Sexual history taking in general practice: managing sexually transmitted infections for female sex workers by doctors and assistant doctors in Vietnam

Abstract

Sexually transmitted infections (STIs) in Vietnam have been increasing. Control of STIs among female sex workers (FSWs) is important in controlling the epidemic. Effective STI control requires that physicians are skilful in taking sexual history for FSW patients. Three hundred and seventy-one physicians responded to a survey conducted in three provinces in Vietnam. The respondents were asked whether they asked FSW patients about their sexual history and information asked during sexual history taking. The respondents were also asked about their barriers for taking sexual history. Over one-fourth (27%) respondents always, over half (54%) respondents sometimes and 19% respondents never obtained a sexual history from FSW patients. Multivariable analysis revealed that factors associated with always taking a sexual history were being doctor, training in STIs and working at provincial level facilities. Physician’s discomfort was found to be inversely associated with training on communication with patients, seeing 15 or fewer patients a week, working at provincial level facilities. Issues in sexual history taking among FSW patients in general practice in Vietnam were identified. These issues can help STI control for FSW patients and need due attention in order to improve STI management in Vietnam.

Keywords

Sexual history sexual health women female sex workers sexually transmitted infection Vietnam

Introduction

Sexually transmitted infections (STIs) are a serious public health problem globally. The global estimate of Chlamydia, gonorrhoea, syphilis and Trichomonas among 15- to 49-year-old men and women increased almost 50% in nine years (340 million in 1999 vs. 498.9 million in 2008).¹ Of these 498.9 million new STI cases, 78.5 million cases were in Southeast Asia.¹ One major challenge for STI control is that many STIs are asymptomatic.² Individuals with STIs can unknowingly spread the infections and have complications if undetected or untreated.^1,3 In Vietnam, the reported number of STI infections increased over 660% in 14 years (45,634 in 1996 vs. 348,134 in 2010).⁴ The 15- to 19-year-old population of Vietnam was 37,049,941 in 1996 and 40,184,600 in 2010.⁵ It also has been estimated that there were one million new STI cases in Vietnam annually.⁶ The higher increase in number of STI cases in Vietnam compared to the rest of Asia may be caused by actual changes in STI infections coinciding with the socio-economic changes during ‘Doi Moi’ era and/or as a consequence of the improved STI reporting system in Vietnam during this 14-year period.

Sex work was high during the Vietnam War and, after the war, the government implemented policy to control sex work which reduced the level of sex work in Vietnam.^7–9 In the late years of the 20th century, with the introduction of ‘Doi Moi’ policy, Vietnam underwent a transition towards a market economy. Alongside economic development, the changes also resulted in greater urbanisation, expanded tourism and a raft of social issues, such as increased rural-to-urban migration, unemployment, larger income gaps between the population and widening economic disparity. Women also experience difficulties in securing employment or earning enough to support their lives and as a result enter the sex work industry. All these factors have contributed to the resurgence of sex work in Vietnam.^8,10,11 Despite sex work being illegal in Vietnam, sex for money can be found in many places in Vietnam.¹² It was estimated that there were 300,000 female sex workers (FSWs) in Vietnam.¹³

It has been noted that sex workers play an important role in STI transmission.^14–17 Among the FSWs in Vietnam, consistent condom use could be as low as 31.3% with first-time clients, 32.4% with regular clients and 5.5% with regular sex partners. There has been evidence suggesting an increasing STI/HIV epidemic among FSWs in Vietnam. From 2006 to 2009, reported HIV prevalence rates among venue-based FSWs have almost doubled in Hanoi and Ho Chi Minh cities.¹⁸ In addition, there has been evidence suggesting that people in Vietnam are becoming more open and relaxed about sexual behaviour.^19,20 It has been reported that a third of sexually active 15- to 29-year-old men in Vietnam have ever visited a FSW.²¹

Effective management of STIs is one of the cornerstones of STI control. Physicians in general practice play a crucial role as most patients first seek medical services from these physicians. It has been reported that three-quarters of STI cases were diagnosed in general practice.^22–25 However, it was also reported that physicians in general practices did not routinely take a sexual history from their patients.^25–29 The infrequency of sexual history taking may lead to missed opportunities for early STI detection and treatment.^30–34 In Vietnam, available data suggest that there are ongoing issues in STI management such as physicians’ tendency to over-diagnose infections,³⁵ physicians’ insufficient knowledge of STIs and improper/inadequate STI treatments.^36–38

Sexual history taking is an important skill for effective STI management as it enables physicians to identify patients’ sexual risks and allows for management issues to be explored further.³⁹ To our knowledge, there are no published studies from Vietnam on routine sexual history taking in general practice. Although the larger study included a range of at risk patients, the present study reports on physicians’ self-reported sexual history practice with FSW patients and the perceived barriers that may influence their sexual history taking.

