|Year : 2023 | Volume
| Issue : 2 | Page : 189-203
Identifying challenges in implementing child rights instruments in Nigeria: A nationwide survey of knowledge, perception, and practice of child rights among doctors and nurses
Qadri Adebayo Adeleye1, Patience Abaluomo Ahmed2, Iretiola Bosede Babaniyi2, Oluseyi Oniyangi2, Mariya Mukhtar-Yola2, Adeola Yetunde Adelayo3, Yewande Osatohanmwen Wey4, Uchenna Nneka Ononiwu5, Usman Abiola Sanni6, Bilkis Bukola Adeleye7, Lamidi Isah Audu8
1 Faculty of Paediatrics, National Postgraduate Medical College of Nigeria, Nigeria; Department of Maternal and Child Health, School of Public Health, James Lind Institute, Geneva, Switzerland; Department of Paediatrics, Alliance Hospital, Jabi, Abuja, Nigeria
2 Department of Paediatrics, National Hospital, Abuja, Nigeria
3 Department of Psychiatry, Banner Behavioural Health Hospital, Scottsdale, Arizona, United States
4 Department of Neonatology, Wirral University Teaching Hospital, Birkenhead, United Kingdom
5 Department of Paediatrics, Federal Medical Centre, Jabi, Abuja, Nigeria
6 Department of Paediatrics, Federal Medical Centre, Birnin Kebbi, Kebbi, Nigeria
7 Department of Nursing, North West Anglia NHS Foundation Trust, Peterborough, United Kingdom
8 Department of Paediatrics, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna, Nigeria
|Date of Submission||06-Dec-2022|
|Date of Decision||03-Jan-2023|
|Date of Acceptance||05-Jan-2023|
|Date of Web Publication||4-Apr-2023|
Qadri Adebayo Adeleye
Department of Paediatrics, Alliance Hospital Abuja, 1-5 Malumfashi Close, Off Emeka Anyaoku Street, Area 11, Garki, Abuja
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: After thirty years of ratifying the child rights convention and nineteen years of the Child Rights Act, implementing child rights instruments remains challenging in Nigeria. Healthcare providers are well positioned to change the current paradigm. Aim: To examine the knowledge, perception, and practice of child rights and the influence of demographics among Nigerian doctors and nurses. Materials and Methods: A descriptive, cross-sectional online survey was done using nonprobability sampling. Pretested multiple-choice questionnaire was disseminated across Nigeria's six geopolitical zones. Performance was measured on the frequency and ratio scales. Mean scores were compared with 50% and 75% thresholds. Results: A total of 821 practitioners were analyzed (doctors, 49.8%; nurses, 50.2%). Female-to-male ratio was 2:1 (doctors, 1.2:1; nurses, 3.6:1). Overall, knowledge score was 45.1%; both groups of health workers had similar scores. Most knowledgeable were holders of fellowship qualification (53.2%, P = 0.000) and pediatric practitioners (50.6%, P = 0.000). Perception score was 58.4% overall, and performances were also similar in both groups; females and southerners performed better (59.2%, P = 0.014 and 59.6%, P = 0.000, respectively). Practice score was 67.0% overall; nurses performed better (68.3% vs. 65.6%, P = 0.005) and postbasic nurses had the best score (70.9%, P = 0.000). Conclusions: Overall, our respondents' knowledge of child rights was poor. Their performances in perception and practice were good but not sufficient. Even though our findings may not apply to all health workers in Nigeria, we believe teaching child rights at various levels of medical and nursing education will be beneficial. Stakeholder engagements involving medical practitioners are crucial.
