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Understanding Osteoporosis Awareness among Non-teaching Female Staff in a Healthcare Institution: A Cross-sectional Study
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Received: ,
Accepted: ,
How to cite this article: Ravi K, Selvi T, Sivaranjani S, Saravanan S. Understanding Osteoporosis Awareness among Non-teaching Female Staff in a Healthcare Institution: A Cross-sectional Study. Glob J Med Pharm Biomed Update. 2026;21:13. doi: 10.25259/GJMPBU_65_2025
Abstract
Objectives:
Osteoporosis is a progressive and asymptomatic disease marked by reduced bone mineral density, which increases the risk of fractures and imposes significant health and economic burdens. Despite its growing prevalence among Indian women, awareness about the condition remains low. Non-teaching female staff working in healthcare settings hold a unique position, potentially serving as informal health educators within their communities. However, their awareness levels have not been extensively studied. This study aimed to assess the knowledge and awareness of osteoporosis among non-teaching female staff at SRM Medical College Hospital and Research Centre, to identify knowledge gaps, and to provide baseline data for planning educational interventions.
Material and Methods:
A descriptive cross-sectional study was conducted among 369 non-teaching female staff members aged 18 years and above. The Osteoporosis Knowledge Assessment Tool was used for data collection. Participants were chosen through simple random sampling, and descriptive statistics were used for data analysis. Awareness levels were categorized as “very poor,” “poor,” “average,” or “good” based on the final scores obtained.
Results:
Most participants (62.3%) were found to have “average” awareness (scores between 41 and 80). However, 21.7% of respondents showed “poor” awareness, and 2.4% fell into the “very poor” category. Subgroup analysis revealed that participants with undergraduate or postgraduate education scored significantly higher than those with lower secondary education or no formal education. Several misconceptions were observed, especially regarding risk factors, physical activity, and dietary calcium sources, highlighting the need for topic-specific educational interventions.
Conclusion:
The study brings to light critical knowledge gaps in osteoporosis awareness among non-teaching female staff, especially those with lower education levels. There is an urgent need to implement customized educational programs to address these gaps and encourage preventive practices. As non-teaching staff members often interact with the broader community, enhancing their awareness could have a positive ripple effect on public health outcomes related to osteoporosis.
Keywords
Awareness
Educational interventions
Knowledge gaps
Non-teaching staff
Osteoporosis knowledge assessment tool
Osteoporosis
Public health
Bone health
INTRODUCTION
Osteoporosis, often described as a condition of “porous bones,” is a progressive skeletal disorder marked by declining bone mineral density, making bones fragile and prone to fractures.[1] It is increasingly recognized as a silent epidemic in India, where women face heightened vulnerability due to nutritional inadequacies, hormonal changes, and low levels of disease awareness.[1] The burden is particularly high among postmenopausal and elderly women, resulting in an increased incidence of fractures that contribute to substantial morbidity, mortality, and financial strain on families and health systems.[1,2] Global estimates from the International Osteoporosis Foundation indicate that one in three women above 50 years is at risk of an osteoporotic fracture, underscoring the urgent need for enhanced preventive strategies and widespread public awareness efforts.[3] In India, the situation is further complicated by rising life expectancy and lifestyle transitions, with prevalence reports ranging from 8% to 62%, reflecting considerable variability in disease burden across different regions and populations.[4]
A major barrier to mitigating osteoporosis is the persistently low awareness among women. Evidence from North India shows limited knowledge among postmenopausal women, strongly influenced by sociodemographic determinants such as income and education.[5] Even among healthcare-affiliated groups such as female nursing students and staff, knowledge gaps have been documented, suggesting that proximity to a medical environment alone does not guarantee adequate understanding of bone health and its preventive measures.[6] The underlying pathophysiology of osteoporosis, involving an imbalance between bone-forming osteoblasts and bone-resorbing osteoclasts, highlights the importance of timely preventive actions such as adequate calcium intake, physical activity, and early screening – concepts that need to be clearly communicated to the wider population.[7]
Despite being embedded within healthcare institutions, non-teaching female hospital staff represent a largely overlooked group in osteoporosis awareness research. Unlike clinical personnel, they usually lack formal health-related training, yet their daily functioning within a medical setting may create an assumption of adequate awareness. Importantly, these women play influential roles within families and communities as informal health advisors, meaning that any improvement in their understanding has the potential to generate broader community impact. Furthermore, given that the foundation for optimal bone mass formation begins during adolescence and early adulthood, awareness among younger women in this workforce becomes even more crucial.[8] However, existing literature offers very limited evidence on osteoporosis knowledge within this specific population. Considering that many osteoporotic fractures remain undiagnosed or untreated in India, addressing the knowledge gap among such under-studied but socially influential groups becomes an essential step toward improving early prevention, timely diagnosis, and adoption of healthy behaviors.[9]
Objectives
This study aimed to evaluate the knowledge and awareness of osteoporosis among non-teaching female staff working at SRM Medical College Hospital and Research Centre. The secondary objective was to identify key knowledge gaps to inform the design of appropriate educational strategies tailored to this population.
