Identity Negotiation and Resilience among Families with Stunted Children

1. Introduction

Child stunting remains one of the most complex public health issues in many developing countries, including Indonesia. Medically, stunting refers to a condition of growth failure characterized by a child's height being below the standard for their age due to chronic malnutrition over a long period of time (Leroy and Frongillo, 2019). A report from the World Health Organization shows that stunting not only affects physical growth, but is also linked to delayed cognitive development, low educational attainment, and reduced productivity in adulthood. In other words, stunting is not just a child health issue, but also a challenge for future human resource development (World Health Organization, 2019). Despite various nutritional intervention programs, the prevalence of stunting in Indonesia remains relatively high in a number of rural areas due to unequal access to basic health and sanitation services. Based on the Indonesian Nutrition Status Study (SSGI), although the national figure continues to decline, the disparity between urban and rural areas remains significant. (Kementerian Kesehatan RI, 2025). In remote areas, determining factors such as lack of access to clean water, limited sanitation facilities, and low levels of parental education regarding parenting practices during the first 1,000 days of life (HPK) are major obstacles to the effectiveness of government programs (Fristiwi, Nugraheni and Kartini, 2023). This shows that the dominant approach has focused on nutrition and health aspects, and has not been able to fully explain the complexity of the problems faced by families with stunted children.

From 2021 to July 2024, Banjarnegara Regency was recorded as the region with the highest prevalence of stunting in Central Java Province (Kementerian Kesehatan RI, 2025). The high rate of stunting is mainly found in a number of mountainous and rural areas with limited basic infrastructure. One of the factors contributing to this condition is limited access to clean water and proper sanitation. As a region with mountainous geographical characteristics, several villages in Banjarnegara still face difficulties in obtaining adequate clean water sources and waste management systems that meet health standards. In addition, the high rate of child marriage is also a serious challenge because it contributes to an increased risk of low birth weight babies who are prone to stunting (Dinas Komunikasi dan Informasi Kabupaten Banjarnegara, 2024). Geographical factors exacerbate the situation, as the relatively difficult terrain in several subdistricts means that nutritional intervention programs and health services cannot always reach all areas evenly. Recognizing the complexity of this issue, the Banjarnegara Regency Government has set a target of reducing the prevalence of stunting to 14% by 2024, in line with the national target in the National Medium-Term Development Plan (RPJMN). To achieve this target, the local government has initiated various programs, including the "Jo Kawin Bocah" movement, which aims to reduce the practice of early marriage, and the optimization of village funds to support supplementary feeding programs (PMT), particularly those based on animal protein for children at risk of stunting (Dinas Komunikasi dan Informasi Kabupaten Banjarnegara, 2023).

When viewed more broadly from a biological perspective, families with stunted children often face social consequences that are no less significant. Parents often encounter comments, judgments, and even accusations from their social environment that associate their child's condition with parenting failure (Lestari, Kristiana and Paramita, 2018). This situation creates psychological and social pressure that can affect how parents view themselves. Within the framework of Stigma Theory introduced by Erving Goffman (1963) (dalam Tyler & Slater, 2018), Certain health conditions can be attributes that lower a person's social value in the eyes of society. Stigma not only attaches itself to individuals experiencing these conditions, but can also extend to family members who are considered responsible (Putri, Kartasurya and Musthofa, 2024). In the context of stunting, parents are often placed in a defensive position to explain or justify their parenting practices. Therefore, understanding stunting solely as a medical problem risks ignoring the social experiences of families living with this condition.

Previous studies have shown that stunting cannot be understood solely as a medical issue, but rather as a phenomenon shaped by complex interactions between social, economic, and cultural factors. Research by Li & Walker (2017) emphasizes that stunting is a multidimensional phenomenon influenced by the interaction between poverty, parental education, access to health services, and parenting practices developed in specific social contexts. In this context, families are not only faced with biological issues concerning their children, but also with social pressures that influence how they interpret and respond to these conditions. In addition, the social dimension of stunting is often linked to the emergence of stigma against families with children who experience growth retardation. Research by Hatzenbuehler et al. (2013) shows that health stigma can exacerbate family vulnerability because they tend to withdraw from social interaction or are reluctant to access health services due to shame or fear of blame. This condition ultimately has the potential to reinforce the cycle of vulnerability, as families who need support become increasingly isolated from available sources of assistance. However, most research on stunting still focuses on nutritional determinants, sanitation, or economic factors (Anggraini et al., 2024; Bahar et al., 2024; Hanifah and Syahrizal, 2024). This approach is certainly very important, but in many cases, it is not yet fully capable of explaining how families socially and emotionally deal with the situation when their child is diagnosed with stunting. Therefore, studies that place family communication and the process of identity negotiation as part of the family's experience with stunted children are becoming increasingly relevant to develop.

