Introduction
The opportunity for individuals from high income countries (HICs) to volunteer in healthcare settings of low and middle income countries (LMICs) has increased significantly over the last few decades.1 Showing a surprising resilience post-Covid 19,2 these models of global health engagement, known collectively as short-term experiences in global health (STEGH), involve volunteer healthcare professionals and students embarking on visits to LMIC healthcare settings lasting anywhere from a few days to a few months.3-6 Traditionally the domain of faith-based organizations, increasingly these experiences are also being organized through the academic sector, non-government organizations (NGOs), independent service learning providers, or for-profit, corporate-sector, social responsibility arms.7
The body of literature that seeks the perspective and voice of host organizations in this context is in its infancy.8,9 According to Rozier et al., where it does include host voices, hosts have reported a spirit of mutual respect, but can see visitors as burdensome and an inefficient approach to healthcare.10 The research presented here emerges from STEGH conducted within the context of an ongoing partnership with the host organizations. It seeks to contribute to the growing body of literature exploring the dynamics between hosts and visitors, while further promoting the voices of the hosts who have traditionally been missing from the literature.11 The partnerships between the Australian NGO at the center of this research and host NGOs have existed for over 20 years. They include collaboratively conducted research and evaluation of programs. This paper, however, focuses on hosts’ experiences of visiting volunteers participating in a STEGH. It contributes to the sparse body of literature that features the voices and opinions of the hosts and provides a unique example of hosting experiences which have emerged from an ongoing partnership.
Background
Strengths of STEGH
Most of the literature on short term experiences in global health problematize these models; however, the benefits reported are usually for the visitors.12,13 In particular, visitors are able enhance their clinical skills, feel a sense of “giving back,” and reconnect with their reasons for entering the field.13,14
Few studies report benefits to the hosts. Where they do, they identify the ability for visitors to temporarily fill staffing gaps, provide free services and equipment, increase skills and knowledge, and attract attention to the host’s facilities, thereby, increasing their profile.5 As a result of volunteer visits, host staff can be provided with a sense of solidarity and hope that ongoing assistance might follow.14
Weaknesses of STEGH
Potential problems with this model occur when there is an assumption of a “unidirectional flow” of knowledge, resources, and people.8 Likewise, power differentials between hosts and foreign agencies can be exacerbated when individuals from high-income countries believe they can make a difference without understanding the complexities of those they are “helping.”15 There are consequences with such a uniform approach, such as matching under-skilled labor with skilled labor needs or a “lack of synchronization with the host countries’ needs and resources.”8,12
Visits can create a burden on the community.16 Researchers evaluating a program based in Guatemala found that while hosts appreciated the individuals and sacrifices made for them to get there, they also observed that it increased their workload.17 They needed to familiarize volunteers with the setting and, at times, the language, and there was a pressure to coordinate food, transportation, accommodation, or even their tourist experiences.
Finally, these experiences can come at the expense of necessary and authentic capacity building, equipment, training, and ongoing partnerships.8,18 They can also lack the necessary follow-up care and can, therefore, foster a community dependence on volunteers to fill in the gaps.10,13 These shortcomings and oversights have the potential to undermine local professionals and their expertise and, additionally, with the prioritization of foreign agencies, hosts are often forced to implement programs not of their devising, which further undermines their agency and contextual knowledge and, thus, leads to less effective outcomes.5,15
Frameworks, principles and guidelines
A number of organizations and academics have developed frameworks and ethical principles to guide the implementation of these experiences, to reduce harm, and to prepare visitors to interact appropriately with host staff and communities.1,4,7,19
In these guides, there is a focus on cultural competency and cultural humility. In one of the existing surveys of host country partners, Cherniak et al. found that hosts expressed appreciation for those visiting, but there was a “strong emphasis” on the need for a “greater focus on cultural learning” and building respect for existing knowledge.20 Laleman, Kegels also found that many volunteers were “ill-prepared” to effectively work in host settings, for both cultural and professional reasons, but they note that language training, in particular, was associated more strongly with positive experiences.21 Cultural competency may be critical for effective participation; however, there is an argument that training in cultural competency provides visitors with only a small part of the picture when it comes to the complexities and richness of a place’s culture. As a consequence, it can lead participants of cultural competency training to hold reductionist and oversimplified views when it comes to understanding the culture of the communities with whom they are working.22
