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Abstract

This study aimed to assess the knowledge and skills of leprosy among healthcare workers (HCWs) and its associated factors in primary healthcare facilities. A total of 150 HCWs from 50 health clinics in six districts in Pahang were assessed using a self-administered knowledge questionnaire and skills assessment checklist, selected through stratified random sampling. The results showed a mean knowledge score of 11.10 (/25) and a median skills score of 12 (/70). HCWs with higher education levels, over 20 years of working experience, and prior leprosy exposure demonstrated better knowledge of the illness. Additionally, male gender and higher education level are associated with greater leprosy-related skills. The study reveals the inadequate knowledge and skills of professionals about leprosy, emphasizing training in diagnosis, prevention, and control of the disease.

Keywords

knowledge skills leprosy healthcare workers Malaysia primary healthcare

What do we know about this topic?

Leprosy, an ancient disease, continues to pose significant public health challenges globally, particularly in regions with endemicity.

Malaysia has been actively engaged in leprosy control efforts through its National Leprosy Control Program since 1969, focusing on early detection and treatment.

Previous studies have indicated that HCWs’ knowledge and skills regarding leprosy are often inadequate, leading to delayed diagnosis and management.

How does research contribute to the field?

The study assesses the knowledge and skills of leprosy among HCWs in primary healthcare facilities in Pahang, Malaysia, revealing inadequate levels of both knowledge and skills.

Higher education levels, more years of working experience, and prior leprosy exposure are associated with better knowledge of leprosy among HCWs.

What are your research’s implications for theory, practice, or policy?

The study emphasizes the urgent need for tailored training programs aimed at enhancing HCWs’ comprehension and practical skills related to leprosy detection, treatment, and prevention.

By enhancing HCWs’ knowledge and skills, overall leprosy control efforts in the region can be improved, contributing to better public health outcomes.

The findings suggest that policymakers should prioritize continuous education and practical training for HCWs, particularly in endemic regions, to ensure effective leprosy management and control.

Introduction

Leprosy, one of the most ancient diseases known to humanity, is believed to have existed for approximately 100,000 years.¹ This disease has posed significant public health challenges in many parts of the world. If left untreated or diagnosed at a late stage, it can lead to irreversible disabilities and disfigurement due to damage to the skin, eyes, and peripheral nerves.^2,3 These physical complications often exacerbate the intense social stigma and discrimination faced by individuals and families affected by the disease.⁴

Globally, the disease remains endemic in over 120 countries, with more than 200,000 new cases reported annually.⁵ Despite achieving global elimination as a public health problem in 2000, defined by a prevalence of less than one case per 10,000 population, several endemic regions continue to struggle with the persistence of the disease.^5,6 In 2022, 174,087 new cases of leprosy were recorded worldwide, corresponding to a rate of detection of 21.8 cases per 1 million inhabitants. India, Brazil, and Indonesia each reported over 10,000 new cases of the disease, collectively accounting for 78.1% of the global total for new cases.⁷

In contrast, Malaysia is among 99 countries that report fewer than 1000 new cases per year, having met WHO’s elimination criteria at the national level in 1994.^5,8 Nevertheless, a resurgence in active cases has been observed in Malaysia in recent years, suggesting that many cases remain undetected or unreported.⁹ Most of these cases occur in remote regions, which involve local communities in Sabah and Sarawak and among indigenous populations in Peninsular Malaysia. Pahang has one of the highest reported numbers of cases in Peninsular Malaysia, with a significant proportion involving indigenous communities. Since 2016, the country’s incidence rate has been rising, with Pahang consistently recording rates above the national average. In 2021, however, a decrease in reported cases was noted, likely due to the slowdown of active case detection (ACD) programs during the COVID-19 pandemic. Despite ongoing efforts, Malaysia has struggled to meet targets for reducing Grade 2 deformities (target: <0.02 cases per 100 000 population) and cases in children (target: <3%) since 2016.^8,10

Malaysia’s National Leprosy Control Program (NLCP), established in 1969, was designed to control and reduce the burden of the disease in the country. Initially focused on early detection and isolation of cases, the program expanded in 2011 to provide treatment and case detection services through primary healthcare facilities.¹¹ The primary goal of the NLCP is to prevent nerve damage, which can lead to disability and disfigurement, through early diagnosis and prompt treatment initiation by healthcare workers (HCWs). However, challenges remain in ensuring HCWs possess adequate knowledge and skills to recognize the early signs and symptoms of the infection.¹² Gaps in these areas among HCWs may impede timely diagnosis, referral, and treatment for affected individuals.

