Article Text

Original research
Violence against physicians working in public tertiary care hospital of Bangladesh: a facility-based cross-sectional study
  1. Mohammad Jahid Hasan1,2,
  2. Tanzeema Younus Sarkar3,
  3. Mostak Ahmed4,
  4. Aporna Banik4,
  5. Salwa Islam2,
  6. Mir Susmita Zaman2,
  7. Faiza Mahmud4,
  8. Ashish Paul5,
  9. Md Nazmus Sakib6,
  10. Anamica Dev4,
  11. Md Jakaria Hossain7,
  12. Jannatul Fardous2,
  13. Nahida Hannan Nishat2,
  14. Monjur Rahman2
  1. 1Research and public Health, Tropical Disease and Health Research Center, Dhaka, Bangladesh
  2. 2Pi Research and Development Centre, Dhaka, Bangladesh
  3. 3North South University, Dhaka, Bangladesh
  4. 4Dhaka Medical College and Hospital, Dhaka, Bangladesh
  5. 5Monowara Hospital (Pvt.) Ltd, Dhaka, Bangladesh
  6. 6Upazila Health Complex, Netrokona, Bangladesh
  7. 7Sir Salimullah Medical College and Mitford Hospital, Dhaka, Bangladesh
  1. Correspondence to Dr Mohammad Jahid Hasan; dr.jahid61{at}gmail.com

Abstract

Background Violence against physicians in the workplace is a prevalent global issue, and Bangladesh is no exception. Such violence significantly disrupts healthcare delivery and the attainment of universal health coverage. This study aimed to comprehensively evaluate the prevalence, nature and associated risk factors of workplace violence (WPV) against physicians in Bangladesh.

Methods This descriptive cross-sectional study was conducted at a public tertiary care hospital involving 441 physicians with a minimum tenure of 6 months. Data were gathered through a structured self-reported questionnaire, and statistical analyses were performed by using SPSS V.25.

Results Out of the surveyed physicians, 67.3% (n=297) reported experiencing violence, categorised as 84.5% psychological, 13.5% physical and 2% sexual in nature. Predominant forms of psychological violence included bullying (48.8%) and threats (40.1%). The mean age of exposed physicians was 32.5±4.3 (SD) years. Those working in the emergency unit (45.8%), surgery and allied departments (54.2%), engaging in rotating shift work (70%), morning shifts (59.6%) and postgraduate trainees (68%) were frequently subjected to violence. Factors significantly associated with WPV included placement in surgery and allied departments (p<0.001), working rotating shifts (p<0.001), marital status (p=0.011) and being a male physician (p=0.010). Perpetrators were primarily identified as relatives of patients (66%). Working in rotating shifts (adjusted OR(AOR):2.6, 95% CI:1.2 to 5.4) and surgery and allied departments (AOR:5.7, 95% CI:3.4 to 9.8) emerged as significant risk factors of violence against physicians.

Conclusion A higher proportion of physicians at the early to mid-level stages of their careers, especially those in rotating shifts and surgery-related departments, reported incidence of WPV. Urgent intervention from policy-makers and healthcare entities is imperative to implement preventive measures. Strengthening security measures, establishing antiviolence policies and providing comprehensive training programmes are crucial steps towards ensuring a safer work environment for healthcare professionals.

  • MENTAL HEALTH
  • Physicians
  • Work Satisfaction

Data availability statement

Data are available on reasonable request. The datasets used in this study will be available from the corresponding author on reasonable request.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • The study explored the experiences of workplace violence among early to mid-career physicians, who encounter diverse professional challenges that contribute to under-reporting of incidents within this specific group.

  • The study took place at Bangladesh’s largest public tertiary care referral hospital, which can accommodate over 2600 patients concurrently and provides various postgraduate academic programmes for healthcare professionals.

  • Because the study was conducted in a single tertiary care hospital, results might underestimate workplace violence and lack generalisability to all physicians across Bangladesh.

