A cross-sectional assessment of burnout presence among pharmacy professionals at Kathmandu Valley,Nepal

Abstract

Introduction:

Burnout is a significant concern among healthcare professionals, including pharmacists, as it can lead to adverse effects on their well-being, job satisfaction, and patient care delivery. However, no previous study was conducted among pharmacy professionals in Nepal to assess their burnout cases. This study aimed to evaluate burnout presence and explore its associated factors among pharmacy professionals in Nepal.

Methods:

A cross-sectional study was conducted among pharmacy professionals of Kathmandu Valley, Nepal. The validated Burnout Assessment Tool measured burnout across multiple domains. Data on demographic and work-related characteristics were also collected. Descriptive statistics and Chi-square tests were used to analyze the data and identify significant associations among the variables.

Results:

Most participants were in the age group of 21–30 (64.7%), had a graduate degree (47.3%), and worked in hospital pharmacy settings (49.1%). Exhaustion was the most common (39.7%) burnout experienced, while mental distance and emotional and cognitive impairment were reported in one-fourth of the participants. Alternatively, only one in five participants showed secondary symptoms of burnout. Gender, working hours, exercise frequency, and substance abuse were significantly associated with burnout domains.

Conclusion:

This study provides valuable insights into the prevalence and factors associated with burnout among pharmacy professionals in Nepal. The findings highlight the significance of addressing burnout in this crucial healthcare sector, with gender, exercise frequency, and substance use emerging as notable contributors. These results underscore the need for targeted interventions and support systems to promote the well-being of pharmacy professionals and ensure the continued delivery of high-quality healthcare services in Nepal.

Keywords

Burnout Nepal pharmacy professionals workplace

Introduction

Burnout is a pathological syndrome leading to emotional depletion and maladaptive detachments repercussions on the well-being of individuals and can lead to detrimental outcomes, including impaired mental and physical health, counterproductive behaviors, and reduced quality of care.^1,2 Healthcare and educational professionals, especially those engaged in direct assistance roles, are particularly vulnerable to experiencing burnout due to the demanding nature of their work such as gradual loss of idealism, enthusiasm or motivation, and a sense of purpose.^3–7 Pharmacy professionals, who often engage in emotionally charged interactions, are no exception to this global trend, including within Nepal.^8–10

Numerous studies have shown the prevalence of burnout among healthcare professionals, with estimates surpassing 50%.¹¹ Clinical and hospital pharmacists in the United States and other countries have reported alarmingly high burnout rates, that is, 53.2%⁷ and 61.2%,¹¹ respectively. Interestingly, a study on burnout among U.S. clinical pharmacists reported over 61% of burnout despite 84% expressing satisfaction with their careers.¹² Similarly, community pharmacists in France and Turkey have demonstrated substantial burnout rates, underscoring the widespread nature of this issue ranging from 56.2% to 73.3%.¹³ Additionally, during the COVID-19 pandemic, health-system pharmacists grappled with burnout and secondary traumatic stress exceeding 50%, highlighting the urgency of tailored support in this critical healthcare sector.¹⁴ Another study found a substantial 74.9% of these pharmacists experienced burnout in at least one of the three Maslach Burnout Inventory^TM (MBI) Human Services subscales, primarily due to emotional exhaustion (68.9%), followed by depersonalization (50.4%) and reduced personal accomplishment (30.7%). Significant risk factors for burnout included fewer years of experience, working primarily in chain pharmacies, and lacking resources for burnout or resiliency.¹⁵ However, despite these global insights, research on burnout among pharmacy professionals in Nepal remains scarce. Limited studies conducted among medical students and health professionals reported the presence of burnout (48.8%–65.9%) in Nepal.^16–20

Primarily, burnout is reportedly associated with unmanageable workload, negatively impacting their emotional and mental health.¹³ Studies have indicated that community pharmacists face significantly higher work-related stress levels than other health professionals.^8,21 Burnout among pharmacists can result in job dissatisfaction, low organizational commitment, intention to quit, increased absenteeism, reduced workaholism, compromised performance and reduced quality of care in dispensing, counseling, and other pharmaceutical services.^22–25 Furthermore, burnout is associated with various adverse physical and mental health conditions such as depression, suicide, and substance abuse.²⁶

Addressing this pressing issue, the 2022 American Society of Health-System Pharmacists (ASHP) National Survey of Pharmacy Practice highlighted efforts to mitigate burnout in hospital pharmacies.²⁷ However, despite these initiatives, comprehensive research investigating the prevalence of burnout and its associated factors among pharmacists remains meager.

