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Abstract

Worldwide, indulgence in high-risk behaviors such as substance abuse is on the rise in street children. Though substance abuse among street children has been investigated and reported in Pakistan, few studies have explored the relationship between narcotic use and its associated factors. This study was conducted to determine factors associated with narcotic use among street children in Islamabad Capital Territory. An analytical cross-sectional survey of a probability-based sample of 443 (males) street children aged 12 to 18 years, was conducted in Islamabad in March 2022. Using self-reported measures, the relationship between narcotic use and associated factors was determined using multivariate regression analysis. Out of 443 street children, with a mean age of 16.3 ± 1.6 years, 244 (55%) were between 17 and 18 years old. 119 (26.9%) worked as garbage collectors and 76 (17.2%) worked as car washers. The most common substance used was cigarettes in 285 (64.3%), naswaar in 172 (38.8%), hashish in 144 (32.5%), and alcohol in 63 (14.2%) street children. There were 164 (37%) street children who admitted having used narcotics (hashish, heroin, and bhang). On multivariate analysis, age > 16 years (OR: 2.3), sleeping on the streets (OR: 2.4), higher monthly income > Rs.18,000 (OR: 1.6), use of drugs by friends (OR: 5), and involvement in the selling of drugs (OR: 10.3) were independently associated with narcotic use. Substance abuse is a concerning trend among street children in Islamabad. When certain high-risk factors are present, these children are prone to narcotic use.

Keywords

cannabis heroin narcotics street children substance-related disorders tobacco products

Introduction

South Asia is home to the highest number of street children in the world.^1-3 Out of 100 to 140 million street children worldwide, 25 million reside in Asia.^2,4 A street child is defined as “any girl or boy, for whom the street has become his or her habitual abode and/or source of livelihood; and who is inadequately protected, supervised, or directed by responsible adults.”² These children face numerous challenges such as poverty, exposure to violence, sexual abuse, and hazardous working conditions, which makes them a highly vulnerable and marginalized group in society.^1,4,5 Due to a lack of parental guidance and elderly support, these children indulge in risky behaviors such as illicit substance use, and unsafe sexual practices including prostitution and various illegal activities.⁴ One of the most pressing problems rife among street children is the common abuse of drugs and other substances. The WHO reports varying global estimates (25%-90%) of substance abuse among street children, including the use of substances such as alcohol, tobacco, inhalants, solvents, glue, and narcotics, including opioids and cannabis products.⁶ The use of narcotic drugs is a significant emerging and largely unaddressed problem among street children, which has serious physical, social, and psychological implications and ultimately leads to drug addiction.^5,7

Children and adolescents who misuse narcotics face a wide range of adverse outcomes, both immediate and long-term. Immediate effects include an increased risk of overdose deaths, the development of opioid use disorder (OUD), and physical health challenges such as impaired immune function and cardiovascular damage.

Over the long term, these individuals may experience academic challenges, persistent physical and mental health issues, and a heightened risk of contracting blood-borne infections such as HIV/AIDS and other sexually transmitted infections (STIs). Additionally, they are more likely to engage in delinquent behavior and face significant social and economic consequences. Narcotic misuse can also lead to developmental delays, stunted learning abilities, increased aggression, anxiety, attention deficits, and other behavioral and cognitive impairments.^8-10

Pakistan is estimated to have between 1.5 million to 2 million street children, although there have been questions regarding the validity of these numbers.^1,4,6 Pakistan along with Afghanistan and Iran forms the Golden Crescent region which is a hub of opium production and distribution.¹¹ It was reported that Pakistan is the most profoundly affected country by narcotics abuse in the world according to the World Drug Report.¹² According to the latest National drug survey, more than 4 million people in Pakistan are dependent on drugs,¹³ with a high number of children and young adults living on the streets using some form of drugs.⁵ Focused group discussions with young boys under 18 years of age revealed that they usually start with smoking and gradually adopt stronger drugs including narcotics.^14,15

In the last decade, the population within larger urban cities in Pakistan has grown rapidly due to internal and external migration, creating unique challenges for cities, including the issue of street children. While past research has focused on street children in a few urban dwellings, Islamabad’s capital territory (ICT) has never been the focus of such investigations. Despite the magnitude of the issue, the extent of drug use, especially the abuse of narcotic drugs among street children in Islamabad, has remained under-reported. With the growing number of street children in ICT and emerging issues of drug abuse, it is useful to examine the patterns of substance abuse with a specific focus on narcotic drug use and understand the underlying factors associated with this behavior. Such an investigation will improve our understanding of the issue and will provide us with evidence to inform policymakers and public health programs to devise interventions to address the issues of substance abuse among street children.

