The Open Dentistry Journal




ISSN: 1874-2106 ― Volume 14, 2020
RESEARCH ARTICLE

Dentists’ Self-perception on Teledentistry: The Changing Landscape Driven by Technological Booming in the 21stCentury.



Alla T. Alsharif1, Shaima S. Al-harbi2
1 Department of Preventive Dental Sciences, Taibah University Dental College & Hospital, Prince, Naif Ibn Abdulazia, Al-Madinah Al-Munawwrah, 42353, Saudi Arabia
2 Department of Conservative Dental Sciences, Jouf University College of Dentistry, Al Aziziyyah, Sakaka , Al Jawf, 72345, Saudi Arabia

Abstract

Aim:

Teledentistry has gained popularity worldwide because it is cost-effective and increase accessibility to dental healthcare. This study assessed the self-perceptions of teledentistry among dental practitioners in Saudi Arabia and examinedany gender-related differences.

Methods:

This cross-sectional study was conducted between January and December 2017 and recruited a convenience sample of dental practitioners, whose self-perceptions of the practice-related use of teledentistry were assessed viaateledentistry survey (TDS). The TDS consisted off our sections:efficiency in patient care, cost reduction,capabilities forimproving practice, and security and confidentiality.Data analyseswere conducted throughdescriptive statistics,internalreliability tests(Cronbach’s alpha), andchi-squaredtests of the TDS.

Results:

The response rate was 620/800(78%). Most respondents were female (62%), and 58% of themworked in the public sector. The internal reliability of the TDS was 0.85 for the whole sampleand 0.85 and 0.90 for males and females, respectively. Among the entire sample, 51% agreed that teledentistry reduced potential cost, and 65% reported shortened waitlists. More females (42%, p<0.001) than males (22%) agreed that teledentistry could help monitor a patient’s condition.More females (35%) than males (13%, p<0.001) considered that teledentistry would require additional appointments for imaging. More females(29%, p=0.0001) than males (22%) expressed great concern aboutpotential violations of confidentiality.

Conclusion:

These findings suggest thatteledentistry in dental practiceis well perceived by practitioners in Saudi Arabia. Gender differences in perceptions are linked to certain aspects of teledentistry.

Keywords: Dentists, Self-perception, Technology, Teledentistry, Teledentistry survey, Sociodemographic characteristics.


Article Information


Identifiers and Pagination:

Year: 2020
Volume: 14
First Page: 291
Last Page: 297
Publisher Id: TODENTJ-14-291
DOI: 10.2174/1874210602014010291

Article History:

Received Date: 24/02/2020
Revision Received Date: 13/04/2020
Acceptance Date: 19/04/2020
Electronic publication date: 16/06/2020
Collection year: 2020

© 2020 Alsharif and Al-harbi

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Preventive Dental Sciences, Taibah University Dental College & Hospital, Prince, Naif Ibn Abdulazia, Al-Madinah Al-Munawwrah, 42353, Saudi Arabia; Tel: +966 504665331; E-mail: dr-alsharif@hotmail.com





1. INTRODUCTION

In healthcare, the fields of Information Technology (IT) and telecommunication are continuously evolving. Terms,like “telemedicine,”“teledentistry,”and “telepharmacy” have emerged in recent decades [1Chen JW, Hobdell MH, Dunn K, Johnson KA, Zhang J. Teledentistry and its use in dental education. J Am Dent Assoc 2003; 134(3): 342-6.
[http://dx.doi.org/10.14219/jada.archive.2003.0164] [PMID: 12699048]
]. The word“teledentistry” was first introduced inthe year1997 by Cook, who defined it as “the practice of using videoconferencing technologies to diagnose and provide advice about treatment over distance” [2Dasgupta A, Deb S. Telemedicine: A new horizon in public health in India. Indian J Community Med 2008; 33(1): 3-8.
[http://dx.doi.org/10.4103/0970-0218.39234] [PMID: 19966987]
, 3Prasai Dixit L, Shakya A, Shrestha M, Shrestha A. Dental caries prevalence, oral health knowledge and practice among indigenous Chepang school children of Nepal. BMC Oral Health 2013; 13: 20.
[http://dx.doi.org/10.1186/1472-6831-13-20] [PMID: 23672487]
].

