Abstract
Introduction
Blood supply shortages remain a pressing global health issue, particularly in resource-limited regions. The West Bank region in Palestine, characterized by frequent conflicts and instability, faces additional challenges due to its fragile healthcare system, where a substantial proportion of blood donations still relies on family-replacement donors rather than voluntary donations.
Objective
This study examines changes in knowledge, attitudes, and practices (KAP) related to blood donation among Palestinians from 2022 to 2025, aiming to guide strategies for a sustainable voluntary donation system.
Methods
A comparative cross-sectional survey was conducted in two phases during January to February 2022 and 2025 using cluster sampling, involving 1,270 adults (626 in 2022; 644 in 2025). Electronic questionnaires on KAP were distributed digitally. KAP scores, demographics, and donation behaviors were analyzed with t-tests, chi-square tests, and binary logistic regression to evaluate trends and predictors.
Results
Blood donation knowledge improved from 47.1% in 2022 to 50.9% in 2025 (p < .001). Positive attitudes were reported by 93.4% of participants, yet 77% had never donated. Voluntary donations accounted for 43.2% of donations, while family-replacement donations remained significant at 34.2%. Males were twice as likely to donate as females (adjusted odds ratio [OR] = 2.0, 95% confidence interval [CI]: 1.5–2.6; p < .001). Unemployed individuals (adjusted OR = 1.9, 95% CI: 1.1–3.2; p = .024) and general workers (adjusted OR = 2.7, 95% CI: 1.5–4.7; p < .001) donated more frequently than health professionals. Lack of opportunity was the main barrier to blood donation for 65.9% of nondonors.
Conclusion
Despite knowledge gains and positive attitudes, a significant gap remains between positive attitudes and actual donation rates, with family-replacement donations still comprising a substantial share. Targeted educational campaigns, improved access to donation facilities, and community engagement with healthcare stakeholders are essential to promoting voluntary donations in resource-limited and conflict-affected regions.
Background
Blood donation is a fundamental component of healthcare, facilitating life-saving interventions such as trauma care, surgeries, and chronic disease management. Despite its critical role, global blood supply frequently fails to meet demand, particularly in low- and middle-income countries (LMICs), where access remains disproportionately low (Kralievits et al., 2015; WHO, 2022).
The Palestinian territories, particularly the West Bank, exemplify the challenges of sustaining blood supply amid systemic healthcare constraints and recurrent crises. With a population exceeding 3.3 million (PCBS, 2024), the region faces economic hardship, strained infrastructure, and frequent conflicts (World-Bank, 2023). In 2023, hospitals and the national blood bank in the West Bank recorded 45,153 donors and 82,740 transfused blood units, corresponding to 13.6 units per 1,000 inhabitants (PHIC, 2024), below the recommended minimum of 15 units per 1,000 (Kundu et al., 2024; WHO, 2022). The ongoing conflict since October 2023 has further widened the demand-supply gap due to conflict-related injuries.
Review of Literature
Knowledge, attitudes, and practices (KAP) regarding blood donation are interconnected determinants of donation behavior. The Health Belief Model suggests that perceived benefits and barriers, along with knowledge levels, significantly influence donation practices (Theodoratou et al., 2024). Understanding these elements’ temporal evolution is crucial for developing targeted interventions, particularly in regions experiencing ongoing conflicts and healthcare challenges (Oliveira & Reis, 2020).
Although voluntary blood donation (VBD) is recognized as the safest and most sustainable method (Alsarafandi et al., 2023), only 41.4% of donations in the West Bank are voluntary, with the remainder largely dependent on replacement donors (PHIC, 2024). Reliance on replacement donations, while vital in emergencies, does not ensure a stable and safe blood supply (Allain & Sibinga, 2016).
Barriers to blood donation include misconceptions, fears of health risks, and limited awareness of eligibility criteria (Alsarafandi et al., 2023; El Bilbeisi et al., 2023; Eltewacy et al., 2024). Even medical students, expected to be public health advocates, often exhibit knowledge gaps and low donation rates (Eltewacy et al., 2024). Furthermore, economic hardship and political instability hinder voluntary donation efforts, as poverty and unemployment reduce engagement opportunities, while conflicts disrupt blood collection and distribution (Kim & Pelc, 2024).
Studies in Gaza highlight positive attitudes toward blood donation despite low participation rates (Alsarafandi et al., 2023; El Bilbeisi et al., 2023). However, temporal changes in blood donation KAP remain unexplored in the West Bank. The unprecedented circumstances between winter 2022 and winter 2025 offer a unique opportunity to examine how crisis conditions influence donation patterns and community responses.
