Epidemiology of human papillomavirus infection of the uterine cervix among women in Adama, Ethiopia: a cross-sectional study

Abstract

Background

Worldwide, human papillomavirus (HPV) is a common sexually transmitted infection affecting at least 50% of sexually active individuals at some point during their Life. The worldwide prevalence among women is 11.7%, and the highest prevalence is in sub-Saharan Africa (24%). Persistent HPV infection with high-risk genotypes is now a well-established cause of cervical cancer (CC) and it is demonstrated that they are present in 99.7% of CC cases worldwide. The main purpose of the study was to determine the epidemiology of HPV infection of the uterine cervix among women in Adama, Ethiopia.

Method

A cross-sectional study was conducted among 383 women in Adama, Ethiopia, from March to June 2023. A systematic sampling technique was employed and data were collected using a pretested, structured questionnaire. The data were entered into Epi-info 7 and analysed using SPSS version 26. Binary logistic regression for bivariate and multivariate analyses with adjusted odds ratios (AORs) and 95% CIs were used to identify factors associated with HPV infection. The level of significance was defined as a p-value < 0.05.

Results

The overall prevalence of HPV infection was 26.6%, with high-risk (hr) HPV genotypes. HPV-16 and HPV-18 constituting 22.5% and 5.9%, respectively. “Other HR-HPV” genotypes accounted for 63.7%. Being divorced (AOR = 2.96: 95% CI: 1.18, 7.40), having post-coital bleeding (AOR = 7.97: 95% CI: 2.17, 29.24), having an early sexual debut (AOR = 3.59: 95% CI: 1.69, 7.65), having multiple sexual partners (AOR = 5.25: 95% CI: 1.73, 15.96), having sexually transmitted infections (AOR = 2.36: 95% CI: 1.32,4.20) and being HIV-positive (AOR = 12.37: 95% CI: 4.57, 33.48) were identified as independent factors significantly associated with HR-HPV infection.

Conclusion

There was a greater prevalence of HPV infection in the study area than the worldwide prevalence 11.7%. “Other HR-HPV” genotypes were the major oncogenic HR-HPV genotypes identified. Multiple factors were identified as independent factors significantly associated with HR-HPV infection. Awareness creation campaigns and educational programmes about the prevention of HPV infection and associated risk factors need to be implemented in the community.

Background

Approximately 218 types of HPV have been isolated and found to be currently causing infections in humans [1]. Approximately 45 types have been implicated in infections of the genital tract, while others cause skin diseases. HPV is a common sexually transmitted infection worldwide that affects at least 50% of sexually active individuals at some point during their life [2]. HPV is a small (approximately 8,000 base pairs), non‑enveloped, double‑stranded deoxyribonucleic acid (DNA) virus belonging to the Papillomaviridae family [3]. Phylogenetically, HPV is classified into five genera, namely, Alpha, Beta, Gamma, Mu, and Nu, based on the homology of DNA sequences in the L1 gene, which encodes the structural L1 capsid protein [4].

Nineteen HPV genotypes were identified as high-risk types associated with cervical intraepithelial neoplasia (CIN) 2/3. Of these, 13 (HPV-16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) are known to be carcinogenic, and six are possibly carcinogenic (HPV-26, 53, 66, 69, 73, 82). However, 9 genotypes (HPV-6, 11, 40, 42, 43, 44, 54, 61, 70) are low-risk HPV types linked to genital warts and low-grade squamous intraepithelial lesions (LSILs) [5]. HPV-16 and 18 are responsible for 60–80% of cervical cancers and precancerous cervical lesions among women aged 25–40 years worldwide [6].

According to a meta-analysis, the prevalence of HPV worldwide among women with normal cytological findings is estimated to be 11.7% [7]. Most HPV infections are harmless and asymptomatic, and almost 90% of these infections are cleared spontaneously by the immune system within 1–2 years of acquiring them [8]. However, some women will experience persistent infection with certain genotypes that cause abnormalities in infected cells. These changes are called ‘precancerous’ because they can develop into invasive cervical cancer. Usually, precancerous lesions progress to cervical cancer within a period of 10–20 years, but rarely do they become malignant within one or two years [9].

Persistent HPV infection with high-risk genotypes is now a well-established cause of cervical cancer [10, 11], and it was demonstrated that high‑risk HPV genotypes were present in 99.7% of cervical cancer cases worldwide [12].

