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Volume 13, Issue 3 (2025)
Health Educ Health Promot 2025, 13(3): 481-485 |
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History
Received: 2025/06/8 | Accepted: 2025/07/25 | Published: 2025/08/19
Received: 2025/06/8 | Accepted: 2025/07/25 | Published: 2025/08/19
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Worker Fatigue Determinants and Work Productivity Levels in Operator Workers at Public Fuel Filling Stations in Makassar City. Health Educ Health Promot 2025; 13 (3) :481-485
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URL: http://hehp.modares.ac.ir/article-4-81322-en.html
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Introduction
High work productivity is determined by the quality of human resources. Skill-oriented human resources enhance individual competencies and character, enabling them to meet job demands effectively. When individuals possess the necessary knowledge, skills, and attitudes, they can perform at their maximum capacity, thereby reflecting greater productivity. As reported by the Ministry of Manpower [1], Indonesia has experienced a rise in labor productivity over the last five years. Labor productivity, which represents the output of goods or services relative to the amount of labor used within a given timeframe, indicates how much labor contributes to economic performance. This metric is calculated by dividing the gross domestic product (GDP) by the total number of workers. Productivity reached IDR 82.56 million per worker annually, with a slight increase in 2019. Despite a decline in 2020 due to the COVID-19 pandemic, productivity rebounded in 2021, reaching a five-year high of IDR 86.55 million. Cumulatively, labor productivity rose by 4.8% from 2018 to 2022. For instance, productivity in Indonesia’s information and communication sector reached USD 23.9 per hour per worker, surpassing Malaysia’s USD 16.7.
Productive workers not only deliver better customer service but also enhance operational efficiency, thereby increasing a company’s competitiveness in a rapidly evolving industry. Since factors, such as motivation, work environment, and training influence productivity, addressing these aspects is essential for improving service quality [2].
Healthcare workers frequently report fatigue as a primary concern. Work-related fatigue can lead to errors and decreased performance across all professions. Therefore, addressing fatigue is essential to maintain productivity and effectiveness, highlighting the need for preventive measures [3].
According to Indonesia’s Social Security Agency for Employment [4], in 2021, a total of 147,000 workplace accidents were reported, with an average of 40,273 incidents occurring each day. Among these, 4,678 cases (3.18%) resulted in disabilities, while 2,575 cases (1.75%) led to fatalities—indicating that, on a daily basis, 12 workers suffered disabilities and 7 lost their lives. The Ministry of Manpower reported an average of 414 daily workplace accidents in 2021, with 27.8% attributed to severe fatigue. Approximately 9.5% (39 individuals) suffered permanent disabilities. On average, Indonesia records 99,000 workplace accidents annually, with about 70% resulting in death or lifelong disability [5].
Work fatigue can impair operator concentration, leading to errors such as incorrect cash handling and misinterpretation of customer requests. It also increases the risk of workplace accidents, such as fuel splashes to the eyes due to a lack of focus during refueling [6]. Fuel stations situated within residential neighborhoods present a considerable risk of fire. Numerous fire incidents have been reported worldwide, especially in developing nations. One such case occurred in Shaanxi Province, China, where an explosion of a fuel tank at a station resulted in several injuries [7].
PT Pertamina (Persero) provides fuel station infrastructure (SPBU) to meet the energy needs of the Indonesian public. Fuel station operators frequently experience fatigue due to prolonged standing and continuous refueling tasks. Additionally, shift work schedules significantly contribute to operator fatigue [8].
In light of the aforementioned issues, this research seeks to examine the correlation between worker fatigue and job productivity among SPBU operators in Makassar City in 2024. Data collection was conducted across several districts, including Biringkanaya, Tamalanrea, Manggala, and Panakukkang, to represent the potential impact of work fatigue on operator productivity. Accordingly, the research is titled “Determinant Analysis of Worker Fatigue and Its Relationship to Work Productivity Among Fuel Station Operators in Makassar City, 2024”.
One of the main sources of fire risk is fuel stations located in residential areas. Gas stations pose a fire hazard, as incidents have been reported globally, especially in developing countries. Fuel station operators are expected to work quickly and responsibly, using both physical and mental energy. PT Pertamina provides fuel through a network of public fuel filling stations to meet national needs. However, gas station operators often face the risk of fatigue due to standing and continuously dispensing fuel throughout their shifts, which frequently leads to exhaustion. The objective of this study was to examine the determinants of work fatigue and assess the level of work productivity among fuel station operators in Makassar City in 2024.
