Well-Being, Mental Health, and Study Characteristics of Medical Students before and during the Pandemic
Abstract
:1. Introduction
1.1. COVID-19 in Austria
1.2. Mental Health
1.3. Thriving
1.4. Burnout
1.5. Study Characteristics: Demands, Resources, Stressors
2. Methods
2.1. Study Design
2.2. Setting and Context
2.3. Participants and Sample Size
2.4. Variables and Measurements
2.4.1. Mental Health
2.4.2. Thriving
2.4.3. Burnout
2.4.4. Study Conditions
2.4.5. Social Support
2.4.6. Study Satisfaction
2.4.7. COVID-19-Related Questions
2.5. Statistical Methods
3. Results
3.1. Cross-Sectional Analyses
3.2. Longitudinal Analyses
4. Discussion
Limitations
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Appendix A
Patient Health Questionnaire (PHQ-9) | |
Over the last 2 weeks, how often have you been bothered by any of the following problems? | |
1. | Little interest or pleasure in doing things |
2. | Feeling down, depressed, or hopeless |
3. | Trouble falling or staying asleep, or sleeping too much |
4. | Feeling tired or having little energy |
5. | Poor appetite or overeating |
6. | Feeling bad about yourself—or that you are a failure or have let yourself or your family down |
7. | Trouble concentrating on things, such as reading the newspaper or watching television |
8. | Moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restlessthat you have been moving around a lot more than usual |
9. | Thoughts that you would be better off dead or of hurting yourself in some way |
Generalized Anxiety Disorder (GAD-7) | |
Over the last 2 weeks, how often have you been bothered by any of the following problems? | |
1. | Feeling nervous, anxious or on edge |
2. | Not being able to stop or control worrying |
3. | Worrying too much about different things |
4. | Trouble relaxing |
5. | Being so restless that it is hard to sit still |
6. | Becoming easily annoyed or irritable |
7. | Feeling afraid as if something awful might happen |
Comprehensive Inventory of Thriving (CIT) | |
1. | There are people I can depend on to help me |
2. | There are people who give me support and encouragement |
3. | There are people who appreciate me as a person |
4. | I pitch in to help when my local community needs something done |
5. | I invite my neighbors to my home |
6. | I look for ways to help my neighbors when they are in need |
7. | I can trust people in my society |
8. | People in my neighborhood can be trusted |
9. | Most people I meet are honest |
10. | People respect me |
11. | People are polite to me |
12. | I am treated with the same amount of respect as others |
13. | I feel lonely |
14. | I often feel left out |
15. | There is no one I feel close to |
16. | I feel a sense of belonging in my community |
17. | I feel a sense of belonging in my state or province |
18. | I feel a sense of belonging in my country |
19. | I get fully absorbed in activities I do |
20. | In most activities I do, I feel energized |
21. | I get excited when I work on something |
22. | I use my skills a lot in my everyday life |
23. | I frequently use my talents |
24. | I get to do what I am good at everyday |
25. | I learned something new yesterday |
26. | Learning new things is important to me |
27. | I always learn something everyday |
28. | I am achieving most of my goals |
29. | I am fulfilling my ambitions |
