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Ophthalmology
Original research
Knowledge, attitude and the associated factors regarding spectacle use among adults living in Debre Birhan Town, North Shewa, Ethiopia, 2023: a community-based, cross-sectional study
  1. Matiyas Mamo Bekele,
  2. Nebiyat Feleke Adimassu,
  3. Tarekegn Cheklie Zeleke,
  4. Abebech Fikade Shumye,
  5. Melkamu Temeselew Tegegn,
  6. Abel Sinshaw Assem
  1. Department of Optometry, College of Medicine and Health Sciences, Comprehensive Specialized Hospital, University of Gondar, Gondar, Ethiopia
  1. Correspondence to Matiyas Mamo Bekele; matthiasm2013{at}gmail.com

Abstract

Objective This study aimed to assess the knowledge, attitude and the associated factors regarding spectacle use among adults living in Debre Birhan Town, North Shewa, Ethiopia.

Design A community-based, cross-sectional study was conducted using a multistage sampling method.

Setting The study was conducted in Debre Birhan Town, North Shewa, Ethiopia.

Participants The study included 1022 adults aged ≥18 years living in Debre Birhan Town for more than 6 months.

Main outcome measures Data were collected using face-to-face interviews completed by an interviewer.

Results The study included 1022 adults with a median age of 45 years. Of the participants, 86.01% (95% CI 83.88, 88.14) had adequate knowledge and 85.32% (95% CI 83.15, 87.50) had favourable attitude towards spectacle use. Older age (adjusted OR (AOR)=1.21, 95% CI 1.17, 1.26), higher educational status (AOR=2.65, 95% CI 1.06, 6.60), history of spectacle use (AOR=3.20, 95% CI 1.31, 7.83) and family history of spectacle use (AOR=4.75, 95% CI 2.31, 9.75) were positively associated with having adequate knowledge of spectacle use. Higher educational status (AOR=2.56, 95% CI 1.26, 5.21), history of spectacle use (AOR=3.22, 95% CI 1.58, 6.55), family history of spectacle use (AOR=1.89, 95% CI 1.13, 3.16) and adequate knowledge about spectacle use (AOR=4.63, 95% CI 2.69, 7.98) were positively associated with having favourable attitude towards spectacle use.

Conclusion This study revealed a good proportion of adults with adequate knowledge and favourable attitude towards spectacle use. Higher educational status, history of spectacle use and family history of spectacle use were significantly associated with having adequate knowledge and favourable attitude towards spectacle use.

  • Contact Lenses
  • Diabetic Retinopathy
  • Dry Eye Syndromes
  • Glaucoma

Data availability statement

Data are available upon reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi-org.ezproxy.u-pec.fr/10.1136/bmjopen-2024-086812

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • This study provides up-to-date information on the proportion of adults with knowledge and attitude towards spectacle use and the associated factors among those living in Northeast Ethiopia, with the aim of reducing ultraviolet radiation-related ocular hazards and visual impairments resulting from refractive errors and presbyopia.

    • As a cross-sectional study, it demonstrates the temporal relationship between knowledge and attitude towards spectacle use and the associated factors rather than establishing a cause–effect relationship.

    • Although the study involves the general population, the results do not specifically address the attitudes and knowledge of adults who use spectacles to correct refractive errors or presbyopia, or of the parents/guardians of children who use them for the same purpose.

    Introduction

    Spectacles are optical devices consisting of a frame with lenses that are used to correct distance and/or near vision impairments, as well as for protection and gaining self-confidence.1 2 Use of spectacles is the world’s most cost-effective method to correct refractive errors.3 In many countries, the proportion of adults who could benefit from spectacles to correct refractive errors but do not currently own or use them is high: 60% in rural China4 and 71.58% in Finote Selam Town, Ethiopia.5 Worldwide, the prevalence of inadequate knowledge and unfavourable attitude towards spectacle use among adults ranges from 8% to 80% and from 0.8% to 69%, respectively.6–9

    Evidence has shown that knowledge about spectacle use is positively associated with male sex, college and above educational status, history of spectacle use, history of eye examination, self-reported reduction in vision and family history of spectacle use,10–13 whereas a favourable attitude towards spectacle use is significantly associated with older age, college and above educational status, urban residency, positive history of spectacle use and knowledge about spectacle use.8 14 15