| Abstract in French|| |
Contexte: Après trente ans de ratification de la convention sur les droits de l'enfant et dix-neuf ans de la loi sur les droits de l'enfant, la mise en œuvre des instruments relatifs aux droits de l'enfant reste difficile au Nigéria. Les fournisseurs de soins de santé sont bien placés pour changer le paradigme actuel. Objectif: Examiner la connaissance, la perception et la pratique des droits de l'enfant et l'influence de la démographie parmi les médecins et les infirmières nigérians. Matériels et méthodes: Une enquête en ligne descriptive et transversale a été réalisée à l'aide d'un échantillonnage non probabiliste. Un questionnaire à choix multiples prétesté a été diffusé dans les six zones géopolitiques du Nigeria. Les performances ont été mesurées sur les échelles de fréquence et de rapport. Les scores moyens ont été comparés aux seuils de 50 % et 75 %. Résultats: Au total, 821 praticiens ont été analysés (médecins, 49,8 % ; infirmiers, 50,2 %). Le ratio femmes/hommes était de 2 : 1 (médecins, 1,2 : 1 ; infirmières, 3,6 : 1). Dans l'ensemble, le score de connaissances était de 45,1 % ; les deux groupes avaient des scores similaires. Les plus informés étaient les titulaires d'une bourse (53,2 %, P = 0,000) et les pédiatres (50,6 %, P = 0,000). Le score de perception était de 58,4 % dans l'ensemble, et les performances étaient également similaires dans les deux groupes ; les femmes et les sudistes ont obtenu de meilleurs résultats (59,2 %, P = 0,014 et 59,6 %, P = 0,000, respectivement). Le score de pratique était de 67,0 % dans l'ensemble ; les infirmières ont obtenu de meilleurs résultats (68,3 % contre 65,6 %, P = 0,005) et les infirmières post-base ont obtenu le meilleur score (70,9 %, P = 0,000). Conclusions: Dans l'ensemble, les connaissances de nos répondants sur les droits de l'enfant étaient médiocres. Leurs performances en perception et en pratique étaient bonnes, mais pas suffisantes. Même si nos conclusions ne s'appliquent peut-être pas à tous les agents de santé au Nigeria, nous pensons que l'enseignement des droits de l'enfant à différents niveaux de la formation médicale et infirmière sera bénéfique. Les engagements des parties prenantes impliquant des médecins praticiens sont cruciaux.
Mots-clés: droits de l'enfant, travailleurs de la santé, connaissances, Nigéria, perception, pratique
Keywords: Child rights, healthcare workers, knowledge, Nigeria, perception, practice
|How to cite this article:|
Adeleye QA, Ahmed PA, Babaniyi IB, Oniyangi O, Mukhtar-Yola M, Adelayo AY, Wey YO, Ononiwu UN, Sanni UA, Adeleye BB, Audu LI. Identifying challenges in implementing child rights instruments in Nigeria: A nationwide survey of knowledge, perception, and practice of child rights among doctors and nurses. Ann Afr Med 2023;22:189-203
|How to cite this URL:|
Adeleye QA, Ahmed PA, Babaniyi IB, Oniyangi O, Mukhtar-Yola M, Adelayo AY, Wey YO, Ononiwu UN, Sanni UA, Adeleye BB, Audu LI. Identifying challenges in implementing child rights instruments in Nigeria: A nationwide survey of knowledge, perception, and practice of child rights among doctors and nurses. Ann Afr Med [serial online] 2023 [cited 2023 Jun 2];22:189-203. Available from: https://www.annalsafrmed.org/text.asp?2023/22/2/189/373563
| Introduction|| |
The emergence of international child rights treaties in the early 20th century was crucial to child protection globally. The United Nations Convention on the Rights of the Child (UNCRC) of 1989 and the African Charter on the Rights and Welfare of the Child (ACRWC) of 1991 provided a comprehensive framework that gave voice to every child., In 2003, Nigeria domesticated these documents by signing the Child Rights Act (CRA) into law. Knowledge gaps, reservations, and concerns are central to weak implementation of child rights laws and policies globally.,,,,,,,
Despite numerous child protection laws and policies in Nigeria, child labor, female circumcision, early marriage, sexual violence, unregistered births, out-of-school children, under-age criminal charges, and physical punishment of children still abound in the country.,,, Sociocultural and religious concerns and inconsistent statutes have been linked to nonadoption, partial adoption, and poor implementation of child centred laws in Nigeria.,, Doctors and nurses are well positioned not only to address medical consequences of child maltreatment, but also to protect and advocate for children., Healthcare workers (HCW) can only play such roles effectively if they sufficiently know and comply with relevant provisions of rights instruments.
Studies on knowledge, perception, and practice of child rights are sparse globally. To the best of our knowledge, no nationwide survey on the subject exists in Nigeria. We hoped this study would reveal the depth of HCW's knowledge of and compliance with child rights instruments. We aimed to determine the respondents' knowledge of child rights, the extent of their compliance (in perception and practice), and the influence of demographic variables on performance.
| Materials and Methods|| |
Study design, site, and population
This was a descriptive cross-sectional online study of Nigerian doctors and nurses practicing at home and abroad.
