Muhammad Bilal Anwaar*, Sana Haider, Fazila Malik, Shamsa Kanwal, and Shehroz Ali
Institute of Applied Psychology, University of the Punjab, Lahore, Pakistan
Beliefs about precarious manhood is a notion stating that manhood is a socially acquired status that needs to be continuously earned and defended because it can be seized. The current quantitative study employed a correlational research design to investigate the relationship among perceptions about precarious manhood, body dissatisfaction, and psychological distress among adult men through the mediating role of body dissatisfaction. This study aimed to provide insights into how men's mental health and body image are influenced by their ideas about masculinity. The data was collected from 200 adult men using a convenience sampling strategy. To collect the data, scales, including Precarious Manhood Beliefs Scale (PMBS), Body Parts Satisfaction Scale for Men (BPSS-M), and Kessler Psychological Distress Scale (K6) were used. It was found that beliefs about precarious manhood were significantly positively correlated with psychological distress among adult men, suggesting that perceptions of masculinity can contribute to emotional strain. Moreover, body dissatisfaction partially mediated this relationship, suggesting that dissatisfaction with physical appearance plays a key role in amplifying the psychological impact of these beliefs. Future research should focus on specific body image factors such as muscularity, fat ratio, and leanness in relation to precarious manhood, while practitioners and policymakers should address how societal gender norms impact men’s mental health and body image.
Beliefs about precarious manhood are the articulation that manhood is a socially attained status that requires continual earning and defense (demonstration of toughness and dominance), as it is susceptible to loss or confiscation (displaying weakness and vulnerability) (Vandello et al., 2022). Manhood, unlike womanhood, is viewed as precarious, which requires constant social validation. This vulnerability makes men feel threatened by challenges to their masculinity, potentially resulting in gender-typed behaviors, such as physical aggression (Vandello & Bosson, 2013).
The desire for status, dominance, toughness, self-reliance, and anti-femininity are highlighted as traits of Traditional Masculinity Ideology (TMI), as well as, what it means to be a man (Levant & Richmond, 2016). Men might experience several forms of social pressure, such as calling them derogatory terms being encouraged to man up or act like a man when they are afraid, look muscular or feeling like they have failed as a man when they lose their job or become physically weaker with age (Burkley et al., 2016).
The beliefs about precarious manhood can have several detrimental effects on men’s psychological and physical health, such as heightened hostility, anxiety, and aggressionVandello & Bosson, 2013; DiMuccio & Knowles, 2020). Moreover, certain threats to livelihood of men, such as death sentence and war threats, has also affected the outlook towards their capabilities to show aggression and anxiety. There is also obvious difference in how the men associated with different ideologies react to it (DiMuccio & Knowles, 2023).
Hearn et al. (2023) describe men as a social category, that is, as people who identify themselves and are defined by others as such. Men's social category is created within the context of gender hegemony, an accepted norm in which gender roles and relations are accepted as an innate trait. The dominant kind of masculinity that exercises control over women and other oppressed groups is known as hegemonic masculinity (Jewkes et al., 2015). This idea, which dates back to the early 1980s in gender studies, explains why men exercise power over women and how it gives an outlook of mutual understanding over different power dynamics then being controlled. Masculinities are produced in response to cultural ideals regarding men within gender regimes. Men, women, and other genders may all perform and maintain masculinities, which are believed to be signals, discourses, practices, and performances that mask inconsistencies (Hearn et al., 2023).
Recently, Vandello et al. (2022), documented the acceptance level of Precarious Manhood Beliefs (PBM) in over 62 countries, including Pakistan, and its link to a range of health behaviors associated with risk. The idea of precarious manhood provides a framework for comprehending the relationship that body image issues may have with men's psychological health. The precarious manhood can be acquired by acting in a manly manner (Vandello & Bosson, 2013). And in order to achieve that masculinity and manliness men would try to acquire a more muscular body which helps them elevate the belief that their masculinity was in danger (Mills et al., 2023).
Body dissatisfaction in men, particularly related to muscularity and masculinity norms, is a significant concern. The conformity to specific masculine norms, such as winning, violence, and irresponsibility can lead to body dissatisfaction, which in turn mediates the development of exercise dependence in men (Fatma, 2022). Moreover, the internalization of muscular-ideal norms, especially in combination with thin-ideal internalization, is associated with increased body dissatisfaction, cognitive restraint, and muscle dysmorphia symptoms in men (Dawson & Hammer, 2020). Additionally, media pressure plays a crucial role in shaping body ideals and dissatisfaction in men, with a focus on muscularity and thinness, highlighting the impact of sociocultural influences on body image perceptions (Convertino et al., 2022).
