Health-oriented leadership and health equity: the role of NGO support in advancing public health policy and nutritional literacy

Abstract

Leadership initiatives are increasingly recognized as crucial drivers of policy implementation, well-being, and nutritional literacy. However, the relationship between health-oriented leadership, healthcare policy, community well-being, and community nutritional literacy remains underexplored. With increasing awareness of health and nutrition in developing countries, this study explores the role of Health-Oriented Leadership (HOL) in the implementation of human health policies, well-being, and nutritional literacy. Based on a multi-source, multi-wave survey of 355 management personnel and 360 community and stakeholder personnel in Pakistan, this study highlights the cross-level trickle-down effect of health-oriented leadership. The proposed model was tested using qualitative methods, and for analysis, this study employed multilevel structural equation modeling and regression analysis to examine direct, mediating, and moderating effects. Drawing on the human needs theory, our findings show that health-oriented leadership positively impacts the implementation of public health policy and fosters well-being and nutritional literacy in communities. Furthermore, NGO support (NS) moderates the relationship between health-oriented leadership and the execution of healthcare policy. This research is innovative and the first to examine HOL’s role in implementing public health policy with NGO backing, promoting well-being, and enhancing nutritional literacy within communities. It makes a valuable contribution to the literature on nutrition and health management by providing practical insights for governments, NGOs, and community stakeholders seeking to implement leadership strategies that protect community health and promote initiatives for a balanced diet and improved living standards.

Introduction

A healthy life is a basic need for human beings, and current estimates indicate that approximately 90% of cases of undernutrition occur in developing countries [1]. This statistic highlights an alarming situation in these regions, characterized by unequal distribution of resources and political instability, where insufficient access to basic needs such as nutrition, healthcare, and essential resources perpetuates a cycle of poverty and poor health [2]. In this era, global leadership and the World Health Organization (WHO) focus on health, nutrition, and sustainable development to address these crises [3]. Research confirmed that well-designed health policies significantly impact health awareness, and nutrition affects community well-being and development [4]. For instance, the World Health Organization [5] report shows that evidence-based health policies and standardized nutritional practices positively contribute to community development [6]. Furthermore, the finding highlights the critical role of health policies in enhancing health and nutrition literacy among the general public, which is a primary factor in improved health outcomes, overall community well-being, and a happy lifestyle [7]. Health, education, and nutrition are the basic needs of society, and research confirmed the positive impact of health and education on socioeconomic conditions, highlighting how comprehensive health policies can drive sustainable development at the community level [8].In developing countries, research shows that nutrition-related problems, including malnutrition, food insecurity, and unequal access to healthy diets, significantly affect community well-being [9]. These challenges affect physical health outcomes and hinder cognitive development, productivity, and long-term socioeconomic progress. This perspective is reinforced by the Organization [10], which emphasizes that improving nutritional standards is fundamental to achieving the Sustainable Development Goals, reducing health inequalities, and promoting overall societal resilience. Furthermore, the literature shows that through the proper implementation of standard health policies, many countries have effectively tackled nutrition challenges, supporting the active role of NGOs in health awareness and policy implementation at the ground level [11]. The previous sentences do not really reveal a significant research gap, they are just stating what is known. Consider changing to: “Together, this body of research suggests there is a growing necessity for a strategic approach, such as policy implementation strategy and leadership practices, to address health and nutrition-related issues and improve community well-being. Developing countries’ nutrition and healthcare systems lack effective implementation of health policies, leading to health crises and food insecurity [12, 13]. These challenges negatively affect the community and increase expenditures on medical treatments and indirect long-term costs, including lost productivity and economic strain on organizations and communities [14]. This highlights the pressing need for standard and effectively implemented health policies to mitigate negative impacts and foster sustainable health and community well-being [12]. Proper implementation of healthy policy and nutrition literacy significantly depends on leaders’ ability to formulate, enhance, and execute health policies and engage stakeholders for further improvement [15]. The leadership capability that addresses health challenges, improves community well-being, and drives sustainable development is sustainable leadership [16, 17]. Per our literature, there is a significant research gap regarding how leaders prioritize health and nutrition-oriented strategies to bridge the disconnect between policy design and execution in the Pakistani context.

Furthermore, this approach is reinforced by advancing several practices, like health policies and nutrition-focused programs, that aim to increase nutrition literacy [18]. These strategies are designed to empower communities to recognize the importance of a balanced diet, make the nutrients educated and informed health decisions, and contribute to community well-being [19]. To implement such significant initiatives into more extensive public health policies, governments and nongovernment organizations can establish sustainable frameworks to enhance community well-being and address widespread nutritional issues [20, 21]. Moreover, the mediating role of policy is critical to understanding how leadership influences public health outcomes [22]. Research indicates that government health policy mediates the relationship between Health-Oriented Leadership and community nutritional literacy and well-being [23]. This mediating effect demonstrates how leadership-driven health initiatives translate into public health benefits through strategically implementing government policies [16]. Such insights emphasize the necessity of collaboration between leadership, government, NGOs, and community actors to achieve optimal health outcomes [24].

Further, research highlights the moderating role of NGO support in strengthening the relationship between leadership and policy implementation [25]. NGO support is often essential in executing health and nutrition programs, particularly in regions with limited government infrastructure [26]. High levels of NGO support enhance the positive influence of leadership on government health policy, fostering collaboration among leadership, policy initiatives, and community health outcomes [27]. While the literature demonstrates that leadership styles significantly impact policy effectiveness, nutrition and healthcare research gaps regarding health-oriented leadership styles persist [28]. This study seeks to bridge these gaps by exploring how health-oriented leadership practices, government policies, and NGO partnerships align to improve community health outcomes. The research contributes to a deeper understanding of how these elements collectively advance public health systems and promote sustainable community development (see Fig. 1).

Fig. 1.

Proposed Conceptual Framework

The current study intends to fill several research gaps and contribute to the literature on nutrition and healthcare. This study introduces a novel leadership concept- Health-oriented leadership to nutrition and healthcare literature. In other sectors, such as education and information technology, extensive research has examined HOL, which has been linked to improved work performance [29]. Accordingly, by implementing HOL in the nutrition and healthcare sectors, we hypothesize that organizations can significantly advance policy and enhance community well-being. Therefore, the first aim of this study is to examine whether HOL influences the implementation of health policies in developing countries such as Pakistan. Second, this study examines Community Well-being (CWB) and CNL as outcomes of HOL, thus extending the nomological network of development and HOL. Third, our research investigates NGO support as a moderator variable in the connection between HOL and health policy implementation. Finally, this study investigates the mediating effect of health policy linking HOL and two outcome factors. Therefore, this study will attempt to answer the research question: RQ1. How does health-oriented leadership directly affect health policy? RQ2. How does health policy mediate the effect of leadership on nutrition literacy and community well-being? RQ3. Does health policy mediate between Health-oriented leadership and nutrition literacy? RQ4. Does health policy mediate between Health-oriented leadership and community well-being? RQ5. Does NGO support moderate the association between Health-oriented Leadership and health policy?

