Assessing the implementation of infection prevention and control measures at private hospitals in Dubai, United Arab Emirates

Abstract

Background

Implementation of rigorous and effective infection prevention and control (IPC) measures is one of the pillars of preventing health care associated infections, reducing inappropriate use of antimicrobials, and combating antimicrobial resistance. Dubai Health Authority has long been implementing IPC programs in Dubai’s health facilities. This study aimed to assess the level of IPC implementation in private hospitals in Dubai, United Arab Emirates.

Methods

This was a hospital based cross-sectional study, using primary data collected between May and July 2023. Data were collected using the World Health Organization’s Infection Prevention and Control Assessment Framework (IPCAF).

Results

Of the 32 hospitals invited to participate in the study, 25 (78%) completed the survey. The overall IPCAF median score of participating hospitals was 752.5 (IQR: 710–760), which corresponds to an advanced level of IPC implementation. No statistically significant difference was observed either in median scores between hospital levels of care (P value = 0.2) or across hospitals with different bed capacity (P value = 0.6). All IPC components achieved high IPCAF scores, with core component 2 (IPC guidelines) and core component 6 (Monitoring and Feedback) having the highest (100) and the lowest (80) median scores, respectively. Notable variation observed within and between components. Despite high overall scores, several gaps were observed, particularly in implementing multimodal strategy, monitoring and assessing safety culture, institutionalizing leadership-driven staff empowerment in certain hospitals.

Conclusion

The study indicated a strong overall IPC implementation in Dubai’s private hospitals. However, targeted interventions such as standardized and continuous training, regular hand hygiene audits with feedback, improved surveillance, and expanded antimicrobial stewardship capacity are needed in specific areas to ensure effective and consistent implementation of the core components across all hospitals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-025-01672-w.

Introduction

Antimicrobial resistance (AMR), the ability of microbes to resist the effect of antimicrobials, diminishes the effectiveness of antimicrobials in preventing and treating infections leading to significant morbidity and mortality globally [1–3]. To date, AMR has been responsible for more than 4.9 million deaths per year worldwide and the fatality is projected to reach 10 million per year by 2050 [4]. In addition, AMR has a major economic impact on patients, health systems and societies [5, 6].

The main driver of the emergence of AMR is the inappropriate and indiscriminate use of antimicrobials [7]. Therefore, decreasing unnecessary use of antimicrobials, and ultimately AMR, depends largely on preventing infections in the first place [8, 9]. One of the main pillars of the World Health Organization (WHO) Global Action Plan to tackle AMR is the implementation of IPC measures for reducing health care-associated infections (HAIs) and, consequently, curb AMR [10].

Healthcare facilities are critical settings where adequate IPC measures must be effectively implemented and monitored. The reasons are: (i) many antimicrobial-resistant infections occur in these facilities due to the admission of patients with severe infections, which often leads to excessive use of antimicrobials. Inadequate IPC measures in such settings further increase the risk of spreading of antimicrobial-resistant infections; and (ii) strict and effective IPC measures are essential to prevent HAIs [10–12]. These infections affect both patients while receiving health care and healthcare workers while providing care [11]. They pose a significant global challenge, affecting millions of patients annually, causing considerable morbidity, and constituting a formidable economic burden on healthcare systems [1–3]. IPC programs are, therefore, fundamental to reducing the incidence of Health care associated Infections (HAIs) and improving the safety of both patient and healthcare providers across healthcare settings, and ultimately tackling the threat of AMR [10].

In Dubai, the second largest emirate of the UAE, IPC measures have long been implemented in its health facilities. In 2019, the Dubai Health Authority (DHA) launched the Health Facility Guidelines 2019 on infection control [13]. The guidelines serve as a road map to achieve high-standard implementation of IPC measures in Dubai health facilities. While efforts and investments are being made on the implementation front, there has been no data on the level of the implemented IPC measures in Dubai. Such information is crucial for monitoring implementation, determining the quality of IPC in health facilities, identifying gaps, and providing recommendations to decision-makers to improve IPC and the overall AMR stewardship program [14]. Previous research on IPC in the UAE was of small scale and focused on assessing certain aspects of IPC components, such as hand hygiene and knowledge, and practices of IPC measures among health care workers (HCWs). In addition, non-standardized assessment tools were used [15, 16]. Using the WHO IPC Assessment Framework (IPCAF) tool for health facilities [17, 18], we carried out this study in Dubai private hospitals to (i) assess the level of implementation of the current IPC measures in Dubai private hospitals and (ii) to evaluate and compare the IPC core components scores.