MATERIAL AND METHODS
Study design
A cross-sectional descriptive study design was employed to assess osteoporosis awareness among non-teaching female staff. This design allowed for the collection of data at a single point in time, offering a snapshot of current awareness levels.
Setting
The study was conducted at SRM Medical College Hospital and Research Centre, Kattankulathur, Tamil Nadu. Data were collected between May 2024 and July 2024 across various non-clinical departments of the hospital.
Participants
Inclusion criteria
Female, non-teaching staff aged 18 years and above
Currently employed at the institution
Willing to give informed consent.
Exclusion criteria
Teaching staff
Individuals with a prior diagnosis or treatment history for osteoporosis
Those with other diagnosed bone disorders
Pregnant or lactating women.
Recruitment procedure
Eligible participants were selected using a convenience sampling method, as all available non-teaching female staff members present in the hospital premises during the data collection period were invited to participate. This approach was chosen due to the feasibility and accessibility of the study population within the institutional setting. Informed written consent was obtained from all participants before their inclusion in the study.
Variables
Primary outcome: Awareness level of osteoporosis assessed using the Osteoporosis Knowledge Assessment Tool (OKAT)
Independent variables: Age, educational qualification, job role, and years of employment
Confounding factors: Prior exposure to health education, access to healthcare, and personal or family history of bone conditions.
Data collection and measurement
Data were gathered using the OKAT, a validated questionnaire that addresses risk factors, symptoms, preventive measures, and common misconceptions. Participants completed the questionnaire in a quiet, designated area to maintain confidentiality and minimize distractions.
Bias management
To ensure the validity of findings:
Selection Bias was minimized by employing random sampling techniques
Response Bias was addressed by ensuring anonymity and voluntary participation
Interviewer Bias was reduced through standardized training for all data collectors and consistent administration of the questionnaire.
Sample size estimation
The sample size was calculated using the standard formula for cross-sectional studies:
n=Z2×P(1−P)d2n = \frac{{Z2 \times P (1 - P)}}{{d2}}
Where:
Z = 1.96 for 95% confidence
P = 40% (assumed awareness level from previous studies)
d = 5% (margin of error) This yielded a minimum sample size of 369 participants.
Quantitative variables and scoring
Responses to the OKAT were scored as follows:
Each correct answer = 1 point
Total number of questions = 20
Total score × 5 = Final score out of 100.
Categorization of awareness levels
Based on the final scores, awareness levels were categorized as:
Very poor awareness: <20 points
Poor awareness: 21–40 points
Average awareness: 41–80 points
Good awareness: ≥81 points.
Statistical analysis plan
All data were analyzed using the Statistical Package for the Social Sciences version 26.0, with statistical significance set at p < 0.05. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarize demographic characteristics, distribution of correct responses, and total awareness scores. Internal consistency of the 20-item questionnaire was assessed using Cronbach’s alpha, which was found to be 0.81, indicating good reliability. Inferential statistics were performed to identify group differences and associations. One-way analysis of variance (ANOVA) was used to compare mean awareness scores across age groups, education levels, and job roles, and whenever ANOVA showed a significant result, post hoc Tukey tests were applied to determine pair-wise differences. Chi-square tests were used to examine associations between categorical awareness levels (Very Poor, Poor, Average, Good) and demographic variables such as age group, education level, and job role. For all mean scores, 95% confidence intervals were calculated to provide an estimate of precision. Data were finally presented in eight consolidated tables to avoid repetition and limit the number of figures as per publication norms. This statistical analysis plan ensured systematic evaluation of awareness levels and allowed identification of key demographic factors influencing knowledge among non-teaching female hospital staff.
