Edited by: Annie Robitaille, University of Ottawa, Canada
Reviewed by: Maria Łuszczyńska, Uniwersytet Papieski Jana Pawła II w Krakowie, Poland; I-Shiang Tzeng, National Taipei University, Taiwan
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Caregiving is a committed role that focuses on providing the required support and care to a care receiver who is either ill, disabled, or dependent to the extent that they are incapable of independent functioning. The topic of caregiving has been extensively studied worldwide, mainly focused on the negative aspects of caregiving, like caregiver stress, burden, role conflicts, and burnout among caregivers. However, limited efforts have been made to understand the positive aspects of caregiving among informal caregivers who spend most of their time in this unpaid role. The present study addresses this concern by exploring the positive aspects of caregiving among family caregivers of older persons in India.
This is a qualitative study, which was conducted, using the existential-phenomenological approach. In this study, a purposive sampling technique was used, and a total of a 100 family caregivers participated from four cities in India, namely Prayagraj, Pune, Visakhapatnam, and Guwahati. Twenty-five family caregivers between the age of 30–50 years participated from each of these four cities. The data was collected using six semi-structured interview questions on positive aspects of caregiving based on the lived experiences of caregivers. The interview schedule was developed based on the PERMA model and finalized after the pilot study. Each interview took 30–50 min and was recorded and transcribed.
The data was analyzed using thematic analysis. Some commonalities and differences were observed in the responses given by family caregivers from the four cities. Four major themes that emerged for the “Nature of positive caregiving” among participants from all four cities are “Caregiver’s attitude,” “Care and compassion,” “Roles and responsibilities,” and “Beliefs and values.” Four significant themes for the “Factors contributing to positive caregiving” are “Meaningfulness in life,” “Sense of belongingness,” “Personal growth,” and “Empathetic understanding.”
Based on the study’s findings, it can be said that the themes were associated with the PERMA model. Positive caregiving is an important indicator of caregivers’ and care receivers’ well-being. The findings have implications for planning some action research, training, and counseling programs for promoting positive aspects of caregiving among informal caregivers.
The older adults population is increasing at a fast pace throughout the world. India is the second most older adults populated country globally, with 103.8 million senior citizens (
Informal caregiving is a dynamic, evolving, and intersubjective life experience in which connections are co-created consciously or unconsciously and manifested in acts and behaviors of care, responsibility, and attention (
Looking into the literature, it is observed that many researchers have focused on the negative side of caregiving and have highlighted factors such as burden, stress, clinical depression, cognitive impairment, physical health problems, and burnout commonly observed in formal and informal caregivers (
Perceptions of caregiving and the factors influencing caregivers differ across cultures (
In the Indian context, caregiving is usually provided by family members. Additionally, extended family, friends, and neighbors feel responsible for caring for older people (
Some of the studies also point out that individual factors also determine the caregiver’s attitude, along with cultural factors. A systematic review (
The literature shows that the researchers’ focus over the last decade has shifted to looking into caregiving outcomes by considering different internal and external factors. Irrespective of the type of care, i.e., providing care to the person with or without physical or psychological or multiple impairments (including activities of daily living, cognition, vision, and hearing), caregivers of older adults experience moderate to higher levels of burden due to factors like characteristics of the care-receivers and their illness, socioeconomic status, caregivers’ physical health, psychopathological symptoms, and disruption of the family routine (
Studies have also pointed out that caregivers of patients with psychiatric and chronic medical illnesses risk experiencing burnout, dysphoria, emotional distress, stress, anxiety, and depression, even though the burnout levels are moderate (
From the above discussion, it can be inferred that individual differences have an essential role in the caregiving outcome, and caregiving generally depends on how well the caregivers adjust to the demands of caregiving. The government and policymakers must consider these cultural and individual differences while framing any policies and schemes. The government must support and facilitate the informal caregivers by teaching them problem-focused coping strategies, providing home health visit services, and identifying different types of needs (like organizational, informational, support, and societal recognition) so that these facilities mitigate the possible adverse effects associated with caregiving (
Although most studies have highlighted the problematic side of caregiving, some researchers have also investigated the positive outcomes associated with caregiving. When the caregivers have a good relationship with the care-receiver, they choose to provide care out of their own will, allocate some time for self-care, vent out emotions occasionally, and are not working out of the home; they have been shown to exhibit satisfaction in their caregiving (
From the above studies, it is evident that a limited number of studies have been done to explore the positive aspects of caregiving. Given this gap, the researchers must explore the flourishing aspects of caregiving and come to a consensus on the domain of factors associated with it so that they can be nurtured and act as preventative factors against any potential negative consequences of caregiving. Given the need, the current study aims to understand the nature of positive caregiving and explore the factors associated with such experiences among informal caregivers using the PERMA model.
