Abstract
Background
The auditory impairment can have a significant impact on communication, mental health, and interpersonal interaction. One of the main interventions to combat these effects is hearing aids, although their real-life efficiency and their impact on the quality of life differ among users. In this study, the efficacy of hearing aids and their correlation with the World Health Organization Quality of Life - Brief version (WHOQOL-BREF) in hearing aid wearers were assessed using the International Outcome Inventory-Hearing Aids (IOI-HA).
Methods
The study was performed as cross-sectional research at the Armed Forces Hospital-Southern Region (AFHSR), Khamis Mushait, Saudi Arabia, between August 2021 and May 2022. A sample of 210 adults of the age group between 18 to 65 years with confirmed hearing loss and prescribed conventional hearing aids was used. The interviews and electronic medical record data were considered, in which demographics, hearing aid features, IOI-HA scores, and WHOQOL-BREF answers were considered. Data were analyzed by SPSS version 22 (IBM Corporation, Armonk, NY).
Results
The average IOI-HA score was 23.8 ± 6.4, with 41.9% (88 participants) of wearers using hearing aids more than eight hours a day and 30.5% (64 participants) claiming the considerable assistance of their aids. Moderate hearing loss, longer hearing aid use, and increased perception of benefit emerged as the factors relating to higher IOI-HA scores. The IOI-HA and WHOQOL-BREF scores showed a positive association, with the psychological and social areas showing the strongest link.
Conclusion
Hearing Aids effectively improve the lives of people with decreased hearing, especially after over a year of usage. Combining hearing-specific outcome measures with measures of the broader quality of life gives a better picture of the patient experience and can drive more personalized and effective strategies of hearing rehabilitation.
Keywords: audiological outcomes, hearing aids, hearing loss, ioi-ha, quality of life, saudi arabia, whoqol-bref
Introduction
Hearing impairment is a common disability affecting human senses and may also reduce the quality of life of a person to a large extent [1]. It influences communication, social interaction, and psychological well-being, especially when they are not addressed [1, 2]. Hearing aids (HAs) are among the most widespread rehabilitative solutions to hearing-impaired people, but they are characterized by efficacy beyond their auditory effects and can be linked to psychosocial and functional enhancements in general [2]. Nonetheless, the process of subjective experience of hearing aid users is different, and it is necessary to consider not only the results in the auditory sphere but also life activities and well-being [3]. One of the standardized and validated tools is the International Outcome Inventory-Hearing Aids (IOI-HA), which was designed to measure the outcomes of using hearing aids in real life in various aspects, including the usage, benefit, satisfaction, residual limitation, and the quality of life [4, 5]. It has found wide use in clinical practice and research due to its simplicity and its universal applicability [6]. The IOI-HA does not fully address other facets of well-being, such as psychological, social, and environmental health, despite offering insightful scientific information about users' experiences with hearing aids [7, 8].
The World Health Organization short form of the multidomain assessment of quality of life, known as WHOQOL-BREF, gauges the quality of life within four domains, which include the physical, psychological, social, and environmental well-being [8, 9]. The tool functions well in supplementing the IOI-HA because it gives a wider picture of what patients experience overall, rather than their outcomes related specifically to hearing [10]. Through examining the relationship between IOI-HA scores and the WHOQOL-BREF domains, researchers will be able to acquire a more holistic picture of the role that hearing aid use plays in all aspects of life, not merely hearing-related outcomes [11]. Therefore, this research would be carried out as a result of seeking to evaluate this connection to achieve a better comprehension of how the use of the hearing aid improves or impacts the life of the subjects participating in the study with hearing loss than restricting the report to focused findings on the nationality group or center-based population. By using this method, we intend to determine whether subjective results from hearing aids are in line with more thorough health-related quality of life data and the degree to which wearing hearing aids is linked to a higher quality of life. Clinicians, audiologists, and public health policymakers may find this finding useful to tailor interventions and follow-up programs towards improving the satisfaction of hearing impaired both on auditory and life satisfaction levels.
Materials and methods
Study design
This cross-sectional analytical study was carried out at a Saudi tertiary care hospital to assess the results of wearing hearing aids and investigate their relationship with quality of life. The study focused on both the hearing-related and general life consequences to present a complete picture of the real-world consequences of hearing aids. This design enabled analysis of the associations between clinical and demographic variables and hearing aid outcomes at one point in time.
