|
 
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| ORIGINAL ARTICLE |
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| Year : 2017 | Volume
: 14
| Issue : 2 | Page : 75-83 |
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Prevalence of hypertension and diabetes and their determinants among commercial drivers in Ibadan metropolis, South-Western Nigeria
Oluwaseun Temitope Odeyinka, IkeOluwapo O Ajayi
Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University College Hospital, University of Ibadan, Ibadan, Oyo State, Nigeria
| Date of Web Publication | 26-Oct-2017 |
Correspondence Address:
IkeOluwapo O Ajayi
Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University College Hospital, University of Ibadan, Ibadan, Oyo State
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/njc.njc_11_17
Introduction: Undetected hypertension and diabetes could result in cardiovascular and cerebrovascular complications and may result in fatal road accidents if they occur while driving. Commercial drivers are prone to risk factors for these diseases. This study determined the prevalence of hypertension and diabetes among commercial drivers in Ibadan metropolis, South-western Nigeria.
Methodology: A cross-sectional study was conducted among 305 commercial drivers selected using multistage sampling technique from motor parks across Ibadan metropolis. The WHO stepwise interviewer-administered questionnaire was used for data collection on respondents' sociodemographic characteristics, work-related characteristics, knowledge about hypertension and diabetes, physical activity, alcohol consumption, and tobacco use. Blood pressure, anthropometry, and blood sugar level measurements were carried out. Hypertension was defined as systolic blood pressure of ≥140 mmHg and diastolic blood pressure of ≥90 mmHg and diabetes was defined as ≥126 mg/dl fasting blood sugar. Data were analyzed using descriptive statistics, Chi-square test. and logistic regression at α = 5%.
Results: Mean age of respondents was 45.3 ± 10.5 years. About 47.5% and 37.8% demonstrated good knowledge about hypertension and diabetes, respectively. About 49% reported to have ever smoked, 78.0% had consumed alcohol, 45.5% ever had traffic accident, and 44.6% reported physical inactivity. The prevalence of hypertension was 27.7% and diabetes was 3.4% while 42.9% had comorbidity. Hypertension was found among 26.2% of those who had ever smoked and 47.2% of those obese (body mass index ≥30 kg/m2). Age ≥41 years (adjusted odds ratio [aOR] = 2.42, 95% confidence interval [CI] = 0.99–5.88) and abdominal obesity (aOR = 2.41, 95% CI = 0.99–5.83) were predictors of hypertension, and frequent fruit consumption was predictor of diabetes (aOR = 2.71, 95% CI = 0.23–32) although not significant.
Conclusions: High prevalence of hypertension and relatively low prevalence of diabetes among commercial drivers in Ibadan metropolis call for health awareness campaign and free health screening in motor parks for early detection and prevention of the diseases. Keywords: Commercial drivers, diabetes, hypertension, Ibadan metropolis
How to cite this article:
Odeyinka OT, Ajayi IO. Prevalence of hypertension and diabetes and their determinants among commercial drivers in Ibadan metropolis, South-Western Nigeria. Nig J Cardiol 2017;14:75-83 |
How to cite this URL:
Odeyinka OT, Ajayi IO. Prevalence of hypertension and diabetes and their determinants among commercial drivers in Ibadan metropolis, South-Western Nigeria. Nig J Cardiol [serial online] 2017 [cited 2023 May 29];14:75-83. Available from: https://www.nigjcardiol.org/text.asp?2017/14/2/75/217268 |
| Introduction | |  |
Noncommunicable diseases (NCDs), such as cardiovascular diseases, diabetes, and cancer, are leading causes of mortality globally, and hypertension and diabetes are the leading causes of cardiovascular diseases.[1],[2] In Nigeria, NCDs account for an annual death of about 36 million with cardiovascular diseases constituting about 17.3 million deaths, followed by cancer – 7.6 million deaths, respiratory diseases – 4.2 million deaths, and diabetes – 1.3 million deaths.[3] In Nigeria, the incidence of hypertension and diabetes, in particular, is on the increase. They both constitute major NCDs of public health importance and have huge effect on the quality of life of individuals and the economy.[4] Hypertension is a chronic medical condition. It is defined as a systolic blood pressure of ≥140 mmHg and diastolic blood pressure of ≥90 mmHg according to the Joint National Committee on hypertension and treatment of high blood pressure.[5] At Present, 8 million Nigerians suffer from hypertension,[3] and according to the report by the International Diabetes Federation in 2013, there were 3.9 million cases of diabetes in Nigeria, the highest in Africa, with a national prevalence of 4.9%. It has been shown that 80% of diabetes deaths occur in the low- and middle-income countries, and by 2030, diabetes will be the seventh leading cause of death in the region.[6]
Of the many risk factors that are implicated in the epidemiology of hypertension and diabetes, behavioral and physiological risk factors have been more prevalent. The behavioral risk factors include smoking, alcohol consumption, unhealthy diet, and physical inactivity while the concerned physiological risk factors are obesity, increased waist-to-hip ratio, hyperglycemia, and increased cholesterol level.
