Open access
Infection in preterm infants receiving
To cite: Getaneh FB, Asmare A,
Abayneh B, et al. Infection
in preterm infants receiving
topical emollient oil massage:
a systematic review and meta-­
analysis of randomised control
trials. BMJ Paediatrics Open
2024;8:e002364. doi:10.1136/
bmjpo-2023-002364
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material is published online
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10.​1136/​bmjpo-2​ 023-​002364).
Received 3 November 2023
Accepted 20 April 2024
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Correspondence to
Mr Fekadeselassie Belege
Getaneh; ​fekadebelege@​gmail.​
com
topical emollient oil massage: a
systematic review and meta-­analysis of
randomised control trials
Fekadeselassie Belege Getaneh ‍ ‍,1 Aden Asmare,2 Bezabih Abayneh,3
Endalk Birre,1 Anissa Mohammed,4 Amare Muche,4 Alemu Gedefie,5
Yibeltal Asmamaw,1 Zemen Mengesha,6 Natnael Moges,7
Dires Mihretie Birhanu ‍ ‍,8 Zebenay Workneh Bitew,9 Asressie Molla4
ABSTRACT
Background Preterm infants are highly susceptible
to infections, which significantly contribute to morbidity
and mortality. This systematic review and meta-­analysis
investigated the effectiveness of topical emollient oil
application in preventing infections among preterm infants.
Methods A comprehensive search was conducted
across multiple electronic databases (PubMed, Cochrane,
Scopus, Clinical trials, Epistemonikos, HINARI and Global
Index Medicus) and other sources. A total of 2185 articles
were identified and screened for eligibility. The quality
of included studies was assessed using the Cochrane
Risk of Bias Tool for randomised controlled trials. Data
analysis was performed using StataCrop MP V.17 software.
Heterogeneity among the studies was evaluated using the
I2 and Cochrane Q test statistics. Sensitivity and subgroup
analyses were conducted. The Preferred Reporting Items
for Systematic Reviews and Meta-­Analyses checklist
guided the presentation of the results.
Results Of 2185 retrieved articles from initial searches,
11 met eligibility criteria and were included in the final
analysis. A random effects meta-­analysis revealed that
infants who received massages with emollient oils had
a 21% reduced risk of infection (risk ratio=0.79, 95% CI
0.64 to 0.97, I2=0.00%). Subgroup analyses indicated
that preterm babies who received topical emollient oil
massages with coconut oil, administered twice a day for
more than 2 weeks, had a lower likelihood of acquiring an
infection compared with their non-­massaged counterparts.
Conclusion It is quite evident from this analysis that
topical emollient oil application in preterm neonates is
most likely effective in preventing infection. However,
further studies, particularly from the African continent, are
warranted to support universal recommendations.
INTRODUCTION
Prematurity is indeed a significant health
concern, with high mortality rates and poten-
tial long-­
term consequences for survivors.
According to the Global Burden of Disease,
prematurity is the most common illness
worldwide.1 It is estimated that over a million
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Review
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newborns globally die each year due to infec-
tions and complications related to premature
birth, out of a total of 15 million preterm
births.2 Due to the lack of a naturally occur-
ring protective cutaneous biofilm, preterm
newborns are at heightened susceptibility to
infections.3 4
In an effort to reduce preventable newborn
deaths and stillbirths by 2035, the WHO and
UNICEF introduced the Every Newborn
Action Plan in 2014.5 Simple and cost-­effective
interventions have the potential to manage or
prevent approximately 70%–80% of neonatal
deaths.6 However, inadequate implementa-
tion of accessible, affordable and appropriate
maternal and infant care disproportionately
impacts low- and middle-­income countries.7
The purpose of developing and imple-
menting guidelines is to effectively organise
and present the most up-­ to-­
date evidence
to support clinical decision-­ making, with
the goal of improving the quality of care,
patient outcomes and cost-­ effectiveness.8
Unfortunately, in numerous countries,
evidence-­based, active implementation strat-
egies are often disregarded or implemented
incorrectly.9
The practice of massaging newborn babies
with different types of oils is a traditional
custom in many regions due to its perceived
potential advantages.10 11 The WHO pres-
ently provides recommendations for skin
care measures for preterm neonates based
on evidence-­ based guidelines.12 However,
there is conflicting research regarding the
effectiveness of various emollient oils, such
as sunflower, coconut, mustard and vege-
table oils, when applied topically in skin care
products, despite their widespread use and
increasing popularity.
1
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Emollient oils have been recognised for their potential
benefits in maintaining the integrity of the skin, reducing
water loss and providing moisturisation for premature
babies.13–15 However, it is important to note that some
studies13 16 17 have not found significant differences in
infection rates, skin health or other outcomes when
comparing the use of emollient oils to not using them.
