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Article History

Received: 7 May 2026

Accepted: 27 July 2026

First Online: 31 July 2026

Declarations

Ethics approval and consent to participate: This study was conducted in accordance with the ethical principles governing research involving human participants, including the Declaration of Helsinki, the CIOMS international ethical guidelines, and WHO recommendations. Administrative authorizations permitting access to participants and clinical data were obtained from both participating health facilities in Djibouti prior to the start of the study; these facility-level authorizations were administrative in nature and did not constitute ethical review. In parallel, a request for ethical review was submitted to the National Ethics Committee for Medical Research of the National Institute of Public Health of Djibouti (INSPD), Ministry of Health, the competent national authority for the ethical review of medical research in Djibouti, before data collection began. The Committee’s evaluation of the protocol was completed after data collection had concluded, issuing a favourable ethical opinion under reference No. 145/INSPD/2026 on 10 June 2026. The authors acknowledge that proceeding with data collection before this formal approval was obtained constitutes a protocol deviation. The study was observational and non-interventional throughout, involving no experimental procedure, biological sampling, or modification of participants’ clinical care; it relied on a validated, non-invasive questionnaire administered with each participant’s oral informed consent, and all data were anonymised.Before inclusion, all participants received clear oral information about the objectives and procedures of the study, the voluntary nature of participation, the confidentiality and anonymization of their data, and their right to decline participation or withdraw at any time without any consequence for their medical care. Given that a substantial proportion of participants had no formal schooling and limited literacy, oral informed consent was obtained from all participants before questionnaire administration. Consent was obtained in a private, one-on-one setting between the participant and the principal investigator, without a third-party witness; each participant's consent was documented by a dedicated checkbox on the structured data collection form, completed by the investigator at the time of interview. The requirement for informed consent was not waived. All responses were anonymised, and confidentiality was strictly maintained throughout the study.

Consent for publication: Not applicable.

Competing interests: The authors declare no competing interests.