Cervical cancer is a cancer of the cervix uteri, and almost all cases are linked to persistent infection with high-risk HPV [13]. It is the second most common female cancer and the second leading cause of cancer deaths in women in Ethiopia. According to 2020 estimates, approximately 7,445 new cervical cancer cases were diagnosed, and 5,338 deaths occurred annually [14].

HPV screening and vaccination are the two strategic approaches for preventing cervical cancer. Unfortunately, these complementary preventive options are often implemented as separate and non-coordinated public health programs in Ethiopia. HPV detection using DNA testing is beyond what many developing countries can afford. This is also a serious problem in Ethiopia. The Ethiopian Ministry of Health started vaccinating schoolgirls aged 14 years using Gardasil-4™ (A quadrivalent HPV vaccine that provides protection against highly prevalent HR-HPV genotypes HPV-16 and 18, and low-risk oncogenic genotypes related to the appearance of 90% of genital warts HPV-6 and 11) since December 2018.

The national approach to prevent cervical cancer in Ethiopia is the ‘Screen and Treat’ using a screening test that gives immediate results (like Visual Inspection with Acetic acid) followed by “on the spot” treatment (e.g. using cryotherapy) of detected lesions, without any further tests unless a suspected cancer is a preferred approach. Therefore, evidence-based epidemiology of this disease is essential to support efforts to prevent and control HPV infection and cervical cancer in the country. To the best of the authors’ knowledge, no research has been conducted on this topic in the study area. Therefore, this study aimed to determine the epidemiology of human papillomavirus infection of the uterine cervix among women in Adama, Ethiopia. The output will provide objective evidence that could be used to develop appropriate guidelines, design policies and conduct further HPV-related studies based on the conclusions drawn from the investigation.

Methods

Study design and setting

An institutional based cross-sectional study design was employed on 383 women from March to June 2023 to determine the epidemiology of human papillomavirus infection of the uterine cervix among women in Adama, Ethiopia. Adama town is located in Ethiopia, 99 km southeast of the capital city of Addis Ababa. The town has 5 private hospitals, 2 non-governmental reproductive health clinics, more than 90 private clinics, 1 public hospital, and 8 public health centres. The study was conducted at three public health facilities in Adama where cervical cancer screening is carried out, namely, Adama Hospital, Geda, and Adama Health Centres.

Inclusion criteria

Women aged 25–49 years who had resided in Adama town for at least six months and attended the selected health facilities during the study period were randomly selected. The reason behind targeting this age group in this study was that cervical screening was recommended for every woman 30–49 years of age, and earlier than this age range (starting from 25 years) for HIV-positive women according to WHO 2021.

Exclusion criteria

Women older than 49 years, confirmed cervical cancer patients, women at an advanced stage of disease who were too ill to participate, who were mentally unstable to consent for participation, and who were unable to communicate properly were excluded from the study.

Sample size

The sample size was calculated using the Raosoft online calculator by considering the following assumptions: margin of error 5%, confidence level 95%, population size 96,432 (Women 15 years and above of age residing in Adama), response distribution 50%, and was determined to be 383. The sample size was proportionally allocated among the three studied health facilities based on their annual plan for cervical cancer screening. A systematic sampling technique was used to select participants at every K^th interval.

Specimen collection procedures and laboratory testing

Prior to the collection of the specimens, the participants who agreed and consented to take part in the study were counselled and instructed not to use vaginal lubricants, vaginal medications, vaginal contraceptives, and douches within 48 h before specimen collection. They were also instructed not to engage in sexual activity within 24 h before specimen collection. The cervical specimens were collected from the participants by trained health professionals using the Abbott Cervi-Collect Specimen Collection Kit (4N73-06). Abbott Real-time High-Risk HPV (HR-HPV) is a qualitative in-vitro test for the detection of DNA from high-risk HPV genotypes in clinical specimens. The collected specimens were labelled with the participants information and transported to the central laboratory for HR-HPV detection. The Abbott m2000rt/SP polymerase chain reaction (PCR) technique was used to conduct laboratory testing. Major oncogenic HR-HPV genotypes determined as “HPV-16”, “HPV-18” and “Other HR-HPV” genotypes.

