The Influence of Emotional Intelligence on

Academic Stress. A Study with University of Medical

Sciences Students
Elham Charoghchian Khorasani 
Mashhad University of Medical Sciences
Mohammad Ardameh 
Mashhad University of Medical Sciences
Hadi Tehrani 
Mashhad University of Medical Sciences
Vahid Ghavami 
Mashhad University of Medical Sciences
Mahdi Gholian-aval 
(

[email protected]
)
Mashhad University of Medical Sciences

Research Article

Keywords: Emotional intelligence, Academic stress, Students, Mental health

Posted Date: January 13th, 2023

DOI: https://doi.org/10.21203/rs.3.rs-2421047/v1

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Abstract
Background
The purpose of this study was to investigate the effect of an intervention based on an emotional
intelligence component on the coping skills of academic stress in medical students.

Methods
This research has been done in two descriptive and quasi-experimental sections in the academic student.
In order to determine the effect of emotional intelligence components on stress levels, this descriptive
study was performed on 200 students. Then, a quasi-experimental study was then conducted to
determine the effect of an emotional intelligence component-based educational intervention on academic
stress coping skills. Data were collected through personal information questionnaire, Bradbury and
Graves emotional intelligence questionnaire and Gadzella’s academic stress questionnaire.

Results
Emotional intelligence components predicted 27.1% of the variance of academic stress among students.
In parallel with the effect of education, the experimental group showed a statistically significant
difference in the mean of each of the components of emotional intelligence and the overall score of
academic stress (p > 0.05).

Conclusions
Educational intervention based on emotional intelligence components can significantly help reduce
students' academic stress.

Background
Stress is present throughout human life, but it reaches its peak during the student period, and if the
student fails to respond appropriately, academic stress develops(1). Academic stress is one of the most
common types of stress and is a feeling of increasing need for knowledge and at the same time, a
person's perception that he does not have enough time to achieve it and arises from a person's attitude to
academic responsibilities and interpersonal and intra-laboratory relationships(2). Academic stress is due
to the tendency of today's world to get the most information in the shortest time, in a competitive
environment where the minds of people with this type of stress are not able to quickly analyze the mass
of information they face, and this leads to physical injuries, become psychological and social(3, 4).
Stress is positively associated with physical illness(5), behavioral disorders(6), mental disorders(7), and
academic problems(8).
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One of the things that can help with stress is emotional intelligence(9). People with higher emotional
intelligence have been reported to have better communication skills and lower levels of stress and
anxiety(10). Emotional intelligence is a relatively new term that refers to a set of non-cognitive abilities,
performance, and skills that affect a person's ability to cope with environmental pressures and help him,
or her overcome environmental stresses and needs(11, 12). According to Mayer et al., emotional
intelligence skills and competencies include four areas: the ability to perceive emotions, use emotions to
speed thinking, understand emotions, and manage emotions(13). Emotional intelligence was negatively
correlated with anxiety(14), depression(15), and stress(16), and positively correlated with empathy(17),
resilience(18), and academic performance(19). Emotional intelligence contains not only a theoretical
psychological aspect, but by generalizing it in practice, it is possible to find suitable answers to many of
life's hidden questions(20).

Entering the university is a very sensitive event in the life of active and efficient forces in any country,
which is accompanied by many changes in their personal and social relationships(21). At the same time,
medical university students are highly exposed to stressors related to community health due to the nature
of their profession(22). Therefore, due to the sensitive role of medical students, this study aimed to
control academic stress through an educational intervention based on an emotional intelligence
component, focusing on students from the Medical University of Neyshabur (Iran).

Methods
Study Design

This study consists of two parts: descriptive and quasi-experimental. In the first part, a descriptive study
was performed on 200 students of Neyshabur university of medical sciences(Iran) to determine the
predictive power of emotional intelligence components. In order to determine the sample size based on
Khodadadi et al., study and considering the prevalence of stress equal to 12%, error level 0.05, accuracy
0.1 and the population size of 800 people, the sample size was determined based on the following
formula about 200 people.

In the second stage, in order to perform training and intervention using the following formula and taking
into account the first type error 0.05, power 80% of the ratio equal to the sample volume in the two groups
(r = 1) and the expected effect size is 0.5, A total of 65 eligible students were studied for each group (130
students in total).

