Randomized controlled evaluation of the effect of music therapy with cognitive-behavioral therapy on social anxiety symptoms.

OBJECTIVE: This study examined the effects of music therapy with cognitive behavioral therapy on social anxiety in a sample of schooling adolescents in south-east Nigeria.
METHODS: We adopted a randomized controlled trial design involving a treatment group and a waiting-list control group. A total of 155 schooling adolescents served as the study sample. The sample size was ascertained using GPower software. A 12-week MTCBP manual for social anxiety was employed to deliver the intervention. Data analyses were completed using repeated measures analysis of variance.
RESULTS: We found that social anxiety significantly decreased in the treatment group over time, whereas the waitlist control group showed no significant changes in social anxiety. Therefore, music therapy with cognitive-behavioral therapy was significantly beneficial in decreasing social anxiety symptoms of the treatment group. The follow-up assessment performed after 3 months revealed a significant reduction in social anxiety for the treatment group.
CONCLUSION: The study, therefore, suggests that the use of music therapy with cognitive-behavioral therapy is significant in reducing social anxiety among schooling adolescents.

RCT Entities:   Population Interventions Outcomes

Introduction

Social anxiety is a persistent fear of situations and it is a common psychologic disorder which usually occur as the individual develop and grow.[ Most times, social anxiety significantly impairs social functioning and could cause social skills practice deficit.[ Earlier studies showed that adolescents with social anxiety are vulnerable to an unhealthy relationship,[ impaired emotional development,[ and comorbid psychologic problem.[ In Nigeria, schooling adolescents are among the most vulnerable populations living with anxiety disorders.[ About 20% of Nigerian adolescents are suffering from anxiety disorder.[ Frank-Briggs and Alikor[ reported that about 34% of in-school adolescents in Nigeria have a social deficit. Beyond Nigeria, adolescents from other developing nations also suffer from anxiety disorder.[ Despite the prevalence of anxiety disorder in developing regions (e.g., Nigeria), many adolescents with social anxiety disorder rarely receive treatment.[ In addition, there are still a few interventions that attempt to treat anxiety disorder in students.[ It is possible that music therapy with cognitive-behavioral therapy (CBT) intervention can help reduce social anxiety among socially anxious schooling adolescents.

Music offers adolescents the opportunity to express, share, and resolve among themselves feelings of anger, rage, grief, longing, and psychologic disintegration.[ Music is a veritable tool for managing dysfunctional feelings and over anxiousness. Music therapy has been used to assist people with social anxiety disorder.[ Researchers are now exploring the benefits of music therapy on adolescents who experience social anxiety disorder and how music can improve health outcomes among patient populations.[ Music therapy has been found to improve wellbeing by providing enjoyment, social interaction, improved memory, and social inclusion.[ Music is a powerful tool for assisting patients with chronic schizophrenia.[

Music can give adolescents the opportunity to open up channels of self-expression at a deeply personal level.[ Music can be used as a tool for socializing and promoting the interaction between people. Many studies that used different designs, sample sizes, and scales showed positive benefits of music intervention on anxiety disorder.[ Guetin et al[ remarked that music intervention can be an excellent mediator to restore social ties. On the contrary, not all studies found that music therapy decreases social anxiety disorder.[ The methodologic limitations of some previous studies and small sample sizes may be responsible for the observed discrepancies in reported findings.[ There are relatively few studies on music intervention for adolescents.[ Given that the potential effects of music intervention on social anxiety disorder appears inconclusive, it is imperative to combine music therapy with CBT.

