Cardiovascular illnesses (CVDs) are acknowledged as a number one reason for morbidity and mortality worldwide. Of 54 million deaths that occurred globally in 2013, round 17.3 million had been attributed to CVDs.1 The main reason for CVD-related deaths was ischemic coronary heart illness (IHD) (8.2 million deaths),2 adopted by cerebrovascular illness (8 million deaths).2 Moreover, the price of CVDs is anticipated to rise from roughly $863 billion in 2010 to $1044 billion in 2030 globally.3 In Qatar, a rustic with a inhabitants of lower than 3 million, 16,750 sufferers had been admitted with acute coronary syndromes (ACS) between 1991 and 2010.4 Furthermore, CVDs had been the main causes of mortality in Qatar, accounting for 17.1 deaths per 100,000 inhabitants in 2010.5 Though there are current registries comparable to Gulf CARE (Gulf Acute Coronary heart Failure Registry), revealed knowledge on the epidemiology of coronary heart failure (HF) in Qatar and different Gulf Cooperation Council (GCC) international locations are scarce.

Literacy typically and well being literacy particularly are of serious significance in guaranteeing sufferers’ engagement and self-management in continual illnesses. Though excessive literacy doesn’t all the time translate to excessive well being literacy and sufferers with excessive literacy degree might have low to average well being literacy, but it is very important gauge each points from well being administration imperatives. In Qatar with a inhabitants of two,891,000 (November 2022), literacy price may be very excessive among the many common inhabitants and has been reported to be 93.5% amongst people ≥15 years and 70.5% amongst aged (≥65 years). Nonetheless, well being literacy degree shouldn’t be instantly reported in medical data of sufferers with ACS/HF or different illnesses.

CVDs, together with, however not restricted to ACS and HF, are complicated circumstances that require sufferers’ high-level of involvement6,7 in addition to data and understanding to handle their illness circumstances.8 Due to this fact, the promotion of self-management, which is “the person’s means to handle signs, remedy, bodily and psychosocial penalties, and life-style modifications inherent in residing with a continual situation”, is important on this affected person inhabitants.9 Insufficient well being literacy hinders many sufferers with ACS and HF from partaking in efficient self-care administration of their circumstances.10,11 Sufferers with restricted well being literacy have a tendency to make use of a passive communication type with their healthcare suppliers, don’t take part in decision-making, and lack the power to self-manage their illnesses and medicines.12 In accordance with a pooled evaluation of 85 research, the prevalence of low well being literacy and marginal well being literacy was 26% and 20%, respectively.13 In accordance with different research, low well being literacy ranged from 17.5% to 97% amongst sufferers with HF14 and from 34% to 44% amongst sufferers with ACS.15,16 Within the final 20 to 30 years, research have proven that low or insufficient well being literacy, in comparison with sufficient well being literacy, has been related to poorer data, well being outcomes, and comprehension of healthcare companies.17 For example, low well being literacy was discovered to be related to decrease remedy adherence,18 elevated incidence of hospitalization,19,20 and better danger of mortality21 in sufferers with HF. Equally, sufferers with ACS and restricted well being literacy had been discovered to have decrease remedy adherence22 and better hospital readmission charges.23,24

Due to this fact, evaluation of well being literacy in sufferers with HF and ACS is essential, with the intention to guarantee optimum therapeutic outcomes. Generally, well being literacy evaluation devices are broadly categorized into generic and disease-specific instruments. Generic devices are for common use to evaluate well being literacy throughout totally different affected person populations.25 A few of the most typical varieties of well being literacy evaluation devices embrace word-recognition checks and checks of useful well being literacy. Phrase-recognition checks measure a person’s means to acknowledge and pronounce phrases in an inventory and are thought of helpful predictors of common studying means. One of the crucial generally used word-recognition checks is the Speedy Estimate of Grownup Literacy in Medication (REALM), which is an inventory of 66 medical phrases that may be accomplished in 3 to five minutes.26 Exams of useful well being literacy embrace word-recognition, studying comprehension, numeracy expertise, and software to real-life conditions. Although these measures are used to evaluate well being literacy amongst totally different populations, their applicability and appropriateness amongst sufferers with CVDs usually are not broadly studied. A scientific evaluation revealed in 2018 recognized the well being literacy evaluation devices obtainable and utilized in coronary artery illness (CAD).27 One other systematic evaluation recognized the obtainable proof pertaining to the devices which have been used to measure well being literacy in sufferers with CVDs.28 On this evaluation, 10 well being literacy evaluation devices used amongst sufferers with CVD within the included research (n = 42) had been generic, just one instrument, the Excessive Blood Stress-Well being Literacy Scale (HBP-HLS), was disease-specific (n = 1).28