30. | I am on track to reach my dreams |
31. | I can succeed if I put my mind to it |
32. | I am confident that I can deal with unexpected events |
33. | I believe that I am capable in most things |
34. | What I do in life is valuable and worthwhile |
35. | The things I do contribute to society |
36. | The work I do is important for other people |
37. | Other people decide most of my life decisions |
38. | The life choices I make are not really mine |
39. | Other people decide what I can and cannot do |
40. | My life has a clear sense of purpose |
41. | I have found a satisfactory meaning in life |
42. | I know what gives meaning to my life |
43. | I am optimistic about my future |
44. | I have a positive outlook on life |
45. | I expect more good things in my life than bad |
46. | In most ways my life is close to my ideal |
47. | I am satisfied with my life |
48. | My life is going well |
49. | I feel positive most of the time |
50. | I feel happy most of the time |
51. | I feel good most of the time |
52. | I feel negative most of the time |
53. | I experience unhappy feelings most of the time |
54. | I feel bad most of the time |
Maslach Burnout Inventory—student version (MBI-SS-GV)—Scale “Emotional Exhaustion” | |
1. | I feel emotionally drained by my studies |
2. | I feel used up at university day’s end |
3. | I feel fatigued in the morning having another day at university ahead |
4. | Studying or attending a lecture is really stressful for me |
5. | I feel burned out by my studies |
Work Analysis Measure for Students (WA-S) * | |
1. | My theoretical (previous) knowledge corresponds to the study requirements. |
2. | My social skills correspond to the requirements of everyday study life |
3. | My practical skills correspond to the study requirements (e.g., computer skills, tasks in the dissection course) |
4. | My self-regulation skills (e.g., self-motivation, perseverance, composure)correspond to the study requirements |
5. | My studies require me to constantly weigh up different things and set priorities before I can complete the tasks |
6. | During my studies, situations arise again and again that I have to think carefully about how I can overcome them |
7. | My studies require me to constantly react to complex situations |
8. | My lecturers give me clear feedback on my academic performance |
9. | My lecturers give me clear feedback on my learning progress |
10. | My lecturers give me clear feedback on how I can do something better in the future |
11. | I can decide for myself how I complete my study tasks |
12. | I can set my own workflow |
13. | I can decide for myself which working methods and work equipment I use in my studies |
14. | I can decide for myself which study tasks I have to complete |
15. | I can influence the course and design of courses |
16. | I can influence the content of courses |
17. | During my studies, I am always confronted with uncertain information/rumors that affect my studies |
18. | In my studies I am constantly confronted with personnel changes/shortages of lecturers/supervisors |
19. | During my studies, I am repeatedly confronted with unplanned organizational changes (e.g., in course content and procedures) |
20. | In my studies I always feel like there are unnecessary prerequisite regulations (e.g., courses to be completed) hindering the progress |
