‘Tranq’: perceptions of xylazine and harm reduction practices among people receiving treatment for substance use disorders

Abstract

Background

Xylazine, commonly known as ‘Tranq,’ is a veterinary tranquilizer that is increasingly found in the recreational opioid supply, complicating the user experience. Xylazine-adulterated fentanyl is associated with a withdrawal syndrome that may not respond to usual treatment, and the opioid overdose reversal agent naloxone does not reverse the effect of xylazine.1 While it remains unclear whether xylazine directly increases overdose deaths, its presence in the drug supply likely elevates overall harm and morbidity. Moreover, due to unintended contact, xylazine poses an often unaccounted for danger to people who use drugs, and there is limited understanding of risk perception among people subject to xylazine exposure. The existing research indicates variations in the extent that individuals desire to use or avoid substances that contain xylazine.2, 3 This study aimed to evaluate how people who use drugs perceive their susceptibility to and severity of exposure to xylazine, and to assess how these perceptions impact their engagement in harm reduction behaviors.

Methods

We recruited people receiving treatment for substance use disorders at a community hospital. We used Spearman correlations to evaluate the associations between patient characteristics and perceptions of xylazine exposure are associated with harm reduction behaviors. The survey instrument was informed by the Health Belief Model.

Results

Over half of participants (26/49), estimated that at least some of the drugs that they use contain xylazine, and 73.5% believed that exposure to xylazine increased their risk of overdose. Approximately 65% of respondents reported never trying to obtain xylazine, and only 12.2% agreed or strongly agreed that they were more likely to use a batch of drugs if they knew it contained xylazine. Overall, engagement in harm reduction behaviors was limited, with 57.1%, reporting that they rarely or never carried naloxone when using drugs and 77.6% reported rarely or never testing their drugs before use. There was a positive association between the belief that xylazine increases the risk of overdose and engagement in harm reduction behaviors (Spearman Rho = 0.290, p = 0.043). Participants who identified xylazine in their drugs and modified their behavior as a result are significantly more likely to regularly practice overdose prevention behaviors.

Conclusion

Xylazine is increasingly present in the drug supply, yet susceptibility to exposure does not appear to influence engagement in harm reduction behaviors. Limited use and knowledge of test strips, as well as other overdose prevention behaviors, highlights the need for targeted harm reduction education. Healthcare providers in all practice settings should be aware of the potential risks posed by xylazine exposure and prioritize evidence-based care, including harm reduction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-025-01249-1.

Introduction

From 1999 to 2022, nearly 727,000 people died from opioid-related overdoses, including nearly 82,000 deaths in 2022 alone.4, 5 Although illicitly manufactured fentanyl is a driving factor, the emergence of xylazine in the recreational drug supply has raised significant public health concerns due to its growing association with overdose and morbidity. Xylazine, commonly known as “Tranq,” was originally synthesized in the 1960s as an alpha-2 adrenergic agonist. It is FDA approved as a sedative and analgesic for use in horses and Cervidae. In recent years, xylazine has been increasingly detected in the opioid supply across the United States, particularly in regions like Philadelphia, where it was involved in nearly 25% of overdose deaths reported in 2020.3 From 2018 to 2021, overdose deaths involving xylazine-adulterated fentanyl rose significantly in the United States, surging from 102 to 3,468.6.

Xylazine’s presence in the drug supply has been linked to complications including prolonged sedation, respiratory depression, and severe skin ulcerations. Despite the risks, many individuals who use opioids are unaware that xylazine may be present in the drugs they consume.7 Xylazine complicates overdose recognition, withdrawal syndromes, and may also reduce the effectiveness of naloxone.1, 8, 9 Additionally, xylazine reversal agents used in veterinary medicine (yohimbine, tolazoline, atipamezole) are not approved for human use and may provide limited benefit or cause harm.10 While it remains unclear whether xylazine directly increases overdose deaths, its presence in the drug supply likely elevates overall harm and morbidity To date, little is published regarding the appeal of xylazine amongst people who use drugs (PWUD). However, in a qualitative study that assessed PWUD’s firsthand experiences with xylazine, users reported undesirable sensations, fear of losing consciousness and awareness, and a harsh withdrawal syndrome.2.

