Applying the realist evaluation framework to a faculty mentorship program: a context–mechanism–outcome analysis at a private medical university

Abstract

Background

The value of mentoring is crucial for the growth of faculty, and assessing its effectiveness is essential to ensure the retention of faculty members. CMO is a conceptual framework used in realist evaluation to understand the context (C), mechanisms (M) and outcomes (O) of any implementation strategy.

Objective

The faculty mentorship program was initiated at Aga Khan University Medical College (AKU- MC) in 2019 to foster faculty development through structured mentor-mentee partnerships, centralized support, and systematic evaluation of mentoring outcomes. The objective of the study was to identify contextual factors (C) that initiate specific mechanisms (M) contributing to particular outcomes (O) in this program, using the CMO framework.

Methodology

A qualitative exploratory study using purposive sampling was conducted at AKU-MC involving program leadership, administrators, mentors and mentees who were invited for in-depth interviews and focus group discussions. All interviews were transcribed; codes, categories and themes were identified as per CMO configuration.

Results

Thirteen faculty members participated in 8 IDIs and 4 FGDs. Context was covered by theme: “Gaining Insights from Mentorship Experiences” based on; Existence of mentorship culture, Initiation of formal mentorship, Mentor- Mentee Pool, Administrative Support, Lack of protected time, challenges of unsuitable pairing and preparation of mentors. The ‘mechanisms’ theme in AKU-MC mentorship program was “Transformative Journey of Mentorship” comprising of mentor mentee matching process, mentor mentee dynamics emerging reflective practices, developing connections, increasing motivation/rewards and recognition, replenishing mentors pool and change in pairing and sharing success stories. Nurturing bonds, Research productivity skill development and improvement in confidence constituted the ‘Outcome’ theme; “The Power of Mentorship: Building a Legacy of Growth”.

Conclusion

The mentorship program functioned within a strong cultural and administrative context supported by mentor-mentee matching and leadership commitment. Mechanisms like reflective dialogue, informal engagement, and recognition promoted mentor–mentee relationships. Despite professional development challenges such as time constraints, limited mentor preparation, and mismatching persisted. Overall, mentorship emerged as a transformative process enhancing confidence, collegiality, and a culture of academic excellence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-08458-z.

Introduction

Mentoring programs have shown a strong association with various benefits for faculty members, such as enhanced recruitment, increased engagement, successful promotion, improved retention, career success, and a positive perception of the institution’s commitment to its faculty (Al-Jewair, Herbert et al. [1]). Academic institutions should therefore focus on retaining motivated and effective faculty members who actively contribute to their academic missions (Sambunjak, Straus et al. [2], Cranmer, Scurlock et al. [3]). They provide cultural relevance, familiarity, knowledge, service, engagement, as well as validation (Johnson, Fuchs et al. [4]). The outcomes of mentorship programs include improved performance in areas such as patient assessment, clinical decision making, cultural competencies, and professionalism. Additionally, these programs have been found to increase willingness to stay in the profession, enhance career development, and create inclusive learning environments [5]. Institutions that invest and support mentoring programs can obtain rewards in the form of enhanced academic productivity, which includes higher clinical revenue, more innovative educational programs, increased research funding, and additional scholarly activities with a reduced risk of faculty burnout (Cranmer, Scurlock et al. [3], Perumalswami, Takenoshita et al. [6])

Poor evaluation of mentoring programs is a grey area that affects the understanding of the impact of program, its weaknesses and challenges, faculty needs and institutional support. Without rigorous and ongoing evaluation, there may be missed opportunities to identify best practices, improve program activities and returns on investment [7]. The assessment of mentoring programs is therefore imperative to ensure their effectiveness, address challenges, and promote the growth and development of mentors and mentees [8]. A number of frameworks can be used to assess the implementation strategies as the mentoring program at AKU-MC [9].

Faculty mentorship program at AKU

The Faculty Mentorship Program (FMP) at Aga Khan University Medical College (AKU-MC), initiated in 2019, under the governance of the Faculty Mentorship Forum, it aims to foster a supportive environment for faculty professional development. It was designed with the primary objective of nurturing and cultivating leaders and critical thinkers who would play a pivotal role in fostering faculty professional development. Its objectives include providing career mentors for all faculty particularly junior and new members enhancing mentor–mentee competencies through a structured curriculum, establishing centralized support and leadership for mentoring activities, and maintaining a database to monitor and evaluate mentoring processes and outcomes (Rehman, Khan et al. [10]).