Cultural humility, on the other hand, may help to counter propensities towards this oversimplification and reductionism.6,23 Penney notes that cultural humility includes “self-reflection, being other-centered, and openness.”19 Additionally, a commitment to cultural humility results in respect for local health workers’ and patients’ autonomy and encourages the visitor to have an awareness of their own limitations. To support the development of cultural humility, Shah et al. suggest that programs should focus on lasting outcomes driven by host organizations.1 Within this paradigm, volunteers should be educated to think less about “saving the world” and the difference that they can make and, instead, reflect on how their skills can align with the desired outcomes indicated by the hosts. Listening to, and respecting, host’s perspectives and knowledge creates mutual trust and effective partnerships.19
On a more practical level, Loh et al. provide a number of recommendations that organizations sending visiting volunteers should follow, such as providing local partners with funding commensurate to the resources consumed, agreeing beforehand on the roles and the responsibilities of each partner, recruiting, preparing, and supervising volunteers effectively, and ensuring sustainability of the programs through regular evaluation of the impact of the program on host partners.4,11
Overarching each of these values, however, is the need to change focus from the visitors to the hosts. These frameworks and principles recommend the inclusion of hosts in the planning, design, implementation, and evaluation of short-term experiences, and Lasker et al. note that existing recommendations and guidelines are almost exclusively written by those in the Global North and should, instead, be informed by research and policies emerging from the host countries.4,11
Methods
This research involves organizations who hosted volunteers participating in STEGHs through the facilitation of Enabled, a health and development NGO in Australia. Enabled partners with approximately 50 NGOs in North India. Through these partnerships, they aim to empower local communities through physical and mental health care, education, disability support, and community mobilization and development.
Since 2006, Enabled has facilitated volunteers to participate in a range of programs, varying in length from two weeks to six months with pre-departure preparation tailored to the program. Short-term exposure trips of two weeks are highly structured and provide volunteers the opportunity to serve in medical clinics, school programs, and social engagements. Volunteers in these programs participate in preparatory meetings where they explore principles of cross-cultural engagement.
Longer study trips of up to two months involve university students working within the scope of their public health or medical studies. Students work closely with their supervising professor who provides cultural and contextual briefings as well as academic guidance to plan and implement the study they will undertake.
Finally, volunteers with allied health or medical credentials also offer their services for periods of up to six months. These are the least structured and most independent of the volunteer engagement types. Health volunteers engage in one-to-one, unstructured briefings after arranging their placement with their sending coordinator. Typically, Enabled will suggest a start date when a staff member will be in the field area.
This research involves semi-structured interviews with 10 leaders of local partner NGOs. These leaders were purposively selected because of their experience hosting at least two short-term volunteers. To be selected, they also needed to have been involved in either training the volunteer, interacting with them in clinical settings, or involved in the coordination of the program.
Interviewees were invited to share their experiences of short-term volunteers and their impact on their organization. They were asked to explore the impact of trip length, training, group size, and preparation on the effectiveness of the program and the qualities in a volunteer that made them effective. Other questions focused on the perceived benefits and both positive and negative impacts of short-term volunteer programs. Consistent with the ethics approval process and the consent obtained from participants, interviews were conducted in English by a student volunteer with an audio recording. A translator was offered to respondents choosing to participate; however, all participants were conversant in English. Ten interviews were conducted and transcribed and the data analyzed through qualitative, thematic analysis. Their comments have been deidentified, and they are represented in the results as Participant 1 (P1), Participant 2 (P2), et cetera. Themes that emerged from this process were coded as positive or negative impacts, contributions, and factors that either fostered or hindered a visitor’s effectiveness. Additionally, comments about group sizes, duration of visit, and visitor characteristics were identified.
Results
This section presents findings emerging from the thematic analysis of interviews concerning hosting short-term volunteers. The results are organized into two key sections: the impacts that volunteers have on the programs, the program’s staff, and their communities; and the factors that impact the effectiveness of the volunteers. As per the study’s aims, the findings in this section represent the perspectives of the host partners.
