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Emergency medicine
Original research
Clinical characteristics and outcomes of traumatic brain injury in patients admitted to surgical ward of Jimma Medical Center, Southwest Ethiopia: a prospective observational follow-up study
  1. Gemechis Belay Dibera1,
  2. Mengist Awoke Yizengaw2,
  3. Gemechu Lemi Yadeta3,
  4. Dinka Dugassa Iticha1,
  5. Busha Gamachu1,
  6. Bruck Tesfaye Legesse4
  1. 1Department of Pharmacy, Wollega University, Nekemte, Ethiopia
  2. 2Jimma University, Jimma, Ethiopia
  3. 3School of Pharmacy, Jimma University, Jimma, Ethiopia
  4. 4Department of Pediatrics and Neonatal Nursing, Wollega University, Nekemte, Ethiopia
  1. Correspondence to Mr Bruck Tesfaye Legesse; brucktesfaye143{at}gmail.com

Abstract

Objective To assess the Clinical Characteristics and Outcomes of Traumatic Brain Injury in Patients Admitted to the Surgical Ward of Jimma Medical Center, Southwest Ethiopia from January to July 2022.

Design and setting A hospital-based prospective observational study was conducted among 175 patients admitted with Traumatic Brain Injury at Jimma Medical Center from January to July 2022. Data were collected by structured questionnaires and a convenient sampling technique was used. For data entry, Epidata V.4.6.0.5 software was used and exported to Stata V.14.0.2 for analysis. The Cox regression model was fitted to evaluate the predictors of mortality and variables with a p value <0.05 at 95% CI were taken as statistically significant predictors.

Results The incidence of in-hospital mortality was 22 (12.6%). The mean length of hospital stay was 6 days. In-hospital complications were recorded in 32.0% of patients. A Glasgow Coma Scale (GCS) score of <8 on admission (adjusted HR (AHR)=6.2, 95% CI 0.75 to 51), hyperthermia (AHR: 1.7, 95% CI 1.02 to 3.05) and lack of prehospital care (AHR: 3.2, 95% CI 2.2 to 8.07) were predictors of mortality in patients with traumatic brain injury.

Conclusion In-hospital mortality was recorded in over one-tenth of patients with traumatic brain injury. The GCS score of <8 on admission, hyperthermia and lack of prehospital care positively affected the outcome of patients with traumatic brain injury. Screening of patients for hyperthermia and antipsychotics should be strengthened to reduce death. However, a multicentred study is needed for further evidence. Giving priority to the patients with those predictors will decrease the number of deaths.

  • TRAUMA MANAGEMENT
  • Trauma Nursing
  • WOUND MANAGEMENT

Data availability statement

Data are available upon reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2023-080598

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • The study was conducted prospectively which enables the collection of maximum variables.

  • The present study was conducted with a shorter follow-up period and the survival status of the study subjects was followed only for the duration of the hospital stay.

  • The study was conducted on monocentric/single-centred.

  • Furthermore, the study was conducted small sample size may have affected the power of the present study.

Background

Traumatic brain injury (TBI) is an alteration in brain function and other signs of brain disease induced by an external force.1 It is classified as mild, moderate, and severe TBI based on the Glasgow Coma Scale (GCS) which is determined at the moment of injury. Mild TBI is with a GCS score of 13–15, moderate as 9–12, and severe as 3–8.2 Severe TBI has a significant mortality rate, which has been estimated to be between 30 and 40% and survivors face significant physical, mental, emotional, and cognitive impairments, which interrupt people’s lives and cost society a lot of money. Such limitations are present not only in situations of severe Traumatic brain injury but also in cases of moderate and mild TBI.3

Traumatic brain injury is the most frequent reason for a neurosurgical emergency visit and continues to be a major cause of morbidity and mortality worldwide.4 About 69 million people experience a TBI per year from all causes,5 and it is becoming one of the top three particular neurological diseases that account for neurological disability globally, both now and in the future.6 It has become a serious public health concern across the world; accounting for 30–40% of all injury-related deaths as well as a significant cause of disability.4

