Public Perceptions of Pharmacists and Pharmacy Services

            Abstract

            Background: One of the essential and ultimate aspects that will help in pharmacy advancement in the nation in the future as well as in the current living is a concise public understanding which is also represented as consumer satisfaction.  This systematic review is therefore purposed for the exploration of satisfaction and perception of patients and the public with services and functions that are provided by pharmacies and pharmacists.

Objectives: The primary goal of the systematic review is to investigate and examine the notions, viewpoints, perspectives, and beliefs of the public concerning pharmacy as a field and pharmacists as having medical roles

            Methods: All relevant articles examining and identified published from January 2000 until December 2015 were searched using various search engine, bibliography searches and authors’ libraries. Studies were included if they: 1) quantitative and qualitative primary research papers, 2) any papers looking at the public perception of pharmacy or pharmacists or pharmacy services.

Results and Discussion: Forty percent (10 out of 25) of studies conducted in developed countries while sixty percent (15 out of 25) of studies conducted in developing countries. In both developed and developing countries, 60% (15 out of 25) of studies demonstrated the satisfaction of public perception towered pharmacists’ activities and pharmaceutical services while 40% (10 out of 25) of studies illustrated the dissatisfied of public expectation overlooked pharmacists’ role and pharmacy services. The satisfaction of public perception towered  pharmacists’ role and pharmaceutical services in developed countries was 40% (4 out of 10) of studies while 73% (11 out of 15) of studies in developing revealed the public fulfilled.

Conclusion:

Based on the review’s results majority of individuals held a perception that was positive in regard to pharmacist’s services as well as positive results at professional pharmacists.  This therefore generates a good suggestion on that there is a great requirement to provide training to the public about the functions, their responsibilities and the services that they offer.  This will therefore help in developing the relationship between pharmacists and the patients thus developing the role of the pharmacist’s thus enhancing patient’s fulfillments.

 

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• INTRODUCTION

            Health and life disciplines are a precarious area, mostly given its connection with the daily lives of people. In that line, Pharmacists have been much about connecting with the individuals in matters relating to their well-being. In a more general perspective, the role of the pharmacists is the role of being as health enhancers. However, the use of pharmaceutical services has been on the rise in the last few decades. The shift experienced has been from a typical view of a pharmacist being mere medication vender to a position where the public now a visions them as doctors. Revisiting the case of the changes of roles in the pharmaceutical environment, it is clear that the public perceives their services in a different point of view.

            The pharmacy services in most cases are the diagnosis of treatment, administration of care and disease prevention. Revisiting the case of the changes of roles in the pharmaceutical environment, it is clear that the public perceives their services in a different point of view. The National Health Service (NHS) England currently has a strategy, the Five Year Forward View, of improving the state of the pharmacy services in the case of pharmacists oversupply, shortage of general practitioners and improved cost effectiveness formulated that much cause of action had to be undertaken in line with better health care service provision. In line with studying the experience of patients and their perceptions towards the pharmacy services, it is critical to conduct an intensive review using the baseline data. Then baseline data should give the experiences of people, attitude, and expectation before the implementation of the NHS strategy and later check the differences arising there from the implementation of the plan ("The National Health Service Five Year Forward View ", 2014).

Guirguis et al., (2005) postulates that further studies support the increasing involvement of pharmacists in the broader healthcare setting will demand transitions in behaviour by pharmacists and the general public as a whole. Other researchers continue to show and support that attitudes, beliefs and views made a dominant part of practice as postulated by Jose et al., (2015).  In that case, there was a need to look at the attitudes of consumers on the healthcare setting mostly pharmacists and pharmacy in addressing persons medical needs.