Teledentistryis being used with increasing frequency around the world – particularly in North America, Australia, South Africa, and the Scandinavian countries [4Estai M, Bunt S, Kanagasingam Y, Tennant M. Cost savings from a teledentistry model for school dental screening: An Australian health system perspective. Aust Health Rev 2018; 42(5): 482-90.
[http://dx.doi.org/10.1071/AH16119] [PMID: 28578759]
-7Lienert N, Zitzmann NU, Filippi A, Weiger R, Krastl G. Teledental consultations related to trauma in a Swiss telemedical center: A retrospective survey. Dent Traumatol 2010; 26(3): 223-7.
[http://dx.doi.org/10.1111/j.1600-9657.2010.00873.x] [PMID: 20406276]
]. In addition, a growing body of literature has investigated theideaand efficacy of teledentistry. For instance, a qualitative andsystematic reviewof 39 studies,which reported attitudes toward teledentistry and the implementation of teledentistry in practice, concluded that “there isa high acceptability for teledentistry amongst clinicians and patients alike” [8Irving M, Stewart R, Spallek H, Blinkhorn A. Using teledentistry in clinical practice as an enabler to improve access to clinical care: A qualitative systematic review. J Telemed Telecare 2018; 24(3): 129-46.
[http://dx.doi.org/10.1177/1357633X16686776] [PMID: 28092220]
]. Teledentistry is also considered a practical and potentially cost-effective method,overcoming geographical time barriers, and increasing access to healthcare services. It has great potential foraddressing challenges at both the patient and providerlevels, especially when dental expertise is urgently required [9Arora S, Dwivedi S, Vashisth P, Mittal M, Nayak S. Teledentistry: A review. Ann Dental Special 2014; 2(1): 11-3.
[http://dx.doi.org/10.5958/2394-4196.2014.00001.6]
].

In some contexts, gender is a significant determinant of intentions to accept new technology, but there are cases in which gender differences cannot be discerned. For example, men are found to be more technologically adeptthan women in the context of IT use computers, email, web services, electronic data management systems,etc. In contrast, the gender difference is not observed with interactionson social media platforms, but males and females do have different agendasfor using social networking sites. Females mainly use social media to maintain existing relationships, whereas males use it to make new friends [10Goswami A, Dutta S. Gender differences in technology usage: A literature review. OJBM 2016; 4(1): 51-9.
[http://dx.doi.org/10.4236/ojbm.2016.41006]
].

Exploring gender differences in the adoption of teledentistry can identify techniques through which the gender gap in teledentistry acceptance if present can be addressed. Dental institutions, both private and public, can accordingly design specific programs aimed to understand the gender difference and enhance the skills of practitioners, who are more apprehensive about using emerging dental technological applications.

However, in the Saudi Arabian context, limited evidence is available on dentists’viewsof adoptingtele dentistry and onthe gender differences affecting technology adoption between male and female general practitioners.Thus, this study assessed dental practitioners’ self-perceptions of teledentistry and searched for possible gender-related differences in Saudi Arabia.Sinceinformation and communication technology has been implemented in almost all modern daily tasks, including dental care delivery, the authors hypothesized that teledentistry would be generally well perceived by dentists in Saudi Arabia and that gender would have no role in this context.

2. MATERIALS AND METHODS

2.1. Study Design and Sampling

This cross-sectional study was conducted between January and December 2017, and the participants were recruited byconvenience sampling. The research survey was distributed using social network sites, such as Twitter, Facebook, LinkedIn, WhatsApp, etc. The researchers’ affiliation networks with their fellow dentists were also used as a strategy to recruit participants from different Saudi regions.

2.2. Measures and Data Collection

The sample size was calculated using Epi Info StatCalc, considering the population size of 16,887 licensed dentists [11AlBaker AA, Al-Ruthia YSH, AlShehri M, Alshuwairikh S. The characteristics and distribution of dentist workforce in Saudi Arabia: A descriptive cross-sectional study. Saudi Pharm J 2017; 25(8): 1208-16.
[http://dx.doi.org/10.1016/j.jsps.2017.09.005] [PMID: 29204070]
] and a 99% confidence level, with expected frequencyof50%. The sample was 164 participants from registered general dental practitioners and dental specialists working in Saudi Arabia with an acceptable power of 80%.A total of 800 anonymous, electronic, self-administered questionnaires were sent to participants using a direct link to a Google form. Upon completion of the survey, respondents were instructed to submit the web form. The web server entered the data into an Excel database created to store and retrieve data for analysis.

