Journal of Human Nutrition and Dietetics

RESEARCH PAPER
Communication skills for behaviour change in dietetic
consultations
K. Whitehead,* S. C. Langley-Evans,* V. Tischler & J. A. Swift*
*School of Biosciences, University of Nottingham, Sutton Bonington, Loughborough, UK
School of Community Health Studies, University of Nottingham, Medical School, Queen’s Medical Centre, Nottingham, UK

Keywords Abstract
behaviour change, communication, dietetic
education, patient-centred. Background: Both the UK’s National Health Service (NHS) and the National
Institute of health and Clinical Excellence (NICE) have recommended increased
Correspondence training for health professionals in communication skills. There is evidence to
Kirsten Whitehead, School of Biosciences, suggest that communication skills are important in helping people to change
University of Nottingham, Sutton Bonington,
health-related behaviour, which is a key role for dietitians. This study investi-
Loughborough LE12 5RD, UK.
Tel.: 0115 951 6136
gated the views of UK dietitians about their training needs and experience in
Fax: 0115 951 6122 relation to communication skills in dietetic practice.
E-mail: kirsten.whitehead@nottingham.ac.uk Methods: In October 2007, a cross-sectional survey was mailed to all British
Dietetic Association members (n = 6013). The survey gathered quantitative
doi:10.1111/j.1365-277X.2009.00980.x data and free-text comments to ascertain the level, type and effect of communi-
cation skills training received by dietitians at both the pre- and post-registra-
tion level.
Results: There were 1158 respondents; a response rate of 19.3%. Ninety-eight
percent (n = 1117) rated communication skills as either very or extremely
important in client consultations. Post-registration training had been under-
taken by 73% (n = 904). Of these, over 90% of respondents perceived that
post-registration training had led to improvements in their relationships with
patients, their confidence in client interviews and their ability to cope with
challenging clients. However, 248 (21.4%) felt time keeping in interviews had
worsened. Lack of time for client interviews was also the most commonly iden-
tified barrier (19%, n = 216) to implementing the skills.
Conclusions: This study has explored an important and under-researched area.
Respondents strongly endorsed the importance of good communication skills
and the benefits of post-registration training in this area. Some felt that good
communication was time consuming but others felt that time management had
improved. Further research and training is required to support the implemen-
tation of these skills into dietetic practice.

approach in which the health care professional explores

Introduction
In recent years, there have been profound changes in the
UK National Health Service (NHS), which have included
a move towards a more patient-centred approach
[Department of Health (DH), 2004, DH, 2005a,b,c].
Although defined in many different ways, patient-centred
care has been described by Stewart et al. (2003) as an
the patients’ main reason for the visit and need for infor-
mation, attempts to understand the whole person, finds
common ground on what the problem is and shares deci-
sion making on what to do. The UK government white
paper ‘Choosing Health: making healthy choices easier’
(DH, 2004), encompassed this more patient-centred
approach and set key principles for supporting the public

