

– Preterm-low birth weight delivery is a major cause of infant morbidity and mortality in sub Saharan Africa.
– Poor periodontal health during pregnancy has been linked to preterm-low birth weight delivery.
– This study aims to investigate the factors that contribute to oral health problems in pregnant women and the association between these problems and infants’ anthropometric status.

Study Highlights:

– 67.0% of the participating pregnant women had periodontal problems.
– 12.1% had poor oral hygiene.
– 29.8% had recent dental visits.
– 65.0% experienced periodontal symptoms.
– 2.0% of the infants were wasted, 6.9% were underweight, and 10.0% were stunted.
– Maternal age, marital status, parity, and the use of mosquito bed nets were associated with periodontal problems.
– Infants of mothers with periodontal problems and poor oral hygiene had worse height-for-age status at 3 weeks postpartum.

Study Recommendations:

– Efforts to prevent oral diseases during pregnancy should be part of the local, state, and national health policy agenda in Uganda.

Key Role Players:

– Oral health professionals
– Health workers
– Dentists
– Researchers
– Policy makers
– Community health workers

Cost Items for Planning Recommendations:

– Oral health education materials
– Training for health workers and community health workers
– Dental care services
– Oral health counseling during antenatal care visits
– Mosquito bed nets
– Research funding

Force de la preuve

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study conducted a community-based prospective cohort study with a large sample size of 713 pregnant women. Multiple logistic regression analyses were used to identify independent determinants of periodontal problems and use of dental services during pregnancy. Analysis of covariance (ANCOVA) was used to investigate the relationship between periodontal problems and the infants’ anthropometric status. However, the abstract does not provide information on the representativeness of the sample and the generalizability of the findings. To improve the evidence, future studies could include a more diverse sample and provide more details on the recruitment process and data collection methods.