The transportation industry makes a significant contribution to the development of any nation and can also serve as a proxy for measuring urbanization and industrialization.[7] It has been estimated that over 1.5 million people are engaged in the road transport sector and accounts for 90% of the subsector's contribution to the gross domestic product.[8] However, the mental and physical health of some of these commercial drivers has been reported to be generally poor [9] as they usually have a challenging lifestyle due to the nature of their job, which includes distant travels, with long hours of sitting, little or no sleep, increased physical inactivity, and unhealthy eating habit.[10] In 2012, commercial driving was reported as the leading causes of occupation-related deaths among all occupational deaths accounting for about 50% of all work-related injury deaths in the US.[11] Risk factors of cardiovascular diseases such as obesity, physical inactivity, unhealthy eating, high blood pressure, sleep apnea, diabetes, and tobacco have also been reported to be common among drivers, which not only affect individual's quality of life but also may impact on the costs, productivity, and safety of the industry [12],[13],[14] as well as the nation's economy at large.[15]
Studies conducted among transport workers have reported increasing trend in the prevalence of risk factors to hypertension and diabetes and their implications among professional drivers including those who carry both goods and passengers.[10],[16],[17] A recent study conducted among transport drivers in rural India showed that nearly half of all respondents consumed unhealthy diets, tobacco, and alcohol while majority lived sedentary lifestyles due to the nature of their job.[18] Makanjuola et al.[19] in Nigeria also reported a prevalence of 57.6% of alcohol consumption among tanker drivers in Lagos.
For effective preventive strategies in fighting NCDs among commercial drivers, there is a need for information on the distribution of the risk factors and their burden among these drivers. This will provide evidence-based information for decision-making on what preventive intervention to develop to combat the menace. Therefore, this study was carried out to determine the prevalence of hypertension and diabetes among commercial drivers in Ibadan metropolis as well as identify the factors that independently associate with hypertension and diabetes among this population.
| Methodology | | |
Study area and site
Ibadan is the capital of Oyo State, located in south-western, Nigeria. It is the third largest city in Nigeria by population after Lagos and Kano with a population estimate of 3.16 million in 2015 and projected to increase to about 3.3 million by 2016 if the growth rate of the population remains at +4.14% per year as in period between 2006 and 2015.[20] The inhabitants of the city are predominantly of the Yoruba ethnic group, and the city is presently made up of 11 local government areas. Ibadan has several institutions: the commercial transport system is governed by the umbrella of the National Union of Road Transport Workers (NURTWs) although private transport companies also exist. This study recruited its participants from the parks governed by NURTW. There are approximately 25 NURTW operated parks each of which has taxi and interstate units. The parks are located at strategic areas in the city where passengers can easily access them. Various activities go on at these parks as they do not only accommodate commercial drivers but also union workers and touts (agberos). Traders made up of food vendors, hawkers of different kinds of goods, those who sell cigarettes and alcohol as well as herbal concoctions prepared with alcohol as well as those who deal in illegal goods and even illicit drugs could be found in the parks.
Study design
This cross-sectional study design was used for a study.
Study population
Intra- and inter-city motor and bus drivers in motor parks within the Ibadan metropolis constituted the study population. All drivers who were >18 years of age and registered with NURTW were recruited. Those selected and not available on the day of interview over the period were excluded and replaced by next in line on the sample list.
Therefore, a minimum number of 218 commercial drivers were recruited for this study.