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The British Dietetic Association Ltd. 2009 J Hum Nutr Diet, 22, pp. 493–500 493
 Communication skills in dietetic consultations
in making healthier and more informed health related
choices. The theme of patient choice continued in ‘Creat-
ing a patient-led NHS: Delivering the NHS improvement
plan’ (DH, 2005c), which described the ambition to deli-
ver changes leading to more choice, more personalised
care, and real empowerment of people to improve their
health. This was seen as a fundamental change in the
relationships between the NHS, patients and the public.
Services were clearly set to move away from doing things
to and for patients, towards becoming patient-led.
What has now been termed as a patient-centred
approach or patient-centred care evolved from the client-
centred approach of Rogers (1951). This approach was
originally described as nondirective and focused on the
concerns of the client. It has gradually been adopted from
counselling into healthcare, primarily led by the medical
profession (Stewart et al., 2003). A growing body of evi-
dence relating to medical consultations has shown that
patient-centred care leads to a positive impact on a wide
range of patient outcomes, including enhanced patient
satisfaction (Stewart et al., 2003; Zachariae et al., 2003),
increased self-efficacy (Zachariae et al., 2003), reduced
emotional distress (Zachariae et al., 2003), compliance
with treatment and medical decisions (Keshishian et al.,
2008), improved patient recall and understanding (Zick
et al., 2007) and improved clinical outcomes (Wagner
et al., 2002; Stewart et al., 2003; Keshishian et al., 2008).
Clearly, communication is a fundamental aspect of the
patient-centred approach. However, the term communi-
cation has often been poorly defined and associated with
a variety of activities, such as interviewing, counselling
and interpersonal skills. For the purposes of the present
study, the term communication referred to those verbal
and nonverbal skills that a health care professional may
use within a patient-centred approach with an individual
client, or patient. There is strong evidence to suggest that
the communication skills of the practitioner are an
important factor in helping people to change health-
related behaviour (Najavits & Weiss, 1994). A recent
public health programme guidance document from the
National Institute for health and Clinical Excellence
(NICE) (NICE, 2007) highlighted the important role that
behaviour plays in people’s health, and reported that
interventions to change behaviour at both the individual
and population level have huge potential to alter disease
risk. Although the evidence base for specific ways of
working was limited, training to equip practitioners with
the necessary competencies and skills to support behav-
iour change, using evidence-based tools, was identified as
a priority.
Clinical communication training has now become a
core part of modern undergraduate medical curriculum
in most medical schools in the UK (Silverman et al.,
494
K. Whitehead et al.
2005; Brown, 2008). Other professional groups such as
nursing and pharmacy have begun to look more closely
at the role of patient-centered communication skills
in promoting behaviour change (Hargie et al., 2000;
Schofield et al., 2008).
Although the role of the dietitian requires a high level
of communication skills [Health Professions Council
(HPC), 2007], there has been little published research
within the dietetic profession about communication skills
for promoting behaviour change. The effectiveness of
training, at either pre- or post-registration level, or the
impact of training on patient outcomes, has not been
explored in detail. However, a survey of all British Die-
tetic Association (BDA) members completed in 1997
(Rapoport & Nicholson Perry, 2000) reported that dieti-
tians recognised a gap in their skills and learning, and
identified a need for more communication skills and
behaviour change strategies to be integrated into both
pre- and post-registration training. Similarly, Rosal et al.
(2001) reported that there was little evidence of education
in behaviour modification and behavioural counselling
skills in dietetic education in the USA.
A new curriculum framework for dietetic training in
the UK was due out for consultation with the profession
in late 2007. In light of the guidance from NICE (2007),
and the development of the new curriculum framework,
the present study aimed to investigate the views of BDA
members about communication skills for behaviour
change in dietetic practice to inform the consultation on
the curriculum framework. The study aimed to ascertain
dietitians’ experiences of, and views on, both pre- and
post-registration dietetic training. It also aimed to identify
any barriers to incorporating a patient-centred approach
and communication skills for behaviour change within
the profession. The key findings from this study were
submitted as part of the consultation. The curriculum
framework was officially launched in April 2008.
Materials and methods
Design and sample
All members of the BDA who were registered in August
2007 were invited to participate in a cross-sectional
survey. Ethical approval was obtained from the University
of Nottingham Medical School Ethics Committee.
Respondents were considered to have consented to taking
part in the study if the questionnaire was completed and
returned.
Questionnaire
The questionnaire (see Supporting Information, Doc. S1)
was developed to ascertain the level, type and effect of
