Abstract
Introduction:
The study focuses on healthcare delivery standards in Pakistan’s tertiary care hospitals. Poor accountability and a lack of financial and human resources are the main contributing factors to a hospital’s substandard performance and low patient satisfaction rates. Feedback surveillance forms are the Achilles tendon in the quality improvement of a facility, and this practice is, unfortunately, not widely practiced in the hospitals of Pakistan. Through this paper and experience, the authors hope to shed light on the need for regular feedback surveys and implementing their results to improve healthcare quality.
Settings and Design:
A prospective, observational study of seven tertiary care hospitals in Pakistan.
Materials and Methods:
The data was collected using a survey form. Each survey form was filled out by a team comprising three public health professionals who observed the hospital and its functioning without interfering with its workings. The questionnaire was developed with the help of Tools for Assessing the Operationality of District Health Systems: Health Facility Questionnaire designated in the respective facilities. The analysis was then draughted as a qualitative narrative review. Finally, the review was broken down into an assessment of the hospital’s outpatient clinic setting, inpatient department, emergency department and other departments.
Results:
The survey was conducted at seven public sector hospitals in three major cities of Pakistan. The survey focused on administrative and nonmedical parameters of healthcare facilities. Overall, the hospitals of Lahore and Islamabad lacked mass casualty apparatus and cleanliness, and staff behaviour can be improved. The hospitals in Rawalpindi have mass casualty apparatuses in place. However, they need improvement in accessibility services and hygiene and staff attitude.
Conclusions:
The survey showed that all the hospitals had good access and accessibility, and the directions were clearly marked for the visitors. The hospital staff is knowledgeable about the hospital, but their behaviour needs to be improved. Also, the quality of the cleanliness and waiting areas is fair but needs improvements. Finally, regular cheques via regular feedback and quality assessments can improve healthcare delivery.
Keywords: healthcare, low and middle-income countries (LMIC), nonmedical, patient-centred care
Introduction
Highlights
The study focuses on healthcare delivery standards showed that all the hospitals had good access and accessibility.
The hospital staff is knowledgeable about the hospital, but their behaviour needs to be improved.
The quality of the cleanliness and waiting areas is fair but needs improvements.
Regular cheques via feedback and quality assessments can improve healthcare delivery.
Quality improvement is significant to healthcare for better health system performance, higher patient satisfaction, and improved health outcomes. However, this facet has not been prioritised in low- and middle-income (LMIC) countries for reasons such as insufficient financial and human resources, a lack of infrastructure, and poor accountability1. The substandard healthcare services in LMICs result in ~5.7–8.4 million deaths annually1 and an extensive financial loss of $1.4–1.6 trillion annually1.
Pakistan has a Health Assessment Questionnaire (HAQ) index of 37.6, a 6-point increase in 6 years. Despite this increase, tertiary care hospitals in Pakistan lag behind neighbouring India, China and even Sri Lanka2. This data emphasises the need to improve the access to quality health services for all patients. To ensure this, tertiary care hospitals must focus on timely, efficient and equal health service delivery. Healthcare should also be patient-centred care and incorporate all aspects of patient safety3. Patient-centred care, or patient satisfaction evaluation, is when health service delivery meets the needs and expectations of the patients3. Globally, one in five hospitals in LMICs does not have sanitation services, one in six hospitals’ points of care does not have hand hygiene services, and one in eight does not even have water service1.
Like many tertiary care hospitals in developing countries, Pakistan lacks basic quality care amenities. Admission department factors such as the entrance, approach, general environment, vehicle and patient management are almost always overlooked. As a result, patients must suffer long waiting times, short consultations and poorly treated diseases adding to the population’s woes of receiving poor standards of care despite having to pay out-of-pocket.
The dilemma for patients concerning poor quality is further reflected in outcomes, such as the willingness to seek medical attention, adherence to treatment plans and follow-up, and referral of services to other patients. Another factor to consider is the socioeconomic disparity in healthcare provision. Most tertiary care hospitals in Pakistan come under the public sector. Private hospitals are known to provide a higher, more expensive standard of care. Approximately 25% of Pakistan’s population lives below the poverty line and is unable to afford treatment in the private sector2. This creates a significant divide in access to quality healthcare and affects Pakistan’s efforts toward universal health coverage. In addition, patient-centred quality surveys are rare in tertiary care hospitals in Pakistan.