Additionally, there is evidence suggesting a potential asso-
ciation between oil massage and the risk of allergic reac-
tions, necrosis and uraemia.18 19 These findings highlight
the need for careful consideration and further research
regarding the use of emollient oils and oil massage in the
care of premature babies, taking into account potential
risks and benefits. Therefore, the objective of this study
was to gather and summarise existing information on the
effects of topical emollient oil treatments on infections in
preterm newborns.
METHODS AND MATERIALS
Protocol registration
The systematic review and meta-­analysis described in this
document were registered in the International Prospec-
tive Register of systematic reviews (PROSPERO) under
the protocol ID CRD42023413770. However, it should be
noted that the registered PROSPERO protocol pertains to
a broader review, and adjustments are required to finalise
the scope of this specific systematic review focusing on
emollients. Moreover, the study results comply with the
Preferred Reporting Items for Systematic Reviews and
Meta-­Analyses reporting checklist for systematic reviews
and meta-­analyses (online supplemental table 1).
Eligibility criteria or inclusion criteria
For the final analysis, each eligible article was inde-
pendently evaluated by FSB and AG based on specific
criteria. The inclusion criteria consisted of randomised
controlled trials (RCTs) worldwide that examined
the impact of emollient oil on infections in preterm
neonates. Articles published or available as grey litera-
ture since 2000 and written in English or easily translat-
able to English were considered.
Search strategies and study selection process
To ensure a comprehensive literature search, three
investigators (FBG AG and ZM) conducted independent
searches on various databases and grey literature sources.
The databases searched included PubMed, Cochrane,
Scopus, Clinical trials, Epistemonikos, HINARI and
Global Index Medicus. In addition, grey literature
sources such as Google Scholar and ScienceDirect were
also searched.
The search was conducted within a specific timeframe,
from July 5 to July 13, 2023. To optimise the search strategy,
the investigators used population, intervention, compar-
ison and outcomes or sensitive searches. These searches
involved combining text words using Boolean operators
with indexing term guidance (online supplemental table
2 Getaneh FB, et al. BMJ Paediatrics Open 2024;8:e002364. doi:10.1136/bmjpo-2023-002364
2). A cross-­reference search was conducted to include any
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additional relevant research that may have been missed
in the initial database search.
After conducting the electronic database search, the
research findings were uploaded to Endnote and Rayyan
web applications to manage duplicate publications. Two
investigators (FBG and AG) independently screened
the articles based on their titles and abstracts. Following
this initial screening, a thorough evaluation of the full-­
text publications was performed to assess their eligi-
bility according to pre-­established inclusion criteria. In
cases of disagreement, discussions were held with other
reviewers (ZM) to reach a consensus on which studies
to include in the final selection for the systematic review
and meta-­analysis.
Quality assessment
The principal investigator, in collaboration with the
coauthor (YA), independently assessed the quality of
each publication using the Cochrane Risk of Bias Tool
for RCTs. This tool consists of seven aspects and three
possible bias levels: low risk, high risk and unclear risk20
After completing the quality assessment, the data were
categorised as good, fair or poor quality based on the
Agency for Healthcare Research and Quality guidelines.
These categories were used to facilitate understanding
(online supplemental table 3). Any discrepancies
between the two reviewers who conducted the full-­text
screening were resolved through discussion with the
third author (AA).
Data extraction and management
The data extraction process used a pretested and struc-
tured data extraction checklist, which was adapted from
the Cochrane Collaboration data extraction format
for interventional reviews of RCTs. Two reviewers, FBG
and AG, independently extracted relevant data from
the included studies. The extracted data encompassed
information such as the last name of the first author,
publication year, study setting, frequency of application,
dose and type of emollient oil, duration of intervention,
sample size, comparison groups and the number of cases
and non-­cases in the intervention and control groups.
Microsoft Word 2013 was employed to summarise this
information.
During the inclusion process, there were no disagree-
ments between the reviewers regarding the selection of
papers. Studies that were incomplete or for which full
texts could not be obtained despite attempts to contact
the corresponding authors were excluded. Lastly, all
investigators examined each included article to ensure
the accuracy and comprehensiveness of the data.
Measurement of outcome variables
The primary objective of this systematic review and
meta-­analysis was to estimate the risk of infection among
preterm neonates who received topically applied emol-
lient oil compared with their counterparts. The effect of