Harm reduction (HR) strategies are critical in addressing many risks associated with illicit drug use including xylazine’s widespread and covert inclusion in the drug supply. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines HR as “an approach that emphasizes engaging directly with people who use drugs to prevent overdose and infectious disease transmission and improve overall wellbeing of those with substance use disorders.”11 One aspect of HR includes implementing strategies to reduce the risk of accidental overdose. Such strategies include not using substances while alone, carrying naloxone, using small or ‘test doses’ to determine drug potency prior to use, advocating for alternate routes of administration, and point of use drug testing to identify adulterants.12.

Evidence suggests that PWUD utilize HR supplies like fentanyl test strips to make informed decisions about substance use13 and similarly express interest in obtaining xylazine test strips to mitigate their risk.2 Xylazine test strips are not yet approved by the FDA; however, testing supplies are available via HR organizations in various parts of the country. A study in Massachusetts among members of the community and PWUD found that 50% of respondents were aware of xylazine and 65% expressed willingness to use xylazine test strips.14 Despite the heightened risk of overdose in the age of fentanyl, PWUD continue to exhibit limited engagement in HR practices overall.15 A qualitative study of women with opioid use disorder and substance use disorder treatment professionals revealed barriers to implementing HR practices, including a lack of HR education, communication, supply availability, and stigma.16.

Given the potential consequences of xylazine’s impact, it is essential to understand how PWUD perceive the risk of xylazine exposure and respond with HR behaviors. Using the Health Belief Model (HBM) as a framework, this study aims to assess the risk perceptions of xylazine among individuals undergoing inpatient treatment for substance use disorders and explore how these perceptions influence HR practices. By exploring these perceptions, the study hopes to inform best practices in delivering education to PWUD and healthcare providers caring for these individuals to reduce the overall incidence of harm associated with xylazine. We expect that our findings will contribute insights to the existing literature on the risk perception of xylazine among PWUD and whether susceptibility to xylazine exposure affects drug use behavior. Additionally, this paper addresses a new population in New York State and assesses in-depth information about xylazine. Our primary objective is to test the hypothesis that individuals who perceive a higher likelihood of encountering xylazine are more likely to engage in HR behaviors.

Materials and methods

This was a cross-sectional study conducted at a community hospital and approved by the Institutional Review Board. A novel electronic-based survey instrument was developed by the authors aimed at assessing knowledge of xylazine, exposure and/or use of xylazine, xylazine risk severity and susceptibility perception, xylazine seeking behavior, and engagement in various HR practices. The HBM served as the theoretical framework for survey item development.17 The HBM often serves as a framework for predicting health behavior change,18, 19 and posits that health behavior is influenced by individuals’ perceived susceptibility to and severity of a health threat, perceived benefits of and barriers to action, and self-efficacy.17 Survey questions were mapped to constructs of the HBM using similar phrasing as quantitative and qualitative literature assessing for PWUD’s risk perception of fentanyl.15, 20, 21 Demographics and past month substance use history was also collected. Eligible participants for this study were individuals over the age of 18 undergoing inpatient treatment for a primary diagnosis of opioid use disorder. Patients with a secondary substance use disorder, such as cocaine use disorder or alcohol use disorder, were included. However, individuals seeking treatment solely for alcohol use disorder were excluded. The treatment center offers detoxification from alcohol and recreational substances, with the option to participate in a 28-day rehabilitation program. The average length of stay in 2024 was 4.5 days for patients completing detoxification and 17.1 days for the rehabilitation program. Patients were identified for study eligibility with the assistance of the data-mining system Sentri7. Sentri7 is a web-based platform that aggregates and monitors patient data in real time.22 Informed consent was obtained prior to survey completion, which was voluntary, non-incentivized, and did not impact clinical care. The survey took approximately 10 min to complete and was administered on a tablet. The survey was completed privately by the patient and then returned to a member of the research team. Survey items were piloted with patients with opioid use disorder for face validity and adjusted prior to survey dissemination. Based on the feedback provided, several questions were removed, particularly questions that asked how individuals communicated with their drug suppliers, which were perceived to not align with participants’ experience. Data collection began in September of 2023 and concluded in August of 2024. From the beginning to end of the data collection period, 337 patients were admitted to the inpatient recovery center for detoxification. Of those 337 patients, Sentri7 identified 183 individual patients who met the criteria for survey inclusion over the time the survey was active.

