Objectives The aim of this study was to assess the health-related quality of life (HRQoL) and associated factors among patients with schizophrenia at comprehensive specialised hospitals in Northwest Ethiopia.
Design and setting A cross-sectional study was conducted among 422 patients with schizophrenia who were followed at comprehensive specialised hospitals in Northwest Ethiopia from 1 June to 30 August 2022.
Participants All adult patients with schizophrenia who had regular follow-up in the outpatient departments of the selected hospitals were study participants.
Main outcome measures The main outcome of this study was HRQoL which was measured using the WHO Quality of Life Scale–Bref Version. Data entry and analysis were done using Epi-data version 4.6.1 and SPSS version 24, respectively. Linear regression was used to assess the association between quality of life and independent variables. Variables with a p value <0.05 at a 95% CI were considered statistically significant.
Results The mean score of the overall Quality of Life Scale–Brief Version was 22.42±3.60. No formal education (ß=−1.53; 95% CI: −2.80 to –0.27), duration of treatment (ß = –3.08; 95% CI: −4.71 to –1.45), comorbidity (ß=−1.14; 95% CI: −1.99 to –0.29), substance use (ß=−0.89; 95% CI: −1.56 to –0.23), extrapyramidal side effects (ß=−2.02; 95% CI: −2.90 to –1.14), non-adherence (ß=−0.83; 95% CI: −1.44 to –0.23), and antipsychotic polypharmacy (ß=−1.77; CI: −2.57 to –0.96) were negatively associated with quality of life.
Conclusion and recommendation In this study, the social domain was recorded as having the lowest mean score, which may indicate that patients with schizophrenia could need better psychosocial support. Patients with a longer duration of treatment, who had comorbid illnesses, were substance users, developed EPS, were non-adherent to medications and were on antipsychotic polypharmacy, needs critical follow-up to improve HRQoL.
- schizophrenia & psychotic disorders
- quality of life
- substance misuse
- adult psychiatry
- observational study
Data availability statement
Data are available upon reasonable request. The datasets used and analysed during the current study are available from the corresponding author upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- schizophrenia & psychotic disorders
- quality of life
- substance misuse
- adult psychiatry
- observational study
STRENGTHS AND LIMITATION OF THIS STUDY
This study is multicentre with a relatively large sample size, which is preferable for generalisability.
Despite this, the cross-sectional nature of the study did not allow for a follow-up and made it difficult to establish a causal relationship.
Even if the WHO BREF assessment tool is cross-culturally valid, it is not validated in the Ethiopian context.
Clinical data relating to disease severity was difficult to assess.
Substance use assessment is prone to social desirability bias.
Schizophrenia is a complicated, chronic mental health illness characterised by an array of symptoms, including delusions, hallucinations, disorganised speech or behaviour and reduced cognitive abilities.1 Disability, typically, stems from both negative symptoms (marked by loss or deficiencies) and cognitive symptoms, such as impairments in attention, working memory or executive function. In addition, relapse may occur because of positive symptoms such as suspiciousness, delusions and hallucinations.1 2 Quality of life is a dynamic concept that can change from time to time and is characterised by its individuality; each individual perceives their quality of life as different from that of others.3 It is an all-inclusive, convenient summary term capable of reflecting the range of impairments and outcomes that sometimes exacerbate a chronic illness such as schizophrenia. In view of these advantages, health-related quality of life has been widely employed as a screening and outcome measure in the rehabilitation of chronic mental illness and, more recently, as an outcome measure in clinical studies using newer antipsychotic drugs.4
The health-related quality of life (HRQoL) of people with schizophrenia has been reported to be reduced compared with general population. This may be due to the influence of schizophrenia on the HRQOL of the patient typically implies decreased functioning because of its chronic nature, lack of completely effective therapy, lack of illness knowledge, social stigma and side effects of medication.3
Characteristics that best describe the HRQoL of patients with schizophrenia are worse than that of other physically ill people and the general population. In addition, psychopathology, particularly negative and depressive manifestations, has a negative relationship with HRQoL as the condition progresses. In addition, older people, men and unmarried people report decreased HRQoL. Likewise, HRQoL is reduced by medication-related side effects and by the only use of psychopharmacological or psychotherapy treatments. Further patients who are excluded from the community assistance programme exhibit a higher HRQoL than institutionalised patients.5 Due to the adverse effects connected to antipsychotic polypharmacy (APP) and its relationship with increased disease severity and treatment resistance, it is predicted that patients on APP will have decreased HRQoL than those on antipsychotic monotherapy.4
Some studies have investigated HRQoL among patients with schizophrenia.3 6 However, comprehensive evidence is still limited, particularly in study settings. Even the existing kinds of literature are single-centred, use varied measuring tools and include relatively small study participants. Generalising and drawing conclusions might be difficult. Thus, this is the first multicentre study with a larger sample size in which additional variables like APP and extrapyramidal side effects were also included. Therefore, the aim of this study was to assess the level of health-related quality of life and associated factors among patients with schizophrenia at comprehensive specialised hospitals in Northwest Ethiopia.
