Abstract
Background
Live lecture remains a ubiquitous form of knowledge delivery in preclinical medical education. However, voluntary live lecture attendance has markedly decreased at several medical schools. This case-control study examined the effect of live lecture attendance on academic achievement in selected basic science courses.
Methods
Cases (n = 174) were defined as students with below average examination scores, and controls (n = 198) were defined as students with above average examination scores. The exposure was absenteeism, which was defined as attending live lecture less than 75% of total live lecture sessions. Second-year and third-year students reported self-estimated frequency regarding live lecture attendance, and they estimated the time spent engaged in various behaviors during live lectures.
Results
Absenteeism was identified as a significant risk factor for having below average score in preclinical medical science courses with a 2.34-fold risk (95% confidence interval [CI]: 1.27–4.33). Distracting behavior more than 25% of live lecture time was a factor with non-significantly increased risk for having below average score (1.36-fold risk, 95% CI: 0.86–2.13).
Conclusions
Absenteeism was compellingly associated with poorer examination performance among medical students in basic science medical courses. Preclinical medical students should be encouraged to attend live lectures as often as possible.
Keywords: Live lecture attendance, Academic achievement, Students’ behaviors, Preclinical medical students
Introduction
Lecture is often criticized as a passive method of teaching. If lecture involves only repetitive delivery of standard texts, it may not initiate or stimulate student comprehension [1]. Therefore, active learning methods, such as problem-based learning, flipped classroom, team-based learning, and small group discussion, are becoming increasingly popular because they provide enhanced experience and engagement, which results in a deeper understanding of course content [2]. However, lecture remains a prevalent form of knowledge delivery in preclinical medical education. It was recently reported that voluntary lecture attendance has markedly decreased at several medical schools worldwide especially in the USA [3, 4]. A significant number of medical students have replaced live lecture with personal learning time, such as viewing video-recorded lectures [5]. This observed change in student behavior has attracted the attention of and has caused concern among faculty members that are questioning the competence, knowledge, and professionalism of these absentee students.[[6] However, there is no report about voluntary live lecture attendance in any medical school from Thailand and South East Asia since class attendance in most South East Asian medical schools is still compulsory. So, this study is the first report of live lecture attendance rate from this region where lecture attendance becomes voluntary.
A meta-analysis study revealed a strong relationship between class attendance and the average grades of general college students [7]. Additionally, there was a positive correlation between attendance and overall examination score among clinical medical students [8, 9]. Importantly, absence from lectures by preclinical medical students had a negative impact on academic achievement, including the academic grades that they earned in those preclinical courses [10–12]. Not surprisingly, regardless of either attending live lectures or viewing video-recorded lectures, the concentration level of preclinical medical students during lecture was found to be correlated with examination scores [13]. A more recent study reported that classroom attendance does not associate with performance on multiple-choice examinations taken by medical students [3]. Whether live lecture attendance relates with the examination performance of preclinical students at our institute remains to be explored.
Live lectures during the preclinical years at our medical school consist of two methods: traditional and interactive lectures. After receiving the permission of instructors to do so, the Undergraduate Education Unit publishes recorded lectures or e-lectures via a learning management system entitled Siriraj E-Learning and Education Community (SELEC) to assist students in lesson review. The recorded lectures present lecturers’ voices, images, and slides with high quality. Almost all lectures are recorded and published at the end of each day. Our medical students can access these e-lectures by logging in to SELEC. Starting in academic year 2017, the Undergraduate Education Unit changed the policy from mandatory to voluntary live lecture attendance. Since that change took effect, an increasing number of preclinical students have decided not to attend live lectures. The studies showing live lecture attendance improved academic performance were mostly conducted in Western medical schools whose cultural context are vastly different from medical schools in Thailand and South East Asia. Whether live lecture attendance correlates with examination performance among the preclinical students at our center has not yet been determined. Therefore, this study, as the first report from this region, aimed to investigate the effect of student lecture attendance and their behaviors during live lecture on academic achievement in selected basic science courses, and to explore and identify factors that influence their decisions to attend or not attend live lecture.
Methods
Study Population
Each year, approximately 320 high school graduates enroll in an undergraduate medical program at our medical school. This 6-year program includes a basic science year, 2 years of foundational organ system–based courses (preclinical years), 2 years performing clinical rotations, and the last clerkship year as an extern. All enrolled second-year (Y2, N = 322) and third-year (Y3, N = 317) medical students during academic year 2018–2019 were informed about the study and were requested to voluntarily participate as a study subject. Ethics approval for this study was granted by the Human Research Protection Unit of Institutional Review Board (IRB) (ethics ID 434/2561; EC2).