Previous studies have shown that inadequate knowledge and skills related to leprosy among HCWs are linked to delayed case detection and misdiagnosis.¹³ The disease is often confused with other conditions, leading to missed diagnoses, even by leprologists.¹⁴ Recent research emphasizes that misdiagnosis remains a significant problem, particularly in China, with cases misdiagnosed as other skin conditions, such as erythema multiforme. This highlights the challenges posed by non-specific symptoms and the lack of experience, particularly in non-endemic areas, which delays treatment and increases patient suffering.¹⁵

Since the integration of control measures into primary care in 2011, research on HCWs’ knowledge and skills in this area has been limited. Therefore, this study aimed to assess the knowledge and skills of leprosy and its associated factors among HCWs working in primary healthcare facilities.

Method

Study Design and Sample Size

This cross-sectional study was conducted at primary healthcare facilities in six randomly selected districts in Pahang, Malaysia, using number generators. The study took place from July to September 2022. We recruited all eligible healthcare workers (HCWs) from four job categories—medical officers, medical assistants, staff nurses, and community nurses—across 50 healthcare facilities based on lists provided by the State Health Department and facility in-charges. The inclusion criteria required HCWs from four job categories to be working in one of the primary health facilities in Pahang and actively providing patient care. Exclusion criteria included those performing only administrative tasks and who had previously undergone leprosy LaKAR (Train, Detect, Analyze, Treat, and Refer) training.

Using the OpenEpi size calculator, the total sample size required was 146 with a significant level of 0.05, an attrition rate of 15%, and assuming a 10% prevalence of good knowledge and skills of leprosy.¹² A total of 150 eligible HCWs were selected through stratified random sampling to ensure the representative of each profession by district.

Data Collection Technique

For data collection, a structured questionnaire and skills assessment checklist were used. The collection of data was done together with dedicated assessors from each selected Health district in Pahang. Before conducting the assessment, a briefing and training were conducted for the assessors to familiarize themselves with the study protocol, study instruments, and techniques for the assessments. Answering the questionnaires and skills assessment sessions were estimated about 20 to 40 minutes each. For a self-administered questionnaire, at least one assessor was there to ensure all the questionnaires were being answered. For the skills assessment session, there were 4 to 8 assessors to conduct the assessment of the participants.

Study Instruments

A structured knowledge questionnaire was adapted from previous studies^12,16,17, which consisted of 25 question items regarding causes, transmission, classification of leprosy, clinical symptoms, leprosy reaction, management, and complication. A score of 1 was given to each correct answer, and a score of 0 was given to a wrong answer. The overall score of the knowledge questionnaire was 25. The skills assessment checklist also was adapted from a previous study¹² and consisted of seven domains, which include history taking, physical examination, peripheral nerves examination, classification of leprosy, symptoms and signs of reaction, proper treatment for complications, and grading the disability. Each domain has 2 to 5 subdomains, and the score was given from 0 to 1 or 0 to 4 for each subdomain. The possible overall score of the skills checklist was 70.

Both the knowledge and skill checklists underwent content validity assessment, measured using the I-CVI index and Kappa statistic, resulting in values ranging from 0.83 to 1 and 0.82 to 1 respectively.¹⁸ We conducted test-retest reliability for the knowledge questionnaire among 40 HCWs in one of the districts in Pahang, which was not selected for the actual study. HCWs reliably reported predictors over time with the Intraclass Correlation Coefficient ranging from moderate to excellent reliability and Cronbach’s alpha exceeding .70, interpreted as acceptable agreement.^19,20 HCWs were also assessed by the assessor for the inter-rater reliability test for the skills checklist. The test was conducted among 20 HCWs not involved in the actual study, ensuring comparable and accurate results. The Kappa value indicated substantial to almost perfect agreement among the raters for skills checklist items.²¹

Analysis

All relevant socio-demographic characteristics and possible risk factors were described among healthcare workers in Pahang. Descriptive statistic was used to describe the sociodemographic characteristics, total score of knowledge, and skills of study participants. While univariate analysis and linear regression were used to assess the association between HCW characteristics, knowledge score with skills score. Variables associated with knowledge at a threshold of 0.25 in univariable analysis were included in the multivariable linear model. We obtained the final model by stepwise selection. All the analyses were performed using SPSS version 26.

