Water, sanitation, and hygiene status of community schools in Nepal Open Access

Safe drinking water, sanitation, and hygiene (WASH) are essential for human health and welfare (World Health Organization 2018). Human rights such as the right to water, sanitary conditions, and children's education are inalienable. People everywhere need to be concerned about WASH. It has a direct impact on people's health, education, and lifestyle. Safe WASH not only supports livelihoods, dignity, and school attendance, but it is also essential for good health. It also creates hygienic surroundings for the community. Drinking unsafe water can lead to health problems such as diarrhea, and untreated waste contaminates surface and groundwaters used for residential, agricultural, and drinking water (World Health Organization 2018). Therefore, identifying and improving its position has been the focus of the world's large international organizations, including the United Nations (UN), United Nations Children's Fund (UNICEF), WHO, and others. In July 2010, the UN General Assembly declared access to clean water and adequate sanitation as human rights.

WHO has developed the Water, Sanitation and Hygiene Strategy (2018–2025) in response to member states for Sustainable Development Goals (SDGs). The World Health Organization (WHO) envisions a significant enhancement of health through the secure management of WASH services across various environments. The SDGs established by the United Nations, specifically goals 4a, 6.1, and 6.2, collectively strive to ensure that everyone has access to safe and affordable drinking water, adequate sanitation, and hygiene, thereby fostering effective learning environments for all (Walsh et al. 2022).

Only 77% of schools have access to basic drinking water facilities, 8% have limited services, and 15% have no services by the year 2023 (UNICEF & WHO 2024). The data from the WHO/UNICEF Joint Monitoring Program (JMP) for Water Supply, Sanitation, and Hygiene, which covers 138 countries and represents 65% of the world's school-age children, indicates that not all school-aged children have access to basic water facilities. Specifically, only 78% of schools provide basic sanitation facilities, while 11% have limited sanitation options and another 11% lack any facilities at all. Furthermore, by 2023, the report reveals that 67% of schools had basic hygiene facilities, with 12% offering limited facilities and 21% having no hygiene facilities available. (UNICEF & WHO 2024). This highlights the critical importance of enhancing WASH conditions globally.

According to JMP reports between 2015 and 2023, the percentage of schools having basic clean drinking water facilities increased from 66 to 77%, basic sanitation services increased from 68% to 78% and basic hygiene has risen from 58 to 67% as a result of numerous activities (UNICEF & WHO 2024). However, there is a big difference in WASH facilities between developed and low-income countries. A review of WASH-related studies conducted in low-income countries has shown that there is a direct relationship between WASH facilities and diseases such as diarrhea in many schools in these countries, affecting student regularity (primarily menstruation-age girls) and student achievement in a multifaceted manner (McMichael 2019). Nepal is also a low-income South Asian country. All citizens of Nepal are guaranteed the fundamental right to live in a clean environment and have access to safe drinking water by the Constitution of Nepal, 2015 (Nepal Law Commission 2020). To ensure the constitution's rights, the government has implemented the National Water Supply, Sanitation, and Hygiene Policy, 2023. It divides the work for water sanitation and hygiene development between federal and municipal levels. This policy targets achieving the sectoral goals of sustainable development, safe drinking water, and providing sanitation services for all by 2100. Some working policies are mentioned in this policy regarding school water and sanitation; for example, ensuring water supply and toilets in schools and other community places, and priority will be given to constructing ponds in open land, places, and courtyards so that schools are not adversely affected (Ministry of Water Supply 2023).

In 1990, just 37% of people in Nepal had access to a basic drinking water system; by 2019, that number had risen to 94% (Ministry of Water Supply 2023). According to the Ministry of Supply, the population that has benefited from sewage treatment services is only about 2% by the year 2020. The basic drinking water facility rate had reached 96.75 by the beginning of 2024 (Ministry of Finance 2024). In Nepal, the high-moderate drinking water facility rate had reached 27.76 by the beginning of 2024 (Ministry of Finance 2023). This fact shows that attention should be paid to the expansion of drinking water facilities as well as quality improvement in Nepal in the future. Similarly, in 2019, Nepal was successful in declaring itself the first open and free country in South Asia by building toilets in all households (Ministry of Water Supply 2023). Its effective use and sustainability are critical. However, the situation of schools remains different.

