Introduction
Palliative care (PC) is an essential component of integrated, person-centered health care for individuals and families facing serious, chronic, or life-limiting illness (Organisation Reference Organisation2021). Globally, an estimated 56.8 million people require PC each year, yet only about 14% receive it, with the greatest unmet need occurring in low- and middle-income countries (Organisation Reference Organisation2023).
Spiritual care is central to the philosophy and practice of PC, particularly in settings where religion strongly shapes understandings of illness, suffering, dying, and death (Gijsberts et al. Reference Gijsberts, Liefbroer and Otten2019; Miller et al. Reference Miller, Addicott and Rosa2023). Across African health systems, spiritual care and chaplaincy services remain unevenly developed and inconsistently supported, particularly for faith traditions outside dominant Christian structures (Orogun Reference Orogun2023).
For Muslims, Islam provides a comprehensive framework addressing health, illness, and death. The Qur’an states, “Verily my prayer, my sacrifice, my living and my dying are for Allah, the Lord of the worlds” (Qur’an 6:162), reflecting the belief that life and death are inseparable from one’s relationship with Allah (Al-Shahri Reference Al-Shahri2016; Al-Ani and Al-Khasawneh Reference Al-Ani and Al-Khasawneh2024). These help interpret serious illness through beliefs in divine will, preparation for the hereafter, and the preservation of dignity at the end of life (Abdallah Abu and Lazenby Reference Abdallah Abu and Lazenby2021; Malik et al. Reference Malik, Allen and Vachharajani2022; Saunders et al. Reference Saunders, Quinn and Duivenbode2024). Muslims cope with serious illness and dying through daily practices such as prayer, Qur’an recitation, and religious support from Islamic Religious Leaders (IRL) (Lipka Reference Lipka2017; Rego and Nunes Reference Rego and Nunes2019; Wijesinghe et al. Reference Wijesinghe, Gunathilaka and Mendis2023).
IRL and other religious leaders may work collaboratively at the hospital chaplaincy to provide spiritual counseling, religious guidance, and mediate between Muslim patients and non-Muslim staff during end-of-life practices (Klitzman et al. Reference Klitzman, Gabrielle Di Sapia and Garbuzova2023; Muishout et al. Reference Muishout, El Amraoui and Wiegers2024). Despite their potential contributions, little is known about their perspectives on PC in Ghana and other settings.
Therefore, this study explored IRL’s perspectives on PC for Muslim patients in Ghana, focusing on their understanding, perceived roles, community engagement, and barriers to care. These findings are intended to inform the development of faith-sensitive and culturally responsive PC guidelines for Muslim patients in Ghana and potentially other multicultural settings.
Methods
Data collection and participants
This qualitative exploratory descriptive study examined IRLs’ perspectives on PC for Muslim patients in Ghana. This design was appropriate because it enabled an in-depth and practice-relevant understanding of participants’ views, experiences, and perceived roles in supporting Muslim patients and families within PC contexts (Sandelowski Reference Sandelowski2000; Colorafi and Evans Reference Colorafi and Evans2016). The study formed part of Phase 1 of a larger multi-method project aimed at developing PC guidelines for Muslim in-patients receiving PC in selected tertiary hospitals in Ghana.
The wider study focused on tertiary hospitals providing PC in Accra, Kumasi, and Tamale. At the same time, this component included IRLs working in hospital-linked, mosque-based, and community settings. Their inclusion was important because healthcare services, religious beliefs, family practices, and community support structures may shape Muslim patients’ PC experiences.
Participants were purposively recruited IRLs with experience supporting Muslim patients and families during serious illness, hospitalization, or end-of-life care. Recruitment was supported through referrals from patients, families, religious leaders, and community networks linked to the study sites. A total of 10 semi-structured interviews were conducted with IRLs.
Data were collected through semi-structured face-to-face or virtual interviews exploring participants’ views on PC, Islamic beliefs, end-of-life practices, family and religious support roles, community education, and collaboration with healthcare providers. Interviews were conducted by the first author, an experienced nurse researcher and PhD candidate with training in qualitative research methods.
Before each interview, the purpose of the study was explained, and informed consent was obtained. Interviews lasted 30–45 minutes, were audio-recorded with permission, and were supplemented with field notes. Data saturation was reached at the 10th participant. Recordings were transcribed verbatim, translated into English where necessary, and reviewed for accuracy before analysis.