Road traffic accidents are the primary cause of TBI cases though the damage pattern varies by region. Patients with TBI in low- and middle-income countries are frequently vulnerable to road users like pedestrians, cyclists, and motorcyclists. Patients in high-income countries are frequently motor vehicle occupants.7 Anybody can suffer a TBI, but those who are at higher risk include young people, low-income individuals, single, members of ethnic minority groups, people who live in cities, those who have a history of substance misuse, men, and those who have already suffered a TBI.8

Even though the frequencies of TBI and TBI-related impairments have been reduced in Healthcare-associated Infections,7 the incidence of Traumatic brain injury in LMICs is high and ranges from 150 to 316 cases per 100 000 inhabitants per year. It is expected to affect 5.980±0.3 million people in Africa by 2050, with 0.15 million people in Eastern Africa. It mostly affects men and is most frequent in young people aged 19 to 40 and is a major cause of death and morbidity in Sub-Saharan Africa.9 It accounted for over 60% of the fatalities among trauma patients admitted to the surgical department in Ethiopia.10

Reports from Africa have found that mortality rates from TBI range from 4.2% to 35%.11 12 In Ethiopia, despite seeking treatment, over 20% of TBI patients die.10 12 According to reports from Ethiopia, the mortality rate among TBI patients ranged from 8.2 % to 50.8 % and it was the cause of 21.5% of all fatalities within 72 hours after presentation.10 13 However, studies assessing hospital complications related to TBI like PTS and incidence of infections are limited.

The incidence of TBI is rising over time though the baseline clinical profiles, in-hospital complications, survival status, and predictors of mortality are still not known in Ethiopia. Knowing the in-hospital complications, survival status, and prognostic factors of TBI patients gives information on patient prognosis and life expectancy. As the ultimate goal of the health sector is ensuring health service quality, assessing the predictors of TBI patients’ survival enables policymakers to design improvements in the management and care for TBI patients. Also, the survival status of TBI patients is a major indicator of monitoring the quality of treatment given.

The output of this study will be used by the concerned bodies in the health service delivery sectors including Jimma Medical Center and other organisations as an important input for designing appropriate evidence-based intervention strategies in improving outcomes of the TBI patients among the general population. So, the findings of this study will benefit the patient by addressing the factors affecting the outcomes of TBI patients. The study will also provide input for the government to allocate resources and make policies for the prevention and management of TBI. Finally, the findings of this study may be used as input for future studies on TBI.

Methods

Study design and setting

The study was conducted in the surgical ward of JMC, Oromia regional state, Southwest Ethiopia from January 10, 2022- July 10, 2022. JMC is one of the oldest public hospitals in the country and it was established in 1938 G.C by Italian invaders for the service of their soldiers. Geographically, it is located in Jimma town 352 km southwest of the capital. It is the only teaching and referral hospital in the southwest of Ethiopia providing services approximately for 15 000 inpatients, 160 000 outpatient attendants, 11 000 emergency cases, and 4500 deliveries per year from the catchment population of about 15 million people. It has 1600 staff members and 32 care units. The surgical department is one of the units having elective, emergency, and outpatient wards.

Population

All TBI patients admitted to the surgical ward of JMC from January 2022 to July 2022 were included in the study. The study population was conveniently selected from eligible TBI patients admitted to the neurosurgical ward of JMC. A convenient sampling technique was used. A total of 780 TBI patients were admitted to this centre from January 2022 to July 2022. All TBI patients fulfilling the inclusion criteria were recruited in the study.

Eligibility criteria

Inclusion criteria: All TBI patients greater than or equal to 18 years.

Exclusion criteria: Known epileptic patients and non-traumatic causes of brain injury.

Sample size and sampling technique

The sample size was calculated based on a single population proportion formula considering the proportion of overall mortality among TBI patients as estimated based on a study done in Jimma University Specialized Hospital which was 21.2%, with an absolute precision of 5% and 95% level of confidence. All TBI patients admitted at the surgical ward of JMC fulfilling the inclusion criteria were selected and followed starting from the date of admission to discharge.