Materials and methods

Study design, population and period

This was a hospital-based cross-sectional study conducted across 32 private hospitals within the Emirate of Dubai. Invitations to participate in the study were disseminated via email between May and July 2023. All invited hospitals were licensed as general or specialty hospital providing inpatient and outpatient services. Facilities licensed exclusively for long-term care, rehabilitation centers, day-surgery, or outpatient services were excluded from this study.

Study setting

General setting

Dubai is the second largest emirate in the UAE with a population size of about 3.4 million people residing an area of 4114 km². The majority of the population in Dubai (88%) are expatriates and only 12% constitute UAE nationals. The population in Dubai has been growing rapidly, doubling every 14 years, with a natural increase rate of 3.9%. This growth places increasing pressure on the healthcare system to meet the demands of a diverse and expanding population [19, 20]. The health service delivery in Dubai is regulated by the DHA through a network of public and private health facilities.

Specific setting

As of 2023, Dubai had four government hospitals and 32 private hospitals. Thus, private hospitals predominantly serve Dubai’s healthcare system, which constitutes approximately 90% of the secondary and tertiary healthcare facilities. Hospitals in Dubai are classified into three categories according to their bed capacity: hospitals with fewer than 50 beds, 50–100 beds, and more than 100 beds. They are also categorized as secondary and tertiary hospitals based on the complexity and scope of services they offer. Secondary hospitals, with a capacity of 50–250 beds, offer a limited range of medical specialties such as internal medicine, obstetrics and gynecology, pediatrics, and general surgery. These facilities often have basic laboratory services and fewer specialized departments, reflecting their more general role in healthcare provision [21]. On the other hand, tertiary hospitals are equipped to handle a broader spectrum of specialized medical services. These include advanced surgical units, intensive care units (ICUs), and fully equipped emergency departments capable of managing a diverse range of complex medical cases. These cases are often referred to the tertiary level from secondary hospitals for more comprehensive management [21].

According to data from Dubai Statistics, the allocation of HCWs also varies according to hospital size and specialization. Larger tertiary hospitals employ significantly more healthcare workers across various disciplines to meet the needs of patients with complex conditions. On average, tertiary hospitals in Dubai have approximately 492 healthcare workers per facility, while secondary hospitals typically employ an average of 192 healthcare workers. In terms of admission volume, tertiary hospitals tend to have significantly higher volumes due to their larger capacity and the complexity of the services they offer. Tertiary hospitals reported 287,176 inpatient admissions and 5,986,134 outpatient consultations in 2021 [21].

Data collection, variables and analysis

The WHO’s IPCAF tool was used to assess the level of the implementation of the IPC programs in each of the hospitals included in the study.

It consists of eight essential components known as the WHO’s core components (CCs) of the IPC programs. These include:

Core component (CC) 1

IPC program

CC2

IPC guidelines

CC3

IPC education and training

CC4

Healthcare associated infection (HAI) surveillance

CC5

Multimodal strategies for implementing IPC interventions.

CC6

Monitoring/auditing IPC practices and feedback.

CC7

Workload, staffing, and bed occupancy.

CC8

Built environment, materials, and equipment for IPC at the facility level

The IPCAF survey was sent in English language to the infection prevention and control focal points of each participating hospital. Each hospital received an Excel-based IPCAF form, along with detailed instructions and guidance for completion. The IPCAF tool was designed as a self-assessment instrument and was completed independently by each hospital included in the study. To ensure secure and standardized data collection, responses were returned to the research team via email and, subsequently, stored in a password-protected database. Upon receipt, each hospital was assigned a unique identification code, and no identifiable information (such as hospital name or address) was retained in the dataset. Only the principal investigator had access to the coded data during analysis. This approach was intended to minimize social desirability bias and ensure confidentiality. The data collected were validated by the principal investigator. The validation process involved reviewing the data for completeness and consistency. In cases where discrepancies were identified or clarification was needed, the principal investigator cross-checked with the IPC focal person. Both the principal investigator and the IPC focal person have strong knowledge of IPC measures, which supports the validity and reliability of the data.

