Kouotou et al.

BMC Dermatology (2017) 17:1

DOI 10.1186/s12895-017-0053-x

RESEARCH ARTICLE Open Access

Knowledge, attitudes and practices of the

medical personnel regarding atopic
dermatitis in Yaoundé, Cameroon
Emmanuel Armand Kouotou1,2,3*, Jobert Richie N. Nansseu4, Alexandra Dominique Ngangue Engome1,2,
Sandra Ayuk Tatah2,5 and Anne Cécile Zoung-Kanyi Bissek1

Abstract
Background: Atopic dermatitis (AD) is a chronic, relapsing and pruritic inflammatory skin disease whose management
remains unclear to most non-dermatologists. This study aimed to assess the knowledge, attitudes and practices (KAP)
of the medical staff regarding AD in Yaoundé, Cameroon.
Methods: This was a cross-sectional study conducted from January to April 2014 in 20 health facilities located in
Yaoundé, the capital city of Cameroon. All medical staff who provided their consent were included in the study.
A score was established for each of the KAP categories, and subsequently grouped into 4 classes considering a
score <50, 50-<65, 65-<85 or ≥85%, respectively.
Results: We enrolled 100 medical personnel, 62% of whom were females. Overall, the level of knowledge on AD
was moderate (65%). Allergy was the main cause of AD, stated by 64% of participants. Only 43% personnel cited
the genetic cause. Asthma was mentioned by 78% as an associated pathology. Regarding attitudes, the majority
(84%) thought that AD is equally common among Black and Caucasian populations; 42% of participants believed
that evolution is favorable when appropriate medical treatment is prescribed. These attitudes were considered
wrong (64%). Similarly, the general level of practice was inadequate: 50%.
Conclusion: Levels of knowledge, attitudes and practices of the medical staff regarding AD were poor, implying
that management of this condition is non optimal in our setting.
Keywords: Atopic dermatitis, KAP study, Medical staff, Cameroon

Background Onset of this condition occurs mostly in the first

Atopic Dermatitis (AD) is a chronic, relapsing and months of life. Indeed, 60–70% of cases start before the
pruritic inflammatory skin disease [1]. It is a condition age of 6 months. Mesrati et al. in a pediatric dermatol-
that predominantly affects children especially of a cer- ogy unit in Tunisia noticed that 7.5% of consultations
tain age, in developed countries and increasingly in the concerned AD [3], which contrasts with a prevalence of
developing world. An epidemiological study conducted 10–25% reported in Western countries [4]. The young
at the Yaoundé General Hospital (Cameroon) by Zoung- and immature immunity of the child underlies this in-
Kanyi et al. found that allergic skin diseases were more creased susceptibility to outbreaks of AD, and conse-
common in children aged 0–5 years with AD as the quently the high prevalence of AD in this age group.
leading one [2]. Indeed, AD is caused by defects in epidermal and cuta-
neous barriers which allow penetration of environmental
molecules in contact with the skin. This results in a
* Correspondence: kouotoea@yahoo.fr; kearm_tosss@yahoo.fr
1
cutaneous inflammaxtion of which T-cells are respon-
Department of Internal Medicine and Specialties, Faculty of Medicine and
Biomedical Sciences, University of Yaoundé I, P.O. Box: 8314, Yaoundé,
sible, directed against environmental allergens (extrin-
Cameroon sic AD) and/or cutaneous auto-antigens (intrinsic AD).
2
Yaoundé University Teaching Hospital, Yaoundé, Cameroon Moreover, AD can occur either in a context of atopy
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Kouotou et al. BMC Dermatology (2017) 17:1 Page 2 of 7

