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Recruitment strategies for cervical cancer screening in three Mediterranean low and middle-income countries: Albania, Montenegro, and Morocco

  • Introduction 

    Cervical cancer (CC) poses a substantial burden in low-and middle-income countries (LMICs), where challenges in implementing effective screening programs and achieving high participation rates persist.

    Aims 

    This study sought to compare different strategies for recruiting women for CC screening in Albania, Montenegro, and Morocco, and compared usual care (ongoing invitation method) with an alternative approach (intervention strategy).

    Methods 

    Within each country, the following comparisons were made: face-to-face (FF) invitations versus phone calls (PCs) in Albania, PCs versus letter invitations in Montenegro, and FF invitations to women attending healthcare centers versus a combined approach termed “Invitation made in Morocco” (utilizing PC and FF for hard-to-reach women) in Morocco. Questionnaires that assessed facilitators and barriers to participation were administered to women who either attended or refused screening.

    Results 

    In Albania, significant differences in the examination coverage were observed between the invitation methods (PC: 46.1% vs. FF: 87.1%, p < 0.01) and between the rural and urban settings (rural: 89.1% vs. urban: 76.3%, p < 0.01). In Montenegro, the coverage varied based on the recruitment method (PC: 17.7% vs. letter invitation: 7.6%; p < 0.01), the setting (urban: 28.3% vs. rural: 13.2%; p < 0.01), and age (<34 years: 10.9% vs. 34+: 9.6%, p < 0.01). In Morocco, no significant differences were observed. Common screening facilitators included awareness of CC prevention and understanding the benefits of early diagnosis, while key barriers included a limited perception of personal CC risk and the fear of testing positive.

    Discussion 

    FF appeared to be effective in promoting participation, but its broader implementation raised sustainability concerns. PC invitations proved feasible, albeit necessitating updates to population registries. Restricting FF contacts for hard-to-reach communities may enhance the affordability and equity.

    Citation: Elisa Camussi, Lina Jaramillo, Roberta Castagno, Marta Dotti, Gianluigi Ferrante, Latifa Belakhel, Youssef Chami Khazraji, Alban Ylli, Kozeta Filipi, Đjurđjica Ostojić, Milica Stanisic, Luigi Bisanti, Livia Giordano. Recruitment strategies for cervical cancer screening in three Mediterranean low and middle-income countries: Albania, Montenegro, and Morocco[J]. AIMS Medical Science, 2024, 11(2): 99-112. doi: 10.3934/medsci.2024009

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  • Introduction 

    Cervical cancer (CC) poses a substantial burden in low-and middle-income countries (LMICs), where challenges in implementing effective screening programs and achieving high participation rates persist.

    Aims 

    This study sought to compare different strategies for recruiting women for CC screening in Albania, Montenegro, and Morocco, and compared usual care (ongoing invitation method) with an alternative approach (intervention strategy).

    Methods 

    Within each country, the following comparisons were made: face-to-face (FF) invitations versus phone calls (PCs) in Albania, PCs versus letter invitations in Montenegro, and FF invitations to women attending healthcare centers versus a combined approach termed “Invitation made in Morocco” (utilizing PC and FF for hard-to-reach women) in Morocco. Questionnaires that assessed facilitators and barriers to participation were administered to women who either attended or refused screening.

    Results 

    In Albania, significant differences in the examination coverage were observed between the invitation methods (PC: 46.1% vs. FF: 87.1%, p < 0.01) and between the rural and urban settings (rural: 89.1% vs. urban: 76.3%, p < 0.01). In Montenegro, the coverage varied based on the recruitment method (PC: 17.7% vs. letter invitation: 7.6%; p < 0.01), the setting (urban: 28.3% vs. rural: 13.2%; p < 0.01), and age (<34 years: 10.9% vs. 34+: 9.6%, p < 0.01). In Morocco, no significant differences were observed. Common screening facilitators included awareness of CC prevention and understanding the benefits of early diagnosis, while key barriers included a limited perception of personal CC risk and the fear of testing positive.

