Factors influencing healthcare access for the elderly in the Middle East and North Africa Region: a scoping review based on the Levesque framework

Introduction

Background

Healthcare access is defined as “a journey that starts with perceiving the need for care, and continues with seeking, reaching, and utilizing care, which results in health consequences” (1). Numerous frameworks conceptualize access to healthcare, but the most used access frameworks are Andersen’s Behavioural Model of Health Services Use, Penchansky and Thomas’ framework and Levesque’s Conceptual Framework for Healthcare Access, which is the most recent among all. Within Levesque’s Conceptual Framework, access is understood as a dynamic process encompassing individuals’ ability to perceive the need for care, be able to seek care, physically reach services, be able to pay for or obtain care, and derive benefit from the services received (1). The framework offers a broad, multidimensional perspective by linking health system characteristics such as approachability, acceptability, availability, affordability, and appropriateness; with corresponding individual capacities to perceive need, seek care, reach services, afford costs, and engage meaningfully with care. Approachability and the ability to perceive care relate to whether people are aware of the services that are available and understand how to access them in ways that can improve their health. Acceptability and the ability to seek care relate to how well healthcare services align with a person’s social and cultural values, as well as those of their community, and whether seeking care feels socially acceptable or personally appropriate. Availability and accommodation, together with the ability to reach, focus on the practical aspects of accessing care, such as how close services are and whether transportation is available. Affordability and the ability to pay consider the overall cost of care in relation to what individuals can reasonably afford. Finally, appropriateness and the ability to engage look at the quality and suitability of the care provided, including whether it meets patients’ real needs and whether they can actively participate in and follow the treatment recommended by healthcare providers (1).

Rationale and knowledge gap

Healthcare access and utilization have been extensively studied worldwide, but research focusing specifically on the elderly population in the Middle East and North Africa (MENA) region remains limited. The MENA region is undergoing major demographic shifts with an increase in the aging population (2,3). Despite the variations in healthcare systems across the MENA region, elderly individuals often face structural, economic, and social challenges, including disparities in healthcare financing, inadequate geriatric services, limited mobility, and cultural perceptions of aging and care (4-6). Understanding the specific factors affecting healthcare access for the elderly is critical. Although some studies have looked at healthcare access for older adults (2,6), the MENA region is still not well covered. Most of the available evidence is scattered, focused on specific diseases, or limited to basic service use data, rather than providing a deeper understanding of the factors influencing access through a comprehensive framework.

Objective

This scoping review explores existing literature to synthesize the most critical factors influencing healthcare access in the MENA region. Levesque et al.’s [2013] conceptual model was used as a guiding reference to support the systematic synthesis and organization of evidence on healthcare access, because it offers the most comprehensive multidimensional perspective that explicitly links health system characteristics with corresponding individuals. Unlike Andersen’s model, which focuses predominantly on individual determinants, Levesque’s framework facilitates systematic mapping of both supply-side and demand-side factors, making it particularly suitable for scoping reviews of heterogeneous evidence.

By providing evidence-based insights, this study can inform policymakers and healthcare stakeholders in designing effective strategies to improve accessibility, reduce disparities, and ensure equitable healthcare delivery. We present this article in accordance with the PRISMA-ScR reporting checklist (available at https://jphe.amegroups.com/article/view/10.21037/jphe-2026-1-0008/rc) (7).

Methods

A scoping review provides a systematic approach for initial exploration of the available research literature which follows a method to map evidence in a particular area and identify its scope, size, and nature (7). The review followed the five-stage framework outlined by Arksey and O'Malley (8), to maintain methodological rigor and transparency. The review protocol was registered in Open Science Framework (doi: 10.17605/OSF.IO/ETMKD; https://osf.io/etmkd/).

Stage 1: identifying the research question

The review sought to answer the following broad research question: what factors influence healthcare access for elderly in the MENA region? The review aimed to view the factors listed in the literature by a perspective of the access dimensions and abilities according to the Levesque framework.

