Social factors influence on anxiety, depression level and psychological trauma of obstetrics and gynecology residents during COVID-19 pandemic

Abstract

Background and aim

The novel coronavirus disease 2019 (COVID-19) has enforced obstetrics and gynecology (ObGyn) residency training process to undergo wide changes including lessons modifications, yet their mental health were not evaluated. Hence, this study aimed to evaluate the influence of social factors on anxiety, depression level, and psychological trauma of ObGyn residents during the COVID-19 pandemic as well as the impact of COVID-19 to residency training program.

Methods

A cross-sectional study was conducted in three institutions in Indonesia: the University of Indonesia, the University of Lambung Mangkurat, and the University of Syiah Kuala. A total of 169 ObGyn residents agreed to participate and were enrolled in this study.

Results

Total 169 residents were eligible with a mean age of 26–42 years. 76.9% of the residents were exposed to COVID-19 patients during clinical rotation. Approximately half of them (52.6%) thought COVID-19 has brought negative effects. Long-distance learning was considered of good quality by 40.2% of participants. The majority experienced enough resting periods, nearly half of them (45.5%) were concerned about the impact of being a less competent specialist.

Conclusion

Overall, no significant statistical relationship were revealed between social factors and depression, anxiety and psychological trauma in ObGyn residents during COVID-19 pandemic.

COVID-19; Obstetrics and gynecology; Residency; Mental health; Psychology trauma.

1. Introduction

The novel coronavirus disease (COVID-19) has dramatically changed the live of healthcare workers. The increasing cases has added a new vulnerable population, healthcare workers who treat COVID-19 patients themselves. The vulnerabilities of healthcare workers at the time of crisis first reported after the death of Dr. Li Wenliang, a doctor in Wuhan who was trying to warn his colleagues about the possibility of a new infectious virus while treating his patients [1]. Moreover, shortage of personal protective equipment (PPE) supplies has augmented the obstacles faced in the beginning of pandemic situation. At the beginning of 2020, Indonesian government directed the health worker to use raincoats as PPE due to the lack of supplies.

Medical residents are considered essential within the healthcare system. Since the pandemic has emerged, a proportion of resident physicians were quickly reorganized and redeployed to the frontline. The training process has undergone widely changes, particularly due to the preventive implementation from the government through health advocacy campaigns, lockdown, and restricting public meetings which have forced universities and institutions to modify lessons, training, and work shifts [2, 3]. The current pandemic situation has imposed a significant adjustment especially in the field of surgery [4]. Obstetrics and gynecology (ObGyn) residency training has to adapt well and quickly into the lockdown period. This quarantine period has led to limiting the presence of residents who are on duty, postponing elective procedures, and cancelling lectures and educational conferences. Besides physical health, latest literature showed that healthcare workers are at a high risk of experiencing mental health problems such as stress, anxiety, depression and sleep disorders with considerable degree due to COVID-19 pandemic^.[5].

In the general population, COVID-19 pandemic can induce psychiatric symptoms or make the existing COVID-19 symptoms even worse. Worrying about the possibility of getting infected can lead to fear of death, anxiety, a sense of helplessness, and a tendency to blame the sick person. Various mental illnesses can occur in this condition include depression, anxiety, panic attacks, somatic symptoms, posttraumatic stress disorder (PTSD), delirium, psychosis, and suicidal thoughts [6, 7, 8, 9]. Studies have reported that health workers, especially those working in the emergency department, intensive care unit, and infectious disease wards have a higher risk of experiencing adverse psychological effects [10]. However, a contradictive finding stated that they did not find significant differences in stress level between frontline health workers and other groups [5]. As this pandemic continues, residents' well-being, environment of clinical practice and medical education are yet to be evaluated. Therefore, the present study aimed to evaluate the social factors influence on the level of anxiety, depression and psychological trauma of ObGyn residents during the current pandemic as these residents were exposed to COVID-19 patients and are prone to COVID-19 infection due to their placement during clinical rotation. This study also aimed to identify possible differences between various main institutions for ObGyn residencies. This manuscript was reported in line SQUIRE 2.0 criteria [11].