RESULTS
The demographic profile of the study participants shows a diverse mix of ages, educational backgrounds, and job roles among non-teaching female hospital staff. Most participants belonged to the 31–40-year age group (36.6%), followed closely by the 18–30-year group (32.5%), indicating that a majority of the workforce is relatively young to mid-aged. A smaller portion was from the 41–50-year group (22.5%), while only 8.4% were above 50 years, showing that older women form a minor part of this workforce [Table 1].
| Variable | Category | n (%) |
|---|---|---|
| Age (years) | 18–30 | 120 (32.5) |
| 31–40 | 135 (36.6) | |
| 41–50 | 83 (22.5) | |
| >50 | 31 (8.4) | |
| Education | No formal education | 81 (21.9) |
| HSC | 76 (20.6) | |
| Diploma | 76 (20.6) | |
| Undergraduate | 71 (19.2) | |
| Postgraduate | 65 (17.6) | |
| Job role | Housekeeping | 142 (38.5) |
| Ward assistant | 110 (29.8) | |
| Administrative support | 78 (21.1) | |
| Other | 39 (10.6) |
HSC: Higher secondary certificate
In terms of education, the largest group had no formal education (21.9%), highlighting a major challenge in health awareness and literacy. Participants with higher secondary certificate (HSC) (20.6%) and Diploma qualifications (20.6%) represented equal proportions, suggesting that a considerable number had at least secondary-level education. A slightly smaller segment had undergraduate degrees (19.2%) and postgraduate qualifications (17.6%), showing that a reasonable proportion of staff was fairly well educated.
Regarding job roles, housekeeping staff (38.5%) formed the biggest group, reflecting their large presence in hospital settings. This was followed by ward assistants (29.8%), who also play a key support role in patient care. Administrative support staff (21.1%) made up one-fifth of the participants, while the other category (10.6%) included various auxiliary roles.
The distribution of correct responses across the 20 knowledge-based items shows noticeable variation in how well participants understood different aspects of the topic. When looking at Questions 1–5, the average number of correct responses was 188, indicating that most participants were familiar with the basic concepts covered in these initial items. Among these, Q4 had the highest number of correct answers, suggesting it was either easier to understand or more commonly known, while Q2 recorded the lowest correct responses, showing some confusion or lack of awareness on that point [Table 2].
| Question range | Mean correct (n) | SD | Highest correct | Lowest correct |
|---|---|---|---|---|
| Q1–Q5 | 188 | 12 | Q4 | Q2 |
| Q6–Q10 | 185 | 11 | Q6 | Q10 |
| Q11–Q15 | 187 | 10 | Q13 | Q14 |
| Q16–Q20 | 186 | 15 | Q18 | Q20 |
| Overall | 186.5 | 10.8 | — | — |
SD: Standard deviation
For questions 6–10, the mean number of correct answers slightly declined to 185, with a similar trend in variability. Here, Q6 had the best performance, but Q10 showed the weakest understanding, indicating that mid-level conceptual questions may have been more challenging.
In questions 11–15, performance improved again, with an average of 187 correct responses. Q13 stood out with the highest accuracy among this group, while Q14 had fewer correct answers, suggesting that specific misconceptions may exist for some topics.
Finally, for questions 16–20, the mean correct responses were 186.5, showing consistent performance. Q18 had the highest accuracy overall, whereas Q20 was the lowest.
The distribution of total awareness scores among participants shows a wide range of knowledge levels within the study population. Only a small fraction of participants, about 2.7%, scored in the 20–30 range, indicating very low awareness. This suggests that a minimal portion of the group had major gaps in basic understanding. Slightly more participants (7.9%) scored between 31 and 40, showing that a few individuals still struggled with many key concepts [Table 3].
| Score range | n | % |
|---|---|---|
| 20–30 | 10 | 2.7 |
| 31–40 | 29 | 7.9 |
| 41–50 | 70 | 18.9 |
| 51–60 | 90 | 24.3 |
| 61–70 | 80 | 21.7 |
| 71–80 | 60 | 16.3 |
| >80 | 30 | 8.1 |
A larger proportion (18.9%) fell within the 41–50 range, which represents a moderate level of awareness but is still below the desirable threshold. The biggest cluster of participants (24.3%) scored between 51 and 60, which was the highest concentration. This indicates that most participants possessed an average or slightly above-average level of awareness. Another substantial segment (21.7%) scored between 61 and 70, showing improved understanding and better grasp of the questionnaire content.
