Prevalence of Soil-Transmitted Helminth Infections and Associated Factors among Mental Illness Patients Attending Psychiatric Clinics at Arba Minch, Sawla and Jinka General Hospitals, Southern Ethiopia, 2022/2023

Background: Mentally ill patients have a higher risk of having intestinal soil-transmitted helminth (STH) infections due to their poor compliance with hygiene practices. However, there is a scarcity of data on STH infections and associated factors among mental illness patients in Ethiopia, particularly in the study area. This study was aimed to assess prevalence and associated factors of STH infection among mental illness outpatients. 

Methods: Facility-based cross-sectional study was conducted among 329 mental illness outpatients attending psychiatric clinic at Arba Minch, Sawla, and Jinka General Hospitals, Southern Ethiopia, from July to November 2023. Systematic random sampling technique was used to select the participants after proportionally allocating total sample size for each hospital. Data on socio-demography, environmental, clinical and behavioral factors were collected using a pre-tested questionnaire. Two grams of stool samples were collected and processed for parasitological examination using the direct wet mount and Kato-Katz methods for consented participants. Descriptive statistics and multivariable logistic regression analysis were done using SPSS version 25, and P-value <0.05 at a 95% confidence level was considered as statistically significant.

Results: Out of 322 study participants, 91 (28.3%) mentally ill patients were infected by one or more species of STH. Hookworm, Ascaris lumbricoides, and Trichuris trichiura were detected in 48 (14.9%), 31 (9.6%), and 18 (5.6%), respectively. Six participants (1.9%) had co-infection of hookworm and Ascaris lumbricoides. The majority (25.8%) of participants have mental illness problems because of schizophrenia. Not washing hands after soil contact [AOR = 2.63, 95% CI: (1.19–5.81), p = 0.016], consumption of unwashed raw fruits or vegetables before eating [AOR = 3.01, 95% CI: (1.08–8.38), p = 0.036], diagnosis of bipolar disorder [AOR = 7.61, 95% CI: (2.81-20.58), p = 0.001] and patients with chronic disease [AOR = 4.35, 95% CI: (2.09–9.04), p = 0.001] were shown statistically significant association with soil-transmitted helminthic infections.

Conclusions: This prevalence of STH was significant among mentally ill patients. Therefore, improving hygienic practices and routinely screening mentally ill individuals for STH infection are advocated in order to mitigate its spread and improve their health status.

Soil-transmitted helminths (STHs) are a group of Neglected Tropical Diseases (NTD), which are the world's most complex and overwhelming health problems [1, 2]. The term "STH" refers to a group of worms, including roundworm (Ascaris lumbricoides), whipworm (Trichuris trichiura), hookworm (Necator americanus, and Ancylostoma duodenale), and threadworm (Strongyloides stercolaris), that spend a portion of their life cycle in the soil and are spread to people by consuming their eggs or penetrating their skin [3, 4]. A. lumbricoides and T. trichiura infections spread via the faecal-oral pathway, where people become infected after swallowing eggs through contaminated water or food, while hookworm and S. stercolaris infections spread transdermally by infective stages/ larvae entering skin in contact with contaminated soil and transmitted primarily by walking barefoot [4-7]. There are three primary species of concern that infect humans are Ascaris lumbricoides, Trichuris trichiura, and hookworms (Necator americanus and Ancylostoma duodenale), with a global prevalence estimated to be 807-1,121 million, 604-795 million, and 576-740 million persons, respectively [1, 4, 8]. STH infections compromise multiple health problems, including abdominal pain, diarrhoea, blood and protein loss, and physical and cognitive growth retardation [1-4]. However, these consequences are proportional to the worm burden (intensity of infections); infections of moderate-to-heavy intensity are associated with greater morbidity whereas infections of light intensity are often asymptomatic [1, 5, 8]. 

The transmission of STH is determined by multiple factors, such as biophysical features that influence egg and larval survival and socio-economic factors such as inadequate sanitation, hygiene, and certain behavioral factors. With overlapping geographical distributions, STH are mostly prevalent in rural areas where there is a lack of access to clean water, poor sanitation and hygiene practices such as walking barefoot, very low coverage of latrines, and a humid climate that favours larvae survival in the environment [1, 4-7]. There have been reports of significant decreases in the severity of STH infections globally over the past few decades through a combination of strategies, including mass drug administration (MDA), improved water quality and sanitation, as well as hygiene education programs implemented at significantly higher risk population groups—infants, children under the age of five, pregnant women, people with weakened immune systems, and migrant workers [8-10]. However, these initiatives less emphasise at-risk and vulnerable populations, such as psychiatric patients despite having a significantly higher risk of STH infections due to the nature of their illness and their poor cooperation with hygienic or health preventive measures [11-13]. 