1. Objectives

The main objective of the review was to scrutinize and observe the ideas, viewpoints, perspectives, and beliefs of the public concerning pharmacy as a field and pharmacists as having medical roles. This systematic review identified that consumers and the pharmacists do have significant roles and specific responsibilities in their relationship, also depicted as a patient pharmacist professional relationship. It is at this point that the satisfaction of the consumer has been an essential component healthcare service. Sightseeing the public awareness helps both in decision making among the pharmacists and pharmacy services as well as assists in improving the patient’s pharmacologist’s relationship. This will therefore ensure that a direct relationship is developed among the patients and pharmacists services and roles. It is important to develop adequate understanding of the perception held by the public in regard to pharmacists and their roles.  With this reason the systematic review is highly necessary because it is a section that not only provides investigations insights but also detailed analysis which will help in developing healthcare experience.

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2. Methods

            A systematic evaluation of the existing research evidence will discourse the question ‘What are the public perceptions of pharmacy, pharmacists and pharmacy services?’ through the utilization of a descriptive examination method. Three electronic databases used in this review MEDLINE (PubMed), Scopus and the Cochrane Library. They identified all relevant articles published in English from January 2000 until December 2015. Furthermore, the search engine Google Scholar, which provides a broad search of academic articles from sources including theses, books and abstracts used to identify the papers published online that are not identified by the databases. In addition, a hand-search done using the bibliographies of the articles found from the electronic database searches. Also as part of the methods, there were two techniques in selection and extraction studies used to assess all articles that were found then applied the Critical Appraisal Skills Program (CASP) tools to examine the quality appraisal for the studies included in this review.

2.1.   SEARCH STRATEGY

The following combination of search terms used in the search strategy with each database: (“public” OR “consumers” OR “patients” OR “clients” OR “customers” OR “users”) AND (“perception” OR “belief” OR “attitude” OR “view” OR “satisfaction” OR “expectation” OR “opinion”) AND (“pharmacy” OR “pharmacist” OR “pharmaceutical service”) AND (“pharmacist” OR “pharmacists”) AND (“hospital” OR “community).

2.2.   Inclusion Criteria

            The inclusion criteria for this review are: 1) quantitative and qualitative primary research papers, 2) any papers looking at the public perception of pharmacy or pharmacists or pharmacy services, 3) papers written in the English language, 4) full text available, 5) papers related to studies in humans aged 19 and above.

2.3.   Study Selection and Data Extraction

There are two different techniques used to examine the articles that were found. First, the author identified, screened articles that retrieved from searching database, and scanning the title and abstract: The titles and abstracts screened against the inclusion criteria. Studies excluded based on titles, abstracts and removal of duplicates that did not related to the public perception of pharmacists and pharmacy services. Second, reading and assessing the full text articles if the abstract provide insufficient details then potential relevant papers identified and screened for eligibility. Studies excluded based on full text screening and that did not related to the public perception of pharmacists and pharmacy services. Finally, the number of articles used and include in the systematic review was 25 articles in total (figure 1).

Figure 1: Study selection process.

 

 

 

 

 

 

 

               

 

 

 

2.4.   Assessing Quality

To assess the quality of selected articles in this review, papers screened against the appropriate Critical Appraisal Skills Program (CASP) checklist and tools that have been validated, to ensure that studies are assessed and critically appraised in a standardized way. Relevant studies included in the review and analysed to form conclusions on the cumulated results. There were 10 studies in developed countries assessed and critically appraised based on Critical Appraisal Skills Programme (figure 2) while 15 studies in developing countries assessed and critically appraised based on CASP tools (figure 3). The Consolidated Standards of Reporting Trials (CONSORT) is a method of assuring proper reporting of Randomised Controlled Trials (RCTs). However, the CASP tools used for assessing the quality of selected articles because it assess the quality of various type of studies such as RCTs, qualitative and quantitative, so the CASP consider as a comprehensive quality appraisal tools for this review.

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Figure 2: Quality appraisal of 10 studies in developed countries based on Critical Appraisal Skills Programme (CASP).

