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[
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6
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7
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,
[
8
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T
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s
e
a
r
ch
h
i
g
h
l
i
g
h
t
s
t
h
e
w
i
d
es
p
r
e
a
d
o
cc
u
r
r
e
n
c
e
o
f
b
u
r
n
o
u
t
,
d
i
s
c
o
n
t
en
t
m
e
n
t
,
a
n
d
s
t
r
es
s
a
m
o
n
g
m
ed
i
c
a
l
p
r
o
f
es
s
i
o
n
al
s
,
e
m
p
h
a
s
i
z
i
n
g
t
h
e
c
r
it
i
c
al
n
a
t
u
r
e
o
f
u
n
d
e
r
s
t
a
n
d
i
n
g
a
n
d
c
o
n
f
r
o
n
t
i
n
g
t
h
e
s
e
c
o
n
c
e
r
n
s
i
n
o
r
d
e
r
t
o
s
a
f
e
g
u
a
r
d
t
h
e
h
e
a
l
t
h
o
f
i
n
d
i
v
i
d
u
a
l
s
a
n
d
t
h
e
i
n
t
e
g
r
i
t
y
o
f
h
e
a
l
t
h
c
a
r
e
s
y
s
t
e
m
s
a
s
a
w
h
o
l
e
[
1
1
]
,
[
1
2
]
.
T
h
e
c
o
r
r
e
l
a
t
i
o
n
b
e
t
w
e
e
n
s
t
r
ess
a
n
d
Q
o
L
i
n
t
h
e
h
e
al
t
h
c
a
r
e
s
et
t
i
n
g
,
p
a
r
t
i
c
u
l
a
r
l
y
h
o
s
p
i
t
al
s
,
is
c
o
m
p
le
x
,
t
h
u
s
a
t
h
o
r
o
u
g
h
e
x
a
m
i
n
a
t
i
o
n
o
f
t
h
e
u
n
d
e
r
l
y
i
n
g
c
a
u
s
es
is
r
e
q
u
i
r
e
d
.
T
h
is
c
o
m
p
r
e
h
e
n
s
i
o
n
i
s
c
r
u
c
i
a
l
i
n
t
h
e
d
e
v
e
l
o
p
m
e
n
t
o
f
e
f
f
i
c
a
ci
o
u
s
i
n
te
r
v
e
n
t
i
o
n
s
t
h
at
c
a
n
e
n
h
a
n
c
e
t
h
e
Q
o
L
o
f
p
h
y
s
i
c
ia
n
s
,
t
h
e
r
e
f
o
r
e
l
e
a
d
i
n
g
t
o
i
m
p
r
o
v
e
d
o
u
t
c
o
m
e
s
i
n
p
a
ti
e
n
t
c
a
r
e
[
1
2
]
,
[
1
3
]
.
L
ig
h
t
o
n
th
e
c
o
m
p
lex
ities
o
f
Qo
L
am
o
n
g
h
ea
lth
ca
r
e
p
r
o
f
es
s
io
n
als
(
HPs
)
,
u
n
d
er
s
co
r
in
g
th
e
n
ec
ess
ity
f
o
r
ad
d
itio
n
al
in
v
esti
g
atio
n
a
n
d
tailo
r
ed
in
ter
v
e
n
tio
n
s
in
t
h
is
p
ar
ticu
lar
s
ettin
g
[
1
4
]
,
[
1
5
]
.
Desp
ite
g
r
o
win
g
r
ec
o
g
n
itio
n
o
f
Qo
L
's
im
p
ac
t
o
n
HPs
,
a
co
m
p
r
eh
en
s
iv
e
ex
p
lo
r
atio
n
o
f
th
e
f
ac
to
r
s
in
f
lu
en
cin
g
Qo
L
am
o
n
g
p
h
y
s
ician
s
in
E
g
y
p
t
r
em
ain
s
r
elativ
ely
lim
ited
.
T
h
is
s
tu
d
y
aim
ed
to
ass
ess
Qo
L
am
o
n
g
p
h
y
s
ician
s
an
d
ex
p
lo
r
e
f
ac
to
r
s
af
f
ec
tin
g
it.
2.
M
E
T
H
O
D
2
.
1
.
Study
des
ig
n
A
s
u
r
v
ey
with
a
cr
o
s
s
-
s
ec
tio
n
al
d
esig
n
was
d
ev
elo
p
ed
an
d
tar
g
eted
d
o
cto
r
s
wo
r
k
in
g
at
v
ar
io
u
s
h
o
s
p
itals
o
r
clin
ics
in
E
g
y
p
t.
T
h
is
s
tu
d
y
in
clu
d
ed
p
h
y
s
ician
s
wo
r
k
in
g
in
a
n
y
h
ea
lth
ca
r
e
f
a
cility
in
E
g
y
p
t
wh
o
ag
r
ee
d
t
o
p
a
r
ticip
ate
an
d
co
m
p
lete
th
e
q
u
esti
o
n
n
air
e,
an
d
th
o
s
e
wh
o
r
ef
u
s
ed
p
a
r
ticip
atio
n
wer
e
e
x
clu
d
e
d
.
Af
ter
ex
p
lain
in
g
th
e
s
tu
d
y
p
u
r
p
o
s
e,
p
h
y
s
ician
s
wh
o
ag
r
ee
d
to
p
ar
ticip
ate
wer
e
ask
ed
to
co
m
p
lete
th
e
o
n
lin
e
s
elf
-
ad
m
in
is
ter
ed
q
u
esti
o
n
n
ai
r
e.
A
we
b
-
b
ased
s
u
r
v
ey
u
s
in
g
Go
o
g
le
Fo
r
m
s
was
cr
ea
ted
,
an
d
its
lin
k
was
s
h
ar
ed
am
o
n
g
d
o
cto
r
s
v
ia
s
o
ci
al
m
ed
ia.
Me
d
C
alc
v
er
s
io
n
1
8
.
2
.
1
wa
s
u
s
ed
to
co
m
p
u
te
th
e
s
a
m
p
le
s
ize
b
ased
o
n
p
r
io
r
r
esear
ch
b
y
Ma
q
s
o
o
d
et
a
l.
[
1
6
]
,
wh
o
r
e
v
ea
led
a
m
ea
n
Q
o
L
s
co
r
e
a
m
o
n
g
p
h
y
s
ician
s
o
f
3
.
3
±
1
.
1
.
A
s
co
r
e
o
f
th
r
ee
was
h
y
p
o
th
esized
as
a
n
u
ll
h
y
p
o
th
esis
v
alu
e.
T
h
e
to
tal
s
am
p
le
s
ize
was
1
7
7
p
h
y
s
ician
s
an
d
was
in
cr
ea
s
ed
to
2
0
0
to
co
m
p
en
s
ate
f
o
r
p
o
s
s
ib
le
n
o
n
-
r
esp
o
n
s
e.
Alp
h
a
an
d
p
o
we
r
wer
e
ad
ju
s
ted
at
0
.
0
5
an
d
0
.
8
,
r
esp
ec
tiv
ely
.
Ou
t
of
2
6
0
d
is
tr
ib
u
ted
f
o
r
m
s
,
2
5
0
HPs
p
ar
ticip
ated
in
th
is
s
u
r
v
ey
,
y
ield
in
g
a
9
6
% r
esp
o
n
s
e
r
ate
.
2
.
2
.
Resea
rc
h ins
t
rum
ent
T
h
e
o
n
lin
e
s
elf
-
a
d
m
in
is
ter
ed
q
u
esti
o
n
n
air
e
co
n
s
is
ted
o
f
tw
o
p
a
r
ts
;
th
e
f
i
r
s
t
in
clu
d
e
d
p
ar
ticip
an
ts
’
d
ata
(
ag
e,
s
ex
,
th
e
h
ig
h
est
ed
u
ca
tio
n
lev
el,
r
esid
en
ce
,
o
cc
u
p
a
tio
n
,
m
ar
ital
s
tatu
s
,
n
u
m
b
er
o
f
ch
ild
r
en
,
s
m
o
k
in
g
s
tatu
s
,
co
-
m
o
r
b
id
ities
,
wo
r
k
in
g
h
o
u
r
s
a
wee
k
,
n
i
g
h
t
s
h
if
ts
,
an
d
y
ea
r
s
o
f
ex
p
er
ien
ce
)
.
T
h
e
s
ec
o
n
d
was
th
e
W
HOQO
L
-
B
R
E
F
(
Ar
ab
ic
v
er
s
io
n
)
.
I
t
co
m
p
r
is
ed
two
g
en
e
r
al
an
d
twen
ty
-
f
o
u
r
s
p
ec
if
ic
c
o
m
p
o
n
e
n
ts
.
T
h
e
2
4
co
m
p
o
n
en
ts
wer
e
g
r
o
u
p
e
d
in
t
o
f
o
u
r
d
o
m
ain
s
: p
h
y
s
ical,
p
s
y
c
h
o
lo
g
ical,
s
o
cial
co
n
tact,
an
d
en
v
ir
o
n
m
en
tal.