(predisposition to atopic states, known as extrinsic AD) participants and confidentiality of collected data were
or not (intrinsic AD) [5]. respected.
Evolution of the disease remains difficult to appreci- This study used as reference model the international
ate over years, although an improvement of signs is consensus on management of AD [6]. An anonymous
observed in regularly monitored patients. In fact, AD is pre-tested and standardized questionnaire was used for
usually characterized by surges and remissions at un- data collection. All participants received the question-
predictable frequencies, varying from one person to naire to be filled; then the investigator returned on an
another with or without the influence of any driving appointed day to retrieve the questionnaire, after en-
factor, making it difficult to infer on the final issue. Fol- suring that this has been properly and extensively
lowing the exponential increase in AD in both devel- completed. The questionnaire, in addition to questions
oped and developing countries, restructuring of various about age, gender, specialty and seniority in job/work
aspects of its management has become essential to pre- experience, consisted of a set of 45 questions divided
vent complications. into three parts:
But prior to this restructuring, an assessment of the
knowledge and practices of the medical staff is mandatory, – Knowledge: theoretical clinical knowledge (primary
which will identify their weaknesses and subsequently lesions, localization, associated pathologies, causes);
enable improvement of their capacities. To the best of clinical knowledge based on recognition of
our knowledge, no study has already assessed the iconography (Additional file 1); knowledge on
knowledge, attitudes and practices (KAP) of the medical prevention (information or advice to give to
personnel towards AD in Cameroon, a developing coun- patients/parents in order to prevent an AD
try. With the ultimate goal of improving the manage- surge/relapse);
ment of AD in Cameroonian hospitals, we undertook – Attitudes: perceptions of medical staff regarding the
the present study which purposed to assess the KAP of frequency of AD (specifically depending on race),
medical professionals practicing in Yaoundé (Cameroon) evolution of AD with treatment, contribution of
with respect to AD. relatives in AD management and capacity of medical
personnel to efficiently manage AD in our setting;
Methods – Practice: number of cases of AD seen during
From January to April 2014, we conducted a cross- consultations, prescription given for surges/relapses,
sectional study including the medical staff practicing route of administration of prescribed drugs,
in the city of Yaoundé. Five out of the seven existing frequency of drug administration and monitoring
health districts of Yaoundé were selected for this of treatment.
study and a total of 20 health facilities were visited.
The choice of health districts and health facilities was The paper from Essi et al. on KAP studies [7] was used
arbitrary, taking into account the convenience for the to establish scores for each part of the questionnaire.
investigators and accessibility of health facilities. The According to the sections (Knowledge, Attitudes, and
study population was comprised medical staff respon- Practice), the categories are distributed as follows:
sible for consultations in the selected health facilities:
doctors (general practitioners and specialists/pediatri- – Knowledge: very poor (score <50%); poor (score:
cians) and nurses. At each visit to the study sites, all ≥50 and <65%); moderate (score: ≥65 and <85%);
consulting staff irrespective of sex, seniority/experi- good (score ≥85%);
ence, who consented to participate, were included. – Attitudes: harmful (score <50%); wrong (score: ≥50
Our sampling was consecutive throughout the study and <65%); approximate (score: ≥65 and <85%);
period. right (score ≥85%);
Before the study began, an ethical clearance was ob- – Practices: harmful (score <50%); inadequate (score:
tained from the Ethical Review Board of the Faculty ≥50 and <65%); average (score: ≥65 and <85%);
of Medicine and Biomedical Sciences of the University adequate (score ≥85%).
of Yaoundé I, Cameroon. Authorizations were equally
issued by health authorities of the selected health dis- Data were recorded and coded using Microsoft Excel
tricts as well as directors of selected health facilities. 2007, then analyzed with SPSS v. 20 (IBM SPSS Inc.,
The procedures were in compliance with the current Chicago, Illinois, USA). Results are presented as frequency
revision of Helsinki Declaration. All aspects and pro- (percentage) for categorical variables and mean ± standard
cedures of the study were fully presented to each deviation (SD) for quantitative variables. To compare
potential participant, and we included only those who qualitative variables, we used the chi-square test. The level
voluntarily signed the consent form. Anonymity of of statistical significance was set at p <0.05.
Kouotou et al. BMC Dermatology (2017) 17:1 Page 3 of 7

