Integration of health promotion in clinical hospital departments: standards fulfilment, documentation of needs and service delivery

Jeff K Svane1, Shu-Ti Chiou2, Yuh-Lin Chang3, Shu-Hua Shen4, Chun-Hsiung Huang5, Chui-Yi Pan6, Ming-Nan Lin7, Ying-Hua Shieh8, Tuoh Wu9, Shu-Chuan Wu10, Tang-Tat Chau11, Ling-Yu Hung12, Yuen-Yee Kan13, Chung-Jing Wang14, Rey-Yue Yuan15, Hui-I Yu16, Ying-Hsiang Chuo17, Miauh-Shin Chen18, Hong-Ting Chan19, Yu-Lan Chou20, Di Pei21, Nai-Phon Wang22, TsungChang Tsai23, Hung-Chi Wu24, Hanne Tønnesen1, 25

About the authors

Clin HP Centre, Bispebjerg & Frederiksberg Hospital, University of Copenhagen, Denmark
2 School of Medicine, National Yang-Ming University, Taipei, Taiwan
3 Yuli Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Department of Internal Medicine, Taiwan
4 Jianan Psychiatric Center, Ministry of Health and Welfare, Department of General Psychiatry, Taiwan
5 Changhua Christian Hospital, Division of Geriatric Medicine, Department of Internal Medicine, Taiwan
6 Chest Hospital, Ministry of Health and Welfare, Department of Internal Medicine, Taiwan
7 Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Joint Center, Taiwan
Taipei Municipal Wanfang Hospital (Managed by Taipei Medical University), Department of Family Medicine and Rehabilitation, Taiwan
9 National Taiwan University Hospital, Hsinchu Branch, Department of Orthopedics, Taiwan 10 Fong-Yuan Hospital, Ministry of Health and Welfare, Department of Rehabilitation, Taiwan
11 Landseed Hospital, Department of Community Medicine, Taiwan
12 Yonghe Cardinal Tien Hospital, Department of Internal Medicine, Taiwan
13 Yuan’s General Hospital, Department of Obstetrics & Gynecology, Taiwan
14 St. Martin De Porres Hospital, Department of Endocrinology & Metabolism, Taiwan
15 Taipei Medical University Hospital, Department of Neurology, Taiwan
16 Ditmanson Medical Foundation Christian Hospital, Department of Endocrinology & Metabolism, Taiwan
17 Taiwan Adventist Hospital, Department of Obstetrics & Gynecology, Taiwan
18 Health Promotion Administration, Ministry of Health and Welfare, Taiwan
19 Puli Christian Hospital, Department of Internal Medicine, Taiwan
20 Taipei City Hospital, Yang Ming Branch, Division of Cardiology, Taiwan
21 Cardinal Tien Hospital, Department of Internal Medicine, Taiwan
22 Kuang Tien General Hospital, Department of Family Medicine, Taiwan
23 Antai Tian-Sheng Memorial Hospital, Department of Surgery, Taiwan
24 Kai-Syuan Psychiatric Hospital, Department of Addiction Science, Taiwan
25 Clin HP Centre, Lund University, Sweden

View PDF: doi.org/10.29102/clinhp.15003

Abstract
Background Integrating health promotion (HP) in clinical settings has tremendous effects on treatment outcomes, patient safety and expenses on short and long-term. WHO-HPH standards and models are used globally - but publications on compliance and provision of HP remain rare. Objective To evaluate WHO-HPH Standards compliance, identification of HP needs and related HP deliveries at hospitals, as well as to identify important factors for high level of service deliveries to patients in need of HP.
Methods 21 clinical departments, each with 50 patient records, were included in Taiwan. Standards compliance was recorded. The 1050 medical records were audited for documentation of patients’ HP need (HPH DATA model) and HP service deliveries (HPH Doc Act model) regarding malnutrition, overweight, physical inactivity, smoking and excessive drinking.
Results The Standards compliance was high; 93% (88-98%). Identification rate was 46% (32-72%) and delivery rate to those with identified HP needs was 33% (22-40%). Of the total deliveries, 17% (5-24%) were given to patients documented as not having HP needs, and 46% (41-59%) to patients without information on HP needs. Modifiable factors of significance for high level of HP service delivery were Standards compliance and HP needs identification; OR 1.89-3.75 and 1.74-12.66.
Conclusion The compliance was high at organisation level, but lower at patient level. Most deliveries were given to patients without identified needs. Future research should include implementation strategies reaching out to the patients.