Meanwhile, 16.3% of participants scored between 71 and 80, reflecting a good level of awareness among this subgroup. Only 8.1% scored above 80, showing that very high awareness levels were less common.
The awareness level classification shows how participants performed overall when their total scores were grouped into meaningful categories. Only a very small number of participants, about 2.4%, fell into the “Very Poor” category, which represents individuals scoring below 30%. This indicates that only a few participants had extremely limited awareness. A larger portion, 21.7%, was classified as “Poor”, meaning they scored between 30% and 49%. This group reflects those who possess only a partial understanding and may require focused guidance to improve their knowledge [Table 4].
| Category | Criteria (%) | n (%) |
|---|---|---|
| Very poor | <30 | 9 (2.4) |
| Poor | 30–49 | 80 (21.7) |
| Average | 50–69 | 230 (62.3) |
| Good | 70–89 | 50 (13.6) |
Many participants belonged to the “Average” awareness category, accounting for 62.3% of the total. These individuals scored between 50% and 69%, indicating a moderate but not fully adequate level of awareness. This dominant category suggests that while most participants have basic familiarity with the concepts, there is still considerable room for improvement, especially in deeper understanding and practical application.
A smaller yet notable subgroup, 13.6%, achieved “Good” awareness, scoring between 70% and 89%. This shows that some participants demonstrated strong conceptual understanding. However, the absence of any participants in the “Excellent” range highlights that very high levels of awareness were not observed in this population.
The comparison of awareness scores across different age groups provides useful insight into how knowledge levels vary with age among the non-teaching female hospital staff. Participants in the 18–30-year group had a mean score of 56.1, which suggests a generally moderate level of awareness. Their relatively younger age may contribute to better exposure to information through mobile phones, social media, and workplace interactions. The 31–40-year group performed slightly better, with a higher mean score of 58.3, and this age range also had the largest number of participants. This could be because individuals in this age group are usually more experienced, more engaged in their job responsibilities, and possibly more attentive to health-related information [Table 5].
| Age group | Mean±SD | 95% CI |
|---|---|---|
| 18–30 | 56.1±9.8 | 54.3–57.8 |
| 31–40 | 58.3±10.5 | 56.5–60.1 |
| 41–50 | 54.7±11.2 | 52.2–57.0 |
| >50 | 53.9±12.4 | 49.4–57.9 |
| ANOVA F-value | 3.12 | — |
| p-value | 0.026 | — |
SD: Standard deviation, CI: Confidence interval, ANOVA: Analysis of variance
Participants aged 41–50 years recorded a mean score of 54.7, indicating a slight decline in awareness compared to the younger groups. Factors such as limited digital literacy or reduced exposure to new information may play a role in this difference. The >50-year group had the lowest mean score of 53.9, which might be due to generational gaps in formal education and access to health information.
The ANOVA test showed a statistically significant difference (p = 0.026), meaning awareness levels truly vary among age groups.
The comparison of awareness scores across different educational levels clearly shows that education plays an important role in shaping health knowledge among the participants. Those with no formal education had the lowest mean score of 50.4, indicating limited understanding and highlighting a major gap in health literacy within this subgroup. This may be due to difficulty in comprehending written information or limited past exposure to structured learning environments.
