1,2Aga Khan University, School of Nursing and Midwifery (AKUSONAM), Pakistan
3Texas Women's Hospital Houston, United States of America
*e-mail: [email protected]
This qualitative study explored parental perceptions regarding parent's choice of quality childcare centers in urban areas of Karachi, Pakistan. Sixteen participants were selected from two centers in different geographical areas. For parents, the most common reason for selecting the childcare centers was the lack of other available options such as family support. Availability and accessibility of childcare centers were reported as supporting factors, while lack of family support, lack of information, and violent city conditions were identified as barriers to choosing childcare centers. In addition, husband support was perceived as a facilitator and a barrier to choosing childcare centers.
Received: March 29, 2021
Revised: April 13, 2021
Accepted: April 15, 2021
Online: May 15, 2021
Choice, Childcare centers, Parent Perceptions, Facilitators, Barriers
Many women join the workforce to support their families and increase their income (Canadian Council on Learning, 2011; Hein & Casseirer, 2010). This paradigm shift has led to increased formal and informal support systems by parents worldwide (Canadian Council on Learning, 2011; Casseirer & Hein, 2010). Due to an increase in nuclear family systems, parents' migration, family support decreases, and parents rely more on childcare centers (Canadian Council on Learning, 2011; Casseirer & Hein, 2010). A local newspaper of Pakistan, Dawn, reported that many women in Pakistan are joining the workforce as well in order to meet their expenses, subsequently increasing the need for childcare centers (Khan, 2018).
Childcare centers play a crucial role in supporting the parents to join the workforce and continue work (Casseirer & Hein, 2010). Nevertheless, the literature demonstrates that in the developing countries, there are inadequate childcare provisions for working mothers, due to which either they are forced to decrease their working hours and reduce their pay or opt for unsatisfactory arrangements (Kurz, Mehra & Paolisso, n.d.; Casseirer & Hein, 2010). As a result of the latter, the child suffers due to the poor quality of childcare arrangement. Moreover, early Childhood Development (ECD programs) for people living in developing countries exist in pockets, e.g., nutrition programs, immunization programs, and very few programs that provide a full range of childcare facilities (Kurz, Mehra & Paolisso, n.d). Henceforth, the availability of childcare centers is a big challenge for working mothers (Casseirer & Hein, 2010).
Childcare centers are relatively a new concept in Pakistan, and very few private and Government-run childcare centers exist in urban and semi-urban areas (Zahidi, 2019), while none are found in rural areas (Khan, 2018). In addition, a local Pakistani newspaper shared that the private childcare centers that exist are costly (Khan, 2018) and unaffordable (Zahidi, 2019). As a result, many women are bound to leave their jobs (Zahidi, 2019).
Informal, home-based Childcare centers are ubiquitous in Pakistan. In many countries, childcare centers are regulated and licensed (National Association of Child Care Resource and Referral Agencies, 2010), yet no accreditation body regulates childcare centers in Pakistan. The other informal support system commonly used in Pakistan is based on family support, whereby grandparents, maids, and nannies, who are mostly not educated to provide early education to children, are available to take care of the children. Maids/nannies are hired at low cost and trained to take care of children at home (Hirani, 2008; Shahid, 2007). In addition, they are trained to take care of children's basic physical needs like feeding, bathing, diaper changing. Also, the family structure in Pakistan is primarily a joint family system (Khan, 2018), so the grandparents, with the help of maids, take care of the children when the parents go to work (Shahid, 2007).
Formal or structured childcare centers are only available for very few children, more commonly in the country's urban areas (Zahidi, 2019; Khan, 2018). According to the International Labor Organization (ILO) report (2008), 50% of children living in Nishter Colony, China Basti in Lahore, remain with their grandparents, neighbors, relatives, or on the streets when their mothers are at work. The quality of the care that the children receive in their mother's absence is poor. If this assistance is not available, the parents lock their houses in their absence, and their children remain hungry during the day. Due to the limited availability of childcare centers, this situation is prevalent in most parts of Pakistan's rural and urban areas (ILO, 2008).