Psychiatric conditions affect how the brain system functions, which affects how a person perceives the world and reacts to it. The disorders impair a person's thinking, feeling, mood, interpersonal relationships, hygienic practice, and entire state of health and the quality of life [14, 15]. Patients with impaired mental health are strongly vulnerable to the risks of having a parasitic infection, mainly STH, associated with its nature of transmission, their poor cooperation with health preventive measures, and a deficiency of essential nutrients or food insecurities. Meanwhile, the drugs used to treat those disorders similarly have effects on gastrointestinal function that may hinder the clinical presentation of STH infections [11, 13, 16]. Even if all human beings are at risks of acquiring STH, certain groups of people such as children, pregnant women, immuno compromised patients, and mentally disabled individuals have been highlighted as highly vulnerable people [14, 15, 17-19]. However, little is known in Ethiopia about the prevalence of STH infections among patients with mental illness, particularly in the study area, where there is a significant gap between the number of patients in need of services and the resources that are readily available. Thus, this study was aimed to assess the prevalence and associated factors of STHs infections among mental illness outpatients attending psychiatric clinic at Arba Minch, Sawla and Jinka General Hospitals, Southern Ethiopia.

Study Setting 

The study was conducted in the three purposively selected General Hospitals in Gamo, Gofa, and South Omo Zones which are found in Southern Ethiopia, namely Arba Minch General Hospital (AMGH), Sawla General Hospital (SGH), and Jinka General Hospital (JGH). The selected study areas are mostly endemic to intestinal parasitic infection due to their geographic and climatic characteristics. These areas are a part of the areas considered under NTD. Those purposively selected hospitals basically provide preventive, curative and rehabilitative care including outpatient psychiatric services for people in their catchment area. Arba Minch, Sawla and Jinka cities are situated around 505 km, 510 km and 644 km away from Addis Ababa capital of Ethiopia, respectively. According to the 2007 census 69, the total population of Gamo, Gofa and South Omo Zone was 2,597,360 2,019,687. The psychiatric patients’ clinics in those hospitals provide a variety of services like psychiatric evaluation, medication management, psychotherapy, counselling, group therapy, crisis intervention and education support.

Study Design and Period 

Facility based cross-sectional study design was conducted from July to November, 2023.

Sample Size Determination and Sampling Technique

The sample size was calculated by using single population proportion formula using the assumptions of 95percent confidence level, 5percent of marginal error and prevalence (p = 26.4percent) of STHs infection among psychiatric patients from previous study done in northern Ethiopia 11.

Thereby, the final sample size of this study with adding of 10percent non-response rate was 329.  A systematic random sampling technique was conducted after proportionally allocating the total sample size for each selected general hospitals as per the number of expected mental illness outpatients attending psychiatric service in each general hospital by referring to the last year's records in line with the study period (444, 291 and 249 mental illness outpatients in Arba Minch, Sawla and Jinka General Hospitals, respectively). Then the K-value is calculated (K almost equal to 3) accordingly and the first participant was selected on the starting day of the study through a lottery method.

Data Collection Technique and Processing

The primary source of data was patients who are diagnosed to have mental illness. Medical records of the participants were also use for extracting data of duration of diagnosis and types of mental illness disorder. Data were collected by using a semi-structured questionnaire administered through a face-to-face interview after being translated into the local language. The questionnaire was used to collect socio-demographic characteristics, clinical factors, and environmental and behavioral factors that can be potentially a risk and/or indicator for STHs infections of the study participant.

Sample Collection and Processing

About 2-3 gm. of the faecal specimen was collected in a sterile wide-mouth screw-capped container labelled with the unique sample number, date, and time of collection, after instructing study participants or guardians how to collect stool specimens. Samples were processed by trained medical laboratory professionals at the diagnostic laboratory of each selected general hospital.

