Assessment of personality factors amongst alcoholics and non-alcoholics in rural part of Central India: A cross-sectional study

Apurva Bezalwar; Pradip Patil

doi:10.12688/f1000research.148080.1

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Study Protocol

Assessment of personality factors amongst alcoholics and non-alcoholics in rural part of Central India: A cross-sectional study

[version 1; peer review: 1 approved with reservations]

Apurva Bezalwar ¹, Pradip Patil²

PUBLISHED 26 Apr 2024

Author details Author details

¹ Junior Resident, Professor, Department of Psychiatry ,Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India
² Professor, Department of Psychiatry ,Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, Maharashtra, India

Apurva Bezalwar
Roles: Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Pradip Patil
Roles: Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Datta Meghe Institute of Higher Education and Research collection.

Abstract

Background

Consuming alcohol has a significant negative impact on an individual’s mental, physical, and overall health in India. Recent data from the World Health Organization reveals that alcohol consumption is a leading cause of numerous fatalities. Some individuals may turn to alcohol as a way to cope with grief and anxiety; however, it diminishes the brain’s serotonin levels, potentially leading to suicidal thoughts and changes in personality. Consequently, there is an immediate need for health education and awareness campaigns addressing the consequences of alcohol use. This research aims to assess and compare the influence of personality factors on individuals who are alcohol-dependent and those who abstain from alcohol, exploring their role in the development of alcohol-related disorders in rural areas.

Methods

This in-hospital cross-sectional study is conducted among adults aged 18 to 65 in the rural region of central India. Employing a non-probability sampling method, specifically the Daniel Formula, a sample size of 180 was determined from the accessible population. The research has received approval from the ethics committee. In both the inpatient and outpatient departments of the Psychiatry unit at the hospital, individuals diagnosed with alcoholism and their non-alcoholic counterparts will be approached. Prior to providing socio-demographic information and completing questionnaires on the Alcohol Use Disorders Identification Test (AUDIT), CAGE Questionnaire, and Sixteen Personality Factor Questionnaire (16 PF), informed consent will be obtained from the participants.

Expected outcome

Upon obtaining responses to the aforementioned questionnaires, we will be able to analyze and determine the correlation of personality factors between individuals who are alcohol-dependent and those who abstain from alcohol.

Keywords

Personality, questionnaire , alcoholics, rural

Corresponding author: Apurva Bezalwar

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2024 Bezalwar A and Patil P. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Bezalwar A and Patil P. Assessment of personality factors amongst alcoholics and non-alcoholics in rural part of Central India: A cross-sectional study [version 1; peer review: 1 approved with reservations]. F1000Research 2024, 13:397 (https://doi.org/10.12688/f1000research.148080.1) First published: 26 Apr 2024, 13:397 (https://doi.org/10.12688/f1000research.148080.1) Latest published: 26 Apr 2024, 13:397 (https://doi.org/10.12688/f1000research.148080.1)

Introduction

In India, alcohol consumption significantly impacts the mental, physical, and overall well-being of individuals. According to recent data from the World Health Organization, the per capita total consumption of alcohol for individuals above 15 years of age is reported to be 6.2 liters per year or 13.5 grams of alcohol daily. Alcohol consumption is linked to approximately 5.1% of diseases, resulting in 3.3 million fatalities annually.¹ The liver rapidly absorbs alcohol, and 95% to 98% of consumed alcohol is eliminated by the kidneys.² Gururaj et al. found that hospital admission rates due to alcohol consumption have increased by 20% to 30%.³

While some people turn to alcohol to alleviate depression and anxiety temporarily, it has adverse effects on the brain by depleting the neurotransmitter serotonin, leading to suicidal tendencies and personality changes.⁴ The consequences of alcohol consumption extend to various aspects, including economic, familial, social, and physical impacts on an individual’s health and personality. Notably, alcohol-related cases constitute 17.6% of emergencies in Indian hospitals.⁵ Hence, there is an urgent need for sensitization programs and health education to manage and control the consequences of alcohol consumption.