Currently, studies that examine mother's knowledge on childcare practices, professional development of teachers, and pre-school program evaluations exist in Pakistan (Abdul Qayyum, Hassan & Zafar, Dec 2015; Hussain & Sultan, 2010; Khan, Bhatti, Hussain, & Bano, 2017; Yousafzai & Gul, 29-31 Mar 2019). However, there are no studies available in Pakistan that explore parents' perceptions regarding how they select childcare centers for their children and the factors they deem important that either facilitate or hamper them from joining the workforce. Hence, this study explored parental views on the perceptions of available options for childcare and the facilitators and barriers that parents perceive as crucial in utilizing formal childcare centers in the urban parts of Karachi, Pakistan.
It is a proven fact that learning begins at birth (Jamieson, Bertrand, & Ibrahim, 2005; Report of the Federal/Provincial/Territorial Advisory Committee on Population Health and Health Security, 2003; Arnold, Bartlett, Gowani, & Merali, 2006; Goodfellow, April 2004; Arnold, 2001; The World Bank Group, 2011; Foley et al., 2000; Weaven & Grace, 2010; Child Care Advocacy Association of Canada Fact Sheet, 2004). Children learn from the environment they live in, and the early years provide children the opportunity to grow and develop (Report of the Federal/Provincial/Territorial Advisory Committee on Population Health and Health Security, 2003; Arnold, Bartlett, Gowani, & Merali, 2006). Childcare centers are pivotal in this regard.
Parents' values and beliefs play a significant role in determining the type of childcare environments they choose for their children (Goodfellow, 2004). It, in turn, influences the type of childcare service parents select (Goodfellow, 2004; Michie, 2014). Michie (2014) cited Weber's theoretical model of how parents choose childcare centers for their children, based on their values and beliefs extracting from the community features. Then, they decide based on the supply of childcare centers, availability of information, social networks, and employment status. Values may be defined as acceptable ways of being and beliefs held as truths (Goodfellow, 2004). While parents' values may not be clearly articulated, they influence their perceptions of the nature and type of care they wish for their children, their reactions to differing childcare environments, and their satisfaction with those environments (Goodfellow, 2004).
Multiple studies have been done to study parents' value as critical ingredients of childcare (Goodfellow, 2004; De-Visscher, Nuffel, Ferla & Vandenbroeck, 2008; Reikes, 2005; Koslowski, McLean & Naumann, 2015; National Poll on Children's Health, November 2017). Results of a multi-care study conducted in 52 care centers in regional and urban areas of the New South Wales for children of below school age group revealed that parents identified trust with caregivers, family environments, child's separation anxiety, educational programs, and development of competence as important indicators while choosing childcare centers for their children (Goodfellow, 2004). A 2017 C.S. Mott Children's Hospital National Poll on Children's health in Michigan concluded that 46% of parents utilizing childcare centers. Considered staff background checks as the most critical factor in selecting childcare centers for their children, 42% believed staff training in early childhood as crucial, 36% considered locked doors of the center as essential, 33% thought the cost was necessary, while 32% felt location of the centers as a critical factor for them (National Poll on Children's Health, November 2017).
A study done to determine how parents choose their childcare providers in four different states of USA (Iowa, Kansas, Missouri, and Nebraska) in 2005 from 1325 parents, conducted by the Gallop Organization, highlighted that parents valued warm, reputed providers that provided stimulating physical activities, had similar values that of the parent, could be trusted and was credentialed (Reikes, 2005). Trust in the caregivers is usually the most critical factor for many parents (Koslowski, McLean & Naumann, 2015). On the other hand, parents valued race, ethnicity, the language of the provider, enrolling children with special needs, and having a child already enrolled with the provider the least. Cost, location of the center, and type of the provider were perceived as in the middle (Reikes, 2005).
Literature review from journals and articles on studies done in the USA concluded that parents with college degrees search for quality features, while those with less than a college dree tend to focus more on safety and practical features such as cost and location. Additionally, availability, accessibility, affordability, employment status, and parent awareness of childcare centers were identified as barriers for parents when selecting childcare centers. Interestingly, the authors found fewer regulated and licensed centers in rural areas than in urban areas (Forry, Tout, Rothenberg, Sandstorm, & Vesely, 2013).
The research paradigm on which this study is based is the Constructivist paradigm. This paradigm is used for naturalistic studies that aim to explore, describe, re-construct or understand the phenomenon from the participants' point-of-view (Creswell, 2008). The constructivist paradigm is central to most qualitative studies (Lobiondo-Wood & Haber, 2006). It proposes that there are different worldviews of participants and that multiple realities exist. Thus, based on the study question, this study explores parents' world view regarding childcare centers that they are utilizing.