The CBT was created by Beck.[ Beck proposed that the way an individual thinks (cognition), feel (emotion), and act (behavior) influences his actions.[ If the thinking pattern is automatic or negative, it leads to dysfunctional behaviors. The cognitive misinterpretation of an event is not responsible for the psychologic disorder, but if skewed it causes negative consequences. CBT seeks to alter distorted thinking.[

Beck noted 3 factors responsible for automatic thought namely cognitive triad, negative self-schemas, and skews in information processing.[ Beck classified the cognitive triad into 3 forms, namely erroneous thoughts about the self, the world, and the future. The interaction among these forms causes malfunctioning in perception, cognition, and behavior.[ Experiences that contribute to negative schemas include rejection, catastrophizing, personalization, minimization, selective abstraction, arbitrary inference, overgeneralization, criticism, and overprotection.[ People with maladaptive cognition and motivational schemas become vulnerable to making inaccurate information processing or drawing an illogic conclusion. The cognitive distortions have different dimensions that could lead an individual to malfunction. These include all-or-nothing thinking, selective abstraction, mind reading, negative prediction, catastrophizing, overgeneralization, labeling and mislabeling, magnification or minimization, and personalization.[

Relating cognitive triad to social anxiety, an adolescent that perceives the world as threat and harmful, catastrophes is likely applied to self.[ It may be catastrophizing to the person in that, where people are assertive, he is usually afraid.[ Some of them maintain this point of view even in their life goals, find it difficult to believe in self while dealing with events they think will be unsafe. Adolescents who are fearful perceive an activity as dangerous and their competence is not adequate.[ Freeman and Simon[ noted that hypervigilance refers to cognitive distortion that enhances anxiety. Patients with hypervigilance often experience anxiety.

Beck suggested that a cognitive therapist helps a person with distorted thoughts about the world and future to change from maladaptive thinking to adaptive direction. Cognitive-behavioral therapist alters faulty belief, leading to the attainment of the individual goal. The therapist reinterprets, modifies, and restructures the schemas already formed by the person. By helping the person to cope he/she develops effective ways of making accurate assumptions.[ Using CBT techniques may be healthful for patients who are socially deficits.

The CBT is a widely accepted treatment modality for pathologic behaviors (e.g., anxiety disorder, social phobia in both children and adolescents).[ Previous investigations found a positive effect of CBT on key behavioral outcomes and problems emanating from social phobia.[ For the past 40 years, the efficacy of CBT for youths with sweat, public phobia, and negative emotional interpretation has been validated.[ According to the cognitive-behavioral model, individuals with anxiety perceive the world as a dangerous place, a potential threat that demands constant surveillance.[ Such individuals experience self-defeat, rejection, self-criticisms, and avoidance of public embarrassment.

Given the existence of automatic beliefs among adolescents with social anxiety, Albano and DiBartolo[ suggested that cognitive-based intervention improves adolescents’ understanding of their nervousness and helps them restructure their dysfunctional thoughts which contribute to their social distress. It is worrisome that in spite of the evidence that CBT is effective for reduction of social anxiety symptoms for more than four decades ago, social anxiety disorder is still causing a lot social malfunctioning among schooling adolescents in Nigeria. More studies are required to improve the wellbeing of people.[ Previous study proposes for the combination of music therapy with CBT in regulating emotions.[ This spurred the present study. Utilizing CBT techniques like mindfulness training, systematic exposure, cognitive restructuring, problem-solving, reframing, and assertive training improve the mental wellbeing of an individual with social phobia. Thus, CBT is healthful for social anxiety patients who suffer cognitive-behavioral and emotional problems.[ Adolescents with social phobia develop automatic negative patterns of thinking that are misinterpreted with reality, maintain anxiety-provoking stimuli, and reduced ability to adjust.[ As the automatic assumption about social experiences is wrongly interpreted it important to replace distorted feelings and belief with more logic beliefs.[ The main objective of the present study is, therefore, to examine the effectiveness of music therapy with CBT on social anxiety disorder in a sample of schooling adolescents in Nigeria. Based on the objectives, it was hypothesized that music therapy with CBT would significantly reduce social anxiety symptoms among schooling adolescents in the treatment group, compared with those in a waitlist control group.

Methods

Ethical approval

The researchers obtained approval to conduct this study from the Faculty of Education, University of Nigeria, Nsukka. In addition, informed written consent was obtained from the participants. This study was conducted in accordance with the ethical standards for conducting research with human participants as stipulated by the American Psychological Association.[ The trial was registered after completion at the UMIN Clinical Trials Registry (UMIN-CTR) (Trial No: UMIN000035508).