Additionally, the Teledentistry Survey (TDS) has become a well-known tool for assessing dental practitioners’ self-perceptions of teledentistry [12Mandall NA, Qureshi U, Harvey L. Teledentistry for screening new patient orthodontic referrals. Part 2: GDP perception of the referral system. Br Dent J 2005; 199(11): 727-9.
[http://dx.doi.org/10.1038/sj.bdj.4812969] [PMID: 16341186]
-15Mandall NA, O’Brien KD, Brady J, Worthington HV, Harvey L. Teledentistry for screening new patient orthodontic referrals. Part 1: A randomised controlled trial. Br Dent J 2005; 199(10): 659-62.
[http://dx.doi.org/10.1038/sj.bdj.4812930] [PMID: 16311569]
].

The structured questionnaire was written in English and included two sections. The first was composed of eight questions relating toparticipants’ sociodemographic characteristics (i.e., age, gender, and nationality) and qualifications (i.e., years of work experience in dentistry, location of themain job, theaverage number of hours/day spent on the internet for work-related matters and general use, and most common way of communicating with colleagues). The second section included the TDS, which comprised foursubsections. Subsection 1 contained seven questions on theusefulness of teledentistry. Subsection 2 posed five questions on teledentistry efficiency. Subsection3 presented sevenquestions onthe benefits of teledentistry, and Subsection 4 included four questions on the practice-related use of teledentistry. Responses were rated on a five-point Likert scale (1= strongly disagree,and 5 = strongly agree) [12Mandall NA, Qureshi U, Harvey L. Teledentistry for screening new patient orthodontic referrals. Part 2: GDP perception of the referral system. Br Dent J 2005; 199(11): 727-9.
[http://dx.doi.org/10.1038/sj.bdj.4812969] [PMID: 16341186]
].

2.3. Statistical Analysis

For analysis, the Excel database was exported into IBM SPSS software (ver.24.0; IBM, Chicago, IL, USA).Descriptive statistics (frequency, percentage, andmean± standard deviation) were gatheredto determine respondents’ characteristicsand dentists’perceptions and concerns in the teledentistry use. The internal consistency (Cronbach’s alpha) of the TDS was also assessed. These analyses were conducted both for the entire sample and for each gender. Chi-squared tests were similarly used to examine the interaction between genders in the TDS item responses. The TDS responses were then collated into ‘Agree and Strongly Agree, ’Neutral,’ and ‘Disagree and Strongly Disagree’ to ease interpretation. The statistical significance tests (p-values) were set to p<0.05.

3. RESULTS

3.1. Sociodemographic Characteristics of the Sample

Out of the 800survey questionnaires disseminated, 620 useful and completed surveys were analyzed.Surveys of dentists who were not licensed to practice dentistry in Saudi Arabia, dental practitioners not working in Saudi Arabia, and surveys with missing datawere excluded. The internal reliability of the TDS was 0.85 for the whole sample and 0.85 and 0.90 for males and females, respectively.

Among respondents, 373 (62.2%) were aged between 20-34 years; 415 (66.9%) were Saudi nationals; and 383 (62%) were female. Over half of the participants (354[57.1%]) were general dentists; 148 (23.9%) were dental specialists; and 118 (19%) were consultants (Table 1). 363 participants (58%) worked in the public sector, and 150 (24%) were engaged in dual practice by working in both the private and public sectors. 459 respondents (74%) had up to ten years’ clinical experience,and 161 (26%) had 11 or more (Table 1).

Table 1
Socio-demographic characteristics of the whole sample (n=620) and chi- squared test results of comparisons between males (n=237) and females (n=383) responding dentists.



3.2. Internet Usage and Preferred Medium of Communication

As shown in Table 2, 406 (66%) participants spent more than five hours per day using the internet for general purposesunrelated to dentistry, and 453 (73%) used the internet for less than four hours per day for work-related issues. The participants reported their preferred methods of communicating with colleagues to be either email (64%) or phone (64.4%). Videoconferencing (9.2%) and forums (5.2) were aless preferable medium of communication among practitioners.

