Health-related quality of life and health utility among patients with diabetes: in Zabol, Southeast Iran
Health-related quality of life and health utility among patients with diabetes
DOI:
https://doi.org/10.22317/jcms.v6i2.727Keywords:
Diabetes, Health-related quality of life, Health utility, EQ-5D-3L, Iran.Abstract
Objective: The current study aimed to assess the factors associated with HRQoL and HU among Patients with diabetes in Zabol, Southeast Iran.
Methods: Among patients referred to Zabol city diabetes clinic, a total of 213 consecutive patients 18 years and older consent to participate in the study in 2015. The Persian version of EuroQol-5D-3L (EQ-5D-3L) using the UK preference weights was applied to derive HU. Logistic regression and ordinary least squares were used for data analysis. The STATA version 13 (StataCorp LP, College Station, TX, USA) was used for statistical analysis.
Results: The highest and lowest proportions of "some or extreme problems" were seen in pain/discomfort (86.6%) and self-care (27.8%) dimensions of the EQ-5D-3L, respectively. About 33% of women and 14% of men rated their health worse than death (p=0.002). The mean EQ-5D-3L index score and visual analogue scale were 0.37 (95% CI: 0.31-0.42) and 51.6 (95% CI: 48.7-54.5), respectively. Older age at diagnosis, longer duration of diabetes, lower education, and history of macrovascular complications were associated with lower HRQoL and HU.
Conclusion: This study highlights the importance of education and diabetes-related complications in HRQoL/HU of diabetes people. The findings suggest that urgent interventions are required to improve HRQoL/HU of diabetes patients in Zabol. Moreover, our results provide inputs for future economic evaluation studies among diabetes patients with similar socioeconomic status in Iran.
References
1. Whiting DR, Guariguata L, Weil C, Shaw J. IDF diabetes atlas: global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract. 2011;94(3):311-321. doi:10.1016/j.diabres.2011.10.029
2. Esteghamati A, Gouya MM, Abbasi M, et al. Prevalence of diabetes and impaired fasting glucose in the adult population of Iran: National Survey of Risk Factors for Non-Communicable Diseases of Iran. Diabetes Care. 2008;31(1):96-98. doi:10.2337/dc07-0959
3. Esteghamati A, Meysamie A, Khalilzadeh O, et al. Third national Surveillance of Risk Factors of Non-Communicable Diseases (SuRFNCD-2007) in Iran: methods and results on prevalence of diabetes, hypertension, obesity, central obesity, and dyslipidemia. BMC Public Health. 2009; 9:167. doi:10.1186/1471-2458-9-167
4. World Health Organization- NCD Country Profiles (2016). Available from: http://www.who.int/diabetes/country-profiles/irn_en.pdf
5. McVeigh GE, Gibson W, Hamilton PK. Cardiovascular risk in the young type 1 diabetes population with a low 10-year, but high lifetime risk of cardiovascular disease. Diabetes Obes Metab. 2013;15(3):198-203. doi:10.1111/dom.12013
6. Goeree R, Lim ME, Hopkins R, et al. Excess Risk of Mortality and Complications Associated with Newly Diagnosed Cases of Diabetes in Ontario, Canada. Canadian Journal of Diabetes. 2009;33(2):93-104. doi:http://dx.doi.org/10.1016/S1499-2671(09)32006-7
7. Emerging Risk Factors Collaboration, Sarwar N, Gao P, Seshasai SR, et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet. 2010;375(9733):2215-2222. doi:10.1016/S0140-6736(10)60484-9
8. Hadaegh F, Khalili D, Fahimfar N, Tohidi M, Eskandari F, Azizi F. Glucose intolerance and risk of cardiovascular disease in Iranian men and women: results of the 7.6-year follow-up of the Tehran Lipid and Glucose Study (TLGS). J Endocrinol Invest. 2009;32(9):724-730. doi:10.3275/6399
9. Franco OH, Steyerberg EW, Hu FB, Mackenbach J, Nusselder W. Associations of diabetes mellitus with total life expectancy and life expectancy with and without cardiovascular disease. Arch Intern Med. 2007;167(11):1145-1151. doi:10.1001/archinte.167.11.1145
10. Morgan CL, Currie CJ, Peters JR. Relationship between diabetes and mortality: a population study using record linkage. Diabetes Care. 2000;23(8):1103-1107.