Statistical analysis

Descriptive statistics for quantitative variables were presented as medians and interquartile ranges (IQRs), while categorical variables were presented as numbers and percentages. Responses to the questions in the IPCAF assessment tool were scored according to the tool’s scoring key. Each answer to a question was assigned a score, with the maximum score being 100 per core component. As such, the maximum achievable score for a hospital was 800. The level of implementation of the IPC measures in each hospital was determined based on the overall score achieved. A score ≤ 200 indicates an inadequate level of implementation, a score of 201–400 indicates a basic level of implementation, a score of 401–600 indicates an intermediate level of implementation, and a score of 601–800 indicates an advanced level of implementation (Table 1). IPCAF scores were compared between tertiary and secondary hospitals using Wilcoxon rank sum test, while comparison across hospitals with < 50 beds, 50–100 beds and > 100 beds were made using Kruskal-Wallis rank sum test. All statistical tests were two-sided and a p-value of less than 0.05 were considered statistically significant. All analyses were performed using R software version 4.3.1 [22].

Table 1.

The grading and interpretations of the WHO IPCAF tool

IPCAF score range	Grading level	Interpretation
0–200	Inadequate	IPC core components are poorly implemented. Significant improvements are required to meet the necessary standards.
201–400	Basic	Some IPC core components are in place, but implementation is insufficient. Further enhancements are needed to strengthen infection control measures.
401–600	Intermediate	Most IPC core components are effectively implemented. The facility should enhance quality, expand the scope, and develop long-term sustainability plans.
601–800	Advanced	IPC core components are fully implemented per WHO recommendations and appropriately aligned with the facility’s needs.

Results

Hospital characteristics, distribution of IPCAF scores, and IPC implementation level

Of the 32 hospitals invited to participate in the study, 25 (78%) completed the online survey. Among these, 10 (40%) were secondary care hospitals and 15 (60%) were tertiary care hospitals. In terms of bed capacity, 12 out of the 25 (48%) participating hospitals had 50–100 beds, six (24%) had less than 50 beds, and seven (28%) hospitals had more than 100 beds. Across all participating hospitals, the IPCAF score ranged from 520 to 797.5, with an overall median score of 752.5 (IQR:710–760). Secondary and tertiary care hospitals achieved median IPCAF scores of 726 (IQR: 705–760) and 755 (IQR:715–780), respectively. Hospitals with less than 50 beds, 50–100 beds, and more than 100 beds achieved median IPCAF scores of 724 (IQR:705–760), 729 (IQR:710–783), and 755 (IQR:753–755), respectively. There was no statistically significant difference in median IPCAF scores between hospital types (P value = 0.2), nor across hospitals with different bed capacities (P value = 0.6) (Table 2). Based on the IPC levels corresponding to IPCAF scores, 23 (92%) of the participating hospitals achieved an advanced IPC implementation level, and two secondary health care hospitals (8%) reached an intermediate level.

Table 2.

Distribution of IPCAF scores by hospital type and bed size in Dubai hospitals in 2023

Hospital characteristic	n (%)	IPCAF score, Median (IQR)	P-value‡
Overall	25 (100)	752.5 (710–760)	–
Type			0.2
Secondary	10 (40)	726 (705–760)	–
Tertiary	15 (60)	755 (715–780)	–
Hospital size			0.6
< 50	6 (24)	724 (705–760)	–
50–100	12 (48)	729 (710–783)	–
> 100	7 (28)	755 (753–755)	–

^‡ Wilcoxon rank sum test was used to compare IPCAF score between tertiary and secondary hospitals, while Kruskal-Wallis rank sum test was used to compare scores across hospitals with < 50 beds, 50–100 beds and > 100 beds

IPCAF scores per IPC core component

Figure 1 presents the distribution of IPCAF scores across the eight IPC core components among hospitals in Dubai. CC1 (IPC Program) showed a median score of 95 (IQR:90–100) with a narrow interquartile range, while CC2 (IPC Guidelines) had a median score of 100 with no visible IQR. CC3 (IPC Education and Training), CC4 (HAI Surveillance), and CC5 (Multimodal Strategies) also showed high median scores of 95 (IQR:85–100); 97 (IQR: 90–100), and 90 (IQR: 85–100) but with wider interquartile ranges. In contrast, CC6 (Monitoring/Audit of IPC Practices and Feedback) had the lowest median score of 85 (IQR: 80–97) with the widest IQR. CC7 (Workload, Staffing, and Bed Occupancy) and CC8 (Built Environment, Materials, and Equipment for IPC) had median scores of 95 (IQR:90–97) and 96 (IQR:90–100), respectively.