Setting and timeframe of research
The Armed Forces Hospital-Southern Region (AFHSR) in Saudi Arabia's Aseer region served as the study's site. One of the largest tertiary public medical facilities in the province, the AFHSR offers free medical care to citizens, military personnel, and their families. Four million individuals are served by the hospital [12]. Interviews with the patients took place between August 2021 and May 2022.
Population
The study population consisted of adults aged 18-65 who were diagnosed with hearing loss at AFHSR between 2017 and 2019 and who were prescribed hearing aids by an otolaryngologist. Of the 361 eligible individuals contacted, 210 gave their consent to take part in the study, resulting in a 58.1% response rate. Participants have a prescription for hearing aids and a documented hearing threshold based on pure-tone audiometry to meet the inclusion criteria. Individuals under the age of 18 or older than 65, those ineligible for AFHSR services, those with implanted hearing devices, patients without pre-fitting audiometric records, and those prescribed hearing aids just for tinnitus masking were among the exclusion criteria.
Data variables and collection procedures
Age, sex, educational attainment, co-morbidities, the type and severity of hearing loss, and the features of hearing aids (type, duration of use, side used) were among the clinical and demographic information that was taken from electronic health records. Specific hearing aid outcomes, such as usage duration, perceived benefit, satisfaction, impact on activity limitations, and social engagement, were evaluated using the IOI-HA [13] (Appendix). The WHOQOL-BREF [14] evaluated general quality of life in four areas. Depending on the participants' accessibility, interviews were conducted in-person or online and lasted roughly thirty minutes. Confidentiality was always maintained, and informed consent was acquired either orally or through chat.
Data analysis
IBM SPSS version 22 (IBM Corporation, Armonk, NY), a statistical tool, was used to modify, code, and input the data once it had been extracted. In the statistical analysis, two-tailed tests were employed. A statistically significant P value was defined as less than 0.05. Descriptive analysis based on frequency and percent distribution was performed on the participants' biodemographic data, hearing loss data, first aid use, clinical symptoms, and IOI-HA items. Each person's overall IOI-HA score (out of 35) was displayed along with its range, mean, and standard deviation. For variables with more than two categories, One-Way Analysis of Variance (ANOVA) was utilized to test for statistically significant differences between groups; for comparisons between two groups, the independent t-test was employed. A P value of less than 0.05 was deemed statistically significant for all two-tailed statistical tests.
Results
The total number of participants was 210. With a mean age of 48.8 ± 13.5 years, the participants' ages varied from 18 to 65. Specifically, 183 individuals (87.1%) were married, while 115 participants (54.8%) were men. Twenty-one (10%) had a university degree, whereas 126 (60%) had less than a high school diploma. There were 112 (53.3%) people without any chronic health issues, 52 (24.8%) with hypertension, 12 (5.7%) with hypothyroidism, and 65 (31%) with diabetes (Table 1).
Table 1. Participants' Bio-demographic Data.
| Bio-demographic Data | No | % |
| Age in Years | ||
| < 40 | 50 | 23.8% |
| 40-59 | 98 | 46.7% |
| 60+ | 62 | 29.5% |
| Gender | ||
| Male | 115 | 54.8% |
| Female | 95 | 45.2% |
| Marital Status | ||
| Married | 183 | 87.1% |
| Not Married | 27 | 12.9% |
| Educational Level | ||
| Below High School | 126 | 60.0% |
| Diploma/High School | 63 | 30.0% |
| University /Above | 21 | 10.0% |
| Chronic Diseases | ||
| None | 112 | 53.3% |
| Diabetes Mellitus | 65 | 31.0% |
| Hypertension | 52 | 24.8% |
| Hypothyroidism | 12 | 5.7% |
| Renal Disease | 4 | 1.9% |
| Asthma | 1 | .5% |
| Depression | 5 | 2.4% |
| Heart Disease | 2 | 1.0% |
| Others | 7 | 3.3% |
Of the research participants, 57 individuals (27.1%) had severe hearing loss, and 72 individuals (34.3%) had moderate hearing loss on the right side. In 140 participants (72.2%) of instances affecting the right side, it was sensorineural hearing loss (SNHL). On the left side, 52 participants (24.8%) of the patients had severe hearing loss, or SNHL, in 145 cases (73.6%) of the instances, while 76 participants (36.2%) had moderate hearing loss. Forty-two (20%) of the subjects had bilateral hearing loss. In the ear (ITE) hearing aids were prescribed to 43 participants (20.5%), and behind-the-ear (BTE) were prescribed to 159 participants (75.7%). Diagnosis for which the hearing aids were prescribed was known to 163 (77.6%) of study participants, and 135 of our participants have used their hearing aids regularly for more than a year. Table 2 displays the characteristics of hearing loss and the use of hearing aids by Saudi Arabian study participants.