 

Introduction
The burden of disease is closely related to smoking, alcohol, overweight and malnutrition as well as physical inactivity (1). In order to reduce this burden and increase public health, the focus worldwide is on the need for and access to health promotion (HP). In addition to the improved health long-term (2), more and more evidence exists on almost immediate beneficial effects of applying HP to clinical settings (3). It works by improving the direct clinical outcome, reducing expenses and increasing patient safety on very short term (4). Improvements to clinical results include faster recovery (5), better disease control (6-8), reduced surgical complications (9-11) and improved mental health (12). Therefore, HP should thus be considered a central issue in treatment quality (13- 15). However, implementation of evidence-based HP in the clinical settings is still a challenge – in line with implementation of other evidence-based interventions.

To support and guide implementation of HP in clinical settings, the World Health Organization (WHO) and the International Network of Health Promoting Hospitals & Health Services (HPH) have developed and validated 5 standards with 40 measurable elements for HP in hospitals: I) management policy, II) patient assessment, III) patient information and intervention, IV) promoting a healthy workplace and V) continuity and co-operation (16;17). The International Society for Quality in Health Care criteria (18) were used for establishment of the Standards for HP in Hospitals. With the standards as a quality management tool, hospital organisations can monitor their HP implementation, including the structures that support the delivery of HP services (13).

To create the necessary in-detail framework for monitoring the implementation at individual patient level, two easy-to-use models for documentation of HP needs and related interventions in the medical records, have also been developed and validated internationally (19;20). These models monitor e.g. lack of physical activity and the following service deliveries, such as motivational counselling or participation in an exercise program. The HPH DATA and Doc-Act models monitor the documentation in the medical records of WHO-HPH Standard II and III.

HPH DATA model includes 9 questions for documenting individual patient needs for HP related to smoking, alcohol, overweight, malnutrition and physical inactivity (19). HPH Doc-Act model with 15 international codes documents HP activities provided to individual patients with HP needs (20). This model differentiates between brief intervention (BI), e.g. motivational counselling, and HP intervention (INT) or rehabilitation programs.

Overall, the standards and models have been shown to be understandable, adequate and easily added to existing local procedures and systems (16-17, 19-20). They have been implemented to varying degrees by a large number of hospitals and health services worldwide - typically as an integrated element in the local and national quality management program. Still, however, publications on compliance with standards and HP service deliveries remain sparse (21;22).

The aim of the present study was to evaluate the compliance with the WHO-HPH Standards, the identification of needs and related service deliveries of HP activities in Taiwanese hospitals. A further aim was to identify important factors for high levels of HP service delivery.

Methods
This study used a cross-sectional design. The English project materials were translated into local languages by the Taiwanese HPH Network, which also supported the study process. The Danish Data Protection Agency for international studies confirmed that the project included no personal identification data, since the data were collected anonymously at source. The Research Board of Bispebjerg & Frederiksberg Hospital and the local ethics boards approved the project before start (ClinicalTrials. gov id: NCT01563575. Danish Data protection Agency J.nr: 2012-41-0152).

Participants and Setting
The inclusion criteria were departments responsible for patient treatment – both in- and out-patient clinics, and each hospital could only join with one department. Exclusion criteria were paediatric departments, palliative departments and nursing homes, owing to the fact that the standards and tools have not yet been validated for these patient groups. Through an open call for participation 21 clinical departments from 21 different HPH hospitals in Taiwan were included in the study after informed consent from both the hospital management and the department management. There were 7 departments of internal or general medicine, 3 of rehabilitation, 2 of oncology, 2 of orthopaedics, 2 of endocrinology, 2 of surgery, 1 of geriatrics, 1 of psychiatry and 1 of cardiology. The departments represented accredited public, private, university, midsized and small rural hospitals (see Table 1 for characteristics).