Data collection instrument

Interviewer administered; close-ended structured questionnaire was used to collect information from the participants. The questionnaire comprised the sociodemographic characteristics of participants, which included age, place of residence, educational status, and monthly income, the reproductive history of the respondents, which included marital status, parity, contraceptive use, condom use, family history of cervical cancer, pattern of menstrual bleeding, and history of post-coital bleeding, the risky sexual behaviour that may put participants at risk of acquiring HPV infection, like age at first sexual intercourse, number of lifetime sexual partners, history of STIs, HIV sero-status and ART usage for HIV-positive participants, history of previous abnormal Pap smear test, cigarette smoking, and long-time usage of corticosteroids, and questions pertaining to cervical cancer screening and treatments, which consisted of the type of screening visit, HPV DNA test and genotypes identified if positive for the test.

The questionnaire was adopted and modified from previous related Literature. Pre-testing of the instrument was done on 19 women (5% of the sample size) at randomly selected health facilities prior to the actual data collection period. During the pre-test, ambiguous or unclear words and sentences were rephrased and corrected to make the tool more understandable and suitable for use for both the data collectors and the respondents, and more importantly, to enhance its validity and reliability.

Statistical analysis

The data were revised, checked for completeness, coded, entered into a computer using the Epi Info 7 software program, and then exported to the Statistical Package for Social Science (SPSS) version 26 for analysis. Descriptive and summary statistics, including frequency, proportion and odds ratio, were used to describe the study population, prevalence, genotype distribution, and risk factors for HPV infection among women at selected health facilities in Adama. Discrete variables are presented with the use of tables and percentages. Binary logistic regression for bivariate and multivariate analyses with AORs and 95% CIs was used to identify factors associated with HPV infection. Variables with P-values less than 0.25 in the bivariate analysis were selected as candidates for multivariate analysis. In multivariate analysis, variables associated with HPV infection were identified after adjusting for confounding effects. A P-value less than 0.05 was considered to indicate a significant association. During analysis, the coefficient of the Omnibus test model was checked for significance, and P < 0.05 indicated that the identified predictor in the multivariate logistic regression was better. Furthermore, the Hosmer and Lemeshow test was used to assess the fit of the model, and the results were not significant (P > 0.05), indicating that the model fit test was good.

Results

Sociodemographic characteristics and reproductive history of the participants

A total of 383 respondents aged 25–49 years participated in the study, with a response rate of 100%. The mean age was 36.7 years (median 37 years), with a standard deviation of ± 6.6 years. One hundred and one (26.4%) of the participants were aged 30–34 years, followed by 87 (22.7%) aged 35–39 years. Concerning their educational status, approximately 176 (46%) of the participants had an elementary/junior (1–8) education. Slightly more than half of the study participants (208; 54.3%) were married. Regarding parity, 305 (79.6%) of the participants gave birth 1–5 times. The vast majority, 365 (95.3%), of the study participants did not have a history of postcoital bleeding (Table 1).

Table 1.

Sociodemographic characteristics and reproductive history of participants, adama, ethiopia, 2023

Variables	Frequency	Percentage (%)
Age
25-29	52	13.6
30-34	101	26.4
35-39	87	22.7
40-44	81	21.1
45-49	62	16.2
Educational status?
Unable to read and write	70	18.3
Elementary/Junior (1-8)	176	46.0
High school (9-12)	69	18.0
Diploma/Degree and above	68	17.7
Occupation
Self-employed	123	32.1
Employed (Govt, private, NGO)	91	23.8
Unemployed	169	44.1
Family Income per month
< 3000 Ethiopian birr (ETB)	129	33.7
3000 – 5000 ETB	200	52.2
>5000 ETB	54	14.1
Marital status
Single	43	11.2
Married	208	54.3
Divorced	88	23
Widowed	44	11.5
Number of births (Parity)
0	69	18.0
1-5	305	79.6
>5	9	2.4
Method of contraception
Oral contraceptive Pills	53	13.8
Depo Provera (Injectable)	99	25.9
Implant	21	5.5
I do not use	210	54.8
Do you use a condom
Yes, always	143	37.3
Yes, sometimes	24	6.3
No, I do not use	216	56.4
Pattern of menstrual bleeding
Regular (21 - 35 intervals)	198	51.7
Irregular	185	48.3
History of postcoital bleeding
Yes	18	4.7
No	365	95.3

Risky sexual behaviour and other health risk factors for the participants

Two hundred seventy (70.5%) of the participants’ sexual debut occurred before age 20. The majority of the participants, 305 (79.6%), had more than one lifetime sexual partner. Two hundred and seventy-two (71.0%) of the study participants were HIV-positive, and all of them were receiving antiretroviral therapy (ART). Almost all of the study participants, 381 (99.5%), did not have a history of abnormal Pap smear tests (Table 2).