Stool Sample Collection and Laboratory Processing

Microscopic Examination of STHs: A direct wet mount smear was prepared by mixing a matchstick head amount of fresh stool with a drop of 0.85percent saline followed by a drop of iodine on a clean microscopic slide and were examined microscopically after placing a coverslip over the smear. Smears were examined for helminths' eggs or larvae with the low-power (10x) and high-power (40x) objectives of the compound microscope. 

Kato-Katz Smear Test: Two Kato-Katz thick smears were prepared from each stool sample for the detection of ova in STHs and to quantify the intensity of infections based on the faecal egg count (eggs per gram (EPG)). The Kato-Katz thick smear was performed as per the standard procedures. All the Kato-Katz slides were prepared immediately after the arrival of the stool specimens in the laboratory and read between 30 minutes and 1 hour after slide preparation for the detection of hookworm ova by experienced laboratory technicians.

Data Quality Management: The quality of data was ensured from data collection up to final laboratory identification by the careful design of data extraction formats and by providing adequate training for data and sample collectors. A pre-test was done on 5% of the total sample size from the nearby psychiatric clinic of Geresie Primary Hospital prior to actual data collection to validate the importance of variables. Moreover, all the data were collected by psychiatric nurse and accordingly guardians were involved to increase the reliability of the data. Randomly cross-checking the data for their completeness, accuracy, and consistency at the end of each day and undertaking corrective discussion will be done during supervision. Standard operating procedures (SOPs) were strictly followed during specimen collection, transportation, processing, and parasite detection. About 10% of the slides were randomly selected and checked by a third technician who is blind to the initial results to ensure the accuracy of the egg counts. Besides, the reagents used for processing stools were checked every week for contamination. 

Data Entry and Analysis: Data were coded and entered by using Epi-data version 4.43, and then exported to Statistical Package for the Social Sciences Software (SPSS) version 25 for further cleaning and analysis. Descriptive statistics like, frequency, mean and percentage were calculated. Binary logistic regression model was used to assess associations between dependent and independent variables. Odds ratio (OR) with its corresponding 95percent confidence interval (CI) was estimated. Variables with p-value less than 0.25 in bivariate analysis were considered as candidate for further multivariable analysis. Backward variable selection technique was applied. Model fitness was checked by Hosmer and Lemeshow test. Multicollinearity of independent variables was assessed by using variable inflation factors (VIF). The strength of associations was measured by adjusted odds ratio (AOR) with corresponding 95% confidence interval, and variables with p-value less than 0.05 was considered as statistically significant. 

Socio-demographic Characteristics of Study Participants

Among the total sample size of 329 mentally ill patients, data from 322 participants—144, 95, and 83—from Arba Minch, Jinka, and Sawla General Hospitals, respectively, were complete for analysis. The remaining 7 mentally ill patients were unable to bring stool samples. Out of a total of 322 participants in the present study, 254 (78.9percent) and 68 (21.1percent) were male and female, respectively. The participants’ ages ranged from 14 to 62 years, with a mean age of 30.56 ±10.54 SD years. About 219 (68percent) of mentally ill patients were urban inhabitants, and only 115 (35.7percent) of the study participants were married. Regarding their educational status, 145 (45%) participants didn’t attend formal education, while 177 (55%) attended primary school or above. The majority of the study participants, 173 (53.7%) had one or two family members, and 159 (49.4%) of the participants had no formal occupation [Table 1].

Table 1: Socio-Demographic Characteristics of Mental Illness Patients Attending Psychiatric Clinics at Arba Minch, Sawla, and Jinka General Hospitals, Southern Ethiopia, 2023

Hygienic Practice of Mentally Ill Patients

Among the 322 mentally ill patients, 276 (85.7percent) and 211 (65.5percent) washed their hands before meals and after soil contact, respectively. One hundred fifty-eight (49.1percent) and 207 (64.3percent) of the participants used unprotected water for drinking and got their food elsewhere than their home, respectively. The majority (173; 53.7percent) of study participants used public latrine, and 171 (53.1percent) of them did not wash their hands with soap after toileting. About 184 (57.1percent) of patients had untrimmed fingernails, and 175 (54.3percent) patients ate raw fruit and vegetables without washing [Table 2].