It was reported that 55% of the schools had basic water service (improved and available), 24% of the schools had limited water service (no facility or unimproved), and 21% of the schools had no water service (no facility or unimproved) until 2023 (UNICEF & WHO 2024). Likewise, 30% of the schools had a basic sanitation service (improved, usable, and single-sex) facility, 40% of the schools had limited sanitation service (improved, not usable, or not single-sex), and 21% of the schools had no sanitation service and no facility in 2023 (UNICEF & WHO 2024).

Nepal has set an ambitious goal of WASH for achieving the objectives of 92% of the total schools ensuring basic WASH facilities by providing clean drinking water, constructing separate accessible toilets and urinals for boys and girls, establishing handwashing areas and changing rooms for adolescent girls, and disposing of waste and sanitary pads and cleaning classes/rooms and schools after 5 years and 99% of the total schools after 10 years from the implemented year 2022/2023 (MoEST 2022).

Despite the situation of WASH, the nutritional assessment for the students showed that the prevalence of weight-for-age Z-score, height-for-age Z-score, and body mass index-for-age Z-score were 72, 75, and 82%, respectively, which are almost similar to the previous survey report of Nepal Demographic and Health Survey (NDHS) 2016 and 2011. Students with z-scores outside the range of ±2 were classified as malnourished. Of them, 27.3, 23, and 16.6% were assessed as underweight, stunted, and thin, respectively, where the midday meal was administered (Acharya et al. 2024), which was almost similar to the prevalence as reported by the NDHS, 2016 (Ministry of Health and Population, New Era and ICF 2023).

The NMDMP played a crucial role in enhancing the nutritional status and educational outcomes of children in public schools in Nepal. The program launched with the dual aim of enhancing school enrollment and retention while improving nutritional status has revealed significant effectiveness in increasing enrollment and providing nutrition to schoolchildren (Sachan & Singh 2016). The anthropometric assessment reveals that MDM alone could not reduce the malnutrition among schoolchildren. Further associated factors equally should be considered for reducing the malnutrition among schoolchildren. Therefore, the program is closely associated with WASH in public schools in Nepal. WASH facilities are crucial for ensuring the health and well-being of school students, whereas poor sanitation and hygiene practices and lack of safe drinking water can be causes of poor health and disease, ultimately diminishing the benefits and positive impact of the midday meal program. However, limited studies have been conducted covering these issues. Therefore, this study evaluates the WASH standards in public schools (community schools) across Nepal.

The study followed a quantitative research method using observation checklists (Creswell & Creswell 2018).

A total of 96 community schools were observed across all the provinces of Nepal, and a descriptive research design was employed.

An observation checklist was utilized as a data collection tool, incorporating records, reports, and physical observations and inspections. Before being administered, the checklist was validated through test–retest methods in 12 community schools across six districts.

Following the completion of administrative tasks like ethical approval, tool validation, and field enumerator training, we obtained permission and a request letter from the Centre for Education and Human Resource Development, Ministry of Education, Science, and Technology. The letter was handed over to concerned municipalities and schools. Ten groups of enumerators, each including a supervisor, were deployed to collect data from 10–31 May 2023.

For this research, WASH facility-related components were considered as outcome variables. They comprised variables directly associated with WASH, such as water availability, toilet facilities, environmental sanitation, hygiene and greenery environment, hygiene facilities, hygiene education, and management of menstruation hygiene facilities. Similarly, institutional variables such as institutionalized management and sustainability, disaster risk management and monitoring, and accountability were also considered as outcome variables (Department of Education 2018). Whereas provinces, type of municipality (urban and rural), type of school (basic and secondary), and ecological region (mountain, hill, and Terai) were considered as independent variables. All the dependent variables were assessed in four categories: no star, one star, two star, and three star, as per the WASH in School Operational Procedures, 2018 (Department of Education 2018). The categorization of stars has been presented in the Appendix.

Descriptive analysis was performed using IBM SPSS Statistics 26 (George & Mallery 2020). Mostly frequency, distribution, and cross tabulation were assessed. The data were analyzed based on WASH indicators, disaggregated by school type, place of residence, ecological region, and province. Further analysis was examined separately for schools categorized as no-star rating and three-star rating to assess the magnitude of severity and availability. This approach aimed to highlight the WASH conditions in different settings, contexts, and qualities as well.