PERMA model is a multi-dimensional approach to defining what it means to flourish in life. It was developed by Martin Seligman (
According to the PERMA model, Positive emotions (P) comprise hope, interest, joy, love, compassion, pride, amusement, and gratitude. They are essential indicators of flourishing and well-being (
In the PERMA model, Meaning (M) is associated with having a purpose in life and is guided by personal values. Studies have highlighted that having a purpose in participants’ lived experiences reduces health problems (
To date, limited studies have been conducted by researchers who looked at the caregiving of the older adults using the PERMA model. Also, the essence of flourishing in caregivers can be understood well qualitatively based on their lived experiences; however, only a few studies have focused on it in this way. The current study incorporated the PERMA Model as it is an evidence-based approach giving a scientific base to exploring flourishing among caregivers based on their positive caregiving lived experiences. Using the PERMA model, the present study aims to understand the nature of positive caregiving and explore the factors contributing to positive caregiving experiences among family caregivers of older adults in India based on the existential-phenomenological approach.
This study is a qualitative study that was conducted using the existential-phenomenological approach. The approach views people as being in a constant process of interpretation as they journey from one situation to another. Each situation has meaning only through people’s interpretation and definition of it. According to this approach, one must understand a person’s experience from their lifeworld. It is the world as lived by the person every day in direct and immediate experience (
In this study, a purposive sampling technique was used, and a total of 100 family caregivers from four cities in India, namely Prayagraj, Pune, Visakhapatnam, and Guwahati participated in this study.
These cities were selected as they have a sizeable population of older adults and because they have an increased number of informal caregivers due to the limited availability of paid caregiving services. Prayagraj from Uttar Pradesh represented North India, Visakhapatnam from Andhra Pradesh represented South India, Pune from Maharashtra is in Western India, and Guwahati is in the Eastern part of India. Twenty-five middle-income family caregivers aged 30–50 years, participated from each of these four cities. From Prayagraj, 19 female caregivers and 6 male caregivers; from Visakhapatnam, 21 female caregivers, and 4 male caregivers; from Pune, 16 female caregivers, and 9 male caregivers; and from Guwahati, 18 female caregivers and 7 male caregivers participated in this study. Across the four cities, the female caregivers were mostly daughters-in-law and daughters, and the male caregivers were sons taking care of their older adults parents.
The data was collected using the interview technique. Six semi-structured interview questions on positive aspects of caregiving based on participants’ lived experiences were asked from each participant. The interview schedule was developed based on the PERMA model. The six questions were focused on exploring positive emotions, engagement, relationships, meaning, and accomplishment of caregivers in their caregiving roles. They are as follows: Discuss how your role of caregiving has impacted your life. Share some of your positive emotional experiences associated with your role as a caregiver. How engaged and involved do you find yourself in your caregiver’s role? What type of relationship do you share with your care receiver? How and in what ways has your role as a caregiver defined the meaning of your life? What type of satisfaction did you get in this role of caregiver? Share some of your accomplishments.
The interview schedule was tested and finalized after the pilot study, which was done in all four cities.
The data collection was done in four phases. Each phase took a month. In phase one, data was collected in Prayagraj; in phase two, data was collected in Visakhapatnam; in phase three, data was collected in Pune; in phase four, data was collected in Guwahati. Each interview in the final study took 30–50 min and was recorded and transcribed. Interviews were primarily conducted in Hindi and English in all four cities. In Visakhapatnam, some interviews were conducted in Telugu, and in Guwahati, some were conducted in Assamese.
To maintain this study’s reliability, before data collection, the researchers practiced bracketing by first writing their preconceptions about family caregiving. This was done to go for data collection with an open mind for accepting participants’ experiences without any preconceived notions. In practice, bracketing is not so easy and difficult to follow; however, the researchers tried to become aware of their own ideas regarding informal caregiving and not to let those ideas interfere in data collection and analysis.
