Barriers to practicing patient advocacy in healthcare setting

Abstract

Aim

To explore barriers to practicing patient advocacy in healthcare setting.

Design

This study used a qualitative research approach to arrive at the study result.

Methods

Twenty‐five Registered Nurses were purposively selected. Semi‐structured interviews were used to collect data and analysed using qualitative content analysis.

Results

The main theme identified was lack of cooperation between healthcare team, care recipients and the health institution which included the health institution and work environment, ineffective communication and interpersonal relationship, patients' family, religious and cultural beliefs. Unsuccessful advocacy resulted in increased complications, death, negative consequence on the health institution and nursing as a profession. This study has significantly created awareness of the need for an improved patient advocacy to enhance the quality and safety in the care of patients.

INTRODUCTION

Evidence has shown that health facility's goal of providing quality care of patients cannot succeed in the absence of nursing advocacy (Black, ; Nsiah, ).

Nsiah, Siakwa, and Ninnoni () described patient advocacy being the patient's voice, acting on behalf of a patient to ensure that his or her needs are met. Many nurses advocate for patients across the globe due to its advantages and ability to increase recovery rate (Abbaszadeh, Borhani, & Motamed‐Jahromi, ; Black, ; Thacker, ).

For instance, Attree () was of the view that professional nursing is about advocating for patients to reduce possible complications that impede speedy recovery. Evidence suggests limited practice of advocacy by nurses, leading to unnecessary health complications and death in some Ghanaian healthcare facilities (Abekah‐Nkrumah, ; Ghana News Agency, ; Norman, Aikins, Binka, & Nyarko, ).

Yet, the specific reasons that hinder Registered Nurses from advocating for patients in the Ghanaian context are not clear in the literature. This study outcome will provide empirical evidence with respect to specific barriers to successful patient advocacy in the healthcare setting. It will further contribute significantly to creating the awareness and understanding the need to enhance successful patient advocacy for improved safety and quality care of patients.

BACKGROUND

Patient advocacy enhances quality of patient care, yet most nurses are limited in their ability to carry out this role. Research has revealed powerlessness, lack of knowledge in law and nursing ethics, limited support for nurses and physicians leading in hospitals as hindrances to nursing advocacy in the Iranian context (Negarandeh, Oskouie, Ahmadi, Nikravesh, & Hallberg, ). Negarandeh and co‐workers as cite in Nsiah () further noted the healthcare setting as the greatest source of hindrance to patient advocacy due to the fact that advocating for patients basically contradicted the cultural systems in the hospital. The nurses also lacked autonomy in the hospital environment.

In addition, the absence of guidelines, fear of making mistakes and its unknown consequences prohibited some nurses from advocating for patients (Vaartio, Leino‐Kilpi, Salanterä, & Suominen, ). A study conducted by Black () in southern Nevada indicated wrong labelling and vindications by employer, coupled with possibility of losing one's job served as barrier during patient advocacy.

On the contrary, as cited by Nsiah (), Abbaszadeh et al. () stated that fear of job loss was not a hindrance to nursing advocacy in Iran. Rather, these authors noted limited educational programmes and less work experience as the main challenge. Thacker (), however, argued that it is rather the working environment that greatly determined whether or not a nurse will advocate for his or her patient.

Furthermore, Hanks () was of the view that individual characteristics of nurses such as self‐esteem, assertiveness and personal values hindered their ability and desire to advocate. Similar to this study finding, Davis and Konishi () as revealed by Nsiah (), found that cultural beliefs hindered nurses from embarking on advocacy for patients in Japan. Meanwhile, Bu and Jezewski () considered limited legal support for nurses as key blockade to advocacy. This finding implies that barriers confronting nurses who advocate for patients differ from one country and health facility to another. Nurses' context of practice greatly influenced their ability to advocate for patients.

Currently, there exist knowledge gap with respect to the exact cause of nurses' inability to advocate for patients in most Ghanaian hospitals (Nsiah et al., ). However, the negative consequences that result from lack of patient advocacy are said to include prolonged patient recovery and death which contradicts health institution's goal of saving lives (Black, ; Nsiah, ; Nsiah et al., ). Hence, the need to research into barriers hinders nurses from advocating for patients in the healthcare setting in the Ghanaian context. This study aimed at answering the following research question: What barriers do Registered Nurses encounter when advocating for patients in the healthcare setting?