Results

A total of 150 HCWs had completed a knowledge questionnaire and skills assessment with proportions of medical officers, medical assistants, staff nurses, and community nurses were 16%, 32%, 37.3%, and 14.7% respectively. Most HCWs were 40 years old or younger (82.7%). Nearly 80% were female, and 82% were married. Since the majority of HCWs in Pahang are Malay, almost all selected participants were Malay (96.7%). In terms of education, 48% held a diploma, and 36% had a certificate. Over half (59.3%) had less than 11 years of service, and 66% had encountered leprosy cases. Nearly all HCWs (94.7%) had never attended leprosy training other than LaKAR and had been in charge of the leprosy unit (96%).

Knowledge of Leprosy

The overall mean knowledge score among HCWs was 11.91 out of 25 (Table 1). Most HCWs (81.3%) correctly identified the cause of leprosy, while only half accurately answered questions on its mode of transmission. There was no significant difference in knowledge across healthcare categories. Medical officers demonstrated significantly better understanding of leprosy symptoms (79.2%), WHO classification (75%), severe types (79.2%), relevant laboratory tests (95.8%), and recognition of Multi-Drug Therapy drugs (70.8%), as shown in Table 2. However, only 2.7% and 8.7% of HCWs correctly answered questions on lepra reactions and treatment of complications respectively, with no significant differences in knowledge among categories.

Table 1.

Sociodemographic, Mean Knowledge Score, and Median Skills Score of Leprosy Among HCWs in Primary Healthcare in Pahang, Malaysia.

Variables	Characteristics	N (%)	Mean + SD	P-value	Median (IQR)	P-value
Age	40 years old and below	124 (82.7)	11.99 + 3.380	.535^a	12 (8.00-23.00)	.404^c
Age	>40 years old	26 (17.3)	11.54 + 3.409		12 (6.00-17.50)
Gender	Male	30 (20)	12.7 + 3.932	.154^a	24 (11.75-31.00)	<.010^c
Gender	Female	120 (80)	11.72 + 3.213		12 (6.25-18.00)
Marital status	Married	123 (82)	11.9 + 3.197	.486^b	12 (7.00-18.00)	.017^d
	Single	21 (14)	12.38 + 4.466		23 (11.00-28.00)
	Divorced/widow	6 (4)	10.5 + 2.739		18 (8.50-34.25)
Race	Malay	145 (96.7)	11.91 + 3.409	.954^a	12 (7.00-21.00)	.039^c
Race	Non-Malay	5 (3.3)	12 + 2.55		19 (13.50-34.50)
Education level	Certificate	54 (36)	10.94 + 3.037	<.01^b	11 (6.00-14.00)	<.010^d
	Diploma	72 (48)	11.38 + 2.919		12 (7.25-20.25)
	Degree and above	24 (16)	15.71 + 2.866		24.5 (19.50-42.25)
Occupation level	Medical officer	24 (16)	15.71 + 2.866	<.01^b	24.5 (19.50-42.25)	<.010^c
	Nurse	48 (32)	10.98 + 2.658		11 (6.00-16.75)
	Community nurse	56 (37.3)	11.09 + 2.994		11 (6.00-14.00)
	Medical assistant	22 (14.7)	11.91 + 3.571		17.5 (10.25-25.25)
Years of service	<11	89 (59.3)	12.25 + 3.491	.046^b	13 (8.00-25.00)	.070^d
	11-20	49 (32.7)	11 + 2.821		12 (6.50-15.50)
	>20	12 (8)	13.17 + 3.996		11.5 (6.25-15.75)
Have seen leprosy cases	Yes	51 (34)	12.57 + 2.837	.088^a	13 (8.00-23.00)	.377^c
Have seen leprosy cases	No	99 (66)	11.58 + 3.592		12 (7.00-21.00)
Have attended leprosy training except LaKAR	Yes	8 (5.3)	14 + 5.182	.072^a	18 (8.50-29.25)	.311^c
Have attended leprosy training except LaKAR	No	142 (94.7)	11.8 + 3.234		12 (7.00-21.00)
Have in charge leprosy unit	Yes	6 (4)	15.67 + 2.338	<.05^a	21 (13.25-35.75)	.057^c
	No	144 (96)	11.76 + 3.329		12 (7.00-21.00)
	Total	150 (100)	11.91 + 3.378		12 (7.00-21.00)

Note. ^aMeans independent t-test.

