Awareness of Menopause and its Associated Factors among Men in Eastern India

ABSTRACT

Introduction:

A menopausal transition is a stressful event in a woman’s life affecting health and quality of life. Spousal awareness of menopausal changes can help them support their wives in coping with the menopausal transition. No studies have explored men’s awareness of menopause in India. Therefore, this study aimed to find the men’s awareness of menopause and its associated factors. The study also explored men’s awareness of the management of symptoms and partner support.

Materials and Methods:

This cross-sectional study of husbands of menopausal women aged 45–60 years in eastern India evaluated their awareness of menopause by a structured questionnaire. A semistructured interview schedule assessed the men’s awareness of menopause, management of symptoms, and partner support.

Results:

Four hundred and twenty consenting men fulfilling inclusion criteria were recruited for the study. The mean age of the husband was 50.7 ± 3.9 years. The mean age of the wife was 56.6 ± 4.4 years. Most men reported symptoms of joint pain (69.3%), low energy level (68.8%), decreased physical strength (63.3%), tiredness (61%), and low backache (51%) in their wives. The overall knowledge of menopause among husbands was inadequate (91.42%). Men reported that their wives avoiding sexual intimacy (85.7%), irritability (58.6%), and mood swings (43.1%) affected their marital relationship. The husband’s knowledge was associated with education (P = 0.014), the wife’s education (P < 0.001), occupation (P < 0.001), family income (P < 0.001), and socioeconomic status (P < 0.001).

Conclusion:

Indian husbands lacked information on menopause. Men need information on menopause to support their menopausal spouses.

INTRODUCTION

Menopause is a critical phase in a woman’s life cycle in which a woman undergoes drastic physical and psychological changes due to a decline in the follicular function of the ovaries.[1] During menopause, most women experience physical, vasomotor, and psychological symptoms that affect their quality of life and the couple’s relationship.[2] Therefore, helping women cope with the menopausal transition is of crucial importance in women’s health. Poor libido, mood swings, anxiety, and irritability in menopausal wives might affect their husbands. As indicated by previous studies abroad, a husband’s awareness of all these symptoms could help improve their relationships and quality of life.[1,2] Studies have explored menopause from a woman’s perspective, such as awareness and attitude toward menopause and the effects of menopausal symptoms on quality of life and partner relationships.[3,4,5] There are very few studies exploring husbands’ awareness of menopause, their perspectives on menopausal symptoms, partner relationships, and partner support during this crucial period.[5,6,7,8] Husband’s contribution to managing the menopausal symptoms of their wives is crucial. Marital relationships are closely related to physical, mental, and sexual health, and gaining knowledge on menopause will enable husbands to promote wife’s health and can help them cope better with the symptoms.[1] No studies in India have explored husband’s awareness of menopause and their support to their wives during menopause. Hence, this study aimed to assess the husband’s awareness of menopause and its associated factors, the partners’ symptoms, and its management.

MATERIALS AND METHODS

Study design

A cross-sectional descriptive research design was used.

Setting and sample

The study was conducted in a tertiary care teaching hospital’s outpatient departments (OPDs). A total of 420 men were recruited from all OPDs by consecutive sampling.

Inclusion and exclusion criteria

All consenting married men with a cohabiting partner of 45–60 years with at least one menopausal symptom, such as hot flashes, insomnia, mood swings, weakness, spotting, and night sweats, screened using a menopausal symptom checklist, who visited OPDs of a tertiary hospital of Odisha were included. Men in long-distance relationships were excluded from the study.

The sample size of 382 was calculated based on the previous study.[9]

Measures/tools

Tools of data collection

A demographic pro forma was used to collect the baseline data. A structured questionnaire on menopause assessed the husband’s knowledge and the partner’s menopausal symptoms. A semistructured interview schedule assessed the partners’ awareness of menopause and partner support. The knowledge questionnaire comprised 20 items on knowledge of menopause and menopausal symptoms with a dichotomous response of “yes” or “no.” A score of 1 for a correct response and “0” for a false response were assigned, with a total possible score of 20. No negative scoring was done. A score of 12 (60%) and above was considered adequate knowledge, and <12 was considered inadequate. A semistructured interview schedule of six items explored the men’s awareness of the partner’s symptoms and six items on the effect of menopausal symptoms on the partner’s relationship. The responses were expressed in frequency and percentage. The tool’s content validity index was 0.86. The tool was reliable (r = 0.79) and was pretested.

