Prevalence, knowledge, and factors associated with urinary incontinence in female students of a physical therapy undergraduate course

ABSTRACT

This study aimed to evaluate the prevalence, knowledge, factors associated with urinary incontinence (UI), and quality of life in female students enrolled in a physical therapy undergraduate course. Students had to answer a form we developed, the International Questionnaire on Incontinence Consultation - Short Form (ICIQ-SF), and a knowledge questionnaire on pelvic floor musculature (PFM) and the occurrence of UI, based on a previous knowledge, attitude, and practice (KAP) study. Out of 248 students, 170 (69%) participated in our study. According to our evaluation form, 111 women (65%) reported urinary loss at some point in their lives. According to ICIQ-SF criteria, 63 (37%) women were incontinent, 41 (65%) suffered from strain urinary incontinence, showing small urinary losses once per week or less, which slightly impacted their quality of life. Most women who have pain during sexual intercourse (59%) and some urogynecological and intestinal symptom, such as straining (92%), intermittent urination (75%), nausea (73%), constipation (53%), excessive effort (53%), and incomplete outlet (70%) also suffered from UI. All women who used pads (100%) and sought medical care (100%) were incontinent. The use of contraceptive was higher among women without UI (84%). Participants built their knowledge on PFM and UI as the course progressed. These results suggest that women who attend undergraduate courses outside physical therapy have limited knowledge about the subject. We find it necessary to spread knowledge about UI and the importance of physical therapy to prevent and treat UI.

Keywords
Pelvic Floor; Pelvis; Female Urogenital Diseases; Urinary Bladder; Quality of Life

RESUMO

O objetivo deste estudo foi avaliar a prevalência, o conhecimento e os fatores associados à incontinência urinária (IU) em mulheres estudantes de um curso de fisioterapia, bem como sua qualidade de vida. Foi aplicada uma ficha de avaliação, o International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) e um questionário de conhecimento sobre a musculatura do assoalho pélvico (MAP) e a ocorrência de IU, baseado em estudo tipo conhecimento, atitude e prática (CAP). Das 248 estudantes do curso, 170 (69%) participaram do estudo. Pela ficha de avaliação, 111 (65%) relataram perda urinária. De acordo com o ICIQ-SF, 63 participantes (37%) são incontinentes, sendo que 41 (65%) dessas apresentam IU de esforço, apresentando pequena perda e com frequência de uma vez na semana ou menos, com baixo impacto na sua qualidade de vida. A maioria das participantes que relataram ter dor na relação sexual (59%) e alguns sintomas uroginecológicos e intestinais, como esforço ao urinar (92%), jato interrompido (75%), incômodo na região vaginal (73%), constipação (53%), esforço ao defecar (53%) e esvaziamento intestinal incompleto (70%), apresentou queixa de IU. Todas as que usam protetor (100%) e procuraram atendimento médico (100%) eram incontinentes. O uso de anticoncepcional foi maior em mulheres sem perda urinária (84%). O conhecimento sobre a MAP e a IU foi adquirido gradualmente com o avançar do curso. Esse resultado sugere que as mulheres que não cursam Fisioterapia não têm domínio do assunto, sendo necessário disseminar o conhecimento sobre a IU e a atuação da fisioterapia.

Descritores
Diafragma da Pelve; Pelve; Doenças Urogenitais Femininas; Bexiga Urinária; Qualidade de Vida

RESUMEN

El objetivo de este estudio fue evaluar la prevalencia, el conocimiento y los factores asociados a la incontinencia urinaria (IU) en mujeres estudiantes de Fisioterapia, así como su calidad de vida. Se aplicó un formulario de evaluación, el International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) y un cuestionario de conocimiento sobre la musculatura del suelo pélvico (MSP) y la ocurrencia de IU, basado en un estudio de conocimiento, actitud y práctica (CAP). De las 248 estudiantes del curso, 170 (69%) participaron en el estudio. Según el formulario de evaluación, 111 (65%) reportaron pérdida urinaria. Conforme el ICIQ-SF, 63 participantes (37%) son incontinentes, y 41 (65%) de ellas tienen IU de esfuerzo, presentando una pequeña pérdida y con frecuencia de una vez a la semana o menos, con bajo impacto en su calidad de vida. La mayoría de las participantes que informaron sentir dolor en las relaciones sexuales (59%) y algunos síntomas uroginecológicos e intestinales, como esfuerzo al orinar (92%), chorro interrumpido (75%), molestias en la región vaginal (73%), estreñimiento (53%), esfuerzo al defecar (53%) y vaciamiento intestinal incompleto (70%), se quejó de IU. Las participantes que usan protectores (100%) y buscan atención médica (100%) eran incontinentes. El uso de anticonceptivos fue mayor en las mujeres sin pérdida urinaria (84%). El conocimiento sobre la MSP e IU se adquirió de manera gradual a medida que avanzaba el curso. Este resultado apunta que las mujeres que no estudian Fisioterapia no tienen dominio del tema y es necesario difundir conocimientos sobre la IU y la actuación de la fisioterapia.