Data analysis
All transcribed data were imported into ATLAS. ti 25 for coding and organization. Data were analyzed using thematic analysis guided by Braun and Clarke’s approach. The researchers repeatedly read the transcripts to become familiar with the data, generated initial codes inductively, and grouped related codes into broader categories and themes.
Themes were refined through an iterative process of comparing patterns across participants and revisiting the transcripts. The findings were interpreted through Cicely Saunders’ Total Pain concept, highlighting the multidimensional nature of suffering and IRL’s contribution to holistic PC. The analysis focused on IRL’s understanding of PC, their perceived roles in supporting Muslim patients and families, and the implications for faith-sensitive guideline development.
To enhance rigor, the research team discussed emerging codes and themes, resolved differences through discussion, and maintained an audit trail of recruitment, coding, and theme development. Credibility was enhanced through purposive sampling, prolonged engagement with the data, and the use of representative quotations. Transferability was supported by providing rich contextual descriptions of participants and study settings.
Results
Participant characteristics
A total of 10 IRL participants participated in the study. Participants were selected based on their knowledge of Islamic teachings and experience supporting Muslim patients and families during serious illness and end-of-life care through spiritual guidance, counseling, family support, education, and practical assistance in hospital, mosque, and community settings.
Participants comprised 6 men and 4 women aged 44–60 years (mean age = 50.7 years). Seven participants were married, 1 was single, and 2 were divorced. Educational attainment ranged from Senior High School to PhD level, with 7 (70%) participants having tertiary education. Participants represented diverse ethnic backgrounds, including Bisa, Fulani, Kotokoli, Gonja, Twi, and Ga. Most identified as Muslim without a specific sectarian affiliation, while 3 identified as Sunni Muslims. The sample reflected diverse demographic, educational, ethnic, and religious backgrounds, providing a broad range of perspectives on faith-sensitive PC. Participant characteristics are presented in Table 1 below.
Participants’ characteristics
Table 1 Long description
Participant characteristics are listed with frequencies. Occupation counts are 2 lecture, 6 Arabic Teachers, and 2 businessmen. Marital Status counts are 7 married, 1 single, and 2 divorced. Number of children is grouped as 1 to 4 with 6 participants and 5 to 10 with 4 participants, plus a separate row labeled 10 plus with a frequency of 8. Education Level counts are 3 Senior High School, 5 Tertiary, and 2 PHD. Ethnicity counts are 2 Bisa, 1 Fulani, 2 kotokoli, 2 Gonja, 2 Twi, and 1 Ga. Religious affiliation or sect identification counts are 7 Muslim with no specific sect specified and 3 Sunni.
Overview of themes
Thematic analysis of interviews with IRLs yielded 5 interrelated themes: (1) conceptualizing PC as holistic and faith-sensitive care; (2) Islamic beliefs as resources for coping with serious illness and end-of-life care; (3) IRLs as providers of holistic and faith-sensitive care; (4) family-centered care and shared decision-making; and (5) barriers and opportunities for faith-sensitive PC. Collectively, these themes illustrate how Islamic beliefs, religious practices, and community structures shape PC experiences and highlight the contributions of IRLs to the spiritual, emotional, social, and practical dimensions of care for Muslim patients and their families. A summary of the themes, their descriptions, and illustrative quotations is presented in Table 2.
Themes, descriptions, and illustrative quotations from interviews with Islamic religious leaders
Table 2 Long description
Two columns list themes and an illustrative quotation for each theme. Row 1, Conceptualising Palliative Care as Holistic and Faith-Sensitive Care, includes quotations describing services for terminally ill people by health professionals, chaplaincy boards, and religious bodies, and mentions hope, visitation, spiritual support, and continuing prayer during illness. Row 2, Islamic Beliefs as Resources for Coping with Serious Illness and End-of-Life Care, includes quotations stating that the final decision about dying belongs to Allah and advising patients not to despair, remain hopeful, repent, and seek forgiveness. Row 3, Islamic Religious Leaders as Providers of Holistic and Faith-Sensitive Care, includes quotations about sitting with patients to console and support families, and helping bedridden patients with ablution or tayammum so they can pray while their senses are intact. Row 4, Family-Centred Care and Shared Decision-Making, includes quotations advising visitors not to tell sick people that others have died, and describing trusted religious leaders providing guidance to reduce fear and misunderstandings about critical illness. Row 5, Barriers and Opportunities for Faith-Sensitive Palliative Care, includes quotations naming mindsets, myths, and ignorance as barriers, describing beliefs about witchcraft or enemies, noting education as a response, and describing loss of a chaplain office affecting work, plus a quotation about fear and misunderstandings and guidance from trusted religious leaders.