Introduction

Workplace violence (WPV) against doctors is a long-standing issue that continues to draw global attention. Instances of doctors being physically assaulted or verbally abused by patients and their relatives frequently capture headlines and circulate widely on social media platforms. The pervasive concern about violence within medical workplaces weighs heavily on nearly every doctor, yet only a minority have received adequate training to prevent or address such confrontations. According to the National Institute for Occupational Safety and Health, WPV encompasses any form of violent behaviour, whether physical, verbal or in any other form, directed towards an individual while they are on duty or at their workplace.1

The increasing trend of violence against physicians is becoming a global issue that cuts across geographical borders and affects all levels of care. This sector may account for nearly a quarter of all WPV around the world.2 Physicians have to face criticism, insults, threats and physical harms at their workplace, and the scenario is almost similar across the world, irrespective of cultures and countries.3–5 A recent systematic review of 17 studies highlighted that 47% of the healthcare professional encounter WPV, where psychological violence (44%) was higher than physical violence (17%) and pooled prevalence of WVP among physicians was 68%.6 Data also suggested that physicians working in Asian and North American countries were more prone to violence, and physicians working in psychiatric and emergency departments experienced more violence than those who worked in other departments.7 8

Several factors contribute to the prevalence of violence in healthcare settings. Primary factors include understaffing, the emotional or mental stress experienced by patients or visitors, insufficient security measures and the lack of legal action following violent incidents.9 Notably, there exists a disparity in the causes of violence between public and private healthcare settings. In public hospitals, long wait times, brief patient interviews, inadequate counselling and a lack of trust between caregivers and patients contribute significantly to instances of violence. Conversely, in private hospitals, despite providing quality care, prolonged hospital stays, increased out-of-pocket expenses and unnecessary testing attempts are among the reasons that perpetuate violence against healthcare professionals.10

Healthcare workers, including doctors, nurses and other professionals in lower-middle-income countries such as Bangladesh, frequently encounter various forms of harassment while on duty.11 Recent report on Bangladeshi healthcare workers indicated that nearly half of them (43%) have experienced some type of violence, with non-physical violence being the most common (84%).12 The authors mentioned that factors such as marital status, employment in emergency departments and involvement in shift work have shown significant associations with WPV.12 Moreover, being a male doctor, serving in entry-level positions such as intern doctors and emergency duty doctors, and working in public hospitals were found to have higher associations with exposure to WPV.11 Another nationwide study in Bangladesh revealed that 12.3% of physicians employed in tertiary hospitals encountered physical violence and over 70% of victims identified patient’s relatives as the primary instigators.13 While previous studies have addressed the prevalence, associated factors, consequences and instigators of WPV among healthcare professionals, our study focused specifically on a vulnerable subgroup: physicians in training or in the early to mid-level stages of their careers. This particular subgroup faces unique challenges and vulnerabilities in their professional journey, leading to a distinct pattern of WPV experiences. Challenges such as navigating complex medical procedures without extensive experience, heavy workloads causing stress and burn-out, hierarchical structures affecting communication, the transition to autonomous decision-making leading to anxiety, developing effective communication skills, maintaining a balance between personal and professional life, and financial strain contribute to under-reporting of violent incidents among this specific group.14

Understanding the dynamics of violence during the training and early career phases can inform targeted interventions to enhance workplace safety and support for physicians at critical stages of their development. By focusing on this specific group, we aim to provide insights that can contribute to more effective prevention and intervention strategies tailored to their needs. Therefore, this study was designed to report the proportion of WPV against physicians in a tertiary care public hospital along with factors associated with it.

Methods

Study design and sample

This descriptive cross-sectional study was conducted at Dhaka Medical College and Hospital, the largest public tertiary care hospital in Bangladesh. This academic medical centre serves a considerable volume, accommodating more than 2600 patients simultaneously and offers multiple postgraduate academic courses involving hundreds of esteemed faculty members and thousands of trainees.15 The study enrolled physicians from 31 hospital departments who had a minimum work tenure of 6 months, using a convenient sampling technique.

Selection criteria

The study encompassed intern doctors, honorary medical officers (postgraduate trainees), MD/MS resident students and medical/emergency medical officers from both indoor and outpatient departments. However, physicians with less than 6 months of service, consultants, registered pharmacists, nurses and other healthcare professionals such as midwives, laboratory technicians, healthcare assistants and administrative staff were excluded from the study. Data collection took place between June 2022 and December 2022.

Sample size estimation

The calculation of sample size was based on Cochran formula (1977) (n=z2pq/d2), taking into account a 95% CI with z=1.96, a 5% margin of error (d=0.05) and a WPV prevalence of 53% from a prior study (p=0.53).16 This estimation yielded a sample size of 384. Considering a 15% anticipated non-response rate, the final calculated sample size was 441 physicians. Therefore, a total of 441 physicians were included in this study.