21. | In my studies you are repeatedly confronted with arbitrary/incomprehensible decisions that you have to accept |
22. | I always have to work particularly quickly and still can’t finish my study assignments |
23. | I always have too much to do at once in my studies |
24. | I am constantly under time pressure during my studies due to unfavorable deadlines |
25. | I always have so much to do during my studies that the quality of my work during my studies suffers |
26. | Information required for my studies is repeatedly not provided |
27. | Information required for my studies is always difficult to obtain |
28. | I repeatedly receive information about my studies that is unclear and/or incomplete |
Salutogenetic Subjective Working Analysis (SALSA)—Scale “Social Support” | |
1. | How much can you rely on the following people if problems arise during your studies? |
(a) Your lecturers|(b) Your fellow students|(c) Other people outside the university (e.g., partners/family/friends…) | |
2. | How willing are these people to listen to your problems in your studies? |
(a) Your lecturers|(b) Your fellow students|(c) Other people outside the university (e.g., partners/family/friends…) | |
3. | How much do these people actively support you so that you have an easier time with your studies? |
(a) Your lecturers|(b) Your fellow students|(c) Other people outside the university (e.g., partners/family/friends…) | |
Study Satisfaction (German Centre for Higher Education Research and Science Studies) * | |
How satisfied are you with… | |
1. | …the support from the teachers in your course of study? |
2. | …the technical quality of the courses? |
3. | …how the teaching material is conveyed by the teachers? |
4. | …the structure of your course of study? |
5. | …the teaching content of the individual subjects of your course of study? |
6. | …the number of participants in the events in your course of study? |
7. | …the factual and spatial equipment in your course of study? |
8. | …the services and advice (e.g., study department) at your university? |
9. | …the knowledge and skills you have achieved so far (total study yield)? |
COVID-19-related questions * | |
(I) | Have you had COVID in the last 12 months? |
(II) | How much alcohol have you been drinking since the beginning of the corona pandemic compared to before the pandemic? |
(III) | How many other intoxicants (cannabis, etc.) have you been consuming since the beginning of the corona pandemic compared to before the pandemic? |
(IV) | How much impact do the pandemic containment measures have on your student life? |
(V) | I feel sufficiently informed about the Corona prevention measures at my university. |
(VI) | I find it difficult to organize my everyday study time in a meaningful way. |
(VII) | I find it difficult to distance myself from my studies at home or during my free time during the periods of online teaching. |
(VIII) | I can maintain personal contact with my fellow students despite the lack of physically attending lectures. |
(IX) | Physical distancing from my fellow students through digital teaching puts a strain on me. |
(X) | Due to the lack of or limited attendance during my studies, I find it difficult to make new friends. |
