Assessment of the level of knowledge, attitude, and preference for myopia management among patients and university students in Trinidad

Kingsley Ekemiri; Robin Seemongal-Dass; Destiny Lawrence; Shaina Oudit; Chioma Ekemiri; Virgina Victor; Magnus C Nsonwu; John Chigozie Ekenze; Oforbuike Onyebuchi Ike; Diane van Staden; Tiwabwork Tekalign

doi:10.12688/f1000research.157916.1

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Research Article

Assessment of the level of knowledge, attitude, and preference for myopia management among patients and university students in Trinidad

[version 1; peer review: 1 approved with reservations, 1 not approved]

Kingsley Ekemiri ¹, Robin Seemongal-Dass², Destiny Lawrence¹, [...] Shaina Oudit¹, Chioma Ekemiri³, Virgina Victor⁴, Magnus C Nsonwu⁵, John Chigozie Ekenze⁵, Oforbuike Onyebuchi Ike⁶, Diane van Staden⁷, Tiwabwork Tekalign⁸

Kingsley Ekemiri ¹, Robin Seemongal-Dass², [...] Destiny Lawrence¹, Shaina Oudit¹, Chioma Ekemiri³, Virgina Victor⁴, Magnus C Nsonwu⁵, John Chigozie Ekenze⁵, Oforbuike Onyebuchi Ike⁶, Diane van Staden⁷, Tiwabwork Tekalign⁸

PUBLISHED 07 Jan 2025

Author details Author details

¹ Optometry Unit, Clinical Surgical Sciences, The University of the West Indies at St Augustine, Saint Augustine, Tunapuna/Piarco Municipal Corporation, Trinidad and Tobago
² Ophthalmology, Clinical Surgical Sciences, The University of the West Indies at St Augustine, Saint Augustine, Tunapuna/Piarco Municipal Corporation, Trinidad and Tobago
³ Health Promotion, The University of the West Indies at St Augustine, Saint Augustine, Tunapuna/Piarco Municipal Corporation, Trinidad and Tobago
⁴ Nursing, The University of the West Indies at St Augustine School of Nursing, Saint Augustine, Tunapuna/Piarco Municipal Corporation, Trinidad and Tobago
⁵ Optometry, Imo State University Faculty of Health Sciences, Owerri, Imo, Nigeria
⁶ Optometry, Bayero University Kano, Allied Health Sciences, Kano, Nigeria
⁷ Optometry, University of KwaZulu-Natal - Westville Campus, Durban, KwaZulu-Natal, South Africa
⁸ School of Nursing, Arba Minch University College of Health Sciences, Arba Minch, Southern Nations, Nationalities, and People's Region, Ethiopia

Kingsley Ekemiri
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Supervision, Validation, Writing – Original Draft Preparation

Robin Seemongal-Dass
Roles: Formal Analysis, Methodology, Resources, Validation, Visualization, Writing – Review & Editing

Destiny Lawrence
Roles: Data Curation, Funding Acquisition, Investigation, Resources, Validation, Writing – Original Draft Preparation

Shaina Oudit
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Resources, Validation, Writing – Original Draft Preparation

Chioma Ekemiri
Roles: Data Curation, Formal Analysis, Methodology, Validation, Visualization, Writing – Review & Editing

Virgina Victor
Roles: Conceptualization, Formal Analysis, Investigation, Project Administration, Resources, Supervision, Validation, Writing – Review & Editing

Magnus C Nsonwu
Roles: Conceptualization, Formal Analysis, Funding Acquisition, Project Administration, Resources, Writing – Review & Editing

John Chigozie Ekenze
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Supervision, Writing – Review & Editing

Oforbuike Onyebuchi Ike
Roles: Conceptualization, Formal Analysis, Methodology, Validation, Visualization, Writing – Review & Editing

Diane van Staden
Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Supervision, Writing – Original Draft Preparation

Tiwabwork Tekalign
Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Resources, Validation, Writing – Original Draft Preparation

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background

Approximately 1.6 billion people worldwide are currently affected by myopia, with estimates suggesting that by 2050, close to half of the global population may experience this condition. Additionally, the prevalence of myopia has been increasing in Trinidad, with rates ranging from 21.5% to 46%. A study has been conducted to determine better patients’ and students’ levels of knowledge, attitudes, and preferences toward the management of myopia in Trinidad.