Qualitative studies are likely to be exploratory, and they provide detailed descriptions of participant's experiences. This design aids in exploring the experiences of the participants whereby the researcher 'explores the phenomena or variable or population of interest (Brinks & Wood, 1998). Experimental designs are used when there is not enough knowledge about the phenomenon of interest (Brinks & Wood, 1998). Since the focus of this study is an exploration of parents' experiences regarding the choice of childcare, a qualitative exploratory design was considered.
The participants were selected from the urban areas of Karachi, Pakistan, according to the inclusion-exclusion criteria outlined in table 1. Initially, it was decided that twenty-one participants would be selected from three childcare centers in three different geographical areas, that is, seven participants from each center. However, due to the worsening security situation in the city, particularly in the two geographical areas where the centers were, data was collected from only two centers with thirteen participants from 1 center and three participants from the other, after approval from the research supervisor.
Those participants who fulfilled the inclusion-exclusion criteria were selected, as detailed below in table 1. Altogether, 16 participants were purposively selected from 2 different childcare centers.
Method for Data Collection
Data was collected through individual in-depth interviews of the sixteen selected participants to explore their experiences in detail (Boyce and Neale, 2006), for which a 20 to 30-minute in-depth interview was conducted in the context of the participants. In addition, a semi-structured interview guide, which consisted of open-ended questions, was developed in English and Urdu. Finally, the interview guide was pilot tested on two individuals.
The proposal and application were sent to the Aga Khan University's Ethical Review Committee (ERC) for approval, and the data collection was initiated after receiving the letter of approval (see appendix B). Each participant was asked about their willingness to participate and sign the consent form before the in-depth interviews. No coercion was used, and the participants had the right to withdraw from the study anytime they wanted to. The consent form was written in both English and Urdu, and they were explained to the participants in detail. Confidentiality and anonymity were maintained, as codes/pseudonyms were used to maintain the confidentiality of the participant during the dissemination of results.
Thematic analysis was done to interpret the results (Brinks & Wood, 1998; Burns & Grove, 2001). The interviews were translated from Urdu to English and used as direct quotes in the selected themes. Data was organized manually, and coding of the data was done. Data transcription was read and re-read many times, and themes, sub-themes, and categories formed. Codes/pseudonyms were allocated to the participants to maintain anonymity. Data were recorded, and notes are taken to avoid recall bias.
As shown in figure 1, the study results showed that the participants shared various childcare selection criteria under all the themes. Thematic analysis of this study revealed four themes; reasons for selecting childcare centers important to parents, unique features of childcare centers utilized by parents, supporting factors, and barriers to work.
Experiences of parents:
Participants shared a variety of experiences regarding the utilization of childcare centers, which are described below.
1. Research Aim 1: Reasons Important to Parents for Selection of Childcare Centers: Selection of childcare centers is imperative for working parents who lack other childcare options. Thus, participant experiences were explored regarding this phenomenon. This study revealed a lack of options, location of the center, and limited choice of childcare centers as crucial in determining childcare facilities for their children.
a. Lack of options: Lack of options became one of the most significant reasons for selecting the childcare facility. Out of sixteen participants, all of them mentioned that they chose this center because they had no family support. The other reason for opting for the center was that they had to re-join work after maternity leave. Out of 16 participants, five of them reported that they lived in a nuclear family. It is why they had no other option. However, the other five participants stated that they have their mother-in-law at home, but they do not want to over-burden them as their physical condition does not allow them to care for the child. One of them also mentioned that she utilized both child care facilities as well as mother-in-law's support. For instance, one of the participants stated that:
"I am working here. I had the support of my mother-in-law at home, but she had some physical issues. She had knee problems so she could not take care [of the child], so there was no other option." (AI 5)
b. Location of the center: The other most commonly stated reason by participants for selecting the center was the in-house center location. All thirteen participants of one center verbalized that the main reason for utilizing this childcare facility was that it was part of their workplace and vicinity. Similarly, 3 participants from the other center also mentioned that location of the center close to their workplace inclined them to use this center. As 1 of the participants reported that:
"…I can go quickly if I receive any call…" (AI 7)
c. Limited Choice of Childcare Centers: Data revealed that choosing childcare centers was a key factor for only those participants who did not have childcare centers as part of their workplaces (n=3). The majority of the participants (n=13) were availing in-house childcare centers for their children. Interestingly, almost all participants (n=15) did not even consider the option of maids as caretakers. Out of sixteen, most participants (n=11) did not explore any other options other than the center they were utilizing. It was mainly due to the perception that the center they were utilizing was inside their workplace. Thus, the choice was not an issue for most of them.
