Open access peer-reviewed chapter

Unmet Supportive Care Needs of General Cancer

Written By

Ezaddin Kamal Mahmod and Saadia Ahmed Khuder

Submitted: 07 October 2020 Reviewed: 18 January 2021 Published: 14 April 2021

DOI: 10.5772/intechopen.96063

From the Edited Volume

Teamwork in Healthcare

Edited by Michael S. Firstenberg and Stanislaw P. Stawicki

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Purpose Aside from their oncology condition, cancer patients often experience many ancillary problems, including negative physical symptoms, social isolation, spiritual suffering, and often psychological distress. Supportive care services can be defined as services designed to help patients, their families, and caregivers with their experiences during the diagnosis, treatment, follow-up, and palliative stages of the cancer journey. In an extensive review of the literature, we identified no previous studies that have investigated the SCNs of cancer patients in Iraq or any other Middle Eastern countries. Therefore, this study aims to determine the SCNs of cancer patients in Iraq. Methods The present cross-sectional study and data was conducted in Rezgary teaching and Nankaly Oncology Hospital in the Kurdistan Federal Region of Iraq. A total of 300 eligible cancer patients were invited to participate in the study from February to August, 2018. Eligibility criteria included: 18 years or above; having a definite diagnosis of any type of cancer; physically or mentally able to participate in the study; and being aware of exact diagnosis for at least three months. Results In 15 items of the SCNs, more than 60% of the participants reported that their needs were unmet. Most frequently, unmet needs were related to health system and information, physical and daily living, psychological, and patient care and support domains, and most met needs were related to physical and daily activity domains. Conclusions Kurdish cancer patients had many unmet needs and there is a need for establishing additional supportive care services and educational programs to increase quality of life in Kurdistan Region- Iraq.


  • unmet
  • cancer patient
  • supportive care needs
  • Kurdistan region

1. Introduction

Cancer is the second leading cause of death worldwide, with an estimated global health burden of 193.6 million disability-adjusted life years. This presents a particular challenge for developing nations, which face additional challenges in delivering complex cancer treatments [1]. As a result, the diagnosis of cancer may be experienced as a stressful event that negatively impacts many aspects of patients’ lives [2].

After the Iraqi regime change in 2003, rapid changes occurred in the lifestyles of Kurdish people that affected patterns and rates of cancer trends in Kurdistan. Additionally, the population suffers from the cumulative impacts of three vicious wars in Iraq, including targeted genocide against the Kurds and the use of chemical weapons, creating long-term environmental pollution and increasing cancer incidence, aside from their immediate casualties, with especially high rates of hematological malignancies. Tentative published data evidences the increasing cancer prevalence in Kurdistan, [3, 4, 5, 6] but related phenomena and care needs have not been explored in detail. This study presents new and more accurate data on the patterns of cancers in Kurdistan and the care needs of cancer patients.

Aside from their oncological condition, spiritual suffering, social isolation, and negative physical and psychological symptoms are among many other problems that cancer patients may experience [7, 8]. Due to this, a variety of supportive care services is needed and has to be reinforced [2, 9]. Such services can be directed to support patients, their families, and caregivers during different stages of the cancer journey, such as at the initial post-diagnosis phase, the duration of treatment and follow-up, and even end of life care [6]. Currently, offering supportive care services is regarded to be of equal importance to the diagnosis and treatment of cancer itself, and it involves more holistic healthcare provision compared to the biomedical approach that dominates mainstream oncology treatment [10]. The first step in planning any supportive care services for cancer patients is identifying their supportive care needs (SCNs) [1, 11, 12].

While several studies have investigated the SCNs of cancer patients worldwide, most were conducted in Western countries [11, 13, 14, 15, 16, 17, 18, 19, 20]. Few studies have investigated the SCNs of cancer patients in non-Western settings, but pioneering research indicates that cancer patients in the latter have many unmet supportive needs, albeit there are numerous methodological issues and diverse findings between studies in Western and non-Western countries [21, 22, 23, 24, 25].

Unmet needs are defined as “the requirement for some desirable, necessary or useful action to be taken or some resource to be provided in order for the person to attain optimal well-being” [26, 27]. A systematic review by Harrison et al. [28] concluded that unmet needs were frequently reported in relation to activities of daily living, psychological and psychosocial issues, the need for information, and physical concerns. Similar findings were reported by Fiszer et al. [29].