Body dissatisfaction consists of a negative subjective evaluation of one’s physical body, such as figure, weight, stomach, and hips (Troisi, 2020). Previous research highlighted the fact that men also struggle with body dissatisfaction and engage in body-altering behaviors (Grieve et al., 2013). While they may not always meet the diagnostic criteria for Body Dysmorphic Disorder (BDD), it is evident that body image concerns are not limited to one gender. This realization suggests that body image may play a significant role in men's mental health. Muscle Dysmorphia (MD) is a subtype of BDD characterized by a preoccupation with not being enough muscular, leading to various negative consequences, such as social withdrawal, excessive exercise, and psychological distress (Blashill et al., 2020).
Body dissatisfaction can have devastating effects on individuals’ well-being. There is a significant positive correlation between body image dissatisfaction and self-esteem (Saini, 2023). Barnes et al. (2020) suggested that there is an association among men’s body dissatisfaction, anxiety, and depression. There is also a significant association between internalization of the mesomorphic ideal, appearance anxiety, and body dissatisfaction in college-aged males (Olivia et al., 2020). Due to conventional masculine views that consider asking for help as a weakness, males are less likely to seek mental health services (Keum et al., 2021). Depression can result from hiding distress; therefore, research indicates that loneliness and feeling misinterpreted might exacerbate depressive symptoms in males.
Men’s psychological well-being requires attentions, since many issues may go unresolved, in part due to the fact that men are less likely than women to reveal mental health issues and seek help (Kastrup et al., 2023). Men who endorse precarious manhood beliefs are at a greater risk for psychological distress (Vandello et al., 2024). Moreover, both conformity to and psychological conflict with traditional masculine gender role expectations are associated with a wide range of health behaviors, body image issues, and poor health outcomes among men, especially in organizational settings that are highly gendered and structured by traditional masculine role norms (for example, toughness, violence, homophobia, and others) (Mankowski & Smith, 2016). Therefore, men who adhere to precarious manhood face an elevated risk of psychological distress (Vandello et al., 2024).
The theoretical background of Precarious Manhood Beliefs (PMB) posits that manhood is a status difficult to attain, easily lost, and must be demonstrated through public actions. This concept is rooted in the social expectations surrounding masculinity, where failure to meet these standards can lead to psychological distress and social repercussions (Bosson et al., 2021; DiMuccio & Knowles, 2020; Kinmore, 2023; Walther et al., 2023).
Men might try to compensate for threatened masculinity by pursuing muscularity. Men’s desire to have higher levels of muscle (Drive for Muscularity or DFM) and engage in behaviors to boost their masculine image (Edwards et al., 2017). The reason behind this mindset is that they feel lack of "masculine capital" and try to compensate for it through Drive for Muscularity (DFM) and traditional masculine activities, such as sports. The pressure men feel to showcase their masculinity in public can result in the exhibition of hyper-masculine behaviors.
Men who feel threatened by their masculinity are likely to have lower self-confidence in their physical abilities (Hunt et al., 2013). Men tend to present themselves as more formidable and stronger in the face of challenges to their masculinity leading to body dissatisfaction and psychological distress. According to the Gender Role Strain Theory (GRST), people go through psychological stress when their identities and experiences don't align with what society expects of them and it is frequently made worse by ingrained gender conventions (Colizza et al., 2024).
The sociocultural model suggests that exposure to idealized images of masculinity and the body (for example, through media representations) leads individuals to internalize such ideals related to concept of masculinity, hence causing them to evaluate their own bodies against an unrealistic standard (Stice, 2002). In men, this often translates to a desire for a muscular and lean physique, which may be unattainable for many. As men internalize these societal ideals, they are more likely to experience body dissatisfaction, which has been linked to various forms of psychological distress, including depression, anxiety, and low self-esteem (Austen & Griffiths, 2024).
