Roseanne Turner - Academia.edu (original) (raw)
Papers by Roseanne Turner
South African Journal of Bioethics and Law
Background. The concept of empathy in students has gained significant attention in medical educat... more Background. The concept of empathy in students has gained significant attention in medical education. Whether implementing formal educational interventions to promote long-term and effective empathy levels leads to sustained increased empathy levels in students, is however less clear. Objectives. The study aimed to evaluate the trajectory of medical students’ self-perceived empathy levels during their 6-year MB ChB degree. Methods. A longitudinal, prospective study was conducted over 4 years. A cohort of 292 medical students was invited to participate. Participants completed the Jefferson Scale of Empathy for Students (JSE-S) at three intervals during their studies. The students attended two workshops related to empathic patient interactions during this time. The JSE-S mean score by age and gender was compared, making use of a linear regression model. Results. A total of 119 students completed the study. Students’ total empathy levels were similar during the first and the last measu...
African evaluation journal, Jan 30, 2020
'effectiveness principles', so that they are able to effectively guide programme implementation, ... more 'effectiveness principles', so that they are able to effectively guide programme implementation, be responsive to evolving social and community needs, and later evaluated to establish if (1) they are clear, meaningful and actionable, (2) they were followed and (3) if they led to the desired results Background: Principles-Focused Evaluation (P-FE) is a new evaluation methodology that allows for the evaluation of contextual adaptations to social innovations, which are being implemented in complex situations. Effectiveness principles guide programme implementation by providing direction for the programmes and can also be adapted to decide on choices. These same principles are evaluated. Objectives: Principles-Focused Evaluation appears to be a useful methodology to support the implementation of social innovation into different, dynamic and complex African systems. However, there are limited empirical reports about the application of this methodology. This article attempts to fill that gap and explores how effectiveness principles can be developed at the start of a developmental, utilisation-focused evaluation to guide project implementation. Method: This retrospective, exploratory case study of a successfully completed and evaluated project was guided by a classic case study methodology. Data were extracted from programme and evaluation reports and interviews in an attempt to identify explicit and implicit values and norms. Results: The values thus obtained were reformulated into effectiveness principles by applying the GUIDE framework. Conclusion: The development of effectiveness principles is essential for P-FE. The process of identifying and articulating effectiveness principles at the start of this project was useful to ensure that both the evaluator and the stakeholders had a thorough understanding of the programme and were fully engaged.
Clinical transplantation, Aug 1, 2013
BackgroundPublished literature suggests that attitudes toward organ donation in South Africa are ... more BackgroundPublished literature suggests that attitudes toward organ donation in South Africa are generally positive. However, there has been a decline in the actual number of transplants taking place annually, which is not consistent with expressed positive attitudes.ObjectivesAssess the attitudes of a representative sample of the urban‐dwelling South African population toward organ donation and how these might affect transplant numbers.MethodsA structured questionnaire was utilized to measure attitudes among a study population of 1048 adults in five major metropolitan areas of South Africa. Field work was undertaken by supervised field workers. Written informed consent was obtained from all participants.ResultsEighty‐nine percent (89%) of respondents had heard of organ donation, and 77% indicated that they would accept an organ transplant if necessary. Seventy percent (70%) of respondents specified they would be willing to donate their own organs after death, while 67% expressed willingness to donate a relative's organs after death. Participants were more positive about kidney donation than any other organ.ConclusionPublic attitudes toward organ donation among this population are generally positive. Recommendations include cultural and linguistic sensitivity in educational and advertising campaigns, as well as extensive research into other possible causes of organ shortage.
African Journal of Primary Health Care & Family Medicine, Jan 31, 2019
Background: Changing global health and development trends have resulted in a need for continued p... more Background: Changing global health and development trends have resulted in a need for continued professional development (CPD) within the health and development sectors. In low-resource settings, where the need for training and CPD may be highest, there are significant challenges for disseminating information and skills. There is a need to improve mental health literacy and reduce levels of stigma about maternal mental illness. The Bettercare series of distance learning books provides a peer-based format for CPD. We aimed to evaluate the Bettercare Maternal Mental Health book as a format for CPD. Aim: The aim of this study was to determine whether the Bettercare Maternal Mental Health book significantly improves knowledge and decreases stigma around mental health for care providers from the health and social development sectors. Setting: One hundred and forty-one participants (social workers, nursing students and health professionals) were provided with the Bettercare Maternal Mental Health book to study. Methods: Before and after studying the book, the same multiple-choice knowledge test and the Mental Illness Clinicians' Attitude Scale were used to assess cognitive knowledge and mental health stigma, respectively. Results: Participants' knowledge showed a statistically significant (p < 0.001) improvement between the pre-and post-test results, for all six chapters of the book. However, participants' attitudes towards mental illness did not show a statistically significant change between the pre-and post-test results. Conclusion: We found that this method of learning elicited significant improvement in mental health knowledge for care providers. Continued professional development policy planners and curriculum developers may be interested in these findings.