Data collection

Data were collected from men presenting to seven OPDs. Of 460 men the researchers approached, 420 consented to participate in the study. The researchers introduced themselves to all men respectfully and established rapport by asking about their whereabouts and addressing their concerns. Confidentiality was ensured, and the purpose of the study was explained to them. The participant information sheet was given for further clarification, their doubts were addressed, and written informed consent was obtained. The data were collected from December 20, 2022, to January 4, 2023. The data were checked for completeness, the participants were thanked, and their doubts were clarified after the interview.

Statistical analysis

Descriptive and inferential statistics were used to analyze the data. The data were presented as frequency and percentage. The association of qualitative variables was analyzed using the Chi-square test. Further logistic regression analysis was performed to calculate the odds ratio. The IBM Corp. Released 2012. IBM SPSS Statistics for Windows, trial Version 21.0. (Armonk, NY: IBM Corp.) was used for data analysis. A statistical significance of 0.05 was adopted throughout the study.

RESULTS

The lowest percentage of husbands (14.76%) were professionals, while the wives were largely unemployed (93.33%). A majority of them were in the low-income group [Table 1]. The overall knowledge of menopause among husbands was inadequate (91.42%) [Figure 1]. More than two-thirds of men were aware of the age of onset of menopause, osteoporosis risk, hot flashes, and contraceptive aspects of menopause [Table 2]. Nearly all husbands (99.8%) reported that their source of information on menopause was their wives. Husbands were aware of their spouse’s cessation of menstruation and their experiencing symptoms of sweating (57.9%), poor memory (49.8%), nervousness (47.4%), joint pain (69.3%), low energy level (68.8%), decreased physical strength (63.3%), tiredness (61%), low backache (51%), and avoiding sexual intimacy (85.7%) [Table 3]. Very few wives sought medical treatment for symptoms [Figure 2]. About one-fourth of men reported that their spouses used over-the-counter pain medications (25.5%), performed exercise or Yoga (22.1%), and consumed healthier diets (25.2%) to manage their symptoms [Figure 3]. Nearly two-thirds of men (68.6%) reported that they were comfortable discussing treatment options, and they suggested their wives seek help from a gynecologist (57.4%) or traditional medicine practitioners (18.8%). However, most husbands (65.02%) did not accompany them to medical facilities. More than half (53.6%) of husbands believed their spouses dealt with their symptoms reasonably well [Figure 4]. Men believed that they were not influential in persuading their wives to seek treatment [Figure 5]. Men reported that wives avoiding sexual intimacy (85.7.9%) affected their relationships. Besides, irritability (58.6%) and mood swings (43.1%) of their wives led to frequent quarrels. A little more than half of the men (54.3%) believed that the causes of their wives’ symptoms were aging, heavy work, or a busy schedule. Men reported that their wives complained of tiring household chores (86.14%). However, most (73.4%) men did not help their wives. Men reportedly had issues dealing with their health and aging-related issues (64.5%), which further strained their relationship. Men (48.56%) expressed that sleeping in separate rooms was a societal norm with grown-up children in the household. The husband’s knowledge was associated with education (P = 0.014), the wife’s education (P < 0.001), occupation (P < 0.001), family income (P < 0.001), and socioeconomic status (P < 0.001) [Table 4]. Husbands who were educated, professional, with a family income of Rs. 45000/-, and educated and employed wives from the upper class had higher odds of having adequate knowledge of menopause [Table 5].

Table 1.

Distribution of demographic variables (n=420)