Methods

This cross-sectional study evaluated the knowledge, attitudes, and preferences for myopia management among a sample of 323 participants, including patients and university students in Trinidad and Tobago, aged 18-40. Participants were randomly selected, and data were gathered using a structured questionnaire administered through telephone interviews for patients and emailed to students. Descriptive statistics and inferential analyses, including ANOVA and T-tests, were applied to identify significant associations, with a p-value threshold of less than 0.05 considered statistically significant.

Results

A total of 317 participants were examined, resulting in a response rate of 98.1%. The average knowledge score of the participants was 12 out of 25. A slight difference was observed in the knowledge scores of males, with a p-value of 0.052. The results also indicated that the majority of the participants had a good attitude score (21.6 out of 30) toward myopia management. Age and gender had a negligible negative correlation (with a coefficient of -0.022 and p-value of 0.692, respectively) with management preference.

Conclusion

This study reveals critical gaps in knowledge and diverse attitudes toward myopia management among participants, highlighting the need for targeted educational interventions. While attitudes are generally positive, age and gender influence preferences for myopia correction, with spectacles and contact lenses being the most preferred methods. These insights can guide healthcare professionals in developing tailored approaches for myopia management in Trinidad and Tobago.

Keywords

Myopia, Eye disease, Management, Knowledge, Trinidad

Corresponding author: Kingsley Ekemiri

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2025 Ekemiri K et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Ekemiri K, Seemongal-Dass R, Lawrence D et al. Assessment of the level of knowledge, attitude, and preference for myopia management among patients and university students in Trinidad [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2025, 14:39 (https://doi.org/10.12688/f1000research.157916.1) First published: 07 Jan 2025, 14:39 (https://doi.org/10.12688/f1000research.157916.1) Latest published: 07 Jan 2025, 14:39 (https://doi.org/10.12688/f1000research.157916.1)

Introduction

Myopia, also known as near-sightedness, is a common condition that affects a large number of people globally.¹ It is a major problem that can cause significant visual loss and other ocular issues.² The prevalence of myopia is increasing and projections indicate that it will affect almost half of the world’s population by 2050.^3,4 Myopia is a prevalent vision disorder impacting people across all age groups and ethnicities. It is linked to several ocular complications, including glaucoma, retinal detachment, and cataracts.^5,6

Globally, around 28.3% of people have mild to moderate myopia, and approximately 4.0% have high myopia.⁷ Studies indicate that myopia is significantly more prevalent in urban Asian populations compared to Western communities, with rates reaching up to 70% in Singapore, 50% in Taiwan, and 40% in Japan. Both young adults and the elderly appear particularly vulnerable to myopia, with various demographic factors—including socioeconomic status, ethnicity, and occupational demands—contributing to its rising incidence in these groups.^8–10

In Trinidad and Tobago, a Caribbean twin-island country with a diverse population primarily consisting of people of South Asian descent, the prevalence of myopia is also increasing. Among school children, the reported prevalence of myopia is 21.5%, while among university students; it is 46%.¹¹ Given that genes play a crucial role in myopia, there is a critical genetic link between high prevalence of the condition in Asian populations, both in Asia and Trinidad and Tobago.

Proper management of myopia is crucial to prevent or delay its progression and minimize the risk of developing associated ocular complications.¹²

Management strategies for myopia encompass optical corrections, including glasses and contact lenses, as well as pharmacological interventions and lifestyle modifications.^12,13 There exists a notable gap in both knowledge and practices related to myopia management within the general population, encompassing both patients and healthcare professionals. Various factors such as age, gender, educational background, socioeconomic status, and cultural beliefs significantly influence preferences for myopia management.¹⁴

While numerous studies have been carried out globally to evaluate the knowledge and practices related to myopia management among healthcare professionals and the broader population, significant gaps in understanding remain.¹⁵ there are still literary gaps on the knowledge, attitude practices (KAP) relating to myopia management in Trinidad, particularly among patients, healthcare professionals, and the younger generation. Given the increasing cases of myopia and other visual issues, especially among school-going children during the recent COVID-19 pandemic¹⁶ and their related consequences¹⁷ in Trinidad and Tobago, it is necessary to understand the public health issue and its potential management approaches.