Data collection tools and procedures

The data was collected through the semi-structured questionnaire developed by referring to different literature in line with the study’s objectives. Following 2 days of training, one BSc Nurse and one general practitioner collected the data. Data on demographics, clinical characteristics, investigation-related, and medication/interventional related were collected from medical charts and interviewing the patients/caregivers/attendants.

Data quality management

First, the data collection tools were written in English, then translated into two local languages (Amharic and Afaan Oromo) and back-translated into English by an independent person to ensure consistency. The tool was pre-tested on nine9 TBI patients at the surgical ward of Shenan Gibe 2 weeks before starting the actual data collection and then the necessary adjustment was made. The data was compiled, coded, and checked for consistency before analysis.

Data processing and analysis

The data was coded and entered into Epidata version 4.6.0.5 and exported to the STATA 14 version for data analysis. The categorical variables were presented with frequency and percentage. For continuous data, a normality test was conducted using the Shapiro-Wilk’sW test. Parametric data was reported with mean±SD, while non-parametric data was presented with median and IQR. Kaplan-Meier survival analysis of mortality was conducted taking the period from hospital admission to discharge/death time frame and severity of TBI as independent factors. The log-rank test was used to compare the in-hospital survival. Bivariate regression was performed to see the associations between in-hospital mortality patients with TBI and independent variables. Then, multivariate Cox regression was performed, including all explanatory variables with a p-value of<0.25 on bivariate cox-regression to evaluate factors predicting mortality. In all the statistics, a p-value<0.05 was considered statistically significant.

Operational and terms definitions

Glasgow coma scale (GCS): scale used for assessing the neurological status of the patient.2

Glasgow outcome scale (GOS): a multi-dimensional scale that assesses various aspects of outcome.5

Mild TBI: an injury to the head with a GCS score of 13–15.2

Moderate TBI: an injury to the head with a GCS score of 9–12.2

Severe TBI: an injury to the head with a GCS score of 3–8.2

Comorbidity: refers to any disease co-existing with an index disease.

Primary outcome: is the death of TBI patients.

Secondary outcomes: outcomes like PTS, LOS, and incidence of infections associated with TBI.

Complication: newly occurring medical events during hospital stay which are associated with the severity of TBI

Time variable: is the time to occurrence of death measured from admission to date of the event.

Immediate PTS: a seizure occurring in<24 hour after TBI.14

Early PTS: a seizure occurring in>24 hour and<7 days after TBI.14

Late PTS: a seizure occurring in>7 days after TBI.14

Hypotension: SBP<90 mmHg measured at any time point during hospitalisation, including the hospital arrival value.7

Hypoxia: SaO2<90% at any time point during hospitalisation, including hospital arrival value.15

Hyperthermia: a temperature>38°C during hospitalisation.15

Hypoglycaemia: random blood glucose concentration level<80 mg/dL during hospitalisation.15

Anaemia: was considered anaemic when a haemoglobin count is <7 mg/dL.

Ethics approval and consent to participate

The study was conducted after an ethical clearance had been obtained from the research review board of the Institute of Health Science, Jimma University (Ref.no:JUIRB24/22). The consent was taken from the patient/caregiver/attendants and the names of the patient were not recorded and other information was kept confidential throughout the study process.

Patient and public involvement

In this study, the study participants and/or the public were not directly involved in the design, conduct, reporting, and dissemination of this work.

Results

Socio-demographic characteristics

Among 175 study participants, 126 (72 %) were males. The mean age of the participant was 29.82(SD±10.68) years. Eight-five (48.6%) of patients were married. Of the total study subjects, 104 (59.4 %) of them live in rural areas. Sixty-seven (38.29%) of the patients had no formal education. Seventy-one (40.6 %) drank alcohol. Regarding occupation, 39.4% and 20% were farmers and daily labourers respectively (table 1).

View this table:
Table 1

Sociodemographic characteristics of TBI patients admitted to the surgical ward of JMC from January to July 2022

Injury-related characteristics

RTAs (58.86 %) and violence/assault (26.86 %) were the main causes of TBI. The majority of the study participants (61.71 %) were directly admitted to the hospital and hospital arrival time for 54.9% of them was>6 hours (table 2).