In communication studies, identity is not understood as something static or inherent to individuals, but rather as a social construct that continues to evolve through interactions with others. This perspective places communication as the primary space where identity is formed, maintained, and negotiated. Stella Ting-Toomey explains that individual identity is always in a process of negotiation between how a person views themselves and how they are perceived by others (Ting‐Toomey, 2015). In everyday life, these two dimensions are not always in harmony. A person may have a certain understanding of themselves, but their social environment may hold a different view. When there is a discrepancy between these two perceptions, individuals tend to employ various communication strategies to maintain, renegotiate, or even reconstruct their identity (Ting-Toomey, 2017). This process becomes even more complex when an individual's identity is vulnerable to social judgment, such as in the context of family health. In situations where families face stigma related to their child's health condition, the process of identity negotiation becomes even more important because their identity as "good parents" may be questioned by their social environment (Dorjee and Ting‐Toomey, 2020).

On the other hand, studies on resilience in communication science provide a perspective that complements our understanding of how individuals and families respond to such social pressures. Resilience is no longer understood as the ability of individuals or families to survive in difficult situations, but as a social process that is formed through daily communication practices. Patrice M. Buzzanell argues that resilience is formed through daily communication practices that help individuals maintain their identity, build social support, and create new meaning from difficult experiences (Buzzanell, 2017). This approach opens up a broader perspective in understanding the experiences of families with stunted children. Instead of viewing families solely as parties affected by stigma, the perspective of communication resilience allows us to see how families actively construct meaning from these experiences (Wilson et al., 2021).

Although Identity Negotiation Theory and Resilience Communication Theory have been widely used in interpersonal and family communication studies, the integration of these two perspectives in the context of families with stunted children is still rare. Most studies on family resilience focus on crisis situations such as chronic illness, disaster, or family conflict (Lillie, Venetis and Chernichky‐Karcher, 2023; Gözen, Tuncay and Kamış, 2025). Meanwhile, the context of stunting as a social experience fraught with stigma has not been widely explored from a communication perspective (Lestari, Kristiana and Paramita, 2018; Situmeang, Sudaryati and Jumirah, 2020; Simbolon and Sitompul, 2024). This gap highlights the need for research that can explain how families interpret their experiences, negotiate identity, and build resilience in the face of social pressures arising from stunting. Based on this background, this study aims to explore the communication experiences of families with stunted children, particularly in the process of identity negotiation and family resilience building. Specifically, this study poses two main questions: (1) how do parents with stunted children interpret their experiences in the context of social interaction and stigma; and (2) how does the communication process within the family help them negotiate identity and build resilience. These research questions are central because they are directly related to the objective of understanding the social processes that shape families' responses to stigma. In addition, this study also explores secondary questions regarding the communication strategies used by parents to maintain or reconstruct their identities in the face of their social environment.

To answer these questions, this study uses a qualitative approach with the Interpretative Phenomenological Analysis (IPA) method, which allows researchers to deeply explore participants' subjective experiences in interpreting the social realities they face (Tuffour, 2017). This approach was chosen because the focus of the study was not on measuring variables, but rather on understanding the meaning of the family's experience in dealing with stigma and social pressure. Through in-depth interviews with parents who have stunted children, this study sought to reveal how these experiences were understood, negotiated, and integrated into the family's identity (Bayer, 2024). Theoretically, this study is expected to enrich communication studies by showing that family resilience is not only related to the ability to adapt to difficulties, but also to the ability to reconstruct identity through communication. In practical terms, the findings of this study are expected to provide insights for health workers, policymakers, and community facilitators to design intervention approaches that are more sensitive to the social experiences of families. By understanding that stigma and identity are part of the family experience with stunted children, interventions designed should not only focus on medical aspects, but also on communication support and strengthening family identity.