E
v
er
y
item
was
r
ated
o
n
a
s
ca
le
f
r
o
m
1
t
o
5
,
with
a
h
ig
h
e
r
s
c
o
r
e
in
d
icatin
g
a
g
r
ea
ter
life
q
u
ality
.
T
h
e
av
er
ag
e
s
co
r
e
o
f
ea
ch
item
in
s
id
e
th
e
d
o
m
ain
was
u
s
ed
t
o
d
e
ter
m
in
e
th
e
d
o
m
ai
n
s
co
r
e.
T
h
e
o
v
er
all
Q
o
L
s
co
r
e
was
ca
lcu
lated
b
y
a
d
d
in
g
th
e
an
s
wer
s
to
ea
ch
s
u
b
s
ca
le.
Gr
e
ater
d
o
m
ain
s
co
r
es
in
d
icate
d
a
h
ig
h
er
Qo
L
.
T
h
e
wh
o
le
q
u
esti
o
n
n
ai
r
e
was
in
Ar
ab
ic
an
d
was
im
p
lem
e
n
te
d
in
a
p
ilo
t
s
tu
d
y
in
v
o
lv
in
g
2
0
p
a
r
ticip
an
ts
to
d
eter
m
in
e
its
clar
ity
,
tim
e
co
n
s
u
m
p
tio
n
,
an
d
d
if
f
icu
lties
,
an
d
it wa
s
m
o
d
if
ied
ac
co
r
d
in
g
ly
.
2
.
3
.
Co
ns
ent
a
nd
et
hica
l a
p
pro
v
a
l
B
ef
o
r
e
s
tar
tin
g
th
e
s
u
r
v
e
y
,
al
l
p
ar
ticip
an
ts
r
ec
eiv
e
d
a
n
ele
ctr
o
n
ic,
wr
itten
p
er
m
is
s
io
n
f
o
r
m
.
T
h
ey
wer
e
r
eq
u
ir
ed
t
o
g
iv
e
th
ei
r
co
n
s
en
t
b
ef
o
r
e
p
ar
ticip
atin
g
.
T
h
e
s
tu
d
y
was
ap
p
r
o
v
e
d
b
y
th
e
I
n
s
titu
tio
n
al
R
ev
iew
B
o
ar
d
o
f
th
e
Natio
n
al
C
an
ce
r
I
n
s
titu
te
at
C
air
o
Un
iv
e
r
s
ity
.
T
h
is
ap
p
r
o
v
al
was
g
r
an
ted
i
n
Dec
em
b
er
2
0
2
2
.
T
h
e
ap
p
r
o
v
al
n
u
m
b
e
r
f
o
r
th
e
s
tu
d
y
is
2
2
1
2
-
5
0
1
-
0
4
3
.
2
.
4
.
Da
t
a
a
na
ly
s
is
Usi
n
g
th
e
o
n
lin
e
s
u
r
v
ey
lin
k
,
MS
E
x
ce
l
s
p
r
ea
d
s
h
ee
ts
co
n
t
ain
in
g
th
e
o
b
tain
ed
d
ata
wer
e
im
p
o
r
ted
an
d
an
aly
ze
d
b
y
I
B
M
SP
SS
v
er
s
io
n
2
3
(
A
r
m
o
n
k
,
USA)
.
Usi
n
g
Ko
lm
o
g
r
o
v
-
Sm
ir
n
o
v
,
Sh
a
p
ir
o
-
W
ilk
test
,
an
d
d
ir
ec
t
v
is
u
aliza
tio
n
m
et
h
o
d
s
,
t
h
e
n
o
r
m
ality
o
f
n
u
m
er
ic
d
ata
was
ex
am
in
ed
.
N
u
m
er
ical
d
ata
wer
e
s
u
m
m
ar
is
e
d
u
s
in
g
m
ea
n
s
an
d
s
tan
d
a
r
d
d
e
v
iatio
n
s
o
r
m
ed
ian
s
an
d
r
an
g
es.
T
h
e
ca
teg
o
r
ical
d
ata
wer
e
s
u
m
m
ar
ized
u
s
in
g
n
u
m
b
er
s
an
d
p
er
ce
n
tag
es.
Stu
d
en
t'
s
t
-
tes
t
was
u
s
ed
to
co
m
p
ar
e
two
g
r
o
u
p
s
with
n
o
r
m
ally
d
is
tr
ib
u
ted
n
u
m
e
r
ic
v
ar
iab
les
.
An
aly
s
is
o
f
v
ar
ian
ce
(
ANOV
A)
was
u
s
ed
to
co
m
p
ar
e
m
o
r
e
th
an
two
g
r
o
u
p
s
with
n
o
r
m
all
y
d
is
tr
ib
u
ted
n
u
m
er
ic
v
a
r
iab
les.
Mu
ltiv
ar
iate
lin
ea
r
r
eg
r
ess
io
n
an
aly
s
is
was
u
s
ed
to
d
eter
m
in
e
p
r
ed
icto
r
s
f
o
r
ea
ch
d
o
m
ai
n
.
All te
s
ts
wer
e
two
-
tailed
.
p
-
v
alu
es<
0
.
0
5
was r
eg
ar
d
e
d
as si
g
n
if
ican
t
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
13
,
No
.
4
,
Dec
em
b
er
20
24
:
1
6
9
6
-
1
7
0
3
1698
3.
RE
SU
L
T
S AN
D
D
I
SCU
SS
I
O
N
All
o
f
th
e
2
6
0
d
is
tr
ib
u
ted
f
o
r
m
s
,
2
5
0
HPs
p
ar
ticip
ated
(
r
esp
o
n
s
e
r
ate=
9
6
%).
T
wo
-
th
ir
d
s
o
f
th
e
p
ar
ticip
an
ts
wer
e
less
th
an
f
o
r
ty
y
ea
r
s
(
6
2
.
2
%).
Fem
ales
p
r
ed
o
m
in
ated
in
th
is
s
tu
d
y
(
6
6
.
5
%).
Mo
s
t
o
f
th
e
p
ar
ticip
an
ts
wer
e
m
ar
r
ied
(
8
2
.
4
%).
Ap
p
r
o
x
im
ately
h
alf
o
f
t
h
e
p
ar
ticip
an
ts
(
5
2
.
4
%)
h
ad
a
n
MD
d
eg
r
ee
.
Mo
s
t
p
ar
ticip
an
ts
(
7
1
.
6
%)
wer
e
f
r
o
m
lo
wer
E
g
y
p
t.
A
b
o
u
t
o
n
e
-
th
i
r
d
(
3
0
.
9
%)
h
ad
c
h
r
o
n
ic
d
is
ea
s
es.
On
ly
3
.
6
%
wer
e
s
m
o
k
er
s
.
Su
r
g
ical
s
p
ec
ialties
r
ep
r
esen
ted
2
4
%.
T
h
e
m
o
s
t
f
r
e
q
u
en
tly
r
ep
o
r
ted
wee
k
ly
wo
r
k
in
g
h
o
u
r
s
ca
teg
o
r
y
was
>1
8
–
≤
3
6
h
o
u
r
s
(
4
6
.
5
%).
Ab
o
u
t
o
n
e
q
u
a
r
ter
(
2
4
.
2
%)
r
e
p
o
r
ted
h
av
in
g
ex
tr
a
wo
r
k
in
g
h
o
u
r
s
.
Ab
o
u
t
two
-
th
ir
d
s
(
6
2
.
8
%)
h
ad
a
wo
r
k
ex
p
er
ien
ce
o
f
less
th
an
o
r
eq
u
al
to
1
5
y
ea
r
s
T
ab
le
1
.
T
ab
le
2
s
h
o
ws
th
e
av
er
a
g
e
Q
OL
s
co
r
e
ac
c
o
r
d
in
g
to
th
e
W
HOQo
L
-
B
R
E
F
d
o
m
ain
s
.
T
h
e
o
v
er
all
Qo
L
s
co
r
e
was
3
.
6
4
±
0
.
8
3
5
.
T
h
e
g
en
er
al
h
ea
lth
s
co
r
e
was
3
.
5
7
±
1
.
0
2
.
T
h
e
p
h
y
s
ical
h
ea
lth
s
co
r
e
was
1
2
.
9
3
±
2
.
4
9
.
T
h
e
p
s
y
ch
o
lo
g
ical
h
ea
lth
s
co
r
e
was
1
2
.
2
9
±
2
.
6
7
.
T
h
e
s
o
cial
r
elatio
n
s
h
ip
s
co
r
e
was
1
2
.
8
7
±
3
.
2
0
.
T
h
e
en
v
ir
o
n
m
en
t sco
r
e
was 1
1
.
0
0
±
2
.
5
8
.
C
r
o
n
b
ac
h
’
s
alp
h
a
f
o
r
ea
c
h
d
o
m
ai
n
is
illu
s
tr
ated
in
T
ab
l
e
2
.
T
ab
le
1
.
Par
ticip
an
t c
h
ar
ac
ter
i
s
tics
V
a
r
i
a
b
l
e
s
N
u
mb
e
r
%
A
g
e
(
n
=
2
4
6
)
≤
4
0
1
5
3
6
2
.
