Staff Experience of a Canadian Long-Term Care Home During a COVID-19 Outbreak: A Qualitative Study

Abstract

Background: COVID-19 has significant impact on long-term care (LTC) residents and staff. The purpose of this paper is to report the data gathered during a COVID-19 outbreak in a Canadian LTC home regarding staff experiences, challenges, and needs, to offer lessons learned and implications.

Methods: A total of 30 staff from multiple disciplines participated in the study, including nurses, care workers, recreational staff, and a unit clerk. Focus groups (n=20) and one-on-one interviews (n=10) were conducted as part of a larger participatory action research (PAR) in a Canadian LTC home. All data collection was conducted virtually via Zoom, and thematic analysis was performed to identify themes.

Results: Four main themes were identified: We are Proud, We Felt Anxious, We Grew Closer to Residents and Staff Members, and The Vaccines Help.

Conclusions: This research details the resilience that characterizes staff in LTC, while highlighting the emotional toll of the pandemic, particularly during an outbreak. LTC staff in this study found innovative ways to connect and support residents and this resulted in stronger connections and relationships. Leadership and organizational support are pivotal for supporting team resilience to manage crisis and adapt positively in times of COVID-19 pandemic, especially during the period of outbreak.

Introduction

COVID-19 has taken an enormous toll on long-term care (LTC) residents worldwide. As of mid-2020, over 80 percent of COVID related deaths were LTC residents (1). Canada has a total of 2,039 long-term care homes; British Columbia (BC) has a total of 293 long-term care homes (1). The majority of residents (80%) are living with cognitive impairments, who also have complex and multiple co-morbidities (2). Although LTC homes serve high-risk and vulnerable populations, they do not share the same resources as other health care settings (3). While there is evidence that many LTC facilities have reported experiencing personal protection equipment (PPE) and staff shortages (4), LTC staff have also experienced growing anxiety and stress throughout the pandemic, particularly during virus outbreaks (5).The World Health Organization (WHO) (2021) underscored that careful attention should be paid to protect people living and working in LTC homes (6). While there has been considerable public concern regarding the impact of the pandemic on residents living in LTC, attention has not been focused on lessons learned from LTC staff themselves, particularly during COVID-19 outbreaks. Knowledge generated from the voices of staff is necessary to inform change and practice development for safety and quality of care.

Food is vital to the quality of life for residents in long-term care (7). Helping residents to eat well is essential for meeting physical, emotional, and social needs. Staff in LTC settings need knowledge, skills, and a person-centred care culture to ensure positive dining experiences for residents. In 2019, we began a participatory action research (PAR) study (Happy2Eat) by to engage residents, families, staff, and leaders to identify priority needs and strategize actions to promote person-centred care at mealtimes. In the first six months, we co-developed practical strategies in a LTC home to enhance the dining experience of residents with dementia through regular weekly staff huddles. Frontline staff (nurses, care workers, dietary staff, rehabilitation, and recreational staff) gathered for team reflections and explored creative ways to promote person-centred care. For example, staff reorganized meal routines and spent more time to provide mealtime care according to individualized needs. In early 2020, the COVID-19 pandemic put the project on hold for 9 months. In the fall when the research resumed, a COVID-19 outbreak was declared at the study site. Frontline staff stepped into the family’s role to support residents’ emotional and nutrient needs by fostering close relationships with residents and decreasing residents’ sense of loneliness and isolation during the facility lockdown (8). This paper reports on data analysis regarding staff experience, challenges, and needs during a COVID-19 outbreak in 2020. Our primary goal is to offer lessons learned and practical implications to inform practice development.

Methods

Study design

This research is guided by the theoretical principles of Collaborative Action Research (CAR) (9). Because nursing practice in LTC is highly complex, a systematic, engaging, and collaborative approach is required to make and sustain successful change (10). The larger study (Happy2Eat) aimed to engage frontline nurses and staff in all disciplines to identify both the challenges and the practical strategies to improve residents' dining experiences. Rather than doing research ‘on’ subjects, we conduct research ‘with people’ who are impacted by the issue being studied to address a pressing need and take actions for change (11). The Happy2Eat research was carried out through three phases: (1) Looking (observation and focus groups), (2) Thinking and Acting (strategizing and taking action for change), (3) evaluation (interviews and focus groups to assess impacts). We have completed the first phase and actively worked with staff at phase 2 - Thinking and Acting. Weekly team huddles were held every Friday; staff gathered to have group conversation and team reflection about challenges regarding mealtime care and possible creative solutions. This article focuses on reporting timely data gathered at phase 2 during a COVID-19 outbreak.