    Adults’ knowledge and attitude towards spectacle use play an important role in encouraging people to seek treatment to correct refractive errors and improve eye health-seeking behaviours.15–17 In addition, wearing glasses to correct refractive errors helps minimise the burden associated with visual impairments.6 15

    In contrast, inadequate knowledge and unfavourable attitude towards spectacle use lead to visual impairments and blindness resulting from uncorrected refractive errors, which hinder education and productivity and result in limited social participation, negative psychological impact and reduced quality of life.18–24 These also lead to an enormous burden on the healthcare system.6 25–28

    Although numerous studies have been conducted to determine the prevalence of refractive error, there are comparatively insufficient data on the knowledge and attitude towards spectacle use. Providing up-to-date information on the knowledge and attitude towards spectacle use is very crucial to policymakers’ and stakeholders’ works on reduction of refractive to design the platform in awareness creation in spectacle use. The main objective of this study was to investigate the knowledge, attitude and associated factors regarding spectacle use among adults in Debre Birhan Town, North Shewa, Ethiopia.

    Methods and materials

    Study design and setting

    A community-based, cross-sectional study was conducted in Debre Birhan Town, North Shewa, Ethiopia, between 8 May and 8 June 2023. The town is located in North Shewa, Amhara National Regional State Government, 130 km away from Addis Ababa, the capital city of Ethiopia, and 688 km away from Bahir Dar, the capital city of Amhara National Regional State. The town has a total population of 88 375 (39 961 male and 48 414 female residents), of whom 56 914 are adults aged ≥18 years.29 It has nine administrative kebeles. The town has a tertiary eye care centre with ophthalmologists, optometrists, ophthalmic nurses and nurses serving more than three million people in the catchment area, as well as a private eye clinic. The town also has more than three optical workshops.

    Study population and eligibility criteria

    All adults aged ≥18 years living in Debre Birhan Town for more than 6 months and who were available during the data collection period were included in the study. Adults who were unable to respond to the questionnaire due to a serious illness or mental impairment were excluded.

    Patient and public involvement

    Patients and/or the public were not involved in the study design, conduct of the study or plan to disseminate the results to the study participants.

    Sample size determination for the first objective

    Sample size was determined using the single proportion formula, n=Embedded Image, with the following considerations: n is the sample size; Z is the value of Z statistics at 95% confidence level, which is equal to 1.96; P is the expected proportion of adults with adequate knowledge and favourable attitude towards spectacle use, which was 90.6% and 90.4%, respectively, and taken from a study done in Gondar, Ethiopia9; and d is the margin of error at 5%. According to this calculation, the sample sizes would be 131 and 134 for adequate knowledge and favourable attitude towards spectacle use, respectively.

    Sample size determination for the second objective

    Educational status is consistently associated with knowledge about spectacle use.9 To determine the sample size for the second objective regarding knowledge about spectacle, the Epi Info V.7 software was used, considering a confidence level of 95%, power of 80%, a ratio of unexposed to exposed patients of 0.989 and an OR of 0.31, with the proportion of cases in the exposed and unexposed groups set at 83.2% and 94.1%, respectively. The computer-generated sample size was 300.

    Occupational status is consistently associated with attitudes towards spectacle use.9 To determine the sample size for the second objective regarding knowledge about spectacle using, the Epi Info V.7 software was used, considering a confidence level of 95%, power of 80%, a ratio of unexposed to exposed patients of 1.00 and an OR of 0.376, with the proportion of cases in the exposed and unexposed groups set at 86.6% and 94.5%, respectively. The computer-generated sample size was 478.

    Finally, the sample size calculated on the basis of occupational status was selected because it was sufficient to meet both objectives. Considering a design effect of 2 and a non-response rate of 10%, we arrived at a final sample size of 1052.

    Sampling procedures and techniques

    A multistage sampling procedure was applied to obtain the sampling unit. First, four kebeles were selected from nine kebeles using lottery method. The sample size was proportionally allocated to the size of the population in each selected kebele. Finally, using a constant interval of 10, a systematic random sampling method was applied to select households. The interval was calculated as the total number of households in the selected kebeles divided by the sample size (K=N/n=10 519/1052=10). We then randomly chose a number between 1 and 10 to select the first household to be included in the sample, and every 10th household was randomly selected. Moreover, if more than one eligible adults aged ≥18 years were found in the selected household, participants were recruited by lottery. If an eligible person could not be found during data collection, the household was visited again. If no eligible person meeting the inclusion criteria was found in the selected household, an adjacent household was surveyed (figure 1).