Table 1 Characteristics of 21 hospital departments included
    Number of departments

Status of hospital: Public 7
  Private not for profit 13
  Private for profit 1
Type of hospital: Community hospital 1
  Large teaching general 15
  University hospital 3
  Specialised hospital 2
Catchment area: Rural 4
  Urban 14
  Mixed 3
Number of beds: <200 2
  200 to 399 3
  400 to 599 3
  >599 13

 

Collection of Data
The departments received a project manual and technical support. They collected data through the self-assessment manual-based tools over 6-8 months, all anonymised at source. The monitoring of the WHO-HPH Standards was done at department level by categorising the measurable elements as either “yes” or “no” regarding fulfilment.

For the HPH DATA and HPH Doc-Act models the local staff performed a manual-based audit. They audited 50 consecutive anonymised patient records at each hospital from a specific date before the inclusion date. For each item in the models, the staff would then mark it either:

  • “Yes” if categorisable information was available in the record, sufficient to determine a need for HP or a delivered service.
  • “No” if categorisable information was available in the medical record, sufficient to determine no need for HP or no service had been delivered.
  • “Unknown”: if information was not categorisable, such as lacking or insufficient to determine need for HP or whether a service had been delivered or not.

Analyses
The outcomes were fulfilment of the 40 measurable elements of the 5 WHO-HPH Standards; the patients identified with or without need for HP (smoking, alcohol, overweight, malnutrition and physical inactivity) as well as patients with said needs, who actually had related HP service deliveries.

The association between need for a specific HP service and the related delivery was calculated as univariate analyses controlled for confounders and effect modifiers and presented as odds ratio (OR) with 95% confidence interval (CI). This was followed by a final multivariate regression analysis. The results were considered significant if CI did not include the value 1.

Results
The hospital departments had a very high compliance eith the 40 measurable elements constituting the 5 WHO-HPH standards; Standard I with 96%, II with 88%, III with 91%, IV with 93% and V with 98%. Overall, 15 of the 21 departments had 100% compliance; median value 40, ranging 20-40 (see Table 2).

 

 

Table 2 Compliance with the WHO-HPH Standards for HP in hospitals, measured by 21 clinical departments in Taiwan
    Departments 1 - 21                        
Standards/Substandards A B C D E F G H I J K L M O P Q R S T U Total

1.1.1. Aims and mission include HP x x x x x x x x x x x x x x x x x x x x 21
1.1.2. Minutes reaffirm agreement w HPH x x x x x x x x x x x x x x x x x x x x 21
1.1.3. Quality/business plans include HP x x x x x x x x x x x x x x x x x x x   20
1.1.4. Personnel and functions ID’ed for HP x x x x x x x x x x x x x x x x x x x x 21
1.2.1 There is a budget for HP x x x x x x x x x x x x x x x x x x x   20
1.2.2. HP procedures available x x x x x x x x x x x x x x x x x x     19
1.2.3. HP structures and facilities can be ID’ed x x x x x x x x x x x x x x x x x x x   20
1.3.1. HP intervention data captured x x x x x x x x x x x x x x x x x x x   20
1.3.2. Assessment of HP established x x x x x x x x x x x x x x x x x x x   20
Total Standard 1: Management Policy                                         96%

2.1.1. Guidelines to ID lifestyle risk exist x x x x x x x x x x x x x x x x x x   x 20
2.1.2. Guidelines have been revised x x x x x x x x x x x x x x x x   x     18
2.1.3. Guidelines to ID HP needs exist x x x x x x x x x x x x x x   x         16
2.2.1. Assessment is documented x x x x x x x x x x x x x x x x x x   x 20
2.2.2. Guidelines for reassessing HP needs x x x x x x x x x x x x x x x x x       17
2.3.1. Info from referring DR available in MR x x x x x x x x x x x x x x x x x x   x 20
2.3.2. MR documents social/cultural background x x x x x x x x x x x x x x x x x x     18
Total Standard 2: Patient Assessment                                         88%

3.1.1. Information given is recorded in MR x x x x x x x x x x x x x x x x x       18
3.1.2. HP activities are documented in MR x x x x x x x x x x x x x x x x x       18
3.1.3. PT satisfaction assessment integrated in QM x x x x x x x x x x x x x x x x x       18
3.2.1. General health information is available x x x x x x x x x x x x x x x x x x x x 21
3.2.2. Info about highrisk diseases is available x x x x x x x x x x x x x x x x x x   x 20
3.2.3. Information on PT organizations available x x x x x x x x x x x x x x x x x x   x 20
Total Standard 3: Patient Information & Intervention                                         91%