Note: Listed measurement items used in this study (except the SF-12 as it is a licensed tool) are either open access or can be received from the authors upon request. Originally, they were all provided in the German language. * Only available in German. |
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Variable | Cross-Sectional Data | Longitudinal Data | ||||
---|---|---|---|---|---|---|
Pre-Pandemic | Peri-Pandemic | |||||
Sample Size (N) | % | Sample Size (N) | % | Sample Size (N) | % | |
Survey time | ||||||
2017 | 147 | 14.9 | 1 | 1.6 | - | - |
2018 | 169 | 17.1 | 10 | 15.9 | - | - |
2019 | 126 | 12.8 | 21 | 33.3 | - | - |
2020 | 100 | 1.1 | 31 | 49.2 | - | - |
2022 | 446 | 45.1 | - | - | 63 | 100 |
Sex | ||||||
Male | 356 | 36.0 | 19 | 30.2 | 20 | 31.7 |
Female | 571 | 57.8 | 39 | 61.9 | 41 | 65.1 |
Nationality | ||||||
Austrian | 530 | 53.6 | 33 | 52.4 | 37 | 58.7 |
German | 209 | 21.2 | 8 | 12.7 | 8 | 12.7 |
Italian | 155 | 15.7 | 16 | 25.4 | 15 | 23.8 |
Other | 32 | 3.2 | 1 | 1.6 | 1 | 1.6 |
Living situation | ||||||
Alone | 192 | 19.4 | 10 | 15.9 | 7 | 11.1 |
With partner | 84 | 8.5 | 5 | 7.9 | 13 | 20.6 |
In shared flat | 511 | 51.7 | 32 | 50.8 | 29 | 46.0 |
With family | 139 | 14.1 | 11 | 17.5 | 12 | 19.0 |
Family status | ||||||
Single | 527 | 53.3 | 36 | 57.1 | 21 | 33.3 |
Married | 8 | .8 | 0 | 0 | 2 | 3.2 |
Relationship | 384 | 38.9 | 22 | 34.9 | 38 | 60.3 |
Other | 7 | .7 | 0 | 0 | 0 | 0 |
Study semester | ||||||
First | 451 | 45.6 | 30 | 47.6 | 0 | 0 |
Second | 250 | 25.3 | 5 | 7.9 | 0 | 0 |
Third | 149 | 15.1 | 9 | 14.3 | 0 | 0 |
Fourth | 90 | 9.1 | 0 | 0 | 2 | 3.2 |
Fifth | 34 | 3.4 | 9 | 14.3 | 0 | 0 |
Sixth | 14 | 1.4 | 0 | 0 | 15 | 23.8 |
Seventh | 0 | 0 | 3 | 4.8 | 0 | 0 |
Eighth | 0 | 0 | 2 | 3.2 | 12 | 19.0 |
Ninth | 0 | 0 | 0 | 0 | 0 | 0 |
Tenth | 0 | 0 | 0 | 0 | 19 | 30.2 |
Have a side job | ||||||
Yes | 328 | 33.2 | 17 | 27 | 20 | 31.7 |
No | 598 | 60.5 | 41 | 65.1 | 41 | 65.1 |
COVID-19 infection (in last 12 months) | ||||||
Yes | 161 | 31.6 | - | - | 20 | 31.7 |
No | 317 | 62.3 | - | - | 42 | 66.7 |
Alcohol in comparison * | ||||||
Much less | 93 | 18.3 | - | - | 9 | 14.3 |
Less | 149 | 29.3 | - | - | 21 | 33.3 |
Equal | 192 | 37.7 | - | - | 27 | 42.9 |
More | 37 | 7.3 | - | - | 5 | 7.9 |
Much more | 5 | 1.0 | - | - | 0 | 0 |
Other drugs in comparison * | ||||||
Much less | 89 | 17.5 | - | - | 4 | 6.3 |
Less | 33 | 6.5 | - | - | 4 | 6.3 |
Equal | 335 | 65.8 | - | - | 50 | 79.4 |
More | 175 | 3.3 | - | - | 4 | 6.3 |
Much more | 2 | .4 | - | - | 0 | 0 |
Age | Sex | PWB | SWB | EE | SA | CD | FBL | AUT | PT | OS | WO | IP | SSL | SSC | SSP | SST | GAD | PHQ | CIT | SS | |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Age | 1 | ||||||||||||||||||||
Sex | .12 ** | 1 | |||||||||||||||||||
PWB | −.14 ** | .04 | 1 | ||||||||||||||||||
SWB | −.10 ** | .05 | .74 ** | 1 | |||||||||||||||||
EE | .07 | −.01 | −.34 ** | −.39 ** | 1 | ||||||||||||||||
SA | −.06 | .08 * | .47 ** | .37 ** | −.36 ** | 1 | |||||||||||||||
CD | −.07 | −.08 * | .18 ** | .03 | .18 ** | .05 | 1 | ||||||||||||||
FBL | −.04 | .07 | .21 ** | .18 ** | −.18 ** | .18 ** | .08 * | 1 | |||||||||||||
AUT | −.16 ** | .02 | .17 ** | .15 ** | −.23 ** | .18 ** | .08 * | .07 * | 1 | ||||||||||||
PT | .01 | .05 | .05 | .07 | −.17 ** | .10 ** | .00 | .39 ** | .15 ** | 1 | |||||||||||
OS | .18 ** | .04 | −.17 ** | −.19 ** | .41 ** | −.21 ** | .17 ** | −.11 ** | −.19 ** | −.01 | 1 | ||||||||||
