Assessment of factors Affecting adherence to recommended diet and exercise among

type II diabetic patient at yobe State specialist hospital Damaturu

BY

Binta bukar lawan

YOBE STATE UNIVERSITY DAMATURU, YOBE

STATE

SEPTEMBER,2025.
 Chapter one

1.1 Background to the study

Diabetes mellitus (DM) is a chronic metabolic disorder characterized by high blood

Sugar (hyperglycemia) resulting from insulin secretion, insulin action or both, it is a

Complex condition affect the body's ability to regulate glucose level properly (World

Health organization, 2021). Type II Diabetes is the most common type of diabetes that
accounts for about 90% of all diabetes cases in the world. Mostly T II D affecting adult as a
result of insufficient insulin production or ineffectiveness of produced insulin.

The prevalence of T II D had increased dramatically during the last decades.

Lifestyle changes such as balanced diet and physical exercise are important factors in achieving
good controlling on TII D and avoiding its long-term complication. Healthy dietary habit such as
minimizing the consumption of high glycemic foods, fat and carbohydrates will lead to reduce
the amount of needed insulin. Physical exercise also reduces blood glucose level there, by
reducing the amount of insulin needed and increasing insulin sensitivity. (Almutairi, K.M 2020)

Globally an estimated 537 million adults aged 2079 years are currently living with diabetes.
This represented 10.5% of the worlds population in this age group in [Link] projects that
the diabetes will be seventh leading cause of death in 2030 ( World Health Organization 2014).
The prevalence of diabetes in South East Asia is 8.5% where the highest prevalence is seen in
India with 8.8% (Ramachandran, Chamukuttan, Samith Shetty, & Nanditha, 2019). Diabetes
mellitus death in Nepal reached 6,482 of total death. The age adjusted death rate is 33.25%per
100,000 of population and Nepal ranks 77 in the world (World Life expectancy 2019).

African Countries are tackling multidimensional challenges from communicable diseases and
increasing trends of non-communicable diseases. Diabetes imposes an economic burden on
Africa, including catastrophic spending in controlling the disease at the individual level.
Diabetes is the priority disease that must be tackled to achieve the SDG target of reducing by
one third premature mortality from non-communicable diseases by 2030. An estimated 24
million people were living with diabetes in Africa in 2021, predicted to increase by 129% to 55
million by [Link] had the second lowest diabetes-related expenditure (US$ 13 billion),
accounting for 1% of global diabetes-related expenditure. In Africa, diabetes spending is health
care-associated for drugs, diagnosis, medical supplies and consultation. More than half (54%)
of people living with diabetes in the African Region are undiagnosed. only 36% of countries in
the African region have essential medicine for chronic disease in public hospitals, according to
2019 WHO survey. Data show's top 5 African countries with diabetes Age between 20_79years
; south Africa 4.2m, Nigeria 3.6m, united Republic of Tanzania 2.9m, Ethiopia 1.9m and
Democratic Republic of Congo 1.9m (Diabetes in Africa 2021). Nigeria the most populous
country in Africa, the prevalence of type II diabetes mellitus has high and still increasing with
the country widely reported as having Africa highest burden of diabetes (Wen, J., vermeire, E.,
Royen, P.V., sabbe, B., &Denekens, N., 2018). About 5 million people are still living with
diabetes in Nigeria while more than 1.56 million were recorded in 2015. Also 40,515 death in
adults due to diabetes were recorded (WHO, 2016). In Nigeria diabetes accounts for 3 to 15
percent of medical admission in most health facilities (Aguocha, Ukpabi, Onyeonoro , Njuka &
Ukegbu, 2017).

Diet and exercise are considered important for the treatment and tertiary prevention in type 2
diabetes, dietary and physical activity changes to produce a 5_7% weight loss successfully,
maintain glycemic control in people diagnosed with type II diabetes (International Diabetes
federation, 2017).Data shows that a Mediterranean is one of the best diet for diabetes
patients and meta- Analysis showed that higher adherence to Mediterranean is link to
cardiovascular disease improvement and reduce mortality. A balanced Mediterranean
emphasizes the consumption of appropriate fats, carbohydrate and proteins that can
contribute to the reduction of blood glucose and insulin resistance.