4.1.1. Working conditions comply w N/R directives x x x x x x x x x x x x x x x x 21 
4.1.2.

Staff comply w health and safety

x x x x x x x x x x x x x x x x x x x x 21
4.2.1. Intro training on HP policy given to new staff x x x x x x x x x x x x x x x x x x x x 21
4.2.2. Staff aware of HP policy x x x x x x x x x x x x x x x x x x x   20
4.2.3. HP performance appraisal system exists x x x x x x x x x x x x x x x   x       17
4.2.4. Practices made by multidisciplinary teams x x x x x x x x x x x x x x x x x x x   20
4.2.5. Staff involved in policy-making x x x x x x x x x x x x x x x x x   x   19
4.3.1. Policies on health issues avaliable for staff x x x x x x x x x x x x x x x x x x x x 21
4.3.2. Smoking cessation programmes offered x x x x x x x x x x x x x x x       x   17
4.3.3. Annual staff surveys are carried out x x x x x x x x x x x x x x x     x x   19 
Total Standard 4: Healthy Workplace                                         93%

5.1.1. Regional policy taken into account x x x x x x x x x x x x x x x x x x x x 21
5.1.2. List of partners avaliable x x x x x x x x x x x x x x x x x x x x 21 
5.1.3. Collaboration based on regional health plan x x x x x x x x x x x x x x x x x x x x 21
5.1.4. Plan for collaboration w partners avaliable x x x x x x x x x x x x x x x x x x   x 20
5.2.1. Follow-up instructions given x x x x x x x x x x x x x x x x x x x   20 
5.2.2. Procedure for info exchange exists x x x x x x x x x x x x x x x x x x x x 21 
5.2.3. Receiving organization gets info on PT x x x x x x x x x x x x x x x x x x x x 21
5.2.4. Rehab plan documented in MR x x x x x x x x x x x x x x x x x x   x 20
Total Standard 5: Continuity and Cooperation                                         98%

Total Number of measurable elements (of 40) 40 40 40 40 40 40 40 40 40 40 40 40 40 40 39 38 35 31 24 20  

Total All standards                                         94%

 

 

Alltogether, data from 21 x 50 = 1050 medical records were analysed. The departments had a low level of documentation of needs or no needs for HP regarding malnutrition, overweight and physical inactivity (see table 3).

Table 3 HPH DATA Model for assessing HP needs: The medical record audit results for the documentation of HP needs among 1050 patients
    Categorisable (%) Not categorisable (%)
  ”Yes” to HP needs (high risk) ” ”No” to HP needs (low risk) Unknown
A - Is the patient at risk of illness-related malnutrition? 26 20 54
A-1 Is the patient’s BMI below 20.5? 12 51 37
A-2 Has the patient lost weight in the past three months? 6 55 39
A-3 Has the patient had reduced appetite in the past week? 6 62 31
A-4 Is the patient severely ill? (i.e., stress-metabolic) 11 60 29
B - Is the patient overweight? 22 10 68
B-1 Is the patient’s BMI above 25? 20 42 38
B-2 Has the patient’s waist exceeded 80 cm (W) or 94 cm (M)? 5 20 75
C - Is the patient active less than 30 min/day? 13 21 66
(Defined by moderate intensity with pulse increase, e.g., walking, cycling, training)      
D - Does the patient smoke daily? 16 56 28
E - Does the patient’s drinking exceed the recommend limits? 7 62 31
(Defined as 7 drinks weekly for W and 14 for M)      

(W: women; M: men

 

Relation between identified HP needs and service delivery
The association between needs for specific HP and related deliveries, for instance daily smoking and related delivery of smoking cessation intervention, was low (Table 4). The majority (68%) of those with identified needs for HP did not receive a related intervention. Interestingly, 17% in median (ranging 5-24%) of those identified as having no risk factors were given HP services. For all risk factors the highest absolute number of HP activities was delivered to patients with unknown and insufficient information about the related risk factor.

