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Abstract

Background

Individuals recovering from acute exacerbation of chronic obstructive pulmonary disease (AECOPD) are most likely to exhibit sedentary behaviour (SB) and low levels of physical activity (PA). This study seeks to explore their choices for adopting current patterns of SB and PA post AECOPD and add to current literature on stable COPD.

Method

A semi-structured interview, based on the broad framework of the Behaviour Change Wheel, was conducted on patients post AECOPD. A phenomenological approach was utilised inductively.

Results

Six participants were interviewed at their homes. Four major themes were identified: (1) low perceived capabilities for engaging in PA; (2) limited understanding on COPD and PA; (3) lack of translation of health knowledge and intentions into actions; and (4) poor adherence to movement-advice from physiotherapist.

Conclusion

Our findings revealed largely psychological and behavioural deficits influencing SB and PA in people post AECOPD, similar to those in stable COPD.

Keywords

Behaviour chronic obstructive pulmonary disease qualitative sedentary physical activity

Introduction

Recent cohort studies have shown patterns of high amount of sedentary behaviour (SB) and low physical activity (PA) in people with chronic obstructive pulmonary disease (COPD).^1–3 PA and SB have been associated with COPD exacerbations and mortality,^4–6 with SB as an independent predictor of mortality among people with COPD. ^4,7 People with COPD who are considered ‘sedentary’ have been found to accumulate more than 70% of their waking time in sitting and lying, and spend more than 30 min in each ‘sedentary’ bout.³ Their accumulation of sitting time and duration of each sitting bout were higher than older adults reported in the Australian Diabetes, Obesity and Lifestyle Study, which also found that greater amounts of sitting time and prolonged sitting time were significantly associated with deleterious cardiovascular health outcomes.⁸

Given moderate-to-vigorous levels of PA are recommended for optimal health benefits in the general population,⁹ improving PA and SB needs to be an essential component in the management of COPD.¹⁰ However, it is acknowledged that increasing PA in people with stable COPD to meet the recommended levels for general healthy adults is challenging, given their reduced exercise capacity and symptoms.¹¹ In addition, evidence on the efficacy of interventions promoting PA in COPD, including exercise training and counselling, is also limited and unclear.¹² Reducing SB by increasing light PA has therefore been suggested instead as a more realistic target for people with COPD.¹¹ Behaviour change is suggested as an approach to develop strategies reducing SB and increasing light activity.^11,13

Multiple studies have investigated determinants to PA and/or SB in COPD; however, these studies were performed predominantly in people with stable COPD or following pulmonary rehabilitation.^13–17 However, little has been reported in people recovering from acute exacerbation of COPD acute exacerbation of chronic obstructive pulmonary disease (AECOPD).¹⁸ Yet, this is a potentially crucial time to address the beliefs and behavioural deficits as early as at post-acute exacerbation, given the cumulative effects of an exacerbation to increased sitting time in the first month, deteriorating lung and physical function, increased breathlessness and fatigue, and recurrence of further exacerbations.^19,20 With the potential to reduce risk of hospitalizations with low intensity PA,²¹ there is a need to deeply explore belief systems on PA and SB in people with AECOPD. It is unclear whether their perceptions towards PA and SB are different from those with stable COPD and/or following pulmonary rehab (where one already has knowledge regarding exercise training).

Engagement in PA and SB in patients with COPD especially after a recent exacerbation can be complex and emotionally laden with multiple hospital appointments, dealing with co-morbidities, lacking social support ¹⁸ and also due to its degenerative nature and lack of spontaneous recovery.²² To better understand the decision-making process for engaging in PA and SB, this study aimed to examine how people with AECOPD make sense of their condition and situation and explore their choices for adopting current patterns of SB and PA post exacerbation.