Men might also experience strain related to their appearance, which can be one of the factors of male body dissatisfaction. The theory of precarious manhood posits that societal expectations might induce anxiety and discomfort in males who perceive themselves as failing to achieve these criteria (Khan et al., 2023). When men internalize societal ideals about the male body, they may begin to objectify themselves, constantly evaluating their appearance against an external standard. This self-objectification is associated with body shame, anxiety, and psychological distress (Naqi et al., 2022; Saunders et al., 2024).
Among men, body dissatisfaction is a major mediator in several psychological and health problems, especially when it comes to sexual minority communities. According to Blashill et al. (2016), body dissatisfaction among men is associated with greater depressive symptoms, decreased sexual self-efficacy, and increased sexual anxiety. The connection between body dissatisfaction and eating disorder symptomatology in men is further mediated by the connection of gender role conflict, negative affect, and social sensitivity (Blashill & Wal, 2009).
Indigenous ResearchSouth Asian men struggle to maintain conventional notions of masculinity due to their challenging socioeconomic circumstances (Aslam, 2014). Adherence to conventional masculine ideals may serve as a deterrent for men seeking assistance, which may have detrimental effects on their health (De Visser et al., 2020). Men have been shown to experience stress and conflict as a result of gender norms; therefore, research attempted to explore the conditions in which such standards can be altered (Amna & Raana, 2023). The way men denote the desire for women via words and actions, which furthermore, reinforces their masculinity and dominance (Fatima, 2016). Men reported greater degrees of gender role strain, which connected positively with violence (Arshad & Shahed, 2023). In Pakistan, where traditional and cultural values enhance the partiality between the gender roles these differences are more visible, which ultimately enforces men to engage in violent behaviors as a mean of reasserting their masculinity while experiencing greater gender role strain (Habib et al., 2024).
The current study draws on precarious manhood theory, gender role strain theory, and the elaborated socio-cultural model to explain how societal expectations of masculinity contribute to body dissatisfaction and psychological distress among men. Body objectification theory further enhances this understanding by highlighting the role of self-objectification in the development of body image concerns. Together, these theories offer a robust explanation of the psychological challenges faced by men in navigating societal pressures related to masculinity and body image.
RationaleThe current study examines the significant implications of Precarious Manhood Beliefs (PMB) on men's mental health (Vandello et al., 2022). With the mediating effect of body dissatisfaction on precarious manhood, current literature tends to focus more on the general stressors associated with traditional masculinity (Pritchard et al., 2021), yet it overlooks the nuanced ways in which precarious manhood beliefs intersect with modern cultural ideals, particularly in relation to body image. This study aims to fill that gap by exploring how men’s internalized beliefs about masculinity exacerbate negative psychological outcomes, such as distress, is associated with body image dissatisfaction.
HypothesesSample For this study, a correlation research strategy was employed. Following the convenience sampling technique, data was collected from men aged between 18 to 35 years who were residing in Lahore city. Men diagnosed with any chronic medical and psychiatric conditions were not included in the study. The predominant participants were students (48%) or employed full-time (35.5%), exhibiting a variety of educational backgrounds from intermediate to master’s degrees. The majority of participants originated from metropolitan environments (79%) and nuclear family structures (63.5%). A significant percentage of the sample was unmarried (84%).
Table 1 Socio-demographic Characteristics of the Participants (N = 200)Sample Characteristics | n | % | M | SD |
---|---|---|---|---|
Age | 23.38 | 3.93 | ||
Education | ||||
Intermediate | 81 | 37 | ||
Bachelor’s Degree | 95 | 47 | ||
Master’s Degree | 31 | 16 | ||
Employment Status | ||||
Employed Full-Time | 71 | 36 | ||
Employed Part-Time | 9 | 4 | ||
Unemployed | 24 | 12 | ||
Student | 96 | 48 | ||
Family Background | ||||
Urban | 158 | 79 | ||
Rural | 42 | 21 | ||
Family System | ||||
Nuclear Family | 127 | 64 | ||
Joint Family | 73 | 36 | ||
Marital Status | ||||
Unmarried | 168 | 84 | ||
Married | 32 | 16 |
Precarious Manhood Beliefs Scale (PMBS) assesses adherence to traditional masculine norms and associated anxieties (Hegarty & Pratto, 2001; Haslam et al., 2006; Vandello et al., 2008). It consisted of total 7 items, ranging from 1 (strongly disagree) to 7 (strongly agree) The item scores were averaged to yield overall scores wherein higher scores indicate stronger endorsement of hostile sexism or precarious manhood beliefs. Cronbach’s alpha given by the original author of the scale was .85 (Vandello et al., 2022).