11. Koopmanschap M, Board C-A. Coping with Type II diabetes: the patient's perspective. Diabetologia. 2002;45(7):S18-22. doi:10.1007/s00125-002-0861-2
12. Fu AZ, Qiu Y, Radican L, Luo N. Marginal differences in health-related quality of life of diabetic patients with and without macrovascular comorbid conditions in the United States. Qual Life Res. 2011;20(6):825-832. doi:10.1007/s11136-010-9819-x
13. Zhang P, Brown MB, Bilik D, Ackermann RT, Li R, Herman WH. Health utility scores for people with type 2 diabetes in U.S. managed care health plans: results from Translating Research Into Action for Diabetes (TRIAD). Diabetes Care. 2012;35(11):2250-2256. doi:10.2337/dc11-2478
14. O'Reilly DJ, Xie F, Pullenayegum E, et al. Estimation of the impact of diabetes-related complications on health utilities for patients with type 2 diabetes in Ontario, Canada. Qual Life Res. 2011;20(6):939-943. doi:10.1007/s11136-010-9828-9
15. Kiadaliri AA, Gerdtham UG, Eliasson B, Gudbjornsdottir S, Svensson AM, Carlsson KS. Health utilities of type 2 diabetes-related complications: a cross-sectional study in Sweden. Int J Environ Res Public Health. 2014;11(5):4939-4952. doi:10.3390/ijerph110504939
16. Ghanbari A, Yekta ZP, Roushan ZA, Lakeh NM. Assessment of factors affecting quality of life in diabetic patients in Iran. Public Health Nurs. 2005; 22(4):311-322. doi:10.1111/j.0737-1209.2005.220406.x
17. Sanjari M, Safari S, Shokoohi M, et al. A cross-sectional study in Kerman, Iran, on the effect of diabetic foot ulcer on health-related quality of life. Int J Low Extrem Wounds. 2011;10(4):200-206. doi:10.1177/1534734611428728
18. Kiadaliri AA, Najafi B, Mirmalek-Sani M. Quality of life in people with diabetes: a systematic review of studies in Iran. J Diabetes Metab Disord. 2013; 12(1):54. doi:10.1186/2251-6581-12-54.
19. Ferrans CE. Definitions and conceptual models of quality of life. In: Lipscomb J, Gotay CC, Snyder C, editors. Outcomes assessment in cancer. Cambridge, England: Cambridge University; 2005. p. 14–30.
20. Torrance GW. Utility approach to measuring health-related quality of life. J Chronic Dis. 1987;40(6):593-603.
21. J. E. Sansoni "Instruments for economic evaluation: session 5", Managing and Measuring Health Outcomes, Menzies School of Health Research, Darwin, 8-11 March 2011.
22. Brooks R. EuroQol: the current state of play. Health Policy. 1996; 37 (1):53-72.
23. Brazier J, Roberts J, Deverill M. The estimation of a preference-based measure of health from the SF-36. J Health Econ. 2002; 21(2):271-292.
24. Hatswell A, Pennington B, Pericleous L, Rowen D, Lebmeier M, Lee D. Patient-reported utilities in advanced or metastatic melanoma, including analysis of utilities by time to death. J Health and Quality of Life Outcomes 2014; 12:14
25. Cruz L.N, Camey S.A, Hoffmann J.F, Rowen D, Brazier J.E. Fleck M. P, Polanczyk C.A. Estimating the SF6D Value Set for a Population-Based Sample of Brazilians. J Value in Health. 2 0 1 1;1 4: 1 0 8 –1 4.
26. Sakamaki H, et al. Measurement of HRQL Using EQ-5D in Patients with Type 2 Diabetes Mellitus in Japan. J International Society for Pharmaco economics and Outcomes Research (ISPOR). 2006: 9(1): 47-53.
27. EuroQol Group. EuroQol—a new facility for the measurement of health-related quality of life. Health
Policy 1990;16:199–208.