    Figure 1
    Figure 1

    Diagrammatic representation of the sampling procedure in Debre Birhan Town, North Shewa, Ethiopia, 2023.

    Operational definitions

    • Knowledge about spectacle use: assessed using 15 ‘yes’ or ‘no’ questions. A correct (yes) answer to the questions was scored 1, while an incorrect (no) answer was scored 0. For the knowledge questions, the sum of the scores ranged from 0 to 15 points, with a median score of 11. Participants who had a median score or above on the knowledge-related questions were considered to have adequate knowledge about spectacle use and inadequate knowledge otherwise.

    • Attitudes towards spectacle use: assessed by 15 attitude-related questions with a 5-point Likert scale. The responses were strongly agree=1, agree=2, neutral=3, disagree=4 and strongly disagree=5. The sum of the scores ranged from 15 to 75 points, with a median score of 57. Thus, participants who answered more than or equal to the median score on the attitude-related questions had a favourable attitude towards spectacle use, while those who answered less than the median score had an unfavourable attitude.

    • History of eye examination: the study participant has performed an eye examination at least once in the last 2 years.17

    • History of eye training: the study participant has received an eye health-related education from an eye care professional at least once before the data collection period.

    Data collection procedures

    Data were collected through face-to-face interviews using pretested structured questionnaires adapted from similar previous studies.7 13 The questionnaires included questions on sociodemographic characteristics, ocular history, personal medical history and knowledge-related and attitude-related questions (online supplemental file 1). Four optometrists participated in the data collection. Interexaminer reliability was assessed, and the Cohen’s kappa statistics were 0.79 and 0.81 for knowledge and attitude towards spectacle use, respectively. After completing the interviews, participants’ distance visual acuity was measured in each eye using a Snellen visual acuity chart at a distance of 6 m. If the participant could not see a letter at 1 m, other measures such as counting fingers, hand motion, light perception and no light perception were used to assess visual acuity. Visual acuity status was classified as follows: normal vision (presenting visual acuity (PVA) in the better eye ≥6/12), mild visual impairment (PVA in the better eye <6/12–6/18), moderate visual impairment (PVA in the better eye <6/18–6/60), severe visual impairment (PVA in the better eye <6/60–3/60) and blindness (PVA in the better eye <3/60), based on the International Classification of Diseases, 11th Revision’s definition of visual impairment.30

    Statistical analysis

    After checking for completeness and consistency, the data were entered in KoboCollect V.2021.4.4 and exported to Stata V.14 for analysis. Both descriptive and analytical statistics were performed. Multicollinearity was checked using variance inflation factor and tolerance. A bivariable logistic regression followed by a multivariable binary logistic regression was fitted to identify possible predictors of knowledge and attitude towards spectacle use. The strength of the association between the predictors and the outcome variables was shown using adjusted OR (AOR) with 95% CI. The model of fitness was ensured through the Hosmer and Lemeshow goodness of fit. A variable with a p value of 0.05 in the multivariable binary logistic regression was considered statistically significant.

    Results

    Sociodemographic characteristics of the study participants

    A total of 1022 study participants were included, with a response rate of 97.15%. The median age of the participants was 45 years (IQR 37–54). Of the study participants, 687 (67.22%) were male, 812 (79.45%) were married and 468 (45.79%) had college and above educational status (table 1).

    View this table:
    Table 1

    Sociodemographic characteristics of the study participants in Debre Birhan Town, North Shewa, Ethiopia, 2023 (N=1022)

    Clinical characteristics of the study participants

    Out of the 1022 participants, about 285 (27.89%) had worn spectacles at least once in their life, 542 (53.03%) had self-reported visual deterioration, 137 (13.41%) had a history of eye training and 424 (41.49%) had a family history of spectacle use (table 2).

    View this table:
    Table 2

    Clinical characteristics of the study participants in Debre Birhan Town, North Shewa, Ethiopia, 2023 (N=1022)

    Knowledge about spectacle use among study participants

    In this study, the proportion of adults having adequate knowledge about spectacle use was 86.01% (95% CI 83.88, 88.14). Regarding detailed knowledge about spectacle use, 249 (24.36%) out of the 1022 participants said that eye-drops can be an alternative to using spectacles for correcting vision, 238 (23.29%) thought that spectacles prescribed for one person can be used by another, 241 (23.58%) assumed that spectacles can be obtained once and then they will always have the same meaning for the rest of one’s life, and only 637 (62.33%) assumed that those who wear spectacles must wear them regularly (online supplemental file 2).