Leaders’ perceptions on the impacts of visitors in their community
a. Volunteer impact on staff and programs
In the STEGH programs relevant to this study, volunteers had participated in short-term interventions, including health promotional activities, medical camps, and the provision of material resources. The hosts saw that volunteers could play a valuable role in supporting and advancing program goals. They were able to offer new resources, ideas, and skills that could help move projects forward and fill gaps. Their contributions, particularly in terms of training and resource provision, were highly valued by program staff and the community. Volunteers could also enhance the overall effectiveness and reach of the programs, the hosts reported, which adds new dimensions to their services and supports the partner organizations to work towards their vision. Moreover, volunteers’ presence gave program organizations an opportunity to showcase their work and to invite longer-term engagement with the community. The extent to which the visitors were useful depended on the resources of the programs they were visiting. For those with few resources, the visits were more critical:
Every individual is needed. We started from zero and so we are grateful for every input (P1).
More generally, the participants felt that the volunteers brought some enthusiasm to the programs and to the staff, and this helped to renew the current staff’s purpose and vision:
Volunteers are really helpful in getting the program moving and filling in the gaps of programs… Staff are very productive when volunteers are here. Volunteers assist with planning and provide resources that are otherwise limited in the community (P10).
The staff get more [engaged], and they have started learning new things, getting more involved in projects. So this helps a lot. And it helps to recall the whole history of the project and why it was started (P9).
Not only did visits reaffirm the staff’s mission or purpose, but it challenged, and even changed, their worldview around health and development. Despite the visits being short term, there was evidence of lasting impacts on the staff:
Volunteers change our worldviews. Our local staff have the same worldview as the community, but the foreigners break the strongholds and points of view of the staff. They share love and teach us a new way. And that has a huge impact in our work in the community – especially in the way we work among widows, and in health. Short-termers are most effective in changing our worldviews (P1).
Finally, nearly all host participants in this study experienced the visits as encouraging for their local staff who were often isolated socially and professionally. As one participant concluded:
Direct impact (on community) may not be visible but indirect impact on staff and program overall is high. For example, it’s encouraging for our staff to see that others come to serve out of generous motivation – they’re here for themselves but also for the staff and community; and that’s encouraging for the staff to see (P4).
It was clear that short-term visits had the potential to make an impact on existing staff, but they were usually not long enough for visitors to develop therapeutic relationships with clients. Where they were able to establish those relationships, their departure could mean that those clients were left without the necessary follow-up care. Volunteers also meant more hands to make assessments, diagnose healthcare needs, and to identify possible treatment plans, but the ongoing work fell on the shoulders of existing staff, adding to their workload beyond what time and resources were available:
Illnesses may be identified [by volunteers] but local teams may not be able to consistently follow them up (P4).
Additionally, a lack of cultural understanding could lead to misaligned or ineffective service contributions, and the limited duration of such trips meant that there was not enough time to develop the necessary skills to work with staff and people in the community effectively. Shorter engagement periods limited the potential, positive impacts on local staff and clients:
It is very necessary to understand the community too. One week is not enough. But like six weeks is good to understand, and then you can work (P8).
b. Volunteer impact on community
The communities where the hosts were situated had wide-ranging opinions about the presence of foreign volunteers. One host described community members as distrustful of the visitors:
Some community members disliked the manner or work of the foreign volunteers and complained to the staff about it (P3).
On the other hand, other communities and community members had expectations that were too high and, consequently, were let down by the scale of what volunteers were able to achieve in short timeframes:
Trust is difficult in remote communities, and there are high expectations that volunteers will fix people straight away (P10).
The variation in opinion could make it difficult for volunteers to engage with the community effectively and meaningfully. Managing these expectations is crucial for hosts coordinating volunteer integration. Where these were managed and the community communicated with effectively, the visitors were more trusted:
The community trusted that our short-term workers are valuable because our staff have told them they are coming and advised the purpose of their visit (P5).
Broadly speaking, the recipients of STEGH volunteers reported that language and historicocultural barriers could hinder relationship-building with both the staff and the community:
Cultural challenges (adjusting to the society, community, way of life) can impede effectiveness (P4).
During short stays, there was little opportunity for volunteers to build trust in the community; however, where hosts were able to communicate effectively with the community and where programs were coordinated collaboratively to maximize the potential of the volunteers within their limitations, volunteers had the potential to provide immediate assistance and foster long-term, sustainable development by contributing to ongoing goals and the shared vision of the partner organizations.
c. Professional benefits of hosting
Respondents highlighted that there were both personal and professional benefits for their staff in hosting volunteers. Professionally, volunteers offered notable training and skill development, through the introduction of new ideas or practices, some of which were customized to the setting and needs of staff and could be continued after the visitors departed:
Staff can learn the culture, the skill, the talent, their knowledge. They are pretty happy. And we can provide better examples to community as staff have gained skills from volunteers. Also, after the volunteer left, the staff continue to teach these things to practice these things (P7).