This study investigates temporal changes in KAP regarding blood donation in the West Bank from 2022 to 2025, assessing the impact of crisis conditions on donation behavior. It aims to (1) evaluate shifts in KAP, (2) identify evolving barriers and opportunities for voluntary donation, and (3) assess broader implications of conflict on community engagement. The findings will inform evidence-based strategies to enhance healthcare resilience in conflict-affected regions and provide guidance for blood donation programs in similarly challenging settings.
Methods
Study Design and Population
This biphasic cross-sectional study aimed to evaluate KAP regarding blood donation among Palestinians residing in the West Bank. Data collection was conducted in two phases: January to February 2022 and January to February 2025. A total of 1,270 participants were included, with 626 respondents in the first phase and 644 in the second.
Research Questions
This study addresses the following questions:
How did blood donation KAP among Palestinians in the West Bank change from 2022 to 2025 amid ongoing instability and conflict? What were the main barriers to voluntary blood donation during this period, and what strategic opportunities for improving donor engagement emerge from the study findings?
Inclusion Criteria
Eligible participants for this survey-based study were adults aged 18 to 65 years, residing in the West Bank, and with at least secondary-level education to ensure sufficient literacy for meaningful survey responses.
Exclusion Criteria
Individuals under 18 years of age, residents outside the West Bank, or those who had participated in the 2022 phase (for the 2025 sample, based on self-reporting). Participants who did not respond to the survey invitation or declined to provide electronic consent were also excluded. Due to the anonymous and voluntary nature of participation, specific reasons for nonparticipation could not be systematically collected.
Ethical Approval and Informed Consent
This study was approved by the Al Quds University Research Ethics Committee (Ref No: 488/REC/2025) and was conducted in accordance with the Declaration of Helsinki and the committee's guidelines. All participants provided electronic informed consent prior to starting the questionnaire, and participation was entirely voluntary. Collected data were anonymized and securely stored on a password-protected computer with restricted access.
Sampling Strategy and Data Collection
A cluster sampling design was employed, with clusters defined as professional associations, educational institutions, and community-based organizations. Recruitment was conducted through multiple channels, including messaging applications (e.g., WhatsApp and Messenger), email, and social media platforms. Diverse community networks—such as alumni networks, professional associations, educational groups, institutional contacts, and local interest groups—were engaged. Within each cluster, a link to the online questionnaire was disseminated. Recruitment strategies were designed to include individuals across a broad range of demographics, including age, educational background, and geographic location. Targeted social media posts further enhanced regional diversity. While efforts were made to ensure broad representation, this study acknowledges the inherent limitations of online survey methods, including potential nonresponse bias.
Participants provided electronic informed consent before beginning the survey, which included acknowledgment of the study's purpose, voluntary participation, and assurance of anonymity. Clear instructions were provided to promote accurate responses, and measures were implemented to prevent duplicate entries, including a self-declaration question about prior survey participation. A 3-year gap between phases further reduced the likelihood of repeat responses across study periods. To ensure the independence of the samples at each time point, participants from 2022 were excluded from the 2025 phase. This strategy minimizes the risk of carry-over effects (e.g., learning and testing bias) that could influence the 2025 results and compromise comparisons between periods.
The electronic questionnaire, included as Supplementary File 2: Questionnaire, was distributed using Microsoft Forms, facilitating efficient data collection and management. To ensure data completeness, all core KAP and demographic questions were set as mandatory within the electronic form. Optional questions were only presented based on respondents’ previous answers—for example, questions related specifically to participants who had actually donated blood. Data quality was monitored by checking for incomplete responses and validating data consistency. Participants were given 2 weeks to complete the survey, with automated reminders sent via the initial recruitment platforms.
Sample Size Calculation
The sample size was calculated using G*Power 3.1, assuming a medium effect size (d = 0.3) for detecting differences in KAP scores between the two time periods, with 80% power and α = 0.05. This calculation yielded a minimum required sample size of 290 participants per period. The final sample sizes of 626 and 644 participants exceeded this requirement, providing adequate power for both cross-sectional analyses and temporal comparisons.
Instrument Development and Validation
The questionnaire was adapted from validated tools used in prior KAP studies on blood donation (Alsalmi et al., 2019; Jemberu et al., 2016; Malako et al., 2019; Melku et al., 2016). The adaptation process included translation into Arabic and cultural modifications to ensure relevance to the Palestinian context. For example, questions about cultural attitudes toward blood donation were tailored to reflect local beliefs and practices.