SCNs are a “culture-dependent” notion. Thus, cultural issues must be taken into consideration when developing an effective supportive care program [23]. After an extensive literature review, no previous studies found to investigate the SCNs of cancer patients in Iraq or in any other Middle Eastern countries. Hence, this study aimed to determine the SCNs of cancer patients in Iraq.


2. Materials and methods

This study was conducted in Rezgary Teaching Hospital and Nankaly Oncology Hospital in the Kurdistan Federal Region of Iraq. Both hospitals are educational centers affiliated with Hawler Medical University, a referral center for sub-special cancer treatment.

A total of 300 eligible cancer patients were invited to participate in the study from February to August, 2018. Participant eligibility criteria included being aged 18 years or above; having a definite diagnosis of any type of cancer; being physically or mentally able to participate in the study; and being aware of exact diagnosis for at least three months.

Participants completed a questionnaire comprising two parts. Participants’ basic socio-demographic and disease-related characteristics were assessed in the first part. In addition, information regarding medical treatments was obtained from the participants’ health records. The second part consisted of an SCNs Survey (SCNS), used to examine the SCNs of cancer patients; it is derived from previous studies [30]. The SCNS comprises 48 items addressing five domains of needs:

  • H&I: health system and information (15 items).

  • NS: non-specific items (4 items).

  • P&D: physical and daily living (7 items).

  • P&S: patient care and support (8 items).

  • Psycho: psychological (11 items).

  • Sex: sexuality (3 items).

Each item was based on a five-point Likert scale (1 = not applicable or no need, 2 = satisfied, 3 = low need, 4 = moderate need, 5 = high need). To determine the SCN score, the five-point Likert scale was dichotomized to unmet need (for moderate need or high need) or no need (for not applicable, satisfied, or low need). Previous researches have used this scoring system widely [23, 24].

The English version of the SCN SF48 was translated into Kurdish by two independent English-Kurdish translators. Eight academic staff at Hawler Medical University (HMU) College of Nursing reviewed the questionnaire to ensure face and content validity. Based on their comments, minor amendments were made. The internal reliability coefficients (Cronbach’s alpha values) of the translated questionnaire were substantial (greater than 0.90) when piloted with 25 cancer patients.

The participants were recruited from inpatient wards of both studied hospitals. Participants were provided with information about the study and the questionnaire to fill in. If participants were incapable to complete the questionnaire due to literacy problems, the researchers assisted them to complete it with a short interview.

Many cancer patients in Iraq may not know the exact diagnosis of their disease, and only limited information is disclosed to them, as highlighted in previous research. Consequently, an important clinical concern in this study was to determine participants’ own awareness of their diagnosis of cancer [3, 4, 5, 6]. In order to identify this and prevent unwanted revelations, this information was obtained from the patients’ caregivers and/or healthcare professionals and then checked with the patients through a short private interview. This procedure was approved by the Regional Ethics Committee at HMU College of Nursing. All participants were informed of the study aims and objectives, and informed consent was obtained. Participants were told that participation was entirely voluntary, and their decision would not affect their care or statutory rights. They were also assured of data anonymity and their right to withdraw from the study at any time.

Data analysis was performed using SPSS version 22 (SPSS Inc., Chicago, Illinois). Analyzing the demographic characteristics, cancer-related information, and unmet and met SCNs of participants was undertaken using descriptive statistics (frequency, percentage, mean, and standard deviation).


3. Results

Participants’ demographic and cancer-related features are reported in Table 1. Most of the participants were female (66.7%), married (84.7%), educated at primary level (19.7%), employed as independent workers (65.7%), and living in urban areas (54.7%). More than half of them were aged above 48 years old. The particular cancer diagnosis, treatment received, and the taking of treatment were noted; over 40% of the 120 patients participating in this study had been diagnosed with breast cancer, and their treatment was primarily chemotherapy and/or radiation therapy. Most of them attended treatment and were receiving chemotherapy.