    Discussion 

    FF appeared to be effective in promoting participation, but its broader implementation raised sustainability concerns. PC invitations proved feasible, albeit necessitating updates to population registries. Restricting FF contacts for hard-to-reach communities may enhance the affordability and equity.


    Abbreviations

    CC:

    Cervical cancer; 

    EuMedCN:

    European Mediterranean Cancer Network; 

    FF:

    Face-to-face; 

    HICs:

    High-income countries; 

    HPV:

    Human Papilloma Virus; 

    IMM:

    Invitation made in Morocco; 

    LMICs:

    Low-and middle-income countries; 

    PC:

    Phone call; 

    WHO:

    World Health Organization

    For any two manifolds (M, g) and (N, h), a harmonic map ψ is the critical point of the energy functional defined as

    E(ψ)=12M|dψ|2dvg.

    The natural generalization of the harmonic maps was given by J. Eells and J. H. Sampson [1]. The established map ψ is called biharmonic if it is the critical point of energy functional

    E2(ψ)=12M|τ(ψ)|2dvg.

    with τ(ψ)=tr(dψ) as the vanishing tensor field for any harmonic map. For the above established E2, the first and second variation was studied by G. Y. Jiang [2]. For the same bi-harmonic functional, the associated Euler-Lagrange equation is τ2(ψ)=0, where τ2(ψ) is called bi-tension field and is defined as

    τ2(ψ)=Δτ(ψ)tr(RN(dψ,τ(ψ))dψ.

    In the above equation, Δ is the rough Laplacian acting on the sections of ψ1(TN) and RN is the curvature tensor for N. For any VΓ(ψ1(TN)) and X, Y Γ(TN), the definitions of Δ and RN are given by

    ΔV=tr(Δ2V),
    RN(X,Y)=[NX,NY]N[X,Y].

    A large number of studies have been done on biharmonic submanifolds [3,4,5,6,7,8]. It is a general fact that every harmonic map is biharmonic, but the vice-versa isn't true. The biharmonic maps, which are not harmonic, are called proper-biharmonic maps. If the harmonic map ψ is isometric immersion from the manifold (M,g) into (N,h), then the manifold M is called minimal submanifold of N. From the definition of proper biharmonic maps, it can be concluded that these are those submanifolds that aren't harmonic. Biharmonic submanifolds in different ambient spaces for different space forms have been extensively studied in the last few decades. Caddeo R. et al. [9] studied biharmonic submanifolds in spheres. Fetcu D. et al. [10,11,12] studied these submanifolds in complex, Sasakian and the product of sphere and real line space forms. J. Roth and A. Upadhyay [13,14] studied the biharmonic submanifolds on product spaces and generalized space forms. Chen B. Y. proved Chen's biharmonic conjecture stating that biharmonic surfaces do not exist in any Euclidean space with parallel normalized mean curvature vectors [15]. Yu F. et al. proved the same conjecture for hypersurfaces in R5 [16].

    The present study establishes the necessary and sufficient conditions for the submanifolds of Kaehler product manifolds to be biharmonic. Our future work then combines the work done in this paper with the techniques of singularity theory presented in [17,18,19,20]. We have derived the magnitude of scalar curvature for the hypersurfaces in a product of two spheres. We have also estimated the magnitude of the mean curvature vector for Lagrangian submanifolds in a product of two spheres. Finally, we proved the non-existence condition for totally complex Lagrangian submanifolds in a product of unit sphere and hyperbolic space.

    Let ˆMn and ˆMp be any Kehlerian manifolds of dimensions n (real dimension 2n) and p (real dimension 2p) respectively. Let us further assume Jn and Jp denote the almost complex structures of ˆMn and ˆMp, respectively. Suppose, ˆMn and ˆMp are complex space forms with constant holomorphic sectional curvatures c1 and c2, respectively. The Riemannian curvature tensor ˆRn of ˆMn(c1) is given by

    ˆRn(X,Y)Z = 14c1[gn(Y,Z)Xgn(X,Z)Y]

    + 14c1[gn(JnY,Z)JnXgn(JnX,Z)JnY+2gn(X,JnY)JnZ].