Selection of departments and participant distribution

Three main departments (medicine and allied, surgery and allied and obstetrics and gynaecology) along with their respective subdepartments (16 subdepartments in medicine, 14 in surgery and allied) were purposefully chosen for this study. A sample collection plan was developed based on the number of physicians in each department, the number of intern doctors placed, the presence of honorary medical officers and the inclusion of residency students. The final sample comprised 441 participants, including 222 physicians from medicine and allied departments, 184 from surgery and allied departments and 35 from the obstetrics and gynaecology department. Further details are available in online supplemental table 1.

Data collection and instrument

The research instrument used in this study was a structured questionnaire that underwent pretesting and modifications based on the ‘Workplace Violence in the Health Sector: Country Case Studies Research Instruments: Survey Questionnaire, 2003’.17 This instrument was originally developed collaboratively by the International Labour Organization (ILO), World Health Organization (WHO), International Council of Nurses (ICN) and Public Services International (PSI). To suit the context of hospitals in Bangladesh, certain questions were omitted, resulting in an adapted version of the questionnaire.

Comprising three sections, the study questionnaire encompassed: Demographic profile and professional background: gathering information on age, gender, marital status, current position, work experience, shift work involvement and assigned department. Exposure to violence, its characteristics and risk factors: exploring the nature and frequency of violence, event location and department, time and day of occurrence, as well as the current position and shift during exposure to violence. Perpetrators and perceived reasons for violence: investigating the identities of perpetrators and understanding perceived reasons behind violent incidents.

Before the final analysis, the study questionnaire underwent a pilot test involving 10 physicians, whose responses were not included in the final dataset. The majority (8 out of 10) reported no difficulties regarding question clarity, comprehension and appropriateness. Data collection was carried out by the authors of the study, all of whom were doctors, medical students or researchers, during their working hours within the hospital setting.

Measures of study

Outcome measure

In this study, violence was defined by the WHO as ‘The intentional use of physical force or power, threatened or actual, against another person or against a group, in work-related circumstances, that either result in or has a high degree of likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation’.18 The primary focus was on assessing exposure to violence, encompassing physical, psychological and sexual forms. Participants were asked a singular question: ‘In the last 6 months, have you experienced any form of violence, including physical, psychological or sexual?’ Responses were categorised into two options: ‘yes’ or ‘no’.

Explanatory measures

Violence-related measures

Three main types of violence were considered for this study: physical, psychological and sexual violence. Physical violence was defined as ‘The use of physical force against another person or group that results in physical, sexual or psychological harm. It includes beating, kicking, slapping, stabbing, shooting, pushing, biting and pinching, use of weapons and objects to harm a person among others’.18 Psychological violence (emotional abuse) was defined as ‘the intentional use of power, including the threat of physical force, against another person or group can result in harm to physical, mental, spiritual, moral or social development. Includes verbal abuse, bullying/mobbing, insults and threats’.18 While sexual violence was defined as ‘any sexual act or attempt to obtain a sexual act, including unwanted sexual comments or advances, or acts to traffic a person for sexual exploitation directed against a person’s sexuality using coercion by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work’ (details in online supplemental table 2online supplemental table 2).19 20 The frequency of reported violence was categorised into three groups: single, dual and multiple occurrences. Single violence referred to exposure to any one specific type of violence, such as physical violence or psychological violence or sexual violence. Dual violence was characterised by exposure to any combination of two types of violence, such as instances involving psychological violence and sexual harassment, physical violence and sexual harassment or any other pairing of different types of violence. Multiple violence was identified by exposure to three forms of violence in any combination. Additionally, various other violence-related factors were assessed, including the location of the event (such as general ward, outpatient department, inpatient department, emergency unit, operation theatre, resuscitation room, postoperative ward, consultation room), department where the event occurred (medicine and allied, surgery and allied, obstetrics and gynaecology), rotating shifts, time of occurrence (morning, evening, night), job position at the time of violence exposure, place of violence (inside facility, outside facility, during teleconsultations) and the day of occurrence (weekdays or weekends).”

Sociodemographic measures and job characteristics

According to the majority of studies, the risk of violence is often linked to gender, age, marital status, working department, rotating shifts and employment category. Therefore, these factors were included in the explanatory variables. Gender was coded as ‘male’ or ‘female’; age was grouped as ‘<30 years’, ’30–39 years’ ‘40–49 years’ and the mean (SD) age; marital status was coded as ‘married’ or ‘unmarried/separated/divorced’; current position was coded as ‘resident student/postgraduate trainee’, ‘indoor medical officer’, ‘outdoor medical officer’ and ‘internee’; department of event was coded as ‘medicine and allied’, ‘surgery and allied’ and ‘obstetrics and gynaecology ’departments and working in rotating shift was coded as ‘yes’ or ‘no’.