Methods

A cross-sectional self-administered questionnaire survey of physicians working in Quang Ninh, An Giang and Can Tho province in Vietnam was conducted in 2010. These sites were among the provinces identified to have a more serious STI/HIV problem in Vietnam.¹⁸ The survey covered physicians working at health facilities at primary level (communal health stations), district and provincial health facilities. The physicians include those working at health facilities specialised for Dermatology and Venereology and those working in non-Dermatology and Venereology facilities. In Vietnam, both doctors and assistant doctors are physicians and entitled to provide medical examinations and treatment. In this study, the general doctors and assistant doctors are categorised in one group ‘non-Dermatology and Venereology’ physicians. As the focus of the present paper is on general practice, data presented are restricted to doctors and assistant doctors working in a non-STI specialist setting. Administratively, Vietnam is organised into 55 provinces. The provinces are further divided into towns and districts. The lowest unit in the administrative system is communes.⁵ In terms of health care, the patients can choose to go first to primary health care facilities or higher level facilities. Generally, health care facilities at higher levels receive more investment in term of human resources, training and other work-related investments. Physicians may also prefer to work at higher level facilities due to better working conditions.

A total of 451 physicians (doctors and assistant doctors) were selected using a multi-stage cluster random sampling where 10 districts among the 29 districts in the three provinces were selected using simple random sampling, and subsequently, a systematic random sampling was conducted among the 10 selected districts to select the required number of physicians.⁴⁰ After having developed the list of selected respondents for the survey, the researcher, together with local health staff, travelled to the districts to meet with the respondents to brief them about the study and distribute information for participant sheets, informed consent forms and survey questionnaires. Respondents had a choice to either complete the questionnaire on the spot or take it with them to complete at convenient time and return the questionnaire together with signed consent forms. Respondents received $5 for the time responding to the survey which was estimated to be 30–45 min. Respondents could choose not to participate or withdraw from the study at any time. Potential respondents received three reminders from researcher or a staff of local health service. Of the 451 selected respondents (152 doctors and 299 assistant doctors), 371 respondents (110 doctors and 261 assistant doctors) completed the survey. Response rate among doctor respondents was 72.4% and among assistant doctor respondents was 87.3%.

In Vietnam, high school graduates who want to study medicine to become doctors need to pass an entrance examination and complete six years of medical education at one of the eight public medical universities. High school graduates aspiring to become assistant doctors also need to pass an entrance examination and complete a two-year medical education at a provincial secondary medical school. Assistant doctors are trained to provide basic medical examination and treatment services and mainly destined for communal and district health facilities while doctors can work at any level in the health care system. Both doctor and assistant doctor medical education covered STI diagnosis and treatment. In addition, the physicians can receive in-service STI training. In Vietnam, assistant doctors account for about half of the total number of physicians (doctors and assistant doctors). In many health facilities at primary level, there were only assistant doctors.⁴¹

The survey questionnaire included items about physicians’ demographic and practice characteristics, and sexual history taking practice for a number of patients who were in the ‘at risk’ categories. However, given the STI/HIV epidemic and expansion of the female sex industry in Vietnam, this population at-risk group deserves particular in-depth focus. The respondents were asked how often they took a sexual history from FSW patients who did not have STI as their primary complaint. Contents of sexual history taking were obtained by an open-ended question and the responses were later grouped into the ‘5Ps’ categories,² with additional categories as recommended by Tideman et al.⁴² The ‘5Ps’ include information about partners; prevention of STIs; prevention of pregnancy; sexual practices; and past STI history. Additional categories based on work of Tideman et al. include patient’s presenting complaints, history of present complaints, sexual relationship status, last sexual contact, etc. The respondents were also asked about their perceived barriers for sexual history taking. The survey was approved by the Human Research Ethics Committee of the University of New England, Australia (HE10/148).