Study participants

The participants were 155 schooling adolescents in secondary schools in south-east Nigeria. During the selection of the participants, the researchers considered students who were present in the school and based on specified inclusion criteria. The set criteria for eligibility selection include being schooling adolescents in public secondary school, age 11 to 18, and participants must have social anxiety symptoms, these symptoms were measured using Severity Measure for Generalized Anxiety Disorder-Child Age 11 to 17 (SMGAD-C), Social Anxiety Scale for Adolescents (SAS-A), Liebowitz Social Anxiety Scale for Children and Adolescents, self-report version (LSAS-CA-SR), parent's written informed consent, and being readily available for the study. Participants that did not meet the specific inclusion were excluded (Fig. 1) and those that have psychotic symptoms, are writing national examination, and taking medical treatment. The sample size used was calculated using GPower 3.1 software[ which gave the statistical power of 0.95. The demographic characteristics of the participants are presented in Table 1.

Figure 1

Participant eligibility flow diagram.

Table 1

Demographic characteristics of participants.

Table 1 shows that the mean age of the MTCBP group was 14.77 ± 2.37 years, and that of the waitlist control group was 13.92 ± 2.81 years (χ2 = 0.268, P = .389). The MTCBP group comprised 43 men (55.1%) and 35 (44.9%) women; the waitlist control group comprised 45 males (58.4%) and 32 (41.6%) females. From the analyses of results, it can be seen that no significant gender difference was observed among the study participants (χ2 = 0.173, P = .746). In the music intervention group, 36 participants (46.2%) were from nuclear family, 29 participants (37.2%) were from extended family, and 13 (16.7%) were from separated family. For the participants in the waitlist control group, 32 participants (41.6%) were from nuclear family, 27 participants (35.1%) were from extended family, and 18 (23.4%) were from a separated family (χ2 = 1.11, P = .580). Regarding economic status, in the treatment group, 32 participants (41.0%) were from a home with good economic status, 22 (28.2%) were from a home with mild economic status, and 24 (30.8%) were from a home with poor economic status. In the waitlist control group, 30 (39.0%) were from a home with good economic status, 26 (33.8%) were from a home with mild economic status, 21 (27.3%) were from a home with poor economic status (χ2 = 0.591, P = .757). In the music intervention group, 34 participants (43.6%) were from democratic family structure, 25 participants (32.1%) were from strict family structure, and 19 (24.4%) were from a very protective family. For the participants in the waitlist control group, 37 participants (48.9%) were from democratic family structure, 25 participants (32.5%) were from strict family structure, and 15 (19.5%) were from a very protective family (χ2 = 0.605, P = .747). In the treatment group, 33 (42.3%) were in university education, 17 (21.8%) were in Colleges of Education, 16 (20.5%) were in secondary schools, and 12 (15.4%) were in primary schools. In the waitlist control group, 36 (46.5%) were in universities, 15 (19.5%) were in Colleges of Education, 16 (20.8%) are in secondary schools, and 10 (13.0%) were in primary schools (χ2 = 0.431, P = .939).

Measures

Severity Measure for Generalized Anxiety Disorder-Child Age 11 to17

The SMGAD-C is a 10-item measure developed by Craske et al[ for assessing the severity of generalized anxiety disorder. Each item asks the respondent to rate the severity of his or her generalized anxiety disorder during the past 7 days. Each item is rated on a 5-point scale as follows: 0 = Never; 1 = Occasionally; 2 = Half of the time; 3 = Most of the time, and 4 = All of the time. The total score can range from 0 to 40, with higher scores indicating greater severity of generalized anxiety disorder. In the present study, internal consistency for this measure was 0.86 alpha.