Design

The study used a qualitative approach to arrive at the study result. The method was chosen to enhance collection of data based on participants' personal experiences with regard to barriers they faced when advocating for patients in the healthcare facility (Creswell, ; Neuman, ).

Setting and participants

The research occurred in a metropolitan hospital in Ghana. All nurses employed in the various wards in the hospital formed the population for this study. These wards and units were chosen to enable the researchers to obtain required information for achievement of the set objectives (Creswell, ). Sampling procedure was purposive because only nurses who were interested and had the ability to provide the needed information were interviewed (Burns & Grove, ; Creswell, ). A total of 25 Registered Nurses participated in the study on achievement of saturation. Detailed information on the study setting and participants can be obtained from Nsiah et al. ().

Data collection

Data collection began in February 2016 and ended in May 2016 by using a semi‐structured interview and an interview guide (Creswell, ). The audio‐taped interviews which lasted between 35 to 45 min excluded the participants' demographic information and made use of pseudonyms for confidentiality purpose. Twenty interviews took place in a designated room in the health facility, with the remaining five occurring in the offices of the participants involved. These participants were asked to tell the barriers they faced when advocating for patients and instances where they could not advocate as a result of some barriers (Nsiah, ).

Ethical considerations

This study was permitted by a  University's ethics committee and that of the hospital. An informed consent was also signed by each participant on voluntary basis. In addition, proper data management, as well as pseudonyms, was used to ensure confidentiality and anonymity of respondents.

Data analysis

The study data were analysed inductively, using a qualitative content analysis (Creswell, ; Miles & Huberman, ). The data analysis occurred alongside with collection of data until saturation was achieved. Themes were directly attained from the content of the participants' responses and not from the personal views of the authors. For detailed data analysis, refer to Nsiah et al. ().

Rigour

Rigour in qualitative study deals with trustworthiness or measures put in place to ensure the quality of a research (Creswell, ). The authors employed necessary measures to assure credibility through the purposeful selection of study participants, member check and peer review (Creswell, ; Polit & Beck, ). Confirmability and transferability were also assured. The identified themes significantly agree with nursing literature. Finally, excerpts from participants' responses were directly quoted to ensure authenticity. Detailed description of rigour can be found in Nsiah et al. ().

RESULT

Study participants

Twenty‐five nurses took part in the study without any coercion. These nurses had practiced in the clinical setting for about 5–21 years and above. Refer to Nsiah et al. () for details on participants.

Main theme: lack of cooperation between healthcare team, care recipients and the health institution

This study aimed at exploring barriers confronting Registered Nurses who advocate for patients in the healthcare setting. Themes that identified have been provided in Table .

