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The peri-urban settings of Kinshasa in the Democratic Republic of Congo are mostly characterized by uneven terrain and limited access to water. A cross-sectional epidemiological study of school-going adolescent girls identified public health risks associated with daily water carrying. Data were collected using a semi-structured paper questionnaire, whereas descriptive and regression analysis was performed using SPSS software. The study established that Head-load transportation of water was the most common mode for 92.3% of the interviewed adolescent girls. Compared to other modes, this mode was most likely to expose adolescent girls to musculoskeletal pains and injuries (p < 0.0001). Most adolescent girls interviewed (79.4%) crossed hilly and mountainous terrain. Some 59.4% of adolescent girls experienced falls, 38.6% and 17.4%, respectively, experienced injuries and strains associated with hilly terrain. Almost all the study participants reported pain (96.3%), with 73% reporting back and chest pains. Other reported problems included permanent muscular pain (59.5%), neck pain (55.6%), permanent headaches (50.6%), lower abdominal pain (23.1%), and prolonged painful menstruation (6.7%). Although these data are based on self-reported pain and injuries, their effects could negatively impact adolescent girls’ school attendance and performance. Evidence from this research first supports policies that provide home water supply systems. Such a supply system offers the advantage of relieving the burden of transporting heavy loads of water over long distances and mountainous terrains. Second, evidence demonstrates that the city of Kinshasa struggles to achieve the 6th SDG, which implies negative impacts on the 3rd and 4th SDGs related to health and equitable education for adolescent girls.

Introduction

In most resource-limited countries, access to water does not meet World Health Organization (WHO) standards for safe water supply with on-site water collection (WHO, 2017). In these countries, achieving target 1 of the 6 sustainable development goals (SDG) is being compromised, and the target to provide safe drinking water to their population by 2030 will not be achieved (Rajapakseet al., 2023).

At the international level, the United Nations (UN) promotes the principle of “leaving no one behind” in access to water. Hence, one of the focuses of the UN’s SDG agenda is to promote equitable access to water to reduce regional disparities. This would positively impact the other SDGs related to health, education, and gender equality (UN, 2017).

Meanwhile, to meet the basic water needs of their households, people in resource-limited countries have to engage in daily water chores (Bazaanah & Mothapo, 2023; Rocheet al., 2017).

Women and girls, who are traditionally the main water collectors when access is limited, bear and cope with the burden of water chores (Aikowe & Mazancová, 2021; Seri, 2023). They travel long distances, perform several round trips, invest a great deal of time, cross rugged and steep terrain, and carry heavy loads of water (Geereet al., 2010; Grosset al., 2018; Hoet al., 2021). Head load carriage is the most common mode of water transport documented in these communities. Such a mode of transport has negative consequences on the well-being, education, physical health, and so forth of adolescent girls (Hamenooet al., 2018; Hoet al., 2021).

Globally, the most overlooked issue concerning the burden of musculoskeletal pains and injuries (MSPI), including other environmental health conditions, is inadequate access to clean water. This gap underlies a worldwide public health and development concern accounting for approximately 17% of disability and years of life lost in at least 160 countries (Ciezaet al., 2020; Osinugaet al., 2022; Safiriet al., 2021). In addition, the MSPI is at the root of 1.4 million deaths, with the majority occurring in low-and middle-income countries (Hutton & Chase, 2017).

Some existing studies on this topic report several negative impacts, most focusing on musculoskeletal disorders in different body systems. The documented clinical disorders are characterized by intermittent or continuous acute and chronic pain, with limitations in functional and productive capacity (Luimeet al., 2005).

Despite the clinical description of concern, very few studies have been carried out on the issue of MSPI in resource-constrained countries. Studies determining the magnitude of the MPIs and other undocumented lesions, including their topography in the body system, are scarce in the Sub-Saharan regions. Studies that establish significant associations between MPIs and environmental causal factors are also lacking, specifically for more vulnerable groups. This is particularly the case for school-going adolescent girls who may deal with compromising health and schooling from MPIs, up to affecting their well-being.

The peri-urban settings of Kinshasa are greatly expanded while public administration does not build and manage water supply systems (Bédécarratset al., 2019). People draw water from an insufficient private community water system, with water points located often away from the majority of households. Such a type of drinking water supply is distant and time-consuming for women and girls involved in water collection (Boazet al., 2020).