Stage 2: identifying the relevant literature

A comprehensive systematic literature search was performed from May to July 2025 in the four databases: MEDLINE/PubMed, Scopus, Web of Science and Google Scholar. The search terms were grouped as ‘Population’, ‘Concept’, and ‘Context’ elements. The targeted population were the elderly aged 50 years and above, the phenomenon of interest was Healthcare accessibility, and the context was a regional focus on the MENA region. The database search was conducted independently by three authors (F.K.A., A.A.A., and A.M.M.) using identical search strings. For MEDLINE/PubMed, the search was performed using the advanced search builder with Medical Subject Headings (MeSH) terms expanded to include all subheadings. For Scopus and Web of Science, the search was limited to article titles, abstracts, and keywords. Google Scholar was searched using the same terms with the first 200 results screened per search iteration due to platform limitations. The search string can be found in Table S1 and Appendix 1. A Boolean approach for the search string was adopted; synonyms denoting the elderly population were combined by the operator “AND” with synonyms for healthcare access, and various countries representing the regional context (MENA). The definition of the MENA region for this review followed the operational boundaries comprising Arab League member states plus Iran (consistent with World Bank classifications for MENA health system comparisons).

Stage 3: study selection

Three authors independently screened records by title and abstract, then by full text. Screening disagreements at title/abstract stage occurred for 47 records (2.9%); these were resolved through discussion between the three reviewers, with consensus achieved in all cases after reviewing the full text when necessary. No restrictions were placed on study design while selecting the articles. For the mapping process to the Levesque framework, two reviewers independently coded each extracted factor to one of the five access dimensions and corresponding abilities based on the framework described by Levesque et al. [2013]. The operational coding definitions were as follows. Approachability (ability to perceive) included awareness, knowledge, health literacy, information, and perceived need. Acceptability (ability to seek) included cultural beliefs, fear, trust, social norms, gender roles, stigma, and attitudes. Availability (ability to reach) encompassed distance, transport, travel time, physical access, waiting times, and hours. Affordability (ability to pay) included service, medication, and transport costs, insurance coverage, out-of-pocket and informal payments, and indirect costs. Appropriateness (ability to engage) included care quality, continuity, provider communication, follow-up, chronic disease management, and patient-centeredness.

Inter-coder agreement was 89%; disagreements were resolved through discussion and, when needed, consultation with a third reviewer. The review included studies that were reporting healthcare access and utilization among the elderly population aged 50 years and above. The age threshold was selected to accommodate variations in how ‘older adults’ are defined across studies conducted in the MENA region, where some investigations operationalize older age as 50 years and above. Only studies conducted within the MENA region were considered relevant for inclusion. Articles had to provide full-text access, had to be in English and had to align with the core focus of the review by explicitly measuring or evaluating empirical factors that correspond directly to the supply-side health system dimensions or demand-side individual capacities of the Levesque framework to be eligible. Only studies published from 2014 onwards were included to ensure contemporary relevance of the evidence. Studies were only considered for inclusion if they addressed the outlined dimensions and abilities in the selected framework. Studies were excluded at multiple stages of the review process as shown in Figure 1. Any discrepancies and differences in judgement were addressed through discussion among the review team and consensus was reached.

Figure 1 PRISMA flow diagram. MENA, Middle East and North Africa.

Stage 4: charting the data

Three researchers independently extracted data pertaining to the country, aim of study, study design, type of healthcare setting, sample size and age criteria. Factors were noted based on their nature and mapped to the relevant dimensions of the conceptual framework. Subsequently, a country-wise comparison of the factors affecting the dimensions were systematically tabulated.

Stage 5: collating, summarizing, and reporting results

Review results are presented through descriptive statistics of included studies, tabulated to categorize the factors and a narrative summary of findings. Implications of the analysis are then discussed.

Results

Following the removal of duplicate records, 1,642 articles were screened by title and abstract by three independent reviewers, leading to the exclusion of 1,597 records due to irrelevance to the topic, region or target population. During full-text assessment, studies were excluded if they did not directly examine healthcare access, but instead focused mainly on outcomes of interventions, clinical effectiveness, or patient satisfaction without addressing access dimensions. Additional reasons for exclusion included wrong population, wrong geographic context, or unavailability of the full text (Figure 1). These exclusion decisions ensured that the final selection accurately reflected the objectives of the scoping review with utmost rigor. Sixteen studies were included in this scoping review, ensuring the final selection aligned with the objectives of exploring healthcare access among elderly in the MENA region. The studies were published between 2014 and 2025, 81% of which were after 2020. The sample size ranged from 14 to 122,219 being recruited by a variety of selection methods.