Hence, this study aims to bridge these knowledge gaps by assessing and evaluating burnout levels among pharmacy professionals in Kathmandu Valley in Nepal. We used the Burnout Assessment Tool (BAT),²⁸ designed to address the limitations of existing instruments such as the MBI General Survey.²⁹ These findings would serve as a foundational step toward developing interventions and strategies to address burnout issues and promote the well-being of pharmacy professionals in Nepal.

Methods

Study design and study settings

A cross-sectional questionnaire-based survey was conducted among pharmacy professionals in Kathmandu Valley, (Kathmandu, Bhaktapur, and Lalitpur districts), Nepal, from March 2021 to March 2022. The Kathmandu Valley is the capital city of the country, retaining the highest population in the country.³⁰ People across the nation migrated permanently and/or temporarily to Kathmandu Valley for better education, job opportunities, and quality of life. The Strengthening the Reporting of Observational Studies Guidelines³¹ were followed while preparing this manuscript.

Ethics approval

Ethical approval was taken from the Institutional Review Committee of Pokhara University (Reference no.: 6-077-078, dated 4 April 2021), Kaski, Nepal. Participants were informed about the objective of the study, participants’ roles, and rewards before receiving information from them. Verbal and written informed consent was taken before their enrollment in the study. Privacy and confidentiality of the participants were assured throughout and even after the completion of the research by using their data solely for the research purpose and by maintaining anonymity during analysis and reporting.

Study participants

The inclusion criteria of the study participants were the pharmacy professionals with any pharmacy education, registered in Nepal Pharmacy Council (NPC) and working in the community and/or hospital pharmacy or pharmaceutical industry. NPC is the sole licensing and pharmacy profession regulating body from the government of Nepal.³² The pharmacy professionals of all age groups and any gender who showed a willingness to respond were included in the study.

Sample size and sampling technique

The sample size was calculated to be 384 using Cochran’s formula considering a 95% confidence interval, 5% margin of error, and 50% estimated proportion of an attribute in the population, as there were no previous studies in the current topic area in Nepal.³³ Pharmacy professionals were selected using convenient sampling based on participants’, personal and professional networks and willingness to participate.

Development of data collection tool

Development of questionnaire

The investigators’ team selected the full version of BAT scale for burnout assessment after a review of the literature available on burnout assessment.²⁸ The questionnaire was kept to allow the respondents to self-administer. The questionnaire contains two sections:

Section A: Sociodemographic information of participants with 14 questions—age, gender, religion, ethnicity, marital status, educational level, occupation field, sector of work, work experience, work hour per week, current annual salary, frequency of exercise per week, regular hobby, and substance consumption habit.

Section B: The standard validated BATs were used to assess burnout.²⁸ BAT consists of two categories of questionnaires: core symptoms (BAT-C, which consists of 23 questionnaires) and secondary symptoms (BAT-S, which consists of 10 questionnaires).²⁸ Furthermore, BAT-C is grouped into four subscales (exhaustion—eight items, mental distance—five items, cognitive impairment—five items, and emotional impairment—five items). The response was recorded in the five-point Likert scale format (1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = always). A higher score indicates a higher risk of burnout, and a lower score indicates a lower risk of burnout. Our study reported the risk of burnout presence using a 50% score (82.5) as a cutoff value because no previous studies in the Nepalese context defined a particular score indicating problematic or clinically experiencing burnout.

Translation of the data collection tool

Though all the pharmacy personnel were fluent in reading and understanding the English questionnaire, its Nepalese translation was also performed and attached to the English version. The principal investigator initially did the translation, and then, other co-investigators reviewed the clarity of the translation. The translated questionnaires’ clarity and comprehensibility were further tested during the pretesting process among participants, and minor revisions were made in the word selection and sentence structure.