    Attitude towards spectacle use among study participants

    Of the total 1022 study participants, 872 (85.32%; 95% CI 83.15, 87.50) had favourable attitude towards spectacle use. Of those who had favourable attitude, 71.10% were male. Of the study participants, 102 (9.98%) strongly agreed that wearing spectacles can result in activity limitations, 230 (22.50%) agreed that wearing spectacles is fashionable, 128 (12.52%) strongly disagreed that wearing spectacles makes one look better, 108 (10.57%) agreed that wearing spectacles worsens vision and 111 (10.86%) agreed that wearing spectacles is uninteresting (online supplemental file 3).

    Factors associated with knowledge about spectacle use

    In the bivariable binary logistic regression analysis, female sex, increasing age, marital status (being widowed), higher educational status (secondary school and college and above), occupational status (being a merchant and a housewife), history of training on the eye, history of eye examination, history of spectacle use, history of self-reported reduction in vision, history of cataract surgery and family history of spectacle use were associated with knowledge about spectacle use. However, the multivariable binary logistic regression analysis revealed that age, educational status, history of spectacle use and family history of spectacle use were significantly associated with knowledge of spectacle use.

    This study revealed that as age increases by one unit the odds of having adequate knowledge about spectacle use increase by 1.21 times (AOR=1.21, 95% CI 1.17, 1.26). The odds of having adequate knowledge among participants with a higher level of education (college and above) were 2.65 times higher compared with those who cannot read and write (AOR=2.65, 95% CI 1.06, 6.60). The odds of having adequate knowledge among participants with a positive history of spectacle use were 3.20 times higher compared with those who had no positive history of spectacle use (AOR=3.20, 95% CI 1.31, 7.83). The odds of having adequate knowledge among participants with a positive family history of spectacle use were 4.75 times higher compared with those who had no family history of spectacle use (AOR=4.75, 95% CI 2.31, 9.75) (table 3).

    View this table:
    Table 3

    Factors associated with knowledge about spectacle use among adults in Debre Birhan Town, North Shewa, Ethiopia, 2023 (N=1022)

    Factors associated with attitude towards spectacle use

    In the bivariable binary logistic regression analysis, female gender, older age, higher educational level (secondary school and college and above), occupational status (being a merchant, a housewife or unemployed), history of eye examination, history of spectacle use, history of self-reported vision reduction, history of cataract surgery, family history of spectacle use and knowledge about spectacle use were significantly associated with attitude towards spectacle use. However, the multivariable logistic regression analysis revealed that educational status, history of spectacle use, family history of spectacle use and knowledge of spectacle use were significantly associated with attitude towards spectacle use.

    The odds of having favourable attitude among those who had higher educational level (college and above) were 2.56 times higher compared with those who could not read and write (AOR=2.56, 95% CI 1.26, 5.21). The odds of having favourable attitude among those who had a positive history of spectacle use were 3.22 times higher than those who had no history of spectacle use (AOR=3.22, 95% CI 1.58, 6.55). The odds of having favourable attitude among those who had a positive family history of spectacle use were 1.89 times higher compared with those who had no family history of spectacle use (AOR=1.89, 95% CI 1.13, 3.16). The odds of having favourable attitude among those who had adequate knowledge about spectacle use were 4.63 times higher than those who had inadequate knowledge about spectacle use (AOR=4.63, 95% CI 2.69, 7.98) (table 4).