2. Method

2.1 Research Design

This study uses a qualitative approach with the Interpretative Phenomenological Analysis (IPA) method. This approach was chosen because the study aims to deeply understand the subjective experiences of parents in dealing with stunting in children and how they interpret these experiences in their daily lives. The IPA method emphasizes the exploration of the meaning of personal experiences and how individuals interpret these experiences in a broader social context (Tuffour, 2017). This approach was developed by Jonathan A. Smith et al. (2009) and is widely used in research focusing on complex and meaningful life experiences (Smith and Osborn, 2004; Bayer, 2024). In the context of this study, IPA allows researchers to explore in depth how parents interpret stunting diagnoses, deal with social pressure from their environment, and develop communication strategies to maintain their family identity (Smith and Osborn, 2004). This study is naturalistic in nature, meaning that the researcher did not manipulate conditions or intervene in any way with the participants. Data was obtained through direct interaction with participants in the form of in-depth interviews that allowed for comprehensive exploration of their experiences (Miller, Chan and Farmer, 2018).

2.2 Participants

Participants in this study were parents who had children with stunting. The inclusion criteria for participants were: (1) having a child who had been diagnosed with stunting by a health worker based on the World Health Organization's growth standards, (2) being the child's parent or primary caregiver, and (3) being willing to participate voluntarily in the study. There were no specific restrictions regarding education level, occupation, or socioeconomic status, as this study aimed to capture the diversity of family experiences. A total of 13 parents participated in this study. The number of participants was in line with the characteristics of IPA research, which generally uses small but in-depth samples to enable detailed analysis of experiences (Oluka, 2025). Most participants were mothers as the primary caregivers of their children, while some participants were fathers who were directly involved in childcare.

2.3 Sampling Procedures

The sampling technique used was purposive sampling, which is the deliberate selection of participants based on specific criteria relevant to the research objectives. Participants were recruited with the help of village health cadres and posyandu (integrated health service post) officers in Banjarnegara Regency, Central Java, who helped identify families with stunted children. The researchers first explained the purpose of the study to prospective participants and ensured their willingness to participate voluntarily. All participants who were contacted were willing to participate in the study, so there were no refusals during the recruitment process. Interviews were conducted in an environment that was comfortable for the participants, generally in their homes or at village health facilities. This study has met the ethical standards for social research. All participants were given an explanation of the purpose of the study, the confidentiality of the data, and their right to withdraw from participation at any time. Participation consent was obtained through an informed consent process, and all participant identities were anonymized in the reporting of the research results.

2.4 Sample Size, Power, and Precision

The number of participants in this study was 13 parents. In the IPA approach, sample size is not determined by the need for statistical generalization, but rather by the depth of exploration of the participants' experiences. A relatively small sample allows researchers to conduct in-depth interpretive analysis of participants' narratives. The characteristics of the participants in this study reflect the family context in the rural area of Banjarnegara, most of whom have a lower-middle socioeconomic background and depend on the informal sector. Therefore, the interpretation of the results of this study focuses on understanding experiences in that context and is not intended to be statistically generalized to a wider population.

2.5 Measures and Data Collection

The main research data was collected through in-depth interviews. The interviews were semi-structured using interview guides designed to explore participants' experiences related to several main themes, namely: experiences of receiving a stunting diagnosis, emotional and social responses that arose, interactions with the social environment, and communication dynamics within the family. Each interview lasted between 45 and 90 minutes and was recorded with the participants' consent (Creswell, 2019). In addition to recording the interviews, researchers also took field notes documenting the context of the interview situation, participants' nonverbal expressions, and researchers' initial reflections on the narratives presented. To improve data quality, interviews were conducted in a dialogical manner so that participants had the space to freely recount their experiences (Oluka, 2025). The researchers also conducted limited member checking by reconfirming some initial interpretations with participants to ensure consistency of meaning.

2.6 Research Design and Data Analysis

Data analysis was conducted following the stages of Interpretative Phenomenological Analysis (Miller, Chan and Farmer, 2018). The analysis process was carried out in several main steps. First, the researcher read the interview transcripts repeatedly to understand the participants' overall narratives. Second, the researcher conducted initial coding by identifying important parts of the narrative related to identity experiences, stigma, and family communication dynamics. Third, these codes were then grouped into emergent themes that reflected patterns of meaning in the participants' experiences. The next stage was to conduct a cross-case analysis to find similarities and differences in patterns of experience among participants (Smith, Flowers and Larkin, 2009). This process produced several main themes that describe how parents negotiate their identities in the face of stigma and how communication within the family plays a role in building resilience. Through this approach, the study not only describes the participants' experiences, but also interprets the deeper meaning of these experiences within the framework of communication and identity theory (Smith and Osborn, 2004; Oluka, 2025).

