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Figure.  Distribution of the Survey Participants Who Scored 0 on the HPV-Associated Oropharyngeal Cancer Knowledge Score and the HPV Risk Perception Score, Stratified by Sex and Race
Distribution of the Survey Participants Who Scored 0 on the HPV-Associated Oropharyngeal Cancer Knowledge Score and the HPV Risk Perception Score, Stratified by Sex and Race

A and B, More men and more black individuals scored 0 on both knowledge and risk perception. HPV indicates human papillomavirus.

Table 1.  Characteristics of the Survey Participants, Stratified by Racea
Characteristics of the Survey Participants, Stratified by Racea
Table 2.  Human Papillomavirus (HPV)–Associated Oropharyngeal Cancer Knowledge Questions and Response of 301 Participants
Human Papillomavirus (HPV)–Associated Oropharyngeal Cancer Knowledge Questions and Response of 301 Participants
Table 3.  Linear Regression Estimating Human Papillomavirus Knowledge
Linear Regression Estimating Human Papillomavirus Knowledge
Table 4.  Linear Regression Estimating Human Papillomavirus Risk Perception
Linear Regression Estimating Human Papillomavirus Risk Perception
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Original Investigation
February 2017

Sociodemographic Factors Associated With Knowledge and Risk Perception of Human Papillomavirus and Human Papillomavirus–Associated Oropharyngeal Squamous Cell Carcinoma Among a Predominantly Black Population

Author Affiliations
  • 1St Louis University Cancer Center, St Louis, Missouri
  • 2Department of Otolaryngology–Head and Neck Surgery, School of Medicine, St Louis University, St Louis, Missouri
  • 3Department of Epidemiology, College for Public Health and Social Justice, St Louis University, St Louis, Missouri
  • 4St Louis University Center for Outcomes Research (SLUCOR), St Louis, Missouri
  • 5currently medical students at St Louis University, School of Medicine, St Louis, Missouri
  • 6Department of Otolaryngology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston
JAMA Otolaryngol Head Neck Surg. 2017;143(2):117-124. doi:10.1001/jamaoto.2016.2784
Key Points

Question  Are sociodemographic factors associated with knowledge and risk perception of human papillomavirus (HPV)–associated oropharyngeal cancer in the community?

Findings  In this survey of 301 adults, 30% scored 0 on 15 knowledge questions; approximately 80% of these individuals were male, and approximately 70% were of black race. Men, black individuals, and those with a high school diploma or less were statistically more likely to have low knowledge of HPV-associated oropharyngeal cancer.

Meaning  Black individuals are an important target for future interventions aimed at increasing knowledge of oropharyngeal cancer risk factors.

Abstract

Importance  The incidence of human papillomavirus (HPV)–associated oropharyngeal squamous cell carcinoma (OPSCC) is increasing in the United States and may be underestimated among black individuals. Characterizing the current knowledge level among black individuals is critical to developing interventions to increase awareness.

Objective  To describe the sociodemographic correlates of knowledge and risk perception of HPV and HPV-associated OPSCC among a predominantly black population.

Design, Setting, and Participants  A cross-sectional survey was conducted at a drag racing event on September 12 and 13, 2015, in Madison, Illinois. The setting was a community-based oral head and neck cancer screening and education initiative. Participants were 301 drag race attendees 18 years or older who were conveniently sampled from attendees at an annual drag racing event predominantly patronized by black individuals.

Main Outcomes and Measures  The primary outcome was knowledge and risk perception of HPV and HPV-associated OPSCC. An electronic-based questionnaire elicited sociodemographic information and contained oral cancer knowledge and risk perception items, which were combined to form knowledge and risk perception scores. Multivariable linear regression analysis assessed estimates of knowledge and risk perception of HPV and HPV-associated OPSCC.