2. Materials and methods

The study protocol was approved by the Ethics Committee of Faculty of Medicine University of Indonesia, number KET-1161/UN2.F1/ETIK/PPM.00.02/2020, and it was developed to conform with the principles of the Helsinki Declaration. The participating residents were informed about the objectives of the study and then invited to participate. Those who agreed signed the informed consent form. This study took place in three different universities in Indonesia that provide ObGyn residency program. The chosen universities are University of Indonesia, University of Lambung Mangkurat, and University of Syiah Kuala. This descriptive cross-sectional survey was conducted during COVID-19 pandemic from September 2020 to March 2021. Participants were from ObGyn resident physicians who were under a five-year standardized residency training in Indonesia, were registered in the ObGyn department in each university, and still actively working during the pandemic situation.

Residents were informed that their participation was completely voluntary and all the answers were guaranteed to be confidential. If the interviewee agreed to participate, the questionnaire was forwarded with consecutive-sampling method and shared through virtual learning environments and social networks (e.g. WhatsApp). The questionnaire consisted of four main parts: (1) basic information (age, marital status and children, living status, educational institution, clinical residency years and rotation) and how COVID-19 impacted the residents' residency program (learning process, moral condition, health condition, financial problem), (2) symptoms of anxiety during the pandemic – scored using General Anxiety Disorder-7 (GAD-7), (3) symptoms of depression related to the pandemic – scored using Patient Health Questionnaire (PHQ-9), (4) symptoms of psychological trauma due to the pandemic – scored using PTSD Checklist-Civilian (PCL-C-17). To ensure data integrity, if any missing data occurred in the e-questionnaire, answers wouldn’t be submitted.

GAD-7 was used for symptoms of anxiety during the pandemic and was containing 7 questions and calculated by assigning score of 0, 1, 2, and 3. The total range will score between 0 and 21. Cut off points of 0–5, 6–10 and 11–15 were interpreted as mild, moderate and severe anxiety level. PHQ-9 was used for symptoms of depression related to the pandemic and was containing 9 questions and calculated by assigning score of 0, 1, 2, and 3. The total range will score between 0 and 27. Cut off points of 0–4, 5–9, 10–14, 15–19, 20–27 were interpreted as minimal, mild, moderate, moderately severe, and severe depression. PCL-C-17 used for symptoms of psychological trauma due to the pandemic and was containing 17 items that correspond to the key symptoms of PTSD and calculated by assigning score of 1, 2, 3, 4, and 5. The total range will score between 17 and 85. Cut off points of 17–29, 30–44, 45–85 were interpreted as little to no severity, moderate severity and high severity.

The samples were accessed through registration of each institution involved. Residents were offered to participate in the study by authors who represents each institution. A total of 169 ObGyn residents agreed to participate and were enrolled in this study. All of the questionnaires were filled therefore there wasn’t any loss and all of the residents included made up the final sample. To assess general characteristics, learning quality, moral, and health condition of the participants, we used the above mentioned questionnaires (Indonesian version) that had been tested for validity and reliability. Pearson-correlation or Spearman test was used to measure the validity while Cronbach Alpha test was used to assess the reliability. Cronbach alpha test results for GAD-7, PHQ-9 and PCL-C-17 are 0.867, 0.885, 0.946. Learning quality was defined as learning effectiveness with adaptation during COVID-19 pandemic. Participants' perception of motivation and mental resilience during COVID-19 pandemic were observed as the moral section in the questionnaire.

Health condition is individual perception about physical and mental health in residency training times during pandemic situation. Data were stored and organized on an electronic spreadsheet. Statistical analyses were performed using Statistical Package for Social Sciences software, version 20.0. Afterwards, data were presented in the form of tables and narratives. Descriptive statistics were used to summarize the data. The relationship between social factors and depression, anxiety, and physiological trauma was tested with appropriate statistical tests. The alpha level was set at p < 0.05. Analysis was done using Kruskal-Wallis to assess participants' age and Fisher exact test to assess the other variables.

3. Results

There were 169 subjects who were eligible to participate in this study. The mean age was 31 years (range 26–42 years). As shown in Table 1, the majority were in the 4th and 5th year of residencies, followed by the 2nd year of residency. More than half participants were married 98/169 (57.9%) while one-third of them were living alone 62/169 (36.6%). Majority of the residents 130/169 (76.9%) were exposed to COVID-19 patients during clinical rotation when giving the optimal patient care.

Table 1.

Participant characteristics.