Literature review and hypotheses development

The human needs theory

The Human Needs Theory offers a gripping lens through which to understand the role of leadership in addressing essential health and food security needs and fostering community well-being [30]. Leaders play a key role by prioritizing basic human health policies and developing strategies to meet basic human needs, such as health, security, and education, which are critical for community sustainable development [31]. In sustainable community development, leaders play a significant role in healthcare systems, aligning SDGs and Governmental visions to provide basic needs at the community level, ensure the equitable distribution of resources, and increase awareness of public health and nutrition literacy [16]. To address these challenges with the support of NGOs, the leaders promoting nutritional awareness empower communities to make informed decisions about their health and contribute to the quality of their lifestyle [32, 33]. From the human needs theory’s perspective, such health-oriented leadership ensures that government health policies align and are implementable for the basic human needs at the community level [30]. The theory ensures that basic health needs, including access to nutritional literacy, resource distraction, and well-being, are essential for sustainable community development [34]. With the collaboration of all stakeholders, like NGOs, the leaders strengthen their impact, bridging gaps in underdeveloped regions and creating sustainable frameworks for well-being [35]. This collaboration addresses unmet needs and brings a collective commitment to enhancing community health, aligning leadership initiatives with the worldwide imperative to secure health and food security.

Hypotheses development

Health-oriented Leadership and Health Policy

Health-oriented leadership (HOL) plays a crucial role in promoting health by fostering a favorable health policy and supportive environment, addressing community health and nutrition challenges, and raising awareness about health and community well-being [16, 36]. This type of leadership contributes to the community’s well-being and development and is essential in improving the implementation of government health policies [37]. Through proper nutrition and health literacy, and policy implementing strategies for launching different programs for health improvement, community welfare, and resource allocation, HOL reduces community stress and enhances overall health [38]. Furthermore, these policies are aligned with national goals and health policies, helping to tackle broader challenges related to community well-being and nutrition literacy, and contributing to the United Nations’ sustainable development goals [39].

Leadership styles, such as transformational, servant, and inclusive, have positively connected with health and community development [40]. These leadership approaches create a supportive environment and address community needs for health and nutrition, reducing food insecurity and boosting nutrition programs for community welfare [41]. Health-oriented leaders’ ability to influence policy implementation and ensure its alignment with community well-being can significantly impact nutrition literacy and overall community health when developing and implementing health policy [16, 20]. Transformational leadership theory supports this view by emphasizing the role of leaders in inspiring and motivating teams toward achieving collective national goals, including health and development [42]. Leadership can improve community well-being and health outcomes by concentrating on higher-order needs and creating an environment that encourages providing basic health facilities and overcoming nutrition challenges [43]. Health-oriented leaders can enhance community well-being and drive the successful implementation of government health policies, contributing to long-term community well-being and improved public health outcomes.

H1

Health-oriented leadership has a positive impact on the implementation of government health policy.

Government health policy and community nutritional literacy

As per the United Nations Sustainable Development Goals, the government health policy is critical in raising community nutritional literacy through shaping public health policies, raising nutrition awareness, and promoting health education [15]. In developing countries, these policies are essential because prioritizing nutrition, such as public health campaigns and nutrition education programs, can increase awareness and promote sustainable dietary habits [44, 45]. Literature shows that government health policies that support improving nutrition literacy can empower individuals to make informed dietary choices and contribute to community development [46, 47].

A healthy country-based government health policy provides the base for extensive health initiatives that can significantly influence community nutritional literacy by correctly accessing necessary resources, improving education, and ensuring individuals know how to make better health decisions [45, 48]. These constrictive policies promote healthy eating in the community and can also be linked to improved public health awareness and reduced healthcare costs in the long run [49]. For instance, health initiatives that encourage proper food like fruits and vegetables, limit the availability of unhealthy foods, and educate the public on nutrition science contribute to a higher level of nutritional awareness and literacy among the local community [50].

In a nutritional literacy context, government organizations and non-organizations’ health policies that align their practices with health support often foster a well-being culture that enhances satisfaction, reduces stress, and encourages healthier lifestyle choices [15]. Healthy communities are deeply intertwined and are more likely to engage in awareness and development, contribute to developing and disseminating nutritional knowledge within their communities, and contribute to the SDGs [51]. A healthy community is more resilient and motivated, which are the main attributes for promoting creative strategies for health and nutrition initiatives [52]. Integrating government health policies with community well-being initiatives can generate a different effect, which improves nutrition, enhances community-level well-being, and contributes to broader national goals, such as nutrition literacy in general [53].

Furthermore, nutrition literacy positively impacts general health awareness, which is critical for developing and implementing effective health policies that can drive nutritional literacy programs [54]. Communities with high nutrition literacy are more likely to engage in health awareness for successful community-based health programs [55]. Government health policy can play a vital role in enhancing nutrition awareness through policy-driven programs that create a healthy environment that promotes nutrition literacy [56]. Therefore, government health policies emphasizing improving community health contribute to raising nutritional awareness, achieving better health outcomes, and contributing to the SDGs [57]. Furthermore, government health policies not only directly influence community nutritional literacy by providing health awareness, education, and resources but also create a base for better community nutritional literacy, fostering and supporting national goals.

H2

Government health policy positively affects community nutritional literacy.

Government health policy and community well-being

National government health policies play a vital role in determining community well-being by providing a supportive framework for improving public health outcomes, reducing health disparities, and promoting overall quality of life [15, 31]. These policies help create healthier environments and enhance public access to care, fostering greater resilience and social equity [58]. These policies focus on health care, health support, nutrition, and overcoming health inequalities, contributing to improved community well-being [59]. Research suggests that people-friendly health policies positively impact individual health and enhance community well-being by promoting a supportive environment for personal and national goals [60].