Studies Retrieved for Quality Appraisal		Appraisal Criteria
		Was there a clear statement of the aims of the research?	Is a methodology appropriate?	Was the research design appropriate to address the aims of the research?	Was the recruitment strategy appropriate to the aims of the research?	Was the data collected in a way that addressed the research issue?	Has the relationship between researcher and participants been adequately considered?	Have ethical issues been taken into consideration?	Was the data analysis sufficiently rigorous?	Is there a clear statement of findings?	How valuable is the research?
Developed Countries	1.      Abukres 2014
	2.      Bishop 2015
	3.      Cavaco 2005
	4.      Franic 2008
	5.      Kelly 2014
	6.      Kwan 2008
	7.      Latif 2013
	8.      McMillan 2014
	9.      Saramunee 2015
	10.  Wirth 2010

Y= “Yes available” ; N= “Not available” ; V= “Valuable” ; NV= “Not valuable

 

Figure 3: Quality appraisal of 15 studies in developing countries based on Critical Appraisal Skills Programme (CASP).

Studies Retrieved for Quality Appraisal		Appraisal Criteria
		Was there a clear statement of the aims of the research?	Is a methodology appropriate?	Was the research design appropriate to address the aims of the research?	Was the recruitment strategy appropriate to the aims of the research?	Was the data collected in a way that addressed the research issue?	Has the relationship between researcher and participants been adequately considered?	Have ethical issues been taken into consideration?	Was the data analysis sufficiently rigorous?	Is there a clear statement of findings?	How valuable is the research?
Developing Countries	1.      Al-Arifi 2012
	2.      Al-Hassan 2009
	3.      Alotaibi 2015
	4.      Bawazir 2004
	5.      Bezverhni 2010
	6.      Catic 2013
	7.      Chen 2012
	8.      El Hajj 2011
	9.      Jayaprakash 2009
	10.  Jin 2014
	11.  Jose 2015
	12.  Oparah 2006
	13.  Rayes 2014
	14.  Saw 2015
	15.  You 2011

Y= “Yes available” ; N= “Not available” ; V= “Valuable” ; NV= “Not valuable”

 

3. Result

            The results of the systematic review about Public perception of pharmacists and pharmacy services are developed through quantitative and qualitative research methods in both developed and developing countries. There were a total of twenty five studies met the inclusion criteria with a pharmacists’ role and pharmacy services outcome measure that was reported as final outcome. There were a total of 37 studies which evaluate the pharmacists’ role and pharmacy services and met the design criterion; however, 12 articles that equivalent (35%) of these did not report any public perception of pharmacists’ role and pharmacy services thus were not included in the review (figure 1). The outcomes of the research on the attitude of the public on pharmacy attendants and pharmaceutical service in developed and developing counties are obtained through structured, semi-structured or across sectional study techniques.  Forty percent (10 out of 25) of studies conducted in developed countries while sixty percent (15 out of 25) of studies conducted in developing countries.

3.1.   Study Design

            In the study design of the twenty five studies, 32% (8 out of 25) of studies used to derive the outcomes through qualitative approach while 68 % (17 out of 25) of studies used to derive the outcomes through quantitative approach. In developed countries, the study design used to derive the outcomes was through 50% (5 out of 10) of studies quantitative approach, 40% (4 out of 10) of studies qualitative approach and 10% (1 out of 10) of studies mixed method (quantitative and qualitative). In the developing countries, the study design used to derive the outcomes was through eighty percent (12 out of 15) of studies quantitative and twenty percent (3 out of 15) of studies qualitative approach (figure 4).

3.2.   Study Aim

In the study aim of the twenty five studies, six studies (24%) assess pharmacists’ role and pharmaceutical services, eight studies (32%) evaluate pharmaceutical services as health care provider and eleven studies (44%) evaluate pharmacists as having medical roles. According to the study aim used to assessing pharmacy services and pharmacists’ role, there were 40% (4 out of 10) of studies conducted in developed countries while 13% (2 out of 15) of studies in developing countries (figure 4).