Statistical analysis

Analysis was performed using SPSS statistical package, version 20.⁴³ Outcomes assessed included frequency, contents and perceived barriers for sexual history taking. Univariate and multivariable analysis were performed to examine possible associations of general and practice characteristics of the physicians with sexual history taking and selected barrier of sexual history taking. Among the barriers, physicians’ discomfort was selected for multivariable analysis as this was found to be inversely associated with patient care in STI.⁴⁴

The independent variables included age, sex, medical degree, training on STI management and communication with patients, duration of medical practice, average weekly client volume, STI diagnoses in the month prior to the survey and place of main practice. Continuous independent variables were recoded into categorical variables including age, duration of medical practice and average weekly client volume. Independent variables found to be associated with outcome variables at p ≤0.2 (Chi square test) were included in multivariable analysis. As frequency of sexual history taking had three possible responses (‘always’, ‘sometimes’ and ‘never’), multinomial logistic regression was performed using ‘never’ as the reference category.^45–47 Regarding multivariable analysis for physicians’ discomfort, binary logistic regression was performed as there were two possible responses (‘yes’ or ‘no’).^48,49

Assumptions for logistic regression were checked to ensure that the fitted model was appropriate for the collected data. Assumptions for logistic regression include absence of multicollinearity and absence of outliers in the solution.^50,51 Variance inflation factor value over 5 is the cut-off point for determining the presence of multicollinearity.⁵⁰ No multicollinearity among the independent variables was detected using the above mentioned criteria. Outlying cases were checked by examination of residuals.⁵¹ In the binary logistic regression, one case with ZResid value over 2.5 was removed from analysis for being an outlier. In the case of the multinomial logistic regression, outlier was examined by running two binary logistic regressions were performed using case selection to compare ‘always’ with ‘never’ and ‘sometimes’ with ‘never’. Prior to performing the multinomial logistic regression, three cases were excluded for having ZResid value over 2.5.

The models were examined for goodness of fit and contribution/importance of each of the independent variables. For binary logistic regression, Goodness of fit was evaluated using Hosmer-Lemeshow Goodness of Fit Test. Poor fit is indicated by a p value less than 0.05. For multinomial logistic regression, deviance Chi square test for goodness of fit was used and insignificant p value represents a good fit. The Wald test was used to evaluate the importance of each of the independent variables. An independent variable was considered significantly associated with the outcome variable if the Wald test resulted in a p value less than 0.05.⁵¹

Results

Sample characteristics

Of the physicians who participated in the study (n = 371), over two-thirds (70.4%) were assistant doctors and the remaining (29.6%) general practitioners. About three-quarters (71.4%) of them were women. Over one-fourth (26.7%) had been in medical practice for 10 years or less, over one-third had been in practice for 11–20 years (34.2%) and the rest 39.1% had been in practice for over 20 years. Since graduation from medical school, more than half of the respondents had received training on doctor-patient communication and training in STI management (52.3% and 60.4%, respectively). In both patient communication and STI training, the proportion of respondents reported having had training was higher among assistant doctors than doctors (54.4% vs. 47.3% and 61.7% vs. 57.3%). However, these differences were not significant.

About half (50.4%) of the respondents had average weekly patient volume of 15 or fewer, one-fourth of the respondents saw 16–30 patients a week and the remaining one-fourth saw more than 30 patients a week (24% and 25.6%, respectively). The mean number of patients per week of doctor respondents was 44.7, whereas the mean number of patients per week of assistant doctors was 33.5 (p < 0.05). In the month prior to the survey, about two-third of the respondents reported having STI diagnosis and about one-third of the respondents reported not having STI diagnosis (64.4% and 35.6% respectively). The proportion of respondents reported having STI diagnosis in the month prior to the survey was higher among doctors than assistant doctors (82.7% vs. 56.7%, p ≤ 0.05). Regarding the place of main practice, more than half (56.3%) of the respondents worked at communal health facilities, 23.5% at provincial health facilities and the rest 20.2% at district health facilities.

