Araştırma Makalesi
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The Effect of Different Earphone Types on Decreased Sound Tolerance and Auditory Functions In University Students Studying Distance Education

Yıl 2024, Cilt: 11 Sayı: 2, 448 - 465, 02.08.2024
https://doi.org/10.21020/husbfd.1303779

Öz

Objectives: It is known that long-term headphone use has negative effects on the hearing system. During the COVID-19 pandemic, university students had to use headphones more often than usual to attend distance education. The study aimed to investigate the effects of differences such as headphone type, sound intensity level, listening environment, and class participation time on decreased sound tolerance (DST) and auditory functions in university students who attended distance education during the pandemic period.
Materials and Methods: The research was conducted via Google Forms link. Information about the type of headphone they preferred, sound intensity levels, listening environment, duration of weekly distance class participation, and tinnitus history were collected from the participants. The Decreased Sound Tolerance Scale-Screening (DSTS-S) was used to evaluate DST, and the Speech, Spatial Perception and Hearing Quality Scale (SSQ) was used to evaluate the subcomponents of hearing. The study included 247 participants totally (67 M, 180 F). The participants' average age was 21.47 (SD=4.91).
Results: According to earphone type, there was no significant difference between the DSTS-S, SSQ scores. According to weekly class attendance, there was a significant difference between the hyperacusis and phonophobia scores, but not between the misophonia or SSQ scores. According to the listening environment, there was a significant difference between the hyperacusis and SSQ scores, but not between the phonophobia or misophonia scores. According to sound intensity there was no significant difference between phonophobia, speech perception, or hearing quality scores, there was a significant difference between hyperacusis, misophonia, and spatial perception. A negative significant correlation was found between DSTS-S and SSQ.
Conclusion: While the type of headphones used during the distance education process was not found to be associated with DST and auditory symptoms, a relationship was found between weekly class attendance time, listening environment and sound intensity levels. It was determined that DST had a negative correlation with speech perception, spatial perception and hearing quality.