To scope the process of exploration, the study aimed to obtain depth and not saturation to better understand the particular phenomenon of low PA and high SB within the context of post exacerbation of COPD. The study adopted an idiographic approach similar to an interpretative phenomenological analysis (IPA), where the goal is not to generalize or generate theory but is intended to achieve a richer analysis of the person as a whole and assume connection between the person’s talk, thinking and emotional state.²³

Methods

Participants

Participants were recruited by a senior physiotherapist, SC, during their hospitalization in Singapore General Hospital between June and December 2019. Patients were included if they were admitted for AECOPD and were community ambulant. Patients were excluded if they were admitted for other reasons despite having a diagnosis of COPD, required moderate assistance in activities of daily living (ADLs), on motorized equipment, wheelchair or bed-bound, if there was presence of cognitive impairment or if they were discharged to a community hospital. As the study team recognized that an exacerbation is a stressful event for the participant,¹⁸ all interviews were conducted at participants’ homes, where they would be expected to feel most comfortable to recover. To ensure data relevancy exploring the phenomenon of PA and SB at recovery from exacerbation, 7–14 days post discharge was chosen as the appropriate window for interview.

This qualitative study was part of a larger cross-sectional cohort study evaluating PA and SB patterns in people at post COPD exacerbation. Written informed consent was obtained from all participants and ethics was approved by the SingHealth Centralised Institutional Review Board (2018/3116) and Singapore Institute of Technology Institutional Review Board (2,019,034). This study was funded by Singapore Institute of Technology Seed Funding under Grant E103-H109.

Design

This study had an idiographic focus, aimed at describing the personal lived experiences of each participant, rather than seeking generalized claims, through semi-structured interviews. The approach to exploration and sense-making of personally lived experience/phenomenon is not an objective exercise of word or theme counting where after various iterations of analyses, no new insights emerge, such attaining thematic saturation.^24,25 While 20–30 interviews have been required for thematic saturation,²⁴ the concept of saturation in this study is less relevant,²⁵ given that the focus of the study is on the individual’s lived experience and the interpretation of that experience. In research related to exploring phenomenon, there is no specific number to determine sample adequacy so far,²⁴ but at least six participants were suggested.^23,26 Although a sample size of six does appear to be small, in a study examining the emergence of themes in relation to the number of interviews analyzed, 94% of the metathemes were shown to emerge with six interviews.²⁷ The small number of participants for IPA studies, for instance was stated to be sufficient enough for the discussion of similarity and differences between participants being overwhelmed by the amount of data generated.²³

A homogenous sample of participants is important in studies adopting IPA to explore shared perspectives on a single phenomenon of interest.²³ Purposive sampling was applied in this study and given the small number of participants, this approach was logical in finding a more closely defined group for whom the research question was relevant and significant.²³ As this study was part of the larger study, we applied the qualitative design for a subset of participants from the larger group. In the larger study, more than 90% of the participants were male. At recruitment, there were higher incidences of male than female patients hospitalized for an acute exacerbation of COPD. Therefore, based on the larger recruitment and an attempt to have a homogenous group for this study, the study team chose male participants for the interviews.

All interviews were conducted in English by three researchers, CC, JW, AI; however, there were certain parts that were better expressed in participants’ native languages of Mandarin or Bahasa Melayu. During transcription, these parts were translated into English. The interviews spanned between 45––60 min and were audio-recorded using a voice recorder. Questions in the semi-structured interview were formulated using the Behaviour Change Wheel (BCW) framework ²⁸ as a guide. According to the BCW, behaviour is influenced by three components; capabilities (C), opportunities (O) and motivation (M), and this interplay results in a sub-model called the COM-B model. The study team chose the COM-B model because it is a singular framework for a comprehensive approach across many theories and ecological models at interpersonal, intrapersonal and community level. In addition, it has been used in COPD research on behaviour change in PA and SB and has the potential to determine the component/s and target specific intervention to achieve optimal behavioural modification for people with COPD.^11,29,30