This is especially true in the peri-urban regions, where it is common to observe adolescent girls walking in search of water, carrying heavy loads over long distances. They frequently cross uneven terrain, which potentially increases the likelihood and magnitude of undocumented MSPIs among water collectors.

In the city of Kinshasa, several factors undermine the adolescent girls’ future, leading to a weak secondary school enrolment rate for girls of around 27%. Several sub-factors, including the water collection tasks emerging as barriers to girls’ schooling, negatively impact the adolescent girls’ chance of completing their schooling (EPST, 2011; UNICEF, 2021).

As aforementioned, carrying heavy loads by adolescent girls may result in MSPIs with various short and long-term negative physical and health impacts (Geereet al., 2010, 2018; Hoet al., 2021; Meierhoferet al., 2022).

Heretofore, this issue attracts very little attention, and no study has yet been carried out in the city of Kinshasa. In contrast, such a study would first help to evaluate the prevalence, severity, and body topography of the MSPIs, as well as the factors likely to cause negative impacts of water-carrying on the musculoskeletal system of adolescent girls. Second, the evidence from the study would help to raise political and public awareness of the possible effects of the daily water fetching burden.

This study has chosen to survey adolescent girls who were attending school to explore the possible interplay between water-carrying related environmental factors and their potential to affect the health and schooling of adolescent girls. First, we analyzed the conditions of water access. Second, we investigated the epidemiology of the MSPIs and their associated factors among adolescent girls fetching water in the peri-urban settings of Kinshasa.

Method

Study Design, Area, and Population

A cross-sectional study design was carried out to assess the prevalence of MSPIs and their associated factors in peri-urban health zones (PUHZ) in the city of Kinshasa. The city is known for its limited access to water availability and its mountainous terrain.

The source population was all school-going adolescent girls chosen through a five-degree random sampling based on the selection of 6 out of the 12 PUHZ. We randomly selected 6 PUHZ, including Binza Météo, Biyela, Kimbanseke, Kisenso, Mont Ngafula I, and Mont Ngafula II. Thereafter, 4 health areas (HA) meeting the major inclusion criteria of being partially or disconnected from the water distribution network were randomly selected from each PUHZ. Within each HA, streets meeting the criteria of containing at least 50 plots were retained for this study. On each selected street, a plot survey identified eligible households meeting the criteria of having at least one school-going adolescent girl involved in water collection.

The study recruited participants meeting the inclusion criteria, which consisted of being aged from 12 to 17 years, being involved in household water collection, staying in the study region for at least 12 months, and being authorized by parents to participate in the study.

Sample Size Determination and Data Collection

The sample size was calculated using the Schwartz formula given in (1) (Inegbenebor, 2017): (1)n≥Z2αpqd2where:

N: the study participants’ number,

Z: the value corresponding to the level of confidence required at 95%,

P: the proportion (0.62) of adolescent girls involved in water collection (Grahamet al., 2016),

q = 1 − p,

d: the margin error.

After applying this formula, we reach 362, as given in (2): (2)n≥Z2αpqd2=(1.96)2×0.62×0.38(0.05)2=0.905080960.0025=362

We increased the power of the test in raising study participants’ recruitment up to a total of 858 adolescent girls. Thereafter, 684 were interviewed after we eliminated 174 (20.3%) to participate because the majority were ready to go to school.

Study Variables

Quantitative Variables

The first type of variable was all those that were independent and were individually stated by study participants, namely the age of the girl, the weight carried per trip, the weekly frequency of water collection, daily round trips, and time devoted to water collection.

The second group was concerned with the distances traveled, which were measured by investigators using a cyclometer guided by the adolescent girls on their route to the water source.

The aforementioned variables were categorized after grouping their data into different classes that provided subgroup proportions, which were compared with each other. As continuous quantitative variables, they were measured based on a continuous scale to construct the logistic regression model.

Categorical Variables

The first type was the MSPI experienced during the last 3 months before the survey. They were considered separately as dependent variables. These concerned muscular pains, neck pain, back pain, chest pain, headaches, hypogastralgia, prolonged and painful menstruation. The binary screening was performed using “Yes” or “No” responses.

