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. 2024 Feb 22;16(2):e54681. doi: 10.7759/cureus.54681

Assessment of Reproductive Health Knowledge Among College Students in Northwestern India: A Cross-Sectional Study

Shilpa Dutta 1,, Akash More 1, Sanket Mahajan 1, Neha Nawale 1, Namrata Choudhary 1, Deepti Shrivastava 2
Editors: Alexander Muacevic, John R Adler
PMCID: PMC10960612  PMID: 38524049

Abstract

Background

Reproductive health knowledge is a critical aspect of overall well-being, particularly among college students who represent a demographic transitioning into adulthood. In northwestern India, where cultural nuances and societal perceptions play a significant role, understanding the factors influencing reproductive health knowledge becomes imperative. This cross-sectional study explores the interplay between demographic factors and awareness of reproductive health and infertility treatment among college students in northwestern India.

Methods

A diverse sample of 564 college students in northwestern India participated in the study, providing information on key demographic variables, including age, gender, marital status, degree, field of study, and college year. Statistical analysis, including the calculation of p-values, was employed to determine the significance of associations between these demographic factors and the participants' knowledge of reproductive health. Descriptive statistics, including percentages and numbers, were calculated to present a comprehensive overview of the data. To evaluate the significance of associations, chi-square tests were conducted for categorical variables such as age, gender, marital status, degree, field of study, and college year. The p-values were computed to determine the statistical significance of observed relationships, with a significance level set at 0.05.

Results

The study uncovered notable findings with implications for targeted interventions. Among age groups, participants aged 23-25 exhibited the highest knowledge percentage at 43.22% (51/564), and this association was statistically significant (p = 0.042). Gender disparities were evident, with females showing higher awareness (46.52% (127/564)) compared to males, and this difference was statistically significant (p = 0.001). Marital status revealed significant differences (p = 0.0012), particularly in single individuals who demonstrated a knowledge percentage of 46.52% (127/564). Significant variations were observed based on the degree held, with doctorate holders having the highest awareness at 49.15% (58/564) (p = 0.01). Field of study significantly influenced knowledge (p = 0.0001), particularly in medical and engineering disciplines. College year also exhibited significance (p = 0.003), with the first-year students demonstrating a knowledge percentage of 42.20% (73/564).

Conclusions

These findings underscore the importance of tailored educational interventions and targeted awareness campaigns. Recognizing the influence of demographic factors on reproductive health knowledge is crucial for developing effective strategies that address the specific needs of college students in northwestern India, promoting a more informed approach to reproductive health and infertility treatment.

Keywords: taboo, health, students, reproduction, knowledge, infertility

Introduction

World Health Organization (WHO) defines infertility as the inability to conceive after at least 12 months of regular sexual activity without contraception [1]. Infertility constitutes a significant global health challenge, affecting approximately 12-15% of couples worldwide [2]. Worldwide, overall fertility rates are declining steeply, possibly influenced by prolonged time to conceive among both men and women for their first child [3]. Current literature suggests that approximately 86% of the young population resides in developing countries, with a total of around 1.7 million young cohorts globally [4]. India hosts about 65% of this young population, according to the latest report of 2020 [5]. Therefore, acquiring proper reproductive health knowledge is imperative to avoid unforeseen fertility issues. The factors contributing to infertility and unfavorable pregnancy outcomes are multifaceted and arise from intricate interactions among genetic, environmental, and lifestyle factors prevalent in the general population [6]. It has been reported that more than one-third of India's younger population suffers from sexually transmitted diseases such as acquired immune deficiency syndrome (AIDS), indicating a lack of active awareness about reproductive health and safety measures among the younger cohort [7].

It has been observed that knowledge about fertility heavily influences decisions concerning reproductive health [3]. In 2017, the International Glossary of Infertility and Fertility Care defined fertility awareness as the understanding of reproduction and fertility, encompassing various individual risk factors such as advanced age, sexual health considerations, sexually transmitted infections, and lifestyle factors like smoking and obesity. Furthermore, it entails the recognition of non-personal risk elements, including environmental and workplace factors. This understanding extends to awareness of the social and cultural influences on family planning decisions, as well as the societal and cultural dynamics impacting the desire for family formation [3].