Proje Numarası

Yok

Kaynakça

  • Akyıldız, N. (1998). Kulak hastalıkları ve mikrocerrahisi. Ankara, Bilimsel Tıp Yayınevi, 86.
  • Allusoglu, S., & Aksoy, S. (2022). The reliability and validity of decreased sound tolerance scale-screening. Brazilian journal of otorhinolaryngology, 88 Suppl 3(Suppl 3), S155–S163. https://doi.org/10.1016/j.bjorl.2021.11.009
  • Asha'ari, Z. A., Mat Zain, N., & Razali, A. (2010). Phonophobia and hyperacusis: practical points from a case report. The Malaysian journal of medical sciences : MJMS, 17(1), 49–51.
  • Båsjö, S., Möller, C., Widén, S., Jutengren, G., & Kähäri, K. (2016). Hearing thresholds, tinnitus, and headphone listening habits in nine-year-old children. International journal of audiology, 55(10), 587–596. https://doi.org/10.1080/14992027.2016.1190871
  • Byeon H. (2021). Associations between adolescents' earphone usage in noisy environments, hearing loss, and self-reported hearing problems in a nationally representative sample of South Korean middle and high school students. Medicine, 100(3), e24056. https://doi.org/10.1097/MD.0000000000024056
  • Camera, S., Tufts, J., & Skoe, E. (2019). Noise Exposure and Background Noise Tolerance in Listeners With Normal Audiograms. Journal of speech, language, and hearing research : JSLHR, 62(7), 2564–2570. https://doi.org/10.1044/2018_JSLHR-H-18-0245
  • Cavanna, A. E., & Seri, S. (2015). Misophonia: current perspectives. Neuropsychiatric disease and treatment, 11, 2117–2123. https://doi.org/10.2147/NDT.S81438
  • Cogen, T., Cetin Kara, H., Kara, E., Telci, F., & Yener, H. M. (2023). Investigation of the relationship between hyperacusis and auditory processing difficulties in individuals with normal hearing. European Archives of Oto-Rhino-Laryngology, 1-9.
  • Couth, S., Mazlan, N., Moore, D. R., Munro, K. J., & Dawes, P. (2019). Hearing Difficulties and Tinnitus in Construction, Agricultural, Music, and Finance Industries: Contributions of Demographic, Health, and Lifestyle Factors. Trends in hearing, 23, 2331216519885571. https://doi.org/10.1177/2331216519885571
  • Feder, K., Marro, L., Keith, S. E., & Michaud, D. S. (2013). Audiometric thresholds and portable digital audio player user listening habits. International journal of audiology, 52(9), 606–616. https://doi.org/10.3109/14992027.2013.798687
  • Fredriksson, S., Hammar, O., Torén, K., Tenenbaum, A., & Waye, K. P. (2015). The effect of occupational noise exposure on tinnitus and sound-induced auditory fatigue among obstetrics personnel: a cross-sectional study. BMJ open, 5(3), e005793. https://doi.org/10.1136/bmjopen-2014-005793
  • Gorai, A. K., & Pal, A. K. (2006). Noise and its effect on human being--a review. Journal of environmental science & engineering, 48(4), 253–260.
  • Hodgetts, W. E., Rieger, J. M., & Szarko, R. A. (2007). The effects of listening environment and earphone style on preferred listening levels of normal hearing adults using an MP3 player. Ear and hearing, 28(3), 290–297. https://doi.org/10.1097/AUD.0b013e3180479399
  • Hong, S. M., Park, I. S., Kim, Y. B., Hong, S. J., & Lee, B. (2016). Analysis of the Prevalence of and Factors Associated with Hearing Loss in Korean Adolescents. PloS one, 11(8), e0159981. https://doi.org/10.1371/journal.pone.0159981
  • Hope, A. J., Luxon, L. M., & Bamiou, D. E. (2013). Effects of chronic noise exposure on speech-in-noise perception in the presence of normal audiometry. The Journal of laryngology and otology, 127(3), 233–238. https://doi.org/10.1017/S002221511200299X
  • Imam, L., & Hannan, S. A. (2017). Noise-induced hearing loss: a modern epidemic?. British journal of hospital medicine (London, England : 2005), 78(5), 286–290. https://doi.org/10.12968/hmed.2017.78.5.286
  • Jansen, E. J. M., Helleman, H. W., Dreschler, W. A. & De Laat, J. A. P. M.. (2009). Noise induced hearing loss and other hearing complaints among musicians of symphony orchestras. International Archives of Occupational and Environmental Health, 82(2), 153-164. doi:10.1007/s00420-008-0317-1