This study entailed a cross-sectional survey to evaluate the administrative aspects of quality health service delivery in seven tertiary care hospitals in Pakistan. The hospitals were surveyed for their administrative care and the presence of specific nonmedical parameters.
The primary objective was to assess key quality indicators such as overall cleanliness, staff attitude, the level of care and everyday emergency services. Tailoring health services according to patients can help bridge the current access interface between hospital services in Pakistan and the community. There is widespread mistrust among the people due to the high incidence of avertible mortality and morbidity in the country due to inadequate medical facilities. The limitation of Pakistan’s healthcare infrastructure reiterates the need for facilities to function at maximum capacity. Not only will this improve the quality but also the resilience of the healthcare system.
Materials and methods
Study design
This was a prospective, observational qualitative study of seven tertiary care hospitals in three major cities of Pakistan. All the hospitals are located in Lahore, Rawalpindi and Islamabad. Hospitals A, B and C are public sector tertiary care hospitals in Lahore, consisting of 1030, 3000 and 1650 beds, respectively. Hospital D is a public sector hospital in Islamabad with 350 beds and 24/7 emergency services. Hospitals E, F and G are public sector tertiary care hospitals in Rawalpindi with 610, 750 and 864 beds, respectively. All the hospitals are multispecialty centres associated with medical education. The population served is primarily of low socioeconomic status. The primary outcome was to assess the quality of nonmedical administration and management services and patient care and the importance of regular quality cheques.
Our work has been reported in line with the strengthening the reporting of cohort, cross-sectional, and case–control studies in surgery (STROCSS) criteria3. Our study has been registered in the Research Registry having UIN researchregistry9235 https://www.researchregistry.com/browse-the-registry#home/registrationdetails/64a65858f800380026e6a4c8/.
Data collection and analysis
The data was collected using a survey form. The form contained six sections as follows: (i) Hospital entrance (ii) Approach, (iii) Environment (iv) Vehicle management (parking services), (v) Patient management and (vi) Emergency. This was followed by a rapid appraisal of the hospital interior and wards section and emergency preparedness. A designated team of public health professionals filled out surveys for each hospital. The results were then compiled and analysed qualitatively. The analyses were then draughted as a qualitative narrative review. Finally, the review was broken down into an assessment of the hospital’s outpatient clinic setting, indoor patient department, emergency department and other departments.
Seven hospitals in Pakistan were surveyed for their administrative care and the presence of specific nonmedical parameters. The hospitals are as follows:
A tertiary care public sector hospital in Lahore. This hospital will be referred to as Hospital A.
A second public tertiary care hospital in Lahore. This hospital will be referred to as Hospital B from here on out.
A third tertiary care public sector hospital in Lahore. This hospital will be referred to as Hospital C.
A tertiary care public sector hospital in Islamabad. This hospital will be referred to as Hospital D.
A second tertiary care public sector hospital in Rawalpindi. This hospital will be referred to as Hospital E.
A tertiary care public sector hospital in Rawalpindi. This hospital will be referred to as Hospital F.
A second tertiary care public sector hospital in Rawalpindi. This hospital will be referred to as Hospital G.
Results
It was found that all hospitals provided patients’ basic medical needs, including health services through the emergency, outdoor and indoor patient departments, along with other allied services like diagnostics, pharmacy and others. Since healing is a holistic process that requires other social determinants to influence health, it can be believed that it may be impacted if adequate nonmedical needs are unmet. The following paragraphs will discuss these parameters and their availability and quality.
Hospital entrance and admission setting
The accessibility of health services is a significant factor contributing to better utilisation of health services at any facility. The accessibility covers the terrane, the signboards or wayfinding signage, gate positions and parking facilities in the health facility. Results from the public sector tertiary care hospitals in Lahore showed that Hospital A had three out of four gates open and well-marked for entry. The main road provided good access, with adequate parking and security guards. Similarly, Hospitals B and C had all three of their respective gates open and offered easy access to entry with proper guards and vehicle parking. Of the two public sector tertiary care hospitals in Islamabad, Hospital D had two gates of entry and exit, both of which remained open and well-marked from the outside. They were also easily accessible from the main road with adequate parking and security guards. However, Hospital E only had one of its two gates open for use, and the entrance was poorly accessible due to obstacles preventing easy access. Nevertheless, both hospitals boasted good adequate parking facilities. In the tertiary care hospitals in Rawalpindi, Hospital F had both its gates available for use, while Hospital G only had two out of its five. However, both hospitals have easily accessible and marked entrances with proper parking facilities and security. For all seven hospitals, the admission facilities were good. The admission staff was knowledgeable about the process and the scope of the services covered in their respective hospitals. However, all seven hospitals lacked seating and waiting areas and did not provide information via multimedia systems.