Theme 1: Conceptualizing PC as holistic and faith-sensitive care
Participants conceptualized PC as holistic, multidisciplinary, and faith-sensitive care that addresses the physical, emotional, spiritual, and social needs of patients and families facing serious illness. Care was perceived as extending beyond symptom management to include emotional reassurance, spiritual support, and assistance with religious practices.
In one of the participants’ words: “From my understanding, it’s the services that are rendered to the terminally ill people… services rendered by health professionals, chaplaincy boards and religious bodies… towards the end of the life of that person” (Participant 3).
Another participant also emphasizes that PC extends beyond symptom control to include spiritual and practical support. The participant claims that: “We give hope to the sick that illness may remove sins, encourage regular visitation and spiritual support in hospitals, and assist patients to continue praying despite their illness” (Participant 7).
Together, these accounts illustrate that participants understood PC as whole-person care that integrates medical, spiritual, and social support to promote comfort and dignity during serious illness.
Theme 2: Islamic beliefs as resources for coping with serious illness and end-of-life care
Participants described illness and death within an Islamic worldview centered on trust in Allah’s will, hope, and spiritual preparation for the hereafter. Faith was portrayed as an important resource that enabled patients and families to cope with uncertainty, maintain hope, and find meaning in suffering. One participant emphasizes sustaining hope despite poor prognoses: “Although health professionals may say that a person is dying, the final decision belongs to Allah. We reassure patients not to despair in the mercy of Allah and to remain hopeful, because Allah has control over everything” (Participant 6).
Similarly, another participant views illness as an opportunity for repentance and spiritual growth: “Illness can be a blessing because it gives a person time to repent and seek Allah’s forgiveness. We remind them not to despair in the mercy of Allah, for He is Most Forgiving and Most Merciful” (Participant 9). Together, these accounts demonstrate how Islamic beliefs provide spiritual resources for coping with serious illness, sustaining hope, and preparing for the end of life.
Theme 3: IRLs as providers of holistic and faith-sensitive care
Participants described IRLs as important providers of spiritual, emotional, and practical support to patients and families throughout serious illness and end-of-life care. Their roles extended beyond religious guidance to include counseling, emotional reassurance, facilitation of religious practices, and support for families navigating illness and death.
The provision of comfort and emotional support emerges as a central aspect of their role in PC: “We sit with patients, console them, give them assurance, and support families to understand the reality of death and manage their emotions” (Participant 5).
Participants also emphasize enabling patients to maintain religious practices despite physical limitations imposed by illness: “Even when patients are bedridden, caregivers can help them perform ablution or tayammum so that they can pray, because prayer remains important as long as their senses are intact” (Participant 1).
Religious leaders further highlighted their role in addressing misconceptions and promoting understanding of serious illness within Muslim communities: “When people hear about critical illness, they often think about death, creating fear and misunderstandings. Trusted religious leaders can help provide guidance and reduce these misconceptions” (Participant 4).
These accounts highlight the multifaceted role of IRLs in delivering holistic, faith-sensitive care that addresses patients’ and families’ spiritual, emotional, and practical needs.
Theme 4: Family-centered care and shared decision-making
Participants viewed PC as a collective responsibility involving patients, families, religious leaders, and the wider community. Family members were regarded as essential sources of emotional, spiritual, and practical support throughout the illness trajectory. Care decisions were often understood within a shared cultural and religious context, with families playing an important role in providing guidance, encouragement, and support to patients facing serious illness. Participants emphasize the importance of communication that preserves hope and promotes emotional well-being. They expressed concern that negative or discouraging conversations could undermine patients’ coping abilities and willingness to engage with treatment and care. One participant explains: “When visitors tell a sick person that others with the same illness have died, the person records death in the mind and loses hope. Visitors should instead pray, encourage them, and support their recovery” (Participant 10).