3.3. Responses to the TDS Items and the Influence of Gender on Each Item

3.3.1. Efficiency in Patient Care

75%of the sample agreed that teledentistry could be useful forimprovinginteraction and communication between dentists; 70% believed it could improve interaction and communication between dentists and patients; and 69% thought it would be helpful for patients in distant or rural locations. A similar percentage (72%) either agreed or strongly agreed with the potential enhancement merits of teledentistry for providingguidance/advice, clinical training, continuous education, and efficient referrals. More females (42%, p<0.001) than males (22%) agreed or strongly agreed that a teledentistry system would help monitor a patient’s condition (Table 3).

3.3.2. Cost Reduction

A slim majority of respondentsagreed that teledentistry could potentially reduce costs (51%) and hadshortened waitlists (65%). Approximately two-thirds of participants (67%) indicated that teledentistry could help reduce unnecessary trips to hospitals. Females weresignificantly (p<0.001) more likely to agree that teledentistry would reduce dental expenses (33.7%) and shorten their waitlists (42.7%) than males (17.3% and22.3%, respectively).

Table 2
Internet usage and communication means of the whole sample (n=620) and Chi- squared test results of comparisons between males (n=237) and females (n=383) responding dentists.


Table 3
Responses of the whole sample (n-620) to Teledentistry survey and both males (n=237) and females (n=383) dentists to Teledentistry survey.


3.3.3. Capabilities to Improve Practice

Just under half of therespondents were unclear about their views concerning whether teledentistry is expensive to set up. More females (35%) than males (13%, p< 0.001) thoughtteledentistry would require additional appointments for imaging. Additionally, more females (36%) than males (14%, p< 0.01) were convinced that teledentistry could provide valid diagnoses comparable to those made in clinical settings (Table 4).

3.3.4. Security and Confidentiality

46% of the participants expressed uncertainty about technicalincompatibility. A series of chi-squared tests found that each item on the security and confidentiality ofteledentistry exhibitedgendered response patterns (p<0.05; Table 4). For example, 29% of female practitioners and 22% of male practitioners were very concerned about potential violations of confidentiality (p=0.0001), and 29% of females and 23% of males were a little or very concerned about the reliability of equipment and potential image forgery (p=0.001).

4. DISCUSSION

Although teledentistry is widely implemented in various dental fields across many countries, limited evidence is availableconcerningdentists’ perceptionsabout adopting it in Saudi Arabia. The most conspicuous general observation arising from the present data is that dentists acknowledge teledentistry for its potential to enhance patient care and improve oral health practices. This confirms the growing interest in adopting telemedicine services [16Boringi M, Waghray S, Lavanya R, Babu DB, Badam RK, Harsha N, et al. Knowledge and awareness of teledentistry among dental professionals: A cross-sectional study. J Clin Diagn Res, 2015;9(8):ZC41-17- Palmer NG, Yacyshyn JR, Northcott HC, Nebbe B, Major PW. Perceptions and attitudes of Canadian orthodontists regarding digital and electronic technology. Am J Orthod Dentofacial Orthop 2005; 128(2): 163-7.
[PMID: 16102398]
-18Alessandretti R, Borba M, Benetti P, Corazza PH, Ribeiro R, Della Bona A. Reliability and mode of failure of bonded monolithic and multilayer ceramics. Dent Mater 2017; 33(2): 191-7.
[http://dx.doi.org/10.1016/j.dental.2016.11.014] [PMID: 27986280]
].These results are promising for future technological implications in dental screening and clinical diagnosis.Teledentistry is aimed to have a strategic importance in the future. In fact, this technology fits with other recently introduced improvements, such as CAD/CAM systems, which allow a digital workflow, with clinical reliability [18Alessandretti R, Borba M, Benetti P, Corazza PH, Ribeiro R, Della Bona A. Reliability and mode of failure of bonded monolithic and multilayer ceramics. Dent Mater 2017; 33(2): 191-7.
[http://dx.doi.org/10.1016/j.dental.2016.11.014] [PMID: 27986280]
] and positive patients feedback [19Sfondrini MF, Gandini P, Malfatto M, Di Corato F, Trovati F, Scribante A. Computerized casts for orthodontic purpose using powder-free intraoral scanners: Accuracy, execution time, and patient feedback. BioMed Res Int 2018; 20184103232
[http://dx.doi.org/10.1155/2018/4103232] [PMID: 29850512]
].CAD CAM technology is easily linkable with telemedicine, and in dentistry, a completely digital workflow, from impression to final framework, is already viable in restorative dentistry, prosthodontics, and orthodontics [20Tunac AT, Celik EU, Yasa B. Two-year performance of CAD/CAM fabricated resin composite inlay restorations: A randomized controlled clinical trial. J Esthet Restor Dent 2019; 31(6): 627-38.
[http://dx.doi.org/10.1111/jerd.12534] [PMID: 31631500]
-21Della Bona A, Pecho OE, Ghinea R, Cardona JC, Pérez MM. Colour parameters and shade correspondence of CAD-CAM ceramic systems. J Dent 2015; 43(6): 726-34.
[http://dx.doi.org/10.1016/j.jdent.2015.02.015] [PMID: 25748670]
].

