EXPLORING FACTORS AFFECTING FOREIGN PHD STUDENTS’ MENTAL HEALTH IN AZERBAIJAN

Several empirical studies mentioned that mental health crisis is escalating among PhD researchers. PhD students were more likely to meet the criteria for clinical depression and anxiety than working professionals. This study's ultimate purpose is to investigate potential risk factors for poor mental health among PhD students. This research followed a descriptive quantitative method. It is a form of study that emphasizes the quantification of data gathering and analysis, and it is known by an initial quantitative survey method of collecting data and analysis. According to the findings of this study, a significant number of PhD students are currently experiencing numerous symptoms of depression as a result of the Azerbaijani language requirement, as the majority of students completely agree with the assertion that they have lost all motivation in everything crucial to their PhD studies. This study is significant because it will bring the attention of the ministry of education and other stakeholders to concerns that may delay or hinder foreign PhD students from progressing in Azerbaijan, as well as deter other international students from continuing their studies in Azerbaijan universities.

INTRODUCTION

A student is a person who is enrolled in a school or other educational institution who is pursuing knowledge, developing professions, and obtaining work in the desired field. In a larger sense, a student is somebody who engages in intense intellectual engagement with a subject to master it as part of a practical problem in which mastery is essential or decisive. The previous study has suggested that a mental health crisis is growing among PhD researchers. PhD students were more likely than working professionals to meet the criteria for clinical depression and anxiety. At universities and beyond, PhD students are the future of research, innovation, and teaching. The mental health of university students is a critical public health issue that necessitates epidemiological data. A Web-based survey was distributed to a random sample of students at a large public university with a demographic profile similar to the national student population. Depressive and anxiety disorders were investigated using the Patient Health Questionnaire (Eisenberg et al., 2007).

Czyz et al., (2013) Participants were non-treatment seekers and high-risk college students who were enrolled in a Web-based treatment linkage intervention for college students. The most common roadblocks noted were a view that therapy is unnecessary (66%), a lack of time (26.7%), and a preference for self-management (26.7%). (26.8 per cent). 18.8% of the population. The findings were influenced by gender, race/ethnicity, and the severity of depression and alcohol abuse. PhD students have a prevalent perception that you must suffer for the sake of your PhD and that if you aren’t anxious or suffering from anxiety and depression, you aren’t doing it “correctly.”

STATEMENT OF PROBLEM

Foreign PhD students studying in Azerbaijan’s various universities lamented the ministry’s requirements that they had to meet before they could defend their PhD thesis. The students held a meeting, and the main issue was that forcing them to pass a B2 Azerbaijani language exam is a difficult task because the majority of them have no prior knowledge of the language, but the exam is used as a condition for them to defend their thesis. Almost all students are emotionally disturbed by this requirement, which they perceive as a barrier to their academic progress. The meeting, which was held via Zoom, was attended by approximately 25 students. They are not averse to learning the language, but they believe it will add to their workload by requiring them to publish an additional five papers and attend three conferences in three years. They merely wanted to study the language, not with the expectation of passing a B2 exam before defending their thesis. Because a meeting with representatives from the ministry was conducted, but no solution to the matter was reached, the students became depressed about the situation. I decided to research the topic further to see how we might reduce student dropout rates, which could harm students’ mental health and lead to suicide risk if they believe they have wasted time and money by dropping out of their PhD program. PhD students have a higher rate of mental health issues than the general population with a high level of education (Gin et al., 2021). PhD students’ mental health is influenced by their work requirements and organizational context. One out of every two PhD students suffers from psychological anguish, and one out of every three is at risk of developing a common psychiatric condition (Levecque et al., 2017b).

PURPOSE OF STUDY

The overall goal of this research is to look into potential risk factors for poor mental health among PhD students. One of the risk factors we focused on was financial uncertainty because not all researchers receive financing to support their course and personal expenditures, and there is no guarantee of a job once their PhD is completed. Another risk factor was a dispute with their academic supervisor and a lack of information from the host university in terms of communication, institution requirement, publication stress, family issue, finding balance between work and research study, settling in a new environment, and accommodation issues.

SIGNIFICANCE OF STUDY

This research is important to draw the attention of the ministry of education and other stakeholders to issues that could delay or prevent the progress of foreign PhD students studying in Azerbaijan, as well as deter the interest of other foreign students interested in continuing their studies in Azerbaijan universities.