Means one-way ANOVA.

Means Mann–Whitney test.

Means Kruskal–Wallis test.

The test is significant if P < .05.

Table 2.

Knowledge of Leprosy by Healthcare Categories.

Selected questions to assess the level of knowledge	MO	SN	CN	MA	Total	P value
	(n = 24)	(n = 48)	(n = 56)	(n = 22)	(n = 150)
	No (%)	No (%)	No (%)	No (%)	No (%)
Cause of leprosy	22 (91.7)	41 (85.4)	40 (71.4)	19 (86.4)	122 (81.3)	.103
Mode of transmission	17 (70.8)	27 (56.3)	29 (51.8)	7 (31.8)	80 (53.3)	.065
Symptoms of leprosy	19 (79.2)	27 (56.3)	27 (48.2)	9 (40.9)	82 (54.7)	<.050
Cardinal sign	15 (62.5)	18 (37.5)	15 (26.8)	10 (45.5)	58 (38.7)	<.050
WHO classification of leprosy	18 (75)	11 (22.9)	8 (14.3)	11 (50)	48 (32)	<.010
Severe type of leprosy	19 (79.2)	34 (70.8)	24 (42.9)	11 (50)	88 (58.7)	<.050
Laboratory test	23 (95.8)	39 (81.3)	38 (67.9)	19 (86.4)	119 (79.3)	<.050*
Lepra reaction	2 (8.3)	1 (2.1)	1 (1.8)	0 (0)	4 (2.7)	.379*
Drugs MDT	17 (70.8)	16 (33.3)	20 (35.7)	8 (36.4)	61 (40.7)	<.050
Management of complication/reaction	3 (12.5)	4 (8.3)	5 (8.9)	1 (4.5)	13 (8.7)	.833

Note. WHO = World Health Organization; MDT = multi-drugs therapy; MO = medical officer; SN = staff nurse; CN = community nurse; MA = medical assistant.

Test is significant if P < .05.

Fisher test.

Univariate analysis (Table 1) revealed significant differences in mean knowledge scores based on education level, occupation, years of service, and prior experience in a leprosy unit. Post hoc Bonferroni analysis indicated that those with a degree scored significantly higher than those with a certificate or diploma (P < 0.01). Medical officers also had higher scores compared to other categories (P < 0.01).

Multivariate analysis (Table 3) showed that higher knowledge scores were associated with having a degree or higher education and more than 20 years of services compared to less than 11 years of services. A significant score difference was observed between those with a degree or higher and those with a certificate (P < 0.01). Specifically, HCWs with a degree scored 4.687 points more than those with a certificate. Additionally, those with more than 20 years of service scored 1.868 points higher than those with 0 to 10 years (P < 0.05). HCWs who had previously encountered leprosy cases scored 1.151 points higher than those without such experience (P < 0.05).

Table 3.

Multivariate Analysis for Knowledge and Skills Score of Leprosy Among HCWs.

Variables	Characteristics	b	95% CI	P-value
Multivariate for knowledge of leprosy
Intercept		10.575	(9.594, 11.555)	<.010
Education level	Certificate	0
	Diploma	0.341	(−0.707, 1.389)	.521
	Degree and above	4.687	(3.202, 6.172)	<.010
Year of service	<11	0
	11-20	−0.354	(−1.438, 0.729)	.519
	>20	1.868	(0.084, 3.651)	<.010
Have seen leprosy cases	No	0
	Yes	1.151	(0.142, 2.16)	<.050
Multivariate for skills score of leprosy
Intercept		11.093	(8.568, 13.617)	<0.010
Education level	Certificate	0
	Diploma	2.433	(−1.043, 5.91)	.169
	degree and above	14.262	(9.054, 19.47)	<.010
Gender	Female	0
Gender	Male	5.321	(0.981, 9.66)	<.050

Note. The test is significant if P < .05.

Skills of Leprosy

The overall median score of skills of leprosy among HCWs was 12/70 (Table 3). Scores across all subdomains were below average, except for history taking (3/5). However, medical officers achieved significantly higher median skills scores across all subdomains compared to other healthcare categories (Table 4).