Objectives of the study

• To determine patients’ and students’ level of knowledge towards the management of myopia in Trinidad
• To determine patients’ and students’ attitudes towards the management of myopia in Trinidad
• To determine patients’ and students’ preferences towards the management of myopia in Trinidad

Method

Study design, setting and population

The study utilized a cross-sectional observational study.¹⁷ Trinidad, which is one of the twin-islands making the country of Trinidad and Tobago. The country boasts a diverse population of about 1.4 million as of 2019, encompassing various ethnic backgrounds.^18–20 This multicultural society includes a variety of ethnic groups, such as Indo-Trinidadians, Afro-Trinidadians, mixed-ethnic individuals, Chinese, and Europeans. This rich tapestry of backgrounds contributes to the unique cultural landscape of the island and plays a significant role in shaping the community’s social dynamics.

Eligibility criteria

Inclusion criteria: Participants aged between 18 and 40 years and able and willing to provide valid information, past or present patients of the clinic diagnosed with myopia, and students who were enrolled at the university at the time of the study.

Exclusion criteria: Students or practitioners of refractive surgery; non-nationals of Trinidad and Tobago; and, eye care professionals not involved in or without much experience in myopia management.

Operational definition

Good (adequate) knowledge: those participants who scored of 60% or more of a potential 25 points.

Satisfactory knowledge: those participants who scored above 15 out of 25 points.

Insufficient knowledge: those participants who scored scores below 15.²¹

To evaluate attitudes toward myopia management, the researchers established criteria where a score of 18 or above, which accounts for 60% or more of the maximum.

Good attitude: those participants who scored score of 30

Poor attitude: those participants who scored scores below 18.²¹

Sample size determination and procedure

A non-probability sampling method was employed for this study. Sample size calculations were conducted using Epitools software by Ausvet (available at epitools.ausvet.com.au).²¹ Utilizing a proportion estimate of 0.3, a precision of 0.05, and a confidence level of 0.95, we determined the required sample size based on a target population of 270,000. The calculated sample size was 323 participants.

Data collection tool

A structured questionnaire^22,23 comprising four sections was administered to participants in both Group 1 (patients) and Group 2 (students). The questionnaire was specifically designed to collect comprehensive data on demographics, knowledge, attitudes, and preferences related to myopia management.

Data collection procedures

Patient interviews

For Group 1 (patients), the questionnaire was administered through telephone interviews. Prior to participation, patients were informed about the study’s purpose and their right to withdraw at any time. Responses were recorded by student researchers (DL, SO) under the supervision of an experienced researcher (KE) to ensure data integrity and adherence to ethical guidelines. A standardized script was employed during the interviews, incorporating prompts to clarify questions and guide participants. This approach minimized variability in question presentation, facilitating clearer and more reliable responses.

University student surveys

Group 2 (university students) received the same structured questionnaire via email. To enhance participation rates, the email included a brief introduction outlining the study’s objectives and detailed instructions for completing the questionnaire. Students were assured of the anonymity and confidentiality of their responses. Completed questionnaires were submitted through a secure online platform that automatically documented responses, thereby reducing the likelihood of data entry errors.

Response tracking

To maximize response rates, a systematic follow-up strategy was implemented. Reminders were sent one week after the initial email and again a few days before the survey closing date to encourage timely completion of the questionnaires.

Data analysis

Data analysis was performed using the Statistical Package for Social Science (SPSS) version 29. Descriptive statistics such as frequencies, percentages, and central tendencies were calculated. Inferential tests including ANOVA and T-tests were conducted to determine significant differences between Trinidadian patients and students in these aspects. The assessment utilized a “Total Knowledge” score^21,24 as a benchmark for participants’ understanding. Additionally, the significance of this score was determined along with established thresholds for categorizing it, factoring in a weightage of 60% for Knowledge and 40% for Attitude. A p-value of less than 0.05 was considered statistically significant.