emollient oil on the incidence of infections was assessed
by calculating the pooled risk ratio (RR) along with its
corresponding 95% CIs. Additionally, the secondary goal
was to identify any adverse events associated with the
administration of topical emollient oil in this population.
Data synthesis and statistical analysis
To provide a comprehensive overview of the included
papers, a summary table was created. This table included
details such as the author, year of publication, region
of study, primary outcome, sample size, adverse events,
quality score and other important findings. This summary
table helped to describe the characteristics of the
included studies. To estimate the pooled effect of emol-
lient oil application on infections in preterm neonates,
STATA V.17 software was used.
Heterogeneity across the studies was assessed using both
graphical tools such as the forest plot and the Galbraith
plot, as well as statistical tests such as Cochran’s Q test
and the I2 test. The I2 test values of 25%, 50% and 75%
were considered representative of moderate, medium
and high heterogeneity, respectively. A significance level
of p<0.05 in Cochran’s Q test indicated the presence of
statistical heterogeneity among the studies.21
To identify and manage sources of heterogeneity among
studies, various methods were employed. Random effect
models, sensitivity analysis and subgroup analysis were
conducted, considering factors such as types of emollient
oil, duration, dose, frequency of intervention and quality
score. Objective methods like Egger’s and Begg’s tests,
along with graphical tests such as funnel plots, were used
to assess publication bias.22 Non-­ parametric trim and
fill analyses were additionally employed to address the
potential influence of small studies.23 Finally, the results
of this meta-­analysis are presented through Forest plots,
summary tables and textual descriptions.
RESULTS
Study selection
Among the 2185 articles initially retrieved, 1563 were
excluded due to duplication, and an additional 586 were
deemed unrelated to the study’s objective based on title
and abstract screening. From the remaining 36 articles
that underwent full-­text screening, 11 met the eligibility
criteria and were included in the final analysis (figure 1
and online supplemental table 4).
Characteristics of the included studies
The studies that were taken into consideration for this
review were all carried out between 2000 and 2023
in 10 different countries extended across four conti-
nents (Asia,4 14 18 24–29 Australia,30 and Europe31 and
Africa13), and they examined the effects of emollient oil
therapy on preterm baby infection prevention. 11 RCT
studies4 14 18 24–31 that included 3965 preterm neonates
(1954 in the intervention group and 2011 in the control
group) were included in this study. Of the 11 studies, two
Getaneh FB, et al. BMJ Paediatrics Open 2024;8:e002364. doi:10.1136/bmjpo-2023-002364
Open access
were carried out in a rural setting,14 18 while the other
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nine were centred in institutions. The included study’s
sample size varied from 3631 to 229414 preterm newborns.
Topical emollient oils such as coconut14 18 26 29 30 sunflower
oil,4 27 28 olive oil,25 iSio431 and aquaporin24 were applied
to the preterm newborns in the intervention group. Out
of the 11 studies, five have been published within the
last 5 years (2018–2022).4 14 18 30 31 Based on the quality
scores, the majority of the studies had good4 18 27–29 and
fair quality14 24–26 30 31 scores, while one has been rated
as poor quality.13 Lastly, only two study14 18 of the nine
that examined the adverse events following topical emol-
lient oil administration documented accidental slip-
page among the intervention groups and a considerably
higher percentage of mothers expressed dissatisfaction
or cumbersomeness with the application process of
coconut oil (table 1).
Effect of emollient oil on infection among preterm babies
In the current study, preterm newborns who received
topical emollient oil massage had a 21% lower likelihood
of infection compared with preterm babies who did not
receive the massage (RR=0.79, 95% CI 0.64 to 0.97). The
I2 test indicated low heterogeneity (I2=26.5%, p=0.19)
(figure 2). To further investigate potential variations in
RRs and provide specific recommendations, a subgroup
analysis was conducted based on factors such as emollient
oil type, duration of therapy, dose of therapy, frequency
of therapy and study quality. Despite the lack of signifi-
cant statistical heterogeneity between studies (I2=26.5%,
p=0.19), the subgroup analysis aimed to explore poten-
tial differences in the risk ratios across these factors.
The subgroup analysis revealed several significant
findings. Preterm infants who received topical emol-
lient oil massages with coconut oil demonstrated a 39%
reduced risk of infection compared with the control
group (RR=0.61, 95% CI 0.43 to 0.88). Similarly, preterm
infants who received massages two times a day and for
more than 2 weeks showed a 40% (RR=0.60, 95% CI 0.38
to 0.94) and 31% (RR=0.69, 95% CI 0.51 to 0.95) lower
risk of infection, respectively, compared with their non-­
massaged counterparts. Furthermore, studies with high-­
quality scores indicated a 35% reduced risk of infection
in the intervention groups (RR=0.65, 95% CI 0.48 to
0.88) (table 2 and online supplemental figure 1).
A sensitivity analysis was conducted to assess the
impact of excluding individual studies on the overall
findings. The results indicated that none of the studies
had a significant influence on the pooled estimates.
The point estimates obtained by excluding each study
fell within the CI of the combined analysis, which was
reported as 0.64 to 0.97 with a 95% CI. This suggests
that the overall results and conclusions of the study are
robust and not heavily influenced by any single study.
The funnel plot was primarily used to assess publica-
tion bias. The asymmetrical distribution of studies in
the funnel plot indicated a lack of small studies with
negative outcomes. However, the results of Egger’s
3
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Figure 1 Preferred Reporting Items for Systematic Reviews and Meta-­Analyses flow diagram pooled effect of topical
emollient oil application on infection of preterm neonate, 2023.