3. Results

This section presents the results of the analysis of interview data obtained from research participants. The findings focus on how parents interpret the experience of having a child with stunting, how they deal with the social pressures that arise, and how the communication process within the family helps them build resilience. The analysis was conducted thematically using the Interpretative Phenomenological Analysis approach developed by Jonathan A. Smith. Through this analysis process, this study identified several main themes that describe the dynamics of parental experiences, namely early identity disruption, identity pressure from the social environment, identity negotiation strategies, and the process of building family resilience.

3.1 Recruitment

The participant recruitment process was conducted between February and July 2025 in Wanayasa Subdistrict, Banjarnegara Regency, Central Java. Prospective participants were identified through collaboration with village health cadres and posyandu (integrated health service post) officers who had data on families with stunted children based on the growth standards used by the World Health Organization. A total of 13 parents agreed to participate in this study. All participants who were contacted expressed their willingness to participate in the interviews after receiving an explanation of the research objectives and assurances of data confidentiality. The interviews were conducted face-to-face at the participants' homes or at village health facilities, such as posyandu.

3.2 Statistics and Data Analysis

Data analysis was conducted through several main stages that characterize the Interpretative Phenomenological Analysis method. The analysis process began with repeatedly rereading the interview transcripts to fully understand the context of the participants' experiences. After that, the researchers conducted initial coding by identifying important parts of the participants' narratives related to experiences of stigma, identity as parents, and communication dynamics within the family. These initial codes are then grouped into identified themes, which reflect patterns of meaning that emerge in the participants' experiences. The next stage is to conduct a cross-case analysis to find similarities and differences in the experiences between participants. This process produces five main themes that describe the dynamics of parents' experiences in dealing with stunting in children.

The first theme is early identity disruption. For most participants, the diagnosis of stunting was a turning point that changed the way they viewed themselves as parents. Many participants expressed feelings of guilt and shame when they first learned of their child's condition. Some parents felt that this condition was proof of their failure to fulfill their role as caregivers. The second theme is external identity pressure. After the diagnosis of stunting became known to their social circle, a number of participants reported comments or judgments from neighbors and extended family members who linked the child's condition to the parents' parenting style. In some cases, these comments made parents feel directly or indirectly blamed.

The third theme is identity negotiation strategies. In facing these social pressures, parents develop various communication strategies to maintain or reconstruct their identities. Some parents choose to build a defensive identity by explaining other factors that influence their children's condition, such as medical history or genetic factors. Others try to reframe their experiences by emphasizing that stunting is a health problem that can be remedied through continuous care and attention. The fourth theme is identity anchoring through family communication. Many participants emphasized the importance of their spouse's support in facing social pressure. Open communication between husbands and wives helps them strengthen each other and reduce feelings of mutual blame. In some families, emotional support from spouses is an important factor that helps parents maintain confidence in their parenting roles. The fifth theme is identity transformation towards resilience (identity-based resilience). Over time, some participants showed a change in their perspective on their experiences. Instead of continuing to see themselves as failed parents, they began to view these experiences as a learning process that strengthened family relationships. This transformation in meaning was often influenced by social support, interactions with health workers, and spiritual beliefs that helped them accept their children's conditions.

3.3 Ancillary Analyses

Data analysis was conducted through several main stages that characterize the Interpretative Phenomenological Analysis method. The analysis process began with repeatedly rereading the interview transcripts to fully understand the context of the participants' experiences. After that, the researchers conducted initial coding by identifying important parts of the participants' narratives related to experiences of stigma, identity as parents, and communication dynamics within the family. These initial codes are then grouped into identified themes, which reflect patterns of meaning that emerge in the participants' experiences. The next stage is to conduct a cross-case analysis to find similarities and differences in the experiences of the participants. This process produced five main themes that describe the dynamics of parents' experiences in dealing with stunting in children.

The first theme is early identity disruption. For most participants, the diagnosis of stunting was a turning point that changed the way they viewed themselves as parents. Many participants expressed feelings of guilt and shame when they first learned of their child's condition. Some parents felt that this condition was proof of their failure to fulfill their role as caregivers. The second theme is external identity pressure. After the diagnosis of stunting became known to their social circle, a number of participants reported comments or judgments from neighbors and extended family members who linked the child's condition to the parents' parenting style. In some cases, these comments made parents feel directly or indirectly blamed.