Realistic evaluation theory

Realist evaluation (RE) is a philosophical approach applied to construct theories that explain how and why programs yield specific results. RE is based on the premise that individuals participating in an intervention operate within a particular social context. This context significantly influences a participant’s behavior in response to the intervention, subsequently affecting how the participant engages with the intervention (McDaniel, Rooholamini et al. [11]). RE seeks to uncover the underlying theory guiding an intervention, operating under the assumption that achieving successful outcomes is contingent upon applying the right concepts to the appropriate context within the relevant social and cultural conditions. A realist program theory not only identifies the outcomes associated with the intervention but also delves into the mechanisms responsible for generating these outcomes and how the social context influences these mechanisms.

We employed RE, which is a mechanism that works on feelings, emotions, and perceptions. For this instance, the researcher adopted a qualitative approach towards the conduct of the study. In the context of a mentorship evaluation, a realist theory approach for examining the effectiveness of a mentorship program can comprehend the principal mechanisms and circumstantial factors that contribute to its success or failure. It allows for the identification of specific mechanisms, consideration of diverse contextual factors, and the development of theories that balance abstraction with empirical relevance in the field of mentorship. Realist inquiry, therefore, endeavors to unravel the intricate relationship between context, mechanism, and outcome, providing insights into instances of success, failure, and everything in between. The resulting theoretical explanations, known as “middle-range theories,” strike a balance between abstraction and proximity to observed data, allowing for empirical testing of propositions [12].

Conceptual framework

The philosophical approach of RE was used by researcher to identify the mentorship in the framework of context (C), mechanism(M) and outcome(O) in the AKU – MC. In this framework, context has been defined as circumstances and environment that influence the behavior and attitude of participants towards the mentorship program. Our context involves considering the organizational culture, the individualities of the mentees and mentors, and the exclusive goals of the mentorship that can influence the behavior and attitude of participants towards the mentorship program. The second component of CMO is mechanism (M) which is process to get the expected outcome. The mechanism in our study included all the elements that derive the mentorship program towards success within given circumstances. It will explore the processes like; aspects of mentors and mentees communication, the quality of relationship, the struggle to achieve the gaols and the compliance of the program to different contexts. The after effects or meaningful results of the program are seen as outcome in CMO framework. Outcomes’ as per the realistic theory, can be both anticipated and inadvertent including improved interpersonal relationships, career advancement and skill development (McDaniel, Rooholamini et al. [11]). In a mentorship evaluation, a middle-range theory can be developed that may suggest that the quality of mentor-mentee relationships (mechanism) is influenced by factors such as shared values and goals (context), leading to positive career development consequences (outcome). This approach offers a richer understanding of why and how mentorship programs can be effective or fall short in different circumstances [13].

Researchers were aware of the fact that knowledge of the faculty mentorship program can be achieved by applying the right concepts in the appropriate context through the well-defined mechanisms in the CMO framework. Therefore, they aimed to explore the mentorship program at AKU- MC by systematically investigating the contextual factors, underlying mechanisms, and resultant outcomes to further strengthen faculty mentorship. The realist approach involves identifying underlying causal mechanisms and exploring how they work under what conditions.

Methodology

Study design

We used a qualitative exploratory design to examine faculty and mentee experiences, guided by realist evaluation principles.

Participants’ selection and recruitment

Study participants included mentors, mentees, and administrators who met specific eligibility criteria: mentors with at least one year of service in faculty mentorship programs and a minimum of two mentee sessions; mentees at the level of senior instructor or assistant professor who participated in at least two feedback sessions; and administrators (chairs, co-chairs, and coordinators) who had served in the mentorship program for at least one year.

Description of interviews

The study participants included in the study were from all hierarchal positions; leaders, founder members, administrators, mentors, and mentees. Interview guides were developed following a literature review with open ended, introductory, probing and concluding questions, validated and reviewed by experts. The guide for in-depth interviews (IDIs) focused on the roles of leadership and administrators (Appendix I), while the focus group discussion (FGD) guide addressed the roles, responsibilities, and challenges of mentors and mentees (Appendix II).