2
>
4
0
93
3
7
.
8
S
e
x
(
n
=
2
4
8
)
M
a
l
e
83
3
3
.
5
F
e
mal
e
1
6
5
6
6
.
5
M
a
r
i
t
a
l
s
t
a
t
u
s
S
i
n
g
l
e
29
1
1
.
6
M
a
r
r
i
e
d
2
0
6
8
2
.
4
O
t
h
e
r
s
(
d
i
v
o
r
c
e
,
w
i
d
o
w
)
15
6
Ed
u
c
a
t
i
o
n
B
a
c
h
e
l
o
r
25
1
0
.
0
M
S
C
d
e
g
r
e
e
94
3
7
.
6
M
D
d
e
g
r
e
e
1
3
1
5
2
.
4
G
o
v
e
r
n
o
r
a
t
e
s
M
e
t
r
o
p
o
l
i
t
a
n
51
2
0
.
4
Lo
w
e
r
Eg
y
p
t
1
7
9
7
1
.
6
U
p
p
e
r
E
g
y
p
t
20
8
.
0
C
h
r
o
n
i
c
d
i
se
a
se
(
n
=
2
4
9
)
No
1
7
2
6
9
.
1
Y
e
s
77
3
0
.
9
S
mo
k
i
n
g
(
n
=
2
4
9
)
N
o
n
-
sm
o
k
e
r
2
3
3
9
3
.
6
S
mo
k
e
r
9
3
.
6
x
-
smo
k
e
r
7
2
.
8
S
p
e
c
i
a
l
t
y
(
n
=
2
4
2
)
S
u
r
g
i
c
a
l
58
2
4
.
0
N
o
n
-
s
u
r
g
i
c
a
l
1
8
4
7
6
.
0
W
o
r
k
i
n
g
h
o
u
r
s
/
w
e
e
k
(
n
=
2
4
5
)
≤
1
8
h
o
u
r
s
50
2
0
.
4
>
1
8
–
≤
3
6
1
1
4
4
6
.
5
>
3
6
–
≤
5
4
56
2
2
.
9
>
5
4
25
1
0
.
2
Ex
t
r
a
w
o
r
k
i
n
g
h
o
u
r
s (
n
=
2
4
8
)
No
1
8
8
7
5
.
8
Y
e
s
60
2
4
.
2
W
o
r
k
e
x
p
e
r
i
e
n
c
e
(
n
=
2
4
2
)
≤
1
5
1
5
2
6
2
.
8
>
1
5
90
3
7
.
2
T
ab
le
2
.
Su
m
m
a
r
y
o
f
th
e
q
u
ali
ty
-
of
-
life
s
co
r
es f
r
o
m
W
HOQo
L
-
B
R
E
F d
o
m
ain
s
V
a
r
i
a
b
l
e
s
M
e
a
n
(
S
D
)
R
a
n
g
e
(
m
in
-
m
a
x
)
C
r
o
n
b
a
c
h
’
s a
l
p
h
a
O
v
e
r
a
l
l
Q
o
L
(
sco
r
e
o
u
t
o
f
5
)
3
.
6
4
(
0
.
8
3
5
)
(
1
.
0
0
-
5
.
0
0
)
-
G
e
n
e
r
a
l
h
e
a
l
t
h
(
sc
o
r
e
o
u
t
o
f
5
)
3
.
5
7
(
1
.
0
2
)
(
1
.
0
0
-
5
.
0
0
)
-
P
h
y
s
i
c
a
l
h
e
a
l
t
h
1
2
.
9
3
(
2
.
4
9
)
(
5
.
7
1
-
1
8
.
8
6
)
0
.
7
8
3
P
sy
c
h
o
l
o
g
i
c
a
l
1
2
.
2
9
(
2
.
6
7
)
(
6
.
0
0
-
1
8
.
0
0
)
0
.
8
3
5
S
o
c
i
a
l
r
e
l
a
t
i
o
n
s
h
i
p
1
2
.
8
7
(
3
.
2
0
)
(
4
.
0
0
-
2
0
.
0
0
)
0
.
6
7
4
En
v
i
r
o
n
m
e
n
t
1
1
.
0
0
(
2
.
5
8
)
(
4
.
0
0
-
1
6
.
5
0
)
0
.
8
3
5
T
h
e
o
v
er
all
Qo
L
s
co
r
e
s
ig
n
if
ican
tly
d
if
f
e
r
ed
ac
co
r
d
in
g
to
s
m
o
k
in
g
s
tatu
s
(
p
=
0
.
0
3
7
)
.
I
t
was
s
ig
n
if
ican
tly
h
ig
h
e
r
in
n
o
n
-
s
m
o
k
er
s
(
3
.
6
6
±
0
.
8
3
)
th
a
n
in
s
m
o
k
er
s
(
3
.
2
2
±
0
.
8
3
)
.
Ad
d
itio
n
ally
,
it
s
ig
n
if
ican
tly
d
if
f
er
ed
ac
co
r
d
in
g
to
wo
r
k
in
g
h
o
u
r
s
(
p
=
0
.
0
1
4
)
.
I
t
was
s
ig
n
if
ican
tly
h
ig
h
er
in
th
o
s
e
with
t
h
e
lo
west
wo
r
k
in
g
h
o
u
r
s
o
f
≤
1
8
h
o
u
r
s
(
3
.
9
6
±
0
.
7
3
)
th
an
in
t
h
o
s
e
with
wo
r
k
i
n
g
h
o
u
r
s
o
f
>
1
8
–
≤
3
6
(
3
.
6
8
±
0
.
7
8
)
T
ab
le
3
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
Qu
a
lity o
f life
a
mo
n
g
p
h
ysici
a
n
s
in
E
g
yp
t
a
n
d
its
in
flu
en
cin
g
…
(
A
mir
a
I
s
ma
il A
b
d
elra
h
m
a
n
)
1699
T
ab
le
3
.
B
iv
ar
iate
an
aly
s
is
h
ig
h
lig
h
tin
g
m
ea
n
d
if
f
er
en
ce
s
in
s
co
r
es f
o
r
h
ea
lth
d
o
m
ain
s
Va
r
iable
s
Ove
r
a
ll
QoL
G
e
ne
r
a
l
He
a
lt
h
P
hys
ica
l
P
s
yc
hologi
c
a
l
S
oc
ial
E
nvi
r
onmen
t
M
e
a
n
(
S
D)
M
e
a
n
(
S
D)
M
e
a
n
(
S
D)
M
e
a
n
(
S
D)
M
e
a
n
(
S
D)
M
e
a
n
(
S
D)
Age
/yea
r
≤40
3.
52
(
0.
93)
3.
38
(
1.
11)
12.
76
(
2.
47)
11.
70
(
2.
64)
12.
85
(
3.
14)
10.
72
(
2.
59)
>
40
3.
85
(
0.
61)
3.
89
(
0.
77)
13.
25
(
2.
52)
13.
27
(
2.
43)
13.
02
(
3.
32)
11.
51
(
2.
47)
p
-
va
lue
0.
676
0.
298
0.
131
<
0.
001
0.
683
0.
020
S
e
x
M
a
le
3.
45
(
0.
74)
3.
54
(
0.
99)
13.
38
(
2.
23)
12.
59
(
2.
78)
12.
71
(
2.
93)
10.
61
(
2.
60)
F
e
male
3.
73
(
0.
86)
3.
58
(
1.
04)
12.
68
(
2.
59)
12.
12
(
2.
62)
12.
96
(
3.
33)
11.
19
(
2.
55)
p
-
va
lue
0.
645
0.
910
0.
034
0.
197
0.
555
0.
095
E
duc
a
ti
o
n
B
a
c
he
lor
3.
04
(
0.
93)
2.
88
(
1.
09)
12.
12
(
3.
17)
a
10.
37
(
2.
38)
a
12.
85
(
3.
26)
10.
02
(
2.
37)
a
M
S
C
de
gr
e
e
3.
48
(
0.
91)
3.
46
(
1.
06)
12.
32
(
2.
40)
a
11.
59
(
2.
70)
a
12.
33
(
3.
42)
10.
34
(
2.
67)
a
M
D
de
gr
e
e
3.
87
(
0.
66)
3.
79
(
0.
90)
13.
52
(
2.
27)
b
13.
15
(
2.
37)
b
13.
27
(
2.
98)
11.
67
(
2.
38)
b
p
-
va
lue
0.
752
0.
278
<
0.
001
<
0.
001
0.
091
<
0.
001
M
a
r
it
a
l
s
tatus
S
ingl
e
3.
62
(
0.
82)
3.
83
(
0.
85)
12.
43(
2.
82)
a
,
b
10.
85
(
3.
15)
a
11.
22
(
3.
75)
a
10.
76
(
3.
20)
M
a
r
r
ied
3.
63
(
0.
84)
3.
55
(
1.
04)
13.
13
(
2.
36)
a
12.
50
(
2.
51)
b
13.
25
(
2.
98)
b
11.
02
(
2.
50)
other
s
3.
73
(
0.
79)
3.
40
(
1.
06)
11.
12
(
2.