Self-care is an importance component in the management of type II diabetic patient. Self-care

management focuses on lifestyle adaptation (diet and physical exercise). Blood glucose
monitoring, medication use and foot and eye care. M. Omer, 2011. Non adherence to
management regimen particularly recommended diet and exercise should therefore be a
concern to all factors associated with it should be considered while caring for patient with
diabetes. Currently there is no known cure for diabetes but the major element in diabetes care
is adequate glycemic control which is achieved by strict adherence to medication, informed
dietary modification, appropriate physical exercise (Al Johani, A.A., Kendall,
G.E.,&Snider,P.D.,2017). In clinical practice both in developed and developing country, reports
have shown that diabetes in most of the patient were poorly controlled due to non-adherence
to regimen (Thomas et al, 2020). Result showed that adherence by subjects was generally
poor, only 36.0% adhere with medications and 25.4% with dietary instructions among T II D
was reported in south zone of Nigeria (Burnet,D.L., Elliott L.D.,&Chin M.H., 2018). Based on the
topic in southern part of Nigeria, the result revealed that most of the diabetes patient do not
really adhere to lifestyle modification (Burnet et al, 2018)

1.2 Statement of the problem

Type II diabetes is a chronic metabolic disorder that results in hyperglycemia due to body's
ineffectiveness in using the insulin produced by the pancreas (World Health organization,
factsheet. Diabetes, 2021). Type II diabetes is also known as adult onset diabetes, diabetes is a
significant public health problem emerging as a pandemic. According to WHO estimate,
around 5million people die every year because of improper management of Diabetes and it is
expected to become the seventh leading cause of death globally by the year 2023.

Diabetes is potentially the most significant health crisis in UK has faced in [Link]
4million people have diabetes in England meaning 1in 15 has the condition (National Diabetes
inpatient Audit, 2018).

Patient living with type II diabetes are more vulnerable to various forms of both short and
long-term complications include heart attack, stroke, kidney failure, leg amputation, vision loss
and nerve damage. In pregnancy, poorly control diabetes increase the risks of fetal death and
other complications (WHO global report, 2015). Glycemic control in type II diabetes is essential
to prevent long term micro and macro vascular complications (American Diabetes, 2016).

Non adherence to management regimen particularly recommended diet and exercise should
therefore be a concern to all factors associated with it should be consider while caring for
patient with diabetes. In Yobe state University Teaching Hospital, the Researcher observed
that some adult patient with type II diabetes mellitus in medical ward were admitted and re
admitted with uncontrolled high glucose level and some of them have complications such as
diabetic foot ulcer, heart attack, stroke and loss vision even while they are on diabetic
medications. Hence this study on factors affecting adherence to recommended diet and
exercise among type II diabetes mellitus patient at Yobe state Specialist Hospital Damaturu.

1.3 Justification of Study

Physiologically, adherence to dietary practices and exercise is fundamental to the

management of T2DM because they target the core mechanisms of the disease—insulin
resistance, β-cell stress, and metabolic dysregulation. Non-adherence not only worsens
hyperglycemia but also accelerates complications and undermines pharmacological therapy.
Therefore, a study that assesses the factors influencing adherence is justified, as it bridges the
gap between physiological knowledge and patient behavior, ensuring that the proven benefits
of diet and exercise are translated into real clinical outcomes.

1.4 Significance of Study

the significance of this study is multi-dimensional: it will empower patients with knowledge
and strategies to manage their condition better, provide healthcare workers with practical
guidance for patient-centered care, inform policymakers on the need for supportive
interventions, and contribute to the academic body of evidence. Its long-term relevance lies in
its potential to reduce the morbidity, mortality, and economic impact of Type II diabetes
through improved adherence to diet and exercise.

1.5 Aim of Study

to assess the factors that influence adherence to recommended dietary practices and regular
physical exercise among patients in Yobe State Specialist Hospital Damaturu with Type II
Diabetes Mellitus (T2DM).

To also to uncover the underlying reasons for poor compliance.

1.6 Research Objective

1. To assess the level of knowledge on recommended diet and exercise among type II diabetes
patient at Yobe State Specialist Hospital Damaturu.

2. To determine the level of practice on recommended diet and exercise among type II
diabetes patient at Yobe State Specialist Hospital Damaturu

3. To assess the Factors affecting adherence to recommended diet and exercise among type II
diabetes patient at Yobe State Specialist Hospital Damaturu.