Table 2.

Risky sexual behaviour and other health risk factors for the participants, adama, ethiopia, 2023

Variables	Frequency	Percentage (%)
Age at first sexual intercourse?
< 20	270	70.5
≥ 20	113	29.5
Life time sexual partner?
One	78	20.4
More than one	305	79.6
Your sexual partner had another partner?
Yes	318	83.0
No	65	17.0
History of any STI?
Yes	124	32.4
No	259	67.6
Partner history of STI?
Yes	124	32.4
No	259	67.6
HIV sero-status?
Negative	111	29.0
Positive	272	71.0
Currently on ART?
Yes	272	71.0
No	111	29.0
History of abnormal Pap smear?
Yes	2	0.5
No	381	99.5
Do you smoke cigarettes?
Yes	5	1.3
No	378	98.7
Long time corticosteroids use?
Yes	6	1.6
No	377	98.4

Prevalence of HPV infection among participants

Among the overall participants who participated in the study, 102 (26.6%) tested positive for HPV (Fig. 1).

Fig. 1.

Prevalence of HPV infection among participants, Adama, Ethiopia, 2023

HPV genotype distribution among HPV-positive participants

The majority of the HPV genotypes identified from the 102 HPV-positive patients were other high-risk HPV genotypes 65 (63.7%), followed by HPV-16 23 (22.5%) and HPV-18 6 (5.9%) (Fig. 2).

Fig. 2.

HPV genotype distribution among HPV-positive participants, Adama, Ethiopia, 2023

Risk factors associated with HR-HPV infection among study participants

Among women who were divorced, those with an HR-HPV infection risk factor were almost 3 times more likely to have an HR-HPV infection risk (AOR = 2.96: 95% CI: 1.18, 7.40). Women who had a history of post-coital bleeding were almost 8 times more likely to have a risk of acquiring HR-HPV infection compared to those women who had no history of post-coital bleeding (AOR = 7.97: 95% CI: 2.17, 29.24). Participants who had a history of early sexual debut before age 20 years were 3.6 times more Likely to have a high risk of acquiring HR-HPV infection than were those who had their first sex at age 20 years or older (AOR = 3.59: 95% CI: 1.69, 7.65). Women who had a history of more than one Lifetime sexual partner were 5 times more likely to have a risk of acquiring HR-HPV infection than their counterparts were (AOR = 5.25: 95% CI: 1.73, 15.96). HIV-positive participants were 12 times more likely to have a risk of acquiring HR-HPV infection than HIV-negative participants were (AOR = 12.37: 95% CI: 4.57, 33.48) (Table 3).

Table 3.

Risk factors associated with HR-HPV infection among study participants, adama, ethiopia, 2023