Table 2. Participants' Use of Hearing Aids and Hearing Loss .
CHL: Conductive Hearing Loss, SNHL: Sensorineural Hearing Loss
| Hearing Loss and Hearing Aids Data | No | % | |
| Right Ear Hearing Loss Degree | Normal | 16 | 7.60% |
| Mild | 27 | 12.90% | |
| Moderate | 72 | 34.30% | |
| Moderately severe | 16 | 7.60% | |
| Severe | 57 | 27.10% | |
| Profound | 22 | 10.50% | |
| Right Ear Hearing Loss Type | CHL | 17 | 8.80% |
| SNHL | 140 | 72.20% | |
| Mixed | 37 | 19.10% | |
| Left Ear Hearing Loss Degree | Normal | 13 | 6.20% |
| Mild | 27 | 12.90% | |
| Moderate | 76 | 36.20% | |
| Moderately severe | 16 | 7.60% | |
| Severe | 52 | 24.80% | |
| Profound | 26 | 12.40% | |
| Left Ear Hearing Loss Type | CHL | 16 | 8.10% |
| SNHL | 145 | 73.60% | |
| Mixed | 36 | 18.30% | |
| Side of Prescribed Hearing Aid | Right | 93 | 44.30% |
| Left | 75 | 35.70% | |
| Bilateral | 42 | 20.00% | |
| Type of Hearing Aid | Behind The Ear | 159 | 75.70% |
| In The Ear | 42 | 20.50% | |
| In The Canal | 6 | 2.90% | |
| Completely In Canal | 2 | 1.00% | |
| Duration of Hearing Aid Use | < 1 month | 6 | 2.90% |
| 3 months | 13 | 6.20% | |
| 6 months | 23 | 11.00% | |
| 1 year | 33 | 15.70% | |
| > 1 year | 135 | 64.30% | |
| Patient's Awareness of The Diagnosis for Which Hearing Aids Were Prescribed | Yes | 163 | 77.60% |
| No | 10 | 4.80% | |
| Not sure | 37 | 17.60% |
Twenty-four patients (11.4%) had auditory trauma, while 17 cases (8.1%) had head trauma. New worsening of hearing (40%), tinnitus (28.6%), vertigo/dizziness (21%), wax impaction while wearing HA (17.6%), and pus ear discharge (11%) were the most common symptoms reported within the previous two weeks before the interview. A total of 27 people (12.9%) had ear surgery. Regarding medical consultations, 76 (36.2%) attend the ENT/audiology clinic every year, whilst 88 (41.9%) never do so. Table 3 shows the clinical symptoms and risk factors for hearing aid users who have received clinical consultation.
Table 3. Risk Factors, Clinical Symptoms Among Hearing Aid Users .
