Abstract
Background
A Public-Private Partnership is commonly defined as a mutual partnership agreement between a public-serving organization and a private organization to strengthen capacity for either a singular need or aimed at larger systems strengthening. In Pakistan, several healthcare initiatives are planned to scale systems strengthening using this model, but there is a dearth of programs to support the women’s health workforce capacity. Although the volume of patients is high in public sector organizations, they have limited opportunities to develop their advanced clinical skills.
Objective
This study aims to explore the perceived impact of a one-year hybrid advanced clinical skill-building program based in three women’s healthcare subspecialities, including Maternal Fatal Medicine, Gynaeoncology, and Urogynaecology, for public sector AMC clinical faculty under the mentorship of private AMC faculty.
Methodology
Program evaluation was done using an observational study design to explore the program’s percieved impact and effectiveness, compare perceived competency scores, and gauge the experiences of the participants. The data was collected as part of their training using structured Google Forms, which had questions customized to explore the program’s effectiveness, with the written information that it will be used for scholarly and research purposes.
Results
All participants perceived the positive impact of the program on their clinical skills for detecting and treating cancers, including ovarian, endometrial, vulvar, and cervical cancer. They reported themselves as proficient in performing procedures like slings of SUI, Sacrospinous Fixation, Abdominal Sacropexy, and fistula repair. Overall, participants perceived that the program enhanced their skills pertinent to their subspeciality, acquired new knowledge, and found clinical mentorship supportive in applying theoretical concepts into practical skills.
Conclusion
This evidence showed a positive impact on subspeciality skills on women’s health management and knowledge of the participants enrolled in the program, highlighting the importance of Public-Private Partnership models for workforce capacity development. This could be one of the models if adapted in Pakistan and other lower-middle-income countries, that can yield benefits in bridging the skills enhancement gap that exists in the women’s health fraternity. However, the small sample size and self-reported data may limit the generalizability of the study’s findings, despite showing a model that can be adapted, implemented, and large-scale and longitudinal studies can also be planned around the same.
Keywords: Public private partnership, Faculty development, Maternal fetal medicine, Urogynaecology, Gynaeoncology
Introduction
Pakistan is the fifth most populous country, with a female population of 117.12 million [1]. There are multifaceted health challenges that are faced in the domain of women’s health [2]. Various factors build on these challenges, including climatic, social, and political conditions, fragmented health investments and policies, lack of resource allocation to health care facilities, lack of skilled staff, and limited opportunities for the existing workforce for their skill enhancement [3]. These barriers cannot be addressed alone by the efforts of the state institutions, hence there is a wide need to consider Public-Private Partnership models to ensure scalable efforts to improve the women’s health indicators [4]. A Public-Private Partnership (PPP) is commonly defined as an agreement between a private entity and a government entity to deliver quality services [5].
There is a dearth of skilled workforce to provide advanced care in women’s health, and there is also a significant lack of healthcare organizations that offer advanced clinical skill-building programs to the existing workforce [6]. Healthcare faculty working in public health sectors face various challenges in enhancing their clinical skills due to limited resources. At the same time, the trend in the private sector is different, as healthcare providers, such as women’s health faculty, have opportunities for capacity building, including faculty development awards in resource-rich countries, to advance their skill set. Moreover, the inequitable distribution of GDP for healthcare expenditures eventually leads to insufficient resources to meet national health needs. Therefore, in a low-middle-income country like Pakistan, the private health sector remains the largest provider of healthcare services, offering quality care.
Moreover, a lack of resources results in the provision of inadequate quality care delivery in the public sector. Additionally, the lack of a required healthcare workforce makes it difficult for healthcare professionals to manage their workload and capacity-building efforts due to patient volume and packed schedules. This situation leaves a major gap in the clinical skills of faculty working in the public sector. In this context, PPP stands as a great value and plays a crucial role in improving outcomes for the women’s healthcare workforce in academic medical centers (AMCs) through faculty mentoring and training models [7]. Academic medical centres are the hubs that integrate medical education, research, and advancements with patient care. In Pakistan, they are also known as tertiary care university hospitals [8].