Palabras clave
Diafragma Pélvico; Pelvis; Enfermedades Urogenitales Femeninas; Vejiga Urinaria; Calidad de Vida

INTRODUCTION

Estimates suggest that almost half of women complain of urinary loss, including young and nulliparous individuals^1,2, which we can attribute to excessive or high-impact physical exercises and constipation and associate it with lack of knowledge of their anatomy and urinary incontinence (UI) ^(3,4.

Urinary loss negatively affects women’s quality of life; many stop exercising to avoid embarrassments and refrain from seeking medical follow-up due to such feelings or ignorance. Depression, anxiety, and stress may also be associated with UI, influencing women’s self-esteem and social life^5,6.

Women-centered physical therapy prevents and treats UI by re-education exercises which voluntarily contract and strengthen pelvic floor muscles⁷, which are fundamental to monitor and educate women with multidisciplinary teams⁸.

Healthcare providers are also susceptible to urinary dysfunctions, either due to pelvic floor overload from strain during their daily activities or the habits of a busy routine, such as decreased water intake and longer intervals between urination episodes⁹. Thus, anatomical knowledge and the correct contraction of pelvic floor muscles (PFM) are paramount to preventing UI during daily activities⁷.

Thus, this study aimed to evaluate the prevalence, knowledge, and factors associated with UI in female physical therapy undergraduates and to analyze how this condition interferes in their quality of life.

METHODS

A quantitative cross-sectional and evaluative study of the knowledge of female students from the first to the tenth period of the physical therapy undergraduate course at Universidade Federal de Pernambuco (UFPE), delineated under Resolution No. 466/2012 of the National Health Council (linked to the Brazilian Ministry of Health), was conducted.

Data were collected between July and December 2018. In this study, 18-year-old nulliparous women were included. Those who underwent physical or surgical treatment for UI, received a diagnosis of neuromuscular or postpartum disorders, who smoked or were pregnant were excluded. Students in classrooms were invited to participate via instant messaging app invitations, with the head of department, the coordination of the course, and their teachers’ consent.

After signing informed consent forms, two questionnaires and an evaluation form we developed-referring to personal information, gynecological background, and UI complaints-were given to participants. Forms and questionnaires were printed and given to participants, who filled them out and returned them, avoiding greater embarrassment on the addressed subject.

The International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF), validated for Brazilian Portuguese¹⁰, was the first questionnaire used. It evaluates incontinent women’s quality of life in the four weeks prior to application, considers urinary loss frequency and amount, and contains a list of situations in which losses occur. ICIQ-SF also evaluates how losses influence daily life via a visual analog scale (VAS), ranked into none (0 points), mild (1-3 points), moderate (4-6 points), severe (7-9 points), and very severe (10 points) ⁽¹¹. Quality of life can also be assessed by a score from 0 to 21 points, in which the higher the score in its first three questions, the greater the impact of urinary loss¹².

Another previously developed and used¹¹ questionnaire assessed participants’ knowledge of UI occurrences, based on knowledge, attitude, and practice (KAP) studies^13,14. Only women’s knowledge of pelvic floor and its dysfunctions were evaluated, considered appropriate if they knew the location and function of PFM, the existence of exercises to strengthen them, and the benefits of strong PFM to prevent UI.