	N (%)/Mean (SD)
Age	31 yrs (26–42)
Year of residency training program
First year	26 (15.3)
Second year	33 (19.5)
Third year	28 (16.5)
Fourth year	41 (24.2)
Fifth year	41 (24.2)
Educational institution
University of Indonesia	115 (68.1)
University of Lambung Mangkurat	20 (11.8)
University of Syiah Kuala	34 (20.1)
Marital status
Married	98 (57.9)
Single	71 (42.0)
Living status
Alone	62 (36.6)
With spouse	59 (34.9)
With parents	48 (28.4)
Clinical rotation exposed with COVID-19
Exposed with COVID-19	130 (76.9)
Unexposed to COVID-19	39 (23.0)
Level of anxiety
Minimal anxiety	144 (85.2)
Mild anxiety	22 (13.0)
Moderate anxiety	2 (1.18)
Severe anxiety	1 (0.59)
Level of depression
Not depressed	125 (73.9)
Mild depression	32 (18.9)
Moderate depression	10 (5.91)
Moderate-severe depression	2 (1.18)
Severe depression	0 (0)
Psychological trauma
Mild symptoms	135 (79.8)
Moderate symptoms	28 (16.5)
Severe symptoms	6 (3.55)

Table 2 reports the impact of COVID-19 to residency training program. Nearly half of the residents 89 (52.6%) thought COVID-19 has brought negative effects on the participants, hence, they prefer to work inside the department. Half of the residents' moral perceptions were unchanged (46.1%) during the pandemic situation. Long distance learning was considered a good quality by 68/169 (40.2%) participants. Participants experienced an enough resting period without fatigue. However, nearly half of them 61/169 (45.5%) concerned about the impact on being a less competent ObGyn specialist.

Table 2.

Impact of COVID-19 on Residency Education Program.

	N (%)
Opinions about COVID-19 effect
Positive	48 (28.4)
Neutral	32 (18.9)
Negative	89 (52.6)
Adaptation process during COVID-19 pandemic
Very easy	5 (2.95)
Easy	40 (23.6)
Moderate	99 (58.5)
Difficult	24 (14.2)
Very difficult	1 (0.59)
Preference of working place
Working inside the department	126 (74.5)
Working outside the department	21 (12.4)
Not working inside the department	20 (11.8)
Not working outside the department	2 (1.18)
Moral perception
Very increasing	1 (0.59)
Increasing	23 (13.6)
Unchanged	78 (46.1)
Decreasing	66 (39.0)
Very decreasing	1 (0.59)
Individual moral
Very increasing	1 (0.59)
Increasing	23 (13.6)
Unchanged	92 (54.4)
Decreasing	53 (31.3)
Very decreasing	0 (0)
Mentoring quality
Excellent	10 (5.91)
Good	64 (37.8)
Average	65 (38.4)
Poor	27 (15.9)
Bad	3 (1.77)
Mentoring quantity
Excellent	8 (4.73)
Good	64 (37.8)
Average	68 (40.2)
Poor	24 (14.2)
Bad	5 (2.95)
Long distance learning effectiveness
Excellent	20 (11.8)
Good	52 (30.7)
Average	68 (40.2)
Poor	27 (15.9)
Bad	2 (1.18)
Individual work effectiveness
Strongly agree	7 (4.14)
Agree	117 (69.2)
Disagree	43 (25.4)
Strongly disagree	2 (1.18)
Colleagues work effectiveness
Strongly agree	7 (4.14)
Agree	113 (66.8)
Disagree	48 (28.4)
Strongly disagree	1 (0.59)
Health condition
Strongly agree	17 (10.0)
Agree	125 (73.9)
Disagree	25 (14.7)
Strongly disagree	2 (1.18)
Overworked condition
Strongly agree	6 (3.55)
Agree	66 (39.0)
Disagree	86 (50.8)
Strongly disagree	11 (6.50)
Enough rest period
Strongly agree	11 (6.50)
Agree	120 (71.0)
Disagree	36 (21.3)
Strongly disagree	2 (1.18)
In need of psychological help
Strongly agree	6 (3.55)
Agree	34 (20.1)
Disagree	73 (43.1)
Strongly disagree	56 (33.1)
Financial problems
Strongly agree	21 (12.4)
Agree	67 (39.6)
Disagree	60 (35.5)
Strongly disagree	21 (12.4)
Less-competent to be an ObGyn specialist
Strongly agree	12 (7.10)
Agree	77 (45.5)
Disagree	61 (36.0)
Strongly disagree	19 (11.2)

Overall no significant statistical relationship were revealed between social factors (such as age, levels of residency, marital status, living status, and COVID-19 exposure during clinical pandemic (Tables 3, 4, and 5). They were most likely to have minimal anxiety, not in a depressed condition, and revealed a psychological trauma with mild symptoms. Less than 5% of all participants experienced moderate to severe anxiety, moderate to severe level of depression, and psychological trauma with severe symptoms.