Statistical analysis

Descriptive statistics were utilized to summarize demographic variables and frequency of engagement in HR behaviors. A total HR score was calculated by summing Likert-like items related to HR behaviors: “when using drugs, I carry naloxone,” “I make sure other people are around,” “I do a test dose,” and “I test my drug of choice.” These items were coded as follows: Always = 4, Usually = 3, Sometimes = 2, Rarely = 1, Never = 0, resulting in a total possible score ranging from 0 to 16.

Spearman rank bivariate correlations was used to examine the relationship between perceived threat of xylazine exposure and engagement in HR behaviors. Perceived threat was measured with two variables: perceived severity (i.e., “Exposure to xylazine increases my risk for overdose,” coded as Strongly Agree = 4, Agree = 3, Neither agree nor disagree = 2, Disagree = 1, and Strongly disagree = 0) and perceived susceptibility (i.e., “What percentage of the drugs that you use contains xylazine?” coded as All = 4, Over half = 3, Most (< 50%) = 2, Some = 1, None/ Don’t Know = 0). These variables were tested independently to assess their association with the total HR score.

We conducted independent sample t-tests to determine whether patients with higher engagement in HR behaviors, greater perceived susceptibility to xylazine exposure, or higher perceived severity of xylazine’s risks were more likely to change their behavior if they encountered xylazine by dichotomizing the following item: If you identified xylazine, or were told that a batch of drugs you purchased contained xylazine, what would you do? Answer choices were as follows: “Throw away the drug,” “Use less drug than usual,” “Use more drug than usual,” “Perform a test shot or dose,” “Change route of administration (i.e., snort instead of injecting),” “Use the drug as I normally would.” All answers other than “Use the drug as I normally would,” were coded as “Yes”– indicating a behavior change.

Lastly, we conducted statistical analysis on demographic characteristics and engagement in HR behaviors. Race was dichotomized into “white” or “non-white” categories, and we examined if patients who had previously experienced an overdose were more likely to engage in individual overdose protective behaviors. Statistical tests were performed in SPSS version 29.

Results

Forty-nine participants consented to take this survey. Characteristics of the survey participants are further outlined in Table 1. Most patients were between 25 and 44 years old and identified as white males. The majority had a lifetime history of treatment with medication for opioid use disorder and reported experiencing at least one overdose. Only four participants indicated that they had not heard of xylazine, or ‘Tranq’, and 38/49 answered ‘yes’ to the question “xylazine can cause severe skin ulcerations or lesions that can diffuse through the body”. Nearly 70% of respondents answered incorrectly (“yes”, or “I don’t know”) that xylazine works the same way as an opioid in the body. Most patients reported using multiple substances non-medically within the past 30 days, most commonly fentanyl and cocaine (smoked, inhaled). Insufflation and injecting into a vein were the predominant routes of administration.

Table 1.

Demographics and patient characteristics (n = 49)

	Number of participants
What is your age? n (%)
18–24  25–34  35–44  45–54  55–64	3 (6.1)
	21 (42.9)
	20 (40.8)
	4 (8.2)
	1 (2.0)
What is your gender identity? n (%)
Man  Prefer not to say  Woman	37 (75.5)
	1 (2.0)
	11 (22.4)
What is your race or ethnicity? n (%)
Black or African American  Hispanic or Latino  Middle Eastern or North African  Multiracial or Multiethnic  White  Other	2 (4.1)
	12 (24.5)
	2 (4.1)
	3 (6.1)
	28 (57.1)
	2 (4.1)
What is the highest level of education you have completed? n (%)
Did not graduate from high school  Graduated from high school  Some college  Graduated from college  Some graduate school  Completed graduate school	6 (12.2)
	12 (24.5)
	19 (38.8)
	9 (18.4)
	1 (2.0)
	2 (4.1)
What is your approximate individual income? n (%)
No income  $0-$24,999  $25,000-$49,999  $50,000-$74,999  Greater than $75,000  N/A	19 (38.8)
	11 (22.4)
	6 (12.2)
	8 (16.3)
	4 (8.2)
	1 (2.0)
What substances have you used non-medically in the past 30 days? n (%)
Fentanyl only  Fentanyl + stimulant  Fentanyl + benzodiazepine  Fentanyl + THC  Fentanyl + benzodiazepine + THC  Fentanyl + stimulant + THC  Fentanyl + stimulant + benzodiazepine  Fentanyl + stimulant + benzodiazepine + THC  Stimulant + benzodiazepine  Stimulant + benzodiazepine + THC  Stimulant only  Missing	5 (10.2) 6 (12.2) 4 (8.2) 7 (14.3) 2 (4.1) 5 (10.2) 5 (10.2) 6 (12.2) 3 (6.1) 1 (2.0) 3 (6.1) 2 (4.1)
What is your usual route of drug use? n (%)
Eat it or swallow it  Inject or shoot into a muscle  Inject or shot into a vein  Smoke  Snort	5 (10.2) 2 (4.1) 17 (34.7) 6 (12.2) 19 (38.8)
How frequently have you used your drug of choice in the past 30 days? n (%)
Less than once per day  1 time per day  2 times per day  3 or more times per day	5 (10.2) 3 (6.1) 3 (6.1) 38 (77.6)
Lifetime history of overdose n (%)
Yes  No  N/A	34 (69.4) 14 (28.6) 1 (2.0)