Social Anxiety Scale for Adolescents

The SAS-A which was developed by La Greca and Lopez[ comprised of 18 items for assessing social anxiety symptoms in adolescents’ population. The SAS-A is rated on a 5-point Likert-type scale, ranging from 1 (not at all) to 5 (all the time). The SAS-A has 3 subscales: Fear of Negative Evaluation (FNE: 8 items), Social Avoidance and Distress specific to new situations or unfamiliar peers (SAD-New: 6 items), and Social Avoidance and Distress that is experienced more generally in the company of peers (SAD-General: 4 items). The scores range from 1 to 40 for the FNE subscale, from 1 to 30 for the SAD-New subscale, from 1 to 20 for the SAD-General subscale. The 3 subscales are summed to give a total SAS-A score, which can range from 18 to 90. Previous studies showed that this instrument is a reliable and valid measure for assessing social anxiety disorder.[ In the present study, internal consistency for the FNE subscale was 0.80; the SAD-New subscale was 0.82; and for the SAD-General subscale, it was 0.82; overall internal consistency for the SAS-A was 0.81.

Liebowitz Social Anxiety Scale for Children and Adolescents, Self-Report Version

The LSAS-CA-SR is a 24-item instrument with 2 main subscales, anxiety and avoidance subscales, developed by Masia-Warner et al[ based on the adult version of LSAS by Liebowitz[ for assessment of social anxiety disorder. The items of the LSAS-CA-SR which comprise of the fear and the avoidance subscales is designed on a 4-point rating scale as follows: fear (0 = none, 1 = mild, 2 = moderate, 3 = severe) and avoidance (0 = never, 1 = occasionally, 2 = often, 3 = usually) with high scores representing more fear and/or avoidance. A total score can also be obtained by summing the total fear and total avoidance subscales, which can range from 0 to 72. Previous studies showed that the LSAS-CA-SR is a reliable and valid social anxiety measure.[ In the present study, internal consistency for the Fear subscale was 0.92, and for the avoidance subscale, it was 0.89; overall internal consistency for the LSAS-CA-SR was 0.90.

Procedure

Participants were orally invited when the researchers visited their schools. The researchers accessed 250 schooling adolescents in secondary schools in south-east Nigeria, and they were screened for eligibility using the telephone screening/clinical interview/questionnaires. The participants were recruited for a period of 9 weeks, that is, from November 2016 to January 2017 in south-east Nigeria. The eligibility screening exercise was conducted by the researchers. Before the commencement of the initial treatment session, a pretest (Time 1) was conducted which enabled the researchers to obtain the baseline data. Those participants (n = 155) with social anxiety symptoms (severe, moderate) were selected as participants. The screened participants who did not meet the criteria were excluded from the study.

The researchers randomly assigned 155 eligible participants to the treatment group and the waitlist control group. During the randomization of the selected participants, the researchers used a simple random allocation sequence with the aid of Random Allocation Software created by Saghaei.[ The random allocation produced a total of 78 participants for the MTCRP and 77 participants for the waitlist control group. The treatment given to the participants was based on the MTCRP manual for reducing social anxiety disorder developed by the researchers. The MTCRP lasted for 12 sessions (12 weeks), 1 session per week. The sessions were conducted every Friday due to academic activities. At the conclusion of the intervention, a posttest was administered to the Treatment group and Waitlist Control groups (Time 2). The researchers conducted follow-up meetings that lasted for 1 month, leading to a 3rd assessment after a 6-months period (Time 3). The sessions were delivered in the English language by the music therapists and cognitive behavioral therapists. These therapists assisted in drafting the contents of intervention. Direct delivery method was used to collect data from all the participants in the treatment and waitlist control groups. To eliminate selection and potential bias during the process of recruitment and randomization, the researchers concealed the treatment allocation from the research assistants (therapists) and participants. In addition, the data analysts were blinded by the researchers until the time of completion of the entire analyses by covering information in the scales that could reveal the group that received the treatment intervention.