ENT: Ear, Nose, Throat
| Count | Column N % | |
| Exposure to | ||
| Acoustic Trauma | 24 | 11.4% |
| Head Trauma | 17 | 8.1% |
| Both of Them | 5 | 2.4% |
| None | 164 | 78.1% |
| Symptoms in the Past 2 Weeks | ||
| None | 52 | 24.8% |
| New Worsening of Hearing | 84 | 40.0% |
| Tinnitus | 60 | 28.6% |
| Vertigo/Dizziness | 44 | 21.0% |
| Wax Impaction While Wearing Hearing Aids | 37 | 17.6% |
| Pus Ear Discharge | 23 | 11.0% |
| Alternative treatment was offered | ||
| Yes | 62 | 29.5% |
| No | 148 | 70.5% |
| Type of Alternative Treatment | ||
| Non-Surgical | 33 | 53.2% |
| Surgical | 29 | 46.8% |
| Undergone Ear Surgeries | ||
| Yes | 27 | 12.9% |
| No | 183 | 87.1% |
| Frequency of ENT/Audiology Clinic Visit | ||
| Never | 88 | 41.9% |
| Every month | 3 | 1.4% |
| Every 3 months | 7 | 3.3% |
| Every 6 months | 36 | 17.1% |
| Every year | 76 | 36.2% |
Approximately 88 participants (41.9%) of research participants reported using HA for more than eight hours per day, 64 participants (30.5%) reported it was very helpful, 39 participants (18.6%) reported no issues, and 25 participants (11.9%) believed it was worth the trouble. However, 25 participants (11.9%) of users said that their ability to accomplish some tasks was unaffected by their hearing impairments, 90 participants (42.9%) said that their hearing was not a hindrance, and 46 participants (21.9%) said that wearing HA significantly improved their quality of life. Out of 35, the average score was 23.8 ± 6.4 (68%). Table 4 shows the summary of participants' answers to the IOI-HA questionnaire.
Table 4. International Outcome Inventory-Hearing Aid (IOI-HA) Score Among Hearing Aid Users.
SD: Standard Deviation
| IOI-HA Factors | No | % | |
| On an average day, how many hours did you use the hearing aid(s)? | < 1 hour / day | 52 | 24.8% |
| 1-4 hours / day | 40 | 19.0% | |
| 4-8 hours / day | 30 | 14.3% | |
| > 8 hours / day | 88 | 41.9% | |
| Over the past two weeks, how much has the hearing aid helped? | Helped not at all | 39 | 18.6% |
| Helped slightly | 48 | 22.9% | |
| Helped Moderately | 42 | 20.0% | |
| Helped Quite A Lot | 17 | 8.1% | |
| Helped Very Much | 64 | 30.5% | |
| When you use your present hearing aid(s), how much difficulty do you still have in that situation? | Very Much Difficulty | 37 | 17.6% |
| Quite A Lot of Difficulty | 30 | 14.3% | |
| Moderate Difficulty | 59 | 28.1% | |
| Slight Difficulty | 45 | 21.4% | |
| No Difficulty | 39 | 18.6% | |
| Do you think your present hearing aid(s) is worth the trouble? | Not At All Worth It | 35 | 16.7% |
| Slightly Worth It | 34 | 16.2% | |
| Moderately Worth It | 46 | 21.9% | |
| Quite A Lot Worth It | 70 | 33.3% | |
| Very Much Worth It | 25 | 11.9% | |
| How much have your hearing difficulties affected the things you can do? | Affected Very Much | 30 | 14.3% |
| Affected Quite A Lot | 22 | 10.5% | |
| Affected Moderately | 46 | 21.9% | |
| Affected Slightly | 59 | 28.1% | |
| Affected Not At All | 53 | 25.2% | |
| How much do you think other people were bothered by your hearing difficulties? | Bothered Very Much | 32 | 15.2% |
| Bothered Quite A Lot | 20 | 9.5% | |
| Bothered moderately | 19 | 9.0% | |
| Bothered Slightly | 49 | 23.3% | |
| Bothered Not At All | 90 | 42.9% | |
| How much has your present hearing aid(s) changed your enjoyment of life? | Worse | 0 | 0.0% |
| No Change | 33 | 15.7% | |
| Slightly Better | 46 | 21.9% | |
| Quite A Lot Better | 85 | 40.5% | |
| Very Much Better | 46 | 21.9% | |
| Overall score | Range | 9-35 | |
| Mean ± SD | 23.8 ± 6.4 | ||
Those with moderately severe right ear hearing loss had significantly higher mean IOI-HA scores (26.7 ± 4.7; P = 0.049), according to the research, which used One-Way ANOVA and independent t-tests. Furthermore, the mean scores of individuals who had been wearing hearing aids for more than a year were significantly higher (25.9 ± 5.4; P = 0.001). Additionally, those who were unsure of why they were wearing their hearing aids also had noticeably higher mean scores (25.7 ± 5.0; P = 0.023). Factors related to research participants' IOI-HA scores are shown in Table 5.