Instrument and Methods
Design and sample
This cross-sectional analytical observational study was done on employees working at several gas stations in the Tamalanrea and Biringkanaya sub-districts of Makassar City from May to June 2024.
The study population consisted of 204 registered employees working at gas stations in the Tamalanrea and Biringkanaya selected through a proportional random sampling. Based on the formula and the total population of 204 gas station operators in the sub-districts, a sample of 135 workers was selected, distributed along the main roads of each sub-district.
Research instrument
Data were collected through official permits, enumerator training, instrument testing, and tool calibration. Respondents completed a work factor questionnaire, underwent anthropometric measurements, participated in reaction time tests, provided subjective fatigue assessments, and recorded productivity. Data quality was maintained through double entry and questionnaire auditing.
Data collection
The primary data in this study were collected through questionnaires to assess the relationship between fatigue and factors, such as age, gender, job monotony, and work shifts. Secondary data were obtained from PT Pertamina in the Tamalanrea and Biringkanaya sub-districts, covering general company information. The tools used included questionnaires, a weighing scale, a microtoise, a reaction timer, and stationery. We employed questionnaires, body scales, a microtoise, and a reaction timer as data collection tools. The body scales and microtoise were standard anthropometric tools, validated and calibrated to ensure reliability. The reaction timer measured reaction time with construct validity, and its reliability was confirmed through the test-retest method, demonstrating consistent results. Thus, all tools were proven to be valid and reliable for this research.
Data analysis
All collected data, both primary and secondary, were processed through editing, coding, entry, and cleaning stages. Data were analyzed using univariate, bivariate, and multivariate analyses. The analysis included descriptive statistics, bivariate tests (Chi-square test, t-test/ANOVA, Mann-Whitney U test), and multivariate analysis using logistic or linear regression using SPSS 25 software.
Findings
A total of 63 respondents had optimal productivity, while 72 respondents had suboptimal productivity. Also, 92 respondents experienced work fatigue, while 43 respondents did not. Additionally, there were 80 male respondents and 55 female respondents. Furthermore, 98 workers had a body mass index within the normal category, while 37 workers fell into the abnormal category. Also, 58 respondents reported having monotonous work, while 77 respondents had non-monotonous work (Table 1).
Table 1. Participants’ characteristics
![src=./files/hehp/images/HTML_Publish/81322/1.png]()
Among the 135 respondents, the majority who reported fatigue experienced both maximum and non-maximum work productivity. There was a statistically significant association between worker fatigue and job productivity among fuel station operators (p=0.039). Most respondents with normal conditions had maximum work productivity, while those with abnormal conditions tended to have lower productivity. There was a statistically significant association between nutritional status and work productivity among fuel station operators (p=0.026). Also, a statistically significant association was found between monotonous tasks and work productivity among fuel station operators (p=0.025). There was no significant association between gender and work productivity (p=0.266; Table 2).
Table 2. The relationship between work fatigue, nutritional status, monotonous work, and gender and worker productivity
![src=./files/hehp/images/HTML_Publish/81322/2.png]()
Discussion
This study aimed to examine the determinants of work fatigue and assess the level of work productivity among fuel station operators in Makassar City. Proper fatigue management, such as ensuring adequate rest and reducing excessive workloads, is crucial for enhancing productivity and job satisfaction, as physical and mental fatigue can decrease efficiency, lower work quality, and reduce employee motivation [9]. Work-related fatigue, both physical and mental, has a significant negative impact on productivity. Higher levels of fatigue are associated with lower productivity, increased errors, and a greater risk of workplace accidents.
A study [10] on employee fatigue at CV Abadi Tiga Mandiri found that work fatigue has a positive and significant effect on employee productivity. The simple linear regression model was valid for predicting work productivity. The regression analysis revealed that fatigue had a positive and significant partial effect on productivity.
Nutritional status is a key aspect of occupational health that significantly affects work productivity. According to Supariasa’s study [11], good nutrition is essential for adults, as poor nutritional status increases the risk of illness. Several studies indicate that employees with poor nutritional status tend to have lower productivity than those with adequate nutrition. Improving nutritional status plays a crucial role in enhancing the quality, health, and productivity of human resources. Balanced nutrition that meets the body’s needs is essential, as both nutrient deficiencies and excesses can have negative effects [12].