Enough well being literacy is important for adherence and higher well being outcomes amongst sufferers with CVDs. The problem of well being literacy has been broadly studied in developed international locations, with only a few research carried out within the Arab world. Due to this fact, proof on the extent of well being literacy amongst sufferers with CVDs is proscribed in Qatar and the bigger Center East area. The excessive prevalence and burden of CVDs within the area, particularly ACS and HF, deserves investigations to evaluate well being literacy in an effort to find out efficient methods to enhance communication and well being outcomes on this inhabitants. Due to this fact, this examine aimed to: (1) assess the extent of well being literacy amongst sufferers with ACS and/or HF utilizing tailored validated well being literacy evaluation devices; (2) decide the prevalence of restricted well being literacy on this inhabitants and; (3) decide the affected person traits which can be related to the extent of well being literacy (i.e. to check the traits of sufferers with restricted well being literacy versus these with sufficient well being literacy).

Sufferers and Strategies

Examine Design and Setting

This was a cross-sectional descriptive examine through which sufferers’ well being literacy ranges had been measured utilizing two well being literacy evaluation devices (the abbreviated model of the Check of Useful Well being Literacy in Adults [S-TOFHLA] and the Three-item Transient Well being Literacy Display [3-item BHLS]). The information had been collected between 1 April 2019 and 30 August 2019 on the Coronary heart Hospital, a member of Hamad Medical Company (HMC) in Qatar. The Coronary heart Hospital is a specialist tertiary hospital that gives care in cardiology and cardiothoracic surgical procedure for grownup inhabitants of Qatar.29

Examine Inhabitants and Eligibility Standards

The goal inhabitants for the examine was grownup sufferers identified with ACS, HF, or each illness circumstances and receiving care on the Coronary heart Hospital in Qatar. Sufferers had been enrolled within the examine in the event that they had been 18 years or older, identified with ACS, HF, or each, and had been outpatients receiving remedy on the Coronary heart Hospital. Each newly identified sufferers and people with pre-existing historical past of ACS and/or HF had been included within the examine. Sufferers had been excluded from the examine in the event that they met any of the next standards: documented sight impairment, listening to impairment, cognitive problem, or sufferers who don’t converse any of the examine languages.

Pattern Measurement and Sampling Approach

The pattern dimension calculation adopted the cross-sectional examine design for qualitative variables30 utilizing a degree of confidence of 95%, type-1 error of 5%, and prevalence of restricted well being literacy of 19%.31,32 The minimal efficient pattern dimension required was calculated to be 237 in keeping with the above assumptions. To account for lacking knowledge, a 30% improve within the pattern dimension was focused. Due to this fact, a handy pattern of 300 sufferers with ACS and/or HF was recruited. Eligible contributors had been recognized by means of an digital medical data database, CERNER. Sufferers had been approached and recruited from the outpatient division whereas ready to be seen by their healthcare suppliers in follow-up cardiology clinics. Sufferers who supplied an knowledgeable consent to take part within the examine and fulfilled the eligibility standards had been included on this examine.

End result Measures

The first final result measure was affected person’s well being literacy degree. Well being literacy was assessed utilizing the Abbreviated model of the Check of Useful Well being Literacy in Adults (S-TOFHLA) and the Three-item Transient Well being Literacy Display (3-item BHLS). The 2 totally different well being literacy evaluation devices had been utilized concurrently for triangulation functions.