The second type of dependent variable checked cutaneous and musculoskeletal lesions, including falls, injuries, sprains, and fractures that occurred during water-drawing activities. The binary screening was also performed using “Yes” or “No”. If one of the responses was “Yes,” the respondent was asked to specify the frequency of occurrence in the last three months.

The third type of variable was the terrain. While measuring the distance between the household and the water point, the investigators’ observations had to be cognizant of and specify with “Yes” or “No” whether the terrain crossed was mostly level, hilly, or mountainous.

Data Analysis

Data were coded, and the completeness of the questionnaire was verified by field supervisors and data clerks. Data entry was done using Epi data V3.1, and SPSS v26.0 was used for statistical analysis.

The Kolmogorov–Smirnov and Shapiro–Wilk tests were used to test the normal distribution of the quantitative variables. SPSS software-generated frequencies and measures of central tendencies are summarized as means with standard deviation. Categorical variables were used to generate proportions, and the independence of attributes was tested using the chi-square test (Campbell, 2007; McHugh, 2013). Means were compared with the Student’s t-test, and associations the multivariate logistic regression with the level of significance set at p < 0.05.

For nominal data, Cremer’s V was used to measure the strength of association for the statistical significance level set at 5%, p < 0.05 in Pearson’s chi-square test (Kotrliket al., 2011).

Ethics Approval and Consent to Participate

This study was approved by the Ethical Committee of the Kinshasa School of Public Health under N° ESP/CE/230/2018. Written informed consent was obtained from parents authorizing the participation of their daughters. Thereafter, each participant expressed informed assent to participate, and the study provided a statement of non-coercion for participation. Participants were not photographed, the confidentiality of the information provided and the principle of non-disclosure were guaranteed.

Results

Descriptive Statistics

Table I shows that the majority of participants interviewed were aged between 16 and 17 years old. More than nine adolescent girls out of 10 invested more than 30 minutes in water collection. Six adolescent girls out of 10 crossed less than 1 kilometer from their households to the nearest water supply point. Furthermore, the majority drew water more than 5 days a week and performed more than 4 daily round trips, carrying an average of 24.1 kg a trip. Almost all adolescent girls (9 out of 10), who participated in this study, carried water on their heads.

Participant characteristics N (%) Mean (SD)
Age groups (years old)
12–13 48 (7.0)
14–15 245 (35.8) 15.6 (1.3)
16–17 391 (57.2)
Time spent (minutes)
12–29 12 (1.8) 188.6 (121.6)
30–150 309 (44.9)
151–920 365 (53.3)
Distance crossed (meters)
25–999 430 (62.8) 951.7 (792.6)
1000–1999 211 (30.9)
2000–5562 43 (6.3)
Weekly water collection days
1–2 4.604
3–4 0.831 5.5 (1.5)
5–7 1.300
Daily round-trips performed
0–1 31 (4.5)
2–3 269 (39.3) 4.0 (1.9)
4–12 384 (56.2)
Carried weight on every single trip (kg)
≤15 19 (2.8)
20–25 574 (83.9) 24.1 (4.0)
30–50 91 (13.3)
Water-carrying modes
Head 630 (92.3)
Hands 34 (5.0)
Others 20 (2.7)
Table I. Characteristics of the Study Sample, Kinshasa’s Peri-Urban Settings

The data in Table II indicate that during the past 3 months, 96.3% of the interviewed girls experienced pains they attributed to water-collection work. The main types of pains stated were multiple body regions, including the back and chest, the neck, the head, lower abdomen, and exacerbation of menstrual pain.

Variables assessed Yes %
Dominant terrain crossed (n = 684)
Mountains/hilly 543 79.4
Flat path 141 20.6
Pains occurrence (n = 684)
Pain feeling in the past 3 months 659 96.3
Type and topography of pain (n = 659)
Back and chest pains 499 73.0
Permanent muscular pain 407 59.5
Neck pain 380 55.6
Permanent headache 346 50.6
Lower abdominal pain 158 23.1
Prolonged painful menstruation 46 6.7
Cutaneous and musculoskeletal lesions (n = 684)
Falls 406 59.4
Injuries 264 38.6
Sprains/trains 119 17.4
Fractures 5 0.7
Table II. Relief Overcame and MSPIs’ Characteristics Among Adolescent Girls Carrying Water

The main cutaneous and musculoskeletal disorders were falls, injuries, sprains, and fractures. Observations performed show that the majority of girls (79.4%) face mountainous or hilly terrains while fetching water in the peri-urban regions of Kinshasa.