Total number of participants were seventeen out of which 3 were founder members, 3 were administrators, 2 were leaders, 4 were mentors and 5 were mentees. Informed consent was obtained from all participants, with each receiving a signed copy. The primary investigator-maintained field notes, and all sessions were facilitated by a trained research assistant. A reflective log was kept to minimize researcher bias. Each session lasted 40–60 min and was audio-recorded with participants’ permission. Data collection continued until thematic saturation was achieved, after which thematic analysis was conducted to identify and organize key patterns and themes. Eight faculty members participated in 8 IDIs (2 females and 1 male who were in association with AKU for more than 15 years and associated with FMF for the last 4 years). A total of four FGDs were carried out at AKU-MC, two for mentors with two participants and two for mentees with two to three participants.

Data collection

The data collection was done by means of in-depth interviews and focus group discussions. The collection process reached saturation, concluding when responses became repetitive or when extracting additional meaningful information was no longer feasible. The researcher and a professional transcriber transcribed all the verbatim to maintain credibility and accuracy (MacLean, Meyer, & Estable [14]),. Two researchers independently coded the transcripts, discussed discrepancies, and refined the coding framework through consensus meetings to enhance reliability and rigor.

Data analysis

An inductive thematic analysis, guided by Braun and Clarke’s principles, was conducted to identify patterns and derive themes from the data [15]. The process involved recognizing patterns, generating and organizing codes, and refining them into coherent themes.

Following this inductive phase, a deductive approach was employed to align the emergent themes with the Context–Mechanism–Outcome (CMO) configuration.

Figure 1 elaborates the process of data analysis.

Fig. 1.

Thematic Analysis Workflow - From Data Collection to Reporting [15]

Results

Three themes for context, mechanism and outcome were identified (Table 1). Context was covered by theme: “Gaining Insights from Mentorship Experiences” which was based on; Existence of Mentorship Culture, Initiation of formal mentorship, Mentor- Mentee Pool, Administrative Support, Lack of Protected Time, Challenges of unsuitable pairing, and Preparation of mentors (Table 2). The recognized theme for ‘mechanisms’ in AKU-MC mentorship program was “The Transformative Journey of Mentorship” which comprised of Mentor mentee matching-process, Mentor mentee dynamics, Encouraging Reflective Practices Developing connections, Replenishing Mentors pool and change in pairing Increasing Motivation/Rewards and recognition, Sharing success-stories (Table 3). Nurturing bonds, Research productivity skill development and Improvement in Confidence constituted the ‘outcome’ theme; “Mentorship Unleashed: A Legacy of Growth” represented in Table 4.

Table 1.

Descriptive themes on context mechanism and outcome of faculty mentorship program at AKU-MC

S. No	Domain	Themes
1	Context	Gaining Insights from Mentorship Experiences
2	Mechanism	The Transformative Journey of Mentorship
3	Outcome	The Power of Mentorship: Building a Legacy of Growth

Table 2.

Categories and illustrative quotes represent context

Theme 1	Subthemes	Illustrative Quote
Gaining Insights from Mentorship Experiences	Existence of Mentorship Culture	• We had informal mentorship through our seniors and role models • I remember my Professors would never leave the lecture hall without erasing the white/blackboard. • The small gesture sets a path
	Initiation of formal mentorship	• A pilot mentorship program for new faculty, senior instructors and assistant professors was planned which could not be implemented due to lack of administrative support. • Faculty Mentorship Forum came into existence in June 2019
	Mentor- Mentee Pool	• We send email to all senior faculty members (Assistant Professors with more than 3 years of experience) and above to submit Expression of Interest to be enrolled as mentors • This mentor’s pool available on the AKU website for past one year. • Mentees search and select three mentors in rank order. After approval from mentors pairing is done • I myself mentor and supervise many students. The administration got us connected via our email and set up one of our initial meet-ups with our mentor, and then every quarter or every six months. They would send us the feedback form, take our feedback.
	Administrative Support	• We should have a full-time admin staff to manage desk records • He should take care of sending reminders to mentors and mentees for meetings
	Lack of Protected Time	• Mentors face difficulty to meet mentees • I could not meet one mentee for the whole year and later the mentee went for some more training. • Mentors are usually not available on the given time for meetings • The culture of face to face communication has to be revived instead of exchanging emails or WhatsApp messages. A solution to improve the communication gap is participation in departmental and coffee meetings
	Challenges of unsuitable pairing	• Young faculty members were facing difficulty to interact with some of the senior faculty members.
	Preparation of mentors	• Mentors should take some responsibility for their development. • A development program with sufficient resources for learning and development is required • training of mentors is required • workshops and formal training opportunities should be introduced for capacity building program of mentors and mentees

Table 3.