The semi-structured interview focused on topics of perceived changes in PA levels and sedentary levels post exacerbation. Attitudes towards and understanding of their condition were explored. In addition, the perceived capability in engaging in PA, opportunities for reducing SB, perceived motivation in being active, and self-management of COPD were also interviewed in detail.²⁸

The interviewers trialed their semi-structured interview questions with two healthy older adults. At the first three interviews with the participants with COPD, RZ was present to mentor the interviewers in the use of the semi-structure questions, and to guide and assist probing deeper levels of patients’ experiences where further clarification was needed. By the third interview, the interviewers showed autonomy in their ability to engage the participants in deep and meaningful conversations.

The larger study required each participant to mount an activity monitor, activPAL monitor (activPAL4^TMmicro; PAL Technologies Ltd, Glasgow, UK) on the anterior of the right thigh for seven consecutive days.³ The activPAL monitor was firstly put on by the research team within 7 days post discharge at patient’s home. For the subset of participants who were interviewed, interview was done on the seventh day of wearing the activPAL when it would be removed. The interview was conducted at this timepoint to avoid confounding the PA and SB data collected in case the interview questions could have influenced the accumulation patterns within the week. Demographics and clinical data were taken from medical records.

Data analysis

The audio files were transcribed by CC, JW and AIK, and the qualitative software NVivo version 12.6 was used for the data analysis process (QSR International Pty Ltd, Version 12, 2019). During the initial coding, meaningful words were highlighted first, analyzed and coded into nodes, or collection of references regarding a common theme. Similar nodes were then grouped into categories to identify concepts. It was then associated with relevant literature to derive major themes. Revision and consensus were made through an experienced qualitative researcher, MAC.

An inductive ground-up approach was utilized to derive themes and concepts from the participant’s experiences since it does not make any prior assumptions, but instead derives results entirely from the data.³¹ The ground-up approach allowed themes to emerge without being restrained by structured methodologies.³² While the questions in the interview were formulated using the COM-B model, the themes were derived directly from the analysis of the raw data. The COM-B framework was only used to help formulate open questions for patients to share their own experiences.

Results

Demographics

For purposive sampling, the recruitment strategy for the larger study made it difficult to control for characteristics such as age, ethnicity, employment and use of oxygen. However, due to overwhelming male participants, gender was selected for purposive sampling.

Six male participants with COPD (P1-P6), mean (SD) age of 72 (5) years, were interviewed. Their demographic data, clinical history and PA and SB patterns are described in Table 1. Generally, the six participants had prolonged periods of sitting and low step counts. The participant with a step count above 10,000 steps returned to work during the study, but also demonstrated long sitting bout of an average of 85 min per day. All, except one, had no other co-morbidities. The participant with a co-morbid was documented to have ischemic heart disease. Only one participant had participated in inpatient pulmonary rehabilitation while others have either declined or not referred for any pulmonary rehabilitation programs. However, all received inpatient physiotherapy, which included corridor ambulation, monitoring of symptoms during exertion, breathing techniques during activities of daily living and home exercise. All participants were encouraged by their physiotherapists to perform home exercises and return to social participation.

Table 1.

Characteristics of six male participants interviewed in this study.

Characteristic	N	Mean (SD) [unless otherwise indicated]	Range
Age, years	-	72 (5)	65–79
BMI, kg/m²	-	20.6 (3.0)	17.0–24.6
FEV_1, %	-	51 (14)	32–69
GOLD classification		-	-
Grade 3, group D	2
Grade 3, group C	1
Grade 2, group D	2
Grade 2, group C	1
Hospitalised at least once in the past 12 months	4	-	-
mMRC dyspnea, 0–4 scale	-	-	1–3
Long term oxygen therapy	1	-	-
Current smoker	2	-	-
Step counts, steps/day	-	Median [IQR]: 6151 [2280–7821]	1,784–16,881
Sitting time/day, minutes	-	Median [IQR]: 1163 [1002–1272]	975–1362
Usual sitting bout duration, minutes	-	Median [IQR]: 85 [84–95]	84–95

BMI = body mass index; FEV₁ = forced expiratory volume within 1 s, GOLD = Global Initiative for Chronic Lung Disease; IQR = interquartile range; mMRC = modified Medical Research Council; SD = standard deviation.