Variables	HPV Negative (# 281)		HPV Positive (# 102)		COR (95%CI)	AOR (95% CI)
	No	%	No	%
Age Group
25–29	34	12.1	18	17.6	3.12(1.26,7.74)*	2.45(0.77,7.81)
30–34	70	24.9	31	30.4	2.61(1.15,5.94)*	2.65(0.94,7.46)
35–39	72	25.6	15	14.7	1.23(0.50,3.02)	0.96(0.32,2.90)
40–44	52	18.5	29	28.4	3.28(1.42,7.61)*	2.46(0.88,6.88)
45–49	53	18.9	9	8.8	1	1
Family Income
< 3000 ETB	91	32.4	38	37.3	2.09(0.93,4.69)*	1.65(0.61,4.42)
3000–5000 ETB	145	51.6	55	53.9	1.90(0.87,4.14)*	2.18(0.85,5.60)
> 5000 ETB	45	16	9	8.8	1	1
Marital Status
Single	29	10.3	14	13.7	1.15(0.46,2.86)	1.19(0.40,3.53)
Married	169	60.1	39	38.2	0.55(0.26,1.15)*	2.52(0.36,17.85)
Divorced	52	18.5	36	35.3	1.65(0.76,3.58)*	2.96(1.18,7.40)*
Widowed	31	11	13	12.7	1	1
Contraceptive Use
Oral contraceptive pills	42	14.9	11	10.8	0.54(0.26,1.10)*	1.29(0.37,4.45)
Depo Provera (Injectable)	81	28.8	18	17.6	0.45(0.25,0.82)*	1.18(0.40,3.49)
Implant	17	6	4	3.9	0.49(0.16,1.48)*	1.53(0.31,7.45)
I do not use any	141	50.2	69	67.6	1	1
Do You Use Condom?
Yes, always	88	31.3	55	53.9	2.84(1.75,4.60)*	2.52(0.38,16.55)
Yes, sometimes	16	5.7	8	7.8	2.27(0.91,5.68)*	1.64(0.21,12.41)
No, I do not use	177	63	39	38.2	1	1
Postcoital Bleeding
Yes	5	1.8	13	12.7	8.06(2.80,23.24)**	7.97(2.17,29.24)*
No	276	98.2	89	87.3	1	1
Age at First Sex
< 20 years	179	63.7	91	89.2	4.71(2.41,9.22)**	3.59(1.69,7.65)*
≥ 20 years	102	36.3	11	10.8	1	1
Lifetime Sexual Partner/s
One	74	26.3	4	3.9	1	1
More than one	207	73.7	98	96.1	8.76(3.11,24.64)**	5.25(1.73,15.96)*
History of STI
Yes	76	27.0	48	47.1	2.40(1.50,3.83)**	2.36(1.32,4.20)*
No	205	73.0	54	52.9	1	1
HIV sero-status
Negative	106	37.7	5	4.9	1
Positive	175	62.3	97	95.1	11.75(4.63,29.80)**	12.37(4.57,33.48)**

1 = reference category 

*significantly associated

**highly significantly associated

Discussion

Summary of the main results

The prevalence of HPV infection was estimated to be 26.6%. The proportions of participants with HPV-16 and HPV-18 were 22.5% and 5.9%, respectively. “Other HR-HPV” genotypes accounted for 63.7% of all HPV-positive participants. Being divorced, having a history of postcoital bleeding, having an early sexual debut before age 20, having a history of more than one sexual partner, having a history of STIs, and being HIV positive were risk factors identified as having a statistically significant association with the acquisition of HR-HPV infection.

Results in the context of published literature

With regard to the prevalence of HPV infection, the findings of our study were comparable with the findings reported from Kazakhstan, with an overall prevalence of 25% [15], and from the Democratic Republic of the Congo, with a prevalence of 27.8% [16]. Comparatively, our findings were much lower than those of studies reported from South Africa (76%) [17] and lower than those reported in Turkey (35%) [3] and Ghana (32.3%) [18].

On the other hand, the prevalence of HR-HPV infection in the current study was much greater than that reported in Israel (9%) [19], Iraq (12.9%) [20], mainland China (19%) [21], Peru (19%) [8], the Canarian Islands (13.6%) [22], Zimbabwe (17%) [23], and Tanzania (18.9%) [24].

In terms of detecting the two most prevalent and highly oncogenic HR-HPV genotypes, the findings of the present study were significantly greater than those of studies performed in Changsha, Hunan, China, with HPV-16 (9.3%) and HPV-18 (3.5%). “Other HR-HPVs” detected included HPV-52 (28.01%), HPV-58 (14.83%), HPV-53 (10.84%), and HPV-39 (9.64%) [25], and HPV-16 and HPV-18 accounted for only 8.5% and 8% of South Africa, respectively. Other HR-HPVs were HPV-59 (13.6%) and HPV-51 (10.8%) [17]. On the other hand, our findings were significantly lower than those of a study performed in Tanzania, in which the most common genotypes identified were HPV-16 (32.5%), HPV-18 (16.7%) and other HR-HPVs, including HPV-58 (19.3%) and HPV-52 (16.7%) [24].

Concerning the risk factors contributing to the acquisition of HPV infection and its progression to cervical cancer, our findings were almost consistent with the findings of Asseffa [26] that high parity, early marriage, having multiple sexual partners, and poverty force a woman to engage in sex work for a living and coinfection with HIV that reduces her immune status. Moreover, the findings of the present study were almost consistent with those of a study performed in South Africa in which having HIV-positive status, having ≥ 3 lifetime sexual partners and having a vaginal discharge currently/in the previous week increased the risk of acquiring HR-HPV infection. In contrast, the present findings were not consistent with those of a study performed in Changsha, Hunan, China, in which the risk factors for HPV infection identified in the study were age and alcohol consumption [25]. Moreover, the findings of this study were not consistent with those of a study performed in Ghana showing that being single, having a steady partner but not living together, living with someone but not being married, and first sexual partner were factors associated with HPV infection. On the other hand, two factors associated with high-risk HPV positivity, being divorced and having more sexual partners, were consistent with the current findings [18].