Sexual history taking among FSWs

Of the 371 respondents, 53.6% reported having seen a FSW patient in the past 12 months. Of these (n = 199), 18.6% reported never, 54.3% sometimes and 27.1% always taking a history from the FSW patients. There were more assistant doctors who reported never taking a sexual history from their patients than medical doctors (20.7% vs. 13.6%, p < 0.1). The proportion of respondents reported always taking a sexual history from their patients was higher among doctors than assistant doctors (37.3% vs. 22.9%, p < 0.1).

Analysis of sexual history taking data by the ‘5 Ps’ showed that asking about patients’ partner (the first P), the most commonly sought information was the number of sexual contacts (39.4%). Only 1.6% respondents asked about the gender of the patients’ partner, and another 1.6% asked whether the patient’s partner had extra sex partners. As for pregnancy prevention (the second P) and prevention of STIs (the third P), more than one-third (36.9%) respondents asked their patients about condom use, while only 6.2% respondents asked their patients about contraceptive usage (6.2%). Regarding sexual practice (the fourth P), only 6.2% respondents asked their patients about types of sexual intercourse (i.e. oral, vaginal or anal sex). With respect to the history of STIs (the fifth P), more than one-tenth (11.6%) of the respondents asked about the history of STIs, and only few respondents asked about past STI examinations and partners’ STI history (1.6% and 1.9%, respectively).

Presenting complaint was mentioned by one-third (33.2%) of the respondents, and history of complaint was asked by one-quarter (22.4%) of the respondents. Occupation of patients’ partner was asked more frequently by assistant doctors (14.2% assistant doctors vs. 7.3% doctors, p < 0.01), while more doctors asked about the use of contraceptive methods (10.9% vs. 4.2%, p < 0.05) and history of complaints (36.4% vs. 16.5%, p < 0.01), respectively, for doctors and assistant doctors.

Multivariable analysis showed that assistant doctor respondents were less likely to always take a sexual history than doctor respondents (Adj odds ratio [OR] = 0.33, 95% confidence interval [CI] = 0.11–0.97); compared with respondents who did not have STI training, those who had STI training were more likely to always take a sexual history (Adj OR = 4.81, 95% CI = 1.73–13.4). Respondents working at a communal health facility were less likely to always take a sexual history than their counterparts who worked at provincial facilities (Adj OR = 0.16, 95% CI = 0.05–0.49) (Table 1).

Table 1.

Multinomial logistic regression analysis of factors associated with sexual history taking among FSW patients.

	Always vs. never		Sometimes vs. never
	Adj OR	95% CI	Adj OR	95% CI
Medical degree
Doctors	1		1
Assistant doctors	0.33	0.11–0.97	0.52	0.19–1.41
Training in STIs
No	1		1
Yes	4.8	1.73–13.4*	2.9	1.22–6.88
Diagnoses of STI in the month prior to the survey
No	1		1
Yes	0.96	0.31–2.97	0.52	0.2–1.36
Place of main practice
Province	1		1
District	0.98	0.2–4.76	3.25	0.72–14.6
Commune	0.16	0.05–0.49*	0.66	0.23–1.86

Adj OR: adjusted odds ratio. *p ≤ 0.01 (Wald test).

Barriers to taking a sexual history among FSWs

The most frequently cited barrier for sexual history taking was patients’ discomfort mentioned by approximately two-thirds of the physicians (67.6%). More than one-third (42.8%) of respondents reported that they did not have sufficient time to take a sexual history from patients. More than half (57.6%) reported discomfort in taking a sexual history, and 37.9% cited lack of training as a barrier to taking a sexual history. One-third (33.1%) of physicians reported that taking a sexual history and not being in regular practice was a barrier.

Citing physicians’ discomfort was a significant barrier for taking a sexual history (see Table 2). Respondents who had training on communication with patients were less likely to mention physician’s discomfort than their counterparts without such training (Adj OR = 0.26, 95% CI = 0.09–0.74). Respondents seeing more patients (16–30 patients a week) were less likely to mention physician’s discomfort (Adj OR = 0.19, 95% CI = 0.06–0.68). Respondents working at district facilities were more likely to mention physicians’ discomfort than their counterparts who worked at provincial facilities (Adj OR = 7.69, 95% CI = 1.52–38.8; Table 2).

Table 2.

Binary logistic regression of factors associated with physicians’ discomfort for taking sexual history with FSW patients.