Survey responses assessing xylazine use and perceptions are displayed in Table 2. When asked what percentage of the drugs they used they believed contained xylazine, over half said at least some, while 19/49 were unsure. Seeking xylazine was rare, with 32/49 respondents reporting they never tried to obtain it, and 5/49 indicating they sought xylazine every time they acquired drugs. Additionally, only six respondents reported they were more likely to use a batch of drugs if they knew it contained xylazine. Overall, 36/49 respondents believed that exposure to xylazine increases the risk of overdose. When asked how often individuals had used xylazine, 12/49 reported daily use.

Table 2.

Survey responses on xylazine use and perceptions (n = 49)

	Number of participants
Have you heard of xylazine, or ‘Tranq’? n (%)
Yes  No	45 (91.8) 4 (8.2)
Xylazine works the same way in the brain and body as an opioid does n (%)
Yes  No  I don’t know	17 (34.7) 15 (30.6) 17 (34.7)
Xylazine can cause severe skin ulcerations or lesions that can diffuse throughout the body n (%)
Yes  No  I don’t know	38 (77.6) 1 (2.0) 10 (20.4)
What percentage of drugs that you use contain xylazine? n (%)
All  Over half  Most (< 50%)  Some  None  I don’t know	5 (10.2) 8 (16.3) 7 (14.3) 6 (12.2) 4 (8.2) 19 (38.8)
How often have you used xylazine? n (%)
Daily  1–6 times per week  1–4 times per month  A few times a year  Never  I don’t know	12 (24.5) 5 (10.2) 2 (4.1) 3 (6.1) 14 (28.6) 13 (26.5)
How often do you try to get drugs with xylazine? n %
Every time you get drugs  Most of the time  Sometimes  Rarely  Never	5 (10.2) 1 (2.0) 4 (8.2) 7 (14.3) 32 (65.3)
Have you ever heard of a xylazine test strip (a thin piece of plastic that can be dipped in the drug sample) that you can use to see if xylazine is in a batch of drugs before you use? n (%)
Yes  No	26 (53.1) 23 (46.9)
Exposure to xylazine is common among people who use heroin and fentanyl n (%)
Strongly agree  Agree  Neither agree nor disagree  Disagree  Strongly disagree	30 (61.2) 12 (24.5) 6 (12.2) 1 (2.0) 0 (0)
Exposure to xylazine increases my risk for overdose n (%)
Strongly agree  Agree  Neither agree nor disagree  Disagree  Strongly disagree	27 (55.1) 9 (18.4) 10 (20.4) 2 (4.1) 1 (2.0)
I am confident in my ability to detect xylazine when using drugs n (%)
Strongly agree  Agree  Neither agree nor disagree  Disagree  Strongly disagree	8 (16.3) 8 (16.3) 13 (26.5) 8 (16.3) 12 (24.5)
I am more likely to use a batch of drugs if I know it contains xylazine n (%)
Strongly agree  Agree  Neither agree nor disagree  Disagree  Strongly disagree	3 (6.1) 3 (6.1) 16 (32.7) 9 (18.4) 18 (36.7)
If you identified xylazine, or were told that a batch of drugs you purchased contained xylazine, what would you do? n (%)
Use the drug as I normally would  Use less drug than usual  Perform a test shot or dose  Change route of administration  Throw away the drug	15 (30.6) 11 (22.4) 3 (6.1) 2 (4.1) 18 (36.7)

Table 3 shows the distribution of each individual HR item. Over half of respondents, 57.1%, reported that they rarely or never carried naloxone when using drugs. Participants reported infrequently performing test doses and often used alone. Over half of the sample answered that they had heard of xylazine test strips, yet 77.6% reported rarely or never testing their drugs before use. In all, 4/49 respondents answered “never” to all four overdose reduction behaviors (total harm reduction = 0) indicating that 91.8% of the sample had performed at least one HR behavior at least rarely.