28. Javanbakht M, Abolhasani F, Mashayekhi A, Baradaran HR, Jahangiri noudeh Y. Health related quality of life in patients with type 2 diabetes mellitus in Iran: a national survey. PLoS One. 2012;7(8):e44526. doi:10.1371/journal.pone.0044526
29. Glasziou P, Alexander J, Beller E, Clarke P, Group AC. Which health-related quality of life score? A comparison of alternative utility measures in patients with Type 2 diabetes in the ADVANCE trial. Health Qual Life Outcomes. 2007;5:21. doi:10.1186/1477-7525-5-21
30. Janssen MF, Lubetkin EI, Sekhobo JP, Pickard AS. The use of the EQ-5D preference-based health status measure in adults with Type 2 diabetes mellitus. Diabet Med. 2011;28(4):395-413. doi:10.1111/j.1464-5491.2010.03136.x
31. Brooks R. EuroQol: the current state of play. Health Policy.1996; 37 (1):53–72. doi: 10.1016/0168- 8510(96)00822-6. [PubMed: 10158943]
32. Brazier J, Deverill M, Green C. A review of the use of health status measures in economic evaluation. J Health Serv Res Policy. 1999; 4 (3):174–84. [PubMed: 10538884].
33. Longworth L, Bryan S. An empirical comparison of EQ-5D and SF-6D in liver transplant patients. Health Econ. 2003; 12 (12):1061–7. doi:10.1002/hec.787. [PubMed: 14673814].
34. Dolan P, Gudex C, Kind P, Williams A. The time trade-off method: results from a general population study. Health Econ.1996;5(2):141-154.doi:10.1002/(SICI)1099-1050(199603)5:2<141::AID-HEC189>3.0.CO;2-N
35. Li L, Fu A. Some methodological issues with the analysis of preference-based EQ-5D index score. Health Services and Outcomes Research Methodology. 2009;9 (3):162-176. doi:10.1007/s10742-009-0053-3
36. Huang IC, Frangakis C, Atkinson MJ, et al. Addressing ceiling effects in health status measures: a comparison of techniques applied to measures for people with HIV disease. Health Serv Res. 2008;43 (1 Pt 1):327-339. doi:10.1111/j.1475-6773.2007.00745.x
37. Pullenayegum EM, Tarride JE, Xie F, Goeree R, Gerstein HC, O'Reilly D. Analysis of health utility data when some subjects attain the upper bound of 1: are Tobit and CLAD models appropriate? Value Health. 2010;13(4):487-494. doi:10.1111/j.1524-4733.2010.00695.x
38. Lee WJ, Song KH, Noh JH, Choi YJ, Jo MW. Health-related quality of life using the EuroQol 5D questionnaire in Korean patients with type 2 diabetes. J Korean Med Sci. 2012;27(3):255-260. doi:10.3346/jkms.2012.27.3.255
39. Solli O, Stavem K, Kristiansen IS. Health-related quality of life in diabetes: The associations of complications with EQ-5D scores. Health Qual Life Outcomes. 2010;8:18. doi:10.1186/1477-7525-8-18
40. Holmes J, McGill S, Kind P, Bottomley J, Gillam S, Murphy M. Health-related quality of life in type 2 diabetes (TARDIS-2). Value Health. 2000;3 Suppl 1:47-51. doi:10.1046/j.1524-4733.2000.36028.x
41. Bagust A, Beale S. Modelling EuroQol health-related utility values for diabetic complications from CODE-2 data. Health Econ. 2005;14(3):217-230. doi:10.1002/hec.910
42. Sparring V, Nystrom L, Wahlstrom R, Jonsson PM, Ostman J, Burstrom K. Diabetes duration and health-related quality of life in individuals with onset of diabetes in the age group 15-34 years - a Swedish population-based study using EQ-5D. BMC Public Health. 2013;13:377. doi:10.1186/1471-2458-13-377
43. Wexler DJ, Grant RW, Wittenberg E, et al. Correlates of health-related quality of life in type 2 diabetes. Diabetologia. 2006;49(7):1489-1497. doi:10.1007/s00125-006-0249-9
44. Sakamaki H, Ikeda S, Ikegami N, et al. Measurement of HRQL using EQ-5D in patients with type 2 diabetes mellitus in Japan. Value Health. 2006;9(1):47-53. doi:10.1111/j.1524-4733.2006.00080.x
45. Beaudet A, Clegg J, Thuresson PO, Lloyd A, McEwan P. Review of utility values for economic modeling in type 2 diabetes. Value Health. 2014;17(4):462-470. doi:10.1016/j.jval.2014.03.003
46. Greiner W, Claes C, Busschbach JJ, von der Schulenburg JM. Validating the EQ-5D with time trade off for the German population. Eur J Health Econ. 2005;6(2):124-130.