Religious leaders also highlighted the role of families and communities in fostering supportive environments that encourage positive coping and acceptance of care. Community education was viewed as important for addressing misconceptions about serious illness and PC, thereby enabling families to make informed decisions and provide appropriate support. Another participant describes: “When people hear about critical illness, they often think about death, creating fear and misunderstandings. Trusted religious leaders can help provide guidance and reduce these misconceptions” (Participant 3). These accounts illustrate how family involvement, hope-preserving communication, and community support contribute to shared decision-making and the delivery of faith-sensitive PC. Participants viewed these elements as essential for supporting patients and families while promoting acceptance and engagement with PC services.
Theme 5: Barriers and opportunities for faith-sensitive PC
Participants identified several barriers to the delivery and uptake of faith-sensitive PC, including misconceptions about illness, inadequate infrastructure, and limited institutional support for spiritual care services. At the same time, they highlighted opportunities to strengthen PC through education, training, and collaboration between healthcare institutions and religious leaders.
Misconceptions and traditional beliefs surrounding illness were perceived as important barriers that may hinder acceptance of PC: “Mindsets, myths, and ignorance are major barriers. Some families believe illness is caused by witchcraft or enemies, which can lead them to resist care. Education is key to overcoming these beliefs” (Participant 2).
Limited institutional recognition and inadequate infrastructure for chaplaincy services were reported as: “When we had a space, Muslims and Christians would come together to pray for the hospital. But now we do not have a chaplain office, and this has affected our work” (Participant 8). Strengthening the capacity of religious leaders and improving public awareness were viewed as important strategies for enhancing PC services: A participant states, “We have the knowledge to care for the sick, but to make it more professional, Imams need training and workshops, and the public also needs education on caring for people with terminal illness” (Participant 7). These accounts highlight the need for greater education, institutional support, and collaboration to strengthen faith-sensitive PC for Muslim patients and families.
Discussions
This study explored IRL’s perspectives on faith-sensitive PC for Muslim patients in Ghana and their potential contribution to the development of culturally and religiously responsive PC guidelines. To our knowledge, this is among the first studies in Ghana and one of the few from sub-Saharan Africa to examine the perspectives of IRL within PC. Five interrelated themes emerged, highlighting PC as a holistic and faith-sensitive approach shaped by Islamic beliefs, family involvement, community support, and collaboration between healthcare professionals and religious leaders. Viewed through Saunders’ Total Pain concept, the findings demonstrate that experiences of serious illness among Muslim patients extend beyond physical symptoms to include psychological, social, and spiritual dimensions. Collectively, these findings highlight the importance of integrating spiritual care into holistic PC and inform the development of faith-sensitive PC guidelines for Muslim patients.
Spirituality plays a significant role in palliative patients’ desired care plans: The findings demonstrate that spirituality is not an adjunct to PC but a central component of holistic care for Muslim patients experiencing serious illness. Participants described how trust in Allah, prayer, Qur’anic recitation, family support, and religious guidance can help patients and families cope with suffering and find meaning during serious illness and end-of-life care. This was consistent with several studies’ descriptions of PC as a holistic approach that improves the quality of life for patients and their families (Komariah et al. Reference Komariah, Hatthakit and Boonyoung2020; Memaryan et al. Reference Memaryan, Ghaempanah and Aghababaei2020). The present study extends prior research by demonstrating that Islamic beliefs, including hope in Allah, prayer, and Qur’anic recitation, serve as practical coping resources that alleviate spiritual and emotional distress and promote resilience and well-being. The findings further revealed that IRL contribute to holistic care by providing spiritual support, emotional reassurance, family mediation, and practical assistance. Evidence from diverse settings highlights the important role of IRLs in enhancing communication, trust, decision-making, and spiritual support within PC (Abdallah Abu and Lazenby Reference Abdallah Abu and Lazenby2021; Nayfeh et al. Reference Nayfeh, Yarnell and Dale2021; Muishout et al. Reference Muishout, El Amraoui and Wiegers2024). These roles position IRL and other faith-based leaders as more than occasional bedside visitors; rather, they may serve as trusted intermediaries among patients, families, communities, and healthcare professionals. In this context, the inclusion of IRLs and other faith-based leaders in PC should be structured, respectful, and collaborative, with clear referral pathways and role boundaries that complement professional healthcare practice. Participants’ accounts suggest that Islamic beliefs, including Qadar (divine decree), Allah’s mercy, and forgiveness, help patients find meaning in suffering, cope with guilt, and prepare for the hereafter. These findings suggest that faith-sensitive PC guidelines should facilitate access to IRLs who can provide compassionate discussions on Qadar, hope, repentance, and spiritual preparation, thereby supporting emotional and spiritual well-being alongside clinical care.