Categories and illustrative quotes representing mechanisms: the transformative journey of mentorship

Theme 2	Subthemes	Illustrative Quote
The Transformative Journey of Mentorship	Mentor mentee matching-process	· There should be no forced pairing of the mentee and mentor. · Mentor mentee matching should be a voluntary exercise. · Forced marriages are usually not considered to be very successful
	Mentor mentee dynamics	· After the initial meeting, regular quarterly meetings or after six months are planned · The administration takes feedback regularly to know about our experiences regarding the mentorship program · A mentee's role, I think is critical because they keep that relationship moving on · Good mentee should try to find means to be in touch with their mentor especially when the mentor is extremely busy and not available on emails. · A mentee's role, I think is critical because they keep that relationship moving on
	Encouraging Reflective Practices	· Informal tea gatherings can be used to break the ice · There should be breakfast and tea meetings between new and old mentors at regular intervals so that they could share their experiences. This way the new mentors will learn the traits of a previous role model
	Developing connections	· Mentor many students/faculties and we connect via emails through administration.
	Increasing Motivation/Rewards and recognition	· It is important to organize awareness sessions and disseminate success stories. · Mentors should be recognized in faculty assemblies by announcing their names. There should be university culture of awards and recognition
	Replenishing Mentors pool and change in pairing	· The list of mentors is reviewed every two years. · The mentees are being provided with option to request and change their mentors
	Sharing success-stories	· Invite role models, request them to share their success stories

Table 4.

Categories and illustrative quotes representing outcomes the power of mentorship: building a legacy of growth

Theme 3	Subthemes	Illustrative Quote
The Power of Mentorship: Building a Legacy of Growth	Nurturing Bonds	· Mentorship is a bunch of intangibles; the utmost success is if the mentee feels that it's successful or if they do something that they're proud of. · Nothing is more precious than having a sense of satisfaction and achievement when seeing the juniors progressing
	Research productivity	· Mentors provide guidance to the mentees · The research office also collaborates and provides mentorship and guidance to all the faculty members
	Skill Development	· I was able to do the literature search by the guidance of my mentor · My mentor demonstrated flow cytometry then under supervision allowed me to run the samples
	Improvement in Confidence	· My mentor listened to my presentation at least three times and gave constructive feedback · Presentation in an international conference with lots of appreciation-built confidence

Figure 2 presents the Context–Mechanism–Outcome (CMO) framework of the peer mentoring program, demonstrating how supportive contextual factors activate mentoring mechanisms that lead to enhanced professional relationships, skill development, research productivity, and confidence among participants.

Fig. 2.

A comprehensive analysis in the framework of context, mechanism and Outcomes

Discussion

This realist evaluation explored how contextual factors within the FMP at AKU-MC shaped the mechanisms that aimed to generate desired outcomes for faculty development. The findings further reveal that the existing mentorship culture, administrative infrastructure, and participant dynamics interacted to influence the activation of mentoring mechanisms and the realization of outcomes. However, contextual factors such as limited administrative resources, lack of protected time, and competing professional responsibilities affected the extent to which mentoring mechanisms could operate effectively.

Context influencing mechanisms

The context in FMP was grounded in a pre-existing culture of informal mentorship and the initiation of a pilot program that laid the foundation of the forum for faculty mentorship (Rehman, Khan et al. [16]).The mentoring initiative was supported by informal mentorship, where senior faculty naturally guided junior colleagues; ‘We had informal mentorship through our seniors and role models’. However, the need of continual training programs for the purpose of understanding the mechanism of mentoring was reflected by the participants; ‘training of mentors is required’ and suggested in the literature (Szabo, Lloyd et al. [17]) [18].

A mentor–mentee pool consisting of senior faculty members and alumni provides an essential resource for nurturing motivated mentees and sustaining mentorship programs [19]. The diversity in mentor experience and hierarchical level also shape the relational mechanisms. Senior faculty mentors bring expertise and institutional insight, but differences in communication style and generational expectations sometimes hinder open dialogue a contextual barrier [20] (Brown, Magaña et al. [21]). Establishment of mentor pool in AKU-MC reflected contextual alignment of personalities, roles, and professional goals is vital to trigger the mechanism of mutual learning and reflection. Periodic replenishment of the mentor pool and reassignment options allowed flexibility, promoted program responsiveness to mentor–mentee compatibility (Rajendran, Jones et al. [22]).