Table 2: Hygienic Practice of Mental Illness Patients Attending Psychiatric Clinics at Arba Minch, Sawla, and Jinka General Hospitals, Southern Ethiopia, 2023

Clinical Data of Mentally Ill Patients

Regarding the causes of mental illness problems, 83 (25.8percent), 62 (19.3percent), and 50 (15.5percent) participants have the disease because of schizophrenia, major depressive disorder (MDD), and substance disorder, respectively. The majority of the participants (60.6percent) had one year or less diagnosed with mental illness, and about 54 (16.8percent) of the participants had chronic disease (human immunodeficiency virus (HIV) (n = 13); diabetic mellitus (DM) (n = 14); hepatitis (n = 11); hypertension (n = 16) [Table 3].

Table 3: Clinical data and diagnosis duration of Mental Illness Patients Attending Psychiatric Clinics at Arba Minch, Sawla and Jinka General Hospitals, Southern Ethiopia, 2023

* HIV (n = 13); DM (n = 14); Hepatitis (n = 11); Hypertension (n = 16) 

Prevalence of Soil Transmitted Helminths

Among 322 participants, 91 (28.3percent) with a 95% confidence interval (22.6-33.2) were tested positive at least for a single species of STH by one or more of the diagnostic methods. Six of the study participants were co-infected by two parasite species, which makes the total detected STH numbers 97 (i.e., hookworm spp. with A. lumbricoides 4 (4.4percent), hookworm spp. with T. trichiura 1 (1.1percent), and A. lumbricoides with T. trichiura 1 (1.1percent)). Hookworm was the most prevalent, accounting for 48 (14.9percent), followed by A. lumbricoides and T. trichiura, with respective frequencies of 31 (9.6percent) and 18 (5.6percent) [Table 4]. The overall intensity of STH infections was moderate (500 to 1999 eggs per one gram of the used stool samples). 

Table 4:  Prevalence of Soil Transmitted Helminths in Mental Illness Patients Attending Psychiatric Clinics at Arba Minch, Sawla and Jinka General Hospitals, Southern Ethiopia, 2023 

Regarding the data collection site, the highest numbers of STH infections were detected in patients attending the psychiatric clinic of Jinka General Hospital, which constituted 38(11.8percent). Of which four patients had Hookworm spp. and A. lumbricoides co-infection. The second highest number of STH infections were detected in patients attending the psychiatric clinic of Sawla General Hospital, which accounted for 32(9.9percent), with one of the participants having co-infections of Hookworm spp and T. trichiura and one of the participants having A. lumbricoides and T. trichiura at Arba Minch General Hospital. 21(6.5percent) of the patients attending the psychiatric clinic were tested positive for a single species of STH. The highest number (n=21) of the prevalent hookworm spp. were detected in mental illness patients attending psychiatric clinics at Jinka General Hospital [Table 4 and Figure 1].

Figure 1: Prevalence of Soil Transmitted Helminths in Mental Illness Patients Attending Psychiatric Clinics at Arba Minch, Sawla and Jinka General Hospitals, Southern Ethiopia, 2023

Factors Associated with STH Infections among Mentally Ill Patients

Both bivariate and multivariable logistic regression analyses were conducted to determine factors associated with STH infections among mentally ill patients. Thus, by using a p-value less than or equal to 0.25 in bivariate analysis as a cut-off point, multivariable logistic regression analysis revealed that those who have no habit of hand washing after soil contact were found to be 2.63 times more likely to acquire STH infection than others [AOR = 2.63, 95percent CI: 1.19–5.81]. Likewise, those who have no habit of washing raw fruits and vegetables before consumption were found to be 3.01 times more likely to have STH infections [AOR = 3.01, 95percent CI: 1.08–8.38]. However, all other considered socio-demographic and hygienic-related factors were not significantly associated with STHs in the multivariate logistic regression analysis [Table 5].

Table 5: Logistic Regression of Factors Associated with STHs Infection among Mental Illness Patients Attending Psychiatric Clinics at Arba Minch, Sawla, and Jinka General Hospitals, Southern Ethiopia, 2023

  Note: *Statistically Significant 

 Association of STH Infection with types of Mental Problems and Clinical Data

A multivariable logistic regression analysis was carried out for the variables whose p-value in the Bivariable logistic regression analysis was less than 0.25. As a result, participants with a mental problem caused by bipolar disorder had a 7.61-fold greater risk of STH infection [AOR = 7.61, 95percent CI: (2.81-20.58), p = 0.001]. Likewise, the probability of having STH-infections is more than four times higher in mentally ill patients with chronic disease [AOR = 4.35, 95percent CI: (2.09–9.04), p = 0.001] [Table 6].