Literature shows that health policies are a key factor in determining an individual’s ability to engage in a community’s well-being [16, 61]. Individuals with proper health awareness will likely take the initiative for community well-being and contribute to the SDGs [62]. This proactive engagement is driven by health resources such as resilience and nutrition awareness, bolstered by supportive health practices [63]. Governments that prioritize health through policies that align with government health initiatives contribute to community well-being [39]. Moreover, health-oriented leadership promotes health at the individual and community levels and can enhance individual commitment and resilience, encouraging them to participate in community well-being [64]. Governments and organizations implement health policies focusing on community well-being, nutrition awareness, fostering creative engagement, reducing burnout, and encouraging continuous community development [53]. Furthermore, according to the Doyal and Gough [30], the Human Needs theory highlights the importance of meeting basic human needs as a health foundation for well-being and societal development. The theory focuses on basic needs like physical health and autonomy, which are essential for individuals to participate fully in their social and cultural contexts [65]. Governments address these foundational needs by implementing health policy at the grassroots level and well-being, enabling individuals to achieve autonomy and contribute meaningfully to their communities’ well-being. On the argument mentioned above, we propose that.

H3

Government health policy has a positive relationship with community well-being.

Mediating role of government health policy

Literature shows that HOL is creative and provides an environment where individuals with national health goals are prioritized [66]. HOL and government health policies are essential for community development, particularly community-level nutritional literacy and well-being [16]. Leaders who emphasize health and well-being motivate the public to use a balanced diet and a healthy lifestyle, and contribute to national and SDGs [67]. The government’s health-supportive policies, such as public health awareness strategies, campaigns, and nutritional programs, contribute to overall fortification [32]. These initiatives and health-oriented leadership ensure proper access to resources [66]. Research shows that comprehensive health policies can increase the impact of HOL by committing to initiatives that promote community levels of nutrition literacy and overall well-being [16]. These policies support individual health literacy and contribute to national developmental goals.

Doyal and Gough [30], the human needs theory supports the relationship between HOL and government health policies. According to this theory, health and education are fundamental to human needs. HOL can address these needs by providing environments that support psychological and physical health [66]. Government policies mediate this relationship by ensuring ground-level structural supports that confirm these needs are met at the community level. For instance, HOL raises awareness about health and basic needs and implements these policies, while government policies operationalize this awareness through programs and resources that educate and empower communities. Together, they fulfill universal needs, enhance community well-being, improve nutritional literacy, and contribute to SDGs. Based on this literature and the theoretical support, this study proposed the following hypothesis.

H4

Government health policy mediates the relationship between health-oriented leadership and community nutritional literacy.

H5

Government health policy mediates the relationship between health-oriented leadership and community well-being.

NGO support as a moderator

Non-governmental organizations (NGOs) play a critical role in supporting the government in implementing health policies at the community level [68]. Furthermore, NGOs support strengthening the relationship between health-oriented leadership (HOL) and government health policy by acting as ingenious mediators [35]. NGOs provide knowledge, funding, and ground-breaking approaches, enhancing HOL’s ability to influence and implement current health policies [69]. NGOs’ participation at the ground level supports the government and communities and ensures equal resource distribution at all levels [24, 70]. NGOs also play a key role in social mobilization, improving population accessibility, and strengthening public trust in health initiatives [71]. This collaboration permits HOL to focus on government policies and NGOs to address ground-level challenges, creating an active partnership that increases the influence of government health policies and implements them on the ground.

According to the Doyal and Gough [30], human needs theory further supports this model by emphasizing that fulfilling basic human needs, like essential health, nutrition, and well-being, is necessary for individual and community well-being and sustainable development [31]. NGOs’ collaborative support HOL to address essential societal needs by addressing structural empowerment and providing critical resources to meet health challenges [72]. To align leadership strategies with community-focused involvements, NGO support ensures that health policies are implemented effectively and resonate with the basic human needs for food security, health, education, and self-esteem, thereby promoting a sustainable foundation for community development.

H6

NGO Support moderates the relationship between health-oriented leadership and government health policy, so organizations with high NGO support are more likely to strengthen this relationship.

Materials and methods

Population and sample

The study population comprised organizations working in Pakistan directly involved in public health, nutrition, and community welfare. Eight major organizations were identified and purposively targeted for their substantial contributions to health-centered policy implementation, service delivery, and leadership practices. These included the Ministry of National Health Services, Regulations and Coordination; provincial health departments of Punjab, Sindh, Khyber Pakhtunkhwa, and Baluchistan; the Benazir Income Support Program, the Nutrition International Pakistan office, the Rural Support Programs Network, the Pakistan Health Research Council, the Shifa Foundation, and the Aga Khan Foundation. The study used a multi-stage sampling design combining purposive, stratified, and random sampling techniques to ensure adequate representation at both the sectoral and community levels. In the first stage, organizations were purposively selected using predefined criteria, including active involvement in public health and nutrition programs, implementation of community-based well-being initiatives, and the existence of formal leadership and administrative structures. Eight organizations met these criteria and agreed to take part in the study. In the second stage (Level 1: sectoral level), purposive sampling was used within the selected organizations to identify managerial and professional staff directly involved in designing, implementing, and supervising health programs. These participants included health-oriented leaders, policymakers, administrators, representatives of non-governmental organizations, and government officials. Three hundred and eighty people from the eight organizations were surveyed at the sectoral level. In the third stage (Level 2: community level), stratified random sampling was used to select three hundred and ninety community respondents that included rural and urban beneficiaries of health programs, community health workers, and local leaders. Stratification was used to represent proportionate representation from rural and urban communities to capture different perspectives regarding community nutritional literacy and well-being. With regard to the hierarchical structure, Level 1 is a sector or the organizational level (organizational employees), while Level 2 is the community level. The eight participating organizations are the institutional context within which three hundred and eighty sectoral-level employees were nested. The three hundred and ninety community respondents have been surveyed to assess community behavior and level outcomes and have been analytically treated as Level 2 units and not as higher-order organizational units. This structure concurs with the logic of conventional multilevel modeling, where higher contextual units are fewer in number than individual respondents, nested within them. Although methodological guidelines generally recommend 20–50 higher-level units for optimal statistical power and 30–50 units for reliable parameter estimation, the relatively large number of respondents at both sectoral (n = 380) and community (n = 390) levels enhances estimation precision and contributes to the robustness of the multilevel analysis conducted in this study. Table 1 shows the targeted organization.

Table 1.

Targeted organizations

S#	Organizations
1	Ministry of National Health Services, Regulations and Coordination
2	Provincial Health Departments, Pakistan
3	Benazir Income Support Program (BISP)
4	Nutrition International, Pakistan, INGO
5	Rural Support Program Network (RSPN)
6	Pakistan Health Research Council (PHRC)
7	Shifa Foundation, NGO
8	Aga Khan Foundation (AKF) INGO

Note. Authors Creation

Measures

The survey items were in English. To safeguard cultural relevance, the English measures were translated into Urdu by the customary translation method suggested by [73]. All items were evaluated on a 5-point Likert-type scale.