The three-star rating system used in the data analysis, which is based on the ‘WASH in School Operational Procedure, 2018’ (see Appendix I), rates of schools according to the quality, quantity, and caliber of WASH indicators that are present in the schools. The purpose of this analysis was to evaluate community schools in Nepal's seven provinces with regard to WASH. Schools were given a rating between zero star (no- tar) to three stars; the highest rating is only given if all WASH requirements are satisfied in accordance with operational procedure norms. A school was not given a star rating if these requirements were not met, which means that it does not uphold the minimal standards outlined in the WASH in School Operational Procedure, 2018. This illustrates the considerable differences in WASH conditions among schools. An overall rating distribution is included in the analysis, followed by classifying the schools.

The general characteristics of the sample were school type, municipality, ecological region, and province, as presented in Table 1.

The survey data were collected from 96 schools across all ecological regions, covering 22 districts within the 7 provinces of Nepal: Koshi (Panchthar, Jhapa, and Solukhumbu), Madhesh (Mohottari, Saptari, and Siraha), Bagmati (Lalitpur, Dolakha, Makawanpur, and Sindhuli), Gandaki (Myagdi, Nawalpur, and Syanja), Lumbini (Arghakanchi, Kapilbastu, and Rukum East), Karnali (Jumla, Jajarkot, and Surkhet), and Sudurpaschim (Darchula, Doti, and Kanchanpur). Of these schools, 55.2% were selected from rural municipalities and secondary schools.

The WASH indicators and their performance level across the schools.

The data includes star ratings for each indicator, providing more detailed pictures of the schools' performance levels and the situation of WASH. The data shows that a larger proportion falls under one star for each indicator. This indicates that a greater number of schools have only a basic level of WASH facilities. The data further show the second largest proportion of schools received two stars in each indicator except disaster risk management. Furthermore, around one-fifth of schools received no star (severe) rating in disaster risk management (22.90) and management of menstruation hygiene facilities (19.80) among the sample schools (see Table 2).

However, toilet facilities, environmental sanitation, and disaster risk management are areas of significant concern, with over 60% of schools falling into the one-star category. Hygiene facilities and education also show weaknesses, with 64.6 and 68.8% of schools, respectively, receiving one-star and no-star ratings. Particularly alarming is the high percentage of schools (22.9%) with no disaster risk management measures in place and the complete absence of three-star ratings in disaster risk management and hygiene facilities. Among the schools, 16.70% of schools received a three-star rating in water facilities, indicating the better management of water facilities in these schools, whereas no school received a three-star rating in the indicators for hygiene facilities and disaster risk management.

Table 3 highlights the disaggregation of data on WASH indicators across the school type, municipality, ecological region, and province, with no star (indicating not having at least the basic facilities of WASH indicators). The assessment of WASH indicators in public schools in Nepal showed notable disparities based on the school type, municipality, ecological region, and province. The data shows that basic schools and school-residing rural municipalities did not meet the minimum standard regarding the WASH indicators in comparison to secondary schools and urban municipalities.

By ecological region, 12 and 32% of the schools located in the mountain region had not met the minimum standard of water facilities and disaster risk management, respectively. Furthermore, among the WASH indicators, toilet facilities, hygiene education, and institutional management and sustainability have the highest percentage in the hill region among the other regions regarding the WASH indicators. Similarly, in most of the schools in the Terai region, WASH indicators for environmental sanitation, hygiene and greenery environment, hygiene facilities, management of menstruation hygiene facilities, monitoring, and accountability did not meet any basic standard of WASH. Among ecological regions, the Terai region covered half of the indicators that did not meet the minimum standards of WASH, while the rest of the indicators were found in hill and mountain regions.

Province data reveals significant shifts in vulnerabilities across provinces. Koshi province faces critical conditions with no star in menstrual hygiene management (50.0) and disaster risk management (25.0). Madhesh province has notable concerns about hygiene facilities (52.9) and menstrual hygiene management (29.4). Lumbini faces challenges in environmental sanitation (16.7) and disaster risk management (33.3) with a no-star rating. Karnali's vulnerabilities are most distinct in toilet facilities (23.1) and monitoring and accountability (30.8) with no-star ratings. Sudurpaschim reveals vulnerabilities in water (15.4), institutional management and sustainability (30.8), and hygiene education (23.1).

Table 4 shows the analysis of WASH indicators in Nepalese public schools across the school type, municipality, ecological region, and province, with a three-star rating (indicating having the full potential of facilities for WASH indicators). Basic schools (grades 1–8) demonstrate good performance in the water (18.6), toilet, and hygiene and greenery environment (9.3) indicators, whereas secondary schools perform better overall, particularly in monitoring and accountability (9.4) and hygiene facilities (7.5).