Results  Of the 301 participants (111 female and 190 male) completing the questionnaire, 194 (64.5%) were black. Overall, respondents ranged in age from 18 to 78 years, with a mean (SD) age of 48.0 (13.0) years. The mean (SD) knowledge score was 5.7 (4.6) of 15, and the mean (SD) risk perception score was 2.2 (1.4) of 6. Using multivariable linear regression, we found that, for every 1-year increase in age, knowledge of HPV-associated OPSCC decreased by 5.0% and was worse in men (β = −1.26; 95% CI, −2.33 to −0.18), black vs white individuals (β = −1.29; 95% CI, −2.35 to −0.23), and those with a high school diploma or less vs college graduates (β = −3.23; 95% CI, −4.67 to −1.80). Black individuals also had lower perceived risk of developing HPV-associated OPSCC (β = −0.36; 95% CI, −0.69 to −0.02) compared with white individuals, and participants with a high school diploma or less had lower perceived risk of developing HPV-associated OPSCC compared with those with a college degree or higher (β = −0.59; 95% CI, −1.04 to −0.14).

Conclusions and Relevance  Age and sex were independent correlates of knowledge of HPV-associated OPSCC, while race and education level were correlates of both knowledge and risk perception of HPV-associated OPSCC. These findings should inform future interventions targeted at increasing knowledge of HPV-associated OPSCC in black communities.

Introduction

Human papillomavirus (HPV) is the most common sexually transmitted disease worldwide, affecting more than 600 million people globally.1 It is so common that virtually all sexually active adults will contract the infection at some point in their lifetime.1 There are more than 150 known strains of HPV.2 Whereas most strains do not result in any clinical manifestation, a few are oncogenic.3,4 In the United States, at least 64% of invasive HPV-associated cancers can be attributed to HPV-16 or HPV-18 (65% for female individuals and 63% for male individuals, with approximately 21 300 cases annually), and 10% are attributed to HPV-31, HPV-33, HPV-45, HPV-52, and HPV-58 (14% for female individuals and 4% for male individuals, with approximately 3400 cases annually).4 The US Food and Drug Administration and the Advisory Committee on Immunization Practices have approved 3 HPV vaccines to protect against HPV-associated cancers, such as oropharyngeal cancers.4 A recent study5 based on the National Immunization Survey found that 60% of girls and 42% of boys between 13 and 17 years old had at least 1 dose of the HPV vaccine in 2014, an increase from 2013. However, vaccination rates remain significantly short of the Healthy People 2020 objective of 80% among girls and boys 13 to 15 years old.6 One reason for the low HPV vaccination rates could be poor public awareness and risk perception of HPV-associated diseases.7

Although HPV has traditionally been associated with cervical cancer, it has emerged as the most important cause of oropharyngeal squamous cell carcinoma (OPSCC).8-10Quiz Ref ID By 2020, the annual incidence of HPV-related oropharyngeal cancer is projected to overtake that of cervical cancer.11 It is estimated that more than 90% of oropharyngeal cancers in the United States are HPV-positive squamous cell carcinomas.3 Although the overall incidence of head and neck cancers has decreased because of reduced tobacco consumption, another major risk factor, HPV-associated OPSCC, continues to rise.3,12 The risk factors for HPV-positive OPSCC include male sex, a high number of oral sexual partners, white race, and the presence of genital warts.13 Despite the significantly higher prevalence of HPV-positive OPSCC among white individuals compared with black individuals, there is a suggestion that the proportion of blacks with HPV-positive OPSCC is on the rise.14,15 A Surveillance, Epidemiology, and End Results analysis of HPV-positive oropharyngeal cancer showed a rise from 0% in 1984 to 1989 to 25% in 1995 to 1999 in a subanalysis restricted to black individuals.15 A single-institution estimate of HPV-positive OPSCC at the University of Maryland also demonstrated an increasing prevalence from 1992 to 2007 among blacks.15,16 In contrast, the incidence of cigarette smoking among adult blacks, a major risk factor for HPV-negative OPSCC, has decreased significantly. In 1985, the age-adjusted incidence of tobacco use was 40.2% among adult black men and 30.9% among adult black women, whereas by 2013 these percentages had decreased by approximately half (21.8% among black men and 14.9% among black women).17 In concert with the significant decrease in smoking rates among black individuals, it is now increasingly important to target HPV, the other major risk factor for OPSCC in this population. This initiative is even more timely because of possible underestimation of an increasing incidence of HPV-associated OPSCC among black individuals.15