Setting 

The study took place in a 250-bed publicly funded Canadian LTC home on British Columbia’s west coast.   The resident population is multicultural and has a complex level of needs, requiring 24-hours nursing care for chronic disease/disabilities. Over 85% of residents have cognitive impairment or dementias. 

Ethics 

The study was approved by the Research Ethics Board at the University of British Columbia and the local health authority.   All staff participants gave written informed consent to participate in the focus group discussion and individual interviews. A small token of appreciation ($15 coffee card) was provided for each participant. 

Recruitment of participants   

A convenient sampling method was used for recruitment. The sample included 30 staff (including nurses, care aides, and dietary staff). Separate posters were posted to invite staff participation for focus groups and individual interviews. The local nurse leaders also sent out group emails to all staff to help recruit participants. The inclusion criteria were staff working full time or part-time at the study site, being willing to participate in the study, and working in the frontline to provide direct care for residents, including those with COVID-19. There was no specific exclusion criterion. The characteristics of the participants are reported in Table 1.

Table 1 Characteristics of the participants

Data generation 

We conducted two focus groups (n=20) by Zoom meeting and individual interviews (n=10) by phone to investigate critical challenges, experiences, and support needed for frontline staff in a long-term care home. A total of 30 staff in multiple disciplines participated in the study. They included Registered Nurses, Licenced Practical Nurses, care staff, recreational staff, and unit clerks. The Primary Investigator moderated two focus groups and LH took notes. The focus group sample composed of a total of six nurses, ten health care aides, one unit clerk, and one recreation worker. Participants were informed of the interview questions a week before the focus group interview to provide them an opportunity to consider and reflect on the questions in advance. In the focus group, we asked: What was your experience about caring for residents, helping them to eat? What are the challenges? What resources do you need for best support?  The focus groups were conducted virtually through zoom meetings in December 2020, each lasted for approximately 60 minutes. The semi-structured telephone interviews were conducted by phone in January 2021, each lasted for approximately 30-40 minutes. We asked: What is it like to care for residents during the outbreak? Tell me about a challenging time when you helped a resident with COVID-19 to eat? Both focus group and interview data were recorded and transcribed verbatim.  

Data analysis

We performed thematic analysis to identify themes (12). The analysis was led by LH and SY and the procedures were completed in three steps. First, all authors read the interview transcriptions independently to gain an understanding of the content. Second, SY searched for the codes and patterns across the data and identified initial themes. Third, all authors discussed the themes together in research meetings (via Zoom) and gained analytic consensus. Then we collectively refined the final themes. 

Results

Using thematic analysis, we identified four themes common to their reported experiences. These themes were: 1) “we are proud” 2) “we felt anxious” 3) “we grew closer together”, and 4) “the vaccines help”. Each theme is further divided into subthemes; Table 2 outlines this. 

Table 2: Common Themes of LTC Staff Experience During a COVID-19 Outbreak

Hearing the voices of staff provided an opportunity to document their perspectives. In focus groups and interviews, the staff candidly shared their narratives and were keen to have their stories heard, often endeavoring to represent the views of their team. They had lots to say about the challenges they faced, their personal experiences – both the positive and the painful, and the supports that helped. In our results, we expand on these themes by focusing on quotes from interview participants.

“We are proud”

Resilience, growing stronger

The staff expressed pride in their resilience amidst tough times. They felt proud for stepping up to the challenge, taking ownership of their duties, and persevering. Growing stronger and feeling prepared to tackle future hardships were common themes evidenced by the following participant quotes. 

Well, we lost a lot of lives … but we always think about the brighter side. At least I do. This is something we can’t control. We just do what we have to and whatever happens, it’s a good experience for us. I feel sorry for those who lost their lives and their families, but life must go on. We’re still standing up. And I think, standing stronger now! (Participant 3)

It’s exhausting … [but] it was a good experience and if anything comes up, we are prepared! That’s what we can say. We are prepared to face any challenge. (Participant 9) 

Interestingly, these participants used the language “a good experience” to refer to the outbreak. This reflects how staff reframed this ordeal into a learning experience as a way to cope with stressors, and as a source of empowerment to keep going.

