Abstract
Background Carers are important facilitators for patients accessing care and having positive experiences. Carers often accompany patients to their consultations, providing emotional and physical support. To our knowledge, there is limited research identifying and describing the specific activities carers are involved in or the translatability of these activities to virtual care.
Aim To identify and describe the activities carers are involved in during consultations with their GP, and to assess how these activities could translate to virtual care consultations.
Design & setting This study screened 281 videos of in-person GP consultations set within eight UK general practices, with 39 eligible for analysis.
Method Secondary analysis of in-person GP consultations was conducted to extract activities involving the carer. A novel evidence-based scoring system was used on each activity, determining the likelihood of whether each carer-related activity could be supported in virtual care.
Results A total of 39 activities (seven categories) where carers were involved were identified. Out of these 39 activities, 25.6% (n = 10) were categorised as ‘health information sharing’, 23.1% (n = 9) were categorised as ‘emotional or physical support’, 20.5% (n = 8) were categorised as ‘history taking’, 12.8% (n = 5) were categorised as ‘health-related at-home activities’, 7.7% (n = 3) were categorised as ‘logistics’, 7.7% (n = 3) were categorised as ‘building a relationship’, and one (2.6%) was categorised as ‘other’. The average score of an activity being translatable to virtual care is 13/15.
Conclusion All activities involving carers were deemed translatable or potentially translatable to virtual care. Future research should examine ways to support carers and their roles during virtual care.
How this fits in
Carers play a vital role in supporting patients during GP consultations (for example, providing physical assistance, sharing information, and managing care plans), particularly for patients with complex or chronic needs. As healthcare delivery shifts to virtual formats, questions remain about which of these roles can be maintained remotely. This study analysed real-life GP consultations and found that most carer contributions were verbal and collaborative, making them well-suited to virtual care. These findings can help clinicians actively engage carers in virtual consultations, ensuring continuity of support for patients.
Introduction
Patients’ carers (for example, family members, partners, companions, caregivers, and paid carers) play a key role in helping patients access care and improving patient outcomes and experiences.1–4 Carers contribute during medical consultations and support ongoing care outside the clinic,1–4 with many patients preferring carer involvement in health-related decision making.5,6 Despite acknowledging the value of carers, most research on patient experience has focused on clinician–patient interactions, leaving carers’ roles underexplored.7
A meta-analytical review by Wolff and Roter reported that of 13 included studies, 37% of adult patients were accompanied by a family companion to consultations, predominately a spouse or adult child.8 Carers assist with emotional support,9 physical examinations, administrative tasks or logistics,4 shared decision making, and fostering clinician–patient rapport.10–12 For example, a study by Rosland et al, reported that patients with diabetes or heart failure who participated in their survey reported that they were more likely to understand primary care clinician advice (77% reported ‘positive’) and discuss difficult topics with the physician (44% reported ‘positive’) when companions participated in clinic visits.12
Since the COVID-19 pandemic, hybrid models of care (that is, in-person and virtual care) have expanded. For example, virtual hospital services such as rpavirtual provide remote hospital-level care supported with technology (for example, video consultations and remote monitoring devices).13 Virtual care can include carers more readily when in-person attendance is limited by location, household separation, or scheduling.14 It may also ease transitions from hospital to home, relieving some patient and carer burdens.
Despite this shift, little is known about what carers do during consultations or how their roles translate to virtual settings. Most research is qualitative (that is, surveys and interviews) and reflects the perspectives of patients or clinicians, not carers. In contrast, this study systematically observes and categorises carer activities using GP consultation videos. It addresses a critical gap by highlighting carer contributions and their relevance to hybrid care.
Rather than evaluating the effectiveness of virtual care itself, this study focuses on carers’ contributions as determinants of consultation translatability. This study aimed to 1) identify and describe the activities carers are observed to be involved in during in-person GP consultations; and 2) assess the extent to which these activities are translatable to virtual care consultations (that is, whether carer activities observed during in-person consultations can be supported during virtual care).