Materials and methods
Study setting, period and design
A cross-sectional study was conducted at the University of Gondar Comprehensive Specialised Hospital (UoGCSH), Felege-Hiwot Comprehensive Specialised Hospital (FHCSH) and Tibebe-Ghion Comprehensive Specialised Hospital (TGCSH) from 1 June to 30 August 2022. Gondar, a city 730 kilometres to the northwest of Addis Abeba, is where UoGCSH is situated (the capital city of Ethiopia). Every year, 12 000 individuals with psychiatric problems have received care from UoGCSH. The UoGCSH’s psychiatry unit has four outpatient departments, 19 inpatient beds and two emergency room beds. FHCSH and TGCSH, on the other hand, are situated in Bahir Dar, 521 kilometres from Addis Abeba. With seven inpatient beds and six outpatient divisions, FHCSH treats 19 200 patients with psychiatric problems each year. The TGCSH contains two inpatient rooms with six beds each, as well as one emergency department.
Population, inclusion and exclusion criteria
All adult patients with schizophrenia having a regular follow-up at the outpatient departments’ psychiatric clinic in the comprehensive specialised hospitals of northwest Ethiopia were the source population. All adult patients with schizophrenia having a regular follow-up at the outpatient departments of UoGCSH, FHCSH and TGCSH during the study period were the study populations. Patients with the age of 18 years and above, taking antipsychotic medication, who had an insight to respond oral questions (satisfy the requirement in the insight assessment tool (get 3 out of 3), and patients who had one or more previous visits were included under the study. Patients who had incomplete medical record were exclude from the study.
Sample size determination
Single population proportion formula was used to determine the number of participants needed for this study. Even if there are studies conducted in our country, as this is a multicentre study, to get better representative sample, we used proportion as 50% in sample size calculation.
where n is the desired sample size for a population of >10 000, Z is the typical normal distribution set at 1.96 (which corresponds to 95% CI), the p value signifies that positive prevalence was used in calculating the optimal sample size, and W is the degree of accuracy 0.05 required (a marginal error is 0.05). Then computing for n = 1.962*0.5 (1–0.5)/0.052, n=384. By adding 10% non-response rate, the final calculated sample size was 422.
Sampling technique and procedure
The comprehensive specialised hospitals in the northwestern Ethiopia were selected by a random lottery method. The total number of patients with schizophrenia on follow-up within 3 months was taken from the patients’ registration document to allocate samples proportionally within study areas. After proportional allocation, a systematic random sampling technique was used to select the study participants. The sampling fraction (k) was calculated by dividing the total number of patients with schizophrenia in the study area by the total sample size (2625/430 gives 6.1 ≈ 6). The starting point was selected randomly from 1 to 6. Then, participants were interviewed, and concurrently, relevant data were reviewed from medical charts for every sixth patient until the requirement for a sample was fulfilled. A unique patient identification card number was used as a questionnaire code in order to prevent the inclusion of the same patient in the study more than once (figure 1).
Health-related quality of life (HRQoL) was the main outcome variable. The independent variables were the sociodemographic characteristics of the participants like marital status, educational status, occupation and monthly income), and patient-related conditions include number of admissions, the presence of comorbidity, duration of illness, duration of treatment, substance use, medication adherence, extrapyramidal side effect and antipsychotic polypharmacy.
