Association between preoperative frailty and 30-day functional disability after surgery: a prospective cohort study using the Edmonton Frail Scale

Abstract

Background

Frailty is a known predictor of adverse surgical outcomes, yet its influence on functional recovery trajectories in South Asian settings remains underexplored. This study evaluated the association between preoperative frailty and achieving a clinically meaningful improvement in disability 30 days after elective surgery.

Methods

A prospective cohort study was conducted at a tertiary hospital in Karachi, enrolling 146 patients aged > 50 years undergoing elective general or orthopedic surgery. Preoperative frailty was assessed using the Edmonton Frail Scale (EFS). Disability was measured using the WHODAS-12 at baseline and 30 days postoperatively. The primary outcome was a meaningful functional improvement, defined as a decrease of ≥ 3.5 points on the WHODAS-12 scale.

Results

Among 146 patients (mean age 64.1 ± 9.4 years), 76.7% (n = 112) were categorized as frail. Frail patients had significantly higher baseline disability than non-frail patients (17.74 ± 6.70 vs. 12.29 ± 7.84; p < 0.001). At 30 days, overall disability improved significantly (mean change: −1.99 ± 8.12, p = 0.036), driven primarily by the frail group (− 2.66 ± 7.33, p = 0.007) compared to the non-frail group (+ 0.35 ± 10.34, p = 0.89). In the multivariable model, higher baseline WHODAS scores were significantly associated with a greater likelihood of improvement (OR 1.18 per point; 95% CI: 1.02–1.35; p = 0.022). Conversely, patients aged > 75 years were 89% less likely to achieve improvement (OR 0.11; 95% CI: 0.01–0.98; p = 0.048). Subgroup analysis indicated that improvement rates peaked in the Moderate frailty category (47.62%) compared to those classified as Vulnerable (12.50%).

Conclusion

Preoperative frailty identifies patients with the greatest potential for functional gain, though this recovery is significantly limited by advanced age. These results suggest that surgery provides a “functional dividend” for frail individuals with high baseline impairment. Routine frailty screening should be utilized to manage expectations and tailor recovery pathways in aging surgical populations.

Background

Frailty, characterized as a state of reduced physiological reserve associated with increased susceptibility to disability, significantly influences outcomes following medical and surgical interventions, particularly in older adults [1]. It is widely recognized as an independent risk factor for adverse postoperative outcomes, with estimates suggesting that frailty contributes to approximately 25–50% of these complications [2]. This underscores its critical importance in clinical settings and the necessity of preoperative frailty assessment to optimize treatment planning, resource utilization, and ultimately, patient outcomes.

Distinct from frailty, disability is defined as difficulty or dependency in carrying out activities essential to independent living, encompassing self-care tasks, home management, and desired quality-of-life activities [3]. While both conditions can exist independently, frailty often precedes disability, increasing the likelihood of its development.

Pakistan faces a rapidly aging demographic, with its population aged 65 years or above projected to rise from 11.3 million currently to an estimated 43.3 million by 2050 [4]. This demographic shift inevitably correlates with an increased demand for surgical procedures. However, in this vulnerable older population, frailty substantially elevates the risk of complications and poor surgical outcomes. To assess this vulnerability to postoperative adverse events, three overlapping yet distinct concepts are commonly employed: comorbidity (chronic conditions), frailty, and disability. Among these, preoperative frailty emerges as a particularly potent predictor of outcomes after surgical procedures, especially those that impair patient mobility. For instance, an orthopedic study observed that patients with higher frailty scores experienced more intense postoperative pain than those with lower scores [5].

Frailty is widely conceptualized as a pre-disability stage, marked by a gradual, age-dependent decline in physiological functioning. Its prevalence increases exponentially in individuals aged 65 years and above [3]. A systematic review involving patients over 50 years from 62 countries reported an overall frailty prevalence of 12% [6]. Furthermore, a Canadian study highlighted that frailty prevalence increases with age in both genders, yet women are more commonly affected. Among individuals aged 85 years or more, 43.3% were frail, with women constituting 45.1% compared to 39.1% of men [7]. This observed gender difference has been partly attributed to lower average muscle mass and strength in women. Additionally, socioeconomic status has been identified as a contributing factor, with lower economic strata often exhibiting higher frailty due to factors such as poor nutrition and limited access to healthcare [8].