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The results of the descriptive study showed that stress was divided into three levels, the score lesser than
102 was considered mild stress, scores 103-153 were moderate stress and scores higher than 154 were
considered severe stress. Then, 130 people with moderate to severe stress were randomly selected and
divided into experimental and control groups(figure 1).

Study 2: Inclusion and Exclusion Criteria

Inclusion Criteria Studied at Neyshabur university of medical sciences and agreed to participate in the
study. Exclusion criteria were: the declaration of non-cooperation during the study, absence of more than
one session in training sessions, student withdrawal from the college for reasons such as dropping out of
school or transfer and having an illness or mental problem or taking psychotic medication.

Study 3: Validity and Reliability of the Instrument

The instruments used in the present study included the personal information questionnaire, the Bradbury
and Jane Graves emotional intelligence questionnaire, and the Gadzella academic stress questionnaire,
each of which has the following information:

Personal Information Questionnaire

This questionnaire included information on the study area and program, age, gender, marital status, and
residence status.

Bradbury and Graves Emotional Intelligence Inventory

Emotional intelligence assessment tool was Bradbury and Graves questionnaire with internal consistency
that was designed to assess emotional intelligence skills. The questionnaire had 28 questions and was
scored on a six-point Likert scale. This questionnaire had 4 subscales: 1- self-awareness, 2- self-
management, 3- social awareness and 4- relationship management. Score questions are aggregated to
obtain a general score for each subscale. Higher scores indicate higher emotional intelligence(23). The
validity and reliability of this questionnaire has been confirmed by Ganji et al. In Iran(24).

Gadzella’s Academic Stress Inventory

The instrument for measuring academic stress was Gadzella’s inventory (1998) with an internal
consistency of r = 0.71 (23), which was designed to study the stressors in students’ life and their reaction
to them. The questionnaire comprised 51 questions and its scoring was as five-point Likert scale. The

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questionnaire had 9 subscales: 1-Frustration 2-Conflicts 3-Pressures 4-Changes 5-Self-imposed 6.
Physiological 7. Emotional 8-Behavioral and 9-Cognitive. The points for questions are summed up to gain
the general scores in each subscale. Higher scores indicate higher academic stress and more responses
to stress (25). The validity and reliability of the scale in the Iran was confirmed by Moradi (26).

Educational intervention based on emotional intelligence components

The educational intervention on the experimental group in the present study was carried out based on the
components of emotional intelligence and with more emphasis on the predictive components determined
in the descriptive study. Details are provided in Table 1. The control group did not receive training in this
course. Questionnaires were completed immediately after the intervention and three months later by two
control and experimental groups.

Table 1: Plan for conduction of the intervention

First Session: Raising students' awareness about emotional intelligence and educative content in this
regard was presented. There is also a discussion about problem solving. Students were then
encouraged to articulate their various issues and problems, especially in the field of education, and
then to analyze different ways of solving the problem. There was also a discussion about realism,
and the use of its techniques in reducing academic stress.

Second session: The strategy of using more adaptation to the surrounding conditions to deal with
possible tensions was expressed and discussed. Then, the importance of emotional self-awareness is
examined, and brainstorming is given on the causes and solutions for eliminating negative emotions
such as stress and even moderately positive emotions. There was also a discussion about self-
respect and ways to achieve and maintain it.

Third Session: The use of self-fulfillment in controlling academic stress was discussed. In addition,
brainstorming and question-and-answer are used to discuss the necessity and benefits of
independence and how to achieve it.

Fourth Session: Describes strategies for coping with stress and tension and managing strong
emotions. There was also talk about improving interpersonal relationships and empathy and its role
in solving life problems.

Fifth Session: Discusses the skill of positive thinking and its role in managing life's problems and
ways to improve it.

Sixth Session: The content was summarized and a review of the proposed strategies based on
emotional intelligence to deal with academic stress was presented.

Data Analysis

After collecting data pertaining to pre-test, post-test (immediately after intervention) and follow-up stage
(3 month after the intervention) in the experimental and control groups, the Kolmogorov-Smirnov test was
used to determine the distribution of variables in terms of normalization. Then, using descriptive
statistics, namely, frequency distribution of variables, mean and standard deviation, data were described
for both experimental and control groups. Analytical statistics were used to compare the mean of
variables in the two groups according to the distribution of variables.