Bakri et al. [13] reveal a significant correlation between employees’ nutritional status and their work productivity at PT Angkasa Pura I in Makassar. Among the 41 participants, individuals with normal nutritional status demonstrated higher productivity levels compared to those who were overweight. They report a statistically significant link between nutritional status and work productivity.
Many workers are engaged in routine tasks that require little initiative or responsibility, with no prospects for advancement or job variation [14]. Often, these tasks are far below their capabilities or educational qualifications. In many industries, jobs have been overly simplified into monotonous and repetitive duties, resembling work more suited for machines than for thinking humans.
Other factors, such as physical fatigue and job placement, may affect productivity regardless of work monotony [15]. Non-monotonous workers report higher productivity than those with monotonous tasks [16]. Many respondents experienced physical fatigue, possibly due to their specific roles or placement as fuel station operators. Questionnaire data further supported the finding that most respondents performed monotonous work.
Utami discovered that there are notable differences in levels of boredom and work productivity between monotonous and non-monotonous jobs at PT Delta Merlin Sandang Tekstil I Sragen. Workers in monotonous roles have higher boredom levels and slightly higher productivity scores compared to those in non-monotonous roles. Productivity is directly related to the nature of the job, whether it is monotonous or not [17].
In terms of strength and muscle power, men and women are different. My experience shows that women’s biological cycles do not affect their physical abilities; rather, they have a greater impact on social and cultural aspects. The body shape and muscle strength of each person vary [18]. Among these differences, women generally have smaller body sizes and lower muscle strength compared to men. Furthermore, women who experience abnormal menstruation, or dysmenorrhea, may feel pain, which causes them to tire more quickly [19].
Gender refers to the distinctions in roles, functions, and responsibilities assigned to men and women by societal norms [20]. It can also influence individual productivity, with studies often indicating that men tend to exhibit higher productivity levels compared to women. These variations suggest that gender differences may play a role in shaping productivity outcomes [21].
This finding is consistent with the study by Kurniasari & Ibrahim [22] on the relationship between age, gender, length of service, and attitudes toward the hybrid work system and employee productivity. Their results suggest that men tend to be more productive due to perceived physical strength. Similarly, Herwati [23] reported that male employees have 0.079% higher productivity than female employees. However, we did not find a significant relationship between gender and employee productivity, indicating that gender is not always a determining factor in work performance.
Gender affects employee motivation and performance. It is well known that high motivation can increase work productivity [24]. In developing countries, the motivation and productivity of male and female workers can differ depending on their jobs. The overall productivity level of women is lower in the field of science, which is typically male-dominated, but this perspective changes when viewed on an individual basis [25]. The dominance of one gender in a profession can impact productivity levels. Additionally, gender plays an important role in influencing productivity levels in small industries, such as the shuttlecock industry [22]. This is influenced by various factors, including those specific to women, such as a lack of physical strength, a tendency to use emotions at work, or biological factors, such as the need for maternity leave [26]. Gender impacts productivity and reflects the distinctions in roles, duties, and functions between men and women shaped by social constructs. Those with experience in this field are expected to obtain positions that match their abilities.
The limitations of this study include the difficulty in engaging many fuel station operators in the Tamalanrea and Biringkanaya districts of Makassar City due to their busy work schedules and short break times.
Conclusion
Work fatigue, monotonous tasks, and nutritional status are significantly related to productivity levels.
Acknowledgments: We extend our heartfelt thanks to all those involved. I also express my highest appreciation and gratitude to all the leaders at every gas station in the Biringkanaya and Tamalanrea subdistricts who allowed us to conduct research in the field.
Ethical Permissions: This research was granted an ethics code with the number: 379/UN4.14.1/TP.01.02/2025.
Conflicts of Interests: There are no conflicts of interests to declare.
Authors' Contribution: Pasanre AA (First Author), Introduction Writer/Methodologist/Main Researcher/Discussion Writer/Statistical Analyst (30%); Muis M (Second Author), Introduction Writer/Discussion Writer/Statistical Analyst (20%); Thamrin Y (Third Author), Introduction Writer/Assistant Researcher/Discussion Writer/Statistical Analyst (20%); Wahyu A (Fourth Author), Introduction Writer/Discussion Writer/Statistical Analyst (10%); Saleh LM (Fifth Author), Assistant Researcher/Discussion Writer/Statistical Analyst (10%); Amqam H (Sixth Author), Introduction Writer/Discussion Writer/Statistical Analyst (10%)
Funding/Support: No external sources provided funding for this study.