Analysis of study result

Statements	Sub‐themes	Themes
The environment The place we nurse the patient doesn't suit for that advocacy Authorities who don't really understand Rules and regulations given by the facility The codes of conduct of the facility The facility itself The institution The institutional authorities serve as a barrier The policies of supervisors don't favour advocacy	The healthcare institution itself	The health institution and work environment
Colleagues discourage you Colleagues see you as a threat or they feel you want to get them to do more work Some colleagues will not do it and they will not allow you to do it They are not ready to change They will not make the place conducive for you to stay	Lack of support from colleagues
You really need to spend time to speak to this patient before they understand It is time consuming It takes too long to get a simple thing We don't have the full time	Limited time
You call a doctor and he says no, I will not come Patients will come and you call the doctor and he says no, continue to monitor The doctors are not cooperative at all The doctors will not agree with you When you suggest to them, some take it, but others will not take it	Physicians
At times you try your best but the hospital is not having those things you need to give out Logistics, we don't get them The facility does not have resources The labs are not working The things that you need, you will not find them There is no bag to collect the blood This hospital lacks many things Transportation means Treatments are also not available in pharmacy We don't have important drug We don't have the material to work with You don't have suctioning machine or NG tube	Inadequate medical equipment and supplies	The health institution and work environment
If you need emergency drugs, the NHIS is not paying The NHIS It's a big problem	The NHIS
Other persons refuse Superiors The facility does not have a social worker The nature and attitude of the person you want to contact for the advocacy The personnel that are also incharge The personnel to act on the problem The personnel to intervene when is beyond the nurse's capacity We don't have specialist here	Lack of personnel to intervene when needed
The ward incharge Your superiors Most dwells on our incharges Ward supervisors	Ward incharges
The patient's educational level A lot of illiteracy among our patients Our patients also don't understand	High illiteracy level	The Patients
Patient doesn't want you to intervene Patient's preconceptions before coming Patients has certain ideologies Some patients are not cooperative They don't see the nurse as a friend to establish that relationship	Patients' preferences
Patients' refusal
The patient says I don't want it You want to advocate but the patient is not willing Patient says I am not going	Patients' right	Legal support
Because of patients' rights, at times you can't force the patient This patient right thing is a problem
Because of the legal backing you can't defend yourself Even though you know what to do but because of the legalities you just can't help Lack of legal support Sometimes the legalities	Legal support for nurses
The result not seems to be coming and it becomes frustrated for the nurse The outcome is also another challenge. The end result Should that thing fail? Fear of being in trouble You might think that if something negative occurs, or the outcome might be bad The consequences might be devastating	Possible outcome of advocacy	Anticipated negative outcome of advocacy
I have reported it to my incharge and she has not said anything about it, I will not stand inn again another time I would not talk about it again If I have advocated for someone and things did not go well for me the next time I will not do it again. The next day, you won't do anything Nothing good will come out of it The response you get from reporting the issues becomes disappointing The result not seems to be coming and it becomes frustrated for the nurse Previous outcome is also another challenge. The end result from past attempts	Previous experience	Anticipated negative outcome of advocacy
Should that thing fail? Fear of being in trouble You might think that if something negative occurs, or the outcome might be bad The consequences might be devastating The risks The risk of travelling are all involved	Risks associated with advocacy
It's a challenge trying to communicate everything so that nothing goes wrong Poor Communication skills The communication Challenges like communication and interpersonal relationship There are people who really don't know how to communicate	Communicating challenges	Ineffective communication and interpersonal relationship
You can get the other person angered by the way you bring out your point The problem is with effective communication	Poor interaction
Awkward relationship between you and there other staff poor human relationship patients don't see eye to eye with the nurse	Awkward relationship
Families are not supportive Relatives may not agree with you Relatives too are not appreciative The husband do not support The relative don't understand The relative are not thankful	Limited family support	Patient's family members
Family just come and dump patient in the hospital and the nurse has to do everything You expect the family, father and mother to even pick calls when you call, but they will not pick	Abandonment of patients
If I try to prescribe and something goes wrong and they call I will not get support If something goes wrong, who will support me? Should anything happen no one will stand behind you?	Limited help for nurses	Lack of support
We don't have clear guidelines as to How nurses are backed You become helpless without a guide No protocol for advocacy	Absent guidelines
Background of the individual nurses It is quiet subjective Commitments of nurses The staff are reluctant to help some nurses don't care about whatever happens to the patient	Personal characteristics and values of nurses	The nurses
Nurses are not assertive enough You should be assertive to always pull things through	Unassertiveness
The bureaucracies The channels you need to pass through To advocate right is not easy You have to move from here to here, go here, do this, it is difficult	Complexity of advocacy	The advocacy process
At the beginning it is very difficult Advocating is extra work Is sometimes tiresome	Advocating is tiring
Prayer camps They prefer prayer to medications Some opted to pray Praying with a pastor for healing	Prayer activities	Religious/cultural beliefs
Husband must be available to accept her admission Our culture and traditions Some refused referral without husband's consent They believe in superstitions	Traditional beliefs
Lack of financial support Poverty The economic status of the patient The patients have no money to pay The patient does not have the money	Patient's financial status	Financial difficulties
Patients need to spend a lot of money for that thing but they don't have You advocate for the patient but there is no money for the patient to go They can't purchase required items, so your hands are tied as a nurse	Cost required for care
Limited education of patients Patients refuse due to limited education Lack of education on health issues I wasn't that skilled to intervene as a nurse	Lack of education	Inadequate knowledge
Lack of knowledge on advocacy process Nurses lack the facts to explain things Other nurses lack understanding Knowledge is a barrier You become helpless due to poor knowledge	Limited understanding

Note:

Lack of cooperation between healthcare team, care recipients and the health institution.

