Knowledge, attitudes and practices of occupational safety among healthcare professionals at Dr. Sumait hospital, Mogadishu, Somalia

Abstract

Occupational safety is a fundamental concern in healthcare settings, where inadequate knowledge, attitudes, and practices (KAP) can increase the risk of infection and other workplace hazards. This study aimed to assess the KAP of healthcare professionals at Dr. Sumait Hospital, SIMAD University, Mogadishu, Somalia, in order to identify strengths and areas requiring improvement in occupational safety practices. A cross-sectional study was conducted between January and February 2025 among 87 healthcare professionals. Data were collected using a structured questionnaire that assessed demographic characteristics as well as participants’ knowledge, attitudes, and practices related to occupational safety. Descriptive statistical analyses were performed using SPSS version 20. Overall, 74.71% of participants recognized occupational safety as a critical issue, and 88.51% acknowledged their responsibility for implementing safety measures. Knowledge of personal protective equipment (95.40%) and infection transmission (89.66%) was high, while awareness of healthcare waste segregation (71.26%) and post-exposure prophylaxis (73.60%) was comparatively lower. Attitude assessment showed strong support for safety precautions (96.55%) and mandatory vaccination (91.95%). However, only 58.62% of respondents reported the availability of infection prevention guidelines in their departments. In terms of practice, most participants adhered to hand hygiene (98.9%) and PPE use (98.9%); however, 74.7% reported recapping needles, which represents an unsafe practice. Despite generally high levels of knowledge and positive attitudes toward occupational safety, notable gaps in safety practices persist, particularly regarding needle handling and infection control. Targeted interventions, including enhanced training, reinforcement of safety policies, and improved access to infection prevention guidelines, are essential to strengthen workplace safety at Dr. Sumait Hospital.

Introduction

Ensuring health and safety in the workplace is essential for all organizations, particularly in healthcare settings, where both healthcare workers and patients are exposed to significant risks¹. Healthcare professionals (HCPs) may inadvertently contribute to the transmission of healthcare-associated infections (HAIs) by acting as carriers of pathogenic microorganisms, thereby compromising patient outcomes^2,3. Effective occupational safety practices are therefore critical for protecting healthcare workers, patients, and visitors from preventable harm^4–8.

Healthcare professionals are routinely exposed to occupational hazards such as contact with blood and body fluids, needlestick and sharp injuries, and splashes to mucous membranes or non-intact skin. These exposures increase the risk of transmission of blood-borne infections, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV)^4,5. The probability of infection following exposure varies by pathogen, ranging from approximately 0.1–0.3% for HIV, about 2% for HCV, and up to 60% for HBV⁴. Preventive strategies, including vaccination and consistent use of personal protective equipment (PPE), remain central components of occupational safety^7,9–11.

Despite advances in healthcare delivery, HAIs continue to pose a major global challenge. The World Health Organization (WHO) reports global HAI prevalence rates ranging from 5.7 to 19.1%¹². Data from Europe and the United States demonstrate that HAIs remain prevalent across health systems regardless of income level^12,13. However, the burden is disproportionately higher in low-resource settings, with prevalence estimates of approximately 6.5% compared to 3.2% in high-income countries^14–16. A WHO-led review further indicated that HAI prevalence in low- and middle-income countries reaches 15.5%, more than double that observed in high-income regions¹⁷. These disparities highlight the unequal occupational risks faced by healthcare workers across different healthcare contexts.

Multiple factors contribute to the persistence of HAIs, including inadequate environmental hygiene, poor waste management systems, limited infrastructure, insufficient staffing, and overcrowding^18,19. Knowledge gaps and poor adherence to infection prevention and control measures also remain common^10,20,21. Unsafe practices such as inadequate hand hygiene, incomplete vaccination coverage, and improper handling of sharps further increase the risk of infection^6,20–23.

In Somalia, where the healthcare system is fragile and resources are limited, occupational risks are compounded by shortages of protective equipment and weak regulatory and policy frameworks. Dr. Sumait Hospital in Mogadishu, a teaching hospital affiliated with SIMAD University, provides a relevant setting for examining these challenges. Therefore, this study aimed to assess the knowledge, attitudes, and practices of healthcare professionals regarding occupational safety, identify existing gaps, and generate evidence to inform infection prevention and occupational health strategies in a low-resource healthcare context.