Results

Socio-demographic characteristics of participants

A sample of 317 participants was examined giving a response rate of 98.1%. The gender distribution was skewed toward females, who made up 64% of the sample. The majority of age (40.4%) falling within the 18-21-year age. Ethnically, East Indians constituted nearly half of the participants at 44.5% ( Table 1).

Table 1. Socio-demographic characteristics of participants.

Variable	Category	Frequency (percent)
Age	18-21	128(40.4%)
	22-25	69(21.8%)
	26-30	51(16.1%)
	30-35	69(21.8%)
Gender	Male	114(36.0%)
Gender	Female	203(64.0%)
Ethnicity	African	73(23.0%)
	East Indian	141(44.5%)
	Mixed	97(30.6%)
	Other	6(1.9%)

Knowledge of patients and university students

According to this study, the average knowledge score was 12/25. When comparing males and females, a marginal difference in knowledge scores was observed with a p-value of 0.052, implying no significant gender-based difference. However, participants aged 26-30 showed significantly lower scores. An ANOVA test further confirmed disparities in knowledge across age groups, with those aged 26-30 notably trailing their counterparts ( Table 2).

Table 2. Knowledge assessment for university students and patients.

		Gender		Age				Total Score (Mean ± SD)
		Male	Female	18-2 1	22-25	26-30	30-35	Total Score (Mean ± SD)
Mean Knowledge Score (Mean ± SD)		11.80	12.60	12.45	12.30	12.12	12.20	12.31 ± 4.20
p-value (Difference in means)		0.052		0.963
Knowledge Rank	Poor	66	94	61	37	26	36
Knowledge Rank	Good	48	109	67	32	25	33
p-value (Chi-Square)		0.048***		0.858

Attitudes of patients and university students

The average attitude score toward myopia management was 21.6/30. Females exhibited a marginally better attitude than males, with a subtle p-value difference of 0.052. The 26-30 age group registered notably lower scores; however, this age-based difference was not statistically significant (p=0.109). In contrast, a gender-based difference in attitude scores was significant (p=0.005) ( Table 3a).

Table 3a. Attitudes of patients and university students toward myopia management.

			Gender		Age				Total Score (Mean ± SD)
			Male	Female	18-21	22-25	26-30	30-35	Total Score (Mean ± SD)
Attitude	Mean Attitude Score		21.45	21.74	20.97	21.52	22.51	22.35	21.64 ± 3.30
	p-value (Difference in means)		0.052		0.007**
	Attitude Rank	Poor	13	7	5	4	7	4
	Attitude Rank	Good	101	196	123	65	44	65
	p-value (Chi-Square)		0.005***		0.109

Subsequent evaluations indicate a distinct disparity in the general attitude between two groups (p=0.007) ( Table 3b). The weighted total score for attitude averaged at 2.68 ± 0.53 ( Table 3c), with no significant gender or age differences (p-values of 0.391 and 0.109, respectively). The total weighted score for attitude was not statistically significant (P=0.730).

Table 3b. ANOVA assessment for attitudes.

Total attitude
	Sum of Squares	Df	Mean Square	F	Sig.
Between Groups	131.791	3	43.930	4.142	0.007
Within Groups	3319.490	313	10.605
Total	3451.281	316

Table 3c. Weighted Total Score for attitude.

			Gender		Age				Total Score (Mean ± SD)
			Male	Female	18-21	22-25	26-30	30-35	Total Score (Mean ± SD)
Weighted Total Score	Mean Attitude Score		2.62	2.71	2.64	2.67	2.72	2.71	2.68 ± 0.53
	p-value (Difference in means)		0.069		0.730
	Weighted Total Rank	Poor	64	91	63	39	21	32
	Weighted Total Rank	Good	50	112	65	30	30	32
	p-value (Chi-Square)		0.391		0.109

Preferences for patients and university students

According to this study result, age and gender have an almost negligible negative correlation (coefficient = -0.022, p=0.692). Age has a weak positive correlation with beliefs about halting myopia progression (coefficient = 0.045). Gender shows a slight negative association (coefficient = -0.036). Preferences for myopia management over traditional optical solutions weakly decline with age (coefficient = -0.042) but show no meaningful connection with gender (coefficient = -0.001). Noteworthy is the current correction method among myopic respondents: it correlates positively with age (coefficient = 0.135) and shows significant ties to beliefs about myopia prevention (coefficient =0.154) and preferences for myopia management (coefficient = 0.144). Gender’s influence remains marginal. The specific preference termed “choice of 9.5” displays only weak connections to both age and gender, each with a coefficient of 0.044 ( Table 4).