Health-oriented Leadership

HOL was measured using 12 items developed by Franke, Felfe [74]. A sample item is “Health is very important to my leaders.” And “My supervisor actively seeks ways to improve the health environment.

Government health policy (GHP)

We assessed government health policy (GHP) using the four-item scale developed by Brazier, Harper [75] and by Brownson, Fielding [76] A sample item is “The government has comprehensive policies addressing nutrition education.”

NGO support (NS)

A 5-item scale was taken from Ui, Heng [77] and Blagescu and Young [42]. Sample items: “The NGO plays an active role in implementing health policies within the community.”

Community nutritional literacy (CNL)

[78] developed the 14-item General Nutritional Literacy with sample items. “I know the correct number of fruits and vegetables that should be consumed each day.”

Community well-being (CWB)

For Community Well-Being, we used the Sirgy, Widgery [79] 6 items with a sample, “I feel that my community provides good services.”

Data collection

Prior to the implementation of the data collection on a large scale, a pilot research study where fifty people were sampled from both levels of analysis was conducted in order to guarantee the clarity, relevance, and contextual appropriateness of the measurement instruments. At Level 1, policymakers and representatives of non-profit-making organizations (NGOs) were selected purposively based on their direct involvement in the formulation of health policy and in the administration of health programs. At Level 2, community members and the beneficiaries of health programs were selected using the convenience sampling methods within the accessible health program areas for the evaluation of the comprehensibility and contextual alignment of the items. The pilot testing was aimed at identifying ambiguous wording, unclear wording, and technical terminology that may hinder the respondent’s understanding. Based on the feedback of the participants, some small modifications were made, such as the rewording of some items, the change of the order of the questions, and simplifying some technical expressions in order to increase clarity and readability. Face validity was determined by the assessment of five expert researchers with expertise in the areas of public health, public policy, and community well-being. In addition, the instrument was reviewed for content validity by a panel of academic scholars and practitioners in the field of health leadership and community nutrition. Their assessment established the survey’s adequacy in capturing stakeholders’ views on the key constructs of health-oriented leadership (HOL), government health policy (GHP), NGO support (NS), community nutritional literacy (CNL), and community well-being (CWB). The suggestions from the experts were incorporated into the final version of the questionnaire to reinforce construct coverage and the conceptual approach to the study objectives. The study was granted ethical approval by the IRB. The IRB reviewed the research protocol to ensure it complied with ethical standards regarding voluntary participation, informed consent, anonymity, and confidentiality. All participants were provided with an informed consent form that explained the purpose of the study, data protection procedures, and their right to withdraw at any stage without penalty. Written informed consent was obtained from respondents prior to their participation. We used a multi-stage sampling approach. At Level 1 (sectoral/organizational level), purposive sampling was carried out within the eight selected organizations to select respondents meeting predetermined inclusion criteria: in managerial, supervisory, or policymaking functions and directly involved in implementation of health policy or administration of health programs, and with at least one year of professional experience within their current position. A total of 380 questionnaires were distributed among ten enumerators who were trained for the survey for two to three weeks. Of these, 355 usable responses were returned, representing a response rate of 93.4%. The Level 1 questionnaire included health-oriented leadership (HOL) and the three criteria (government health policy (GHP) and NGO support (NS). At Level 2 (community level), stratified random sampling of rural and urban communities served by participating organizations was used to select respondents, ensuring proportional representation across different geographical contexts. Fifteen enumerators administered 390 questionnaires over three weeks, 360 responses were obtained, and the usable response rate was calculated as 92.3%. A separate self-administered questionnaire was used at this level to assess community nutritional literacy (CNL) and community well-being (CWB). Although two separate and complementary instruments were used for Levels 1 and 2, both used a similar Likert-scale format and measurement structure to maintain methodological coherence. A two-week gap between the two phases of data collection was maintained to minimize potential common method bias and to allow preliminary screening of the data before moving on to the second phase. Table 2 demonstrates the evidence of reliability and composite reliability (CR). All constructs were above the recommended maximum criterion values of 0.70.

Table 2.

Reliability

Construct	Items	Cronbach’s α	Composite Reliability (CR)
Health-Oriented Leadership	12	0.89	0.91
Government Health Policy	4	0.86	0.88
NGO Support	5	0.84	0.87
Community Nutritional Literacy	14	0.88	0.9
Community Well-Being	6	0.85	0.89

Source: Author’s Creation

Demographic information for the participants is shown in Table 3. The statistics demonstrate that at level 1, there were 30% female and 70% male participants. It was further revealed that 20% of the participants were between 20 30-year age, 40% of the participants were between 31 and 40 years of age, 25% of the participants were between 41 and 50 years of age, and 15% of the participants were between 51 and above years of age, respectively. About 30% of respondents had an undergraduate level of education, whereas 70% of the participants had a graduate level of education. Lastly, based on the designation, 15% of the participants were policymakers, 25% were government officials, 30% were NGO personnel, and 30% were health administrators. At level 2, there were 40% female and 60% male participants. Further, 35% of the participants were between 20 30-year age, 30% of the participants were between 31 and 40 years of age, 20% of the participants were between 41 and 50 years of age, and 15% of the participants were between 51 and above years of age, respectively. About 60% of respondents had an undergraduate level of education, whereas 40% of the participants had a graduate level of education. Lastly, based on the designation, 50% of the participants were community members, 30% were program beneficiaries, 10% were health workers, and 10% were community leaders.

Table 3.

