Southern African Journal of Infectious Diseases

ISSN: 2312-0053 (Print) 2313-1810 (Online) Journal homepage: www.tandfonline.com/journals/ojid20

Patients’ knowledge, attitudes and practices

regarding antibiotic use at a regional hospital in
KwaZulu-Natal, South Africa 2017

K Ramchurren, Y Balakrishna & S Mahomed

To cite this article: K Ramchurren, Y Balakrishna & S Mahomed (10 Sep 2018): Patients’
knowledge, attitudes and practices regarding antibiotic use at a regional hospital in
KwaZulu-Natal, South Africa 2017, Southern African Journal of Infectious Diseases, DOI:
10.1080/23120053.2018.1516393

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Southern African Journal of Infectious Diseases 2018; 0(0):1–6
https://doi.org/10.1080/23120053.2018.1516393 South Afr J Infect Dis
ISSN 2312-0053 EISSN 2313-1810
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Creative Commons License [CC BY-NC 4.0]
http://creativecommons.org/licenses/by-nc/4.0 RESEARCH

Patients’ knowledge, attitudes and practices regarding antibiotic use at a

regional hospital in KwaZulu-Natal, South Africa 2017
K Ramchurrena* , Y Balakrishnab and S Mahomedc
a
School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
b
Biostatistics Unit, South African Medical Research Council, Durban, South Africa
c
School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
*Corresponding author, email: [email protected]

Background: Antibiotic resistance is a major public-health problem globally and inappropriate antibiotic use is being
increasingly recognised as the main force driving this resistance. Communities can contribute to the reduction of antibiotic
resistance by using antibiotics appropriately and as prescribed. The purpose of this study was to assess the knowledge,
attitudes and practices of patients regarding antibiotic use at a regional hospital in South Africa.
Method: An observational analytic, cross-sectional study was conducted at Prince Mshiyeni Memorial Hospital between May and
June 2017. A validated questionnaire consisting of closed-ended questions was administered to outpatients. Patients’ responses
were scored and categorised as poor or good for knowledge, attitude and practice.
Results: A total of 386 patients were interviewed. Only 205 (53%) patients had a good level of knowledge. Although 270 (70%)
patients knew that antibiotics are indicated for the treatment of bacterial infections, 211 (55%) patients incorrectly thought that
antibiotics are also used to treat viral infections. Only 168 (44%) patients were aware of the resistance associated with overusing
antibiotics. With regard to patients’ attitudes, 164 (42%) patients believed that taking antibiotics for the common cold helped
them to recover faster and 178 (46%) patients expected the doctor to prescribe more than one antibiotic for a severe cold.
Overall, 157 patients (40%) reported having shared antibiotics with friends or family. Patients with good knowledge were six
times more likely to have good antibiotic practices (OR 5.8; 95% CI 0.3–10.6; p < 0.001).
Conclusion: A well-planned education programme for the public should be undertaken to improve the knowledge and uses of
antibiotics among patients.

Keywords: attitude, knowledge, practice, resistance

Introduction Health developed the Antimicrobial Resistance National Strategy

Antibiotics revolutionised the platform for medical develop- Framework with the aim of reducing further increases in resistant
ments and are indispensable around the world. Triumphs in bacterial infections and improving patient outcomes.7 This fra-
modern medicine such as cancer chemotherapy and surgery mework emphasises communication with the public to create
would have been impossible without the use of effective treat- antibiotic awareness, and patient education on the dangers
ment for bacterial infections.1 However, globally, several pre- associated with inappropriate use of antibiotics.7
viously susceptible bacteria have developed resistance to
antibiotics.2 The World Health Organization defines antibiotic Patients’ knowledge of and attitude towards antibiotics has
resistance as the ability of bacteria to resist the effects of anti- been shown to influence their use of antibiotics.8,9 Misuse of
biotic treatment to which they were once sensitive.3 Antibiotic antibiotics by patients plays an important role in driving the
resistance has become a serious threat to public health. emergence and dissemination of bacterial resistance.8 Under-
standing patients’ knowledge and practices concerning anti-
Antibiotic resistance has resulted in prolonged illness and hospi- biotics can help to mitigate antibiotic resistance and sustain
tal stays due to the challenges in treating infections and result- antibiotic effectiveness.
ing increased mortality and morbidity has financial implications
for the individual as well as the healthcare system.4 The World There is currently no research in South Africa on patients’ knowl-
Health Organization has referred to the twentky-first century edge of antibiotics. The aim of this study was to assess patients’
as the post-antibiotic era in which minor injuries and common knowledge, attitude and practice regarding antibiotic use
infections can threaten the lives and the general well-being of amongst outpatients at a regional hospital in KwaZulu-Natal.
all populations.4