  • Jastreboff, P. J., & Jastreboff, M. M. (2014, May). Treatments for decreased sound tolerance (hyperacusis and misophonia). In Seminars in hearing (Vol. 35, No. 02, pp. 105-120). Thieme Medical Publishers.
  • Kamerer, A. M., Harris, S. E., Kopun, J. G., Neely, S. T., & Rasetshwane, D. M. (2022). Understanding Self-reported Hearing Disability in Adults With Normal Hearing. Ear and hearing, 43(3), 773–784. https://doi.org/10.1097/AUD.0000000000001161
  • Khalfa, S., Dubal, S., Veuillet, E., Perez-Diaz, F., Jouvent, R., & Collet, L. (2002). Psychometric normalization of a hyperacusis questionnaire. ORL; journal for oto-rhino-laryngology and its related specialties, 64(6), 436–442. https://doi.org/10.1159/000067570
  • Kılıç, N., Şahin Kamışlı, G. İ., Gündüz, B., Bayramoğlu, İ., & Kemaloğlu, Y. K. (2021). Turkish Validity and Reliability Study of the Speech, Spatial and Qualities of Hearing Scale. Turkish archives of otorhinolaryngology, 59(3), 172–187. https://doi.org/10.4274/tao.2021.2021-4-3
  • Kim, M. G., Hong, S. M., Shim, H. J., Kim, Y. D., Cha, C. I., & Yeo, S. G. (2009). Hearing threshold of Korean adolescents associated with the use of personal music players. Yonsei medical journal, 50(6), 771–776. https://doi.org/10.3349/ymj.2009.50.6.771
  • Landälv, D., Malmström, L., & Widén, S. E. (2013). Adolescents' reported hearing symptoms and attitudes toward loud music. Noise & health, 15(66), 347–354. https://doi.org/10.4103/1463-1741.116584
  • Martin, W. H., Sobel, J., Griest, S. E., Howarth, L., & Yongbing, S. H. I. (2006). Noise induced hearing loss in children: Preventing the silent epidemic. Journal of Otology, 1(1), 11-21.
  • Natarajan, N., Batts, S., & Stankovic, K. M. (2023). Noise-Induced Hearing Loss. Journal of Clinical Medicine, 12(6), 2347.
  • Parsons, J., Reed, M. B., & Torre Iii, P. (2019). Headphones and other risk factors for hearing in young adults. Noise & health, 21(100), 116–124. https://doi.org/10.4103/nah.NAH_35_19
  • Peng, J. H., Tao, Z. Z., & Huang, Z. W. (2007). Risk of damage to hearing from personal listening devices in young adults. The Journal of otolaryngology, 36(3), 181–185.
  • Pienkowski M. (2021). Loud Music and Leisure Noise Is a Common Cause of Chronic Hearing Loss, Tinnitus and Hyperacusis. International journal of environmental research and public health, 18(8), 4236. https://doi.org/10.3390/ijerph18084236
  • Portnuff, C. D., Fligor, B. J., & Arehart, K. H. (2011). Teenage use of portable listening devices: a hazard to hearing?. Journal of the American Academy of Audiology, 22(10), 663–677. https://doi.org/10.3766/jaaa.22.10.5
  • Portnuff C. D. (2016). Reducing the risk of music-induced hearing loss from overuse of portable listening devices: understanding the problems and establishing strategies for improving awareness in adolescents. Adolescent health, medicine and therapeutics, 7, 27–35. https://doi.org/10.2147/AHMT.S74103
  • Priya, J. S., & Hohman, M. H. (2023). Noise Exposure and Hearing Loss. In StatPearls. StatPearls Publishing.
  • Royster J. D. (2017). Preventing Noise-Induced Hearing Loss. North Carolina medical journal, 78(2), 113–117. https://doi.org/10.18043/ncm.78.2.113
  • Sachdeva, S., & Kumar, M. (2018). Study on health impacts of ear and headphones among students lives in Chandigarh. Int J Res Appl Sci Eng Technol, 6(3), 3527-31.
  • Shehabi, A. M., Prendergast, G., Guest, H., & Plack, C. J. (2023). Noise Exposure in Palestinian Workers Without a Diagnosis of Hearing Impairment: Relations to Speech-Perception-in-Noise Difficulties, Tinnitus, and Hyperacusis. Journal of speech, language, and hearing research : JSLHR, 66(3), 1085–1109. https://doi.org/10.1044/2022_JSLHR-22-00461
  • Vielsmeier, V., Kreuzer, P. M., Haubner, F., Steffens, T., Semmler, P. R., Kleinjung, T., ... & Schecklmann, M. (2016). Speech comprehension difficulties in chronic tinnitus and its relation to hyperacusis. Frontiers in aging neuroscience, 8, 293.
  • World Health Organization (WHO) (2021). Make Listening Safe. https://cdn.who.int/media/docs/(WHO)default-source/documents/health-topics/deafness-and-hearing-loss/mls-brochure-english-2021.pdf?sfvrsn=bf19b448_5 adresinden 19.11.2023 tarihinde alınmıştır.