Despite their recognized importance in healthcare, the involvement of religious leaders in PC remains largely informal and ad hoc, reflecting governance gaps and inconsistent access to spiritual support (Knaul et al. Reference Knaul, Farmer and Krakauer2018; Al-Riyami et al. Reference Al-Riyami, Abdulhadi and Al-Azri2020; Sohail Malik Reference Sohail Malik2020; Al-Abdali Reference Al-Abdali2024). In Ghana, several studies have revealed that IRLs have limited access to PCs that are responsive to their religious and cultural needs, as well as to inadequate culturally appropriate services (Shhadat et al. Reference Shhadat, Wobst and Meyer2025; Lampinley et al. Reference Lampinley, Filmalter and Orogun2026). Consistent with PC remaining an evolving field, a study reports challenges in timely access, cultural responsiveness, and service delivery (Quaidoo et al. Reference Quaidoo, Adu and Iddrisu2024). At the same time, another study recommended structured end-of-life training and culturally aligned PC guidelines for PC providers to improve PC in Ghana and beyond across Sub-Saharan Africa (Osei et al. Reference Osei, Aquah and Appiah2025). Consistent with several studies, participants in the present study revealed several structural and institutional barriers to faith-sensitive PC, including limited awareness of PC, financial and transportation challenges, inadequate facility space, and insufficient institutional support for spiritual care. These barriers suggest that faith-sensitive PC requires system-level support, including institutional policies, trained personnel, appropriate infrastructure, and formal collaboration with IRLs within multidisciplinary PC services. Participants highlighted prayer, ablution, tayammum, and Qur’anic recitation as important sources of spiritual comfort. These findings suggest that faith-sensitive PC guidelines should support these practices while safeguarding patients’ dignity, privacy, autonomy, and clinical safety.
Collectively, these findings suggest that faith-sensitive PC cannot rely solely on individual efforts but requires system-level commitment through supportive policies, workforce training, dedicated spaces for spiritual care, and stronger collaboration between healthcare institutions, chaplaincy services, and community religious organizations. This aligns with the World Health Organization’s recommendation that effective PC requires integration into health systems through appropriate policies, education, and resource allocation (Organisation Reference Organisation2018).
Communication and decision-making emerged as deeply family-centered and faith-informed. Participants described serious illness decisions as collective processes involving patients, relatives, and religious leaders. They helped families interpret clinical decisions through an Islamic ethical lens, supported communication around sensitive issues, and facilitated decision-making that preserved dignity, hope, and religious values. The findings suggested that faith-sensitive PC guidelines should promote communication practices that respect patient preferences, appropriately involve families, and preserve hope without withholding essential information. This is consistent with the literature emphasizing the need to balance cultural and religious values with patients’ own preferences for information-sharing and decision-making (Abdullah et al. Reference Abdullah, Guo and Harding2020; Malek et al. Reference Malek, Saifuddeen and Abdul Rahman2021; Tareen Reference Tareen2025). Participants’ views reflected the Islamic concept of Qadar, suggesting that understanding death as Allah’s will may promote hope, acceptance, and peace. These findings support involving IRLs in faith-sensitive end-of-life discussions to facilitate spiritual preparation while respecting patients’ autonomy and dignity. Participants viewed education as both health- and faith-informed, with IRLs playing an important role in correcting misconceptions, reducing stigma, and promoting appropriate healthcare-seeking behavior for PC.
Participants identified key health-system barriers to faith-sensitive PC, including limited awareness of PC, inadequate resources, insufficient training in spiritual care, and weak institutional support. This was consistent with several studies reported across diverse settings on the absence of Islamic-sensitive PC guidelines, shortages of trained personnel, and limited integration of spiritual care within health services (Bany Hamdan et al. Reference Bany Hamdan, Al-odeh and Sherwynn2020; Memaryan et al. Reference Memaryan, Ghaempanah and Aghababaei2020). Participants also emphasized the importance of community engagement, including mosques, schools, community centers, and social media platforms for education. Engaging IRLs and other religious leaders in community education may therefore help demystify PC, reduce stigma, and promote earlier access to supportive care services. These findings suggest that addressing the spiritual needs of Muslim patients requires more than individual efforts and depends on supportive policies, workforce development, and institutional commitment to faith-sensitive care. IRLs described their role as extending beyond religious rituals to providing spiritual support, emotional reassurance, family mediation, ethical guidance, and community education.