South Africa is faced with an increasing burden of antibiotic resist- Methods

ance5 and a collaborative effort between effective antibiotic use
and appropriate infection control is needed to curb the spread of Study setting
these resistant organisms. One of the objectives of the South The study was conducted at Prince Mshiyeni Memorial Hospital
African Antibiotic Stewardship Program is to promote rational (PMMH) located in Ethekwini district, KwaZulu-Natal. This 1 200-
use of antibiotics and antibiotic education for healthcare bed hospital offers both regional and district level services to an
workers and the public.6 In response to the global health risk estimated population of two million. Approximately 600 patients
that antibiotic resistance poses, the National Department of are seen in the Medical Outpatient Department (MOPD) daily.

Southern African Journal of Infectious Diseases is co-published by NISC (Pty) Ltd, Medpharm Publications, and Informa UK Limited
(trading as the Taylor & Francis Group)
2 Southern African Journal of Infectious Diseases 2018; 0(0):1–6

Study population and sample frame characteristics of the patients. Part 2 of the questionnaire con-
The study population included all adult patients attending the sisted of 13 statements to assess the patients’ knowledge of anti-
MOPD. Patients older than 60 years or patients who took anti- biotics. The aspects assessed were the use of antibiotics (five
biotics as part of their chronic treatment were excluded. statements), identification of antibiotics (five statements) and
dangers of using antibiotics (three statements). Part 3 of the
A systematic random sampling approach was used to select the questionnaire consisted of seven statements that assessed the
sample. A practical sample size of 30 patients was chosen to be attitudes of patients towards antibiotic use and part 4 consisted
interviewed per day. A sample fraction was calculated based on of seven statements that assessed patients’ practices regarding
the average number of patients seen daily. The selection of the antibiotics. A three-point Likert scale ranging from ‘agree’,
first patient was random. Thereafter every twentieth patient was ‘unsure’ to ‘disagree’ was used to assess patients’ responses.
enrolled. This ensured an even spread of participants through- One mark was awarded for each correct answer and zero for
out the day. each incorrect or unsure answer. Each of the domains assessed
was categorised as poor or good based on the score achieved. In
the knowledge section, patients with scores of 7 and above were
Sample size categorised as having good knowledge. In the attitude and prac-
A sample size of 384 was estimated to be effective for this study. tice sections, patients with scores of 4 and above were classified
This sample size produced a two-sided 95% confidence interval as having good attitudes and good practice. The questionnaire
with a precision of ± 8% when the actual proportion was near was designed in two language versions: English and isiZulu,
50%. The calculation is based on normal distribution and the the latter being the predominant language spoken in
assumption that there would be more than 30 participants. KwaZulu-Natal.

Study design and questionnaire development Face and content validation of the questionnaire was done by
This was an observational analytic cross-sectional study. The three senior hospital staff members (hospital medical
questionnaire, which comprised four parts, was adapted from manager, clinical manager of Medical Outpatient Department,
previous studies 10–12 and modified to suit the local population. and a senior pharmacist). Reliability of the questionnaire was
Part 1 of the questionnaire pertained to the sociodemographic assessed by calculating the Cronbach’s α. The results showed
good consistency yielding an α of 0.732 for the knowledge state-
ments, 0.814 for the practice statements and 0.9 for the attitude
Table 1: Sociodemographic characteristics of patients at the Medical statements.
Outpatient Department at Prince Mshiyeni Memorial Hospital, 2017