Perpetrators and perceived reasons for violence

The perpetrators of violence were identified by asking participants, ‘Who attacked you?’ Responses from victims included ‘patients’, ‘patients’ relatives’, ‘hospital staff/coworkers’ and ‘general public in the hospital’.

Furthermore, participants were asked to provide their perceived reasons for encountering WPV using the question, ‘What do you think are the possible reasons for violence?’ Victims shared their insights regarding the perceived causes behind experiencing violence in the workplace.

Data analysis

Descriptive statistics were completed relating to respondent’s characteristics which were expressed as frequencies and percentages for categorical variables and means and SDs for continuous variables. Pearson’s χ2 test and independent Student’s t-test analysis were performed to determine the differences in exposure to violence according to respondent’s characteristics. We employed a binary logistic regression model to determine the risk factors responsible for violence towards physicians. An initial unadjusted regression analysis was conducted using only separated explanatory variables gender, marital status, working in rotating shift, department of event. In the final adjusted model, potential explanatory variables were included only if any category of the covariate showed statistical significance (p≤0.05) in the unadjusted model. Data were analysed using the Statistical Package for Social Sciences (SPSS) V.25. A p<0.05 was considered statistically significant in the analysis.

Patient and public involvement

Participants did not partake on the study design, developing outcome measures, interpretation of the result or contribute to the drafting or revision of the manuscript. Nevertheless, they were encouraged to assess the study questionnaire and offer constructive feedback.

Results

Demographic and job-related characteristics

Table 1 presents the demographic and job-related characteristics of the study population. Among the physicians surveyed, a majority were male (58%), married (70.5%) and under the age of 40 (94.6%). Nearly half of them had clinical experience ranging from 1 to 5 years (46.5%), with a substantial proportion serving as resident students or postgraduate trainees within the hospital (68.5%). Their primary working departments were predominantly in medicine (50.3%) and surgery (41.7%) wards, and a large proportion of physicians were engaged in shift work (90.7%).

Table 1

Characteristics of the respondents (n=441)

Incidence of WPV

In this study, a significant portion, accounting for 67.3% (n=297) of the respondents, reported exposure to WPV. The majority experienced non-physical violence, comprising 48.8% bullying, 40.1% threats, 9.1% racial assaults and insults, 8.1% mobbing and 2% sexual harassment. Moreover, 13.5% reported instances of physical violence. A striking 84.2% of the physicians encountered at least one form of workplace-related violence, whether physical, non-physical or sexual.

Physicians in the surgery and allied department (54.2%) and the emergency unit (45.8%) encountered a higher proportion of violence. Similarly, those working in rotating shifts (70%) and during morning shifts (59.6%) were more susceptible to experiencing violence. Notably, among all designations, resident students/postgraduate trainees were the most exposed to violence, accounting for 68% of reported incidents.

Regarding the timing of violence, 144 physicians were unable to recall whether the incidents occurred on weekdays (Saturday to Thursday) or during weekends/national holidays, while of the 153 who remembered, 87% reported events occurring on weekdays and 13% on weekends/national holidays. The majority of WPV, approximately 91.2%, occurred within the health facility during duty hours (n=273). However, 6.4% of violence incidents faced by physicians occurred outside the health facility as a result of events initiated in the hospital. Notably, frequent places of violence within the hospital included the general ward (35.3%) and the resuscitation room (23.9%) (table 2).

Table 2

Prevalence and characteristics of workplace violence

Perpetrators and perceived reasons for work place violence

Regarding the perpetrators, family members or relatives accounted for the majority, being the chief perpetrators of violence in 66% of the reported incidents. In 15.2% of cases, physicians experienced violence from their coworkers, with the majority of these incidents involving other physicians (62.2%). Notably, 10% of the reported violence was initiated by the patients themselves, while 12.2% was attributed to the general public who were present in the hospital during the incidents of violence (figure 1).

Figure 1

Perpetrators of workplace violence (WPV) against physicians (n=297).