South African Medical Journal, Jan 9, 2014
Transplantation is available in almost all major centres around the world. The principles are fai... more Transplantation is available in almost all major centres around the world. The principles are fairly standardised and outcomes are generally good. Transplantation is currently considered the treatment of choice for most patients with endstage organ failure. South Africa (SA) has an established track record in transplantation, as well as a network of active transplant programmes. [1] One of the major challenges in transplantation, both internationally and locally, is the shortage of donor organs. Several factors are thought to contribute to this problem in SA, including lack of public awareness about organ donation. Numerous strategies have been employed in an attempt to address this problem. These include promotions and advertising in the lay media and education programmes in schools and other institutions. [1] Despite these efforts, the overall number of transplants performed each year has decreased. [1] Of particular concern is a decrease in the consent rate among families of brain-dead potential donors, from 55% in 1991 to 50% in 2001 and 32% in 2011. [2] The question arises whether the decline in the consent rate for organ donation is related to changes in the attitudes of the general public towards transplantation. In a 1993 survey, [3] the majority of the study population expressed a willingness to donate both their own organs and the organs of a family member after death, should the circumstances arise. The aim of the present study was to repeat the 1993 survey as far as possible to ascertain whether public attitudes to organ donation in certain sectors of SA have changed. A cross-sectional study design and statistical analysis were employed.
Clinical Transplantation, 2013
Published literature suggests that attitudes toward organ donation in South Africa are generally ... more Published literature suggests that attitudes toward organ donation in South Africa are generally positive. However, there has been a decline in the actual number of transplants taking place annually, which is not consistent with expressed positive attitudes. Assess the attitudes of a representative sample of the urban-dwelling South African population toward organ donation and how these might affect transplant numbers. A structured questionnaire was utilized to measure attitudes among a study population of 1048 adults in five major metropolitan areas of South Africa. Field work was undertaken by supervised field workers. Written informed consent was obtained from all participants. Eighty-nine percent (89%) of respondents had heard of organ donation, and 77% indicated that they would accept an organ transplant if necessary. Seventy percent (70%) of respondents specified they would be willing to donate their own organs after death, while 67% expressed willingness to donate a relative's organs after death. Participants were more positive about kidney donation than any other organ. Public attitudes toward organ donation among this population are generally positive. Recommendations include cultural and linguistic sensitivity in educational and advertising campaigns, as well as extensive research into other possible causes of organ shortage.
South African Medical Journal, 2018
South African Medical Journal, 2016
This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.
African Journal of Primary Health Care & Family Medicine
African Evaluation Journal
'effectiveness principles', so that they are able to effectively guide programme implementation, ... more 'effectiveness principles', so that they are able to effectively guide programme implementation, be responsive to evolving social and community needs, and later evaluated to establish if (1) they are clear, meaningful and actionable, (2) they were followed and (3) if they led to the desired results Background: Principles-Focused Evaluation (P-FE) is a new evaluation methodology that allows for the evaluation of contextual adaptations to social innovations, which are being implemented in complex situations. Effectiveness principles guide programme implementation by providing direction for the programmes and can also be adapted to decide on choices. These same principles are evaluated. Objectives: Principles-Focused Evaluation appears to be a useful methodology to support the implementation of social innovation into different, dynamic and complex African systems. However, there are limited empirical reports about the application of this methodology. This article attempts to fill that gap and explores how effectiveness principles can be developed at the start of a developmental, utilisation-focused evaluation to guide project implementation. Method: This retrospective, exploratory case study of a successfully completed and evaluated project was guided by a classic case study methodology. Data were extracted from programme and evaluation reports and interviews in an attempt to identify explicit and implicit values and norms. Results: The values thus obtained were reformulated into effectiveness principles by applying the GUIDE framework. Conclusion: The development of effectiveness principles is essential for P-FE. The process of identifying and articulating effectiveness principles at the start of this project was useful to ensure that both the evaluator and the stakeholders had a thorough understanding of the programme and were fully engaged.