Participants with HSC qualifications performed slightly better, with a mean score of 55.1, suggesting that even basic school-level education contributes to improved awareness. Those with Diploma qualifications scored 56.6, showing a gradual improvement that could be linked to more technical or job-related training [Table 6].
| Education | Mean±SD | 95% CI |
|---|---|---|
| No formal education | 50.4±8.9 | 48.4–52.3 |
| HSC | 55.1±9.4 | 53.0–57.2 |
| Diploma | 56.6±10.1 | 54.3–58.7 |
| Undergraduate | 60.8±10.5 | 58.3–63.3 |
| Postgraduate | 62.9±9.8 | 60.5–65.2 |
| ANOVA F-value | 12.48 | — |
| p-value | <0.001 | — |
SD: Standard deviation, CI: Confidence interval, ANOVA: Analysis of variance, HSC: Higher secondary certificate
A more notable increase was seen among participants with undergraduate degrees, who had a mean score of 60.8. This group likely benefits from higher cognitive skills, better understanding of health concepts, and greater confidence in interpreting information. The highest scores were observed among postgraduate participants, with a mean of 62.9, reflecting strong awareness and the ability to understand complex information more easily.
The ANOVA test showed a highly significant association (p < 0.001), meaning that education level has a clear and measurable effect on awareness.
The comparison of awareness scores across different job roles highlights how the nature of work may influence the level of health-related knowledge among non-teaching female hospital staff. Participants working in housekeeping had the lowest mean score of 52.3, indicating relatively limited awareness. This could be because housekeeping staff typically have fewer opportunities for direct exposure to health information, less participation in training sessions, and lower educational backgrounds compared to other groups [Table 7].
| Job role | Mean±SD | p-value (Post hocTukey) |
|---|---|---|
| Housekeeping | 52.3±9.5 | — |
| Ward assistants | 55.7±10.3 | 0.041* |
| Administrative Staff | 61.4±11.2 | <0.001* |
| Other staff | 58.0±10.5 | 0.128 |
| Overall ANOVA | F=9.62 | p<0.001 |
SD: Standard deviation, ANOVA: Analysis of variance. *Statistically significant at p< 0.05.
The ward assistants scored slightly higher, with a mean of 55.7. Since ward assistants work more closely with nurses and patients, they are likely to overhear or observe health-related discussions and procedures, which may contribute to their better awareness. The administrative support staff had the highest mean score of 61.4, suggesting that those involved in clerical or office duties may have better access to written material, educational posters, or communication from hospital management, which can improve their understanding.
Participants in the “other” job category scored moderately well at 58.0, reflecting mixed levels of exposure depending on their roles. The ANOVA test showed a statistically significant difference (p < 0.001) across job roles, and post hoc analysis indicated that housekeeping staff scored significantly lower than ward assistants and administrative staff.
The results from the association analysis between awareness levels and key demographic variables provide a deeper understanding of how different characteristics influence knowledge among the participants. The Chi-square test for age group and awareness showed a value of 11.4 with a p = 0.075, indicating that although younger participants seemed to perform slightly better, the difference was not statistically significant. This means age alone may not be a strong determining factor for awareness levels in this group.
In contrast, the association between education level and awareness showed a Chi-square value of 29.6 with a highly significant p < 0.001. This clearly demonstrates that higher education strongly contributes to better knowledge and understanding. Participants with more formal education were more likely to fall into “good” or “average” awareness categories, while those with low or no education tended to cluster in the “poor” or “very poor” groups. This finding aligns with common patterns seen in health literacy research.
The analysis of job role and awareness also showed a statistically meaningful association, with a Chi-square value of 18.2 and a p = 0.005. This suggests that the type of work participants perform influences their exposure to information and training. Administrative staff and ward assistants tended to have higher awareness compared to housekeeping staff, who showed lower levels of knowledge [Table 8].
| Variable | χ2 value | df | p-value |
|---|---|---|---|
| Age group×Awareness | 11.4 | 6 | 0.075 |
| Education×Awareness | 29.6 | 6 | <0.001* |
| Job role×Awareness | 18.2 | 6 | 0.005* |
DISCUSSION
The findings of this study reveal notable gaps in osteoporosis awareness among non-teaching female hospital staff, despite their daily presence in a healthcare environment. Although the majority demonstrated average levels of awareness, a considerable proportion fell into the poor and very poor categories, suggesting that basic understanding of osteoporosis, risk factors, and preventive strategies remains insufficient in this population. This aligns with findings from Indian community-based studies that reported similarly low knowledge scores among women with limited education and enduring socioeconomic constraints.[10-12]
A key observation from the present study is the strong influence of educational status on awareness scores. Participants with undergraduate or postgraduate education performed significantly better than those without formal schooling. Comparable trends have been reported in studies among women in Kerala and Karnataka, where higher educational attainment was strongly associated with improved osteoporosis knowledge.[13-15] Considering that more than one-fifth of our participants lacked formal education, this knowledge gap is understandable and highlights the need for simplified and culturally appropriate educational materials.