Nigeria comprises more than 250 ethnic groups living in two main geographical regions – the north and the south. The regions are further divided into six geopolitical zones: north-central, north-west, north-east, south-south, south-east, and south-west. As of 2021, Nigerian doctors and nurses were estimated to be 106,291 and 281,586, respectively.,
Included in this study were Nigerian doctors and nurses registered with the Medical and Dental Council of Nigeria (MDCN) or the Nursing and Midwifery Council of Nigeria (NMCN), as appropriate.
Sample size estimation
Using finite population correction of the Cochran's formula, the minimum sample required for the study was estimated with:
N is the estimated finite population size (doctors – 106,291 and nurses – 281,586). We presumed 50% (p) in each group have sufficient knowledge of children's rights and sufficient compliance with child rights laws, assuming a 5% margin of error (d) at 95% confidence interval (z = 1.96).
Thus, 383 and 384 were estimated for doctors and nurses, respectively.
Questionnaire development, sampling, and data collection
A structured multiple-choice nonleading questionnaire was prepared on Google form. Knowledge, perception, and practice of specific child rights were examined based on the UNCRC, ACRWC, CRA, and relevant laws on child labor, child adoption, criminal responsibility, female circumcision, and physical punishments.,,,,, All but one question had mutually exclusive options from which respondents were expected to select their answers. In all, there were 13 knowledge, 31 perception and 10 practice questions. Details of responses are shown in [Appendix 1], [Appendix 2], [Appendix 3].
After a pilot test of 14 respondents and minor adjustments, participants were recruited using a nonprobability sampling technique. The link to the questionnaire was sent through WhatsApp and E-mail. Potential respondents were reached in the six geopolitical zones through personal contacts and professional groups, including Nigerian Medical Association, National Association of Nigerian Nurses and Midwives, Association of Resident Doctors, medical guilds, Alumni associations, and specialty groups. To possibly guarantee the most honest responses, no identifying information was required. Respondents were required to fill the form once; the re-submission link was also disabled. Data were collected between September 2021 and January 2022.
The study was conducted in accordance with the Declaration of Helsinki. Approval was obtained from the health research ethics committee of the Federal Capital Territory, Abuja, Nigeria (FHREC/2021/01/106/07-09-21). The first page of the questionnaire contained information about the survey, and respondents were required to consent before they could proceed.
Each correct or compliant response was awarded a score of 1. One question was excluded from the perception score – personal belief considered in tension with child rights instruments. Three questions were excluded from the practice score due to scanty valid responses – child's age at the time of employment for domestic work, child's age at the time of employment for business/trade, and child's place of abode. Thus, a total of 13 knowledge, 30 perception and 7 practice questions were analyzed.
The data were analyzed using IBM SPSS Statistics, Version 25.0. Armonk, NY, USA: IBM Corp. Descriptive statistics were used to analyze the demographic profile, the distribution of responses, and the mean scores. Chi-square was used to compare the proportions. Individual total scores show normal distribution in each domain of assessment [Figure 1], [Figure 2], [Figure 3].
Mean scores were compared against contrived thresholds (50% and 75%) using one-sample Student t-test. Scores comparable to at least 50% were considered good performance, those comparable to at least 75% were considered sufficient performance, and those significantly below 50% were considered poor performance. Student t-test and analysis of variance were used to analyze the influence of dichotomous and polychotomous demographic variables, respectively. Post hoc analysis was done with Tukey honest significant difference to identify pairs that truly differ. Statistical significance was set at P < 0.05.
| Results|| |
Participants and sociodemographic profile
A total of 821 respondents were analyzed; medical doctors accounted for 49.8% while nurses represented 50.2% [Figure 4]. Most respondents hail from the south, but majority practice in the north [Table 1]. Each geopolitical zone (as place of origin) accounted for between 15% and 23% except for north-east with 4.9%. Female-to-male ratio was 2:1 (1.2:1 for doctors, and 3.6:1 for nurses). Majority were between 21 and 50 years old with a preponderance of 31–40 years old respondents.
|Figure 4: Flow chart showing the number of excluded and included participants|
Click here to view
Distribution of knowledge responses
At least 50% of respondents were aware of UNCRC, ACRWC, CRA, and existence of child adoption laws in Nigeria [Appendix 1]. Exceedingly small proportions (<2%) knew that minimum age of criminal responsibility (MACR) in Nigeria is 7 years, and the minimum employable age is 12 years.