1.7 Research Question

1. What is the level of knowledge on recommended diet and exercise among type II diabetes
patient at Yobe State Specialist Hospital Damaturu?

2. What is the level of practice on recommended exercise and diet among type II diabetes
mellitus patient at Yobe State Specialist Hospital Damaturu

3. What are the Factors affecting adherence to recommended diet and exercise among type II
diabetes patient at Yobe State Specialist Hospital Damaturu?

regimen among diabetic patient at Yobe State Specialist Hospital Damaturu. But is delimited to
type II diabetic patient.

1.8 Research hypothesis

socio-demographic, psychological, health system–related, and cultural/environmental factors

significantly influence adherence to recommended diet and exercise among Type II diabetic
patients

1.9 Definition of Terms

Diabetes mellitus: is a group of disease that result in too much sugar in the blood.

Type II diabetes: is a chronic condition that affects the way the body processes blood sugar.

Adherence: the quality or process of sticking fast to an object or subject.

Recommendation: the act of saying that someone or something is good and deserve to be
chosen.

Exercise: is any movement that make your muscles work and requires your body to burn
calories.

CHAPTER TWO

2.1 literature review

2.1.1 Concept of Diabetes Mellitus

Diabetes is a disease in which the body does not control the amount of glucose (a type of
sugar) in the blood and the kidneys make a large amount of urine. (U.S national institutes of
Diabetes, 2019). This occurs when the body does not make enough insulin or does not use it
the way it should.

According to Wen (2018) define diabetes as an endocrine disorder in which there is deficiency
or lack of insulin production in the pancreas leading to metabolic disorder of carbohydrate, fat
and protein which characterize by hyperglycemia.

2.1.2 Diagnosis and Classification of Diabetes Mellitus

Diabetes mellitus is a clinical syndrome characterized by hyperglycemia due to absolute or

relative deficiency of insulin (Davidson, 2013). The disease is define by fasting plasma glucose
of 7.0mmol/l or above, or random plasma glucose of 11.1mmol/l or above or an abnormal oral
glucose tolerance test of 11.1mmol/l or above (Davidson, 2013). This chronic disease can be
classified etiologically into type 1, type 2, gestations diabetes and others specific types. Type 1
diabetes is usually immune mediated in origin but in type II diabetes, insulin resistance is the
main defect which is usually followed by beta cell exhaustion, and often associated with
obesity (Mcwhinney, 2015). In gestational diabetes (GDM), occurrence of the disease is first
noted during pregnancy, which remits after the pregnancy ,but is associated with a risk of type
II in late life .Repeated pregnancy may increase the likelihood of developing diabetes,
especially type II, particularly in obese women. 80% of women with gestational diabetes would
ultimately develop clinical diabetes requiring life-long treatment (Davison, 2013 & White, M.
C, 2020). Davidson, 2018 define other specific type of diabetes as those secondary to other
causes such as genetic defects of beta cell function, genetic defects of insulin action,
pancreatic disease (for example pancreatitis, neoplastic disease, pancreatectomy and cystic
fibrosis) excess endogenous production of hormonal antagonist to insulin (for example growth
hormone, glucagon, glucocorticoids, and thyroid hormone), drug induced (for example
thiazide diuretics, phenytoin and corticosteroid).

Impaired fasting glucose or impaired glucose tolerance (IGT) is a clinical condition with
impaired glucose metabolism without clinical diabetes. Impaired fasting glucose (IFG) is said to
develop when the fasting plasma glucose is between 6.1 and 6.9mmol/l (Davidson,2013),
while impaired glucose tolerance (IGT) is defined as abnormal intermediate reading of
random plasma glucose and 2 hours after glucose load between 7.0-11.0mmol/l and 7.8-
11.0mmol/l respectively (Davidson, 2013). Both conditions indicate the need for further
evaluation with oral glucose tolerance test (OGTT) in order to make a definitive diagnosis. A
quarter of individuals with IGT develop symptomatic diabetes after five years, and two-third
after ten years (Ramachandra,et al. 2019). Both IGF and IGT have an increased risk of
developing vascular disease and it May be necessary to keep such individual under scheduled
and follow up.