Results Evolution
Characteristics of the study population Most participants 77% (77/100) described AD as a chronic
We included 100 participants, predominantly females disease; 54% (54/100) thought the condition is rather
(62/100; 62.0%), giving a M/F sex ratio of 0.6/1. Our acute and 46% (46/100) thought it is both acute and
sample consisted of specialists (40/100; 40%), namely chronic (Table 1).
pediatric residents (20/100; 20%) and pediatricians (20/
100; 20%), general practitioners (38/100, 38%) and State Theoretical clinical knowledge
Registered Nurses (22/100; 22%). Primary lesions in AD
Concerning primary lesions of AD, the majority of health
Knowledge care providers cited xerosis cutis (86%; 86/100), erythema
General knowledge (81%; 81/100) and desquamation (58%; 58/100) as the
Definition of AD main signs observed in AD (Table 2).
The majority of participants (75/100; 75%) were able to
accurately define AD (Table 1). Sites in infants and young adults
In infants (0–5 years old), participants declared that the
Associated pathologies face (44/100; 44%) and torso (48/100; 48%) were the
In our series, 78% (78/100) and 58% (58/100) respect- most likely localizations for AD (Table 2). On the other
ively thought that asthma and conjunctivitis can occur hand, the face (76/100; 76%) and trunk (58/100; 58%)
in a patient with AD (Table 1). were declared not to be privileged sites of AD in young
adults (25–34 years old). Also, a little over half of par-
Causes ticipants (59/100; 59%) believed the lower limbs were a
Allergy was cited as the main cause of AD by 64% (64/100) preferred site of AD lesions in adults (35 years old and
of our participants, and genetics by 43% (43/100) (Table 1). above) (Table 2).
Table 1 General knowledge of medical staff
Question Right response Number (%) Wrong response Number (%)
General knowledge (N = 100)
Definition
AD is chronic and inflammatory 75 (75) 25 (25)
AD is chronic or inflammatory 7 (7) 93 (93)
AD is inflammatory and acute 13 (13) 87 (87)
AD is inflammatory or acute 2 (2) 98 (98)
I do not know 3 (3) 97 (97)
Associated pathologies
Asthma is an associated pathology 78 (78) 22 (22)
Conjunctivitis is an associated pathology 58 (58) 42 (42)
Chronic cough is an associated pathology 16 (16) 84 (84)
There is no associated pathology 12 (12) 88 (88)
Causes
The cause is psychological 2 (2) 98 (98)
The cause is allergic 64 (64) 36 (36)
The cause is genetic 43 (43) 57 (57)
The cause is infectious 18 (18) 82 (82)
I do not know 5 (5) 95 (95)
Evolution (n = 100)
Evolution could be acute 54 (54) 46 (46)
Evolution could be chronic 77 (77) 23 (23)
Evolution is acute and chronic 46 (46) 54 (54)
Evolution is exclusively acute 1 (1) 99 (99)
Evolution is exclusively chronic 14 (14) 86 (86)
Kouotou et al. BMC Dermatology (2017) 17:1 Page 4 of 7

Table 2 Clinical theoretical knowledge as medical personnel

Question Right response Number (%) Wrong response Number (%)
Theoritical clinical knowledge (n = 100)
Primary lesions
Xerosis cutis is a sign of AD 86 (86) 14 (14)
Erythema is a sign of AD 81 (81) 19 (19)
Desquamation is a sign of AD 58 (58) 42 (42)
Diffuse ulcerations is are signs of AD 17 (17) 83 (83)
Moist skin is a sign of AD 13 (13) 87 (87)
Cyanosis is a sign of AD 2 (2) 98 (98)
Sites in children (0–5 years old)
The face is a site of AD 44 (44) 56 (56)
The torso is a site of AD 48 (48) 52 (52)
The lower limb is a site of AD 32 (32) 68 (68)
Sites in adults (25 years old and above)
The face is a site of AD 24 (24) 76 (76)
The torso is a site of AD 42 (42) 58 (58)
The upper limb is a site of AD 79 (79) 21 (21)
The lower limb is a site of AD 41 (41) 59 (59)