Refers to the co-prescription of more than one antipsychotic drug for a particular patient for at list 1 month and above.7 8
Extrapyramidal side effect
Was screened as Simpson Angus Scale (SAS) score of 0.65 and above.9
Health-related quality of life
Based on the WHOQOL-BREF 26 items, an individuals with the score approaches to 100 indicates the best possible quality of life, and individuals with the score approaches to zero indicates the poorest quality of life.10
It was used to select eligible respondents to include in the study. The tool has three questions which ask about participant’s illness, necessity of treatment and the necessity of treatment to stay well. To be included in the study, they should score 3 out of 3.
It is defined as the extent to which patients take medications as prescribed by their healthcare providers.11 Adherence is defined as a Medication Adherence Rating Scale (MARS) score of 6 or higher, while non-adherence is defined as a MARS value of less than 6.12
Current users: using at least one of a specific substance (alcohol, Khat or cigarettes) for non-medical purposes within the last 3 months, according to the alcohol, smoking and substance involvement screening tool (ASSIST).13
Data collection instrument, procedures, and quality control
A structured questionnaire was adopted from previous literature3 14 with some modifications for the context of the study area and sociodemographic characteristics of study participants was used. It was translated to the local Amharic language and then back translated to the English version to check consistency. Translation was not required for variables obtained from medical records of the patients. The data collected by patient interview include sociodemographic characteristics substance use, extrapyramidal side effect, medication adherence and HRQoL. The patients’ medical charts were used to fill in clinically related variables like duration of illness, duration of treatment, number of admissions, the presence of comorbidity, type of antipsychotics and the presence of antipsychotics polypharmacy. The data collection tool had six parts. The first part contains sociodemographic characteristics of the study participants, such as sex, age, marital status, residence, religion, educational level, occupation and income level. The second section consisted of clinical and medication related characteristics like duration of illness, the presence of comorbidity, patients medication record, duration of treatment and number of admissions.
The third section consisted of the current substance use assessment tool. ASSIST was used to briefly screen patients’ use of psychoactive substances. The tool was developed and validated by WHO.13
The fourth section consisted of an extrapyramidal side effect assessment tool. The Simpson-Angus Scale (SAS) was used to measure antipsychotic induced side effect on a 10-item rating scale. It has been commonly used in both clinical and research setups. It consists of one item measuring gait (hypokinesia), six items measuring rigidity, and three items measuring glabella tap, tremor and salivation, respectively. The cut-off value for screening for neuroleptic induced parkinsonism is 0.65 or more.9 It has been used in Ethiopia.7 15 16
The fifth section consisted of the HRQoL measuring tool. HRQoL was assessed by using the WHO Quality of Life Scale–Bref Version (WHOQoL-BREF), which is a 26-item self-administered generic questionnaire. The WHOQoL-BREF is a sound, cross-culturally valid assessment of HRQoL, as indicated by its four domains: physical, psychological, social and environment.17 It is appropriate for the measurement of HRQoL in individuals with schizophrenia. It creates a profile with four domain scores: physical health (7 items), psychological health (6 items), social relationships (3 items) and environmental domain (8 items), as well as two individually scored items concerning the individuals’ impressions of their quality of life (QI) and health (Q2). Each of these items was scored from 1 to 5 on a response scale, which is agreed up on as five-point Likert scale.18 To compare domain scores, the mean score of all items in each domain was multiplied by 4, resulting in a ‘domain raw score‘ (which ranged from 4 to 20). This domain’s raw score was translated linearly into a domain score out of 100. The overall HRQoL was defined as the average of the four domain scores.19WHO QoL–BREF has been used in Ethiopia.3 6 14
The sixth section consisted of an adherence measuring tool. Medication Adherence Rating Scale (MARS) was used to evaluate antipsychotic medication adherence, which is a 10-item yes/no self-report questionnaire.20 The overall scores of MARS range from 0 (low chance of drug adherence) to 10 (great likelihood).21 The MARS was adopted as a measure of medication adherence in the Psychological Prevention of Relapse in Psychosis experiment.22 MARS has been used in Ethiopia.12 23 24
Face-to-face interviews were used to gather data using a pretested and structured questionnaire. Three psychiatry nurses with bachelor’s degrees worked under the supervision of a psychiatrist with a master’s degree at the UoGCSH, while three psychiatry nurses with bachelor’s degrees worked at the FHCSH under the supervision of a psychiatrist with a bachelor’s degree, and two psychiatry nurses with bachelor’s degrees worked at the TGCSH under the supervision of a psychiatrist with a bachelor’s degree. On each day of data collection, the supervisors provided all required supplies to the data collectors and were responsible for verifying the accuracy of the completed questionnaires and promptly resolving any issues that were brought to his or her attention. The lead researcher gave the required resources for all study areas.