WO | .07 * | −.06 | −.13 ** | −.21 ** | .56 ** | −.22 ** | .31 ** | −.14 ** | −.17 ** | −.15 ** | .49 ** | 1 | |||||||||
IP | .12 ** | .01 | −.19 ** | −.22 ** | .39 ** | −.22 ** | .07 | −.17 ** | −.17 ** | −.09 ** | .62 ** | .44 ** | 1 | ||||||||
SSL | −.04 | .05 | .21 ** | .23 ** | −.31 ** | .21 ** | .03 | .48 ** | .13 ** | .35 ** | −.29 ** | −.28 ** | −.32 ** | 1 | |||||||
SSC | −.15 ** | −.03 | .40 ** | .31 ** | −.19 ** | .23 ** | .07 | .09 * | .12 ** | −.01 | −.12 ** | −.08 * | −.16 ** | .20 ** | 1 | ||||||
SSP | −.01 | −.10 ** | .39 ** | .28 ** | −.07 | .16 ** | .14 ** | .07 | .06 | −.01 | −.04 | −.01 | −.09 * | .05 | .31 ** | 1 | |||||
SST | −.12 ** | .02 | .38 ** | .34 ** | −.33 ** | .28 ** | .06 | .39 ** | .16 ** | .24 ** | −.28 ** | −.24 ** | −.32 ** | .82 ** | .73 ** | .21 ** | 1 | ||||
GAD | .00 | −.25 ** | −.37 ** | −.53 ** | .39 ** | −.22 ** | .11 * | −.04 | −.19 ** | −.06 | .12 * | .25 ** | .16 ** | −.18 ** | −.15 ** | −.05 | −.21 ** | 1 | |||
PHQ | .04 | −.19 ** | −.49 ** | −.62 ** | .46 ** | −.24 ** | .04 | −.05 | −.17 ** | −.03 | .17 ** | .24 ** | .20 ** | −.17 ** | −.18 ** | −.14 ** | −.22 ** | .71 ** | 1 | ||
CIT | −.14 ** | .05 | .98 ** | .85 ** | −.37 ** | .46 ** | .15 ** | .21 ** | .17 ** | .06 | −.18 ** | −.16 ** | −.21 ** | .29 ** | .40 ** | .38 ** | .39 ** | −.43 ** | −.55 ** | 1 | |
SS | −.14 ** | .02 | .36 ** | .34 ** | −.41 ** | .31 ** | .08 * | .31 ** | .24 ** | .19 ** | −.38 ** | −.33 ** | −.49 ** | .45 ** | .16 ** | .10 ** | .41 ** | −.22 ** | −.29 ** | .37 ** | 1 |
Variable | Sample Size Pre (N) | Sample Size Peri (N) | T-Value | p-Value | Mean ± SD Pre | Mean ± SD Peri | Scale Range | |
---|---|---|---|---|---|---|---|---|
Overall | EE | 384 | 360 | 3.62 | <.001 | 2.87 ± 1.09 | 2.59 ± 1.02 | 0–6 |
OS | 400 | 369 | 5.60 | <.001 | 2.92 ± 0.82 | 2.60 ± 0.78 | 1–5 | |
CD | 400 | 369 | 3.15 | .002 | 4.10 ± 0.74 | 3.93 ± 0.75 | 1–5 | |
WO | 400 | 369 | 7.17 | <.001 | 3.37 ± 0.95 | 2.90 ± 0.87 | 1–5 | |
IP | 400 | 369 | 3.66 | <.001 | 2.92 ± 0.99 | 2.66 ± 0.94 | 1–5 | |
SST | 400 | 368 | 2.31 | .021 | 3.35 ± 0.57 | 3.45 ± 0.61 | 1–5 | |
SSL | 400 | 368 | 3.97 | <.001 | 2.54 ± 0.84 | 2.77 ± 0.80 | 1–5 | |
SS | 492 | 360 | −3.44 | <.001 | 3.66 ± 0.59 | 3.81 ± 0.61 | 1–5 | |
Men | PT | 162 | 148 | −2.41 | .016 | 1.73 ± 0.81 | 1.96 ± 0.85 | 1–5 |
SS | 187 | 144 | −3.03 | .003 | 3.65 ± 0.64 | 3.86 ± 0.63 | 1–5 | |
Women | PWB | 217 | 227 | 2.21 | .028 | 3.95 ± 0.42 | 3.86 ± 0.42 | 1–5 |
CIT | 217 | 227 | 2.01 | .045 | 3.94 ± 0.45 | 3.85 ± 0.45 | 1–5 | |
IP | 238 | 221 | 3.42 | .001 | 2.93 ± 0.98 | 2.63 ± 0.93 | 1–5 | |
1st year | EE | 220 | 124 | 2.19 | .029 | 2.75 ± 1.04 | 2.50 ± 1.01 | 0–6 |
OS | 231 | 127 | 3.47 | .001 | 2.76 ± 0.80 | 2.46 ± 0.74 | 1–5 | |
WO | 231 | 127 | 3.22 | .001 | 3.29 ± 0.93 | 2.99 ± 0.78 | 1–5 | |
SSL | 231 | 127 | −2.83 | .005 | 2.66 ± 0.79 | 2.91 ± 0.84 | 1–5 | |
2nd year | EE | 76 | 121 | 2.11 | .036 | 3.02 ± 1.15 | 2.71 ± 0.89 | 0–6 |
CD | 78 | 121 | 3.04 | .003 | 4.22 ± 0.66 | 3.90 ± 0.77 | 1–5 | |
AUT | 78 | 121 | −2.21 | .029 | 3.49 ± 0.94 | 3.77 ± 0.78 | 1–5 | |
PT | 78 | 121 | −2.76 | .006 | 1.54 ± 0.78 | 1.85 ± 0.75 | 1–5 | |
OS | 78 | 121 | 4.82 | <.001 | 3.20 ± 0.74 | 2.66 ± 0.79 | 1–5 | |
WO | 78 | 121 | 5.70 | <.001 | 3.62 ± 0.91 | 2.88 ± 0.88 | 1–5 | |
IP | 78 | 121 | 3.46 | .001 | 3.15 ± 0.85 | 2.69 ± 0.95 | 1–5 | |