    View this table:
    Table 4

    Factors associated with attitude towards spectacle use among adults in Debre Birhan Town, North Shewa, Ethiopia, 2023 (N=1022)

    Discussion

    In this study, about 86.01% (95% CI 83.88, 88.14) of the study participants had adequate knowledge about spectacle use. This is lower than the studies conducted in Gondar, Ethiopia (90.6%),9 South Africa (94%)22 and India (92%).16 The difference could be because sociodemographic characteristics, ocular history and study population vary from country to country. For instance, in the study done in Gondar, Ethiopia, the number of spectacle users was higher than in the current study,9 which led to an overestimation of the proportion of those with adequate knowledge in Gondar. The use of spectacles has been shown to have a major impact on knowledge of spectacle use.13 31 Furthermore, the studies in India and South Africa were conducted among participants with high educational status, with the Indian study including secondary school students and the South African study including university students. Therefore, different levels of education of study participants could lead to different levels of knowledge about spectacle use. Knowledge about spectacle use is influenced by participants’ level of education.8 9 16 22 32

    In contrast, the result of the present study is higher than those conducted in Egypt (67%),33 Ghana (38.5%),13 Nigeria (38%),34 Saudi Arabia (23%),14 China (33.3%)31 and Indonesia (20%).8 This difference could also be due to variations in study setting and study population. The study in Saudi Arabia was conducted among women, while in the present study most of the participants were men who can easily obtain information about spectacles from their colleagues and from trainings compared with women, resulting in the high proportion of individuals with adequate knowledge about spectacle use.34 35

    The odds of having adequate knowledge about spectacle use among study participants who had a higher level of education (college and above) were 2.65 times higher than those who were unable to read and write. This finding is consistent with the findings of the studies conducted in Gondar, Ethiopia9 and Indonesia.8 This association might be because individuals with a high level of education are more likely to attend health education programmes, understand written and visual documents, and approach different sources of information that builds knowledge about spectacle use.36 It has been suggested that all stakeholders, particularly the ministers of health and education, collaborate on implementing a plan to educate students about eye health issues at all levels of education, with the aim of reducing the impact of visual impairment resulting from presbyopia and refractive errors by ensuring appropriate use of spectacles.

    Age was significantly associated with having adequate knowledge about spectacle use. As age increases by one unit, the odds of having adequate knowledge about spectacle use increase by 1.21 times. This is in line with other research conducted in Nigeria37 and Indonesia.8 This association might be because older people are more likely to be presbyopic38 39; they need spectacles for near vision. This exposes to those population to get enough information about their spectacles.8

    The odds of having adequate knowledge about spectacle use among study participants who had a positive history of spectacle use were 3.20 times greater than those who did not use spectacles. This finding is supported by studies conducted in Ghana13 and China.31 This might be due to spectacle users seeing the advantages of spectacle use, such as in improving their vision or providing protection. The methods of wearing spectacles may be explained to patients before dispensing them, so respondents may understand what spectacle use is. This implies the need for eye care education, especially on the use of spectacles, when providing them to certain individuals.

    The odds of having adequate knowledge about spectacle use among study participants with a family history of spectacle use were 4.75 times higher compared with those who had no family history of spectacle use. This is in line with the findings of the studies conducted in Nigeria12 and Swaziland.40 This might be due to the chance of obtaining information from family experiences about the advantages of spectacle use.12 This implies the need for eye care education, particularly on use of spectacles, when providing them to certain individuals.

    In the present study, the proportion of adults with favourable attitude towards spectacle use was 85.32% (95% CI 83.15, 87.50). This finding is lower than the studies conducted in Gondar (90.4%)9 and India (99.2%).6 This may be due to the higher knowledge about spectacle use among the population in those studies, as attitude is influenced by knowledge.8 9 Moreover, in India, eye health information and eye care centres are easily accessible,41 which can influence people’s attitude towards spectacle use, thus facilitating a positive attitude.

    In contrast, the finding of the present study was higher than the studies performed in Nigeria (36%, 61.62%),34 42 India (23.5%),43 Oman (53.5%)15 and Indonesia (50%).8 The difference could also be due to variations in study population. In previous studies, the participants were between 15 and 35 years old, whereas in the present study most of the participants were older than 35 years old and were more likely to be presbyopic and thus more likely to use spectacles for near vision. As a result, their attitude towards spectacle use became favourable as practice changed.38 39

    The odds of having favourable attitude among participants with a higher level of education (college and above) were 2.56 times higher than those who cannot read and write. This finding is supported by studies in Gondar,9 Oman15 and Indonesia.8 This might be because with higher educational level, people might be highly concerned about their vision and thus may use spectacles to improve their vision. They may also have good attitude towards use of spectacles. Moreover, their visual needs may also be a factor for these educated groups, which prompts them to be spectacle users.44 This implies that stakeholders, especially the Ministry of Health and Education, should develop a plan to provide eye health education at all levels of education, with the aim of reducing the impact of visual impairment resulting from refractive errors and presbyopia by ensuring adequate information is provided about spectacles and their proper usage.