A research study highlights the challenges women often face while receiving care, including the lack of required healthcare facilities, which result in maternal and perinatal mortality and morbidity [9]. The World Health Organization (WHO) defines maternal mortality ratio (MMR) as the number of maternal deaths during a given time period per 100,000 live births during the same time period [10]. However, the Current Maternal Mortality Rate (MMR) in Pakistan is reported to be 154 deaths per 100,000 live births [11]. Skilled healthcare professionals play a significant role in managing women’s health issues and improving overall health outcomes. A study reveals that 65% of pregnant women seek routine antenatal care & half of the pregnancy cases are handled by unskilled healthcare professionals, with a postpartum care-seeking rate of less than 50% [12]. These outcomes highlight the need to build healthcare workforce capacity and skills specifically for public sector hospitals in order to manage high-risk cases in women’s health to achieve better health outcomes. Similarly, there are also issues pertinent to general women's health, like anemia, obesity, reproductive health issues, and increasing cancers demanding more skilled workforce to meet the current and upcoming challenges.
A study conducted by Iroz et al. showcases that the Public–Private partnerships (PPP) Model is considered a significant pathway to improve the health and well-being of individuals in LMICs. PPPs in LMICs emphasize several key areas that require improvement, including the overall health status of the population through the provision of skills and knowledge, and through the capacity of the healthcare workforce. The private sectors are usually concerned with health service delivery, while the public sector deals with procurement and supply chain of equipment, medicines, and technical assistance [13].
On the contrary, there is a lack of research and authentic data, particularly focusing on building advanced clinical skills and Public Public-Private Partnership for Women Healthcare Workforce in Pakistan. Hence, the underlying reasons elaborate the focus to explore perceived effectiveness of the clinical skill building program offered in three subspecialty streams of women’s health, the perceived impact of the skill building program on participating faculty’s knowledge and skills, and to analyse the perceived evaluation of program effectiveness from participants’ viewpoint.
Research objectives
To explore the perceived before and after impact of the training program on the skills and knowledge enhancement of the participating faculty from the public sector AMC.
To investigate the reported evaluation of the training program.
Methodology
Design
Program evaluation was done using an observational study design to explore the program’s percieved impact and effectiveness, compare perceived competency scores and gauge the experiences of the participants. Data from the year-long hybrid training program were taken for this study. An advanced clinical skill-building program was offered by a highly recognized and advanced AMC in Pakistan in the private sector to a public sector AMC in Karachi.
Research setting
The participating institutions, both public and private sector AMCs, are known for their highest volumes to cater to the patients and offer all tertiary care level services on a university hospital pattern. Both the AMCs have well-structured ObGyn wards and faculty having FCPS (Fellowship of the College of Physicians and Surgeons with speciality in ObGyn). The private sector AMC have faculty who are trained from outside Pakistan on advance clinical skills whereas the public sector university did have limited training on advance clinical competencies pertinent to the three subspecialities of ObGyn.
Infrastructure of private sector AMC
The private sector AMC is a JCI-accredited medical center equipped with 560 beds, 122 private and 117 semi-private air-conditioned rooms, 251 General Ward beds, and 52 special care beds available in ICU, CCU, and NICU. The department of ObGyn alone constitutes 2 operating theatres and 110 beds in shared facilities.
Infrastructure of public sector AMC
On the other hand, the public sector academic medical centre is a tertiary care hospital with 2000 beds and 31 departments, including the Department of ObGyn. The department consists of 3 units with 60 beds each, 3 Operating Rooms, and 2 Emergency operating Rooms. The wards have 10 pre-op op 10 antenatal, 10 post-natal,10 post-op beds, and 10 beds in HDU. The department has been providing dedicated services for general gynaecology. The specialized services of women’s care needed a focused and more structured approach based on further advancements in skills and capacity building. In addition, a few essential surgical instruments were not available.
Study population and sampling
The participants were clinical faculty members of the public sector AMC working in ObGyn departments. Six clinical faculty members were enrolled as trainee/mentee faculty with two faculty in each subspecialty. The trainee faculty were MBBS with CPSP accreditation and enriched training with high case volumes and a practicing experience of over 10 years in local academic centres of Pakistan.
Data collection tool and method
The data collection tools were specifically designed using the Google Forms platform. They included basic details related to participants’ academic profiles, perceived competency in their respective sub-specialties, and reported program effectiveness. The academic profile tool captured educational qualifications and sub-specialty details. The perceived competency tool assessed sub-specialty-specific skills, with three categories to rate competency levels at the start and end of the program—beginning, intermediate, and proficient. The program evaluation tool included items related to participants’ reported effectiveness and satisfaction regarding the program’s structure, the effectiveness of observer ship and clinical mentorship, and how well the program supported their knowledge enhancement, hands-on practice opportunities, and areas for improvement. Data was collected through Google Forms. Since this was a program evaluation, no standard tool was used; instead, it was tailored to meet the program’s needs and shared with the ObGyn chairpersons of both the AMCs to assess its utility in line with the program’s objectives.