Nature of Examinations Used to Assess Academic Performance
For the course, entitled Foundation of the Human Body: Neural and Hormonal Regulation (SIID 213) for Y2 students, the examination consisted of 90-item multiple-choice questions, making up 55% of the final grade, and 5-item short answer questions, making up 5% of the final grade. The average examination score is 39.42 ± 7.12 (range: 16.69–55.49) from the total mark of 60. The rest of 40% of the final grade was class participation, small group discussion, and in-class quizzes. The passing grade was minimum of 60% of the final grade. The class attendance in live lecture was not counted as class participation score. Only four of total 322 students failed this course.
For the course, entitled Immune Responses and Inflammation (SIID 312) for Y3 students, the examination consisted of 110-item multiple-choice questions, which made up 55% of the final grade. The average examination score is 39.18 ± 5.41 (range: 17.00–52.50) from the total mark of 55. The rest of 45% of the final grade was class participation, small group discussion, and online quizzes. The class attendance in live lecture was not counted as class participation score. The passing grade was minimum of 60% of the final grade. Only four of total 317 students failed this course.
Survey and Data Collection
This case-control study explored the effect of live lecture attendance on academic achievement in selected basic science courses. Student samples were dichotomized into cases and controls. Cases were defined as Y2 students with below average examination scores (< 39.42) in SIID 213 and as Y3 students with below average examination scores (< 39.18) in SIID 312. The controls were students who scored above average in each of those two courses. The exposure was irregular live lecture attendance, which was defined as self-reported attendance of live lecture less than 75% of the total sessions. Students with exposure were labeled absentees, while their peer counterparts were categorized as regular attendees. All participating students were asked to report self-estimated frequency regarding live lecture attendance as a percentage of the total number of live lecture sessions, and factors that influenced their decisions to attend and not to attend live lectures. In order to study whether students utilized recorded lectures as a replacement for live lecture attendance, students were asked to report the frequency of recorded lecture usage. The questionnaire was designed based on previously studied reasons for live lecture attendance and/or absence in the USA [5, 14]. There was a 6-month delay between time of taking courses and answering self-reported questionnaires.
The present study also explored the effects of distracting behaviors during live lectures on academic achievement by asking the regular attendees to report the estimated time that they spent for various behaviors during live lectures. The behaviors were classified into two groups as focused behaviors (i.e., taking notes, listening to or following lecture, and browsing the internet on related topics) and distracting behaviors (i.e., using tablet/phone for topics unrelated to live lecture, feeling asleep or losing focus, and talking to classmates on unrelated topics). The regular attendees were divided into cases and controls, similar to the first part of the study. Exposure was defined as spending more than 25% of lecture time engaged in distracting behaviors. Students with exposure were labeled as distracted students, and their counterparts were considered focused students. The results of that analysis (reported as odds ratio) revealed whether the exposure is a risk factor for scoring below average in basic medical science courses.
Statistical Analysis
Data were analyzed by SPSS 18.0 software (SPSS, Inc., Chicago, IL, USA) to calculate risk scoring below average in relation to absenteeism and distracting behaviors during live lectures among regular attendees. The results of those analyses are reported as odds ratio (OR), 95% confidence interval (CI), and p value. Percentage and OR were used to describe factors that influence students to regularly attend or not regularly attend live lectures. A p value less than 0.05 was regarded as being statistically significant.
Results
Live Lecture Attendance by Class Year
Of the 539 subjects, 372 students (58.2%) completed online surveys. Of the 322 Y2 subjects, 195 students (60.6%) completed online responses. Of the 317 Y3 subjects, 177 students (55.8%) completed online responses. The live lecture attendance rate among the second-year students (Y2, 93.8 ± 14.3%) was significantly higher (p < 0.0001) than that among the third-year students (Y3, 80.8 ± 26.5%). The attendance rate of regular attendees and absentees was 95.2 ± 6.8% and 39.7 ± 23.7% respectively. The proportion of absentees was higher in Y3 than in Y2 (38 of 177 vs. 13 of 195) (Table 1).
Table 1.
