A rational-emotive stress management intervention for reducing job burnout and dysfunctional distress among special education teachers: An effect study.

BACKGROUND: Job-related burnout and distress are adverse stress responses which affect individuals in their occupational environment. This study aimed at investigating the effect of a rational-emotive stress management program on job burnout and dysfunctional distress among special education teachers in Nigeria.
METHODS: A pretest-posttest randomized control group design was used. The participants in the study were 54 special education teachers. Data were collected using self-report questionnaires. Participants were allocated to either the treatment group (n = 28 [59.1%]) or the waitlist control group (n = 26 [48.1%]), respectively. A rational-emotive stress management manual was used to deliver the intervention. We statistically analyzed the data collected at three-time points with repeated-measures analysis of variance.
RESULTS: At baseline, the job-related burnout symptoms and distress scores of participants were high. However, an intention-to-treat analysis showed that the rational-emotive stress management intervention program was efficacious in reducing the levels of job-related burnout symptoms and dysfunctional distress among participants assigned to the treatment group, compared to a waitlisted group at post-treatment and follow-up meetings.
CONCLUSION: Our study demonstrates the effectiveness of a rational-emotive stress management intervention in reducing the level of job-related burnout and distress in a sample of special education teachers in Nigeria. Occupational health counsellors and other clinicians with sufficient knowledge of rational-emotive behavior therapy framework are urged to employ this approach in assisting other employees in managing job burnout symptoms, and distress.

RCT Entities:   Population Interventions Outcomes

Introduction

Job-related burnout and distress are adverse stress responses which affect individuals in their occupational environment. Burnout is a reaction to chronic stress among workers.[ Scholars indicated that teachers in Nigeria are vulnerable to job burnout and distress.[ Burnout results in frustration, depression, insomnia, low appetite, suicidal ideation, job ineffectiveness, anger, exhaustion, boredom, irritability, fatigue, helplessness, cynical attitude, alcoholism, and substance abuse among others.[ Burnout is detrimental to teacher well being.[ Job burnout among teachers is also related to reduced quality of teaching,[ diminished tolerance for misbehavior[ and more use of cruel disciplinary measures.[ From a rational-emotive behavior therapy (REBT) viewpoint, irrational beliefs may increase worker's vulnerability to burnout in the workplace. Researchers indicated that work-related irrational beliefs may be associated with burnout even among medical practitioners.[ In a study by Bernhardt et al,[ distress-related beliefs were found to be positively correlated with burnout symptoms of workers in a healthcare setting.

Distress can be categorized into dysfunctional and functional distress. Dysfunctional distress that refers to maladaptive, negative feelings go with functional distress, for instance, feeling depressed also involves sadness.[ Therefore, dysfunctional distress often corresponds to significant problems like depression and anxiety, but functional distress like sadness and concern correspond to normal negative responses to stressful events.[ Therefore, in the REBT perspective, rational beliefs are theorized to be related to functional distress, whereas irrational beliefs are theorized to be related to dysfunctional distress.[ In Albert Ellis’ cognitive model of distress, undesirable events which activate either rational and/or irrational beliefs result in consequences, which can by nature, be behavioral, cognitive, or emotional.[ Thus, the outcomes of rational beliefs are adaptive, while the outcomes of irrational beliefs are maladaptive. In this regard, the goal of rational-emotive behavioral treatment is to assist individuals to therapeutically dispute irrational beliefs and attain adaptive and/or efficient beliefs.[