Clinical knowledge based on iconography Practice

Pictures 1 (80/100; 80%), 4 (75/100; 75%) and 5 (67/100; Of the 100 participants, 91% (91/100) reported having
67%) were selected for the diagnosis of AD while pictures encountered cases of AD during consultations. Table 4
9 (15/100; 15%), 11 (15/100; 15%) and 13 (20/100; 20%) shows their usual practice for every patient with this
were not (Additional file 1). pathology.
Half of our sample (51/100; 51%) said they had received
Prevention between 1 and 10 cases of AD per month at their consul-
The majority of participants (95/100; 95%) said they provide tations while 25% (25/100) reported having consulted
patients with advice and information about prevention. Fur- more than 20 cases of AD.
thermore, 91 (91) and 88 (88%) participants thought that Over half (79/100) of our sample chose to prescribe a
cotton clothing are recommended and a relapse requires a medication for a patient with AD.
new consultation, respectively. When a patient came to consult for AD, 88% (88/100) of
the staff prescribed corticosteroids, most often topical (80/
Attitudes 83; 96.4%) and to be applied 2 times a day (46/88; 52.3%).
Occurrence of AD based on race
Management of xerosis cutis and pruritus
AD is a disease that affects both Blacks and Caucasians
alike according to 84% (84/100) of the medical staff. Xerosis cutis was supposed to be treated as declared by
81% (81/100) of the staff interviewed. For complaints of
pruritus, 90% (90/100) of participants prescribed anti-
Opinion on evolution of AD
histamines and frequently associated antihistamines
For 59% (59/100) of our sample, AD is a disease which and corticosteroids, 63% (63/100) (Table 4).
evolves towards complete remission when patients receive
the right treatment (Table 3). Association of knowledge, attitudes and practices
of medical staff
Patient care by the relatives Score of knowledge among medical staff
A total of 42 participants (42%) thought that patients The level of knowledge was conditioned by experience
could be taken care of by their relatives (Table 3). of the specialists. Indeed, more than half of pediatricians
had a moderate level of knowledge (14/20; 70%), while
Management in our setting 50% of residents had a poor level of knowledge (10/20;
In our series, 85% (85/100) thought that management of 50%). General practitioners had poor to moderate levels
AD could be adequately provided in our setting (Table 3). of knowledge about AD (Table 5).
Kouotou et al. BMC Dermatology (2017) 17:1 Page 5 of 7

Table 3 Attitudes of medical personnel

Question Right response Number (%) Wrong response Number (%)
Opinion on occurrence of ad depending on race (N = 100)
AD mostly affects Blacks 3 (3) 97 (97)
AD equally affects Caucasians and Blacks 84 (84) 16 (16)
No idea 13 (13) 87 (87)
Opinion on the evolution of ad with treatment (N = 100)
Discouraging evolution 21 (21) 79 (79)
Favorable evolution 59 (59) 41 (41)
No idea 20 (20) 80 (80)
Opinion on contribution of relatives in management of ad (n = 100)
Discouraging contribution 28 (28) 72 (72)
Favorable contribution 42 (42) 58 (58)
No idea 30 (30) 70 (70)
Opinion on ability to adequately manage ad in our setting (N = 100)
AD can be managed 85 (85) 15 (15)
AD cannot be managed 7 (7) 93 (93)
No idea 8 (8) 92 (92)

Score for attitudes among medical staff

Table 4 Practice of medical staff in case of AD relapses Less than half (40/100) of pediatricians had a right attitude
Question Right Response Number (%)
towards AD, Fifty percent of pediatric residents had an ap-
Number ad cases seen during consultations (N = 100)
proximate score, General practitioners had approximate
1-10 cases 51 (51) to harmful attitudes and nurses had approximate attitudes
11-20 cases 13 (13) in relation to AD (Table 5).
> 20 cases 25 (25)
No cases 11 (11) Score for practices among medical staff
*
Drug prescription for ad relapse (N = 100) Practices by all the professional categories were inadequate
Corticosteroids 88 (88) (Table 5).
Antihistamines (AH) 64 (64) After making an overall score for each parameter
Antifungal 14 (14)
(knowledge, attitudes and practices), we observed that
the medical staff of Yaoundé had a moderate level of
Antibiotics 12 (12)
knowledge (65%) with wrong attitudes (64%) and inad-
Corticosteroids + AH 56 (56)
equate practices (50%) concerning AD.
Management of xerosis cutis: yes 81 (81)
Drug prescription in case of pruritus
Discussion
Antihistamines (AH) 90 (90) This study on AD enabled us to assess the knowledge of
Corticosteroids + AH 63 (63) medical professionals, their attitudes and clarify their
*
Administration route of corticosteroids (N = 100) different practices. A total of 100 subjects agreed to an-
Oral 17 (20.2) swer the questionnaire. Levels of knowledge, attitudes and
Topical 80 (96.4) practices were respectively 65%, 64% and 50%. It clearly
Oral + Topical 12 (70.6) appears thus that urgent measures need to be taken to
Administration modalities of topical corticosteroids (n = 88) strengthen our medical staff capacities in order to improve
1 application/day 38 (43.2)
management of AD in Cameroonian hospital settings.
2 applications/day 46 (52.3)
Knowledge of the medical staff
3 applications/day 4 (4.5)
Overall, most of the medical personnel had already
Duration of the topical corticosteroid treatment (N = 100)
heard about AD and was able to define it correctly. They
< 2 weeks 43 (43)
were also able to recognize the characteristic lesions of
2 weeks 30 (30) the condition, probably as a result of their experience.
1 month 12 (12) The most frequently mentioned cause of AD was allergy
> 1 month 0 (0) (64%) in contrast to the genetic cause (43%). These re-
*
More than one answer was possible sults are significantly different from those found in the
Kouotou et al. BMC Dermatology (2017) 17:1 Page 6 of 7