The primary objective of the present study is to assess personality factors among alcoholics and non-alcoholics, aiming to determine the association of these factors in the rural part of central India.

Aim

To evaluate personality factors among both individuals with alcohol dependence and those without.

Objectives

1. To examine the correlation of personality factors between individuals with alcohol dependence and those without.
2. To investigate the influence of personality factors on the outcomes of alcohol-related disorders.

Rationale

Alcohol abuse contributes to three million fatalities globally annually, posing a significant public health concern. While personality is recognized as a crucial element in the origin of alcohol consumption, there is a notable lack of research in the context of alcoholics compared to non-alcoholics. Exploring this field would provide valuable insights into understanding the association of personality factors in both alcoholics and non-alcoholics.

Protocol

Methods

Study design: Cross sectional comparative hospital based study.

Study population: Individuals diagnosed with alcoholism and their counterparts, who do not have a diagnosis of alcoholism, participating in both the inpatient and outpatient departments of the Psychiatry unit at a hospital situated in the rural region of central India.

Sample size:

180 (90 alcoholics and 90 non alcoholics)

Formula used:

n = \frac{{(2 α / 2)}^{2} \cdot P \cdot (1 - P)}{d^{2}}

Where, 2α/2 is the level of significance at 5% i.e. 95%

confidence interval = 1.96

P = prevalence of drinking problem = 12.8% = 0.128

d = desired error of margin = 7% = 0.07

Therefore,

\begin{array}{l} n = \frac{1 . 96^{2} \times 0.128 \times (1 - 0.128)}{0 . 07^{2}} \\ = 87.50 \\ = 90 \end{array}

Methods

The patients’ informed consent as well as socio-demographic information will be gathered. The following questionnaire’s will subsequently be given to the patients:

1. Socio-demographic Performa
2. Alcohol Use Disorders Identification Test (AUDIT)
3. CAGE Questionnaire
4. Sixteen Personality Factor Questionnaire (16 PF)

Ethics and consent

The Institutional Ethics Committee granted approval for the study with the reference number DMIMS (DU)/IEC/2022/14 on July 15, 2022. In this study, patients selected for participation will be requested to provide their informed consent.

Inclusion criteria

1. Age between 18-65 years.
2. The patients who are clinically diagnosed with Alcohol Use Disorder using the International Classification of Diseases 10th revision (ICD-10) and ICD -11^th revision (ICD -11) Diagnostic criteria for research.
3. Patients and non-alcoholic counterparts who visit PSY OPD as well as IPD hospitalized patients and their non-alcoholic counterparts.

Patients and non-alcoholiccounterparts willing for written informed consent.

Exclusion criteria

1. Patients and non-alcoholiccounterparts not willing for written informed consent.
2. The patients who are acutely ill.
3. The patients with other co-morbid psychiatric disorders.
4. The patients with other co-morbid medical and surgical disorders