Methods

Study design and setting

An institution-based cross-sectional study was conducted from January to February 2025 at Dr. Sumait Hospital, SIMAD University, Mogadishu, Somalia. Dr. Sumait Hospital is a multidisciplinary teaching hospital with approximately 50 inpatient beds and provides services through key departments, including internal medicine, surgery, obstetrics, pediatrics, intensive care, and emergency care²⁴.

Study population and eligibility criteria

The study population consisted of healthcare professionals working at Dr. Sumait Hospital during the study period, including medical doctors, nurses, midwives, pharmacists, laboratory personnel, radiology staff, and sterilization staff. Eligible participants were aged 18 years or older and actively employed at the hospital. Healthcare workers were excluded if they were not currently on duty, were on maternal leave, declined to participate, or refused to provide informed consent or sign the study agreement.

Sample size and sampling technique

A convenience sampling technique was employed, whereby participants were selected based on their availability and willingness to participate. The total number of healthcare professionals available during the study period was 87, and all were invited to take part in the study. As a result, the sample size represented a census of the accessible population rather than a statistically calculated sample size. Although convenience sampling may limit the generalizability of the findings, this approach was considered appropriate given the study context and accessibility of participants. It also allowed for efficient data collection and provided valuable insights into the target population.

Research instruments and measurements

Data were collected using a well-structured and validated questionnaire²⁵. The questionnaire was initially developed in English and subsequently translated into Somali to ensure clarity and cultural appropriateness. Content validity was assessed using the Item Objective Congruence method, with input from three external experts²⁶. A pilot study involving 30 participants was conducted to assess reliability and comprehension, yielding a Cronbach’s alpha of 0.79, which indicated acceptable internal consistency.

Data collection techniques

The questionnaire was first prepared in English and then translated into Somali by qualified language experts to ensure consistency and accuracy. The Somali version was used to develop an online questionnaire for data collection. Eligible healthcare workers who met the inclusion criteria were invited to complete the questionnaire online. Participants were fully informed about the study objectives, eligibility criteria, and the voluntary nature of participation, and verbal consent was obtained prior to participation. Anonymity was ensured by not collecting names or personal identifiers, and confidentiality was maintained by storing data in password-protected files. Hospital administrative staff provided logistical support to facilitate data collection.

Data analysis

Collected data were cleaned, coded, and entered into a spreadsheet before being imported into SPSS version 20 (SPSS Inc., Chicago, IL, USA) for analysis. Descriptive statistics were used to summarize the characteristics of the study population. Categorical variables are presented as frequencies and percentages, while continuous variables are expressed as means with standard deviations. Knowledge and practice responses were scored as 1 for correct responses and 0 for incorrect responses. Attitude responses were scored using a three-point Likert scale: 1 = disagree, 2 = neutral, and 3 = agree.

Mean scores were calculated and used to categorize outcome variables. Scores below the mean were considered indicative of inadequate knowledge, unfavorable attitudes, or poor practices, whereas scores equal to or above the mean were classified as adequate knowledge, favorable attitudes, or appropriate practices. The mean was selected as the cut-off point rather than the median or predefined thresholds to allow classification based on the actual distribution of scores within the study sample, consistent with previous KAP studies^27–30. The cut-off values for knowledge, attitude, and practice scores were derived from comparable studies^27–30.

Data categorization in knowledge and practice sections

Knowledge

In the knowledge section, the final four questions included explicit answer options. The first question assessed knowledge of the maximum recommended filling level of safety boxes for sharp medical waste, with response options ranging from half-full to completely full, as well as an “I do not know” option. The “I do not know” response was scored as incorrect, while the remaining options were scored as correct. The second question assessed knowledge of the WHO-recommended maximum delay for initiating HIV post-exposure prophylaxis, with options of 24, 48, or 72 h, and “I do not know.” Again, “I do not know” was classified as incorrect, and all other options were classified as correct. The final two questions assessed awareness of health risks associated with healthcare waste and the effectiveness of PPE in reducing infection risk. Responses of “No” and “I do not know” were scored as incorrect, while “Yes” was scored as correct.

Practice

In the practice section, responses were categorized as “always,” “sometimes,” or “not at all.” For analytical purposes, “always” was considered the correct response, while “not at all” was considered incorrect. This categorization was applied to simplify assessment and ensure consistency in data interpretation.