The health institution and work environment

Sub‐themes under this section ranged from working environment, limited medical equipment, colleague nurses and physicians. Direct quotes from participants as cited in Nsiah () are presented below:

…We face a lot of challenges when sometimes you try to help or speak for a patient. You speaking for the patient may bring awkward relationship between you and the other staff. When you come to the facility itself, I will say they don't give you the chance to advocate for the patients in terms of the rules and regulations given by the facility… (Mrs. OP1, 1‐5 yr of experience)

…It is the doctors that don't support us at times. Sometimes patients will come and you call the doctor, he refuse to come and say, continue to monitor, but you know something bad will happen if they don't come and do something…This hospital lacks many things. Even a bag for patients to donate blood there is none available… (Mrs. T2, 11‐15 yr of experience)

…At times to some of the doctors are not cooperative at all because they think that they are ahead of us, so at times when you suggest to them, some take it, but others will not take it and refuse your offer… (Mrs. M2, 6‐10 yr of experience)

The patients

Individual patients were noted by the respondents as hindrances to the advocacy process due to limited understanding of their conditions, superstitions and ideologies as indicated below:

We have a lot of illiteracy among our patients, so sometimes they don't understand what is going on. So when you try to tell them their attitude pushes you away… (Mrs. OP1, 1‐5 yr of experience)

…I think some of the patients have certain perceptions and ideologies before they come to the hospital. So it doesn't matter how you educate them when they come they still stick to what they know from the house, they are not ready to change… (Mrs. O2, 1‐5 yr of experience)

Legal support

The nurses disclosed that in some instances, they could not advocate for patients because of the absence of legal backing in the case of lawsuit. Some of respondents cited the following example:

Hmm, because of patients' rights, you can't force the patient…So if a patient says this is what I want you can't say I would not do it for you. At times this is what the patient wants but you know that this is not good for the patient…. Sometimes you would want to do it by force but because of the legal backing, you can't defend yourself… (Mrs. O4, 1‐5 yr of experience)

Anticipated negative outcome of advocacy

According to participants, their failure in previous attempt to advocate for patients hindered them from advocating further because they believed the outcome would surely be negative. Participants gave the following examples:

…There are several cases where you attempt to advocate, but whatever you write, your superior comes and cancels it. So the next day, you wouldn't want to do anything again because nothing good will come out of it… (Mr. P3, 6‐10 yr of experience)

Fear of loss of job was another anticipated negative outcome revealed by the nurses. Participants disclosed how hospital authorities threatened to transfer them if they kept speaking on behalf of patients as noted below:

…Because I do it once and am told if I don't take care I am going to be transferred, then I will not do it again. In fact when I come to work and do my duties, if I leave the work that is all, nothing about work again. Because if am transferred to a place where my family is not there, I will not go… (Mrs. C1, 1‐5 yr of experience)

Ineffective communication and interpersonal relationship

Ineffective communication and interpersonal relationship constituted barriers to advocating for patient as revealed in the excerpt below:

…They already have their preconceptions before coming to the hospital. So they don't see the nurse as a friend to establish that relationship with you for you to be able to get to know their need to be able to help them. (Mrs. C2, 6‐10 yr of experience)

…Another challenge is about communication skills. There are people who really don't know how to communicate. You might be saying a good thing, but you can get the other person angered by the way you bring out your point… (Mrs. T1, 6‐10 yr of experience)

Patient's family members

The result pointed out patients' family members as a hindrance to nurses' ability to advocate for patients as quoted below:

…Sometimes families are not supportive…There have been cases whereby families just come and dump patient in the hospital and vanish. The nurse has to do everything like the parents. You expect the family, father and mother to even pick calls when you call, but they will not… (Mr. P3, 6‐10 yr of experience)

…Another challenge is Lack of education on health issues, especially concerning women. Also, superstitions, because they have a lot of ideas before they come so if you want to change everything at once you normally face a challenge… (Mrs. O7, 1‐5 yr of experience)

Lack of support for nurses

Insufficient backing from nursing authorities coupled with absent policies on the kind of assistance for nurses who faulted during the advocacy process emerged as barrier confronting nurses who advocate for patients (Nsiah, ).