Table 4. Correlation between Gender and Age for preferences.

		Age	Gender	Which option do you think would work best for preventing myopia progression?	Would you be interested in myopia management over traditional optical corrections?	If you have myopia, which of the following do you currently use to correct it?	Which methods of myopia management would you prefer the most as your choice of 9.5?
Age	Correlation Coefficient	1.000	-0.022	0.045	-0.042	.135^*	0.044
	Sig. (2-tailed)		0.692	0.429	0.457	0.016	0.472
	N	317	317	317	317	317	317
Gender	Correlation Coefficient	-0.022	1.000	-0.036	-0.001	-0.017	0.044
	Sig. (2-tailed)	0.692		0.520	0.993	0.764	0.467
	N	317	317	317	317	317	317
Best option for preventing progression	Correlation Coefficient	0.045	-0.036	1.000	0.033	.154^**	0.084
	Sig. (2-tailed)	0.429	0.520		0.563	0.006	0.168
	N	317	317	317	317	317	317
Interest in management over traditional	Correlation Coefficient	-0.042	-0.001	0.033	1.000	.144^*	0.017
	Sig. (2-tailed)	0.457	0.993	0.563		0.010	0.785
	N	317	317	317	317	317	317
Currently using management	Correlation Coefficient	.135^*	-0.017	.154^**	.144^*	1.000	-0.007
	Sig. (2-tailed)	0.016	0.764	0.006	0.010		0.905
	N	317	317	317	317	317	317
Management preference most as your choice of 9.5?	Correlation Coefficient	0.044	0.044	0.084	0.017	-0.007	1.000
	Sig. (2-tailed)	0.472	0.467	0.168	0.785	0.905
	N	317	317	317	317	317	317

Association between age and gender with management preference

The result of cross-tabulation showed that there is statistically significant association between preference and age with management preference ( Table 5).

Table 5. Association between preference and age and gender category.

Variable		Bad preference	Good preference	Chi-square Test of Association (p-value)
Age	18-22	71	57	0.010*
	22-26	37	32
	26-30	39	12
	30-35	32	37
Gender	Male	65	49	0.882
Gender	Female	114	89	0.882

Myopia management preference

Participants reported a diverse range of preferred treatments for managing myopia, illustrating the multifaceted approach that individuals and practitioners may adopt in response to this common visual impairment ( Figure 1). Notably, the most popular choices among participants were spectacles and soft contact lenses. This preference aligns with the accessibility and familiarity of these treatments, as spectacles remain the most widely prescribed correction method due to their simplicity, cost-effectiveness, and ease of use ( Figure 1).

Figure 1. Participants’ preferred treatment for myopia management.

Discussion

This study examines the association between knowledge, attitude, and myopia management preferences with socio-demographic variables. The findings of this study support existing literature^16,25 that demonstrates the significant impact of socio-demographic factors such as age, gender, ethnicity, and education level on the management of myopia and other visual impairments. The distribution of age and gender provides valuable insights into how these variables may interact with knowledge, attitudes, and preferences regarding myopia.