Results and interpretation

Sociodemographic characteristics

A total of 87 healthcare professionals participated in the study. Most participants were male (56.32%) and single (58.62%). The majority held a first-degree qualification (71.26%), with nurses (37.93%) and medical doctors (33.33%) representing the most common professional groups. Participants were primarily working in hospital wards (20.69%), followed by intensive care units (19.54%) and outpatient departments (16.09%).

Regarding training and vaccination status, 67.82% of respondents reported having received prior training in risk assessment. Most participants (87.36%) had been vaccinated against hepatitis B virus (HBV), and among those vaccinated, 78.48% had completed the full three-dose schedule. In terms of occupational safety resources, 59.77% of respondents reported having sufficient personal protective equipment available in their departments, while 62.07% indicated that safety manuals or guidelines were accessible in their work areas (Table 1).

Table 1.

Sociodemographic characteristics.

Socio-demographic and HC related variables	Variable category	Frequency n (%)
Gender	Male	49 (56.32%)
	Female	38 (43.68%)
Age group	≤ 25 years	26(29.9%)
	26–30 years	36(41.4%)
	≥ 31 years	25(28.7%)
Marital status	Single	51 (58.62%)
	Marriage	35 (40.23%)
	Divorced	1 (1.15%)
	Window	0(0%)
Profession	Medical Doctor	29 (33.33%)
	Medical Laboratory	11 (12.64%)
	Midwifery	3 (3.45%)
	Nurse	33 (37.93%)
	Pharmacy	5 (5.75%)
	Radiology	4 (4.60%)
	Sterilization	2 (2.32%)
Educational level	Diploma	1 (1.15%)
	First degree	62 (71.26%)
	Second degree and above	24 (27.59%)
Working department/section	OPD	14 (16.09%)
	Ward	18 (20.69%)
	I C U	17 (19.54%)
	OT	5 (5.75%)
	Laboratory Room	13 (14.94%)
	Emergency	11 (12.64%)
	Sterilization	2 (2.30%)
	Radiology	5 (5.75%)
	NICU	2 (2.30%)
Work experience in years	0–5	50(57.5%)
	6–10	25(28.7%)
	> 10	12(13.8%)
Have you taken risk assessment training before?	Yes	59 (67.82%)
	No	28 (32.18%)
Have you taken the HBV vaccine?	Yes	76 (87.36%)
	No	11 (1264%)
If your answer on Last Q is yes, how many doses have taken?	The first dose only	8 (10.13%)
	The second dose only	9 (11.39%)
	Third dose (complete)	62 (78.48%)
Are there sufficient personal protective devices available in your department/ section?	Yes	52 (59.77%)
	No	18 (20.69%)
	I am not sure	17 (19.54%)
Are safety manuals/guidelines available in your department/section?	Yes	54 (62.07%)
	No	22 (25.29%)
	I am not sure	11 (12.64%)

Knowledge of occupational safety

Overall, healthcare professionals demonstrated a high level of knowledge regarding occupational safety. Nearly three-quarters of respondents (74.71%) recognized occupational safety as a significant concern for healthcare organizations, and 88.51% acknowledged their personal responsibility for occupational health and safety.

Knowledge was particularly high regarding the use of personal protective equipment (95.40%), awareness of infection transmission mechanisms (89.66%), and performance of risk assessments (83.91%). Most participants were familiar with hand hygiene practices (94.25%) and aware of hazards in their working environments (97.70%). Similarly, 97.70% reported knowing how to handle used needles and sharps safely.

However, comparatively lower levels of knowledge were observed in specific technical areas, including healthcare waste segregation (71.26%), appropriate use of safety boxes (73.60%), and the recommended timing for initiation of HIV post-exposure prophylaxis (73.60%). Despite these gaps, 90.8% of respondents believed that the use of personal protective equipment effectively reduces the risk of infection (Table 2).

Table 2.

Knowledge of occupational safety.