Themes

Theme 1

Low perceived capabilities for engaging in PA

Overall, participants lowered their perceived capabilities in engaging in PA due to physical limitations and psychological barriers.

Breathlessness and fatigue were most mentioned as physical barriers to PA. The anticipation of breathlessness and fatigue contributed to some degree of task-avoidance in some participants.

“[Walking] depend[s] on [the level of] breathlessness and confidence to continue” (P1).

“. . .washing [makes me] breathless. that’s why [I] cannot. . .” (P5)

“. . .more easily tired out after the episode. . .” (P1)

Psychological factors were also found to influence PA and SB. Firstly, participants reported low self-efficacy with regards to their ability to be in the community and tended to perceive physical tasks to be more difficult than it was.

“I’m not confident of going out. What if I get breathless when I’m outside?” (P5)

This lack of self-efficacy was reflected in a low health locus of control, where most participants relied extrinsically on the presence of healthcare professionals to improve confidence in engaging in PA. Participants would feel more ‘more inclined to move’ (P1) when guided by a physiotherapist to exercise who would ‘teach you everything’ (P6).

Secondly, there was a widely held belief that PA was not beneficial post-exacerbation.

“. . . my condition hasn’t recovered; they won’t ask me to do exercise. . .” (P4).

“my condition isn’t so good [to be walking around]” (P3).

Theme 2

Limited understanding of COPD and PA

Participants generally lacked knowledge about COPD and its prognosis. Most participants had difficulty naming the condition and described COPD superficially as ‘lung blockage’ or ‘lung damage’. The limited understanding of COPD as a disease was also observed from participants’ polarized outlook towards disease recovery. Some participants held unrealistic optimism about recovery, using narratives of ‘when I recover’ (P4) while others were pessimistic about their condition.

“when the time comes [death], let nature take its course, [I] don’t have to do so many things” (P6).

When asked about engaging in more PA as a COPD management technique, participants had a general held belief that PA was good for COPD and overall health, and that being sedentary could worsen COPD.

“[PA] it’s better for my legs…increases the strength.” (P1)

“the lungs will open when you exercise” (P5)

However, concepts on PA were not well understood by participants. Participants interpreted the terms ‘PA’ and ‘exercise’ loosely to describe both deliberate and undeliberate bodily movements. Some participants considered working and unstructured PA, such as walking, as ‘exercise’ (P1) while others only considered vigorous movements like ‘running’ as exercise (P2).

Theme 3

Lack of translation of health knowledge into action

When asked if participants were able to broadly categorize what constituted being more/less active, participants considered standing tasks as ‘more active’ compared to sitting or lying. However, this awareness was contradictory in their lifestyle in which participants reported prolonged periods of being sedentary.

“5 hours sitting down, nap and then 3 h sitting down to play game” (P4)

“sitting down for around maybe more than 18 h” (P5).

Similarly, most participants only responded with intentions for behavioural change but were not actively engaged in efforts to overcome reported barriers.

“....have [plans]...but needs to slowly adjust...recently time [barrier] is not accommodating” (P2).

Only one participant took a step further for some active modification of behaviour. P5 described himself doing a type of Chinese hand-swing exercise ‘Ping Shuai Gong’ daily. Nonetheless, we noted that while there were efforts to be more active, P5 was still highly sedentary with >18 h of sitting in his daily routine.