    Similarly, the Riemannian curvature tensor ˆRp of ˆMp(c2) is given by

    ˆRp(X,Y)Z = 14c2[gp(Y,Z)Xgp(X,Z)Y]

    + 14c2[gp(JpY,Z)JpXgp(JpX,Z)JpY+2gp(X,JpY)JpZ].

    For any generalized submanifold M of any complex space form N, the almost complex structure J induces the existence of four operators on M, namely

    j:TMTM,k:TMNM,l:NMTM,m:NMNM,

    defined for all X TM (tangent bundle) and ζNM (normal bundle) by

    JX=jX+kX,Jζ=lζ+mζ. (2.1)

    Since J is the almost complex structure, it satisfies J2 = Id. For any X, Y tangent to N, we also have g(JX,Y)=g(X,JY). Using the above properties of J, the relations for the operators, j, k, l and m are given as

    j2X+lkX+X=0, (2.2)
    m2ζ+klζ+ζ=0, (2.3)
    jlζ+lmζ=0, (2.4)
    kjX+mkX=0, (2.5)
    g(kX,ζ)+g(X,lζ)=0. (2.6)

    for all X Γ(TM) and ζΓ(NM). Also, j and m are skew-symmetric.

    Now, let us consider the Kaehler product manifold ˆMn(c1)׈Mp(c2) denoted by ˆM. If P and Q denote projection operators of the tangent spaces of ˆMn(c1) and ˆMp(c2), then we always have P2=P, Q2=Q and PQ=QP. If we put F=PQ, the properties of P and Q establish F2=I. This F is almost product structure of ˆMn(c1)׈Mp(c2). Moreover, we define a Riemannian metric g on ˆM as

    g(X, Y) = gn(PX,PY) + gp(QX,QY).

    Where X and Y are vector fields on ˆM. It further follows, g(FX,Y)=g(X,FY). If we put JX=JnPX+JpQX, we get JnP=PJ, JpQ=QJ, FJ=JF, g(JX,JY)=g(X,Y), ˆJ = 0. Thus J is the Kaehlerian structure on ˆM. The Riemannian curvature tensor ˆR of the product manifold ˆM is given as [21]

    R(X,Y)Z=c1+c216[g(Y,Z)Xg(X,Z)Y+g(JY,Z)JXg(JX,Z)JY+2g(X,JY)JZ+g(FY,Z)FXg(FX,Z)FY+g(FJY,Z)FJXg(FJX,Z)FJY+g(FZ,JY)FJZ]+c1c216[g(FY,Z)Xg(FX,Z)Y+g(Y,Z)FXg(X,Z)FY+g(FJY,Z)JXg(FJX,Z)JY+g(JY,Z)FJXg(JX,Z)FJY+2g(FX,JY)JZ+2g(X,JY)JFZ]. (2.7)

    The product structure F induces the existence of four operators:

    f:TMTM,h:TMNM,s:NMTMandt:NMNM,

    defined for all X TM (tangent bundle) and ζNM (normal bundle) by

    FX=fX+hX,Fζ=sζ+tζ. (2.8)

    These four operators follow the following relations

    f2X+shX=X, (2.9)
    t2ζ+hsζ=ζ, (2.10)
    fsζ+stζ=0, (2.11)
    hfX+thX=0, (2.12)
    g(hX,ζ)=g(X,sζ). (2.13)

    for all X Γ(TM) and ζΓ(NM). Also, f and t are symmetric.

    The first theorem gives necessary and sufficient condition for the manifold to be biharmonic.