About the clinical skills building program
The clinical skills building program was designed by adapting the Analysis, Design, Development, Implementation, and Evaluation (ADDIE) model [14], which was done in five stages, and tailored to meet the needs of faculty from the public resource constraint settings:
Analyse: The team conducted a needs analysis to understand the capacity of the participating faculty, assess the infrastructure for the feasibility of case mix surgical mentoring, and institutional commitment for implementation.
Design: The program outline was designed and shared by the public sector AMC faculty participants for their review.
Develop: The program was then designed based on the requirements shared by the participating faculty members and was sent for review by the Department of Continuing Medical Education (DCPE) to explore its alignment with the Accreditation Council of Continuous Medical Education. Logbooks were designed to ensure that all data from clinical observations and mentorship are well-documented, including case debrief reflection entries.
Implement: The Program was implemented as a hybrid model of building capacity for one whole year. The details are presented in Table 5 in Appendix.
Evaluate: At the end of the program, an effectiveness and skill enhancement survey was conducted among the participants.
Statistical analysis
We analyzed the data using the Statistical Package for the Social Sciences (SPSS). Measures of central tendency were used to explore the trends, and to explore the difference between the pre- and post-test.
Ethical consideration
The study obtained a standard. Ethical approval from the Institution’s Ethical Review Committee (ERC No. 2025–10161−33677). Informed written consent from each participant was taken, in which they were provided information about the purpose, potential benefits, and voluntary nature of participation. Unique identifiers were given to each participant to ensure confidentiality and anonymity. Also, participants were clearly informed regarding their voluntary participation, withdrawal from the study at any time during the study.
Results
Overall, participants across all three sub-specialities, Gynae-oncology, Urogynaecology, and Maternal Fetal Medicine, reported a self-perceived increase in impact and proficiency in their clinical skills after this program.
In the gynaecology group, participants reported themselves as proficient in clinical skills for detecting and treating ovarian, endometrial, vulvar, and cervicalcancers after receiving training. Similarly, in urogynaecology, after training, participants demonstrated progress from beginner to intermediate and proficient levels in performing surgeries for SUI, Sacrospinous Fixation, Abdominal Sacropexy, and fistula repair. The participants learned about Maternal Fetal Medicine skills and perceived proficiency in all areas, including Doppler studies, growth scans, anomaly scans, and nuchal translucency (Table 1 in Appendix). Furthermore, the participants reported that this program helped them gain knowledge and skills, build their networks, and boost their confidence while performing procedures. (Table 2 in Appendix).
Moreover, participants also reported they were very satisfied with the overall structure of the program. They perceived that this program was effective in enhancing their clinical skills, and the clinical mentorship sessions were beneficial for applying new knowledge in practice. The program met their expectations in enhancing their theoretical knowledge and provided them with sufficient practical skills, as shown in the Table 3 in Appendix. Participants perceived that the outcomes and impact of programs help them to enhance their confidence in applying these skills in daily practice. They also strongly agreed that it will have a lasting impact on professional growth, and all of them will recommend this program to others, as shown in the (Table 4 in Appendix).
Discussion
This study shares self-reported data on the enhanced skills development of participating faculty in women’s health across three sub-specialties of obstetrics and gynaecology following a clinical skill-building program supported by firsthand mentoring. As can be seen in the results, all participants from all three subspecialities reported benefits of the training program in almost all facets, i.e., execution, effectiveness, skill enhancement, and enhancing levels of proficiency, highlighting the significant role the PPP model plays in workforce capacity development. These studies are also in line with several other studies conducted in different fields that reported benefits of PPP in skill enhancement, particularly in resource constraints and public sector settings [15–18].
A substantial level of skills was enhanced before and after the program in all three subspecialties, as reported by the participants. This may be due to several factors. One of the factors is the program design, which was conceptualized with the principles of andragogy in mind, treating adults as co-creators of knowledge. The essence of this principle was administered throughout the program. The mentor faculty from the private sector AMC would provide first-hand mentoring in the clinical settings and operating theatres of participating public sector AMC. This allowed faculty from the public sector to learn hands-on surgical skills in their own context with their own limited resources. Several studies emphasize the role of providing structured and close clinical mentoring support and its positive impact on trainee outcomes [19–21].