The initial questionnaire underwent content validation by a panel of five experts in public health and hematology. Discrepancies in expert feedback were resolved through discussion until consensus was reached. The finalized questionnaire consisted of 56 items grouped into the following categories:
Pilot Testing and Reliability
A pilot study with 20 participants was conducted, aligning with survey research guidelines. Feedback was used to refine the questionnaire for clarity and ease of use. Reliability testing, using the Kuder-Richardson Formula 20 (KR-20), yielded coefficients of 0.73 (knowledge), 0.78 (attitudes), and 0.71 (practices), indicating acceptable internal consistency across all sections.
Statistical Analysis
Data were analyzed using IBM SPSS® version 29. Knowledge and attitude questions received 1 point for correct/desirable responses and 0 for incorrect responses. Descriptive statistics summarized demographic characteristics and KAP scores. Inferential analyses included chi-square tests for categorical variables and independent t-tests and analysis of variance (ANOVA) for mean comparisons. Assumptions of normality (Shapiro-Wilk test) and homogeneity of variance (Levene's test) were assessed; non-normal data were analyzed using nonparametric methods. Adjustments for multiple comparisons included Bonferroni corrections when necessary. Binary logistic regression identified predictors of donation practices and temporal trends, with study phase as the primary predictor, adjusted for demographic factors. Interaction terms tested for differential temporal trends across subgroups. Missing data (<5%) were handled through listwise deletion. Sensitivity analyses were not performed due to complete data and the straightforward analytical approach. Statistical significance was set at p < .05, with effect sizes reported for comprehensive interpretation.
This study was conducted and reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for cross-sectional studies. A completed STROBE checklist is submitted as Supplemental material (von Elm et al., 2007).
Results
Demographic and Socioeconomic Characteristics of Participants
The study included 1,270 participants: 626 (49.3%) in 2022 and 644 (50.7%) in 2025. Table 1 shows a predominantly female sample (52.8%), with most aged under 23 years (40.6%) and from Southwest Bank (41.6%), followed by Northwest Bank (32.9%) and Middle West Bank (25.5%). Students (42.1%) and health-related job holders (21.2%) were the largest occupational groups; most held a BSc degree (55.3%) and reported monthly family income of 800 to 1500 USD (45.1%). No demographic characteristics differed significantly between phases (p > .05 for all), ensuring that any observed changes in KAP are not confounded by shifts in demographic composition.
Demographic and Socioeconomic Characteristics of Participants by Study Phase.
Knowledge of Blood Donation by Study Phase
Overall knowledge of blood donation significantly improved between 2022 and 2025 (mean score: 47.1% vs 50.9%; p < .001, Cohen's d = 0.14). Table 2 details these gains, notably in understanding whole blood donation frequency (31.5% vs 39.6%; p = .002), platelet donation frequency (32.6% vs 40.7%; p = .003), and universal donor blood type identification (52.1% vs 61.6%; p = .001); a high proportion of participants also recognized the necessity of pre-donation blood screening (84.1%). However, knowledge gaps persisted, with overall correct responses low for donation process duration (33.6%), minimum age requirements (33.9%), and post-childbirth waiting period (23.5%).
Participant Knowledge Regarding Blood Donation by Study Phase.
Attitudes Toward Blood Donation
As detailed in Table 3, participants exhibited consistently positive attitudes toward blood donation, reflected in a high overall positive attitude score (93.4%). Notably, a large majority endorsed blood donation as an act of kindness (98.3%) and expressed willingness to donate to both family (95.8%) and anonymous recipients (94.6%). Furthermore, most participants indicated they would motivate others to donate (97.3%). Attitude scores remained stable across all study phases, with no significant differences observed (p > .05 for all comparisons).
Participant Attitudes Regarding Blood Donation by Study Phase.