Table 4.

Skills of Leprosy by Healthcare Categories.

Skills based on subdomains	MO median (IQR)	SN median (IQR)	CN median (IQR)	MA median (IQR)	Total median (IQR)	P-value
History taking (/5)	4.0 (3.25-5.00)	3.0 (2.00-4.00)	3.0 (2.00-4.00)	3.5 (2.75-5.0)	3.0 (2.00-4.00)	<.010
Physical examination (/12)	5.0 (3.00-7.00)	2.0 (1.00-4.00)	2.0 (1.00-3.00)	3.0 (1.75-5.00)	2.0 (1.00-4.00)	<.010
Peripheral nerve function (/28)	8.5 (4.25-14.00)	0.5 (0.00-3.00)	0.0 (0.00-3.00)	2.5 (0.00-5.25)	1.0 (0.00-5.00)	<.010
Diagnosis classification (/2)	1.0 (0.00-2.00)	0.0 (0.0-1.00)	0.0 (0.0-1.00)	1.0 (0.00-1.00)	0.0 (0.00-1.00)	<.050
Leprosy reaction (/3)	1.0 (0.25-2.00)	0.5 (0.00-1.00)	1.0 (0.00-1.00)	1.0 (0.00-2.00)	1.0 (0.00-1.00)	<.050
Management and referral (/8)	4.0 (2.00-5.75)	2.0 (1.00-3.75)	2.0 (1.00-4.00)	3.0 (1.00-4.25)	2.5 (1.00-4.00)	<.050
Disability recognition (/12)	3.0 (2.00-6.00)	0.5 (0.00-2.00)	0 (0.00-2.00)	2.0 (0.00-4.00)	1.0 (0.00-3.00)	<.010

Note. MO = medical officer; SN = staff nurse; CN = community nurse; MA = medical assistant.

Test is significant if P < .05.

In univariate analysis (Table 1), significant differences in median skills scores were found based on gender, marital status, race, education, and occupation. Males scored significantly higher (24, P < 0.01) than females, and non-Malays scored higher (19, P < 0.05) than Malays. Single HCWs had better median scores (23, P < 0.05) than those of other marital statuses. HCWs with a degree or higher education had better median skills scores (24.5, P < 0.05) compared to other educational categories, and medical officers outperformed other healthcare categories (24.5, P < 0.01).

In multivariate analysis (Table 3), degree-level education and male gender were independently associated with higher skill scores. HCWs with a degree or higher scored 14.262 points more than those with a certificate (95% CI: 9.054, 19.47), while male HCWs scored 5.321 points higher than females (95% CI: 0.981, 9.66).

Discussion

This study revealed limited knowledge and poor skills regarding leprosy among HCWs working in primary healthcare in Pahang. Based on the findings, medical officers consistently demonstrated higher proficiency, followed by staff nurses, medical assistants, and community nurses in which the majority of professionals did not have specific training in this area. Similar results were found in the study in Ethiopia,¹² Sri Lanka²², and India²³ for low knowledge. Additionally, poor practical skills were observed, particularly in Ethiopia.¹²

According to Table 2, HCWs displayed a low level of knowledge on cardinal signs (38.7%), WHO classification (32%), lepra reaction (2.7%), multidrug therapy (40.7%), and treatment of complications or reactions (8.7%). This contrasts with findings from a study in Haryana, India, where medical students exhibited better in-depth knowledge, except for recognition of cardinal signs.¹⁷ To establish an efficient leprosy control program, it is crucial for HCWs to possess knowledge not only basic but also in-depth knowledge including knowledge on reactions and complications, and to understand how to manage them, particularly in emergency situations such as neuritis.

The lack of skills, particularly among community nurses, is likely due to insufficient training in primary care settings. Most hands-on skills are taught by specialists in district or tertiary hospitals. Current training programs often focus on lectures or general physical examination techniques, which are inadequate for developing the necessary practical expertise. Project managers and trainers should consider incorporating practical methods for teaching psychomotor skills in designing future training programs. These skills must be taught in primary healthcare settings to equip HCWs with the knowledge and skills they need to detect the disease in the field.