A subset of individuals may engage in novel behaviors such as substance abuse, unprotected sexual activity, and involvement with multiple sexual partners due to hormonal changes, depression, and peer influence [8]. There is a scarcity of research, primarily conducted abroad, concerning the knowledge base of university students regarding infertility. Despite their aspirations for parenthood, these students exhibit a heightened risk of infertility due to intensive efforts to achieve academic and career objectives [9,10]. Gavin et al. observed that fostering positive youth development programs plays a crucial role in advancing the sexual and reproductive health of adolescents and young individuals [11].

Studies have reported that university students tend to express a desire to have children as they approach a stage of declining reproductive capacity. Nevertheless, they exhibit a deficit in understanding age-related decreases in fertility, along with relevant risk factors and infertility issues [8,12,13]. Hence, this article focuses on assessing the reproductive health knowledge among college students in northwestern India and their awareness of infertility treatment. The results of this study will help evaluate further plans needed for the targeted population to improve fertility outcomes accordingly.

Materials and methods

Study design

The study design for the article was cross-sectional. It included 600 elected participants through a snowball sampling technique. A Google form was distributed among the participants with a preset of questionnaires having 16 multiple-choice questions. Individuals were conveniently selected and were further encouraged to circulate the questionnaire survey among other participants who met the criteria of the study. Initial participants were elected through known connections, communities, and pre-existing networks. Further, participants were elected through known contacts of the initial group of selected participants, which fostered a snowball sampling method. After thorough data cleaning, 564 eligible participants’ answers from the questionnaire were selected to be evaluated for the study. The anonymity of the respondents was maintained throughout to ensure the participant's privacy, and hence, the offered responses were candid and truthful. 

Data analysis

Descriptive statistics was utilized for the quantification of the answers obtained through the Google form survey. The chi-square (χ2) test was used for the calculation of the statistical value. A p-value less than 0.05 was considered to be statistically significant for the analysis of the data collected. SPSS 26.0 for Windows Student Version (IBM Inc., Armonk, New York) was used for the evaluation of the study.

Ethical considerations

Prior to conducting the online questionnaire survey, informed consent was diligently obtained from all participants. This study has been ethically approved by the Institutional Review Board of Datta Meghe Institute of Higher Education and Research in its meeting held on September 2, 2023, having reference number DMIHER(DU)/IEC/2023/1321.

Results

As shown in Table 1, the demographic data reveals a diverse distribution of participants across various age groups, genders, and marital statuses. In terms of age, the majority of respondents fall within the 23-25 age bracket, comprising 45.04% (254/564) of the sample, followed by those aged 20-22 (24.11% (136/564)) and 17-19 (8.69% (49/564)). The gender distribution shows a relatively balanced representation, with 48.05% (271/564) identified as male and 51.95% (293/564) as female. Regarding marital status, the participants are spread across single (40.78% (230/564)), married (34.93% (197/564)), and separated (24.29% (137/564)) categories. This demographic snapshot provides valuable insights into the composition of the surveyed population, allowing for a more nuanced understanding of the factors under consideration in the study.

Table 1. Demographic data of the participants.

The data has been represented as N = Total number of participants who selected the aforementioned option among all the choices available; % = N/Total number of participants selected for the study (564)

Demographic Data Number (N) %
Age (years)  
17-19 49 8.69 (49/564)
20-22 136 24.11 (136/564)
23-25 254 45.04 (254/564)
25-27 74 13.12 (74/564)
27-29 32 5.67 (32/564)
30+ 19 3.36 (19/564)
Gender  
Male 271 48.05 (271/564)
Female 293 51.95 (293/564)
Marital Status  
Single 230 40.78 (230/564)
Married 197 34.93 (197/564)
Separated 137 24.29 (137/564)

The participant background data, as shown in Table 2, provides a comprehensive overview of the educational and academic profile of the surveyed individuals. Among the degrees held by respondents, the majority possess a Bachelor's degree (29.61% (167/564)), followed closely by those with a Master's degree (24.11% (136/564)) and Doctorate holders (21.45% (121/564)). Diploma holders constitute 14.36% (81/564), and there is a notable presence of individuals with other qualifications (10.46% (59/564)). When considering college years, the distribution is fairly even, with the highest representation in the first year (28.72% (162/564)) and descending proportions in subsequent years. The field of study diversity is evident, with Commerce (18.44% (104/564)), Arts (12.41% (70/564)), and Law (14.01% (79/564)) being the most prevalent disciplines. This comprehensive breakdown of participant backgrounds illuminates the varied educational journeys and fields of expertise within the surveyed group, providing valuable context for interpreting responses and drawing insights into the research study.