Intervention

Music Therapy with Cognitive Behavioral Program (MTCBP manual): The goal of the MTCBP manual was to enable the researchers to assist the participants to reduce the severity of social anxiety. The intervention lasted for 12 weeks, once a week. Within the weeks, 12 sessions were held. Each session lasted for an hour. Each of the session was accompanied with musical interlude (e.g., morning star by Osita Osadebe, Igodo by Paul Nwokeocha, Gollibe by Flavour) in that sessions of music therapy and cognitive behavioral therapy was alternating from 1 session to the other. In addition, the sessions took place in a group setting. This was to engage the participants in a social setting and improve self-confidence in them. The manual also emphasized the use of cognitive restructuring for identifying, challenging and modifying social anxiety-related phobia of participants. This program manual also adopted techniques of music therapy such as opera, rock, pop, classical and folk music relaxation skills, song, and breathe control, as well as cognitive-behavioral and psycho-educational techniques (e.g., cognitive restructuring, reframing, rhythmic-based skills, attention training, and mood monitoring skills).[ The techniques for the disputation are cognitive disputation, emotional disputation, and behavioral disputation. MTCBP manual uses these techniques to deal with cognitive and behavioral responses that are socially unacceptable. Participants were exposed to the connection between activating events in the school, interpretation of social activities in school, and the emotional and behavioral consequences that occur. Homework assignments were included in the manual for the schooling adolescents to practice regularly after each session to enhance compliance (Table 2).

Table 2

Summary of the MTCBP.

Study design and data analysis

The study used a randomized controlled trial design. Statistical analysis used was a repeated-measures analysis of variance (ANOVA) to examine the effects of the MTCBT treatment. We reported partial η2 as a measure of the effect size. The Mann–Whitney U test (U) was also conducted to compare changes across the treatment group and waitlist control group participants. To increase the transparency of the study process and analyses, we used the musical experience as a control variable since the musicians were obviously not excluded. The 1-sample t test was used to analyze the follow-up test of the treatment group. The paired-samples t test was also performed to determine whether the posttest and follow-up assessment scores differed between the schooling adolescents in the treatment group. To test for differences in categorical data representing characteristics of the participants, we used Chi-squared (χ2) statistic. Screening for missing values and violation of assumptions was conducted with the aid of SPSS 20.[

Results

Table 3 reveals the study outcomes for the participants in the treatment group compared to the waitlist control group over the 3 periods. Based on the SMSAD, the Mann–Whitney U test indicated that there were no baseline differences in social anxiety disorder between participants in the treatment and waitlist control conditions (U = 2777.50, P = .411). The ANOVA test also indicated that there were no baseline differences in symptoms of social anxiety disorder between participants in the treatment and waitlist control conditions, F(1, 154) = 1.838, P = .177, η2 = 0.012. Based on the SAS-A, the Mann–Whitney U test indicated that there were no baseline differences in social anxiety disorder between participants in the treatment and waitlist control conditions (U = 2922.50, P = .774). The ANOVA test also indicated that there were no baseline differences in symptoms of social anxiety disorder between participants in the treatment and waitlist control conditions, F(1, 154) = 1.938, P = .166, η2 = 0.013. Based on the LSAS-CA-SR, the Mann–Whitney U test indicated that there were no baseline differences in social anxiety disorder between participants in the treatment and waitlist control conditions (U = 2700.50, P = .279). The ANOVA test also indicated that there were no baseline differences in symptoms of social anxiety disorder between participants in the treatment and waitlist control conditions, F(1, 154) = 1.214, P = .272, η2 = 0.008 (Table 3).

Table 3

Means and standard deviations of the participants’ scores on SMSAD, SAS-A, and LSAS-CA.

Using the SMSAD, results revealed a significant treatment × time interaction effect for social anxiety disorder, F(1, 154) = 4708.364, P < .001, η2 = 0.968. Using this measure, the Mann–Whitney U test results revealed significant decreases from Time 1 to Time 2 in social anxiety disorder (U = 0.000, P < .001) for the treatment group participants, but the waitlist control group did not show any significant change in social anxiety disorder over the same period. Based on the 1-sample t test analysis, the follow-up assessment performed after 3 months revealed a significant reduction in social anxiety disorder for the treatment group, t(77) = 176.675, P < .001. The paired-samples t test of the pretest and posttest scores for the SMSAD was significant for the treatment group, t(154) = 11.904, P < .001. The paired-samples t test showed that the posttest and follow-up scores for the SMSAD, t(77) = 5.285, P < .001, was also significant for the schooling adolescents exposed to the Music Therapy with Cognitive-Behavioral Therapy (MTCBT) treatment, which is an indication of the program's sustainability effect on social anxiety disorder reduction over the time period (Table 3).