These findings are also consistent with studies in medical education, where clinical skill-building programs complemented by mentoring have yielded benefits. In the field of gynae-oncology over the last few decades, gynaecological procedures, especially gynaecologic oncology, have had considerable expansion as a surgical specialty. Nonetheless, organized training programs in this field are still lacking in many parts of the world. Beyond the years spent in training programs, developing surgical skills involves proper training, mentorship, and self-evaluation as a continuous process [22]. Another study from India provided comprehensive skills-based training in gynaecologic oncology to participants, including surgical and clinical skills for managing ovarian, endometrial, vulvar, and cervical cancers. The program emphasized the need to support a gynaecologic oncologist through skills development [23]. Additionally, participants reported that they had gained a deeper understanding of history taking, examination methods, and surgical skills. Further qualitative feedback appraised excellence in mentorship, hands-on training, and immediate feedback [24]. In our study, the participants, as mentees, were already working practitioners at a consultant level; however, they still reported improvements in skills when mentored in a dedicated training program. Similarly, in the field of Urogynaecology, a study from the United States (US) reported that medical students and professionals gained significantly enhanced knowledge and confidence in gynaecologic procedures through simulation-based training. The knowledge and confidence were enhanced threefold in skills of laparoscopy and other surgical skills [17]. Participants of a study from Canada regarding the postgraduate training in paediatric and adolescent gynaecology reported 100% agreement with the gained knowledge and skills development. Our clinical skill-building program used various ways to develop knowledge and skills, including monthly tumor board sessions, low-resource-based teaching using cow tongue to teach urogynaecological skills, and stimulation-based lab support. Similarly, in specialties like OBGYN, where practical experience is essential, supervised teaching clinics (STCs) have also become a cutting-edge method of medical education for both under- and postgraduate cohorts. Medical professionals and medical students are frequently placed in passive roles during traditional clinical rotations, which restricts their ability to participate and learn critical clinical skills [22] actively. These faculty participants belonged to a public sector AMC that lacks clinical compliance, unlike private AMCs. Their experience of having observership in a private AMC might also have enhanced their understanding of clinical compliance and enhanced knowledge pertinent to the same [25].
Moreover, all participants rated the program’s structure, organization, academic sessions, clinical mentorship, observership, and coordination as effective. This could be for several reasons. One of the primary reasons is the educational quality and standing of the private AMCs, which is world-recognized for its quality medical education. Another factor is the co-creation of the initial program outline, which was done in consultation with the participating faculty. There is a body of evidence that supports the idea that, in adult education, co-designed programs promote better engagement, ownership, and satisfaction [26–29]. Despite positive feedback and enhanced skills, participants in this study demanded more hands-on skills training and more teaching and interactive sessions when asked for recommendations. Overall, the findings suggest that a structured PPP model for workforce capacity development can significantly enhance clinical skill acquisition. While the sample size was modest, the results surface a significant systems gap and point to the value of scaling well-designed PPP arrangements to strengthen ObGyn competencies at the population level. The evidence underscores a timely opportunity: leveraging PPP mechanisms to build a more capable, future-ready maternal health workforce and reduce persistent disparities in clinical proficiency.
Conclusion
This study highlights the importance of collaborative efforts in gynaecological training, as evidenced by the effectiveness of teaching sessions and hands-on exercises in managing complex cases and advancing academic knowledge. Such programs also have a significant potential to improve patient outcomes by referral linkages, whereby participating faculty for difficult cases can refer their faculty mentors for clinical advice. It also enhances professional networking. The combination of various teaching and assessment methods, such as direct observations, supervised surgical practice, clinical projects, workshops & community engagement activities, along with formative and summative assessment events, made it an actual confidence-boosting experience for mentors. It resulted in increased engagement for learning and was reported to support the quality of clinical instruction when compared to traditional teaching methods [30]. Further research is required with a multi-approach teaching methodology and involving various centres to understand the impact of such programs on Gynaecological skills.