In the past few years, there has been an emerging literature on population awareness and knowledge of an association between HPV and OPSCC,8,12,18-21 which has mostly found low knowledge of this association. However, only 1 study20 focused on a predominantly black population. A cross-sectional study18 of a large, nationally representative sample showed that knowledge of the risk factors associated with HPV-associated OPSCC is low; however, the survey was conducted online, participants were predominantly of white race, and the results were mostly descriptive. Another recent study12 had a more diverse population but focused more on health literacy and only reported percentages and rates of health literacy and HPV knowledge. The lack of a robust statistical analysis and a preponderance of white respondents were also observed in other studies.8,19 Our group’s previous study20 of a predominantly high-risk black population in 2013 used logistic regression analyses and showed significantly low knowledge of HPV and its association with head and neck cancer among black individuals; however, other sociodemographic correlates of low knowledge were not assessed in the population at that time. In addition, none of the above studies evaluated estimates of risk perception in developing HPV-associated OPSCC. Health behaviors are often a function of risk perception, and individuals are more likely to adopt a healthier behavior when they perceive that they are susceptible.22 To our knowledge, the only study23 that has accessed risk perception in association with head and neck cancer focused on smoking vs nonsmoking among a predominantly white population of National Association for Stock Car Auto Racing (NASCAR) attendees. Both knowledge and risk perception of the risk factors of HPV and HPV-associated cancers in high-risk populations and in the general community are key components to identifying and facilitating necessary behavioral changes to prevent HPV-associated OPSCC and to help inform future interventions targeting higher-risk individuals for HPV education. Therefore, the objective of our study was to describe how sociodemographic variables influence knowledge and risk perception of HPV and HPV-associated OPSCC among a racially diverse group that included a large black population at an annual community event.

Methods

The study was approved by the St Louis University Institutional Review Board. A cross-sectional study was conducted at the 2015 United Black Drag Racers Association event on September 12 and 13, 2015, in Madison, Illinois. Study participants consisted of drag racers, vendors, and fans who attended the drag race event. Participants responded to a 78-item questionnaire survey that was based on previously validated surveys.24-26 The questionnaire was administered using research electronic data capture (REDCap) methods and software tools hosted at St Louis University.27 REDCap is a secure, web-based application designed to support data capture for research studies providing (1) an intuitive interface for validated data entry, (2) audit trails for tracking data manipulation and export procedures, (3) automated export procedures for seamless data downloads to common statistical packages, and (4) procedures for importing data from external sources.27 Questions elicited demographic information, awareness of the risk factors associated with HPV and HPV-associated OPSCC, and knowledge of HPV and its characteristics, including transmission, viral properties, treatment, and prevalence. Trained volunteer survey administrators approached participants around the racing area. Potential enrollees were informed of the anonymous nature of the survey and the objective of the study, and oral informed consent was obtained. The data collected represents a convenience sample of 301 participants 18 years or older.

Independent Variables

The independent variables were sociodemographic factors, including age, sex, race, marital status, annual income, education level, alcohol drinking history, cigarette smoking history, and number of oral sex partners. Each variable was categorized as follows: race (white, black, or other [which combined low-frequency responses]), marital status (married, single but dating, or single and not dating), annual income (<$25 000, $25 000-$49 999, $50 000-$74 999, $75 000-$99 999, or ≥$100 000), education level (high school diploma or less, associate degree, some college, or college degree or higher), alcohol drinking history (never drinker, former drinker, or current drinker), cigarette smoking history (never smoker, former smoker, or current smoker), and number of oral sex partners (1, 2, 3, 4, or 5).

HPV-Associated Oropharyngeal Cancer Knowledge Score

Answers to a 15-question knowledge portion of the questionnaire were scored as 1 for correct responses and as 0 for incorrect responses. Each participant’s answers were summed to create an HPV-associated oropharyngeal cancer knowledge score ranging from 0 to 15.

HPV Risk Perception Score

Answers to a 6-question risk perception portion of the questionnaire were scored as 1 for correct responses and as 0 for incorrect responses. Each participant’s answers were summed to create an HPV risk perception score ranging from 0 to 6.