Sociocultural factors also appear to contribute to inadequate understanding. In many Indian households, women often prioritize family responsibilities over their own health, resulting in lower attention to preventive care. In addition, lifestyle habits such as habitual tea drinking, low dietary calcium intake, early marriage, and restricted outdoor physical activity have been shown to increase osteoporosis risk in several regional studies.[16,17] These factors may indirectly influence how non-teaching staff perceive bone health and its importance.
The Health Belief Model helps explain the behavioral patterns observed in this study. Many participants may have low perceived susceptibility, as osteoporosis is commonly believed to affect only the elderly. Limited perceived severity, especially when the disease is asymptomatic in early stages, may reduce motivation to engage in preventive behaviors. Poor cues to action – such as lack of structured health education programs, limited access to credible information, and inadequate communication channels – further contribute to delayed adoption of preventive practices. Strengthening these components through regular informational sessions and visual reminders within the workplace could significantly enhance awareness and health-seeking behavior.
Another important finding is the variability in responses across different knowledge items. Misconceptions were especially prevalent regarding dietary sources of calcium, benefits of weight-bearing exercises, and the silent progression of the disease. Studies from Tamil Nadu and Maharashtra have reported similar patterns, emphasizing that Indian women commonly confuse general nutrition with bone-specific nutrition.[18,19] This highlights the need for structured, targeted education rather than general health messages.
The implications of these findings extend beyond the workplace. Non-teaching female staff often play key roles as caregivers and decision influencers within families and communities. With improved knowledge, they can act as informal health advocates, encouraging preventive behaviors among their social circles. Evidence from community outreach programs in India shows that empowering women with basic health literacy results in significant improvements in household-level preventive practices.[20]
In summary, the study highlights a critical need for tailored educational interventions that focus on improving awareness, correcting misconceptions, and encouraging early preventive actions among non-teaching female hospital staff. Strengthening health literacy among this often-overlooked workforce group can have long-term benefits for both individual and community-level osteoporosis prevention.
Strengths
This study provides a focused and detailed assessment of osteoporosis awareness among a clearly defined and largely understudied workforce group – non-teaching female hospital staff. The use of a structured, pre-validated questionnaire ensured uniformity in data collection, while subgroup analyses allowed meaningful exploration of how education and job roles influence awareness. By examining an overlooked but socially influential population, the study offers important insights for workplace-based health education strategies.
Limitations
Despite its strengths, the study has several limitations. First, as responses were based on self-reported information, there is a possibility of recall bias and social desirability bias. Second, the study was conducted in a single tertiary-care center, which limits the generalizability of the findings to other settings. Third, the use of convenience sampling may have introduced selection bias. Finally, although inferential statistics were applied, the cross-sectional design prevents the determination of causality.
Future directions
Future research should involve larger and more diverse samples across rural, semi-urban, and urban regions to obtain a more comprehensive understanding of awareness patterns. Longitudinal studies may help monitor changes in knowledge and behavior following structured educational interventions, while the inclusion of comparator groups would allow more robust assessment of factors influencing osteoporosis awareness.
CONCLUSION
This study highlights moderate but inadequate awareness of osteoporosis among non-teaching female staff working in a healthcare institution. Although most participants demonstrated average levels of knowledge, significant gaps were identified, particularly among individuals with lower educational backgrounds and limited exposure to health information. Educational status and job role were found to significantly influence awareness levels. These findings emphasize the need for targeted health education programs within healthcare institutions to improve understanding of osteoporosis risk factors, prevention, and early detection. Strengthening awareness among non-teaching staff may also contribute to broader community health promotion, as these individuals often serve as informal sources of health information within their families and communities.
Ethical approval:
The research/study was approved by the Institutional Review Board at SRM Medical College, number SRMIEC-ST0924-1495, dated 04th September, 2024.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that they have used artificial intelligence (AI)-assisted technology solely for language refinement and to improve the clarity of writing. No AI assistance was employed in the generation of scientific content, data analysis or interpretation.
Financial support and sponsorship: Nil.
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