The third theme is identity negotiation strategies. In facing such social pressure, parents develop various communication strategies to maintain or reconstruct their identities. Some parents choose to build a defensive identity by explaining other factors that influence their children's condition, such as medical history or genetic factors. Others try to reframe their experiences by emphasizing that stunting is a health problem that can be remedied through continuous care and attention. The fourth theme is identity anchoring through family communication. Many participants emphasized the importance of their spouse's support in facing social pressure. Open communication between husbands and wives helps them strengthen each other and reduce feelings of mutual blame. In some families, emotional support from spouses is an important factor that helps parents maintain confidence in their parenting roles. The fifth theme is identity transformation towards resilience (identity-based resilience). Over time, some participants showed a change in their perspective on their experiences. Instead of continuing to see themselves as failed parents, they began to view these experiences as a learning process that strengthened family relationships. This transformation in meaning was often influenced by social support, interactions with health workers, and spiritual beliefs that helped them accept their children's conditions.

3.4 Baseline Data

The basic characteristics of the participants show that the majority of participants are mothers who are the primary caregivers of their children. Most families live in rural areas with their main livelihoods in the informal sector, such as agriculture, small trade, or domestic work. The participants' education levels varied, ranging from elementary school to high school. Most of the children who were the focus of the participants' experiences were toddlers when they were first diagnosed with stunting. The diagnosis was generally obtained through routine checkups at health posts or local health facilities.

4. Discussion

This study aims to understand how families with stunted children negotiate their identities while building resilience through communication processes that occur in everyday family life. The findings of this study are in line with the family resilience framework proposed by Walsh (2016)which emphasizes that a family's ability to survive and adapt in difficult situations depends not only on individual strength, but also on how the family builds shared meaning, maintains open communication patterns, and develops emotional support among family members. The findings of this study show that the experience of having a child with stunting is not only related to health issues, but also gives rise to social and psychological dynamics that affect parental identity (Potts and Henderson, 2020). In general, the results of this study support the main hypothesis that identity negotiation is an important mechanism in the process of forming family resilience. Through interpersonal communication, parents attempt to reconstruct the meaning of their experiences so that they can maintain a positive identity as caregivers (Johansen and Varvin, 2020). This finding also reinforces the secondary hypothesis that social stigma against stunting triggers identity pressure that encourages families to develop adaptive communication strategies (Theiss, 2018).

One of the main findings of this study was the emergence of early identity disruption when parents first received a diagnosis of stunting in their children. Many participants revealed that this moment became a turning point that brought up various emotional feelings such as guilt, shame, and even doubts about their abilities as parents (Ligar, Kartasurya and Musthofa, 2024). This emotional reaction shows that a stunting diagnosis is not only understood as medical information, but also as a social experience that can influence how parents interpret their parenting roles. These findings are in line with research by Wulandari et al. (2025) which shows that children's health conditions are often linked to assessments of parents' abilities, particularly mothers, in carrying out their caregiving roles. In the literature on social stigma developed by Erving Goffman, stigma is understood as a process of social labeling that can damage an individual's identity (Tyler and Slater, 2018). In the context of stunting, social labeling of families often reinforces feelings of failure among parents, especially when society associates the child's condition with parenting patterns or the family's socioeconomic status (Putri, Kartasurya and Musthofa, 2024).

The findings of this study also show that identity pressure from the social environment plays an important role in shaping parents' experiences. Comments from neighbors, extended family members, and the surrounding community often reinforce the perception that parents are fully responsible for their children's condition. These findings are in line with research by Nabunya et al. (2020) which shows that families with members who have certain health conditions often face a form of stigma known as courtesy stigma, which is stigma experienced by individuals because of their association with others who are considered socially "problematic." In this context, parents become the target of social judgment that can affect the way they view themselves (Tekola et al., 2020). However, this study also found that parents did not passively accept these negative labels. Instead, they developed various identity negotiation strategies to maintain or reconstruct their identities as responsible parents (Masten, 2018). Some participants built a defensive identity by explaining that stunting is not always caused by parenting mistakes, but is also influenced by health factors or environmental conditions. Another strategy that emerged was reframing, which is an attempt to reframe the experience of having a stunted child as a learning process that encourages parents to be more attentive to their child's health.

The process of negotiating identity occurs primarily through communication within the family. Many participants emphasized the importance of their spouse's support in dealing with social pressure from their environment. Open communication between husband and wife helps them reduce mutual blame and strengthen family solidarity. These findings are in line with the perspective of resilience communication developed by Some participants built a defensive identity by explaining that stunting is not always caused by parenting mistakes, but is also influenced by health factors or environmental conditions. Another strategy that emerged was reframing, which is an attempt to reframe the experience of having a stunted child as a learning process that encourages parents to be more attentive to their child's health.