Administrative support, availability of resources, funding and institutional backing are key enablers to effective mentorship. (Phillips, Lee et al. [23]). The support, particularly in coordinating mentor–mentee pairing and tracking meetings, served as an enabling contextual condition in the program. Conversely, strengthening of administrative support, ‘He should take care of sending reminders to mentors and mentees for meetings’ was pointed out by both the mentors and mentees to strengthen the processes. Mentors and mentees in the program cited time constraints as barriers to sustained engagement and relational depth conditions that has also been highlighted in prior studies [24] (Szabo, Lloyd et al. [17]). Regular meetings and administrative follow-up-maintained engagement; however, scheduling conflicts and overdependence by mentees occasionally hindered progress, aligning with challenges identified by researchers (Hulton, Sawin et al. [25]). Within this context, several mechanisms were activated that generated meaningful outcomes.

Effective mentor–mentee matching, based on mutual interests, compatibility, and comfort level, is essential for “Transformative Journey of Mentorship” [26],. The mechanisms that facilitated mentorship success cantered on mentor–mentee dynamics, reflective practice, and motivation through reward and recognition. At AKU-MC, mentees selected mentors based on ranked preferences, which promoted ownership and improved matching similar to findings by Birkeland et al. [27]. (Birkeland, Davies et al. [27]). To build relationships, mentors should present themselves as a helper to the mentees to create a safe, non-judgmental environment, where mentees feel comfortable sharing their challenges and were receptive to feedback {Alidina, 2021 [28]} Informal interactions act as psychological safety nets that deepen relationships and sustained engagement hence ‘developing connections’ [29, 30]. Structured mentor- mentee pairing encouraged goal-directed interaction, while reflective practice through informal meetings, shared experiences, and feedback loops nurtured mutual growth and learning.

Mismatched pairings also affected mentorship quality, ‘Forced marriages are usually not considered to be very successful’. Differences in expectations, communication styles, and generational perspectives between junior and senior faculty can create barriers, as reported in similar studies [20] (Brown, Magaña et al. [21]).

Mentor motivation emerged as another pivotal mechanism. Recognition through institutional forums and sharing of success stories reinforced mentors’ sense of purpose and self-efficacy [31] When such acknowledgment is absent, mentors express reduced engagement, demonstrating the dependency of motivational mechanisms on supportive organizational context. The program’s provision for re-pairing and replenishment of mentors every two years ensured adaptability, allowing mechanisms of choice and fit to operate and sustaining mentoring continuity [22]. ‘Encouraging Reflective Practices’ in the program supported both formal and informal interactions. Informal gatherings, such as tea sessions and small group meetings, proved valuable in building rapport and trust, consistent with literature (Farid, Bain et al. [29])(Nassour, Balentine et al. [30]). Ethical considerations, particularly confidentiality and trust, were also emphasized as vital to sustaining productive relationships (Kow, Teo et al. [32]). Recognition and sharing of success stories served as motivational mechanisms that reinforced commitment and strengthened the mentoring culture (Choi, Moon et al. [31]).

Mechanisms leading to outcomes

As these mechanisms operated within enabling contexts, they produced outcomes of personal and professional development. Faculty reported nurtured bonds, enhanced confidence, and skill acquisition, particularly in teaching and research domains findings supported by Walters et al. [33]. Mentees noted improvement in presentation skills and scholarly writing, while mentors expressed satisfaction in witnessing mentee success reflecting the mechanism of reciprocal growth [33]. The program also fostered an emerging research culture by promoting collaboration and shared learning, even though quantitative evidence of research productivity could not be measured. and were receptive to feedback These outcomes align with studies linking mentoring to sustained academic motivation and retention [34]. The relational and reflective mechanisms activated under supportive contextual conditions thus contributed to the evolution of a collegial environment that enhances both professional identity and institutional belonging.The mentorship experience also enhanced workplace well-being, reducing stress and supporting career transitions, consistent with Ivey and [35].