OBJECTIVE OF STUDY

The study’s objective is to look into the numerous issues that foreign PhD students in Azerbaijan face which may cause them to get depressed and drop out of their various programs of study or quit completely.

RESEARCH QUESTION

1. What are the challenges that international PhD students in Azerbaijan face?
2. What are the most prevalent issues that foreign PhD students in Azerbaijan face that could lead to depression?

LITERATURE REVIEW

This section of the research looks at many studies that have been done on the topic of student mental health, as well as the influence and elements that contribute to academic issues. This literature review extracts and examines previous studies that have been published in the last ten years, from 2012 to the present. According to Kowalczyk et al., (2021) depression is statistically more common in people who are not in any relationship with another person and anxiety and insomnia are statistically more common in women than in men and statistically less frequent in doctoral students of general universities than technical universities (p. 6) Furthermore. Nagy et al., (2019)” Sleep discomfort, a lack of energy, and thoughts of harming yourself or others are some early indicators of mental health disorders (p. 4). 

CONCEPTUAL FRAMEWORK

The current study’s concept is depicted in the diagram below, which attempts to look into factors affecting the mental health of international PhD students in Baku, Azerbaijan. The figure depicts the relationship between the demands of their institution, the environment, and external and internal factors that contributed to the students’ poor mental health (Mortier et al., 2018, p. 558).

FOREIGN STUDENTS MENTAL STRESS

Depending on the subject of study, some studies have presented varied definitions of mental stress. Mental stresses are defined in this study as the ability to improve one’s quality of life while keeping conscious of personal, societal, and cultural constraints (Kitzrow, 2009, Corona et al., 2017). Mental health is influenced by diet, exercise, stress, substance abuse, social ties, and relationships. Impairment in these areas is associated with mental illnesses. Students who were lonely, far away from home, and faced rejection in the host nation, or who had to go through a lot of unpleasant situations to acquire necessities for their education and life, was stressed out and were in quest of self-worth or self-identity (Sontag-Padilla et al., 2018). Some cases result in a shift of care from host institutions, or a lack of communication produces a condition of uncertainty regarding their research project, and they do not have the resources to address the issues. Kazakova & Shastina, (2019) detailed how socio-cultural differences on development of intrinsic motivation of foreign language students are more likely to endure mental and even bodily distress, which reinforces their belief in their ability to achieve their goal in which I believe that goal achieved under stress or through hardship could be linked to long term students’ mental health problem. On the other hand, Bai, (2016) argued that the university’s apparent support was found to be a major significant correlate of stress. The findings have significant implications for educators and other professionals who work with overseas students in higher education settings. Though we all know, studying abroad in a country far away from home can provide several challenges, including feelings of isolation, self-worth, self-identity, stress, and inability to focus on one’s schoolwork. Graduate school, on the other hand, is a significant adjustment that necessitates even greater time management skills in addition to increased academic demands and pressure. These are some of the most prevalent university-related stresses and obstacles (Alharbi & Smith, 2018).

Figure 1 Conceptual Framework Exploring Factors Affecting Foreign PhD Students’ Mental Health in Baku Azerbaijan

INFLUENCING FACTORS AFFECTING FOREIGN STUDENTS’ MENTAL HEALTH

Joblessness has been demonstrated to harm an individual’s emotional well-being, self-esteem, and mental health in general (Soria & Horgos, 2021). Increased unemployment has been demonstrated to have a negative influence on the mental health, particularly depression, of many young people. In today’s Sweden, exclusion from the labour market appears to be a primary predictor of psychological health disparities (Sidorchuk et al., 2017). When stress reaches too much and lasts too long, the chances of mental health and physiological problems rise. Stress is an inevitable part of life, but when it becomes excessive, it may be dangerous. Academic stress, institution requirement, accommodation stress and meeting up with other personal needs could positively affect foreign students as the stress piled, it would affect the student’s emotional level and create a quest for self-worth and mental health (Liao & Wei, 2014). Factors affecting university students’ mental health at the individual, interpersonal, and institutional levels (Byrd & McKinney, 2012). In a group of college students, depression, anxiety, and stress were found (Beiter et al., 2015). Colleges all over the world are grappling with increased rates of mental illness, and in many cases, demand for treatment on campus vastly outnumbers available resources (Auerbach et al., 2018). Individuals from diverse racial and ethnic minority groups experience racial
microaggressions in different ways, according to the findings (Nadal et al., 2014).