View this table:
Table 2

Cause and injury-related characteristics of TBI patients admitted to the surgical ward of JMC from January to July 2022

Clinical characteristics and CT scan findings

On admission, only 12.6 %(n=22) of the study participants had underlying medical conditions. Of the clinical findings on admission, hypotension (13.4 %) and anaemia (15.43 %) were frequently noted. Regarding the CT scan findings, fractures (33.4 %), and EDH (13.7 %) were the most common findings (table 3).

View this table:
Table 3

Baseline clinical profiles of TBI patients admitted to the surgical ward of JMC from January to July 2022

Intervention/management at the surgical ward

In this study, the majority of patients 119 (68.0%) managed surgically. Of the total study participants, 42 (24.0 %) patients were resuscitated before admission to the hospital. Among the participants, 14.29% of the patients developed ICP. Fracture elevation 52 (43.7%) and burr hole 26 (21.85%) were the common neurosurgical procedures done for the candidate patients. Seizure prophylaxis was initiated for 127 (72.6%) of study subjects included in the study. Antibiotics were initiated for 135 (79.1 %) of TBI patients (table 4).

View this table:
Table 4

Overall management status of TBI patients admitted to the surgical ward of JMC from January to July 2022

Treatment outcomes

In this study, a total of 175 patients were followed for a minimum of 1 day and a maximum of 45 days, with a mean follow-up/length of hospital stay of 5.66±0.36 days. The incidence of death was 0.033% of persons- 990 days of follow-up. During the study period, 22 (12.6 %) patients were died. In hospital, complications were recorded in 31.43 %(n=55). Of the study participants, 16.0% and 4.6% developed early and late PTS, respectively. Among study subjects who developed early PTS, 72.2% experienced the event on their third day of injury. However, 11.1% and 16.67% of them experienced a seizure on the second and fifth day of injury respectively. Of the total participants, 11.43% (n=20) of them developed infectious diseases (table 5).

View this table:
Table 5

Clinical outcomes of TBI patients admitted to the Surgical Ward of JMC from January to July 2022

Survival status of TBI patients

In this study, a total of 175 TBI patients prospectively followed up for a total of 990 days and the median survival time was 34 days. Survival estimation based on the Kaplan-Meier curve showed that the overall estimated survival rate after diagnosis of TBI was 34%. Among 11 (6.3%) TBI patients diagnosed with severe TBI (GCS≤8) based on their GCS score at admission, the incidence of death was 17.6% and the median survival rate was 3% (95% CI; 2 to 4%). For the patients diagnosed with moderate TBI, the incidence of death was 3.04% and the median survival time was 37 days (95% CI: 35 to 38%) for the remaining mild TBI patients, the incidence of death and the median survival time was 3.1% and 34 days (95% CI: 33 to 36%) respectively.

The survival time differed among the TBI patients based on their GCS on admission. Ten percent (10%) of patients with mild TBI had died after 32 days (95 % CI 2 to 32) as opposed to 3 and 1 days for moderate and severe TBI patients respectively (figure 1).

Figure 1
Figure 1

Kaplan–Meier curve for estimating the survival status of patients with TBI patients based on the severity at the surgical ward of JMC, Jimma, Ethiopia, from 10 January 2022, to 10 June 2022. JMC, Jimma Medical Center; TBI, traumatic brain injury.

Factors affecting outcome

According to the bivariate Cox regression model smoking (adjusted HR (AHR): 1.8, 95 % CI, 1.03 to 3.1, p=0.038), Arrival by public transport (AHR: 0.5, 95 CI, 1.13 to 2.12, p=0.007), poly-trauma (AHR: 0.58, 95% CI, 0.43 to 0.8, p=0.001) were associated with TBI related mortality. Among clinical factors, GCS scores 3–8 on admission (AHR: 1.8, 95 % CI, 1.03 to 3.1, p=0.038), hypoxia (AHR: 0.67, 95 % CI, 0.49 to 0.9, p=0.018) were predictors of mortality on bivariate cox regression analysis. However, of intervention-related factors seizure prophylaxis (AHR: 0.53, 95 % CI 1. 0.7–0.74, p=0.00), neurosurgery (AHR: 2.1, 95 % CI, 1.5 to 2.91, p=0.00), lack of pre-hospital care (AHR: 1.4, 95% CI, 1. 1.05–1.98, p=0.023,), antibiotic not initiated (AHR: 3.7, 95 % CI, 2.4 to 5.9, p=0.00), and initiating antipsychotics (AHR: 0.68, 95 % CI, 0.47 to 1.0, p=0.039) were all associated with TBI related mortality.