Theme 4

Poor adherence to movement-advice from physiotherapist

None of the participants mentioned the recollection of any movement- or exercise-related advice for their condition. The overall carry-over effect from physiotherapy sessions seemed to be poor as participants either could not recall home exercises taught (P1, P2) or did not attempt to practice home exercises prescribed (P3). Some participants also described their experience with physiotherapy as underwhelming and not beneficial.

“[In hospital] they just ask me to walk around slowly. . . She just held me and walked around then asked me to rest” (P1).

“. . . I did not [continue] because [I] just sat down and lifted my leg. . . I find that it doesn’t help” (P6).

In contrast, all patients showed good adherence to medical-related advice. When asked about participant’s coping strategies, almost all participants mentioned the use of the inhaler and medications to ease their symptoms.

Discussion

This study reveals insights on the perspectives and patterns of SB and PA in patients post AECOPD. There was clearly an intention-action gap. Our participants perceived a lower level of capability to engage in PA as a result of ongoing physical and psychological symptoms experienced and lacked confidence or self-efficacy to reduce SB and engage in PA. While they were aware of both health risks of prolonged sitting and benefits of PA, they did not understand the concepts of PA. Participants also demonstrated limited understanding of COPD and its trajectory which may have contributed to a strong illness perception. They also had poor adherence to movement-related advice given by physiotherapists during hospitalization.

The paucity of studies in AECOPD exploring the behavioural factors for SB and PA post exacerbation underpinned the rationale for our study. Understanding their choices and beliefs for adopting patterns of SB and PA is an important process prior to designing behaviour change strategies to reduce SB.^28,33 More recent work evaluating determinants of SB and on SB-reduction using a behavioural-based framework has been performed on stable COPD and following pulmonary rehabilitation.^{13–15,17,29} However, it is unclear whether people post exacerbation demonstrate similar SB and PA determinants as those with stable COPD. So far, our findings of reduced capability and low self-efficacy to engage in PA, limited understanding of PA, adopting an ‘illness’ identity and having awareness of consequences are consistent with the factors influencing SB and PA in stable COPD.^13,15,17

A finding in our study that was less mentioned in other studies in stable COPD was the intention-action gap. The study participants conveyed intentions to sit less and move more but did not translate their intentions into action. Intention is regarded as a precursor to action in some behavioural models or frameworks, such as the Transtheoretical Model of Stage of Change ^34,35 and the Health Action Process Approach.³⁶ Our participants showed awareness of risks of SB, which may have predisposed the intention to reduce SB ^36,37 but this awareness was evidently insufficient to bridge the intention-action gap. The misconception of PA found in our study may partly explain this gap. Our participants seemed ambivalent to stand, move or walk because these light activities were perceived as ‘exercise’ or moderate-to-vigorous intensity and would trigger their symptoms. This apparent cognitive dissonance is similarly found in other studies with COPD ^6,15 and also in other conditions, such as stroke.³⁸ However, a recent study using the Theoretical Domains Framework found that intention was relevant but not a key determinant to SB.¹⁵

Low perceived capability to engage in PA may also explain for the lack of translation from intention to action in our study participants.^36,39 Self-efficacy refers to an individual’s confidence in the ability to exert control over one’s own motivation, behaviour, and social environment.^40,41 Self-efficacy is seen as the most consistent influence to improving PA across many groups – people with COPD,^5,6,13,15 Type II diabetes,⁴² obesity-related conditions ^43,44 and even healthy older adults.⁴⁵ Self-efficacy could be influenced by four determinants; (1) own or mastery experience; (2) vicarious experience; (3) verbal persuasion and (4) emotional arousal.⁴¹ Low self-efficacy amongst our participants could be propagated by negative experiences during PA, such as exercise-associated symptoms like dyspnea and fatigue, resulting in low mastery.^15,41 Notwithstanding, more empirical research is needed to explore the factors affecting one’s perceived self-efficacy in reducing SB and increasing light PA in persons post AECOPD.