On the other hand, the remaining 5 participants reported that they had explored other childcare centers. The center they were utilizing was perceived as best for various reasons such as clean environment, feasibility, affordability, proximity, security, personal nature of the owner and supervisor. For instance, 1 of the participants mentioned that:
"I have been to other daycares as well like in Gulshan and Hyderi area, but I was not satisfied with the environment... The second thing was that what they were charging was not appropriate. However, the major thing was that I find these two [ladies], Ms. Aisha2 and Ms. Zainab's nature is very good and inclined towards children. It was the major thing. Otherwise, the rest of the places I went, their rooms were quite dirty and not clean. Their fridge was not clean…" (GI 15)
When asked why they did not choose maids over childcare centers, all 15 participants thought they did not opt for maids as under the current city situation, they do not trust them, and someone would be required to supervise them. 1 participant who had used the maid service earlier shared her experience by saying that:
"In the initial days, I kept maid at home for one and a half months but was not satisfied. The reason was that nobody was there to supervise her. Whatever she was doing could not be observed. I do not know about food, but cleanliness, like a diaper, was not changed timely. It was happening that she kept my child lying and [made her] watch TV." (AI 13)
2. Research Aim 2: Features of the Child Care Center Being Utilized by Parents: Data demonstrated that all participants shared various features of the daycare centers they utilized, such as a clean and homely environment, affordability, and child development.
a. Clean and Homely Environment: Four participants shared that the childcare centers they were utilizing had clean and homely environments. E.g., one of the participants mentioned that:
"Here, the environment is spotless. I have seen no wrapper on the floor. The water is clean. The baby is kept clean. Ventilation is good. Every child's diaper is changed on time; dresses are changed regularly, washing system is good…" (AI 13)
b. Affordability: Many participants (n=7) from both the center also felt that cost of the daycare centers was an essential feature for them during selection. It was important for the participants who utilized the center, which was not part of their workplace. As one of the participants exclaimed that:
"…Cost wise also, I find it reasonable because I have seen/compared other centers. It has the best cost…" (GI 15)
c. Child development: Almost all participants (n=13) shared that they appreciated children's social and cognitive development at the centers. However, physical development was acknowledged by only three parents out of sixteen. One parent even mentioned emotional development as one of the features, while two parents did not mention anything. On the other hand, one parent thought that learning activities were not conducted as per Montessori Method. The participants acknowledged the regular growth monitoring of children, the learning activities that children above 18 months received, and how the children mingled with each other. Surprisingly, growth monitoring and learning activities were offered by only one center and not the other. As one of the participants verbalized that:
"…Children socialization improves here. They play together, mix and children develop this better. You can work with peace of mind. They have started to celebrate color day to give color concepts to children. Height and weight are checked and e-mailed by Zubaida.…" (AI 3)
On the other hand, many parents (n=12) also shared some childcare services that needed improvements, such as small and congested spaces. Lack of flexible hours as well as overall flexibility, not following Montessori method, uneducated caregivers, lack of knowledge, lack of communication with caregivers, increase the chance of infections due to close contact of children, location of the daycare at the rear end, inappropriate structure (with an asbestos sheet), lack of sunlight and lack of training. For instance, one of the participants mentioned that:
"Definitely. It [trained caregivers] is very important. They have trained both their supervisors, but they should train lower-level maids [caregivers] because they are spending more time with the children…" (AI 6)
3. Research Aim 3: Supporting factors: All participants (n=16) shared various factors that helped them continue work, such as the availability of a trusted and system-based childcare center close to their workplaces and husband's support. Also, participants mentioned that daycare center features such as grooming the child and guiding parents' time-to-time also support them in working with peace of mind.