To establish the validity in the present research study, the following strategies were applied:
Prolonged engagement in the field: the researcher’s prolonged engagement in the field is an important strategy for establishing validity. According to experts (
Theoretical sampling: theoretical sampling refers to the process of selecting informants who represent the community, not statistically, but theoretically, in the sense of having more knowledge about the community for which the study is designed or any specific aspect of the community life (
Extensive quotations: extensive quotations from field notes and transcripts of the interviews are also an essential way of establishing credibility in qualitative research (
Member checking: member checking has been described as the most crucial technique for establishing credibility (
Multiple researchers checking the data: it involves more than one researcher reviewing the data and its interpretation (
After the checking of transcripts by researchers and participants the transcribed responses were treated as final data for the analysis.
The data was analyzed using thematic analysis.
The thematic analysis of the responses of participants from each of the four cities was done separately but simultaneously. In the case of each city’s data, thematic analysis was done flexibly following six steps stated by Braun and Clarke ( Step 1: familiarizing oneself with the data—this was the first step of data analysis. In this step, the researchers transcribed all 25 interviews collected in the case of each city. After that, all 25 transcriptions were read and re-read by the researchers one by one, specifically for each of the six semi-structured questions asked in case of each interview. Based on the readings of each transcription, some ideas related to each question were identified. Step 2: generating initial codes—in this step, based on the ideas noted in the earlier step, codes were generated. Codes identify a feature of the data that appears significant to the analyst and refer to the distinctive features of the raw data that can be analyzed in a meaningful way regarding the phenomenon ( Separate coding for each of the six questions in each participant’s case from four cities was done. Though coding was done based on the questions asked, if any participant gave any response which was not directly related to the question but the participant confirmed it to be the answer for the same question, then it was also noted because being a phenomenological study any response from the participant was considered significant. Step 3: searching for themes—in this step, two separate lists of codes, one for the nature of positive caregiving and another one for factors related to positive caregiving, were prepared, which were extracted under the respective six questions in the earlier step from each of the 25 interviews. After this, based on those codes, themes were identified for nature and factors related to positive caregiving. Step 4: reviewing themes—in this step, the themes were refined, which were prepared in the earlier step. During this review phase, the researchers combined some sub-themes and made them into one theme. Step 5: defining and naming themes—in this step based on the ‘essence’ of what each theme is about and what aspect of the data each theme captures, all the themes generated were defined and named. Step 6: producing the report—after the final themes were named and defined, a write-up containing the description of each theme (with responses) was prepared, which is a part of this study’s result and discussion chapter.
Though these steps are mentioned separately, in practice, the researchers often worked simultaneously on reading transcripts, preparing codes, making themes based on codes, and reviewing themes. The same procedure was followed for the data in all four cities.
Based on the thematic analysis of the responses given by the 100 family caregivers in this study, four major themes that emerged for the “Nature of positive caregiving” are “Caregiver’s attitude,” “Care and compassion,” “Roles and responsibilities,” and “Beliefs and values.”
Caregiver’s attitude was the dominant theme among participants from all four cities. The respondents emphasized that since caregiving has brought meaningfulness to their life, they want to give their best in this role by serving the care receivers with the utmost respect. Most of the participants from Pune and Guwahati mentioned that taking care of older adults family members is like expressing one’s gratitude for what they did for these caregivers when they were young. Like a caregiver (Daughter, 35 years) from Pune said, “This caregiving role gives me lots of satisfaction as I am serving my father who fulfilled all my wishes when I was a kid.” Another caregiver (Son, 40 years) from Guwahati mentioned, “When I was a child, my mother took good care of me, and now it is my responsibility to give back through my caregiving role.” Most caregivers from Prayagraj and Visakhapatnam emphasized fulfilling their caregiving role with utmost seriousness to inculcate positive values in their younger generation. A caregiver from Prayagraj (Daughter-in-law, 39 years) said, “I am doing my caregiving duty for my mother-in-law with all my heart so that my children should learn such good values now and perform such roles when required.” Similarly, a caregiver (Daughter-in-law, 35 years) from Visakhapatnam said, “I am glad that I am able to fulfill my caregiving role with dedication which I am sure will inspire my children to learn good values like taking care of older adults parents and grandparents.”