Sampling technique
A multistage sampling technique was used to select participants for this study
- Stage 1: The NURTW has about 25 parks within Ibadan metropolis. Fifteen of these parks were selected randomly from the list of all the parks
- Stage 2: To determine the number of respondents (n) selected from each park, the sample size (N) was divided by the number of selected parks and this gave 15 drivers per park
- Stage 3: A total of 15 drivers were recruited from each park. Respondents from each park were randomly selected by balloting from drivers listed in the NURTW's register who were in the park on the day of interview. In a park, five drivers were selected for the study every day for 3 days. Repetition of respondents was prevented by using their union identification cards for registration. This procedure was repeated for all the 15 parks visited.
Data collection method
Data were collected from respondents using a semi-structured interviewer-administered questionnaire. Information on sociodemographic characteristics, dietary pattern, physical activities, alcohol consumption, smoking habits (past and/or present), and knowledge of the risk factors for hypertension and diabetes were elicited from respondents. Assessment of respondents' biochemical indices (fasting blood glucose), anthropometric measures (weight, height, and waist and hip circumference), and blood pressure was also determined using standard instruments. The questionnaire was adapted from the WHO stepwise questionnaire.[21] The WHO stepwise questionnaire is an instrument used for NCD risk factor surveillance among different populations. It was developed for developing countries to monitor and evaluate various interventions for combating NCDs.
The questionnaire was translated to the local language of the community, Yoruba and back translated to English to ensure the accuracy of translation. Furthermore, the questionnaire was pretested among twenty commercial drivers in “Ikire” town outside Ibadan to ensure comprehensibility, clarity as well as identify other issues peculiar to the population which were not included in the questionnaire before using it for this study. The internal consistency of each item on the questionnaire was 0.873 using Cronbach's alpha on the Statistical Package for the Social Sciences (SPSS) Version 16 (IBM Corporation).
Operational definition
High blood pressure
High blood pressure was classified as blood pressure (BP) of ≥140/90 mmHg and/or self-reported treatment of hypertension with antihypertensive medication taken in the past 2 weeks according to the WHO/International Society of Hypertension Guidelines.[5],[22]
Body mass index
The BMI was determined as weight (in kg) divided by height (in m 2). The BMI results were categorized as obesity if the BMI was ≥30 kg/m 2, overweight if the BMI was >25 but <30 kg/m 2, and normal if the BMI is between 18 and 25 kg/m 2 and underweight if <18 kg/m 2.[21]
Waist-hip ratio
Waist-hip ratio (WHR) was estimated as waist circumference (in cm) divided by the hip circumference (in cm). Central obesity was defined as WHR >0.85 for females and >0.90 for males.[23]
Diabetes
Diabetes was defined as fasting blood sugar ≥126 mg/dl or ≥7.0 mmol/L.[21]
Physical activity
Sedentary activity (e.g., walking) = 3.3 (time of activity × number of days of activity) per week. Moderate activity (e.g., washing and climbing) = 4.0 (time of activity × number of days of activity) per week. Vigorous activity (e.g., playing football and jogging) = 8.0 (time of activity × number of days of activities) per week. Physical inactivity was calculated as <600 mets-min/per week. Moderate activity was calculated as 600-1499 mets-min/per week and vigorous activity was calculated as ≥1500 mets-min/per week.[24]
Alcohol intake
One drink was defined as one shot of spirits (gin or local gin), one glass of wine, or half a bottle of beer. Current drinker was measured as taking at least one shot of spirit/one glass of wine/half bottle of beer every day or some days in the past 30 days.[21]
Smoking status
Smoking status was determined using current smoking measured as smoking cigarettes every day or some days in the past 30 days.[21]
Data analysis
All analyses were performed using SPSS Version 16. The outcome variables for this study were hypertension and diabetes while the independent variables were smoking, alcohol consumption, physical inactivity and diet as well as the sociodemographic characteristics of respondents. Questions on knowledge were scored to give an aggregate score of 13. Respondents with score <10 were categorized as having poor knowledge while those with scores between 10 and 13 were said to have good knowledge.
Descriptive statistics such as means, proportions, and percentages were used to summarize the data, and inferential statistics such as Chi-square test was used to test for associations between categorical variables. Multiple regression analysis was carried out to determine predictors of hypertension and diabetes among the commercial drivers. Results were interpreted as statistically significant at P < 0.05.