a. Availability and accessibility: Most participants (n=11) verbalized that more quality-based daycare centers should be available and accessible along with employer support. One participant who emphasized that daycare centers should be part of the workplace reiterated that:
"…But as the policy is saying, daycare should be there at every working place...so whenever we want to avail, we can. Daycare should be there in the system and in particular, in the branch [workplace], where I am working, because feeding mothers suffer…" (GI 14)
b. Husband support: Five parents also deemed husband support an essential support system in coping with their workplace issues. As one of the participants mentioned that:
"Husband is the main support system…Because if husband is supportive but family is not supportive, then somehow they [women] can cope…." (GI 15)
4. Barriers to Work: Almost all participants perceived lack of family support, lack of information about the availability of centers, violent city conditions, and lack of husband support as barriers for working parents.
a. Lack of family support: Due to the cultural unacceptability of leaving children at childcare centers, two of the parents strongly highlighted that family issues were a barrier. One parent also cried while sharing her views, and she was given time for ventilation of her feelings. She shared that:
"From my in-laws [side], they do not live with us, but they create issues like one of my in-laws asked, 'why do you leave children at the daycare? Why do you leave children with others?' I do get comments from them. Even I get a comment from my sister-in-law, 'when he gets older, I will ask him not to call you his mom (aap ko maan na boley) because you leave him in the daycare'…" (AI 13)
Similarly, the other participant said that:
"Particularly in-laws perceive that we are not taking good care of children…Indeed they pass remarks like 'we are heartless people'…In-laws think we are not good mothers. They do not understand my helplessness [majboori]." (GI 14)
b. Lack of information: Moreover, one of the parents also mentioned a lack of information about daycare centers as a barrier. According to her:
"There are not enough daycares in Karachi, Pakistan. No, no, and people do not have information...." (AI 6)
Similarly, another participant stated that:
"Even I did not know where daycare is located…If I need an ambulance, I know where to contact but for daycare, where should I go? Then friends guide you." (AI 7)
c. Violent City Conditions: Apart from this, there is a safety issue related to unsafe city conditions that were also verbalized as barriers by two parents. As one of the parents reiterated that:
"Other than this, the reason is that our [city] condition is such that child has to take home plus has to be brought in the morning, this is an issue. If the city condition is not good, we can accommodate ourselves if we are alone, but with children, it is tough…" (AI 5)
d. Lack of husband support: Though husband support was perceived as a supporting factor by many participants, two parents perceived it as a barrier to not participating in household chores. As per the participant:
"My husband and I often fight [that] if I can work as a male outside in the society, [why can't you]? But my husband does not do any household chores. Huge barrier..." (AI 6)
As outlined in the result, the participants shared diverse experiences related to parental choice and utilization of childcare centers. It was evident from the data that childcare centers' choice was primarily driven by necessity, i.e., returning to work, limited options and choice, rather than the center's quality. The data revealed that the most common reason for opting for childcare centers was that most of them lived in a nuclear family and did not have any other option available. The participants who lived in a joint family system believed that although the family members wanted to support them, they could not over-burden their mother-in-law due to their age factor. Strikingly, participants of both the centers were of the view that either they had limited or no choice. Based on Khan (2018) and Malik (2009), the authors agree that there are fewer childcare centers in Pakistan than needed.
Some participants also verbalized that resuming complete-time work and the nuclear family system were other reasons for opting for present childcare centers. A study was done by Henthorne and Harkins (2005) to identify parents' demand and access to childcare in Scotland found that 54% of parents stated that the most common reason for parents utilizing childcare was to enable them to work. Likewise, all parents in the present study perceived that they could work due to the childcare center they were utilizing for their children.
Interestingly, all thirteen participants who had childcare service in the vicinity of their workplace did not explore any other options except the one in-house. Only five parents, who were utilizing childcare services that were a bit far from their workplace, had explored other childcare centers but were not satisfied with their quality in terms of cleanliness and safety. They all mentioned that the child being near to them was very important for them. Some of them had even mentioned a waiting list in the daycares they were utilizing, but they had chosen to pay more to get their child admitted to the present center. It shows that the availability of the childcare center near the mother's workplace is deemed crucial by parents utilizing childcare centers. International Labor Organization (ILO) report (Hein & Casseirer, 2010) also recommends in-house, employer-sponsored childcare centers as a workable solution for their employees.