Fig. 1.

Score distribution across the eight core components of the WHO IPCAF tool in Dubai hospitals, 2023.

Boxplot showing the median, interquartile range (IQR), and outliers of the eight core components assessed using the World Health Organization’s IPCAF tool. Each core component has a maximum score of 100.

CC1: IPC Program

CC2: IPC Guidelines

CC3: IPC Education & Training

CC4: HAI Surveillance

CC5: Multimodal IPC Strategies

CC6: Monitoring & Feedback of IPC Practices

CC7: Staffing, Workload & Bed Occupancy

CC8: IPC Environment & Equipment

IPC programs

All participating hospitals (100%) reported having an IPC team, with clearly defined objectives, and an annual activity plan. In 20 (80%) of the hospitals, the teams are multidisciplinary, consisting of physicians and nurses. In addition, all hospitals (100%) had an IPC committee supported by the hospital leadership. Furthermore, all hospitals have a designated focal person responsible for overseeing the IPC program.

IPC guidelines

All hospitals reported having IPC guidelines based on either national or international standards. Guidelines based on international standards were updated and adapted to the local context within the past two years.

IPC education and training

To reduce the risk of HAIs, 22 (88%) of the participating hospitals reported conducting specific IPC training for patients or their family members.

Surveillance of HAIs

All hospitals 25 (100%) reported having personnel responsible for HAIs surveillance activities. Two (8%) hospitals reported a lack of IT support for conducting surveillance. Pathogen’s detection and antimicrobial susceptibility testing were reportedly performed in 21 (84%) of the participating hospitals. Three hospitals (12%) had the capacity to detect pathogens only. Only one hospital reported not analyzing antimicrobial drug resistance on a regular basis. Moreover, seven hospitals (28%) did not use surveillance data to inform facility-based IPC plans. Eight hospitals (32%) reported irregular analysis of antimicrobial resistance data.

Multimodal strategies for implementation of IPC interventions

Almost all participating hospitals 24 (96%) reported to have employed a multimodal strategy to implement IPC interventions. Around two thirds 15 (60%) of hospitals reported implementing interventions to ensure the necessary infrastructure and continuous availability of supplies. These efforts also addressed ergonomics and accessibility, such as optimizing the placement of central venous catheter sets and trays for ease of use and efficiency and trays. In addition, only nine (36%) of the hospitals indicated leadership support to promote culture change.

Monitoring/auditing IPC practices and feedback

According to the survey, 23 hospitals (92%) had qualified staff responsible for monitoring and auditing IPC activities. However, the monitoring process varied across hospitals. While almost all hospitals indicated regular monitoring of wards cleaning, and reported monitoring data at least annually, only 13 hospitals (52%) monitored wound dressing change. Furthermore, 21 (84%) hospitals monitored disinfection and sterilization of medical equipment and instruments. An equal proportion of hospitals 21 (84%) reported assessing safety culture, whereas 24 (96%) hospitals reported adoption of a “blame-free” culture for improving IPC practices.

Staffing and bed occupancy

Nearly all participating hospitals 24 (96%) reported using national or international standards to assess staffing needs. Most of the hospitals 21 (84%) reported maintaining the recommended WHO or national ratio of healthcare workers-to-patient ratio. In addition, 24 hospitals (96%) maintained a distance of at least one meter between patients’ beds in all departments.

Infrastructure, materials, and equipment

All hospitals reported the availability of uninterrupted water and power supplies, appropriate sanitation activities, effective ventilation, and robust cleaning protocols. All hospitals reported consistent availability of hand hygiene stations, personal protective equipment, proper waste management systems, and dedicated patient isolation and decontamination services.

Discussion

This is the first study conducted in the UAE using the WHO IPCAF tool to assess the level of IPC program implementation in Dubai’s private hospitals. The study showed a strong IPC program implementation, with 92% of the participating hospitals achieving an Advanced level and only two hospitals classified at an intermediate level. IPCAF median scores above 80 were observed across all core components, reflecting overall adherence to IPC standards. However, varying levels of variability were found both between and within components, indicating inconsistencies in program implementation, which highlights potential areas for improvement.