47. Badia X, Roset M, Herdman M, Kind P. A comparison of United Kingdom and Spanish general population time trade-off values for EQ-5D health states. Med Decis Making. 2001;21(1):7-16.
48. Johnson JA, Ohinmaa A, Murti B, Sintonen H, Coons SJ. Comparison of Finnish and U.S.-based visual analog scale valuations of the EQ-5D measure. Med Decision Making. 2000;20(3):281-289.
2. Esteghamati A, Gouya MM, Abbasi M, et al. Prevalence of diabetes and impaired fasting glucose in the adult population of Iran: National Survey of Risk Factors for Non-Communicable Diseases of Iran. Diabetes Care. 2008;31(1):96-98. doi:10.2337/dc07-0959
3. Esteghamati A, Meysamie A, Khalilzadeh O, et al. Third national Surveillance of Risk Factors of Non-Communicable Diseases (SuRFNCD-2007) in Iran: methods and results on prevalence of diabetes, hypertension, obesity, central obesity, and dyslipidemia. BMC Public Health. 2009; 9:167. doi:10.1186/1471-2458-9-167
4. World Health Organization- NCD Country Profiles (2016). Available from: http://www.who.int/diabetes/country-profiles/irn_en.pdf
5. McVeigh GE, Gibson W, Hamilton PK. Cardiovascular risk in the young type 1 diabetes population with a low 10-year, but high lifetime risk of cardiovascular disease. Diabetes Obes Metab. 2013;15(3):198-203. doi:10.1111/dom.12013
6. Goeree R, Lim ME, Hopkins R, et al. Excess Risk of Mortality and Complications Associated with Newly Diagnosed Cases of Diabetes in Ontario, Canada. Canadian Journal of Diabetes. 2009;33(2):93-104. doi:http://dx.doi.org/10.1016/S1499-2671(09)32006-7
7. Emerging Risk Factors Collaboration, Sarwar N, Gao P, Seshasai SR, et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet. 2010;375(9733):2215-2222. doi:10.1016/S0140-6736(10)60484-9
8. Hadaegh F, Khalili D, Fahimfar N, Tohidi M, Eskandari F, Azizi F. Glucose intolerance and risk of cardiovascular disease in Iranian men and women: results of the 7.6-year follow-up of the Tehran Lipid and Glucose Study (TLGS). J Endocrinol Invest. 2009;32(9):724-730. doi:10.3275/6399
9. Franco OH, Steyerberg EW, Hu FB, Mackenbach J, Nusselder W. Associations of diabetes mellitus with total life expectancy and life expectancy with and without cardiovascular disease. Arch Intern Med. 2007;167(11):1145-1151. doi:10.1001/archinte.167.11.1145
10. Morgan CL, Currie CJ, Peters JR. Relationship between diabetes and mortality: a population study using record linkage. Diabetes Care. 2000;23(8):1103-1107.
11. Koopmanschap M, Board C-A. Coping with Type II diabetes: the patient's perspective. Diabetologia. 2002;45(7):S18-22. doi:10.1007/s00125-002-0861-2
12. Fu AZ, Qiu Y, Radican L, Luo N. Marginal differences in health-related quality of life of diabetic patients with and without macrovascular comorbid conditions in the United States. Qual Life Res. 2011;20(6):825-832. doi:10.1007/s11136-010-9819-x
13. Zhang P, Brown MB, Bilik D, Ackermann RT, Li R, Herman WH. Health utility scores for people with type 2 diabetes in U.S. managed care health plans: results from Translating Research Into Action for Diabetes (TRIAD). Diabetes Care. 2012;35(11):2250-2256. doi:10.2337/dc11-2478
14. O'Reilly DJ, Xie F, Pullenayegum E, et al. Estimation of the impact of diabetes-related complications on health utilities for patients with type 2 diabetes in Ontario, Canada. Qual Life Res. 2011;20(6):939-943. doi:10.1007/s11136-010-9828-9
15. Kiadaliri AA, Gerdtham UG, Eliasson B, Gudbjornsdottir S, Svensson AM, Carlsson KS. Health utilities of type 2 diabetes-related complications: a cross-sectional study in Sweden. Int J Environ Res Public Health. 2014;11(5):4939-4952. doi:10.3390/ijerph110504939
16. Ghanbari A, Yekta ZP, Roushan ZA, Lakeh NM. Assessment of factors affecting quality of life in diabetic patients in Iran. Public Health Nurs. 2005; 22(4):311-322. doi:10.1111/j.0737-1209.2005.220406.x
17. Sanjari M, Safari S, Shokoohi M, et al. A cross-sectional study in Kerman, Iran, on the effect of diabetic foot ulcer on health-related quality of life. Int J Low Extrem Wounds. 2011;10(4):200-206. doi:10.1177/1534734611428728
18. Kiadaliri AA, Najafi B, Mirmalek-Sani M. Quality of life in people with diabetes: a systematic review of studies in Iran. J Diabetes Metab Disord. 2013; 12(1):54. doi:10.1186/2251-6581-12-54.