Furthermore, it was evident from the results that cost and affordability were also perceived as imperative by almost all participants. Interestingly, all thirteen participants who utilized in-house childcare centers and the three participants of one of the centers who had assessed various centers in the neighborhood chose the center they were utilizing based on cost-effectiveness and affordability. Although the participants utilizing the in-house childcare centers were aware of the childcare subsidies by their organization, they nevertheless perceived cost as necessary. Researchers have also confirmed that cost is a significant factor in determining childcare arrangements (Ispa, Thornburg, & Venter-Barkley, 1998; Da Silva, & Wise, 2009; Pearlmutter, & Bartle, 2004). In countries such as the USA, the government or employers offer childcare subsidies to make it more affordable for parents (Pearlmutter, & Bartle, 2004). In Pakistan, however, the Governments are not providing this benefit, and only a handful of organizations that have established childcare services at their workplaces have subsidized costs for their employees. Henceforth, this is a crucial element for parents when selecting childcare arrangements for their children.
Parents shared some of the unique features of the childcare centers they were utilizing for their children. The data showed that the most common positive features came out to be a clean environment, affordability, and child development related to social, physical, and cognitive development were also some of the other essential features of the centermost of the parents appreciated. Cognitive development was thought to be crucial by all thirteen parents utilizing the same center. Physical development, on the contrary, was highlighted by only four participants of the same center as an essential feature of their center. It was evident from the results that most of the parents were satisfied with the features of the childcare centers they were utilizing, such as cleanliness, affordability, cognitive and social development. The authors were not sure if the quality of these centers was measured as per international standards, but despite that, parents had their worldview. Studies have also shown that parent's satisfaction in terms of program features is higher than the trained observer's (Bassok, Markowitz, Payer & Zagardo, 2018).
In the end, parents shared their views on the supporting factors and barriers in accessing childcare centers in Karachi, Pakistan. Most of the participants acknowledged that the availability of a trusted childcare center in the vicinity of their workplaces would be a supporting factor and a barrier for them. All of the parents thought that more quality childcare centers should be available in order for them to work with peace of mind, while a few of them reiterated that it should be part of their workplaces. Some of them even mentioned that the lack of these centers would become a barrier and may quit their jobs. A study conducted to assess the role of childcare in women's labor market provision and their attitude towards childcare provision in the United Kingdom also revealed that mothers perceived lack of access to childcare centers as a barrier to quality childcare and believed that there were very few childcare services available where they lived. Although the cultural context of the UK is different from Pakistan, the participants in both the studies perceived lack of access as a hindering factor.
Despite that, the participants did not opt for maids to determine childcare centers for their children, as they could not trust them. One of the participants even had a bad experience, whereby the maid did not take appropriate care of her child. Thus, participants recommended that employer support, additional childcare centers which are feasible, quality-based, help the child develop and guide parents' time-to-time should be available and accessible in order for them to have a range of available choices. Employer support was also highlighted as a supporting factor for mothers.
Similarly, the husband's support also came out to be both a supporting factor and a hindering factor. Most of the parents verbalized that husband support was solid support for them. On the contrary, some of the participants highlighted that lack of husband support could be a barrier for working mothers. They wanted their husbands to participate in the daily household chores. One of them pointed out that it would be possible for her to cope if she has husband's support rather than family support. In Pakistan, it is culturally unacceptable for husbands to assist in household chores. The families perceive it as "weak," and men are always the stronger ones. Nonetheless, the trend is changing now, especially in the urban areas, whereby wives are also working to meet their expenses.
Many participants identified family support as one of the other significant barriers. Two participants had an extreme view, and one participant even cried while expressing her views. Both of them shared that lack of family support was a significant barrier for them. Apart from this, violent city conditions, lack of information related to the availability of centers, daycare center features such as lack of caregiver training were also some of the other barriers.
In short, all participants of this study determined their childcare centers primarily based on necessity rather than the quality of the centers. They had no other option than to utilize their present childcare centers in order to be able to continue work. The unique features of their childcare centers were a clean and homely environment, affordability, and child development. The primary supporting factors perceived by parents were availability, accessibility of more daycare centers, and husband support, which was perceived as both a supporting factor and a barrier. On the other hand, lack of family support, husband support, information, and violent city conditions were barriers for working mothers to re-join or continue work.
Future Research and Recommendations
This study could not analyze how parents with different socio-economic backgrounds determine childcare centers. Thus, future research in this area would assist us in understanding the gap.
Funding and Conflicts of Interest:
This article is a part of a student paper of authors in University College London. There is no funding and conflicts of interest for this research
For all the study participants, without whom this research would not have been possible.
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