According to REBT practitioners, irrational beliefs are one of the major factors that sustain distress.[ Also, evidence suggests that in about 80% of all work-related injuries and 40% of workplace turnover, work-related distress is a major contributory factor.[ Elsewhere, work-related distress affects up to 28% of workers.[ Research also suggests that people could suffer from distress in virtually all aspects of their lives, beginning from the workplace to family and society, with higher levels of distress having a direct effect on the immune system, and escalating various medical conditions.[ Per job-related distress, workers exposed to job-related distress to a high degree tend to report illness symptoms more frequently, need additional time off work for medical reasons, and can bring about increase in their employer's healthcare expenses.[ In addition to direct health expenditures, job-related distress results in various secondary expenses for organizations because of absenteeism and poor performance.[ Distress may lead to anxiety and mood disorders.[ Also, distress has become a major issue due to the reduction in productivity, lost time as a result of illness, and workers’ absenteeism following distress.[ For these reasons, early evaluation and identification of distress-related beliefs are indispensable to psychological therapies tilting toward reducing distress[ such as the REBT approach.[ Thus, interventions based on REBT theoretical approach might be helpful because there is a growing body of empirical literature confirming the strong correlation between distress and irrational beliefs of individuals.[ Besides, Ellis noted that REBT could be an effective therapy for reducing distress because it focuses on core beliefs, which in turn, not only result in individuals “feeling better” but also “getting better.”[ In addition, several previous studies have revealed that therapeutic interventions based on the REBT theoretical framework have a significant effect in reducing distress. [

Despite the foregoing, to our knowledge, only a few studies seem to have employed the REBT approach in reducing burnout symptoms and distress in Nigerian sample. A Nigerian study applied the rational-emotive behavior therapy to successfully assist Nigerian adolescents to adjust emotionally.[ Another Nigerian study employed the rational-emotive behavior therapy approach to assist individuals in school setting to significantly reduce burnout symptoms.[ There are also other recent Nigerian studies which have used the rational-emotive behavior therapy approach to reduce job-related stress of teachers in vocational and technical school settings.[ However, not much is known about any psychological therapy which aimed to assist the Nigerian special education teachers in decreasing job-related burnout symptoms and distress. Outcomes of previous studies are indications that Nigerian special education teachers are vulnerable to job burnout and distress in the workplace.[ The special education teachers experiencing job-related burnout and distress could be assisted through exposure to a rational-emotive stress management program. According to rational-emotive practitioners, people's thinking pattern and feeling may be associated with their pattern of symptomatology.[ Popov and Popov[ found that irrational beliefs, which is a major psychological construct in rational-emotive behavior therapy approach, make an autonomous contribution to burnout and distress prediction among individuals. These authors observed that irrational and/or rational beliefs play important role in both burnout and distress prediction. Howlett[ found that there are links between patients’ general patterns of beliefs and their symptomatology. The author revealed that there was no significant gender effect in this regard.[ Thus, irrational beliefs are important cognitive vulnerability constructs, which can predict how individuals emotionally respond to stressful events.[ The impact of irrational beliefs on emotional regulation has also been explained in previous research.[ Indeed, a huge amount of empirical evidence showed that irrational beliefs can negatively impact emotional problems.[ Therefore, the objective of this study was to ascertain the effect a rational-emotive stress management program would have on job burnout and dysfunctional distress among special education teachers in Southeast zone of Nigeria. The hypothesis of the present study is that the rational-emotive stress management intervention would result in significant reduction in job burnout and dysfunctional distress among special education teachers in the treatment group compared to a waitlisted group both at post-treatment and follow-up evaluation periods.

Methods

Statements of ethical consideration

The Research Ethics Committee of the Department of Educational Foundations, University of Nigeria Nsukka approved this research. The authors also adhered firmly to the ethical standard for carrying out research with human participants as stated by the American Psychological Association.[ The ethical considerations in carrying out research with human participants was further upheld by the researchers based on the World Medical Association's Declaration of Helsinki.[

Participants

The participants in this study were 54 special education teachers in schools for students with special needs in Southeast zone of Nigeria. Based on gender, the participants were 24 (44.44%) males and 30 (55.56%) females. Mean age of the participants was 36.67 ± 5.3 years, t (53) = 50.783, P = .000, CI: 35.218–38.115. There was no statistically significant difference in the number of participants assigned to each treatment conditions,χ2(1) = .074, P = .785. Table 1 revealed the demographic variables of the participants according to gender and group.

Table 1

Participants’ demographic characteristics.