Using the SAS-A, results revealed a significant treatment × time interaction effect for social anxiety disorder, F(1, 154) = 1409.327, P < .001, η2 = 0.902. Using this measure, the Mann–Whitney U test results revealed significant decreases from Time 1 to Time 2 in social anxiety disorder (U = 3.000, P < .001) for the treatment group participants, but the waitlist control group did not show any significant change in social anxiety disorder over the same period. Based on the 1-sample t test analysis, the follow-up assessment performed after 3 months revealed a significant reduction in social anxiety disorder for the treatment group, t(77) = 34.067, P < .001. The paired-samples t test of the pretest and posttest scores for the SAS-A was significant for the treatment group, t(154) = 12.331, P < .001. The paired-samples t test showed that the posttest and follow-up scores for the SAS-A, t(77) = 4.029, P < .001, was also significant for the schooling adolescents exposed to the MTCBT treatment, which is an indication of the program's sustainability effect on social anxiety disorder reduction over the time period (Table 3).

Using the LSAS-CA-SR, results revealed a significant treatment × time interaction effect for social anxiety disorder, F(1, 154) = 404.357, P < .001, η2 = 0.725. Using this measure, the Mann–Whitney U test results revealed significant decreases from Time 1 to Time 2 in social anxiety disorder (U = 425.00, P < .001) for the treatment group participants, but the waitlist control group did not show any significant change in social anxiety disorder over the same period. Based on the 1-sample t test analysis, the follow-up assessment performed after 3 months revealed a significant reduction in social anxiety disorder for the treatment group, t(77) = 60.152, P < .001. The paired-samples t test of the pretest and posttest scores for the LSAS-CA-SR was significant for the treatment group, t(154) = 11.428, P < .001. The paired-samples t test showed that the posttest and follow-up scores for the LSAS-CA-SR t(77) = 0.782, P > .437, was not significant for the schooling adolescents exposed to the MTCBT treatment, which is an indication of the program's sustainability effect on social anxiety disorder reduction over the time period (Table 3).

Discussion

The main purpose of this study was to investigate the effect of music therapy with CBT on social anxiety disorder in a sample of schooling adolescents in Nigeria. Our finding indicated that music therapy with MTCBT decreased the severity of social anxiety in those participants exposed to the treatment intervention, relative to a waitlist control group. Furthermore, the positive effect of the MTCBT was maintained at follow-up. Eells[ showed that music therapy is a significant therapeutic approach to improve social well-being and social integration. The current finding supports the assertions by Thoma et al[ and Montánchez et al[ that music intervention reduces the fear of social situations. Other literatures that are in accordance with the present study include Nilsson[ and Richards et al[ which indicated that social skills could be improved through music intervention. Indeed, the efficacy of music therapy on young people’ emotional exhaustion and tension had been indicated in a different context.[ It is therefore noteworthy for helping professionals to provide music intervention services to schooling adolescents with social-limiting disorders.[

On the contrary, cognitive behavioral literature suggested that CBT is a successful treatment for youth social anxiety disorder.[ CBT decreases inappropriate behaviors of children and adolescents.[ Additionally, adolescents exposed to cognitive-behavioral approach have higher health-related quality as well as reduction of social distress.[ In an earlier study, a group of patients with depression received psychosocial intervention through which the study established treatment fidelity of CBT on sustenance of reduced anxiety of people.[ It was noted that the applicability of CBT improves the health of children and adults.[ In the same vein, other studies further indicated that CBT is effective in the treatment of adolescents with depressive symptoms.[ More literature maintained that CBT brings about a cognitive change in adolescents if applied.[ CBT helps therapists to dispute unrealistic social thoughts that could cause anxiety in schooling adolescents.