Methods

Study Design and Subjects

This study used an analytical cross-sectional survey design to examine the patterns of substance abuse, specifically narcotic abuse (heroin, bhang, hashish), among street children in the Islamabad Capital Territory. The study was conducted from March 2022 to May 2022. We used the STROBE cross-sectional checklist when writing our report.¹⁶

Inclusion Criteria

• Both “on the street” (work on the streets and return home at night) and “of the street” (work and sleep on the streets) children were included in the study.

• All the children 12 to 18 years were eligible for inclusion.

Exclusion Criteria

Children under 12 were excluded, as they are generally less capable of reflecting on past experiences and relating them to their current situation.¹⁷

Any eligible participant unwilling to provide information was excluded from the study. During pilot testing, we found a few girls within this age group on the street and faced major reluctance to participate in the study. Hence, we excluded females from the final survey and limited our analysis to street boys.

The study sample therefore included street boys between 12 and 18 years of age who are usually seen on the streets and involved in menial work such as cleaning cars, selling goods, begging, collecting garbage, etc.

Sample Size and Sampling Procedures

The sample size was calculated to determine the prevalence of narcotic drugs among street children and to detect factors associated with narcotic use, with an alpha error of 5% and a power of 80%. The sample size was calculated using the formula:

n = Z^{2} α /_{2} P (1 - P) / D^{2}

The total sample size thus calculated was 450 street children to assess the patterns of narcotic use as well as its associated factors. Of these, 450 were approached, and 443 completed the interviews. We followed a probability-based sampling approach based on a sampling frame obtained by mapping all street spots where street children were found. The sampling frame was developed as a first step, where all street spots for street children were identified, and a spot list was developed, including the approximate number of street children at each spot. In the next stage, a proportion allocation of the required sample was performed, and street children were randomly selected from the spots at varying times of the day to gather a representative sample of the street children population.

Field Teams and Data Collection Process

A quick readiness assessment was done before the actual data collection process, to assess the feasibility of the sampling and implementation approaches and address any community concerns which might hamper field data collection. This also helped us identify peer group members who helped the research team in facilitating data collection at various spots. Data were collected by trained interviewers, using a structured questionnaire to collect information from study subjects in a face-to-face interview. Field teams comprised 4 interviewers and a field supervisor, who had prior experience of conducting similar research with street children. In addition to the interviewers, the field teams also included facilitators who were members of the population under study. In total, 6 street children facilitated the study at various spots. Field teams were trained on the questionnaire and study procedures in a 2-day training, which helped in clarifying field-related issues. The training provided information on the objectives of the study, the process of random selection, and the recruitment of subjects, and updated the field team on ethical considerations and issues of confidentiality. Basic information about drugs was provided, and teams were trained on substances and narcotics as well as on how to conduct interviews. The questionnaire and field procedures were pretested in 10% of the study sample in Rawalpindi, a large metropolitan city adjacent to ICT.

Field teams visited the selected spots at varying times of the day and the interviewers randomly selected the number of respondents required from each spot. Random selection was done by assigning a number to each street boy present at the time of the interview and then randomly selecting a random number. Once the respondent was selected the facilitator initiated a short discussion with the eligible respondents and informed them about the study, ensured confidentiality of information, and also discussed the benefits of the study for the community. This short discussion served as a rapport-building exercise and the facilitation done by peer members provided confidence to the respondents to share their information with relative ease and confidence. If agreed to participate, they were accompanied to a less crowded area nearby, where the questionnaire was administered after verbal informed assent was taken. In addition, the principal investigator (PI) also visited the field to conduct interviews and monitor the quality of data collected by the field team. No monetary compensation was given, but all children were provided drinks (juices or tea) and light snacks during the interview, which was suggested by the community members in the readiness assessment phase. Interviews were conducted in the local language and lasted approximately 25 min on average.