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The British Dietetic Association Ltd. 2009 J Hum Nutr Diet, 22, pp. 493–500
K. Whitehead et al.
communication skills training received by dietitians at
both the pre- and post-registration level. For the purposes
of this questionnaire, the term communication skills for
behaviour change was defined as ‘the communication
skills that a dietitian may use within a person-centred
approach in one-to-one communication with an individ-
ual client. This may include, but is not limited to, skills
that enable clients to make appropriate choices, express
their thoughts and feelings, feel heard and understood,
feel valued, respected and supported’.
Sections within the questionnaire recorded demo-
graphic details, pre- and post-registration training
received, and views on current pre- and post-registration
training for dietitians. Opinions on the importance of
communication skills for behaviour change in dietetic
practice and further training needs were also sought.
Examples of questions asked include ‘Did you have any
dedicated training in ‘communication skills for behaviour
change’ as part of your pre-registration training?’; ‘Which
teaching methods do you think should be used to teach
communication skills for behaviour change?’; and ‘If you
have been able to put some of your learning into practice,
what effect, if any, do you think this has had on your
work?’ During development of the questionnaire, com-
ments were sought from three colleagues, outside the
research team, with experience in questionnaire design
and communication skills in healthcare, after which
minor changes in wording and layout were made. The
questionnaire was then piloted with a group of registered
dietitians (n = 5) who suggested further minor changes.
Items were written as statements on a five-point Likert
scale (e.g. not at all important to extremely important, or
open-ended questions). The questionnaire was anony-
mous. A copy of the questionnaire is available from the
corresponding author on request.
Data collection
The questionnaire was sent out with the October 2007
BDA monthly mailing of Dietetics Today and a Freepost
envelope provided for return of completed forms.
Reminders were inserted in the November issue of Dietet-
ics Today and displayed on the BDA website. Further
copies of the questionnaire were available if requested.
No incentives were provided.
Data analysis
Numerical data from 1158 completed questionnaires was
inputted into spss, version 15 (SPSS Inc., Chicago, IL,
USA) and free text responses from open-ended questions
were transcribed into Microsoft Word 2003 (Microsoft
Corp., Redmond, WA, USA). Six individuals were involved
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The British Dietetic Association Ltd. 2009 J Hum Nutr Diet, 22, pp. 493–500
Communication skills in dietetic consultations
in data entry. Numerical data were screened for accuracy.
Frequencies were run to look for data items that could not
be correct and each of these were then checked back to the
original questionnaire and corrected. Each batch of 100
questionnaires had 10% of the data from the original ques-
tionnaires entered again by the lead researcher. This dem-
onstrated an error rate of 0.4%, which was within what is
considered to be an acceptable level and unlikely to have a
significant effect on the data analysis (Day et al. 1998).
Results
Response rate and respondent characteristics
One thousand, one hundred and fifty-eight of the 6013
BDA members who were invited to participate returned a
completed questionnaire, giving a response rate of 19.3%.
It is notable, however, that not all respondents provided
complete data for every question. Compared to nonre-
sponders, respondents (98%, n = 1130) were significantly
more likely to be full members of the BDA (P < 0.01)
and were more likely to female (98%, n = 1132,
P < 0.05). The majority (77%, n = 894) were working in
England, although there were respondents from Scotland,
Wales and Northern Ireland. An open question asking for
job title suggested that the majority of respondents
worked in the National Health Service, including those
from graduate to highly specialist/managerial level and
from a wide range of clinical specialities. There were also
respondents who worked in other areas, such as higher
education and private practice.
Importance of communication skills for behaviour
change
Ninety-eight percent of respondents (n = 1117) rated
communication skills for behaviour change as either very
important or extremely important when working with cli-
ents (Fig. 1). Over 90% of respondents rated greeting a
client appropriately and putting them at their ease, com-
municating at an appropriate level for individual clients,
listening attentively, appropriate nonverbal communica-
tion, recognising and responding appropriately to nonver-
bal cues from the client, responding to client concerns
and summarising and closing the interview as highly
important (scoring 4 or 5 on a Likert scale ranging from
1–5). Those aspects involved with the dietary information
exchange part of the interview (e.g. providing information
(76.7%, n = 888) and integrating communication skills
with taking a diet history (61.5%, n = 712) were consid-
ered to have slightly lower levels of importance (Table 1).
Although 62% (n = 697) of respondents rated their
skills as either very good or excellent, 92% (n = 1031)
stated that they would still like further training. The
495
 Communication skills in dietetic consultations K. Whitehead et al.