The questionnaire contained 10 statements to be answered as “true,” “false,” and “I do not know” (Chart 1). Knowledge was considered appropriate for those who answered “true” for correct statements and “false” to incorrect ones; and inappropriate if they answered “false” or “I do not know” for correct statements and “true” or “I do not know” to incorrect ones. The number of correct answers was calculated with a minimum of 70% of correct answers as a cutoff point, i.e., women who correctly answered seven or more questions were considered as having adequate knowledge, whereas those who did less than that, inadequate¹¹.

Chart 1
Questions in the knowledge questionnaire about urinary incontinence in high-impact sports, based on knowledge, attitude, and practice (KAP) studies

Knowledge questionnaire (KAP)
1. The pelvic floor is a structure at the base of the pelvis and is formed by muscles, fascias, and ligaments.
2. Urinary incontinence is defined as any involuntary loss of urine.
3. Urinary incontinence affects only older women and is considered a physiological alteration due to aging.
4. All urinary loss happens due to pelvic floor muscle weakness.
5. Strong pelvic floor muscles can prevent urinary incontinence.
6. There are specific strengthening exercises for this musculature.
7. High-impact sports such as basketball, volleyball, athletics, handball, among others, show a higher risk for the development of urinary incontinence.
8. The activities which most provide urine loss in high-impact sports are those which include jumps, landings, and running.
9. Urinary incontinence is not associated with training time, duration, and frequency.
10. High-impact sports can cause urinary incontinence due to increased force overload transmitted to the pelvic floor muscles.

Statistical analysis was performed via the Statistical Package for Social Sciences, version 18.0, from an Excel 2013 database. Descriptive analysis was performed by means, medians, and standard deviations for quantitative variables and via absolute (n) and relative frequencies (%) for qualitative ones.

The association between UI and sociodemographic variables, gynecological antecedents, and urogynecological and intestinal symptoms was analyzed; and between knowledge of urinary loss, course period, and quality of life, via the likelihood-ratio chi-square test, Fisher’s exact test, and Spearman’s correlations.

RESULTS

Of the 248 female students at the physical therapy undergraduate course, 178 volunteered (72%), and we excluded eight of them for failing to meet our eligibility criteria. Thus, 170 (69%) participated in this study (Figure 1).

Figure 1
Sample flowchart

According to our evaluation form, 111 women (65%) reported urinary loss at some point in their lives, 52 (31%) had no loss, and 7 (4%) failed to respond. According to the ICIQ-SF questionnaire, 63 (37%) were incontinent.

Association analyses of sociodemographic variables, gynecological antecedents, and urogynecological and intestinal symptoms used the ICIQ-SF questionnaire, as it is a validated research instrument (Table 1). Students’ mean age was 21.7±2.52 (mean±standard deviation).

In our analysis, most women who had pain during intercourse (59%) and some urogynecological and intestinal symptoms, such as strained urination (92%), interrupted flow (75%), vaginal discomfort (73%), constipation (53%), strained defecation (53%), and incomplete intestinal outlet (70%) complained of urinary loss. All women who wore protectors and sought medical attention were incontinent. Contraceptive use was higher in women without complaints of urinary loss. Most students neither practiced physical activities nor showed UI.

Table 1
Analysis of the association between urinary incontinence and sociodemographic variables, gynecological antecedents, and urogynecological and intestinal symptoms