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Ethical Considerations

The study conduction process began after obtaining the approval from the Deputy of research and
obtaining permission from the Ethics Committee (IR. MUMS. REC. 1398. 294) and coordinating with the
officials of Medical University of Neyshabur. At first, the purposes of the research project were explained
to the subjects, and after obtaining informed consent, the students were provided with questionnaires and
completed it as self-report. The right to abandon participation was considered for those who were
unwilling to cooperate.

Results
In this study, the sample included 47% female and 18% male participants. 43.1% of the study sample
were 20–24 years old, of whom 95.4% were undergraduates and 40% were third-year students, most of
whom were single (72.3%) and non-native speakers (63.1%) (Table 2). Based on the results, there was no
significant difference between the two groups before and after intervention in terms of gender, age group,
field of Study, academic year, grade, marital status and residence status (p > 0.05).

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 Table 2
Frequency distribution of demographic variables
Variable experimental Control P-value

N % N %

Gender Female 47 72.3 56 86.2 0.05 *

Man 18 27.7 9 13.8

Age group < 20 21 32.3 18 27.7 0.85**

20–24 28 43.1 36 55.4

> 24 16 24.6 11 19.6

Field of Study Nursing 5 7.7 5 7.7 0.58***

Anesthesia 4 6.2 3 4.6

surgery room 6 9.2 10 15.4

Public health 9 13.8 6 9.2

Environmental Health 8 12.3 6 9.2

Health Professional 11 16.9 6 9.2

Medical urgency 8 12.3 6 9.2

Food Science and Technology 3 4.6 2 3.1

Health Information Technology 5 7.7 12 18.5

Midwifery 6 9.2 9 13.8

Academic year First year 8 12.3 9 13.8 0.27**

Second year 25 38.5 32 49.2

Third year 26 40 18 27.7

Forth year 6 9.2 6 9.2

Grade Associate Degree 3 4.6 2 3.1 0.65**

Masters 62 95.4 63 69.9

Marital status Single 47 72.3 41 63.1 0.26*

Married 18 27.7 24 36.9

* Chi-square

** Mann whitney

*** Fisher's exact test

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 Residence status Native 24 36.9 17 26.2 0.18*

Non-native 41 63.1 48 73.8

* Chi-square

** Mann whitney

*** Fisher's exact test

Table 3 shows that the effective subscales of emotional intelligence on the total academic stress score
are: self-management (p < 0.001), relationship management (p < 0.001), and self-awareness (p = 0.01).
This model predicts 27.1% of students' academic stress (Table 3).

Table 3
Results of linear regression before intervention to determine the most important
components of emotional intelligence
Dependent variable Independent variable Beta P R2

Academic stress Self-management -0.272 0.001> 0.271

Relationship management -0.216 0.001>

Self-awareness -0.130 0.019

Intergroup analysis using independent t-test on the mean scores of self-awareness, self-management,
social awareness, relationship management, self-imposed stress, physiological response, emotional
response, behavioral response and overall score of academic stress and Mann-Whitney test in the mean
scores of conflict, Changes, stress, failure and cognitive response showed that at each stage of the study,
there was no statistically significant difference between the experimental and control groups (p > 0.05).
But in the case of social awareness, failure, emotional response and the score of academic stress in the
stage immediately and 3 months after the intervention, this difference was significant (p < 0.05) and in
the case of stress, self-imposed stress, physiological response and behavioral response. This difference
was significant (p < 0.05) at 3 months post-intervention. (Table 4)

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 Table 4
Comparison of mean and mean structures of emotional intelligence and stress before, immediately after
the intervention and three months later in the experimental and control groups
Variable Group Before After Follow up stage P-
intervention intervention (3 months after) value*