The process of negotiating identity occurs primarily through communication within the family. Many participants emphasized the importance of their spouse's support in dealing with social pressure from their environment. Open communication between husband and wife helps them reduce mutual blame and strengthen family solidarity. These findings are in line with the perspective of resilience communication developed by Buzzanell (2017) which explains that resilience is not only an individual trait, but is also built through daily communication practices that enable individuals to negotiate the meaning of difficult experiences. Within the framework of resilience communication theory, processes such as crafting normalcy, affirming identity anchors, and maintaining communication networks become important mechanisms in building psychological and social resilience (Buzzanell and Houston, 2018). The results of this study show that families with stunted children actively engage in this process. For example, some parents try to recreate a sense of "normality" in family life by continuing to carry out daily activities as usual. At the same time, they strengthen their family identity through emotional support, religious values, and the belief that their child's condition can still be improved through joint efforts.

Another important finding is the transformation of identity towards resilience (Groeninck et al., 2020). Over time, some parents began to change the way they interpreted the experience of having a child with stunting. While initially they felt ashamed and depressed, in the long term some participants actually saw the experience as a process that strengthened family relationships. This transformation in meaning shows that family resilience does not happen instantly, but develops through a process of communication that enables families to rebuild their identity in a positive way (Masten, 2018; Wilson et al., 2021).

However, the results of this study need to be understood with consideration of several limitations. First, this study was conducted in a specific cultural and geographical context, namely families in rural areas of Banjarnegara Regency. The social, cultural, and economic conditions in this region may influence the experience of stigma and family communication strategies. Therefore, the findings of this study cannot be directly generalized to different social contexts. Second, the number of participants in this study was relatively small because it followed the characteristics of qualitative research, which emphasizes in-depth analysis of experiences. Although this approach allows for in-depth exploration of experiences, the results of this study still need to be supplemented with other studies involving a more diverse range of participants. In addition, this study focused on the experiences of parents as the primary caregivers of children, so the perspectives of other family members, such as grandparents or siblings, were not explored in depth. Future research could broaden the focus of analysis by exploring broader family communication dynamics, including the role of community and social networks in shaping family resilience.

Despite these limitations, this study makes an important contribution to the development of health communication and family communication studies. Theoretically, the findings of this study broaden our understanding of resilience communication by showing that identity negotiation is a central mechanism in the adaptation process of families facing health stigma. In this context, resilience is not only related to the ability to survive difficulties, but also to the ability of families to reconstruct their identities through communication. Practically, the findings of this study also have implications for the development of public health intervention programs. Efforts to address stunting have often focused on medical and nutritional aspects, while the social and family communication dimensions are often overlooked. The results of this study show that an approach that is more sensitive to the dynamics of identity and social stigma can help families deal with stunting in a more adaptive manner. Health workers and community empowerment programs can integrate communication strategies that support the strengthening of family identity and reduce stigma that develops in the community.

Overall, this study confirms that families' experiences with stunted children are not only related to health issues, but also to the dynamics of identity and communication within the family. Family resilience is formed through a process of identity negotiation that allows parents to transform the meaning of their experiences from a source of stigma to a source of strength. These findings emphasize the importance of viewing stunting not only as a nutritional problem, but also as a socio-communicative phenomenon that affects family life more broadly.

Author Contributions: Conceptualization, P.S.N. and W.M.; Methodology, P.S.N.; Formal Analysis, P.S.N.; Investigation, P.S.N.; Data Curation, P.S.N.; Writing – Original Draft Preparation, P.S.N.; Writing – Review & Editing, P.S.N., W.M., D.T.K., A.N.R.; Validation, W.M., D.T.K., A.N.R.; Supervision, W.M., D.T.K., A.N.R.; Project Administration, W.M.

Funding: This research received no external funding

Conflicts of Interest: The authors declare no conflict of interest

Informed Consent Statement/Ethics approval: This study employed a non-interventional qualitative research design. All participants provided written informed consent prior to participation and were informed about the purpose of the study as well as the confidentiality of the data. Participants’ anonymity was maintained throughout all stages of the research in accordance with the principles of social research ethics.

Declaration of Generative AI and AI-assisted Technologies: This study has not used any generative AI tools or technologies in the preparation of this manuscript.