To assure the quality of the data, one-day training was given by the principal investigator at each study area for data collectors and supervisors. A pre-test was conducted on 22 (about 5% of sample population) patients with schizophrenia at Dessie Comprehensive Specialised Hospital’s outpatient department. It was used to identify potential problems with the data collection tool and check the clarity, consistency and ease to use of the questionnaire. Some modifications, such as correction of typing errors and the rearranging of questionnaires were made. The internal consistency of ASSIST, SAS, WHOQoL–BREF and MARS was assessed, and the Cronbach’s alpha was 0.76, 0.88, 0.83 and 0.75, respectively, which was acceptable.
Data processing and analysis
Collected data were cleaned, coded, and entered into Epi Data 4.6.0 and analysed using SPSS V.24. In descriptive analysis, the mean with SD, frequency and percentages were used to check the distribution of the data. Bivariate and multivariate linear regression was computed to identify the relation between HRQoL and predictor variables. The linearity assumption was checked by a scatter plot, which indicated a negative association between HRQoL and all continuous predictor variables. The assumption of normality was checked by histogram and normal P-P plot which showed that it was normally distributed. The skewness ranged between±1 which was taken as normally distributed. The Durbin–Watson range of 1.5–2.5 was taken as independent observations. Multicollinearity was checked, and the maximum variance inflation factor (VIF) reported was less than 5, which was within the acceptable level. Variables with a p value of <0.25 during the simple linear regression were selected for multiple linear regression. A p value of <0.05 was considered an independently associated factor for multivariable linear regressions. The model fitness was run and found to be statistically significant at F=8.75, p value<0.001, R=0.588, R2=0.356, and adjusted R2=0.316. Unstandardised beta coefficients with a 95% CI were used to assess the level of association and statistical significance in multiple linear regression analysis.
Patient and public involvement
Patient and public involvement in the study design and methodology was not applicable.
Sociodemographic characteristics of patients
In this study, of the 422 respondents, 177, 185 and 60 were from UoGCSH, FHCSH and TGCSH, respectively. The majority of participants (58.3%) were females with a mean (±SD) age of 36.4 (±11.5) years. Almost half (51.2%) of participants were married, and more than two-thirds (69.4%) of them live in urban areas. More than a quarter (28.7%) of the participants’ educational level was high school, and around one-fifth (22.5%) of them were privately employed. More than three-quarters (76.1%) of participants had a monthly income above 1200 birr (table 1).
Clinical, substance and medication-related characteristics of participants
With regard to clinical characteristics, nearly half (46.9%) and almost three-quarters (73.2%) of participants had a duration of illness and treatment of less than 5 years, respectively. About one-seventh (14.5%) of patients had other comorbid illnesses, of which hypertension (22.9%) and diabetes mellitus (21.3%) were the predominant. Around quarter (25.6%) of respondents had two or more inpatient admissions and 32.2% of participants were substance users. From those respondents, more than one-third (42.6%) used alcohol. Concerning medication-related characteristics, the prevalence of APP was 22.7%. Nearly half (48.4%) of participants took second-generation antipsychotics (SGA). From this, more than three-fourths (80.2%) constitute a combined first-generation antipsychotics (FGA). Extrapyramidal side effects (EPS) were screened on one-seventh (14.7%) of participants, and more than half (54.3%) of them were non-adherent to antipsychotic medications (table 2).
Self-rated perceived quality of life and health satisfaction of participants
More than one-third (38.4%) of respondents reported that their perceived HRQoL was poor. In relation to perceived health satisfaction, about two-fifths (40.0%) were reported as satisfied, followed by above quarter (28.2%), which were stated as dissatisfied (online supplemental table).
Health-related quality of life of respondents
In this study, the overall mean score of quality of life among patients with schizophrenia was 22.42 (95% CI: 22.06 to 22.78) with a SD of 3.60. The minimum and maximum mean scores of the study participants in overall quality of life were 11.25 and 31.25, respectively. Among the four domains of quality of life, respondents scored the lowest mean in the social relationship domain (14.66±8.59) and the highest mean in the environmental domain (28.15±6.39) (table 3).