Variables	Frequence (%)
1. Wife’s age (years), mean±SD	50.7±3.9
2. Husband’s age (years), mean±SD	56.6±4.4
3. Husband’s education
a. No formal education	26 (6.2)
b. Primary school certificate	89 (21.2)
c. Middle school certificate	84 (20.0)
d. High school certificate	104 (24.76)
e. Intermediate	17 (4.04)
f. Graduate and above	100 (23.81)
4. Wife’s education
a. No formal education	64 (15.23)
b. Primary school certificate	127 (30.23)
c. Middle school certificate	94 (22.38)
d. High school certificate	75 (17.85)
e. Intermediate	11 (2.61)
f. Graduate and above	49 (11.66)
5. Wife’s occupation
a. Unemployed	392 (93.33)
b. Elementary occupation	2 (0.48)
c. Craft and related trade workers	2 (0.48)
d. Fishery workers and skilled agriculture	5 (1.19)
e. Skilled workers and sales workers	4 (0.95)
f. Clerks	1 (0.23)
g. Technicians	2 (0.48)
h. Professionals	12 (2.85)
6. Husband’s occupation
a. Unemployed	13
b. Elementary occupation	34 (8.1)
c. Plant and machine operators and assemblers	5 (1.2)
d. Craft and related trade workers	10 (2.3)
e. Fishery workers and skilled agriculture	113 (26.9)
f. Skilled workers and shop and market sells worker	118 (28.1)
g. Clerks	44 (10.48)
h. Technicians and associate professionals	21 (5.0)
i. Professionals, legislators, senior officials, and managers	62 (14.76)
7. Monthly family income (in rupees)
a. ≤9226	112 (26.7)
b. 9223–27,648	177 (42.1)
c. 27,654–46,089	86 (20.5)
d. 46,095–68,961	24 (5.7)
e. 68,967–92,185	9 (2.1)
f. 92,191–184,376	4 (1.0)
g. ≥184,376	8 (1.9)
8. Socioeconomic status
a. Upper class	8 (1.9)
b. Upper middle class	68 (16.2)
c. Lower middle class	165 (39.3)
d. Upper lower	173 (41.2)
e. Lower class	6 (1.4)
9. Family type
a. Joint family	152 (36.2)
b. Nuclear family	268 (63.8)

SD: Standard deviation

Figure 1.

Percentage distribution of men’s knowledge of menopause

Table 2.

Distribution of husband’s knowledge on menopause (n=420)

Items	Frequence (%)
Occurrence of menopause
1. Absence of menses for more than 12 months	105 (25)
2. Menopause occurs between 45 and 60 years in most women	291 (69.3)
3. Hereditary affects the occurrence of menopause	32 (7.62)
4. Menopause occurs due to decreased sex hormones	27 (6.43)
5. Menopause occurs irrespective of the woman’s physique	46 (10.95)
6. Women experience symptoms before attaining menopause	136 (32.38)
Symptoms of menopause
7. Menopause increases the risk of uterine cancer	102 (24.3)
8. Menopausal symptoms are preventable	165 (39.3)
9. Menopause increases the risk of cardiac diseases in women	47 (11.19)
10. Menopause increases osteoporosis in women	290 (69)
11. Menopause causes weight gain and obesity	160 (38.1)
12. Menopause causes vaginal dryness and painful intercourse	99 (23.6)
13. Menopause decreases sex drive	109 (26)
14. Tobacco use increases symptoms of menopause	45 (10.7)
15. Menopause affects memory and power of concentration	168 (40.0)
16. Severity of hot flashes increases after attaining menopause	236 (60)
17. Menopause causes increased urinary frequency and dysuria	184 (43.8)
18. Level of stress and depression increases in menopause	173 (41.2)
19. One year after menopause, contraception is not necessary	332 (79.0)
20. Regular exercise prevents osteoporosis in menopausal women	295 (70.2)

Table 3.

Husband’s awareness of their spouse’s menopausal symptoms (n=420)

Variables	Frequence (%)
1. Vasomotor
a. Sweating	243 (57.9)
b. Hot flashes	176 (41.9)
c. Night sweats	147 (35)
2. Psychological
a. Poor memory	209 (49.8)
b. Nervousness	199 (47.4)
c. Impatience	186 (44.3)
d. Less accomplishment	77 (18.3)
e. Depression	52 (12.4)
f. Dissatisfied life	52 (12.4)
g. Prefers to stay alone	34 (8.1)
3. Physical
a. Joint pain	291 (69.3)
b. Less energetic	289 (68.8)
c. Decrease physical strength	266 (63.3)
d. Feeling tired	256 (61)
e. Low backache	214 (51)
f. Gas pain	181 (43.1)
g. Headache or neck ache	146 (34.8)
h. Decrease stamina	146 (34.8)
i. Sleep difficulty	136 (32.4)
j. Weight gain	53 (12.6)
k. Frequent urination	43 (10.2)
l. Feeling bloated	30 (7.1)
m. Drying skin	24 (5.7)
n. Facial hair	6 (1.4)
o. Appearance, texture, and tone of skin changes	2 (0.5)
p. Involuntary urination with laughing or coughing	2 (0.5)
4. Sexual
a. Avoiding intimacy	360 (85.7)
b. Sexual desire changes	50 (11.9)
c. Vaginal dryness during intercourse	26 (6.2)
5. Husband’s perception of causes of symptoms
a. Menopause	100 (23.8)
b. Underlying medical problems	90 (21.4)
c. Personal crisis	38 (9)
d. Being overweight	18 (4.3)
e. Aging	228 (54.3)

Figure 2.