Uzaktan Eğitim Gören Üniversite Öğrencilerinde Farklı Kulaklık Tiplerinin ve Farklı Dinleme Koşullarının Azalmış Ses Toleransı ve İşitme Fonksiyonları Üzerine Etkisi

Yıl 2024, Cilt: 11 Sayı: 2, 448 - 465, 02.08.2024
https://doi.org/10.21020/husbfd.1303779

Öz

Amaç: Uzun süreli kulaklık kullanımının işitme sistemi üzerine olumsuz etkileri bilinmektedir. COVİD-19 pandemisi döneminde üniversite öğrencileri uzaktan derslere katılmak için normalden daha sık kulaklık kullanmak zorunda kalmışlardır. Bu çalışma, pandemi döneminde uzaktan eğitime katılan üniversite öğrencilerinde kulaklık tipi, ses şiddet düzeyi, dinleme ortamı ve derse katılım süresi gibi farklılıkların azalan ses toleransı (AST) ve işitsel işlevler üzerindeki etkisinin araştırılmasını amaçlamaktadır.
Gereç ve Yöntem: Araştırma Google Forms bağlantısı üzerinden gerçekleştirilmiştir. Katılımcılardan tercih ettikleri kulaklık tipi, ses şiddet seviyeleri, dinleme ortamı, haftalık uzaktan derse katılım süresi, tinnitus öyküsü bilgileri alınmıştır. AST’yi değerlendirmek için Azalmış Ses Tolerans Ölçeği- Tarama (ASTÖ-T), işitmenin alt bileşenlerini değerlendirmek amacıyla Konuşma, Uzaysal Algı ve İşitme Kalitesi Ölçeği (KUİK) kullanılmıştır. Araştırmaya toplam 247 birey katılmıştır (67 E, 180 K). Katılımcıların yaş ortalaması 21,47 (SS=4,91)’dir.
Bulgular: Kulaklık tipine göre ASTÖ-T, KUİK puanları arasında anlamlı fark bulunmamıştır. Haftalık derse katılım süresine göre hiperakuzi ve fonofobi puanları arasında anlamlı fark bulunurken, mizofoni ve KUİK puanları arasında anlamlı fark bulunmamıştır. Dinleme ortamına göre hiperakuzi ve KUİK puanları arasında anlamlı fark bulunurken, fonofobi veya mizofoni puanları arasında anlamlı fark bulunmamıştır. Ses şiddet seviyesine göre fonofobi, konuşma algısı ve işitme kalitesi puanları arasında anlamlı bir fark bulunmazken, hiperakuzi, misofoni ve uzaysal algı arasında anlamlı fark vardı. ASTÖ-T ile KUİK arasında negatif yönde anlamlı ilişki bulunmuştur.
Sonuç: Uzaktan eğitim sürecinde kullanılan kulaklık türü AST ve işitsel belirtilerle ilişkili bulunmazken, haftalık derse devam süresi, dinleme ortamı ve ses şiddeti düzeyleri arasında ilişki bulunmuştur. AST ile konuşma algısı, uzaysal algı ve işitme kalitesinin negatif korelasyon gösterdiği belirlenmiştir.

Destekleyen Kurum

Yok

Proje Numarası

Yok

Teşekkür

Araştırmaya katılım sağlayan tüm gönülllülere teşekkür ederiz.