Demographic

Attributes	Cluster	Level 1 (n = 355)	Frequencies	Level 2 (n = 360)	Frequencies
Gender	Female	106	30%	144	40%
	Male	249	70%	216	60%
Ages	20–30	71	20%	126	35%
	31–40	142	40%	108	30%
	41–50	89	25%	72	20%
	51 & above	53	15%	54	15%
Education	Undergraduate	107	30%	216	60%
	Graduate	248	70%	144	40%
Designation	Policy Maker	53	15%	--	--
	Govt Officials	89	25%	--	--
	NGO Personnel	107	30%	--	--
	Health Administrators	106	30%	--	--
	Community Members	--	--	180	50%
	Program Beneficiaries	--	--	108	30%
	Health Workers	--	--	36	10%
	Community Leaders	--	--	36	10%

Source: Authors’ Creation

Analytical strategy

We used Jamovi software to evaluate the multilevel regression modeling (MLRM) via bootstrapping to evaluate relationships between study variables. The MLRM is an appropriate technique for the hierarchical nature of data. The dataset included two levels: Level 1 (policymakers, government officials, NGO personnel, and health administrators) and Level 2 (community members, program beneficiaries, health workers, and leaders). The study model evaluates how the predictors of Level 1 (HOL, NS, and GHP) affect the outcome variables at Level 2 (CNL and CWB). The data was vetted for outliers and missing values and handled using the imputation technique to ensure its integrity. We also examined the descriptive statistics, including standard deviation and means of study variables, to comprehend the data distribution and cases matched with group sizes at both levels for viable statistical analysis [80]. To determine the variability at Level 1 and Level 2, the null model was estimated via intra-class correlation coefficients (Maas & Hox, 2005). The Akaike information criterion (AIC) and Bayesian Information Criterion (BIC) were estimated to evaluate the attribution of variability proportion at both levels. Fixed effects were measured to estimate the impact of predictors, whereas random effects would capture variability across the organizations or regions. Hypotheses are evaluated with multiple-group path analysis to compare direct and intervening relationships with bootstrapping (10,000) to examine the intervening effects with a 95% CI thereof [81]. An interaction term was developed to examine moderation effects, and then simple slopes were analyzed to understand the effects at high and low levels of NGO support in Fig. 3. Furthermore, the construct validity was examined via the comparative fit index (CFI) and the root mean square of approximation (RMSEA).

Fig. 3.

Moderating Effect of NGO support (NS) in between health-oriented leadership (HOL) and government health policy (GHP). The line graph showing the interaction between NS and HOL on GHP. A strong NS situation results in a much steeper increase in GHP as HOL moves from low to high compared to a weak NS situation. Source: Author’s Creation

Results

Table 4 demonstrates the study inter-correlation, standard deviation, and mean of the study factors, including government health policy, health-oriented leadership, NGO support, community nutritional literacy, and community well-being. The values indicate a positive association between variables.

Table 4.

Correlation & descriptive stats

Factors	Mean	SD	1	2	3	4	5
Level 1
1. Health-oriented leadership	2.20	0.42	--
2. Govt health policy	2.15	0.45	0.341*	--
3. NGO support	2.29	0.44	0.411**	0.369*	--
Level 2
4. Community nutritional literacy	2.70	0.52	0.520**	0.458**	0.347*	--
5. Community well-being	2.10	0.49	0.329*	0.422**	0.502*	0.363**	--

Note. Level 1 N = 355, Level 2 N = 360 ^* p<.05, ^** p<.01

Source. Author’s Creation

Measurement model estimation

We carried out confirmatory factor analysis (CFA) to evaluate the model’s fitness. Each item was encapsulated in its associated construct. The statistical outcome of the five-factor model was found to fit [χ²= 959.20, df = 451, CFI = 0.90; RMSEA = 0.050], for the four-factor model, i.e., HOL, GHP, NGO support, and CNL was found fit [χ²= 1024.7, df = 414, CFI = 0.86; RMSEA = 0.062], and for the three-factor model, i.e., HOL, GHP, and NGO support was also found to fit [χ²= 1212.4, df = 425, CFI = 0.83; RMSEA = 0.078]. Table 5 shows all of the model’s fitness.

Table 5.

Model fitness

Model	Factors	χ2	df	χ2/df	RMSEA	CFI	SRMR within	SRMR b/w
Model 1	5 Factors: HOL, GHP, NS, CNL, CWB	965.32	451	2.12	0.050	0.90	0.05	0.08
Model 2	4 Factors: HOL, GHP, NS, CNL	1024.7	414	2.47	0.062	0.86	0.07	0.12
Model 3	3 Factors: HOL, GHP, NS,	1212.4	425	2.85	0.078	0.83	0.11	0.15

Note. HOL: Health-oriented leadership, GHS: Government Health Policy, NS: NGO Support, CNL: Community Nutritional Literacy, CWB: Community well-being, χ2: Chi-square, df: degree of freedom, RMSEA: Root mean square error of approximation, CFI: Confirmatory fit index, SRMR: Square root mean residual, b/w: Between Source: Authors’ creation

Convergent validity

Table 6 exhibits the convergent validity. Average variance extraction (AVE) quantifies the extent to which the observed variable of interest is accounted for by the corresponding latent construct relative to measurement error. The AVE values lie between 0 and 1 with a cutoff point of 0.50; this indicates that the latent construct has higher variance than measurement errors. Convergent validity was established if the AVE values for each scale were higher than 0.50 Hair Jr, Sarstedt [82] because it shows that the items on a scale capture the same concept and are correlated. The statistical outcome revealed that the weight of all the factor items was higher than 50%, which approved the AVE threshold Hair, Sarstedt [83], confirming the convergent validity. Internal consistency was evaluated using the Cronbach alpha coefficient and composite reliability (CR). According to the statistical outcomes, the values of Cronbach’s alpha and CR of all item construct loadings were above 0.70, indicating the validity of the measurement model [84].

Table 6.

Convergence validity

Factors	Items	Loads	Reliability	CR	rho_A	AVE
Health-Oriented Leadership	HOL-1	0.873
	HOL-2	0.859
	HOL-3	0.890
	HOL-4	0.830
	HOL-5	0.814	0.851	0.739	0.860	0.735
	HOL-6	0.751
	HOL-7	0.762
	HOL-8	0.812
	HOL-9	0.729
	HOL-10	0.802
	HOL-11	0.841
	HOL-12	0.820
Government Health Policy	GHP-1	0.678
	GHP-2	0.774
	GHP-3	0.869	0.840	0.769	0.873	0.695
	GHP-4	0.846
NGO Support	NS-1	0.805
	NS-2	0.728
	NS-3	0.659	0.802	0.751	0.838	0.645
	NS-4	0.789
	NS-5	0.687
Community Nutritional Literacy	CNL-1	0.754
	CNL-2	0.859
	CNL-3	0.870	0.811	0.779	0.851	0.765
	CNL-4	0.844
	CNL-5	0.769
	CNL-6	0.823
	CNL-7	0.811
	CNL-8	0.726
	CNL-9	0.837
	CNL-10	0.879
	CNL-11	0.814
	CNL-12	0.836
	CNL-13	0.811
	CNL-14	0.759
Community Well-being	CWB-1	0.819
	CWB-2	0.885
	CWB-3	0.839
	CWB-4	0.756
	CWB-5	0.841	0.831	0.792	0.870	0.759
	CWB-6	0.804

Source: Authors’ Creation

Discriminant validity

The discriminant validity was examined by taking the square root of AVE. According to Huang, Chau [85] the discriminant validity factor should have a greater AVE score than the correlation coefficient. We also used the Fornell-Larcker criterion (FLC) to analyze the external construct by squaring the AVE for every construct and comparing it with the correlation existing between the elements of the exterior construct model. Moreover, the discriminant validity was also examined via the HTMT ratio, which has scores below the 0.90 limit. The statistical scores revealed that all the values are in the appropriate range; therefore, discriminant validity is established (see Table 7).

