Abstract
BACKGROUND:
Vaccination is a quick, safe, and effective way to avoid contracting hazardous diseases, but it often causes pain and discomfort. Various pharmacological and non-pharmacological pain management techniques are used to treat pain. This study aimed to compare the effectiveness of breastfeeding, musical therapy, and oral sucrose in infant’s pain relief during pentavalent vaccination.
MATERIALS AND METHODS:
A quasi-experimental posttest-only research design was used. A total of 150 infants were enrolled using the purposive sampling technique (50 in the breastfeeding, 50 in the musical therapy, and 50 in the oral sucrose groups) coming for the first, second, and third doses of pentavalent vaccination. The data were collected using observation and the Neonatal Infant Pain Scale (NIPS). The results were calculated by descriptive and inferential statistics.
RESULTS:
The study revealed that half of the infants in the breastfeeding group felt severe pain, whereas the majority of infants in the musical therapy and oral sucrose groups felt severe pain during pentavalent vaccination. The median pain score in breastfeeding, musical therapy, and oral sucrose was 4.50, 6, and 7, respectively. Breastfeeding was significantly different from both musical therapy and oral sucrose in terms of pain scores. However, no significant difference was observed between musical therapy and oral sucrose. Overall, the results indicate that breastfeeding had a distinct impact on pain relief during pentavalent vaccination compared with the other interventions, while musical therapy and oral sucrose did not differ significantly in their effectiveness.
CONCLUSION:
The study concluded that breastfeeding is a safe, reliable, cost-effective, and easily accessible method to relieve an infant’s pain during pentavalent vaccination. It is a simple method to alleviate pain among infants during vaccination.
Keywords: Breastfeeding, infant, musical therapy and oral sucrose, pain, pentavalent
Introduction
Pain is a global health problem that is faced by every living being at any stage of life from birth till death. It has also been proven that infants also feel pain in response to any painful stimuli. Pain in infants during vaccination is a frequent and worrisome problem. While vaccines are essential for their health and well-being, they can induce discomfort and distress.[1] Infant pain is evident through facial expressions, crying patterns, and body movements. Crying serves as the most prominent and noticeable reaction of infants to pain.[2]
Infancy is the age of rapid growth in all aspects. Infants are the most significant age group in society among the subgroups because there is a growing understanding that early childhood is when the foundations for infectious and chronic diseases are set. Infants should be immunized against serious fatal diseases during this period when they gurgle, crawl, laugh, cry, and hear a wonderful lullaby, with a diverse population spread across a large area, India. Being underweight, infections including those preventable through immunization and oral rehydration are the leading causes of newborn mortality.[3]
The most important preventive health strategy for a child is immunization.[4] Vaccination is a quick, safe, and effective way to avoid contracting hazardous diseases. Vaccines strengthen immunity by stimulating the body to make antibodies, much as natural immunity does in response to infection.[5] Infants frequently experience pain and discomfort due to vaccinations, which are virtually always administered to young children.[6] Pain throughout the developmental stage may negatively impact growing neural circuits and have long-term negative impacts on neurodevelopment, cognition, and behavior.[7]
Pain management and alleviation are crucial rights and treatment priorities, as they can prevent detrimental consequences and severe effects on infants. Ensuring effective pain management not only promotes the well-being of infants but also safeguards them from potential harm.[8] A study indicated that nurses demonstrate substantial expertise derived from their extensive work experience, particularly in pediatric units. This experience equips them with the capability to recognize various types of pain and make dedicated efforts to efficiently manage it.[9] There are now more attempts being made to diagnose, assess, and manage pain as a result of knowledge of the effects of untreated pain. Many pharmacological and non-pharmacological techniques can both be used to alleviate pain and suffering during painful procedures and operations. Non-pharmaceutical therapies have received increased attention because research has shown that they can effectively and safely diminish pain and reduce children’s suffering.[10]
Distraction is a non-pharmacological technique that helps children undergoing invasive medical procedures feel less pain and behave less anxiously. Effective pain treatment involves the utilization of pharmacological or non-pharmacological methods. To distract the baby’s attention from the discomfort brought on by tissue injury, a variety of other treatments are employed. These methods include stroking the baby’s skin, breastfeeding, sugar in the mouth, music therapy, numbing drugs, and skin-to-skin contact.[10,11]