Ethical considerations
Ethical approval for the study was obtained from the Ethical Review Committee, Ministry of Health, Oyo State. Permission for study was obtained from the NURTW branch chairman of the parks selected for the study.
Written informed consent was obtained from all participants. The informed consent form was translated into Yoruba and back translated to English to ensure correct translation.
Confidentiality of participants' information was ensured by adopting a de-identified approach to data handling, with the use of unique identifiers for study participants.
All participants received counseling on the importance of maintaining a healthy weight and engaging in healthy lifestyle. Each consenting participant was able to know their sugar level and blood pressure, and those requiring attention were advised to see a doctor accordingly.
| Results | | |
The study recruited 305 male respondents with a mean age 45.3 ± 10.5 years and majority, i.e., 94.3% were married. More than half of the respondents, i.e., 198 (65.1%) practiced the Islamic religion while 103 (33.9%) and 3 (1.0%) belong to the Christian and traditional religion, respectively. They were predominantly of the Yoruba ethnicity (94.4%). Less than half (43.2%) had secondary level of education, and 35.1% earned <₦30,000 (US dollars equivalent $150 in 2015) every month. One-third (n = 203, 66.6%) of respondents were intercity commercial drivers while the others plied routes within Ibadan metropolis (33.4%). Ninety-one (35.5%) respondents had been involved in road traffic accidents while 53 (18.2%) mentioned that they used stimulants while driving. However, 38 (71.7%) and 15 (28.3%) of the inter- and intra-city drivers, respectively, reported to have used stimulants while 65 (71.4%) and 26 (28.6%) of the inter- and intra-city drivers said that they have been involved in road traffic accidents.
The respondents' characteristics are summarized in [Table 1]. | Table 1: Frequency distribution of sociodemographic characteristics of the respondents
Click here to view |
In general, less than half of the respondents had a good knowledge of hypertension (n = 122, 47.5%) and diabetes (n = 108, 37.8%) as well as their risk factors. [Table 2] shows that 92.8% said that both hypertension and diabetes can cause body impairment. More than half of the respondents reported that smoking (n = 156, 53.6%), alcohol consumption (n = 169, 58.1%), unhealthy diet (n = 158, 54.3%), physical inactivity (n = 157, 54.0%), high salt intake (n = 176, 60.5%), and obesity (n = 166, 57.0%) can make one to develop hypertension while n = 207 (71.1%), n = 178 (61.2%), and n = 167 (57.2%) said that alcohol consumption, unhealthy diet, and high salt intake, respectively, can make one to develop diabetes. About one-fifth, 22.0% and 22.1%, respectively, said that hypertension and diabetes cannot be cured but rather managed. Majority of the respondents reported that hypertension (n = 265, 91.1%) and diabetes (n = 263, 90.4%) can be prevented while two-thirds said that hypertension (66.0%) and diabetes (63.6%) cannot be transmitted from one person to another. | Table 2: Knowledge of respondents on hypertension and diabetes in relation to their risk factors
Click here to view |
This study found the prevalence of hypertension and diabetes among the respondents to be 27.7% and 3.4%, respectively.