Table 7.

Discriminant validity

Factors	1	2	3	4	5
1. Health-Oriented Leadership	0.857	--
2. Government Health Policy	0.214	. 833	--
3. NGO Support	0.234	0.539	0.803	--
4. Community Nutrition Literacy	0.187	0.411	0.217	0.874	--
5. Community Well-being	0.090	0.251	0.119	0.202	0.871
Heterotrait-Monotrait Ratio (HTMT)	1	2	3	4	5
1. Health-Oriented Leadership	--
2. Government Health Policy	0.738	--
3. NGO Support	0.602	0.732	--
4. Community Nutrition Literacy	0.555	0.605	0.602	--
5. Community Well-being	0.601	0.548	0.538	0.651	--

Source: Authors’ Creation

Common method variance (CMV)

Some vital measures were taken at both levels to mitigate the social desirability bias and the common method variance (CMV). First, the study variables were placed conceptually and in logical sequence in the survey instrument. To mitigate the social desirability bias, the researchers cared immensely about the participants’ confidentiality and anonymity at Level 1 and Level 2. Second, unbiased and simple questions were developed and written in the survey instrument to mitigate the tendencies of social desirability bias. To overcome the CMV, Harman’s Single-Factor evaluation was tested. This method gives the percentage of total variance of the individuals of one factor among all the study factors. The CMV is considered a concern if a single factor accounts for more than 50% of the total variance ([86]. The statistics revealed that Level 1 accounted for only 25.49% of the variance, whereas Level 2 accounted for 15.19% of the variance, indicating that there was no CMV issue in the study (see Table 8).

Table 8.

Variance Explained

Levels	Extraction Sum of Square Weighs
	Total	% of Variance	Cumulative %
Level 1	12.718	25.495	25.495
Level 2	6.582	15.197	15.197

Source: Author creation

Note. Principal component analysis

Regression assumptions

Before evaluating the MLRA, the key assumptions are checked in Table 7. Data normality was evaluated by the Kolmogorov-Smirnov test, which produced insignificant outcomes for Level 1 (KS = 0.715, 𝑝 = 0.147) and Level 2 (KS = 0.812, 𝑝 = 0.241), revealing normal distribution (Razali & Wah, 2011). Levene’s statistics were used to examine the data homoscedasticity. Results were found to be insignificant for Level 1 and Level 2 variables. This indicates that the homoscedasticity of variances between Level 1 and Level 2 exists (Hayes & Cai, 2021). Durbin-Watson’s statistic was used to assess autocorrelation. The statistics found at Level 1 (1.85) and Level 2 (1.79) indicated no autocorrelation for residuals [87]. Multicollinearity was measured using Variance Inflation Factors (VIF), which should be less than 10, and tolerance, which must be greater than 0.20, to ensure no multicollinearity concerns [87]. Based on the scores, the result shows no multicollinearity concern in the data. This further revealed that the current dataset meets the assumption of MLRA (See Table 9).

Table 9.

Multilevel regression assumptions

Data Normality	Kolmogorov-Smirnov	Sig
Level 1 HOL, GHP, NGO Support	0.715	0.147
Level 2 CNL, CWB	0.812	0.241
Homoscedasticity	Levene’s Score	Sig
Health-Oriented Leadership	1.24	0.29
Govt Health Policy	1.07	0.36
NGO Support	0.97	0.40
Autocorrelation	Durbin Watson
Level 1 HOL, GHP, NGO Support	1.94
Level 2 CNL, CWB	1.88
Multicollinearity	VIF	Tolerance
Health-Oriented Leadership	1.34	0.73
Govt Health Policy	1.43	0.69
HOL x NGO Support Interaction	1.22	0.85

Source: Authors’ Creation

Note. HOL: Health-oriented leadership, GHS: Government Health Policy, NS: NGO support, CNL: Community Nutritional Literacy, CWB: Community Well-being

Multilevel regression

The results presented in Table 10; Fig. 2 illustrate the relationships between the constructs included in the study at the sectoral (Level 1) and the community (Level 2) level. At Level 1, the direct effect of health-oriented leadership (HOL) on government health policy (GHP) was significant and positive (b = 0.42, t = 4.21, p <.001, 95 (% CI [0.20, 0.49]), suggesting that HOL is a significant predictor of GHP. Additionally, NGO support (NS) was found to significantly moderate the relationship between HOL and GHP (b 0.19, t 3.24, p < .001, 95% CI [0.14, 0.29]), meaning that the effect of HOL on GHP is stronger when NS is higher, as shown in Fig. 2. These results confirm the hypothesized direct and moderating relationships at the sectoral level. At the cross-level, GHP was a positive predictor of CNL (beta = 0.31, t (2) = 3.21, p <.001, 95% CI [0.10, 0.41]) and CWB (beta = 0.29, t (2) = 4.39, p <.001). At Level 2, HOL also had a significant positive direct effect on both CNL (b = 0.35, t = 3.27, p <.001, 95% CI [0.18, 0.38]) and CWB b = 0.39, t = 3.10, p <.001, 95% CI [0.17, 0.44]) showing that leadership practices at the sectoral level translate to tangible benefits at the community level. Conditional indirect effects were examined in order to assess mediation. The indirect effect of HOL on CWB through GHP was significant at low (b = 0.15, t = 2.24, p <.001, 95% CI [0.18, 0.28]) and high levels of GHP (b = 0.28, t = 4.08, p <.001, 95% CI [0.19, 0.95]), suggesting that GHP to some extent mediates the relationship between HOL and community well-being. Overall, the results show that HOL has a positive impact on policy implementation and community outcomes and that NGO support enhances the impact of HOL on GHP, showing the importance of sectoral leadership and institutional support in driving community health improvements.

Table 10.