One participant, however, noted that the very best part of hosting was, in fact, “learning together” and “teaching one another” (P3). Participants perceived benefits to be mutual; that they too were able to offer knowledge and insights to the volunteers.
We learn new techniques from them. [They have] a very positive effect on our staff who are poorly educated and minimally trained – the short-term workers help build up their knowledge. The exchange is two-way [The best parts of hosting are] learning together [and] teaching one another (P3).
Despite these benefits, hosting also entailed several professional and logistical challenges. Visitors could create significant diversions from routine work, which for some staff and programs was rather burdensome, and program hosts needed to invest time into managing cultural expectations and misunderstandings:
Volunteers can sometimes be difficult to look after when we are also trying to run programs for the community (P9).
They need to spend a long time becoming familiar with the context and procedures, and that is very time consuming. It takes me away from what I need to be doing, which is sometimes difficult (P3).
In equal measure, the building of new relationships was as highly valued for the opportunity to gain and share professional knowledge as it was for creating ongoing friends; however, for authentically mutual benefit, it was necessary for trip organizers and volunteers to be considerate of what burdens they may be placing on staff and host organizations and work to limit additional workload.
Factors impacting the effectiveness of the volunteers
a. Volunteer characteristics and dynamics
For the respondents, there was a strong emphasis on the positivity and enthusiasm that a volunteer demonstrated and interpersonal dynamics stemming from volunteers’ demeanor, character, or practices were positively associated with their effectiveness. Respondents described four areas (characteristics, preparation, coordination, and time for relationship-building) that contributed to the effectiveness of short-term volunteer programs and which could have been managed by individual visitors and the organizations who sent them. One participant summarized what it looks like when an individual volunteer is effective:
Short-termers are very clear on what they are doing; translation is available; [they show] cultural sensitivity, including their clothing; we have prepared the way; [they demonstrate] willingness to embrace the circumstances and the people as they find them. [Their successful integration is a reflection of] the extent of experience and challenges they have faced in life/work (P5).
Cultural sensitivity, life experience, openmindedness, and flexibility were identified as crucial traits that contribute to effective cross-cultural engagement in these settings. Respondents perceived that volunteers possessing these qualities were more likely to navigate the cultural differences and adapt to the new environment more successfully. Those that were unable to be flexible, to be resilient in rural low resource settings, or to be open-minded could make it difficult for hosts and their communities:
If we aren’t able to proceed with plans, some of our medical volunteers have been insistent on what they need to do and not flexible to change with our changes. Some didn’t want to get involved very much. We couldn’t build friendships with them, they stayed quiet and separate from us (P3).
[They’re] So friendly… we share the motivation for serving the community. Some aren’t comfortable travelling in mountainous terrain and to unclean environments, but most adjust well (P5).
In reflecting on these examples, the participants stressed the importance of carefully matching volunteers to the experience and preparing them well for any challenges they may encounter.
b. Group sizes and trip duration
Participants noted that the number of volunteers could alter the scope and impact of programs but did not noticeably affect collaboration with or influence on staff. The benefit of smaller groups was the ability for hosts to work closely alongside each volunteer, whereas bigger groups could complete bigger tasks (P3). Regardless of the size, the focus was on utilizing volunteers effectively.
For teams, our focus is on supporting their logistics (because they engage with multiple agencies, e.g. educational, medical) and maximizing the value for the community and local teams. We feel that we ought to wisely and judiciously spend the support provided (P4).
The implications of group size particularly related to the organization’s efforts of hosting; individuals were able to have a customized workload and could fit in more with the organization’s preexisting arrangements, whereas groups required significant logistical arrangements. Participants noted that it was the length of stay rather than the group size that created more variable effects, and they highlighted the positive impacts of longer engagements:
A longer visit is more worthwhile to maximize the input they can have. But any visit length provides something more than we have (P2).
Volunteers are also human beings – you can’t expect them to learn enough in under 1 week… (P1).
In addition to more sustained inputs, longer engagement fostered more effective and relevant knowledge transfer, relationship-building, and community impact; however, longer stays could also bring their own challenges:
Community impact work needs time. But the longer they stay, the greater our dependency on them because they become part of us (P3).