African Journal of Primary Health Care & Family Medicine
Background: Patient-centred care is a model of care that demands healthcare providers change thei... more Background: Patient-centred care is a model of care that demands healthcare providers change their focus from the disease to the patient and his or her perceived physical and psycho-social needs. This model requires healthcare workers to listen actively and to have effective communication skills and well-developed levels of empathy.Aim: The aim of this study was to determine the suitability of the Jefferson Scale for Empathy (JSE-S) as a valid test for empathy in third-year medical students at a South African university and also to determine the baseline level of empathy in this same group of students.Setting: The study took place at a medical school in the Western Cape, South Africa. This medical degree (MB ChB) is a 6-year programme. Students are first exposed to patients within their second year of training, but it is during their third-year that they start their clinical rotations. We wanted to test whether our empathy training would give students the necessary skills and enable...
African Journal of Primary Health Care & Family Medicine
Background: Changing global health and development trends have resulted in a need for continued p... more Background: Changing global health and development trends have resulted in a need for continued professional development (CPD) within the health and development sectors. In low-resource settings, where the need for training and CPD may be highest, there are significant challenges for disseminating information and skills. There is a need to improve mental health literacy and reduce levels of stigma about maternal mental illness. The Bettercare series of distance learning books provides a peer-based format for CPD. We aimed to evaluate the Bettercare Maternal Mental Health book as a format for CPD.Aim: The aim of this study was to determine whether the Bettercare Maternal Mental Health book significantly improves knowledge and decreases stigma around mental health for care providers from the health and social development sectors.Setting: One hundred and forty-one participants (social workers, nursing students and health professionals) were provided with the Bettercare Maternal Mental ...
Southern African Journal of Critical Care, Aug 1, 2007
Southern African Journal of Critical Care, Mar 7, 2008
A wide range of databases was searched including Medline, CINAHL and the Cochrane database. Furth... more A wide range of databases was searched including Medline, CINAHL and the Cochrane database. Further references were obtained from the reference lists of relevant articles and Lilly Laboratories provided data relating to the stability of insulin in solution and storage recommendations. Expert knowledge and experience were also considered. The data were graded according to the strength of evidence and recommendations made for clinical practice. These recommendations include using isotonic saline as the carrier, not preparing solutions in advance, remixing every 12 hours and priming the syringe and tubing before use. The use of a protocol is advisable but this is dependent on accurate measurement of blood glucose by properly trained staff. Capillary blood is adequate for most patients except for those who are in shock and on vasopressors. The signs of hypoglycaemia and hypokalaemia and the management of these complications are included.
Southern African Journal of Critical Care, Aug 6, 2008
South African Medical Journal, 2014
Transplantation is available in almost all major centres around the world. The principles are fai... more Transplantation is available in almost all major centres around the world. The principles are fairly standardised and outcomes are generally good. Transplantation is currently considered the treatment of choice for most patients with endstage organ failure. South Africa (SA) has an established track record in transplantation, as well as a network of active transplant programmes. [1] One of the major challenges in transplantation, both internationally and locally, is the shortage of donor organs. Several factors are thought to contribute to this problem in SA, including lack of public awareness about organ donation. Numerous strategies have been employed in an attempt to address this problem. These include promotions and advertising in the lay media and education programmes in schools and other institutions. [1] Despite these efforts, the overall number of transplants performed each year has decreased. [1] Of particular concern is a decrease in the consent rate among families of brain-dead potential donors, from 55% in 1991 to 50% in 2001 and 32% in 2011. [2] The question arises whether the decline in the consent rate for organ donation is related to changes in the attitudes of the general public towards transplantation. In a 1993 survey, [3] the majority of the study population expressed a willingness to donate both their own organs and the organs of a family member after death, should the circumstances arise. The aim of the present study was to repeat the 1993 survey as far as possible to ascertain whether public attitudes to organ donation in certain sectors of SA have changed. A cross-sectional study design and statistical analysis were employed.