Data collection

1. Socio-demographic and Clinical Data Sheet: This study utilizes a semi-structured template specifically tailored for its purposes. The template encompasses details related to socio-demographic variables, such as the individual’s age, gender, educational background, marital status, religion, employment status, and domicile background. Additionally, the clinical data sheet captures information regarding the age of onset, precipitating factors, the course of illness, and any previous history of treatment.
2. Alcohol Use Disorders Identification Test (AUDIT): The AUDIT is a 10-item screening tool developed by the World Health Organization (WHO) to evaluate drinking behaviors, alcohol-related issues, and assess the level of alcohol consumption. A score of 8 or higher indicates a potentially hazardous or harmful pattern of alcohol consumption. This tool is validated for use with both male and female individuals and is applicable across a diverse range of ethnic groups. Moreover, it is suitable for implementation in primary care settings. The AUDIT also includes a chart at the end that delineates the number of standard drinks in different types of alcoholic beverages.
3. CAGE Questionnaire: It is a four question tool
Cut down Annoyed Guilty Eye-opener
Scoring for the CAGE questionnaire involves assigning 0 for “no” responses and 1 for “yes” responses to its items. A higher cumulative score is suggestive of potential alcohol-related problems, and a total score equal to or greater than two is considered clinically significant.
4. Sixteen Personality Factor Questionnaire (16 PF): This tool, developed by Raymond Cattell, is designed to analyze the fundamental structural elements of personality. Its primary purpose is to predict human characteristics such as altruism, leadership skills, authoritarianism, and creativity based on core personality traits. As an internationally originated instrument, it has been translated into numerous languages globally. It has undergone significant revisions, and the latest edition comprises 187 multiple-choice questions. Designed for individuals aged 16 and above, the questionnaire is untimed and features clear, straightforward instructions, making it suitable for minimal supervision at both group and individual levels. The administration time is approximately 35-50 minutes for a traditional pencil-and-paper format and 25-40 minutes for a computer-based format. The publisher provides scoring services and reports. Recent translations are adapted to local norms, ensuring reliability and validity. This questionnaire finds applications in various contexts, including counseling, basic research, and medical and educational settings. Its purpose is to offer a comprehensive and integrated understanding of an individual, aiding in the development of self-awareness, fostering rapport and empathy, and addressing adjustment issues.

Statistical analysis

The data analysis using SPSS Software version 27.0 using appropriate statistical tools. According to the scores obtained by the tools applied – CHI SQUARE TEST, Z TEST, Pearson’s Correlation Coefficient will be applied to see the association between Personality factors among alcoholics and non alcoholics. Descriptive analysis will be used for obtaining socio-demographic data of the patients. Continuous variables will be calculated by mean and standard deviation.Categorical variables will be calculated by frequency and percentage.

Ethical or other implications

The Institutional Ethics Committee has given approval for the study DMIMS (DU)/IEC/2022/14 on 15^th July 2022 and informed consent will be taken from the targeted patients and their counterparts who will be participating in this study. All participants will be assured confidentiality. They will be informed of their right to opt out of the study at any time by withdrawing their consent. The goal of the study will be completely made clear to participants.

Limitations

1. The study design is cross sectional.
2. Age of participants is 18 to 65 years.
3. Adults with medical and surgical co-morbidities and with diagnosed psychiatric illnesses are not included in this study.

Bias

Open ended questionnaire will be used for data collection to avoid measurement bias.

Discussion

A study done by Sharma et al. (2016)⁶ proposes that issues faced by alcoholics wives and coping mechanisms utilized by them were in the physical, psychological, social, and most prominently in the emotional domains. Several therapies were used successfully to lessen their pain and suffering.¹

Bekman et al. (2010) noted the role of cognitive factors regarding the consequences of not drinking and drinking under peer pressure, This links the danger of emotional and personality-based factors to young adults’ decision not to drink, and they discovered that their beliefs about not drinking and drinking under peer pressure play major roles between affective and personality types on adolescence alcohol use The varied affective profiles of risk for beginning alcohol use and its use during adolescence may be explained by these cognitive variations, and they may also offer techniques for its prevention.⁵

Littlefield and Sher (2010) concluded that the models presented are neither comprehensive nor contradictory, and they do not represent the particular way that personality could relate to problematic alcohol use. Instead, they indicate the many ways that personality may influence AUDs over the course of a person’s lifetime. Therefore, personality may have an effect on the amount of alcohol ingested and how it is used inappropriately through a number of concurrent pathways.⁷

Beaudoin et al. (1997) seen as having the personality elements of adult children of alcoholics (ACOAs), who are depressed or alcoholic. These results suggested that the characteristics that set ACOAs apart from non-ACOAs include low self-esteem, high neuroticism, and high psychoticism, and that two ways in which ACOAs can display these characteristics are through drunkenness and depression.⁸

Miller (1889) When personality characteristics between alcoholic and non-alcoholic brothers were compared, the two groups only differed on two scales: the non-alcoholic group differed more in dominance, while the alcoholic group differed more in heterosexuality.⁹

Expected outcome

Once we get answers to the above questionnaires from the 180 participants, we will be able to compare the association of personality factors amongst alcoholics and non alcoholics and to study the impact of personality factors in outcome of alcohol related disorders

Dissemination

Both a presentation of the study and its publication in an index journal are planned for National Conference Proceedings.