Time commitment did not have to be limited to the length of stay, however. Volunteers that were committed to building relationships were able to have a positive impact beyond their stay by keeping in touch via social media, and their relationships were able to strengthen ties between partner organizations.
c. Trip coordination
Having a designated point person on the volunteer side who is familiar with the host and context side facilitates coordination, communication, and positive impact:
We need to know what they are coming for, for how long, etc. so we can prepare things for them (P3).
You need the correct link person who knows the program on this side and who can identify individuals to make up the team to correspond to the needs – only then will the team be truly effective (P4).
Language was identified as a barrier, and some participants noted that “things can get lost in translation or interpreted in unintended ways” (P10). Consequently, ensuring the availability of language support (organizing for accompaniment by translators/interpreters) was also crucial.
Most significantly, however, clarity about their roles and responsibilities was essential for volunteer preparedness, and this required strong collaborative communication between partner organizations and volunteers. Volunteers who understood their tasks and objectives were better equipped to contribute effectively to the program:
We need to define the goals for the short-termer, and then we can have a most effective visit (P4).
As this section demonstrates, it is essential that volunteers are equipped with cultural knowledge and understanding, are prepared to work within their limitations, and are committed to building relationships with hosts. When volunteers approach STEGH in this way, these exchanges can be effective and mutually beneficial.
Discussion
Reported here are the contributions of host organization participants. While these findings are limited to their perceptions and experiences of STEGHs, they are particularly worthwhile as it is their voices that are often left out of the research despite representing those who are most impacted by the experiences.24
Most notable in these findings is the framing of such experiences as a learning exchange, where both hosts and volunteers have knowledge, skills, and attributes to share with, and to teach, each other. As Ventres and Wilson state, where mutual exchanges in this context are encouraged, they “foster interpersonal dialogue, intentional practice, and social action aimed at advancing human well-being.”25 This mindset of reciprocal exchange can help to disrupt post colonialist attitudes that underpin many such exchanges and foster collaborative learning environments for both parties which contribute to long-term, professional growth and personal fulfillment for staff members.26
Within this desire for a mutual exchange, it is understandable that the participants focus on the interpersonal skills of the volunteers as these attributes helped form the basis of ongoing relationships; the formation of both short-lived and sustained friendships were greatly encouraging and prominent markers of a successful exchange in the findings. Studies on STEGHs emphasize the importance of relationship-building and its positive impact on both volunteers and host communities and for creating a supportive atmosphere within the organization.27,28 Participants noted that positive relationships between host and volunteer flowed out into the community. As one respondent mentioned above, the commitment of volunteers “out of generous motivation” boosts staff morale and enhances their generous spirit within the community. Likewise, several hosts spoke of the impact that volunteers had on them personally, which effected their overall motivation and their demeanor among staff and community. As others have found, the preparation of volunteers should be considered a crucial stage of the program planning and needs to address the contextual limitations of the visitor’s skills, knowledge, and qualifications.6,19,29 Training in cultural expectations is critical to reduce harm; however, the presence of cultural humility in a volunteer is helpful for establishing relationships and ongoing partnerships in ways that support justice and value the autonomy of the host partners.
This preparation, along with a commitment to a bi-directional sharing of knowledge, acknowledges the expertise and knowledge of the hosts. Hawkins argues that the disproportionate needs experienced by those in low-income countries has, in many contexts, necessitated short-term mission models of healthcare.30 However, Dainton and Jessani note that there has been a shift since the COVID-19 pandemic, where providers in LMICs have had no choice but to manage without volunteers, and, in doing so, have had the opportunity to demonstrate their capability without outside influence.2,31 Short-term experiences in global health in a post-COVID-19 world need to shift away from the idea that the volunteers are there to do something that the hosts are unable to do and towards mutually beneficial, jointly developed partnerships with, at its foundation, shared resources and rewards.32 This move requires cross-cultural humility and effectiveness, bi-directional participatory relationships, local capacity building, and sustainability of programs.6 Ventres and Wilson make the case for a transformation in thinking from short-term, global health experiences to engagement.25 Engagement requires developing contextual inquisitiveness, structural awareness and insightful understanding, the nurturing of global humility, and the critical engagement with the “pursuit of creating equitable and just societies.” Engagement, the authors argue, creates genuine possibilities for partnerships and disruption of the root causes of healthcare inequalities.