Table 5. Factors Associated With International Outcome Inventory-Hearing Aid (IOI-HA) Score Among Study Participants.
IOI-HA: International Outcome Inventory-Hearing Aids, CHL: Conductive Hearing Loss, SNHL: Sensorineural Hearing Loss
| Factors | IOI-HA Score | p-value | ||
| Mean | SD | |||
| Age in years | < 40 | 24.3 | 6.3 | 0.344 |
| 40-59 | 23.1 | 6.7 | ||
| 60+ | 24.4 | 6.0 | ||
| Gender | Male | 23.6 | 6.5 | 0.640 |
| Female | 24.0 | 6.3 | ||
| Marital status | Married | 23.8 | 6.4 | 0.883 |
| Not married | 23.6 | 6.3 | ||
| Educational level | Below high school | 24.4 | 6.2 | 0.165 |
| Diploma/ high school | 22.8 | 6.4 | ||
| University / above | 22.6 | 7.1 | ||
| Right Ear Hearing Loss Degree | Normal | 21.2 | 7.3 | 0.049 |
| Mild | 25.4 | 5.0 | ||
| Moderate | 23.0 | 6.1 | ||
| Moderately severe | 26.7 | 4.7 | ||
| Severe | 24.2 | 6.5 | ||
| Profound | 22.9 | 8.0 | ||
| Right Ear Hearing Loss Type | CHL | 24.2 | 5.7 | 0.498 |
| SNHL | 23.7 | 6.4 | ||
| Mixed | 25.0 | 6.3 | ||
| Left Ear Hearing Loss Degree | Normal | 24.5 | 7.4 | 0.548 |
| Mild | 25.7 | 5.3 | ||
| Moderate | 22.9 | 5.9 | ||
| Moderately severe | 23.6 | 7.1 | ||
| Severe | 23.9 | 6.6 | ||
| Profound | 23.7 | 7.4 | ||
| Left Ear Hearing Loss Type | CHL | 24.0 | 5.3 | 0.718 |
| SNHL | 23.5 | 6.3 | ||
| Mixed | 24.4 | 6.9 | ||
| Side of Used Hearing Aid | Right | 24.0 | 6.3 | 0.191 |
| Left | 22.8 | 7.0 | ||
| Bilateral | 25.0 | 5.2 | ||
| Duration of Hearing Aid Use | < 1 month | 16.5 | 6.0 | 0.001 |
| 3 months | 15.5 | 5.1 | ||
| 6 months | 19.5 | 5.7 | ||
| 1 year | 22.7 | 5.9 | ||
| > 1 year | 25.9 | 5.4 | ||
| Patient's Awareness of The Diagnosis for Which Hearing Aids Were Prescribed | Yes | 24.2 | 6.4 | 0.023 |
| No | 25.7 | 5.0 | ||
| Not sure | 21.2 | 6.2 | ||
Discussion
In this research study, the WHOQOL-BREF and IOI-HA were administered to assess the correlation between quality of life and the hearing aids effectiveness. The overall IOI-HA score was analyzed, and it was found that the average of the score is 23.8 ± 6.4, which shows positive satisfaction levels about the use of the hearing aids among the participants of the study. This observation is in line with a population-based study of Houmøller et al. [15], who also validated the IOI-HA and found similar outcomes scores between groups. Furthermore, the majority of hearing aid users reported satisfactory results and daily usage exceeding eight hours, according to earlier research by Houmøller et al. [16]. This pattern was mirrored in our study, where 41.9% (88 participants) reported wearing their hearing aids for more than eight hours daily. The constancy in usage patterns emphasizes the significance of daily hearing aid use in improving patient-reported outcomes, even though Houmøller et al.'s study focused predominantly on older persons with presbycusis and did not report population-specific IOI-HA scores.
According to our survey, 64 (30.5%) of participants said their hearing aids were very helpful to them, and 46 participants (21.9%) said they made their lives much better by using them. This result corresponds with those of Brannstrom et al. [17] and Pronk et al. [18], who have found that regular use of hearing aids results in a significant increase in the ability to communicate and enjoy life. Interestingly, those who had been using their hearing aids for over a year had considerably higher scores on the IOI-HA, which again confirms that adaptation and long-term usage are important, and so it was in the research of Dornhoffer et al. [19], who observed higher results with longer use duration and better fitting support.