Body Parts Satisfaction Scale for Men (BPSS-M)Body Parts Satisfaction Scale for Men (BPSS-M) was developed by McFarland and Petrie (2012). This scale consisted of 25 items that evaluate satisfaction with specific body parts. Each item asks respondents to rate their satisfaction with the appearance of the respective body parts on a scale ranging from 1 (extremely dissatisfied) to 7 (extremely satisfied). There were three defined components: face (five items; α .85), legs (four items; α .94), and Upper body (17 items; α .98). Factor intercorrelations range from .65 to .79. These criteria comprise measures evaluating leanness and muscularity. Support was established for the factors' concurrent, discriminant, and convergent validity. The factors were also determined to be internally consistent and stable over a period of six months. Furthermore, body satisfaction has a special role in men's experiences with disordered eating, mood, and psychological well-being, even after adjusting for social desirability and the urge for muscularity. Total score range was 25 to 150 (McFarland & Petrie, 2012).
Kessler Psychological Distress Scale (K6)Kessler Psychological Distress Scale (K6) developed by Kessler et al. (2002), is used to measure non-specific psychological distress. Psychological distress was operationalized as the presence of negative emotional states, including feelings of nervousness, agitation, restlessness, hopelessness, depression, and worthlessness. It consisted of 6 items. The respondents were asked to indicate how often they have experienced each of these feelings on a five-point Likert scale, ranging from 0 (none of the time) to 4 (all of the time). The total score ranges from 0-24. K6 exhibit comparable psychometric features across significant socio-demographic subsamples and high accuracy in the 90th–99th percentile range of the population distribution (Kessler et al., 2002).
To initiate the research, formal approval was obtained from the institutional review board. Also, for data collection, the permissions were granted from the institute. Subsequently, to utilize the scales in the current study, permission was requested from the scales' authors. In order to make sure that participants could easily comprehend and complete the questionnaire, pilot testing was conducted prior to the data collection phase. Participants were informed about the goal of the study as well as their obligations and rights prior to enrolling in the research. To confirm voluntary involvement, each participant additionally completed an informed consent form. Additionally, the researchers answered and acknowledged study-related questions from participants. The data collected from research participants was analyzed using SPSS (Version 27).
The results of a thorough statistical analysis of the data gathered are presented in this section.
Table 2 Test of Normality for Distributional Characteristics of the Key Variables (N = 200)Variables | Mean | Median | Skewness | Kurtosis | Kolmogorov-Smirnov Test (p) |
---|---|---|---|---|---|
PMB | 28.27 | 30.00 | -0.23 | -1.20 | .110 |
BPSS-M | 94.42 | 99.50 | 0.03 | -1.13 | .119 |
Face | 15.62 | 16.00 | -0.07 | -1.11 | .106 |
Upper Body | 63.82 | 67.00 | 0.04 | -1.08 | .088 |
Legs | 14.97 | 15.00 | 0.07 | -0.98 | .071 |
K6 | 11.60 | 12.00 | -0.17 | -0.98 | .088 |
The Table 2 shows that the data is normally distributed.
Table 3 Psychometric Properties of the Key Variables (N = 200)Scales | k | M | SD | Range | α | |
---|---|---|---|---|---|---|
Potential | Actual | |||||
PBMS | 7 | 28.27 | 9.32 | 7 - 49 | 11 - 45 | .83 |
BPSS-M | 25 | 94.42 | 29.78 | 25 - 150 | 35 - 147 | .91 |
Face | 4 | 15.62 | 4.99 | 4 - 24 | 5 - 23 | .81 |
Upper Body | 4 | 63.82 | 20.80 | 17 - 102 | 23 - 101 | .92 |
Legs | 17 | 14.43 | 5.43 | 4 - 24 | 3 - 21 | .89 |
K6 | 6 | 11.60 | 5.32 | 0 - 24 | 1 - 22 | .84 |
The above Table shows the internal consistency values of the different scales with a coefficient of α=.83, the Precarious Manhood Beliefs Scale (PMB) exhibits a good degree of internal consistency. With a value of α=.91, Body Parts Satisfaction Scale for Men (BPSS-M) has excellent reliability. However, with a coefficient of α=.84, the Kessler Psychological Distress Scale (K6) exhibits a high degree of internal consistency as well.