[Figure 1] shows that among the respondents with diabetes, 42.9% of them also had hypertension, an association that was not statistically significant (P = 0.380). | Figure 1: Comorbidity of hypertension and diabetes among commercial drivers
Click here to view |
[Table 3] shows the distribution of known risk factors of hypertension and diabetes. About half, 49.2%, of respondents had ever smoked any tobacco products, 54.1% of whom started smoking between 18 and 30 years, and 46.9% were still current smokers (74.6% of whom smoked frequently [≥4 days]). About three quarter, 78.0%, had ever consumed alcohol, out of which 84.2% were currently taking it and 47.7% took alcohol on a daily basis. On diet, only 12.1% mentioned that they add extra salt to already cooked meal and less than one-third consumed fruits (27.8%) and vegetables (22.3%) on a daily basis. Hundred and seventy-one (60%) respondents used vegetable oil for cooking and 125 (44.1%) ate out frequently (≥4 days per week). | Table 3: Frequency distribution of lifestyle and dietary pattern among respondents
Click here to view |
[Table 4] shows a summary of the factors that are independently associated with hypertension and diabetes among respondents | Table 4: Risk factors associated with hypertension and diabetes among respondents
Click here to view |
| Discussion | | |
In this study, more than half of the respondents were between 36 and 55 years of age. All respondents were male, majority of who were married. Out of all the respondents, about two-fifth of them had secondary level of education with less than one-third of then earned between ₦31,000 and ₦60,000, and about 53% had between one and three adults dependent on them. This is a reflection of the socioeconomic situation of Nigeria, where a higher number of dependents increase the financial and psychological stress of respondents, and these have been reported to be associated with higher blood pressure and overwhelming cardiovascular profile.[25]
More than half of the respondents were intercity drivers who drove an average distance of 481 km/day (median distance travelled) for an average of 6 h, and about three-quarter of these use stimulants while driving. While the habit to consume sleep inhibitors exerted a protective effect on the possibility of developing arterial hypertension as shown in a study among heavy truck drivers in Sao Paulo state in Brazil,[26] the use of stimulants suggests that drivers experience sleep while driving hence the prevention. Sleeping on wheels may likely be due to stress as they spent long hours on the road driving. The stress could be risk factor for complications of hypertension which may lead to road traffic accidents while driving if not controlled.[19] The self-reported prevalence of road traffic accidents among the respondents was more among intercity drivers (71.4%) compared to intracity which was more than the 35% prevalence reported by Cavagioni and Pierin [26] among intercity drivers. In line with findings by Cavagioni and Pierin, the use of stimulants suggests that the drivers use stimulants mostly to keep awake while driving, a practice which needs to be discouraged and drivers enjoined not to drive when tired, stressed, or feel sleepy and also as stimulants are risk factors for high systolic blood pressure which may contribute to highway traffic accident.
Overall, less than half, 40%, of the respondents had a good knowledge about hypertension which is more than the 28.8% by Erhiano et al., 2015,[27] in a study conducted among commercial bus drivers in Sokoto State. Although studies have revealed that there is poor knowledge of hypertension,[28] but of the 40% respondents with good knowledge in this study, 75% of them did not have hypertension which showed that good knowledge aid prevention of the disease.[27]
The prevalence of hypertension in this study was 27.7% and falls within the average found in a review of hypertension prevalence and its complication among Nigerian Africans by Ogah et al.,[29] where the prevalence of hypertension was reported to be 8.1%–42.0% in the urban setting. The site of this study is urban. The prevalence is, however, lower than that reported among truck drivers in Iran [23] and commercial bus drivers in Sokoto but higher than that reported among professional drivers in Sagamu, Nigeria.[30] This prevalence might appear to reflect, although lower, the prevalence of hypertension in a slum community in Oyo State as Ajayi et al., 2016[31] showed a prevalence of 33.1% among the community dwellers. The incidence of elevated blood pressure in the drivers may be related to their sedentary lifestyle, diet, and the physical and psychological stress associated with their job.
There was an association between hypertension and body mass index indicating that those who were obese are one and a half times more likely to develop hypertension than those who are not, thus indicating that BMI ≤30 kg/m 2 is protective of hypertension which is in agreement with the report of Wofford et al.[32] that obesity is a singular risk for developing cardiovascular diseases, one of which is hypertension.[33]
Furthermore, there was an association between age and hypertension where respondents' age ≥41 years are more than two times more likely to develop hypertension than those aged ≤40 years which corroborate the report from the association between age and hypertension in the study among drivers in Abuja, where respondents older than 40 years were more likely to develop hypertension.[34] In the review of hypertension among workers, almost all the studies with available data consistently showed a direct relationship between age and mean systolic and diastolic BP and hypertension irrespective of sex or geographical setting.[35] The association between hypertension and WHR though showed a nonstatistical relationship (P = 0.051) suggests that those who had abdominal obesity (WHR ≥0.90) have an odd of more than two times likelihood of developing hypertension compared with those who do not have abdominal obesity.
In this study, the prevalence of diabetes was 3.4%, which is in contrast with findings of Abu Dabrh et al. in a review on health assessment of commercial drivers: a meta-narrative systematic review, where the prevalence of diabetes was 33%[36] and the study in Abuja,[34] where diabetes had a prevalence of 10%. The reduced prevalence of diabetes in this study could be due to the fact that the adoption of Western lifestyle in Abuja, being the Federal Capital Territory of Nigeria, is more prevalent than it is in Ibadan despite that the two cities are urban. In addition, there were older drivers studied in Abuja compared with this study and the risk of diabetes increases with age. This reduced prevalence could also be as a result of the high nonresponse rate for blood test in this study.