3.3.   Public Satisfaction

            Table 1 illustrate the twenty five studies used in the systematic review. The outcome expressed based on the satisfaction, expectation and perception of the customers and patient towered pharmacists’ role and pharmacy services in developed and developing countries. In both developed and developing countries, 60% (15 out of 25) of studies demonstrated the satisfaction of public perception towered pharmacists’ activities and pharmaceutical services while 40% (10 out of 25) of studies illustrated the dissatisfied of public expectation overlooked pharmacists’ role and pharmacy services. However, the fulfilment of public expectation towered  pharmacists’ role and pharmacy services in developed countries was 40% (4 out of 10)  of studies while 73% (11 out of 15) of studies in developing showed the public fulfilled. On the other hand, the dissatisfaction of public perception overlooked  pharmacists’ role and pharmaceutical services in developed countries was 60% (6 out of 10)  of studies whereas 27% (4 out of 15) of studies in developing revealed the public dissatisfied (figure 4).

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Figure 4: study design, aim and finding of 25 studies included in the systematic review

 

Table 1: Summarize of 25 studies for developed and developing countries in the systematic review

Developed Countries
No.	Publication details	Country	Study aims	Study design and participant details	Key findings	Public perception of pharmacy and pharmacists	Comments on key findings    and study limitations
1						The CD model portrays a high degree of acceptance from its users. The importance of model is that it could facilitate the process of supply of medication to the sick persons. Moreover, there could be an alleviation of the negative consequences which resulted by the therapy interruption.
2							The restriction for the success of this model is on the basis that there lack a coordinated approach to health care. That positive relationship advocated is hard together, in that instance, there is a need for patient education on the pharmaceutical services’ importance.
3							Localised qualitative study therefore no knowledge of prevalence of perceptions; findings should not be extrapolated to the Portuguese population. Minimum involvement in therapeutic process; pharmacists need to genuinely and effectively respond to patients’ needs; professional fee for service might improve public image.
4					Approximately half of the study respondents were unfamiliar about pharmaceutical care term after they asked for the meaning of this term. In case of pharmacies’ services and practices, the majority of respondents observed their pharmacist fill their prescriptions and check it for accuracy and safety. Moreover, clinical services available such as blood pressure monitoring and that available convenience services include drive-through window.
No.	Publication details	Country	Study aims	Study design and participant details	Key findings	Public perception of pharmacy and pharmacists	Comments on key findings    and study limitations
5	Kelly DV, Young S, Phillips L, Clark D. Patient attitudes regarding the role of the pharmacist and interest in expanded pharmacist services. Canadian Pharmacists Journal : CPJ = Revue des pharmaciens du Canada : RPC. Jul 2014;147(4):239-247.
6	Kwan D, Boon HS, Hirschkorn K, et al. Exploring consumer and pharmacist views on the professional role of the pharmacist with respect to natural health products: a study of focus groups. BMC Complementary And Alternative Medicine. 2008;8:40.
7							Need for inter-professional culture change and visible collaboration. Limitations include unknown a) extent of transferability of findings; b) long-term impact of advice. Study of 1 specific service not exploring public perception overall. Success of future services based on public understanding or pharmacist’s role, perceived hierarchy of health services & patients’ experiences.
8	McMillan SS, Kelly F, Sav A, King MA, Whitty JA, Wheeler AJ. Consumer and carer views of Australian community pharmacy practice: Awareness, experiences and expectations. Journal of Pharmaceutical Health Services Research. 2014;5(1):29-36.
No.	Publication details	Country	Study aims	Study design and participant details	Key findings	Public perception of pharmacy and pharmacists	Comments on key findings    and study limitations
9							The public is interested in taking up pharmacy public health services, and pharmacists must consider barriers if uptake of services is to increase. A limitation in the study is generalisation of the findings to the wider population could be limited and the social desirability for those that the interviewer assisted.
10	Wirth F, Tabone F, Azzopardi LM, Gauci M, Zarb-Adami M, Serracino-Inglott A. Consumer perception of the community pharmacist and community pharmacy services in Malta. Journal of Pharmaceutical Health Services Research. 2010;1(4):189-194
Developing Countries