Level of knowledge	Frequency N (%)	Frequency N (%)
Knowledge statements	Correct answer n (%)	Wrong answer n (%)
Is occupational safety a problem for healthcare organizations?	65 (74.71%)	22 (25.29%)
Are healthcare workers responsible for occupational health and safety?	77(88.51%)	10 (11.49%)
Do you know how to use personal protective equipment?	83(95.40%)	4 (4.60%)
Do you know how to perform a risk assessment?	73(83.91%)	14(16.09%)
Do you know transmission mechanisms of infectious agents?	78(89.66%)	9(10.34%)
Do you wash your hands before and after you contact with patents?	82(94.25%)	5(5.75%)
Are you aware of the risks of your working environment?	85(97.70%)	2(2.3%)
Do you know how to handle used needles and sharps safely?	85(97.70%)	2(2.30%)
Do you know about color coding segregation of healthcare wastes?	62(71.26%)	25(28.74%)
How maximum full should be the safety box containing sharp medical supplies?	64 (73.6%)	23(26.4%)
According to the World Health Organization guideline, what is the maximum delay to start HIV post-exposure prophylaxis?	64 (73.6%)	23(26.4%)
Is there any health hazard associated with healthcare wastes?	69(79.3%)	18(20.7%)
Does wearing personal protective equipment reduce the risk of infection?	79(90.8%)	8(9.2%)

Attitudes toward occupational safety

The findings indicate that most healthcare professionals held positive attitudes toward occupational health and safety. Almost all respondents agreed that safety precautions are important for healthcare organizations (96.55%) and that occupational health and safety training is essential for healthcare workers (93.10%). A large proportion recognized the presence of occupational hazards in their work environment (83.91%) and acknowledged that healthcare workers are at high risk of infection (90.98%).

Most participants supported the provision of personal protective equipment in their departments (86.21%) and emphasized the importance of risk assessment (95.40%). While 87.36% agreed that sharp materials should be disposed of in safety boxes, 62.07% believed that needles should be recapped after use. The majority expressed willingness to receive the HBV vaccine if unvaccinated (83.91%) and agreed that masks and eye protection should be used during aerosol-generating procedures (81.61%). Support for mandatory vaccination of healthcare workers was high (91.95%), and 82.76% recognized the potential for HBV transmission through biomedical waste. Notably, only 58.62% of respondents reported the presence of safety or infection prevention guidelines in their departments (Table 3).

Table 3.

Attitudes toward occupational safety.

Level of attitude	Frequency N (%)	Frequency N (%)
Attitude statements	Agree n (%)	Neutral n (%)		Disagree n (%)
Safety precaution is important for healthcare organizations	84 (96.55%)	3(3.45%)		(%)
Occupational health and safety training is important for healthcare workers	81(93.10%)	4(4.60%)		2(2.30%)
Your healthcare environment may expose you to occupational hazards	73(83.91%)	9(10.34%)		5(5.75%)
Health care workers are at high risk of infection	79(90.98%)	4(4.60%)		4(4.60%)
All personal protective equipment should be accessible in the working department/ section of the healthcare facility.	75(86.21%)	7(8.05%)		5(5.75%)
Individual workplace risk exposure should be considered as a crisis of community	62(71.26%)	11(12.64%)		14(16.09%)
Risk assessment is important for occupational health and safety.	83(95.40%)	3(3.35%)		1.15(%)
Sharp materials should be discarded in a safety box	76(87.36%)	6(6.90%)		5(5.75%)
Needles should be re recapped after use	54(62.07%)	8(9.20%)		25(28.74%)
If you didn’t have taken HBV vaccine before, are you willing to take it?	73(83.91%)	13(14.94%)		1(1.15%)
Wearing facemask and eye goggles during procedures with aerosol production is mandatory	71(81.61%)	11(12.64%)		5(5.75%)
Vaccination for healthcare workers is mandatory	80(91.95%)	4(4.60%)		3(3.45%)
Hepatitis B virus may be transmitted through biomedical wastes	72(82.76%)	8(9.2%)		7(8.05%)
Is there any safety/ infection prevention guideline/ document in your department?	51(58.62%)	22(25.29%)		14(16.09%)

Safety practices and exposure history

Overall, healthcare professionals reported good compliance with occupational safety practices. However, 32.18% of participants reported having experienced a needlestick or sharp injury within the past 12 months, and among those individuals, only 20% had received HIV post-exposure prophylaxis following the incident.

Most respondents reported frequent adherence to safety measures, including regular use of safety guidelines or manuals (90.8%), wearing gloves during high-risk procedures (98.9%), washing hands after patient contact (98.9%), and using appropriate personal protective equipment during routine practice (98.9%). In addition, most participants reported cleaning their working areas at the end of shifts (94.3%) and monitoring waste management systems (98.9%).