Measures

The Teacher Burnout Scale (TBS), a 25-item scale adapted by the authors from the Shirom-Melamed Burnout Questionnaire[ was used for collection of data on teachers’ burnout levels. The TBS has 3 subscales: physical fatigue [P, 9 items], emotional exhaustion [E, 8 items], and cognitive weariness [C, 8 items]. A seven-point Likert-type scale ranging from 0 (never) to 6 (always) was used to score the TBS. In the TBS, high scores in the TBS reflect high burnout. Reliability coefficients are .89 for the physical fatigue subscale, .85 for emotional exhaustion subscale, and .81 for cognitive weariness subscale. The TBS has a demographic information section which asked participants about their age and gender.

Profile of Emotional Distress (PED). The PED[ is a 26-item self-report instrument that measures functional and dysfunctional negative emotions from the “concern/anxiety” and “sadness/depression” categories. Using a 5-point Likert-type scale, the PED asked respondents to rate each item (adjectives expressing emotions) based on how they felt during the past 2 weeks. The PED allow researchers to compute a global score of distress. High scores in the PED reflect high distress level. Researchers reported a good internal consistency for the PED: the total scale (Cronbach's alpha = 0.94) and subscales Cronbach's alpha (between 0.80 and 0.94).[

Procedure

Information regarding recruitment and possible participation in the stress management program were sent to special education teachers in schools in the Southeast zone of Nigeria. A total of 146 special education teachers were accessed for eligibility by the researchers using the measures of job-related burnout and distress. Potential participants had to meet inclusionary criteria set by the researchers. The study inclusionary criteria were: a participant being a special education teacher and must meet the criteria for job burnout and distress levels at the pre-treatment evaluation. Other criteria include that the participant must complete an informed consent form and must be willing to focus on the program till the end without accepting any intervention program on job burnout and distress during the intervention period. The first 54 special education teachers who met the study inclusionary criteria were enrolled to participate in the study (see Fig. 1). Participants were randomized to either the treatment group (n = 28 [59.1%]) or the waitlist control group (n = 26 [48.1%]), respectively. First of all, participants were matched based on gender (male/female), and then treatment condition based on a computer-generated random list.[ Participants allocated to the treatment group completed a 12-week stress management intervention program aimed at reducing job burnout and distress while those participants assigned to the control group completed a 12-week waiting period concurrently. The program was 2 hours in length and took place at a large public school hall. Pretest (Time 1), posttest (Time 2), and follow-up (Time 3) measures were completed independently but in small groups of about 4 participants over the course of the stress management program. In order to eliminate selection bias during participants’ recruitment and randomization, the researcher carefully concealed the assignment/allocation sequence from the participants. In order to minimize the risk of potential bias, the researchers also blinded the data analyst until the statistical analysis was completed by concealing some information in the measures, which could unveil the group that received the stress management intervention, as in Ugwoke et al.[

Figure 1

Participants eligibility criteria using CONSORT flow diagram.

Intervention

REBT Program Manual

The rational emotive behavior therapy program manual which followed similar procedures contained in Ogbuanya et al.[ can be used for assisting individuals in managing job burnout and distress-related beliefs, thoughts and behaviors. The REBT program manual enabled the authors to boost participants’ understanding of their burnout and distress-related feelings and to facilitate the participants in defeating these feelings. In the current intervention, behavioral, cognitive, and emotive techniques of REBT were used to assist the study participants. We implemented cognitive restructuration of self-defeating beliefs that the participants might have developed which have resulted in job burnout and distress. Techniques such as direct teaching, goal-setting, relaxation, role-play, disputing, use of rational self-talk, motivational interviewing techniques, Socratic questioning, cognitive rehearsal, desensitization techniques, homework assignments, and imagery techniques were used to assist the study participants. More elaboration of an intervention program manual for burnout reduction including the techniques, therapeutic goals, and activities can be found in Ogbuanya et al.[ Also, other evidence-based therapeutic techniques of recent stress management programs based on the REBT model which were included in the manual can be found in Ogbuanya et al.[ and Ugwoke et al.[