Table 5 Scores of health care personnel according to the professional category

Consultant* Scores**
very poor/harmful/harmful poor/wrong/inadequate moderate/approximate/average good/right/adequate
K A P K A P K A P K A P
Pediatricians 0 (0) 0 (0) 4 (20) 4 (20) 6 (30) 16 (80) 14 (70) 6 (30) 0 (0) 2 (10) 8 (40) 0 (0)
Residents 0 (0) 4 (20) 5 (25) 10 (50) 5 (25) 15 (75) 9 (45) 10 (50) 0 (0) 2 (5) 1 (5) 0 (0)
General practitioners 1 (2.6) 10 (26.3) 15 (39.5) 18 (47.4) 12 (31.6) 23 (60.5) 18 (47.4) 10 (26.3) 0 (0) 0 (0) 6 (15.8) 0 (0)
Nurses 2 (9.1) 2 (9.1) 9 (41.0) 11 (50) 2 (9.1) 12 (54.5) 9 (45) 7 (31.8) 1 (4.5) 1 (0) 11 (50) 0 (0)
Total 3 (3) 16 (16) 33 (33) 43 (43) 25 (25) 66 (66) 50 (50) 33 (33) 1 (1) 4n 26 (26) 0 (0)
*Figures represent the number (percentage); **The scores were classified into: very poor/harmful/harmful = less than 50%; poor/wrong/inadequate = less than 65%;
moderate/approximate/average = less than 85%; good/right/adequate = more than 85% correct answers; K = Knowledge; A = Attitude; P = Practice