    Theorem 3.1. Let M be a u-dimensional submanifold of the Kaehler product manifold ˆM = ˆMn(c1)׈Mp(c2) with A, B and H, respectively denoting the shape operator, second fundamental form and mean curvature vector. Then, this submanifold is biharmonic if and only if the following equations are satisfied:

    H+tr(B(.,AH.))+c1+c216[uH+3klH+hsHtr(f)tH+2(hjflH+tkflH+hjsmH+tksmH)tr(fj+sk)(hlH+tmH)]+c1c216[tr(f)HutH+3(kflH+ksmH)tr(fj+sk)(mH)+3(hjlH+tklH)]=0. (3.1)
    u2grad|H|2+2tr(AH(.))+c1+c28[3jlH+fsHtr(f)sH+2(fjflH+skflH+fjsmH+sksmH)tr(fj+sk)(flH+smH)]+c1c28[sHusH+3(jflH+jsmH)tr(fj+sk)(lH)+3(fjlH+sklH)]=0. (3.2)

    Proof. The equations of biharmonicity have been already established in [12,22,23]. Projection of the equation τ(ψ)=0 on both tangential and normal bundles establishes the following equations

    H+tr(B(.,AH.))+tr(ˉR(.,H.)=0,u2grad|H|2+2tr(AH(.))+2tr(ˉR(.,H.)=0. (3.3)

    Suppose that {Xi}ui=1 is a local orthonormal frame for TM, then by using the Eq 2.7 of curvarture tensor ˉR, we have

    tr(ˉR(.,H.)=ui=1ˉR(Xi,H)Xi, (3.4)

    tr(ˉR(.,H.) = ui=1{c1+c216[g(H,Xi)Xig(Xi,Xi)H+g(JH,Xi)JXi

    g(JXi,Xi)JH+2g(Xi,JH)JXi+g(FH,Xi)FXig(FXi,Xi)FH

    +g(FJH,Xi)FJXig(FJXi,Xi)FJH+g(FXi,JH)FJXi]

    +c1c216[g(FH,Xi)Xig(FXi,Xi)H+g(H,Xi)FXig(Xi,Xi)FH

    +g(FJH,Xi)JXig(FJXi,Xi)JH+g(JH,Xi)FJXig(JXi,Xi)FJH

    +2g(FXi,JH)JXi+2g(Xi,JH)JFXi]},

    Introducing the established sets of four operators, j, k, l and m and f, h, s and t for J and F respectively, we get the simplified equation as

    tr(ˉR(.,H.) = c1+c216[uH+ui=1g(lH,Xi)JXi+ui=12g(Xi,lH)JXi

    +F(FH)tr(f)FH+FJ(FJH)tr(fj+sk)FJH+FJ(FJH)]

    +c1c216[(FH)tr(f)HuFH+J(FJH)tr(fj+sk)JH

    +ui=1g(lH,Xi)FJXi+2J(FJH)+ui=12g(Xi,lH)JFXi],

    or tr(ˉR(.,H.) = c1+c216[uH+3JlH+fsH+hsHtr(f)sHtr(f)tH

    +2FJ(flH+smH)tr(fj+sk)FJH]

    +c1c216[sHtr(f)HuFH+J(flH+smH)tr(fj+sk)JH+

    3FJlH+2J(flH+smH)],

    tr(ˉR(.,H.) = c1+c216[uH+3jlH+3klH+fsH+hsHtr(f)sHtr(f)tH

    + 2(fjflH+hjflH+skflH+tkflH+fjsmH+hjsmH+sksmH+tksmH)

    tr(fj+sk)(flH+hlH+smH+tmH)]

    + c1c216[sHtr(f)HushutH+3(jflH+kflH+jsmH+ksmH)

    tr(fj+sk)(lH+mH)+3(fjlH+hjlH+sklH+tklH)].

    By identification of tangential and normal parts, we get the required equations.

    Corollary 3.2. If M is a u-dimensional totally real submanifold of the Kaehler product manifold ˆM = ˆMn(c1)׈Mp(c2). Then, this submanifold is biharmonic if and only if the following equations are satisfied

    H+tr(B(.,AH.))+c1+c216[uH+3klH+hsHtr(f)tH+2(tkflH+tksmH)tr(sk)(hlH+tmH)]+c1c216[tr(f)HutH+3(kflH+ksmH)tr(sk)(mH)+3(tklH)]=0. (3.5)
    u2grad|H|2+2tr(AH(.))+c1+c28[fsHtr(f)sH+2(skflH+sksmH)tr(sk)(flH+smH)]+c1c28[sHusHtr(sk)(lH)+3(sklH)]=0. (3.6)

    Proof. If M is a totally real submanifold, then we know that for any XΓ(TM), we have

    JX=kX,

    In other words, jX=0. Using this fact in Theorem 3.1, we get the required equations.