Pretesting, validation, and reliability testing

The pretesting of the questionnaire was conducted among 42 participants (10% of the total sample). Participants were asked to respond to the questionnaires and provide feedback on their clarity, comprehensibility, and suitability in assessing burnout-related concerns in their practice settings. Further, the questionnaire was consulted with pharmacy professionals and lecturers to confirm its usefulness and relevance in the context of Nepalese pharmacy professionals. As per the feedback from the participants, investigators’ group discussion and consultation with the experts, two questions were removed from BAT-C (one from the “exhaustion” subscale and one from the “mental distance” subscale) as they were declared to have similar meaning. Then, the final data collection tool consisted of 21 questions in BAT-C (exhaustion—7 items, mental distance—4 items, cognitive impairment—5 items, and emotional impairment—5 items) and 10 questions in BAT-S (Supplemental file 1). The internal consistency of the questionnaire was assessed using Cronbach’s alpha coefficient, which showed an alpha value of 0.74, confirming a satisfactory internal consistency.³⁴

Data collection technique

The pharmacy personnel working in the community and/or hospital pharmacy and pharmaceutical industry sector were conveniently selected based on ease of access and through the circle of colleagues. After that, pharmacy students reached out to them in person and approached to participate in the study. Participants were informed about the study in detail and their responses were collected with their verbal and informed consent. The printed form of the questionnaire was shared with the interested participants, and the fill-out questionnaire was collected from them. Total 422 pharmacy personnel (including 10% of 384 non-response) were approached to participate

Statistical analysis

The collected field data were initially reviewed and stored on Epidata version 3.1, developed by EpiData Association, Denmark. The second author cross-checked the accuracy and completeness of transferring raw data from paper to electronic version. Afterwards, the statistical analysis was conducted using IBM Statistical Package for Social Sciences (SPSS) version 20.0. Findings were interpreted using frequency and percentage, and the relationship among sociodemographic variables with five domains of burnout was assessed using Chi-square test.

Results

Sociodemographic and work-related characteristics of the participants

Table 1 presents the sociodemographic and work-related characteristics of the participants (n = 385). Most participants were in the age group of 21–30 (64.7%), with a mean age of 29.4 ± 5.6 years, had a graduate degree (47.3%), and worked in a hospital pharmacy (49.1%) with 2–5 years of working experience (46.8%). Only a small percentage of participants were using substances.

Table 1.

Sociodemographic and work-related characteristics of the participants (n = 385).

Characteristics	Frequency (n)	Percentage (%)
Age Group (in years) (Mean ± SD: 29.4 ± 5.6, range: 19–53)
⩽20	3	0.8
21–30	249	64.7
31–40	111	28.8
41–50	21	5.5
>50	1	0.3
Gender
Male	238	61.8
Female	147	38.2
Religion
Hindu	363	94.3
Buddhist	16	4.2
Islam	2	0.5
Kirat	1	0.3
Christian	3	0.8
Ethnicity
Dalit	7	1.8
Janajati	97	25.2
Madhesi	23	6.0
Muslim	3	0.8
Chhetri	80	20.8
Brahmin	170	44.2
Others	5	1.3
Marital status
Single	190	49.4
Married	195	50.6
Education level
Diploma in pharmacy	146	37.9
Graduate	182	47.3
Postgraduate	56	14.5
Doctorate	1	0.3
Field of practice
Hospital pharmacy	189	49.1
Community pharmacy	92	23.9
Pharmaceutical industry	104	27.0
Working sector
Government	19	4.9
Private	366	95.1
Total work experience (in years)
<2	101	26.2
2–5	180	46.8
>5	104	27.0
Work experience at the current practice setting (in years)
<2	67	17.4
2–5	183	47.5
>5	135	35.1
Working hour per week (in hours)
0	1	0.3
20–40	23	6.0
41–50	342	88.8
>50	19	4.9
Annual salary (NR.s.)*
<200,000	65	16.9
>200,000	320	83.1
Exercise frequency in hours per week
0–1	108	28.1
2–3	179	46.5
4–5	71	18.4
>5	27	7.0
Substance use
Alcohol	23	6.0
Tobacco	7	1.8
Both	67	17.4
None	288	74.8

<1500 and >1500 USD (based on conversion of 1 Nepali rupee = 0.0075 United States Dollar of 8 October 2023).

Burnout experienced by participants

Table 2 overviews burnout prevalence among 385 participants under various domains. Exhaustion was the most common (39.7%) burnout symptom experienced by the participants. Mental distance and emotional and cognitive impairment were reported in one-fourth of the participants. Alternatively, only 19.5% of participants exhibited secondary symptoms of burnout.

Table 2.

Burnout experienced by the participants (n = 385).