Percentage distribution of women seeking medical treatment for symptoms

Figure 3.

Modalities to manage menopausal symptoms

Figure 4.

Husbands’ perception of wives’ coping with menopausal symptoms

Figure 5.

Husbands’ influence in seeking treatment for their wife

Table 4.

Association of husband’s knowledge level with demographic variables (n=420)

Variables	Inadequate knowledge (frequency)	Adequate knowledge (frequency)	FE; df; P
1. Wife age (years)			FE=5; df=3; P=0.141
a. 45–48	133	19
b. 49–52	127	10
c. 53–56	89	4
d. 57–60	35	3
2. Husband age (years)			FE=6.461; df=5; P=0.264
a. 45–48	7	0
b. 49–52	70	12
c. 53–56	93	10
d. 57–60	148	10
e. 61–64	53	3
f. 65–68	13	1
3. Husband’s education			χ2=6.069; df=1; P=0.014*
a. No formal education-middle school	189	10
b. High school-graduate and above	195	26
4. Wife’s education			χ2=15.149; df=1; P<0.001*
a. No formal education-middle school	271	14
b. High school-graduate and above	113	22
5. Occupation of husband			χ2=24.770; df=1; P<0.001*
a. Unemployed-skilled workers and market sales workers	281	12
b. Clerks-professionals, legislators, seniors, officials, and managers	103	24
6. Occupation of wife			FE=19.606; df=1; P<0.001*
a. Unemployed-skilled workers and market sales workers	37530
b. Clerks-professionals, legislators, seniors, officials, and managers	9	6
7. Family income (INR)			FE=16.204; df=1; P<0.001*
a. ≤46,000	350	25
b. >46,000	34	11
8. Socioeconomic status			χ2=22.539; df=1; P<0.001*
a. Upper– and upper–middle class	59	17
b. Lower–middle, upper–lower, and lower class	325	19
9. Family type			FE=0.779; df=3; P=0.854
a. Joint family	139	13
b. Nuclear family	245	23

*P<0.05 is statistically significant. Level of significance P<0.05. χ²: Chi-square test, FE: Fisher’s exact

Table 5.

Logistic regression of menopausal knowledge with sociodemographic variables (n=420)

Sociodemographic variables	Knowledge on menopause		OR	(95% CI)	P
	Inadequate frequency (%)	Adequate frequency (%)		Lower
Husband’s education
≤Middle school	189	10	2.5	1.2	0.02*
≥High school	195	26			Reference
Wife’s education
≤Middle school	271	14	3.8	1.9	0.001*
≥High school	113	22			Reference
Occupation of husband
Unemployed and skilled workers	281	12	5.5	2.6	<0.001*
Clerks-professionals	103	24			Reference
Occupation of wife
Unemployed and skilled workers	375	30	8.3	2.8	<0.001*
Clerks-professionals	9	6			Reference
Annual family income (INR)
≤46,000	350	25	4.5	2.01	<0.001*
>46,000	34	11			Reference
Socioeconomic status
Lower class	325	19	4.9	2.4	<0.001*
Upper class	59	17			Reference

*P<0.05 is statistically significant. 95% CI: 95% confidence interval, OR: Odds ratio

DISCUSSION

In the present study, most men lacked awareness of the menopause spectrum, which is consistent with the findings of other studies.[7,10,11] Poor awareness is explained by the source of husbands’ information being wives rather than healthcare providers. Similar findings were reported worldwide in countries such as USA, China, and Brazil.[3,8,11] Men obtained information from the Internet,[8] family, and friends,[12] probably due to urbanization, digital literacy, and better education. Globally, men seem to have blind spots during menopause.[8,11,13,14] In the present study, most husbands were aware of their spouse’s menopausal symptoms such as low energy (68.8%), joint pain (69.3%), sweating (57.9%), poor memory (49.8%), difficulty sleeping (32.4%), and avoiding sexual intimacy (85.7%). Similar symptoms were reported by menopausal women in other Indian studies and abroad as well.[2,15,16,17]