Live lecture attendance among students with below average scores
| Group | Cases | Controls | OR | 95% CI | p value |
|---|---|---|---|---|---|
| Y2 students | |||||
| - Absentees | 9 | 4 | 2.57 | 0.76–8.64 | 0.1277 |
| - Regular attendees | 85 | 97 | 1.0 | ||
| Y3 students | |||||
| - Absentees | 24 | 14 | 2.54 | 1.21–5.33 | 0.0137 |
| - Regular attendees | 56 | 83 | 1.0 | ||
| Preclinical students (Y2 and Y3) | |||||
| - Absentees | 33 | 18 | 2.34 | 1.27–4.33 | 0.0067 |
| - Regular attendees | 141 | 180 | 1.0 | ||
A p value < 0.05 indicates statistical significance
OR, odds ratio; CI, confidence interval; Y2, year 2; Y3, year 3
Frequency of Live Lecture Attendance and Examination Score
Absenteeism, which was defined as attending live lecture less than 75% of the total sessions, was identified as a significant risk factor for having below average score in preclinical medical science courses in Y3 with a 2.54-fold risk (95% CI: 1.21–5.33), and for both Y2 and Y3 students when combined together with a 2.34-fold risk (95% CI: 1.27–4.33) (Table 1).
Reasons Behind Live Lecture Attendance and Absence
The three most frequently selected reasons affecting all students’ decision to attend live lectures were not wanting to watch the recorded lectures, showing respect to the lecturer, and talking with classmates. The three most commonly selected reasons by absentees for attending live lectures were not wanting to watch the recorded lectures, talking with fellow students, and good and clear vocal delivery by a lecturer (Table 2). Students that attend the lecture to show respect for the lecturer were more likely to be regular attendees with a 4.77-fold OR (95% CI: 2.44–9.31). Other reasons with their respective odds ratios are shown in Table 2.
Table 2.
Reasons given why students attend live lecture
| Reasons | Regular attendees | Absentees | OR | 95% CI | p | ||
|---|---|---|---|---|---|---|---|
| (n = 321) | % | (n = 51) | % | ||||
| You think that attending live lecture is a way to show respect toward lecturers. | 199 | 62.0 | 13 | 25.5 | 4.77 | 2.44–9.31 | < 0.0001 |
| Lecturers know the sequences of a lecture well. | 61 | 16.2 | 3 | 5.9 | 3.75 | 1.13–12.45 | 0.0306 |
| You want to ask lecturers questions immediately after the end of the lecture. | 42 | 19.0 | 3 | 5.9 | 2.41 | 0.72–8.08 | 0.1547 |
| Lecturers regularly emphasize important points. | 163 | 50.8 | 16 | 31.4 | 2.26 | 1.20–4.24 | 0.0114 |
| Lecturers can answer student’s questions clearly. | 95 | 29.6 | 10 | 19.6 | 1.72 | 0.83–3.58 | 0.1448 |
| You do not want to watch the recorded lectures (e-lecture). | 224 | 69.8 | 30 | 58.8 | 1.62 | 0.88–2.96 | 0.1522 |
| Attending live lecture is an opportunity to meet and talk with classmates. | 168 | 52.3 | 21 | 41.2 | 1.57 | 0.86–2.86 | 0.1408 |
| Lecturers present with clear and audible delivery. | 85 | 26.5 | 19 | 37.3 | 0.61 | 0.33–1.13 | 0.1137 |
| Lecturers present at a speed that is easy to follow. | 68 | 21.2 | 17 | 33.3 | 0.54 | 0.28–1.02 | 0.0576 |
A p value < 0.05 indicates statistical significance
OR, odds ratio; CI, confidence interval
The three most frequently selected factors affecting a student’s decision to be absent from live lectures were a lecturer who delivers contents with inappropriate speed (e.g., too slowly or too quickly), finding that other learning styles are more suitable, and deciding to create their own schedule based on their belief that they could improve their productivity, such as using live lecture time to study other courses (Table 3). Students absent from lecture because of their preference for other learning styles or because of their decision to skip morning classes were more likely to be absentees with strong statistical significance (p < 0.0001). Other reasons with their respective odds ratios are shown in Table 3.
Table 3.