METHODOLOGY

The descriptive quantitative approach was used in this study. This measure is known by an initial quantitative survey process of collecting data and analysis, it is a type of study that emphasize the quantification of data collection and analysis.

DATA COLLECTION

A total of 27 foreign PhD students from various universities in Baku, Azerbaijan, attended a focus group meeting to address issues affecting PhD students as well as collaboration among all students from different universities. The conference voice recording transcript was created, and the important issues that came up repeatedly throughout the meeting were used as variables in a survey questionnaire that was circulated via WhatsApp to the foreign PhD students and a total number of 20 students responded to the survey questionnaire.

RESULT AND FINDINGS

Demography Data

The descriptive data in the table and figure below shows that the majority of the study participants are male (N=14-70%) and female (N=6-30%). The participants’ (students’) marital status shows that most of the students are single (N= 10-50 %), followed by married living with a partner (N=9-45%), and divorced/widowed (1-5%). The plurality of participants is in the second year of study (N=12-60 %), followed by the first year of study (N=4-20 %), the third year of study (N=3-15 %), and the fourth year of study (N=1-5%). As seen in (Table 1) descriptive for gender, marital status, and year of study and (Table 2) descriptive analysis for age and (Figure 2) gender, marital status, study level and age.

Table 1 Descriptive Analysis for Gender, Marital Status and Year of Study

Figure 2 Descriptive Analysis for Gender, Marital Status and Year of Study

FIRST RESEARCH QUESTION ANALYSIS

1. What are the challenges that international PhD students in Azerbaijan face?

International PhD students in Azerbaijan confront a variety of problems. However, the data analysis revealed that family issues, which are represented by the number of children, and employment opportunities, which compare the numbers of PhD students who were actively employed in their respective countries before pursuing their degree in Baku, Azerbaijan, but are now jobless. The number of PhD students with one to three children is (N=12), accounting for 60% of the total number of participants. While the employment variable accounts for the number of PhD students who hold jobs before beginning their program (N=17), accounting for 85 per cent of the participants. While there are (N=19) students who do not have jobs after commencing their degree, accounting for 95% of the participants.

Table 2 Descriptive analysis for Age

Figure 3 Descriptive analysis for Age

Other criteria included for this study include frequent meetings with supervisors, with 60% of students meeting with their supervisor at least once a week and 40% meeting with their supervisor only once or twice a semester. The participants’ difficulties in publishing their work were examined; nevertheless, this does not appear to be an issue for them, as the majority of the students (85%) put in some or a lot of effort. The analysis of the students’ responses to balancing work and family demonstrates that managing work and family is extremely challenging for them some difficulty 50% and great difficulty at 50%. The participants were asked if it is difficult to settle in Azerbaijan, and the response revealed that 80% of the participants find it difficult to settle there. The prerequisite for the Azerbaijani language was included as one of the variables because it was the dominant discourse among the students during the meeting. According to the findings, the overwhelming of students replied to moderate difficulty (10%) and tremendous difficulty (75%), while 15% answered nearly no difficulty. The part 1 and 2 descriptive variables analysis table can be found below.