Strengths and limitations
This training program and the study are of the first kind in Pakistan, where a formal one-year hybrid advanced clinical skill-building program was initiated using a PPP model, and have great potential for scalability in the medical education milieu. However, the significant limitations of the study are its small sample size, self-reported impact, and no data on the longitudinal patient outcome indicators or the evaluated performance of participating faculty. Additionally, the study participants were self-selected, and there was no control group, making it challenging to determine the association between the outcomes and the intervention. Hence, we cannot establish generalizability. However, this also opens up new research avenues for implementing such programs with a structured assessment, such as evaluations and the use of OSCEs, as well as long-term patient outcome tracking. Additionally, a large-scale study using a similar model can also be conducted in other PPP women’s healthcare settings, utilizing RCTs, to assess its potential impact on women’s health indicators. Additionally, it will be vital to explore the perspective of the institutional heads to explore systemic barriers and the potential of sustainability of such programs as a qualitative study.
Acknowledgements
We would like to acknowledge the contributions made by all the participating subspecialty leads and the participating faculty, who, on the ground, have provided skill-building program support. Also, we would like to acknowledge participating faculty trainees as well for their contribution and commitment.
Abbreviations
- AMC
Academic Medical Centre
- PPP
Public Private Partnership
- OBGYN
Obstetrics and Gynaecology
- SUI
Stress Urinary Incontinence
- MFM
Maternal Fetal Medicine
- STC
Supervised Teaching Clinics
Appendix
Table 1.
Impact of clinical skill-building program offered in three subspecialties (n = 6)
| Characteristics | n | |
|---|---|---|
| Before | After | |
| Gynaecology (n = 2) | ||
| Ovarian Cancer | ||
| Beginner | 0 | 0 |
| Intermediate | 2 | 0 |
| Proficient | 0 | 2 |
| Endometrial Cancer | ||
| Beginner | 1 | 0 |
| Intermediate | 1 | 0 |
| Proficient | 0 | 2 |
| Vulvar Cancer | ||
| Beginner | 1 | 0 |
| Intermediate | 1 | 0 |
| Proficient | 0 | 2 |
| Cervical Cancer | ||
| Beginner | 1 | 0 |
| Intermediate | 1 | 0 |
| Proficient | 0 | 2 |
| Uro-Gynaecology (n = 2) | ||
| Slings of SUI | ||
| Beginner | 2 | 0 |
| Intermediate | 0 | 1 |
| Proficient | 0 | 1 |
| Sacrospinous Fixation | ||
| Beginner | 2 | 0 |
| Intermediate | 0 | 1 |
| Proficient | 0 | 1 |
| Abdominal Sacropexy | ||
| Beginner | 2 | 0 |
| Intermediate | 0 | 0 |
| Proficient | 0 | 2 |
| Fistula Repair | ||
| Beginner | 2 | 0 |
| Intermediate | 0 | 2 |
| Proficient | 0 | 0 |
| Maternal Fetal Medicine (n = 2) | ||
| Doppler Studies | ||
| Beginner | 2 | 0 |
| Intermediate | 0 | 0 |
| Proficient | 0 | 2 |
| Growth Scan | ||
| Beginner | 2 | 0 |
| Intermediate | 0 | 0 |
| Proficient | 0 | 2 |
| Anomaly Scan | ||
| Beginner | 2 | 0 |
| Intermediate | 0 | 0 |
| Proficient | 0 | 2 |
| Nuchal Translucency | ||
| Beginner | 2 | 0 |
| Intermediate | 0 | 1 |
| Proficient | 0 | 1 |
Table 2.
Participants’ responses on the impact of the clinical skill-building program impacted clinical and surgical skills (n = 6)
| Characteristics | n |
|---|---|
| How has this Clinical Skill Building Program impacted your clinical and surgical skills? | |
| Gained knowledge and skills | 3 |
| Developed networking | 1 |
| Boost confidence and perform procedures alone | 2 |
Table 3.