If you are advocating definitely you will need the help of a physician, a nutritionist, or maybe a physiotherapist, the lab people might have to come in. and if they are not ready …It will kind of make your job more difficult. Because when you get to one level and the other person refuses to take it up, there is a gap and advocacy becomes difficult. (Mrs. C 1, 1‐5 yr of experience)

Sometimes a patient come at midnight and there is no doctor …Even though you know what to do but because of the legalities you just can't help. If I try to prescribe and something goes wrong and they call I will not get support… (Mrs. OP1, 1‐5 yr of experience)

…should the advocacy fail the fear of being in trouble make you think twice… (Mrs. O6, 1‐5 yr of experience)

The nurses

According to the result, some nurses do not believe in advocacy as part of nursing, while others are not committed nor assertive enough. Hence, they did not advocate for the patients as expected as disclosed below:

…sometimes we as nurses are not assertive enough… (Mrs. M4, 1‐5 yr of experience)

Sometimes the staff ourselves are bit a reluctant to help the patients but myself when I see certain things I can't stay… (Mrs. O2, 1‐5 yr of experience)

…some nurses don't care about whatever happens to the patient… (Mrs. C1, 1‐5 yr of experience)

The advocacy process

The processes nurses went through to accomplish the advocacy action were noted as being too difficult. Hence, most nurses could not intervene for hospitalized patients.

Oh, the challenges are many, you have to know, move from here, go there, do this, the bureaucracies, the channels you need to pass through are many and it is just difficult pushing it … (Mr. P1, 1‐5 yr of experience)

…when I first tried to advocate for a patient…, I got fed up and I said why don't I stop? … (Mrs. T2, 11‐15 yr of experience)

Religious and cultural beliefs

It is evident from participants' responses that patients and family's religion and culture hindered the advocacy process. As indicated in Nsiah (), some patients opted going to pray in camps than to be referred for proper care in another health facility, whereas some refused referral without husband's consent:

…The husband is also saying that the conditions that we want to refer he is not ready to take the woman to the place. Rather he wants to take the woman to a prayer camp… The BP was very high. We gave her a drug and needed her to sleep but she told me she will not sleep and that she is praying with a pastor….We admitted her but she went to the house because the man was not available to accept her admission per the tradition… (Mrs. O5, 1‐5yr of experience)

Financial difficulties

The research showed that most patients could not afford the money required to accomplish the needed advocacy. Excerpts from participants' responses have been provided below:

…I also think poverty is a barrier. Because let's say if there is referral, at the end of the day you advocate for the patient but there is no money for the patient to go. (Mrs. O7, 1‐5 yr of experience)

…At times too we don't have the drugs in the hospital and the patient does not have the money to buy. We have a case here, we want to refer the case. We gave her the drugs we have here in the emergency kit. She is supposed to replace it and she doesn't have the money… (Mrs. O6, 21 yr of experience)

Inadequate knowledge

This theme is about the nurses' own limited knowledge of  patients' conditions and how to approach the advocacy process. Also, some patients rejected the advocacy process initiated by nurses as a result of poor knowledge. Below are direct quotes from participants:

When I first tried to advocate for a patient, I got fed up due to limited education…Some patients do not agree with you, other nurses also lack understanding. Then I realized that this is someone's life we are talking about. So whether the person at the superior end likes it or not, you have to find a way around it. So I think is about lack of knowledge… (Mrs. T1, 6‐10 yr of experience)

…Knowledge and education is a hindrance. …So knowledge is very important. It has really helped some of us in advocating for the patients… (Mrs. M2, 6‐10 yr of experience)

DISCUSSION

This study explored barriers to practicing patient advocacy in healthcare setting. The main theme was noted as a lack of cooperation between the healthcare team, care recipients and the health institution itself. The overall theme was identified from 10 themes which included the health institution and work environment, ineffective communication and interpersonal relationship, patients' family, religious and cultural beliefs. This result agrees with several study findings in nursing literature. For instance, Negarandeh et al. () revealed poor motivation coupled with powerlessness as a barrier to advocating for patients in the Iranian context, while complexity of the advocacy process was what Negarandeh, Oskouie, Ahmadi, and Nikravesh () found as a great obstacle to patient advocacy.

Also, Kohnke () similarly pointed the healthcare institution and the environment where nursing occurs as a key obstacle during nursing advocacy. Furthermore, a report by Black () showed that fear of labelling and retaliation in the workplace restricted nurses from advocating for their patients. Contrary to fear of losing one's job as noted in this study, Abbaszadeh et al. () found limited educational programmes for nurses as the main problem that prevented nurses from advocating in an Iranian hospital. Meanwhile, the finding is consistent with Negarandeh et al. () in a different hospital in Iran. Hence, it can be concluded from this study finding that success in patient advocacy differs based on prevailing conditions in the individual healthcare settings.