Mean SD Mean SD Mean SD

Self-awareness Experimental 21.29 6.39 23.04 6.33 23.30 6.25 0.01

Control 21.23 6.46 21.27 6.41 21.41 6.20 0.14

P-value** 0.95 0.11 0.08  

self- Experimental 26.76 7.93 28.95 7.60 28.40 7.76 0.02

management
Control 26.43 8.09 26.49 7.92 26.46 8.01 0.52

P-value** 0.81 0.07 0.164  

Social Experimental 17.87 4.31 19.89 4.25 19.70 4.17 0.03

awareness
Control 17.64 4.12 17.56 4.17 17.61 4.19 0.40

P-value** 0.75 0.002 0.005  

relationship Experimental 22.55 7.53 24.24 7.60 24.40 7.74 0.04

management
Control 22.30 6.25 22.49 6.05 22.50 6.19 0.09

P-value** 0.84 0.148 0.126  

Conflict Experimental 10.27 3.63 9.29 3.83 9.13 3.57 0.11

Control 9.44 3.64 9.40 3.83 9.26 3.71 0.06

P-value*** 0.170 0.843 0.844  

Changes Experimental 10.04 3.68 9.70 3.41 9.52 3.54 0.77

Control 10.01 3.32 10.06 3.70 10.29 3.45 0.02

P-value*** 0.822 0.416 0.169  

Pressure Experimental 13.38 3.73 11.90 3.63 12.09 3.73 0.25

Control 13.23 3.66 13.30 3.84 13.43 3.70 0.22

P-value*** 0.929 0.054 0.049  

Failure Experimental 19.73 3.25 18.46 3.15 18.38 3.10 0.06

Friedman*

T-test**

Mann whitney***
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 Control 20.53 3.61 20.81 3.60 20.72 3.69 0.23

P-value*** 0.141 0.001> 0.001>  

Self-imposed Experimental 21.70 4.10 20.56 4.07 20.43 3.80 0.63

stress
Control 21.86 4.21 21.76 4.10 21.93 4.21 0.46

P-value** 0.83 0.09 0.03  

physiological Experimental 30.84 7.59 28.58 6.84 28.21 7.12 0.011

response
Control 29.93 6.00 29.89 6.22 30.58 6.13 0.012

P-value** 0.451 0.257 0.044  

Emotional Experimental 15.58 2.60 13.95 2.75 14.16 2.57 0.25

response
Control 15.06 2.58 15.18 2.41 15.18 2.62 0.41

P-value** 0.25 0.008 0.02  

Behavioral Experimental 19.49 5.62 17.84 5.64 17.63 5.15 0.80

response
Control 19.32 5.75 19.47 5.76 19.58 5.83 0.20

P-value** 0.866 0.106 0.045  

Cognitive Experimental 7.40 1.99 7.30 1.99 7.24 1.70 0.49

response
Control 7.47 2.05 7.29 2.19 7.36 1.84 0.59

P-value*** 0.804 0.946 0.605  

Total academic Experimental 148.47 15.92 137.63 15.83 136.83 14.86 0.04
stress
Control 146.89 13.25 147.20 13.75 148.36 13.25 0.03

P-value** 0.539 0.001 0.001>  

Friedman*

T-test**

Mann whitney***

The results of intra-group test using Friedman test showed that the difference between the mean of self-
awareness, self-management, social awareness and relationship management in the immediate stage
and 3 months after the intervention compared to before the intervention was significant only in the
experimental group (p < 0.05). There was no significant difference in the control group (p > 0.05). But the
results of intra-group test using Friedman test showed that the difference between the mean scores of
changes in the immediate stage and 3 months after the intervention compared to before the intervention
was significant only in the control group (p < 0.05). And the results of intra-group test on the difference

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between the mean scores of conflict, stress, failure, self-imposed stress, emotional response, behavioral
response, cognitive response shown in the stage immediately and 3 months after the intervention
compared to before the intervention in none of the educational groups was not significant (p > 0.05). As
to the difference between the mean score of physiological response and the overall score of academic
stress, the results of intra-group test using Friedman test showed that the mean difference in the stage
immediately and 3 months after the intervention compared to before the intervention in each of the two
educational groups was significant(p < 0.05). (Table 4)

Discussion
The results obtained in the present study showed that the intervention based on the components of
emotional intelligence has been able to reduce students' academic stress and develop self-awareness,
self-management, social awareness and student relationship management.

There was a significant difference between the overall score of emotional intelligence and age in the
study, so that with increasing age, the overall score of emotional intelligence increased. Results of a study
of nursing students by El Dahshan et al showed that older students had higher emotional intelligence
than younger students(27). Ghaderi et al. In their study, a significant relationship was found between age
and self-management, while other variables were not significantly associated with age(28). In our study,
there was a significant relationship between age and overall scores for emotional intelligence, self-
management, and relationship management. This difference in results may be due to differences in the
cultures and universities studied and the fields studied. The results of this study also showed that
emotional intelligence increased with the academic year. Interpreting these results, it can be said that
emotional intelligence expands and increases with age and experience.