Practices and Experiences with Blood Donation
Data in Table 4 shows that 77.0% of participants had never donated blood, with no significant difference between study phases (77.3% vs 76.7%, p = .797). Among donors, voluntary donation was the primary motivation (43.2%), followed by donations for relatives (34.2%) and nonrelatives (16.1%), with no significant changes between phases. The majority of participants (95.0%) indicated likelihood of future donation, with a statistically nonsignificant increase from 2022 to 2025 (93.8% vs 96.1%, p = .056). Most donors (89.2%) reported positive experiences after donation. For nondonors, lack of opportunity remained the predominant barrier (65.9%), defined as limited access to blood donation drives, lack of awareness about donation opportunities, or logistical constraints (e.g., time or location). This barrier reflects external limitations rather than unwillingness, as evidenced by the high likelihood of future donation (95.0%) reported by most participants, including nondonors. Other barriers included no specific reason (14.1%), health problems (11.0%), and fear (7.1%), with no significant changes between phases (p > .05 for all comparisons).
Participant Practices and Experiences Regarding Blood Donation by Study Phase.
Knowledge Scores by Demographic and Socioeconomic Factors
Table 5 details knowledge scores (out of 25). Health professionals demonstrated the highest scores, with a significant improvement from 2022 to 2025 (16.1 vs 18.6; p = .005). Education level significantly influenced knowledge scores (p < .001), with BSc holders showing significant improvement between phases (12.4 vs 13.6; p = .009). Income analysis revealed significant improvements between phases for the 800 to 1500 USD group (11.3 vs 13.0; p = .003) and the 1501 to 3000 USD group (12.4 vs 14.0; p = .046). Gender showed no significant difference in knowledge scores (mean = 12.3).
Knowledge Total Scores by Demographic and Socioeconomic Factors Across Study Phases.
*p-Value between two phases.
Associations Between Demographic and Socioeconomic Factors and the Likelihood of Ever Donating Blood
Multivariate analysis, detailed in Table 6, indicated that males were significantly more likely to donate blood (adjusted odds ratio [OR] = 2.0, 95% confidence interval [CI]: 1.5–2.6; p < .001). Age over 50 showed a nonsignificant trend toward lower donation compared to the <23 years group (adjusted OR = 0.6, 95% CI: 0.4–1.0; p = .064). Occupation significantly influenced donation likelihood, with unemployed (adjusted OR = 1.9, 95% CI: 1.1–3.2; p = .024) and general workers (adjusted OR = 2.7, 95% CI: 1.5–4.7; p = .001) showing higher donation rates compared to health professionals.
Association Between Demographic and Socioeconomic Factors and the Likelihood of Ever Donating Blood.
*Adjustment is for age, sex, job, and region.
CI=confidence interval; OR=odds ratio.
Discussion
Blood donation is a cornerstone of healthcare systems globally, particularly in conflict-affected regions like the West Bank, where ensuring a stable blood supply is a persistent challenge. This study explored KAP related to blood donation in this context, providing valuable insights into trends, gaps, and potential interventions to enhance donation rates in resource-limited and unstable settings.
Improvement in Blood Donation Knowledge
This study documented a statistically significant rise in blood donation knowledge, from 47.1% in 2022 to 50.9% in 2025 (p < .001), with a small effect size (Cohen's d = 0.14). Though modest, this improvement is meaningful in a region grappling with healthcare disruptions and aligns with evidence from developing countries where educational campaigns have bolstered awareness (Alkalash et al., 2024). Specific areas of progress included knowledge of whole blood donation frequency, which increased from 31.5% to 39.6% (p = .002), and identification of the universal donor blood type, rising from 52.1% to 61.6% (p = .001). These gains suggest that factors within the Palestinian context—potentially including general health education, media exposure, or community discussions—may have contributed to improved understanding of critical knowledge domains essential for fostering voluntary donation cultures (Alsarafandi et al., 2023; El Bilbeisi et al., 2023; Mussema et al., 2024).
Despite these advances, significant gaps in knowledge persist, particularly in understanding the duration of the donation process (33.6% correct responses) and post-childbirth waiting periods (23.5% correct). These deficiencies are consistent with observations in diverse cultural settings, indicating a need for targeted educational efforts to address these specific areas (Weng et al., 2024).
Health-related professionals exhibited the most substantial knowledge gains, with scores improving from 16.1 to 18.6 (p = .005). This finding reinforces their potential as advocates for blood donation, a role supported by studies of health-focused students which highlight the influence of knowledge on donation behavior (Alsarafandi et al., 2023; Mussema et al., 2024).