Passion for their role

Participants displayed passion for their work, reflecting on the sense of purpose they derived from serving the residents. They took pride in their efforts in caring for the residents coming to fruition, especially when witnessing the recovery of previously COVID-positive residents.

Knowing them all, I was quite touched when I saw [the residents] starting to go out of their rooms and those patients who were positive… We thought they really couldn’t make it. Now, they’re out in the dining room being their normal selves again. It’s quite rewarding! ... It’s a really nice feeling thinking about how hard we worked for them, and [how] it actually worked …

… I always tell my coworkers, especially the care aides, “we signed up for this job”. This is actual nursing! Before the pandemic, we just thought “it’s good pay, we have job openings,” that’s why I took nursing. But right now? It’s a passion ... Because sometimes we get burnt out, right? So busy, and here’s the supervisor being bossy to us, “Do this and that.” But we signed up for this. It’s like the army, but now you go to war. It’s the real deal. (Participant 3)

I was the one who discovered [this resident] with a very warm temperature. We did the swabbing and  found that she was positive. She went to the hospital and came back. We did our proper PPE, I fed her in her room, gave her medications … always made sure she was eating and drinking, and she was all good! ...

… the whole time, I was on her wing and I care for her up to this day! (Participant 2)

Evidently, staff were passionate and continue to be proud of the work they do. They displayed a desire to tell their stories, with many expressing gratitude at the end of interviews for the opportunity to share their experiences. They spoke with conviction about their roles and wish to celebrate their work.

“We felt anxious”

Safety & safety protocols

Psychological stress from the possibility of contracting or spreading COVID-19 was common amongst participants. Additionally, routine tasks such as mealtimes came with the added responsibilities of safety procedures such as changing Personal Protective Equipment (PPE) every time they entered and exited a resident’s room. Staff members spent considerable energy to meet these demands.

It’s like we had a fear inside because we have families too, and other residents. (Participant 8)

On feeding a COVID-positive patient: I tried to make sure I did everything right… But sometimes they cough or spit a little bit. There are some things we can’t avoid - like if they cough, I can’t just run away. So I just move back or to the side a little. Sometimes, it’s bit scary to some of us. But we have lots of PPE available and we just make sure to follow the procedures. (Participant 6)

Contrastingly, there were participants who were not as worried about personal safety. This finding is surprising but revealing. It exposes this instinctual tendency of many frontline staff: care for residents first, think about personal consequences later. 

We are not really scared of getting the virus from the residents because we know our unit is good with preventing it. I’m not worried. I’m worried about myself giving it to [residents], that is the only worry I have. (Participant 10)

I feel confident with the PPEs and the teaching that was done but I also have an attitude that worrying about getting sick or about getting something doesn’t help me. I don’t live my life worrying about how I might get ill. (Participant 21)

In either case, infectious disease education and availability of PPE/resources raised confidence to work safely. Participants indicated that they felt supported by these provisions.

Everyone was anxious and scared ... but the infection control team was really good and gave us an in-service about what COVID is, how it spreads, and how we can protect ourselves by wearing proper PPE … they convinced us we’re protected. That gave us a little confidence and we learned a lot, going through the difficult situation. (Participant 9)

Resident mental health

Participants chronicled the heartache of watching the residents’ mental health decline. During the outbreak, residents were required to stay in their rooms and forgo activities such as having meals and coffee in dining rooms or going for walks around the facility. Staff saw the effects that social isolation and disruption of routines had on the residents – many of them distressed, confused and lonely. Comforting residents of varying cognitive abilities proved challenging. 

I’ve had residents tell me they feel like a prisoner, like “What did I do wrong?” You try to explain to them, “No, you didn’t do anything wrong.” I remember one resident in the beginning, long before the outbreak happened. He was sitting by the window one day and goes, “Is this virus still out there?” and I go, “yeah, unfortunately it’s still out there,” and he goes, “But I can’t see anything!” That just broke my heart … 

… It was very stressful. I would leave there some days with my heart broken because I’m thinking of these poor people. They’re stuck in a 5 by 5-foot room, and I could leave there and had freedom where they didn’t have freedom. (Participant 4)

One of our Chinese resident’s son used to come take her out … She was telling [my co-worker] “My son left me here! He is not coming to see me.” She was trying to explain to her that it’s because of this virus and once it’s over, she can see go and her son. But then she would forget …Then she keeps repeating the same thing over and over. (Participant 18)

… There was one resident who had a roommate … And the roommate passed away because they were COVID-positive. Later on, they got really depressed. It was really hard to see. They were just waiting, “When am I going? What’s happening to me?” They need more encouragement, so you talk to them… You have to make them feel better. (Participant 5)

Empathy is evident in the staff’s voices. While empathy is a requisite for comforting residents, it often comes at a cost to their own wellbeing. Despite the stressors related to safety and mental health, they consistently showed compassion to residents.