Participants’ responses on program structure and content (n = 6)
| Characteristics | n |
|---|---|
| How satisfied are you with the overall structure of the program? | |
| Very Satisfied | 3 |
| Satisfied | 3 |
| Neutral | 0 |
| Dissatisfied | 0 |
| Very Dissatisfied | 0 |
| How would you rate the effectiveness of the observer ship in enhancing your clinical skills? | |
| Extremely Effective | 2 |
| Effective | 4 |
| Neutral | 0 |
| Ineffective | 0 |
| Extremely Ineffective | 0 |
| How useful were the clinical mentorship sessions in applying new knowledge to your cases? | |
| Extremely Useful | 4 |
| Useful | 2 |
| Neutral | 0 |
| Not Very Useful | 0 |
| Not Useful at All | 0 |
| How beneficial were the academic sessions in enhancing your theoretical knowledge? | |
| Exceeded Expectations | 0 |
| Met Expectations | 6 |
| Somewhat Met Expectations | 0 |
| Did Not Meet Expectations | 0 |
| Did the program provide sufficient opportunities for hands-on practice? | |
| Strongly Agree | 0 |
| Agree | 5 |
| Neutral | 1 |
| Disagree | 0 |
| Strongly Disagree | 0 |
| What aspects of the program did you find most beneficial? | |
| Hands-on sessions and skills development | 3 |
| Academic sessions | 1 |
| Mentorship and discussion | 2 |
| Were there any areas of the program that you felt were lacking or could be improved? | |
| More practical and educational sessions | 2 |
| Tumor board meeting | 1 |
| Clinical observations | 3 |
| Can you describe a specific case or situation where the program directly improved your clinical practice? | |
| Able to manage complex cases | 3 |
| Assessing patients for surgery and surgical skill | 3 |
Table 4.
Participants’ responses on program outcomes and impact
| Characteristics | n |
|---|---|
| How confident do you feel in applying the skills you learned through the program in your daily practice? | |
| Very Confident | 3 |
| Confident | 3 |
| Neutral | 0 |
| Somewhat Confident | 0 |
| Not Confident at All | 0 |
| Do you feel that the mentorship provided during the program has had a lasting impact on your professional growth? | |
| Strongly Agree | 5 |
| Agree | 1 |
| Neutral | 0 |
| Disagree | 0 |
| Strongly Disagree | 0 |
| Would you recommend this program to other ObGyn faculty members? | |
| Definitely | 6 |
| Probably | 0 |
| Not Sure | 0 |
| Probably Not | 0 |
| Definitely Not | 0 |
| In what ways has the program influenced your approach to teaching or mentoring others? | |
| Boost confidence to mentor others | 2 |
| Evidence-based practice | 1 |
| Improved patient outcomes | 2 |
| More collaboration | 1 |
| What long-term impact do you anticipate this program will have on your career? | |
| Better care for patients | 3 |
| Collaboration and constant partnership for future opportunities | 2 |
| Lifelong impact | 1 |
| Is there anything else you would like to share about your experience in the program? | |
| Nice comprehensive program | 2 |
| Great learning experience | 2 |
| Great mentorship | 2 |
| Please provide any additional suggestions or comments on how this program could be improved in the future. | |
| Providing a proper fellowship degree | 2 |
| Increasing the time duration to 2 years | 1 |
| Increase clinical visits and have more meetings | 2 |
| Collaboration in academics and clinicals | 1 |
Table 5.
Details of implementation of program
| Needs Identification |
• Meeting with the potential faculty and reviewing their skill set • Facility assessment • Determining academic and clinical skill needs |
| Academic Program |
The one-year academic program was based on three streams of women’s health: gynae oncology, maternal-fetal medicine, and urogynaecology, having components such as: • Academic sessions: These sessions were sessions taken for the fellows and residents, whereby the participating faculty from the public sector university were invited to attend. These are one session per month that are more related to the content base of a particular subspeciality. • Observations at private academic medical centre clinics and operating theatres were organized, allowing participating faculty to observe the cases and surgeries performed by their mentoring faculty. • Clinical mentoring at the public sector academic medical centre was provided by the senior physician from the private sector AMC to the participating faculty from the public sector AMC during their clinics and surgeries. |
| Logbook | For data keeping and tracking, the participants were provided with stream-wise and online Google logbooks, allowing participants to input their surgical and clinical cases and academic activities throughout the year. |
Authors’ contributions
Shelina Bhamani- Conceptualization, Supervision, and writing the first draft and approving the final manuscript.Abdur Rehman and Adeeb Kanji – Writing and Compilation of the first and final Draft. Drs Haleema Yasmin and Lumaan Sheikh, co-conceptualized the program, supervised the data analysis and writing, reviewed and approved the final manuscript.
Funding
No funding was received.
Data availability
Available on reasonable request to the corresponding author.
Declarations
Ethics approval and consent to participate
Ethical approval was obtained from the Ethics Committee of Aga Khan University Karachi, Pakistan (ERC Ref #2025-10161-33677). Informed written consent was obtained from all the participants prior to the data collection. Our study followed all the Declaration of Helsinki, and all participants were provided with informed consent and also the right of choice whether or not to use their data for scholarly purposes.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
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Data Availability Statement
Available on reasonable request to the corresponding author.