Kaynakça

  • Akyıldız, N. (1998). Kulak hastalıkları ve mikrocerrahisi. Ankara, Bilimsel Tıp Yayınevi, 86.
  • Allusoglu, S., & Aksoy, S. (2022). The reliability and validity of decreased sound tolerance scale-screening. Brazilian journal of otorhinolaryngology, 88 Suppl 3(Suppl 3), S155–S163. https://doi.org/10.1016/j.bjorl.2021.11.009
  • Asha'ari, Z. A., Mat Zain, N., & Razali, A. (2010). Phonophobia and hyperacusis: practical points from a case report. The Malaysian journal of medical sciences : MJMS, 17(1), 49–51.
  • Båsjö, S., Möller, C., Widén, S., Jutengren, G., & Kähäri, K. (2016). Hearing thresholds, tinnitus, and headphone listening habits in nine-year-old children. International journal of audiology, 55(10), 587–596. https://doi.org/10.1080/14992027.2016.1190871
  • Byeon H. (2021). Associations between adolescents' earphone usage in noisy environments, hearing loss, and self-reported hearing problems in a nationally representative sample of South Korean middle and high school students. Medicine, 100(3), e24056. https://doi.org/10.1097/MD.0000000000024056
  • Camera, S., Tufts, J., & Skoe, E. (2019). Noise Exposure and Background Noise Tolerance in Listeners With Normal Audiograms. Journal of speech, language, and hearing research : JSLHR, 62(7), 2564–2570. https://doi.org/10.1044/2018_JSLHR-H-18-0245
  • Cavanna, A. E., & Seri, S. (2015). Misophonia: current perspectives. Neuropsychiatric disease and treatment, 11, 2117–2123. https://doi.org/10.2147/NDT.S81438
  • Cogen, T., Cetin Kara, H., Kara, E., Telci, F., & Yener, H. M. (2023). Investigation of the relationship between hyperacusis and auditory processing difficulties in individuals with normal hearing. European Archives of Oto-Rhino-Laryngology, 1-9.
  • Couth, S., Mazlan, N., Moore, D. R., Munro, K. J., & Dawes, P. (2019). Hearing Difficulties and Tinnitus in Construction, Agricultural, Music, and Finance Industries: Contributions of Demographic, Health, and Lifestyle Factors. Trends in hearing, 23, 2331216519885571. https://doi.org/10.1177/2331216519885571
  • Feder, K., Marro, L., Keith, S. E., & Michaud, D. S. (2013). Audiometric thresholds and portable digital audio player user listening habits. International journal of audiology, 52(9), 606–616. https://doi.org/10.3109/14992027.2013.798687
  • Fredriksson, S., Hammar, O., Torén, K., Tenenbaum, A., & Waye, K. P. (2015). The effect of occupational noise exposure on tinnitus and sound-induced auditory fatigue among obstetrics personnel: a cross-sectional study. BMJ open, 5(3), e005793. https://doi.org/10.1136/bmjopen-2014-005793
  • Gorai, A. K., & Pal, A. K. (2006). Noise and its effect on human being--a review. Journal of environmental science & engineering, 48(4), 253–260.
  • Hodgetts, W. E., Rieger, J. M., & Szarko, R. A. (2007). The effects of listening environment and earphone style on preferred listening levels of normal hearing adults using an MP3 player. Ear and hearing, 28(3), 290–297. https://doi.org/10.1097/AUD.0b013e3180479399
  • Hong, S. M., Park, I. S., Kim, Y. B., Hong, S. J., & Lee, B. (2016). Analysis of the Prevalence of and Factors Associated with Hearing Loss in Korean Adolescents. PloS one, 11(8), e0159981. https://doi.org/10.1371/journal.pone.0159981
  • Hope, A. J., Luxon, L. M., & Bamiou, D. E. (2013). Effects of chronic noise exposure on speech-in-noise perception in the presence of normal audiometry. The Journal of laryngology and otology, 127(3), 233–238. https://doi.org/10.1017/S002221511200299X
  • Imam, L., & Hannan, S. A. (2017). Noise-induced hearing loss: a modern epidemic?. British journal of hospital medicine (London, England : 2005), 78(5), 286–290. https://doi.org/10.12968/hmed.2017.78.5.286
  • Jansen, E. J. M., Helleman, H. W., Dreschler, W. A. & De Laat, J. A. P. M.. (2009). Noise induced hearing loss and other hearing complaints among musicians of symphony orchestras. International Archives of Occupational and Environmental Health, 82(2), 153-164. doi:10.1007/s00420-008-0317-1
  • Jastreboff, P. J., & Jastreboff, M. M. (2014, May). Treatments for decreased sound tolerance (hyperacusis and misophonia). In Seminars in hearing (Vol. 35, No. 02, pp. 105-120). Thieme Medical Publishers.
  • Kamerer, A. M., Harris, S. E., Kopun, J. G., Neely, S. T., & Rasetshwane, D. M. (2022). Understanding Self-reported Hearing Disability in Adults With Normal Hearing. Ear and hearing, 43(3), 773–784. https://doi.org/10.1097/AUD.0000000000001161