While comparing municipalities, schools from rural municipalities show strong performance in hygiene and greenery environments (11.3) and water (11.3). Furthermore, schools from urban areas exhibit higher performance in water (23.3) and toilet facilities (9.3), indicating better infrastructure and resources in urban areas.

Table 4 shows the analysis of WASH indicators in Nepalese public schools across the school type, municipality, ecological region, and province, with a three-star rating (indicating having the full potential of facilities for WASH indicators). Basic schools (grades 1–8) demonstrate good performance in the water (18.6), toilet, and hygiene and greenery environment (9.3) indicators, whereas secondary schools perform better overall, particularly in monitoring and accountability (9.4) and hygiene facilities (7.5).

While comparing municipalities, schools from rural municipalities show strong performance in hygiene and greenery environments (11.3) and water (11.3). Furthermore, schools from urban areas exhibit higher performance in water (23.3) and toilet facilities (9.3), indicating better infrastructure and resources in urban areas.

According to the ecological region, the hill region demonstrates good performance in water (18.9) and toilet facilities (8.1). The Terai region shows a balanced performance, with moderate strengths in water (17.6) and institutional management and sustainability (5.9). The mountain region got a good rating in hygiene and greenery environment (12.0) and environmental sanitation and management of menstruation hygiene facilities (4.0).

Province shows the variation level in the performance of WASH indicators. Koshi province exhibits water (25.0) and hygiene and greenery environment (25.0) for three stars. Similarly, Bagmati province excels in high performance in water (25.0) and toilet facilities (18.8), highlighting significant investment in WASH indicators. Gandaki performs well in environmental sanitation (15.4) and hygiene and greenery environment (23.1). Lumbini province has strengths in hygiene education, management of menstruation hygiene facilities, institutional management and sustainability (8.3), and monitoring and accountability (16.7). On the contrary, Madhesh province has zero percent in most indicators except water (23.5). Karnali, Sudurpaschim, and Madhesh provinces show low performance across most of the WASH indicators, indicating a need for significant improvements in WASH indicators.

The provided WASH indicators offer valuable insights into the state of essential services within a given population. Across various indicators, most indicators fall into the ‘one-star’ and ‘two-star’ ratings, indicating that basic services are present but not fully optimized. For instance, access to water (Koenarso & Aziza 2022) and toilets, environmental sanitation and hygiene, and the greenery environment are relatively good, but there is space for improvement; similar studies also show the same need for improvement (Abebe & Ashenafi 2021). A study highlights the poor state of sanitation facilities, which negatively impacts the health of students, calling for urgent attention from government and school authorities to address these threats (Nlunda et al. 2023). Notably, disaster risk management has alarmingly high percentages in the no-star category with the absence of the three-star category, emphasizing the need for strengthening preparedness measures. These findings align with the findings of Schwemlein et al. (2016) and Pacheco et al. (2021). The data shows that while there are areas of moderate to good performance, many areas still fall predominantly under one star, indicating basic conditions. Targeted interventions are needed to raise more areas to three-star levels, ensuring a higher standard of WASH services across all indicators. Policymakers and practitioners should focus on targeted interventions to enhance sustainability, hygiene education, and disaster resilience.

Management of menstruation hygiene facilities, institutionalized management, and sustainability and hygiene facilities also need improvement, as a significant portion of schools lack adequate facilities and management practices. A similar study also shows that women and girls globally encounter significant challenges in managing their menstruation, especially in environments lacking sufficient menstrual hygiene management support (USAID 2019).

The analysis shows that while there are areas of excellence, particularly in water access and hygiene and greenery environments, most schools fall into the one-star category, indicating basic performance. There is a significant need for improvement in disaster risk management, hygiene facilities, and management of menstruation hygiene facilities. Targeted interventions are essential to elevating the overall WASH standards, aiming to increase the number of schools achieving two-star and three-star ratings, which ultimately enhance the good health of students during the midday meal program in school.