Attitudes Toward Blood Donation
Attitudes toward blood donation were overwhelmingly positive, with an overall score of 93.4%. Participants largely viewed donation as an act of kindness (98.3%) and expressed willingness to donate to family members (95.8%) and anonymous recipients (94.6%). These results align with regional research. For instance, a Syrian study found that 40.4% of medical students considered donation a duty (Salem et al., 2024). Similarly, studies in Saudi Arabia reported 80.3% of adults with positive attitudes (Alkalash et al., 2024), while in Gaza, 67.1% of adults expressed favorable views (El Bilbeisi et al., 2023). Despite this positivity, 77.0% of participants never donated, a disconnect observed across the Middle East. For example, only 22.7% of university students in a 16-country study had donated (Eltewacy et al., 2024). Similarly, a recent study in Gaza reported that 82.1% of Gazan adults had never donated blood (El Bilbeisi et al., 2023). Similarly, a recent UAE study among university students revealed high willingness but low donation rates, attributing the gap to fear, misconceptions, and limited outreach (Babker et al., 2024). Even in resource-rich settings like the UAE, these findings highlight common regional barriers such as inadequate awareness of donation procedures, restricted access to donation sites, cultural preferences for family-based donation, and lack of clarity on how to donate. These factors collectively hinder the translation of positive attitudes into actual donation behavior.
Socioeconomic Factors and Barriers to Blood Donation
Socioeconomic factors significantly shaped knowledge and donation behavior. Health professionals showed marked knowledge improvement, from 16.1 to 18.6 (p = .005), likely due to their access to health-related training. Participants with higher education (e.g., Bachelor's degrees) and greater family incomes also demonstrated better knowledge, consistent with findings linking socioeconomic status to donation rates in China and Brazil (Lin et al., 2023; Mazurkievz de Freitas et al., 2024).
Gender disparities in blood donation were evident, with males twice as likely to donate (adjusted OR = 2.0, 95% CI: 1.5–2.6; p < .001). Lower female participation may reflect gender-specific barriers, such as misconceptions about health risks during menstruation, cultural norms discouraging female donation, and fears of postdonation weakness. These patterns are consistent with findings from Saudi Arabia and other Gulf countries (Alkalash et al., 2024; Eltewacy et al., 2024) and LMICs (Zucoloto et al., 2019). Targeted outreach strategies, including women-led blood drives, engagement of female healthcare professionals, and educational campaigns clarifying donation safety for menstruating, pregnant, or lactating women, could enhance female participation.
The leading barrier was lack of opportunity (65.9%), reflecting limited access to donation centers or drives. Additional obstacles included health concerns (11.0%) and fear (7.1%), echoing global studies citing logistical and informational barriers (Eltewacy et al., 2024; Mazurkievz de Freitas et al., 2024). Addressing these requires structural interventions, such as increasing the availability of donation facilities and mobile collection units, alongside educational efforts to dispel fears and clarify health-related misconceptions.
Impact of Conflict on Blood Donation Practices
Voluntary donations accounted for 43.2% of the blood supply in this study, closely mirroring the national rate of 41.4% reported by the Palestinian Ministry of Health (PHIC, 2024), with family-replacement donations at 34.2% and nonrelative donations at 16.1%. Compared to the global family-replacement rate of 15.9% (WHO, 2022), this study's 34.2% figure is notably higher, reflecting a heavy reliance on this system typical of conflict-affected regions (Laermans et al., 2022; Raykar et al., 2021). Donation patterns showed no significant change from 2022 to 2025 (p > .05), indicating limited adaptability in a context of persistent need. This dependence on family-replacement donations raises concerns about blood safety and supply reliability, especially during crises when family networks are disrupted (Allain & Sibinga, 2016; Van Denakker et al., 2023). Although this study was conducted in the West Bank, the findings may be relevant to other conflict-affected or resource-constrained regions facing similar healthcare infrastructure challenges and donation patterns. The diverse sample and temporal design strengthen the potential for cautious generalization, though cultural and systemic differences should be considered when applying these findings elsewhere.
One particularly unexpected finding was that health professionals were less likely to donate blood than unemployed individuals and general workers. This counter-intuitive result suggests potential barriers specific to healthcare professionals that merit further investigation. Possible explanations include time constraints due to demanding work schedules, perceived conflicts of interest in donating to facilities where they work, or greater awareness of potential complications. Targeted strategies to increase donation among healthcare workers might include workplace donation drives with protected time allocations, peer recognition programs, and addressing specific concerns through educational interventions. These findings align with previous research, which similarly identified a discrepancy between knowledge and actual donation practices among healthcare professionals in Saudi Arabia and India (Al Zadjali et al., 2023; Desai & Satapara, 2014).