Method
Study design
A secondary analysis was conducted of video recordings and transcripts of consultations between GPs and their patients, recruited from 10 GPs across eight general practices in England in 2017. This dataset contained 281 consultations, obtained from an NHS-ethically approved project titled ‘Harnessing resources from the internet to maximise outcomes for GP consultations (HaRI): a mixed qualitative methods study’ (see section ‘Ethical approval’ in the metadata).15
A custom-made software was developed in-house to blur the faces of individuals appearing in consultation videos, ensuring the privacy of patients and health personnel before any analysis was conducted.
Data screening
Overall, 281 consultations from the HaRI archive were screened through inclusion and exclusion criteria, conducted by KW and confirmed by AYSL, resulting in a total of 39 eligible consultations to be included for analysis. Transcripts were included when: 1) derived from the HaRI dataset; 2) there was ethics approval to analyse video and audio-recordings; and 3) there was a carer present, as defined as any person who accompanied the patient in the consulting room such as a friend, partner, or caregiver.16 No limitations were applied to patient age, gender, or patient concerns (see Supplementary Table S1 for detailed eligibility criteria). The 39 consultations were conducted with 39 different patients and with eight out of ten participating GPs.
Data analysis
Content analysis and descriptive statistics
Descriptive statistics were conducted to report patient demographics and consultation characteristics. Patient demographics were obtained using a patient questionnaire survey conducted by authors of the HaRI dataset.15 Patient health concerns were obtained based on observation from the content discussed during consultations and guided by a health topic coding scheme (see Supplementary Table S2).
All included consultation transcripts and video recordings were read, watched, and coded by KW, HW, and VC using NVivo (version 14). Multiple coders (see acknowledgements) coded a subset of consultations each to verify that all activities present were identified, ensuring each consultation was coded by >1 person. An inductive approach, informed by Kocaballi et al’s consultation activity framework,17 guided the identification of carer activities (see Supplementary Table S3). Both verbal and non-verbal roles, including out-of-clinic support (for example, travel or at-home care), were analysed.
Visualisation approach
Visual inspection was used to identify the role of the carers during consultations. Lucidchart software was used to create flowcharts, with guidance from the coding scheme proposed by Kocaballi et al17 to illustrate when these activities were occurring during the consultation.
Translatability to virtual care scoring system
A scoring system was developed by all four authors, guided by the authors’ previous study that assessed the translatability of clinical tasks to telehealth.18–20 The scoring system of this study was used to determine how ‘translatable’ the carers’ observed roles were from in-person GP–patient consultations to virtual care. We assessed how each carer-related activity could be supported virtually, considering dependence on physical artefacts, clinical endorsement, and the type of carer support required. Higher scores represent activities where carer roles were more easily transferable to remote settings or patients could fulfil them independently. Scoring was led by one primary author (KW), informed by analysing consultation videos, discussions between authors and acknowledged coders, and reviewing relevant literature. Three factors were derived to indicate how readily activities could be replicated to virtual care, namely whether the activity ‘requires clinical endorsement’, ‘requires physical artefacts or physical interaction’, and ‘type of carer support required’.
This scoring system assesses each activity as follows:
Step 1: Assess the extent to which an activity ‘requires clinical endorsement’, based on a five-point score (see Table 1, metric 1).
Step 2: Assess the extent to which an activity ‘requires physical artefacts or physical interaction’, based on a five-point score (see Table 1, metric 2).
Step 3: Assess the ‘type of carer support required’, based on a five-point score (see Table 1, metric 3).
Step 4: Sum up the scores from steps 1, 2, and 3 to calculate an overall score out of 15 that describes how well this activity can be translated to virtual care, that is, translatability to virtual care score (see Table 1). A higher score represents a high translatability to virtual care (see Table 2).
Step 5: Categorise the type of virtual care solution proposed for this activity, based on the 15-point translatability to virtual care score from step 4.
Results
Participant and consultation characteristics
Overall, 39 GP–patient consultations were analysed in this study. Figure 1 provides a breakdown of the transcript selection process. Table 3 describes the patient and consultation demographics based on patient consultation questionnaires, and observations from transcripts and consultation video recordings.