Statistical Analysis

Analyses were performed using statistical software (SAS, version 9.4; SAS Institute Inc). Descriptive statistics (number and percentage) were used to analyze characteristics of the respondents. We compared sociodemographic characteristics and other behavioral factors by sex using χ2 tests for categorical variables and independent samples t tests for continuous variables. Univariate and multivariable linear regression models were used to examine estimates of HPV-associated oropharyngeal cancer knowledge and risk perception. Unadjusted and adjusted β coefficients were reported with their respective 95% CIs. All variables were included in the adjusted models based on a knowledge of the literature. In addition, we assessed multicollinearity among all the variables, and none had a variable inflation factor above 2, suggesting that there was no collinearity among the independent variables. Analyses were 2-tailed, and statistical significance was set at P < .05.

Results

Table 1 summarizes characteristics of the study participants both overall and stratified by race. A total of 301 individuals (111 female and 190 male) completed the questionnaire. Overall, respondents ranged in age from 18 to 78 years, with a mean (SD) age of 48.0 (13.0) years. Most of the study participants were of black race (64.5% [n = 194]), were married (55.5% [n = 167]), and had some college or a college degree or higher (47.8% [n = 144]). The rate of current smoking was 22.6% (n = 68), while 72.8% (n = 219) reported current drinking. Quiz Ref IDThe mean (SD) HPV-associated oropharyngeal cancer knowledge score for the study population was 5.7 (4.6), with 29.9% (n = 90) scoring 0 of 15. Among those who scored 0, approximately 80.0% (n = 72) were male, and approximately 70.0% (n = 63) were of black race. The mean (SD) HPV risk perception score for the study population was 2.2 (1.4), with 13.3% (n = 40) scoring 0 of 6. Among those who scored 0, approximately 68.0% (n = 27) were male, and approximately 63.0% (n = 25) were of black race (Figure). There were no statistically significant differences between white and black individuals in all sociodemographic and behavioral factors except for the HPV-associated oropharyngeal cancer knowledge score and the HPV risk perception score. Table 2 lists the HPV-associated oropharyngeal cancer knowledge score questions used in the study and participants’ responses. The HPV risk perception score questions used in the study and participants’ responses are listed in the eTable in the Supplement.

HPV-Associated Oropharyngeal Cancer Knowledge

Table 3 summarizes adjusted linear regression results for HPV-associated oropharyngeal cancer knowledge. Quiz Ref IDAge, sex, race, and education level were significant estimates of HPV-associated oropharyngeal cancer knowledge in multivariable analysis. For every 1-year increase in age, knowledge of HPV-associated OPSCC decreased by 5.0%. Compared with women, men had lower HPV-associated oropharyngeal cancer knowledge (β = −1.26; 95% CI, −2.33 to −0.18), as did black compared with white individuals (β = −1.29; 95% CI, −2.35 to −0.23). Participants with a high school diploma or less had lower HPV-associated oropharyngeal cancer knowledge compared with those with a college degree or higher (β = −3.23; 95% CI, −4.67 to −1.80).

HPV Risk Perception

Table 4 summarizes adjusted linear regression results for HPV risk perception. Race and education level were significant estimates of HPV risk perception. Compared with white individuals, black individuals had lower perceived risk of developing oropharyngeal cancer (β = −0.36; 95% CI, −0.69 to −0.02). Participants with a high school diploma or less had lower perceived risk of developing oropharyngeal cancer compared with those with a college degree or higher (β = −0.59; 95% CI, −1.04 to −0.14).

Discussion

To our knowledge, this study is the first to evaluate the sociodemographic correlates of knowledge and risk perception of HPV and HPV-associated OPSCC in a predominantly black population. We found that age and sex were independently correlated with knowledge of HPV-associated oropharyngeal cancer, while race and education level were correlated with both knowledge and risk perception of HPV-associated oropharyngeal cancer. Similar to previous studies,8,12,18-20 our results showed an overall low knowledge of HPV-associated OPSCC among all 301 participants in this study. More concerning, 29.9% had no knowledge of the association of HPV with OPSCC and scored 0 on 15 knowledge-based questions. While many participants were aware of the sexual transmission of HPV, knowledge gaps were evident concerning important characteristics of the virus, such as symptoms and treatment. For instance, only 13.3% (n = 40) correctly responded that most HPV infections can resolve on its own, and 27.2% (n = 82) knew that HPV infection is usually asymptomatic (Table 2). However, respondents were generally unaware of the prevalence of HPV, with only 27.9% (n = 84) correctly responding that most sexually active people will contract HPV in their lifetime. This finding highlights a great need for efforts to increase the understanding of HPV beyond its association with a sexual transmission.