Factors associated with overall health-related quality of life
After adjusting for multiple linear regression analysis, some variables were found to have a significant association with HRQoL. Consequently, participants who had no formal education had about 1.53 times lower overall HRQoL than those who had educational levels of college diploma and above (ß=−1.53; 95% CI: −2.80 to –0.27). In terms of the duration of treatment, patients whose treatment duration was above 10 years had a 3.08-fold lower overall HRQoL than those whose treatment duration was less than 5 years (ß = - 3.08; 95% CI: - 4.71 to –1.45). Similarly, patients who had medical comorbid illness had 1.14 times lower overall HRQoL than those who had no comorbidity (ß=−1.14; 95% CI: −1.99 to –0.29). Furthermore, patients who were psychoactive substance users had decreased overall HRQoL by 0.89 compared with those who were not users (ß=−0.89; 95% CI: −1.56 to –0.23). Developing an extrapyramidal side effect also reduced overall HRQoL by 2.02 times as compared with those who did not experience any extrapyramidal side effect (ß=−2.02; 95% CI: −2.90 to –1.14). Compared with those who were adherent, being non-adherent decreased overall HRQoL by 0.83 (ß=−0.83; 95% CI: −1.44 to –0.23). More importantly, the HRQoL of patients who received APP was found to have a decreased overall quality of life by 1.77 times as compared with those who did not receive APP (ß: −1.77, 95% CI: −2.57 to –0.96) (table 4).
This study was aimed at assessing the level of HRQoL and its associated factors among patients with schizophrenia at comprehensive specialised hospitals in the Northwest of Ethiopia. The HRQoL of people with schizophrenia has been reported to be worse than other physically ill people and the general population. In this study, the mean overall HRQoL score among study participants was 22.43, with an SD of 3.59. Of the four domains, the one with the lowest mean score was social domains (14.66±8.59). The current study also identified important variables that affected the HRQoL among patients with schizophrenia. Consequently, no formal educational level, a longer duration of treatment, the presence of physical comorbidity, substance use, extrapyramidal side effects, medication non-adherence and APP were negatively associated with overall HRQoL.
Consistent with previous evidence,3 14 25 26 the current study showed a compromised HRQoL, in particular with a lower score of the social domains. The reason for the low score in the social domain might be due to the negative symptoms present in these patients; asociality, avolition and apathy are common, which hamper living independently, the performance of day-to-day activities, and social relationships. Also, stigma has a role in affecting patients' social interaction.6 25 In contrast, findings from Portugal27 and Nigeria indicated that the mean value for each domain of HRQoL was high as compared with this study, and the lowest mean score was in the physical domain.28 This discrepancy might be due to differences in the sociodemographic characteristics of respondents, differences in the clinical set-up, and inclusion and exclusion criteria. For example, the study in Nigeria excluded respondents older than 64 and those with a physical comorbid disease. In addition, the number of samples was 151, which is lower than the current study.
In the current study, patients with no formal education had lower HRQoL than those who had educational levels of a college degree and above. This finding is in line with studies in Addis Ababa, Ethiopia, Brazil and Jordan.3 29 30 This might be due to a difference in socioeconomic status, like no adequate income, or a job that may directly or indirectly negatively affect HRQoL.31 The findings may implicate that patients with lower educational level may need close follow-up.
Relating to the duration of treatment, patients with long durations of treatment above 10 years had lower HRQoL as compared with those with shorter durations of treatment below 5 years. This goes in line with the study conducted in Jimma, Ethiopia.14A probable reason might be that the extended duration of drug therapy has a negative impact on patients’ adherence to antipsychotics, consequently reducing patient HRQoL.14 Also, the need for taking medication is tiresome and disrupts one’s life and daily activities, and a longer duration of treatment without cure diminishes ones hope and satisfaction with treatment and relates this to reduced HRQoL. In addition, patients with physical comorbidity had decreased overall HRQoL. This goes in line with different literature.14 32 33 This could be explained by the fact that chronic medical illness affects HRQoL by impairing it physically through the impacts of sickness on the body, such as increased pain, loss of balance and muscular strength.34 As a result, the findings may indicate that the quality of patient care needs to improve in patients with longer duration of treatment and comorbidities.