SSL | 78 | 121 | −3.78 | <.001 | 2.32 ± 0.88 | 2.77 ± 0.80 | 1–5 | |
SS | 98 | 121 | −3.99 | <.001 | 3.53 ± 0.54 | 3.82 ± 0.55 | 1–5 | |
3rd year | WO | 41 | 66 | 3.35 | .001 | 3.48 ± 0.81 | 2.86 ± 0.97 | 1–5 |
SSC | 41 | 65 | −2.20 | .030 | 3.94 ± 0.74 | 4.24 ± 0.62 | 1–5 | |
SS | 57 | 62 | −2.45 | .016 | 3.49 ± 0.55 | 3.75 ± 0.62 | 1–5 | |
4th year | EE | 33 | 35 | 3.07 | .003 | 3.22 ± 1.17 | 2.38 ± 1.08 | 0–6 |
OS | 35 | 36 | 3.62 | .001 | 3.29 ± 0.85 | 2.56 ± 0.86 | 1–5 | |
WO | 35 | 36 | 2.44 | .017 | 3.32 ± 1.07 | 2.75 ± 0.90 | 1–5 | |
IP | 35 | 36 | 2.35 | .021 | 3.19 ± 1.02 | 2.64 ± 0.96 | 1–5 | |
5th year | IP | 14 | 12 | 2.75 | .012 | 3.43 ± 1.02 | 2.56 ± 0.56 | 1–5 |
Questions | Correlations | |||||||
---|---|---|---|---|---|---|---|---|
CIT | PWB | SWB | GAD | PHQ | EE | |||
(I) | COVID-19 infection | r | −.05 | −.06 | −.03 | −.04 | .04 | .03 |
(II) | COVID-19 and alcohol | r | −.03 | −.03 | −.04 | .06 | .12 * | .07 |
(III) | COVID-19 and intoxicants | r | −.03 | −.05 | .01 | .03 | .08 | −.03 |
(IV) | Impact of measures | r | −.04 | −.04 | −.06 | .10 * | .08 | .13 ** |
(V) | Informed about measures | r | .13 ** | .14 ** | .07 | −.08 | −.07 | −.21 ** |
(VI) | Organize study time | r | −.23 ** | −.22 ** | −.20 ** | .17 ** | .23 ** | .16 ** |
(VII) | Distancing from studies | r | −.19 ** | −.17 ** | −.20 ** | .20 ** | .18 ** | .43 ** |
(VIII) | Personal contact with colleagues | r | .17 ** | .15 ** | .17 ** | −.13 ** | −.11 * | −.07 |
(IX) | Physical distancing | r | −.07 | −.06 | −.09 | .09 | .14 ** | .05 |
(X) | Difficulties making new friends | r | −.20 ** | −.18 ** | −.19 ** | .10 * | .13 ** | .06 |
Question | Compared Study Years | Sample Size | Middle Ranks | U-Value | p-Value |
---|---|---|---|---|---|
(IV) How much impact do the pandemic containment measures have on your student life? | 1 vs. 2 | 1:147 | 12.46 | 6829.50 | <.001 |
2:130 | 159.97 | ||||
1 vs. 3 | 1:147 | 107.46 | 4918.00 | <.001 | |
3:91 | 138.96 | ||||
1 vs. 4 | 1:147 | 91.88 | 2628.00 | <.001 | |
4:53 | 124.42 | ||||
(V) I feel sufficiently informed about the Corona prevention measures at my university. | 1 vs. 3 | 1:146 | 129.36 | 513.50 | .001 |
3:91 | 102.38 | ||||
1 vs. 5 | 1:146 | 94.07 | 1961.50 | .034 | |
5:34 | 75.19 | ||||
(X) Due to the lack of or limited attendance during my studies. I find it difficult to make new friends. | 1 vs. 2 | 1:142 | 125.54 | 7673.00 | .012 |
2:130 | 148.48 | ||||
1 vs. 4 | 1:142 | 91.04 | 2774.00 | .006 | |
4:52 | 115.15 | ||||
1 vs. 5 | 1:142 | 82.60 | 1575.50 | .001 | |
5:34 | 113.16 |
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Huber, A.; Rabl, L.; Höge-Raisig, T.; Höfer, S. Well-Being, Mental Health, and Study Characteristics of Medical Students before and during the Pandemic. Behav. Sci. 2024, 14, 7. https://doi.org/10.3390/bs14010007
Huber A, Rabl L, Höge-Raisig T, Höfer S. Well-Being, Mental Health, and Study Characteristics of Medical Students before and during the Pandemic. Behavioral Sciences. 2024; 14(1):7. https://doi.org/10.3390/bs14010007
Chicago/Turabian StyleHuber, Alexandra, Luna Rabl, Thomas Höge-Raisig, and Stefan Höfer. 2024. "Well-Being, Mental Health, and Study Characteristics of Medical Students before and during the Pandemic" Behavioral Sciences 14, no. 1: 7. https://doi.org/10.3390/bs14010007