    Corollary 3.3. a): If M is any hypersurface of the Kaehler product manifold

    ˆM=ˆMp(c1)׈Mnp(c2).

    Then, M is biharmonic if and only if the following equations are satisfied

    H+tr(B(.,AH.))+c1+c216[(n2)H+hsHtr(f)tH+2(hjflH+tkflH)tr(fj+sk)(hlH)]+c1c216[tr(f)H(n1)tH+3(kflH)+3(tklH)]=0. (3.7)
    n12grad|H|2+2tr(AH(.))+c1+c28[fsHtr(f)sH+2(fjflH+skflH)tr(fj+sk)(flH)]+c1c28[sH(n1)sH+3(jflH)tr(fj+sk)(lH)3sH]=0. (3.8)

    b): If M is any totally real hypersurface of the Kaehler product manifold

    ˆM=ˆMp(c1)׈Mnp(c2).

    Then, M is biharmonic if and only if the following equations are satisfied:

    H+tr(B(.,AH.))+c1+c216[(n2)H+hsHtr(f)tH+2(tkflH)tr(sk)(hlH)]+c1c216[tr(f)H(n1)tH+3(kflH)+3(tklH)]=0. (3.9)
    n12grad|H|2+2tr(AH(.))+c1+c28[fsHtr(f)sH+2(skflH)tr(sk)(flH)]+c1c28[sH(n1)sHtr(sk)(lH)3sH]=0. (3.10)

    Proof. a): For any hypersurface M,J maps normal vectors to tangent vectors as such m=0. Using this fact with the Eqs 2.3 and 2.4 for H, we get the required equations from Theorem 3.1.

    b): For any totally real hypersurface M, we have j=0 and m=0.

    Corollary 3.4. If M is a u-dimensional Lagrangian manifold of the Kaehler product manifold

    ˆM=ˆMn(c1)׈Mp(c2).

    Then, M is biharmonic if and only if the following equations are satisfied

    H+tr(B(.,AH.))+c1+c216[(u+3)H+hsHtr(f)tH+2(tkflH)tr(sk)(hlH)]+c1c216[tr(f)HutH+3(kflH)+3(tklH)]=0. (3.11)
    u2grad|H|2+2tr(AH(.))+c1+c28[fsHtr(f)sH+2(skflH)tr(sk)(flH)]+c1c28[sHusHtr(sk)(lH)3(sH)]=0. (3.12)

    Proof. If M is a Lagrangian manifold, then j=0 and m=0. Using this fact with Eq 2.3, we get the required equations from Theorem 3.1.

    From now on, the authors will consider the ambient space to be product of two 2-spheres of same radius (for simplicity radius equals 1 unit). The reason for taking 2-sphere follows from[24] as it is the only sphere which accepts Kaehler structure. In the following equations, we will have

    c1+c216=c18=18andc1c28=b=0.

    To estimate the magnitude of mean curvature vector and scalar curvature, the authors will further assume the cases where F will map the whole of tangent bundle or normal vectors to respective bundles only. The reason being the equations involve the product of almost complex structure J and product structure F. As such it isn't possible to get simpler equations involving dimensions of submanifolds and mean curvature vector only.