1Age group18–27 years268.7
28–37 years3511.7
38–47 years5819.3
48–57 years7625.3
58–67 years7224.0
68–77 years289.3
78–87 years51.7
3Living situationUrban16454.7
4Marital statusMarried25484.7
5Education statusIlliterate12943.0
Read and write3712.3
Primary school5919.7
High school graduate5016.7
College and postgraduate258.3
6Occupational statusStudent124.0
Independent worker19765.7
7Cancer originBreast cancer12040.0
Colon cancer289.3
Non-Hodgkin’s lymphoma62.0
Ovarian cancer237.7
Pancreatic cancer41.3
Prostate cancer103.3
Lung cancer3411.3
Rectal cancer20.7
Uterine cancer20.7
8Type of treatmentHormonal therapy5418.0
Surgical removal of cancer13444.7
Bone marrow treatment4515.0

Table 1.

Participant demographic and disease-related characteristics.

The data analysis shows that in 13 items of SCNS, more than 65% of the participants reported that their SCNs were not satisfied (Table 2). This demonstrates that the participants have many unmet SCNs. In terms of domain, 6 of these 13 items concerned H&I; 3 were Psycho; 2 were in NS; and 1 each was in P&D and the P&S domains. In H&I, three 3 of the most unmet needs were “Being given information (written, diagrams, drawings) about aspects of managing your illness and side-effects at home,” “Being informed about your test results as soon as feasible,” and “Being adequately informed about the benefits and side-effects of treatments before you choose to have them.” These results highlight that the patients have many unmet needs, especially in the information domain. Within the Psycho domain, the 3 most unmet needs were for “Concerns about the worries of those close to you,” “Anxiety,” and “Concerns about the ability of those close to you to cope with caring for you.” This means that the patients were distressed about the outcomes of the disease or worried about the changes in the routines of their disease and their families. The most frequent unmet needs were “Concerns about your financial situation” and “Concerns about getting to and from the hospital,” which were related to the non-specific domain. In the P&S domain, only one item was reported as highly unsatisfactory by more than 83% of participants, which was “Lack of energy and tiredness.”

Lack of energy and tirednessP&D25183.7
Concerns about the worries of those close to youPsycho24983
Being given information (written, diagrams, drawings) about aspects of managing your illness and side-effects at homeH&I24983.0
Being informed about your test results as soon as feasibleH&I24481.3
Being adequately informed about the benefits and side-effects of treatments before you choose to have themH&I24180.3
Concerns about the ability of those close to you to cope with caring for youPsycho23277.3
Being informed about cancer which is under control or diminishingH&I23177.0
Being informed about things you can do to help yourself get wellH&I22474.7
Having access to professional counseling (e.g., psychologist, social worker, counselor, nurse specialist) if you/your family/friends need itH&I22374.3
Concerns about your financial situationNS21170.3
Concerns about getting to and from the hospitalNS20969.7
Family or friends being allowed with you in hospital whenever you wantP&S19765.7

Table 2.

Top 15 unmet SCNs of cancer patients.

Participants’ mean scores in the SCNS domains are illustrated in Table 3. In four domains (Psycho, H&I, P&D, and P&S), the participants gained scores of more than 10, which indicates that most of the participants had many unmet needs. However, only the sexuality domain had a score of less than 10. The most unmet needs were for the domains of H&I (36.42), P&D (35.56), Psycho (28.4), P&S (14.27), sexuality (7.76) and non-specific (6.07).

DomainMeanStd. Deviation
Health system and information36.428.15
Patient care and support14.274.68
Physical and daily activity35.569.50

Table 3.

The score of participants in each domain on SCNs survey.

The 10 most frequently met needs of participants are reported in Table 4. More than 70% of the participants reported that they have no needs in these items. As shown in this table, in terms of the studied domains, 4 of the commonly met needs related to aspects of physical and daily activity; and 3 each related to the H&I domain. Interestingly, 4 of these items are related to P&D (3 items) and H&I mean no need to help in physically and patients have equal rights to being treatment and follow-up.

Being treated like a person, not just another caseH&I25284
Keeping a positive outlookPsycho23377.7
Nausea and vomitingP&D21973.0
Swelling of arms, legs, or abdomenP&D21772.3
Being treated in a hospital or clinic that is as physically pleasant as possibleH&I20468
Learning to feel in control of your situationPsycho20367.7
Having one member of hospital staff with whom you can talk about all aspects of your condition, treatment, and follow-upH&I19866
Feelings about death and dyingPsycho19565
Prickling or numb sensationP&D18561.7

Table 4.

Top 10 most frequently met needs of participants.