    The odds of having a favourable attitude among participants with a positive history of spectacle use were 3.22 times higher compared with those who did not have a positive history of spectacle use. This is supported by studies performed in Ghana13 and Saudi Arabia.14 This might be because when individuals use spectacles, they improve their vision and they receive advice when spectacles are dispensed. This finding implies that properly distributed spectacles for correction or protection can result in a positive attitude towards their use.

    The odds of having a favourable attitude among participants with a family history of spectacle use were 1.89 times higher compared with those who did not have a family history of spectacle use. This is supported by studies performed in Nigeria12 and Indonesia.8 Parents who wear spectacles were more likely to allow their family members to wear spectacles.12 This result indicates that optometrists or opticians should exert extra effort to provide the necessary corrective or protective glasses, and that trust should be established between individuals who need spectacles and the professionals who provide them.

    The odds of having a favourable attitude among participants with adequate knowledge about spectacle use were 4.63 times higher compared with those who had inadequate knowledge about spectacle use. This is in agreement with the findings of studies conducted in Gondar9 and Indonesia.8 This might be due to individual knowledge improvement, which can positively change the attitude of participants towards spectacle use.8 15 This further implies that having sufficient information is necessary to develop a positive attitude towards use of spectacles and that it requires a multidisciplinary approach to raise awareness about spectacles and their usage.

    Strengths and limitations of this study

    This study provides up-to-date evidence on the proportion of adults with knowledge and attitude towards spectacle use and the associated factors among those living in Northeast Ethiopia, with the aim of reducing ocular hazards related to ultraviolet rays as well as visual impairments resulting from refractive error and presbyopia. Being a cross-sectional study, this study can show the temporal relationship between the associated factors and the knowledge and attitude towards spectacle use rather than the actual cause–effect relationship. Although the study involves the general population, the results did not specifically address the attitudes and knowledge of adults who use spectacles to correct refractive errors or presbyopia, or the parents/guardians of children who use them for the same purpose. Furthermore, this study mainly focuses on quantitative information, but limited information on the qualitative aspects and their impact relationship.

    Conclusion

    This study revealed a good proportion of adults having adequate knowledge and favourable attitude towards spectacle use. Increasing age, higher level of education, positive history of spectacle use and family history of spectacle use were significantly associated with having adequate knowledge of spectacle use. In addition, higher educational status, positive history of spectacle use, family history of spectacle use and adequate knowledge of spectacle use were positively associated with having favourable attitude towards spectacle use. We recommend strengthening the existing knowledge and attitudes towards spectacle use by disseminating information among individuals with low levels of educational status during community meetings. It is also recommended that both large-scale qualitative and quantitative comparative cross-sectional studies be conducted to better estimate the prevalence of knowledge and attitude towards spectacle use and the associated factors.

    Data availability statement

    Data are available upon reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Ethical Review Committee of the University of Gondar College of Medicine and Health Sciences, Comprehensive and Specialized Hospital and the School of Medicine. A letter of support was provided by the administration of Debre Birhan. Verbal informed consent was obtained from all participants after detailed explanation of the purpose of the study. Verbal informed consent was approved by the Ethical Review Committee of the University of Gondar (ethical approval number 622/05/2023). All included participants were informed of their right to withdraw from the study at any time during the interview. No risk was taken for the selected study participants. Confidentiality was maintained by not using personal identifiers in the data collection tools and using password-protected data on a computer. Participants gave informed consent to participate in the study before taking part.

    Acknowledgments

    We would like to express our appreciation to the study participants for their willingness to participate in this study. We also would like to acknowledge the dedicated data collectors.

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    Supplementary materials

    Footnotes

    • Contributors MMB conceptualised the research design, formulated the research questions, takes full responsibility for the work, designed and implemented the research methodology, and conducted extensive reviews of the manuscript. NFA and ASA contributed to refining the research objectives and conceptualisation of the study, conducted statistical analyses and interpreted the results. NFA, ASA and TCZ assisted in refining the methodological approach and the methodological decisions, led the data collection efforts, organised and managed the data sets, and ensured data quality and integrity. MTT and AFS conducted statistical analyses, interpreted the results, drafted the initial manuscript, outlined the research background, methodology and results, and reviewed the manuscript. MMB acts as the guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.