Activities performed by carers during in-person consultations
Carers were observed to be involved in a total of 39 activities across 39 in-person consultations. Activities were categorised into seven categories. Out of these 39 activities, 25.6% (n = 10) were categorised as ‘health information sharing’, 23.1% (n = 9) were categorised as ‘emotional or physical support’, 20.5% (n = 8) were categorised as ‘history taking’, 12.8% (n = 5) were categorised as ‘health-related at-home activities’, 7.7% (n = 3) were categorised as ‘logistics’, 7.7% (n = 3) were categorised as ‘building a relationship’, and one (2.6%) was categorised as ‘other’.
Observations of the role of carers during GP–patient consultations
Role in discussing present complaint and history taking
Carers were observed to have an integral role in facilitating history-taking discussions during consultations. Particularly during consultations where the carer was the primary guardian (that is, parent), the carer dominated the discussion by answering on behalf of the patient. For example, the carer provided the presenting complaint, described the patient’s symptoms, the evolution of their condition, or recalled events and current treatments on behalf of the patient:
Practice [P]3GP5 recording [R]136; discussing present complaint.Patient (aged 0–18 years, female, general and unspecified) and carer (parent)
GP: ‘How can I help?’Carer: ‘For a week she’s been having temperature and a very bad cough.’GP: ‘Temperature and a cough, okay.’Carer: ‘It gets worse in the night …’
Summary: Carer recounts the patient’s present complain and key events leading them to present to the GP. The carer speaks on behalf of the patient.
Carers were also observed to contribute to discussions of medical and family history, either inciting patients to respond to the GP’s questions or answering on behalf of the patient if the patient was unable (that is, paediatric patient) or had omitted details. Discussions also extended to the patient’s current healthcare plans or previous interventions, where carers had contributed to at-home interventions or management strategies. Carers at times were observed to contribute incorrect information during history taking or interrupt the patient and/or GP, which negatively impacted the flow of the consultation or rapport building:
P1GP2R26; discussing present complaint.Patient (aged 0–18 years, male, general and unspecified) and carer (parent)
Carer: ‘So, basically, he has been sent home the last 2 days because of his hay fever.’GP: ‘Hay fever. Nose, eyes?’Carer: ‘It’s not as bad because we sprayed allergy spray from the chemist.’
Summary: Carer plays a role in purchasing and administering medications to the patient at home. They also participate in describing the patient concern and medication history.
Role in providing emotional support
Carers were observed to play an important role in providing emotional support during consultations. To calm patients, carers were observed to offer a supportive presence or physical touch, such as holding the patient’s hand or giving them a hug. They also provided validation to the importance or prevalence of the patient’s symptoms, which was observed to enable patients to contribute further to information sharing discussions and have a sense of confidence:
P3GP5R136; parent calming child patient.Patient (aged 0–18 years, female, general and unspecified) and carer (parent)
Carer: ‘That’s okay. That’s okay, [name of patient] … It’s okay.’
Summary: Carer plays a role in calming the patient through hugging and coddling to keep them calm for the GP to conduct the physical examination and prevent interruptions.
P1GP1R129; carer providing validation of patient symptoms.Patient (aged >65 years, male, respiratory) and carer (spouse)
Patient: ‘Even in the church choir, now I struggle with the hymns, she says she can hear me alright, but I know it’s not as good as it should be.’ Carer: ‘I can hear it, though.’
Summary: Carer validates patient’s symptoms by commenting on their existence and communicating the impact on the patient’s lifestyle to the GP.
P4GP6R162; carer providing emotional support to patient.Patient (aged 26–35 years, female, respiratory and endocrine or metabolic and nutritional) and carer (companion)
Patient: ‘Sit with me, come back.’Carer: ‘I’ll be in the way.’Patient: ‘No, you won’t. You’re a friend, that’s very helpful.’
Summary: Carer prepares to move out of the way during the consultation; however, the patient requests the carer to stay close to provide emotional support.