The possible reasons for the discrepancies in HPV prevalence, genotype distribution, and associated factors among the studies might be geographic variations and host immunogenetic factors. The discrepancies might also be due to differences in the sociodemographic characteristics of the study participants, the study setting, and the study periods.

HPV vaccines are very effective at preventing infections and diseases related to the vaccine-specific genotypes in women with no evidence of past or current HPV infections. On the other hand, screening programs have consistently been associated with a reduction in cervical cancer incidence and mortality, which are the consequences of HPV infection. Unfortunately, these complementary preventive options often implemented as separate and non-coordinated public health programs. A combined strategy of these two preventive approaches aims to address this disconnect by combining both strategies to accelerate the reduction of cervical cancer incidence and mortality and make the programs both cost-effective and sustainable.

Limitations of the study

This study attempted to base its generalizations on diverse scientific vantage points. However, it can be affected by the following limitations: Because of the cross-sectional nature of the data, it is difficult to establish cause-and-effect relationships. The study was restricted to three public health institutions where cervical cancer screening services were provided in the study area. Therefore, the findings may not be full reflection of other health facilities. Some self-reported data might have biases.

Implications for practice and future research

No genotype distribution of HPV has been studied in the current study area. Even at the national level, only a few studies have been conducted. Therefore, this evidence-based epidemiology of HPV infection is essential to support efforts to prevent and control the infection in Ethiopia. Future research is needed to assess community-based cervical cancer screening and associated factors in women aged 25/30 to 49 years.

Conclusions

There was a high prevalence of HPV infection among participants in the study area. “Other HR-HPV” genotypes were the major oncogenic HR-HPV genotypes identified, followed by HPV-16 and HPV-18. Being divorced, having a history of postcoital bleeding, having an early sexual debut, having more than one sexual partner, having an STI, and being HIV-positive were risk factors identified as having a statistically significant association with the occurrence of HR-HPV infection. Therefore, awareness campaigns and education programs about the prevention of HPV infection and associated risk factors need to be developed for the community. The findings of this study will provide objective evidence that could be used to design appropriate strategies, develop guidelines and implement health care approaches in the clinical area to mitigate the impact of HPV infection and its sequela cervical cancer across the country. The findings of this scientific inquiry may also help shape the health policies and contribute to the country’s healthcare system. Moreover, it will also be used as a baseline to conduct further HPV-related studies based on the conclusions drawn from the investigation.

Abbreviations

AOR

Adjusted Odds Ratio

CC

Cervical Cancer

CIN

Cervical Intraepithelial Neoplasia

COR

Crude Odds Ratio

DNA

Deoxyribonucleic Acid

FMOHE

Federal Ministry of Health Ethiopia

HIV

Human Immunodeficiency Virus

HPV

Human Papillomavirus

HR-HPV

High-risk Human Papilloma Virus

LR-HPV

Low-risk Human Papillomavirus

OR

Odds Ratio

PHR-HPV

Probably high-risk Human Papilloma Virus

SPSS

Statistical Package for Social Science

STI

Sexually Transmitted Infection

UNISA

University of South Africa

WHO

World Health Organisation

Authors’ contributions

T.F.L developed the study objective, data management and analysis and wrote the first draft of the manuscript. Additionally, T.F.L contributed to the study design, interpreted the results, and drafted and revised the manuscript. M.M and A.M reviewed the manuscript for critical input, supervised all the data analysis and manuscript writing and provided critical input to the manuscript. All the authors have read and approved the final manuscript.

Funding

The corresponding author and the UNISA funded this research. The UNISA provided a small deal of money through a student bursary award to the author that covered only a language editor’s payment. The corresponding author covered all the other expenses.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from the College of Human Sciences Research Ethics Review Committee at the University of South Africa (UNISA). Reference number (Rec − 240816-052). All participants gave informed consent to participate in the study before taking part.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.