Table 3 Descriptive variables analysis Part 1

Figure 4 Descriptive variables analysis Part 1

Table 4 Descriptive variables analysis Part 2A

Table 5 Descriptive Variable Analysis Part 2B

Figure 5 Descriptive variables In Azerbaijan, it is difficult to settle in

Figure 6 Descriptive Variable Azerbaijan Language Requirement

SECOND RESEARCH QUESTION

2. What are the most common problems that influence depression among international PhD students in Azerbaijan?

To address the second research question, we used descriptive analysis to look for the most common issues that prompted PhD  students into stress and gradually go into depression. Participants were asked: Because of the Azerbaijani language requirement, I have lost all motivation in anything vital to my PhD studies. The total number of students who agree (N=15-75%), somewhat agree (N=3-15%), and somewhat disagree (N=2-10%). On the other hand, students were also asked if the nostrification requirement method and procedure had an impact on their studies. The results demonstrate that students who entirely agreed (N=11-55 %), slightly agreed (N=8-40%), and disagreed (N=1-5%) with the proposition. To have a better understanding of how the aforementioned variables have influenced the student’s stress and depression levels. We asked the students if they agreed or disagreed with the following statement: “I’m concerned because my university’s thesis writing style and format are not clearly explained.” The students responded that they completely agreed (N= 13-65%) and somewhat agreed (N=7-35%). The following comment was I’m irritated, have poor attention, sleeping problems, and guilt feelings, all of which indicate mild depression. Completely agree (N=3-15%), somewhat agree (N=17-85%), We used the statement “You are having a depressed feeling” to gauge the prevalence of stress and depression among pupils. Somewhat agree (N=13-65 %), completely agree (N=3-15 %), are the most common responses. Somewhat disagree (N=2-10 %), and completely disagree (N=2-10%) all the results of the analysis are listed below in (table 6 and 7) as well as in (figure 4).

Table 6 Descriptive Analysis for Common Variables influencing PhD Students Depression Level

Table 7 Descriptive Analysis for You are having a depressed feeling

Figure 7 Descriptive Analysis for Common Variables influencing PhD Students Depression Level

Figure 8 Descriptive Analysis for You are having a depressed feeling

DISCUSSION

Although the study’s sample size was modest, we were able to produce empirical estimates for the prevalence of mental health symptoms among international PhD students in Baku, Azerbaijan, based on representative data that included all elements of their concerns. The finding of this study analysis indicated that because of the Azerbaijani language requirement, a significant number of PhD students are currently experiencing numerous symptoms of depression, as the majority of students completely agree with the assertion that they have lost all motivation in everything crucial to their PhD studies. They agree that the nostrification requirement process and procedure have an impact on their studies. They are concerned since the thesis writing style and format at their university are not well communicated. Irritation, poor attention, sleeping problems, and guilt emotions all indicate mild depression and concur to having a depressing sensation. As a result, university students appear to be a group of people who are particularly susceptible to acquiring depression symptoms. Other co-occurring conditions may aggravate depression symptoms (Peluso et al., 2011). To support this finding, the study of (Levecque et al., 2017a) stated the percentages indicate that a significant number of PhD students are experiencing psychological distress or are at risk of developing a common psychiatric condition. Feelings of persistent stress, sadness, and depression are the most common, as are sleeping issues caused by anxieties, inability to overcome obstacles and inability to enjoy day-to-day activities. Some obligations from the institution of the ministry of education (MOE) are the source of PhD students’ stress, according to this current study. For example, one of the major sources of student stress is the Azerbaijani language, which requires students to pass a B2 Azerbaijani language exam before they could be allowed to defend their thesis (Stecker, 2004) stated that based on the association between stress, social support, and depression symptoms, organizing anti-depression groups may be the most effective way to reduce the severity and frequency of symptoms in students. Job stress, housing troubles, and the environment all have a significant impact. The university-provided housing is for bachelor students because PhD students would not be able to share a hostel room with undergraduate students due to the age difference and study level. Few PhD students are married, so they would need to hunt for family-friendly housing. However, there has been a lot of drama between students and landlords, all of which adds stress to PhD students’ depression levels. On the other hand, there’s is absence of PhD students socialization in their field of study or recreation , this is where the macro and micro environment plays significant role in giving the candidate to settle in well in their host university and host country according to (Sverdlik & Hall, 2020) Such application approaches, according to the author, should boost doctorate students’ motivation by both socializing them into their disciplinary community and developing their proficiency in a specific professional activity (e.g. teaching, conference presentation). These are a few suggestions that may be made because PhD students are specialists in their fields and could make a significant contribution to the environment if given the opportunity. The findings summary show that PhD students are gradually sliding into depression as a result of the following factors: Azerbaijani language examination tied to their thesis defence, nostrification of documents, lack of job opportunity, housing problem, family issues (indirectly linked to balancing their PhD study with family problems), communication and social activity with the host university, research funding due to high costs of article publication. 

STUDY LIMITATIONS

The authors are aware that there may be other Ph.D. foreign students in Azerbaijan’s other regions who were unable to participate in the study.

It should also be remembered that the presented results relate to the foreign PhD students’ respondents living in Baku, Azerbaijan.

A psychologist interview with participants could provide useful information for a subsequent exploratory study on the same issue.