Another way carers provided emotional support during consultations was through engaging in activities that assisted with relationship-building between patients and their healthcare providers. Carers were frequently observed to use encouraging language to inspire the patient to respond to the GP, either with health information sharing or rapport-building conversations. This would assist with open discussions between patients and GPs, leading to improved shared decision making and perception of overall patient experience outcomes (for example, patient satisfaction):
P1GP2R21; encouraging shared decision making.Patient (aged >65 years, male, musculoskeletal and cardiovascular) and carer (spouse)
Carer: ‘What do you want to do, [name of patient]?’Patient: ‘Oh, I don’t know. I suppose try it.’Carer: ‘Well, you could try it, couldn’t you, because I mean it’s better than how you are now. I would say, yes doctor?’ Summary: Carer asks the patient questions about their preferences for treatment, encouraging involvement and shared decision making with the GP.
Role in providing physical support
Carers were observed to play an important role in providing physical support during consultations and outside of clinic settings. Physical examinations are an important tool for GPs to confirm diagnosis.21 Carers were observed to assist in conducting physical examinations, assist with using the physical artefacts used for physical examinations, and assist with conducting demonstrations (for example, exercises), particularly parent carers with paediatric patients, or partners or adult-children as carers for patients with low mobility. Importantly, carers assisted with gathering consent for physical examinations on behalf of patients:
P5GP7R202; conducting physical examination.Patient (aged 0–18 years, male, skin) and carer (parent)
GP: ‘Look at that. Do you mind if I?’Carer: ‘No.’GP: ‘Just start undoing his buttons while you’re telling me.’
Summary: Carer has a role of assisting with taking the patient’s clothes off to assist with a physical examination. Carer holds the patient still while the GP examines them and provides the consent on behalf of the patient for the physical examination to take place.
P3GP5R136; conducting physical examination.Patient (aged 0–18 years, female, general and unspecified) and carer (parent)
GP: ‘If you could just put her hands over–’Carer: ‘Yeah … It’s okay. It’s okay. It’s okay. It’s okay.’GP: ‘I’ll have a listen to her chest.’
Summary: Carer facilitates the physical examination taking place by holding the patient still and in a position that allows the GP to conduct the physical examination effectively.
Carers were observed to engage in activities that related to outside of the clinic or consultation. Carers were observed to also discuss their ongoing at-home assistance that they provide to patients in the management and monitoring of their care. This was common for partners or adult-children as carers. Patients and carers were observed to discuss the assistance they received from carers with administering at-home treatments, conducting at-home examinations, monitoring their sleep or medicine intake, diet discussions, organising referrals and other appointments, travel assistance, financial assistance, stay-at-home orders, and assisting with other day-to-day activities.
P3GP5R141; role in assisting with at-home physical care.Patient (aged >65 years, male, neurological) and carer (older child as carer)
GP: ‘Any other significant problems?’Carer: ’Well, his dribbling is his biggest problem ... I’m not quite sure whether that’s drug effects or not, but it’s a relatively new problem. And I’m trying to keep him home as long as possible ... I employ a live-in carer for him.’
Summary: Carer plays a role in describing the patient medical history and paying to employ an at-home carer for the patient.
P3GP5R136; role in at-home care management and support.Patient (aged 0–18 years, female, general and unspecified) and carer (parent)
GP: ‘Has she had a temperature today?’Carer: ‘She had it in the morning, like five o’clock, so I gave her some Calpol.’
Summary: Carer plays an out-of-clinic role in purchasing and administering medications to the patient at home. They also speak on behalf of the patient in describing the patient concern and treatments.
Visualisation of the role of carers and where the activities they are involved in occur during GP–patient consultations
Content and visualisation analysis revealed seven categories of activities where carers were involved during GP–patient consultations, namely: history taking, health-related at-home activities, logistics, emotional or physical support, health information sharing, building a relationship, and other. Figure 2 provides an example of how the carer provides support during a GP consultation.
Translation score of carer activities in virtual care settings
Supplementary Table S4 describes the observed activities, description, and scores of translatability to virtual care. Because the score integrates carer dependency, higher scores indicate consultations where carer participation could feasibly be maintained in virtual care. Higher scores also indicate consultations where carer participation may not be required if patients can act independently. Across the 39 activities, the average score for the virtual care method of:
clinical endorsement score was 4/5;
physical artefacts or physical interactions score was 4/5;
type of patient concern and level of caregiver support required score was 4/5; and
translatability to virtual care was 13/15.