Outpatient department
Despite having apparent signs and access to reception, the outdoor patient section of the Lahore-based hospitals, Hospital A, Hospital B and Hospital C, all lacked a counter for the elderly. Furthermore, in contrast to common cultural practices in Pakistan, sex segregation was not used in the OPD waiting room of Hospitals A and C. However, Hospital B did provide said segregation. Additionally, patients in all three hospitals reported that the OPD support workers did not treat them respectfully; however, when asked, the support staff helped them with their queries.
In the Islamabad-based public tertiary care hospitals, both had good signs and access to the outdoor department and reception. Similar to the Lahore hospitals, Hospital D did not have a separate counter for the elderly, nor did it have any sex-specific segregation. On the other hand, Hospital E boasted the availability of an old age counter and provided sex-segregated seating areas for patients and their attendants. The staff of Hospital E was friendly and provided all kinds of guidance and help as needed. Hospital D, similar to its Lahore counterparts, had staff that was unfriendly to the patients but did provide help and guidance as needed.
In Rawalpindi, Hospitals F and G showed the availability of a separate counter for the elderly and provided sex-based segregation similar to Hospital E. However, unlike Hospital E, Hospitals F and G had support staff that was not as friendly to the patients but did help and guide patients when asked.
An essential component of patient recovery is a healing atmosphere, which patients of most hospitals could not receive due to small sitting places, a lack of water and poor lighting and sanitation. Only Hospitals E and G could claim good OPD cleanliness and sitting areas. OPD services in all hospitals offered adequate fundamental doctor consultations. However, empathy in the form of active dialogue was not used. It is noteworthy, however, that despite the lack of a counter for the elderly in either hospital, the elderly were treated well and received some degree of protocol and special care once inside the doctor’s office.
Emergency department
Located in one of Pakistan’s most urbanized cities, Hospitals A, B and C provide emergency care services to their patients 24 h a day. The ground-floor location of all three emergency rooms provided convenient access from the main road and allowed adequate ambulance services to and from the emergency room. The emergency room was equipped with medications and supplies to give the patients emergent gynaecological, obstetrical, paediatric and medical care. However, the absence of an emergency surgical operating theatre in Hospital A meant that patients requiring surgical emergency care and operations were not accommodated and had to be referred. Likewise, there was no separate room in the hospital emergency department for burn patients, leaving them to be handled in the trauma room and susceptible to wound contamination and infection. Hospitals B and C did not have these problems as they enjoyed the facilities of both an emergency surgical operating theatre and a separate dedicated area for burn victims. The lack of mechanical ventilators in the emergency rooms of Hospitals A and B was concerning, but the presence of adequate remaining devices and tools ensured proper care of patients. Hospital C did have the availability of mechanical ventilators in the emergency department. However, the availability of instruments and tools depended on the doctors as they had to bring their own. Across all three hospitals, none of them had a designated mass trauma centre preventing the hospital from effectively handling any serious mass trauma casualty emergency.
Hospitals D and E faced similar problems despite being in the country’s capital. Unlike Hospital E, the emergency department of Hospital D was not on the ground floor, but the emergency department was easily accessible to both ambulances and patients. Similar to Hospitals A and B, the emergency departments of Hospitals D and E were well equipped with medications and supplies but also lacked a dedicated emergency operating theatre, separate burn centres, emergency ventilators and a mass trauma casualty centre, leaving it vulnerable to high-intensity emergency events.
Over in Rawalpindi, Hospital F and Hospital G had all the essential tools and instruments available. Neither hospital had the availability of an emergency surgical operating theatre or a burn area, but they both had the spaces and facilities to deal with massive casualty events. While Hospital F did not have mechanical ventilators in the emergency department, Hospital G did and provided critical care to patients as needed.
The emergency rooms of all seven hospitals did not have sufficient seats for patients and visitors and the restrooms were not kept clean. Overall, the level of hygiene was substandard, and the administration failed to offer hand-washing facilities but provided doctors with stations to use hand sanitisers. However, all hospitals boasted the presence of a capable staff of nurses and medical officers responsible for immediately tending to patients’ emergent needs. Storerooms and appropriate biochemical waste management facilities in Hospitals A, D, E, F and G allowed for standard cleanliness and proper sanitation. The availability of adequately sized areas designated for patient care coupled with easy access to a minor procedure room within all emergency departments allows for standard healthcare delivery to patients.