Care and compassion was the second dominant theme among respondents from all four cities. The respondents emphasized that caregiving is a pious job as the caregiver not only takes care of the care receiver but also motivates them when they feel low due to illness and disability. In this way, they raise the care receiver’s self-worth through their caring behavior and compassionate service. Like a caregiver from Prayagraj (Daughter, 40 years) said, “Whenever my mother feels low because of her illness, I try to cheer her up. It makes me feel good.” Another caregiver from Visakhapatnam (Son, 50 years) said, “My father is 80, and sometimes he feels low because of his mobility issues; during that time as a son and caregiver, I encourage him to think positively.” Similarly, a caregiver from Guwahati (Daughter-in-law, 38 years) said, “I think caregiver’s role is a very holy job as in this way we help someone in need.” Some caregivers from Pune further shared their experiences of raising the care receiver’s confidence level through their care and determination. Like a caregiver (Son, 42 years) mentioned, “Whenever my parents want to go for long walks, it is hard for them to do that; in that situation, I join them and boost their self-confidence.”
Most participants across the four cities emphasized that the caregiving role and responsibility gives a purpose to their life through engagement and involvement. According to caregivers, this brings satisfaction in their life and makes the family bond stronger. Like a respondent from Pune (Daughter-in-law, 37 years) said, “Serving my parents-in-law is my main responsibility; this work gives me satisfaction and keeps me busy.” Another caregiver from Prayagraj (Daughter-in-law, 35 years) said, “This caregiving responsibility adds more importance to my life. I will fulfill my responsibility with utmost sincerity.” Some respondents from Guwahati and Visakhapatnam emphasized that this role has strengthened their family bonding. Like a caregiver from Guwahati (Daughter, 44 years) said, “I am satisfied that I am in a position to take care of my mother; this is strengthening our bonding.” Another one from Visakhapatnam (Son, 45 years) said, “I am glad that I am taking care of my parents in their old age, it is making our relationship stronger.”
This theme revolves around caregivers’ belief that their caregiving role contributes to their spiritual development and family welfare. It also highlights the importance or value they give to their caregiving role, which is bringing good deeds (Karma). Here most participants from Prayagraj and Pune mentioned that their caregiving role is helping them to attain their spiritual development. Like a caregiver from Prayagraj (Daughter-in-law, 46 years) said, “Taking care of elders is a holy job which is helping me in my spiritual growth.” Another caregiver from Pune (Daughter-in-law, 49 years) said, “This caregiving is a pious work and a means to spiritual attainment.” Some participants from Guwahati believed it led to the building of intergenerational bonding in the family. Like a participant (Daughter, 41 years) said, “Due to this role, I have become closer to my parents, and my children have become closer to me. We all respect and love each other.” Some others in Visakhapatnam related it to good karma. Like a participant (Daughter-in-law, 39 years) said, “I am sure these deeds of mine in the form of caregiving will bring good karma for my family and me.”
Based on the thematic analysis, the four significant themes that emerged as factors contributing to positive caregiving are “Meaningfulness in life,” “Sense of belongingness,” “Personal growth,” and “Empathetic understanding.” Here also, some commonalities and differences were observed in the responses given by participants across four cities.
In the case of the theme “Meaningfulness in life,” participants from Prayagraj, Visakhapatnam, and Guwahati derived meaningfulness in their work and life because of the sense of satisfaction and fulfillment they experienced in this role. Thus, highlighting meaningfulness and purposefulness is an essential factor in caregivers’ positive caregiving experiences. Like a participant from Prayagraj said (Son, 48 years), “This duty of mine towards my parents gives a purpose to my life.” Another caregiver from Visakhapatnam (Daughter, 38 years) said that “I am satisfied that I am taking care of my parents in their old age. It adds meaning to my life.” Similarly a caregiver from Guwahati (Daughter-in-law, 35 years) said, “This caregiving role is tough, but I am glad that my life is useful for someone.” Most participants from Pune equated it more with positive self-worth. Like a caregiver (Daughter-in-law, 40 years) said, “My caregiving role adds more value to my life and makes my life meaningful.”