Characteristic	Students n (%)	Continent n (%)	Incontinent n (%)	p-value
ICIQ-SF	170 (100)	107-63	63 (37)
Age (years)	21.7±2.52*			0.17
Household income (R$)	2,800			0.21
BMI				0.56
Underweight	18 (11)	11-61	7 (39)
Ideal weight	113-68	75-66	38 (34)
Overweight	23 (14)	12-52	11 (48)
Obesity	11 (7)	8 (73)	3 (27)
Marital status				0.35
Single	155 (95)	98 (63)	57 (37)
Married	7 (4)	4 (57)	3 (43)
Divorced	1 (1)	0 (0)	1 (100)
Sexually active				0.82
Yes	91 (54)	58 (64)	33 (36)
No	79 (46)	49 (62)	30 (38)
Dyspareunia				0.01
Yes	27 (26)	11 (41)	16 (59)
No	77 (74)	54 (70)	23 (30)
Contraceptive use				0.00
Yes	38 (24)	32 (84)	6 (16)
No	122 (76)	68 (56)	54 (44)
Age at menarche	12.2±1.27*			0.53
Symptoms of urination
Urinary hesitancy				0.71
Yes	42 (25)	25 (60)	17 (40)
No	128 (75)	82 (64)	46 (36)
Small amount				0.79
Yes	15 (9)	9 (60)	6 (40)
No	155 (91)	98 (63)	57 (37)
Strain				0.00
Yes	13 (8)	1 (8)	12 (92)
No	157 (92)	106 (68)	51 (32)
Pain/burning				1.00
Yes	13 (8)	8 (62)	5 (38)
No	157 (92)	99 (63)	58 (37)
Interrupted flow				0.05
Yes	8 (5)	2 (25)	6 (75)
No	162 (95)	105 (65)	57 (35)
Bleeding	0 (0)
Urinary infection				0.07
Yes	13 (8)	5 (38)	8 (62)
No	157 (92)	102 (65)	55 (35)
Urinary urgency
Yes	27 (16)	16 (59)	11 (41)
No	143 (84)	91 (64)	52 (36)
Prolapse symptoms
Vaginal pain				0.06
Yes	5 (3)	1 (20)	4 (80)
No	165 (97)	106 (64)	59 (36)
Protuberance	0 (0)
Dragging sensation				0.37
Yes	1 (1)	0 (0)	1 (100)
No	169 (99)	107-63	62 (37)
Vaginal discomfort				0.02
Yes	11 (6)	3 (27)	8 (73)
No	159 (94)	104 (65)	55 (35)
Intestinal symptoms
Constipation				0.00
Yes	57 (34)	27 (47)	30 (53)
No	113 (66)	80 (71)	33 (29)
Strain to defecate				0.00
Yes	59 (35)	28 (47)	31 (53)
No	111 (65)	79 (71)	32 (29)
Incomplete outlet				0.00
Yes	27 (16)	8 (30)	19 (70)
No	143 (84)	99 (69)	44 (31)
Hemorrhoids				0.50
Yes	10 (6)	5 (50)	5 (50)
No	160 (94)	102 (64)	58 (36)
Pain				0.61
Yes	18 (11)	10 (56)	8 (44)
No	152 (89)	97 (64)	55 (36)
Bowel incontinence				0.06
Yes	5 (3)	1 (20)	4 (80)
No	165 (97)	106 (64)	59 (36)
Involuntary loss				0.06
Yes	5 (3)	1 (20)	4 (80)
No	165 (97)	106 (64)	59 (36)
Urgency				0.47
Yes	8 (5)	4 (50)	4 (50)
No	162 (95)	103 (64)	59 (36)
Nocturia				0.42
Yes	66 (39)	39 (59)	27 (41)
No	104 (61)	68 (65)	36 (35)
Physical activity practice				0.04
Yes	51 (30)	26 (51)	25 (49)
No	116 (70)	79 (68)	37 (32)
Protector use				0.00
Yes	10 (7)	0 (0)	10 (100)
No	141 (93)	93 (66)	48 (34)
Water retention				0.22
Yes	20 (12)	10 (50)	10 (50)
No	145 (88)	95 (66)	50 (34)
Medical care				0.01
Yes	5 (3)	0 (0)	5 (100)
No	151 (97)	96 (64)	55 (36)

• *mean±standard deviation; **family income in medians; ICIQ-SF: International Consultation on Incontinence Questionnaire - Short Form, quality of life questionnaire; BMI: body mass index. In total, five women failed to report their weight and/or height for BMI calculation; seven, their marital status; 66, pain during sexual intercourse; 10, contraceptive use; three, physical activity; 19, protector use; 5, water retention; and 14, medical care. P-value calculated via Fisher’s exact test and Spearman’s correlation (for age, family income, and age at menarche).

Via the ICIQ-SF questionnaire, most women who have urinary incontinence reported loss small losses (95%) once a week or less (79%) during exertion (65%), which slightly impacted their quality of life (Table 2).