4. Discussion

To our knowledge, this is the first study that has investigated the SCNs of cancer patients in the Kurdistan Federal Region, and indeed Iraq in general. The results demonstrate that Kurdish cancer patients have many unmet SCNs, especially in the domains of health system, information, P&D. Most of the participants reported unmet SCNs in 13 items of SCNs.

In an extensive review of the literature, it was found that some studies reported that cancer patients have low needs; [11, 19] but most studies highlight that cancer patients in both non-Western [17, 18, 19, 20, 21] and Western countries [9, 14, 31] have many SCNs. None of the analyzed studies reported such high levels of needs as reported by the participants of our study.

The results of our study demonstrate that 6 out of 15 most frequently unmet SCNs of cancer patients are related to the H&I domain. This finding is to some degree different with previous studies conducted in Western countries, which reported the H&I domain to be the second or third domain in which cancer patients’ needs are unmet [6, 9, 13, 32, 33, 34, 35, 36]. Conversely, the findings of other studies conducted in Southwest Asia indicated that H&I domain needs are among the most frequent unmet SCNs of cancer patients [17, 20, 21, 34]. Likewise, a comparative study revealed that Hong Kong breast cancer patients ranked H&I needs as the most frequent unmet SCNs, while German women consider needs from P&D and Psycho needs to be the most frequently unmet supportive care they experienced [19]. Therefore, this finding supports that SCNs are a culture-dependent issue [19]. Additionally, survivors’ needs are dynamic and might change over time. A shift in perceived cancer survivors’ needs from informational needs to Psycho needs has been found by researchers, partly attributable to improvements in information delivery over the years [37]. Further research is required to ascertain whether the predominance of H&I needs in the Kurdistan region can be justified by reasons like changing expectations for information provision due to ease of access to internet-based information, or an institutional deficit instigated by other possible reasons, such as lacking clinical resources or insufficient staff education. No additional evidence could be established on the prevalence of cancer patients’ informational needs, and whether these needs have changed over time or been influenced by contemporary changes in information seeking practices.

The results of our study also indicated that Psycho needs are the second category of unmet SCNs of Kurdish cancer patients, after H&I needs. This finding is consistent with the results of other studies in non-Western countries [17, 20, 21, 37]. It should be noted that Kurdish cancer patients are often unaware of the prognosis of their diseases, and consider cancer to be a conventional, curable disease. Consequently, it can be inferred that the nondisclosure of cancer prognosis for most Kurdish cancer patients may explain the unusually low level of Psycho SCNs found among Kurdish cancer patients.

The results of this study have important clinical implications, particularly in demonstrating that cancer patients in the Kurdistan Region of Iraq have many SCNs in different domains. Few established supportive care programs are available for patients with cancer in Iraq, and our findings underline that there is an urgent need for such programs to be established. Most unmet SCNs cancer patients in Iraq are from the perspective of the domains of H&I and P&D. Thus, educating cancer patients and meeting their H&I and Psycho needs should be considered as a fundamental part of supportive care programs.

There are limitations to our study. This study was conducted in two oncology centers in the Kurdistan Region of Iraq; even though the setting comprises the main referral center for a large province in northern of Iraq, it does not include all areas of Iraq. The findings related to non-specific SCNs ought to be interpreted with caution, considering the taboo associated with sexual issues in Iraq and Kurdish culture. Further studies are necessary that investigate the SCNs of different cultures in the Middle East. Using other data collection methods, including private interviews, may increase the validity of results in the sexual domain of SCNs.


5. Conclusion

This study highlights that Kurdish cancer patients have many unmet needs in all domains of SCNs. These findings indicate that programs and services to address the SCNs are urgently needed. Future research in Iraq should shed light on the particular SCNs of patients in cultural contexts, to help tailor more comprehensive and holistic care, particularly for cancer patients, in order to improve the quality of healthcare services provided.

Ethical considerations

The research project was approved by the Ethics Committee of Hawler Medical University, College of Nursing (Project No. 3, approval date: 2016/03/16).