Despite growing evidence from high-income countries, there remains a lack of prospective, longitudinal data from low- and middle-income countries, particularly Pakistan, examining how preoperative frailty influences postoperative disability trajectories. Furthermore, the combined use of the Edmonton Frail Scale and WHODAS 2.0 has not been previously studied in the Pakistani surgical population. Although WHODAS 2.0 is a globally endorsed measure of disability, its application in South Asian surgical settings remains limited, representing an important contextual and cultural evidence gap.

This is among the first prospective studies in a South Asian LMIC to examine the relationship between frailty (using EFS) and postoperative disability trajectories using WHODAS. We aim to quantify the burden of frailty and examine its association with changes in postoperative disability among patients undergoing Orthopedic and General Surgery procedures in Pakistan. Specifically, we seek to determine whether preoperative frailty is associated with a greater likelihood of improvement in functional disability after surgery. By identifying frailty as a key preoperative factor, our goal is to inform more individualized and physiologically appropriate perioperative care plans, ultimately improving patient-centered surgical outcomes.

Methods

Study design and setting

We conducted a prospective cohort study at Aga Khan University Hospital (AKUH), Karachi, Pakistan, a tertiary care, private-sector teaching hospital serving a population of over 16 million. AKUH receives referrals from across Pakistan and neighboring countries. Eligible patients aged > 50 years undergoing elective general or orthopedic surgery during a one-month recruitment period were included. Emergency procedures and patients declining consent were excluded. The one-month recruitment period was chosen for feasibility; while this may limit generalizability, surgical volume, and patient characteristics at AKUH remain relatively stable throughout the year.

Sample size

Sample size was calculated based on an anticipated frailty prevalence of 60%, derived from a comparable LMIC population. At 95% confidence with 8% absolute precision, the minimum required sample size was 145 participants. The observed frailty prevalence was higher (76.7%), likely reflecting the high-risk case mix at this tertiary referral center. The sample size was determined based on frailty prevalence rather than effect size for postoperative disability change, which may limit statistical power for regression analyses.

Outcomes

Primary outcomes

Preoperative frailty was assessed using the Edmonton Frail Scale (EFS) and categorized as non-frail (0–5; fit/vulnerable) or frail (6–17; mild, moderate, or severe).

The primary outcome was clinically meaningful functional improvement at 30 days postoperatively. This was defined as a decrease of ≥ 3.5 points in the WHODAS-12 score (on the 0–48 scale). While Shulman et al. (2020) established a minimum clinically important difference (MCID) of 5% (equivalent to 2.4 points) for surgical cohorts [9], we adopted a more conservative threshold of 3.5 points for this study.

Secondary outcomes

Functional disability was assessed using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) [10] at two time points: preoperatively and 30 days postoperatively. WHODAS-12 scores range from 0% (no disability) to 100% (complete disability). Change in functional disability was calculated as the difference between preoperative and postoperative scores and is reported descriptively to characterize overall recovery patterns.

Data collection and management

Eligible patients were identified from the operating room schedule 48 h prior to surgery. Patients were approached one day before surgery, provided with study information, and written informed consent was obtained. A copy of the signed consent form was given to participants, and the original was stored in the study master file. Baseline demographic and clinical data, including age, sex, comorbidities, and surgical characteristics, were collected by study investigators. Preoperative frailty was assessed using the Edmonton Frail Scale (EFS), and baseline functional disability was measured using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0).

Follow-up WHODAS assessments were conducted at 30 days postoperatively. Assessments were performed in person when patients returned for their scheduled 30-day follow-up visit with the primary surgeon. For patients who did not attend this visit, WHODAS assessment was completed via structured telephone interview, as the instrument does not require in-person evaluation. Of 146 enrolled participants, 52.1% completed the 30-day follow-up. No imputation methods were applied, and all analyses were conducted using complete-case data. All data were anonymized and stored on password-protected servers accessible only to the study team. Data entry was performed using standardized spreadsheets and retained for seven years in accordance with institutional policy.

Data analysis

Continuous variables are presented as mean ± standard deviation and categorical variables as frequencies (%). Comparisons between groups were performed using independent t-tests or chi-square tests, as appropriate, with two-sided p < 0.05 considered statistically significant. Change in continuous WHODAS-12 scores was summarized descriptively to characterize overall recovery patterns. The primary outcome was clinically meaningful improvement of functional disability, defined as a ≥ 3.5-point decrease in WHODAS-12 score at 30 days postoperatively. Predictors of improving disability were evaluated using Firth’s penalized logistic regression to reduce small-sample bias and address potential quasi-complete separation. A parsimonious multivariable model was specified a priori, including frailty status, age category, sex, and baseline WHODAS score. Statistical analyses were performed using STATA version 15.