Inpatient department
The indoor facilities offered at all seven hospitals shared many similarities. All indoor departments were easily accessible from the emergency room, ICU and operating room, allowing for quick and seamless transfer of patients and managing care effectively. Emergency trolleys in the departments were heavily stocked with almost all life-saving medications and equipment. They were placed near the nursing counter, allowing quick access. The inpatient wards themselves were properly ventilated in most wards. Hospitals A and G had central heating and cooling, while Hospitals D, E and F had air conditioners and heaters, allowing a comfortable patient stay environment. Hospitals B and C, however, only utilised fans and no heating. The general cleanliness and lighting of the ward and restrooms were deemed inadequate in most hospitals, with only Hospital D and Hospital F having adequate and reasonable sanitation. These unwelcome factors in Hospitals A, B, C, E and G may lead to delayed healing and even hospital-acquired infections. This could inadvertently lead to lengthier hospital stays resulting in worse patient outcomes in morbidities, further overburdening the already burdened healthcare system. Of note are the poor condition of the bed and the facilities in Hospital C. These beds have been broken before and barely replaced, and as in the emergency department, the doctors also use their own essential apparatuses rather than having access to any hospital-placed instruments.
Other departments
To the pleasure of the observers, other departments aimed at improving patients’ health by enhancing their patient experience, diagnostics, pharmacies and other related departments, such as security, housekeeping and sanitary, were found to be delivering suitable services in all hospitals. In Hospitals A, B, C and E, while the fees and estimated cost of admitted stay were not mentioned, the other hospital procedures, policies and SOPs were displayed and brought to the patient’s knowledge. Hospitals D and F were better able to provide the patient’s family with an estimated cost of the patient’s stay in the hospital. Additionally, each patient in all hospitals received a unique identification number in accordance with patient safety guidelines allowing for streamlined test result documentation and transfer. Consent was obtained before hospital admissions and any procedure or operation. The general cleanliness of all hospitals was reported to have deteriorated in the passing times, which is paradoxical for a healing place.
Discussion
Modern-day medicine does not only entail the facilitation of medications and a bill of good health from the doctor. In today’s ever-evolving world, a holistic approach https://www.webmd.com/balance/guide/what-is-holistic-medicine covering medical and nonmedical aspects of healthcare is needed for proper patient care. Of course, medical elements such as doctors, apparatuses and medications are essential. Still, at the same time, nonmedical factors such as cleanliness, courtesy and facilitation of the old and the ill in a busy healthcare system are needed to ensure the proper return to health.
Over the course of our research, it was found that the participating hospitals were providing adequate medical care to their patients. The hospitals were almost fully stocked with the appropriate medications and instruments and most were ready to deal with everyday emergencies and inpatient and outpatient care. The absence of facilities for any mass trauma event was noted but can be explained by the inadequate funding these hospitals receive. However, for regular care, these hospitals were more than sufficient to provide care.
What was found to be majorly lacking was the nonmedical aspect of healthcare. For example, a lower standard of cleanliness in the wards and the restroom facilities provided by the hospital indicated a possibility of the system giving less importance to the cleanliness of areas. Another aspect that the teams noted during the data collection period was the habits of the patients and their attendants. Constantly showing nonadherence to rules and poorly complying with the trash bins and measures put in place by the institute, some degree of blame for the conditions in the hospital must be shared by the attendants of patients.
Additionally, the lack of hygiene in the ward may have been thought to be due to inadequate knowledge about hygienic practices and the importance of vector control via fomite cleanliness. However, in a study done by Aftab et al.4 in Karachi, it was shown that there is a gap between knowledge and practices among young doctors. This indicated that even though the doctors know about proper practices and are aware of the necessary protocols, they are not very careful with adhering to them, indicating a problem that must be addressed.
This nonadherence to cleanliness can be linked to the increasing incidences of hospital-acquired infections responsible for adverse clinical effects, as shown by a study done by Rampling et al.5 showing the incidence of hospital-acquired infections and their link to a lack of hygiene. Thus, the negative impact of the lower standards of cleanliness is easily visible and impresses further the need to be careful about every aspect of the healthcare that physicians and hospitals provide.