Data Management and Analysis

The questionnaire was developed in English and was later translated into Urdu. Data were collected on key variables, including sociodemographic information (age, education, family information, mother tongue, parental marital status, place of sleeping, etc.), work-related information (monthly income, occupation, time on the street, part of a group, adult supervision, etc.), and various risk behaviors, including information on drug use (types of substances ever or currently used, injection drug use, substance use by family and close friends, substances used in a group, accessibility to drugs, etc.). Data were field-edited, verified, and entered into a database before analysis was conducted using IBM SPSS Statistics version 25.0. Descriptive analysis included calculating the mean, median, and standard deviation for all continuous variables, while frequencies and percentages were presented for categorical variables. The outcome variable “Narcotic use” was a binary variable defined as “any child who has ever used narcotics (Bhang/Cannabis leaves and/or Heroin/morphine and/or Hashish/Cannabis resin) in their lifetime.” Based on the responses, the children were assigned to either the narcotic drug user group or the non-user group. Multivariate logistic regression analysis was conducted to examine the binary associations between the dependent variable and various independent factors associated with narcotic drug use.

All assumptions for logistic regression were met, i.e., observations were independent of each other; independent variables had no multicollinearity and were normally distributed, and the sample size was sufficiently large to give power to study results. The validity of the logistic regression was tested by the Hosmer-Lemeshow test for the goodness of fit of the model (P = .26).

Ethical Considerations

The study protocol adhered to international ethical standards, ensuring the safety, rights, and well-being of all child participants. Given the study’s sensitive nature, all possible measures were taken to minimize mental distress. Ethical approval was obtained from the institutional ethics review board, where the research’s value and benefits were demonstrated to outweigh any potential risks. The study was thoroughly assessed, and duly approved; the ethics review board approved obtaining verbal assent from the participants.

Children legally cannot give true informed consent until they are 18, so before taking part in any research, they are asked for their assent. Assent means that they have agreed to be a part of that study. They may also give dissent, meaning that they do not agree.¹⁸ ‘Assent means a child’s affirmative agreement to participate in research. Mere failure to object should not, absent affirmative agreement, be construed as assent.’¹⁹ For recruitment, the assent form was read and explained by the interviewers to the children participating before each interview. Once the child agreed, the interviewer signed the form on behalf of the child. To ensure the privacy and confidentiality of information and to reduce potential bias, participants were allotted serial numbers/codes without obtaining any personal identifying information such as names, addresses, etc.; no monetary compensation was provided, although children were provided light snacks and beverages as an appreciation for participation in the study. The children were informed about their right to quit the survey at any time they wanted. The study has followed the STROBE cross-sectional reporting guidelines.

Results

In this study, 443 street children completed the interviews from a total of 450 participants. As mentioned earlier, the study was limited to boys alone, as the females on the street did not provide consent or want to participate.

Sociodemographic Characteristics of Street Children

Table 1 presents the characteristics of the participants included in the study. The mean age was 16.3 ± 1.6 years and the largest proportion of children (55.1%) were 17 years old and above. Nearly half of the children interviewed had no education and only 1% received secondary education (9-10 grade). A large proportion (85.6%) of children were currently living with their families. Most of the children were involved in minor work to earn a living. The median monthly income was reported to be PKR 21 000 (mean = 23 289 ± 9378). Nearly two-thirds of the children interviewed started working between the ages of 7 and 12 years, with the mean age of initiation of work reported to be 11.7 ± 2.5 years. Almost half of the surveyed street children reported spending more than 10 hours on the street every day.

Table 1.

Sociodemographic Characteristics of Street Children, ICT, Pakistan, 2022.

Variables	Number (%)
Age (in years)
Below 15 years	113 (25.5)
15-16 years	86 (19.4)
17-18 years	244 (55.1)
Mean ± SD	16.3 ± 1.6
Mother tongue
Punjabi	200 (45.1)
Pushto	213 (48.1)
Others	30 (6.8)
Years of education
Never been to school	223 (50.1)
Primary	121 (27.2)
Middle	95 (21.3)
Secondary	4 (1.0)
Currently living with family	379 (85.6)
Usual sleeping place at night
Home	363 (82)
Streets/shrines/footpath	36 (8.1)
Workplace/friend etc.	42 (9.5)
Occupation
Laborer	26 (5.9)
Car wash	76 (17.2)
Street hawker	61 (13.8)
Beggar	14 (3.2)
Garbage collector	119 (26.9)
Hotel/cart	65 (14.7)
Time spent on the streets each day
Upto 10 h	218 (49.2)
>10 h	224 (50.8)
Age at initiation of work (years)
1-6	4 (0.9)
7-12	285 (64.3)
13-18	148 (33.4)
Mean ± S. D	11.7 ± 2.5
Monthly income (PKR)*
Up to 15 000	96 (21.7)
15 001-21 000	161 (36.3)
21 001-24 000	49 (11.1)
24 001-30 000	85 (19.2)
Above 30 000	52 (11.7)
Median income	Pak Rupees 21 000 (23 289 ± 9378)