Table 3.

Relationship between social factors and anxiety levels.

Social Factors	Minimal anxiety	Mild anxiety	Moderate anxiety	Severe anxiety	P-value
Age	31 (26–40)	30 (27–42)	28.5 (28–29)		0.064
Year of residency training program					0.670
First year	20 (76.9)	5 (19.2)	1 (3.8)	0 (0)
Second year	28 (84.8)	4 (12.1)	1 (3)	0 (0)
Third year	24 (85.7)	3 (10.7)	0 (0)	1 (3.5)
Fourth year	35 (85.3)	6 (14.6)	0 (0)	0 (0)
Fifth year	37 (90.2)	4 (9.7)	0 (0)	0 (0)
Educational institution					0.085
University of Indonesia	99 (86)	14 (12.1)	2 (1.7)	0 (0)
University of Lambung Mangkurat	14 (70)	6 (30)	0 (0)	0 (0)
University of Syiah Kuala	31 (91.1)	2 (5.8)	0 (0)	1 (2.9)
Marital status					0.780
Married	62 (87.3)	9 (12.6)	0 (0)	0 (0)
Single	82 (83.6)	13 (13.2)	2 (2)	1 (1)
Living status					0.592
Alone	52 (83.8)	9 (14.5)	1 (1,6)	0 (0)
With spouse	50 (84.7)	9 (15.2)	0 (0)	0 (0)
With parents	42 (87.5)	4 (8.3)	1 (2)	1 (2)
Clinical rotation exposed with COVID-19					0.514
Exposed with COVID-19	32 (82)	6 (15.3)	1 (2.5)	0 (0)
Unexposed to COVID-19	112 (86.1)	16 (12.3)	1 (0.7)	1 (0.7)

Table 4.

Relationship between social factors and depression levels.

Social Factors	Not depressed	Mild depression	Moderate depression	Moderate-severe depression	P-value
Age	31 (26–42)	31 (26–40)	31 (28–36)	30 (29–31)	0.900
Year of residency training program					0.324
First year	21 (80.7)	2 (7.6)	3 (11.5)	0 (0)
Second year	26 (78.7)	6 (18.1)	0 (0)	1 (3)
Third year	21 (75)	4 (14.2)	3 (10.7)	0 (0)
Fourth year	29 (70.7)	9 (21.9)	3 (7.3)	0 (0)
Fifth year	28 (68.2)	11 (26.8)	1 (2.4)	1 (2.4)
Educational institution					0.773
University of Indonesia	82 (71.3)	23 (20)	8 (6.9)	2 (1.7)
University of Lambung Mangkurat	14 (70)	5 (25)	1 (5)	0 (0)
University of Syiah Kuala	29 (85.2)	4 (11.7)	1 (2.9)	0 (0)
Marital status					0.461
Single	53 (74.6)	12 (16.9)	4 (5.6)	2 (2.8)
Married	72 (73.4)	20 (20.4)	6 (6.1)	0 (0)
Living status					0.837
Alone	44 (70.9)	12 (19.3)	5 (8)	1 (1.6)
With spouse	43 (72.8)	13 (22)	3 (5)	0 (0)
With parents	38 (79.1)	7 (14.5)	2 (4.1)	1 (2)
Clinical rotation exposed with COVID-19					0.910
Exposed to COVID-19	31 (79.4)	6 (15.3)	2 (5.1)	0 (0)
Unexposed to COVID-19	94 (72.3)	26 (20)	8 (6.1)	2 (1.5)

Table 5.

Relationship between social factors and psychological trauma.