South African Journal of Bioethics and Law
Background. The concept of empathy in students has gained significant attention in medical educat... more Background. The concept of empathy in students has gained significant attention in medical education. Whether implementing formal educational interventions to promote long-term and effective empathy levels leads to sustained increased empathy levels in students, is however less clear. Objectives. The study aimed to evaluate the trajectory of medical students’ self-perceived empathy levels during their 6-year MB ChB degree. Methods. A longitudinal, prospective study was conducted over 4 years. A cohort of 292 medical students was invited to participate. Participants completed the Jefferson Scale of Empathy for Students (JSE-S) at three intervals during their studies. The students attended two workshops related to empathic patient interactions during this time. The JSE-S mean score by age and gender was compared, making use of a linear regression model. Results. A total of 119 students completed the study. Students’ total empathy levels were similar during the first and the last measu...
African evaluation journal, Jan 30, 2020
'effectiveness principles', so that they are able to effectively guide programme implementation, ... more 'effectiveness principles', so that they are able to effectively guide programme implementation, be responsive to evolving social and community needs, and later evaluated to establish if (1) they are clear, meaningful and actionable, (2) they were followed and (3) if they led to the desired results Background: Principles-Focused Evaluation (P-FE) is a new evaluation methodology that allows for the evaluation of contextual adaptations to social innovations, which are being implemented in complex situations. Effectiveness principles guide programme implementation by providing direction for the programmes and can also be adapted to decide on choices. These same principles are evaluated. Objectives: Principles-Focused Evaluation appears to be a useful methodology to support the implementation of social innovation into different, dynamic and complex African systems. However, there are limited empirical reports about the application of this methodology. This article attempts to fill that gap and explores how effectiveness principles can be developed at the start of a developmental, utilisation-focused evaluation to guide project implementation. Method: This retrospective, exploratory case study of a successfully completed and evaluated project was guided by a classic case study methodology. Data were extracted from programme and evaluation reports and interviews in an attempt to identify explicit and implicit values and norms. Results: The values thus obtained were reformulated into effectiveness principles by applying the GUIDE framework. Conclusion: The development of effectiveness principles is essential for P-FE. The process of identifying and articulating effectiveness principles at the start of this project was useful to ensure that both the evaluator and the stakeholders had a thorough understanding of the programme and were fully engaged.
Clinical transplantation, Aug 1, 2013
BackgroundPublished literature suggests that attitudes toward organ donation in South Africa are ... more BackgroundPublished literature suggests that attitudes toward organ donation in South Africa are generally positive. However, there has been a decline in the actual number of transplants taking place annually, which is not consistent with expressed positive attitudes.ObjectivesAssess the attitudes of a representative sample of the urban‐dwelling South African population toward organ donation and how these might affect transplant numbers.MethodsA structured questionnaire was utilized to measure attitudes among a study population of 1048 adults in five major metropolitan areas of South Africa. Field work was undertaken by supervised field workers. Written informed consent was obtained from all participants.ResultsEighty‐nine percent (89%) of respondents had heard of organ donation, and 77% indicated that they would accept an organ transplant if necessary. Seventy percent (70%) of respondents specified they would be willing to donate their own organs after death, while 67% expressed willingness to donate a relative's organs after death. Participants were more positive about kidney donation than any other organ.ConclusionPublic attitudes toward organ donation among this population are generally positive. Recommendations include cultural and linguistic sensitivity in educational and advertising campaigns, as well as extensive research into other possible causes of organ shortage.
African Journal of Primary Health Care & Family Medicine, Jan 31, 2019
Background: Changing global health and development trends have resulted in a need for continued p... more Background: Changing global health and development trends have resulted in a need for continued professional development (CPD) within the health and development sectors. In low-resource settings, where the need for training and CPD may be highest, there are significant challenges for disseminating information and skills. There is a need to improve mental health literacy and reduce levels of stigma about maternal mental illness. The Bettercare series of distance learning books provides a peer-based format for CPD. We aimed to evaluate the Bettercare Maternal Mental Health book as a format for CPD. Aim: The aim of this study was to determine whether the Bettercare Maternal Mental Health book significantly improves knowledge and decreases stigma around mental health for care providers from the health and social development sectors. Setting: One hundred and forty-one participants (social workers, nursing students and health professionals) were provided with the Bettercare Maternal Mental Health book to study. Methods: Before and after studying the book, the same multiple-choice knowledge test and the Mental Illness Clinicians' Attitude Scale were used to assess cognitive knowledge and mental health stigma, respectively. Results: Participants' knowledge showed a statistically significant (p < 0.001) improvement between the pre-and post-test results, for all six chapters of the book. However, participants' attitudes towards mental illness did not show a statistically significant change between the pre-and post-test results. Conclusion: We found that this method of learning elicited significant improvement in mental health knowledge for care providers. Continued professional development policy planners and curriculum developers may be interested in these findings.