Our finding supports that of Trimmer et al[ who showed that music with CBT has a significant effect in regulating emotions in that it serves as a motivator and reinforcer to participants. All in all, music therapy with cognitive behavioral therapy alters the automatic perception of schooling adolescents in that it builds their self-esteem and lessen social phobia. Therefore, psychotherapists should encourage help-seeking behaviors, teach adolescents mindfulness (learning to pay attention with interest rather than judging), assertive training, attention skills, curiosity training, and cognitive restructuring (thought defusion). CBT practitioners should collaborate with music therapists in lessening the fear of judgments and other social phobias among adolescents.

Limitations

We noted some limitations in this study. Firstly, since the participants were only schooling adolescents, other populations as well as adolescents from different locations, were not included in the study, as such the results may suffer from the nested data structure of the sample. Thus, the generalizability of the findings should be treated with care. We could not collect data about the family models of participants and other family types. Therefore, we recommend that future studies could consider other populations with social anxiety as well as the family models of the participants.

In the case of available data, we failed to investigate a long-term impact of the intervention within this group and after they have been exposed to the intervention and to concurrently compare long-term effects in the original intervention group. In addition, the researchers could not collect qualitative data because of limited resources, thus it was difficult for us to ascertain the complete acceptability of the intervention. We strongly suggest that other researchers should fill this limitation.

Acknowledgment

The authors are grateful to all the participants who participated in the study.

Author contributions

Conceptualization: Nkechi Egenti, Moses Onyemaechi Ede, Edith N. Nwokenna, Bonaventure N. Nwokeoma, Daniel Mezieobi, Kelechi R. Ede, Chijioke Amoke, Maduka L. Nweke.

Data curation: Nkechi Egenti, Moses Onyemaechi Ede, Edith N. Nwokenna, Bonaventure N. Nwokeoma, Kelechi R. Ede, Chijioke Amoke, Maduka L. Nweke.

Formal analysis: Nkechi Egenti, Moses Onyemaechi Ede, Edith N. Nwokenna, Bonaventure N. Nwokeoma, Kelechi R. Ede, Chijioke Amoke, Maduka L. Nweke.

Funding acquisition: Nkechi Egenti, Moses Onyemaechi Ede, Edith N. Nwokenna, Theresa Oforka, Bonaventure N. Nwokeoma, Daniel Mezieobi, Sabastian O. Onah, Kelechi R. Ede, Chijioke Amoke, Edmund E. Offordile, Ngozi E. Eze, Celestine O. Eze, Patrick E. Eluu, Kingsley C. Amadi, Benedict E. Ugwuanyi, Ngozi C. Uzoagba, Grace O. Ugwonna, Maduka L. Nweke.

Investigation: Nkechi Egenti, Moses Onyemaechi Ede, Edith N. Nwokenna, Theresa Oforka, Bonaventure N. Nwokeoma, Daniel Mezieobi, Sabastian O. Onah, Kelechi R. Ede, Chijioke Amoke, Edmund E. Offordile, Ngozi E. Eze, Celestine O. Eze, Patrick E. Eluu, Kingsley C. Amadi, Benedict E. Ugwuanyi, Ngozi C. Uzoagba, Grace O. Ugwonna, Maduka L. Nweke, Vera Victor-Aigbodion.

Methodology: Nkechi Egenti, Moses Onyemaechi Ede, Edith N. Nwokenna, Theresa Oforka, Bonaventure N. Nwokeoma, Daniel Mezieobi, Sabastian O. Onah, Kelechi R. Ede, Chijioke Amoke, Edmund E. Offordile, Ngozi E. Eze, Celestine O. Eze, Patrick E. Eluu, Kingsley C. Amadi, Benedict E. Ugwuanyi, Ngozi C. Uzoagba, Grace O. Ugwonna, Maduka L. Nweke, Vera Victor-Aigbodion.