French national survey of professional practices on the by the dearth of information on AD in our setting where
treatment of AD [8]. In this survey, the genetic cause it is considered a foreign pathology.
was indeed cited by almost all; regarding the allergic
cause, two sources were cited by the different categories Attitudes and practices of the medical staff
of professionals (allergists, dermatologists, general practi- Half of our prescribers reported meeting between 1 and
tioners and pediatricians), namely food and inhaled aller- 10 cases of AD per month at consultations while only
gens [8]. The psychological cause meanwhile was rarely 25% had already received more than 20 cases/month.
mentioned by those participating in our survey, which This result is contrary to those from the French survey
mirrors findings from the French national survey indi- where among various professional categories, 2 (pediatri-
cating that 80% of physicians rarely or never suggested a cians and allergists) saw more than 30 cases per month
psychological cause [8]. while only half of GPs (55%) saw less than 10 cases of
The medical staff demonstrated some confusion when AD per month [8]. AD is a disease that equally affects
asked about chronicity of AD because 77% of the staff Blacks and Caucasians according to 84% of our sample,
declared that evolution could be chronic while 14% said a somewhat contradictory result given that only 54% said
it was exclusively chronic. Furthermore, half of our they had not encountered many cases.
sample thought that this evolution could be acute. This For 59% of our participants, AD usually has a favor-
significant confusion could be explained by the fact that able evolution when properly treated whereas 21% felt
in AD, the pruritic erythema is usually attributed to an the outcome is actually unfavorable. Yet, AD classically
acute pathology. involves intermittent periods of relapse and recovery
The medical staff had average knowledge on preven- even when properly treated. Overall, the staff had wrong
tion. Pure cotton clothing was proposed by 90% of the attitude in relation to AD.
staff as a preventive method. This choice of clothing is In case of AD relapses, our medical staff most frequently
one of the recommendations of the 2005 consensus on said they prescribe corticosteroids; 80% of these partici-
the management of AD in children [6]. Most often, the pants chose a topical corticosteroid, which is higher than
staff believed a patient must return for consultation at those of the French study where dermatologists and gen-
every relapse of AD (87%) while 15% thought that the eral practitioners generally prescribed topical corticoster-
prescribed treatment would be sufficient to handle every oid as first-line treatment in 60% and 28% of cases,
relapse. Also, 63% of participants declared that moisturiz- respectively [8]. Moreover, in our study 56% reported pre-
ing body lotions were prescribed for prevention. Certainly scribing a corticosteroid and an antihistamine in case of
the 2005 consensus conference on the management of AD AD relapse but from the 2005 consensus conference on
is in favor of keeping the skin moisturized permanently; the treatment of AD, antihistamines have no place in the
however the medical professional must ensure that the treatment of AD [6]. The 2013 consensus from the experts
chosen lotion or cream is conducive for treatment of xero- recommends the use of sedating antihistamines in case of
sis cutis [6]. Furthermore 54% of our participants encour- intense pruritus [9].
aged the use of antiseptic solutions for baths which is in Regarding the application of topical corticosteroid, half
contradiction with the 2013 consensus on AD, bolstering of medical staff recommended 2 applications per day
that the use of antiseptics for baths is indicated only for while only 42% thought that the application of a topical
superinfected AD [9]. The moderate level of knowledge corticosteroid once daily would be sufficient. According to
on AD in our sample (65%) already predicted an inappro- Aubert et al., the use of corticosteroids differs depending
priate management of the condition. This can be justified on symptomatic variations in the patient and should be
reasonable in order to avoid the risk of dependence or
Kouotou et al. BMC Dermatology (2017) 17:1 Page 7 of 7

addiction [10]. Xerosis cutis is the sign in AD which Competing interests

prompted prescription of a treatment in 81% of our The authors declare that they have no competing interests.

sample. Almost all prescribers said pruritus requires Consent for publication
prescription of an antihistamine. Also, a combination of Not applicable.
antihistamines and corticosteroids is systematic according
Ethics approval and consent to participate
to 63% of participants, although the 2005 consensus on An ethical clearance was granted by the Ethical Review Board of the
AD states that administration of a topical corticosteroid Faculty of Medicine and Biomedical Sciences of the University of Yaoundé I,
alone would be effective because of its antipruritic and Cameroon. Authorizations were equally issued by health authorities of selected
health districts as well as directors of selected health facilities. All aspects and
anti-inflammatory properties [6]. Clearly, the medical procedures of the study were presented to each potential participant, and we
personnel adopted a poor practice in cases of AD most included only those who had voluntarily signed the consent form.
probably influenced by the moderate knowledge and in-
Author details
adequate attitude towards the condition. 1
Department of Internal Medicine and Specialties, Faculty of Medicine and
The non-random selection of health facilities and the Biomedical Sciences, University of Yaoundé I, P.O. Box: 8314, Yaoundé,
relatively small number of enrolled participants may consti- Cameroon. 2Yaoundé University Teaching Hospital, Yaoundé, Cameroon.
3
Biyem-Assi District Hospital, Yaoundé, Cameroon. 4Department of Public
tute limits to the generalization of our results. Furthermore, Health, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I,
many medical staff had not agreed to take part in this study Yaoundé, Cameroon. 5Department of Paediatrics and Specialties, Faculty of
and some were absent during our multiple visits to the Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé,
Cameroon.
facilities. Nevertheless, the use of the gradation developed
by Essi et al. [7] allowed us to have a clear idea of the level Received: 23 September 2016 Accepted: 7 February 2017
of knowledge, attitudes and practices of our participants.
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Acknowledgments
The authors gratefully acknowledge all the medical personnel who have
volunteered to participate in the present study.
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