Quiz Ref IDIn our study, women had a significantly higher HPV-associated OPSCC knowledge than men. Of the 40 participants who scored 0 on their HPV-associated oropharyngeal cancer knowledge score, 32 (80.0%) were men (Figure). As we have observed anecdotally from prior community oral cancer screening and education events, men tend to consider HPV as an issue only for women. The findings from the present study are consistent with previous literature citing higher awareness and knowledge of HPV and HPV-associated OPSCC among women.28,29 This result could be attributed to more frequent health care visits among women than men, as well as increased social marketing and screening efforts targeting women.8 The knowledge gap is concerning because men are at a much higher risk of developing HPV-associated oropharyngeal cancer than women, and the rate of HPV-associated oropharyngeal cancer has increased by 225% during the past 3 decades.14 In addition, HPV vaccines have been proven to be effective against the oral HPV strains responsible for more than 90% of HPV-associated oropharyngeal cancer,30 and these vaccines have been approved for routine administration since 2011 to young boys.1 Therefore, there is a need to target interventions aimed at increasing awareness and knowledge of HPV-associated cancers toward boys, who need the vaccine as much as girls.

Our study revealed that black respondents had significantly lower knowledge of HPV-associated OPSCC, a trend previously reported in non-OPSCC studies.31,32 This finding is clinically and epidemiologically relevant because prior studies33,34 have reported that black individuals who develop HPV-positive OPSCC have poorer health outcomes and survival compared with white individuals. If that is indeed the case, it is imperative for clinicians and public health professionals to provide more education and increase health literacy related to HPV and associated cancers.12,35

Quiz Ref IDIn addition to lower HPV knowledge, black individuals in our study had lower perceived risk of HPV, and 62.5% (n = 25) of the participants with a 0 HPV risk perception score were of black race (Figure). This finding suggests that populations with lower knowledge of HPV may also have low perceived risk of HPV. An explanation could be that populations with low knowledge of HPV, HPV-associated diseases, and HPV risk may fail to recognize the seriousness of the infection and be unable to identify any high-risk self-behaviors that increase HPV susceptibility. This rationale is consistent with the health belief model,36 which states that susceptibility or an individual’s perceived risk of being exposed to or having a certain condition influences his or her health-promoting behaviors, including obtaining vaccinations.37 Therefore, higher HPV risk perception or susceptibility among the public could encourage more individuals to engage in preventive measures, such as vaccination and screening. Increasing education and awareness is one way to heighten risk perception, and without improved HPV education, individuals may be less likely to pursue the appropriate steps to correct their high-risk behaviors, as also relevant to participants’ education levels in our study. Previous studies8,28 have shown that individuals with a high school diploma or less may have lower knowledge and perceived risk of HPV-associated diseases. Eighty-five percent (n = 34) of participants in our study with a 0 HPV risk perception score had educational attainment less than a college degree. In the study by Williams et al,8 most respondents with higher knowledge of HPV reported that they had learned about HPV in school. In the study by Capogrosso et al,28 which assessed HPV knowledge among 934 first-time patients and nurses in a uroandrologic health clinic, the authors found that higher education level was a significant estimate of HPV awareness and knowledge. Therefore, there may be a need for awareness of HPV, HPV-related diseases, and preventive measures in the school setting (preferably at the high school level or earlier), as well as in health care settings.