1 USD = 303 PKR* (Aug 2023).

Risky Behaviors

Several risky behaviors were reported, as shown in Table 2. For most children, exposure to drugs was through friends (256 [57.8%]) and family (98 [22.1%]). More than half of the children reported using drugs within a group. Nearly 10% were involved in selling drugs and less than 2% were arrested. Three percent of the children interviewed reported drug injections. Among sexual behaviors, 6% sold sex, while 39% bought it from another male or female. One-tenth of the children interviewed had multiple sex partners, and 72% never used a condom in their sexual encounters. Nearly 30% of the children reported being part of a street gang and one-third had been involved in physical fights in the last 1 year. A small proportion also reported involvement in petty crimes.

Table 2.

Risky Behaviors of the Street Children, ICT, Pakistan,2022.

Variables	Number (%)n = 443
Drug using behaviors
Involved in selling drugs	44 (9.9)
Arrested for using drugs	30 (6.8)
Arrested for selling drugs	7 (1.6)
Offered money to sell drugs	38 (8.6)
Injected drugs	13 (2.9)
Substance use by family	98 (22.1)
Substance use by friends	256 (57.8)
Substances used in a group	230 (52)
Sexual behaviors
Sold sex	27 (6.1)
Bought sex	174 (39.3)
Has multiple sex partners	44 (9.9)
Never used a condom	318 (71.8)
Ever been raped	51 (11.5)
Other behaviors
Part of a street gang	130 (29.3)
Physical fight in last 1 year	151 (34.1)
Petty crimes in the last 1 year	17 (3.8)

Substance Use History

Figure 1 shows the patterns of substance use among street children. We inquired about “ever use of various substances” shown by the darker bars and “current use” shown by the lighter bars. Tobacco use in the form of cigarette smoking (current use, 62.5%) and naswaar/chewed tobacco (current use, 38%) was most frequently used, followed by Hashish (current use, 30.5%). Narcotic drug use was reported by 164 (37%) children, including hashish (32.5%), heroin (5%), and Bhang (4.7%).

Figure 1.

Substance abuse reported by street children in ICT, Pakistan,2022.

Univariate and Multivariate Analysis for Narcotic Use

Table 3 shows the factors associated with narcotic use among street children using a multivariate logistic regression. Among the various factors that showed independent associations with narcotic use included age of more than 16 years (OR: 2.3, 95% CI: 1.4-3.8), sleeping on the streets (OR: 2.4, 95% CI: 1.1-5.4), substance/drug use by close friends (OR: 5.0, 95% CI: 1.8-14.2), selling drugs (OR:10.3, 95% CI: 3.8-27.9) and having a higher average monthly income. (OR:1.6, 95% CI: 1.2-2.2).

Table 3.

Univariate and Multivariate Analysis for the Narcotic Use and Factors Associated Among Street Children, ICT, Pakistan, 2022.

Univariate analysis		Multivariate analysis
Variables	Odds ratio (95% CI)	Odds ratio (95% CI)
Age
≤16 years	1	1
>16 years	4.7 (3.1-7.3)	2.3 (1.4-3.8)
Ever been to school
Yes	1	-
No	1.3 (0.9-1.9)	-
Years of education
0-3 years	1.09 (0.6-1.7)	-
4-10 years	1	-
Mostly sleeping at
Streets	3.2 (1.6-6.4)	2.4 (1.1-5.4)
Others (Home)	1	1
Occupation
Hawker	0.4 (0.1-1.7)	-
Laborer	1.1 (0.3-3.3)	-
Begging	1	-
Adult supervision
Yes	2.3 (1.5-3.5)	-
No	1	-
Part of a group
Yes	0.7 (0.5-1.1)	-
No	1	-
Times on the streets (since)
<5 years	2 (1.3-3)	-
>5 years	1	-
Time spent on streets (hours)
<10 h	2.1 (1.4-3.2)	-
>10 h	1	-
Monthly income (PKR)
Up to 18 000	1	1
18 001 and above	2.8 (1.7-4.8)	1.6 (1.2-2.2)
Involved in selling substances
Yes	5.9 (3.0-11.2)	10.3 (3.8-27.9)
No	1	1
Alcohol ever used
Yes	3.5 (2.0-6.2)	-
No	1	-
Substance use by family
Yes	1.6 (1.0-2.4)	-
No	1	-
Substance use by friends
Yes	10.6 (4.2-27.0)	5.0 (1.8-14.2)
No	1	1
Substances used in a group
Yes	3.5 (2.3-5.4)	-
No	1	-
Ever had sex
Yes	5.8 (3.0-11.4)	-
No	1	-
Sold sex
Yes	1 (0.4-2.2)	-
No	1	-