Table 6: Logistic Regression of Clinical Data with STH Infections of Mental Illness Patients Attending Psychiatric Clinics at Arba Minch, Sawla, and Jinka General Hospitals, Southern Ethiopia, 2023

Note: *statistically Significant

As a segment of society, mental patients should be given special attention, so it is very important to study the prevalence of STH infections and its associated factors in order to give preventive and immediate treatment. This study is imperative to consider the prevalence of STHs and the factors that contribute to them in individuals with mental illness to design appropriate intervention strategies. The significant prevalence of STHs in the present study (28.3%, 95% CI: 23.7–32.9) suggested that mental illness directly influences hygiene and sanitary practices 11, 12, 17, 19, 21. The finding was in line with studies conducted in Bahir Dar, Northwest Ethiopia (26.4%) 11. Our finding, however, was higher than that of research conducted in Gahanna (13.5%) [21]. In contrast, our findings were lower than studies done in Bahir Dar, Northwest Ethiopia (56.7%) 12, Tanzania (48.3%) 19, and Nigeria (38.4%) 17. The variation in occurrence might be due to differences in the geographical region, study period, socio-demographic characteristics of the study population, and sample size variation. Moreover, variation in the age group of the study participants may contribute to differences in STH prevalence. Laboratory methods used also have a significant role in the difference in STH prevalence across studies. In the present study, only direct wet mount and Kato-Katz were used, whereas the previous studies 11, 12, 19 used a combination of direct wet mount, Kato-Katz, Richie’s concentration, and modified Ziehl Neelsen staining, which may increase the detection rate as compared to the present study.

The present study revealed that hookworm (14.9%) was the most predominant parasite, followed by A. lumbricoides (9.6%) and T. trichiura (5.6%). The predominance sequence in this finding agrees with a previous study done in Bahir Dar, Northwest Ethiopia, which found hookworm spp. (17.1%), A. lumbricoides (8.6%), and T. trichiura (0.7%) 11. However, the detected number of hookworms in this study is higher than the prevalence reported in Bahir Dar (6.2%) 12 and Nigeria (8.4%) 17. On the contrary, the prevalence of hookworm (37.93%) in Tanzania 19 was much higher than the finding reported in this study. In the present study, the second most prevalent STH was A. lumbricoides (9.6%), which is in line with the study result of 8.6–9.6% in Bahir Dar 11, 12. However, the present prevalence of A. lumbricoides was lower than previous results of 15.3% from Nigeria 17. On the other hand, the prevalence of T. trichiura (5.6%) in this study is much higher than the study done in Bahir Dar, Northwest Ethiopia (0.7%) 11. The difference might be due to the variation in hygienic practice and infection prevention strategy implementation and endemicity in the geographical settings, as well as the difference in the diagnostic techniques 11, 12. 

In the present study, mentally ill patients who had a habit of eating unwashed raw fruit or vegetables were 3.01 times at higher risk of acquiring STH, and likewise, mentally ill patients who had no habit of washing their hands after soil contact were 2.63 times more likely to acquire STH infections. This is supported by studies done in Bahir Dar, northwest Ethiopia, among psychiatric patients 11, 12. This might be due to the infective stages or ova of many STHs that can be collected from soil-contaminated hands and raw vegetables, which results in the ingestion of parasites during feeding and when there is direct finger-to-mouth contact 11, 12. Contrary to the previous study done in Bahir Dar, northwest Ethiopia 11, mentally ill patients with bipolar disorder put them at higher risk for STHs, as confirmed in the present study, in that participants with mental problems caused by bipolar disorder were 7.61 times at higher risk of infection compared with those with other than bipolar disorder. However, psychiatric patients with bipolar disorder are known for maintaining good personal hygiene and giving themselves value 11. In addition, mentally ill patients with chronic disease were 4.35 times more likely to have STH infections than others. The possible reason for the presence of association might be due to alterations in the immune system that simultaneously affect the general health and well-being of the patient, which could make them more anxious about following up and taking care of their own personal hygiene 19, 21.