Regarding the metric of virtual care solution types, the majority of the 39 activities observed were deemed translatable or potentially translatable to virtual care. Overall:
one (2.6%) activity was rated type 1;
one (2.6%) activity was rated type 2;
15.4% (n = 6) of activities were rated type 3;
53.8% (n = 21) of activities were rated type 4; and
25.6% (n = 10) of activities were rated type 5.
Discussion
Summary
To our knowledge, this is the first study to categorise carer activities and assess their translatability to virtual care using a novel scoring framework. Carer activities were diverse, with most involving information sharing, support, or history taking. Most activities (average translatability score 13/15) are highly translatable to virtual settings, especially those involving information sharing and emotional support. Just over half of these activities (53.8%, n = 21) can be conducted in virtual care settings with patients conducting simple self-assessments at home and communicating self-reported findings (for example, weight), or receiving assistance from carers. Translatability may increase with adequate digital and health literacy.
Strengths and limitations
A major strength of our study lies in analysing a primary source of in-person primary care consultations, the HaRI archive. Objectively observing these video consultations and transcripts minimises biases (for example, recall and confirmation) and measurement errors often associated with self-reported data (for example, surveys and interviews). Multiple coders were involved, which mitigated implicit bias and measurement error.
A limitation of our study is the small sample size of 39 GP–patient consultations, which may have limited the scope of types of carer activities observed or our ability to analyse variations in interactions across different patient concerns and conditions. Translatability may vary based on health literacy, case complexity, and carer involvement. Factors such as socioeconomic status, digital access, and patient preferences were not assessed, which may influence the suitability of carer-supported activities in virtual care. However, our included 39 consultations do indeed cover a range of types of carers. While our small sample precluded formal comparison between carer types, observable variation by relationship type suggests future research should explore how carer role and relationship influence consultation dynamics. Multiple GPs and practices were recruited in the HaRI study, so observations are not limited to the habits of a single clinician or practice. All consultations in the dataset were conducted in the UK and spoken in English, reducing generalisability to other parts of the non-English speaking world or countries with different healthcare systems. Participants only represent a cross-section of the population in the UK.
Our translatability to the virtual care scoring system was developed through discussions between researchers and reviewing relevant literature. However, given that the scoring system and the preceding inductive data analysis to develop the score were conducted by the same group of authors, there is a potential confirmation bias, despite attempts to remain objective throughout. Furthermore, patient factors impacting patient experience, such as measuring health literacy, language barriers, and socioeconomic status, were not considered in this study. Further use of the scoring system with different patient populations is required to further ascertain the tools’ appropriateness and validity.
Comparison with existing literature
Our study builds on prior research that used the translatability to virtual care tool previously applied to in-person GP consultations involving chronic conditions and physical examinations,18 patients with diabetes and cardiovascular disease,19 patients with respiratory conditions,20 and paediatric patients.22 Unlike these earlier studies, which primarily focused on the clinician’s role and the translatability of clinician-led clinical tasks, our study exclusively explored activities involving carers. We did not assess tasks performed solely by clinicians. A key contribution of this study is the inclusion of a novel scoring criterion, the ‘type of carer support required’ score, which captures the specific involvement of carers during consultations. This addition provides a more nuanced understanding of how carers facilitate healthcare delivery, particularly in virtual care settings.
While previous studies report challenges to the translatability of clinical tasks to virtual care,21 our findings show that many carer-related activities are highly translatable (for example, emotional support, information sharing, and logistical assistance). The involvement of carers participating in emotional and information support activities during consultations observed in this study aligns with the findings of a systematic review by Laidsaar-Powell et al.7 Emotional and physical support activities can be facilitated through simple self-assessments, communicating self-reported findings, and with assistance from carers.