test (p=0.458) indicated that there was no significant
publication bias present (figure 3).
DISCUSSION
The implementation of preventive measures to reduce
the risk of infection is crucial for improving the health
and survival of preterm infants, as neonatal infections
are significant contributors to morbidity and mortality in
this population. This systematic review and meta-­analysis
contribute evidence regarding the impact of emollient
oil application on infection prevention in premature
babies.
The findings of this review support the hypothesis that
topical oil application can provide benefits for preventing
infections beyond basic skin care. These results align
with previous Cochrane reviews that have also suggested
the potential advantages of emollient oil application
for infection prevention in preterm infants.32 There

4 Getaneh FB, et al. BMJ Paediatrics Open 2024;8:e002364. doi:10.1136/bmjpo-2023-002364

 Table 1 Characteristics of Included studies showed pooled effect of topical emollient oil application on infection of preterm neonate, 2023.
Quality score
(Agency for
Healthcare
Sample Reported Research and
First author Study Sample size size Total Dose (ml/ Duration Emollients Comparison Primary outcome adverse Quality
name, year Country Study setting population intervention control participant Frequency (# kg/day) (days) type N group parameters outcome standards)

Erdemir (2015)24 Turkey NICU <34 weeks 100 97 197 1 1.5 21  Aquaporin  Routine  Infection prevention  No adverse  Fair
skin care events
Strunk (2018)30 Australia NICU <30 weeks 36 36 72 2 5 21  Coconut oil  Routine  Neonatal skin  No adverse  Fair
skin care condition events
Al-­Abdullah Saudi Arabia NICU <34 weeks 26 25 51 2 1.5 14  Olive oil  Routine     
Weight and NR  Fair
(2012)25 skin care     
infection
prevention
Bautista, (2012)26 Philippines NICU ≤34 24 28 52 2 4 28  Coconut oil  Routine  Infection prevention NR  Fair
weeks skin care
Kukreja (2018)4 India NICU Preterm 39 39 78 3 4 7  Sunflower oil  Routine  Infection prevention  No adverse  Good
skin care events