As can be seen in Table III, an increase of one daily round trip collecting water (aOR = 2.039, 95% CI [1.531-2.714], p = 0.001); of a weight of one liter of water (aOR = 1.435, 95% CI [1.067-1.931], p = 0.017); of the walking time to the water point (aOR = 1.075, 95% CI [1.014-1.140], p = 0.015) increased the onset risk of permanent muscle pain by at least one time. By contrast, reducing the total time spent collecting water (aOR = 0.969, 95% CI [0.959-0.979], p = 0.002) mitigated the occurrence of muscle pain among adolescent girls who collected water.

Outcome variable Factors assessed aOR (95% IC) p-value
Permanent muscular pains Age 0.876 (0.752–1.021) 0.090
Water-fetching days last week 0.996 (0.897–1.106) 0.940
Number of daily round trips 2.039 (1.531–2.714) <0.001*
Daily carried weight 1.050 (1.010–1.092) 0.015*
Distance 1.000 (1.000–1.000) 0.070
Walking time to the water point 1.019 (1.007–1.032) 0.002*
Queuing time 1.073 (0.977–1.178) 0.139
Overall water collection time 0.969 (0.959–0.979) <0.001*
Back and chest pains Age 1.165 (0.994–1.366) 0.059
Water fetching days last week 1.106 (1.013–1.209) 0.025*
Number of daily round trips 1.435 (1.067–1.931) 0.017*
Daily carried weight 1.075 (1.014–1.140) 0.015*
Distance 1.001 (1.001–110) 0.019*
Walking time to the water point 1.019 (1.007–1.032) 0.002*
Queuing time 0.998 (0.909–1.096) 0.973
Total water collection time 1.002 (0.913–1.099) 0.971
Neck pains Age 1.091 (0.948–1.255) 0.225
Water-fetching days last week 1.065 (0.980–1.158) 0.132
Number of daily round trips 0.082 (0.869–1.347) 0.481
Daily carried weight 1.050 (1.010–1.092) 0.013*
Distance 1.000 (1.000–1.001) 0.062
Walking time to the water point 0.998 (0.988–1.008) 0.655
Queuing time 1.000 (0.998–1.001) 0.735
Total water collection time 1.005 (0.961–1.131) 0.316
Table III. Factors Associated with MSPIs, Using Multivariate Logistic Regression

As for chest and back pain, the data illustrate that an increase of one day of water collection per week (aOR = 1.106, 95% CI [1.013-1.209], p = 0.025); of one daily round trip for water collection (aOR = 1.435, 95% CI [1.067-1.931], p = 0.017); of one liter of water to be carried (aOR = 1.075, 95% CI [1.014-1.140], p = 0.015); and each 30-minute increase in walking time to the water point (aOR = 1.019, 95% CI [1.007-1.132], p = 0.002), both increased by at least one time the risk of chest and back pain among adolescent girls collecting water.

Finally, the increase of one liter of water above 24.1 liters of water to be carried increased the risk of neck pain occurrence by at least one time (aOR = 1.050, 95% CI [1.010-1.092], p = 0.013) among girls collecting water.

Table IV shows that all reported cutaneous and musculoskeletal lesions except fractures and back/chest occurred in mountainous terrain with steep slopes daily crossed by study participants during water collection in the study region.

Cutaneous and musculoskeletal lesions Mountainous and hilly terrain
χ2 OR (95% CI) p-value Cramer’ V
Muscular pains 6.363 1.104 (1.025–1.190) 0.012* 0.096
Back and chest pains 1.071 1.239 (0.825–1.860) 0.301
Neck pains 3.863 1.450 (1.001–2.102) 0.049* 0.075
Fall down 10.319 1.835 (1.263–2.666) 0.001* 0.123
Injuries 4.094 1.502 (1.011–2.230) 0.043* 0.077
Sprains 4.524 1.829 (1.042–3.211) 0.033* 0.081
Fractures 0.001 1.039 (0.115–9.369) 0.973
Table IV. Relationship Between the MSPIs and the Terrain, Using Pearson’s Chi-Square Test

Data displayed in Table V show that when we evaluate and compare the incidence of MSPIs among adolescent girls carrying water, we observe that adolescent girls who reported head-load transportation were more likely to suffer from MSPIs compared with those who used other modes of water transportation, including hands, back, and manual traction.