Evolutionary biology and clinical practice are connected via breastfeeding. This is of clinical importance since natural therapies work when many non-pharmacological ones do not, and pain is frequently experienced in hospital settings, even by healthy neonates. Breastfeeding is practical since it is simply achievable from the viewpoints of healthcare providers and parents, especially in situations where there is acute pain experience, such as during immunization injections among newborns. It also efficiently lowers the response to pain. As a result, breastfeeding is a simple, safe, and effective analgesic against pain perception in newborn.[12,13]
Breastfeeding activates sensory receptors in the skin and taste buds. The presence of fats, proteins, and various flavors in breast milk triggers the release of opioids, which in turn reduces the transmission of pain signals to the brain. In simpler terms, breast milk acts as an analgesic, providing pain relief.[14] Research studies have provided evidence that breast milk effectively reduces neonatal pain during minor painful procedures. Due to its widespread availability and its positive impact on the mother–baby bond, breastfeeding is considered the most commonly used non-pharmacological method for pain relief.[15]
Music therapy is a specialized approach that involves the intentional use of music or musical elements such as rhythm, sound, and melody by a trained music therapist. Its purpose is to enhance and improve the quality of life for individuals, families, or groups. Through the therapeutic application of music, music therapists aim to address physical, emotional, cognitive, and social needs and promote overall well-being.[16]
Music therapy has been employed not only for pain management but also for various clinical conditions in both children and adults. Its application extends beyond pain relief, encompassing a wide range of therapeutic interventions. Music therapy has been recognized as an effective approach to addressing various physical, emotional, and cognitive challenges across different populations and age groups.[17] A readily available, nonsedating drug with immediate effects is sucrose. According to Hatfield et al.’s research, oral sugar delivery during regular immunization was a quick and simple procedure with short-term effects.[18]
Newborns’ responses to oral sucrose have been thoroughly examined, and they appear to be both effective and developmentally appropriate for reducing newborns’ pain during procedures. The use of oral sucrose has received the most research attention in baby pain management to date.[19] Many standardized scales are available that tend to measure pain score among newborns and infants. These include the The Children's Revised Impact of Event Scale (CRIES), The Face, Legs, Activity, Cry, and Consolability (FLACC), Premature Infant Pain Profile (PIPP), Neonatal Infant Pain Score (NIPS) pain scales.[17] Since infants cannot communicate their pain verbally, it is crucial for nurses to have access to user-friendly and precise neonatal pain scales to provide optimal care. It is important to assess both behavioral and physiological responses to pain to gain a comprehensive understanding of the infant’s pain experience. By examining these indicators, nurses can ensure the delivery of high-quality care to infants in pain.[11]
Infants often undergo various procedures during their hospitalization without sufficient pain relief, which can be attributed to their inability to express their pain and relief, as well as the challenges faced by healthcare providers in objectively measuring their pain. This situation leads to an unfortunate lack of humane treatment for infants in pain. Non-pharmacological methods are preferred for pain management to avoid the potential adverse effects of analgesic drugs. These methods are also advantageous as they do not necessarily require specific orders from pediatricians to be implemented. Non-pharmacological techniques include providing oral sucrose to infants, utilizing music therapy, cuddling the neonate, encouraging breastfeeding, or comforting the baby in the caregiver’s lap, and practicing kangaroo care. A recent Cochrane review has indicated that administering oral sucrose to neonates is effective in reducing pain during minor procedures such as venepuncture and heel lancing.[20] This study aimed to investigate and compare the effectiveness of breastfeeding, music therapy, and oral sucrose in relieving pain among infants during pentavalent vaccination. Understanding which pain relief method provides the most significant benefits can inform healthcare professionals and parents about the most suitable and effective interventions to minimize pain and promote a more comfortable vaccination experience for infants.
Materials and Methods
Study design and setting
The study used a quasi-experimental posttest-only research design and focused on infants who were scheduled to receive the routine vaccination of the first, second, and third doses of the pentavalent vaccine. The research was conducted in the immunization room at the Department of Pediatrics in a tertiary teaching super-specialty SGRD Hospital, which is associated with a postgraduate medical college.