Getaneh FB, et al. BMJ Paediatrics Open 2024;8:e002364. doi:10.1136/bmjpo-2023-002364

Darmstadt  Bangladesh NICU ≤33 weeks 159 181 340 3 4 14  Sunflower oil  Routine  Infection prevention  No adverse  Good
(2008)27 h skin care events
Darmstadt  Bangladesh NICU Week 33 of 159 181 340 3 4 14  Sunflower oil  Massage  Infection prevention  No adverse  Good
(2005)28 h gestation without oil events
Salam (2015)29 Pakistan NICU 26–37 128 130 258 2 5 28  Coconut oil  Routine  Infection prevention  No adverse  Good
weeks skin care and weight events
Darmstadt Egypt NICU <34 weeks 51 52 103 3 4 28  Sunflower oil  Routine  Infection prevention  No adverse  Poor
(2004)13 GA skin care events
Khatun (2021)18 India  Community Preterm 119 128 247 4 5 30  Coconut oil  Massage Weight gain  Accidental  Good
without oil slippage
Armand (2022)31 France NICU Very 18 18 36 1 10 5  Oil ISIO4  Massage Weight gain NR  Fair
premature without oil
Konar (2020)14 India  Community Less than 1146 1148 2294 4 10 28  Coconut oil  Massage  Infection prevention  Cumbersome  Fair
37 weeks without oil

GA, gestational age; NICU, neonatal intensive care unit; NR, Not reported;.
Open access

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Open access

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Figure 2 Forest plot showed the effect of emollient oil on preterm baby infection in a preterm neonate in 2023.

are several potential reasons for the observed decrease
in infection risk among the intervention group (those
receiving topical emollient oil) in the study. One possible
explanation is that the application of emollient oils
enhances the function of the skin barrier. By creating a
protective barrier on the skin, emollient oils can prevent
the entry of microorganisms and reduce the risk of infec-
tion.11 33 Additionally, these oils have moisturising prop-
erties that can support the skin’s natural defenses and
help maintain skin integrity, further reducing the risk of
infection.34
Another notable finding of this study was that preterm
neonates who received massages with coconut oil had
a higher likelihood of preventing infection compared
with the control groups. One possible explanation for
this observation is that the fatty acid, linoleic acid and
vitamin D content present in coconut oil may enhance its
binding to peroxisome proliferator-­activated α receptors

Table 2 Subgroup analysis showed pooled risk ratio effect of topical emollient oil application on infection prevention of
preterm neonate, 2023.
S. no Subgroups Category No study Risk ratio 95% CI I2 P value
1 Emollient oil type Coconut oil 5 0.61 0.43 to 0.88 27.00 0.24*
Sunflower oil 2 0.85 0.58 to 1.26 0.00 0.99
Other oil 4 0.95 0.68 to 1.32 29.32 0.24
2 Duration of therapy Less than 2 weeks 5 0.90 0.67 to 1.21 7.93 0.36
2 weeks and above 6 0.69 0.51 to 0.95 39.98 0.14*
3 Dose of therapy Less than 5 mL/kg/day 6 0.86 0.70 to 1.05 0.00 0.98
5 mL/kg/day and above 5 0.68 0.39 to 1.19 66.13 0.02
4 Frequency of therapy Two times a day 4 0.60 0.38 to 0.94 4.85 0.37*
Three times a day 3 0.80 0.59 to 1.09 0.00 0.88
Four times a day 2 0.65 0.36 to 1.16 55.33 0.13
5 Study quality Good 5 0.65 0.48 to 0.88 24.55 0.26*
Fair 6 0.93 0.74 to 1.17 0.00 0.47
Bold values and * revealed the key variables that demonstrated statistically significant associations in the subgroup analysis.