Study characteristics

The included studies were conducted in Saudi Arabia (9-17), Morocco (18-20), Iran (21), Egypt (22), Jordan (23), and Tunisia (24). The studies employed quantitative (n=13), qualitative (n=2), and mixed-method (n=1) designs, with settings ranging across primary healthcare centers, hospitals, outpatient clinics, and community environments as shown in Table 1.

Factors influencing healthcare access in the MENA region

Individual characteristics

Consistently mentioned across most articles was the variable of age itself. Not only was it related to increased use of the services, but it also was pointed out as a significant access barrier (10-17,19,21-24). Disparities in the healthcare access based on gender were noted in the studies (10,12,19,21,22,24). Lower education levels were linked to reduced health literacy and poorer utilization of preventive services (11,12,14,19-23). Residential location, particularly rural area, was associated with poorer access to health services (10,19,20,22). Marital and employment status influenced access through social and financial support, respectively (10,23). Table 2 summarizes the key factors influencing healthcare access among older adults across selected MENA countries, organized according to the access dimensions framework. It highlights common barriers and facilitators affecting different stages of access, including awareness, acceptability, physical access, affordability, and engagement with care. The table provides a cross-country comparison and illustrates how contextual, socioeconomic, and health system factors shape access experiences among the elderly.

Ability to perceive health needs and approachability

These aspects of the framework refer to the older adult’s ability to identify health needs, seek information, and understand healthcare services. The necessity of healthcare, including perceived importance of screening and preventive services, affected access patterns (10,12,19,20,22). Level of health problems and presence of chronic conditions were key facilitators of healthcare access (19,21), while frequency of healthcare visits and place of care utilization were dependent upon perceived urgency and severity of illness among the old (23). A significant barrier noted across studies is the lack of information and awareness regarding specific health conditions and available preventive services (13,14,17). Older patients often receive inadequate information provision from healthcare providers about disease causes or prevention unless they specifically ask for it (22). In the case of mHealth initiatives, limited digital literacy contributes to older adults’ inability to understand and utilize technology (12,16). One other finding about approachability was absence of Braille signage which would hinder accessibility for visually impaired individuals (15). Educational initiatives and health promotion campaigns were important for enhancing awareness (13). In Tunisia, knowledge of influenza and its severity was associated with a higher willingness to get vaccinated (24). Physicians played a key role as trusted sources of information, especially for vaccine-related decisions (24).

Ability to seek and acceptability

The barriers related to acceptability, shaped by health beliefs, fear, and trust, were reported as critical determinants of healthcare access. In Egypt, low health literacy and limited understanding of health information reduced elderly engagement with available services (22). Studies from Saudi Arabia reported fear-based avoidance of preventive services, including cancer screenings (17) and vaccinations (14), as well as mistrust about the aspects of digital health technologies and their use (12). Cultural resistance and hesitancy based on belief were observed in Iran (21); it was also discussed related to the telehealth settings in the region (10). The patterns indicate that service availability alone is insufficient to ensure utilization, particularly for preventive and technology-enabled care. A positive attitude toward mHealth, including perceived usefulness, need, and ease of use, facilitated acceptance among users (12). Providing patient-centered care and respecting cultural beliefs were facilitators of acceptability (17).

Ability to reach and availability/accommodation

Limited availability of services and uneven health system capacity emerged as a significant barrier to elderly healthcare access across MENA countries. Studies from Egypt (22) and Morocco (19) reported unavailability of some services for the old, in addition to medicine shortages, and longer waiting times within public healthcare facilities. In Iran, rural versus urban disparities in health resource allocation were noted, with rural elderly populations experiencing markedly reduced access to essential services (21). In Saudi Arabia, availability challenges noted in the selected studies were more system-specific, including constraints in preventive and screening services (17); and broader system level capacity and insurance coverage gaps (11). Similarly, in Tunisia, limitations in vaccination service availability at primary care centers affected elderly uptake of preventive care (24). The findings indicate that even in comparatively developed health systems, service availability remains uneven across care settings and regions for the elderly.

Geographic accessibility was a dominant challenge across both low- and middle-income contexts. Transportation availability and physical access to facilities were repeatedly identified as major barriers, especially for older adults with mobility limitations (14,15,17,22-24). Distance and travel time to healthcare facilities further constrained access, particularly in rural and underserved areas (19-21). In Jordan, transportation difficulties were strongly associated with reduced Primary Health Care (PHC) utilization among older adults (23). Comparable barriers were documented in Saudi Arabia, where distance and transport limitations affected access to general healthcare services (15); screening programs (17); and routine care (13). In Morocco and Tunisia, geographic barriers disproportionately affected elderly populations residing outside urban centers (19,24). Even where services available, physical barriers within facilities such as stairs, lack of handrails, and inaccessible layouts further limited reachability (15). Social support and living with spouse were enablers of healthcare access in Saudi Arabia (9,12) and Iran (21).