MSPIs Modes of water-carrying P-value
Head (%) Others (%) χ2 (95% CI)
Pains (n = 659) 92.0 4.5 1012.631 (84.5259–89.7680) <0.0001
Falls (n = 420) 58.2 3.1 299.591 (49.8759–59.8956) <0.0001
Injuries (n = 282) 38.9 2.3 115.272 (30.5571–42.5279) <0.0001
Sprains (n = 27) 17.7 0.8 4.508 (0.465–3429970) 0.0337
Fractures (n = 5) 0.7 0.0 0.032 (−427538–44.2337) 0.8582
Table V. MSPIs Difference Between Water Carrying Modes, Using Fisher-Irwin Chi-Square Test

Discussion

Our study aimed to analyze the conditions of water access in the study region and has demonstrated that following studies from other African Sub-Saharan regions, more than nine households surveyed experience water shortages in the study region (Matchaweet al., 2022). The factors likely to explain this water scarcity in Kinshasa include the fact that the study was carried out in overcrowded new outskirts lacking urbanization and basic social services. Poverty and the lack of attention by current policies lead to the failure to apply the right of access to water for all in these regions (Côrteset al., 2016; Matchaweet al., 2022).

This study is one of the first to describe the health impacts arising from water-carrying activities in Kinshasa’s peri-urban settings, though similar studies have been done in other African contexts (Robsonet al., 2013). Our results highlight the head-load carrying mode as the main and common practice of water transportation for 9 out of 10 adolescent girls surveyed carrying heavy containers and performing a daily average of 4 round trips in the study area. Such modes of water transportation and their daily implications were documented in South Africa and Malawi, where almost the entire group of adolescent girls studied reported head-load as their mode of water transportation (Geereet al., 2010).

In our study region, the average weight of water loads (24.1 kg) carried was significantly above the international recommendation, stating that adolescent girls lift and carry a maximum of 12 kg to prevent musculoskeletal disorders (Mairiauxet al., 2008; Schmitter, 2003). Anyway, the average load reported in our study was lower than 28.9 kg, as documented by a South African study and another carried out in Benin (Akploganet al., 2016; Geereet al., 2010).

These practices consisting of head-load transportation mode and overload carried appear to be the root cause and explanation of the high prevalence of adolescent girls complaining of musculoskeletal pains that they attributed to water carrying. Such high prevalence was similar to that reported among adolescent girls studied collecting water in Malawi (Robsonet al., 2013) as well as among other head-load workers in India (Kasale & Chicholikar, 2021), who expressed feeling back and chest pains they attributed to daily water-carrying during the past three months.

Our finding also corroborates previous studies in Nepal, reporting that a proportion of 61% of adolescent girls fetching water declared back pains (Meierhoferet al., 2022). However, lower proportions of 12% and 38% were reported from South Africa and other African contexts (Geereet al., 2010; Louwet al., 2007). This difference could be explained by the length of time chosen for the study. We assessed feelings of pain over a period of 3 months, whereas the study in South Africa evaluated back pains based on water-carrying for the past 7 days. The differences in results compared with other African contexts can also be explained by the age of the studies. For example, the Louwet al. (2007) study was carried out early in 2006.

This study also corroborates another study that found a relationship between back pain and load-carrying practice, as well as the frequency, duration, and carried weight (Kadotaet al., 2020). In addition, more than half of our sample reported experiencing neck pain in the last 3 months. This result is similar to 69% of adolescent girls who reported spinal (neck) pain in a South African study (Geereet al., 2010) and 35% from a study in Malawi (Robsonet al., 2013). Our finding is also supported by a multi-centric study evidencing the fact that people who carry water had an increased relative risk of experiencing neck pain due to the spinal axial compression in the cervical region (Geereet al., 2018).

The high proportion of girls who complained of neck pain associated with the weight they carried and their walking time from the water source to home demonstrates the magnitude of this concern, and such association was reported by multiple other studies performed in other contexts (Deleleet al., 2018; Kadotaet al., 2020; Robsonet al., 2013).