Ethical considerations

The study received approval from the Aga Khan University Ethical Review Committee (ERC) after full review (ERC reference number: 2024-10358-30925). No patient identifiers were recorded. All collected data were stored in a password-protected file accessible only to the study team. In accordance with institutional policy, the data will be securely retained for up to seven years and then permanently destroyed to ensure confidentiality and data protection.

Results

Study population

Our study included 146 patients undergoing elective surgeries. The baseline demographic and clinical characteristics of the cohort, stratified by frailty status, are presented in Table 1. The mean age of the total population was 64.1 ± 9.4 years, and 52.7% were female. The cohort had a mean BMI of 29.62 ± 8.47 kg/m², with obesity (52.1%) as the most common BMI category. Orthopedic procedures predominated (66.4%), and most surgeries were open (82.1%) compared to laparoscopic. Comorbidities included hypertension (54.8%), diabetes (49.3%), dyslipidemia (17.8%), COPD (5.5%), and CHF (4.8%). Medication burden was moderate (48.6% on 1–2 medications). The mean preoperative WHODAS-12 disability score was 16.47 ± 7.33. Follow-up at 30 days was completed by 52.1% of participants.

Table 1.

Baseline Characteristics of the Study Cohort Stratified by Frailty Status

Characteristics	All Patients (n = 146)	Non-Frail (n = 34)	Frail (n = 112)	p-value
Age, years (Mean, SD)	64.07, 9.42	62.3, 9.37	64.6, 9.41	0.21
Age Category
<65	72 (49.32)	19 (55.88)	72 (49.32)	0.574
65–75	60 (41.10)	13 (38.24)	60 (41.10)
>75	14 (9.59)	2 (5.88)	14 (9.59)
Gender
Female	77 (52.74)	16 (47.06)	61 (54.46)	0.449
Male	69 (47.26)	18 (52.94)	51 (45.54)
BMI (Mean, SD)	29.62, 8.47	27.99, 5.00	30.09, 9.19	0.257
BMI Category
Underweight	5 (3.42)	0 (0.00)	5 (4.46)	0.261
Normal	32 (21.92)	10 (29.41)	22 (19.64)
Overweight	33 (22.60)	5 (14.71)	28 (25.00)
Obese	76 (52.05)	19 (55.88)	57 (50.89)
Surgical Specialty
General Surgery	49 (33.56)	15 (44.12)	34 (30.36)	0.137
Orthopedics	97 (66.44)	19 (55.88)	78 (69.64)
Procedure Type
Laparoscopic	26 (17.93)	8 (23.53)	18 (16.22)	0.331
Open	119 (82.07)	26 (76.47)	93 (83.78)
Comorbidities
Diabetes	72 (49.32)	15 (44.12)	57 (50.89)	0.489
Hypertension	80 (54.79)	19 (55.88)	61 (54.46)	0.884
CHF	7 (4.79)	3 (8.82)	4 (3.57)	0.209
COPD	8 (5.48)	4 (11.76)	4 (3.57)	0.066
Dyslipidemia	26 (17.81)	9 (26.47)	17 (15.18)	0.132
Smoking status
Yes	36 (24.66)	9 (26.47)	27 (24.11)	0.779
No	110 (75.34)	25 (73.53)	85 (75.89)
Medications Prescribed
None	14 (9.59)	4 (11.76)	10 (8.93)	0.177
1–2	71 (48.63)	16 (47.06)	55 (49.11)
3–4	37 (25.34)	5 (14.71)	32 (28.57)
5+	24 (16.44)	9 (26.47)	15 (13.39)
Preoperative WHODAS-12 (Mean, SD)	16.47, 7.33	12.29, 7.84	17.74, 6.70	< 0.001
Follow-up Completed
Yes	76 (52.05)	17 (50.00)	59 (52.68)	0.784
No	70 (47.95)	17 (50.00)	53 (47.32)