In the present study, a statistically significant difference was observed between academic stress and
gender, and girls experienced more academic stress than boys. Girls are more influenced by themselves
and their ideals than boys, and women are better at understanding and expressing their emotions, but
men are better at controlling impulses and stress. So,  girls suffer more stress than boys. This study is
consistent with the study by Miri et al.(10) Pau and Croucher(29), Nasir and Masrur(30), where there is a
significant relationship between gender and academic stress, but Bar- On and Parker found no difference
in emotional intelligence between girls and boys(31). Emotional intelligence components, including self-
management, relationship management, and self-awareness, were significant predictors of academic
stress coping skills among Neyshabur students. Along with this study, Naik (32)obtained the most
important factors of emotional intelligence: self-awareness and self-management.
Goleman(33) considers emotional intelligence as an essential element for success in life and work in
today's challenging social environment. He believes that emotional intelligence enables people to face the
high pressures and severe challenges of social and perceptual development. Rakhshani et al.
(12) also,The relationship between emotional intelligence and job stress was also examined, which was
significant and inverse, showing that self-awareness, social awareness, and income predicted 25% of
nurses' job stress. Of course, the tool used in the study by Rakhshani et al. different from the tools used in
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our research. What's more, the target groups and types of stress for the studies were different. Our study
examined academic stress, but the study by Rakhshani et al. examined job stress.

Ruiz-Aranda et al.(34) found that participants with higher emotional intelligence reported lower levels of
perceived stress. Which is in line with the study of Trigueros et al.(18) and our study. Emotional
intelligence has a significant and inverse relationship with stress. In contrast, Sen et al.(35) in their study
of students at the university of the arts in India showed that there was no significant relationship between
emotional intelligence and perceived stress, which is a difference in results from the tools used and the
different target groups. Rostami et al. (36) also, shown in their study that there is a statistically significant
difference between participants' emotional intelligence and stress coping styles. The results of the
present study showed a significant inverse relationship between each of the components of emotional
intelligence with academic stress coping skills. This item means that by increasing each of the
components of self-awareness, self-management, social awareness and relationship management,
academic stress decreases. Hence, by increasing each of these components, it is possible to reduce
academic stress in students.

In a study aimed at identifying the causal relationship between emotional intelligence and academic
stress by Yoo et al.,(37) it was found that academic stress is indirectly affected by emotional intelligence.
Findings from Frazier et al.'s (38) study showed that graduate students with higher emotional intelligence
scores had less perceived stress. Therefore, increasing emotional intelligence skills can help reduce stress
and create better stress coping skills. In a study, Miri et al.(10) examined the relationship between
emotional intelligence and academic stress in students of Birjand university of medical sciences, which
showed that there is no significant correlation between students' emotional intelligence and academic
stress scores. The results of this study differ from ours. However, the tools used in this study are different
from those used in our study. In addition, target group, cultural and geographical differences are also
effective for differences in results.

The results showed a significant difference between the scores of self-awareness, self-management,
social awareness and relationship management in the experimental group during the study, so that the
mean scores of these variables show a positive effect of education immediately and after the
intervention but in the control group. There was no statistically significant difference. Zachariah et al.
(39) in their study showed that education through peers can increase self-awareness and also have a
positive effect on the development of emotional intelligence. In their study, Kazemi et al.(40) and
Sepehrian(41) reported that emotional intelligence training has an effect on increasing students' self-
awareness. But in the study by Kazemi et al., there was no significant difference between the
experimental group and the control group in terms of self-management and self-awareness. The
difference in these results may be due to insufficient training to make profound changes in Kazemi's
study because self-management is a practical aspect of emotional intelligence and is the result of three
other emotional skills (self-awareness, social awareness, and relationship management)(40).