Ability to pay/affordability

Household income strongly affected healthcare utilization, with lower-income individuals facing greater barriers (11,18,20-23). Affordability barriers were consistently reported across diverse healthcare financing models. In Egypt, elderly individuals faced compounded financial barriers, including service costs, transport expenses, and informal payments (22). Insurance coverage was a key facilitator, particularly in settings relying on out-of-pocket payments (11,21). In Saudi Arabia, though an extensively covered public healthcare system exists, a few studies highlighted the growing impact of out-of-pocket payments, insurance coverage gaps, and service-specific costs for the elderly (11,14). Financial barriers were also evident in the context of digital health, where the cost of devices and internet connectivity limited telehealth access for elderly users (10). The findings suggest that financial protection mechanisms remain insufficiently responsive to the needs of aging populations.

Ability to engage and appropriateness

Lack of follow-up services and long-term chronic care management were significant issues, leading to fragmented, disease-centric care approaches (22). Inadequate information by healthcare providers and poor patient-provider communication hinder engagement (22). Lack of family support and living alone significantly reduced engagement in healthcare (11,17). The absence of an internal complaints mechanism also limits older adults’ ability to resolve issues and engage effectively (22). No standard protocol for lifestyle counseling was found in one of the studies reported (15). For mHealth, technical issues, glitches, and inconsistent interfaces make user engagement difficult (16).

Good communication skills and continuity of care are critical for improving engagement. Health care providers’ recommendations significantly influence vaccine uptake (14). Tailored interventions, including comprehensive geriatric assessment and educational initiatives, were vital for promoting health and self-care (13). Training of physicians on telehealth was also a facilitator (10). Positive perceptions of mHealth utility, such as for booking appointments, tracking health, medication reminders, and telemedicine, increased engagement (16). Table 3 provides a cross-country comparison of the core barriers to healthcare access identified across the six MENA countries included in this review.

Discussion

Key findings

The Levesque et al. (1) framework guided the review of identifying influencing factors of healthcare access and provided useful insights into the study population. The ‘ability to perceive/approachability’ and ‘ability to reach/availability’ dimensions were most frequently addressed, reflecting majority research focusing on awareness, transportation, and geographic access barriers. The ‘ability to pay/affordability’ dimension also appeared frequently, primarily in studies from Morocco, Egypt, and Iran where out-of-pocket payments are substantial. In contrast, the ‘ability to seek/acceptability’ dimension was addressed less often, and the ‘ability to engage/appropriateness’ dimension was the least represented. This pattern suggests that while the literature adequately documents entry-level access barriers (knowing about and reaching services), it comparatively neglects downstream dimensions concerning whether older adults can meaningfully engage with and benefit from the care received.

The identified factors in the review are not independent of each other but rather deeply interconnected, forming a complex system that impacts older adults’ journey of health service utilization. For instance, socio-demographic factors such as lower education and income levels frequently intensify economic barriers, including the lack of health insurance or the inability to afford essential services. These economic constraints, in turn, severely restrict access, especially when they are coupled with geographic barriers like inadequate public transportation, long distances to facilities, or the limited availability of local care services.

Across the included studies, perception of need emerged as the most consistently reported determinant of healthcare access, influencing whether older adults recognized the necessity of seeking care regardless of service availability or affordability. Our findings noted that a higher level of education is a crucial determinant in enhancing healthcare utilization among older adults, which has been corroborated by other studies in the literature (25,26). Even when need was perceived, logistical barriers frequently delayed or prevented care. Older adults who lived alone without family support were associated with lower abilities to reach out for care, indicating the need for someone to accompany them to the hospitals to ensure timely care and service access among older adults. A similar pattern is noted across the literature (27).