The data highlights significant disparities in WASH indicators across the different school types, municipalities, ecological regions, and provinces. Basic schools and schools located in rural municipalities are especially lagging behind in meeting the minimum WASH standards compared to secondary schools and schools from urban municipalities. Similarly, the JMP reports also highlight the disparities in WASH services between rural and urban areas, along with inequalities between school type and region (WHO & UNICEF 2018; UNICEF & WHO 2024). A study also found the urban schools had better WASH facilities, and practices and rural schools lagged behind (Vijayalakshmi et al. 2023). Addressing these gaps requires targeted investments to improve WASH standards. Community engagement is crucial, involving local stakeholders in planning and implementing tailored WASH projects. Engaging teachers and school staff will help to maintain and manage these indicators, which can optimize resource utilization.

Schools in the mountain region reveal notable deficits in water facilities and disaster risk management. Moreover, the Terai region has a higher percentage of no-stars for WASH indicators, particularly in environmental sanitation, hygiene greenery environment, hygiene facilities, management of menstruation hygiene facilities, and monitoring and accountability. Similarly, a report also highlights the significant challenges and strategies for implementing sustainable sanitation intervention in the Terai region of Nepal (Paudyal 2014). A systematic review paper found that the differential impact of WASH interventions on the educational outcomes of students, particularly in disadvantaged regions (Dibaba et al. 2024). This suggests a need for targeted intervention to address these challenges in a specific region.

The data reveals a shift in vulnerability across the provinces, highlighting the need for urgent and targeted intervention, with particular focus on hygiene facilities, management of menstruation hygiene facilities, disaster risk management, institutional management and sustainability, and monitoring and accountability.

Similarly, a report identifies critical vulnerabilities in various provinces, such as menstrual hygiene management, disaster risk management, and environmental sanitation in provinces like Koshi, Madhesh, and Sudurpachim (UNICEF 2024). A study also shows the WASH facilities in the primary schools are generally inadequate, with a significant gap in availability, accessibility, and functionality (Ahmed et al. 2022). Another study also highlights the need for improved WASH facilities in government schools to enhance students' health (Bute et al. 2023). A WASH research report for Nepal highlights the challenges in implementing WASH facilities in schools (Tiberghien 2015).

The analysis of WASH indicators in Nepalese public schools shows the discrepancy across the school type, municipality, ecological region, and province settings, highlighting the need for targeted interventions to address these gaps. Basic schools received three star in water, toilet, and hygiene, and greenery environments, while secondary schools reveal commendable performance in monitoring and accountability and institutional management and sustainability. This suggests WASH infrastructure is relatively better in basic schools, whereas management, sustainability, monitoring, and accountability practices are better in secondary schools.

Furthermore, schools from rural municipalities exhibit strong performance in hygiene and greenery environment and monitoring and accountability. On the contrary, schools from urban municipalities demonstrate good performance in water, toilet, environmental sanitation, hygiene education, management of menstruation hygiene facilities, and institutional management and sustainability, reflecting better infrastructure (Sangalang et al. 2022) and resource availability and management in urban municipalities. It highlights the necessity for strategies to enhance WASH indicators in rural municipalities. A similar study also shows the need for targeted interventions to improve WASH indicators, particularly in rural areas of schools (Phoju et al. 2021).

Comparing ecological regions, the hill region excels in water and toilet facilities, whereas the Terai region reveals balanced performance across the WASH indicators. The mountain region performs well in environmental sanitation, hygiene, and greenery environment, and management of menstruation hygiene facilities. These discrepancies call for ecological region-specific approaches to enhance WASH outcomes (UNICEF Nepal 2018).

Provincially, Koshi province leads in water, hygiene, and greenery environment, institutional management and sustainability, and monitoring and accountability. Bagmati province shows better performance in toilet facilities, but Bagmati and Madhesh's provinces demonstrate high performance in water. Gandaki province is explicitly better in environmental sanitation and hygiene and greenery environment. In contrast, Karnali, Sudurpaschim, and Madhesh provinces exhibit low performance and the absence of a three-star rating across most of the WASH indicators, highlighting the urgent need for significant improvements. These findings indicate and align with the study (Phoju et al. 2021) the importance of focused interventions to address the diverse WASH challenges across the provinces to uplift WASH standards.