Patients with COPD often described their experience of dyspnea, especially during exacerbation, as a situation of heightened anxiety and emotional arousal.⁴⁶ Dyspnea may predispose them to the deliberate attempt to avoid PA due to anticipatory anxiety ,^47,48 and propagate SB further. In people with stable COPD, simplifying daily activities is often used as a form of energy conservation techniques to manage COPD symptoms and encourage disruption to sitting bouts throughout the day ⁴⁹; however, this was not observed in our study. Instead, our participants chose to avoid activities completely as a result of fear of triggering symptoms. This may be the difference between persons post AECOPD and those with stable COPD.

Another high emotional arousal that may contribute to high SB and low PA in COPD is the adoption of a ‘sick-role’ identity and having poor health status.^15,17,18,50 contributing to the phenomenon of self-limitation of activity.⁵¹ In other populations, patients with stroke also adopted a protective behaviour where being sedentary was ‘normal and important’ for recuperation and prevention of health decline.³⁸ For people with COPD, it was suggested that the perception of limitations due to illness was a stronger influence to low PA than the awareness of health benefits to increase PA.¹³ Similarly, for people post AECOPD, this illness identity may be amplified with the additional burden of coping with the uncomfortable experience of the recent exacerbation¹⁸ and also possibly with the belief of a need to rest fully before returning to work, which resonated with findings in our study. The perception of ‘being too ill or frail or disabled’ as one of the top barriers (24%) to attending pulmonary rehabilitation immediately post AECOPD underscored the influence of illness perception to PA,⁵² despite strong recommendations both internationally and nationally.^10,53 The limited evidence seems to suggest a potential temporal factor in their readiness to embrace PA and/or SB-reduction strategies when feeling better and thus, changing illness perception is crucial as first steps to changing PA and SB.^13,15

There appears to be an overlap in the determinants of SB and PA in COPD, despite the disparate definitions in terms of movement behaviour and energy expenditure. A principal component analysis revealed communalities between SB and light PA, having significant associations with dyspnea, mobility, daily activities and health status, independent of moderate-to-vigorous PA.¹⁷ The overlap between SB and light PA suggests that these constructs should not be discussed in isolation. Similarly, our study participants could describe what being sedentary meant but could not differentiate light PA from exercise or vigorous activities. Patients with COPD may be unaware that the closest possible step to reducing the health risks of SB would be through the performance of light activities, rather than by the ‘need to exercise’.¹¹ Furthermore, the evidence of a strong inverse relationship between SB and light PA in cohort studies, while not causal, strengthens the proposition to replace prolonged sitting bouts with light PA in COPD.^3,54 This appears to strengthen our earlier claim to evaluate the factors for the lack of action replacing prolonged bouts of SB with light PA in people post AECOPD.³⁷

Poor recollection and the reliance on encouragement from physiotherapists (extrinsic support) had been found in other studies.^15,55 It was not surprising then that our participants demonstrated poor adherence to movement-related advice given by physiotherapists. They also seemed to prioritize medical advice over mobility. This could be explained by the perceived level of importance of the information given by each group of healthcare professionals.⁵⁶ The overwhelming effort to cope with the immediate effects of exacerbation found in the study by Orme and colleagues¹⁸ seems to reinforce this need to prioritize efficient energy use for immediate tangible outcomes, for example rapid relief of dyspnea with medications prioritised over the threat of triggering dyspnea with moving.