“We grew closer to residents and staff members”

Residents

Staff members felt that relationships with residents grew stronger. Many participants attributed this to the extra staffing provided during the outbreak, which enabled more one-on-one time with residents. 

More staff makes everything smoother and everything worked well, everybody was taken care of. We had more time to interact with the residents… (Participant 2)

I noticed [that] when I have time to talk to them, they will tell me the story of their life or something and it’s really interesting. They really want to talk. Some of them really want to listen to music, different types of music! (Participant 5)

Mealtimes were an important time of socialization. Prior to the pandemic, loved ones often visited to help feed the residents, but this responsibility fell on the staff during the outbreak. They helped fill social gaps from absence of family, volunteers, and other resident interactions. These interactions provided opportunities to get to know the residents in ways that they previously did not have before. 

Some of the residents’ families always used to come to feed - but [now] we had the chance to feed them. Now we know them more and feel more attached to them. (Participant 3)

One of my residents, he likes to talk. I go in in the morning, we have breakfast, and he usually asks me “How does it look outside?” I open the curtain and tell him it’s a nice day, or it’s rainy. He says, “I can’t go out?” and I say “Not for now.” so I just hold his hand, or he has a cellphone [to] call his wife or daughter. We have to make them comfortable, right? (Participant 8)

We go in the room and talk about the food. For the drinks, like “You have your cocktail here! Why don’t you take some?” and they drink it! And for the medication, like “Okay, here’s your chocolate!” and it’s so funny! Just to keep them going, right? (Participant 2)

Working in a multicultural facility, staff members found that using residents’ own languages and culture to connect was an effective way to boost their spirits and put them at ease. One participant talked about their attempts to learn the language of the residents; another talked about connecting staff and residents with similar backgrounds.

 I don’t speak the language, but I try to learn a few words of Cantonese. That puts joy on the residents’ face ... I’d put on a Chinese drama in Cantonese language or music – you see that they enjoy it … 

… There’s just things that are important [to] learn, like the word for water … (Participant 11)

If we have non-English speaking residents, we try to engage them with staff that speaks that language. It really helps …There used to be a resident and when this staff member came to feed her, she would eat everything ... These things do make a difference. (Participant 9)

Staff members

Similarly, staff members grew closer to one another. Keeping the same people on each unit during the outbreak helped build community. They mentioned having daily team meetings where they shared their experiences and the strategies that worked for them that day. There was a sense of solidarity to provide the best, safest care possible while looking out for one another.

If you worked in one unit, you couldn’t work in another unit because of the outbreak. [And] we were working more. We’d work more shifts. That made the team close! (Participant 29)

The nurses would never [use to] talk - like on your shift exchange, you just see people and go. [But now] we get to see them more. And the staff, we would laugh at jokes, and if someone was in a room and couldn’t come out because of PPE we would say “Okay, no worries, just call me and I’ll bring you everything.” (Participant 22)

Before, care aides and nurses had conflict. But right now, we’re like “Don’t think about that, we have to do this!” We have to help each other. (Participant 3)

Staff members felt that the strengthened connections with residents and other staff members was a main positive outcome. They described the heightened level of teamwork as crucial to their success. Many emphasized that the extra staffing provided was a helpful support that made work more efficient and enabled more one-on-one time with residents.

“The vaccines help”

Protection against outbreak & increased confidence for safety

This facility was amongst the first in their jurisdiction to receive vaccinations. At the onset of the outbreak, the majority of staff and residents were recently immunized. Some staff believe the vaccine helped cushion the effects of the outbreak since they mostly observed mild illness and kept the outbreak relatively well-controlled.