On multivariate regression, living on the street (AHR: 0.17, 95 % CI 0 .033–0.85 p=0.031), GCS score 9–12 on admission (AHR: 0.18, 95 % CI 0.13 to 0.76 p=0.019), and initiating antipsychotics (AHR: 0.57, 95 % CI 0.34 to 9.7p=0.038) were protective predictors of mortality in TBI patients. GCS score 3–8 on admission (AHR: 6.2, 95 % CI, 1.75 to 15.1, p=0.001), hyperthermia (AHR: 1.7, 95 % CI, 1.02 to 3.05, p=0.043), lack of pre-hospital care (AHR: 3.2, 95 % CI, 2.2 to 8.07, p=0.005), and were all associated with TBI related mortality (p<0.05) (table 6).

View this table:
Table 6

Bivariate and multivariable Cox regression analysis to identify predictors of in-hospital mortality among patients with TBI at JMC, Ethiopia

Discussion

This study assessed the clinical profiles and outcomes of 175 TBI patients admitted to the surgical ward of JMC. During their hospitalisation, 22 (12.6%) deaths were recorded. A higher deaths were recorded in patients with severe TBI (54.55%) as compared with moderate (40.1%) and mild TBI (4.55%). The overall incidence of in-hospital complications was 10.86%. The GCS score on admission of<12, living on the street, hyperthermia, lack of pre-hospital care, and initiating antipsychotics were the independent predictors of in-hospital mortality.

The incidence of in-hospital mortality was 12.6% (22/175) in the current study. A similar finding was reported in Dutch 12.3 %, Rwanda 12.8% and Hawassa, Ethiopia 12.7%.15–17 The current finding is lower than the studies conducted in South India 17.7 %, Uganda 33 %, and Jimma 21.2%. This could be due to the progression and advancement in patient care over the years.

This study showed that the mean length of hospital stay was 5.65±0.36 days. This finding is lower contrary to a study done in South India at 4.97±5.4 days18 and a study done in Dutch at 8±13 days.17 This difference could be due to either the variations in study design or sample size, service delivery, and treatment protocol across the countries.

In the current study, the overall in-hospital complications were found to be 31.43% (n=55). This finding is higher than the study done in China (5 %). This could be due to variations in advanced care and availability of higher quality neurotrauma centres and well-established prehospital care between the countries. This implies that there is a lack of special emphasis to be given to traumatic patients in our country.

Of in-hospital complications of study subjects, the incidence of posttraumatic seizure was 20.6%. This finding is almost similar to a study conducted in the USA which revealed the incidence of PTS as high as 8.9 % to 20.5 %.19 Seizure prophylaxis was initiated for 72.6% (n=127) of patients in our study. This implies that there should be a multidisciplinary approach to enhance the rational use of anti-seizure drugs in TBI patients.

Incidence of infections was 10.86% (n=19) among the study subjects in this study. Of these, 2.9% (n=5) developed aspiration pneumonia, and 8.0 % % developed HAIs. This finding is lower compared with the study done in Greece20 which showed 47% for lower respiratory tract and 17% for HAIs. This could be due to advancement in treatment because of the difference in study periods.

This study found that there was a statistical association between patients who live on the street and in-hospital mortality compared with those who live at home. The higher risk of death could be due to a lack of on-time healthcare for financial reasons or a lack of supporting relatives and a delay in hospital arrival time.

The risk of death among patients with severe TBI was 6.2 times higher than mild TBI. This was in agreement with different studies,15 17 21 the possible reason might be an increased risk of infections, not being assisted with a ventilator, and poor adherence to evidence-based treatment guidelines. Hence, there should be multidisciplinary involvement to reduce the risk of mortality and morbidity.