Domains of burnout scale	Frequency (n)	Percentage (%)
Exhaustion
Absence	232	60.3
Presence	153	39.7
Mental distance
Absence	289	75.1
Presence	96	24.9
Cognitive impairment
Absence	278	72.2
Presence	107	27.8
Emotional impairment
Absence	296	76.9
Presence	89	23.1
Secondary symptoms
Absence	310	80.5
Presence	75	19.5

Association of burnouts with sociodemographic factors

Table 3 presents the associations of presence or absence of different burnout domains with various characteristics. Gender, working hours, exercise frequency, and substance abuse were significantly associated with burnout domains. Gender exhibited a significant association with mental impairment (p = 0.046), working hours with secondary symptoms (p = 0.026), exercise frequency with mental distance (p = 0.020) and cognitive impairment (p = 0.040) domains, substance use with exhaustion (p = 0.025), and emotional impairment (p = 0.020).

Table 3.

Factors associated with different domains of burnout scale (n = 385).

Characteristics		Exhaustion			Mental distance			Cognitive impairment			Emotional impairment			Secondary symptoms
Characteristics		Absence	Presence	p-Value	Absence	Presence	p-Value	Absence	Presence	p-Value	Absence	Presence	p-Value	Absence	Presence	p-Value
Age group (in years)	⩽20	2	1	0.597	3	0	0.547	2	1	0.710	2	1	0.520	3	0	0.691
	21 to 30	152	97		191	58		184	65		192	57		196	53
	31 to 40	62	49		78	33		75	36		82	29		92	19
	41 to 50	15	6		16	5		16	5		19	2		18	3
	> 50	1	0		1	0		1	0		1	0		1	0
Gender	Male	137	101	0.198	174	64	0.277	163	75	0.046*	178	60	0.263	196	42	0.289
Gender	Female	95	52	0.198	115	32	0.277	115	32	0.046*	118	29	0.263	114	33	0.289
Education level	Diploma in Pharmacy	87	59	0.227	104	42	0.324	103	43	0.772	112	34	0.959	123	23	0.213
	Graduate	104	78		144	38		135	47		140	42		146	36
	Postgraduate	40	16		40	16		39	17		43	13		40	16
	Doctorate	1	0		1	0		1	0		1	0		1	0
Field of practice	Hospital Pharmacy	109	80	0.593	135	54	0.180	135	54	0.620	141	48	0.061	148	41	0.560
	Community Pharmacy	58	34		75	17		70	22		79	13		76	16
	Pharmaceutical Industry	65	39		79	25		73	31		76	28		86	18
Working sector	Government	12	7	1.000	13	6	0.586	12	7	0.431	14	5	0.781	15	4	0.772
Working sector	Private	220	146	1.000	276	90	0.586	266	100	0.431	282	84	0.781	295	71	0.772
Working experience (in years)	< 2	63	38	0.515	73	28	0.717	71	30	0.836	75	26	0.513	84	17	0.309
	2 to 5	103	77		138	42		130	50		137	43		139	41
	> 5	66	38		78	26		77	27		84	20		87	17
Work experience at the current place (n years)	< 2	43	24	0.527	52	15	0.813	52	15	0.244	52	15	0.648	54	13	0.111
	2 to 5	105	78		135	48		125	58		137	46		140	43
	> 5	84	51		102	33		101	34		107	28		116	19
Working hour per week (in hours)	0	1	0	0.058	1	0	0.480	1	0	0.242	1	0	0.199	0	1	0.026*
	20-40	14	9		19	4		17	6		19	4		22	1
	41-50	211	131		257	85		250	92		265	77		275	67
	> 50	6	13		12	7		10	9		11	8		13	6
**Annual salary (NR.s.)	< 200000	38	27	0.782	49	16	1.000	51	14	0.287	49	16	0.748	52	13	0.865
**Annual salary (NR.s.)	> 200000	194	126	0.782	240	80	1.000	227	93	0.287	247	73	0.748	258	62	0.865
Exercise frequency per week (in hours)	0 – 1	76	32	0.081	93	15	0.020*	89	19	0.040*	92	16	0.110	88	20	0.364
	2 – 3	99	80		126	53		121	58		132	47		140	39
	4 – 5	42	29		51	20		48	23		53	18		57	14
	> 5	15	12		19	8		20	7		19	8		25	2
Substance use	Alcohol	10	13	0.025*	14	9	0.175	16	7	0.051	15	8	0.020*	16	7	0.182
	Tobacco	2	5		4	3		2	5		3	4		4	3
	Both	35	32		48	19		46	21		47	20		53	14
	None	185	103		223	65		214	74		231	57		237	51

Note: *p value < 0.05 = significant association; provided in bold text for ease of visibility.