Study status

The participant recruiting has not yet begun.

Ethical considerations

Institutional Ethical Committee approval was obtained from Datta Meghe.

Institute of Medical Sciences, Sawangi (Meghe) Wardha on 15^th July 2022.

IEC no. - DMIMS (DU)/IEC/2022/14

Written Informed consent will be taken from the targeted patients and their counterparts who will be participating in this study.

Data availability

No data is associated with this article.

Extended data

Zenodo : STROBE checklist for 1. Apurva Bezalwar. Assessment Of Personality Factors Amongst Alcoholics And Non Alcoholics In Rural Part Of Central India : A Cross-Sectional Study. 10.5281/zenodo.8379312.¹⁰

References

1. World Health Organization: Management of Substance Abuse Unit. Global status report on alcohol and health, 2014. World Health Organization; 2014.
2. Sachdeva S, Nagar M, Tyagi A, et al.: Alcohol consumption practices amongst adult males in a rural area of Haryana. Med. J. DY Patil Univ. 2014 Mar 12; 7(2): 128. Publisher Full Text
3. Gururaj G, Isaac MK: Psychiatric epidemiology in India: Moving beyond numbers. Mental health—an Indian perspective. 1946-2003.
4. Peng MC, Chou WJ, Chen SS: Neurological problems in chronic alcoholics. Gaoxiong yixuekexue za zhi= The Kaohsiung Journal of Medical Sciences. 1991 Aug 1; 7(8): 404–412.
5. Bekman NM, Cummins K, Brown SA: Affective and personality risk and cognitive mediators of initial adolescent alcohol use. J. Stud. Alcohol. Drugs. 2010 Jul; 71(4): 570–580. PubMed Abstract | Publisher Full Text | Free Full Text
6. Sharma N, Sharma S, Ghai S, et al.: Living with an alcoholic partner: Problems faced and coping strategies used by wives of alcoholic clients. Ind. Psychiatry J. 2016 Jan; 25(1): 65–71. PubMed Abstract | Publisher Full Text | Free Full Text
7. Littlefield AK, Sher KJ: The multiple, distinct ways that personality contributes to alcohol use disorders. Soc. Personal. Psychol. Compass. 2010 Sep; 4(9): 767–782. PubMed Abstract | Publisher Full Text | Free Full Text
8. Beaudoin CM, Murray RP, Bond J Jr, et al.: Personality characteristics of depressed or alcoholic adult children of alcoholics.Pers. Individ. Differ.1997 Oct 1; 23(4): 559–67. Publisher Full Text
9. Miller L: Personality Differences in Alcoholic and Nonalcoholic Brothers ( 1964). Master's Theses. 1889. https://ecommons.luc.edu/luc_theses/1889
10. Bezalwar A: Assessment Of Personality Factors Amongst Alcoholics And Non Alcoholics In Rural Part Of Central India: A Cross-Sectional Study. Zenodo. 2023. Publisher Full Text

Comments on this article Comments (0)

Version 1

VERSION 1 PUBLISHED 26 Apr 2024

Author details Author details

¹ Junior Resident, Professor, Department of Psychiatry ,Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India
² Professor, Department of Psychiatry ,Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, Maharashtra, India

Apurva Bezalwar
Roles: Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Pradip Patil
Roles: Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (1)

version 1

Published: 26 Apr 2024, 13:397

https://doi.org/10.12688/f1000research.148080.1

Copyright

© 2024 Bezalwar A and Patil P. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Bezalwar A and Patil P. Assessment of personality factors amongst alcoholics and non-alcoholics in rural part of Central India: A cross-sectional study [version 1; peer review: 1 approved with reservations]. F1000Research 2024, 13:397 (https://doi.org/10.12688/f1000research.148080.1)