An important finding in this study is that 42.9% of the respondents with diabetes also had hypertension, a result that corresponds with that of Unadike et al., who reported a prevalence rate of 54.2% hypertension among diabetics in their study conducted in Benin City.[37]
The kind of oil used in cooking in the respondents' household had a significant association with the development of diabetes. Respondents who consumed vegetable oil are 33 times less likely to develop diabetes compared to those who consumed other kinds of oil (margarine, butter, etc.) while those who used palm oil were 100 times less likely to develop diabetes than those who consumed other kinds of oil, including vegetable oil (P = 0.04 and 0.02, respectively). This corroborates the result of a study in Iran that reported that higher intakes of partially hydrogenated vegetable oil were associated with a greater risk of individual cardiovascular risk factors while those of nonhydrogenated vegetable oil were associated with a reduced risk.[38] The respondents who add extra salt to already cooked meal were almost 17 times less likely to have diabetes, a statistically significant association (P = 0.004).
Limitations
Due to the nature of the job of the commercial drivers, it was difficult to get some of them as they were usually on turn waiting to load passengers. Reliance on self-reported information on age, smoking, alcohol consumption, salt intake, and physical activities may have affected the findings by social desirability bias. Some of them did not consent to having their blood taken for blood sugar estimation for superstitious reasons. Some of the respondents could not carry out the fasting blood sugar test because they did not return from travel every day. The postprandial test could not be carried out due to financial constraints; therefore, the prevalence of diabetes from this study may not be representative of the diagnosis. This study was conducted in one city and may not be generalizable to all commercial drivers. However, the findings highlighted the need to pay attention to hypertension and diabetes control among commercial drivers and the determinants. These findings could also inform further studies in different parts of the country.
| Conclusions | | |
The prevalence of hypertension among commercial drivers in Ibadan metropolis is high compared to the 9% prevalence (using cutoff of 160/95 mmHg) among commercial drivers in Jabi [34] and the national figure of 5%–7%.[31] Similarly, the prevalence of diabetes, 3.4% among these commercial drivers, is higher than the 2.2% national prevalence reported by Nyenwe et al.[39] but lower than the prevalence of diabetes recorded among commercial drivers in Abuja.
Less than half of the respondents, 40% and 35.4%, in this study had a good knowledge of hypertension and diabetes, respectively, which indicates that there is a need to increase the awareness about these diseases and their risk factors.
The risk factors for hypertension and diabetes in this study corroborate that reported in the past studies in this environment and low-income settings. The distribution of the risk factors for hypertension among the respondents showed that urgent attention is needed to prevent hypertension and its complications among the respondents. About 43% of the respondents with diabetes from this study also had hypertension which showed that the risk of having either or both of diseases is intertwined in their independent risk factors. Therefore, avoidance from any of the risks of having either hypertension or diabetes is the key to prevention of the diseases.
Public health implications
The findings of this study highlight high level of hypertension among commercial drivers in urban city. The drivers are among the sedentary group of workers in the informal sector who are rarely targeted by national cardiovascular health programs or policies. Models for workplace or employee well-being programs are almost exclusively based on structured formal sector workplaces.[40] It is thus important for national programs on occupational health and NCDs to target these informal sector workers through their unions and associations and integrate these programs into their workplace-related activities.[41]
We therefore recommend that public health unit of the Oyo State Ministry of Health collaborates with the state NURTW to organize health education and awareness programs on hypertension and diabetes among commercial drivers. Regular screening exercise should be made mandatory by the NURTW in association with the Federal Road Safety Corps and recertification of driving license be based on production of this medical certificate. Such screening exercise should be within the motor park as a package for workplace intervention considering the fact that the drivers do not have time to go to health facilities. Sales of stimulants and alcohol should also be prohibited within the motor parks to reduce their use and abuse.
Acknowledgments
The authors appreciate the support of Dr. O.O. Akinyemi and Mr. Martins Imhansoloeva for their contributions during the analyses of the data from this study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4]
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