I heard from some of my coworkers that it’s really helping. Because some unfortunately got COVID and she said that if she didn’t have the first vaccination, then maybe it would be worse. She overcame the whole process of recovering …

… I think [the vaccine helped the residents] … because up to the time we discovered the last case, we maintained that number and didn’t have more after that… [and] they were mild. Of course, we had a few pass away, but I think it’s because they had other health issues. (Participant 26)

Having most residents and staff members immunized helped staff members feel safer to work.

In your head, you have peace of mind that you’re protected already ... 

… We all had a first dose, the residents and us. It gives you confidence… (Participant 8)

Starting to see return to old routines

With the protection of the vaccines, the facility started to see a return to old routines once the outbreak ended, such as permitting residents to leave their rooms and allowing for some family visits. This came as a relief to many residents after spending over a month confined to their rooms and was a positive and important step by staff towards a return to normalcy. 

[Since] this Monday, we were all clear! … It’s an absolutely different environment ... [Residents] say “Can I go out now?” and they say “Really?” Some of them can’t believe it! Already now we are permitting some family to come. (Participant 15)

Discussion

The findings that resulted from this research provide important insight into what is occurring in LTC homes during a COVID-19 outbreak. To date there has not been much investigation into the experiences of staff during this critical and stressful time, when a care home goes into lockdown. While the pandemic has laid bare the many long-standing issues that exist in LTC, it is also vital to underscore the important work and effort of LTC staff during this time, as well as the positive lessons learned. Accessing the voices of frontline staff has provided a detailed description of their emotional experiences, and the positive stories about caring for residents that emerged from this research are particularly worthy of discussion. In the context of this study, this relates to the staff’s obvious dedication and compassion, which permeated all of their shared accounts of working and caring for residents during the outbreak. Overall, frontline staff displayed a heart for resident care with a spirit of perseverance despite risks. This perseverance speaks not only to the dedication but to the resilience of the LTC staff who participated in this study. Resilience was a significant finding in this study, and is a concept often discussed in health care literature, particularly in the context of health care workers’ ability to cope with the negative effects of stress while striving to maintain mental wellbeing (13). It is notable that this study’s participants were able to facilitate resilience and manage their stress using humour and by connecting well with one another, as well as to the residents. 

The impact of building relationships is another important piece that has come out of this work. Staff noticed that they were able to build stronger relationships with residents, in part because they had to connect with them more frequently without family there, and also because staffing levels were augmented at the study site during the outbreak. This shows the need for increased and adequate staffing in LTC moving forward, and for society to critically reflect on how best to equitably support the LTC sector once the pandemic is over. Pre-pandemic, family members played an important role in supporting residents with their daily needs (14). While it will be crucial to embrace family members back into existing care teams, it will be equally essential for there to be recognition of the need for ongoing staffing that is adequate, even once the COVID-19 crisis has resolved. This is particularly important as we know that Canadian seniors who have close relationships with LTC staff members have a relatively lower risk of mortality (15). Person-centered care principles are also an underlying thread in the findings, possibly prevalent due to the recent Happy2Eat project, which may have provided an opportunity for staff to connect with residents more readily. LTC homes can be microcosms of society and are culturally diverse milieus, and it is encouraging to see that participants spoke of the effort they took during the outbreak to engage with residents in person-centered and culturally specific ways. In addition, building and strengthening working relationships amongst staff members was critical in getting through the outbreak. Certainly, the complexity of the human experience was revealed in this study, in terms of people’s abilities to connect and bond with one another during challenging and difficult times. Notably, it seemed that hierarchical structures, which can be problematic in health care (16), were flattened as nurses, care aides and other staff worked together to support one another and to ensure that residents were cared for.

While it important to highlight the resilience of the care home staff in this study, the strengths of the relationships they built, and the valuable work that they did during the outbreak, it is equally crucial to recognize the issues that challenged them at the same time. For instance, while it seemed that staff at the care home overall felt resilient, and that they were able to manage the challenges of the COVID-19 outbreak, the anxiety that they experienced was also palpable. Working as direct care workers during a global pandemic, like COVID-19, can be very challenging and stressful, with concerning implications for health and wellbeing (5,13),The World Health Organization (2020) has warned about the potential negative impact that the pandemic has had on direct-care staff’s mental wellbeing (17). Globally, many health care workers have spoken about the trauma that this pandemic has incurred in their lives, such as the experience of losing patients, and the stress of being at the frontlines (18). Health care workers who have had to make challenging decisions during the pandemic can experience moral injury, which can lead to the development of burnout and other mental health concerns (19,20). This is most relevant for LTC staff, where the impact of the pandemic has been profoundly felt. It is also important to consider that burnout in LTC settings was already an issue for health care workers prior to the pandemic (21,22) likely compounding the effects of the pandemic. Findings from this study revealed the psychological stress and anxiety that participants felt at the possibility of contracting or spreading COVID-19, particularly for the health care aides who participated in the study. Notably, health care aides in LTC are more vulnerable than other staff to infection in part because they provide the extended personal care required by this setting, with regular prolonged close proximity with residents (23).