2.1.3 Risk Factors Associated with Type II Diabetes Mellitus

Inappropriate weight gain leading to obesity is one of the major risk factors for type II diabetes
and risk of the disease increase steadily with increasing body mass index BMI (IDF diabetes
Atlas 2010). Around 90% of type II diabetes mellitus cases are attributed to overweight (IDF
diabetes Atlas 2020). Evidence suggest that obesity (especially central obesity), physical
activity, high fat diet, diet rich in saturated fatty acids, low intake of dietary fibers, low
glycemic carbohydrate, and whole grain cereals increases the risk of type II diabetes (Bazzano,
et al, 2017). Individual with a diet at highest level of the glycemic index or glycemic load are
more likely to develop type II diabetes mellitus than those at the lowest levels (Bazzano,et al,
2017).

Modest weight reduction through dietary improvement and gentle aerobic exercise can
substantially like those with impaired glucose tolerance and impaired fasting glucose (IDF
Diabetes Atlas, 2020). This intervention prevents and delays the development of associated
complications among individuals with diagnosed type II diabetes. The DPPR group (2013) has
demonstrated that modest weight loss and increase physical activity (for example, brisk
walking 3 hours per week) would significantly reduce the proportion of individuals with
impaired glucose tolerance developing type II diabetes. Hence healthy dietary habits and
increase physical activity play a role in the prevention and management of type II diabetes.
Engaging in regular physical activity is known to improve glucose, blood pressure, and lipid
abnormalities that serve as the principal risk factors for the associated micro vascular and
macro vascular complications of diabetes (Wen et al, 2015). Encourage more physical activity
among patient with type II diabetes is a known standard of practice and should be part of
routine patient education program in all health care settings across the globe, but requires an
understanding of individual exercise preferences and potential barriers.

2.1.4 Type II Diabetes and its Management

Type II diabetes results from failure of the pancreas to produce adequate insulin or failure of
body cells to utilize insulin or both and account for about 3% to 15% of medical admissions in
most health facilities (Aguocha, Ukpabi, 2017). Type II diabetes is common in individuals older
than 40 years, who are obese with body mass index equal or greater than 25kg/m but is now
also being seen more commonly in younger people and acknowledged as a very important and
growing problem (IDF Diabetes Atlas 2020)

The natural cause of obesity is a risk factor for type II diabetes is associated with increased
consumption of beverages with high sugar content, exercise eating of unhealthy diets and
reduced physical activity (Burnet et al, 2018).

Approximately 50% of new cases of type II diabetes can be controlled adequately by lifestyle
changes (diet and exercise). Twenty to thirty percent (20-30%) will need oral hypoglycemic
drugs (as an additional measure) and 20-30% will require insulin (Davidson 2013), the
management of type II diabetes should begin with an individualized regimen of diet, exercise,
and medical counseling targeted to reduce body weight, maintain ideal glycemic control and
cardiovascular disease .Prescribe lifestyle recommendations help in preventing diabetes
complications by improving and maintaining glycemic control .strategies for lifestyle
recommendations for people with type II diabetes must be incorporated in the management
and should include joint care between physicians, dieticians, diabetes nurses, diabetes
educators, behavior consultants exercise experts and community resources.

2.1.5 Barriers to Management

Adherence to diet and exercise recommendations minimizes cost of care involved in managing
type II diabetes by reducing related morbidities. Health workers need constant and up to date
information on barriers to the recommended exercise and diet regimens in order to be in a
better position to mitigate them with effective and more acceptable options tailored to
individual capacities.

Seour et al, (2020) identified unwillingness (48.6%), difficulty in following a diet regimen
different from that of the rest of the family (50.2%), high frequency of social gatherings
(13.7%), no advice given by the health care providers (4.2%), workload (3.3%), as barriers to
adherence diet. Barriers to adherence to regular exercise include lack of time (39.0%),
coexisting disease (35.6%), lack of exercise partner (3.7%), (Serou, et al, 2010). While overall
factors influencing adherence to lifestyle recommendations (both diet and exercise) were
stress (70.7%), a high consumption of fast food (54.5%), high frequency of social gatherings
(59.6%), and excessive use of cars (83.8%), (Serous, et al, 2010).

Result from study by Wens et al (2018), suggest patients deficient knowledge on diabetes, lack
of communication skills by the attending physician, lack of multidisciplinary support, over-
reliance on modern/alternative medicine, fear of social isolation, patients underestimating
diabetic conditions, opposition of change and lack of patients motivations as some of the
barriers to treatment adherence including therapeutic diet and exercise in people living with
type II diabetes (Wens, et al, 2018). However, scheduled consultations based on patient
centeredness, multidisciplinary teamwork, shared decision making based on patients
participation and partnership, and motivational counseling have been proven to encourage
better adherence to treatment including diet and exercise in people living with type II
diabetes.