91)
b
12.
18
(
3.
15)
a
,
b
10.
93
(
3.
54)
a
11.
23
(
2.
53)
p
-
va
lue
0.
902
0.
309
0.
005
0.
008
<
0.
001
0.
825
C
hr
onic
d
is
e
a
s
e
No
3.
65
(
0.
83)
3.
59
(
1.
02)
13.
26
(
2.
41)
12.
27
(
2.
56)
12.
93
(
3.
20)
11.
08
(
2.
62)
Ye
s
3.
62
(
0.
86)
3.
52
(
1.
03)
12.
19
(
2.
53)
12.
31
(
2.
94)
12.
71
(
3.
21)
10.
82
(
2.
52)
p
-
va
lue
0.
107
0.
259
0.
002
0.
905
0.
617
0.
459
S
moki
ng
Non
-
s
moker
3.
66
(
0.
83)
a
3.
59
(
1.
03)
12.
95
(
2.
53)
12.
26
(
2.
66)
12.
86
(
3.
22)
11.
01
(
2.
58)
S
moker
3.
22
(
0.
83)
b
3.
11
(
0.
93)
12.
51
(
1.
67)
13.
56
(
2.
45)
13.
48
(
2.
53)
10.
50
(
1.
71)
x
-
s
moker
3.
43
(
0.
98)
a
,
b
3.
43
(
0.
98)
12.
33
(
2.
29)
11.
14
(
3.
39)
12.
19
(
3.
80)
11.
00
(
3.
65)
p
-
va
lue
0.
037
0.
072
0.
711
0.
191
0.
727
0.
846
S
pe
c
ialty
S
ur
ge
r
ies
3.
34
(
0.
97)
3.
26
(
1.
24)
12.
52
(
2.
78)
12.
02
(
3.
09)
12.
16
(
3.
24)
10.
16
(
2.
82)
Othe
r
s
pe
c
ialti
e
s
3.
74
(
0.
78)
3.
68
(
0.
93)
13.
04
(
2.
38)
12.
39
(
2.
52)
13.
15
(
3.
19)
11.
29
(
2.
39)
p
-
va
lue
0.
601
0.
847
0.
164
0.
415
0.
041
0.
007
W
or
king
hour
s
/we
e
k
≤18
hour
s
3.
96
(
0.
73)
a
3.
78
(
1.
00)
a
13.
57
(
2.
52)
a
12.
56
(
2.
32)
13.
57
(
2.
90)
a
11.
91
(
2.
36)
a
>
18
-
≤36
3.
68
(
0.
78)
b
3.
71
(
0.
90)
b
13.
05
(
2.
32)
a
12.
39
(
2.
75)
13.
06
(
3.
29)
a
11.
07
(
2.
53)
a
>
36
-
≤54
3.
55
(
0.
81)
a
,
b
3.
46
(
1.
06)
a
,
b
12.
77
(
2.
63)
a
,
b
12.
33
(
2.
55)
12.
90
(
3.
29)
a
,
b
10.
88
(
2.
34)
a
>
54
3.
04
(
1.
02)
a
,
b
2.
76
(
1.
16)
a
,
b
11.
63
(
2.
42)
b
11.
20
(
2.
99)
11.
04
(
2.
20)
b
9.
10
(
2.
69)
b
p
-
va
lue
0.
014
0.
026
0.
013
0.
180
0.
010
<
0.
001
E
xtr
a
wor
king
hour
s
No
3.
81
(
0.
70)
3.
69
(
0.
95)
13.
19
(
2.
39)
12.
68
(
2.
46)
13.
09
(
3.
09)
11.
35
(
2.
52)
Ye
s
3.
10
(
1.
0)
3.
18
(
1.
14)
12.
11
(
2.
63)
11.
03
(
2.
96)
12.
27
(
3.
50)
9.
88
(
2.
50)
p
-
va
lue
0.
430
0.
549
0.
003
<
0.
001
0.
085
<
0.
001
W
or
k
e
xpe
r
ienc
e
≤15
3.
51
(
0.
91)
3.
41
(
1.
11)
12.
80
(
2.
45)
11.
74
(
2.
58)
12.
98
(
3.
12)
10.
73
(
2.
55)
>
15
3.
83
(
0.
64)
3.
83
(
0.
81)
13.
26
(
2.
49)
13.
21
(
2.
58)
12.
77
(
3.
30)
11.
44
(
2.
58)
p
-
va
lue
0.
615
0.
247
0.
156
<
0.
001
0.
617
0.
038
N
o
t
e
:
D
i
f
f
e
r
e
n
t
sm
a
l
l
l
e
t
t
e
r
s
i
n
d
i
c
a
t
e
s
i
g
n
i
f
i
c
a
n
t
p
a
i
r
T
h
e
g
en
e
r
al
h
ea
lth
s
co
r
e
s
i
g
n
if
ican
tly
d
i
f
f
er
ed
ac
co
r
d
in
g
to
wo
r
k
in
g
h
o
u
r
s
(
p
=
0
.
0
2
6
)
.
I
t
was
s
ig
n
if
ican
tly
h
ig
h
er
i
n
th
o
s
e
wit
h
th
e
lo
west
wo
r
k
in
g
h
o
u
r
s
o
f
≤
1
8
h
o
u
r
s
(
3
.
7
8
±
1
.
0
0
)
th
an
in
th
o
s
e
with
wo
r
k
in
g
h
o
u
r
s
o
f
>1
8
–
≤
3
6
(
3
.
7
1
±
0
.
9
0
)
T
ab
le
3
.
T
h
e
p
h
y
s
ic
al
s
co
r
e
was
s
ig
n
i
f
ican
tly
h
ig
h
er
in
m
ales
t
h
an
in
f
em
ales
(
1
3
.
3
8
±
2
.
2
3
v
s
.
1
2
.
6
8
±
2
.
5
9
,
r
esp
ec
tiv
ely
,
p
=
0
.
0
3
4
)
,
th
o
s
e
with
o
u
t
ch
r
o
n
ic
d
is
ea
s
es
th
an
in
th
o
s
e
with
(
1
3
.
2
6
±
2
.
4
1
v
s
.
1
2
.
1
9
±
2
.
5
3
,
r
esp
ec
tiv
ely
,
p
=
0
.
0
0
2
)
,
an
d
th
o
s
e
with
n
o
ex
tr
a
wo
r
k
in
g
h
o
u
r
s
th
an
i
n
th
o
s
e
with
ex
tr
a
h
o
u
r
s
(
1
3
.
1
9
±
2
.
3
9
v
s
.
1
2
.
1
1
±
2
.
6
3
,
r
esp
ec
tiv
e
ly
,
p
=
0
.
0
0
3
)
.
Ad
d
itio
n
ally
,
t
h
e
p
h
y
s
ical
s
co
r
e
s
ig
n
if
ican
tly
d
if
f
er
e
d
ac
co
r
d
in
g
to
ed
u
ca
tio
n
(
p
<
0
.
0
0
1
)
,
m
ar
ital
s
tatu
s
(
p
=0
.
0
0
5
)
,
a
n
d
wo
r
k
i
n
g
h
o
u
r
s
(
p
=
0
.
0
1
3
)
,
an
d
all
p
o
s
t h
o
c
a
n
aly
s
es a
r
e
s
h
o
wn
in
T
ab
le
3
.
T
h
e
p
s
y
c
h
o
lo
g
ical
s
co
r
e
was
s
u
b
s
tan
tially
g
r
ea
ter
in
th
o
s
e
with
ag
e
>4
0
th
a
n
i
n
t
h
o
s
e
≤
40
(1
3
.
2
7
±
2
.
4
3
v
s
.
1
1
.
7
0
±
2
.
6
4
,
p
<
0
.
0
0
1
)
,
th
o
s
e
with
n
o
ex
tr
a
wo
r
k
in
g
h
o
u
r
s
th
an
in
th
o
s
e
with
(
1
2
.
6
8
±
2
.
4
6
v
s
.
1
1
.
0
3
±
2
.
9
6
,
p
<
0
.
0
0
1
)
,
a
n
d
th
o
s
e
with
wo
r
k
ex
p
e
r
ien
ce
>1
5
y
ea
r
s
th
an
in
th
o
s
e
≤
1
5
y
e
ar
s
(
1
3
.
2
1
±
2
.
5
8
v
s
.
1
1
.
7
4
±
2
.
5
8
)
.
A
d
d
itio
n
ally
,
t
h
e
p
s
y
ch
o
lo
g
ical
s
co
r
e
d
if
f
e
r
e
d
ac
co
r
d
i
n
g
to
e
d
u
ca
tio
n
(
p
<
0
.
0
0
1
)
,
an
d
m
ar
ital
s
tatu
s
(
p
=
0
.
0
0
8
)
,
an
d
all
p
o
s
t
h
o
c
an
aly
s
es
ar
e
s
h
o
wn
in
T
a
b
le
3
.
T
h
e
s
o
cial
s
co
r
e
was
s
ig
n
if
ican
tly
h
ig
h
er
in
non
-
s
u
r
g
ical
s
p
ec
ialties
th
an
in
s
u
r
g
ical
s
p
ec
ialties
(
1
3
.