Table 4 Inter-Correlation among Demographic Variables, and Study Variables (N=200)Variables | 1 | 2 | 3 | 4 | 5 | 6 | 7 |
---|---|---|---|---|---|---|---|
1 Age | - | ||||||
2 GL | .09 | - | |||||
3 FB | .06 | .12 | - | ||||
4 MS | .57** | .11 | .07 | - | |||
5 PMB | .05 | .04 | .05 | .08 | - | ||
6 BD | .04 | .40* | .09 | .04 | .55** | - | |
7 PD | .10 | .10 | .10 | .02 | .59** | .68** | - |
Note. GL = Geographical Location (0 = Urban, 1 = Rural), FB = Family Background (0 = Nuclear, 1 = Joint), MS = Marital Status (0 = single, 1 = married), PMB = Precarious Manhood Beliefs, BD = Body Dissatisfaction, PD = Psychological Distress.
** = p<.01. * = p<.05.
Table 4 illustrates relationships among Precarious Manhood Beliefs (PBM), Body Dissatisfaction (BD), and Psychological Distress (PD). PBM was positively correlated with both BD (r=.55, p<.01) and PD (r=.59, p<.01). Moreover, BD and PD are also positively linked with each other (r=.68, p<.01), MS was moderately linked with age (r=.57, p<.01), and there was a weak correlation between geographical location and BD (r=.40, p<.05), which indicates that men in urban areas are more likely to experience BD than men in rural areas.
Table 4 Mediation Analysis Results for Precarious Manhood Beliefs (IV), Body Dissatisfaction (M), and Psychological Distress (DV) among Adult Men (N = 200)Variables/Paths | β | SE | t | p | 95% CI |
---|---|---|---|---|---|
PBM → BD | .63** | .04 | 24.241 | .001 | [0.02, 0.85] |
BD → PD | .57** | .01 | 7.051 | .001 | [0.49, 0.64] |
Direct Effect | .18** | .04 | 5.184 | .001 | [0.11, 0.25] |
Indirect Effect (BD) | .25** | .03 | [0.13, 0.27] |
The above table presents the variables, Precarious Manhood Beliefs (PMB) and Psychological Distress (PD), in the mediating relation to Body Dissatisfaction (BD), as well as the direct and indirect mediating effects of the variables. There is a significant mediating relationship between PMB and BD (a=.63, p<.001), which supports the assumption that men with PBM were likely to experience body dissatisfaction. Resultantly, the increase in body dissatisfaction is likely to result in an increase in psychological distress, which is demonstrated by the positive coefficient between BD and PD (b=.57, p<.001). The direct impact of PMB on PD is shown by the positive coefficient (c=.18, p<.001), suggesting that men with PBM experience PD. Moreover, the indirect effect of PBM on PD through the mediating factor of BD among adult men is significant (c’=.25).
Figure 1 Statistical Model of the Research (N=200)
The current study aimed to determine if beliefs about precarious manhood, body dissatisfaction, and psychological distress among men were related to one another. As per the findings, there is a substantial relationship among beliefs about precarious manhood, body dissatisfaction, and psychological distress among men. The previously published literature also supported the findings based on the first hypothesis. As stated by the researchers that manhood was perceived as a precarious condition that needs to be earned via public display of masculinity in all cultures (Vandello & Bosson, 2022). Threats to men's perception of inadequacy and self-worthlessness are identified by precarious manhood theory as challenges to masculinity. Within our social environment Masculinity is frequently challenged and masculinity is a status that is both elusive (it does not come from development alone) and tenuous (it is not always maintained after it is attained). Men will take a variety of compensating measures to regain their manhood if it is lost (Glick et al., 2007). Hence, the research was supported by the previous studies that men take various actions to preserve their manhood and one of many strategies would be to appear more masculine and muscular (Hunt et al., 2013; Mills et al., 2023). The men who are threatened by lack of their masculinity are likely to have lower self-confidence in their physical abilities, leading to actions that can preserve their manhood.