The findings also showed that the HRQoL of respondents who used psychoactive substances was lower than that of non-users. This is consistent with the results of various studies.14 35 36Patients that use psychoactive substances may have less social integration with the community than patients who do not use substances, which may be the cause of their lower HRQoL. In addition, psychoactive substances may alter behaviour, aggravate psychiatric symptoms, and harm psychological health.37 In addition, it impairs functioning and the capability to manage and adjust to the environment. Hence patients who use psychoactive substances require psychological support to withdraw from psychoactive substances in order to improve HRQoL.
Developing an extrapyramidal side effect reduced overall HRQoL by two times as compared with those who did not experience any extrapyramidal side effect. This result is in line with certain literature.38 39 This might be due to a developing side effect that hampers day-to-day activities, mobility, work capacity and energy, which impacts ones quality of life negatively. Consequently, patients who developed EPS require better treatment of the side effect and improved selection of antipsychotics so as to enhance HRQoL. Respondents who were non-adherent to antipsychotics were more likely to have decreased overall HRQoL than those who were adherent. This goes in line with the studies done in Jimma, Ethiopia and Nigeria.6 40 This could be due to non-compliance with medications, which may signal a worsening of signs and symptoms and a further decline in mental health with a reduced quality of life. Some literature has also indicated that drug non-adherence may have an indirect consequence on participants' QoL through symptom severity and adverse effects due to antipsychotics.41 Therefore, patients who were non-adherent to medications needs continues counselling and decisive follow-up so as to enhance their HRQoL.
Patients who were on APP had decreased HRQoL by 1.7 times as compared with those who were not taking APP. This finding is consistent with a study conducted in Germany and Turkey.42–44 This might be due to patients’ QoL being negatively affected by APP, which leads to higher overall doses of several antipsychotics, higher use of concurrent anticholinergic medications, and underuse of atypical antipsychotics, adverse drug reactions from medications, drug interactions and compliance problems. The daily dose of an antipsychotic drug was correlated with a decline in cognitive function.45 Thus, patients who were on APP need better antipsychotic utilisation programme and follow-up to improve HRQoL.
Conclusion and recommendation
This study concluded that the social domain had the lowest mean score compared with other HRQoL measuring domains and may implicate that psychosocial support could be crucial. More importantly, for those patients who are substance users, adequate psychosocial support and counselling on the cessation of psychoactive substance use should be provided regularly. Antipsychotics-related side effects and APP should also be screened routinely to prevent their negative influence on HRQoL. At each visit, continuous and adequate counselling should be given regarding medication adherence. Future research could need to be conducted by using a comparator group which would give a better idea about the extent of the effect on the HRQoL of schizophrenia patients.
Data availability statement
Data are available upon reasonable request. The datasets used and analysed during the current study are available from the corresponding author upon reasonable request.
Patient consent for publication
Ethical approval was obtained from the ethical review committee of School of Pharmacy, University of Gondar, with a reference number of SOPS/206/2014, and authorisation was secured from all hospital authorities to perform this study. The study was conducted following the Declaration of Helsinki, in which it stated that in medical research using identifiable human material or data, physicians must normally seek consent for the collection, analysis, storage, and reuse. Written informed consent was gathered from individuals. All study participants were informed about the purpose of the study, and their participation was voluntary. The participants were informed that a lack of desire to engage in the research would not affect the service they obtained. The privacy of participants was guaranteed as patients were differentiated using their card number (no name) alone.
We would like to acknowledge study participants, UoGCSH, FHCSH and TGCSH for facilitating data collection.
Contributors FBT wrote the protocol, designed the study, facilitated data collection, analysed the data, and drafted the manuscript. FDS revised the manuscript and critically reviewed the article. AKS participated in the analysis and interpretation of the results. EAM and TSS were involved in the facilitation of the data collection and critical review parts. FBT is responsible for the overall content as the guarantor of this paper.
Funding This research work is part of the partial fulfillment requirement of a Master of Science degree in clinical pharmacy at the University of Gondar and hence it was funded by the University of Gondar (ምር/ህብ/አገ/ም/ፕ/02/1091/2022).The funding agent did not have any role in the study design, data collection, analysis and manuscript preparation.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
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