Table 2. Background of the participants.

The data has been represented as N = Total number of participants who selected the aforementioned option among all the choices available; % = N/Total number of participants elected for the study (564)

Participant Background Number (N) %
Degree  
Diploma 81 14.36 (81/564)
Bachelor's 167 29.61 (167/564)
Master's 136 24.11 (136/564)
Doctorate 121 21.45 (121/564)
Others 59 10.46 (59/564)
College Year  
First 162 28.72 (162/564)
Second 97 17.19 (97/564)
Third 136 24.11 (136/564)
Fourth 91 16.13 (91/564)
Fifth 78 13.83 (78/564)
Field of Study  
Medical 48 8.51 (48/564)
Engineering 49 8.69 (49/564)
Arts 70 12.41 (70/564)
Commerce 104 18.44 (104/564)
Science 40 7.09 (40/564)
Law 79 14.01 (79/564)
Humanities 86 15.25 (86/564)
Management 68 12.05 (68/564)
Others 20 3.55 (20/564)

The data on reproductive health awareness, as shown in Table 3, sheds light on participants' attitudes, knowledge, and confidence regarding this critical aspect of well-being. A significant portion of respondents actively seek information about their reproductive health, with 52.66% (297/564) indicating that they do so sometimes and 18.62% (105/564) doing it very often. In contrast, 28.72% (162/564) of participants never seek such information. The distribution of previous knowledge about reproductive health and infertility treatment is varied, with 48.40% (273/564) being unsure, 30.67% (173/564) having no previous knowledge, and 20.92% (118/564) affirming their awareness. Confidence levels in the accuracy of reproductive health information vary as well, with 40.60% (229/564) expressing a lack of confidence and 22.16% (125/564) feeling somewhat confident. The most common sources for seeking information are friends (48.76% (275/564)) and the internet (24.11% (136/564)), showcasing the role of social networks and online platforms in disseminating reproductive health knowledge. This comprehensive data provides insights into the participants' engagement with and trust in reproductive health information, highlighting areas for targeted awareness campaigns and education.

Table 3. Reproductive health awareness among the participants.

The data has been represented as N = Total number of participants who selected the aforementioned option among all the choices available; % = N/Total number of participants elected for the study (564)

Reproductive Health Awareness Number (N) %
Do you seek information regarding your reproductive health?  
Very often 105 18.62 (105/564)
Sometimes 297 52.66 (297/564)
Never 162 28.72 (162/564)
Do you have previous knowledge about reproductive health and infertility treatment?  
Yes 118 20.92 (118/564)
No 173 30.67 (173/564)
Not sure 273 48.40 (273/564)
How confident are you in the accuracy of the reproductive health information you come across?  
Very confident 94 16.67 (94/564)
Somewhat confident 125 22.16 (125/564)
Neutral 116 20.57 (116/564)
Not confident 229 40.60 (229/564)
Where do you usually seek information about reproductive health and fertility?  
Friends 275 48.76 (275/564)
Family 71 12.59 (71/564)
Internet 136 24.11 (136/564)
Healthcare professionals 24 4.25 (24/564)
Others 58 10.28 (58/564)

The social outlook data, as shown in Table 4, provides valuable insights into the perceptions and attitudes of participants towards reproductive health in the broader societal context. A substantial majority, comprising 50.35% (284/564), strongly agree that there is societal pressure associated with the ability to reproduce, and an additional 28.72% (162/564) agree with this sentiment. Conversely, only a small percentage, 7.97% (45/564), disagrees with this notion, emphasizing the prevalence of societal expectations regarding fertility. A significant portion, 62.94% (355/564), believe that there is a stigma attached to discussing or seeking help for infertility, while 14.54% (82/564) are unsure. Assessing their knowledge about factors influencing infertility and methods to conceive, participants express a range of confidence levels, with 21.63% (122/564) rating their knowledge as very good and 15.43% (87/564) as very poor. This data underscores the importance of understanding societal perceptions and stigma surrounding reproductive health, advocating for more open conversations, and addressing knowledge gaps to foster a supportive and informed community.

Table 4. Social outlook of the participants.