The other complaint of patients and their attendants were the discourteous and harsh treatment from the support staff. This lack of professionalism from the support staff and, at times, from the doctors was severely troubling. In a study by Van de Ven6, the patient’s overall hospital experience was significantly affected by their doctor’s attitude and the general courtesy of the staff. It only stands to reason that, like poor experiences with doctors, poor experiences with the support staff also significantly affect patients’ overall hospital visits6.
While unacceptable, this poor attitude could reflect a system that causes the support staff and, at times, doctors to discard a sense of professionalism7. Decreased emphasis on professionalism and courtesy during training curriculums for all personnel can be a cause for this behaviour, as shown in a study done by Jalil et al.7
In addition, working in immensely challenging conditions with a high patient load on an already overburdened system and working with little respite and poor financial compensation may have led many of the support staff to feel fatigued and burnt out, further leading to behaving this way8. Also of note is the possible need for more education among the support and ancillary care regarding the nonmedical aspects of healthcare.
The authors of this article believe that the holistic approach to medicine is the correct way to deal with patients in today’s day and age. However, seeing that there are numerous areas for improvement in tackling the nonmedical aspects of medicine, the authors believe that proper quality surveys and feedback assessments can ensure the proper delivery of care9. Therefore, this article hopes to highlight its importance and encourage such a culture.
Recommendations
The authors of this article suggest that policies aimed at incentivizing and enforcing hygiene-centred rules should be implemented to increase adherence to hygiene practices. In addition, regular cleaning and maintenance of infrastructure should be conducted with a focus on improving conditions and improving and expanding the number of available medications and facilities in the hospital. Finally, regular assessments and cheques will also allow us to assess better which way and direction this change is occurring, and we recommend welcoming a culture of internal accountability.
The authors also recommend the introduction of additional support staff to alleviate the high stress and the adverse working conditions, as the removal of these factors may increase the positive attitude of the team towards the patients7.
Limitations
This study was done in only seven government hospitals, and the results and observations may not apply to the entire hospital population of Pakistan. Also, the difference in federal and Punjab government hospital funding may result in significantly different hospital conditions.
Conclusions
The survey showed that, all the hospitals had good access and accessibility and the directions are clearly marked out for the visitors. The hospital staff is knowledgeable about the hospital, but their behaviour needs to be improved. Also, the quality of cleanliness and waiting areas is fair but needs improvement Tables 1–3.
Table 1.
Result of administrative care and the presence of certain nonmedical parameters for Lahore Hospitals.
| Result table for Lahore Hospitals: | |||
| Characteristics | Hospital A | Hospital B | Hospital C |
| Hospital entrance and accessibility | Good and easy access | Good and easy access | Good and easy access |
| Signs outside of Hospital | Well demarcated | Well demarcated | Well demarcated |
| Signs inside of Hospital | Well demarcated and mapped out | Well demarcated and mapped out | Well demarcated and mapped out |
| Admission staff | Knowledgeable about hospital information | Knowledgeable about hospital information | Knowledgeable but needs to improve efficiency |
| Parking facilities | Excellent | Good | Good |
| Emergency department | |||
| Access | Easy ground floor access | Easy ground floor access | Easy ground floor access |
| Facilities | Present in good conditions | Present in good conditions | Present in good conditions |
| Procedure room | Present | Present | Present |
| Trauma OR | Absent | Present | Present |
| Apparatuses | Sufficiently present sans ventilator | Sufficiently present sans ventilator | Sufficiently present including ventilator |
| Medications | Sufficiently present | Sufficiently present | Sufficiently present |
| Mass casualty facilities | Absent | Absent | Absent |
| Inpatient department | |||
| Ward cleanliness | Fair. Can be improved | Fair. Can be improved | Poor |
| Apparatuses | Sufficiently present | Sufficiently present | Inadequate |
| Emergency drugs and facilities | Sufficiently present | Sufficiently present | Sufficiently present |
| Outpatient department | |||
| Access | Easily accessible | Easily accessible | Easily accessible |
| Cleanliness | Fair. Can be improved | Fair. Can be improved | Poor |
| Waiting area | Fair. Can be improved | Fair. Can be improved | Fair. Can be improved |
| Medical care provided | Excellent | Excellent | Excellent |
| Office conditions | Good | Good | Good |
| Staff behaviour | Needs to be improved | Needs to be improved | Needs to be improved |
| Diagnostic facilities | Sufficiently present | Sufficiently present | Sufficiently present |
| Pharmacy | 24/7 easy access | 24/7 easy access | 24/7 easy access |
| Security | Sufficiently present | Sufficiently present | Sufficiently present |
Table 3.