No.	Publication details	Country	Study aims	Study design and participant details	Key findings	Public perception of pharmacy and pharmacists	Comments on key findings    and study limitations
11							To improve the patient satisfaction with pharmacists’ role as health care provider it recommend appointing of at least one pharmacist in each community pharmacies for only consultations, and augment the pharmacists for studying extra course in pharmaceutical care. Also, there is need to provide drug information in patient centred manner. Pharmacists need to reach out to patient, assess their hesitations and promptly offer solution that appreciated by patients as survey indicates.
No.	Publication details	Country	Study aims	Study design and participant details	Key findings	Public perception of pharmacy and pharmacists	Comments on key findings    and study limitations
12	Al-Hassan MI. A survey on consumer need and opinion about the community pharmacists in Riyadh, Saudi Arabia. Journal of Medical Sciences. 2009;9(1):36-40
13					72% of consumers think that pharmacists are not committed to dispense medications with prescription. Almost half of the consumers (48%) feel embarrassed when they speak with the pharmacist regarding their health. A large number of the consumers (48%) believed that pharmacists in community pharmacies did not give enough counselling about their medications. Finally, (26%) of consumers believed that they encountered a dispensing error earlier.
14							The act of creating a private area for discussion served as a real instrument of seeking confidential health matters in the pharmacy. The limitation is that the pharmacists have been omitted whereas they could give out essential information on service provision.
15							There is big gap between expected and provided information about medicines. There are no major barriers in implementing pharmaceutical services but pharmacists are not very optimistic about this.
16							There is still room for improvement of relationships and pharmaceutical services. This first study conducted in field of public perception of pharmacists and pharmacy services and the relationship between pharmacist and patients which can be used as bias for the further research in this field.
No.	Publication details	Country	Study aims	Study design and participant details	Key findings	Public perception of pharmacy and pharmacists	Comments on key findings    and study limitations
17						A majority of respondents were less than positive perceptions toward community pharmacists; however, their responses revealed some level of awareness of the services that pharmacists may be able to provide, trust of pharmacists and satisfaction with services provide by pharmacist
18			Assess the public’s attitudes towards community pharmacist’s role. Investigate the public’s use of community pharmacy and determine the public’s views and satisfaction with community pharmacy services.
19							Making attendance to continue education program a mandatory for the renewal of licence for pharmacists. The public should be educated on the role of pharmacists to know what to expect from them. A limitation of the study is that the views expressed may not be generalized for large population of Bangalore as the study conduct only in northern of Bangalore.
20							The public should be educated on the role of pharmacists in the health care systems by focusing on how services provided by the pharmacists can add improvement to general public health.  A limitation of the study is that the results cannot be generalised for only 3 cities out of 4 were involved, only the public that came to the pharmacy within the 4 hour data collection period were considered the respondents and the lack of an electronic database made the study tiring.
No.	Publication details	Country	Study aims	Study design and participant details	Key findings	Public perception of pharmacy and pharmacists	Comments on key findings    and study limitations
21	Jose J, Al Shukili MN, Jimmy B. Public's perception and satisfaction on the roles and services provided by pharmacists - Cross sectional survey in Sultanate of Oman. Saudi Pharmaceutical Journal : SPJ : Nov 2015;23(6):635-641.
22	Oparah AC, Kikanme LC. Consumer satisfaction with community pharmacies in Warri, Nigeria. Research in Social and Administrative Pharmacy. 2006;2(4):499-511.
23	Rayes IK, Hassali MA, Abduelkarem AR. A qualitative study exploring public perceptions on the role of community pharmacists in Dubai. Pharmacy Practice 2014;12(1):363.
24	Saw PS, Nissen LM, Freeman C, Wong PS, Mak V. Health care consumers’ perspectives on pharmacist integration into private general practitioner clinics in Malaysia: A qualitative study. Patient Preference and Adherence.2015;9: 467-477.
25							Awareness should be created on how patients can perform self-care on themselves and the role of pharmacists in self-medication and self-care.  The government should consider developing doctors-pharmacists partnership programs in the community, enhancing the role of pharmacists in primary care. The limitation was the description of self-care activities in the survey inadequate