Patients were stratified into frail (n = 112) and non-frail (n = 34) groups. Frail and non-frail patients did not significantly differ in age (64.6 vs. 62.3 years, p = 0.21), gender (female: 54.5% vs. 47.1%, p = 0.45), BMI (30.09 vs. 27.99 kg/m², p = 0.26), procedure type (open: 83.8% vs. laparoscopic: 76.5%, p = 0.33), or comorbidities (all p > 0.05). However, frail patients had significantly higher baseline WHODAS scores (17.74 ± 6.70 vs. 12.29 ± 7.84, p < 0.001). Follow-up rates were comparable between groups (frail: 52.7% vs. non-frail: 50.0%, p = 0.78). Overall, WHODAS scores showed a small but significant improvement 30 days postoperatively (mean change: −1.99 ± 8.12, p = 0.036), described below in Table 2. Stratified by frailty, non-frail patients had minimal change (+ 0.35 ± 10.34, p = 0.89), while frail patients demonstrated significant improvement (− 2.66 ± 7.33, p = 0.007), which is illustrated in Fig. 1 for patients who completed follow-up.

Table 2.

Preoperative and Postoperative Disability Scores by Frailty Status

Group	Preop WHODAS (mean ± SD, n	Postop WHODAS (mean ± SD, n)	WHODAS Change (mean ± SD, n)	p-value
Total (n = 146)	16.47 ± 7.33 (146)	16.07 ± 6.78 (76)	−1.99 ± 8.12 (76)	0.036
Non-frail (n = 34)	12.29 ± 7.84 (34)	13.29 ± 6.04 (17)	+ 0.35 ± 10.34 (17)	0.890
Frail (n = 112)	17.74 ± 6.70 (112)	16.86 ± 6.82 (59)	−2.66 ± 7.33 (59)	0.007

Fig. 1.

Comparison of WHODAS 2.0 scores for frail and non-frail patients among patients who completed follow-up (n = 76)

Predictors of clinically significant improvement

Firth’s penalized likelihood logistic regression was used to identify predictors of achieving an MCID improvement of 3.5 points or more. The results of this multivariable model are summarized in Table 3. In the adjusted model, age was a significant predictor; patients aged > 75 years were 89% less likely to achieve improvement compared to those < 65 years (OR 0.11; 95% CI: 0.01–0.98; p = 0.048). Higher baseline WHODAS scores were significantly associated with a greater likelihood of improvement (OR 1.18 per point increase; 95% CI: 1.02–1.35; p = 0.022). While frailty showed a strong directional association with improvement (OR 4.05), it did not reach statistical significance (p = 0.167) in this sample size. Furthermore, a subgroup analysis across five frailty categories (Fit, Vulnerable, Mild, Moderate, and Severe) revealed a distinct clinical trend. The proportion of patients achieving improvement was substantially higher in the Mild (42.11%), Moderate (47.62%), and Severe (42.11%) frailty groups compared to those classified as Vulnerable (12.50%; Fisher’s Exact p = 0.148). These findings suggest that patients with higher baseline impairment possess a greater potential for measurable functional gain postoperatively.

Table 3.

Firth’s Penalized Logistic Regression for Predictors of Functional Improvement

Variable	Odds Ratio	95% Confidence Interval	p-value
Frailty Status (Ref: Non-Frail)
Frail	4.05	0.56–29.46	0.167
Age Category (Ref: <65 years)
65–75 years	0.35	0.10–1.27	0.111
> 75 years	0.11	0.01–0.98	0.048
Gender (Ref: Female)
Male	3.45	0.92–13.00	0.067
Baseline WHODAS Score	1.18	1.02–1.35	0.022

Discussion

This study demonstrates that surgical intervention in a Pakistani cohort leads to a significant reduction in perceived disability by the 30-day postoperative mark. However, this recovery was not uniform; the functional gain was predominantly concentrated among patients with baseline frailty, while non-frail patients showed no significant change. These results are particularly relevant given the current lack of standardized geriatric surgical protocols in Pakistan [4]. While frailty screening is increasingly prioritized in high-income settings, its application in LMICs remains sparse, often due to the perceived complexity of assessment tools [11]. By prospectively pairing the Edmonton Frail Scale with the WHODAS 2.0, this study addresses a documented evidence gap regarding functional trajectories in South Asian surgical populations [6]. Our findings suggest that in high-volume, resource-constrained environments, frailty screening can effectively identify patients who possess the greatest potential for measurable functional recovery postoperatively.