Social Factors	Mild symptoms	Moderate symptoms	Severe symptoms	P-value
Age	31 (26–42)	31 (26–36)	30 (29–32)	0.604
Year of residency training program				0.434
First year	22 (84.6)	4 (15.3)	0 (0)
Second year	28 (84.8)	4 (12.1)	1 (3)
Third year	25 (89.2)	3 (10.7)	0 (0)
Fourth year	30 (73.1)	7 (17)	4 (9.7)
Fifth year	30 (73.1)	10 (24.3)	1 (2.4)
Educational institution				0.994
University of Indonesia	92 (80)	19 (16.5)	4 (3.4)
University of Lambung	15 (75)	4 (20)	1 (5)
Mangkurat	28 (82.3)	5 (14.7)	1 (2.9)
University of Syiah Kuala
Marital status				0.279
Married	58 (81.6)	9 (12.6)	4 (5.6)
Single	77 (78.5)	19 (19.3)	2 (2)
Living status				0.896
Alone	48 (77.4)	11 (17.7)	3 (4.8)
With spouse	49 (83)	8 (13.5)	2 (3.3)
With parents	38 (79.1)	9 (18.7)	1 (2)
Clinical rotation exposed with COVID-19				0.213
Exposed with COVID-19	35 (89.7)	4 (10.2)	0 (0)
Unexposed to COVID-19	100 (76.9)	24 (18.4)	6 (4.6)

4. Discussion

The participants of this research were ObGyn residents from three different universities located in Indonesia. The average age of the participants was 31 (range 26–42) years with the majority of participants in the 4th and 5th year of standardized residency training. Balance distribution of total participants provides an advantage to obtain a good variation of results to describe the population.

Despite an approximate 85% of the participants classified as minimal anxiety, 2% experienced moderate to severe anxiety. On the other hand, 7% had moderate to severe depression compared with 18.9% who experienced mild depression. The results in this study showed a lower value than previous studies, particularly in the outcome of anxiety and depression. Meta-analysis by Li et al. shows that the incidence of anxiety is 22% along with depression which accounted for 21% [15]. Another study conducted in Indonesia on health workers showed a high level of anxiety in 33% of all research subjects during pandemic [13]. These discrepancies might be caused by a different population of only ObGyn resident physicians included in our study. Previous research showed that 26% pregnant women did not perform antenatal care during the pandemic which supported the abovementioned factors [14]. Limited exposure to patients with symptoms of COVID-19, decreasing workload, and COVID-19 screening before taking care of patients can produce a secure feeling that reduces the occurrence of anxiety and depression. Those who suffered from psychological trauma, however, revealed a higher percentage (20%) compared to other psychopathologies. This result appeared to be similar with the previous study (21.5%) [15].

ObGyn residents felt that COVID-19 has brought a negative impact to the training program. The negative perception of ObGyn residents can be studied further with the perception of the adaptation, moral, training guidance, performance, health, and financial condition. Fifteen percent experienced learning adaptation difficulties during the pandemic. Adaptation can occur in both teaching and learning processes with long distance learning which has never been done before, as well as in providing patient care services during pandemic. Majorities have preferences in performing services inside the department due to the presence of more optimal guidance by the teachers. In addition, a tertiary hospital would affect the types of patients. In a tertiary hospital, patients surely have undergone meticulous screening and gradual referrals. In this study, it can be shown that the residents' moral declined because of the pandemic. This was also demonstrated by the presence of unchanged or increased moral in 60% participants. Eighty percent of total participants considered an average to excellent quality of training guidance. This good result was strongly influenced by the effectiveness of long-distance learning which was classified as moderate to very good in 85% subjects. The use of internet platforms and new teaching modalities greatly influences resident teaching during pandemic. All educational institutions suspended their face-to-face teaching, providing online lecture to guarantee students' teaching and their right to study do to the lockdown period [3, 16]. The use of several meeting platforms from the internet for the dissemination of teaching material and educational meetings, however, has built bridges, albeit virtual, between resident and teachers [15]. The development of new and more structured teaching modalities is crucial to increase the effectiveness of teaching, compared to direct teaching.

However, the drawback of using internet platforms during this pandemic is the lack of clinical practice, especially in the field of surgery, expressed in the residents' concern of being less competent ObGyn specialists. Hence, this issue should be tackled accordingly by dividing working shifts with a smaller number of residents to reduce the spread of disease [17].

Analysis between social factors and psychological trauma showed no significant relationship with anxiety disorders, depression, and psychological trauma. This might be caused by the low prevalence of anxiety and depression found in this study, thus, it could not describe the social factors that exist in the population.