Examine Instrument

The information assortment instrument for this analysis mission consisted of three sections: baseline demographic and scientific traits part, the S-TOFHLA part (36 gadgets), and the 3-item BHLS part (three gadgets). The S-TOFHLA and 3-item BHLS had been chosen, as a result of they’re generally used validated and dependable devices for the evaluation of well being literacy.33,34 Moreover, S-TOFHLA and 3-item BHLS, which had been initially developed in English, had been translated and validated into Arabic.35 Essentially the most generally used useful well being literacy evaluation instrument is TOFHLA.28,36 This measure takes a comparatively very long time (22 minutes) to finish. The abbreviated model of TOFHLA, S-TOFHLA, takes about 12 minutes to finish and its outcomes had been properly correlated with the unique TOFHLA.33 The S-TOFHLA contains of 36-item studying comprehension and 4-item numeracy. The S-TOFHLA studying comprehension rating is from 0–36. Scores of 0–16 and 17–22, respectively, determine sufferers as insufficient and marginal well being literacy, whereas scores ≥23 determine sufferers as sufficient well being literacy. The BHLS rating ranges from 0–12 and categorized as 0–6 (insufficient), 7–9 (marginal), and 10–12 (sufficient) useful well being literacy. Well being literacy degree is categorized otherwise in keeping with the evaluation instrument used (Table 1). Beneath is an outline of the well being literacy scoring methodology that was used for this examine:33,34

  • Enough well being literacy: Sufferers who’re in a position to learn, perceive, and interpret most well being texts.
  • Marginal or insufficient well being literacy: Sufferers who’ve problem understanding and/or deciphering most well being supplies. Because of this, they’d not be capable to comply with instructions for his or her well being care (e.g. take their medicines incorrectly, fail to comply with prescribed diets, and so on).

Table 1 Health Literacy Assessment Tools’ Scoring System*

Data Collection Method

Eligible patients were identified through CERNER. The data collection process lasted for 10 to 15 minutes per patient on average. First, demographic and clinical data were obtained from the CERNER and verified by asking the patient. Then, an interviewer administered the 3-item BHLS. Finally, the S-TOFHLA was administered face-to-face, where the interviewer presented the tool from a scripted introduction. Once introduced, the patient was given the reading comprehension passages and numeric calculations to complete.

Data Analysis

The collected data were analyzed using IBM Statistical Package for Social Sciences (SPSS®) software for Windows version 23.0 (IBM Corp, Armonk, New York, USA). Patients’ demographic information, clinical data, and health literacy scores were presented descriptively as median (IQR) for continuous variables and as counts with percentages for categorical variables. The Mann–Whitney U and the Kruskal–Wallis tests were applied to compare statistical differences in health literacy scores between groups. The association between different variables and health literacy scores were tested using Spearman rho correlation test for continuous or ordinal variables and Pearson’s Chi-square or Fisher’s Exact tests for categorical variables. For all statistical tests, a two-sided P-value <0.05 was considered statistically significant. Cohen’s Kappa test was used to determine the level of agreement between S-TOFHLA and 3-item BHLS.

Ethical Considerations

Ethics approval was obtained from both the Medical Research Center of the HMC [approval reference number: MRC-02-17-087] and the Institutional Review Board at Qatar University [approval reference number: QU-IRB 955-E/18]. Informed consent was obtained from all participants. Participants were informed that their participation was voluntary and their information will be kept strictly confidential. All the procedures performed in this study were in accordance with good clinical practice, the Declaration of Helsinki, and other comparable ethical standards.


Demographic Characteristics

Three hundred patients were enrolled in this study from April to August 2019. The demographic characteristics of the study participants are presented in Table 2. The median (IQR) age of the pattern was 55 (11) years, 88% had been male, and 94% had been non-Qatari. A big proportion of the contributors (48%) had accomplished college schooling, whereas about 40% had a most of highschool schooling or much less. The bulk (89%) of the contributors can learn and write in English, 54% can learn and write in Arabic, 41% can learn and write in Hindi, and 34% can learn and write in Urdu. Moreover, most contributors had obtained well being info throughout the previous 6 months from a doctor (93%), a pharmacist (78%), or a nurse (67%).

Table 2 Demographic and Clinical Characteristics of the Study Participants (n=300)

Clinical Characteristics

The clinical characteristics of the study population are presented in Table 2. The bulk (89%) of contributors had ACS, whereas 21% had HF. Essentially the most generally reported continual comorbidities included hypertension (66%), diabetes (48%), and dyslipidemia (41%). The median (IQR) variety of comorbidities was 3 (2) illnesses. Essentially the most generally reported continual oral medicines utilized by the contributors had been antiplatelets (94%), statins (91%), beta-blockers (88%), and angiotensin changing enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) (77%) with a median (IQR) variety of medicines of 6 (3) . The median (IQR) BMI of the examine contributors was 28 (6.6) kg/m2, which is taken into account as obese.