RECOMMENDATION

This research advocated developing improved specialized doctoral student mental health assistance; a concrete discussion on the subject of Azerbaijan language exams since many students want to learn the language but do not want it to be connected as a condition of their PhD thesis defence. We propose implementing a new system in which Azerbaijani language and culture are taught as a semester or two-semester courses at all levels. Several research investigations have concluded that mastering a new language takes many years; therefore, asking PhD students to acquire a language in just a few months and pass a B2 exam would necessitate the use of a magic wand.

The international student’s department at universities should implement a system that permits some house landlords to rent their flats to international foreign PhD students through the university channel, alleviating the stress of finding a place to live. Adopting a PhD student start-up program, in which PhD students can use their talents to create and register a business, would enable them to become self-employed and contribute significantly to the nation’s economic development. This study has set a precedent for other Azerbaijani and foreign researchers to investigate issues impacting the mental health of students, instructors, and other academic employees. If mental health issues are not addressed, they can quickly deteriorate into depression. We must identify the source of the stress and address it before it spirals out of control. Stress management and support systems can also be effective. To examine the issues raised in this present study on PhD students’ mental health, more research is needed.

References

¹ Alharbi, E. S. & Smith, A. P. (2018). Review of the Literature on Stress and Wellbeing of International Students in English-Speaking Countries. International Education Studies, 11(6), 22. https://doi.org/10.5539/ies.v11n6p22
² Auerbach, R. P., Mortier, P., Bruffaerts, R., Alonso, J., Benjet, C., Cuijpers, P., Demyttenaere, K., Ebert, D. D., Green, J. G., Hasking, P., Murray, E., Nock, M. K., Pinder-Amaker, S., Sampson, N. A., Stein, D. J., Vilagut, G., Zaslavsky, A. M. & Kessler, R. C. (2018). WHO world mental health surveys international college student project: Prevalence and distribution of mental disorders. Journal of Abnormal Psychology, 127(7), 623–638. https://doi.org/10.1037/abn0000362
³ Bai, J. (2016). Perceived support as a predictor of acculturative stress among international students in the United States. Journal of International Students, 6(1), 93–106. https://doi.org/10.32674/jis.v6i1.483
⁴ Beiter, R., Nash, R., McCrady, M., Rhoades, D., Linscomb, M., Clarahan, M. & Sammut, S. (2015). The prevalence and correlates of depression, anxiety, and stress in a sample of college students. In Journal of Affective Disorders (Vol. 173, pp. 90–96). https://doi.org/10.1016/j.jad.2014.10.054
⁵ Byrd, D. A. R. & McKinney, K. J. (2012). Individual, interpersonal, and institutional level factors associated with the mental health of college students. Journal of American College Health, 60(3), 185–193. https://doi.org/10.1080/07448481.2011.584334
⁶ Corona, R., Rodríguez, V. M., McDonald, S. E., Velazquez, E., Rodríguez, A. & Fuentes, V. E. (2017). Associations between Cultural Stressors, Cultural Values, and Latina/o College Students’ Mental Health. In Journal of Youth and Adolescence (Vol. 46, Issue 1, pp. 63–77). Springer New York LLC. https://doi.org/10.1007/s10964-016-0600-5
⁷ Czyz, E. K., Horwitz, A. G., Eisenberg, D., Kramer, A. & King, C. A. (2013). Self-reported bar. In Journal of American College Health (Vol. 61, Issue 7, pp. 398–406). https://doi.org/10.1080/07448481.2013.820731
⁸ Eisenberg, D., Gollust, S., … E. G.-A. journal of & 2007, undefined. (2007). Prevalence and correlates of depression, anxiety, and suicidality among university students. Wiley Online Library, 77(4), 534–542. https://doi.org/10.1037/0002-9432.77.4.534
⁹ Gin, L. E., Wiesenthal, N. J., Ferreira, I. & Cooper, K. M. (2021). Phdepression: Examining how graduate research and teaching affect depression in life sciences phd students. CBE Life Sciences Education, 20(3). https://doi.org/10.1187/cbe.21-03-0077