behaviour change during their pre-registration training.

Paraphrasing
Of these, lectures (85%, n = 433), demonstration of skills
Nonverbal (72%, n = 436) and opportunities to practise skills (86%,
n = 433) were the most common teaching methods at
Listening
university. Observation and informal feedback from
Communication supervisors (78%, n = 400) were the most common tech-
niques for developing and enhancing these skills during
Greeting clinical placements.
Pre-registration training in communication skills was
0

20

40

60

80

0
10
% of respondents thought to be the responsibility of both university and
clinical placement. However, teaching methods favoured
Figure 1 Principal skills required in client interview. Survey partici- at university included lectures and being videoed, whereas
pants identified Greeting a client, Communication at an appropriate practising on real patients was favoured during clinical
level, Listening attentively, Nonverbal communication and Paraphras- practice (Table 2).
ing the clients story as the most important skills required for conduct-
ing a successful client interview. The graph shows the combined
percentage of responses in the Important and Extremely Important Post-registration training
categories on the questionnaire. For full category definitions, see
Table 1. Post-registration training had been undertaken by 73%
(n = 904) respondents of whom 87% (n = 791) had
preferred options for training included 1-day refresher attended at least one training course. Peer observation
courses (55%, n = 638), on the job training (37%, and feedback had been undertaken by 27% (n = 245) and
n = 432), peer observation (34%, n = 398) and reading/ 38% (n = 339) reported extensive reading around the
literature (22%, n = 256). subject. Only 2% (n = 21) felt that they had not been
able to put at least some of their training into practice.
The effects of post-registration training on the work envi-
Pre-registration training
ronment were strongly positive (Fig. 2). Over 90% of
Forty-four percent of all respondents (n = 512) reported respondents who answered this question perceived
having had dedicated training in communication skills for improvements in their relationships with patients, their
Table 1 Communication skills identified as important elements of client interviews
1. Not at all
important, n (% 2. n (% of 3. n (% of 4. n (% of 5. Extremely important, Missing, n (% of
Skill of respondents) respondents) respondents) respondents) n (% of respondents) respondents)

Greeting a client appropriately and 0 (0) 1 (0.1) 27 (2.3) 191 (16.5) 935 (80.7) 4 (0.3)
putting them at their ease
Communicate at an appropriate 0 (0) 0 (0) 8 (0.7) 129 (11.1) 1017 (87.8) 4 (0.3)
level for individual clients
Listening attentively 0 (0) 0 (0) 8 (0.7) 153 (13.2) 992 (85.7) 5 (0.4)
Appropriate nonverbal 0 (0) 0 (0) 44 (3.8) 324 (28.0) 782 (67.5) 8 (0.7)
communication
Paraphrasing the client’s story 0 (0) 13 (1.1) 151 (13.0) 441 (38.1) 546 (47.2) 7 (0.6)
Recognising and responding 0 (0) 1 (0.1) 34 (2.9) 305 (26.3) 812 (70.1) 6 (0.5)
appropriately to nonverbal cues
Providing information 1 (0.1) 23 (2.0) 236 (20.4) 468 (40.4) 420 (36.3) 10 (0.9)
Responding to patient concerns 0 (0) 3 (0.3) 19 (1.6) 302 (26.1) 830 (71.6) 4 (0.3)
Reflecting the client’s feelings 1 (0.1) 12 (1.0) 145 (12.5) 476 (41.1) 518 (44.7) 6 (0.5)
back to them
Maintaining the direction of the 1 (0.1) 15 (1.3) 133 (11.5) 448 (38.7) 552 (47.7) 9 (0.8)
interview
Summarising and closing the 1 (0.1) 5 (0.4) 56 (4.8) 389 (33.6) 697 (60.2) 10 (0.9)
interview
Keeping to the allocated time slot 8 (0.7) 59 (5.1) 255 (22.0) 487 (42.1) 333 (28.8) 16 (1.4)
Integrating communication skills 21 (1.8) 96 (8.3) 312 (26.9) 421 (36.4) 291 (25.1) 17 (1.5)
with taking a diet history

Data are shown as number of respondents (n) and percentage (%) of the total sample.

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496 The British Dietetic Association Ltd. 2009 J Hum Nutr Diet, 22, pp. 493–500
K. Whitehead et al. Communication skills in dietetic consultations

Table 2 The preferred teaching methods Setting for delivery of training

identified for undergraduate training in
communication skills University, n (% of Placement, n (% of Both, n (% of
Teaching method respondents) respondents) respondents)

Lectures/tutorials 555 (52) 11 (1) 502 (47)

Demonstration of skills 512 (46) 36 (3) 569 (51)
(video or live
demonstration)
Opportunities to practise 348 (31) 53 (5) 727 (64)
skills (e.g. role play)
Practising on real patients 7 (1) 889 (80) 219 (20)
Being videoed during role 728 (70) 28 (3) 292 (28)
play and viewing yourself
Observation and informal 303 (28) 152 (14) 640 (59)
feedback by peers
Observation and informal 104 (9) 195 (18) 818 (73)
feedback by tutor/supervisor
Formal assessment 156 (17) 167 (19) 582 (64)

Data are shown as numbers of respondents (n) and percentages (%) of the total sample.