Abstrait

Participating women were members of a multi-center cluster-randomized behavioral intervention trial: Safety and Efficacy of Exclusive Breast feeding Promotion in the era of HIV in Sub Saharan Africa –PROMISE EBF (Id {“type”:”clinical-trial”,”attrs”:{“text”:”NCT00397150″,”term_id”:”NCT00397150″}}NCT00397150 at http://clinicaltrials.gov) conducted in Uganda, Burkina Faso, Zambia and South Africa. The aim of PROMISE EBF was to develop and test an intervention to promote exclusive breastfeeding, to assess its impact on infants in African contexts and to strengthen the evidence base regarding optimal duration of exclusive breastfeeding [28]. In Uganda, the Mbale district was purposively selected as the intervention site. The units for randomization were clusters made up of 1–2 villages with an average of 1000 inhabitants (35 infants per year given a birth rate of 3.5%). All pregnant women in 24 clusters (18 rural and 6 urban), were eligible for the study. Clusters were selected according to accessibility in terms of being on a main road with reasonable standard especially during the rainy season, access to church, school, trading center and water from the village well. The women were recruited into the PROMISE EBF study between January 2006 and June 2008. There were a total of 6 interviews and 1 oral examination scheduled for each participant: a recruitment interview and a clinical oral examination at 7 months of gestational age, followed by interviews of mothers and anthropometric measurement of infants at 3-, 6-, 12-, and 24 weeks post- partum. Women who did not intend to breastfeed and infants born with serious diseases or deformities that prevented breastfeeding were excluded from participation. A total of 886 pregnant women were eligible for the study and information was obtained from 877 of the participants (participation rate 98.9%) (mean age 25.6, SD 6.4). Of these, 713 women participated in the oral interview and clinical oral examination conducted between 2006 and 2008. The number of participants satisfied a sample size of 800 pregnant women calculated for the oral sub study, assuming a prevalence of tooth loss (i.e. at least one tooth lost) of 50%, a precision of 0.05 and a design effect of 2. At three weeks post- partum, 635 mothers were re-interviewed in their homes and 593 of their infants were assessed for anthropometric status. The procedures of recruitment and participation are detailed in the PROMISE EBF study profile [18,29-31]. Ethical Clearance was obtained from the Ethical Review Board, Faculty of Medicine, Makerere University. Written consent was obtained from all participants in the study and prior to each examination and interview a verbal consent was obtained. Structured interviews, designed on a desk- top PC using Epi-Handy and then down loaded to handheld computers, were conducted in face- to- face settings with participating women at household level. The interview schedules were developed in English and translated into the local language of Lumasaba. Oral health professionals reviewed the interview schedule for semantic, experiential and conceptual equivalence. Sensitivity to culture was considered and words selected appropriately. The interview schedules were piloted before administration. Gilbert [32] has described a model that explicitly conceptualizes the relationship of oral health conditions with predisposing and enabling immutable and mutable factors, such as socio-demographics, parity (predisposing factors) and exposure to oral health counseling during pregnancy (enabling factors). This model was used to guide the identification of exploratory variables utilized in this study. The following self-reported outcome variables were assessed: Use of dental care was assessed by asking “When was your last dental visit “and recorded as (0) never attended and (1) within the recent 6 months or more seldom. Periodontal symptoms were measured by five items in terms of “During the previous 3 months have you experienced: bleeding gums when brushing/eating, spontaneous bleeding from gums, pain in gums, changed gum color, swollen gums?” Each item was recorded as (0) no and (1) yes. A sum score was constructed by adding the items and dichotomizing based on a median split into (0) mild symptoms, (1) severe symptoms. Predisposing explanatory variables were identified as place of residence, age, educational level, marital status, parity and previous birth outcome experience. Enabling explanatory variables related to information received about own teeth/child’s teeth were assessed by 6 items in terms of “have you ever received information regarding how to take care of own teeth from health worker, dentist, radio, MCH clinic, newspapers and other sources?”. Each item was recorded as (0) no and (1) yes. A sum score was constructed and dichotomized into (0) never received information and (1) received information from one or more sources. A similar score was computed for information received about children’s teeth. Attendance at antenatal care and use of bed nets were each recorded as (0) no and (1) yes. The predictor variables employed and their coding are depicted in Table Table11. Frequency distribution of self-reported and clinically assessed exploratory variables at 3 weeks post- partum (total n = 877) The total number of the various categories does not add to 877 due to missing values. A trained and calibrated dentist (MW) carried out oral examinations under field conditions based on the WHO criteria [16]. An assistant recorded the data on a prepared record sheet. All fully erupted permanent teeth were scored excluding third molars. All examinations were performed at household level with subjects seated on the left hand side of the examiner who used a headlamp as source of illumination. No radiographic examination or drying of teeth was performed. The periodontal status was assessed using a plane –faced dental mirror and a specially designed lightweight CPITN probe with a 0,5 mm ball tip. Using the epidemiological part of the CPITN, the Community Periodontal Index (CPI) [15] with 10 index teeth (17,16,11,26,27,47,46,31,36 and 37) and 6 sextants per individual, four indicators of periodontal status were applied. Periodontal pockets were measured from the edge of the free gingiva to the bottom of the pocket. The criteria used were; healthy (code 0), bleeding on probing observed (code 1), calculus detected during probing (code 2), pocket 4–5 mm (code 3) and pocket >5 mm (code 4). Each index tooth was scored on two sites (buccal and lingual) and each sextant was scored according to its highest CPI score. In accordance with the hierarchical assumption, teeth with score 3 were assumed positive with respect to bleeding and calculus whereas teeth with score 2 were assumed positive with respect to bleeding [33]. Prevalence of healthy-, bleeding-, calculus and pocket sextants was assessed as the percentage of subjects affected (having at least one sextant affected). Severity of periodontal condition was assessed by the mean number of sextants having CPI code 0–3 and by the mean number of sextants in affected persons. The CPI recordings, total CPI, were also presented as the percentage distribution of dentate subjects according to the highest score in the mouth. Oral hygiene status was measured using the Oral Hygiene Index- Simplified (OHI-S) by Greene and Vermillion [34]. The index has two components (debris index- simplified (DI-S) and calculus index – simplified (CI-S). Debris and calculus were graded on a numeric scale from 0 to 3, divided by number of sites recorded and categorized in terms of low debris/calculus (0) (score 0.0-0.67) and fair debris/calculus score (1) (score 0.69-1.67). A total of 593 infants were examined regarding their weight and recumbent length in accordance with the WHO recommendations [35]. Standardized 25 kg portable Salter Spring scales measuring to the nearest 0.1 kg were used to determine weight. Recumbent length was measured to the nearest 0.1 cm with specially designed length boards. Using the WHO Child Growth Standards [35], anthropometric indices were constructed on the basis of weight, length, age and sex. Wasting was defined as weight-for-height z-scores (WHZ) < −2 SD, stunting as height-for-age z-scores (HAZ) < −2 SD and underweight as weight-for-age z-scores (WAZ) < −2 SD [35]. Predisposing and enabling variables used as explanatory variables in the analyses as well as the outcome variables and the numbers of subjects (%) according to categories are depicted in Table Table11. Duplicate clinical examinations were carried out with 50 mothers considered to be representative of the study participants after a period of one month. Kappa values for indicators of periodontal condition ranged from 0.48 (CPI index tooth 11) to 0.85 (CPI index tooth 31). The figures indicate moderate to good intra examiner reliability [36]. Data was entered into the Epi-Handy program on the handheld computers and analyzed using SPSS version 19.0 (Chicago, IL, USA). Cross tabulation, chi square statistics and ANOVA were used to assess bivariate relationships. Multiple variable logistic regression analyses were conducted with maternal oral health indicators as dependent variables using the logit model and 95% confidence intervals (CI) for the odds ratios. ANCOVA was used to assess the relationship between children’s anthropometric status and mothers’ periodontal status during pregnancy.

Matériaux

N/A

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile Dental Clinics: Implementing mobile dental clinics that can travel to rural areas and provide oral health services to pregnant women. This would increase access to dental care for women who may not have easy access to a dental clinic.

2. Oral Health Education: Developing and implementing oral health education programs specifically targeted towards pregnant women. This would help increase awareness about the importance of oral health during pregnancy and encourage women to seek dental care.