Aligning with the idea of moving toward engagement, the experiences reported in this study, as others, also highlight the need for STEGHs to collaborate with local health organizations, communities, and providers in order to build long-term and sustainable partnerships with the host and ensure that the mission aligns with hosts’ needs.18,33 It was clear that volunteers could bring new ideas, techniques, and practices, but it was particularly effective when tailored to the specific needs of the staff and the program which could only result from effective shared planning and goals, communication, and preparation. Well-defined objectives and tasks help volunteers contribute more effectively to the program and minimize misunderstandings. This can come from establishing robust coordination and communication frameworks, such as designating a point person on both the volunteer and host sides, and ensuring the availability of translators during the experience. Additionally, working towards shared goals and planning collaboratively can help to reduce the burdens of additional workload for host organizations. It is worth noting that longer volunteer engagements appeared to be more beneficial, providing the opportunity for more effective knowledge transfer, relationship-building, and community impact, making the added effort more worthwhile.34
While it is essential to avoid burdening hosts with added workload, hosts do also have several responsibilities, and their investment in the program may have long-term benefits, such as attracting attention to their organization and helping with future recruitment efforts. One of the areas where they have a responsibility is in driving positive community relations. Respondents in our study noted that community perceptions, including suspicion and biases, can pose significant challenges. On one hand, positive perceptions fostered trust and acceptance, while on the other, negative perceptions can hinder effectiveness of the volunteer exercise. Consistent with other studies, communities could have unrealistic expectations of what is achievable, and it is incumbent upon the hosts to manage community expectations and provide clear communication about volunteer roles and objectives.35,36 As such, building positive community perceptions and overcoming biases are essential to maximize the benefits of volunteer engagement. Hosts need to leverage the clarity of volunteer roles and responsibilities to manage community expectations and mitigate suspicion or biases. Positive community perceptions foster trust and acceptance and, thus, enhance the overall effectiveness of volunteer efforts.
Despite being a localized study, the conclusions from this report suggest the need to view short-term, global health engagements as an exchange that can be mutually beneficial when approached with a collective vision and a commitment to the development of interpersonal relationships and increased, critical awareness from both communities. There are limitations with these results. First, given the potential for social desirability bias, it is possible that respondents underreported the challenges and limitations of hosting volunteers. There is a possibility that the perceived benefits were influenced by a desire to present the program in a positive light, particularly if respondents felt that their feedback might affect future volunteer involvement. As with other similar endeavors, the research is conducted by outsiders, and research conducted by the hosts themselves may see different perspectives emerging.11 Secondly, from the 10 NGOs involved, we only interviewed the 10 program leaders. As such, this may not be representative of all staff experiences, and there are discrepancies in how different respondents perceive the influence of volunteers. Finally, the geographically specific nature of the study limits the generalizability of the findings to other settings or organizations.
Conclusion
Our study contributes to the body of literature giving voice to the often-overlooked perspectives of hosts within volunteer programs. Most significantly, it identifies the importance of continuing friendships and mutual support, respect, and appreciation. Commitment to these values ameliorates many of the weaknesses associated with STEGHs.
By elevating hosts’ narratives, we have gained insight into the challenges they face in the context of enabled operations, including the impact of volunteer activities on their communities and the strategies they prefer to facilitate meaningful engagements. As such, we aim to use these findings to inform the design, implementation, and evaluation of future programs.
These results contextualized within the wider research identify the need for partnerships and engagements between hosts and volunteers and their supporting organizations. Emerging from the perspectives presented here, additional research is needed to better understand a) what effective planning and the creation of shared visions and goals look like at an organizational level and b) effective preparation and cultural humility training methods for volunteers.
Author Contribution Statement
The authors confirm contribution to the paper as follows: study conception and design: NG, NB, MR, SM; data collection: MR; data and thematic analysis: NB; draft manuscript preparation: NB, JW; manuscript: JW; manuscript review: NG, NB, JW. All authors approved the final version of the manuscript.
Ethics and Consent Statement
All participants were fully informed about the purposes of this research and how their responses would be used and stored. Each participant provided their consent to participate. Ethics approval for this research was obtained by the Community Health Global Network - Uttarakhand Cluster (CHGN-UKC) Ethics Committee.
Data Accessibility Statement
Due to the qualitative and sensitive nature of the data, the extent to which it can be made publicly available is limited. The corresponding author may be contacted for further information.
Competing Interests
None declared.