Design and data analyses

The researchers adopted a pretest-posttest randomized control group design in this study. A repeated-measures analysis of variance (ANOVA) was used for the analysis of data. Partial eta squared () and adjusted R2 were reported in order to confirm the effect size of the rational-emotive stress management intervention. The confidence intervals of results were also reported. Time points were entered as within-subjects variables, whereas group was entered as between-subjects factors. Chi-square and t-test analysis were conducted in regard to the participants’ demographic variables. All results were considered significant at P≤.05. Our test for violation of assumptions showed that the Mauchly's test of Sphericity was not statistically significant (Mauchly's W = .925, P = .147), thus, the assumption of Sphericity was met. Furthermore, test for normality of data using the Shapiro-Wilk test of normality was not statistically significant for both treatment (Shapiro-Wilk = .940, P = .112) and waitlisted groups (Shapiro-Wilk = .962, P = .442), which is an indication that the data was normally distributed. Also, there were no outliers and no missing values in the data across the groups. All statistical data were entered and analyzed using IBM SPSS, version 22.[

Results

Table 2 showed the results of 3 periods of assessments of the study participants using the Teacher Burnout Scale (TBS) and Profile of Emotional Distress (PED).

Table 2

Repeated-measures ANOVA showing effect of the rational-emotive stress management intervention on job burnout by time and group.

As can be seen in Table 2, there was no significant pre-treatment difference in the level of physical fatigue as measured by TBS between participants in the treatment and waitlisted control groups, F(1,52) = 1.722, P = .195,  = .032,∆R2 = .013. The assessment after the rational-emotive stress management intervention program showed a significant decrease in the level of physical fatigue among participants in the treatment group compared to the waitlisted control group, F(1,52) = 7673.157, P = .000,  = .993,∆R2 = .993. Also, the follow-up assessment (Time 3) indicated that there was a significant decrease in the level of physical fatigue among participants in the treatment group compared to the waitlisted control group, F(1,52) = 3671.544, P = .000,  = .986, ∆R2 = .986. This means that rational-emotive stress management intervention was efficacious in reducing the level of physical fatigue among participants.

Also, Table 2 showed that there was no significant pretreatment difference in the level of emotional exhaustion as measured by TBS between participants in the treatment and waitlisted control groups, F(1,52) = .099, P = .754,  = .002, ∆R2 = −.017. The assessment after the rational-emotive stress management intervention program showed a significant decrease in the level of emotional exhaustion among participants in the treatment group compared to the waitlisted control group, F(1,52) = 1217.750, P = .000,  = .959, ∆R2 = .958. Also, the follow-up assessment (Time 3) indicated that there was a significant decrease in the level of emotional exhaustion among participants in the treatment group compared to the waitlisted control group, F(1,52) = 5269.883, P = .000,  = .990, ∆R2 = .990 This means that rational-emotive stress management intervention was efficacious in reducing the level of emotional exhaustion among treatment group participants compared to their counterparts in a waitlisted group.

Also, Table 2 showed that there was no significant pretreatment difference in the level of cognitive weariness as measured by TBS between participants in the treatment and waitlisted control groups, F(1,52) = 1.104, P = .298,  = .021, ∆R2 = .002. The assessment after the rational-emotive stress management intervention program showed a significant decrease in the level of cognitive weariness among participants in the treatment group compared to the waitlisted control group, F(1,52) = 5086.623, P = .000,  = .990, ∆R2 = .990. Also, the follow-up assessment (Time 3) indicated that there was a significant decrease in the level of cognitive weariness among participants in the treatment group compared to the waitlisted control group, F(1,52) = 4655.349, P = .000,  = .989, ∆R2 = .989. This means that rational-emotive stress management intervention was efficacious in reducing the level of cognitive weariness among participants in the treatment group compared to those in the waitlisted group.