1
5
±
3
.
1
9
v
s
.
1
2
.
1
6
±
3
.
2
4
,
p
=
0
.
0
4
1
)
.
Ad
d
itio
n
ally
,
it
s
ig
n
if
ican
tly
d
if
f
er
ed
a
cc
o
r
d
i
n
g
to
m
ar
ital
s
tatu
s
(
p
<
0
.
0
0
1
)
an
d
wo
r
k
in
g
h
o
u
r
s
p
er
wee
k
(
p
=
0
.
0
1
)
,
an
d
all
p
o
s
t h
o
c
an
al
y
s
es a
r
e
illu
s
tr
ated
in
T
ab
le
3
.
T
h
e
en
v
ir
o
n
m
en
tal
s
co
r
e
was
s
ig
n
i
f
ican
tly
h
ig
h
er
in
th
o
s
e
ag
ed
>4
0
y
ea
r
s
th
an
in
th
o
s
e
≤
4
0
y
ea
r
s
(
1
1
.
5
1
±
2
.
4
7
v
s
.
1
0
.
7
2
±
2
.
5
9
,
r
esp
ec
tiv
ely
,
p
=
0
.
0
2
)
,
th
o
s
e
with
n
o
n
-
s
u
r
g
ical
s
p
ec
ialties
th
an
in
th
o
s
e
with
s
u
r
g
ical
s
p
ec
ialties
(
1
1
.
2
9
±
2
.
3
9
v
s
.
1
0
.
1
6
±
2
.
8
2
,
r
esp
ec
tiv
e
ly
,
p
=
0
.
0
0
7
)
,
th
o
s
e
with
n
o
e
x
tr
a
wo
r
k
in
g
h
o
u
r
s
th
an
in
t
h
o
s
e
with
(
1
1
.
3
5
±
2
.
5
2
v
s
.
9
.
8
8
±
2
.
5
0
,
r
esp
ec
tiv
ely
,
p
<
0
.
0
0
1
)
,
an
d
th
o
s
e
with
wo
r
k
ex
p
er
i
en
ce
>1
5
y
ea
r
s
th
an
in
th
o
s
e
≤
1
5
y
ea
r
s
(
1
1
.
4
4
±
2
.
5
8
v
s
.
1
0
.
7
3
±
2
.
5
5
,
p
=
0
.
0
3
8
)
.
Ad
d
itio
n
ally
,
t
h
e
e
n
v
ir
o
n
m
en
tal
s
co
r
e
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
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8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
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Vo
l.
13
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No
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4
,
Dec
em
b
er
20
24
:
1
6
9
6
-
1
7
0
3
1700
s
ig
n
if
ican
tly
d
if
f
e
r
ed
ac
co
r
d
i
n
g
to
e
d
u
ca
tio
n
(
p
<
0
.
0
0
1
)
an
d
wo
r
k
in
g
h
o
u
r
s
p
er
wee
k
(
p
<
0
.
0
0
1
)
,
an
d
all
p
o
s
t
h
o
c
an
aly
s
es a
r
e
s
h
o
wn
in
T
ab
le
3
.
Mu
ltiv
ar
iate
lin
ea
r
r
e
g
r
ess
io
n
an
aly
s
es
wer
e
co
n
d
u
cte
d
to
p
r
ed
ict
Q
o
L
s
co
r
es
in
d
if
f
er
e
n
t
d
o
m
ai
n
s
.
Fo
r
th
e
p
h
y
s
ical
d
o
m
ai
n
,
th
e
p
r
e
d
icto
r
s
wer
e
f
em
ale
g
e
n
d
er
(
B
=
-
0
.
1
6
6
,
p
=
0
.
0
2
5
)
,
s
in
g
le
m
ar
ital
s
tatu
s
(
B
=0
.
2
4
3
,
p
=
0
.
0
2
)
,
m
ar
r
ied
m
ar
ital
s
tatu
s
(
B
=0
.
3
3
5
,
p
=
0
.
0
0
1
)
,
p
r
esen
ce
o
f
ch
r
o
n
ic
d
is
ea
s
e
(
B
=
-
0
.
2
4
4
,
p
<0
.
0
0
1
)
,
MD
d
eg
r
ee
(
B
=0
.
2
8
3
,
p
=
0
.
0
1
2
)
,
wo
r
k
in
g
h
o
u
r
s
>3
6
–
≤
5
4
h
o
u
r
s
(
B
=
-
0
.
2
5
5
,
p
=
0
.
0
0
5
)
,
an
d
wo
r
k
in
g
h
o
u
r
s
>5
4
h
o
u
r
s
(
B
=
-
0
.
2
6
8
,
p
<
0
.
0
0
1
)
T
ab
le
4
.
Fo
r
th
e
p
s
y
ch
o
l
o
g
ical
d
o
m
ain
,
th
e
o
n
ly
p
r
ed
icto
r
was
th
e
MD
d
eg
r
ee
(
B
=3
.
7
9
9
,
p
<
0
.
0
0
1
)
.
Fo
r
th
e
s
o
cial
d
o
m
ain
,
th
e
p
r
ed
icto
r
s
wer
e
m
ar
r
ied
m
ar
ital
s
tatu
s
(
B
=0
.
3
1
5
,
p
=
0.
0
0
4
)
an
d
wo
r
k
in
g
h
o
u
r
s
>5
4
(
B
=
-
0
.
2
3
2
,
p
=
0
.
0
0
4
)
.
Fo
r
th
e
en
v
ir
o
n
m
en
tal
d
o
m
ain
,
th
e
p
r
ed
icto
r
s
wer
e
MD
d
eg
r
ee
(
B
=
0
.
2
9
0
,
p
=0
.
0
1
3
)
an
d
wo
r
k
in
g
h
o
u
r
s
>5
4
(
B
=
-
0
.
2
2
5
,
p
=
0
.
0
0
5
)
.
Fo
r
th
e
o
v
er
all
d
o
m
ain
,
th
e
s
ig
n
if
ican
t
p
r
ed
icto
r
was
wo
r
k
in
g
h
o
u
r
s
>1
8
–
≤
3
6
(
B
=0
.
2
8
1
,
p
=
0
.
0
0
3
)
T
ab
le
4
.
L
if
e
o
f
d
o
cto
r
s
p
u
ts
th
em
at
a
h
ig
h
lev
el
o
f
ch
allen
g
es
an
d
s
tr
ess
th
at
ca
n
ad
v
er
s
ely
in
f
lu
en
ce
th
eir
Qo
L
.
Ou
r
r
esear
ch
aim
ed
t
o
e
v
alu
ate
Qo
L
am
o
n
g
p
h
y
s
ician
s
an
d
e
x
p
lo
r
e
th
e
i
n
f
lu
en
ci
n
g
f
ac
to
r
s
af
f
ec
tin
g
it
b
y
ap
p
ly
i
n
g
a
co
n
cise
v
er
s
io
n
o
f
th
e
W
HO
q
u
esti
o
n
n
a
ir
e,
th
e
W
HOQO
L
-
B
R
E
F,
d
esig
n
ed
f
o
r
Qo
L
ev
alu
atio
n
.
O
u
r
wo
r
k
was
c
o
n
d
u
cted
in
E
g
y
p
t,
a
n
atio
n
wh
o
s
e
h
ea
lth
ca
r
e
s
y
s
tem
is
s
ig
n
if
i
ca
n
tly
b
u
r
d
en
e
d
b
y
a
h
ig
h
d
em
a
n
d
f
o
r
m
ed
ical
s
er
v
ices
an
d
a
r
elativ
ely
lim
ited
n
u
m
b
er
o
f
p
h
y
s
ician
s
.
T
h
is
d
is
p
ar
ity
b
etwe
en
th
e
p
o
p
u
latio
n
'
s
h
ea
lth
ca
r
e
r
eq
u
ir
em
en
ts
an
d
th
e
av
ailab
le
h
ea
l
th
ca
r
e
wo
r
k
f
o
r
ce
cr
ea
tes
s
ig
n
if
ican
t
o
b
s
tacle
s
to
g
u
ar
an
teein
g
ex
ce
llen
t
h
ea
lth
ca
r
e
d
eliv
er
y
an
d
m
ay
af
f
ec
t
p
h
y
s
ician
s
'
h
ea
lth
[
1
7
]
–
[
1
9
]
.
T
h
er
ef
o
r
e,
it
is
v
ital
to
co
m
p
r
eh
en
d
t
h
e
Qo
L
o
f
E
g
y
p
tian
p
h
y
s
ician
s
an
d
th
e
f
ac
to
r
s
t
h
at
im
p
ac
t
it
to
p
r
o
m
o
te
th
e
co
u
n
tr
y
'
s
h
ea
lth
ca
r
e
en
v
ir
o
n
m
en
t.
T
h
e
p
h
y
s
ician
s
’
well
-
b
ein
g
is
cr
u
cial
f
o
r
th
eir
s
atis
f
ac
tio
n
an
d
p
r
o
d
u
ctiv
ity
an
d
f
o
r
en
s
u
r
in
g
th
e
d
eliv
er
y
o
f
q
u
alit
y
h
ea
lth
ca
r
e
s
er
v
ices to
t
h
e
p
o
p
u
latio
n
.
