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Authors
M., Premikha
Mogi, J. G.
Gittelsohn, J.
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Funding
Funding for this research was provided by:
Leroy Burney Fund, Johns Hopkins University
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Article History
Received: 30 September 2025
Accepted: 16 January 2026
First Online: 29 January 2026
Declarations
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: All methods were performed in accordance with the Declaration of Helsinki. Ethics approval was obtained from the Institutional Review Board (IRB No.: 22949) at Johns Hopkins Bloomberg School of Public Health and RSUP Prof. Dr. R. D. Kandou Health Research Ethics Committee (No. 212/EC/KEPK-KANDOU/XI/2022). In addition, a local permit was obtained from the Southeast Maluku Agency of National Unity and Politics ( Kesbangpol Malra ) on behalf of the Regent of Southeast Maluku (No.: 070/186/SIP/BKBP/2022) to conduct the study on Kei Besar Island. Written informed consent was waived by both ethics committees, and verbal informed consent was approved and obtained from all participants. An oral consent script, reviewed and approved by both ethics committees, was read aloud in the local language to ensure understanding, and participants had the opportunity to ask questions before providing verbal consent for participation. This approach fostered a conversational atmosphere and aligned with local norms, where signing formal documents was uncommon and may be perceived as intimidating. All participants were adults (≥ 18 years) and able to provide informed consent independently; therefore, Legally Authorized Representative consent was not applicable. To safeguard against potential coercion, the verbal consent process was not audio-recorded. Participants were reimbursed 50,000 Indonesian rupiah (approximately US$3.25) for each interview or activity.
: Written media permission was obtained from all participants using the Johns Hopkins Bloomberg School of Public Health Media Permission Form for adults (≥ 18 years), authorizing the publication of any photographs or recordings taken during fieldwork. Only anonymized textual data from interview transcripts are published in this manuscript; no identifiable images or audio recordings of participants are included.
: The authors declare no competing interests.