Table 3.

Response distributions on harm reduction behavior items (n = 49)

Survey question	Mean (SD)	Never (0)	Rarely (1)	Sometimes (2)	Usually (3)	Always (4)
When using drugs, I carry naloxone	1.6 (1.53)	34.7%	22.4%	8.2%	18.4%	16.3%
When using drugs, I make sure other people are around	1.67 (1.2)	20.4%	24.5%	28.6%	20.4%	6.1%
I do a test dose before using drugs (a small hit)	1.6 (1.71)	46.9%	8.2%	6.1%	16.3%	22.4%
How often do you test your drugs when using your drug of choice?	0.84 (1.26)	59.2%	18.4%	10.2%	4.1%	8.2%

Survey data did not support the hypothesis that increased perception of xylazine exposure (perceived susceptibility) would be associated with the increased engagement in overdose prevention behaviors (Spearman Rho = -0.124, p = 0.394). However, there was a positive association between the belief that xylazine increases the risk of overdose (perceived severity) and engagement in HR behaviors (Spearman Rho = 0.290, p = 0.043).

There was no correlation between overdose history and likelihood of using alone (p = 0.692, 95% CI: -0.743- 1.097). Additionally, participants who identified themselves as non-white were more likely to test their drugs when using their drug of choice (p = 0.009, 95% CI: 0.282–1.791).

We also assessed for a behavior change after identifying xylazine. Overall, 34 patients indicated they would change their behavior in this scenario, compared to 15 respondents who reported they would use the drug as they normally would. The group that chose to modify their behavior after identifying xylazine was significantly more likely to regularly engage in HR behaviors (p = 0.013, 95% CI: 1.2–5.98).

Discussion

Consistent with prior qualitative and quantitative research assessing PWUD’s experiences with xylazine,2, 23 our sample associated xylazine exposure with an increased risk of overdose and generally did not actively seek it out.24 Drug testing before use was infrequent in our sample, and carrying naloxone was inconsistent, with over half reporting that they rarely or never carried it when using drugs. These findings align with prior research on HR behaviors related to unintentional fentanyl exposure.25 We expect that our findings will contribute insights to the existing literature on the risk perception of xylazine among PWUD and whether susceptibility to xylazine exposure affects drug use behavior.

The low engagement with xylazine test strip usage is likely driven by a general lack of knowledge that the strips exist and their accessibility. This is evidenced by 53.1% of the sample reporting they had knowledge of the test strips. Another possibility for infrequent use of test strips is an assumption that the substance is present. This is often the case with fentanyl test strips as the recreational heroin market has become saturated with fentanyl,26 however, we are unsure if this reasoning applies to xylazine. Most of our sample reported using multiple substances, which is common among PWUD.27 Low naloxone carry rate may be more complex and affected not only by perceived susceptibility and severity, but also community naloxone distribution efforts and knowledge of how to use it.

Interestingly, 91.8% of our sample reported engaging in at least one HR behavior at least “rarely.” However, our study does not support our hypothesis that perceptions about the presence of xylazine in the drug supply impact engagement in HR behaviors. Instead, our findings align with prior work linking perceived risk of overdose (severity of harm) from adulterants in the drug supply (i.e., fentanyl) to engagement in protective behaviors.25 In other words, PWUD are not necessarily going to shift their behavior because they know a substance is in the drug supply, but protective behavior change is more likely if they perceive the prevalent drug to be dangerous.