19. Ferrans CE. Definitions and conceptual models of quality of life. In: Lipscomb J, Gotay CC, Snyder C, editors. Outcomes assessment in cancer. Cambridge, England: Cambridge University; 2005. p. 14–30.
20. Torrance GW. Utility approach to measuring health-related quality of life. J Chronic Dis. 1987;40(6):593-603.
21. J. E. Sansoni "Instruments for economic evaluation: session 5", Managing and Measuring Health Outcomes, Menzies School of Health Research, Darwin, 8-11 March 2011.
22. Brooks R. EuroQol: the current state of play. Health Policy. 1996; 37 (1):53-72.
23. Brazier J, Roberts J, Deverill M. The estimation of a preference-based measure of health from the SF-36. J Health Econ. 2002; 21(2):271-292.
24. Hatswell A, Pennington B, Pericleous L, Rowen D, Lebmeier M, Lee D. Patient-reported utilities in advanced or metastatic melanoma, including analysis of utilities by time to death. J Health and Quality of Life Outcomes 2014; 12:14
25. Cruz L.N, Camey S.A, Hoffmann J.F, Rowen D, Brazier J.E. Fleck M. P, Polanczyk C.A. Estimating the SF6D Value Set for a Population-Based Sample of Brazilians. J Value in Health. 2 0 1 1;1 4: 1 0 8 –1 4.
26. Sakamaki H, et al. Measurement of HRQL Using EQ-5D in Patients with Type 2 Diabetes Mellitus in Japan. J International Society for Pharmaco economics and Outcomes Research (ISPOR). 2006: 9(1): 47-53.
27. EuroQol Group. EuroQol—a new facility for the measurement of health-related quality of life. Health
Policy 1990;16:199–208.
28. Javanbakht M, Abolhasani F, Mashayekhi A, Baradaran HR, Jahangiri noudeh Y. Health related quality of life in patients with type 2 diabetes mellitus in Iran: a national survey. PLoS One. 2012;7(8):e44526. doi:10.1371/journal.pone.0044526
29. Glasziou P, Alexander J, Beller E, Clarke P, Group AC. Which health-related quality of life score? A comparison of alternative utility measures in patients with Type 2 diabetes in the ADVANCE trial. Health Qual Life Outcomes. 2007;5:21. doi:10.1186/1477-7525-5-21
30. Janssen MF, Lubetkin EI, Sekhobo JP, Pickard AS. The use of the EQ-5D preference-based health status measure in adults with Type 2 diabetes mellitus. Diabet Med. 2011;28(4):395-413. doi:10.1111/j.1464-5491.2010.03136.x
31. Brooks R. EuroQol: the current state of play. Health Policy.1996; 37 (1):53–72. doi: 10.1016/0168- 8510(96)00822-6. [PubMed: 10158943]
32. Brazier J, Deverill M, Green C. A review of the use of health status measures in economic evaluation. J Health Serv Res Policy. 1999; 4 (3):174–84. [PubMed: 10538884].
33. Longworth L, Bryan S. An empirical comparison of EQ-5D and SF-6D in liver transplant patients. Health Econ. 2003; 12 (12):1061–7. doi:10.1002/hec.787. [PubMed: 14673814].