T
h
e
cu
r
r
en
t
s
tu
d
y
o
b
tain
e
d
a
9
6
%
r
esp
o
n
s
e
r
ate
with
2
5
0
HPs
p
ar
ticip
atin
g
.
Mo
s
t
p
ar
tic
ip
an
ts
wer
e
u
n
d
er
f
o
r
ty
a
n
d
p
r
ed
o
m
in
an
tl
y
f
em
ale,
r
ef
lectin
g
a
cu
r
r
e
n
t
in
ter
n
atio
n
al
a
n
d
n
atio
n
al
tr
en
d
o
f
“f
em
i
n
izatio
n
”
o
f
m
e
d
icin
e
[
2
0
]
,
[
2
1
]
.
T
h
e
o
v
er
all
Qo
L
s
co
r
e
was
3
.
6
4
±
0
.
8
3
5
,
with
th
e
g
r
ea
test
s
co
r
es
in
th
e
p
h
y
s
ical
h
ea
lth
d
o
m
ain
(
1
2
.
9
3
±
2
.
4
9
)
.
C
o
n
s
is
ten
t
with
o
u
r
f
in
d
in
g
s
,
a
s
tu
d
y
ass
ess
ed
th
e
p
h
y
s
ician
s
’
Qo
L
u
s
in
g
th
e
W
HOQO
L
-
B
R
E
F
q
u
esti
o
n
n
air
e.
T
h
e
y
r
e
p
o
r
te
d
a
r
esp
o
n
s
e
r
ate
o
f
9
3
%.
On
th
e
o
th
er
h
a
n
d
,
a
s
tu
d
y
co
n
d
u
cte
d
in
C
h
in
a
am
o
n
g
clin
ician
s
h
a
d
a
r
esp
o
n
s
e
r
ate
o
f
8
4
.
6
%
[
2
2
]
,
an
d
an
o
th
e
r
s
tu
d
y
in
I
n
d
ia
am
o
n
g
Me
d
ical
s
tu
d
en
ts
m
en
tio
n
ed
a
r
esp
o
n
s
e
r
ate
o
f
7
7
%
[
2
3
]
.
T
h
er
ef
o
r
e,
we
r
ea
s
o
n
o
u
r
g
o
o
d
r
e
s
p
o
n
s
e
r
ate
to
th
e
s
im
p
lifie
d
way
o
f
s
h
o
win
g
th
e
q
u
esti
o
n
n
air
e
o
n
lin
e
an
d
c
o
n
tactin
g
p
ar
ticip
an
ts
in
s
o
cial
m
ed
ia
m
ess
ag
in
g
ap
p
s
,
wh
ich
en
c
o
u
r
a
g
ed
th
e
m
to
co
m
p
lete
th
e
s
u
r
v
ey
.
O
u
r
f
i
n
d
i
n
g
s
w
e
r
e
i
n
li
n
e
w
it
h
M
a
q
s
o
o
d
e
t
a
l
.
[
1
6
]
.
I
n
t
h
e
i
r
f
i
v
e
-
c
i
t
y
,
m
u
l
ti
-
c
e
n
t
e
r
r
es
e
a
r
c
h
i
n
S
a
u
d
i
A
r
a
b
i
a
,
t
h
e
W
H
O
Q
o
L
-
B
R
E
F
in
s
t
r
u
m
e
n
t
w
as
e
m
p
l
o
y
e
d
t
o
r
e
c
o
r
d
t
h
e
Q
o
L
v
i
a
a
n
e
l
e
c
t
r
o
n
i
c
i
n
s
t
it
u
t
i
o
n
a
l
s
u
r
v
e
y
.
T
w
o
h
u
n
d
r
e
d
n
i
n
e
t
y
HP
s
p
a
r
ti
c
i
p
a
t
e
d
i
n
t
h
e
s
t
u
d
y
.
T
h
e
q
u
al
i
t
y
-
of
-
l
i
f
e
s
c
o
r
es
we
r
e
3
.
6
6
±
0
.
8
8
f
o
r
t
h
e
g
e
n
e
r
a
l
h
e
a
l
t
h
d
o
m
a
i
n
,
1
1
.
6
7
±
2
.
1
6
f
o
r
t
h
e
p
h
y
s
i
c
a
l
d
o
m
ai
n
,
1
3
.
0
8
±
2
.
1
4
f
o
r
t
h
e
p
s
y
c
h
o
l
o
g
i
c
a
l
d
o
m
a
i
n
,
1
3
.
2
2
±
3
.
3
1
f
o
r
t
h
e
s
o
c
i
al
d
o
m
a
i
n
,
a
n
d
1
2
.
3
8
±
2
.
5
9
f
o
r
t
h
e
e
n
v
i
r
o
n
m
e
n
t
a
l
d
o
m
a
i
n
.
T
h
e
o
v
e
r
a
l
l
s
c
o
r
e
w
as
3
.
3
7
±
0
.
9
7
.
T
h
e
cu
r
r
en
t
d
em
o
n
s
tr
ated
s
e
v
er
al
s
ig
n
if
ican
t
ass
o
ciatio
n
s
b
etwe
en
d
em
o
g
r
ap
h
ic
an
d
wo
r
k
-
r
elate
d
f
ac
to
r
s
an
d
Qo
L
s
co
r
es.
No
n
-
s
m
o
k
er
s
h
ad
h
ig
h
e
r
o
v
er
all
Q
o
L
s
co
r
es
co
m
p
ar
ed
to
s
m
o
k
e
r
s
.
W
o
r
k
in
g
f
ewe
r
h
o
u
r
s
was
ass
o
ciate
d
with
h
i
g
h
er
o
v
er
all
a
n
d
g
en
er
al
h
ea
l
th
s
co
r
es.
Ma
les,
th
o
s
e
with
o
u
t
ch
r
o
n
ic
d
is
ea
s
es,
an
d
th
o
s
e
wh
o
d
id
n
o
t
wo
r
k
ad
d
itio
n
al
h
o
u
r
s
h
ad
b
ette
r
p
h
y
s
ical
h
ea
lth
s
co
r
es.
Ag
e
>
4
0
,
n
o
ex
tr
a
wo
r
k
i
n
g
h
o
u
r
s
,
a
n
d
wo
r
k
ex
p
er
ien
ce
o
f
>
1
5
y
ea
r
s
wer
e
ass
o
ciate
d
with
h
ig
h
er
p
s
y
ch
o
l
o
g
ical
s
co
r
es.
No
n
-
s
u
r
g
ical
s
p
ec
ialties
h
ad
h
ig
h
e
r
s
o
cial
s
co
r
es,
wh
ile
o
ld
e
r
ag
e
,
n
o
n
-
s
u
r
g
ical
s
p
ec
ialties
,
n
o
e
x
tr
a
wo
r
k
in
g
h
o
u
r
s
,
a
n
d
lo
n
g
er
wo
r
k
ex
p
er
ie
n
ce
wer
e
ass
o
ciate
d
with
h
ig
h
er
en
v
ir
o
n
m
en
tal
s
co
r
es.
Alm
alk
i
et
a
l.
[
2
4
]
r
e
p
o
r
ted
th
at
f
em
ales
an
d
th
o
s
e
with
n
o
ex
t
r
a
wo
r
k
i
n
g
h
o
u
r
s
h
ad
h
ig
h
er
p
h
y
s
ical
h
ea
lth
s
co
r
es.
Ph
y
s
ical
h
ea
lth
s
co
r
e
was
s
ig
n
if
ican
tly
ass
o
ciate
d
with
th
e
ag
e
o
f
th
e
d
o
cto
r
s
,
with
d
o
cto
r
s
b
etwe
en
3
0
-
3
9
y
ea
r
s
h
a
v
in
g
th
e
lo
west sco
r
e
co
m
p
ar
ed
to
th
e
o
th
e
r
ag
e
g
r
o
u
p
s
.
Ad
d
itio
n
ally
,
a
g
e
was
s
ig
n
if
ican
tly
r
elate
d
to
p
s
y
ch
o
l
o
g
ical
h
ea
lth
,
with
th
e
d
o
ct
o
r
s
b
etwe
en
3
0
–
3
9
an
d
b
etwe
en
2
0
–
2
9
y
ea
r
s
h
av
in
g
th
e
lo
west
s
co
r
e
co
m
p
ar
e
d
t
o
th
e
r
em
ain
in
g
a
g
e
g
r
o
u
p
s
.
I
n
c
o
n
tr
ast,
th
ey
r
ep
o
r
ted
th
at
n
o
n
-
s
u
r
g
ical
s
p
ec
ialties
,
s
u
ch
as
p
ed
iatr
ics,
wer
e
n
o
ticed
to
h
av
e
th
e
least o
v
er
all
Qo
L
.
Ma
q
s
o
o
d
et
a
l.