Hudon et al, (2018) shows that levels of physical activity are lower among low income earners,
low socioeconomic status, low educational status, decrease with age and are low among
people with functional incapacities.

Wadden et al (2017) demonstrates lack of self-monitoring, injuries from physical activity, on-
going medical problems that is concurrent medical and surgical illness and emotional or
psychiatric problem as reason for not adhering to therapeutic lifestyle interventions.

2.1.6 Patients Knowledge of Diet and Exercise Lifestyle Recommendation

The study by Serour, et al, 2010 stated that most patients (69.1%) had strong beliefs and
knowledge that adherence to a diet regimen and regular exercise could have a positive effect
on their diabetes condition. knowledge, beliefs and responses to diabetes condition
significantly influence adherence to lifestyle measure. For example, adherence may be
compromise if people with type II diabetes do not have knowledge that lifestyle
recommendations healthy diets and physical activity affect their glycemic control.

Study by Thomas, et al (2020) found that more than two third of individuals with diabetes
believe exercise would improve their diabetic control, but majority find it difficult to initiate
and sustain. Knowledge about the consequences and controllability of diabetes and the
perceived effectiveness of intervention affects patient adherence to lifestyle measure
recommendation.

People with type II diabetes will achieve the outcomes of adherence to diet and exercise only
if they have been equipped with the knowledge the self-management is the key in overall
diabetes management. Effect of this knowledge should be reflected in patents willingness and
capability to manage their condition adequately on daily basis. (Farmer et al 2014).

2.2 Theoretical framework

The information-motivation-behavioral skill (IMB) model was developed in 1992 by Jeffrey D.

fisher and William A. fisher as they sought to understand the mechanism behind HIV-risk
behavior change. They found that behavioral change was a function of an individuals
possession of three factors, information, motivation, and behavioral skill. They consolidated
these findings into a generalizable model that has served as a framework for interventions and
as a reference for understanding various behavior changes both within and outside the health
field. The three elements of the model interplay to influence a behavioral change.

Information: Individual has relevant information concerning the behavior and its implications.

Motivation: Individuals attitude toward the behavior and the consequences of the behavior.
This attitude is influenced by both personal and social motivation.

*personal motivation: attitude toward the behavior and self-perception about own
performance of behavior.

*social motivation: societys acceptance of the behavior and the individuals desire to adhere to
social norms.

Behavioral skills: The resources necessary to individual to carry out behavior. The individual
must have both ability and self-efficacy.

*Objective ability: Individuals capability to practice behavior.

*Self-Efficacy: Individuals self-belief in their capability to practice behavior.

Both information and motivation activate the behavioral skill necessary for behavior change.
2.3 Empirical Study

Farmer, et al, (2014) from Department of nursing science, faculty of health science and
technology, university of Jos, conducted a research on the topic knowledge, attitude and
practice to recommended exercise among type II diabetes mellitus at jos university teaching
hospital. The sample comprises of 130 for the study.

The result shows that 93(71.5%) respondents have had diagnosis of diabetes and have been
on treatment for less than 10 years, while 37(28.5%) have been on treatment for more than
10 years ,66(50.8%) have a family history of diabetes mellitus, while 64(49.2%) do not have
family history of the disease.60(46.1%) of the respondents have good knowledge of
recommended,40(30.7%) have fair knowledge while 30(23.1%) have poor
knowledge,90(69.3%) 0f the respondents have poor practice of recommended exercise while
40(30.7%) have good practice.60(49.6%) of the respondents practice brisk walking ,14(10.2%)
practice jogging ,6(4.4%) are into sports activities ,9(6.6%) ride bicycle ,5(3.6%) are into
dancing ,1(0.7%), swim while 1(0.7%) go for hiking ,16(11.7%)work in the garden,2(1.5%)carry
free weight at gym while 1(0.7%) lift light object and 14(10.2%) climb stairs.