34. Dolan P, Gudex C, Kind P, Williams A. The time trade-off method: results from a general population study. Health Econ.1996;5(2):141-154.doi:10.1002/(SICI)1099-1050(199603)5:2<141::AID-HEC189>3.0.CO;2-N
35. Li L, Fu A. Some methodological issues with the analysis of preference-based EQ-5D index score. Health Services and Outcomes Research Methodology. 2009;9 (3):162-176. doi:10.1007/s10742-009-0053-3
36. Huang IC, Frangakis C, Atkinson MJ, et al. Addressing ceiling effects in health status measures: a comparison of techniques applied to measures for people with HIV disease. Health Serv Res. 2008;43 (1 Pt 1):327-339. doi:10.1111/j.1475-6773.2007.00745.x
37. Pullenayegum EM, Tarride JE, Xie F, Goeree R, Gerstein HC, O'Reilly D. Analysis of health utility data when some subjects attain the upper bound of 1: are Tobit and CLAD models appropriate? Value Health. 2010;13(4):487-494. doi:10.1111/j.1524-4733.2010.00695.x
38. Lee WJ, Song KH, Noh JH, Choi YJ, Jo MW. Health-related quality of life using the EuroQol 5D questionnaire in Korean patients with type 2 diabetes. J Korean Med Sci. 2012;27(3):255-260. doi:10.3346/jkms.2012.27.3.255
39. Solli O, Stavem K, Kristiansen IS. Health-related quality of life in diabetes: The associations of complications with EQ-5D scores. Health Qual Life Outcomes. 2010;8:18. doi:10.1186/1477-7525-8-18
40. Holmes J, McGill S, Kind P, Bottomley J, Gillam S, Murphy M. Health-related quality of life in type 2 diabetes (TARDIS-2). Value Health. 2000;3 Suppl 1:47-51. doi:10.1046/j.1524-4733.2000.36028.x
41. Bagust A, Beale S. Modelling EuroQol health-related utility values for diabetic complications from CODE-2 data. Health Econ. 2005;14(3):217-230. doi:10.1002/hec.910
42. Sparring V, Nystrom L, Wahlstrom R, Jonsson PM, Ostman J, Burstrom K. Diabetes duration and health-related quality of life in individuals with onset of diabetes in the age group 15-34 years - a Swedish population-based study using EQ-5D. BMC Public Health. 2013;13:377. doi:10.1186/1471-2458-13-377
43. Wexler DJ, Grant RW, Wittenberg E, et al. Correlates of health-related quality of life in type 2 diabetes. Diabetologia. 2006;49(7):1489-1497. doi:10.1007/s00125-006-0249-9
44. Sakamaki H, Ikeda S, Ikegami N, et al. Measurement of HRQL using EQ-5D in patients with type 2 diabetes mellitus in Japan. Value Health. 2006;9(1):47-53. doi:10.1111/j.1524-4733.2006.00080.x
45. Beaudet A, Clegg J, Thuresson PO, Lloyd A, McEwan P. Review of utility values for economic modeling in type 2 diabetes. Value Health. 2014;17(4):462-470. doi:10.1016/j.jval.2014.03.003
46. Greiner W, Claes C, Busschbach JJ, von der Schulenburg JM. Validating the EQ-5D with time trade off for the German population. Eur J Health Econ. 2005;6(2):124-130.
47. Badia X, Roset M, Herdman M, Kind P. A comparison of United Kingdom and Spanish general population time trade-off values for EQ-5D health states. Med Decis Making. 2001;21(1):7-16.
48. Johnson JA, Ohinmaa A, Murti B, Sintonen H, Coons SJ. Comparison of Finnish and U.S.-based visual analog scale valuations of the EQ-5D measure. Med Decision Making. 2000;20(3):281-289.
Downloads
Published
2020-04-26
How to Cite
Hedayati, S. P., Haghparast-Bidgoli, H., A. Kiadaliri, A., & Mohabati, F. (2020). Health-related quality of life and health utility among patients with diabetes: in Zabol, Southeast Iran: Health-related quality of life and health utility among patients with diabetes. Journal of Contemporary Medical Sciences, 6(2), 59–65. https://doi.org/10.22317/jcms.v6i2.727
Issue
Section
Articles