The overall level of IPC program implementation observed in Dubai’s hospitals exceeds the global median IPCAF score of 605 reported by the WHO global survey [23], which assessed IPC program implementation in 4440 healthcare facilities across 81 countries and similar to the level reported from other high-income countries (HICs) such as Germany and Austria [17, 18]. This strong performance can be attributed to sustained investment; robust regulatory frameworks, and strong institutional leadership commitment, which have been reported to drive progress in IPC program implementation [13].

The strengths of this study are: (i) the use of globally acceptable and validated instrument, the WHO IPCAF tool, for data collection ensures data reliability and comparability across all hospitals (ii) data were collected by the IPC focal person in each hospital and was validated by the principal investigator, all of whom have strong knowledge of IPC measures, which supports the reliability of the data; (iii) both secondary and tertiary hospitals participated in the study, which allows for wider generalizability of the results; and (iv) we adhered to the STROBE guidelines for reporting the findings of the study [24].

We acknowledge the limitations of our study. First, the data were self-reported by IPC focal persons, which might have led to overestimation of scores. However, efforts were made to minimize potential self-reporting bias by maintaining confidentiality and validating the data by the principal investigator. Second, the cross-sectional design of the study captures the implementation level of the IPC program at a certain point in time and thus may not reflect trends or changes over time. However, the study provides baseline data, which serves as a benchmark for future follow up studies. Third, public hospitals, long-term care facilities, rehabilitation centers, and outpatient clinics were not included in the study, which may limit the generalizability of the findings across the wider healthcare system. Further research encompassing all types of hospitals is warranted to provide a more comprehensive overview of the IPC status in the Emirate of Dubai. Finally, we were unable to assess community-based factors that influence IPC status. Such factors may include public education on infection prevention, hygiene practices, and socioeconomic conditions of IPC staff per hospital. However, these factors are beyond the scope of the study. In addition, the IPCAF tool is designed to assess IPC measures at health facility-level.

Despite the limitations, our study revealed important findings with implications for policy and practice that merit further discussion. First, while most hospitals (92%) achieved the advanced level of IPC implementation, two hospitals were categorized at the intermediate level. This may be related to the inconsistencies in IPC implementation observed across hospitals in our study. Other possible reasons include insufficient resources, gaps in education and training, and inadequate infrastructure [25]. Further research is needed to investigate the underlying reasons and inform tailored interventions to address these challenges.

Second, the prevailing assumption is that tertiary care hospitals, due to their larger size, have higher specialized services, and greater availability of resources, are better equipped compared to secondary care hospitals to implement IPC programs. However, this perception is context-specific and may not be applicable in all settings. While some studies reported significantly higher IPCAF scores in tertiary hospitals [26, 27], others found no difference [14, 28]. In our study, we found no statistically significant difference in the median IPCAF scores between the secondary and tertiary hospitals. This indicates strong national commitment and equitable efforts to comprehensively implement IPC program across all hospitals, irrespective of their level. However, two secondary care hospitals were classified at an intermediate level. The reasons for this were not investigated in our study and further research is needed. Third, four of the participating hospitals reported lacking the capacity to perform antimicrobial susceptibility testing (AST), and one hospital had no laboratory. Lack of microbiological data hampers identification of patients with resistant pathogens and undermine implementation of measures to prevent cross-transmission of resistant infections [29]. In addition, without AST results clinicians will be compelled to prescribe empirical antimicrobials, which increase the use of inappropriate antimicrobials which, in turn, exacerbate the emergence and spread of AMR and lead to poor patient outcome [30].

All core components achieved a median IPCAF score of more than 80, with some components such as CC2 and CC8 reaching median or upper quartile scores of 100. This indicates strong overall performance. However, the variability observed both between and within components reflects inconsistencies in IPC program implementation across hospitals. For instance, CC3 (IPC Education and Training), CC5 (Multimodal strategies) and CC6 (Monitoring and Feedback of IPC practices) showed the greatest variability. Findings from our study may help explain this variability. For example, 12% of the participating hospitals reported not providing IPC training to patients or their family members, which may partially explain the discrepancies observed in CC3. Among hospitals providing training, differences in training curriculum, frequency of conducting the training, and target audience may lead to discrepancies in the performance of this component across hospitals [9, 31–33]. Therefore standardized, continuous and tailored IPC education is key to ensure even and effective performance across all facilities.