Table 2
International Consultation on Incontinence Questionnaire (Short Form)

Characteristic	Students n (%)
Incontinent	63 (100)
Urinary loss frequency
Once a week or less	50 (79)
Two to three times a week	5 (8)
Once a day	5 (8)
Several times a day	3 (5)
Urinary loss amount
Small	60 (95)
Moderate	2 (3)
Large	1 (2)
VAS
None	16 (25)
Mild	29 (46)
Moderate	13 (21)
Severe	5 (8)
Score
Mild	41 (65)
Moderate	22 (35)
Urinary loss situations
Before getting to the bathroom
Yes	21 (33)
No	42 (67)
Cough/sneeze
Yes	41 (65)
No	22 (35)
Asleep
Yes	2 (3)
No	61 (97)
Physical activity
Yes	15 (24)
No	48 (76)
Getting dressed after urinating
Yes	12 (19)
No	51 (81)
For no obvious reason
Yes	5 (8)
No	58 (92)

• Impact of urinary loss on quality of life, classified by the visual analog scale (VAS) into none (0 points), mild (1-3 points), moderate (4-6 points), severe (7-9 points), and very severe (10 points). Impact of urinary loss on quality of life, classified by score into none (0 points), mild (1-3 points), moderate (4-6 points), severe (7-9 points), and very severe (10 points).

According to the knowledge questionnaire, 122 students (72%) showed adequate knowledge about the pelvic floor and UI, most of which were in later stages of their undergraduate courses. Table 3 shows the association between course period, UI, and quality of life, which was significant only for school period.

Table 3
Knowledge of urinary incontinence and associations

Characteristic	Knowledge n (%)	Adequate n (%)	Inadequate n (%)	p-value
	167 (100)	122 (73)	45 (27)
Period				0.00
First to fourth	65 (39)	30 (46)	35 (54)
Fifth to seventh	41 (25)	32 (78)	9 (22)
Eighth to tenth	61 (36)	60 (98)	1 (2)
UI				0.86
Continent	105 (63)	76 (72)	29 (28)
Incontinent	62 (37)	46 (74)	16 (26)
Quality of life - VAS				0.31
None	105 (70)	76 (72)	29 (28)
Mild	28 (18)	19 (68)	9 (32)
Moderate	13 (9)	12 (92)	1 (8)
Severe	5 (3)	4 (80)	1 (20)
Quality of life - Score (ICIQ-SF)				0.29
None	102 (61)	74 (73)	28 (27)
Mild	44 (26)	30 (68)	14 (32)
Moderate	21 (13)	18 (86)	3 (14)

• UI: urinary incontinence; VAS: visual analog scale; ICIQ-SF: International Consultation on Incontinence Questionnaire - Short Form. In total, three women failed to answer the questionnaire and 17, to report VAS. P-value calculated via chi-square and Fisher’s exact tests.

DISCUSSION

We found a difference in UI prevalence, according to both questionnaires. ICIQ-SF, which considers the occurrence of urinary loss in the four weeks prior to evaluation, showed a 37% prevalence of young and nulliparous women with UI. However, according to our evaluation form, which considers loss without a time limit, 65% of women declared themselves incontinent since they lost urine at some point in their lives.

According to the definition from the International Continence Society, an isolated report of urinary loss is insufficient to diagnose dysfunction¹⁵. Our results suggest that women’s perception and judgment of their bodies are more rigorous than what is actually the case and may stem from their lack of anatomical knowledge and of the dysfunctions which can occur.

Nevertheless, our form showed a prevalence which resembled that in Dias and Rodrigues⁴, who assessed physical therapy students in another Brazilian institution and evaluated UI via ICIQ-SF; and that in Cardoso, Lima, and Ferreira¹¹, who also evaluated UI via ICIQ-SF in young athletes.

Urinary loss due to strain was the most frequent symptom in our sample (65%), as observed in other studies with young and nulliparous women^4,11. This occurs when the pelvic floor is unable to maintain the adequate contraction of the urethral sphincter during the sudden increase of intra-abdominal pressure¹⁶ or by hypermobility of the urinary bladder due to inadequate support of the vaginal wall¹⁷.

Most women who reported constipation, strained defecation, and a feeling of incomplete outlet¹⁸ were incontinent. Evacuation requires the puborectalis muscle to relax and the anorectal angle to open. If this fails, women need to contract their abdominal muscles¹⁷. These conditions can stretch the PFM¹⁹, impairing the support of the pelvic organs and interfering in the proper functioning of the urethral and anal sphincters¹⁷.

Most women who showed interrupted flow and strain to urinate were incontinent. These symptoms indicate urethral narrowing, which may stem from inflammatory process (urinary infection), constipation, prolapse of one or more pelvic organs or altered contraction of sphincter muscles^20,21. These women also reported vaginal discomfort, a symptom of prolapse due to muscle injury and endopelvic fascia failure¹⁵.