Strengths and Limitations
Strengths: This study's strengths include its biphasic design comparing 2022 and 2025 data in the West Bank, a large sample size (N = 1,270), a culturally adapted questionnaire, and the use of multivariate analysis.
Limitations: This study relies on self-reported data, which may introduce response bias and limit generalizability. Conducting research in conflict settings further complicates data collection, as noted in prior work on ethical and methodological challenges in such contexts (Ford et al., 2009). While multivariate analysis was used to examine donation behavior, additional tests, such as interaction terms (e.g., age × sex and occupation × region), were not included due to journal word count limits. These analyses are recommended for future studies to uncover subgroup-specific trends in demographic influences on donation behavior. Future studies should incorporate objective measures, such as donation records, to validate findings and explore longitudinal trends. Additionally, research could investigate culturally tailored interventions and subgroup-specific trends to address persistent barriers in similar regions, enhancing the applicability of results.
Implications for Practice
Bridging the gap between knowledge and practice is essential to converting positive attitudes toward blood donation into consistent donor behavior. Although awareness and attitudes have shown encouraging progress, sustaining donor engagement remains a critical challenge. To address the discrepancy between favorable perceptions and actual donation rates, evidence-based strategies are recommended.
Targeted public health campaigns that clarify eligibility criteria and demystify donation processes can enhance donor engagement, as demonstrated by social media initiatives in Saudi Arabia (Alanzi et al., 2023). Improving accessibility through mobile blood collection units in underserved areas and extended operating hours can mitigate opportunity-related barriers identified among nondonors—a cost-effective approach proven in the United Kingdom (Grieve et al., 2018; Li et al., 2023; Sharma et al., 2024). Promoting workplace donation drives with incentives like protected time and peer recognition has increased participation in settings like China (Cao et al., 2024). Collaborating with community leaders and religious figures can align voluntary donation messages with cultural values, fostering trust, and participation. Finally, adopting hybrid models that integrate regional customs with voluntary donation systems offers a culturally sensitive path toward sustainability.
These global strategies provide a practical framework for locally adapted interventions to promote consistent blood donation behaviors, ultimately supporting the development of resilient and effective donation systems.
Conclusion
Blood donation knowledge in the West Bank increased notably from 2022 to 2025, driven partly by heightened awareness during conflict escalation in 2023, alongside improved attitudes; yet 77% of participants remain nondonors, with 34.2% of donations reliant on family-replacement systems. These findings underscore the need for integrated strategies that address both educational deficits and structural barriers. By combining enhanced access, community engagement, and workplace initiatives, stakeholders can foster a robust voluntary donation system. This work provides a foundation for future efforts to align blood donation practices with global standards while respecting regional context.
Supplemental Material
sj-docx-1-son-10.1177_23779608251376516 - Supplemental material for Blood Donation Knowledge, Attitudes, and Practices Amid Instability: A Biphasic Cross-Sectional Study in West Bank, Palestine (2022 vs 2025)
Supplemental material, sj-docx-1-son-10.1177_23779608251376516 for Blood Donation Knowledge, Attitudes, and Practices Amid Instability: A Biphasic Cross-Sectional Study in West Bank, Palestine (2022 vs 2025) by Ibrahim Amer Ghannam in SAGE Open Nursing
Footnotes
Acknowledgments
The authors thank all participants for completing the questionnaire, colleagues, and friends for assisting in its distribution, Dr. Rania Abu Seir for guidance on questionnaire design, and Yahya and Lara Ghannam for their support in recruitment and proofreading.
Ethical Considerations
This study was approved by the Al Quds University Research Ethics Committee (Ref No: 488/REC/2025) and conducted in accordance with the Declaration of Helsinki and the committee's guidelines. Participants provided electronic informed consent at the start of the questionnaire, with participation being entirely voluntary. All collected data were anonymized and securely stored on a password-protected computer with restricted access.
Consent to Participate
In compliance with the Declaration of Helsinki and ethical committee guidelines, electronic informed consent was obtained from all participants on the questionnaire's start page. The questionnaire was accessible only after participants had reviewed the consent information and explicitly agreed to participate by clicking the designated consent button.
Authors’ Contributions
The author was solely responsible for the study conception and design, data collection, analysis and interpretation of the data, drafting and critical revision of the manuscript, and gave final approval of the version to be published.
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.
Data and Materials Availability
The researchers are willing to provide the datasets generated and/or analyzed as part of this study to interested parties upon reasonable request to the corresponding author.
Supplemental Material
Supplemental material for this paper is available online.
References
Supplementary Material
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