On the overall, results in Table 2 showed that there was no significant pretreatment difference in the level of job burnout between participants in the treatment and control groups, F(1,52) = .380, P = .540,  = .007, ∆R2 = −.012. The assessment after the rational-emotive stress management intervention program showed a significant decrease in the level of job burnout among participants in the treatment group compared to the waitlisted control group, F(1,52) = 8772.047, P = .000,  = .994, ∆R2 = .994. Also, the follow-up assessment (Time 3) indicated that there was a significant decrease in the level of job burnout among participants in the treatment group compared to the waitlisted control group, F(1,52) = 6121.388, P = .000,  = .992, ∆R2 = .991. This means that rational-emotive stress management intervention was efficacious in reducing the level of job burnout among participants in the treatment group compared to those in the waitlisted group.

Results in Table 3 showed that there was no significant pretreatment difference in the level of distress as measured by PED between participants in the treatment and waitlisted control groups, F(1,52) = .002, P = .968,  = .000, ∆R2 = −.019. The assessment after the rational-emotive stress management intervention program showed a significant decrease in the level of distress among participants in the treatment group compared to the waitlisted control group, F(1,52) = 670.769, P = .000,  = .928, ∆R2 = .927. Also, the follow-up assessment (Time 3) indicated that there was a significant decrease in the level of distress among participants in the treatment group compared to the waitlisted control group, F(1,52) = 661.444, P = .000,  = .927, ∆R2 = .926. This means that rational-emotive stress management intervention was efficacious in reducing the level of job-related distress among participants in the treatment group compared to those in the waitlisted group.

Table 3

Repeated measures ANOVA showing effect of the rational-emotive stress management intervention on distress by time and group.

Discussions

The purpose of this study was to investigate the effect of a rational-emotive stress management intervention on job-related burnout and dysfunctional distress among special education teachers in Southeast zone of Nigeria. The findings of the study showed that at the pretest assessment, high levels of job burnout and dysfunctional distress were found among the study participants. Previous findings showed that many employees in Nigerian occupational environments are vulnerable to job burnout and distress.[ However, assessment after the intervention program showed that rational-emotive stress management intervention was efficacious in reducing the level of physical fatigue, emotional exhaustion, cognitive weariness, and the overall job burnout among participants in the treatment group compared to the waitlisted control group. We also found that the rational-emotive stress management intervention was efficacious in reducing the level of distress among study participants in the treatment group compared to the waitlisted control group. These findings are in agreement with some recent and previous studies which revealed that therapeutic interventions based on the REBT theoretical framework have a significant effect in reducing job burnout,[ distress and distress consequences.[ Other REBT practitioners[ demonstrated that rational-emotive behavior therapy contributes independently to the understanding of burnout symptoms and distress.

Considering the evidence that REBT is significantly effective in decreasing job burnout and distress at follow-up period, we would like to emphasize that several studies support the consistent effect of REBT in reducing burnout and psychological distress.[ This study has added to the extant literature showing that REBT is an invaluable therapy for burnout and distress reduction in an occupational environment. Unhealthy emotional responses (in this case, burnout and distress) are capable of leading to reduced productivity and health problems. Turner[ indicated that irrational beliefs can result in unhealthy negative emotions, a multiplicity of psychopathological conditions, and maladaptive behaviors that affect people's mental health. One of the aims of REBT approach is, therefore, to decrease irrational beliefs and increase rational beliefs, and also encourage decreases in unhealthy negative emotions and increased healthy negative emotions.[ Prior studies on both clinical and nonclinical population confirmed the effectiveness of REBT in improving the overall well being of people from varied culture and orientation.[ Turner[ remarked that REBT is a preventative treatment modality that can reduce unhealthy negative emotion and strengthen the mental well being of individuals. Several authors[ have also noted that REBT is an important interventional approach for use by clinicians and non-clinicians who work with teachers.