Most participants from all four cities reported a sense of belongingness between caregiver and care receiver as a significant contributing factor to positive caregiving. Here many participants emphasized the strengthening of family bonding and the development of a friendly relationship between caregiver and care receivers. Like a participant from Pune (Daughter, 36 years) said, “I always share all my information with my mother, and she shares everything with me. We are emotionally connected to each other,” Another participant from Prayagraj (Daughter-in-law, 45 years) said, “Through this caregiving role I have come closer to my mother-in-law. This has strengthened our relationship. She admires me for my hard work.” Under this theme, some caregivers also emphasized on building friendly relationships with their care receivers. Like a caregiver from Visakhapatnam (Daughter-in-law, 39 years) said, “While taking care of my parents-in-law, we have become good friends.” Similarly, a caregiver from Guwahati (Son, 48 years) said, “Me and my parents have become very good friends, we share every aspect of our lives with each other.”
In the context of this theme, all caregivers from four cities shared that their caregiving role has made them more self-regulated, disciplined, flourished, and organized which in turn has contributed to their positive caregiving experiences. Like a participant from Pune (Daughter-in-law, 40 years) said, “Due to caregiving role, I learned how to manage my time in between my work and family.” Similarly, another caregiver from Guwahati (Daughter, 50 years) said, “This caregiving role is tough, but it also teaches lots of self-discipline, which I am learning while caring for my father.” Regarding personal growth, some participants have also reported that their caregiving role has made them more patient and self-regulated. Like a participant from Prayagraj (Daughter-in-law, 37 years) mentioned, “I do have a lot of stress issues, but when I think for a while and interact with my mother-in-law, I feel relaxed.” Similarly, another caregiver from Visakhapatnam (Son, 48 years) said, “My caregiving role for my parents has taught me to be patient and manage things well.”
Regarding the theme “Empathetic understanding,” most participants from Prayagraj and Visakhapatnam reported that due to their caregiving role, they have become more empathetic and can recognize care receiver’s emotions well and thus feel optimistic about it. Due to this, they can provide need-based emotional support to care receivers. Like participants from Prayagraj (Daughter, 38 years) said, “While taking care of my parents, I have become more understanding towards their needs. I am glad I am able to fulfill my responsibility as a daughter.” Similarly, another participant from Visakhapatnam (Daughter-in-law, 40 years) said, “People often talk about tussles between daughter-in-law and mother-in-law; this happens because of lack of understanding. In our case, I make special efforts to understand her situation and provide emotional support to my mother-in-law. She also appreciates this.”
Compared to the above, most participants from Pune and Guwahati emphasized that they can empathetically understand the challenges faced by their care receivers, work on resolving those challenges, and thus experience positive caregiving experiences. Like a caregiver from Pune (Daughter-in-law, 40 years) said, “My mother-in-law is very old, and she cannot walk on her own, so I have made it a habit that in the morning every day, I assist her in her walks. In this way, she meets other elders and interacts with them. She feels good about it, which gives me satisfaction.” Similarly, another participant from Guwahati (Daughter, 50 years) said, “As my parents are mostly staying at home, I help them connect with their friends and extended family via WhatsApp and Zoom. I know they like doing that. It makes me feel happy.”
The findings of this study clearly indicate that informal caregiving, which is often considered burdensome, can be a flourishing experience for a family or informal caregiver, which not only contributes to their personal and spiritual growth but also strengthens their family bonding.
Based on the study’s findings, it can be said that the themes have been found to be associated with the PERMA model. All four themes for the Nature of Caregiving, namely Caregiver’s attitude, Care and compassion, Roles and responsibilities, and Beliefs and values, are related to the domains of the PERMA model like Positive Emotion (P), Engagement (E), Relationships (R), Meaning (M), and Accomplishment (A). In the case of the first theme, Caregiver’s attitude, many caregivers across four cities reported that their caregiving experiences had helped them develop positive attitudes, making life more meaningful and satisfying. This is strongly related to the “meaning” domain of the PERMA model and justifies that getting involved in a cause that matters can bring more meaning to life (
In the case of the second theme, Care and compassion, most caregivers shared the positive feelings they experienced while providing care to their older adults parents or in-laws. The positive emotions experienced by most of these caregivers are hope, interest, joy, love, compassion, pride, amusement, and gratitude, which are very similar to the ones mentioned in the “positive emotion” domain of the PERMA model (
Similarly, through the third theme, roles and responsibilities, caregivers reported that their caregiving roles have added purpose to their life through engagement and involvement in the care receiver’s life. This is related to the “engagement” domain of the PERMA model, which emphasizes on being mindful of the present moment and focusing on the current endeavors (
Regarding the fourth theme, beliefs and values, most participants shared their beliefs and values about their caregiving roles and emphasized how it contributes to their well-being. Based on their lived experiences, most of them considered caregiving a pious and holy duty that would bring them good karma and help them attain their spiritual growth. This is very similar to the “meaning” domain, which is associated with having a purpose in life and guided by personal values. Some association can also be established with the domain of “accomplishment,” which means achievement, mastery, or competence, as many caregivers reported their caregiving role as a valued accomplishment in their life.