<1500 and >1500 USD (based on conversion of 1 Nepali rupee = 0.0075 United States Dollar of 8 October 2023).

Discussion

The present study aimed to assess burnout among pharmacy professionals in Nepal and explore its associated factors. The findings provide valuable insights into the prevalence of burnout and its implications for healthcare professionals. The prevalence of burnout among healthcare professionals, including pharmacists, has been a growing concern worldwide. In line with previous research, our study revealed the presence of burnout among pharmacy professionals in Nepal. This is consistent with studies conducted in the United States,⁷ France,²¹ and Turkey,²³ where high levels of burnout have been reported among pharmacists.

One of the important findings of our study was the association between gender and mental aloofness. A higher proportion of males reported the absence of mental burnout than females. Findings from multiple studies indicate that women have a higher prevalence of burnout. Hagemann et al.³⁵ also reported this trend, while Youssef et al.³⁶ found that Lebanese female community pharmacists were 1.6 times more prone to burnout than males. Similarly, a study conducted by Odonkor and Frimpong³⁷ among healthcare professionals in Ghana confirmed that females were 1.2 times more vulnerable to burnout than men. Chou et al.³⁸ also observed significantly higher work-related burnout scores among women than men in a study involving medical professionals in Taiwan. This gender difference in mental burnout highlights the need for gender-specific interventions and support systems to address male and female pharmacy professionals’ unique challenges and stressors.

No significant associations were found among age group and education level with the presence or absence of burnout. These results suggest that these factors might not significantly influence the burnout risk among Nepal’s pharmacy professionals. A cross-sectional study by Rahme et al.¹³ among Lebanese community pharmacists found that higher education, like a Master’s degree, significantly affected mental work fatigue compared to other education levels. One study showed that married community pharmacists are less likely to suffer from higher burnout than those without a partner.³⁶ Pharmacists without a good family life, children or a partner have a higher incidence of burnout, likely due to the devoid of strong family support.³⁹ Similarly, a study done by Haase⁴⁰ concluded that burnout is less likely to occur in married than single health workers. Nevertheless, a survey among pharmacy residents in Alabama, U.S. reported that single and married have similar mean stress levels.⁴¹ Contrarily, our study did not show any association of burnout with marital status. However, it is essential to consider that the absence of significant associations does not necessarily imply the absence of other potential contributing factors. Further research is needed to explore additional factors that might affect burnout among pharmacy professionals.

Our study did not find significant associations among profession, working sector, total work experience, or work experience at the current place, except working hours per week, with the presence or absence of burnout. These results suggest that these specific factors might not significantly influence burnout risk. However, it is essential to acknowledge that many occupational characteristics, such as overwhelming workload, job demands, and work–life balance, may still play an indispensable role in burnout occurrence.^42–44 Future research could explore these factors in more depth to better understand their impact on burnout among pharmacy professionals.

In a study by Rahme et al.,¹³ emotional work fatigue was found in 50.12% of pharmacists, mental work fatigue in 55.01%, and physical work fatigue in 54.78%. They observed that higher emotional work fatigue was significantly associated with higher stress levels, working more than 40 hr per week compared to ⩽16 hr and having 6 months to less than 1 year of practice. Furthermore, a study by Jovanović et al.²⁴ showed that the highest level of burnout among pharmacists was related to reduced personal accomplishment (53%). These findings from other studies provide additional insights into the factors contributing to burnout among pharmacists, highlighting the importance of unmanageable workload, emotional exhaustion, and specific work environments.²⁴

Interestingly, exercise frequency and substance use showed significant associations with burnout in specific domains. Specifically, exercise frequency was associated with burnout in the mental and emotional domains. Many studies have already reported that physical exercise benefits the person physically, mentally, and emotionally.^45,46 This finding of the association with the mental and emotional domain confirmed the potential benefits of regular exercise in reducing the risk of burnout among pharmacy professionals. On the other hand, substance use was associated with burnout across all domains. Various studies have determined that substance abuse is a coping approach^47,48 and is very noxious to person, family, and community.⁴⁹ Therefore, as this study confirmed the use of substances with burnout presence, it is essential to mitigate the situation to prevent its untoward consequences. Interventions targeting substance use and promoting healthy coping strategies are imperative to prevent and manage burnout among pharmacy professionals.