The study outcomes can have implications for school health counseling, occupational health, and behavioral medicine. Since, several studies indicated that there is a positive connection between individuals’ irrational beliefs and their mental health outcomes,[ the rational-emotive stress management intervention program may be used in several occupational contexts and in different populations to decrease work-related irrational beliefs among employees. There is need for school health counselors, occupational therapists and behavior medicine specialists to develop a therapeutic system for helping workers to overcome job burnout and distress. Given that rational-emotive stress management intervention demonstrated a significant effect in reducing job burnout and distress among a sample of workers in this population, we hope that similar interventions will be adopted as a method of managing and preventing job burnout and distress among individuals in various occupational settings. It should be incorporated into the workplace whereby employees are encouraged to participate, thus creating a rational-emotive organization. Once job-related irrational and negative thoughts and beliefs have been successfully disputed, rational and adaptive thoughts will be developed and the individual will invariably become free from job burnout symptoms and distress. Also, since working as a special education teacher is highly demanding, they need to be exposed to interventions that will enable them to learn emotional regulation at the workplace and have increased awareness of indicators of job-related burnout and distress.

Even though this study demonstrates a significant effect of rational-emotive stress management intervention on job burnout and distress reduction, its limitations have to be addressed. In this study, data collection was through self-reported measures, thus, the results may be prone to the common-method bias. Though the participants can at best, identify their own emotions and feelings, future research may use additional data sources such as observation, interview, case review, and cumulative records. The pretest–posttest randomized design used in the study is a useful research design. But, researchers can employ the Solomon four-group because it can help overcome the flaws of the pretest–posttest design. Also, the participants were residing in Southeast Nigeria, and therefore, results cannot be generalized to teachers in other parts of the country. Future studies are also encouraged to use multilevel analysis to examine the effect of rational-emotive stress management intervention on job burnout and distress. Also, our sample size was not very large as many would expect. A larger number of participants should be accessed for eligibility in future studies.

Conclusion

This study examined the effect of rational-emotive stress management intervention on job burnout and distress among special education teachers. The results revealed a significant effect of a rational-emotive stress management intervention in reducing job burnout and distress at post-treatment and follow-up phases compared to a waitlisted group. The study supports the development and implementation of manualized stress management interventions in the workplace for combating job-related burnout and distress based on the rational-emotive behavior therapy framework. Finally, occupational health counselors and other clinicians with sufficient knowledge of rational-emotive behavior therapy framework are urged to employ this approach in assisting employees in managing job burnout symptoms, and distress.

Acknowledgments

We are grateful to all the participants for taking part in the study. We are also grateful to the anonymous reviewers and editor-in-chief for their significant comments about this work.

Author contributions

Conceptualization: Samuel C Ugwoke, Chiedu Eseadi, Liziana Nnenna Onuigbo, Chibueze T Orji, Eucharia U Onu, Joachim C Omeje.

Data curation: Samuel C Ugwoke, Chiedu Eseadi, Liziana Nnenna Onuigbo, Eucharia N Aye, Anthonia U Nwobi, Bernedeth Ezegbe, Moses O Ede, Chibueze T Orji, Joseph Onuoha, Eucharia U Onu, Patricia Agu.

Formal analysis: Samuel C Ugwoke, Chiedu Eseadi, Liziana Nnenna Onuigbo, Eucharia N Aye, Immaculata N Akaneme, Angie Oboegbulem, Ifeyinwa Ezenwaji, Anthonia U Nwobi, Okechukwu O Nwaubani, Bernedeth Ezegbe, Moses O Ede, Chibueze T Orji, Joseph Onuoha, Eucharia U Onu, Patricia Agu, Joachim C Omeje, Faith Omeke, Romanus Ugwu, Florence Arumede, Annastasia Eneh.

Funding acquisition: Samuel C Ugwoke, Chiedu Eseadi, Liziana Nnenna Onuigbo, Eucharia N Aye, Immaculata N Akaneme, Angie Oboegbulem, Ifeyinwa Ezenwaji, Anthonia U Nwobi, Okechukwu O Nwaubani, Bernedeth Ezegbe, Moses O Ede, Chibueze T Orji, Joseph Onuoha, Eucharia U Onu, Francisca okeke, Patricia Agu, Joachim C Omeje, Faith Omeke, Romanus Ugwu, Florence Arumede, Annastasia Eneh.