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Open Peer Review

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PUBLISHED 26 Apr 2024

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Reviewer Report 12 Sep 2024

Johnson Pradeep Ruben, St. John’s Medical College Hospital, Bengaluru, Karnataka, India

Approved with Reservations

https://doi.org/10.5256/f1000research.162347.r312294

Summary of the Protocol

The protocol is a research methodology that focusses on evaluating personality traits among rural Central India's alcoholics and non-alcoholics. The purpose of the study is to compare how personality traits affect people who ... Continue reading

Summary of the Protocol

The protocol is a research methodology that focusses on evaluating personality traits among rural Central India's alcoholics and non-alcoholics. The purpose of the study is to compare how personality traits affect people who abstain from drinking and those who suffer from alcohol dependence. A non-probability sampling technique was used to choose 180 participants for the cross-sectional comparison study, 90 of whom were alcohol use disorders and 90 of whom were not. The study is conducted in a hospital. Sociodemographic data and questionnaires such as the Alcohol Use Disorders Identification Test (AUDIT), CAGE Questionnaire, and Sixteen Personality Factor Questionnaire (16 PF) are used in the data collection process. The Institutional Ethics Committee has approved the trial, and participants' informed consent will be sought. The relationship between personality traits in alcohol use disorders and non-alcohol users will be evaluated using statistical analysis utilising SPSS software and a variety of tests. The study is still in the process of recruiting participants and intends to provide light on the role that personality variables play in alcohol-related diseases.

Major: The personality qualities of people with and without alcohol use disorders can be distinguished from this study. Finding these elements will support a therapeutic strategy that emphasises psychological input for characteristics more frequently seen in alcohol use disorders. But that is only one side of the tale; if they had been able to create an intervention based on their findings and give it a trial run on a few subjects, it might have been helpful.
Some of the queries include:
(1) what is the role of the CAGE questionnaire when you are using AUDIT. Better to use AUDIT.
(2) Kindly mention the reference study for the sample size calculations.
(3) Kindly give the rationale for using the 16 PF ; when you have newer and shorter personality scales available

Minor queries
(1) Be consistent with your terminologies in terms of alcohol dependence or Alcohol use disorders (Avoid the word “alcoholics” due to the discriminatory nature of the word.
(2) The reference Sharma et al (2016) and Beaudoin et al. (1997) are irrelevant in this study. Kindly give more relevant references.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Partly
Are the datasets clearly presented in a useable and accessible format?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Alcohol use disorders, Community Psychiatry, Digital innovations in managing depression in underserved rural areas

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Johnson Pradeep Ruben, St. John’s Medical College Hospital, Bengaluru, India

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Reviewer Report

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12 Sep 2024 | for Version 1

Johnson Pradeep Ruben, St. John’s Medical College Hospital, Bengaluru, Karnataka, India

1 Views Cite this report Responses(0)

Approved With Reservations

Summary of the Protocol

The protocol is a research methodology that focusses on evaluating personality traits among rural Central India's alcoholics and non-alcoholics. The purpose of the study is to compare how personality traits affect people who abstain from drinking and those who suffer from alcohol dependence. A non-probability sampling technique was used to choose 180 participants for the cross-sectional comparison study, 90 of whom were alcohol use disorders and 90 of whom were not. The study is conducted in a hospital. Sociodemographic data and questionnaires such as the Alcohol Use Disorders Identification Test (AUDIT), CAGE Questionnaire, and Sixteen Personality Factor Questionnaire (16 PF) are used in the data collection process. The Institutional Ethics Committee has approved the trial, and participants' informed consent will be sought. The relationship between personality traits in alcohol use disorders and non-alcohol users will be evaluated using statistical analysis utilising SPSS software and a variety of tests. The study is still in the process of recruiting participants and intends to provide light on the role that personality variables play in alcohol-related diseases.