The level of anxiety in this study showed a non-significant relationship with age, year of residency training program, and institution. Only one subject experienced severe anxiety whereas two subjects experienced moderate anxiety. Previous studies have shown that anxiety level in younger subjects is lower than in older subjects [18]. The relationship between marital status and living conditions with the level of anxiety showed no significant results due to the limited number of research subjects experiencing anxiety during the pandemic. The increased anxiety levels could be caused by concern about the possibilities of transmitting COVID-19 to the closest family especially to married participants.

In depressive disorders, residents' age did not show a significant difference between groups. Previous studies have revealed that the highest risk at being depressed was experienced by age group 21–25 years, followed by the group consists of 26–30 years and 31–35 years, consecutively [17]. The incidence of moderate to severe depression was also resulted higher in residents from University of Indonesia compared to the two others with a 9% prevalence. University of Indonesia is both a teaching hospital and a tertiary hospital which is the main national referral hospital. This reason led to a greater workload and higher teachers' expectations of ObGyn residents. Marital status and living conditions did not show significant results. All participants who felt major depression were residents who were not-yet married. This can be caused by the influence of marriage on the incidence of depression [19]. Spouse support has been identified as a major protective factor against depression in difficult circumstances. Apparently, exposure to COVID-19 during clinical rotation did not reduce the incidence of depression in ObGyn residents.

Participants with mild, moderate, and severe symptoms of psychological trauma had an age ranged 30–31 years. Previous research revealed that incidence of psychological trauma generally increases with age [20]. However, the age range between 26 and 42 years of the participants indicated that there was a limitation of age variation. This was also shown by the non-significant relationship between year of residency and psychological trauma. The incidence of psychological trauma with severe symptoms was mostly found at the 4th year of residency because of the workload and exposure to different stressors compared to other levels. Workload and stressors in the workplace can increase the risk of psychological trauma [21].

Psychological trauma with severe symptoms mostly occurs in ObGyn residents from the University of Indonesia for similar reasons. Social support from the closest ones is of utmost importance. Studies have proven a decreased complex psychological trauma in married subjects [12, 19, 21]. Clinical rotations exposed to COVID-19 did not show significant results on the severity of symptoms of psychological trauma. Many of the residents reported undergoing severe psychological trauma related to their concern over contracting the disease after being exposed to COVID-19, fear they would infect their family and having to witness the death of close colleagues, which was considered an emotional loss and a reminder of the risk they themselves were taking.

Our study has several limitations. This study was conducted in only three institutions in Indonesia that provide ObGyn residency, and thus, further research including other institutions which provide ObGyn residency is needed to validate and extend these findings in similar situations as well as outbreaks of other infectious diseases. Other factors that could potentially contribute to the complex psychosocial responses of an individual such as personality variables, cognitive appraisal mechanisms, and past trauma were not examined in this study. Our study is a cross-sectional study therefore it is not possible to establish cause-effect relationships. This study use self-referenced questionnaires and it is possible that there are no errors when measuring the variables, also the questionnaire were taken online without random sampling so the results cannot be directly extrapolated to the rest of the population of medical residents.

Despite the limitations, our study provide initial information and stepstone regarding social factors influence on anxiety, depression level, and psychological trauma of ObGyn residents during COVID-19 pandemic. This may increase the need to evaluate mental health problems during COVID-19 pandemic on ObGyn residents in other institutions, other residents or healthcare workers in general as they are at a high risk of experiencing mental health problems.

5. Conclusion

In conclusion, the rapidly spreading COVID-19 on a global scale has led many educational systems to face tough times due to social distancing recommendation. ObGyn residents who should quickly adapt into the current situation experienced a negative impact due to COVID-19 pandemic. However, our study concluded that social factors did not influence the occurrence of anxiety, depression, and psychological trauma of the ObGyn residents during COVID-19 pandemic.

Declarations

Author contribution statement

Donny Damiar Santoso Lukman: Performed the experiments; Analyzed and interpreted the data; Wrote the paper.

Mila Maidarti; Achmad Kemal Harzif; Kanadi Sumapraja: Conceived and designed the experiments; Wrote the paper.

Fistyanisa Elya Charilda; Azizah Fitriayu Andyra: Analyzed and interpreted the data; Wrote the paper.

Natalia Widiasih Raharjanti; Monika Kristi Levania; Hilwah Nora; Cut Meurah Yeni; Hardyan Sauqi; Ferry Armanza: Analyzed and interpreted the data.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability statement

The authors are unable or have chosen not to specify which data has been used.

Declaration of interest’s statement

The authors declare no competing interests.

Additional information

No additional information is available for this paper.