Most men (73.8%) in the current study expressed that menopausal symptoms are a thing of women, and they have to handle it themselves. Asian women endorse the men’s view that they should endure the menopausal symptoms in silence as they must suffer through the symptoms themselves.[18] In Indian culture, women are expected to be tolerant, tough, emotionally stable, catering to the family’s needs, and not self-centered throughout all the life stages, including the menopausal transition.[19] There is a possibility of underreporting of their wives’ symptoms in the present study, as men attribute these symptoms to the natural process of aging, similar to other Indian studies.[1,19] Contrary to the findings of the current study, the most frequent symptoms Spanish men associated with menopause were hot flashes, vaginal dryness, decreased sexual desire, and weight gain (93.7%, 48%, 45.2%, and 44.1%).[10] In yet another study, sleeplessness (54%) was the most commonly identified symptom, followed by tiredness (49%), low libido (48%), mood swings (47%), and hot flashes (46%).[12] In China, most of the husbands were aware of the neuropsychiatric and vasomotor symptoms of their wives.[8] The differences in the awareness of symptoms experienced by women may be attributed to their genetic makeup, lifestyle, aging, midlife crises, cultural influences, and nutrition. Asian women reported more somatic symptoms than vasomotor symptoms compared to their western counterparts.[18,20] Overall, the number of menopausal symptoms and the intensity reported by Asian women were lesser than their western counterparts,[18] as menopause is viewed as a transition phase in Indian women rather than a “disease model” of the west. Decreased sexual interest was the primary symptom expressed by Asian immigrant women, findings which are consistent with the current study. However, the psychosomatic menopausal symptoms reported by women were higher than those reported by their partners, both from India and other countries.[16,18] Inconsistencies in the findings could be due to taboos, lack of awareness, and communication among spouses. Poor knowledge of menopause tends to impede communication, affecting the couple’s relationship and causing psychological distress in women.[6]

Men in the current study, much to their dismay, were concerned about their spouses avoiding sexual intimacy or low libido, which contradicts the reports by Indian women who reportedly had minimal[15] or no sexual problems.[19] Men in the current study (63.7%) expressed that sleeping in separate rooms was a societal norm after the children were grown up. In India, sexual activity in middle age is considered age-inappropriate as society is prejudiced against sex beyond a prescribed age with gender differences in sexual intimacy attitudes.[21] The sexual functioning of a menopausal woman is affected by several psychological, social, and cultural factors. Women in India view menstruation as taboo, impure state, which prevents them from practicing religious rituals.[22] Most women view menopause as freedom to be religious and perceive themselves to be in better status.[17,21,22] Many women globally perceive menopause as a positive experience as it offers relief from the worries of menstruation, freedom from the necessity of contraception, and increased sexual freedom.[16,17,20,21,22] Menopause in the western world is a topic that is primarily medicalized, a disease state that demands treatment rather than a natural transition; hence, symptoms are better reported.[18,20] Sexual health is essential for a healthy couple’s relationship. Fostering couple counseling and educative programs by the healthcare team in a culture-specific context could effectively address relationship issues.[1]

Besides, sexual intimacy, mood swings, and irritability affected their marital relationship par with other studies.[23,24] Men in the current study reportedly had issues dealing with their aging-related health issues, which further strained their marital relationship. Most of the husbands in this study reported bringing up their partners’ treatment options; however, they were not influential in getting their wives to seek expert consultation for their symptoms, which contradicts the findings in the USA, where 75% of spouses were influential.[9] The difference in the reporting could be because of social desirability bias among Indian husbands placing blame on their wives, reflected by poor support and low health-seeking rates in their wives. Despite awareness of their wives’ symptoms, men were not ready to seek knowledge on menopause from healthcare providers, provide emotional support, or share household chores, as menopause was considered a “woman thing” that she had to deal with herself. Similar findings were reported elsewhere, too,[7,25,26] probably due to the patriarchal mindset of men, lack of communication, or poor awareness. However, in a few studies abroad, men were supportive of their menopausal wives[9,27] and reported that their partners deserve quality health care.[8] In another study, one-third of the husbands did not support their wives, but most agreed to provide emotional support.[11] In Asian culture, a woman is expected to take care of the whole family and put the family first and the self-last.[18] In India, almost half of the women are dependent on the consent of their family members to seek healthcare services; moreover, only one-third of the women reached out to healthcare professionals after the appearance of symptoms, and they were unaware of the health facilities near them.[28] A large majority of Indian menopausal women suffer from ill health due to a lack of knowledge, with most rural women having no access to health services.[16]