The frailty paradox: baseline disability and recovery potential

A key finding of this study is the divergence in functional trajectories based on baseline frailty status. Our results show that frail patients demonstrated a statistically significant reduction in disability scores (p = 0.007), whereas the non-frail group experienced a slight, non-significant increase in perceived disability (Table 2). This difference is likely rooted in the baseline functional gap observed in Table 1, where frail patients presented with significantly higher preoperative disability scores than their non-frail counterparts (17.7 ± 6.7 vs. 12.3 ± 7.8, p < 0.001). This suggests a ceiling effect for non-frail patients; since they enter surgery with relatively high levels of independence, there is limited mathematical and clinical room for improvement on the WHODAS-12 scale [12]. In contrast, the higher initial disability burden in frail patients allows the surgical resolution of the underlying pathology to manifest as a more pronounced shift in functional status [13]. These findings support the argument that preoperative disability levels are a strong predictor of the magnitude of postoperative gain, as those with the greatest impairment often have the most to recover.

Threshold effects in frail patients

When frailty was analyzed across a five-category gradient (Fit, Vulnerable, Mild, Moderate, and Severe), a distinct clinical trend emerged: the proportion of patients achieving a clinically meaningful improvement was substantially higher in the Mild (42.1%), Moderate (47.6%), and Severe (42.1%) frailty groups compared to those classified as Vulnerable (12.5%). While this trend did not reach statistical significance (p = 0.148), it suggests a potential threshold effect rather than a linear relationship between frailty and recovery. This implies that a certain level of baseline impairment is necessary to observe significant functional restoration following surgery, as those in the “Vulnerable” or “Fit” categories may lack the symptomatic capacity to achieve a 3.5-point gain on the WHODAS-12 scale [12, 13]. These findings support the use of the EFS not just as a binary risk marker, but as a tool to identify the specific strata of patients most likely to experience a transformative functional rebound [14, 15].

The impact of advanced age

While a high baseline disability burden appears to facilitate improvement, our regression model identifies advanced age as a significant counter-regulator of this potential. Patients aged over 75 years were 89% less likely to achieve a clinically meaningful improvement compared to those under 65 (OR 0.11, p = 0.048). This indicates a clear tension between biological frailty, which offers room for improvement, and chronological age, which may represent a hard physiological limit to short-term recovery. This finding is consistent with the systematic review by Oakland et al., which identifies advanced age as a consistent predictor of poorer postoperative functional outcomes across various surgical specialties [15]. In our cohort, the reduced likelihood of recovery in the oldest-old may reflect a depletion of physiological reserve that precludes the rebound in function typically seen in younger, although frail, individuals. These results suggest that while surgery remains a viable option for the frail, preoperative counseling for patients over 75 should be tempered with realistic expectations regarding the magnitude of functional gain achievable within the first 30 days [16].

Defining meaningful outcomes

Establishing a robust threshold for the Minimal Clinically Important Difference (MCID) is essential to prioritize patient-centered meaning over mere statistical thresholds [17]. In this study, we defined clinically meaningful improvement as a decrease of ≥ 3.5 points on the WHODAS-12. This choice is situated within a broader spectrum of established MCID estimates for the WHODAS 2.0, which range from 3.1 to 4.7 points in populations with chronic musculoskeletal pain [15] to as low as 2.4 points (the “5% rule”) in large-scale perioperative trials [16]. While some literature suggests a 10% threshold which is equivalent to approximately 4.8 points on the 48-point scale as a marker of significant change [18], we adopted the 3.5-point cutoff to achieve a balance between clinical sensitivity and statistical rigor. This threshold is specifically supported by recent anchor-based derivations in recovery cohorts [19] and aligns with the distribution-based benchmark of 0.5 standard deviations of our cohort’s baseline scores (3.66 points). By utilizing this conservative 3.5-point bar, we ensure that the identified functional gains in the frail group represent substantial shifts in independence that exceed the acute fluctuations and measurement error common in the 30-day postoperative period [20].

Practicality and scalability of the EFS

The implementation of the EFS in this study highlights its practical utility within the resource-constrained environment of a Pakistani surgical center. Unlike more labor-intensive tools or those requiring specialized equipment, the EFS is a multidimensional instrument that can be administered in approximately five minutes by non-specialist staff [21]. This scalability is critical in high-volume LMIC clinics where time and personnel are often limited. Furthermore, the EFS offers a more structured and objective assessment than the Clinical Frailty Scale (CFS), while capturing essential psychosocial domains such as mood and social support that are often overlooked in purely physical models like the Fried phenotype [8, 21]. This represents one of the first prospective applications of the EFS in a Pakistani surgical population, addressing a significant gap in regional perioperative literature [4, 11]. Our results suggest that the EFS is not only a feasible screening tool but also a culturally appropriate one, offering a comprehensive snapshot of patient vulnerability that can guide surgical decision-making and discharge planning in settings where specialized geriatric input is rare.