Characteristic Frequency (n = 386) Percentage (%) Data collection and analysis

Age: The interview with the patient was conducted in a private con-
sulting room by the researcher and a designated nurse. Written
18–30 71 18.4
informed consent was obtained before participation in the
31–40 67 17.4 study.
41–50 102 26.4
51–60 146 37.8 Data were analysed using Stata version 14 (StataCorp, College
Gender: Station, TX, USA). Pearson’s chi-square or Fisher’s exact test
Male 203 52.6 was used to test associations between categorical variables.
Continuous variables were described as means (with standard
Female 183 47.4
deviations), and tested for differences using ANOVA. A multi-
Race: variate logistic regression was used to determine the association
Black 353 91.5 between demographic variables and knowledge, attitude and
White 16 4.2 practice scores. Results were considered significant for p < 0.05.
Indian 9 2.3
Coloured 8 2.1 Ethical considerations
Gatekeeper permission was obtained from the hospital medical
Education:
manager and the KwaZulu-Natal Provincial Health Research and
No formal education 29 7.5
Ethics Committee. The research was approved by the Huma-
Primary school 127 32.9 nities and Social Sciences Research Ethics Committee of the Uni-
Secondary school 208 53.9 versity of KwaZulu-Natal (HSS/1063/016M).
Tertiary 22 5.7
Monthly income: Results
< R500 48 12.4
R500–R1 399 131 33.9
Sociodemographic characteristics
As indicated in Table 1, the sample consisted of 386 patients of
R1 400–R10 000 92 23.8
whom 203 (53%) were males. The majority of patients were over
> R10 000 3 0.8 the age of 40 years (n = 248, 64%) and just over half the study
Do not wish to answer 112 29.0 population (n = 208, 54%) had completed secondary school.
Marital status:
Single 119 30.8 Knowledge of antibiotics
Married 192 49.7 Overall, 205 (53%) patients were classified as having good
knowledge based on the scoring (Table 2). Regarding the use
Widowed 69 17.9
of antibiotics, although 270 (70%) patients identified that anti-
Divorced 6 1.6 biotics are used for treating bacterial infections, 211 (55%) of
Patients’ knowledge, attitudes and practices regarding antibiotic use 3

Table 2: Patients’ knowledge of antibiotics at Prince Mshiyeni Memorial the patients also thought that antibiotics are used to treat viral
Hospital 2017 infections. In terms of the identification of antibiotics, only 138
(33%) patients knew that the influenza vaccine was not an anti-
Agree Unsure Disagree Total
biotic. Regarding the dangers of using antibiotics, 152 (39%)
Statement n (%) n (%) n (%) n (%) patients indicated they were unsure about the effectiveness of
Use of antibiotics: overusing antibiotics and 146 (38%) patients were unsure
Antibiotics are 270 (70) 76 (20) 40 (10) 386 (100) about the causes of antibiotic resistance. Only 235 (61%)
medicines that patients believed that antibiotics have no side effects.
treat bacterial
infections
In the multivariate analysis (Table 3), patients in the age category
Antibiotics are 211 (55) 69 (18) 106 (27) 386 (100)
used to treat viral
51–60 years were less likely to have good knowledge of anti-
infections biotics compared with younger patients (odds ratio (OR = 0.3;
Antibiotics treat 168 (44) 67 (17) 151 (39) 386 (100)
95% CI 0.1–0.9; p = 0.025). Patients with a secondary level of edu-
all infections cation were almost six times more likely to have good knowl-
Antibiotics 106 (27) 62 (16) 218 (57) 386 (100)
edge compared with patients with no formal education (OR
relieve pain and 5.5; 95% CI 1.6–18.8; p = 0.007).
inflammation
Antibiotics treat 153 (40) 73 (19) 160 (41) 386 (100) Attitude towards antibiotics
fevers
Just over half the sample (n = 211, 55%) of patients were classi-
Identification of antibiotics: fied as having good attitudes towards antibiotic use. Some 178
Penicillin is an 246 (64) 101 (26) 39 (10) 386 (100) (46%) patients believed the doctor must prescribe more than
antibiotic one antibiotic in cases of severe influenza (Table 4). Approxi-
Aspirin is an 32 (8) 57 (15) 297 (77) 386 (100) mately one-third of patients (n = 131, 34%) requested anti-
antibiotic biotics even if the doctor had advised against their use. Two
A cough 32 (8) 45 (12) 309 (80) 386 (100) hundred and forty-nine (65%) patients believed that antibiotics
mixture is an must be taken according to the doctor’s or pharmacist’s
antibiotic
instructions.
The flu vaccine 138 (36) 121 (31) 127 (33) 386 (100)
is an antibiotic
In the bivariate analysis, patients in the age categories 41–50
All injections are 69 (18) 117 (30) 200 (52) 386 (100) years (OR = 0.5; 95% CI 0.3–1.0; p = 0.047) and 51–60 years (OR
antibiotics only
= 0.4; 95% CI 0.2–0.7; p = 0.002) were less likely to have good atti-
Dangers of using antibiotics: tudes towards antibiotic use compared with younger patients,
Overuse of 168 (44) 152 (39) 66 (17) 386 (100) but this association was not significant in the multivariate analy-
antibiotics make sis (Table 5). Patients with good knowledge of antibiotics were
them less effective
over time almost four times more likely to have good attitudes toward
antibiotic use compared with patients with poor knowledge
Antibiotic 150 (39) 146 (38) 90 (23) 386 (100)
resistance is due (OR = 3.8; 95% CI 2.2–6.8; p < 0.001).
to unnecessary
use of antibiotics
Antibiotic practices
Antibiotics have 76 (20) 75 (19) 235 (61) 386 (100) Two hundred and seventy-three (71%) patients reported that
no side effects
they take antibiotics according to the directions on the label
(Table 6). Almost half the sample (n = 181, 48%) reported that
they stop taking their antibiotic when they feel better, and