Limitations

We acknowledged some limitations in this study. The small and homogenous sample of six male participants would limit generalizability and translation of results to future research or clinical practice. However, the intent of our study is not to achieve generalizability but to make sense of each person’s psyche for their choice of PA and SB patterns during recovery of AECOPD. Similar to IPA studies, having smaller sample sizes without being overwhelmed by the amount of data generated facilitated understanding of the phenomenon.²³ Given the small sample size and the desire to explore shared perspectives on this phenomenon of interest, a homogenous group of participants makes sense.²³ Behavioural differences in PA choice and motivators between men and women, together with the suggestion to tailor gender-specific PA interventions,^57,58 support our approach to purposively explore a single-gender sample to allow scoping of shared perspectives. Furthermore, the all-male sample seems to reflect the actual higher incidence of men than women hospitalized due to AECOPD, which we have observed throughout our years of clinical experience. It appears that the prevalence of men than women hospitalized for and dying from COPD in Singapore has not changed for the past decades.⁵⁹

Next, each interview was transcribed by different interviewers which may have led to the subjective interpretation of the information. Nonetheless, all the transcriptions were reviewed by two independent researchers (MAC and RZ). Discussions between interviewers also allowed each to be aware of own perceptions and how these may have influenced interpretations.²³

Conclusion

Understanding patient’s psyche and needs are key to developing behaviour-based interventions. Our study’s aim was not intended to focus on what and how one thinks an intervention would work nor to generate theories, but to delve deeper into the reasons influencing the adoption of current patterns of SB and PA made by people post COPD exacerbation. Common reasons were low perceived capability and self-efficacy of performing PA, limited understanding of PA concepts, lack of awareness to replace SB with light PA, and poor adherence to movement-related advice. In general, the eventual outcome observed from their reasons was the lack of translation from intention to action. Overall, this study found the choices and perspectives on PA and SB for AECOPD similar to stable COPD. It would be interesting to see whether targeted behavioural interventions for stable COPD can be used to time the break the cycle of disability during the recovery of AECOPD. More empirical research is needed to confirm behavioural determinants of SB and PA in AECOPD.

Supplemental Material

sj-pdf-1-psh-10.1177_20101058211066418 – Supplemental Material for Understanding perspectives and choices for sedentary behaviour and physical activity in older adults’ post-acute exacerbation of chronic obstructive pulmonary disease

Supplemental Material, sj-pdf-1-psh-10.1177_20101058211066418 for Understanding perspectives and choices for sedentary behaviour and physical activity in older adults’ post-acute exacerbation of chronic obstructive pulmonary disease by Chevonne Chang, John Wong, Ahmad Iqbal Kamari, Sophia C Hui Cheah, Mark A Chan and Rahizan Zainuldin in Proceedings of Singapore Healthcare

Footnotes

Acknowledgements

We would like to acknowledge the physiotherapy cardiopulmonary team at Singapore General Hospital for their contribution to this study and helping us identify eligible patients under their care.

Author contributions

CC collected and analysed data and prepared and wrote the first draft of the manuscript. JW collected and analysed data. AIK collected and analysed data. SCCH designed the study, gained ethical approval and recruited patients. MAC conceptualized and designed the study, contributed to data collection and was involved in data analysis. RZ conceptualized and designed the study, gained ethical approval, contributed to data collection and analysis, and acquired the funding support for this study. All authors reviewed and reviewed the manuscript critically and approved the final version of the manuscript.

Declaration of conflicting interests

A declarations form must be submitted for ALL types of manuscript. PoSH operates a double-blind peer review process, so please do not include names of any authors or institutions in this form as it will be seen by peer-reviewers. The PoSH declaration policy document should be read before filling in this form. This provides options for many of the declarations below.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This work was supported by theThis work was supported by Singapore Institute of Technology Seed Grant, Grant ID E103-H029.

Ethical approval

(Include full name of committee approving the research and if available mention reference number of that approval): Ethical approval for this study was obtained from the SingHealth Centralised Institutional Review Board (2018/3116) and Singapore Institute of Technology Institutional Review Board (2019034).

Informed consent

Written informed consent was obtained from all participants before the study.

Trial registration

(where applicable): Not applicable because no intervention is applied and there is no evaluation of health outcomes with the intervention. There is no testing of hypothesis.

Data availability

The data generated during the study is available with the corresponding author.

ORCID iD

Rahizan Zainuldin

Supplemental material

Supplemental material for this article is available online.

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