  1. 1. Global Burden of Disease Cancer Collaboration, Fitzmaurice C, Dicker D, Pain A, Hamavid H, Moradi-Lakeh M, et al. The Global Burden of Cancer 2013. JAMA Oncol 2015; 1:505-527
  2. 2. Carey M, Lambert S, Smits R, Paul C, Sanson-Fisher R, Clinton-McHarg T. The unfulfi lled promise: A systematic review of interventions to reduce the unmet supportive care needs of cancer patients. Support Care Cancer 2012; 20:207-219
  3. 3. Khoshnaw N, Francis B, Safar B, et al (2014) Cytogenetic response in chronic myeloid leukaemia patients treated with imatinib mesylate homolog-drugs: 6 year’s transitional study. J Cancer Therapy, 5,453-459
  4. 4. Majid R, Mohammed H, Hassan H, et al (2012). A populationbased study of Kurdish breast cancer in northern Iraq: Hormone receptor and HER2 status. A comparison with Arabic women and United States SEER data. BMC Women’s Health, 12, 16
  5. 5. Zangana A, Garota S (2012). Risk factors of breast cancer in a sample of Kurdish women of Kurdistan Region - Iraq: a comparative study between pre-menopausal and postmenopausal women, Zanco. J Med Sci, 16,3
  6. 6. Othman RT, Abdulljabar R, Saeed A, et al (2011). Cancer incidence rates in the Kurdistan region/Iraq from 2007-2009. Asian Pac J Cancer Prev, 12, 1261-1264
  7. 7. Fujisawa D, Park S, Kimura R, Suyama I, Koyama Y, Takeuchi M, et al. Unmet supportive needs of cancer patients in an acute care hospital in Japan--a census study. Support Care Cancer 2010;18:1393-1403
  8. 8. Stiefel F, Guex P. Palliative and supportive care: At the frontier of medical omnipotence. Ann Oncol 1996; 7:135-138
  9. 9. Johnston G, Vukic A, Parker S. Cultural understanding in the provision of supportive and palliative care: Perspectives in relation to an indigenous population. BMJ Support Palliat Care 2013;3:61-68
  10. 10. Fincham L, Copp G, Caldwell K, Jones L, Tookman A. Supportive care: Experiences of cancer patients. Eur J Oncol Nurs 2005; 9:258-268
  11. 11. Whelan TJ, Mohide EA, Willan AR, Arnold A, Tew M, Sellick S, et al. The supportive care needs of newly diagnosed cancer patients attending a regional cancer center. Cancer 1997;80:1518-1524
  12. 12. Jones R, Regan M, Ristevski E, Breen S. Patients’ perception of communication with clinicians during screening and discussion of cancer supportive care needs. Patient Educ Couns 2011; 85:209-215
  13. 13. Beesley VL, Price MA, Webb PM, O’Rourke P, Marquart L, Butow PN, Australian Ovarian Cancer Study Group, Australian Ovarian Cancer Study-Quality of Life Study Investigators. Changes in supportive care needs after fi rst-line treatment for ovarian cancer: Identifying care priorities and risk factors for future unmet needs. Psychooncology 2013; 22:1565-1571
  14. 14. Bender JL, Wiljer D, To MJ, Bedard PL, Chung P, Jewett MA, et al. Testicular cancer survivors’ supportive care needs and use of online support: A cross-sectional survey. Support Care Cancer 2012; 20:2737-2746
  15. 15. Chambers SK, Girgis A, Occhipinti S, Hutchison S, Turner J, Morris B, et al. Psychological distress and unmet supportive care needs in cancer patients and carers who contact cancer helplines. Eur J Cancer Care Engl 2012;21:213-223
  16. 16. Janda M, Steginga S, Dunn J, Langbecker D, Walker D, Eakin E. Unmet supportive care needs and interest in services among patients with a brain tumour and their carers. Patient Educ Couns 2008; 71:251-258
  17. 17. Rainbird K, Perkins J, Sanson-Fisher R, Rolfe I, Anseline P. The needs of patients with advanced, incurable cancer. Br J Cancer 2009;101:759-764
  18. 18. Smith DP, Supramaniam R, King MT, Ward J, Berry M, Armstrong BK. Age, health, and education determine supportive care needs of men younger than 70 years with prostate cancer. J Clin Oncol 2007;25:2560-2566