Among the total STH-infected mentally ill patients, the prevalence was higher in males (82.4%) than females. However, the difference was not statistically significant, which was similar to findings from Tanzania 19 and Bahir Dar, northwest Ethiopia 11, 12. On the contrary, according to studies from Ghana 21 and Nigeria 17, males were significantly at higher risk of STHs compared with females. These discrepancies in the exposure levels of males and females could be explained by occupational and socio-cultural variables that go beyond mental health issues.  In line with the previous different studies 11, 12, 17, 21, among all infected mentally ill patients, patients with schizophrenia disorder 28 (30.8%) were predominant, followed by bipolar disorder 22 (24.2%) and major depressive disorder (MDD) 17 (18.7%). However, none of the other characteristics thought to be causes of mental disorders were substantially associated with STHs, similar to socio-demographic factors. Nonetheless, the findings necessitate an additional thorough cohort investigation to validate the potential variables associated with STH infections in individuals with mental illnesses.

Due to financial and logistical limitations, only one stool sample per participant was taken and analyzed; however, because intestinal parasites have a cyclical life cycle, each participant must provide at least three consecutive samples over the course of three days. This may understate the actual frequency of STHs among research participants who are mentally ill. Nevertheless, because the patients have mental health issues, we cannot be certain that their answers to each question are grounded in reality and their daily experiences, which could introduce response bias and unidentified confounders into the analysis of the study's overall findings.

Conclusions and Recommendations

The prevalence of STHs among mentally ill patients was significant in the study setting. Hookworm was one of the most predominantly identified STHs, followed by A. lumbricoides. The overall intensity of STH infections was moderate. Among the study participants, more than 25 percent of the mental illnesses were caused by schizophrenia, and more than 16 percent of the participants had chronic diseases. Unwashed hands after soil contact and consumption of unwashed raw fruits or vegetables, bipolar disorder, and chronic disease were the factors significantly associated with STHs. Policymakers should therefore take mental health patients into consideration when developing a plan to manage and intervene in STH transmissions, as a result of these findings. In addition to routinely screening and treating mentally ill patients for STHs, healthcare professionals employed by each hospital's psychiatric clinic ought to provide on-going health education to promote better hygiene habits. Other healthcare practitioners ought to likewise educate their patients about the potential health risks and preventative measures, since other populations may serve as potential sources of infection for these extremely susceptible patients. 

AMGH, Arba Minch General Hospital; CI, Confidence Interval; IPs, Intestinal Parasites; JGH, Jinka General Hospital; MDA, Mass Drug Administration; NTDs, Neglected Tropical Diseases; OR, Odds Ratio; SGH, Sawla General Hospital; SNNP, Southern Nations Nationalities and People’s; SOZ, South Omo Zone; STHs, Soil- Transmitted Helminths; WASH, Water Sanitation and Hygiene

Data Sharing Statement

The original data for this study is available from the corresponding author.

Ethical Considerations

The study was approved by Institutional Research Ethics Review Board of Arba Minch University, College of Medicine and Health Sciences. Official letter of co-operations will be provided to respective Zonal health bureau. All the study participants were informed about the purpose of the study, their right to refuse or acceptance. Informed consent was obtained from each study participants (mild–moderate mental illness) prior to the interview, whereas informed written assent was obtained from parents or guardians for individuals under the age of 18 years old. To overcome confession and recall bias, there was also the involvement of parents or guardians for those mentally ill patients who are unable to respond research questions appropriately. Participants/guardians were informed about that all the information obtained will be kept confidentially by using codes. To overcome the issue of COVID-19, all standard precautions were followed when collecting and processing the sample.  Positive (STHs and/or other intestinal parasites) laboratory results were reported to the health care providers on time with patient’s code/card number accordingly. 

Acknowledgments

We acknowledge the contributions of health experts working at the psychiatric clinics of Arba Minch, Jinka, and Sawla General Hospital during data collection. We thank Arba Minch University, College of Medicine and Health Sciences, office of the Collaborative Research and Training Center of Neglected Tropical Diseases (CRT-NTD) for providing technical and financial support. Our gratitude also goes out to the study participants for agreeing to take part in the research.

Author Contributions

All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published; and agree to be accountable for all aspects of the work.

Funding

Arba Minch University funded for data collection. No fund was obtained for data analysis and manuscript preparation.

Disclosure

The authors declare that they have no conflicts of interest for this work.