Reasons given why students do not attend live lecture
| Reasons | Absentees | Regular attendees* | OR | 95% CI | p | ||
|---|---|---|---|---|---|---|---|
| (n = 51) | % | (n = 252) | % | ||||
| You think other learning methods are more suitable for you than attending live lectures. | 34 | 66.7 | 78 | 31 | 4.46 | 2.35–8.47 | < 0.0001 |
| You do not want to attend a live lecture scheduled in the morning session. | 29 | 56.9 | 64 | 25.4 | 3.87 | 2.08–7.22 | < 0.0001 |
| Delivery speed of lecture is not suitable for you. For example, too slow or too fast. | 40 | 78.4 | 135 | 53.6 | 3.15 | 1.55–6.42 | 0.0016 |
| You do not want to take notes during a live lecture and you prefer to have a classmate’s notes. | 21 | 41.2 | 48 | 19 | 2.98 | 1.57–5.64 | 0.0008 |
| Absence from live lecture saves your study time. | 24 | 47.1 | 61 | 24.2 | 2.78 | 1.50–5.18 | 0.0012 |
| Absence from live lecture allows me to easily manage my own schedule to improve productivity. For example, I can watch recorded lectures at any time depending on my readiness. | 31 | 60.8 | 95 | 37.7 | 2.56 | 1.38–4.75 | 0.0028 |
| I miss the opening of a live lecture. | 24 | 47.1 | 80 | 31.7 | 1.91 | 1.04–3.52 | 0.0376 |
| I want to attend lectures at my own pace. | 32 | 62.7 | 121 | 48 | 1.82 | 0.98–3.39 | 0.0572 |
| Absence from a live lecture reduces my study time. | 20 | 39.2 | 68 | 27.0 | 1.75 | 0.93–3.27 | 0.0817 |
| You think that lecturers would not be able to answer your question clearly. | 4 | 7.8 | 14 | 5.6 | 1.45 | 0.46–4.59 | 0.5306 |
| Lecturers present with unclear voice. | 8 | 15.7 | 38 | 15.1 | 1.05 | 0.48–2.40 | 0.9123 |
| You think that lecturers do not regularly emphasize important points. | 4 | 7.8 | 25 | 9.9 | 0.77 | 0.26–2.32 | 0.6464 |
*Exclude 69 students who answered “not applicable; I attend 100 percent live lecture”
A p value < 0.05 indicates statistical significance
OR, odds ratio; CI, confidence interval
Distracting Behaviors and Academic Achievement
Distracting behavior more than 25% of live lecture time was a factor with non-significantly increased risk for having below average score (1.36-fold risk, 95% CI: 0.86–2.13) (Table 4).
Table 4.
Behavior during lecture among students with below average scores
| Group | Cases | Controls | OR | 95% CI | p value |
|---|---|---|---|---|---|
| Y2 students | |||||
| - Distracted | 40 | 41 | 1.21 | 0.68–2.18 | 0.5166 |
| - Focused | 45 | 56 | 1.0 | ||
| Y3 students | |||||
| - Distracted | 22 | 25 | 1.50 | 0.74–3.06 | 0.2637 |
| - Focused | 34 | 58 | 1.0 | ||
| Preclinical students (Y2 and Y3) | |||||
| - Distracted | 62 | 66 | 1.36 | 0.86–2.13 | 0.1851 |
| - Focused | 79 | 180 | 1.0 | ||
A p value < 0.05 indicates statistical significance
OR, odds ratio; CI, confidence interval; Y2, year 2; Y3, year 3
Recorded Lecture Utilization
The self-reported recorded lecture utilization rate among absentees (59.80 ± 34.99%) was significantly higher (p < 0.0001) than that among regular attendees (29.28 ± 29.53) in the combination second- and third-year medical student group. The recorded lecture utilization rate among Y3 students (38.46 ± 32.70) was significantly higher (p = 0.0041) than that among Y2 students (28.93 ± 30.85%).
Discussions
Live Lecture Attendance by Class Year
The average of self-reported live lecture attendance was still considerably high in both Y2 and Y3 (93.8 and 80.8, respectively) even though live lecture attendance had become optional. However, some studies reported a substantially low attendance rate (24%) for non-mandatory classes [3]. Not being motivated to watch the recorded lectures on their own, which was the most frequently reported reason for attending the live lecture (68.3%), might have contributed to the high live lecture attendance rate among both regular attendees and absentees.
The live lecture attendance rate of Y2 students (93.8%) was significantly higher than the rate among Y3 students (80.8%). These differences in live lecture attendance rates between class years are consistent with the findings from other studies [14, 15]. This difference may be explained by the observed greater use of recorded lecture by Y3 students (38.5%) than by Y2 students (28.9%). Interestingly, 14% of the second-year medical students in the USA (which is equivalent to third-year students in Thailand) reported that having lecture videos available online led to a decrease in the live lecture attendance rate [15]. Furthermore, more than half of American preclinical students reported that they would attend live lecture more frequently if recorded lectures were not available [14].