High work productivity is determined by the quality of human resources. Skill-oriented human resources enhance individual competencies and character, enabling them to meet job demands effectively. When individuals possess the necessary knowledge, skills, and attitudes, they can perform at their maximum capacity, thereby reflecting greater productivity. As reported by the Ministry of Manpower [1], Indonesia has experienced a rise in labor productivity over the last five years. Labor productivity, which represents the output of goods or services relative to the amount of labor used within a given timeframe, indicates how much labor contributes to economic performance. This metric is calculated by dividing the gross domestic product (GDP) by the total number of workers. Productivity reached IDR 82.56 million per worker annually, with a slight increase in 2019. Despite a decline in 2020 due to the COVID-19 pandemic, productivity rebounded in 2021, reaching a five-year high of IDR 86.55 million. Cumulatively, labor productivity rose by 4.8% from 2018 to 2022. For instance, productivity in Indonesia’s information and communication sector reached USD 23.9 per hour per worker, surpassing Malaysia’s USD 16.7.
Productive workers not only deliver better customer service but also enhance operational efficiency, thereby increasing a company’s competitiveness in a rapidly evolving industry. Since factors, such as motivation, work environment, and training influence productivity, addressing these aspects is essential for improving service quality [2].
Healthcare workers frequently report fatigue as a primary concern. Work-related fatigue can lead to errors and decreased performance across all professions. Therefore, addressing fatigue is essential to maintain productivity and effectiveness, highlighting the need for preventive measures [3].
According to Indonesia’s Social Security Agency for Employment [4], in 2021, a total of 147,000 workplace accidents were reported, with an average of 40,273 incidents occurring each day. Among these, 4,678 cases (3.18%) resulted in disabilities, while 2,575 cases (1.75%) led to fatalities—indicating that, on a daily basis, 12 workers suffered disabilities and 7 lost their lives. The Ministry of Manpower reported an average of 414 daily workplace accidents in 2021, with 27.8% attributed to severe fatigue. Approximately 9.5% (39 individuals) suffered permanent disabilities. On average, Indonesia records 99,000 workplace accidents annually, with about 70% resulting in death or lifelong disability [5].
Work fatigue can impair operator concentration, leading to errors such as incorrect cash handling and misinterpretation of customer requests. It also increases the risk of workplace accidents, such as fuel splashes to the eyes due to a lack of focus during refueling [6]. Fuel stations situated within residential neighborhoods present a considerable risk of fire. Numerous fire incidents have been reported worldwide, especially in developing nations. One such case occurred in Shaanxi Province, China, where an explosion of a fuel tank at a station resulted in several injuries [7].
PT Pertamina (Persero) provides fuel station infrastructure (SPBU) to meet the energy needs of the Indonesian public. Fuel station operators frequently experience fatigue due to prolonged standing and continuous refueling tasks. Additionally, shift work schedules significantly contribute to operator fatigue [8].
In light of the aforementioned issues, this research seeks to examine the correlation between worker fatigue and job productivity among SPBU operators in Makassar City in 2024. Data collection was conducted across several districts, including Biringkanaya, Tamalanrea, Manggala, and Panakukkang, to represent the potential impact of work fatigue on operator productivity. Accordingly, the research is titled “Determinant Analysis of Worker Fatigue and Its Relationship to Work Productivity Among Fuel Station Operators in Makassar City, 2024”.
One of the main sources of fire risk is fuel stations located in residential areas. Gas stations pose a fire hazard, as incidents have been reported globally, especially in developing countries. Fuel station operators are expected to work quickly and responsibly, using both physical and mental energy. PT Pertamina provides fuel through a network of public fuel filling stations to meet national needs. However, gas station operators often face the risk of fatigue due to standing and continuously dispensing fuel throughout their shifts, which frequently leads to exhaustion. The objective of this study was to examine the determinants of work fatigue and assess the level of work productivity among fuel station operators in Makassar City in 2024.