In Saudi Arabia, dental professionals prefer more traditional communication methods (i.e., phone calls and emails), and their least preferred modes of communication are video conferencing and forums. However, the flexible, diverse modes of telehealth are essentialforsupporting communication at a distance, especially for patients in rural and remote communities where healthcare access is usually inadequate.

Although technology provides modern and time-efficient methods to improve knowledge or facilitate work tasks, inthis study, dental practitioners used the internet for work-related purposes far less than for general information-seeking purposes. Further investigation is warranted to understand the possible reasons behind this finding.

Most participants agreed that teledentistry could optimize proper dental referrals. A high degree of accuracy was observed in several teledentistry studies when a digital intraoral photographic assessment method was compared with a direct visual examination in various clinical disciplines [23Estai M, Kanagasingam Y, Huang B, et al. Comparison of a smartphone-based photographic method with face-to-face caries assessment: A mobile teledentistry model. Telemed J E Health 2017; 23(5): 435-40.
[http://dx.doi.org/10.1089/tmj.2016.0122] [PMID: 27854186]
-26O’Brien K, McComb JL, Fox N, Bearn D, Wright J. Do dentists refer orthodontic patients inappropriately? Br Dent J 1996; 181(4): 132-6.
[http://dx.doi.org/10.1038/sj.bdj.4809188] [PMID: 8840582]
]. Thus, teledentistry has great potential to reduce inappropriate referrals and shorten the waitlist for senior consultations [27Estai M, Kanagasingam Y, Tennant M, Bunt S. A systematic review of the research evidence for the benefits of teledentistry. J Telemed Telecare 2018; 24(3): 147-56.
[http://dx.doi.org/10.1177/1357633X16689433] [PMID: 28118778]
, 28Mandall NA, O’Brien KD, Brady J, Worthington HV, Harvey L. Teledentistry for screening new patient orthodontic referrals. Part 1: A randomised controlled trial. Br Dent J 2005; 199(10): 659-62.
[http://dx.doi.org/10.1038/sj.bdj.4812930] [PMID: 16311569]
].

Another factor associated with teledentistry modulation is thefinancial cost. Half of the sampled participantsagreed that teledentistry could potentially reduce costs, and two-thirds indicated that it could reduce unnecessary expenses incurred when traveling to hospitals. Evidence indicates that the cost associated with a teledentistry model of dental screening is lower than that associated with conventional, face-to-face dental screening in both rural and urban regions [29Scuffham PA, Steed M. An economic evaluation of the Highlands and Islands teledentistry project. J Telemed Telecare 2002; 8(3): 165-77.
[http://dx.doi.org/10.1177/1357633X0200800307] [PMID: 12097178]
].The primary driver for net savings is linked to avoiding travel and accommodation and to the low salaries of dental therapists [30Estai M, Kruger E, Tennant M, Bunt S, Kanagasingam Y. Challenges in the uptake of telemedicine in dentistry. Rural Remote Health 2016; 16(4): 3915.
[PMID: 27893947]
, 31Estai M, Kanagasingam Y, Huang B, et al. The efficacy of remote screening for dental caries by mid-level dental providers using a mobile teledentistry model. Community Dent Oral Epidemiol 2016; 44(5): 435-41.
[http://dx.doi.org/10.1111/cdoe.12232] [PMID: 27111291]
].Such savings could be redirected to improve infrastructure and provide much-needed oral health services to underserved patients.