Implications

Our findings suggest that preoperative frailty should be viewed as a marker of recovery potential rather than a reason for surgical exclusion. First, the observation that patients with the highest baseline disability achieved the greatest gains underscores that surgery can provide a functional dividend by addressing the primary source of impairment. This challenges the view that poor preoperative function is a contraindication and suggests counseling should prioritize potential functional benefits. Second, the 89% reduction in recovery odds for patients over 75 identifies a physiological threshold where advanced age limits short-term gains, necessitating multidisciplinary pathways for the aging to support reduced physiological reserve [22]. Third, the successful use of the EFS proves that a five-minute screening tool is a scalable solution for high-volume clinics in Pakistan. Ultimately, by utilizing a 3.5-point MCID on the WHODAS-12, this study advocates for a shift toward disability-free survival as a primary metric for independence in aging surgical populations.

Limitations

This study has limitations. The most significant is the high loss to follow-up, with only 52% of patients completing 30-day assessment. Likely contributors included reliance on telephone follow-up, limited digital literacy among older patients, and challenges contacting individuals in rural or resource-limited areas. Although baseline characteristics were comparable between completers and non-completers, this attrition raises the risk of selection bias and limits generalizability. Second, the follow-up duration was short (30 days), precluding assessment of long-term disability trajectories. Methodologically, our modest sample size resulted in small cell counts within certain frailty strata, which we addressed by utilizing Firth’s penalized likelihood regression to ensure robust and biologically plausible estimates. We also considered the potential for statistical fluctuations in patients with high baseline disability. To mitigate this, we utilized a conservative 3.5-point MCID threshold. By selecting a cutoff that exceeds 0.5 standard deviations of the baseline scores, we ensured that the functional gains identified represent clinically significant recovery rather than mere measurement noise [19, 23]. Finally, our categorization of ‘laparoscopic’ procedures was broad; the physiological differences between laparoscopic general surgery and orthopedic pathways are substantial, and this heterogeneity may have masked approach-specific influences on functional recovery.

Conclusion

In conclusion, this study demonstrates that preoperative frailty, when assessed via the Edmonton Frail Scale, identifies a subset of patients with significant potential for postoperative functional recovery in a Pakistani surgical cohort. Our data reveals a “frailty paradox” where individuals with the highest baseline disability achieve the greatest functional gains, suggesting that frailty should be viewed as a marker of recovery potential rather than a reason for surgical exclusion. However, the significantly lower likelihood of improvement among patients over 75 indicates a physiological limit to short-term recovery, emphasizing the need for age-stratified perioperative support. By utilizing the WHODAS 2.0 and a conservative 3.5-point MCID, this research advocates for the adoption of patient-centered metrics that prioritize the preservation of independence in the global aging population.

Abbreviations

EFS

Edmonton Frail Scale

WHODAS

World Health Organization Disability Assessment Schedule

LMIC

Low–and Middle–Income Country/Countries

AKUH

Aga Khan University Hospital

MCID

Minimal Clinically Important Difference

AKU

ERC–An ethical review committee of Aga Khan University

CFS

Clinical Frailty Scale

Authors’ contributions

Ebadullah Shahood Ahmed (ESA) conceived the study idea, developed the research question, and was the primary author responsible for drafting the manuscript. Mohammad Khozema Safri (MKS) contributed to the study design and drafting of the protocol. Aashir Aslam (AA) and Sharjeel Ahmad (SA) assisted with data analysis and contributed to manuscript writing. Fatemah Batool (FB) and Khushi Saleem (KS) were responsible for data collection and contributed to manuscript drafting. Akbar Jaleel (AJ), Asad Latif (AL), and Mohsin Nazir Butt (MNB) critically reviewed the manuscript and provided expert feedback. Mohsin Nazir Butt (MNB) served as the principal investigator and supervised all stages of the study.

Funding

This research received no external funding.

Data availability

Data were obtained from surveys conducted among patients undergoing treatment at AKUH and are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the Ethical Review Committee of the Aga Khan University (review reference: 2024-10358-30925) and conducted in accordance with the principles of the Declaration of Helsinki [24]. Informed consent obtained from all the participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.