Waste segregation and infection control practices were also commonly reported. Separate disposal of healthcare waste was practiced by 90.8% of respondents, and 98.9% reported routinely performing risk assessments in their departments. Most participants removed gloves between contacts with different patients (97.7%) and washed their hands after glove removal (97.7%). However, a substantial proportion of respondents (74.7%) reported recapping used needles, which represents a significant occupational safety risk. Segregation of healthcare waste at the point of generation was reported by 73.6%, and treatment of infectious waste with disinfectants by 88.5%, indicating overall high compliance with safety measures despite the persistence of unsafe practices (Table 4).

Table 4.

Safety practices and exposure history.

Level of practice	Frequency N (%)	Frequency N (%)
Have you ever encountered any sharp /needlestick injury in the last 12 months?	28 (32.18%)	59 (67.82%)
If yes, on question No 401 have you taken prophylaxis for HIV?	14 (20%)	56(80%)
Did you answer your cell phone with the glove while calling before?	20 (22.99%)	67(77.01%)
How often do you use safety guideline/ manual at your workplace?	78(90.8%)	8(9.2%)
How often do you wear gloves during risky procedures?	86 (98.9%)	1(1.1%)
How often do you wash your hands with proper detergent after contact with patients/ working time?	86 (98.9%)	1(1.1%)
How often do you use proper personal protective equipment during your professional practice?	86 (98.9%)	1(1.1%)
How often do you clean your working area after the end of working shift?	82(94.3%)	5(5.7%)
How often do you monitor your working area waste management system?	86 (98.9%)	1(1.1%)
How often do you practice separate disposal of healthcare wastes?	79(90.8%)	8(9.2%)
How often do you perform risk assessment in your working department/section?	86 (98.9%)	1(1.1%)
How often do you change gloves between contacts with different patients?	85(97.7%)	2(2.3%)
How often do wash your hands after removal of gloves?	85(97.7%)	2(2.3%)
How often do you recap used needles?	65 (74.7%)	22(25.3%)
Do you segregate healthcare wastes according to their type at the point of generation?	64(73.6%)	23(26.44%)
How often do you treat infectious wastes with disinfectants?	77(88.5%)	10(11.5%)

Discussion

This study assessed the knowledge, attitudes, and practices (KAP) related to occupational safety among healthcare professionals at Dr. Sumait Hospital in Mogadishu, Somalia. Overall, the findings are encouraging, indicating that many healthcare workers possess good knowledge of occupational hazards and hold positive attitudes toward safety. At the same time, the results reveal important gaps in actual safety practices that continue to place healthcare professionals at risk of preventable occupational injuries and infections.

Knowledge levels were high across several key domains. Nearly all participants demonstrated strong awareness of personal protective equipment (PPE) use and modes of infection transmission, findings that are consistent with studies conducted in Ethiopia and Nigeria, where healthcare workers similarly exhibited good understanding of standard precautions^1,25. However, gaps were observed in more specific technical areas, particularly healthcare waste segregation and the correct timing of HIV post-exposure prophylaxis. These deficiencies have also been reported in studies from India and Lebanon, where limited training opportunities and resource constraints contributed to reduced awareness of specialized infection prevention measures^4,5,31. The finding that only 58.6% of respondents reported the availability of infection prevention guidelines within their departments suggests that institutional and structural barriers, rather than individual knowledge alone, play a significant role in these shortcomings^17,32.

Attitudes toward occupational safety were generally positive. Most participants emphasized the importance of occupational health and safety training and supported mandatory vaccination and routine risk assessment. These findings align with studies from Jamaica and Ethiopia, which demonstrated that access to training programs improves safety awareness and promotes compliance with preventive measures^9,10,32. Nevertheless, the persistence of unsafe beliefs, particularly the perception held by more than 60% of participants that needles should be recapped after use, remains concerning. Needle recapping is explicitly discouraged by the World Health Organization due to its strong association with needlestick injuries and transmission of blood-borne pathogens^17[,33. This highlights a critical disconnect between general safety awareness and the consistent application of evidence-based practices.