Strengths and limitations

This scoping review has several strengths. The rigorous methodological approach, guided by PRISMA-ScR, ensured transparency and reproducibility. However, some limitations should be acknowledged. The heterogeneity of study designs and outcomes limited the ability to directly compare findings or conduct meta-analysis. Additionally, the included studies varied in their operationalization of healthcare access dimensions, which may have led to underrepresentation of some dimensions in reported findings. Although this review included a small number of studies with a population of 50 years and above to ensure adequate representation of the research scope in the MENA context, this may limit generalizability to regions where older age is conventionally defined as 60 or 65 years and above. The geographic coverage of this review is substantially limited. Nine of sixteen included studies were conducted in Saudi Arabia, while only a single study represented Iran, Egypt, Jordan, and Tunisia, and three studies from Morocco. Despite these limitations, the review offers valuable insights into key equity issues in healthcare access for older adults in the region. The review confirmed that a supportive family presence facilitates healthcare access for the elderly (12,21).

Comparison with similar research

The findings of this review align with global evidence on healthcare access for older populations. The consistent identification of transportation barriers, financial constraints, and rural-urban disparities as major challenges has been documented in systematic reviews from other world regions, including South Asia (27), sub-Saharan Africa (28,29), and Latin America (30). Residing in rural areas is linked to delayed or foregone care due to infrastructural constraints, a pattern documented across other studies (31,32).

Studies in India and Indonesia have similarly reported that lower education and lack of family support are strong predictors of reduced healthcare utilization among older adults (25,33). The finding that supportive family presence facilitates access is consistent with broader literature on the role of social support in geriatric care (33,34). However, the extent of family reliance observed in MENA countries may be culturally specific, given the region’s strong norms of intergenerational co-residence and filial responsibility (34).

Explanations of findings

The predominance of barriers related to ‘ability to perceive’ and ‘ability to reach’ can be explained by the demographic and infrastructural realities of the MENA region. Rapid urbanization has concentrated health resources in cities, while rural populations age in place with declining service availability. Low health literacy, documented across multiple studies, reflects both limited educational attainment among current cohorts of older adults (many of whom did not have access to universal education in their youth) and insufficient health promotion efforts targeted to this age group. The finding that affordability barriers persist even in countries with publicly funded healthcare systems (e.g., Saudi Arabia, Egypt) can be explained by the structure of coverage gaps.

The findings highlighted structural challenges in rural healthcare facilities, including poor infrastructure and limited resources (20), consistent with existing literature on rural health access (28,29). Geographic disparities between rural and urban areas were evident, with transportation challenges, long travel distances, and uneven service distribution restricting access to healthcare. For instance, studies in Egypt and Iran highlighted the challenges of uneven distribution of resources and insufficient services as factors affecting access (21,22). In Saudi Arabia, some studies have reported that transportation barriers and limited screening services further restricted access to essential care (14,17). In Morocco, geographic barriers led to long travel times that markedly hindered healthcare access for elderly, especially in the underserved regions (19). Addressing geographic and transportation barriers could include establishing satellite clinics in underserved areas or deploying mobile health units, linking community clinics to district hospitals. The Moroccan context further emphasizes that healthcare planning must account for transport availability, road conditions, and older adults’ mobility limitations, not just physical distance. Without addressing these factors, geographic barriers will continue to create unequal healthcare access despite service availability.

Ability of paying for care was highly influential in specific services such as dental and insurance dependent services (9). However, studies reported affordability related challenges, with out-of-pocket payments and lack of insurance being consistent barriers across the region (11,18,20). These findings align with the broader understanding that financial vulnerability in older populations often intersects with healthcare inaccessibility, especially in contexts where health insurance coverage is limited or absent (30,35). Insurance availability and use have been a dominant enabler of healthcare access as the literature has shown, mitigating affordability barriers and promoting equitable access (33,36).

Acceptability reflected cultural, psychological, and informational barriers. Fear of diagnoses, misconceptions about preventive care (e.g., vaccines), and low health literacy contributed to reduced service uptake among older adults in Saudi Arabia, Iran, and Egypt (17,21,22). Though promising for future directions, digital health services faced challenges in acceptability among older populations due to digital literacy gaps and mistrust in technology (10,12). Poor service quality, lack of coordination, and systems not designed for older adults reduced engagement, while family support partially mitigated these barriers and improved the ability to engage (10,12,22). Key barriers such as low digital literacy, mistrust, and poor interface design can be addressed through simplified and accessible platforms, digital literacy training, family or peer support, and hybrid models combining digital and human assistance. Usability can be improved through simplified interfaces with large icons, high-contrast displays, voice-activated commands, and error-tolerant designs that minimize cognitive load. Accessibility features should include text magnification, screen reader compatibility, and alternative input methods for older adults with visual or motor impairments. Without such adaptations, digital health expansion may worsen healthcare access inequities among older adults. User-centric design for mHealth, including continuous practice and motivational elements, can foster engagement (10). Together, these findings illustrate that meaningful access extends beyond utilization to sustained engagement with appropriate care.