Distribution of perception responses
Seventy percent believed there is no friction between their personal beliefs and child rights laws. At least 50% supported child rights, free and compulsory education for boys and girls, education as a fundamental human right, childhood immunization, recommendation on MACR and employable age, child adoption, sex education in primary and secondary schools, complete transfer of parental rights from biological to adoptive parents, children's freedom to choose a career, and a complete ban on female circumcision regardless of who performs it [Appendix 2].
Only 11% and 5% agreed physical punishment and scolding, respectively, are not justifiable. Meanwhile, 21% and 45% supported a complete ban on physical punishment at home and in school, respectively.
Distribution of practice responses
At least 70% of respondents were ready to be child rights advocates, had not employed persons <18 years old and had neither circumcised a female child nor had their daughters been circumcised [Appendix 3]. Only 7% had never scolded a child.
Respondents' knowledge of child rights was below average and both groups of HCW had similar scores [Table 2]. Performances in perception and practice were above average, with nurses scoring much higher in the practice domain. Average cumulative scores were significantly <75% in all domains.
|Table 2: Overall performance in knowledge, perception, and practice of child rights|
Click here to view
Influence of demographics
South-southerners, married respondents, Christians, pediatric HCW, and medical fellows were the most knowledgeable about child rights [Table 3] and [Table 4]. Also, respondents' knowledge improved with age, number of children, and years in medical practice. However, region of origin, place of practice and sex did not influence how much they knew about child rights.
|Table 4: Demographic variables with true difference in performance after post hoc analysis|
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In the perception domain, southerners and female respondents were more compliant with child rights instruments. Singles, Christians, and south-easterners recorded the best scores. Respondents practicing in the north-central and south-south geopolitical zones also had the best scores, even though a true difference was only observed between north-central and north-west. However, region of practice, age, number of children, field of practice, years in practice, and highest qualification were not influential in this domain.
In the practice domain, married and single respondents recorded comparable scores. Postbasic nurses earned the best score and significantly so when compared to doctors with fellowship qualification. Other demographic variables did not significantly impact on respondents' practice of child rights.
| Discussion|| |
Extensive literature search did not return population-based surveys involving all fields of medical practice to appropriately compare our findings with. Notwithstanding, our results have areas of similarities to those of previous studies that examined the same subject.
Knowledge of child rights
In the present study, 68% of respondents were aware of the UNCRC, and most could identify specific rights in the CRA. In Malaysia, up to 62% of 102 pediatric doctors were aware of the UNCRC, but only 19% could identify specific rights.
On the ratio scale, our respondents' performance in the knowledge domain was poor overall; doctors and nurses had similar scores, and only pediatric practitioners had a good score. In a similar Pakistani study involving 183 pediatric doctors and nurses, 85% of respondents were aware of child rights, and doctors performed better. Since ratio scales are more informative and precise compared to frequency scale, our results are likely more reflective of respondents' performance. Nonetheless, the performances of pediatric practitioners in both studies suggest that regular contact with children is associated with better knowledge of child rights.
Although the scores were below average, region of origin and religion appear to have influenced our respondents' knowledge of child rights – southerners and Christians scored higher than their northern and Muslim counterparts. The reason for this difference is not exactly clear from our study. Most southerners are Christians while most northerners are Muslims, a picture that was also observed in our study where southerners were 84% Christians and northerners were 69% Muslims. It is possible that adoption of the CRA in the entire Christian-dominated southern Nigeria has created considerable awareness about child rights – as of August 2022, all 17 southern states have signed the Act into law compared to 14 of the 19 northern states.
Knowledge of child rights improved with age, marriage, number of children, years in medical practice, and advanced medical qualification. Such influence on knowledge could be considered intuitive. Chin et al., in the Malaysian study, similarly reported that respondents' knowledge about the UNCRC improved with their years of experience in medical practice. In the Pakistani study, however, knowledge was not significantly influenced by age and years of experience. The contrast in outcome between the Pakistani study and ours could be explained by the fact that our sample size was four times larger.