Discussion

This study investigated the patterns of narcotic use and its associated factors among street children in Islamabad, Pakistan. The results of this research show that substance use is rampant among street children, with more than one-third (37%) of the children reporting the use of narcotic drugs, including Heroin, Hashish, and Bhang. In addition to understanding the patterns of narcotic use, this study also identified independent predictors of narcotic use, including older age, sleeping on the streets, higher monthly income, having close friends involved in substance use, and drug sales.

Other than the use of Narcotic drugs, this study found high consumption of tobacco products including cigarette/naswaar (chewed tobacco) and Alcohol by street children. This is in concurrence with previous research conducted in Pakistan, which showed a high consumption of tobacco products by street children.^15,20,21 Cigarettes and other tobacco products serve as “gateway drugs” by creating changes in the brain that make young people more apt to experiment with harder addictive substances such as cocaine and heroin.²² This research also highlights a temporal shift in the use of glue and solvent sniffing (petrol/gasoline, thinner/acetone). While these substances are very commonly used among street children, as shown in previous research, our study did not find these substances to be very popular in ICT. While the reasons for this shift from solvent abuse to other drugs are not known, it could be due to different geographical locations or the availability and affordability of harder drugs in Islamabad.²³ In comparison to studies conducted in other countries, alcohol use by street children in our study was fairly low, which could be due to issues related to accessibility and sociocultural differences.^20,24,25

In the present study, a multitude of factors that present a complex interplay between individual and social factors were found to be associated with narcotic use. The period of transition from childhood to adulthood is extremely important, and continued exposure to stress leads to various detrimental outcomes.²⁶ Living and working on the streets is full of stress and hardships, and without adult supervision, children might choose various survival strategies, such as drug abuse, which is destructive to their health and well-being.²⁷ Narcotic initiation and adoption were found to be associated with older age and having friends who indulge in such activities, and peer influence is a known driver of substance use.^28-31 As street children grow older, they tend to indulge in risky behaviors usually due to peer pressure and the absence of adult supervision.²⁶ Peers play an important role in people’s lives, especially during adolescence, when young people attempt to become more independent. Research has shown that peer pressure can make people become involved in activities that they normally don’t indulge in. For example, children with friends involved in substance abuse find it easy to acquire narcotics for their use, and as a source of income. Our study also showed a very strong independent association of narcotic use with selling drugs and being in the higher financial income groups. Street Children minors are known to be targeted by drug traffickers in pushing and peddling drugs on the street as law enforcement agencies might not suspect them, and even if caught, there are no severe penalties for them.^31,32 Selling drugs has a huge financial incentive as they give financial empowerment, which influences drug use behaviors because of affordability as well as availability of drugs. Exposure to the narcotic market provides the knowledge and basis for income generation, financial independence, and personal inclination.^31,33-35 These findings support previous research that has shown affluent children to be at greater risk for alcohol and drug use during their transition to adulthood.

Contrary to the popular belief that street children completely disengage from their families, this was not supported by our research, as we found that most of the children (86%) lived with their families and slept at home. These are the children “on the street” who work on the streets during the day and return to their families at night. On the other hand, this study highlighted an independent association between narcotic use and children who do not have family homes to return to and move from place to place, sleeping on the streets, in shelters, and in abandoned buildings (Children of the Street). These children have a much higher odds of using narcotic drugs which could be a way to escape reality and the hardships of everyday life, as a disengagement-based stress coping strategy.³⁶ Research also shows that escapism may also be understood as an exploration of the adventurous side of life that is, despite a move away from pain or anxiety, but rather a life-affirming move toward pleasure, excess, and indulgence.³⁷ Whatever may be the underlying etiology, this is an important finding and warrants concrete drug abuse prevention efforts, especially focusing on “children of the street.”