Thus, based on the findings and the above discussion, it can be concluded that caregiving can be a flourishing and positive experience among informal caregivers The attributes of positive caregiving will mainly comprise of caregiver’s positive attitude towards their life and caregiving role, care and compassion towards their care receivers, commitment towards their caregiving roles and responsibilities, and their profound beliefs and values which they associate with their caregiving duty.
After discussing the nature of positive caregiving, the next important step is to explore the determinants or contributing factors of positive caregiving among informal caregivers. The four significant themes that emerged as factors contributing to positive caregiving are “Meaningfulness in life,” “Sense of belongingness,” “Personal growth,” and “Empathetic understanding.” All these themes have a strong association with the PERMA model.
Regarding meaningfulness in life, most caregivers reported that they found their caregiving role significant and worthwhile. Thus, it has added more meaningfulness to their life. This is very similar to the “meaning” domain of the PERMA model, which is associated with doing things that give individuals a sense of purpose and worth. This sense of meaning can be different for everyone and is guided by personal values (
The second contributing factor to positive caregiving is sense of belongingness. In this regard, most caregivers mentioned that caregiving leads to the strengthening of family bonding and the building of friendly relationships. This highlights the “relationship” domain of the PERMA model, which relates to how people connect with others (
The theme of personal growth emphasizes the growth and gains that caregivers have reported due to the caregiving role. Many shared that due to their caregiving role, they are leading a self-regulated and disciplined life and are experiencing various signs of personal growth like spiritual development, a sense of personal control, control of anger, and high self-esteem. These experiences are related to the “accomplishment” domain of the PERMA model, which emphasizes competence and personal growth (
Another important contributing factor is empathetic understanding. Most caregivers reported that as they spend maximum of their time with their care receivers, they have become empathetic towards them. This empathy is not only helping the care receivers but also serving the caregivers in experiencing positive emotions, building positive relationships, and finding meaningfulness in their roles. All these are essential determinants of flourishing (
Thus, based on the findings and the above discussion, we can say that positive caregiving is an important indicator of caregivers’ and care receivers’ well-being. The results suggest that when the caregivers looked at caregiving with a positive attitude by considering their caregiving role as pious and assigning meaningfulness to their act of caregiving, it not only made them connect with the care receivers on an emotional level but also contributed to their family bonding and personal growth. Findings also highlight that, in the context of older adults care receivers, positive caregiving in the family not only promotes healthy aging and reduces the percentage of older adults seeking institutional support but also contributes to building intergenerational bonding and making societies elder-friendly. The findings have implications for planning some action research, training, and counseling programs for promoting positive aspects of caregiving among informal caregivers.
The study has certain limitations that need to be considered by researchers who wish to explore this area further. The study utilized a purposive sampling technique, which may not represent the entire population of caregivers of the older adults in India. The study was limited to only four cities in India, so the results may not be generalized to other regions. This study relied on self-reported data from caregivers, which may have been subject to social desirability or recall bias.
Future studies could use a larger sample size and employ a mixed methods approach to triangulate qualitative findings with quantitative data results and provide a more comprehensive understanding of the positive aspects of caregiving. Future studies could also investigate the effectiveness of intervention programs that are designed to promote positive caregiving. This could include exploring the impact of training, support groups, or counseling programs on the well-being of caregivers and care receivers. It is also necessary to plan longitudinal studies to investigate how the dimensions of positive caregiving might change over time and to explore the factors that contribute to sustained positive caregiving practices among caregivers.
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.
NM conceptualized and designed the study, reviewed, and analyzed the data. RD reviewed the data and checked the methodological quality. AT reviewed the data and edited the manuscript. MS reviewed the data and guided the field investigators along with NM to conduct interviews. All the authors contributed to data collection, interpretation of the data, manuscript writing and review of the manuscript.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
The authors would like to thank all the participants, field investigators, and other stakeholders who were involved during the data collection process.