We also found that older age was inversely related to knowledge of HPV-associated OPSCC. This phenomenon may result from greater use of the internet among younger populations, as described in a previous study28 that identified online and other media as the public’s main source of information about HPV. In addition, the increased HPV knowledge among younger individuals could be due to the fact that parents and caregivers with infants and young children are more likely to visit health care professionals compared with their older counterparts, potentially leading to increased exposure to information on HPV.35 Most HPV awareness programs and screening events thus far have focused on the younger, vaccine-eligible population. There is a need for additional methods of HPV education beyond the internet that are more tailored toward older populations and individuals who do not have children within the vaccine-eligible age range. Possibilities could include greater physician teaching for patients with access to health care or more community outreach programs targeting older populations. Educating these individuals on the severity of HPV infection and HPV-associated diseases may reduce missed opportunities for prevention, early detection, and decreased HPV-associated OPSCC disease burden.

In our study, 51.0% (n = 154) of participants correctly identified HPV as a risk factor for cervical cancer compared with 27.0% (n = 82) of participants who correctly implicated the role of HPV in OPSCC. This finding may likely result from a discrepancy in marketing initiatives regarding cervical cancer compared with oropharyngeal cancer despite the prevalence of the latter. It could also be due to the fact that HPV vaccines were originally developed to prevent cervical cancer, while the Papanicolaou smear test was successfully used to detect cervical lesions early in women before the HPV vaccine era.

Beyond the association of HPV with OPSCC, there was generally a poor understanding of the risk factors associated with OPSCC in our study population. While 78.0% (n = 236) understood the role of smoking in the origin of head and neck cancer, only 28.0% (n = 85) identified alcohol as a risk factor. This finding demonstrates a need for more education regarding the risk factors for OPSCC, including the risk of alcohol and tobacco.

Our study has several limitations. First, the data were collected from a convenience sample; therefore, our results are susceptible to selection bias. It is possible that individuals who participated in the survey were more health conscious and curious about HPV than the general population. If true, it suggests that the knowledge of HPV and HPV risk perception may be even lower than that indicated in our population. Second, most participants in our study were black men; therefore, our results cannot be generalized to the US population. However, because studies on the knowledge of HPV and HPV-associated OPSCC have predominantly focused on women, information from male participants, who are more susceptible to both HPV-positive and HPV-negative OPSCC, is invaluable in identifying education gaps to tailor methods to improve interventions. Third, our small sample size of 301 participants could have prevented us from detecting any significant differences among them. In the future, it would be relevant to include strategies to improve knowledge (eg, informational brochures and one-on-one education on HPV and HPV-associated OPSCC) and to assess their association with knowledge and risk perception scores.

Conclusions

Our study shows that male participants, those of black race, and individuals with a high school diploma or less had lower knowledge of HPV-associated OPSCC. Similarly, there was lower perceived risk of developing HPV-associated OPSCC among black individuals and participants with a high school diploma or less. The sociodemographic correlates demonstrated in this study should inform future interventions targeted at increasing knowledge of HPV-associated oropharyngeal cancer in black communities.

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Article Information

Corresponding Author: Nosayaba Osazuwa-Peters, BDS, MPH, CHES, Department of Otolaryngology–Head and Neck Surgery, School of Medicine, St Louis University, 3635 Vista Ave, Sixth Floor, Desloge Towers, St Louis, MO 63110 (nosazuwa@slu.edu).

Accepted for Publication: July 27, 2016.

Published Online: October 6, 2016. doi:10.1001/jamaoto.2016.2784

Author Contributions: Dr Osazuwa-Peters and Mr Adjei Boakye had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Osazuwa-Peters, Adjei Boakye, Chen, Varvares.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Osazuwa-Peters, Adjei Boakye.

Administrative, technical, or material support: Osazuwa-Peters.

Study supervision: Osazuwa-Peters, Adjei Boakye, Varvares.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported.

Funding/Support: This study was supported by the United Black Drag Racers Association St Louis members and executives; Scott Fosko, MD, Dell Yates, MA, and Michell Nickerson, all from St Louis University Cancer Center; Rebecca L. Rohde, BS, St Louis University School of Medicine; Tami Hanks, BS, REDCap Product Manager, Ronald J. Walker, MD, Jastin Antisdel, MD, Josh Hentzelman, MD, Sean T. Massa, MD, Lauren Cass, MD, MPH, Matt Gropler, MD, Matt Leach, MD, and Zach Bear, MD, all from St Louis University; and medical student volunteers. None received any compensation.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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