Recorded Lecture as a Replacement for Live Lecture
Absentees utilized recorded lectures more than regular attendees in both the Y2 and Y3 groups. Among absentees, self-reported frequency of live lecture attendance and of lecture recording utilization was 39.7% and 59.8%, respectively. It is possible that absentees used recorded lectures as a replacement for live lecture attendance because both courses (SIID 213 and SIID 312) published lecture recordings from almost every live lecture session. With the availability of lecture recordings, second-year American medical students utilized lecture recording as a replacement [14]. Approximately 27% of second-year American medical students replaced live lecture with recorded lectures [15]. Absentees probably benefited from the speed-changing feature of lecture recording because 62.7% of absentees reported that they wanted to watch lectures at their own pace.
Live Lecture Attendance and Examination Score
The odds ratio of absenteeism for scoring below average in Y2 was not statistically significant. This might be due to the relatively small sample size that could have limited the statistical power of this study. To support the aforementioned assertion, when we combined the Y2 and Y3 samples, the odds ratio was numerically increased and the result was shown to be statistically significant (p < 0.05). The odds ratio with a 2.34-fold risk strongly suggested that absenteeism has strong association with scoring below average in preclinical science courses, which implies that absenteeism has a considerably negative impact on academic achievement. This same finding was observed in other studies conducted in various courses in physiology, pharmacology, and anatomy from both prior to and during the era of recorded lecture utilization [10–12, 16–19]. It is plausible that students with higher rates of participation achieve better grades not due to better understanding of material but due to explicit or implicit cues to the content of examinations given during live lecture [17]. However, if absentees utilize recorded lecture as a replacement, they should receive similar explicit and implicit cues given during live lecture via lecture videos. Live lecture attendance might reflect better adaptation of students because students who reported incompatibility with speed and rhythm of a lecturer were more likely to be absentees with an OR of 3.15-fold.
Low achievers might present as absentees [20]. Live lecture attendance may reflect high intrinsic motivation and self-discipline. Highly motivated and disciplined people, including medical students, are more likely to achieve their goals, such as high scores on examinations. However, a meta-analysis revealed that lecture attendance, while showing strong association with class grades, had weak relationship with student characteristics like motivation and conscientiousness [7].
Overlearning might also explain the positive impact of regular attendance on examination score. Live lectures at our school are designed to always be delivered before the following related active learning sessions, such as mandatory small group discussions or team-based learning. While absentees might not watch lecture recording before time of active learning sessions [6], regular attendees would automatically be more prepared to participate in active learning sessions. Consequently, absentees did not benefit as much as did regular attendees from those learning sessions. In other words, regular attendees were likely to overlearn materials [16].
Interestingly, a more recent study reported conflicting findings. That study found and reported lecture attendance not to be significantly associated with academic performance [3]. Kauffman et al. commented on the availability of outside classroom materials where all lecture material at their school was available online. In contrast, most studies that reported association between live lecture attendance and examination performance appeared to be in academic settings where the lecture materials were not obtainable outside of the classroom [3]. Interestingly, even though all lecture materials are available outside of the classroom online, including lecture recordings, our finding yielded a negative impact of absenteeism. In contrast to the actual records of live lecture attendance in the Kauffman et al. study, we included data in the present study that was self-reported by the study population. It is, therefore, possible that inaccuracies associated with recollection could have adversely affected the accuracy of our data and findings.
Reasons for Live Lecture Attendance
The top three reasons affecting all students’ decision to attend live lectures, i.e., (1) not being motivated to watch the recorded lectures on their own, (2) showing respect to a lecturer, and (3) talking with classmates, were consistent with the top reported reasons for attending and not attending live lectures at Harvard Medical School [5]. The most popular factors affecting students’ decision to attend live lecture were all lecturer-related, including qualities, such as good preparation, organized presentation, good vocal delivery, high level of knowledge, and understanding of the topic [14]. However, only about 50% of students in this study attended class because of lecturer-related factors. In other words, factors associated with lecturers are less important than previously thought. This observation might be attributed to limited exposure to each lecturer, which is a common unique feature in preclinical teaching whereby students have different instructors for almost every lecture session [21].