Physicians identified several perceived causes of violence, including dissatisfaction with the treatment or care provided by the physician (30.2%), unrealistic expectations from patients and their families regarding treatment success (26.9%), patient death (24.2%), prolonged waiting times (22.8%) and inadequate security measures (21.1%). Furthermore, reasons such as a shortage of hospital staff (11.1%), insufficient medical supplies (8.4%) and a lack of surgical skills (1.4%) were also cited as contributing factors. Additionally, other issues including administrative shortcomings, physicians’ duty schedules, mental health conditions and unrealistic expectations from colleagues were reported by 4.7% of the physicians (figure 2).

Figure 2

Perceived reasons of workplace violence against physicians (n=297).

Associated-factors of WPV

Table 3 illustrates the correlation between respondent characteristics and their exposure to violence. The results revealed a significantly higher percentage of exposure to violence among males (72.3%) compared with females (p=0.010). Further assessment regarding the types of violence indicated that males were notably more susceptible to threats (71.4%, p=0.008), whereas females were significantly more prone to sexual assault (83.3%, p=0.020).

Table 3

Association between exposure to violence and respondent’s characteristics (n=441)

Additionally, marital status (p=0.010) and working in rotating shifts (p<0.001) were significantly associated with exposure to violence. Moreover, the department in which the event occurred was significantly linked to exposure to violence; physicians in the surgery and allied department (87.5%) exhibited higher vulnerability to violence compared with those in other departments. However, age and the current designation or position of the physician did not show a significant association with exposure to violence.

The results of both unadjusted and adjusted ORs for respondent exposure to violence were examined. The multivariate adjusted ORs revealed that physicians working in surgery and allied departments showed a notably higher likelihood of experiencing violence (OR 5.75; 95% CI 3.4 to 9.8; p<0.001). Similarly, working in rotating shifts emerged as another significant predictor for violence against physicians (OR 2.6; 95% CI 1.2 to 5.4; p=0.010) (table 4).

Table 4

Regression analysis for predictors of violence against physicians

Discussion

This study explored the prevalence and context of WPV as reported by physicians in a hospital setting. The key finding revealed that 67.3% of interviewed physicians had experienced WPV in the past 12 months. This percentage aligns with previous studies conducted among healthcare professionals in Bangladesh, although it varies, with a lower prevalence of 43% reported by Shahjalal et al,12 higher prevalence of 77.29% reported by Rony et al,21 and compared with rates reported in studies conducted in Pakistan (53.4%),22 India (63%)23 and Nepal (45.5%).24

The high prevalence of violence among respondents may stem from several factors including social instability, lack of administrative support, apprehension about unfair treatment, lengthy legal procedures and the absence of government-level policies addressing violence against healthcare workers. Additionally, shortages of medicines and supplies, dissatisfaction with treatment, care delays, inadequate security and unrealistic patient expectations contribute to this situation.25 26 Previous studies have revealed profound impacts of WPV on healthcare professionals, including a strong desire to leave the profession, job dissatisfaction, decreased work performance, work–life imbalance, feelings of anger, depression, fear, stress, loss of self-confidence, suicidal tendencies and a diminished quality of life.12 13 21 These findings underscore the complex and severe repercussions of WPV, affecting both the professional and personal spheres of individuals in the healthcare sector. It emphasises the critical need to address these issues urgently to foster a safer and healthier work environment.

In our study, the exposure of males to threats and physical violence was notably higher compared with females, a trend often attributed to prevalent cultural norms that emphasise respect for females in society.27 The study by Hasan et al reported that the majority of entry-level physicians, such as trainees, encountered WPV,28 which was similar to the findings in this study since most of the postgraduate trainees reported experience violence events. One plausible explanation for this correlation could be the hierarchical structure within healthcare, where older physicians typically hold higher ranks, resulting in reduced direct patient interactions and consequently lower violence incidents. Additionally, interns and entry-level physicians, primarily handling preliminary and emergency services, are more prone to facing violence, as patients tend to consult senior physicians once stabilised.

In our study, 84.2% of the physicians were reported to encounter at least one violent event, and verbal/emotional violence such as bullying and threats were the major forms of violence experienced by physicians, which was higher than the report in Pakistan (verbal abuse=58.8% and bullying=26.9%)29 and similar to the 84.6% of non-physical violence reported by Shahjalal et al.12 A study has highlighted a positive association between psychological violence, particularly verbal aggression and adverse outcomes such as burnout, emotional exhaustion, cynicism and diminished professional efficacy among healthcare workers.30 The impact of violent incidents significantly affects the psychological and moral conduct of healthcare professionals. Moreover, recurrent episodes of violence or a major traumatic event can profoundly undermine the trust between patients and physicians, ultimately resulting in compromised health outcomes.