Interestingly, the results suggest that people with moderately severe hearing loss reported the best average IOI-HA scores, which implies that they experienced better perceived outcomes compared to people with milder or more severe hearing loss. It is consistent with the results prior study by Barnett et al. [20], showing that hearing aid satisfaction remains low when compared with the degree of hearing loss, where little to no amplification is useful in profound impairment. These results accentuate the significance of meticulously aligning hearing aid services to the level of loss and identifying alternative interventions to use in individuals with a severe to profound loss.
In the overall quality of life, WHOQOL-BREF scores were positively correlated with higher scores of IOI-HA, including the psychological and social areas. This validates a study by Vas et al. [21], which revealed that users of hearing aids usually experience not only improved interpersonal communication but also in social interaction and mood. Our findings support the significance of the combination of audiological treatment and the use of psychosocial support to achieve better general results. In addition, the results demonstrated that patients who routinely visited the ENT/audiology department reported improved performance from their hearing aids. This is in line with the findings of Barker et al. [22], who highlighted the significance of continuous counseling and maintenance.
Finally, 64.3% (135 participants) of the subjects of study had used their hearing aids for more than one year, and thus, the findings of the study did not naturally evaluate the influence of educational level and chronic co-morbidities on hearing aid performance or the level of learning of participants. Future investigations might, thus, play a role in evaluating the effects of health literacy and co-morbidities on compliance with wearing hearing aids and patient satisfaction, particularly in groups with different educational levels and health conditions [23]. Future studies are also advised to use longitudinal studies to monitor the changes in hearing aid outcomes and quality of life over time, since cross-sectional studies are not able to freely conclude as to causation. Also, investigating the results of interventions among individuals with severe to profound hearing impairments, where the effectiveness of standard hearing aids may be too limited, would be useful to determine the compatible interventions and enhance overall patient care plans. The main strengths of this study are the combination in the design of two validated assessments, IOI-HA and WHOQOL-BREF, which help to determine hearing aid device-specific outcomes and broad quality-of-life categories measured in a clinical subject in the territory of an actual health care establishment. The relatively wide sample size of the study and the varied patient profile of a major tertiary care facility also contribute to the greater reliability and generalizability of the results. The cross-sectional design restricts causative inferences, and the use of self-reported measures creates the risk of recall or reporting bias. Future research is challenged to utilize qualitative approaches in addition to the quantification tools to better understand patients' lived experiences, satisfaction, and impediments to productive hearing aid use.
Conclusions
As evidenced by the IOI-HA scores and positive correlations with WHOQOL-BREF domains, especially in the areas of psychological and social well-being, this study showed that daily use of hearing aids improves the quality of life for people with hearing loss. The participants with longer duration of use of hearing aids and with moderate hearing loss were more satisfied and found more benefit. These results indicate the efficiency of traditional hearing aids in a real-life context and underline the necessity of further support, follow-up, and patient education to maximize the results. The combination of audiological and quality-of-life measurements used in clinical work could contribute to the adaptation of the rehabilitation approach and the enhancement of patient satisfaction.
Appendices
Figure 1. International Outcome Inventory-Hearing Aids (IOI-HA) Questionnaire.
[13].
Disclosures
Human subjects: Informed consent for treatment and open access publication was obtained or waived by all participants in this study. Armed Forces Hospital South Region Research Ethical Committee issued approval AFHSRMREC/2021/ ENT/509. The Committee has received the above-mentioned research proposal and carefully reviewed it and it was approved.
Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:
Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.
Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.
Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.
Author Contributions
Concept and design: Ahmad M. Alrasheed, Khalid Ardi, Omar Z. Alaidaroos
Acquisition, analysis, or interpretation of data: Ahmad M. Alrasheed, Montasir Junaid, Rakan M. Alrasheed, Salmah M. Alharbi, Mona Alshehri, Amirah Abumismar
Drafting of the manuscript: Ahmad M. Alrasheed, Montasir Junaid
Critical review of the manuscript for important intellectual content: Ahmad M. Alrasheed, Khalid Ardi, Rakan M. Alrasheed, Omar Z. Alaidaroos, Salmah M. Alharbi, Mona Alshehri, Amirah Abumismar
Supervision: Ahmad M. Alrasheed
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