	Physician’s discomfort
	Adj OR	95% CI
Training on communication
No	1
Yes	0.26	0.09–0.74*
Average weekly patient volume
≤15	1
16–30	0.19	0.06–0.68*
>30	0.61	0.19–1.94
Place of main practice
Province	1
District	7.69	1.52–38.8*
Commune	2.65	0.8–8.8

Adj OR: adjusted odds ratio. *p ≤ 0.05 (Wald test).

Discussions

This physician survey yielded a high response rate. Earlier research has documented that the main barriers for physicians’ non-response to surveys included lack of time, belief that surveys have low value, concern about confidentiality and belief that questionnaires have bias or limited range of responses.^52,53 In this survey, those barriers were dealt with, possibly leading to a higher response rate. Regarding time barriers, the potential respondents were allowed to take time off work to meet with the researcher and to respond to the survey. They could also opt to respond to the survey at a time convenient to them. Issues regarding nature of the survey, questionnaire and confidentiality were attended to by the briefing conducted by researcher and local health staff. Such support for respondents to assist them in completing the questionnaire led to higher completion rates. It has been reported that financial incentives may help to increase response rates to surveys.^54,55 However, the value of incentive provided in this survey was very small and is not perceived to have been a significant cause of recruitment bias among the respondents. In this study, the higher response rate among assistant doctors could have been caused by the lower average number of patients seen per week of these assistant doctors compared to doctors. As mentioned above, time constraint is one of the main barriers for physicians’ non-response to surveys.^52,53

The present study identified several issues with sexual history taking among FSW patients in general practice in Vietnam which may adversely affect STI prevention and control among the FSW sub-population. Improvements in these areas are required in order to strengthen STI control in Vietnam. The findings of the present study are discussed in the context of available literature on sexual history taking from developed countries. Literature on sexual history taking from regional countries with similar socio-cultural profiles to Vietnam could not be located.

First, the physicians in this study reported less frequent sexual history taking than by physicians in the United States, United Kingdom and Australia.^{25,27,29,56–59} Among the studies mentioned above, only one study reported sexual history taking among FSWs, while the others reported sexual history taking among general clients.²⁷ Studies based on patient surveys conducted in South Korea and Switzerland show that up to three quarters of the patients reported never being asked by their physicians about their sexual history.^26,28 However, it should be noted that data from patient surveys could show different patterns of history taking compared to physician surveys.^60,61 Results of multivariable analysis showed that factors associated with better sexual history taking were being a doctor, having trained on STIs and communication with patients and working at provincial facilities.

Second, information gathered in sexual history taking was also insufficient and much lower in the present study compared to the data reported by other studies. Among all the sexual history items, number of partners was the only sexual history information that was sought more frequently by physicians in the present study than by physicians in the other studies. For all other areas of sexual history, namely drug use, STI history, sex of partners, route of sex, and sexual abuse experience, information was sought by far fewer physicians in the present study than physicians in the other studies.^{25,29,56,58,59} Results of previous studies in Vietnam reported that being promiscuous was perceived to be the most common cause of STIs and patients faced a judgmental attitude from physicians.^37,38,62 It is plausible that in the present study the higher proportion of physicians enquiring about number of sexual contacts is influenced by similar attitudes. The low percentage of physicians in the present study eliciting specific information from their patients about their sexual history suggests that, in addition to the generally low skill level in taking a sexual history, talking to patients about drug use, types of sex, history of sexual abuse or sexual orientation should be areas of priority in future interventions to improve sexual history taking in Vietnam.

Physicians’ and patients’ discomfort were the two leading barriers for taking a sexual history. Results of multivariable analysis showed that physicians’ discomfort was inversely associated with training on communication with patients and weekly client volume. Physicians working at district facilities were more likely to mention physicians’ discomfort. All these suggest potential areas for interventions to reduce physicians’ discomfort for taking a sexual history for FSW patients. Talking about sex is a taboo in Vietnam and sex work is considered a ‘social evil’.⁶³ In the past, sex workers in Vietnam were placed in compulsory rehabilitation centres.⁶⁴ Starting July 2013, sex workers will no longer be placed in rehabilitation centres but will only be required to pay fines.⁶⁵ This policy change could enable the sex workers to be more open in talking about their risks. It has been reported that decriminalisation of sex work is associated with better health programmes for sex workers.⁶⁶ However, it is the physicians who need to be better prepared and willing to initiate the conversation about sexual history. Improvements in knowledge and skills for sexual history taking can be achieved by enhancing training in communication for physicians.^67–70 In the present study, training in communication with patients was a strong predictor of physicians not reporting discomfort taking a sexual history from FSW patients. Although patients’ discomfort was cited frequently by the physicians in present study as a barrier for sexual history taking, it has been reported elsewhere that most of the patients had positive attitude toward sexual history taking and would like physicians to ask them about their sexual history.^26,28 Without data on patients’ perspectives from Vietnam, it may be insufficient to validate the physicians’ opinion about patients’ discomfort regarding sexual history taking.