Investigation: Samuel C Ugwoke, Chiedu Eseadi, Liziana Nnenna Onuigbo, Eucharia N Aye, Immaculata N Akaneme, Angie Oboegbulem, Ifeyinwa Ezenwaji, Anthonia U Nwobi, Okechukwu O Nwaubani, Bernedeth Ezegbe, Moses O Ede, Chibueze T Orji, Joseph Onuoha, Francisca okeke, Joachim C Omeje, Faith Omeke, Romanus Ugwu, Florence Arumede, Annastasia Eneh.

Methodology: Samuel C Ugwoke, Chiedu Eseadi, Liziana Nnenna Onuigbo, Eucharia N Aye, Immaculata N Akaneme, Angie Oboegbulem, Ifeyinwa Ezenwaji, Anthonia U Nwobi, Okechukwu O Nwaubani, Bernedeth Ezegbe, Moses O Ede, Chibueze T Orji, Joseph Onuoha, Eucharia U Onu, Francisca okeke, Joachim C Omeje, Faith Omeke, Romanus Ugwu, Florence Arumede, Annastasia Eneh.

Project administration: Samuel C Ugwoke, Chiedu Eseadi, Liziana Nnenna Onuigbo, Eucharia N Aye, Immaculata N Akaneme, Angie Oboegbulem, Anthonia U Nwobi, Okechukwu O Nwaubani, Bernedeth Ezegbe, Moses O Ede, Chibueze T Orji, Francisca okeke, Joachim C Omeje, Faith Omeke.

Supervision: Samuel C Ugwoke, Chiedu Eseadi, Liziana Nnenna Onuigbo, Immaculata N Akaneme, Ifeyinwa Ezenwaji, Anthonia U Nwobi, Okechukwu O Nwaubani, Joachim C Omeje.

Validation: Samuel C Ugwoke, Chiedu Eseadi, Liziana Nnenna Onuigbo, Eucharia N Aye, Immaculata N Akaneme, Angie Oboegbulem, Ifeyinwa Ezenwaji, Anthonia U Nwobi, Okechukwu O Nwaubani, Bernedeth Ezegbe, Moses O Ede, Chibueze T Orji, Joseph Onuoha, Eucharia U Onu, Francisca okeke, Patricia Agu, Joachim C Omeje, Faith Omeke, Romanus Ugwu, Florence Arumede.

Visualization: Samuel C Ugwoke, Chiedu Eseadi, Liziana Nnenna Onuigbo, Eucharia N Aye, Immaculata N Akaneme, Angie Oboegbulem, Ifeyinwa Ezenwaji, Anthonia U Nwobi, Okechukwu O Nwaubani, Bernedeth Ezegbe, Moses O Ede, Chibueze T Orji, Joseph Onuoha, Eucharia U Onu, Francisca okeke, Patricia Agu, Joachim C Omeje, Faith Omeke, Romanus Ugwu, Florence Arumede, Annastasia Eneh.

Writing – original draft: Samuel C Ugwoke, Chiedu Eseadi, Liziana Nnenna Onuigbo, Eucharia N Aye, Immaculata N Akaneme, Angie Oboegbulem, Ifeyinwa Ezenwaji, Anthonia U Nwobi, Okechukwu O Nwaubani, Bernedeth Ezegbe, Moses O Ede, Chibueze T Orji, Joseph Onuoha, Eucharia U Onu, Francisca okeke, Patricia Agu, Joachim C Omeje, Faith Omeke, Romanus Ugwu, Florence Arumede, Annastasia Eneh.

Writing – review & editing: Samuel C Ugwoke, Chiedu Eseadi, Liziana Nnenna Onuigbo, Eucharia N Aye, Immaculata N Akaneme, Angie Oboegbulem, Ifeyinwa Ezenwaji, Anthonia U Nwobi, Okechukwu O Nwaubani, Bernedeth Ezegbe, Moses O Ede, Chibueze T Orji, Joseph Onuoha, Eucharia U Onu, Francisca okeke, Patricia Agu, Joachim C Omeje, Faith Omeke, Romanus Ugwu, Florence Arumede, Annastasia Eneh.