The data has been represented as N = Total number of participants who selected the aforementioned option among all the choices available; % = N/Total number of participants elected for the study (564)

Social Outlook Number (N) %
Do you believe it is not perceived well by society if someone is not able to reproduce?  
Strongly agree 284 50.35 (284/564)
Agree 162 28.72 (162/564)
Neither agree or disagree 70 12.41 (70/564)
Disagree 45 7.97 (45/564)
Strongly disagree 3 0.53 (3/564)
In your opinion, is there a stigma associated with discussing or seeking help for infertility?  
Yes 355 62.94 (355/564)
No 127 22.52 (127/564)
Not sure 82 14.54 (82/564)
How would you rate your knowledge about the factors influencing infertility and methods to conceive?  
Very Poor 87 15.43 (87/564)
Poor 104 18.44 (104/564)
Neutral 180 31.92 (180/564)
Good 71 12.59 (71/564)
Very Good 122 21.63 (122/564)

The data on infertility awareness, as shown in Table 5, reflects a spectrum of knowledge and perceptions among participants. A significant portion, comprising 24.82% (140/564), is aware of factors contributing to infertility, while 31.56% (178/564) are not and 43.62% (246/564) are unsure. Interestingly, when asked to enumerate factors contributing to infertility, participants demonstrated varied levels of awareness. Notable factors such as age, lifestyle choices, and medical conditions were well-recognized, with 94.15% (531/564) identifying sexually transmitted infections (STIs) like AIDS and 90.78% (512/564) associating smoking, excessive alcohol consumption, and drug use with infertility. However, unconventional factors like weather, tight underwear, and laptop use also garnered responses. About 66.49% (375/564) of participants believe that infertility can be treated, while 18.08% (102/564) think otherwise and 15.43% (87/564) are unsure. This diversity in responses underscores the need for targeted education to enhance public awareness about infertility causes and treatments, fostering informed perspectives on this significant reproductive health issue.

Table 5. Infertility awareness among the participants.

The data has been represented as N = Total number of participants who selected the aforementioned option among all the choices available; % = N/Total number of participants elected for the study (564)

Infertility Awareness Number (N) %
Are you aware of factors that can contribute to infertility?  
Yes 140 24.82 (140/564)
No 178 31.56 (178/564)
Maybe 246 43.62 (246/564)
Can you enlist all factors that can contribute to infertility by selecting from the below options?  
Age 487 86.35 (487/564)
Smoking, excessive alcohol consumption, drug use 512 90.78 (512/564)
Weight gain/loss 375 66.49 (375/564)
Stress 278 49.29 (278/564)
Sexually transmitted infections (STIs) like AIDS 531 94.15 (531/564)
Poor diet 364 64.54 (364/564)
Weather 201 35.64 (201/564)
Medical Conditions: Conditions like diabetes, thyroid disorders, etc 215 38.12 (215/564)
Hormonal Imbalance 97 17.20 (97/564)
Genetic Factors 82 14.54 (82/564)
Reproductive organ Issues 112 19.86 (112/564)
Medications 107 18.97 (107/564)
Previous Surgeries 71 12.59 (71/564)
Tight Underwear 136 24.11 (136/564)
Laptop Use 46 8.16 (46/564)
Cycling 30 5.32 (30/564)
Cell Phone Radiation 89 15.78 (89/564)
Birth Control Pill Use 53 9.39 (53/564)
Masturbation 78 13.83 (78/564)
Breastfeeding 15 2.66 (15/564)
All of above 249 44.15 (249/564)
Not sure of options given 278 49.29 (278/564)
Do you think infertility can be treated?  
Yes 375 66.49 (375/564)
No 102 18.08 (102/564)
Not sure 87 15.43 (87/564)

The presented data, as shown in Table 6, illustrates the distribution of participants' responses based on their knowledge of reproductive health and infertility treatment, segmented by various factors. The p-values associated with each factor indicate the statistical significance of the observed differences, with a p-value less than 0.05 considered as statistically significant. In terms of age, respondents aged 23-25 exhibited the highest awareness, with a p-value of 0.042. Gender significantly influenced knowledge, as males displayed higher awareness compared to females (p = 0.001). Marital status also played a significant role, with single individuals having greater knowledge than their married or separated counterparts (p = 0.0012). The educational background showed a noteworthy impact, with participants holding doctorate degrees being the most informed group (p = 0.01). Field of study emerged as a crucial factor, with medical and engineering students exhibiting higher awareness compared to other disciplines (p = 0.0001). Additionally, college years demonstrated a statistically significant effect on knowledge, with fifth-year students being the most informed (p = 0.003). These findings underscore the importance of considering demographic variables in understanding and addressing awareness levels regarding reproductive health and infertility treatment.