 

4. Discussion

            The level of relevance attached to pharmacy and pharmacists seems unexpectedly not in tandem with the global acceptance and usage of health services when an evaluation is made to determine the perception people in developed and developing nations have regarding pharmacists’ role and pharmacy services. A key objectives of this paper are to help improving the pharmacists’ role and pharmacy services, the patients-pharmacists relationship, and the overall healthcare systems. The question is what are the public perceptions of pharmacy, pharmacists and pharmacy services?

In the developed countries the percentages of qualitative and quantitative studies were almost equal.  They assessed public perception by statistical and psychological methods to cover their whole perception. However, 80% of the studies were quantitative and 20% qualitative in terms of the developing countries. This shows a need of improvement for the qualitative methods in developing countries because the qualitative technique gives emphasis on the issues and subjects covered can be evaluated in depth and in detail. In addition, the data in qualitative approach depends on human experience and this is more compelling and powerful than the data collected through only a quantitative technique. There is a possibility that the quantitative methods are higher in developing countries due to illiteracy and the rapid rhythm of life for the population (Al-Arifi, 2012). Moreover, the population in these countries do not value the technique of qualitative and psychological method, so if they were to have more qualitative studies then we can assess this percentage of satisfaction carefully.

In the developed countries 40% of studies assessed both pharmacists’ roles and pharmacy services while only 13% assessed the pharmacists’ activities and pharmaceutical services in the developing countries. This shows a lack of studies that evaluate both pharmacists’ roles and pharmacy services together in developing countries which means a lot of studies needs to be done to measure the public perception precisely. For instance, in Saudi Arabia there are four studies conducted to assess the public perception towered pharmacist and pharmacy services. 3 out of 4 evaluate pharmacists’ role while only one study assess the pharmacy services. Two-third studies that assessing the pharmacists’ activity showed the satisfaction of public perception while the studied evaluate pharmacy services revealed the unfulfilled of consumers perception (Al-Arifi, 2012; Al-Hassan, 2009; Alotaibi & Abdelkarim, 2015; Bawazir, 2004). This is verify the importance of doing both pharmacists’ roles and pharmacy services together when evaluate the public perception in developing countries.

In the developed countries, the satisfaction of public perception was low (40%) while 60% of public in developed countries were not satisfied. It is important to understand that some developed countries may have proper health care system but may have lack proper channels to administer the services (Latif, Boardman, & Pollock, 2013; Saramunee et al., 2015). For example, United Kingdom has very advanced medicine field but one of the setback arising is shortage of general practitioners which translates into poor services. Also, public know what the pharmacists’ role and responsibility should offer and the pharmacy services that should be delivered. This kind of limitation in services and high level of public education creates a negative perception of the people towards the health care system in general and pharmacists’ role and pharmacies’ services in specific (Latif et al., 2013). Therefore, it is important to improve the patients-pharmacists relationship, and develop community pharmacists as primary care practitioners.