Table 4 Distribution of the specific identified risk factors compared to the distribution of related intervention; brief intervention (BI) more intensive intervention (INT).
  Identification of risk factor Related BI/INT p-value
 
Risk Factor n (%) n (%)  

Malnutrition          
Risk 275 (26) 72 (30) 0.133
No Risk 212 (10) 58 (24) 0.083
Unknown Risk 563 (54) 110 (46) 0.006*
Total 1050 (100) 240 (100) -
Overweight          
Risk 232 (22) 83 (34) 0.000*
No Risk 101 (10) 16    
Unknown Risk 717 (68) 141 (59) 0.000* 
Total 1050 (100) 240 (100)
Physical Inactivity          
Risk 132 (13) 68 (40) 0.000*
No Risk 171 (16) 32 (19) 0.364
Unknown Risk 747 (71) 70 (41) 0.000* 
Total 1050 (100) 170 (100) -
Smoking          
Risk 172 (16) 50 (37) 0.000*
No Risk 557 (53) 22 (17) 0.000* 
Unknown Risk 321 (31) 62 (46) 0.000*
Total 1050 (100) 134 (100) -
Excessive Alcohol          
Risk 72 (7) 12 (22) 0.000*
No Risk 602 (57) 3 (5) 0.000*
Unknown Risk 376 (36) 39 (53) 0.000* 
Total 1050 (100) 54 (100) -

* Statistically significant (P<0.05)

Overall, the multivariate analysis of important factors for HP deliveries of specific life-style factor interventions showed that identification of the risk factors, (except for malnutrition) and complete standard compliance were significantly associated with increased deliveries. Being a public hospital was associated with significantly lower delivery of interventions for all lifestyle interventions (table 5). HP activities targeting nutrition problems were associated with urban hospitals and hospitals with a mixed urban/rural catchment area. Intervention against physical inactivity was negatively associated with being a smaller size hospital and having an urban or mixed urban/rural catchment area, but positively associated with medical and psychiatric departments. On the other hand smaller size hospitals were significantly associated with both alcohol and smoking interventions. There was no difference between community hospitals and larger teaching/university hospitals concerning the HP deliveries.

Table 5 Multivariate analyses on assoc. between HP deliveries and characteristics; OR: odds ratio; CI: 95% confidence interval; MN: malnutrition; OW: overweight
    Nutrition Physical Inactivity Smoking Alcohol
    OR (CI) OR (CI) OR (CI) OR (CI)

Identified Risk vs No & Unknown Risk MN: 0.98 (0.68 - 1.42) 8.15* (4.96 - 13.39) 4.22* (2.65 - 6.71) 12.66* (3.91 - 40.98)
  OW: 1.74* (1.22 - 2.49)
Complete vs Incomplete Standard Compliance   1.89* (1.23 - 2.93) 3.75* (2.15 - 6.52) 3.66* (1.76 - 7.61) 2.24* (0.43 - 11.58)
Public vs Private Hospitals   0.25* (0.16 - 0.38) 0.61* (0.38 - 0.99) 0.19* (0.10 - 0.34) 0.22* (0.07 - 0.65)
Community vs teaching & University Hospitals   0.98 (0.16 - 6.19) 1.00  - 1.00 - 1.00 -
Urban & Mixed vs Rural Catchment   16.66* (3.88 - 71.54) 0.16* (0.06 - 0.45) 1.43 (0.53 - 3.89) 6.77 (0.51 - 90.78)
< 599 Beds vs > 600 Beds   1.15 (0.79 - 1.66) 0.17* * (0.10 - 0.30) 2.14* (1.38 - 3.31) 31.40* (10.51 - 93.78)
Med & Psych vs Surgical Department   1.80 (1.00 - 3.23) 17.63* (5.53 - 56.17) 2.27 (0.92 - 5.59) 1.00 -

* Statistically significant (P<0.05)    

 

Discussion
We found that the present hospital departments from Taiwan fulfilled the WHO-HPH Standards almost completely and to a significantly higher degree than reported in previous studies (16;17;21;27). This very high compliance at organisational level was not followed by a correspondingly high degree of implementation at patient level. Overall, about half of the patients had their needs for HP evaluated and documented in the medical record, while the required HP services were delivered to less than one third of those patients identified with HP needs. These results are not quite different from other publications (19;20;22;23).

Another part of the results in the present study are the factors of significance for a high level of delivery in Taiwan. Both complete fulfilment of the WHO-HPH standards and having identified the risk factors were significant for delivery of all the related HP services. This is important, because these two factors can be modified relatively easy. Other significant factors, albeit not so changeable, are hospital size, urban catchment area and being a public hospital - amongst others. Furthermore, the university and teaching hospitals did not have higher delivery rates. Especially, the modifiable factors should be included in the future considerations of better implementation of HP targeting patients.