  19. 19. Snyder CF, Garrett-Mayer E, Blackford AL, Brahmer JR, Carducci MA, Pili R, et al. Concordance of cancer patients’ function, symptoms, and supportive care needs. Qual Life Res 2009;18:991-998
  20. 20. Sutherland G, Hill D, Morand M, Pruden M, McLachlan SA. Assessing the unmet supportive care needs of newly diagnosed patients with cancer. Eur J Cancer Care Engl 2009;18:577-584
  21. 21. Au A, Lam W, Tsang J, Yau TK, Soong I, Yeo W, et al. Supportive care needs in Hong Kong Chinese women confronting advanced breast cancer. Psychooncology 2013; 22:1144-1151
  22. 22. Chen, S.C., Lai, Y.H., Liao, C.T., Chang, J.T.C., Lin, C.Y., Fan, K.H. and Huang, B.S., 2013. Supportive care needs in newly diagnosed oral cavity cancer patients receiving radiation therapy. Psycho-Oncology, 22(6), pp.1220-1228
  23. 23. Lam WW, Au AH, Wong JH, Lehmann C, Koch U, Fielding R, et al. Unmet supportive care needs: A cross-cultural comparison between Hong Kong Chinese and German Caucasian women with breast cancer. Breast Cancer Res Treat 2011; 130:531-541
  24. 24. Liao YC, Liao WY, Shun SC, Yu CJ, Yang PC, Lai YH. Symptoms, psychological distress, and supportive care needs in lung cancer patients. Support Care Cancer 2011; 19:1743-1751
  25. 25. Okuyama T, Akechi T, Yamashita H, Toyama T, Nakaguchi T, Uchida M, et al. Oncologists’ recognition of supportive care needs and symptoms of their patients in a breast cancer outpatient consultation. Jpn J Clin Oncol 2011; 41:1251-1258
  26. 26. Lattimore-Foot GG. Needs Assessment in Tertiary and Secondary Oncology Practice: A Conceptual and Methodological Exposition. University of Newcastle; 1996
  27. 27. Campbell HS, Sanson-Fisher R, Taylor-Brown J, Hayward L, Wang XS, Turner D. The cancer support person’s unmet needs survey: Psychometric properties. Cancer 2009; 115:3351-3359
  28. 28. Harrison JD, Young JM, Price MA, Butow PN, Solomon MJ. What are the unmet supportive care needs of people with cancer? A systematic review. Support Care Cancer 2009;17:1117-1128
  29. 29. Fiszer C, Dolbeault S, Sultan S, Brédart A. Prevalence, intensity, and predictors of the supportive care needs of women diagnosed with breast cancer: A systematic review. Psychooncology 2014; 23:361-374
  30. 30. Bonevski B, Sanson-Fisher R, Girgis A, Burton L, Cook P, Boyes A. Evaluation of an instrument to assess the needs of patients with cancer. Supportive Care Review Group. Cancer 2000; 88:217-225
  31. 31. Zebrack BJ, Mills J, Weitzman TS. Health and supportive care needs of young adult cancer patients and survivors. J Cancer Surviv 2007; 1:137-145
  32. 32. Jorgensen ML, Young JM, Harrison JD, Solomon MJ. Unmet supportive care needs in colorectal cancer: Differences by age. Support Care Cancer 2012; 20:1275-1281
  33. 33. Sanders SL, Bantum EO, Owen JE, Thornton AA, and Stanton AL. Supportive care needs in patients with lung cancer. Psycho oncology 2010; 19:480-489
  34. 34. Steginga SK, Occhipinti S, Dunn J, Gardiner RA, Heathcote P, Yaxley J. The supportive care needs of men with prostate cancer (2000). Psycho oncology 2001;10:66-75
  35. 35. Minstrell M, Winzenberg T, Rankin N, Hughes C, Walker J. Supportive care of rural women with breast cancer in Tasmania, Australia: Changing needs over time. Psychooncology 2008; 17:58-65
  36. 36. McDowell ME, Occhipinti S, Ferguson M, Dunn J, Chambers SK. Predictors of change in unmet supportive care needs in cancer. Psychooncology 2010; 19:508-516
  37. 37. Sanson-Fisher, R., Girgis, A., Boyes, A., Bonevski, B., Burton, L., Cook, P. and Supportive Care Review Group, 2000. The unmet supportive care needs of patients with cancer. Cancer, 88(1), pp.226-237

Written By

Ezaddin Kamal Mahmod and Saadia Ahmed Khuder

Submitted: 07 October 2020 Reviewed: 18 January 2021 Published: 14 April 2021