¹⁰ Kazakova, J. K. & Shastina, E. M. (2019). The impact of socio-cultural differences on formation of intrinsic motivation: The case of local and foreign students. Learning and Motivation, 65, 1–9. https://doi.org/10.1016/j.lmot.2018.10.001
¹¹ Kitzrow, M. A. (2009). The Mental Health Needs of Today’s College Students: Challenges and Recommendations. NASPA Journal, 46(4), 646–660. https://doi.org/10.2202/1949-6605.5037
¹² Kowalczyk, M., Karbownik, M. S., Kowalczyk, E., Sienkiewicz, M. & Talarowska, M. (2021). Mental health of phd students at polish universities—before the covid-19 outbreak. International Journal of Environmental Research and Public Health, 18(22). https://doi.org/10.3390/ijerph182212068
¹³ Levecque, K., Anseel, F., De Beuckelaer, A., Van der Heyden, J. & Gisle, L. (2017a). Work organization and mental health problems in PhD students. Research Policy, 46(4), 868–879. https://doi.org/10.1016/j.respol.2017.02.008
¹⁴ Levecque, K., Anseel, F., De Beuckelaer, A., Van der Heyden, J. & Gisle, L. (2017b). Work organization and mental health problems in PhD students. Research Policy, 46(4), 868–879. https://doi.org/10.1016/j.respol.2017.02.008
¹⁵ Liao, K. Y. H. & Wei, M. (2014). Academic stress and positive affect: Asian value and self-worth contingency as moderators among chinese international students. Cultural Diversity and Ethnic Minority Psychology,
20(1), 107–115. https://doi.org/10.1037/a0034071
¹⁶ Mortier, P., Cuijpers, P., Kiekens, G., Auerbach, R. P., Demyttenaere, K., Green, J. G., Kessler, R. C., Nock, M. K. & Bruffaerts, R. (2018). The prevalence of suicidal thoughts and behaviours among college students: A meta-analysis. In Psychological Medicine (Vol. 48, Issue 4, pp. 554–565). https://doi.org/10.1017/S0033291717002215
¹⁷ Nadal, K. L., Wong, Y., Griffin, K. E., Davidoff, K. & Sriken, J. (2014). The adverse impact of racial microaggressions on college students’ self-esteem. Journal of College Student Development, 55(5), 461–474. https://doi.org/10.1353/csd.2014.0051
¹⁸ Nagy, G. A., Fang, C. M., Hish, A. J., Kelly, L., Nicchitta, C. V., Dzirasa, K. & Rosenthal, M. Z. (2019). Burnout and mental health problems in biomedical doctoral students. CBE Life Sciences Education, 18(2), 1–14. https://doi.org/10.1187/cbe.18-09-0198
¹⁹ Peluso, D. L., Carleton, R. N. & Asmundson, G. J. G. (2011). Depression Symptoms in Canadian Psychology Graduate Students: Do Research Productivity, Funding, and the Academic Advisory Relationship Play a Role? In Canadian Journal of Behavioural Science (Vol. 43, Issue 2, pp. 119–127). https://doi.org/10.1037/a0022624
²⁰ Sidorchuk, A., Engström, K., Johnson, C. M., Kayser Leeoza, N. & Möller, J. (2017). Employment status and psychological distress in a population-based cross-sectional study in Sweden: The impact of migration. BMJ Open, 7(4). https://doi.org/10.1136/bmjopen-2016-014698
²¹ Sontag-Padilla, L., Dunbar, M. S., Ye, F., Kase, C., Fein, R., Abelson, S., Seelam, R. & Stein, B. D. (2018). Strengthening College Students’ Mental Health Knowledge, Awareness, and Helping Behaviors: The Impact of Active Minds, a Peer Mental Health Organization. In Journal of the American Academy of Child and Adolescent Psychiatry (Vol. 57, Issue 7, pp. 500–507). https://doi.org/10.1016/j.jaac.2018.03.019
²² Soria, K. M. & Horgos, B. (2021). Factors associated with college students’ mental health during the COVID-19 pandemic. In Journal of College Student Development (Vol. 62, Issue 2, pp. 236–242). https://doi.org/10.1353/csd.2021.0024
²³ Stecker, T. (2004). Well-being in an academic environment. Medical Education, 38(5), 465–478. https://doi.org/10.1046/j.1365-2929.2004.01812.x
²⁴ Sverdlik, A. & Hall, N. C. (2020). Not just a phase: Exploring the role of program stage on well-being and motivation in doctoral students. Journal of Adult and Continuing Education, 26(1), 97–124. https://doi.org/10.1177/1477971419842887