Not surprisingly, students attending classes in order to show respect to a lecturer were the most likely to be regular attendees with an OR of 4.77 (95% CI: 2.44–9.31). Showing respect to all, especially to those who are more senior, is one of the core values at our medical school for seniority, integrity, responsibility, innovation, respect, altruism, and journey to excellence and sustainability. Regular attendees might be students that more closely follow Thai collectivist cultural norms, or that are more likely to feel pressured to conform to the school culture or to seniors by at least showing up to the live lecture session.
Reasons for Live Lecture Absence
The top three reasons affecting absentees’ decision to skip live lectures were a lecturer who delivers lectures with inappropriate speed, finding that other learning styles are more suitable, and deciding to create their own schedule believing that this will improve their productivity, such as using live lecture time to study other courses. Interestingly, these reasons were comparable with those reported from the aforementioned Harvard study [5]. In other words, if students perceived that they would not be able to follow certain lecturers’ speed and understand the materials, students would be absent from the class and spend that time finding other ways to comprehend the materials.
Distracting Behaviors and Academic Achievement
Distracting behaviors that occupy more than 25% of live lecture time among regular attendees were not found to be a statistically significant risk factor for scoring below average; however, there was a numerically increased likelihood of below average scoring with a 1.36-fold risk (95% CI: 0.86–2.13). The relatively small sample size (321 students) may have given our study insufficient power to identify a statistically significant relationship, if one exists. Distracting behavior among absentees was not analyzed because the strong negative effect of absenteeism on scoring below average probably overshadowed any effect exerted by distracting behaviors.
Our finding that interrupting behaviors during lecture increased the likelihood of poorer score was consistent with that from a study conducted in medical students and their performance in histology class and even poorer technical skills in surgical boot camp [13, 22]. This negative impact of multitasking on academic performance was demonstrated in non-medical students as well [23]. Information retention was affected detrimentally by multitasking behaviors [13]. Therefore, we recommend that all students that participate in live lectures should focus their attention on the subject matter being taught during class.
However, if distracting behaviors are actually not a risk factor for scoring below average, it is probably the secondary effect of distracting behaviors on focused students, who were unintentionally interrupted. This secondary effect results in equally poor performance in both distracted and focused students. There is no other report about this observation and hypothesis in medical education, so association between distracting behaviors and poor academic performance in medical students needs to be further explored.
Limitations
This study has some mentionable limitations. First, the results of this study were derived mainly from one foundation course in each class (2 courses in total), which limits the generalizability of these results to other courses. Second, the fact that these two foundation courses were taken in early school year might influence students’ frequency of live lecture attendance especially second-year students who recently transitioned from their first premedical year. Finally, very high rates of live lecture attendance in Y2 students might reflect the limitation of this study that did not monitor actual voluntary class attendance and time delay of 6 months between time of taking courses and answering self-reported questionnaires, resulting in that medical especially Y2 students recalled their attendance and class behaviors incorrectly.
Conclusion
Consistent with the majority of previous literature, absenteeism was compellingly associated with poorer examination performance of medical students in basic science medical courses. Furthermore, distracting behaviors during live lectures may increase the likelihood of poorer examination scores. Factors that increased live lecture attendance were mostly related to student-related factors, not lecturer-related factors. However, students’ decisions not to attend live lectures were mostly their preference for other learning methods and lecturer’s speed.
Acknowledgments
The authors gratefully acknowledge the second- and third-year medical students who participated in this study, and Dr. Patompong Ungprasert of the Clinical Epidemiology Unit, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, for suggestions relative to statistical analysis and interpretation.
Author Contribution
Wasit Wongtrakul: study design, data collection, statistical analysis, and writing manuscript.
Yodying Dangprapai: study design, data collection, statistical analysis, and writing manuscript.
Funding Information
Yodying Dangprapai received grant from the Faculty of Medicine Siriraj Hospital, Mahidol University (grant no. R016261005).
Data availability
The datasets generated during and/or analyzed during the current study are not publicly available due to ethical restrictions, e.g., their containing information that could compromise the privacy of research participants, but are available from the corresponding author on reasonable request.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
Ethics Approval
Ethics approval for this study was granted by the Human Research Protection Unit of Siriraj Institutional Review Board (SIRB) (ethics ID 434/2561(EC1)).
Consent to Participate
Informed consents were provided to all participants prior to taking part in this study.
Consent to Publish
Not applicable
Code Availability
Not applicable
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated during and/or analyzed during the current study are not publicly available due to ethical restrictions, e.g., their containing information that could compromise the privacy of research participants, but are available from the corresponding author on reasonable request.