The analysis of strategies adopted in planning, designing and implementation of the FMP at AKU-MC can be seen as a step towards nurturing the faculty members with the passionate power of mentoring. A holistic approach, multidisciplinary mentorship team, psychologically safe relationships, accessibility of mentors, supportive and availability of a receptive implementation environment was provided {Alidina, 2022 [36]}. Additionally, favorable contextual conditions, such as an existing mentorship ethos, structured administrative support, and mentor commitment, triggered mechanisms of trust, reflective dialogue, and motivation, which in turn generated outcomes of faculty growth and institutional cohesion. Conversely, challenging contexts including time constraints, inadequate mentor training, and mismatched pairings—attenuated these mechanisms, leading to variable outcomes.

Conclusion

The mentorship program at AKU-MC was grounded in a strong cultural and administrative context, driven by structured mentor–mentee matching and supported by institutional leadership. Mechanisms such as reflective dialogue, informal engagement, and recognition cultivated meaningful mentor–mentee relationships. While the program effectively promoted professional development, challenges such as time constraints, inadequate mentor preparation, and occasional mismatching warrant attention. The outcomes, though qualitative, underscore mentorship as a transformative process that enhances confidence, collegiality, and growth, contributing to a sustainable culture of academic excellence.

Implications, strengths, limitations, and future directions

The findings of this study have important implications for the design and implementation of faculty mentorship programs. Institutions should prioritize structured mentor- mentee pairing, administrative support, and capacity-building workshops to sustain a culture of mentorship. Embedding protected time and recognition mechanisms for mentors can enhance program effectiveness and faculty engagement.

A key strength of this study lies in its application of the Realist Evaluation Framework, which provided a nuanced understanding of how context and mechanisms shape outcomes. The inclusion of diverse stakeholders across hierarchical levels enriched the data. However, limitations include the single-institution setting, limited participant numbers, and the qualitative nature of analysis, which may restrict generalizability.

Future research should adopt longitudinal and mixed-method designs to assess measurable outcomes such as faculty retention, research productivity, and career progression. Programmatic refinements should focus on mentor training, structured feedback loops, and broader institutional integration to ensure sustainability and scalability.

Lessons Learned from the Realist Evaluation of the Faculty Mentorship Program (FMP) at AKU-MC.

1. Contextual foundations

   A pre-existing culture of informal mentorship with administrative structure and leadership support provided a strong base of FMP. Diversity in mentor seniority and experience, limited resources, lack of protected time, and challenging professional roles were the key characteristic of the program. Continuous mentor training and periodic replenishment of the mentor pool and flexible re-pairing were identified as necessary contextual reinforcements to improve program responsiveness and compatibility between mentors and mentees.

2. Mechanisms triggered by context

   Structured mentor-mentee matching based on mentee preference, reflective practice through informal interactions, mutual feedback, and shared experiences helped as a mechanism for personal and professional growth. Recognition and reward mechanisms, such as sharing success stories and institutional acknowledgment were the mechanisms of mentor motivation and sustained engagement.

3. Outcomes generated by activated mechanisms

   Enhanced faculty confidence and effective communication, among mentees and mentors and strengthening of mentor satisfaction viewing mentee’s growth, were the key outcomes. Emergence of a positive research and learning culture, characterized by collaboration, mutual learning, and increased academic motivation improved in psychological well-being of the participants.

Abbreviations

C

Context

M

Mechanisms

O

Outcomes

RE

Realist evaluation

AKU- MC

Aga Khan University Medical College

IDI

In-Depth Interviews

FGD

Focus Group Discussions

Authors’ contributions

Dr Rehana has made substantial contributions to conception and design of the study, acquisition of data, its analysis and interpretation with the CMO framework.Dr Quratul Ain Javed has contributed to writing the manuscriptMs Saira Khalid has contributed to the analysis of data and review of manuscript.Dr Tazeen have contributed to the design of the study, analysis and interpretation of the data, review of the manuscript, and revising it criticallyDr Rahila has been involved in analysis and interpretation of the data, drafting the table, review of the manuscript, and revising it critically.All authors have read and approved the final manuscript.

Funding

Bahadur Ali Kamruddin Jessani family

Data availability

All data and supplementary material are available upon request from the corresponding author.

Declarations

Ethics approval and consent to participate

Ethics approval and consent to participate: All methods were carried out in accordance with relevant guidelines and regulations. Participation in the study was voluntary. Informed Consent was taken before the in depth interviews and the focus group discussions. The Ethics Review Committee at Aga Khan University after careful review of the application, granted the ethics approval (ERC letter Ref no. 2021-6127-17832).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Clinical trial number

Not applicable.