The barriers identified in this review also reflect inefficiencies in healthcare resource allocation across the MENA region. Specialized geriatric services are concentrated in urban tertiary hospitals, while rural primary care centers remain under-resourced, leading to overcrowding and long waiting times in public hospitals alongside underused rural clinics, particularly in Egypt and Morocco. This imbalance highlights a preference for centralized hospital-based care over accessible, age-appropriate primary care. Addressing these issues requires demand-driven resource allocation that considers the geographic distribution, healthcare needs, and transportation challenges of the elderly population. New age technologies and artificial intelligence-based interventions must be adopted. The studies show that integrating artificial intelligence (AI) and simulation has the potential to improve the efficiency of healthcare management, optimize resource allocation, and reduce waiting times (37).

In addition, framing the observed system-level challenges within a capacity constraints and demand-supply imbalance perspective reveals important insights. Rapid population aging in the MENA region has not been matched by sufficient growth in geriatric care capacity, trained personnel, or age-friendly infrastructure. Consequently, healthcare systems rely more on acute, episodic care rather than effective chronic disease management. The underutilization of preventive services among older adults in MENA reflects a complex interplay of low perceived risk, fear of diagnosis, and provider-related factors. Unlike acute care, which is often illness-driven, preventive care requires proactive engagement, a challenge when health literacy is low. Digital health presents both opportunities and challenges. While mHealth offers potential for medication reminders, appointment booking, and teleconsultations, the digital divide among older adults characterized by low digital literacy, mistrust, and lack of age-appropriate design severely limits uptake. Addressing these issues requires strategic workforce planning, infrastructure investment, and service models aligned with the needs of an aging population.

Implications and actions needed

Based on the synthesized evidence, we propose a tiered framework for policy action organized by resource availability.

Low-resource settings

The suggested practices include: train community health workers to conduct basic health education and referral linkage for elderly in underserved areas; establish simple referral protocols between primary care and district hospitals; implement age-friendly communication practices (clear signage, slower appointment scheduling, family involvement protocols); develop illustrated health information materials addressing local literacy levels.

Medium-resource settings

Introduce mobile health units for preventive screenings (hypertension, diabetes, osteoporosis) in rural catchment areas; expand transportation support programs (vouchers, community transport schemes, coordination with existing public transport); strengthen insurance coverage for geriatric preventive services and chronic medications; develop age-appropriate telehealth platforms with digital literacy support; establish family caregiver training programs integrated into primary care.

High-resource settings

Redesign primary care networks with age-friendly infrastructure and dedicated geriatric services; integrate electronic health records to improve care continuity and reduce fragmentation; implement value-based payment models incentivizing preventive and chronic care coordination; establish regional geriatric assessment units with multidisciplinary teams; develop national digital health strategies with age-inclusive design standards and mandatory usability testing with older adults.

Conclusions

This scoping review shows that healthcare access for older adults across six MENA countries is shaped by a wide range of interconnected barriers and facilitators across all dimensions of the Levesque framework. However, findings are limited by geographic concentration in specific high-income nations and the small number of countries represented. Common challenges included low awareness of services, cultural and social constraints, transportation difficulties, financial limitations, and problems related to service quality and continuity of care. At the same time, factors such as the presence of chronic conditions, higher education, family and social support, insurance coverage, and physician recommendations were found to support access. The findings also highlight clear differences among countries, reflecting variations in health system organization, infrastructure, and social contexts. Overall, the evidence points to the need for more comprehensive and context-specific strategies that address multiple dimensions of access simultaneously, rather than focusing solely on service availability or utilization.

Acknowledgments

The authors would like to thank the Scientific Research Deanship at Jazan University and the Research Ethics Committee at Universiti Kebangsaan Malaysia.

Footnote

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://jphe.amegroups.com/article/view/10.21037/jphe-2026-1-0008/rc

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-2026-1-0008/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-2026-1-0008/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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