Time constraints were also reported as an impediment to taking a sexual history in the present study. Time constraint is a common impediment in clinical practice.^23,71,72 In addition to interventions to improve physicians’ skills to elicit a sexual history, recent innovations in sexual history taking should be investigated for application in Vietnam. These approaches include a paper-based patient-administered questionnaire or a computerised tool for sexual history taking. It has been reported that the use of patient-administered questionnaire for history taking, either paper or computer based, was acceptable to patients and resulted in equal or more information compared to face-to-face interview.^73–77

The physicians in the present study had inconsistent knowledge about what comprised a sexual history. For example, presenting complaint and history of complaint were mentioned by the physicians in the present study as part of sexual history taking. Although these two items were included among the core questions for sexual history by Tideman et al.,⁴² they are not part of sexual history as per the 2010 Sexually Transmitted Diseases Treatment Guidelines.² In addition, inconsistencies have been observed in the Vietnam National Guidelines for Reproductive Health Services (NSG). Important items in the ‘5Ps’ are not listed in NSG such as sex of patients’ partner, types of sexual intercourses and exchange of sex for money. There were also inconsistencies in the medical history/case history and risk assessment for STIs in the NSG. For example, injecting drug use was listed under medical history but not risk assessment. In the NSG, there is no mention of the term ‘sexual history’ nor a session dedicated for sexual history.^2,78 The absence of a standard set of questions for sexual history is an obstacle to clinical medicine and public health.⁵⁸ Based on the available literature and local situation, a core set of questions for sexual history taking should be developed for use in Vietnam.^{2,42,56,59,79} From this set of questions, a screening index that predicts the possibility of STI infections amongst different risk groups can be developed.⁸⁰ Of course, patients are an important dyad in the relationship with physicians. Perhaps as part of the self-education campaign directed towards FSW, empowering these women to initiate a dialogue about their sexual history with physicians may be required, but how this is culturally achieved with both the professional and cultural relationship is a complex matter deserving more public health attention.

The limitations of the present study need to be acknowledged. The present study used a self-administered questionnaire to elicit information on STIs. Self-reported responses could be prone to social desirability bias⁸¹ and answers about events in the past could be subjected to recall bias.⁸² In this study, the respondents were asked to list their barrier(s) for taking a sexual history for FSW patients. Measuring physicians’ discomfort as a dichotomous response may be subject to bias as underlying the organisational barriers could be issues of stigma and prejudice. The present study was not designed to collect data from FSWs. It is recommended that future research on this topic should include data collection from FSWs about their experiences of medical consultation for STI services as this will provide the important and much-needed patient perspective on management of STIs. In addition, our sample resulted in a higher proportion of physicians being assistant doctors and women than the national average. This suggests non-representativeness of the sample in representing the health care workforces of the country. Therefore, additional cautions should be made in interpreting and generalising the findings of this study. Future studies should be carried out on a national sample to monitor improvements on sexual health management.

Conclusion

STIs are a serious public health problem in Vietnam. Sexual history taking from FSWs is important for STI control due to the role sex workers play in STI transmissions. Our study revealed that sexual history taking from FSW patients was limited in general practice in Vietnam with both infrequent sexual history taking and limited imformation taken. This may lead to STI cases being missed, and the FSWs can continue to transmit STIs through unprotected sex. Improvements in sexual history taking in general practice require strategies to improve physicians’ knowledge, skills and attitude toward sexual history taking from FSWs and other at risk groups. Further research is needed to develop tools that allow physicians to quickly and comprehensively obtain patients’ sexual history and empower FSWs to be more proactive about their sexual health.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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