Table 3: Sociodemographic characteristics associated with good knowledge of antibiotics amongst patients at Prince Mshiyeni Memorial Hospital 2017

Factor Category Unadjusted OR (95% CI) p-value Adjusted OR (95% CI) p-value
Age 18–30 Reference Reference
31–40 0.6 (0.2–1.2) 0.126 0.9 (0.3–2.4) 0.773
41–50 0.3 (0.1–0.5) < 0.001 0.4 (0.1–1.0) 0.052
51–60 0.2 (0.1–0.4) < 0.001 0.3 (0.1–0.9) 0.025
Gender Male Reference Reference
Female 0.9 (0.7–1.5) 0.969 1.2 (0.7–2.1) 0.460
Education No formal Reference Reference
Primary 1.3 (0.5–3.6) 0.553 1.6 (0.5–5.2) 0.464
Secondary 8.6 (3.4–22.2) < 0.001 5.5 (1.6–18.8) 0.007
Tertiary 1a 1a
Income < R500 Reference Reference
R500–R1 399 1.1 (0.6–2.1) 0.807 0.9 (0.4–1.9) 0.799
R1 400–R10 000 2.7 (1.3–5.4) 0.008 1.0 (0.4–2.5) 0.907
> R10 000 2.6 (0.2–30.3) 0.453 1a
a
Predicts good knowledge perfectly and therefore was not included in the model.
4 Southern African Journal of Infectious Diseases 2018; 0(0):1–6