Table 6. Factors associated with participants' knowledge about reproductive health and infertility treatment.

The data has been represented as N = Total number of participants who selected the aforementioned option among all the choices available; % = N/Total number of participants elected for the study (564)

P-value < 0.05 is considered as statistically significant in the study

Factors Do you have previous knowledge about reproductive health and infertility treatment? P-Value
Yes Not Sure No
Number (N) % Number (N) % Number (N) %
Age (years)             0.042
17-19 6 5.08 (6/564) 17 6.23 (17/564) 26 15.03 (26/564)
20-22 21 17.79 (21/564) 64 23.44 (64/564) 51 29.48 (51/564)
23-25 51 43.22 (51/564) 136 49.82 (136/564) 67 38.73 (67/564)
25-27 21 17.79 (21/564) 35 12.82 (35/564) 18 10.40 (18/564)
27-29 8 6.78 (8/564) 15 5.49 (15/564) 9 5.20 (9/564)
30+ 11 9.32 (11/564) 6 2.19 (6/564) 2 1.16 (2/564)
Gender             0.001
Male 71 60.17 (71/564) 146 53.48 (146/564) 54 31.21 (54/564)
Female 47 39.83 (47/564) 127 46.52 (127/564) 119 68.79 (119/564)
Marital Status             0.0012
Single 21 17.79 (21/564) 127 46.52 (127/564) 82 47.40 (82/564)
Married 52 44.06 (52/564) 78 28.57 (78/564) 67 38.73 (67/564)
Separated 45 38.14 (45/564) 68 24.91 (68/564) 24 13.87 (24/564)
Degree             0.01
Diploma 11 9.32 (11/564) 48 17.58 (48/564) 22 12.72 (22/564)
Bachelor's 17 14.40 (17/564) 86 31.50 (86/564) 64 36.99 (64/564)
Master's 24 20.34 (24/564) 67 24.54 (67/564) 45 26.01 (45/564)
Doctorate 58 49.15 (58/564) 44 16.12 (44/564) 19 10.98 (19/564)
Others 8 6.78 (8/564) 28 10.26 (28/564) 23 13.29 (23/564)
Field of Study             0.0001
Medical 36 30.50847 10 3.66 (10/564) 2 1.16 (2/564)
Engineering 12 10.16949 28 10.26 (28/564) 9 5.20 (9/564)
Arts 11 9.322034 35 12.82 (35/564) 24 13.87 (24/564)
Commerce 8 6.779661 57 20.88 (57/564) 39 22.54 (39/564)
Science 19 16.10169 13 4.76 (13/564) 8 4.62 (8/564)
Law 17 14.40678 46 16.85 (46/564) 16 9.25 (16/564)
Humanities 5 4.237288 36 13.19 (36/564) 45 26.01 (45/564)
Management 3 2.542373 40 14.65 (40/564) 25 14.45 (25/564)
Others 7 5.932203 8 2.93 (8/564) 5 2.89 (5/564)
College Year             0.003
First 22 18.64407 67 24.54 (67/564) 73 42.20 (73/564)
Second 15 12.71186 53 19.41 (53/564) 29 16.76 (29/564)
Third 17 14.40678 82 30.03 (82/564) 37 21.39 (37/564)
Fourth 28 23.72881 42 15.38 (42/564) 21 12.14 (21/564)
Fifth 36 30.50847 29 10.62 (29/564) 13 7.52 (13/564)

Discussion

The findings from this study of the cross-sectional data set aimed at assessing reproductive health awareness among northwestern Indian college students are profound. It has been observed by researchers that due to insufficient knowledge about reproductive health, college students tend to make less use of existing reproductive healthcare facilities available [14]. Thus, this leads to an increasing trend of reproductive health problems among the reproductive age cohorts. Studies from Kenya, China, Kerala, Turkey, and other countries have reportedly evaluated and pointed out the fact that there is a substantial lack of reproductive health knowledge among different sociodemographic profiles, and the percentage of the population that contributes majorly belongs to the college students [4,15-18].