In the current study, the sex of respondents did not impact on how much they knew about child rights and child rights instruments. Although the striking female predominance in our study may have obscured any influence of sex, the outcome may still not be a surprise since knowledge acquisition in Nigeria is not gender restrictive.
Previous studies have also demonstrated poor knowledge of child rights among Nigerian non-HCW. First, among 121 Nigerian graduates in a multi-national survey that also involved Americans and Ghanaians. Second, among 260 Nigerian parents with mostly primary and secondary education in Ilorin, Kwara state, north-central Nigeria. Although samples in these studies are smaller, the similarity to our findings suggests that, regardless of social status, knowledge of child rights is generally poor in the Nigerian population.
Perception of child rights
Doctors and nurses in this study recorded good and comparable performances in their perception of child rights. However, their perception was not sufficiently compliant with provisions of relevant child rights laws and policies. In specific terms, fewer HCW were compliant in areas of marriageable age, age of sexual consent, reproductive health, physical punishment, family court, and freedom of religion. Poor knowledge of child rights could partly explain why compliance in this domain was not sufficient.
Only 10% of respondents in our study agreed physical punishment is not justifiable, while 21% and 45% supported a total ban in homes and schools, respectively. Apparently, a section of HCW, who perhaps believe that “reasonable” physical punishment has a role in child upbringing, would still prefer it banned completely. The reasons for and implications of such discordance could be investigated in the future. Similar studies in the US, UK, and Turkey show that 40−75% of health workers and the general population would not want physical punishment of children banned outrightly.,, These may suggest that the practice (of physical punishment) transcends nationality, culture, educational attainment, profession, and medical specialty. It is worthy of note that recent studies in the US show a steady decline in the prevalence of corporal punishment in the last three decades. The decline could be the impact of effective child rights advocacy and strong enforcement policies noticeable in developed countries.
The vast majority of respondents in our study did not know that Nigeria's MACR is 7 years. Meanwhile, a similar majority – around 90% aligned with at least 15 years (a recommendation of the African Union) to be the MACR in the country. Such overwhelming support for recommended benchmark, despite poor knowledge of what is obtainable, may indicate that Nigerian HCW would likely endorse a legislative push for an upward review.
Healthcare workers in this study, irrespective of cultural or religious affiliations, demonstrated good albeit insufficient compliance in perception of child rights. Their good compliance shows that child rights instruments are not entirely in contention with religion or culture in Nigeria. This is consistent with the fact that majority of respondents (70%) in the current study believe that child rights laws do not contradict their belief system. The reason for insufficient compliance may not be clear from our study; yet it could be related to reservations often expressed by religious faithful. For example, some Christians have challenged the concept of adolescent sexual rights, the ban on corporal punishment of children, and the “undue interference” of child rights instruments in sensitive domestic matters. Furthermore, some Muslim writers have disagreed with the definition of a child, the minimum marriageable age, the legitimacy of a child born out of wedlock, the complete transfer of parental rights to adoptive parents,,, the role of family courts, and the complete ban on corporal punishment of children.,
Like in the knowledge domain, more compliance in perception by southerners and Christians may be attributed to domestication of the CRA in the entire southern part of the country. Meanwhile, the pattern of perception was different when respondents were grouped into their geopolitical zones of practice – those practicing in the north-central were most compliant with child rights laws. This may be because the zone is the seat of power and where child rights campaign was officially launched in Nigeria.
It is not precisely clear why female respondents in our study conformed better in their perception of child rights. Again, unequal distribution of sex in our study may have exaggerated this observation. Even then, the putative notion that women are more children-friendly may have played a role. On the other hand, married respondents, despite better performance in knowledge, scored less in perception than singles. The reason for this paradox becomes less clear when we consider the fact that married respondents are more likely to have children under their care than single respondents. How domestic experience with children influences perception of child rights could be explored in future studies.