From a prevention perspective, the neck and upper back pains stated by our study participants carrying water in the study area should attract the attention of political decision-makers given that carrying heavy loads had been implicated in the risk of cervical injuries, especially hyper-flexion of the cervical spine as well as inducing degeneration at all spinal levels, as a systematic review and meta-analysis demonstrated (Geereet al., 2010; Hoqueet al., 2012; Macedo & Battié, 2019).

More than half of the participants surveyed in our study area stated permanent headaches, lower abdominal pain, and prolonged menstruation, which they attributed to water-carrying. Such musculoskeletal pains had been reported from a systematic review of diverse health impacts of domestic water carrying, where high proportions of water collectors complaining of headaches attributed to routinely transporting excessively heavy loads (Hoet al., 2021; Meierhoferet al., 2022; Robsonet al., 2013).

In parallel, this study’s evidence on the prevalence of headaches might attract the attention of policymakers due to several studies that have associated headaches with lower quality of life as well. As a health concern, headaches may also affect female students’ functioning, resulting in poor school attendance or absenteeism, which negatively impacts their global school performance and outcomes, culminating in lower grades in school or failing the school year (Al-Hashelet al., 2020; Jurišić, 2018; Rocha-Filho & Santos, 2014; Szperka, 2021).

Our study also reported a proportion of 59,4% of school-going adolescent girls who fell while crossing steep terrain during water collection activities. Relatively, uneven terrain is an additional environmental factor documented to increase the risk of falls leading to injuries related to the water fetching route traffic (Mocket al., 2017).

In accordance with our result, Venkataramananet al. (2020) reported a high proportion of 76.4% of falls among water collectors, of which 69.4% occurred in dangerous terrains in 21 low-income and middle-income countries (Venkataramananet al., 2020). The difference with our study could be explained by the variety of study sites included or the multi-centric approach used, as well as the great sample size of 6,291 water collectors compared to 684 in our study, representing about one-tenth in the study of Venkataramanan.

In addition, our study reported injuries, sprains, and fractures in about one out of three adolescent girls fetching water in the peri-urban settings of Kinshasa.

This musculoskeletal disorder has also been found commonly among water collectors, of which up to 61.1% of injuries have been documented by Venkataramananet al. (2020) in their multi-centric country study. Comparatively, up to 20% of injuries had been reported among women collecting surface water in Bolivia, where basic water services were associated with 48% lower odds of injury from water-collecting (Rosingeret al., 2021).

Our statistics imply that specific attention might be paid to prevent such disorders, which may have negative impacts on the schooling process of adolescent girls as injuries and strains/sprains have been associated with time lost from schooling and other lifelong disabilities in adolescent girls’ lives in different contexts (Jaffeet al., 2021; Murphyet al., 2003; Schofieldet al., 2022).

Limitations

Data from a cross-sectional study such as this does not allow causal conclusions to be drawn. For this reason, we suggest an additional randomized and controlled design to better demonstrate the strength of the association between the aforementioned environmental water-related predictors with the burden of the MSPI reported in this study. Such an approach will allow us to overcome the confusing bias that could be due to MSPI from other activities, including domestic work and schoolwork.

Also, we recognize the limited validity of self-reported pains, but we had to assume the validity of self-reported pain while recognizing that most are subjective and emotional experiences.

Finally, this research lacked a complementary qualitative approach that could provide a better understanding of the study participants’ experiences, feelings, and expectations of their schooling concerning the MSPI they attribute to the burden of water-harvesting activities.

Conclusion

Our study population in peri-urban areas of Kinshasa reported a high frequency of musculoskeletal pains and injuries associated with water-carrying activities as environmental factors. These factors include methods of water-carrying, carried weight, distance, walking time to the water point, weekly water fetching days, daily round trips, total time of water collection as well as the characteristics of the terrain especially mountainous terrain with steep slopes. Although these health risks are based on self-reported pain and injury, we feel that provide evidence for the development of policies for providing piped water in peri-urban households.

Further studies combining qualitative and quantitative approaches are also needed to better understand how these adverse risks may affect adolescent girls’ school performance, well-being, and mental health.

Abbreviations

aOR: adjusted odds ratio; CI: Confidence Interval; HA: Health area; Kg: Kilogram; MSPIs: Musculoskeletal pains and injuries; OR: Odds ratio; SD: Standard deviation; SDGs: Sustainable development goals; SPSS: Statistical package for social science; UQAC: Université du Québec à Chicoutimi; WHO: World Health Organization.

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