The discrepancies observed in WASH indicators can be attributed to Nepal's unique geographical structure, with its three ecological regions: the mountains, hills, and Terai. Each of these regions faces distinct challenges related to infrastructure, accessibility, and resource distribution (Wang et al. 2019). Additionally, there are two types of schools in Nepal – basic and secondary schools. Basic schools generally have fewer facilities compared to secondary schools, which contributes to the disparities in WASH indicators (Sharma & Adhikari 2022). Rural schools face greater challenges compared to urban schools due to limited resources and infrastructure regarding WASH (UNICEF Nepal 2019). Historically, community-established public schools in Nepal received minimal government support, and even today, while public schools do receive more government aid, this support is often unevenly distributed across different school types, urban and rural areas, and ecological regions. These factors contribute to the significant discrepancies in WASH conditions across schools in Nepal (Budhathoki 2019). By the constitution of Nepal 2015, community schools are mainly managed by local people, i.e. parents and local government. If the local leader is aware of the WASH, then they are more likely to allocate a budget for the WASH sector.

WASH in schools can significantly enhance the MDMP's outcomes by addressing both nutritional needs and promoting better health and hygiene practices (Sangalang et al. 2022). The WASH indicators require emphasis on preparing and consuming a midday meal in a clean environment and reinforce the importance of safe drinking WASH among schoolchildren. The WASH approach fosters a sense of responsibility among students, staff, and teachers, contributing to the sustainability of the midday meal program in schools. Ultimately, the WASH indicators can act as a catalyst for improving midday meal programs in schools, particularly in rural, basic schools and underperforming ecological regions and provinces, by providing a holistic solution that combines nutrition, education, sanitation, and hygiene. Therefore, the investment in WASH infrastructure is crucial for reducing inequalities and improving overall health outcomes and learning performance as well. Improved WASH indicators ensure the students have access to clean water and sanitation facilities while receiving the midday meal, promoting better hygiene practices and overall good health, including academic outcomes. By integrating WASH indicators with the midday meal program, schools can create a healthier and more supportive environment, which ultimately enhances the learning outcomes of students.

The analysis of WASH indicators demonstrates the significant disparities across the school type, municipality, region, and province. Most WASH indicators are rated at one star, reflecting significant shortcomings in disaster management, hygiene facilities, and management of menstrual hygiene. There is an urgent need for targeted intervention in disaster management and hygiene facilities. Basic schools and schools from rural municipalities exhibit notable disparities in WASH indicators compared to secondary and urban schools, respectively. Additionally, a fluctuation gap exists across the ecological regions and provinces. The mountain and Terai regions, as well as the Madhesh, Karnali, and Sudurpaschim provinces, are exhibiting a poorer WASH outcome. Addressing these disparities is crucial for strengthening overall WASH standards in schools. These findings suggest the need for targeted intervention, comprehensive planning, infrastructure development, regular maintenance, collaboration efforts, community involvement, behavioral change, and a strong monitoring system with all-around support to strengthen WASH indicators. With these interventions, the midday meal program can be highly effective, thereby contributing to the overall health and well-being of students.

• This study covers a wide range of areas, such as provinces, ecological zones, and urban/rural settings.

• The use of a validated checklist based on the School Operational Procedure, 2018, ensures methodological reliability and alignment with national standards.

• Categorizing schools into star ratings provides a clear and interpretable framework for evaluating WASH conditions.

• The study does not explore the qualitative aspects, such as student, teacher, and management committee perspectives, which would provide deeper insight regarding WASH challenges and their impact on health, education, and nutrition.

• While disparities are noted in reference to ecological region, province, and urban–rural settings, the study might not include contextual factors influencing the WASH status. Only sampling one school in an urban and rural area in each province is a limitation in this study.

• No statistical analysis is performed because of the observational type of study.

The authors would like to express their gratitude to the Research Coordination and Development Council (RCDC), Research Directorate, Office of the Rector, Tribhuvan University, for providing financial support for this research. We also thank all the research participants for their valuable time and support.

The research was supported by RCDC, Research Directorate, Office of the Rector, Tribhuvan University [Project # TU-NPAR-078/79-2-02]

DA, OCT, TRB, KBT, and SG conceptualized the study and analyzed the data. DA and OCT developed the manuscript. TRB, KBT, MN, and SG revised and edited the manuscript rigorously with their critical feedback and inputs. All authors read and approved the final manuscript for publication and authorship.

The Ethical Review Board [ERB] of Tribhuvan University reviewed and approved the study proposal on 17 April 2023 [Ref# 384-079/80: ERBTU-079-001]. All data were kept confidential as per the research norms and ethical guidelines.

Data cannot be made publicly available; readers should contact the corresponding author for details.

The authors declare there is no conflict.