[
1
6
]
r
e
p
o
r
ted
th
at
ag
e
ab
o
v
e
4
0
,
m
ale
g
en
d
er
,
m
ar
r
ia
g
e,
wo
r
k
ex
p
er
ien
c
e
o
f
m
o
r
e
th
an
1
5
y
ea
r
s
,
an
d
n
o
a
d
d
itio
n
al
wo
r
k
h
o
u
r
s
wer
e
ass
o
ciate
d
with
b
etter
s
co
r
es
f
o
r
s
ev
er
al
Qo
L
d
o
m
ain
s
an
d
th
e
o
v
er
all
Q
o
L
.
Of
n
o
te,
s
taf
f
o
v
e
r
4
0
wo
u
ld
h
a
v
e
h
a
d
m
o
r
e
wo
r
k
ex
p
e
r
ien
ce
an
d
a
g
r
e
ater
co
m
p
r
eh
en
s
io
n
o
f
th
e
n
atu
r
e
o
f
wo
r
k
an
d
jo
b
cir
cu
m
s
tan
ce
s
.
Du
r
i
n
g
t
h
eir
y
ea
r
s
o
f
em
p
lo
y
m
en
t,
th
ey
m
ay
h
av
e
b
u
ilt
m
an
y
p
r
o
f
ess
io
n
al
co
n
tacts
an
d
h
a
d
en
o
u
g
h
p
o
s
s
ib
ilit
ies
f
o
r
f
u
r
th
er
ed
u
ca
tio
n
.
A
d
d
itio
n
ally
,
th
ey
c
o
u
ld
h
av
e
ac
h
iev
ed
a
b
etter
wo
r
k
-
life
b
al
an
ce
an
d
s
o
cio
ec
o
n
o
m
ic
lev
el
[
1
6
]
,
[
2
5
]
,
[
2
6
]
.
T
h
e
cu
r
r
en
t
s
tu
d
y
o
b
s
er
v
ed
t
h
at
p
h
y
s
ical
s
co
r
e
was
s
ig
n
if
ican
tly
h
ig
h
er
in
m
ales
th
an
i
n
f
em
ales.
Ad
d
itio
n
ally
,
p
h
y
s
ical,
s
o
cial,
an
d
p
s
y
ch
o
lo
g
ical
s
co
r
es
s
ig
n
if
ican
tly
d
i
f
f
er
ed
ac
co
r
d
in
g
to
m
ar
ital
s
tatu
s
.
An
o
th
er
s
tu
d
y
[
1
6
]
f
o
u
n
d
th
at
p
h
y
s
ical
s
co
r
es
wer
e
s
ig
n
if
ican
tly
h
ig
h
er
in
f
em
ales
th
an
m
a
les.
I
t
d
o
cu
m
en
ted
th
at
m
ar
r
ied
in
d
i
v
id
u
als
r
ec
ei
v
ed
b
etter
m
ea
n
s
co
r
es
f
o
r
th
e
ab
o
v
em
e
n
tio
n
ed
d
o
m
ain
s
a
n
d
o
v
e
r
all
h
ea
lth
.
A
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
Qu
a
lity o
f life
a
mo
n
g
p
h
ysici
a
n
s
in
E
g
yp
t
a
n
d
its
in
flu
en
cin
g
…
(
A
mir
a
I
s
ma
il A
b
d
elra
h
m
a
n
)
1701
s
tu
d
y
o
f
th
e
h
ea
lth
ca
r
e
s
taf
f
in
th
e
Pak
is
tan
i
h
ea
lth
s
ec
to
r
ass
ess
ed
th
e
cu
r
r
en
t
lev
el
o
f
h
ea
lth
-
ass
o
ciate
d
Qo
L
(
HR
QOL
)
am
o
n
g
HPs
u
tili
zi
n
g
th
e
s
elf
-
ad
m
in
is
ter
ed
r
ese
ar
ch
to
o
l
"WHOQOL
-
B
R
E
F"
r
ev
ea
led
th
at
th
o
s
e
wh
o
wer
e
m
ar
r
ie
d
h
a
d
h
ig
h
er
Qo
L
s
co
r
es
[
2
7
]
.
Fu
r
th
e
r
m
o
r
e
,
m
ar
ital
s
tatu
s
was
an
o
th
er
f
a
cto
r
af
f
ec
tin
g
Q
o
L
,
ac
co
r
d
in
g
t
o
Alm
alk
i
et
a
l.
[
2
4
]
,
with
s
in
g
le
d
o
cto
r
s
s
co
r
in
g
th
e
lo
west
in
p
s
y
ch
o
lo
g
ical
an
d
s
o
cial
r
elatio
n
s
h
ip
d
o
m
ai
n
s
co
m
p
ar
ed
to
m
ar
r
ie
d
d
o
cto
r
s
.
Fu
r
th
e
r
m
o
r
e,
a
s
tu
d
y
d
o
n
e
in
th
e
J
az
an
r
eg
io
n
,
Sau
d
i
Ar
ab
ia,
o
n
th
e
q
u
ality
o
f
wo
r
k
life
(
QW
L
)
am
o
n
g
p
r
im
a
r
y
h
ea
lth
ca
r
e
n
u
r
s
es
r
ep
o
r
ted
th
at
m
ar
ital
s
tatu
s
p
lay
s
a
s
ig
n
if
ican
t r
o
le
i
n
Q
o
L
in
th
at
s
tu
d
y.
An
o
th
er
r
esear
ch
in
a
Pak
is
tan
i
h
o
s
p
ital
f
o
u
n
d
a
g
r
ea
ter
s
tr
ess
lev
el
am
o
n
g
s
in
g
le
p
ar
tici
p
an
ts
[
2
8
]
.
Sin
g
le
HC
Ps
m
ay
h
av
e
to
en
d
u
r
e
th
e
jo
b
s
tr
ess
alo
n
e,
b
u
t
m
ar
r
ied
HC
Ps
m
ay
b
e
ab
le
to
s
h
ar
e
it
with
th
eir
p
ar
tn
er
s
an
d
h
a
v
e
a
g
r
ea
ter
ca
p
ac
ity
f
o
r
co
p
i
n
g
.
Su
c
h
m
eth
o
d
s
m
ay
m
in
im
ize
s
tr
ess
,
an
d
a
s
a
r
esu
lt,
m
ar
r
ied
HC
P
s
m
ay
h
av
e
a
h
ea
lth
ier
w
o
r
k
-
life
b
alan
ce
[
1
6
]
,
[
2
9
]
.
Mu
ltiv
ar
iate
lin
ea
r
r
eg
r
ess
io
n
an
aly
s
es
r
ev
ea
led
s
ig
n
if
ican
t p
r
ed
icto
r
s
o
f
Qo
L
s
co
r
es
ac
r
o
s
s
d
if
f
er
en
t
d
o
m
ain
s
.
Fem
ale
g
en
d
e
r
,
m
a
r
ital
s
tatu
s
,
ch
r
o
n
ic
d
is
ea
s
e,
MD
d
eg
r
ee
,
an
d
wo
r
k
i
n
g
h
o
u
r
s
wer
e
f
o
u
n
d
t
o
in
f
lu
en
ce
p
h
y
s
ical
Q
o
L
.
An
MD
d
eg
r
ee
was
th
e
s
o
le
p
r
ed
icto
r
f
o
r
th
e
p
s
y
ch
o
lo
g
ical
d
o
m
ain
,
wh
ile
m
ar
ital
s
tatu
s
an
d
wo
r
k
in
g
h
o
u
r
s
wer
e
s
ig
n
if
ican
t
p
r
ed
icto
r
s
f
o
r
th
e
s
o
cial
d
o
m
ain
.
I
n
th
e
e
n
v
ir
o
n
m
en
tal
d
o
m
ain
,
a
n
MD
d
eg
r
ee
an
d
wo
r
k
in
g
h
o
u
r
s
p
lay
ed
a
s
ig
n
if
ican
t
r
o
le.
W
o
r
k
in
g
h
o
u
r
s
s
h
o
we
d
a
s
ig
n
if
i
ca
n
t
im
p
ac
t
o
n
th
e
o
v
er
all
Q
o
L.
A
r
ec
en
t
s
tu
d
y
o
n
1
6
7
p
h
y
s
ician
s
f
r
o
m
ter
tiar
y
ca
r
e
h
o
s
p
itals
in
E
g
y
p
t
to
ev
alu
ate
p
r
o
f
ess
io
n
al
Qo
L
co
m
p
o
n
e
n
ts
an
d
th
eir
p
r
ed
icto
r
s
d
o
cu
m
e
n
ted
th
at
p
o
s
s
es
s
in
g
g
r
ea
ter
ed
u
ca
tio
n
al
b
ac
k
g
r
o
u
n
d
,
m
ar
ital
s
tatu
s
,
an
d
wo
r
k
in
g
h
o
u
r
s
wer
e
s
ig
n
if
ican
t
p
r
e
d
icto
r
s
f
o
r
th
e
p
h
y
s
ical
an
d
s
o
cial
Qo
L
d
o
m
ain
s
[
1
5
]
.
Similar
ly
,
W
an
g
et
a
l.