    Proposition 3.5. Let M be any hypersurface of S2×S2 with non-zero constant mean curvature such that FXΓ(TM) and FNΓ(TM) for any XΓ(TM) and NΓ(TM). Then M is biharmonic if we have

    |B|2=18[1+1|H|2tr(sk)FJH,H]. (3.13)

    Proof. By the established hypothesis on F, we have f=0 and t=0. Using these equations along with Eqs 2.9 and 2.10 in Eq 3.7, we get

    H+tr(B(.,AH.))18[H+tr(sk)(hlH)]=0, (3.14)

    Since M is a hypersurface, the above equation becomes,

    tr(B(.,AH.))18[H+tr(sk)(hlH)]=0, (3.15)

    Since tr(B(.,AH.)) = |B|2H, on further simplifying, we get,

    |B|2H2=18[H2+tr(sk)hlH,H], (3.16)

    or

    |B|2=18[1+1|H|2tr(sk)FJH,H]. (3.17)

    Remark 3.6. It can be easily concluded from above proposition that there doesn't exist any hypersurface of S2×S2 when FXΓ(TM) and FNΓ(TM) for any XΓ(TM) and NΓ(TM) for

    tr(sk)FJH,H+|H|20.

    The above proposition can be used to derive the value of scalar curvature for biharmonic hypersurface M when FXΓ(TM) and FNΓ(TM) for any XΓ(TM) and NΓ(TM).

    Proposition 3.7. Let M be any proper-biharmonic hypersurface of S2×S2 with non-zero constant mean curvature such that FXΓ(TM) and FNΓ(TM) for any XΓ(TM) and NΓ(TM). Then the scalar curvature τ of M is given by

    τM=18[5+tr(sk)21|H|2tr(sk)FJH,H]+3|H|2.

    Proof. By the equation of Gauss, we have,

    τM=n1i,j=1ˉR(Xi,Xj)Xj,Xi|B|2+(n1)|H|2,

    The curvature tensor ˆR for S2×S2 is given by Eq 2.7 with

    c1+c216=c18=18andc1c28=0.

    And,

    ˆR(Xi,Xj)Xj,Xi=18[1+FXj,XjFXi,XiFXi,Xj2+FJXj,XjFXi,Xi], (3.18)

    Since FXiΓ(TM) and f=0. We have

    n1i,j=1ˆR(Xi,Xj)Xj,Xi=18[6+tr(sk)2]. (3.19)

    Using the value of |B|2 gives the required equation.

    Proposition 3.8. Let M be any totally complex-hypersurface of S2×S2 with non-zero constant mean curvature such that FXΓ(TM) and FNΓ(TM) for any XΓ(TM) and NΓ(TM). Then for trivially biharmonic M, we have

    |B|2=18. (3.20)

    Proof. By the established hypothesis on F, we have f=0 and t=0. Using these equations along with Eqs 2.9 and 2.10 in Theorem 3.1, we get

    H+tr(B(.,AH.))18H=0, (3.21)

    Since M is a hypersurface, the above equation becomes

    tr(B(.,AH.))18H=0. (3.22)

    Since tr(B(.,AH.)) = |B|2H. On further simplifying, we get the required equation.

    Proposition 3.9. Let M be any proper-biharmonic totally complex-hypersurface of S2×S2 with non-zero constant mean curvature such that FXΓ(TM) and FNΓ(TM) for any XΓ(TM) and NΓ(TM). Then the scalar curvature τ of M is given as

    τM=18[5+tr(sk)2]+3|H|2. (3.23)

    Proof. By the equation of Gauss, we have

    τM=n1i,j=1ˆR(Xi,Xj)Xj,Xi|B|2+(n1)|H|2,

    The curvature tensor ˆR for S2×S2 is given by Eq 2.7 with

    c1+c216=c18=18andc1c28=0.

    Then,

    ˆR(Xi,Xj)Xj,Xi=18[1+FXj,XjFXi,XiFXi,Xj2+FJXj,XjFXi,Xi]. (3.24)

    Since FXiΓ(TM) and f=0. We have

    n1i,j=1ˆR(Xi,Xj)Xj,Xi=18[6+tr(sk)2]. (3.25)

    Using the value of |B|2 gives the required equation.

    Corollary 3.10. Let M be u-dimensional Lagrangian submanifold of S2×S2 with non-zero constant mean curvature such that FXΓ(TM) and FNΓ(TM) for any XΓ(TM) and NΓ(TM). Let us further assume [tr(sk)FJH,H]0 Then we have

    a): If M is a proper-biharmonic, then 0<|H|2u+28u.

    b): If |H|2=u+28u, then M is biharmonic if and only if it is pseudo-umbilical manifold, H=0 and tr(sk) = 0.