Interventions should focus on increasing PWUD understanding of the potentially negative effects of xylazine exposure (e.g. increased dependence, wounds, overdose complications, etc.), not only that it is present in the drug supply. This analysis shows that individuals who perceive xylazine exposure to be dangerous are more likely to engage in HR behaviors. However, less than a third of patients surveyed agreed or strongly agreed that they were confident in their ability to detect xylazine when using drugs, further emphasizing the importance of reliable identification methods. Our results support the provision of xylazine test strips. Many of the study participants were not aware of the strips existence but reported that if they did have them and found that xylazine was in their drugs, they would change their behavior. A survey conducted among 293 PWUD in Ohio revealed that over 75% considered it very or extremely important to know whether xylazine was present in the substances they were using.28 Our results provide additional context to these findings by highlighting the potential behavioral impact of identifying xylazine. This demonstrates the need for increased efforts to inform PWUD about point of use drug testing and distribute test strips.

Inpatient substance use and detoxification treatment programs are ideally positioned to educate PWUD on HR techniques. Overall, engagement in substance use treatment services is low and return to use rates are high.29 However, prior work suggests that PWUD are generally receptive to HR services when offered in a hospital setting and reduce negative outcomes associated with substance misuse.30 Patients leaving treatment facilities after a period of abstinence are increasingly vulnerable to overdose,31 thus engaging in overdose prevention behaviors may be of an increased importance. The heightened risk of xylazine-related overdose or medical complications underscores the critical need for comprehensive HR education during inpatient care. Although HR education is needed for PWUD and healthcare providers, education alone may not be sufficient if HR supplies are inaccessible. One way to approach this disparity is to equip healthcare providers with not only the knowledge of HR techniques and principles, but also with point of use test strips, naloxone, and safe injection supplies. Hospitals who care for PWUD should advocate for onsite availability of HR supplies, and members of the treatment team can help patients obtain HR resources in the community. Many states have access to funding that provides HR supplies at no cost to the institution. Although patients receiving treatment for a substance use disorder in a hospital setting are a small fraction of those at risk to xylazine exposure, capitalizing on this point of contact as a controlled environment for HR education could set the tone for safer drug use at the time of discharge, potentially reducing mortality. Future longitudinal research that assesses the impact of HR interventions during inpatient treatment is warranted.

Limitations

There are some limitations to this study. First, our small sample size may limit the external validity of our findings. Additionally, participants were recruited from a single acute care treatment facility, meaning individuals were actively seeking treatment for their substance use disorder. Patients not seeking treatment may have differing opinions on xylazine. Because of this, our findings may not be generalizable to those not in treatment settings and are vulnerable to selection bias. Furthermore, it is possible that some participants surveyed were not informed about overdose prevention behaviors prior to survey administration, which may have influenced their responses. These limitations may affect the results because patients in different stages of treatment may have differing views on xylazine. Another limitation is the geographic area of the study. All patients assessed were based out of a hospital in New York State. The prevalence and awareness of xylazine may differ in other geographic regions.

Due to the cross-sectional design, we are unable to determine a causal relationship between the perceived threat of xylazine and drug use behavior. Further limitations of the cross-sectional design include the observational nature of the survey that was conducted at a single point in time. With additives and substances available to use frequently changing, this limits the applicability of this study. Moreover, the survey instrument did not assess participants’ current state of drug craving (i.e., withdrawal), which prior research in the era of fentanyl has shown to influence PWUD’s risk-involved behavior.32 Additionally, participants may have had differences in interpreting survey questions, which may further impact the generalizability of our findings. Specifically, the survey instrument did not provide a definition of ‘overdose,’ which may have led to varying interpretations among participants.

Conclusion

Xylazine is present in the drug supply, despite our sample generally not seeking it out. Most individuals associated xylazine exposure with an increased risk of overdose, but fear of encountering xylazine did not significantly influence engagement in overdose risk reduction behaviors. Knowledge of xylazine point of use test strips, as well as the practice of drug checking was limited. Educating individuals on the risks posed by xylazine, as well as informing on various HR techniques, are strategies to reduce harm associated with xylazine. Healthcare providers and those caring for PWUD in a hospital setting should be mindful of the added risks of xylazine and continue to offer evidence-based treatments for substance use disorders.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

A.S. prepared the survey instrument, performed data analysis, and wrote the manuscript with assistance from all authors. K.D. assisted with the implementing the theoretical model into the survey instrument, data analysis, and manuscript revisions. D.G. assisted with idea development and manuscript review / editing. A.A. assisted with manuscript writing. B.B. assisted with statistical analysis, manuscript writing, summative analysis, and manuscript revisions.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.