South African Medical Journal, Jan 9, 2014
Transplantation is available in almost all major centres around the world. The principles are fai... more Transplantation is available in almost all major centres around the world. The principles are fairly standardised and outcomes are generally good. Transplantation is currently considered the treatment of choice for most patients with endstage organ failure. South Africa (SA) has an established track record in transplantation, as well as a network of active transplant programmes. [1] One of the major challenges in transplantation, both internationally and locally, is the shortage of donor organs. Several factors are thought to contribute to this problem in SA, including lack of public awareness about organ donation. Numerous strategies have been employed in an attempt to address this problem. These include promotions and advertising in the lay media and education programmes in schools and other institutions. [1] Despite these efforts, the overall number of transplants performed each year has decreased. [1] Of particular concern is a decrease in the consent rate among families of brain-dead potential donors, from 55% in 1991 to 50% in 2001 and 32% in 2011. [2] The question arises whether the decline in the consent rate for organ donation is related to changes in the attitudes of the general public towards transplantation. In a 1993 survey, [3] the majority of the study population expressed a willingness to donate both their own organs and the organs of a family member after death, should the circumstances arise. The aim of the present study was to repeat the 1993 survey as far as possible to ascertain whether public attitudes to organ donation in certain sectors of SA have changed. A cross-sectional study design and statistical analysis were employed.
Clinical Transplantation, 2013
Published literature suggests that attitudes toward organ donation in South Africa are generally ... more Published literature suggests that attitudes toward organ donation in South Africa are generally positive. However, there has been a decline in the actual number of transplants taking place annually, which is not consistent with expressed positive attitudes. Assess the attitudes of a representative sample of the urban-dwelling South African population toward organ donation and how these might affect transplant numbers. A structured questionnaire was utilized to measure attitudes among a study population of 1048 adults in five major metropolitan areas of South Africa. Field work was undertaken by supervised field workers. Written informed consent was obtained from all participants. Eighty-nine percent (89%) of respondents had heard of organ donation, and 77% indicated that they would accept an organ transplant if necessary. Seventy percent (70%) of respondents specified they would be willing to donate their own organs after death, while 67% expressed willingness to donate a relative's organs after death. Participants were more positive about kidney donation than any other organ. Public attitudes toward organ donation among this population are generally positive. Recommendations include cultural and linguistic sensitivity in educational and advertising campaigns, as well as extensive research into other possible causes of organ shortage.
South African Medical Journal, 2018
South African Medical Journal, 2016
This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.
African Journal of Primary Health Care & Family Medicine
African Evaluation Journal
'effectiveness principles', so that they are able to effectively guide programme implementation, ... more 'effectiveness principles', so that they are able to effectively guide programme implementation, be responsive to evolving social and community needs, and later evaluated to establish if (1) they are clear, meaningful and actionable, (2) they were followed and (3) if they led to the desired results Background: Principles-Focused Evaluation (P-FE) is a new evaluation methodology that allows for the evaluation of contextual adaptations to social innovations, which are being implemented in complex situations. Effectiveness principles guide programme implementation by providing direction for the programmes and can also be adapted to decide on choices. These same principles are evaluated. Objectives: Principles-Focused Evaluation appears to be a useful methodology to support the implementation of social innovation into different, dynamic and complex African systems. However, there are limited empirical reports about the application of this methodology. This article attempts to fill that gap and explores how effectiveness principles can be developed at the start of a developmental, utilisation-focused evaluation to guide project implementation. Method: This retrospective, exploratory case study of a successfully completed and evaluated project was guided by a classic case study methodology. Data were extracted from programme and evaluation reports and interviews in an attempt to identify explicit and implicit values and norms. Results: The values thus obtained were reformulated into effectiveness principles by applying the GUIDE framework. Conclusion: The development of effectiveness principles is essential for P-FE. The process of identifying and articulating effectiveness principles at the start of this project was useful to ensure that both the evaluator and the stakeholders had a thorough understanding of the programme and were fully engaged.