Al Johani,et al (2022) conducted a research on the topic compliance (adherence) to diet and
exercise among diabetic patient at Referral hospital Morang district,[Link]: A total of
141 participants were included in this study, of them 55.3% were males. The rate of
compliance to diet and exercise was 48.2% and 22.7%, respectively. Compliance to diet was
higher in people of age above 50 years (p=0.029) and those who are single (p=0.037), patient
with duration of diagnosis less than 5 years (p=0.01) and those who had dietary counselling
(p=0.007). The rate of compliance to exercise among type-2 diabetes patients in Morang
district was low, and it could be attributed to a combination of several socio-demographic and
clinical factors.

Seour, et al, (2020) conducted a research on the topic factors associated with non-adherence
to diet and physical activity among diabetes patients in Surat city. A cross sectional study was
carried out among indoor and outdoor diabetes patients in a tertiary care hospital in Surat
city. The sample size of 133 respondents. Result shows that majority of the study participants
(76%) were adhere which means follow healthful diet plan (high fiber diet, low fat diets, eat
fruits and vegetables, eat very few sweets) at least 3-4 days per week. Only 24% participants
were not adhered which means followed diet management practices for only 1-2 days per
week. Most of the patients (45.6%) believed that high frequency of food gathering (functions
or festivals) with family and friends affect their healthy diet plan .33.8% patients said that
situational factors like eating out at restaurant and inappropriate foods offers by other affect
their healthful diet plan cording to health care team (Doctors, dietitians) advice. Regarding
barriers to physical activity,36.7% patients had lack of time due to 9-10 hours daily
working ,30.2% patients could not exercise due to negative attitude or laziness,17.7% patients
believed that surrounding environment or weather doesnt suit them to exercise regularly.

CHAPTER THREE

3.1 RESEARCH DESIGN

The study adopted a non-experimental research design (Descriptive) to Assess Factors

Affecting Adherence to recommend die and exercise among type II diabetes mellitus patient
at Yobe State specialist hospital Damaturu.
3.2 Study Area

This study was conducted within Damaturu yobe state is found in the North-East part

of Nigeria. It is located between latitude 11.7470° N, 11.9662° E and longitude 11.7470°

N, 11.9662° E,.Yobe State's population is estimated at approximately 3.4 million. The

sex ratio is approximately 100.2 men to 100 women. Women constitute 49.95% of the

population, while men make up 50.05%.

3.3 Target Population

The target population of the study are all diabetic patient attending medical outpatient clinic
and medical ward at specialist hospital. Base on the information obtain from medical record as
of last year 2023 are 300 diabetes patient at Yobe State Specialist Hospital.

3.4 Sample Size

A sample size of the study was 75% of the target population. According to taro Yamane
method of sample size calculation was formulated by the statistician Tara Yamane in 1967.

n=N/1+N (e) ^2

Where

n=signifies the sample size

N=signifies the population under study

E=signifies the margin error

n=300/1+300*(0.10) ^2

n=300/1+300*0.01

n=30

0/1+3

n=300/4

n=75

3.5 Sampling Technique

The sample technique that was used is simple random technique where everyone has an equal
chance of being selected.

3.6 Instrument for Data Collection

The data was collected using self-administered questionnaire. The questionnaire was compose
of three section A, B, C and D.

Section A: elicited socio demographic data of the respondents.

Section B: cover the knowledge of recommended exercise and diet

Section C: Adherence to recommended diet and exercise regimen

Section D: Factors affecting adherence to recommended diet and exercise regimen.

3.7 Validity of the Instrument

The questionnaire was developed and submitted to the research supervisor and other experts
in the field of the subject matter who scrutinized and ensure both face and content validity.

3.8 Reliability of the Instrument

The test re-test method was used to determine the reliability of the instrument where the
instrument was administered twice to a sample of 30 type II diabetes mellitus patient in the
clinic and was retrieved and then the results was correlated to obtain the co-efficient of the
reliability.

3.9 Method of Data Collection

A letter of introduction was collected from the college research screening committee and
taken to the unit manager. Data was collected using questionnaire which was distributed to
the respondents by the researcher with the help of research assistance.

3.10 Method of Data Analysis

All information received from the respondents was analyzed using frequency distribution
table, percentage and mean.

3.11 Ethical Consideration

Approval was secured from the hospital ethical research committee. Informed consent was
obtained from each participant prior to enrolment in the research. Patients was informed that
they are allowed to withdraw from the study at any time without jeopardizing the care they
are usually provided in the clinic.