Project administration: Nkechi Egenti, Moses Onyemaechi Ede, Edith N. Nwokenna, Theresa Oforka, Bonaventure N. Nwokeoma, Daniel Mezieobi, Sabastian O. Onah, Kelechi R. Ede, Chijioke Amoke, Edmund E. Offordile, Ngozi E. Eze, Patrick E. Eluu, Kingsley C. Amadi, Ngozi C. Uzoagba, Grace O. Ugwonna, Maduka L. Nweke, Vera Victor-Aigbodion.

Resources: Nkechi Egenti, Moses Onyemaechi Ede, Edith N. Nwokenna, Theresa Oforka, Bonaventure N. Nwokeoma, Daniel Mezieobi, Sabastian O. Onah, Kelechi R. Ede, Chijioke Amoke, Edmund E. Offordile, Ngozi E. Eze, Celestine O. Eze, Patrick E. Eluu, Kingsley C. Amadi, Ngozi C. Uzoagba, Grace O. Ugwonna, Maduka L. Nweke, Vera Victor-Aigbodion.

Software: Nkechi Egenti, Moses Onyemaechi Ede, Edith N. Nwokenna, Theresa Oforka, Bonaventure N. Nwokeoma, Sabastian O. Onah, Kelechi R. Ede, Chijioke Amoke, Edmund E. Offordile, Ngozi E. Eze, Celestine O. Eze, Patrick E. Eluu, Kingsley C. Amadi, Ngozi C. Uzoagba, Grace O. Ugwonna, Maduka L. Nweke.

Supervision: Nkechi Egenti, Moses Onyemaechi Ede, Edith N. Nwokenna, Theresa Oforka, Bonaventure N. Nwokeoma, Daniel Mezieobi, Kelechi R. Ede, Chijioke Amoke, Ngozi E. Eze, Patrick E. Eluu, Kingsley C. Amadi, Benedict E. Ugwuanyi, Ngozi C. Uzoagba, Grace O. Ugwonna.

Validation: Nkechi Egenti, Moses Onyemaechi Ede, Edith N. Nwokenna, Theresa Oforka, Bonaventure N. Nwokeoma, Sabastian O. Onah, Kelechi R. Ede, Chijioke Amoke, Ngozi E. Eze, Celestine O. Eze, Patrick E. Eluu, Kingsley C. Amadi, Benedict E. Ugwuanyi, Ngozi C. Uzoagba, Grace O. Ugwonna, Maduka L. Nweke, Vera Victor-Aigbodion.

Visualization: Nkechi Egenti, Moses Onyemaechi Ede, Edith N. Nwokenna, Theresa Oforka, Bonaventure N. Nwokeoma, Daniel Mezieobi, Sabastian O. Onah, Kelechi R. Ede, Chijioke Amoke, Edmund E. Offordile, Ngozi E. Eze, Celestine O. Eze, Patrick E. Eluu, Kingsley C. Amadi, Benedict E. Ugwuanyi, Ngozi C. Uzoagba, Grace O. Ugwonna, Maduka L. Nweke, Vera Victor-Aigbodion.

Writing – original draft: Nkechi Egenti, Moses Onyemaechi Ede, Edith N. Nwokenna, Theresa Oforka, Bonaventure N. Nwokeoma, Daniel Mezieobi, Kelechi R. Ede, Chijioke Amoke, Ngozi E. Eze, Celestine O. Eze, Patrick E. Eluu, Kingsley C. Amadi, Benedict E. Ugwuanyi, Ngozi C. Uzoagba, Grace O. Ugwonna, Maduka L. Nweke, Vera Victor-Aigbodion.

Writing – review & editing: Nkechi Egenti, Moses Onyemaechi Ede, Edith N. Nwokenna, Theresa Oforka, Bonaventure N. Nwokeoma, Daniel Mezieobi, Sabastian O. Onah, Kelechi R. Ede, Chijioke Amoke, Edmund E. Offordile, Ngozi E. Eze, Celestine O. Eze, Patrick E. Eluu, Kingsley C. Amadi, Benedict E. Ugwuanyi, Ngozi C. Uzoagba, Grace O. Ugwonna, Maduka L. Nweke, Vera Victor-Aigbodion.