Gender-wise distribution of reproductive knowledge appears to be balanced; however, upon a closer analysis of the respondents’ data, it is observed that males had a slight upper hand as compared to females in reproductive health knowledge. This finding can be attributed to the fact that males have comparatively easier access to available information about reproductive health awareness or social expectations. Studies from India are scarce, and from the limited research literature available, it has been reported that females tend to generally have poor knowledge of sexual health, leading to several fertility-related issues [19,20]. Upon analyzing the answers from an educational background perspective, it has been observed that individuals holding degrees in medical, engineering, and higher educational qualifications, such as doctorates, tend to have better reproductive knowledge as compared to other qualifications. Both developed, and developing countries have a trend of high-risk sexual behaviors predominantly among the younger age cohorts, thereby increasing incidents of unwanted pregnancies due to a lack of safer intercourse knowledge [21]. Hence, it is a matter of utmost importance to spread awareness about reproductive health among college students to curb the incidence of unwanted pregnancies. Parents hold the primary role as the initial educators of the young population regarding these topics, influencing the development of adolescents' attitudes and behaviors toward sexuality significantly [21]. However, many studies have reported that young adults tend to seek reproductive health knowledge from social sites, friends, and unreliable sources, while parents and siblings are the least used knowledge sources [22]. These generally lead to incorrect sharing of information among the reproductive groups, thereby increasing stances of high-risk sexual behaviors, leading to STIs and infertility.

Although the majority of college students have shown intention in many literatures to postpone childbearing, their understanding of age-related fertility decline was found to be limited, and they tended to overestimate the success rates of fertility treatments [23]. Previous studies from the United States and Sweden have highlighted that individuals having college degrees tend to have their first child above the age of 30 years, which is much higher than those having lesser qualifications [24,25]. However, such studies in India are limited, which is why this study tried to bridge the knowledge gap. Our study was in line with other research around the world that the younger age cohort particularly lacks awareness of reproductive health and participates in unsafe intercourse, which majorly contributes to STIs in India. Thus, it is of utmost importance to build a robust awareness plan to increase the knowledge of fertility health and stances related to infertility to gain control over the increasing rate of infertility rise in India and improve the overall reproductive health of the major population group of India.

Conclusions

Our study sheds light on the intricate relationship between demographic factors and reproductive health knowledge among college students in northwestern India. The findings underscore the significance of age, gender, marital status, educational background, field of study, and college year in influencing awareness of reproductive health and infertility treatment. Noteworthy patterns emerged, such as higher awareness among individuals aged 23-25, females, singles, doctorate holders, and students in specific fields like medical and engineering disciplines. These insights emphasize the need for targeted educational interventions and awareness campaigns tailored to the diverse characteristics of college students. Recognizing the influence of demographic factors on reproductive health knowledge is imperative for developing effective strategies that empower this population to make informed decisions about their reproductive well-being. Addressing these demographic-specific needs has the potential to enhance overall awareness and contribute to a more proactive and informed approach to reproductive health and infertility treatment among college students in northwestern India.

The authors have declared that no competing interests exist.

Author Contributions

Concept and design:  Shilpa Dutta

Acquisition, analysis, or interpretation of data:  Shilpa Dutta, Akash More, Sanket Mahajan, Neha Nawale, Namrata Choudhary, Deepti Shrivastava

Drafting of the manuscript:  Shilpa Dutta, Sanket Mahajan, Neha Nawale

Critical review of the manuscript for important intellectual content:  Shilpa Dutta, Akash More, Namrata Choudhary, Deepti Shrivastava

Human Ethics

Consent was obtained or waived by all participants in this study. Datta Meghe Institute of Higher Education and Research issued approval DMIHER(DU)/IEC/2023/1321. The Institutional Ethics Committee in its meeting held on September 2, 2023, has approved the following research proposed to be carried out at Jawaharlal Nehru Medical College and Acharya Vinoba Bhave Rural Hospital, Datta Meghe Institute of Higher Education and Research (DU), Sawangi (Meghe), Wardha. This approval has been granted on the assumption that the proposed research work will be carried out in accordance with the ethical guidelines prescribed by the Central Ethics Committee on Human Research (CECHR).

Animal Ethics

Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

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