Similarly, 60% of hospitals in the current study reported that they did not implement interventions to ensure adequate infrastructures and consistent availability of supplies, while 9% reported that teams and individuals feel empowered to take ownership of the intervention through leadership support for promoting culture change-both of which are essential elements of the multimodal strategy. These gaps explain the wide range of scores for CC5. Although multimodal strategy has been shown in several studies to be effective in enhancing implementation of IPC interventions and improving overall IPC practice [34–36], challenges in implementing this strategy has been reported in different settings, including in high income countries [37]. The most commonly reported challenges align closely with our findings, including insufficient resources, suboptimal leadership support and lack off long-term planning [34–38]. This finding underscores the need for strong leadership commitment, sustained investment in infrastructures, and adequate allocation of resources to ensure effective and consistent implementation of the multimodal strategy across Dubai’s hospitals. Furthermore, while most hospitals (92%) had a person responsible for and auditing IPC practices, items or activities related to patient and provider safety, such as wound dressing change, and the disinfection and sterilization of medical equipment and instruments remained insufficiently monitored in a significant proportion of hospitals (48% and 16%, respectively). These findings may account for both the considerable variability and the relatively lowest performance observed in CC6. In addition, the limited leadership support observed under CC5 may have also contributed to the relatively low performance of CC6. Committed and supportive leadership is key to ensuring accountability and promoting a culture of effective and continuous feedback. Similar gaps in monitoring IPC practices were reported across diverse settings [14, 23, 39]. In a study conducted in Japan by Nomoto et al., CC6 scored the lowest (median IPCAF score: 67.5) of all core components, with substantial deficiencies identified in monitoring safety measures, akin to those observed in our study [40]. The authors speculated that these deficiencies may arise from underutilization of the HAIs surveillance system [40]. Likewise, Kaiwen et al. in a study conducted in China identified CC6 as the lowest performing component (IPCAF median score: 65), with only 10.4% of the assessed hospitals were reportedly monitoring safety interventions [14].

Safety culture is a critical factor in reducing HAIs and improving overall performance of IPC programs [41, 42]. Although the median IPCAF score of 80 for CC6 in our study is significantly higher than the scores reported in the aforementioned studies and categorized at the advanced performance level, actions are needed to elevate the performance of CC6 to a level comparable with other core components. To this end, hospitals should implement robust and standardized monitoring systems to ensure consistent monitoring of all safety interventions.

Conclusion

This study showed overall advanced IPC implementation level in Dubai’s private hospitals. However, notable variability was observed in the implementation of IPC components, particularly CC3 (IPC Education and Training), CC5 (Multimodal strategies) and CC6 (Monitoring and Feedback of IPC practices). To ensure effective and consistent implementation of IPC core components across hospitals, we recommend adopting standardized and tailored IPC education materials, promoting leadership commitment, investing in infrastructures and ensuring availability of continuous supplies, and enhancing the monitoring of safety interventions across all hospitals.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

AMR

Antimicrobial resistance

AST

Antimicrobial susceptibility testing

CC

Core component

DHA

Dubai health authority

HAIs

Healthcare associated infections

HCWs

Health care workers

IPC

Infection prevention and control

IPCAF

Infection prevention and control assessment framework

UAE

United Arab Emirates

WHO

World Health Organization

Author contributions

Conceptualization: AME, IE, RHR, and MK. Data curation: AME, IE, RHR, SA, AS, EM, and MK. Formal analysis: AS and EM. Investigation: AME, IE, RHR, SA, AS, EM, and MK. Methodology: EM and MK. Project administration: AME and MK. Resources: MK EM Software: AS. Supervision: MK. Validation: SA, AS, EM, YAME and MK. Visualization: AS. Writing—original draft: AME, YAME and MK. The authors AME, YAME, AS, RZ, ADH, YS, and MK critically revised the manuscript. All the authors contributed to the review and editing of the manuscript and approved the final version.

Funding

This research did not receive any specific funding.

Data availability

All data supporting this study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and adhered to internationally recognized standards for research. Ethical approval was granted by Dubai Scientific Research Ethical Committee (DSREC-GL09-2023). Informed written consent was obtained from all IPC focal points before the study commenced.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.