3. Integration of Oral Health into Antenatal Care: Integrating oral health screenings and education into routine antenatal care visits. This would ensure that pregnant women receive regular oral health check-ups and appropriate referrals for treatment if needed.

4. Community Health Workers: Training community health workers to provide basic oral health education and screenings to pregnant women in their communities. This would help reach women who may not have access to traditional healthcare facilities.

5. Telemedicine: Utilizing telemedicine technology to provide remote oral health consultations and advice to pregnant women. This would be particularly beneficial for women in remote areas who may not be able to travel to a dental clinic.

These innovations would help improve access to maternal health by addressing the specific oral health needs of pregnant women and ensuring that they receive appropriate care and education.

AI Innovations Description

The study mentioned investigates the determinants of periodontal health in pregnant women and its association with infants’ anthropometric status in Eastern Uganda. The aim of the study was to identify factors that contribute to poor oral health during pregnancy and to assess the impact of periodontal problems on infants’ growth.

The study was conducted as part of a larger multi-center cluster-randomized behavioral intervention trial called PROMISE EBF (Safety and Efficacy of Exclusive Breastfeeding Promotion in the era of HIV in Sub Saharan Africa). The intervention aimed to promote exclusive breastfeeding and assess its impact on infants in African contexts.

In Uganda, the study was conducted in the Mbale district, and pregnant women from 24 clusters were recruited between January 2006 and June 2008. A total of 713 pregnant women participated in interviews and oral examinations. Anthropometric assessments of their infants were conducted 3 weeks after delivery.

The study found that 67.0% of the women had periodontal problems, 12.1% had poor oral hygiene, 29.8% had recent dental visits, and 65.0% experienced periodontal symptoms. Among the infants, 2.0% were wasted, 6.9% were underweight, and 10.0% were stunted.

The study identified several factors associated with periodontal problems in pregnant women, including maternal age, marital status, parity, and the use of mosquito bed nets. It also found that infants of mothers with periodontal problems and poor oral hygiene during pregnancy had worse anthropometric status at 3 weeks postpartum.

The study suggests that efforts to prevent oral diseases during pregnancy should be included in local, state, and national health policies in Uganda.

Overall, the study highlights the importance of addressing oral health issues during pregnancy to improve maternal and infant health outcomes. It provides valuable insights into the determinants of periodontal health in pregnant women and its impact on infants’ growth.

AI Innovations Methodology

The study mentioned in the description focuses on the determinants of periodontal health in pregnant women and the association between periodontal problems during pregnancy and infants’ anthropometric status. The aim of the study was to identify factors that contribute to poor oral health in pregnant women and to understand how these factors impact the health of their infants.

To improve access to maternal health, the following recommendations can be considered:

1. Increase awareness: Implement educational programs to raise awareness about the importance of oral health during pregnancy. This can be done through community outreach programs, antenatal care visits, and media campaigns.

2. Integration of oral health into antenatal care: Integrate oral health screenings and preventive measures into routine antenatal care visits. This can include providing oral hygiene instructions, dental cleanings, and referrals for further dental treatment if needed.

3. Training healthcare providers: Provide training to healthcare providers, including midwives, nurses, and doctors, on the importance of oral health during pregnancy and how to provide basic oral health care and counseling.

4. Collaboration between dental and maternal health professionals: Foster collaboration between dental and maternal health professionals to ensure comprehensive care for pregnant women. This can involve joint training programs, shared resources, and referral systems.

To simulate the impact of these recommendations on improving access to maternal health, a methodology can be developed as follows:

1. Baseline data collection: Collect baseline data on the current access to maternal health services, including oral health care, in the target population. This can involve surveys, interviews, and analysis of existing data.

2. Define indicators: Define indicators to measure the impact of the recommendations on access to maternal health. This can include indicators such as the percentage of pregnant women receiving oral health education, the percentage of pregnant women receiving dental screenings, and the percentage of pregnant women accessing dental treatment.

3. Implement interventions: Implement the recommended interventions in the target population. This can involve training healthcare providers, conducting educational programs, and integrating oral health into antenatal care.

4. Data collection after intervention: Collect data after the interventions have been implemented to assess the impact on access to maternal health. This can involve surveys, interviews, and analysis of data from healthcare facilities.

5. Data analysis: Analyze the data collected before and after the interventions to determine the impact on access to maternal health. This can involve statistical analysis, comparison of indicators, and identification of trends and patterns.

6. Evaluation and refinement: Evaluate the results of the simulation and refine the interventions as needed. This can involve feedback from healthcare providers and stakeholders, identification of challenges and barriers, and adjustment of strategies.

By following this methodology, it will be possible to simulate the impact of the recommendations on improving access to maternal health and make informed decisions on how to implement these recommendations effectively.

Auteurs et co-auteurs

Statistics:

Citations: 12

Authors: 4

Identifiers:

DOI: 10.1186/1471-2393-12-90

Research Areas:

Community Interventions, Environmental, Food Security, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health

Study Countries:

Burkina Faso, Multi-Countries, South Africa, Uganda, Zambia

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study, Exploratory Study, randomised-control-trial

Study Approach:

Quantitative

Participants Gender:

Female

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