Instrument and Methods
Design and sample
This cross-sectional analytical observational study was done on employees working at several gas stations in the Tamalanrea and Biringkanaya sub-districts of Makassar City from May to June 2024.
The study population consisted of 204 registered employees working at gas stations in the Tamalanrea and Biringkanaya selected through a proportional random sampling. Based on the formula and the total population of 204 gas station operators in the sub-districts, a sample of 135 workers was selected, distributed along the main roads of each sub-district.
Research instrument
Data were collected through official permits, enumerator training, instrument testing, and tool calibration. Respondents completed a work factor questionnaire, underwent anthropometric measurements, participated in reaction time tests, provided subjective fatigue assessments, and recorded productivity. Data quality was maintained through double entry and questionnaire auditing.
Data collection
The primary data in this study were collected through questionnaires to assess the relationship between fatigue and factors, such as age, gender, job monotony, and work shifts. Secondary data were obtained from PT Pertamina in the Tamalanrea and Biringkanaya sub-districts, covering general company information. The tools used included questionnaires, a weighing scale, a microtoise, a reaction timer, and stationery. We employed questionnaires, body scales, a microtoise, and a reaction timer as data collection tools. The body scales and microtoise were standard anthropometric tools, validated and calibrated to ensure reliability. The reaction timer measured reaction time with construct validity, and its reliability was confirmed through the test-retest method, demonstrating consistent results. Thus, all tools were proven to be valid and reliable for this research.
Data analysis
All collected data, both primary and secondary, were processed through editing, coding, entry, and cleaning stages. Data were analyzed using univariate, bivariate, and multivariate analyses. The analysis included descriptive statistics, bivariate tests (Chi-square test, t-test/ANOVA, Mann-Whitney U test), and multivariate analysis using logistic or linear regression using SPSS 25 software.
Findings
A total of 63 respondents had optimal productivity, while 72 respondents had suboptimal productivity. Also, 92 respondents experienced work fatigue, while 43 respondents did not. Additionally, there were 80 male respondents and 55 female respondents. Furthermore, 98 workers had a body mass index within the normal category, while 37 workers fell into the abnormal category. Also, 58 respondents reported having monotonous work, while 77 respondents had non-monotonous work (Table 1).
Table 1. Participants’ characteristics
Among the 135 respondents, the majority who reported fatigue experienced both maximum and non-maximum work productivity. There was a statistically significant association between worker fatigue and job productivity among fuel station operators (p=0.039). Most respondents with normal conditions had maximum work productivity, while those with abnormal conditions tended to have lower productivity. There was a statistically significant association between nutritional status and work productivity among fuel station operators (p=0.026). Also, a statistically significant association was found between monotonous tasks and work productivity among fuel station operators (p=0.025). There was no significant association between gender and work productivity (p=0.266; Table 2).
Table 2. The relationship between work fatigue, nutritional status, monotonous work, and gender and worker productivity
Discussion
This study aimed to examine the determinants of work fatigue and assess the level of work productivity among fuel station operators in Makassar City. Proper fatigue management, such as ensuring adequate rest and reducing excessive workloads, is crucial for enhancing productivity and job satisfaction, as physical and mental fatigue can decrease efficiency, lower work quality, and reduce employee motivation [9]. Work-related fatigue, both physical and mental, has a significant negative impact on productivity. Higher levels of fatigue are associated with lower productivity, increased errors, and a greater risk of workplace accidents.
A study [10] on employee fatigue at CV Abadi Tiga Mandiri found that work fatigue has a positive and significant effect on employee productivity. The simple linear regression model was valid for predicting work productivity. The regression analysis revealed that fatigue had a positive and significant partial effect on productivity.
Nutritional status is a key aspect of occupational health that significantly affects work productivity. According to Supariasa’s study [11], good nutrition is essential for adults, as poor nutritional status increases the risk of illness. Several studies indicate that employees with poor nutritional status tend to have lower productivity than those with adequate nutrition. Improving nutritional status plays a crucial role in enhancing the quality, health, and productivity of human resources. Balanced nutrition that meets the body’s needs is essential, as both nutrient deficiencies and excesses can have negative effects [12].
Bakri et al. [13] reveal a significant correlation between employees’ nutritional status and their work productivity at PT Angkasa Pura I in Makassar. Among the 41 participants, individuals with normal nutritional status demonstrated higher productivity levels compared to those who were overweight. They report a statistically significant link between nutritional status and work productivity.