In principle, HP should ideally take place outside hospitals, such as in families, institutions, work places, schools and primary care. However, when entering hospitals about 80-90% of patients have at least one risk factor, like smoking, excessive alcohol drinking, risk of malnutrition, overweight and physical inactivity, all of which can significantly reduce treatment outcome on short term and health gain on longer term (19-23). Nevertheless, it is possible to improve immediate outcome by adding HP services to patient pathways in surgery, internal medicine and psychiatry (4-12). A first significant step for this is to identify patients’ needs for HP services.

From this study, it appears that such systematic recording of needs for HP is a key prerequisite to also delivering associated HP services systematically. Knowing the beneficial effect on treatment outcome on short term as well as the benefit on longer term (1-3), many hospitals and health services worldwide have adopted the tools assessed in this study to varying degrees (e.g. Denmark, Sweden, Ireland, Canada etc.). However, in order to harvest the benefits of outcome- and cost-effectiveness it is necessary to systematic implement effective HP services, and our study clearly showed the need for improved implementation at patient level. The focus should be on those in need of HP services. From the present study it seems that the highest numbers of activities were actually given to patients documented to either be without risk or without information on risk. Health policies, reimbursement strategies and agreements on specific standards and clinical guidelines are highly relevant, but seldom sufficient to secure implementation at patient level (24-25) and as a result the clinical implementation of evidence is often years delayed.

In addition to facilitating the implementation process with teaching and training of staff to be able to handle the new activities, also staff and managerial attitudes (27;28) and individual lifestyle are surprisingly important for successful implementation of HP (28). Interestingly, the patients are positive towards new interventions, and especially positive to being offered HP services as an integrated part of patient pathways (29-32).

Bias and Limitations
Some bias and limitations apply to the present study. On one hand, the HP Services have been delivered by different staff groups across the hospitals, which may increase the variety. On the other hand, HPH members in Taiwan are evaluated by the WHO-HPH Standards when joining HPH as part of their local membership criteria. Overall, the data were collected by self-assessment, which may overestimate the compliance and deliveries. Another bias could arise from updates to the Standards over time (13). The present study used the latest edition. Further bias on the Standard compliance might originate from the settings, because the standards were developed for entire hospitals as organizations and this study included just singular clinical departments. It could be argued that it is more difficult to get an entire hospital to comply with a set of standards, than it is to get just a single department to comply. In practice, however, many of the topics dealt with by the standards are naturally applied to the whole hospital organization – especially for issues like overall policy, healthy work places, teaching and training of staff, common guidelines, general processes etc.

It is a strength that the study was performed under real life conditions; however, all participating hospitals were HPH members, which may limit the generalisation outside HPH and Internationally.

Perspectives
The perspectives of monitoring and improving the implementation and deliveries of HP in clinical settings are tremendous for the patient and society at large. They include better treatment results and increased health gain. From a clinical perspective, it is necessary to secure teaching and training regarding HP for staff and management in addition to offering the HP programs to support and facilitate meeting the patients’ needs for HP. Finally, the present study underlines the need for additional research on the topic of clinical HP implementation and related strategies in high quality designs.

Conclusion
WHO-HPH Standards are complied with to a high degree in the present study, but the identification of HP needs and related HP delivered to patients are lower. Important factors of high delivery levels the fulfilment of the WHO-HPH Standards and identification of risk. Additionally, about 17% of patients without HP needs and 46% of patients with no documented risk still received HP services. Development of effective implementation strategies, reaching out to patients, and evaluation in randomised trials are urgently required.

Contribution Details
Conception and design: JKS, HT, STC Acquisition of data: STC, YLC, SHS, CHH, CYP, MNL, YHS, TW, SCW, TTC, LYH, YYK, CJW, RYY, HIY, YHC, MSC, HTC, YLC, DP, NPW, TCT, HCW Analysis and interpretation of data: JKS, HT Drafting manuscript: JKS, HT Revising manuscript: STC, YLC, SHS, CHH, CYP, MNL, YHS, TW, SCW, TTC, LYH, YYK, CJW, RYY, HIY, YHC, MSC, HTC, YLC, DP, NPW, TCT, HCW

Competing Interests
None declared.

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