Study participants and sampling
A total of 150 infants were enrolled using the purposive sampling technique. Each group comprises 50 infants, that is, 50 breastfeeding, 50 musical therapy, and 50 oral sucrose. The study subjects were selected using a lottery method. The name of each group was written on a slip and mixed in a box. In total, there were 150 slips, with 50 slips for each of the three intervention groups. The parents were informed about this process and were involved in selecting one slip from the box. The group corresponding to the selected slip was then determined.
Sample size
The researchers used G-power, a widely used software tool for power analysis, to calculate the sample size. The effect size was estimated to be 0.33, representing the anticipated magnitude of the intervention’s impact on the outcome variable. The significance level (alpha) was set at 0.05, indicating a 5% chance of committing a type I error. The desired statistical power (1 - beta) was determined to be 0.90, corresponding to a 90% probability of correctly rejecting the null hypothesis. Based on these parameters, G-power estimated a sample size of 123 infants. However, the study ultimately selected a sample of 150 infants.
Data collection tool and technique
The intervention was initiated two minutes before the pentavalent vaccination and continued during and after the vaccine for up to five minutes. In group I, mothers initiated breastfeeding for their infants following the provided explanation. In group II, 1–2 ml of 25% oral sucrose was administered to the infants using a dropper. In group III, musical therapy with a toy was implemented.
The pain levels were observed, and the pain score was recorded using the Neonatal Infant Pain Scale (NIPS). This scale is based on six parameters, which include facial expression, cry, breathing pattern, arms, legs, and state of arousal. The total score was recorded, and the level of pain was determined based on the following categories: 0–2 indicated no or mild pain, 3–4 indicated mild or moderate pain, and scores greater than 4 indicated severe pain.
Statistical analysis
All statistical analyses were performed using IBM SPSS Statistics software (version 26) from IBM SPSS Statistics, Armonk, USA. Statistical significance was determined by a P value of less than 0.05. To ensure the normality of variables, the Kolmogorov–Smirnov and Shapiro–Wilk tests were used. Based on the results, appropriate statistical tests were applied for data analysis.
Ethical consideration
For each participant, informed written assent was obtained from their parents or guardians. The study was approved by the SGRD University of Health Sciences, Sri Amritsar, Punjab (Approval No. SGRD/IEC/2022-70, dated May 4, 2022).
Results
In the study, it was observed that nearly half of the infants in the breastfeeding and musical therapy groups were aged between 7 and 12 weeks, while more than half of the infants in the oral sucrose group were older than 12 weeks. Additionally, over half of the infants receiving pentavalent vaccination were male. The average weight of infants was 5.26 Kg in the breastfeeding group, 5.18 Kg in the musical therapy group, and 5.19 Kg in the oral sucrose group. The distribution of pentavalent vaccine doses was relatively equal in the breastfeeding and musical therapy groups, whereas more than half of the infants in the oral sucrose group received the third dose. Most infants received their vaccinations on time [Table 1].
Table 1.
Baseline data of infants in breastfeeding, musical therapy, and oral sucrose groups (n=150)
| Variables | Breastfeeding (n=50) n (%) | Musical therapy (n=50) n (%) | Oral sucrose (n=50) n (%) | ꭓ 2 | P |
|---|---|---|---|---|---|
| Age (wks.) | |||||
| Up to 6 wks. | 10 (20) | 14 (28) | 09 (18) | 4.529 | 0.339NS |
| 7–12 wks. | 21 (42) | 16 (32) | 14 (28) | ||
| >12 wks. | 19 (38) | 20 (64) | 27 (54) | ||
| Mean SD | 11.38±4.237 | 11.08±3.958 | 12.06±3.628 | ||
| Gender | |||||
| Male | 28 (56) | 30 (60) | 30 (60) | 0.220 | 0.896NS |
| Female | 22 (44) | 20 (40) | 20 (40) | ||
| Weight | |||||
| 3–5 kg | 21 (42) | 27 (54) | 22 (44) | 1.661 | 0.436NS |
| 6–8 | 29 (58) | 23 (46) | 28 (56) | ||
| Mean SD | 5.26±1.002 | 5.18±1.058 | 5.19±1.216 | ||
| Dose | |||||
| 1st | 16 (32) | 18 (36) | 13 (26) | 6.494 | 0.165NS |
| 2nd | 19 (38) | 15 (30) | 11 (22) | ||
| 3rd | 15 (30) | 17 (34) | 26 (52) | ||
| Time | |||||
| On time | 34 (68) | 35 (70) | 32 (16) | 0.424 | 0.809NS |
| Delayed | 16 (32) | 15 (30) | 18 (36) | ||
NB: NS=Nonsignificant, significant level at 0.05
In terms of pain levels, approximately half of the infants in the breastfeeding group reported severe pain, while a majority of infants in the musical therapy and oral sucrose groups experienced severe pain. The median pain score was lower in the breastfeeding group compared with the other two groups [Table 2].