Table 4: Patients’ attitudes towards antibiotic use at Prince Mshiyeni In the bivariate analysis age, income and education were sig-
Memorial Hospital 2017 nificantly associated with good antibiotic practices but these
associations were not significant in the multivariate analysis
Agree Unsure Disagree Total
(Table 7). Patients with good knowledge were six times more
Statement n (%) n (%) n (%) n (%) likely to have good antibiotic practices (OR 5.8; 95% CI 3.1–
I always need an 142 (37) 34 (9) 210 (54) 386 (100) 10.6; p < 0.001).
antibiotic when I
develop a sore
throat Discussion
Antibiotics help 164 (42) 37 (10) 185 (48) 386 (100) This study has identified important gaps in patients’ knowledge
me recover from a of antibiotics. The lack of knowledge on the rationale for anti-
cold much quicker
biotics is not unique to South Africa. The proportion of patients
I always expect the 128 (33) 36 (9) 222 (58) 386 (100) who thought that antibiotics are effective for viral infections
doctor to prescribe
an antibiotic when (55%) is comparable with a survey conducted in England
I feel ill (56%).13 The low proportion of patients who believed antibiotic
I request 131 (34) 38 (10) 217 (56) 386 (100) resistance is due to the unnecessary use of antibiotics may be
antibiotics even if because patients are not well informed concerning the term
the doctor has ‘antibiotic resistance’. The World Health Organization has ident-
advised against it ified a reduction in the unnecessary use of antibiotics as a key
The doctor must 178 (46) 54 (14) 154 (40) 386 (100) issue for public involvement.14
prescribe more
than one antibiotic
if I have severe flu Several studies have revealed that patients’ expectations are
important determinants of antibiotic prescribing.15 In this
If I don’t take 249 (65) 61 (15) 76 (20) 386 (100)
antibiotics as study, only 33% of patients expected antibiotic treatment for
instructed by my common cold symptoms, which is lower than the 44% reported
doctor or from a survey in Windhoek, Namibia.16 In contrast, a higher pro-
pharmacist, the portion (46%) of patients in our study expected the doctor to
antibiotic may not
help me the next
prescribe additional antibiotics in cases of severe influenza
time I use it than the 41% of patients recorded in the Namibian study. The
I prefer to be able 165 (43) 56 (14) 165 (43) 386 (100)
decision to prescribe antibiotics can be influenced by the
to buy antibiotics doctor–patient relationship, in which the doctor may want to
from the pharmacy satisfy the patient’s request even though the doctor feels that
without a doctor’s an antibiotic is unnecessary.15 Under the circumstances, the
prescription. doctor patient–patient relationship in South Africa is generally
vulnerable for patients as they are more inclined to rely on the
doctor’s decision than question it.
200 (52%) reported that they stop taking their antibiotic if they
feel it is not helping them. One hundred and fifty-seven patients Nearly half our sample (47%) reported discontinuing antibiotic
(41%) reported sharing antibiotics with friends and family if they therapy when they began to feel better. Several recent studies
needed them. Overall, 230 (60%) patients were classified as have demonstrated that shorter-course antibiotic regimens
having good antibiotic practices. are also effective although this new research is limited to

Table 5: Sociodemographic characteristics associated with good attitudes towards antibiotic use amongst patients at Prince Mshiyeni Memorial Hospital
2017

Factor Category Unadjusted OR (95% CI) p-value Adjusted OR (95% CI) p-value
Age 18–30 Reference Reference
31–40 0.7 (0.3–1.3) 0.254 0.9 (0.4–2.3) 0.913
41–50 0.5 (0.3–1.0) 0.047 1.6 (0.7–4.1) 0.281
51–60 0.4 (0.2–0.7) 0.002 0.8 (0.3–2.0) 0.651
Gender Male Reference Reference
Female 0.9 0.535 0.7 (0.3–1.1) 0.130
Education No formal Reference Reference
Primary 0.8 (0.3–1.8) 0.589 0.6 (0.2–1.8) 0.385
Secondary 2.1 (1.0–4.6) 0.065 0.9 (0.3–2.8) 0.869
Tertiary 4.2 (1.2–14.4) 0.023 1a
Income < R500 Reference Reference
R500–R1 399 0.9 (0.5–1.8) 0.802 0.8 (0.4–1.7) 0.553
R1 400–R10 000 1.8 (0.9–3.6) 0.113 0.9 (0.4–2.3) 0.994
> R10 000 1a 1a
Knowledge Poor Reference
Good 4.0 (2.6–6.1) < 0.001 3.8 (2.2–6.8) < 0.001
a
Predicts good attitude perfectly and therefore was not included in the study.
Patients’ knowledge, attitudes and practices regarding antibiotic use 5