Major: The personality qualities of people with and without alcohol use disorders can be distinguished from this study. Finding these elements will support a therapeutic strategy that emphasises psychological input for characteristics more frequently seen in alcohol use disorders. But that is only one side of the tale; if they had been able to create an intervention based on their findings and give it a trial run on a few subjects, it might have been helpful.
Some of the queries include:
(1) what is the role of the CAGE questionnaire when you are using AUDIT. Better to use AUDIT.
(2) Kindly mention the reference study for the sample size calculations.
(3) Kindly give the rationale for using the 16 PF ; when you have newer and shorter personality scales available

Minor queries
(1) Be consistent with your terminologies in terms of alcohol dependence or Alcohol use disorders (Avoid the word “alcoholics” due to the discriminatory nature of the word.
(2) The reference Sharma et al (2016) and Beaudoin et al. (1997) are irrelevant in this study. Kindly give more relevant references.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Partly
Are the datasets clearly presented in a useable and accessible format?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Alcohol use disorders, Community Psychiatry, Digital innovations in managing depression in underserved rural areas

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Respond to this report

Responses (0)

[1] 1. World Health Organization: Management of Substance Abuse Unit. Global status report on alcohol and health, 2014. World Health Organization; 2014.

[2] 2. Sachdeva S, Nagar M, Tyagi A, et al.: Alcohol consumption practices amongst adult males in a rural area of Haryana. Med. J. DY Patil Univ. 2014 Mar 12; 7(2): 128. Publisher Full Text

[3] 3. Gururaj G, Isaac MK: Psychiatric epidemiology in India: Moving beyond numbers. Mental health—an Indian perspective. 1946-2003.

[4] 4. Peng MC, Chou WJ, Chen SS: Neurological problems in chronic alcoholics. Gaoxiong yixuekexue za zhi= The Kaohsiung Journal of Medical Sciences. 1991 Aug 1; 7(8): 404–412.

[5] 5. Bekman NM, Cummins K, Brown SA: Affective and personality risk and cognitive mediators of initial adolescent alcohol use. J. Stud. Alcohol. Drugs. 2010 Jul; 71(4): 570–580. PubMed Abstract | Publisher Full Text | Free Full Text

[6] 6. Sharma N, Sharma S, Ghai S, et al.: Living with an alcoholic partner: Problems faced and coping strategies used by wives of alcoholic clients. Ind. Psychiatry J. 2016 Jan; 25(1): 65–71. PubMed Abstract | Publisher Full Text | Free Full Text

[7] 7. Littlefield AK, Sher KJ: The multiple, distinct ways that personality contributes to alcohol use disorders. Soc. Personal. Psychol. Compass. 2010 Sep; 4(9): 767–782. PubMed Abstract | Publisher Full Text | Free Full Text

[8] 8. Beaudoin CM, Murray RP, Bond J Jr, et al.: Personality characteristics of depressed or alcoholic adult children of alcoholics.Pers. Individ. Differ.1997 Oct 1; 23(4): 559–67. Publisher Full Text

[9] 9. Miller L: Personality Differences in Alcoholic and Nonalcoholic Brothers ( 1964). Master's Theses. 1889. https://ecommons.luc.edu/luc_theses/1889

[10] 10. Bezalwar A: Assessment Of Personality Factors Amongst Alcoholics And Non Alcoholics In Rural Part Of Central India: A Cross-Sectional Study. Zenodo. 2023. Publisher Full Text

Assessment of personality factors amongst alcoholics and non-alcoholics in rural part of Central India: A cross-sectional study

Abstract

Background

Methods

Expected outcome

Keywords

Introduction

Aim

Objectives

Rationale

Protocol

Methods

Methods

Ethics and consent

Inclusion criteria

Exclusion criteria

Data collection

Statistical analysis

Ethical or other implications

Limitations

Bias

Discussion

Expected outcome

Dissemination

Study status

Ethical considerations

Data availability

Extended data

References

Comments on this article Comments (0)

Open Peer Review

Comments on this article Comments (0)

Open Peer Review

Reviewer Status

Reviewer Reports

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