Furthermore, media pressures, which emphasize masculinity, muscularity, and thinness, have a significant impact on how men see their bodies and contribute to their discontent with them. This underscores the significance of societal influences on how men view their bodies (Convertino et al., 2022). Both of these factors can lead to a number of detrimental effects on men’s psychological and physical health, such as heightened hostility, and anxiety (Vandello & Bosson, 2013). The precarious manhood notion suggests that there may be dangers to masculinity, which could explain increased perceived strength and muscle discontent (Frederick et al., 2017). The results demonstrate the intricate relationship between men's body dissatisfaction and beliefs about precarious manhood. Additionally, men feel the need to continually prove their manhood status (Vandello & Bosson, 2013). Any perceived threat or failure to meet societal standards of masculinity can evoke distress, which eventually impacts mental health.
The second hypothesis was that body dissatisfaction would likely mediate the relationship between beliefs about precarious manhood and psychological distress among men. The results from regression analysis, as well as, previously published research supported the mediation analysis (Blashill et al., 2016; Blashill & Wal, 2009; Burlew & Shurts, 2013). Adhering to certain stereotypical ideals for men can cause body dissatisfaction, which then act as a mediator in the development of men's exercise habits, which then leads to heightened feelings of body dissatisfaction, cognitive restriction, and symptoms of muscular dysmorphia (Dawson & Hammer, 2020; Fatma, 2022).
According to the third hypothesis, there would be a significant difference due to marital status regarding beliefs about precarious manhood, body dissatisfaction, and psychological distress. The results of the current study didn’t support this hypothesis.
The present study underscores the profound influence of precarious manhood beliefs on psychological distress and body dissatisfaction among Pakistani men. Findings revealed a significant positive relationship among precarious manhood beliefs, body dissatisfaction, and psychological distress, indicating that men are more likely to feel dissatisfied with their bodies and experience psychological distress when they believe that their masculinity is somewhat temporary, and they must exhibit dominance in society. Thus, it was concluded that an association exists among beliefs about precarious manhood, body dissatisfaction, and psychological distress. This association is particularly relevant in the Pakistani cultural context, where social norms promote masculine ideals such as dominance, power, and self-reliance, creating more pressure on men to maintain a perceived idealized appearance. The study highlights the need for culturally sensitive mental health interventions that address the rigid masculinity expectations contributing to distress and low body satisfaction in men.
As we used convenience sampling in the study, which was not entirely representative of the population, since the use of convenience sampling can introduce bias. More varied samples should be the goal of future research in order to improve the generalizability of findings. To better reflect the whole population, include a sample that would be more diverse in terms of age, ethnicity, socioeconomic level, and geography. By adding additional participants and enlarging the sample size, future researchers can also employ qualitative techniques to investigate beliefs about precarious manhood in greater detail. Indigenous instruments should be created in order to reach the local community, in addition to scales, such as PMBS, BPSS-M, and K6. Additional mediating or moderating variables can be included in future study to evaluate the complicated relationship among precarious manhood beliefs, body dissatisfaction, and psychological distress. Furthermore, future research should investigate these dimensions in other cultural contexts in order to comprehend cross-cultural differences and common trends. Future research should also investigate the more specific aspects of body dissatisfaction experienced by men and its association with belief about precarious manhood, and the aspects which were not included in the study, such as, muscularity, fat ratio, and leanness (Olivia et al., 2020). Lastly, future studies should examine the function of media in the formation of beliefs about precarious manhood, body dissatisfaction, and psychological distress, as well as the manner in which media moderates or mediates the association between these variables.
The findings of this study have significant policy implications, particularly in the realm of mental health and gender studies. Understanding the adverse effects of rigid masculinity norms on men's mental health and self-perception is essential for shaping public policy. This research underscores the need for public health campaigns aimed at raising awareness about the detrimental impacts of societal expectations related to masculinity. Such initiatives could promote healthier self-perceptions, reduce the stigma surrounding mental health issues, and encourage men to seek help without fear of judgment. Policymakers can also use these insights to design interventions that promote gender equity, challenging harmful stereotypes while advocating for a more inclusive definition of masculinity that allows for emotional vulnerability and self-care. Addressing these issues holistically may contribute to improving men's overall quality of life and reducing psychological distress caused by body dissatisfaction and the pressure to conform to traditional masculine ideals.
The author of the manuscript has no financial or non-financial conflict of interest in the subject matter or materials discussed in this manuscript
The data associated with this study will be provided by the corresponding author upon request.
No funding has been received for this research.