When it comes to infection control, evidence shows that many LTC facilities are still experiencing PPE shortages (4, 24-26). Ensuring ongoing and adequate PPE, training on how to use it properly, and organizational support for LTC staff will be critical for alleviating anxiety, contributing to a sense of safety, protecting mental wellbeing and facilitating resilience. More importantly, adequate mental health support, and resources are required to support healthcare workers as they process and deal with the challenges that they have faced, especially as the pandemic recedes. The importance of the vaccines as a public health measure is noteworthy, especially as early vaccination efforts focused on the LTC sector and worked to protect residents and staff. Many of the staff who participated in this study were optimistic about where things were headed, especially as vaccination efforts ramped up. They were also hopeful that their anxiety would improve as they foresaw routines eventually going back to normal, and as vaccinations became more widespread in the community.

Strengths and Limitations

This study was conducted against the background of the outbreak of COVID-19 so our timely analysis provided useful insights to inform practice and support resident care.  Similar to other research studies conducted during COVID-19 pandemic, in person access to the LTC home and staff was impossible (27). Virtual focus groups and phone interviews limited researchers’ capacity to read participants’ emotional expression. Observation and ethnographic fieldnotes could have provided in-depth understanding of contextual details and circumstances.   

Conclusion

While public health measures and vaccination uptake have resulted in positive outcomes in LTC, such as decreased outbreaks, scaling back of restrictions and increased family presence, it is important to critically consider what has been learned from this study, and what actions and changes can be implemented long term. This study has revealed the important work of caring that was occurring in a LTC home during an outbreak, bringing much needed attention to the valuable work that is regularly taking place in the LTC sector. LTC staff should feel empowered by what has been achieved during the pandemic, as well as what has been revealed, in terms of demonstrating that the work that they do counts and that the efforts they have undertaken have made a difference. Nevertheless, moving forward it will be crucial that the lessons learned from the pandemic and from outbreak situations are acted upon. Namely, that staffing levels remain adequate so that LTC staff are able to continue to provide supportive and person-centered care. This study has demonstrated that positive relationships are possible during challenging times and in care environments like LTC, settings that are often maligned or unfairly represented in media. Continued emphasis on the need for supportive relationships between residents and staff will be critical, as well as amongst staff members for residents to thrive. In addition, supporting the mental health and wellbeing of LTC staff will be paramount, for all concerned to be able to move forward from the pandemic in healthy and supported ways. Hopefully health care leaders, policy makers, and all members of society will act on lessons learned during the COVID-19 pandemic to ensure that the LTC setting is a safe and supported environment for health care workers to work in, as well as for the residents who live here and call these settings home.

Declarations

Acknowledgements

            We would like to thank participants in the study and funding support by the Vancouver Coastal Health Research Institute.

Ethics approval and consent to participate

The study was approved by the Research Ethics Board at the University of British Columbia and the local health authority (H19-01778 and V19-01778).   All staff participants gave written informed consent to participate in the focus group discussion and individual interviews. A small token of appreciation ($15 coffee card) was provided for each participant. All methods were performed in accordance with the University Research Ethics Boards' policies and Vancouver Coastal Health Authority’s regulations.    

Consent for publication

Written informed consent to publish information was obtained from study participants.

Availability of data and materials

Dr. Lillian Hung may be contacted if someone would like to request the data. 

Competing interests 

The authors declare no competing interests.

Funding 

            The project was funded by Vancouver Coastal Health Research Institute Team Grant 

Authors’ contributions

The concept and design of the study: LH; data analysis and interpretation: led by SY and involved all authors; drafting article: LH, SY, EG, MS, revising and approval of the final manuscript: all authors.

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