Table 2.
Level of pain among infants in the breastfeeding, musical therapy, and oral sucrose groups (n=150)
| Groups | Level of pain |
Median (IQR) | ||
|---|---|---|---|---|
| No or mild f (%) | Mild/moderate f (%) | Severe f (%) | ||
| Breastfeeding | 12 (24) | 13 (26) | 25 (50) | 4.50 (3) |
| Musical therapy | 06 (12) | 10 (20) | 34 (68) | 6.00 (3) |
| Oral sucrose | 02 (04) | 08 (16) | 40 (80 | 7.00 (2) |
NB: IQR=Interquartile range
The mean rank of pain in the breastfeeding group was 43.20, whereas that in the musical therapy group was 57.80. The Mann–Whitney test was applied to find the statistical significance between the groups. The results revealed that U = 885, Z = 2.573, and P = 0.010, which indicates statistical significance at a 0.001 level of significance. Thus, breastfeeding as compared to musical therapy was found to be effective in pain relief among infants during pentavalent vaccination [Table 3].
Table 3.
Comparison of pain among infants in the breastfeeding and musical therapy groups (n=100)
| Groups | Mean rank | Sum of ranks | Mann–Whitney U | Z | P |
|---|---|---|---|---|---|
| Breastfeeding | 43.20 | 2160 | 885 | 2.573 | 0.010* |
| Musical therapy | 57.80 | 2890 |
NB: *Significant at 0.05 level
The mean rank of pain in the breastfeeding group was 39.64, whereas that in the oral sucrose group was 61.36. The results revealed that U = 707, Z = 3.874, and P = 0.001, which indicates statistical significance at a 0.001 level of significance. Thus, breastfeeding as compared to oral sucrose was found to be effective in pain relief among infants during pentavalent vaccination [Table 4].
Table 4.
Comparison of pain among infants in the breastfeeding and oral sucrose groups (n=100)
| Groups | Mean rank | Sum of ranks | Mann–Whitney U | Z | P |
|---|---|---|---|---|---|
| Breastfeeding | 39.64 | 1982 | 707 | 3.874 | 0.001** |
| Oral sucrose | 61.36 | 3068 |
NB: **Significant at 0.01 level
The mean rank of pain in the musical therapy was 46.58, whereas that in the oral sucrose group was 54.42. The results revealed that U = 1054, Z = 1.444, and P = 0.149, which indicates statistical nonsignificance at a 0.001 level of significance. Thus, musical therapy as compared to oral sucrose was found to be effective in pain relief among infants during pentavalent vaccination [Table 5].
Table 5.
Comparison of pain among infants in the musical therapy and oral sucrose groups (n=100)
| Groups | Mean rank | Sum of ranks | Mann–Whitney U | Z | P |
|---|---|---|---|---|---|
| Musical therapy | 46.58 | 2329 | 1054 | 1.444 | 0.149NS |
| Oral sucrose | 54.42 | 2721 |
NB: NS=Nonsignificant, significant level at 0.05
The mean rank pain scores were observed across three groups: breastfeeding (57.34), musical therapy (78.88), and oral sucrose (90.28). The Kruskal–Wallis test was applied to examine whether there were significant differences in pain scores among these groups. The test statistic value was found to be 15.973, with a P value of 0.001, indicating a significant difference in pain scores across the three groups [Table 6a].
Table 6a.
Comparisons of pain score in three groups (n=150)
| Group | n | Mean rank | Kruskal–Wallis test value | P |
|---|---|---|---|---|
| Breastfeeding | 50 | 57.34 | 15.973 | 0.001** |
| Musical therapy | 50 | 78.88 | ||
| Oral sucrose | 50 | 90.28 |
NB: **Significant at 0.01 level
The results of post hoc pairwise comparisons further examine the differences between the groups. In the comparison between breastfeeding and musical therapy, the test statistic was 21.540, and the P value was 0.010. This suggests a significant difference in pain scores between these two groups. Similarly, the comparison between breastfeeding and oral sucrose yielded a test statistic of 32.940 and a P value of 0.001, indicating a significant difference in pain scores between these groups as well. However, the comparison between musical therapy and oral sucrose resulted in a test statistic of 11.400 and a P value of 0.173, indicating no significant difference in pain scores between these two groups [Table 6b].