Multilevel structural path analysis

Level 1 (Sector Level)	Relationship	β	t	95% CI	p	Support
Direct	HOL → GHP	0.42	4.21	[0.20, 0.49]	< 0.001	Yes
Moderation	NS × HOL → GHP	0.19	3.24	[0.14, 0.29]	< 0.001	Yes
Cross-Level Effects (L1 → L2)	Relationship	β	t	95% CI	p	Support
Direct	GHP → CNL	0.31	3.21	[0.10, 0.41]	< 0.001	Yes
Direct	GHP → CWB	0.29	4.39	[0.22, 0.48]	< 0.001	Yes
Level 2 (Community Level)	Relationship	β	t	95% CI	p	Support
Direct	HOL → CNL	0.35	3.27	[0.18, 0.38]	< 0.001	Yes
Direct	HOL → CWB	0.39	3.10	[0.17, 0.44]	< 0.001	Yes
Conditional Indirect Effects	Relationship	β	t	95% CI	p	Support
Indirect (Low GHP)	HOL → GHP → CWB	0.15	2.24	[0.18, 0.28]	< 0.001	Yes
Indirect (High GHP)	HOL → GHP → CWB	0.28	4.08	[0.19, 0.95]	< 0.001	Yes

Source: Authors’ Creation

Note. HOL: Health Oriented Leadership, GHP: Government Health Policy, NS: NGO Support, CNL: Community Nutritional Literacy, CWB: Community Well-Being, CI: Confidence interval

Fig. 2.

Multilevel path diagram. A multilevel path diagram showing the impact of variables on community nutritional literacy (CNL) and community well-being (CWB) at the community level. Source: Author’s Creation

Interclass correlation and model comparison

Table 11 shows the interclass correlation coefficients (ICC) that exhibit the quantity of variability between levels. The outputs of the hierarchical model include the estimates of total between-cluster variance and model fit. For CNL, the within-group variance is 0.50, and the between-group variance is 0.25, adding up to an overall variance of 0.75. The ICC estimate shows that about 33% of the variance in CNL is due to between-group variability. For the CWB, the total variance of Level 1 is 0.40 while that of Level 2 is 0.30, thus obtaining a total variance of 0.70. The observed ICC variance that exists between groups is 43%. Comparing models indicates, in the general sense, that fit improves as the complexity of the models increases locally. According to the descriptive statistics, the null model has the most significant AIC number (1520.00) and a BIC number of 1530.00. The addition of random intercepts unveils even better results (AIC = 1300.00, BIC = 1312.00) and additional and highly significant coefficients with p <.001. Random slopes introduced an improvement in the fit: (AIC = 1220.00; BIC = 1235.00; p <.001). Hence, the Full Model with interaction terms was found to be the most appropriate model, giving an (AIC = 1170.00, BIC = 1185.00, t = 19.55, p <.001). Based on the values, the present results underscore the necessity of controlling for group-level variances and interaction terms to understand the variation across levels [88].

Table 11.

Interclass correlation & model comparison

Endogenous	Level 1 Variance	Level 2 Variance	Total	ICC
Community Nutritional Literacy	0.50	0.25	0.75	0.33
Community Wellbeing	0.40	0.30	0.70	0.43
Model Comparison	χ2	df	AIC	BIC	Sig
Null Model	1500.02	10	1520.19	1530.04	--
Random Intercept	1280.49	8	1302.49	1312.65	0.000
Random Intercept and slopes	1200.24	7	1220.41	1235.41	0.000
Full model (interaction terms)	1150.85	6	1170.10	1185.90	0.000

Source: Author creation

Note. ICC: Interclass correlation coefficients, χ2: Chi-square, df: degree of freedom, AIC: Akaike information criteria, BIC: Bayesian information criteria

Discussion on implications and limitations

Theoretical Implications

The findings offer implications for theory and practice. The theoretical implications are multifold. First, drawing on human needs theory and social exchange theory, this study underscores the central role of health-oriented leadership in promoting the implementation of government health policies. By integrating the role of HOL with public health governance, this research aligns with previous studies by Johnson [43], emphasizing the leader’s ability to inspire and align teams with broader societal goals [37].The positive influence of health-oriented leadership on policy implementation, awareness, and stakeholder engagement increases understanding of how effective health leadership can shape public health systems and confirm the ground-level implementation of health policies to benefit community welfare. Second, as effective policy implementation plays a key role in community awareness, the current study confirms the significant role of implementing government health policies in increasing health and community nutritional literacy. The study of Thomson, Hillier-Brown [45] supports our findings, which highlight the essential role of government policies in promoting the equitable distribution of resources, nutritional literacy, and public awareness. In light of the Sustainable Development Goal, current findings support the notion that the standard design of government health policies can increase awareness and sustainable improvements in community development through proper monitoring and local community awareness of nutrition knowledge and healthy living practices.

Third, the present study further enhances understanding of how effective implementation of government health policies positively affects community well-being. By examining the direct relationship between government health policies and community well-being, and by considering the SDGs’ emphasis on inclusive and sustainable development, our study confirms that these findings align with the objectives of the Organization [39], particularly its commitment to strengthening health systems, promoting equitable access to healthcare, and enhancing overall population well-being. This study promotes complete public health strategies targeting physical and mental health and community well-being. This positive association recognized the strengthening of the theoretical framework connecting government health policies to community well-being, offering an understanding of how systemic efforts can increase the public’s physical and mental health and contribute to SDGs and national developmental goals for health [2].

Fourth, our research introduces the mediating role of government health policies in linking health-oriented leadership to community nutritional literacy and well-being. This study further enhances the theoretical understanding of leadership’s role in building and implementing policies and work, and contributes to the SDGs. As supported by Laar, Barnes [11] and Shah, Adler [17], leadership prioritizes and plans health policies focused on nutrition awareness, which is critical for improving community health literacy. This study enriches the theoretical model by demonstrating that policies are the conduit through which health-oriented leadership can directly influence community well-being. Furthermore, our findings are supported by the work of Santa Maria, Wolter [23], which suggests that HOL also affects followers’ well-being by promoting health-related self-care and that strong policy frameworks can lead to improvements in public health outcomes [36]. The study findings provide empirical evidence in support of Doyal and Gough [30], the theory of the human need to align health-oriented leadership roles in policy implementation to increase health awareness, provide basic human needs such as health and nutrition, and contribute to the SDGs.

Finally, the current research framework introduces a moderating effect of NGO support on the relationship between health-oriented leadership and the implementation of government health policy. This increases the understanding of NGOs’ role in facilitating the proper implementation of public health initiatives. The findings are supported by Khan, Meghani [33] who highlight the importance of NGO support in enhancing governmental health efforts, and NGO support enhances policy implementation [24]. This study provides new insights into the role of external stakeholders, such as NGO Support, in strengthening the effects of health-oriented leadership. Overall, in light of the SDGs, the current research enriches theoretical understanding of how health-oriented leadership, health policy, and external support from NGO initiatives synergize with health, nutrition, and community well-being. This study offers new contributions to leadership theory, human needs theory, public health policy, and an understanding of NGOs’ roles in health initiatives.