Encouragingly, reported compliance with several core safety practices was very high. Nearly all participants indicated regular hand hygiene and consistent use of PPE, findings that mirror global evidence identifying these measures as among the most effective strategies for preventing healthcare-associated infections^2,11. These results are particularly reassuring in a fragile health system such as Somalia’s, where reducing the risk of cross-infection is essential for both patient and staff safeties. However, despite this high level of reported compliance, one-third of respondents experienced a needlestick injury within the previous year, and only one in five received HIV post-exposure prophylaxis following exposure. Similar patterns have been reported in studies from rural India and Ethiopia, where weak reporting mechanisms and limited access to prophylaxis undermined effective management of occupational exposures^5,9,26.

The continued practice of needle recapping by 74.7% of respondents is especially alarming and underscores how deeply entrenched unsafe behaviors can persist despite adequate knowledge and favorable attitudes. This practice substantially increases the risk of transmission of blood-borne infections such as HBV, HCV, and HIV. Addressing such behaviors requires more than knowledge dissemination alone; it necessitates sustained supervision, behavioral reinforcement, and institutional accountability.

These findings have important implications for occupational health policy and practice. Strengthening institutional safety protocols is a critical priority. Infection prevention and control guidelines should be consistently available in all hospital departments, and training initiatives should be continuous rather than episodic, with particular emphasis on sharps handling, waste management, and post-exposure prophylaxis procedures^22,34. Hospital management should also prioritize ensuring a reliable supply of PPE, establishing supportive and non-punitive reporting systems for occupational injuries, and implementing regular monitoring through occupational safety committees. In resource-limited settings such as Somalia, even low-cost interventions, such as visual reminders, peer monitoring, and job aids, can substantially improve compliance and reduce occupational risks^2,9,11.

Study limitations

This study has several limitations that should be acknowledged. First, the use of a convenience sampling technique limits the generalizability of the findings, as the participants may not fully represent all healthcare professionals in Somalia. Second, as a single-institution study, the results reflect the specific context of Dr. Sumait Hospital and may not be applicable to other healthcare settings. Third, reliance on self-reported data introduces the potential for recall bias and social desirability bias, as participants may have over reported their adherence to safety practices. Finally, the analysis was limited to descriptive statistics. While this approach provided valuable baseline information, it did not allow for the examination of associations or predictors of occupational safety behaviors. Future studies should employ inferential statistical methods, larger and more representative samples, and multicenter designs to provide a more comprehensive understanding of occupational safety practices.

Conclusion

This study presents a mixed picture of occupational safety among healthcare professionals at Dr. Sumait Hospital. While knowledge of fundamental infection prevention measures and positive attitudes toward occupational health are encouraging, persistent unsafe practices, particularly widespread needle recapping, underreporting of occupational injuries, and limited uptake of post-exposure prophylaxis, indicate that substantial risks remain.

Addressing these challenges requires a comprehensive and sustained approach. Training programs should be continuous and practice-oriented, with a specific focus on correcting entrenched unsafe behaviors. Hospitals should ensure that infection prevention and control guidelines are readily available in all departments and reinforced through regular supervision and audits. At the policy and management levels, leadership must ensure consistent access to personal protective equipment, establish functional occupational safety committees, and implement supportive systems for reporting and responding to workplace injuries.

By directly aligning interventions with the gaps identified in this study, healthcare institutions in Somalia can make meaningful progress in protecting their workforce. Improving occupational safety will not only reduce the risk of infection among healthcare professionals but also enhance patient safety and contribute to building resilience within a healthcare system operating under significant constraints. In fragile healthcare settings such as Somalia, these improvements are not optional, they are essential.

Author contributions

A.H.E. conceived the original study idea. The study design was developed collaboratively by A.H.E., M.M.A., M.M.H., and N.I.D. All authors contributed to the preparation of study materials, data collection, and analysis. Data analysis and interpretation were primarily conducted by A.H.E., M.M.A., and M.M.H. A.H.E. drafted the initial manuscript, and all authors reviewed, revised, and approved the final version to enhance clarity and accuracy.

Funding

The authors did not receive any funding for the research, writing, or publication of this article.

Data availability

The data supporting this study’s findings are available from the corresponding author upon reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Ethical approval

and participant consent: Ethical approval was granted by the Institutional Review Board of SIMAD University, Mogadishu, Somalia (approval dated January 12, 2025; Ref. 2025/SU-IRB/FMHS/P0010). Written informed consent was obtained from all participants prior to enrolment; for participants under the age of majority, written consent was obtained from a parent/guardian in addition to participant assent. All methods were performed in accordance with the relevant guidelines and regulations, including the Declaration of Helsinki and SIMAD University IRB requirements.