Table 6b.
Post hoc pairwise comparisons of pain score in three groups (n=150)
| Comparison groups | Test statistic | P |
|---|---|---|
| Breastfeeding vs musical therapy | 21.540 | 0.010* |
| Breastfeeding vs oral sucrose | 32.940 | 0.001** |
| Musical therapy vs oral sucrose | 11.400 | 0.173NS |
NB: *Significant at 0.05 level, **Significant at 0.01 level, NS=Nonsignificant, significant level at 0.05
The results suggest that there are significant differences in pain scores across the three groups, with breastfeeding showing significantly different scores compared with both musical therapy and oral sucrose. However, no significant difference was observed between musical therapy and oral sucrose.
Discussion
The study found that breastfeeding was significantly more effective in relieving infants’ pain during pentavalent vaccination compared with musical therapy and oral sucrose. The median pain score for breastfeeding was 4.50, while musical therapy and oral sucrose had median pain scores of 6 and 7, respectively.
These findings are consistent with previous research by Wu et al.,[21] which highlighted the benefits of breastfeeding as a non-pharmacological intervention for reducing infant pain during vaccination. Various interventional methods such as breastfeeding, sweeteners, and non-nutritive sucking were analyzed. The study highly supported the use of breastfeeding during painful procedures among neonates and infants, which may help to feel less pain, divert mind, and close skin-to-skin contact with the mother.
Another study by Mukhopadhya et al.[16] also supported the results that breastfeeding could help alleviate pain. The study concluded that infants in the breastfeeding group have decreased intensity of pain and duration of cry compared with infants in the control group during immunization. Bhurtel et al.’s[22] study showed that in the breastfeeding group, not only was the mean pain score (7.10) but also the median duration of cry (25 seconds) was less than in the control group where the mean pain score was 7.56 and the crying duration was 42.5 seconds.
The study is also consistent with the findings of Bhattacharya and Batra.[23] The study randomly enrolled 120 infants coming for pentavalent vaccination into three interventional groups, that is, breastfeeding, buzzy device, and Helfer technique, and the control group. On comparing the pain score, it was found that the mean pain score was less in the breastfeeding group than in the other three groups. Hence, the study concluded that breastfeeding effectively reduces pain among infants during pentavalent vaccination. Ercan and Ozmen[24] revealed that the infants receiving recent breastfeeding undergo less crying and reduced pain and discomfort.
Suleiman et al.[25] conducted a study that highly supports the present study. The study compared the efficacy of paracetamol and breastfeeding in infant’s reduction in pain during vaccination. The former stated that breastfeeding was proven and effective in pain reduction among infants during vaccination. García-Valdivieso et al.[26] supported the superiority of the present study by showing that, on comparison, breastfeeding was found to be effective toward pain and contributed to decreased cry in pain management. Koukou et al.[27] revealed that breastfeeding and non-nutritive sucking were first-hand methods that may help in managing pain among neonates.
A study conducted by Avcin and Kucukoglu[28] provided support for the effectiveness of breastfeeding, kangaroo care, and facilitating tucking in reducing pain. However, it was found that facilitating tucking resulted in less crying and inflicted less pain on neonates compared with the other methods. Another study by Bavarsad et al.[29] demonstrated that breastfeeding significantly reduces pain severity during painful experiences in neonates.
In contrary to the present study, Ting et al.[30] conducted a study that revealed that by demonstrating different styles of music among neonates and infants, music therapy significantly reduces pain during procedural pain and postoperative pain in the pediatric population. Jain et al.[31] conducted a study enrolling 50 infants during immunizations. The results revealed that music therapy was highly recommended in using as a pain-reducing intervention during immunization. It has long and effective results that conclude its high use among infants.
However, Mangat et al.[32] reported that sucrose was ineffective but still more effective than music therapy. It is worth noting that while various non-pharmacological methods of analgesia offer some degree of relief for preterm infants, none of them are entirely effective, and there is no evident superior method identified thus far. Chad et al.[33] demonstrated that music therapy was effective in reducing pain in children receiving immunizations.