Practical implications

To support the SDGs, the present study offers key managerial and practical implications for health management and policy implementation, particularly for government officials, community leaders, and non-governmental organizations. These implications are particularly appropriate to health management, where the interaction between leadership, policy, and community outcomes is crucial. The practical implications are threefold. First, our findings recommend that the government, non-governmental organizations, and public-sector leaders, such as those in health, focus more on leadership style and adopt health-oriented leadership as a substitute for implementing government health policies at the ground level, and support the SDGs. Leaders who adopt a health-oriented leadership style can play a noteworthy role in influencing and driving the adoption and implementation of health policies. HOL practices highlight the community’s mental and physical health, support the police’s successful implementation, and contribute to the SDGs. By ensuring that leaders are skilled at engaging with policies in a health-oriented way, they can loop in stakeholders and motivate others to become key influencers, ultimately driving the effective implementation of policy and sustainable community development.

Second, the government should focus on sustainable health management and on designing community-friendly, implementable health policies that are communicated effectively to improve community awareness and nutrition literacy. This research indicates that health-implemented policies play a significant role in enhancing community nutritional literacy, ensuring accurate awareness, and ensuring that individuals are well-prepared to make informed health and nutrition decisions. Government and policymakers should develop and execute targeted nutrition awareness campaigns and education programs that align with existing health policies, utilizing available resources and strategies to meet diverse community needs and promote sustainable development.

Third, our findings show a positive association between government health policy and community nutrition literacy and well-being. In this study, government health policies positively influence community well-being. Governments and local leaders must ensure that policies align with community needs and health priorities to promote physical and psychological well-being. Practical, friendly policy deployment must involve continuous feedback and stakeholder engagement from the community to ensure that the policies address fundamental needs and enhance sustainable development and the quality of life. Fourth, the role of government health policy as a mediator in the relationship between health-oriented leadership and community outcomes is essential. This study shows that health policies act as intermediaries that influence the effect of health-oriented leadership on community outcomes, such as nutritional literacy and well-being. Healthcare leaders should focus on creating frameworks that support and strengthen health policies to enhance community outcomes. In practice, this means aligning leadership strategies with the broader goals set by health policies to maximize their positive impact on the community.

Finally, our findings indicate that NGO support can mediate the link between health-focused leadership and government health policies. Health organizations with strong NGO backing are more likely to benefit from health policies, as leadership promotes proper nutrition and addresses food insecurity. NGO support plays a crucial role in raising awareness and mobilizing resources. They can provide all necessary resources, expertise, skills, knowledge, and outreach capacity to improve the reach and effectiveness of government health initiatives and contribute to sustainable development goals. In the current health environment in developing countries, government and community leaders should work with NGOs to ensure that their health policies are effectively supported by community efforts, thereby promoting broader participation and improved policy outcomes. Organizations, governments, and NGOs can collaborate to build a sustainable community where everyone has access to basic facilities at their doorsteps.

Limitations and future research directions

This research focuses on health-oriented leadership in implementing government health policy, NGO support, community nutrition literacy, and well-being in developing countries. The Pakistani context in the health sector may not be generalizable to a broader-level understanding, particularly given differences in governmental structures and sector dynamics. To support brother-level understanding and applicability, future research should explore HOL across sectors such as education, hospitality, and NGOs.

In this study, we used the time-lag approach with cross-sectional data, which limits the ability to establish causal relationships. Future research should consider longitudinal designs to examine the long-term impacts of HOL on health policy, NGO support, community nutrition literacy, and well-being. Additionally, since we relied on self-reported data, which can introduce bias, using multiple data sources, such as health improvement standards or feedback from other stakeholders, would give a more comprehensive view. Finally, we used NGO support as a moderator in this study. Future research should investigate additional moderating variables, such as political environment, top management support, and stakeholder role, to better understand the mechanisms linking HOL to the success of health policy.

Conclusions

This research, conducted in Pakistan, examines the crucial role of health-oriented leadership in shaping government health policies with NGO support and its effects on community nutrition and well-being. Our findings confirm that health-oriented leadership can positively influence the implementation of health policies and enhance nutritional literacy and welfare. It also analyzes the mediating role of public health policy in the relationship between leadership and community outcomes, and the moderating effects of NGO support. These insights have important implications for researchers, policymakers, the government, organizations, NGOs, and practitioners, especially those focusing on leveraging leadership for health and sustainable development, supporting the SDGs, and preparing for future challenges.

Abbreviations

AIC

Akaike information criterion

AKF

Aga Khan Foundation

AVE

Average variance extraction

BIC

Bayesian Information Criterion

BISP

Benazir Income Support Program

CFI

Comparative fit index

CMV

Common Method Variance

CNL

Community nutritional literacy

CR

Composite reliability

CWB

Community well-being

FLC

Fornell-Larcker criterion (

HOL

Health-oriented leadership

GHS

Government Health Policy

HTMT

Heterotrait-Monotrait Ratio

INGO

Nutrition International, Pakistan

ICC

Interclass correlation coefficients

MLRM

Multilevel regression modeling

NGOs,

Non-government Organization

PHRC

Pakistan Health Research Council

RSPN

Rural Support Program Network

SDGs

Sustainable developmental goals

SRMR

Square root mean residual

VIF

Variance Inflation Factors

Author contributions

Conceptualization: Muhammad Zada and Shagufta Zada; supervision: Nicolás Contreras-Barraza; literature search: Muhammad Zada, Nicolás Contreras-Barraza, Shagufta Zada; data collection: Muhammad Zada and Shagufta Zada; data analysis: Alejandro Vega; funding: Muhammad Zada, Alejandro Vega, Nicolás Contreras-Barraza. Original draft writing: Muhammad Zada and Shagufta Zada. Review: Muhammad Zada, Alejandro Vega.

Funding

This work was supported by Hanjiang River Culture Research, Hanjiang Normal University (Project Number: HSWH2024002).

Data availability

Data will be made available upon reasonable request to the corresponding author.

Declarations

Ethical approval

The author obtained ethical approval from the Research Ethics Board of the School of Economics and Management at Hanjiang Normal University in Shiyan, China, and the Department of Business Administration, Faculty of Management Sciences at Ilma University in Karachi, Pakistan. The study also complied with ethical standards.

Informed consent

Informed consent was obtained from all subjects involved in the study.

Competing interests

The authors declare no competing interests.