In Ghana and similar settings, guideline development for PC should include practical recommendations for identifying patients’ spiritual needs and facilitating access to religious leaders when desired to support appropriate end-of-life care (Selman et al. Reference Selman, Brighton and Sinclair2018). These findings support the development of faith-sensitive PC guidelines that may enhance dignity, trust, communication, spiritual well-being, and quality of life while complementing professional healthcare.
Strengths and limitations
This study addresses an important gap by exploring the perspectives of IRLs. This stakeholder group has received limited empirical attention in PC research in Ghana and sub-Saharan Africa. To our knowledge, it is among the first studies in the region to examine the role of IRLs in faith-sensitive PC. The use of in-depth qualitative interviews and thematic analysis enabled a rich understanding of how Islamic beliefs, family involvement, and community support influence PC and inform the development of culturally and religiously responsive guidelines.
Several limitations should be considered when interpreting the findings. The study was conducted within the Ghanaian context and may not reflect the diversity of perspectives across other Muslim populations or healthcare settings. As a qualitative study, the findings are intended to provide contextual understanding rather than statistical generalization. Furthermore, the study focused on the perspectives of IRLs and did not include Muslim patients, family caregivers, or healthcare professionals. Although these perspectives formed part of the broader multi-method study, future research should examine how these stakeholder groups can collaboratively implement and evaluate faith-sensitive PC in clinical practice.
Overall, the findings demonstrate that IRLs are important stakeholders in faith-sensitive PC for Muslim patients in Ghana. Their perspectives support integrating Islamic spiritual care, family-centered communication, community engagement, and structured collaboration with healthcare professionals into PC practice. These findings provide an important foundation for developing culturally and religiously responsive PC guidelines for Muslim patients in Ghana and may also inform similar initiatives in other multicultural settings.
Conclusions
This study offers new insights into IRLs’ perspectives on faith-sensitive PC for Muslim patients. The findings demonstrate that Islamic beliefs, spiritual practices, family involvement, and community support are integral to holistic PC and contribute to addressing the physical, psychological, social, and spiritual dimensions of suffering. IRLs were identified as important partners in providing spiritual guidance, emotional support, family counseling, and community education, thereby complementing professional healthcare.
The findings support the development of culturally and religiously responsive PC guidelines that integrate Islamic spiritual care, family-centered communication, and structured collaboration between healthcare professionals and IRLs. Such an approach has the potential to strengthen holistic, person-centered PC for Muslim patients in Ghana. It may also inform the development of faith-sensitive PC policies and practices in other multicultural settings and countries seeking to integrate religious and cultural values into PC.
Acknowledgments
The authors would like to thank all the Islamic religious leaders who generously shared their time, experiences, and perspectives for this study. We also acknowledge the support of the participating institutions and communities that facilitated recruitment and data collection. This study forms part of a PhD project undertaken by Ajaratu Lampinley at the University of Pretoria, South Africa. The authors are grateful to the supervisory team for their guidance and support throughout the research process. The authors used Grammarly during manuscript preparation to assist with grammar checking, language editing, and improving the text’s clarity and readability. All suggestions were carefully reviewed, edited, and approved by the authors, who take full responsibility for the accuracy, integrity, and originality of the manuscript. No artificial intelligence tools were used for data collection, data analysis, coding, theme development, or interpretation of the study findings.
Author contributions
A.L. conceptualized the study, contributed to the study design, coordinated data collection, conducted data analysis and interpretation, and drafted the manuscript. C.J. F. and D.O. contributed to the study design, supervision, interpretation of findings, and critical revision of the manuscript for important intellectual content. All authors read and approved the final manuscript.
Funding
This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Competing interests
The authors declare that they have no known competing financial, professional, or personal interests that could have appeared to influence the work reported in this paper.
Ethical approval
The study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the University of Pretoria and the relevant institutional review boards of the participating study sites.
Ethics and consents
All participants received study information and provided informed consent before data collection. Participation was voluntary, and confidentiality and anonymity were maintained throughout the study.
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