Well being Literacy Traits

The well being literacy traits of the examine contributors are introduced in Table 3. Among the many contributors, 36% had insufficient or marginal well being literacy in keeping with S-TOFHLA, whereas over half (54%) had insufficient or marginal well being literacy in keeping with 3-item BHLS. Cohen’s Kappa check indicated a considerably average settlement between S-TOFHLA and 3-item BHLS scoring (okay=0.46, p≤0.001) (Table 4).

Table 3 Health Literacy Characteristics of the Study Participants (n=300)

Table 4 Health Literacy Assessment Agreement Between S-TOFHLA and 3-Item BHLS (n=300)

The patient’s characteristics associated with adequacy of health literacy were determined. The demographic characteristics of patients with adequate versus inadequate or marginal health literacy based on S-TOFHLA are presented in Table 5. Seventy-eight p.c of sufferers with sufficient well being literacy had both undergraduate or postgraduate college schooling as in comparison with lower than 10% of sufferers with insufficient or marginal well being literacy (p≤0.001). As well as, 63% of sufferers with sufficient well being literacy can learn and write in Arabic as in comparison with 37% of sufferers with insufficient or marginal well being literacy (p≤0.001). Related outcomes had been obtained between the demographic traits of sufficient versus insufficient/marginal well being literacy sufferers based mostly on BHLS instrument. About 91% of sufferers with sufficient well being literacy had undergraduate or postgraduate college schooling as in comparison with 21% of sufferers with insufficient or marginal well being literacy (p≤0.001). Equally, 63% of sufferers with sufficient well being literacy had been literate in Arabic as in comparison with 46% of sufferers with insufficient or marginal well being literacy (p=0.004).

Table 5 Demographic Characteristics Based on S-TOFHLA Category

Table 6 presents S-TOFHLA scores throughout totally different demographic traits, scientific traits, and well being literacy ranges. There was a statistically important distinction in well being literacy based mostly on marital standing, the place the median (IQR) S-TOFHLA rating was 19 (16) amongst single sufferers in comparison with 31 (15) amongst married sufferers (p=0.010). Equally, there was a statistically important distinction in well being literacy rating based mostly on schooling degree, the place the median (IQR) rating for sufferers with highschool schooling or much less ranged from 16 (6) to 19 (9) as in comparison with 34 (4) to 35 (3) for sufferers with undergraduate or postgraduate college schooling, respectively (p≤0.001). Furthermore, the median (IQR) S-TOFHLA scores differed considerably in keeping with whether or not or not the affected person speaks Arabic, English, Hindi, Urdu, Malayalam, or different languages (p-values vary from ≤0.001 to 0.035). The S-TOFHLA scores additionally differed considerably based mostly on nation of origin (p≤0.001), occupation (p≤0.001), and whether or not or not the affected person obtained well being info throughout the previous 6 months from a pharmacist (p=0.008), physiotherapist (p≤0.001) or nurse (p=0.004).

Table 6 Differences in S-TOFHLA Scores Across Different Demographic Characteristics, Clinical Characteristics, and Health Literacy

Patients with NYHA Class I and Class II had higher health literacy scores than those with NYHA Class III and Class IV. Further, patients with dyslipidemia had significantly higher HL score than those with no such comorbidity. However, no differences were found for most other co-morbidities. As expected, participants with adequate health literacy had significantly higher health literacy scores compared to those with inadequate or marginal health literacy. In addition, for the purpose of triangulation, the same comparisons (demographic characteristics, clinical characteristics, and health literacy levels) were repeated using 3-item BHLS health literacy categorization and the findings were similar.

Among all patients’ characteristics, there was a significant positive correlation between the number of comorbidities and S-TOFHLA (r=0.138, p=0.017). All other demographic and clinical characteristics did not show significant correlation with either S-TOFHLA or 3-item BHLS scores.


Key Findings

Patients’ health literacy is a critical determinant of patients’ active participation in their healthcare decision and disease management. In particular, adequate health literacy is essential for adherence and better health outcomes among patients with CVDs. Our study determined the prevalence of health literacy and identified the associations between demographic characteristics that may be used to identify Middle Eastern patient’s with CVD at risk of having low or marginal health literacy. The S-TOFHLA was used to assess the functional health literacy of the patients, whereas the 3-item BHLS helped to assess the overall confidence of patients in health-related tasks. These two different health literacy assessment instruments were utilized for triangulation purposes.