The use of oral sucrose to alleviate pain in infants has been supported by several studies. For instance, Abukhaled and Cortez[34] conducted a study that demonstrated a reduction in parental concern following the administration of oral sucrose during immunization, resulting in a decrease in pain levels among infants. The study found a statistically significant difference between the treatment groups (experimental and control groups), with infants in the oral sucrose group experiencing less pain, which led to decreased crying and reduced parental concern for their infants. Another study by Kaur and Charan[35] further supports the effectiveness of oral sucrose in reducing infant pain during vaccination. The mean pain score in the experimental group was 4.22, while it was 6.67 in the control group.
Similarly, Odekunle[36] reported a significant decrease in mean NIPS scores among infants who received oral sucrose before immunization injections, compared with the control group. Tasgaonkar and Gaikwad[37] further supported these findings by demonstrating that the experimental group experienced less pain than the control group, emphasizing the effectiveness of oral sucrose in reducing pain levels. Additionally, Kumar et al.[38] found that infants who were given a 24% oral sucrose solution before immunization exhibited a significant reduction in pain when compared to the control group. Furthermore, Gomes et al.[11] showed that oral sucrose significantly reduced pain compared with the control group. Moreover, Barandouzi et al.[39] demonstrated that the pain score in the three intervention groups (sucrose, music, and combination groups) was significantly lower than in the control group.
Limitations
The present study had certain limitations that need to be acknowledged. Firstly, pain assessment was exclusively based on the NIPS scale. Although this tool is validated, relying solely on one assessment measure may not fully capture the multifaceted nature of pain experiences. Secondly, pain scores were measured only once, without multiple follow-up assessments over time, potentially missing important variations in pain intensity and duration. Lastly, the study focused on comparing three specific interventions, which may restrict the exploration of other potential approaches to pain relief during vaccination. As the research was conducted in a single center, it is important to recognize that the obtained results can only be generalized to the specific sample group involved in the study. These limitations highlight the need for future research to employ a more comprehensive range of assessment measures and consider additional interventions to gain a more comprehensive understanding of pain management in this context.
Strength
The strength of this study lies in its robust analytical methods for assessing pain, a subjective and qualitative variable. The use of the nonparametric Mann–Whitney test for data analysis is commendable, as it is suitable for such scenarios. Additionally, the study employed post hoc pairwise comparisons using the Kruskal–Wallis test to examine the effects of the three interventions. These appropriate statistical methods contribute to the accuracy and validity of the results, particularly in the comparison among the three groups.
Suggestion
In terms of future directions, it would be valuable to expand the research to encompass infants experiencing other types of painful procedures beyond the scope of the current study. This could involve investigating the effects of interventions on infants undergoing different types of vaccinations, not limited to pentavalent vaccination. Additionally, exploring the impact of the interventions on infants undergoing painful invasive procedures could provide further insights into the effectiveness of the studied techniques. Similarly, studies can be conducted on a larger scale to assess the impact of various non-pharmacological methods, such as music therapy, swaddling, aroma therapy, and alternatives to toys, in comparison with breastfeeding. It is essential to explore these avenues to gain comprehensive insights, improve strategies to mitigate vaccine hesitancy, and enhance the overall experience of infants during vaccination.
Conclusion
The findings of this study highlight significant differences in pain ratings among the intervention groups. Breastfed infants experienced significantly less pain during pentavalent vaccination compared with those in the music therapy and oral sucrose groups. These results underscore breastfeeding as the most effective intervention for reducing pain perception. Moreover, breastfeeding is a safe and practical method that can be easily incorporated into existing immunization programs. Implementing breastfeeding as a pain relief strategy during vaccination procedures has the potential to benefit infants and enhance their overall immunization experience.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgements
The authors express their gratitude to the SGRD University of Health Sciences, Sri Amritsar, Punjab, for approving and supporting this research project. Their authorization and backing have been instrumental in the successful implementation of the study. The authors extend our heartfelt appreciation to all the relevant authorities at the university for their valuable guidance and assistance throughout the research process. Furthermore, the authors would like to thank all the participants who willingly took part in this study. Their active involvement and cooperation have been crucial in generating meaningful data and insights. The authors acknowledge and appreciate their time, effort, and contributions, which have significantly enriched the findings of this research.
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