In the developing countries, the satisfaction levels were high (73%) due to the pharmacists did not only give the base features of a “vendor” by giving dosage only, but they go an upper hand by formulating a positive interaction with the patients. Interaction created leads to the build-up of the new opinions which in the long run is crucial in promoting the quality of the service provision. These goes further and create a positive perception of the consumers to their facilities, so the public in this case were not know exactly what the pharmacists’ role and the services they should offer (Al-Arifi, 2012; Jin et al., 2014). Therefore, no wonder in developing countries the satisfaction derived from the pharmacies’ use and services provided goes to an extent of (73%) acceptability, so there is need to educate the public about the role of pharmacists in health care systems and the services that should be delivered. On the other hand, (27%) of public in developing countries were unfulfilled. This is because some studies indicated that pharmacists have had a history of confidentiality problems when handling health information from the public (Al-Hassan, 2009; Bawazir, 2004). In addition, some developing countries, for example Moldova, has number of pharmacists very small, so this inhibits their operation and limit number of people can access their services (Bezverhni, 2010). This can be solved by increasing the number of pharmacists to a suitable ration with the statistical figure of the people and develop consultation area with more confidential and high privacy to patient.

4.1.   Strength and Limitation

            The main strength of this systematic review is the first review conducted in field of public perception of pharmacists and pharmacy services nationwide. However, the differentiation from country to others in health care system, education level of resident, public culture and status of life may consider as limitation.

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5. Conclusion

            The systematic review demonstrates public perception on pharmacists and pharmacy services across the globe. It has reveals the majority of public had positives perception regarding the services offered to them by the pharmacists as well as perception towered their profession although suggests that steps and initiatives to improve clinical skills and social relationships. Satisfaction, on the other hand, comes to the act pharmacies embracing new actions which make the services better such as the counselling. When such proactive measures are integrated into the healthcare provision, there is a likelihood of consumer getting the highest level of satisfaction. The result of this improved satisfaction is translated into a positive perception towards the pharmaceutical services. Lastly, the case on the expectation as highlighted on the paper is connected with a factor of attitude. It is noted that educated persons in the society have the belief of being more cautious in matters concerning their health care and the level of services should received. Therefore, there is dire need for public awareness that seek to educate populations on different aspects of pharmacist roles and functions. The above analysis surmises the review creating insight and adding knowledge on public attitudes and perceptions of pharmacy as a medical practice. Steps must be taken to enhance the administration's gave, relationship kept up and in this manner enhance the fulfillment of clients. Using the three forms outline on matters of expectations, satisfactions, and expectation, then a realization is understood on how various opinions are reached upon leading to either creation of a positive or a negative perception. This type of research would provide a solid foundation for future research in professional or stockholder perception of pharmacists and pharmacy services.

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            Acknowledgement

            Following, an intensive research period, writing my note of thanks is the completing touch of my thesis. This has been an intense learning period for me both in the research arena and at an individual level. Writing this research has thus made a huge effect on me.  I would therefore, wish to mirror on the individuals who assisted and supported me throughout the whole period.

            First, I would wish to thank all my colleagues from school for their great and lovely collaboration. It would be an ungrateful act to assume thank you supported me because you had too. Your support is well appreciated and it was of great help to me as you were all willing to help me at all times. In particular I would wish  to single out my research professor and supervisor, I want to thank you so much for your reliable  cooperation, support and for the general opportunities that you provided for me to perform my research and also to further my research project.

            Additionally, I would wish to thank my tutors, for offering their valuable knowledge as well as guidance.  Definitely you were great to me because you provided me with the necessary tools which I mostly needed in selecting an accurate direction.  This gave me the power to complete my research thesis without worry as the knowledge and power of working everything out was well exposed.

            Moreover, I wish to thank my parents for their general wise support, counsel as well as the sympathetic ear that they always landed to me. I would not have made it without your support as this is all that I needed during this period.  Finally, I cannot be done without thanking my friends. We did not only offer deliberate support to each other over the issued that we shared as well as findings but we were additionally involved in happy talks in regard to general things in exemption of the papers which made a huge impact based on the generated happiness.

To everyone, I say thank you.

            Funding

            This research did not receive any particular funding grants from agencies in commercial, public or from the profit generating sectors.