The present study has established that 36% of patients with ACS and/or HF had inadequate or marginal health literacy based on S-TOFHLA, while more than 50% had inadequate or marginal health literacy based on 3-item BHLS. These findings demonstrate an alarming low health literacy level among patients with CVDs in Qatar. These results are in line with a number of previous studies conducted to assess the prevalence of low health literacy.14–16,37 For example, within the first in depth nationwide grownup literacy evaluation carried out in United States (US), it was discovered that 36% of adults had both beneath fundamental or fundamental well being literacy.37 As well as, solely 12% of the grownup inhabitants was proficient in well being literacy.37 Nonetheless, the degrees of well being literacy particularly amongst sufferers with ACS and/or HF reported within the literature various in keeping with the area and the setting the place the examine was carried out. The prevalence of low well being literacy amongst sufferers with ACS within the US was 34%.15 Nonetheless, one other examine carried out in an analogous setting indicated a prevalence price of 44% amongst sufferers with ACS.16 Furthermore, a scientific evaluation reported that the prevalence of low well being literacy amongst HF sufferers various enormously from 17.5% to 97%, with a median of 39% of examine contributors having low well being literacy.14 Due to this fact, our examine outcomes concerning the prevalence of low well being literacy amongst sufferers with ACS or HF reaffirm the outcomes reported by different research carried out elsewhere.

There have been some variations between sufferers who had sufficient well being literacy and those that had insufficient or marginal well being literacy when it comes to some demographic traits, together with, academic degree, spoken languages and socioeconomic standing. These traits are widely known as elements related to well being literacy within the literature. This examine discovered that 78% of the sufferers with college schooling had sufficient well being literacy, whereas lower than 10% had insufficient or marginal well being literacy. The median (IQR) S-TOFHLA rating for sufferers with highschool schooling or much less ranged from 16 (6) to 19 (9) as in comparison with 34 (4) to 35 (3) for sufferers with undergraduate or postgraduate college schooling. Remaining interpretation of our examine outcomes and revealed literature spotlight that the schooling background, affected person’s data, and previous experiences, are vital elements that affect sufferers’ capability to search for and comprehend well being info, particularly in figuring out trusted sources of well being info.38,39 Nonetheless, different research have additionally proven that attainment of excessive ranges of schooling doesn’t assure having excessive ranges of well being literacy.38,40–45

In concurrence with earlier research, this examine established that sufferers who usually are not proficient in the principle language of the nation the place they obtain healthcare, on this case Arabic, are likely to have decrease ranges of well being literacy because the language barrier is a barrier for efficient communication.40,42,44–51 The median (IQR) S-TOFHLA scores differed considerably in keeping with the language spoken by sufferers. As well as, 63% of sufferers who may learn and write in Arabic (the official language in Qatar) had sufficient well being literacy, whereas 37% had insufficient or marginal well being literacy. Conversely, of the sampled sufferers who may converse Hindi, 29% had sufficient well being literacy in comparison with 62% who had insufficient or marginal well being literacy. Communication between sufferers and healthcare suppliers is an integral element of well being literacy.48 Sufferers of various nationalities would more than likely face problem in understanding and speaking with healthcare suppliers as a consequence of language obstacles. Earlier research have recognized sufferers’ spoken language as one of many most important elements affecting communication and well being literacy.44

Sufferers’ revenue degree, which could possibly be associated to their occupation, was additionally discovered to be a contributing issue to well being literacy in earlier research.38,42,43,45,48,51 Whereas the entire contributors who labored as drivers had insufficient or marginal well being literacy, solely about 7% of the contributors who had managerial positions had insufficient or marginal well being literacy. On the social degree, lack of household help has been recognized as a barrier for well being literacy.38,42–44,48,50,51 The current examine revealed some potential variations in well being literacy ranges based mostly on marital standing. The median (IQR) S-TOFHLA rating was 19 (16) amongst single sufferers as in comparison with 31 (15) amongst married sufferers. A scientific evaluation of the views of healthcare suppliers and sufferers on well being literacy discovered that the dearth of household help is among the many perceived obstacles.42 Jordan et al additionally concluded that having a very good help system, together with household help, was related to larger ranges of well being literacy.38