The surgery and allied departments, notably the emergency department, emerged as the primary areas where physicians were most susceptible to violence. The nature of patient distress and heightened emotions among healthcare workers in these departments often leads to increased agitation, consequently escalating situations to violence.25 28 Our study indicated that physicians working in surgery and allied departments faced a threefold higher risk of experiencing WPV. This finding partially aligns with another study, wherein 51% of general surgery attendees reported encountering WPV, and attendees in general surgery were 1.22 times more likely to experience WPV.12 In Bangladesh, most of the violence events are reported in the emergency department,13 and another study reported that over 90% of emergency department healthcare providers experienced WPV, which was mostly verbal abuse, and attackers were usually identified as those who accompanied the patient to the emergency department, commonly referred to as bystanders or attendants, rather than the patients themselves.31 Similarly, the main perpetrators of violence reported in this study were usually relatives of the patients/clients rather than the patients/clients themselves. However, a concerning aspect was the proportion of violence instigated by coworkers and supervisors, accounting for 18.8%. This might be attributed to insufficient staffing levels, work-related stress and poor job satisfaction, all of which could contribute to the emergence of aggressive behaviours directed at coworkers and colleagues.

The slightly higher incidence of reported violence in our study compared with other reports in Bangladesh might be attributed to the specific study site, DMCH, functioning as a tertiary referral care centre. Critical patients often bypass secondary healthcare facilities and are directly referred to tertiary centres such as DMCH, particularly those from urban and semiurban areas. This practice imposes a significant workload on healthcare workers, leading to shortened consultation times and subsequently, lower patient satisfaction, which may contribute to instances of violence in tertiary healthcare centres.

Because the study was conducted in a single tertiary care hospital, our study findings may be an underestimation of work place violence and may not be broadly applicable to the entirety of the healthcare sector of Bangladesh. Moreover, the study employed a retrospective data collection method, which could introduce recall bias as individuals might not accurately remember and report past events or experiences. Furthermore, the significant values observed could be partially attributed to the large sample size since it contributes to increased likelihood of finding statistically significant results even for differences that are insignificant, due to increased statistical power linked to large sample size.

Conclusion

This study employed a comprehensive approach to identify the incidence, nature, consequences and potential risk factors for work place violence against physicians in a public hospital. WPV can lead to serious negative consequences in the physician’s quality of life and emotional well-being and may adversely impact the delivery of healthcare services and quality of care. Therefore, there is a dire need to introduce legal policies and strategies for prevention and management of WPV, encouragement of violence incident reporting and provide adequate physical and psychological support to victims of WPV. The result of the study can serve the basis of further studies in the country. Further research on WPV in healthcare setting is needed to better understand how to prevent WPV.

Data availability statement

Data are available on reasonable request. The datasets used in this study will be available from the corresponding author on reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

Ethical considerations were paramount throughout the study. The study protocol underwent review by the ethics review committee (ERC) of the Dhaka Medical College review board (ERC-DMC/ECC/2022/207). Participants provided informed written consent after receiving explanations about the study’s purpose, objectives, benefits and assurances regarding the confidentiality of their information. The study adhered to ethical principles outlined in the Declaration of Helsinki.

Acknowledgments

The authors would like to express their sincere gratitude to Pi Research Development Center (www.pirdc.org) for their support and assistance for this study particularly in manuscript revision and formatting. The author group also thanks to Dr Mohiuddin Sharif, Dr Zannatul Adneed Mou, Dr Mostak Ahmed for their constant support in this study.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Contributors All authors read and approved the final version of the manuscript. Conceptualisation: MJH, TYS, MA, AB, MSZ and SI. Formal analysis: MJH, SI, MR, MJH, TYS, MA, AB and MSZ. Investigation: FM, AP, MNS, AD, MJH, JF, TYS, MA, NHN, AB, MSZ. Methodology: FM, AP, MNS, AD, MJH, JF, NHN and SI. Resources: FM, AP, MNS, AD, MJH, JF, MSZ, NHN and MR. Supervision: MJH, TYS, MA, AB and MSZ. Writing: SI, FM, AP, MNS, AD, MJH, JF, NHN and MJH.The guarantor:MJH

  • Funding The study was partially supported by Bangladesh Medical Research Council (BMRC/Research Grant Revenue/2022-2023/54(1-23)), Bangladesh.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.