6 Getaneh FB, et al. BMJ Paediatrics Open 2024;8:e002364. doi:10.1136/bmjpo-2023-002364


Figure 3 Funnel plot showed the effect of emollient oil on preterm baby infection in a preterm neonate in 2023.
on keratinocytes. This, in turn, can accelerate skin devel-
opment and maturation, thereby preventing conditions
like hypothermia and apnoea.31 35 Furthermore, coconut
oil has demonstrated efficacy in preventing hypothermia
and apnoea in preterm infants by reducing insensible
water loss and minimising tactile stimulation during
massage.14
Additionally, the findings of the study suggested that
preterm newborns who received massages two times a
day and for a duration longer than 2 weeks had a lower
likelihood of developing infections compared with
those who did not receive massages. This observation
may be attributed to the indirect effects of frequent
and prolonged massage on the immune systems of
preterm newborns. Mechanical stimulation provided by
oil massage can have a positive impact on the immune
system. Previous research has indicated that receiving a
massage can activate the parasympathetic nervous system,
leading to relaxation and reduced stress levels.33 36 Oil
massage, in particular, may contribute to strengthening
the immune system of preterm newborns by lowering
stress and promoting relaxation, which in turn could
help reduce the risk of infection.37
The findings of this systematic review and meta-­analysis
hold significant importance for programme planners,
policymakers and clinicians, particularly in regions with
a high burden of prematurity. However, it is important
to acknowledge certain limitations of the study. The
analysis was unable to estimate the risk difference across
different continents and ethnicities due to the scarcity of
primary studies, particularly from Africa. Additionally,
Getaneh FB, et al. BMJ Paediatrics Open 2024;8:e002364. doi:10.1136/bmjpo-2023-002364
Open access
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studies published in languages other than English, those
with only abstracts available and those lacking sufficient
details after communication attempts were excluded,
potentially reducing the generalisability of the findings.
In conclusion, the analysis demonstrated that preterm
neonates who received massages two times a day with
coconut oil for an extended duration had a reduced risk
of infection compared with those who did not receive
such massages. These findings highlight the potential of
topical emollient oil application to significantly improve
the survival rate of preterm infants. Addressing the
issue of preterm birth and reducing neonatal mortality
requires the widespread adoption of low-­cost, accessible
interventions such as topical emollient oil application.
Given the global public health impact of premature birth
and associated mortality, further research and implemen-
tation efforts are warranted.
Author affiliations
1
Pediatrics and child health nursing, Wollo University, Dessie, Ethiopia
2
NICU, Dessie Hospital, Desse, Ethiopia
3
Debre Berhan University, Debre Berhan, Amhara, Ethiopia
4
Public health, Wollo University, Dessie, Ethiopia
5
Medical Laboratory, Wollo University, Dessie, Ethiopia
6
Nursing, Wollo University, Dessie, Ethiopia
7
Pediatrics and child health Nursing, Debre Tabor Univeristy, Debre Tabor, Ethiopia
8
Pediatrics and child health nursing, Dilla University College of Health Sciences,
Dilla, Ethiopia
9
Pediatrics and child health nursing, St. Paul’s Hospital Millennium Medical College,
Addis Ababa, Ethiopia
X Fekadeselassie Belege Getaneh @fkie
7
 Open access
Acknowledgements We are thankful to the authors of the original studies
included in this systematic review and meta-­analysis, and to those who contributed
a lot in this work.
Contributors All authors made a substantial contribution to this study. FBG, YA and
AG conducted the systematic review (quality evaluation, study selection and data
extraction). FBG designed the study and conducted the meta-­analysis. NMM, DBM,
AG and AA drafted the manuscript. AMo, AM, BA and ZM critically reviewed the
manuscript, interpreted the findings and approved the final version. All authors had
full access to all of the data in the study and can take responsibility for the integrity
of the data and the accuracy of the data analysis. As the senior authors, AsM and
ZWB affirm that the manuscript is an honest, accurate and transparent account of
the study being reported.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests No, there are no competing interests.
Patient consent for publication Not applicable.
Ethics approval Not applicable.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has
not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
peer-­reviewed. Any opinions or recommendations discussed are solely those
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
of the translations (including but not limited to local regulations, clinical guidelines,
terminology, drug names and drug dosages), and is not responsible for any error
and/or omissions arising from translation and adaptation or otherwise.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-­commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the
use is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iDs
Fekadeselassie Belege Getaneh http://orcid.org/0000-0001-8729-1784
Dires Mihretie Birhanu http://orcid.org/0000-0002-1492-3733
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