[
3
0
]
f
o
u
n
d
t
h
at
m
ar
r
iag
e
a
n
d
m
ar
it
al
s
tatu
s
wer
e
p
o
s
itiv
ely
r
elate
d
to
co
m
p
ass
io
n
s
atis
f
ac
tio
n
,
a
co
m
p
o
n
e
n
t
o
f
p
r
o
f
ess
io
n
al
Qo
L
.
Mo
r
eo
v
er
,
R
u
iz
-
Fer
n
án
d
ez
et
a
l.
[
3
1
]
r
e
p
o
r
te
d
th
at
p
ar
ticip
an
ts
with
h
ig
h
er
ed
u
ca
tio
n
al
lev
els
ex
h
ib
ited
h
ig
h
e
r
Qo
L
lev
els.
Als
o
,
Alh
ar
b
i
et
a
l.
[
2
6
]
s
h
o
wed
t
h
at
h
ig
h
er
ag
e,
m
o
r
e
wo
r
k
e
x
p
er
i
en
ce
,
f
u
ll
-
tim
e
em
p
lo
y
m
e
n
t,
m
ar
r
ied
s
tatu
s
,
r
o
tatin
g
s
h
if
t,
an
d
s
p
ec
ialty
u
n
its
wer
e
ass
o
ciate
d
with
g
r
ea
ter
QW
L
s
co
r
es.
T
h
is
s
tu
d
y
h
as so
m
e
lim
itatio
n
s
.
I
t r
elied
o
n
s
elf
-
r
ep
o
r
ted
d
ata
an
d
a
s
elf
-
ad
m
in
is
ter
ed
q
u
esti
o
n
n
air
e,
wh
ich
m
ay
in
tr
o
d
u
ce
b
iases
an
d
lim
itatio
n
s
in
ca
p
tu
r
i
n
g
th
e
f
u
ll
s
p
ec
tr
u
m
o
f
p
h
y
s
ician
s
'
well
-
b
ein
g
.
Seco
n
d
ly
,
m
o
s
t
p
h
y
s
ician
s
wer
e
f
r
o
m
l
o
wer
E
g
y
p
t,
wh
ich
li
m
its
th
e
g
en
er
aliza
b
ilit
y
o
f
th
e
f
in
d
in
g
s
to
o
t
h
er
r
eg
io
n
s
o
r
p
o
p
u
latio
n
s
.
T
h
er
ef
o
r
e,
m
o
r
e
m
u
lti
-
r
e
g
io
n
al
s
tu
d
i
es
s
h
o
u
ld
b
e
p
er
f
o
r
m
e
d
o
n
a
b
r
o
ad
e
r
p
o
p
u
latio
n
o
f
p
h
y
s
ician
s
in
E
g
y
p
t
.
T
ab
le
4
.
R
esu
lts
o
f
r
eg
r
ess
io
n
an
aly
s
is
f
o
r
v
ar
iab
les ass
o
ciate
d
with
d
o
m
ai
n
s
o
f
QOL
in
p
h
y
s
ician
s
Va
r
iable
s
Ove
r
a
ll
QoL
G
e
ne
r
a
l
he
a
lt
h
P
hys
ica
l
P
s
yc
hologi
c
a
l
S
oc
ial
E
nvi
r
onmen
t
β
p
β
p
β
p
β
p
β
p
β
p
Age
:
≤40
(
r
e
f
)
>
40
-
0.
071
0.
663
-
0.
003
0.
984
0.
085
0.
562
0.
4
0.
689
0.
145
0.
357
-
0.
053
0.
730
S
e
x:
M
a
le
(
r
e
f
)
F
e
male
0.
003
0.
971
-
0.
025
0.
762
-
0.
166
0.
025
-
0.
088
0.
930
0.
039
0.
624
0.
063
0.
412
M
a
r
it
a
l
s
tatus
:
Divor
c
e
d,
widow
(
r
e
f
)
S
ingl
e
-
0.
063
0.
584
0.
146
0.
210
0.
243
0.
02
0.
301
0.
764
0.
059
0.
593
0.
105
0.
335
M
a
r
r
ied
-
0.
092
0.
418
0.
06
0.
601
0.
336
0.
001
1.
51
0.
133
0.
316
0.
004
0.
093
0.
382
C
hr
onic
dis
e
a
s
e
:
No
(
r
e
f
)
Ye
s
0.
123
0.
089
0.
064
0.
378
-
0.
244
<
0.
001
-
1.
786
0.
075
-
0.
055
0.
431
-
0.
122
0.
073
E
duc
a
ti
o
n:
B
a
c
he
lor
(
r
e
f
)
M
S
C
-
0.
098
0.
39
-
0.
155
0.
180
0.
064
0.
53
1.
883
0.
061
-
0.
111
0.
313
0.
062
0.
561
MD
-
0.
087
0.
481
-
0.
143
0.
251
0.
283
0.
012
3.
799
<
0.
001
0.
048
0.
686
0.
290
0.
013
S
pe
c
ialty
o
the
r
s
(
r
e
f
)
s
ur
ge
r
y
-
0.
028
0.
719
-
0.
06
0.
453
-
0.
06
0.
398
0.
592
0.
554
-
0.
2
0.
793
-
0.
043
0.
568
W
or
king
hou
r
s
/we
e
k:
≤18
h
(
r
e
f
)
>
18
-
≤36
0.
281
0.
003
0.
177
0.
061
-
0.
123
0.
143
0.
368
0.
713
-
0.
91
0.
312
-
0.
069
0.
433
>
36
-
≤54
0.
107
0.
226
0.
052
0.
560
-
0.
225
0.
005
-
0.
481
0.
631
-
.
113
0.
184
-
0.
13
0.
120
>
54
.
055
0.
512
0.
026
0.
758
-
0.
268
<
0.
001
-
1.
289
0.
199
-
.
232
0.
004
-
.
225
0.
005
E
xtr
a
w
o
r
king
h
ou
r
s
:
No
(
r
e
f
)
Ye
s
-
.
107
0.
175
0.
014
0.
864
-
0.
042
0.
548
-
1.
323
0.
187
0.
015
0.
838
-
.
088
0.
234
E
xpe
r
ienc
e
:
≤15
(
r
e
f
)
>
15
-
0.
005
0.
974
0.
076
0.
632
0.
02
0.
888
0.
903
0.
368
-
0.
157
0.
303
.
151
0.
307
B:
R
e
g
r
e
ss
i
o
n
c
o
e
f
f
i
c
i
e
n
t
4.
CO
NCLU
SI
O
N
Ou
r
s
tu
d
y
r
ev
ea
led
th
at
p
h
y
s
ician
s
g
en
er
ally
ex
p
er
ien
ce
a
m
o
d
er
ate
q
u
ality
o
f
life
(
Qo
L
)
,
with
s
ig
n
if
ican
t
d
if
f
er
en
ce
s
ac
r
o
s
s
v
ar
io
u
s
d
o
m
ain
s
.
Sp
ec
if
icall
y
,
n
o
n
-
s
m
o
k
er
s
a
n
d
th
o
s
e
w
ith
f
ewe
r
wo
r
k
i
n
g
h
o
u
r
s
te
n
d
to
r
ep
o
r
t
h
i
g
h
er
o
v
er
all
Qo
L
s
co
r
es
co
m
p
ar
ed
to
th
eir
co
u
n
ter
p
a
r
ts
.
Mo
r
e
o
v
er
,
s
ev
er
al
f
ac
to
r
s
s
u
ch
as
ag
e,
g
en
d
e
r
,
a
n
d
m
ar
ital
s
ta
tu
s
,
alo
n
g
with
p
r
o
f
ess
io
n
al
asp
ec
ts
lik
e
s
p
ec
ialty
,
ed
u
ca
tio
n
al
b
ac
k
g
r
o
u
n
d
,
an
d
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
13
,
No
.
4
,
Dec
em
b
er
20
24
:
1
6
9
6
-
1
7
0
3
1702
wo
r
k
ex
p
er
ien
ce
,
p
lay
cr
u
cia
l
r
o
les
in
in
f
lu
e
n
cin
g
s
p
ec
if
i
c
d
o
m
ain
s
o
f
Qo
L
.
T
h
ese
f
in
d
in
g
s
h
ig
h
lig
h
t
th
e
co
m
p
lex
in
ter
p
lay
b
etwe
en
p
e
r
s
o
n
al
an
d
p
r
o
f
ess
io
n
al
ch
ar
ac
ter
is
tics
in
d
eter
m
in
in
g
th
e
o
v
er
all
well
-
b
ein
g
o
f
p
h
y
s
ician
s
,
an
d
u
n
d
e
r
s
co
r
e
th
e
n
ee
d
f
o
r
tar
g
eted
in
ter
v
e
n
tio
n
s
th
at
ad
d
r
ess
th
e
u
n
iq
u
e
ch
allen
g
es
f
ac
ed
b
y
d
if
f
er
en
t
p
h
y
s
ician
g
r
o
u
p
s
,
u
lt
im
ately
aim
in
g
to
e
n
h
an
ce
t
h
e
ir
o
v
er
all
well
-
b
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