The hazard rate of death among TBI patients who were exposed to hyperthermia was 2.1 times higher as compared with normothermic patients. This finding is consistent with another study4; this could be due to increased brain metabolic demand, ICP, and cell damage secondary to elevation in body temperature.

The risk of death among patients who did not get pre-hospital care was 3.2 times higher than those who gained pre-hospital care. Different studies15 16 22 were in line with this finding. This implies that early resuscitation should be done to prevent secondary brain injury. Therefore, healthcare providers and concerned bodies should emphasise the pre-hospital care of TBI patients.

In the current study, there was a statistical association among study subjects for whom antipsychotics were initiated (n=48) and in-hospital mortality. This tells us about two-tenths of TBI patients on either haloperidol or risperidone died. This warns healthcare providers that a multidisciplinary approach must be needed in caring for and selecting antipsychotics for TBI patients.

In this study, 13.4% (n=23) of TBI patients were hypotensive during surgical ward admission. This result is lower compared with studies done in Pittsburgh at 7 %,23 Scandivia at 17%, and India at 25.34%.24 25 The variation could be due to the difference in the study setting since this study was conducted at a surgical ward after a majority of them got resuscitation before this ward admission. This implies to improve patient survival timely diagnosis and aggressive resuscitation at earlier golden hours of hospital arrival must be taken into account to halt secondary brain injury due to hypotension.

In the present study, 30.86% of TBI patients were hypoxic on admission. Similar findings were obtained in a study done in Addis Ababa, Ethiopia.26 But, the findings are higher compared with those of Hawassa and Bahir Dar.15 27 The dissimilarity could be due to delay in on-time diagnosis and resuscitation compared with the arrival time of the study subjects included in our study.

This study found that 15.8% (n=18) of study subjects were anaemic on admission. This finding is in line with different studies and it is higher compared with a study done in Hawassa, Ethiopia 9.64%.15 The discrepancy may be due to variations in the availability of blood products for transfusion across the regions.

In this study, 143 (81.7 %) did a CT scan of the brain. The the most common lesion was fracture either basilar or depressed (58.0%). However, the study done in Nigeria showed the most common abnormal findings of CT scans were diffuse axonal injury (31.88%).28 The the most common lesion of CT scan was contusion according to the study done in Uganda (67.85%).29 This variation might be due to dissimilarities in causes and severity of injuries. The majority of study participants in the current study were mild TBI with RTA cause compared with the studies in Nigeria and Uganda.

In the present study, the majority (68.0%) were managed surgically. This finding is higher compared with studies done in Uganda 18 %, Tanzania 24% and Ethiopia 32.8%.30–32 The variation might be due to the study setting difference since the present study area is the medical centre where the majority of cases with referrals from different areas of the country.

Conclusion and recommendations

In-hospital mortality was recorded in over one-tenth of TBI patients. More than one-fourth of patients had in-hospital complications. The GCS score of<8 on admission, hyperthermia, and lack of pre-hospital care were the predictors of in-hospital mortality in TBI patients. Healthcare providers should give special attention to TBI patients with a GCS score of<8 on admission, hyperthermia, and lack of pre-hospital care. The federal government and concerned bodies should work on improving road safety and strict follow-up on traffic rules and regulations. Researchers should conduct further prospective studies to overcome the limitations of this study.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

The study was conducted after ethical clearance had obtained from research review board of Institute of Health Science, Jimma University (Ref.no:JUIRB24/22). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

We would like to say thanks to Jimma University Medical Center, and Institute of Health Sciences for facilitating this study. Lastly, our gratitude goes to the data collectors for their excellent effort during the data collection.

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Footnotes

  • Contributors GBD worked on designing the study, training the data collectors, and analysing and interpreting the result and BTL worked on preparing the manuscript. BTL is a guarantor of this study. The co-authors namely MAY, GLY, DDI, BG and BTL had a part in conceptualising the study, conducting the analysis, and evaluating the findings. The final manuscript was reviewed and approved by all authors.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer-reviewed.