In multivariable analysis, higher knowledge scores were associated with higher education levels, more than 20 years of service, and prior experience with the disease. Meanwhile, higher skill scores were linked to HCWs with higher education levels and male HCWs. In contrast, a study in Ethiopia found that knowledge was strongly affected by the type of health profession and training received, while both profession and years of experience were related to skill level.¹² However, this study was only conducted using univariate analysis.

The study found that most male HCWs belonged to the medical officer or medical assistant categories, with none from the nursing category. HCWs with advanced degrees, such as doctors or other healthcare professionals with specialized training, tend to have a deeper understanding due to rigorous training, access to more resources, and opportunities for continuing education. However, even HCWs with lower-level qualifications, such as diploma or certificate holders, can make significant contributions to leprosy treatment and care with appropriate training and ongoing learning. Experience with cases also positively impacted knowledge levels, indicating that exposure plays a key role in proficiency.

Therefore, providing in-service training and refreshment courses for HCWs of all levels is critical to improve their awareness and skills in controlling the disease. A study in Bangladesh demonstrated that post-training knowledge significantly improved among field workers and supervisors, highlighting the value of continuous learning.²⁴

As a cross-sectional study, this research cannot establish causality between variables. Additionally, it was confined to primary health clinics in Pahang, which may limit the generalizability of the findings to HCWs in clinics across the country. However, the results could be relevant to similar HCWs working in similar contexts in other states. Another limitation is the potential for response bias due to the self-administered questionnaires, although assessors were present to help ensure accuracy in responses. Moreover, the exclusion of HCWs who had previously undergone intensive LaKAR training may have narrowed the study’s scope. This decision allowed the focus to remain on those with either no prior training or experience in non-intensive programs, but it potentially limits the applicability of the findings to HCWs with more advanced, specialized training in disease management.

Conclusion

This study highlights a significant gap in leprosy-related knowledge and skills among HCWs in primary healthcare settings in Pahang. Despite the disease’s relative rarity, current training and practice may not adequately address its complexities, impacting early detection and patient care. Given the vital role of healthcare professionals, it is imperative to strengthen their knowledge and skills of the disease. The findings highlight the need for training programs that focus on diagnosis, prevention, and control while ensuring the inclusion of up-to-date information. Incorporating comprehensive leprosy education into medical and paramedical curricula is also equally important. Future research should evaluate the effectiveness of such training to strengthen national control efforts, alleviate the disease burden, and improve patient outcomes.

Supplemental Material

sj-docx-1-inq-10.1177_00469580241312059 – Supplemental material for Knowledge and Skills of Leprosy Among Healthcare Workers and Its Associated Factors in Primary Healthcare

Supplemental material, sj-docx-1-inq-10.1177_00469580241312059 for Knowledge and Skills of Leprosy Among Healthcare Workers and Its Associated Factors in Primary Healthcare by Tengku N. Zafirah, Rafdzah Ahmad Zaki, S. H. Lim, Rafidah Baharudin and Z. Nur Aiza in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Footnotes

We extend our deepest gratitude to the study participants who willingly volunteered their time and openly engaged with our questions and assessments. Our heartfelt thanks also go to the Leprosy Sector Unit of the Ministry of Health,Malaysia,along with the Pahang State Health Department and the Pahang District Health Offices,for their unwavering support and assistance throughout the fieldwork.

Author Contributions

Tengku N. Zafirah collected and analyzed the data and drafted the manuscript. Rafdzah Ahmad Zaki conceptualized the study and developed the methodology. S. H. Lim reviewed and edited the manuscript and validation. Rafidah Baharudin contributed to data interpretation. Z. Nur Aiza worked on data analysis tools. All authors contributed to the writing,revision,and final approval of the manuscript and are accountable for the work.

Data Availability Statement

Data related to the study are available from the corresponding author upon reasonable request.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research,authorship,and/or publication of this article: The publication of this article was supported by the Military Institute of Science and Technology (MIST).

Ethical Approval and Informed Consent Statements

The study was approved on 7th December 2021 by the Medical Research and Ethics Committee (NMRR-21-1829-61236),Malaysia Ministry of Health. All participants were informed about the objectives of the study. Written consent from the participants was obtained before participating in the study.

ORCID iDs

Tengku N. Zafirah

Rafdzah Ahmad Zaki

S. H. Lim

Supplemental Material

Supplemental material for this article is available at

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