Many workers are engaged in routine tasks that require little initiative or responsibility, with no prospects for advancement or job variation [14]. Often, these tasks are far below their capabilities or educational qualifications. In many industries, jobs have been overly simplified into monotonous and repetitive duties, resembling work more suited for machines than for thinking humans.
Other factors, such as physical fatigue and job placement, may affect productivity regardless of work monotony [15]. Non-monotonous workers report higher productivity than those with monotonous tasks [16]. Many respondents experienced physical fatigue, possibly due to their specific roles or placement as fuel station operators. Questionnaire data further supported the finding that most respondents performed monotonous work.
Utami discovered that there are notable differences in levels of boredom and work productivity between monotonous and non-monotonous jobs at PT Delta Merlin Sandang Tekstil I Sragen. Workers in monotonous roles have higher boredom levels and slightly higher productivity scores compared to those in non-monotonous roles. Productivity is directly related to the nature of the job, whether it is monotonous or not [17].
In terms of strength and muscle power, men and women are different. My experience shows that women’s biological cycles do not affect their physical abilities; rather, they have a greater impact on social and cultural aspects. The body shape and muscle strength of each person vary [18]. Among these differences, women generally have smaller body sizes and lower muscle strength compared to men. Furthermore, women who experience abnormal menstruation, or dysmenorrhea, may feel pain, which causes them to tire more quickly [19].
Gender refers to the distinctions in roles, functions, and responsibilities assigned to men and women by societal norms [20]. It can also influence individual productivity, with studies often indicating that men tend to exhibit higher productivity levels compared to women. These variations suggest that gender differences may play a role in shaping productivity outcomes [21].
This finding is consistent with the study by Kurniasari & Ibrahim [22] on the relationship between age, gender, length of service, and attitudes toward the hybrid work system and employee productivity. Their results suggest that men tend to be more productive due to perceived physical strength. Similarly, Herwati [23] reported that male employees have 0.079% higher productivity than female employees. However, we did not find a significant relationship between gender and employee productivity, indicating that gender is not always a determining factor in work performance.
Gender affects employee motivation and performance. It is well known that high motivation can increase work productivity [24]. In developing countries, the motivation and productivity of male and female workers can differ depending on their jobs. The overall productivity level of women is lower in the field of science, which is typically male-dominated, but this perspective changes when viewed on an individual basis [25]. The dominance of one gender in a profession can impact productivity levels. Additionally, gender plays an important role in influencing productivity levels in small industries, such as the shuttlecock industry [22]. This is influenced by various factors, including those specific to women, such as a lack of physical strength, a tendency to use emotions at work, or biological factors, such as the need for maternity leave [26]. Gender impacts productivity and reflects the distinctions in roles, duties, and functions between men and women shaped by social constructs. Those with experience in this field are expected to obtain positions that match their abilities.
The limitations of this study include the difficulty in engaging many fuel station operators in the Tamalanrea and Biringkanaya districts of Makassar City due to their busy work schedules and short break times.
Conclusion
Work fatigue, monotonous tasks, and nutritional status are significantly related to productivity levels.
Acknowledgments: We extend our heartfelt thanks to all those involved. I also express my highest appreciation and gratitude to all the leaders at every gas station in the Biringkanaya and Tamalanrea subdistricts who allowed us to conduct research in the field.
Ethical Permissions: This research was granted an ethics code with the number: 379/UN4.14.1/TP.01.02/2025.
Conflicts of Interests: There are no conflicts of interests to declare.
Authors' Contribution: Pasanre AA (First Author), Introduction Writer/Methodologist/Main Researcher/Discussion Writer/Statistical Analyst (30%); Muis M (Second Author), Introduction Writer/Discussion Writer/Statistical Analyst (20%); Thamrin Y (Third Author), Introduction Writer/Assistant Researcher/Discussion Writer/Statistical Analyst (20%); Wahyu A (Fourth Author), Introduction Writer/Discussion Writer/Statistical Analyst (10%); Saleh LM (Fifth Author), Assistant Researcher/Discussion Writer/Statistical Analyst (10%); Amqam H (Sixth Author), Introduction Writer/Discussion Writer/Statistical Analyst (10%)
Funding/Support: No external sources provided funding for this study.