Practice of child rights
In this survey, the performance of HCW in the practice of child rights was good but not sufficient, and why nurses performed better is hardly evident. Even though sex did not have a significant influence, we may be tempted to relate nurses' performance to the preponderance of women (78%) among nurses compared to their population (56%) among doctors. A number of studies have shown that women are less likely than men to violate children's rights.,,
Our study shows that physical discipline of children is still prevalent in Nigeria – 72% of HCW had applied physical punishment. This is even higher than the 52% reported by Nuhu et al. in the Ilorin study. The sample size in the Ilorin study was smaller, physical punishments other than beating were not examined and the respondents were parents from lower socioeconomic class. These areas of differences may account for the apparently higher prevalence of the practice (of physical punishment) among Nigerian doctors and nurses. Both outcomes may nonetheless indicate that, despite increasing child rights campaigns globally and locally, enforcement is not yet pervasive in Nigeria.
Doctors with fellowship qualification, despite a good knowledge of child rights, obtained the lowest score in the practice domain, and significantly so compared to nurses with postbasic qualification. Such counterintuitive relationship between knowledge and practice among fellows may indicate that awareness of child rights laws and policies does not necessarily translate into compliant practices.
Strengths and limitations
A noteworthy strength of this study is the adequacy of sample size for both groups of health workers. Also, we consider the spread of respondents, especially across geopolitical zones (of origin), good enough to make meaningful interpretations. Furthermore, evaluation on ratio scale gives the true individual and collective performances of respondents.
One limitation is that the nonprobability sampling used may have introduced unintended bias. The method was, however, the most feasible for the researchers considering Nigeria's huge population and size; this also ensured that virtually all geopolitical zones (of origin) were represented. Second, two-thirds of respondents were practicing in the northern part of the country. Such unintended skewed distribution calls for caution when interpreting our findings, particularly with respect to place of practice.
| Conclusions|| |
In our study, knowledge of child rights was poor among Nigerian doctors and nurses. Their performances in perception and practice were good but not sufficient.
Inclusion of child rights into medical and nursing curricula at both undergraduate and postgraduate levels would not only equip HCW with the requisite knowledge, but would also enhance optimal compliance with child rights instruments. A mandatory prelicensure refresher training, organized by the MDCN and NMCN, would give doctors and nurses a sense of responsibility towards protecting children's rights. In addition, engagement of critical stakeholders is most crucial to implementing child rights instruments in Nigeria; medical professionals should feature prominently in such engagement.
We are very thankful to all doctors and nurses who took out time to participate in the survey.
We are also thankful to the following lawyers for their valuable inputs at the early stages of the draft: Barr Aishat Abiodun Adeleye, Barr Banjo David Ogirima Jeremiah, Prof Abdulrasheed Musa Yusuf.
We are deeply indebted to the following doctors who gave suggestions to the initial draft and assisted in facilitating the distribution of the questionnaire in different parts of the country: Dr Denis Richard Shatima, Dr Adewunmi Bolanle Oyesakin, Dr Amsa Baba Mairami, Dr Adekunle Otuneye, Dr Chidi Charles Ulonnam, Dr Gabriel Ezeh, Dr Effiong Okon, Dr Nubwa Papka, Dr Lawan Musa Tahir, Dr Chikodili Ngozi Olomukoro, Dr Ramatu Mohammed Nafiu, Dr Zainab Iliyasu, Dr Naja'atu Hamza, Dr Olajumoke Rasheedat Muhammed Bukayo, Dr Nurat Omobolanle Adeleye, Dr Idris Ayodeji Saka, and Dr Michael Ajene Enokela.
We are also very grateful to the following doctors and nurses who also facilitated the distribution of the questionnaire: Dr Kefas Jibir, Dr Igoche Peter, Dr Lauretta Mshelia, Dr Vincent Nwatah, Dr Ukpai Nwankwo Ukpai, Dr Gideon Nwankwo, Dr Francis Chinweuba, Dr Fatima Ibrahim, Dr Kamal Ismail, Dr Jamiu Adebiyi, Dr Olusegun Shoyombo, Dr Azizat Abiodun Lebimoyo, Dr Temitayo Aminat Mohammed, Dr Jimoh Ola Badmus, Dr Afolabi Wasiu Babalola, Dr Jamiu Omar, Dr AbdulWahab Egberongbe, Dr Utomi Nkemjika, Nrs Angela Onuorji, Nrs Kelechi Linda Oguike, Nrs Gambo AbdulKadir, Nrs Joy Amedu, Nrs Nuhu Aminu, Nrs Cynthia Nwankwo, Nrs Omonowo Anumah, and Nrs Ernest Otuya.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]