    Proof. By the given hypothesis for F, we have f=0 and t=0.

    Implementing the above conditions along with Eq 2.9 in Corollary 3.4 a), we get,

    ΔH+tr(B(.,AH.))18[(u+2)Htr(sk)(hlH)]=0. (3.26)

    By taking the inner product with H, we get

    ΔH,H+|AH|218[(u+2)|H|2+tr(sk)FJH,H)]=0, (3.27)

    where AH is the shape operator associated with mean curvature vector H.

    Using Bochner formula, we get

    18(u+2)|H|2=|AH|2+|H|2+18tr(sk)FJH,H). (3.28)

    By the Cauchy-Schwarz inequality, we have |AH|2u|H|4. Using this fact, we have

    18(u+2)|H|2u|H|4+|H|2+18tr(sk)FJH,H)u|H|4+18tr(sk)FJH,H)u|H|4. (3.29)

    Since H is a non-zero constant, we have

    0<|H|2u+28u.

    If |H|2u+28u and M is proper-biharmonic, all of the above inequalities become equalities. Thus, we have H|2=0 and tr(sk)=0 as FJ is an isometry. Since the Cuachy-Schwarz inequality becomes equality, we have M as pseudo-umbilical.

    Remark 3.11. The cases for which FXΓ(TM) and FNΓ(TM) for any XΓ(TM) and NΓ(TM) establish the results comparable to those established in this paper. The proofs of all those results follow a similar procedure; thus, they haven't been discussed here.

    Finally, we discuss a non-existence case for the product of a unit sphere and a hyperbolic space. Out of all the discussed cases, the non-existence result can be found only for totally-complex Lagrangian submanifolds. Same has been discussed here:

    Proposition 3.12. There doesn't exist any proper biharmonic totally complex Lagrangian submanifold (dimension 2) with parallel mean curvature in S2×Hn2 such that FXΓ(TM) and FNΓ(TM) for any XΓ(TM) and NΓ(TM).

    Proof. Since mean curvature H is parallel and not identically zero. Therefore, FH isn't zero identically.

    M is trivially biharmonic, according to Theorem 3.1, we have

    u2grad|H|2+2tr(AH(.))+c1+c28[fsHtr(f)sH]+c1c28[sHusH3(sH)]=0. (3.30)

    For the above equation, we have c1+c2=0 and c1c2=2,

    or

    u2grad|H|2+2tr(AH(.))+14[(u+2)sH]=0. (3.31)

    Using the hypothesis, we have sH=0 or FH=0, which isn't possible.

    We established the necessary and sufficient conditions for the submanifolds of Kaehler product manifolds to be biharmonic. And we derived the magnitude of scalar curvature for the hypersurfaces in a product of two unit spheres. Also, for the same product, the magnitude of the mean curvature vector for Lagrangian submanifolds has been estimated. Finally, we proved the non-existence condition for totally complex Lagrangian submanifolds in a product of unit sphere and a hyperbolic space.

    The authors declare no conflict of interest.



    Author contributions



    Camussi Elisa: statistical analysis, writing, review & editing; Jaramillo Lina: study design, statistical analysis, writing; Castagno Roberta: writing, review & editing; Dotti Marta: writing; Ferrante Gianluigi: writing, review & editing; Belakhel Latifa: study design, writing, review & editing; Chami Khazraji Youssef: study design, writing, review & editing; Ylli Alban: study design, writing, review & editing; Filipi Kozeta: study design, writing, review & editing; Ostojić Đjurđjica: study design, writing, review & editing; Stanisic Milica: study design, writing, review & editing; Bisanti Luigi: writing, review & editing; Giordano Livia: study design, validation, writing, review & editing, supervision. All authors have read and approved the final version of the manuscript for publication.

    Conflict of interest



    The authors report there are no conflicting interests to declare.

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