Challenging patients Discussion

Time-keeping
Confidence
Clinical outcomes
DNA rates
Patient satisfaction
Job satisfaction
Colleague relationship
Patient relationship
0 20 40 60 80
% of respondents
Figure 2 Change in dietetic practice following training. The survey
participants considered that key aspects of their professional practice
had improved following training in communication skills. The graph
shows the percentage of respondents reporting that these skills had
improved on the questionnaire. For full category definitions, see
Table 3. DNA, Did not attend.
confidence in client interviews and their ability to cope
with challenging clients (Table 3). Seventy-nine percent of
respondents had experienced greater job satisfaction and
85.8% (n = 701) perceived that their patients were more
satisfied. Seventy-four percent (n = 592) also felt that
there had been improvements in clinical outcomes,
whereas 51.9% (n = 449) felt that they had experienced
improved relationships with other staff. However, time-
keeping in client interviews was considered by some to
have improved (31.7%, n = 272) and by a similar number
to have worsened (28.9%, n = 248) (Table 3).
Lack of time for client interviews was also the most
commonly identified barrier to implementing the skills
learnt, with 216 (19%) dietitians stating that time was an
issue. Lack of confidence in the skills taught (5.3%,
n = 61) and lack of support from colleagues/management
(4%, n = 46) were also perceived as barriers.
The present study has provided a unique insight into
BDA members’ views on the use of communication skills
for behaviour change in dietetic practice at a key stage of
development within the NHS. Patient choice and patient-
centred approaches have been repeatedly endorsed by the
Department of Health (DH, 2004, 2005a,b,c, 2008). The
100
skills needed to enable staff to work in a patient-centred
way have been identified and changes to professional
training have been recommended (NICE, 2007). Dieti-
tians are required to use appropriate forms of verbal and
nonverbal communication with their patients and to be
able to translate the science of nutrition into practical
advice (HPC, 2007). However, for changes to take place
in the dietetic profession, practising dietitians need to
positively engage with the current recommendations,
undergo training and put the skills into practice.
Respondents to this survey were very positive towards
communication skills for behaviour change. Over 70%
had accessed some post-registration training and per-
ceived that they had benefited from it in many ways that
should clearly impact on the delivery of dietetic services.
If dietitians perceive that they have better relationships
with staff and patients and improved job satisfaction, this
may lead to an improved working environment and bet-
ter retention of staff. Similarly, dietitians feeling that they
are better able to cope with challenging clients could
reduce work stress and increase job satisfaction. These
results suggest that there are benefits beyond patient out-
comes, which has been shown to be the case when nurses
received communication skills training (Arranz et al.,
2005). The perception that patients are more satisfied and

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The British Dietetic Association Ltd. 2009 J Hum Nutr Diet, 22, pp. 493–500 497
 Communication skills in dietetic consultations K. Whitehead et al.

Table 3 Impact of communication skills training on professional practice

Improved a lot, Improved a little, No change, A bit worse, A lot worse, Missing data,
n (% of n (% of n (% of n (% of n (% of n (% of
respondents) respondents) respondents) respondents) respondents) respondents)

Relationship with 388 (33.5) 422 (36.4) 61 (5.3) 0 (0) 0 (0) 287 (24.8)
patients
Relationship with 135 (11.7) 314 (27.1) 415 (35.8) 1 (0.1) 0 (0) 293 (25.3)
colleagues
Job satisfaction 297 (25.6) 388 (33.5) 176 (15.2) 4 (0.3) 1 (0.1) 292 (25.2)
Patient satisfaction 283 (24.4) 418 (36.1) 113 (9.8) 3 (0.3) 0 (0) 341 (29.4)
Patient DNA rates 57 (4.9) 205 (17.7) 516 (44.6) 1 (0.1) 0 (0) 379 (32.7)
Patient clinical 118 (10.2) 474 (40.9) 200 (17.3) 0 (0) 0 (0) 366 (31.6)
outcomes
Your confidence in 418 (36.1) 377 (32.6) 67 (5.8) 7 (0.6) 0 (0) 289 (25.0)
client interviews
Your time keeping in 74 (6.4) 198 (17.1) 339 (29.3) 221 (19.1) 27 (2.3) 299 (25.8)
client interviews
Coping with 345 (29.8) 440 (38.0) 78 (6.7) 3 (0.3) 0 (0) 292 (25.2)
challenging clients