Result of administrative care and the presence of certain nonmedical parameters for Rawalpindi Hospitals.
| Result table for Rawalpindi Hospitals: | ||
| Characteristics | Hospital F | Hospital G |
| Hospital entrance and accessibility | Good and easy access | Poor access |
| Signs outside of Hospital | Well demarcated | Poorly visible |
| Signs inside of Hospital | Well demarcated and mapped out | Fairly demarcated and mapped out |
| Admission staff | Knowledgeable about hospital information | Knowledgeable about hospital information |
| Parking facilities | Good | Good |
| Emergency department | ||
| Access | Easy ground floor access | Easy ground floor access |
| Facilities | Present in good conditions | Present in good conditions |
| Procedure room | Present | Present |
| Trauma OR | Absent | Absent |
| Apparatuses | Sufficiently present sans ventilator | Sufficiently present including ventilator |
| Sufficiently present | ||
| Medications | Sufficiently present | Present |
| Mass casualty facilities | Present | |
| Inpatient department | ||
| Ward cleanliness | Fair. Can be improved | Fair. Can be improved |
| Apparatuses | Sufficiently present | Sufficiently present |
| Emergency drugs and facilities | Sufficiently present | Sufficiently present |
| Outpatient department | ||
| Access | Easily accessible | Easily accessible |
| Cleanliness | Fair. Can be improved | Good |
| Waiting area | Fair. Can be improved | Fair. Can be improved |
| Medical care provided | Excellent | Excellent |
| Office conditions | Good | Good |
| Staff behaviour | Needs to be improved | Needs to be improved |
| Diagnostic facilities | Sufficiently present | Fair. Can be improved |
| Pharmacy | 24/7 easy access | Fair. Can be improved |
| Security | Sufficiently present | Sufficiently present |
Table 2.
Result of administrative care and the presence of certain nonmedical parameters for Islamabad Hospitals.
| Result table for Islamabad Hospitals: | ||
| Characteristics | Hospital D | Hospital E |
| Hospital entrance and accessibility | Good and easy access | Poor access |
| Signs outside of Hospital | Well demarcated | Poorly visible |
| Signs inside of Hospital | Well demarcated and mapped out | Fairly demarcated and mapped out |
| Admission staff | Knowledgeable about hospital information | Knowledgeable about hospital information |
| Parking facilities | Good | Good |
| Emergency department | ||
| Access | Fair first floor access | Easy ground floor access |
| Facilities | Present in good conditions | Present in good conditions |
| Procedure room | Present | Present |
| Trauma OR | Absent | Absent |
| Apparatuses | Sufficiently present sans ventilator | Sufficiently present sans ventilator |
| Medications | Sufficiently present | Sufficiently present |
| Mass casualty facilities | Absent | Absent |
| Inpatient department | ||
| Ward cleanliness | Fair. Can be improved | Fair. Can be improved |
| Apparatuses | Sufficiently present | Sufficiently present |
| Emergency drugs and facilities | Sufficiently present | Sufficiently present |
| Outpatient department | ||
| Access | Easily accessible | Easily accessible |
| Cleanliness | Fair. Can be improved | Good |
| Waiting area | Fair. Can be improved | Fair. Can be improved |
| Medical care provided | Excellent | Excellent |
| Office conditions | Good | Good |
| Staff behaviour | Needs to be improved | Good |
| Diagnostic facilities | Sufficiently present | Fair. Can be improved |
| Pharmacy | 24/7 easy access | Fair. Can be improved |
| Security | Sufficiently present | Sufficiently present |
Ethical approval
The ethical approval was obtained from the institutional ethical review board of HSA Hospital (Reference number: 197/ERC/HSA, dated 28 June 2022).
Consent
Consent obtained from all participants using Helsinki’s Declaration.
Author contribution
M.H.H., T.S., and Z.B.: substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; I.H.B. and Z.A.K.: draughting the work or revising it critically for important intellectual content; H.M.: final approval of the version to be published; A.A. and S.A.: agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Conflicts of interest disclosure
No conflicts of interest declared by the authors.
Research registration unique identifying number (UIN)
Name of the registry: Research Registry.
Unique identifying number or registration ID: researchregistry9235.
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Guarantor
Hassan Mumtaz.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Data availability statement
Available on request to corresponding author.
Acknowledgements
None.
Footnotes
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Published online 5 September 2023
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Associated Data
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Data Availability Statement
Available on request to corresponding author.