Moreover, as cited in Nsiah (), lack of legal support as a theme in this study seems to provide evident to support the work of Vaartio et al. () and Bu and Jezewski () who noted that nurses allowed patients' preferences to prevail even though they knew it was wrong due to fear of being left alone without support in the event of lawsuit. Another barrier found was ineffective communication and interpersonal relationship. Yet, researchers have  revealed that effective patient advocacy required good interpersonal and therapeutic communication skills MacDonald () and Peplau (). It is therefore evident from the study that a gap exists in nursing theory and practice. Hospital authorities should enhance availability of adequate information and cordial relationship between nurses, members of healthcare team and care recipients to promote quality advocacy, job satisfaction and patient safety.

Hanks () showed that nurses' own personalities could either promote or hinder them from advocating for their patients which is exactly what was found in this study suggesting that advocacy is subjective. Hence, regardless of patients' conditions and peculiar needs, advocating for patients will depend basically on the individual nurse attending to the patient. Nursing leaders should therefore discharge their supervisory role efficiently in health facilities to promote safety and speedy recovery.

Finally, respondents pointed patients' family, financial difficulty and inadequate knowledge, culture and religion as limitations to advocating for patients. According to the participants, as pointed out in Nsiah () several attempts made to advocate for a change in patients' drug and transfer for better care failed as a result of monetary constraints. Thacker arrived as similar findings () and Davis and Konishi () in Japan. It therefore behoves on the government to put measures in place to assist care recipients while on admission. Interpersonal dialogue between patients, their families and religious leaders is very vital to effective advocacy to promote safety and quality care.

LIMITATIONS

The scope of this study was restricted to a single hospital. Also, participants could have been extended to include physicians and patients as well for broader perspectives of existing hindrances to the patient advocacy activities in the healthcare setting.

CONCLUSIONS

The goal of this study was to explore barriers confronting Registered Nurses who advocate for patients in the healthcare setting. Lack of cooperation between the healthcare team, care recipients and the health institution was the overall theme that identified from analysis of the data. Themes identified included but not limited to patients, the health institution, inadequate knowledge, ineffective communication and interpersonal relationship, financial constraints, and religious and cultural beliefs. It was found in the study that negative consequences including health complication and death resulted from unsuccessful advocacy initiated by the nurse in the healthcare setting. Notwithstanding, therapeutic communication and good interpersonal relationship were noted as facilitators in the advocacy process during clinical practice. This study concluded that patients and families' cultural believes, available finance, determined whether or not their attending nurse could advocate for them. The result suggests that physicians had higher autonomy in relation to patient care in the hospital. Therefore, success in advocating for patients requires cooperation between physicians, nurses and the entire healthcare team. This study significantly created the awareness and understanding of the challenges faced by Registered Nurses when advocating for their patients, its corresponding consequences and the need to promote successful patient advocacy for an improved quality and safety in caring for patients. More importantly, it has also contributed to the overall body of nursing knowledge which could be beneficial to other countries with similar context.

IMPLICATIONS FOR RESEARCH, EDUCATION AND PRACTICE

The existing physicians' autonomy in the Ghanaian healthcare facility necessitates research into physician's viewpoints on nurses having to advocate for patients in hospitals. Secondly, the Ministry of Health should ensure inclusion of therapeutic communications and interpersonal skills in the curriculum of all nursing educational programmes. It also behoves on hospital managers to support Registered Nurses to participate in continuous education programmes that will boost their competency in advocating for hospitalized patients. Finally, this study showed that advocating for patients is a teamwork. Hence, it requires involvement of the entire healthcare team, patients, family member and their religious leaders to promote its success in the care setting.

ACKNOWLEDGEMENTS

Our sincere gratitude goes to the study participants for their time and voluntary contribution to the success of the study. We also thank professor Janet Gross, Ms Dzigbodi Kpikpitse, Dr. Joseph Agyenim Boateng and Dr. Francis Nsiah for their valuable suggestions and support.

CONFLICT OF INTEREST

There is no conflict of interest to be declared in this study by the authors.

AUTHOR CONTRIBUTIONS

All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/recommendations/)]:

• Significant contributions to conception and design, data collection, or analysis and interpretation of data.
• Drafting the manuscripts or critical revision of the content.