While lack of formal school education is associated with substance abuse among street children, this study did not find any significant association between education and narcotic drug use. We also noted a high prevalence of other risky behaviors, including a high proportion of children being sexually active. These findings are similar to the results of previous research conducted with street children in Pakistan, which showed that street children are sexually active, have multiple sex partners, and have very low condom use.^20,21,23,25 None of these behaviors were found to be significantly associated with narcotic use. However, it is a known fact that the use of substances can compromise the use of protective barrier methods during sexual activities. This information is alarming and a matter of growing concern regarding the spread of HIV/AIDS, Hepatitis B & C, sexually transmitted infections, and other blood-borne infections among street children.²³

A few limitations of this research need to be highlighted. Our results are mostly based on data collected from boys, as girls on the street were reluctant to participate; therefore, only male street children were included. Additionally, caution is required when considering the generalizability of this study and its applicability to other cities in Pakistan. This is due to the different sets of socioeconomic and security thresholds in the capital of Islamabad and other cities. The reliance on self-reported substance use and social desirability bias may have led to an underestimation of correct responses.

Conclusion

This research revealed that exposure to street life presents a highly vulnerable environment for street children, which leads to the use of various psychoactive substances, including narcotics. Our results show that peers play a crucial role in determining the substance use behavior of children, who might start with lighter substances such as tobacco and later switch to stronger drugs as they grow. We have also identified various risks and behaviors associated with narcotic use, and the findings could be used to develop strategies and interventions to protect the well-being of these children. A multi-prong approach needs to be used that requires targeting street children by providing them with awareness of the risks they encounter and how to deal with them. This would require a sustainable program that builds basic knowledge, counseling, and improving decision-making abilities. At the same time, interventions at the community and family levels should be initiated with concerted efforts directed toward connecting them back with their families and ensuring the availability of resources for these children.

Supplemental Material

sj-docx-1-inq-10.1177_00469580251324047 – Supplemental material for Risk Factors for Narcotic Use in Street Children: A Cross-Sectional Analysis From a Low-Middle-Income Country

Supplemental material, sj-docx-1-inq-10.1177_00469580251324047 for Risk Factors for Narcotic Use in Street Children: A Cross-Sectional Analysis From a Low-Middle-Income Country by Anum Waheed, Mariyam Sarfraz, Amna Mahfooz, Tahira Reza and Faran Emmanuel in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Supplemental Material

sj-docx-2-inq-10.1177_00469580251324047 – Supplemental material for Risk Factors for Narcotic Use in Street Children: A Cross-Sectional Analysis From a Low-Middle-Income Country

Supplemental material, sj-docx-2-inq-10.1177_00469580251324047 for Risk Factors for Narcotic Use in Street Children: A Cross-Sectional Analysis From a Low-Middle-Income Country by Anum Waheed, Mariyam Sarfraz, Amna Mahfooz, Tahira Reza and Faran Emmanuel in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Supplemental Material

sj-docx-3-inq-10.1177_00469580251324047 – Supplemental material for Risk Factors for Narcotic Use in Street Children: A Cross-Sectional Analysis From a Low-Middle-Income Country

Supplemental material, sj-docx-3-inq-10.1177_00469580251324047 for Risk Factors for Narcotic Use in Street Children: A Cross-Sectional Analysis From a Low-Middle-Income Country by Anum Waheed, Mariyam Sarfraz, Amna Mahfooz, Tahira Reza and Faran Emmanuel in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Footnotes

Acknowledgements

None.

Author Contribution Statement

AW contributed to concept, design, data collection and analysis, and manuscript writing.

AM contributed to data collection and analysis and manuscript writing.

TR, MS, and FE contributed to the concept, manuscript writing, and critical manuscript review.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

This study was approved by the Institutional Review Board (IRB) of the Health Services Academy, Islamabad, Pakistan, on January 3, 2022 (Reference No: 000057-HSA/MSPH-2020), following a thorough review process. As part of the ethical considerations, the board approved obtaining verbal assent from the participants. It is important to note that standard IRB approval letters do not typically specify the type of consent obtained from study participants. However, for clarification, a copy of the study proposal, which was reviewed and approved by the IRB committee, has been submitted as a supplementary file alongside the original IRB approval document.

ORCID iD

Anum Waheed

Supplemental Material

Supplemental material for this article is available online.

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