These findings counsel the necessity for figuring out the prevalence of restricted well being literacy and acknowledge the traits of sufferers with restricted well being literacy. This may be useful to determine this section of sufferers who might have focused interventions probably the most. The findings point out the necessity for efficient methods, instruments, and interventions to help healthcare professionals in enhancing well being literacy amongst sufferers with ACS and HF, which may probably enhance well being outcomes on this inhabitants.17 For efficient self-management, ACS or HF sufferers’ means to learn, assess, comprehend medical info, make knowledgeable choices, and entry applicable healthcare needs to be improved.10,11 Affected person well being literacy is a crucial component of efficient well being info sharing in addition to self-management of continual illnesses.12 Lack of expertise in these areas brought on by restricted well being literacy can undoubtedly prohibit many ACS and HF sufferers from being concerned in efficient self-care administration of their circumstances. It’s because sufferers with restricted well being literacy are likely to let their healthcare suppliers make vital choices concerning their well being with out their enter.52 Certainly one of Qatar’s present nationwide technique targets is affected person empowerment by means of data and well being literacy in addition to energetic involvement of group in elevating well being consciousness, promotion of wholesome behaviors, and creation of a tradition of public participation.53

Implications for Future Analysis, Coverage and Observe

This analysis concerning the prevalence of restricted well being literacy will play an vital position within the improvement of insurance policies, methods, and interventions designed to enhance well being literacy amongst sufferers with CVDs. As Qatar’s healthcare system has develop into centered in adopting prevention and self-management methods, more practical options are required. In the end, the consequence might result in enhancements in data, well being literacy expertise, self-management expertise, and well being outcomes.


This examine has some limitations, nearly all of that are inherent to its cross-sectional survey design. Though it was deliberate to incorporate sufferers who converse widespread languages in Qatar together with Arabic, English, Hindi, Urdu, Tamil, Tagalog, and Malayalam, the examine included solely sufferers who may converse Arabic and/or English. It’s because the validity of the devices in languages beside English and Arabic couldn’t be established. Due to this fact, contributors whose native language was neither Arabic nor English or had been unable to talk these languages had been under-represented, subjecting the examine to choice bias. Consequently, the findings might not be generalized to all sufferers with CVDs in Qatar or the Arab world. Though generic questionnaires permit cross-condition comparability and comparability with wholesome people, one among their limitations is that they could be much less attentive to detect and quantify refined modifications associated to a selected illness.25 Alternatively, disease-specific devices give attention to particular points of a selected illness and are extra delicate to measure small modifications that may be vital to clinicians and sufferers.25 It’s worthwhile to notice that the examine pattern might not be consultant of the CVD inhabitants within the Gulf Cooperation Council (GCC) or the Center East area. The reason being that there are some demographic variations between the international locations. As well as, the findings had been susceptible to social desirability bias because the measurement of the extent of well being literacy was by means of interviewer-administered approach. Lastly, the well being literacy evaluation instruments used (S-TOFHLA and BHLS), though broadly used, usually are not disease-specific; nevertheless, the sufferers had a number of comorbidities making it unattainable to have the participant fill out a number of disease-specific well being literacy devices.


The well being literacy degree noticed amongst sufferers with CVDs, notably ACS and HF, on this examine was low. This means that many CVD sufferers would wrestle to know varied health-related info and directions wanted to handle their well being circumstances. Healthcare suppliers in cardiology settings ought to take additional care when educating sufferers, bearing in mind sufferers with restricted well being literacy. As well as, applicable methods and interventions needs to be developed and applied to deal with well being literacy points. These may embrace using patient-centered communication, enhancing academic supplies, coaching healthcare suppliers, and using a multilingual employees. There’s a must design research that assess instruments and interventions for the advance of well being communication and well being outcomes amongst sufferers with CVD and low well being literacy; these research ought to examine and consider the influence of enhancing literacy on well being outcomes of sufferers with CVDs.


We acknowledge that this paper is a part of a grasp’s diploma thesis that had already been deposited in Qatar College’s QSpace Institutional Repository.54 Open Entry funding supplied by the Qatar Nationwide Library.


This analysis was funded by Qatar College below Pupil Grant quantity QUST–2–CPH–2017–15 [Approved amount QAR 20,000.00 (~US$ 5480)]. The funders had no position within the design, planning, and implementation of the examine. The content material is the only real accountability of the authors.


The authors report no conflicts of curiosity on this work.


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