Respondents recorded their ability to put some of their learning and training into practice, and the impact this has had on areas of their work.
Data are shown as numbers of respondents (n) and percentages (%) of the total sample. DNA, did not attend.

have better outcomes needs to be examined in more
detail. The work of Stewart et al. (2008) suggests that care
delivered by dietitians using more behaviour change tech-
niques is better received by patient and their carers.
Interestingly, although some dietitians perceived time-
keeping in client interviews had improved, a similar num-
ber of dietitians felt that time-keeping had worsened and
that more time was required to effectively utilise
improved communication skills. Time was also identified
as the greatest barrier to trying to implement these skills.
The effective use of time that leads to the best patient
outcomes has to be a long-term goal for service delivery.
Our findings in this area were consistent with those of
MacLellan & Berenbaum (2007) who reported a lack of
time as a major barrier to implementing a patient-centred
approach.
Whether training is most effectively delivered at a pre-
or post-registration level needs further consideration. The
BDA has addressed pre-registration training by commis-
sioning an evaluation project in 2004 that examined the
changes made to the education and training of dietitians
introduced in 2000. Information was gathered from stake-
holders and was used to inform the development of the
new curriculum framework for the pre-registration educa-
tion and training of dietitians. This project covered the
whole curriculum and included aspects relating to com-
munication skills for behaviour change, such as the ability
to demonstrate good listening skills, communicate effec-
tively, demonstrate empathy and use of a client/patient-
centred approach. Various aspects of communication
skills were identified as important through the consulta-
tion process, which is consistent with the results of the
present study. However, the present study has been able
to ascertain more detail on how those skills might be
delivered. Respondents have clearly indicated that they
feel there is a joint responsibility between Higher Educa-
tion Institutes and their partners in clinical practice to
deliver skills training at a pre-registration level. There
does, however, also appear to be a continuing need for
further training post-registration. Many dietitians did not
perceive that they received adequate pre-registration
training, and others felt that their training required
updating. Although many had undertaken some post-reg-
istration training, they still perceived that they would
benefit from more.
Recruitment for the present study was conducted
through the BDA because the majority of Registered
Dietitians in the UK are members. It is, therefore, possible
that some Registered Dietitians practicing in the UK were
not invited to participate in this study. Considering that
no incentives were offered, the study produced a reason-
able response rate. Despite this, the majority of individuals
approached were not sufficiently motivated to complete
the questionnaire. It is possible that participants were
more positive about communications skills than nonre-
spondents. There is an increasing volume of literature in
this area, but also an inconsistency in the use of terminol-
ogy such as patient-centred care, behaviour change tech-
niques and communication skills (Cant & Aroni, 2008;
Stewart et al., 2008). This could have led to some misun-
derstanding about what was being asked in the question-
naire, and therefore key terms such as ‘communication
skills for behaviour change’ were defined on the front
page of the questionnaire in an attempt to overcome this.

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498 The British Dietetic Association Ltd. 2009 J Hum Nutr Diet, 22, pp. 493–500
K. Whitehead et al.
The present study has explored an important area
where little research has previously been undertaken.
Respondents were very positive about the use of commu-
nication skills for behaviour change in dietetic practice
and were seeing tangible benefits when appropriate train-
ing was provided. Most were interested in developing
their skills further and believed that this would lead to
improved patient outcomes. The results of the present
study suggest that many dietitians are likely to embrace
the drive to develop and enhance their communication
skills (NICE, 2007). However, the perceived barrier of
time needed to use communication skills for behaviour
change was raised among even these overwhelmingly
positive individuals. Further research might usefully
investigate strategies to improve time-keeping in consulta-
tions at the same time as maintaining a patient-centred
approach.
Acknowledgments
The authors would like to thank all the British Dietetic
Association members who took part in this study. We
would like also like to acknowledge the assistance of those
involved during the development of the questionnaire
and data entry, the British Dietetic Association, and Pro-
fessor Pat Judd for information regarding the curriculum
framework development and providing comments on a
draft of this manuscript.
Conflict of interest, source of funding and
authorship
The authors have no conflicts of interest to declare.
This project was funded by the University of Nottingham.
KW, JS and VT assisted with design of the questionnaire.
KW and JS assisted with data collection, data analysis and
manuscript writing. All authors critically reviewed the
manuscript and approved the final version submitted for
publication.
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