Table 6: Patients’ practices regarding antibiotic use at Prince Mshiyeni resistance was not evidence-based and more research is war-
Memorial Hospital 2017 ranted in this area.21
Agree Unsure Disagree Total
Education was associated with good knowledge and good atti-
Statement n (%) n (%) n (%) n (%)
tudes. Similar observations were also reported in studies con-
I take my 273 (71) 10 (2) 103 (27) 386 (100) ducted in Malaysia, Palestine and Hong Kong, which
antibiotics
according to
demonstrated that patients with higher levels of education were
directions on the more likely to have good antibiotic knowledge and positive atti-
label tudes towards antibiotic usage.11,22,23 An epidemiological study
I take extra 145 (37) 3 (1) 238 (62) 386 (100) in Scotland reported that education (as measured by an IQ-type
antibiotic pills if test) in childhood predicts substantial differences in adult morbid-
my condition ity and mortality.24 One possible explanation for these results is
worsens that education enhances an individual’s maintenance of his/her
I stop taking my 181 (48) 4 (1) 201 (52) 386 (100) own health because it represents reasoning, learning and
antibiotic when I problem-solving skills useful in the prevention and treatment of
start feeling better
disease and injury.24 In addition, higher education results in jobs
I stop taking my 195 (51) 7 (2) 184 (48) 386 (100) with better income and therefore improved health through diet
antibiotic if I
experience side and lifestyles that are affordable and sustainable.
effects without
consulting a The age of the patient was associated with good antibiotic knowl-
doctor or edge in the current study, with older patients having significantly
pharmacist
less knowledge than younger patients. Antibiotic resistance has
I stop taking my 200 (52) 7 (2) 179 (46) 386 (100) recently become a priority on health agendas and it is likely
antibiotic if I feel it
is not helping me that younger patients may be more aware of this concept
through messages in the media, particularly through online and
I share antibiotics 157 (41) 3 (1) 226 (58) 386 (100)
with friends and social media platforms.25 However, in the study in Malaysia,
family if they need older patients were more likely to have better knowledge of anti-
them biotics and other studies have found no association between the
I reserve 109 (28) 3 (1) 274 (71) 386 (100) age of the patient and the patient’s knowledge, suggesting a
antibiotics to self- need for further investigation of this association.22,23
medicate for future
use
Our finding that good knowledge of antibiotics predicts good
attitude and practice regarding antibiotics has also been
the treatment of community-acquired pneumonia, urinary reported in research from Palestine.22 Knowledge–attitude–
tract infections, tonsillitis and intra-abdominal infections.17–19 behaviour models have theorised that knowledge is one of
Current international recommendations are that patients several determinants of attitude.26 Increased knowledge is
must complete their antibiotic course, regardless of clinical likely to lead to attitudes that are more stable and resistant to
symptoms.20 However, these recommendations have come negative changes.27 Some mechanisms underlying the associ-
under scrutiny as the ideology that stopping antibiotic treat- ation of knowledge with attitude and practices conceptualise
ment before the course is complete will lead to antibiotic that greater knowledge predictably leads to enhanced

Table 7: Sociodemographic characteristics associated with good practices regarding antibiotic use amongst patients at Prince Mshiyeni Memorial
Hospital 2017

Factor Category Unadjusted OR (95% CI) p-value Adjusted OR (95% CI) p-value
Age 18–30 Reference Reference
31–40 0.7 (0.3–1.6) 0.433 0.9 (0.3–2.8) 0.884
41–50 0.3 (1.4–0.5) < 0.001 0.6 (0.2–1.7) 0.310
51–60 0.3 (0.2–0.6) < 0.001 0.5 (0.2–1.6) 0.250
Gender Male Reference Reference
Female 0.8 (0.5–1.2) 0.210 0.8 (0.4–1.4) 0.386
Education No formal Reference Reference
Primary 0.7 (0.3–1.7) 0.485 0.6 (0.2–1.8) 0.380
Secondary 3.2 (1.4–7.0) 0.004 1.8 (0.6–5.7) 0.320
Tertiary 7.8 (1.9–32.3) 0.005 1.7 (0.1–20.6) 0.662
Income < R500 Reference Reference
R500–R1 399 1.5 (0.8–2.9) 0.230 1.4 (0.6–3.1) 0.382
R1 400–R10 000 2.0 (1.0–4.1) 0.050 0.7 (0.3–1.8) 0.523
> R10 000 1a 1a
Knowledge Poor Reference
Good 7.4 (4.6–11.7) < 0.001 5.8 (3.1–10.6) < 0.001
a
Predicts good practice perfectly and therefore was not included in the study.
6 Southern African Journal of Infectious Diseases 2018; 0(0):1–6

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S Mahomed http://orcid.org/0000-0001-7095-9186 www.mahoninghealth.org/health/mission-critical-preventing-
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content/uploads/2015/09/Antimicrobial-Resistance-National-
Strategy-Framework-2014-2024.pdf Received: 5-12-2017 Accepted: 23-08-2018