African Journal of Primary Health Care & Family Medicine
Background: Patient-centred care is a model of care that demands healthcare providers change thei... more Background: Patient-centred care is a model of care that demands healthcare providers change their focus from the disease to the patient and his or her perceived physical and psycho-social needs. This model requires healthcare workers to listen actively and to have effective communication skills and well-developed levels of empathy.Aim: The aim of this study was to determine the suitability of the Jefferson Scale for Empathy (JSE-S) as a valid test for empathy in third-year medical students at a South African university and also to determine the baseline level of empathy in this same group of students.Setting: The study took place at a medical school in the Western Cape, South Africa. This medical degree (MB ChB) is a 6-year programme. Students are first exposed to patients within their second year of training, but it is during their third-year that they start their clinical rotations. We wanted to test whether our empathy training would give students the necessary skills and enable...
African Journal of Primary Health Care & Family Medicine
Background: Changing global health and development trends have resulted in a need for continued p... more Background: Changing global health and development trends have resulted in a need for continued professional development (CPD) within the health and development sectors. In low-resource settings, where the need for training and CPD may be highest, there are significant challenges for disseminating information and skills. There is a need to improve mental health literacy and reduce levels of stigma about maternal mental illness. The Bettercare series of distance learning books provides a peer-based format for CPD. We aimed to evaluate the Bettercare Maternal Mental Health book as a format for CPD.Aim: The aim of this study was to determine whether the Bettercare Maternal Mental Health book significantly improves knowledge and decreases stigma around mental health for care providers from the health and social development sectors.Setting: One hundred and forty-one participants (social workers, nursing students and health professionals) were provided with the Bettercare Maternal Mental ...
Southern African Journal of Critical Care, Aug 1, 2007
Southern African Journal of Critical Care, Mar 7, 2008
A wide range of databases was searched including Medline, CINAHL and the Cochrane database. Furth... more A wide range of databases was searched including Medline, CINAHL and the Cochrane database. Further references were obtained from the reference lists of relevant articles and Lilly Laboratories provided data relating to the stability of insulin in solution and storage recommendations. Expert knowledge and experience were also considered. The data were graded according to the strength of evidence and recommendations made for clinical practice. These recommendations include using isotonic saline as the carrier, not preparing solutions in advance, remixing every 12 hours and priming the syringe and tubing before use. The use of a protocol is advisable but this is dependent on accurate measurement of blood glucose by properly trained staff. Capillary blood is adequate for most patients except for those who are in shock and on vasopressors. The signs of hypoglycaemia and hypokalaemia and the management of these complications are included.
Southern African Journal of Critical Care, Aug 6, 2008
South African Medical Journal, 2014
Transplantation is available in almost all major centres around the world. The principles are fai... more Transplantation is available in almost all major centres around the world. The principles are fairly standardised and outcomes are generally good. Transplantation is currently considered the treatment of choice for most patients with endstage organ failure. South Africa (SA) has an established track record in transplantation, as well as a network of active transplant programmes. [1] One of the major challenges in transplantation, both internationally and locally, is the shortage of donor organs. Several factors are thought to contribute to this problem in SA, including lack of public awareness about organ donation. Numerous strategies have been employed in an attempt to address this problem. These include promotions and advertising in the lay media and education programmes in schools and other institutions. [1] Despite these efforts, the overall number of transplants performed each year has decreased. [1] Of particular concern is a decrease in the consent rate among families of brain-dead potential donors, from 55% in 1991 to 50% in 2001 and 32% in 2011. [2] The question arises whether the decline in the consent rate for organ donation is related to changes in the attitudes of the general public towards transplantation. In a 1993 survey, [3] the majority of the study population expressed a willingness to donate both their own organs and the organs of a family member after death, should the circumstances arise. The aim of the present study was to repeat the 1993 survey as far as possible to ascertain whether public attitudes to organ donation in certain sectors of SA have changed. A cross-sectional study design and statistical analysis were employed.