The null hypothesis of this study was rejected, as gender was a significant variable influencing theacceptance and professional use of teledentistry.More female respondents agreed that teledentistry could help monitor patients’ conditions, reduce cost, shorten waitlists, and prevent unnecessary travel to hospitals, especially in rural locations. Interestingly, female practitioners raised more concerns than male practitioners about patient confidentialityissues and the reliability of equipment associated with teledentistry practice. Females were also more convinced about the validity of diagnostic records, but, unlike the males, theybelievedteledentistry would necessitate additional appointments for photography.This confirms previous findings in the literature [10Goswami A, Dutta S. Gender differences in technology usage: A literature review. OJBM 2016; 4(1): 51-9.
[http://dx.doi.org/10.4236/ojbm.2016.41006]
,32Haluza D, Wernhart A. Does gender matter? Exploring perceptions regarding health technologies among employees and students at a medical university. Int J Med Inform 2019; 130103948
[http://dx.doi.org/10.1016/j.ijmedinf.2019.08.008] [PMID: 31442846]
]. Although our results differ to some extent from those of Zhang [33Zhang X, Guo X, Lai KH, Guo F, Li C. Understanding gender differences in m-health adoption: A modified theory of reasoned action model. Telemed J E Health 2014; 20(1): 39-46.
[http://dx.doi.org/10.1089/tmj.2013.0092] [PMID: 24161004]
],it could, nevertheless, be argued that the male gender imbalance ratio along with small sample size are the primary reasons for this rather contradictory result.Therefore, addressing gendered perceptions during teledentistry introduction mayhasten the public and private adoption of the technology.

The main limitation of this study is that it did not address thenon-technological, organizational, or political barriers associated with teledentistry. Self-selection into the study could also have biased the results; that is, those who were interested in teledentistry responded.More female practitioners were involved than males, and thus, conclusions drawn from the results must be made cautiously. The body of literature on teledentistry acceptance is also limited to the perceptions of itsend-usersandcare providers. There is not enough conclusive data on thecost-effectiveness and long-term use of teledentistry to make evidence-based policy decisions [31Estai M, Kanagasingam Y, Huang B, et al. The efficacy of remote screening for dental caries by mid-level dental providers using a mobile teledentistry model. Community Dent Oral Epidemiol 2016; 44(5): 435-41.
[http://dx.doi.org/10.1111/cdoe.12232] [PMID: 27111291]
]. Further in-depth research is required to examine patients’ acceptance of teledentistry.

CONCLUSION

Applying teledentistry in dental practice was generally well perceived by dental practitioners in Saudi Arabia. Gender differences in perceptions were linked to certain aspects of the efficiency and cost reduction of teledentistry. Although most dentists expressed positive opinions on teledentistry,female practitioners raised concerns about security and confidentiality.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Ethical clearance to conduct this study was obtained from the Research Ethical Committee of the Taibah University College of Dentistry , Saudi Arabia (TUCDREC2070209AL Harbi).

HUMAN AND ANIMAL RIGHTS

No animals were used in this research. All research procedures followed on humans were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2008.

CONSENT FOR PUBLICATION

A cover page was included in the questionnaire to summarize the study and provide the researchers’ contact details for any research related queries. No personal information (names or telephone numbers) was required for participation. All data were collected into one database without differentiation, and information confidentiality was assured.

AVAILABILITY OF DATA AND MATERIALS

The data sets analyzed during the current study are available from the corresponding author [A.A] upon request.

FUNDING

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

The authors would like to thank Anwaar M. Alruhaili, Al-Anoud A. Shahwan, Rayan M. Al-Qahtani, Abdulaziz A. AlHindi, Sarah S. Alshudukhi, Samaher M. Masmali, and Khuloud M. AlJazaeri for their assistance indata collection.

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