  • Khalfa, S., Dubal, S., Veuillet, E., Perez-Diaz, F., Jouvent, R., & Collet, L. (2002). Psychometric normalization of a hyperacusis questionnaire. ORL; journal for oto-rhino-laryngology and its related specialties, 64(6), 436–442. https://doi.org/10.1159/000067570
  • Kılıç, N., Şahin Kamışlı, G. İ., Gündüz, B., Bayramoğlu, İ., & Kemaloğlu, Y. K. (2021). Turkish Validity and Reliability Study of the Speech, Spatial and Qualities of Hearing Scale. Turkish archives of otorhinolaryngology, 59(3), 172–187. https://doi.org/10.4274/tao.2021.2021-4-3
  • Kim, M. G., Hong, S. M., Shim, H. J., Kim, Y. D., Cha, C. I., & Yeo, S. G. (2009). Hearing threshold of Korean adolescents associated with the use of personal music players. Yonsei medical journal, 50(6), 771–776. https://doi.org/10.3349/ymj.2009.50.6.771
  • Landälv, D., Malmström, L., & Widén, S. E. (2013). Adolescents' reported hearing symptoms and attitudes toward loud music. Noise & health, 15(66), 347–354. https://doi.org/10.4103/1463-1741.116584
  • Martin, W. H., Sobel, J., Griest, S. E., Howarth, L., & Yongbing, S. H. I. (2006). Noise induced hearing loss in children: Preventing the silent epidemic. Journal of Otology, 1(1), 11-21.
  • Natarajan, N., Batts, S., & Stankovic, K. M. (2023). Noise-Induced Hearing Loss. Journal of Clinical Medicine, 12(6), 2347.
  • Parsons, J., Reed, M. B., & Torre Iii, P. (2019). Headphones and other risk factors for hearing in young adults. Noise & health, 21(100), 116–124. https://doi.org/10.4103/nah.NAH_35_19
  • Peng, J. H., Tao, Z. Z., & Huang, Z. W. (2007). Risk of damage to hearing from personal listening devices in young adults. The Journal of otolaryngology, 36(3), 181–185.
  • Pienkowski M. (2021). Loud Music and Leisure Noise Is a Common Cause of Chronic Hearing Loss, Tinnitus and Hyperacusis. International journal of environmental research and public health, 18(8), 4236. https://doi.org/10.3390/ijerph18084236
  • Portnuff, C. D., Fligor, B. J., & Arehart, K. H. (2011). Teenage use of portable listening devices: a hazard to hearing?. Journal of the American Academy of Audiology, 22(10), 663–677. https://doi.org/10.3766/jaaa.22.10.5
  • Portnuff C. D. (2016). Reducing the risk of music-induced hearing loss from overuse of portable listening devices: understanding the problems and establishing strategies for improving awareness in adolescents. Adolescent health, medicine and therapeutics, 7, 27–35. https://doi.org/10.2147/AHMT.S74103
  • Priya, J. S., & Hohman, M. H. (2023). Noise Exposure and Hearing Loss. In StatPearls. StatPearls Publishing.
  • Royster J. D. (2017). Preventing Noise-Induced Hearing Loss. North Carolina medical journal, 78(2), 113–117. https://doi.org/10.18043/ncm.78.2.113
  • Sachdeva, S., & Kumar, M. (2018). Study on health impacts of ear and headphones among students lives in Chandigarh. Int J Res Appl Sci Eng Technol, 6(3), 3527-31.
  • Shehabi, A. M., Prendergast, G., Guest, H., & Plack, C. J. (2023). Noise Exposure in Palestinian Workers Without a Diagnosis of Hearing Impairment: Relations to Speech-Perception-in-Noise Difficulties, Tinnitus, and Hyperacusis. Journal of speech, language, and hearing research : JSLHR, 66(3), 1085–1109. https://doi.org/10.1044/2022_JSLHR-22-00461
  • Vielsmeier, V., Kreuzer, P. M., Haubner, F., Steffens, T., Semmler, P. R., Kleinjung, T., ... & Schecklmann, M. (2016). Speech comprehension difficulties in chronic tinnitus and its relation to hyperacusis. Frontiers in aging neuroscience, 8, 293.
  • World Health Organization (WHO) (2021). Make Listening Safe. https://cdn.who.int/media/docs/(WHO)default-source/documents/health-topics/deafness-and-hearing-loss/mls-brochure-english-2021.pdf?sfvrsn=bf19b448_5 adresinden 19.11.2023 tarihinde alınmıştır.
Toplam 36 adet kaynakça vardır.

Ayrıntılar

Birincil Dil Türkçe
Konular Odyoloji
Bölüm Makaleler
Yazarlar

Serpil Alluşoğlu 0000-0002-8684-8023

Emine Ayça Ödemişlioğlu Aydın 0000-0002-6381-0508

Deniz Tuz 0000-0002-9265-2940

Erva Değirmenci Uzun 0000-0002-8745-2776

Proje Numarası Yok
Erken Görünüm Tarihi 23 Temmuz 2024
Yayımlanma Tarihi 2 Ağustos 2024
Gönderilme Tarihi 30 Mayıs 2023
Yayımlandığı Sayı Yıl 2024 Cilt: 11 Sayı: 2

Kaynak Göster

APA Alluşoğlu, S., Ödemişlioğlu Aydın, E. A., Tuz, D., Uzun, E. D. (2024). Uzaktan Eğitim Gören Üniversite Öğrencilerinde Farklı Kulaklık Tiplerinin ve Farklı Dinleme Koşullarının Azalmış Ses Toleransı ve İşitme Fonksiyonları Üzerine Etkisi. Hacettepe University Faculty of Health Sciences Journal, 11(2), 448-465. https://doi.org/10.21020/husbfd.1303779