The study found that the average score for “Total Knowledge” was 12 out of 25 possible points, which is considered suboptimal. This aligns with previous literature that has also identified similar knowledge gaps in various demographic settings.^26–29 Additionally, the study revealed that the age group of 26-30 showed significantly lower scores, indicating a knowledge disparity within this specific age range. These findings support the idea that targeted educational interventions could be beneficial in managing myopia.^30–33 Therefore, any effective myopia management strategy should consider the diverse socio-demographic nature of the population.³⁴

The overall cohort had a positive attitude towards myopia management. Interestingly, females had a slightly better attitude than males (p=0.052), which is in line with previous research indicating that females are more proactive about healthcare.^35–37 The difference in attitude scores between the two groups (p=0.007) suggests that there may be underlying demographic or psychosocial factors that warrant further investigation. These findings are somewhat contrary to existing literature, which often highlights the role of age in shaping attitudes towards healthcare.^38–40

Most notably, our findings indicate significant associations between the current correction method for myopic individuals and their age (p=0.010). This is a salient finding because current literature^41–44 has been largely inconclusive about the extent of such correlations. Moreover, specific preferences such as the “choice of 9.5” and beliefs about the most effective myopia prevention strategies correlated significantly with age, underscoring the complex relationship between age and healthcare decision-making. However, gender remained a less influential variable throughout our analysis, which is somewhat at odds with studies^45–47 that gender plays a significant role in healthcare choices.

Preferences regarding myopia management can be shaped by a multitude of factors, including lifestyle, age, cultural background, and personal beliefs. For instance, while some patients may favor contact lenses over traditional eyeglasses, others might opt for orthokeratology or atropine eye drops. Consequently, understanding these preferences is essential in myopia management, as they significantly impact the treatment options chosen by both patients and healthcare providers.

Conclusion

This cross-sectional study highlights the significance of knowledge, attitudes, and practices (KAP) in myopia management within Trinidad. The findings reveal a concerning gap in both knowledge and positive attitudes towards myopia management among patients and students. While female participants exhibited a more favorable attitude, the correlations between age, gender, and myopia management preferences were found to be weak. To enhance patient outcomes and mitigate the impact of myopia on quality of life, it is essential to provide patients and students with accurate and accessible information regarding their treatment options, while also considering their individual preferences and goals. This approach can foster better-informed decision-making and ultimately improve the management of myopia in the population.

Limitations of the study

The study findings indicate that patients and students in Trinidad have inadequate knowledge and poor attitudes toward managing myopia. However, female patients and students exhibited a positive attitude towards myopia management, while age and gender did not show strong correlations with myopia preferences. Providing accurate and clear information to patients and students about their treatment options can significantly reduce the impact of myopia on their quality of life.

Ethical and consent

This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the University of The West Indies Ethics Approval Committee, with reference number CREC-SA.1806/10/2022, dated 10th October 2022.

For patient participants, a willingness request was sent to their addresses. Following their agreement, informed consent was obtained in writing prior to conducting telephonic interviews. For student participants, consent was sought before distributing the questionnaires via email. Written informed consent was also obtained from students prior to the commencement of data collection. All participants were assured of the confidentiality of their responses and their right to withdraw from the study at any time without penalty.

Authorship contributions

Kingsley Ekemiri led the design and article drafting. Dass Robin and Virgina Victor focused on data and methods and refined the methodology. Destiny Lawrence managed the data and analysis. Oudit shaped results and vetting while Chioma Ekemiri and Tiwabwork Tekalign aided in the study design and data analysis. Osaze Okonedo and Diane van Staden contributed to data interpretation and manuscript compilation.

Data availability

OSF: Assessment of the level of Knowledge, Attitude, and Preference for Myopia Management among Patients and University Students in Trinidad Doi: https://doi.org/10.17605/OSF.IO/XNWB2⁴⁸

This project contains the following underlying data:

• Patients_UWI Students Questionnaire (Responses) (3).xlsx
• Questionnaire (Px & UWI Students) (2).docx

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

Reporting guidelines

STROBE guideline was used to report the findings of the study.

Software availability

Epitools software by Ausvet (available at epitools.ausvet.com.au) was utilized for sample size calculations. For those seeking free alternatives, the G*Power software (available at gpower.hhu.de) can also perform similar statistical analyses.

Acknowledgements

The authors extend their gratitude to the University of the West Indies (UWI), specifically the Optometry Unit within the Department of Clinical Surgical Sciences at the Faculty of Medical Sciences. Their invaluable expertise and supportive environment were instrumental in the realization of this study. We also thank the Couva Multi-Training Facility, the Marketing & Communications Office of UWI, and all the participants for their invaluable contributions and unwavering support throughout the research process.

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