Most students who reported dyspareunia complained of urinary loss. Pain is a symptom of sexual dysfunction which can stem from urinary incontinence²². This result resembles that in Latorre et al. ⁽²³, who evaluated the prevalence of sexual dysfunctions in students of a physical therapy course.

Contraceptive use was associated with urinary continence, which we may explain by hormones which can neutralize muscular degenerative changes and positively influence muscle strength and recovery, depending on the period of the menstrual cycle. However, the mechanism behind this remains unclear^24-27.

Physical activity constitutes a predisposing factor of UI strain in nulliparous women²⁸. However, most women we evaluated failed to practice physical activities.

Adequate knowledge was higher among students from the eighth to the tenth period, which we can explain by the undergraduate course offering the discipline “Physical Therapy Applied to Women’s Health” in its eighth period, which teaches students about pelvic floor structures, urogynecological dysfunctions, and physical therapy resources to treat and prevent them, such as kinesiotherapy (Kegel exercises) with or without biofeedback, electrical stimulation, vaginal cones, and virtual reality²⁹.

The first and second periods of the undergraduate course offer two anatomy courses, in which students learn about pelvic floor structures; whereas the fifth, a discipline on gynecology and obstetrics. The course further develops knowledge of urogynecological dysfunctions and physiotherapeutic treatment only in its eighth period³⁰. Thus, volunteers gradually receive knowledge, justifying their greater familiarity with the subject only in the later stages of the course, evincing that students attending physical therapy undergraduate courses ignore that PFM voluntary contraction prevents and treats UI symptoms^5,6.

A previous study applied the same knowledge questionnaire we used to female, young, and nulliparous athletes, confirming subjects’ lack of understanding outside academia and healthcare¹¹. Santos and Vaz³¹ also found other healthcare providers’ poor knowledge of how physical therapy can treat UI and proposed a greater interaction between specialties, which would optimize patient care.

Most women also reported a slight influence of UI on their quality of life, as did those in Cardoso, Lima, and Ferreira¹¹. Our participants also reported small losses (95%) once a week or less (79%), consistent with that in a study which assessed undergraduate students in physical therapy⁴⁾ via ICIQ-SF. We believe this explains the low demand for adequate treatment, embarrassment of women in this situation or their lack of knowledge about the problem and treatment³².

Another study showed improved quality of life for women with UI strain, comparing their results before and after a six-week physical therapy intervention³³. A psychological study evaluated the relevance of physical therapy for the quality of life of women with UI via a global self-esteem scale, finding that physical therapeutic treatment also benefits volunteers’ psychosocial sphere³⁴, improving their quality of life.

We showed that students who attend physical therapy undergraduate courses have little knowledge of UI and of the relevance of physical therapy to treat and prevent it, reflecting the lack of knowledge of society, which can cause future problems or worsen existing conditions. Thus, public policies must be implemented to encourage and guide self-knowledge, as must strategies to improve physical therapists’ performance with multidisciplinary teams.

CONCLUSION

This study showed urinary loss in young and nulliparaus women, occurring more often during exertion and associated with constipation, strained urination, and interrupted flow, which interfered in the proper functioning of continence mechanisms. Women also reported a slight influence of incontinence on their quality of life.

We also showed that students at the end of physical therapy undergraduate courses have adequate knowledge of the subject, which they gradually acquired during their studies. This suggests that women who attend courses other than in physical therapy would know little of the pelvic floor and its importance to preventing urinary incontinence.

Thus, research must overcome taboos and disseminate knowledge of urinary incontinence and physical therapy to both other health specialties and society, ensuring the better care for patients.

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• 5
  Study developed at the Physical Therapy Laboratory of Women’s Health and Pelvic Floor (LAFISMA) at the Department of Physical Therapy of the Universidade Federal de Pernambuco.
• 6
  Financing source: nothing to declare
• 8
  Approved by the Research Ethics Committee: Opinion No. 2.968.333.

Publication Dates

• Publication in this collection
  05 Dec 2022
• Date of issue
  Jul-Sep 2022

History

• Received
  05 Aug 2019
• Accepted
  30 June 2022