In general, men lacked awareness about dealing with menopausal symptoms and strategies to support their partners. A better understanding by men of the changes experienced by menopausal women fosters the development of better emotional support for their wives, improving the quality of marital relations.[10] Men can share the household chores, provide psychological support, and persuade women to seek consultation for their menopausal symptoms. Women wished that their husbands and family members were educated about the menopausal symptoms as the reason for their physical and mental changes during the menopausal transition so that they could help cope with the symptoms.[24] Women, too, should be educated and empowered to discuss their health problems with their husbands, seek information from healthcare providers, and utilize the available healthcare facilities. In Iran, educated menopausal women were more likely to seek medical treatment to alleviate their symptoms due to better awareness.[29]

The present study’s findings revealed that the husband’s and wife’s education was associated with knowledge about menopause, consistent with a study in Iran, where the husband’s education influenced the quality of life in postmenopausal women as they have a better understanding and support of their partners.[4] Besides, educated women are more likely to seek treatment to cope better with their symptoms.[29,30] Literacy influences awareness and fosters good communication among partners regarding menopausal symptoms, and it shows appreciation for the benefits of healthcare services from qualified personnel.

In the current study, partners’ profession and socioeconomic status were associated with menopausal awareness, concordant with findings from Nigeria in which men holding high government posts were more inclined toward seeking appropriate health care than workers holding lower posts.[31] Professional spouses are more literate and likely to be open-minded when discussing menopausal symptoms with their partners, and they have a better-paying capacity for healthcare expenditure. Socioeconomic status in India determines the decisions regarding health care, as healthcare cost matters more than the quality of care.[30] Educating men on supporting their spouses during the menopausal transition helps deal with the symptoms, improves the quality of life of menopausal women, and improves the marital relationship.[3,4,27]

Strength and limitations

In this study, face-to-face interviews facilitated us to explain the purpose of the survey, ensuring no attrition. We did not explore difficulties men face due to aging, financial constraints, work-related issues, or countercheck with women on their relationship issues. We could rely on their verbal responses only. In this study, we did not explore the wives’ perspectives, comorbid conditions, or mineral supplements they took. Wives were not clinically examined, so their symptoms could not be confirmed. Sampling bias might have occurred owing to the nonrandom selection of participants. Many men were shy and reluctant to talk, as all researchers were females, escalating the chances of underreporting. There is a chance of courtesy and social desirability bias as the researchers wore uniforms. We did not explore men’s perceptions of factors that affected partner support.

Recommendations

Further studies should explore men’s perceptions of menopause, which affects partner support. Lack of information, adverse effects of their wives’ menopausal symptoms, and their stresses may have interfered with husbands’ ability to provide social support. Studies on the effectiveness of community-based education and awareness among men on managing menopausal symptoms of their partners can be conducted involving grassroots-level healthcare providers. Further research is recommended on the husband’s role in easing the menopausal symptoms in the transition period for their wives and how they can support them during this crucial phase of life.

CONCLUSION

The majority of the husbands lacked information on menopause and were affected by the menopausal symptoms of their wives. In Indian families, the husband is a significant decision-maker for health-seeking behavior and a source of support to their wife. To create a more positive attitude toward menopause, men need positive information from health professionals. Educating husbands to engage in various activities with their wives during menopause, such as open communication, sharing household chores, exercising together, encouraging health checkups, and providing psychological support, can positively affect their well-being and improve their coping and quality of life.

Potential conflicts of interest

The authors have no conflict of interest to declare. The authors alone are responsible for the content and writing of the paper.

All authors reviewed and approved the final version; no other person contributed substantially to the paper.

Data sharing

The data used in this pooled analysis can be shared upon written request to the corresponding author.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.