Perspective for future studies and practical implications

The assessment of burnout symptoms and effects among employees is essential. As there is a lack of clinically validated tools to confirm the evaluation of burnout scenarios among the employees in the Nepalese context, we used the validated self-administered questionnaires to assess the presence of burnout symptoms in pharmacy professionals in our study. Therefore, further clinical examination of participants is needed to confirm the presence of problematic burnout symptoms among the participants categorized as having burnout symptoms. Similarly, the potential variables tested with burnout presence were measured following a broad margin without being very specific, which can be a potential area to explore in future. For example, the length of exercise activities associated with burnout presence.

However, the findings of this study have important implications for the well-being of pharmacy professionals in Nepal. Given the incidence of burnout and its potential negative consequences, it is crucial to implement preventive measures and interventions to support pharmacy professionals’ mental health and well-being. These measures may include developing support programs and mechanisms, stress management workshops, promoting work–life balance, and fostering a supportive and positive work environment.

Strengths and limitations

This is the first study conducted documenting the burnout symptoms among pharmacy professionals in Nepal as per authors’ knowledge based on a search performed on different electronic databases such as PubMed/Medline, Scopus, and Science Direct. This study has several limitations as well that should be acknowledged. First, the cross-sectional design used in this study inherently restricted us from establishing causal relationships between the factors and burnout. Future research employing longitudinal methods would provide more substantial evidence regarding the temporal associations between these factors and burnout over time. Second, reliance on self-report questionnaires introduced the possibility of response biases. Moreover, the study focused solely on quantitative data. Future studies could consider incorporating both qualitative and quantitative measures to gain a more comprehensive understanding of burnout among pharmacy professionals. Notably, this study was conducted solely among pharmacists working in three districts of Kathmandu Valley, which may not fully represent the entire country’s scenario. Furthermore, convenience sampling used in this study limited the generalizability of the findings to the broader population of pharmacy professionals in Nepal. Therefore, while this study provides valuable insights into burnout among pharmacy professionals, it is essential to consider these limitations when interpreting the results, extrapolating them to other populations, and drawing definitive conclusions about causality.

Conclusion

In conclusion, our study highlights the incidence of burnout among pharmacy professionals in Nepal and the importance of addressing this issue to promote their well-being. The results emphasize the need for proactive measures to address and mitigate burnout among pharmacy professionals, one of the integral members of healthcare delivery. Several noteworthy findings emerged: gender differences were observed, female pharmacy professionals experienced higher levels of mental impairment; regular exercise was linked to reduced burnout, particularly in terms of mental aloofness and cognitive impairment; and substance use, including alcohol and tobacco, was associated with increased burnout, especially exhaustion and emotional impairment. While certain work-related factors did not show significant associations, it is clear that burnout is a multifaceted issue influenced by a combination of personal and organizational factors. These findings enrich the existing literature on burnout in pharmacy professionals and underscore the imperative for tailored interventions and support mechanisms to alleviate burnout and foster the holistic well-being of healthcare professionals in Nepal.

Supplemental Material

sj-docx-1-smo-10.1177_20503121231215237 – Supplemental material for A cross-sectional assessment of burnout presence among pharmacy professionals at Kathmandu Valley, Nepal

Supplemental material, sj-docx-1-smo-10.1177_20503121231215237 for A cross-sectional assessment of burnout presence among pharmacy professionals at Kathmandu Valley, Nepal by Rama Ranabhat, Anil Giri, Binaya Sapkota, Rajeev Shrestha and Sunil Shrestha in SAGE Open Medicine

Footnotes

Acknowledgements

We want to thank all the participants for their invaluable responses and time during the data collection process.

Author contribution

RR, AG, and SS conceptualized and designed the study. RR coordinated and monitored the data collection. RS conducted the data analysis. RR, RS, and SS wrote the draft of the manuscript. BS and SS critically reviewed, contributed to data analysis and edited the manuscript. SS and AG supervised the overall study and critically reviewed the manuscript. All authors reviewed and approved the final manuscript. RR, RS, and SS contributed equally to this work.

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.

ORCID iDs

Binaya Sapkota

Rajeev Shrestha

Sunil Shrestha

Supplemental material

Supplemental material for this article is available online.

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