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Emami Moghadam, et al.(4) in their study, which aimed to determine the effect of emotional intelligence
skills training program on high school girls 'academic stress, showed that the mean of students'
academic stress scores after the intervention in the experimental group from 136±23.7  to 126±23.01
decreased while the mean scores in the control group did not change. This study is consistent with our
study that the total score of academic stress in the experimental group after educational intervention
increased from 148.4±15.9 to 136.8±14.8, while the control group increased from 146.8±13.2 to
148.3±13.2. The average score of academic stress in our study was higher than the average of students'
academic stress in the study by Emami Moghadam et al. the reason for this is the students' fields of
study in our study that medical students suffer more stress than other fields due to the nature of their
field. However, the results show that training in emotional intelligence skills has been able to significantly
reduce the average stress in the experimental group while in the control group there has been an increase
in the average stress. The results of the study by Shahni et al.(42) and Nooryan et al.(43) consistent with
this study, which reported that teaching the components of emotional intelligence can reduce stress.
Therefore, anything that increases emotional intelligence can help manage emotions, including stress.
Emotional intelligence skills enable a person to overcome negative emotions and prevent stress(4).

The results of the present study showed that the mean scores of conflict, changes, stress, failure, self-
imposed stress, physiological response, emotional response, behavioral and cognitive response in the
immediate stage and 3 months after the intervention decreased compared to before the intervention, but
This decrease was not significant, Emami Moghadam et al.(4) reported in their study that all scores under
the components of academic stress in the experimental group decreased and only in failure the average
scores increased, which is due to possible students errors how to apply skills.

Aghajani et al.(44) performed an intervention based on emotional intelligence skills training on academic

stress of nursing students. The results of the study showed a significant difference in the mean score of
total academic stress in the experimental group, which is consistent with our study. Furthermore, in the
study by Aghajani et al., there were no significant differences in conflict, academic stress, changes, and
self-imposed stress, which is consistent with our study. But in the study of Aghajani et al.,(44) the results
of the study showed a significant difference in the mean of emotional response and physiological
response in the experimental group compared to the control group these results are different from our
study, the reason may be that the Meyer and Salvia model was used as an educational model for the
study by Aghajani et al.(44) another reason is the difference in outcomes during the follow-up period, in
our study the questionnaire was completed 12 weeks after the educational intervention, but in the study
by Aghajani et al.(44) it was done two weeks later. But finally, in two studies, teaching the components of
emotional intelligence has been able to improve academic stress.

Limitations

Some training sessions took place between classes, which reduced students' motivation to attend
classes. Therefore, in some cases, classes have been postponed to prevent a decline in the research
sample. In the 3 months after the intervention, due to the prevalence of Covid-19 virus and the closure of

Page 13/18
students, filling out the questionnaires was delayed, and we had to complete the questionnaires in
absentia. Another limitation of the present study was the self-reporting data collection, in which case the
actual performance of individuals may not be reflected.

Conclusion
The results indicate that the components of emotional intelligence can be a good predictor of coping
skills with academic stress and educational intervention based on the components of emotional
intelligence has been able to reduce students' academic stress and develop self-awareness, self-
management, social awareness and relationship management. It appears that the use of the components
of emotional intelligence could offer a promising way to develop coping skills with academic stress. This
has important implications for policy makers and researchers to include emotional intelligence
components in the design and implementation of educational programs for medical students, Therefore,
to overcome academic stress and promote health among medical students, appropriate training
programs must be implemented in the universities.

Declarations
Acknowledgement

 This article is based on the master’s thesis of health education and promotion of health, approved by
Mashhad University of Medical Sciences. In this way, we express our gratitude to the distinguished
professors and all the people who provided the opportunity to do this research with our cooperation.

Authors’ contributions 

 ECh, MA, HT, VGh and MGh designed the study. ECh, MA, HT and MGh participated in the conception of
the study. ECh and VGh managed and conducted the statistical analyses and interpreted the data. MA
wrote the frst draft and ECh and MGh revised it to make the final manuscript. All authors have approved
the final manuscript.

Funding

 Mashhad University of Medical Sciences funded this project. 

Availability of data and materials 

All data generated or analysed during this study are included in this published article. 

 Ethics approval and consent to participate 

This study is based on a research project approved by Ethics Committee of Mashhad University of
Medical Sciences with the code of ethics IR.MUMS.rec.1398.294. All procedures performed in this study

Page 14/18
were in accordance with the ethical standards of the institutional and/or national research committee
and with the 1964 Helsinki declaration and its later amendments or comparable. Written Informed
Consent was obtained from all subjects and/or their legal guardian(s) and for illiterate participants. 

Consent for publication

 Not applicable 

Competing interests 

The authors declare that they have no competing interests

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Figures

Figure 1

Flowchart of the study

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