We did not categorise clinician-led physical examination tasks (for example, blood pressure or weight measurement) in detail, as the role of the carers was limited to providing physical support. Activities such as some physical examinations (for example, palpation and demonstrations) can be facilitated by self-examinations. Hassan et al report patients are encouraged to conduct self-examinations for breast cancer screening to facilitate access to care and low cost.23 Furthermore, various studies highlighted significant companion and carer involvement (for example, parents) in decision making during consultations, consistent with our study.24,25
Implications for research and practice
This study demonstrates that carers play an active and multifaceted role in GP consultations. They not only facilitate information exchange (for example, self-management, treatment options, or diagnoses) but also shape the flow, accuracy, and emotional tone of encounters. However, the activities related to providing present complaints and medical history may be challenging for patients, carers, and clinicians in virtual care owing to requiring in-person clinical presence or higher levels of health literacy. Research is needed to address disparities in health literacy for both patients and their carers, such as appropriate patient education and guidance tools.
Although carers often enhance consultations, their presence can sometimes constrain patient autonomy or disclosure.26 We observed instances of interruption or over-speaking in our dataset that illustrate this risk. Detecting coercive or dominating behaviours in in-person consultations requires tact and skill.26 This may be even harder to do in virtual consultations where the carer may not be identified as being present or these cues may be hidden when carers are off-camera or muted. Clinician training should therefore include strategies for recognising and managing such dynamics.
As hybrid models of care become more common, clinicians must adapt not only to the absence of in-person cues but also to the increasing reliance on carers for practical assistance and offering reassuring support to patients. This includes reconsidering how physical examinations are conducted and how information provided by carers is verified remotely.27 Patient experience relies on both establishing relationships and clinical effectiveness (that is, accurate diagnosis and physical examinations).28 Certain tasks, such as physical examinations, may require additional support or guidance to be performed virtually. Research is needed to determine how to verify the accuracy of self-reported medical information virtually (for example, at-home medical devices or remote monitoring tools). The scoring system developed in this study offers a practical tool to evaluate and support carer roles in virtual care, informing clinician training and digital service design.
Virtual consultations introduce new challenges, such as managing disruptions or access barriers (for example, access to technology, internet disruptions, and considerations for setting and acoustics).29 Patient experience may be dependent on how healthcare providers can manage interruptions. Carers, particularly children, may interrupt discussions by fussing or talking over the patient. Additionally, adult carers may interject during discussions with the intention to assist the patient in information sharing but may reduce productivity or create delays.
Importantly, experiences can differ across virtual care modalities. For example, video consultations add visual cues and allow clinicians to identify who is present in the room, whereas telephone consultations limit these cues to verbal communication alone. Video platforms offer tools to manage these dynamics more effectively, such as controlling turn-taking during video calls and muting. However, they introduce new technical and relational challenges, such as buffering, audio-lag, and delayed responses, which can be amplified in three-way interactions when carers and patients speak simultaneously.29,30
Future research should investigate how different virtual care modalities mediate carer participation and clinician awareness. It should also explore how virtual care platforms can better support carer involvement while minimising disruptions. Future work should explore how virtual care can be designed to deliberately support productive carer involvement, ensuring consistently positive and effective patient experiences. Building on this observational work, we are extending this framework to virtual hospital models of care31 to examine how carers’ roles evolve in virtual environments.31,32
In conclusion, this study establishes that patients’ carers are not only commonly present during their consultations with GPs but also engage in a range of activities that support tasks. Carers were commonly reported to facilitate information exchange within consultations, assisting with discussions about patient history, and coordinating care-related tasks and care management activities outside of clinic settings. Importantly, findings identified tasks were commonly discussion-based or involved carers providing physical assistance that was translatable to virtual care. Future research should examine how carers can be better supported in virtual care to ensure positive patient and carer experiences.
Notes
Funding
Kanesha Ward was supported with a Higher Degree Research – Research Excellence scholarship from Macquarie University and Australian Government Research Training Program scholarship. Annie YS Lau was supported by the New South Wales Health Early-Mid Career Fellowship, and her research was supported by the National Health and Medical Research Council (NHMRC) Centre of Research Excellence (CRE) in Digital Health (reference: APP1134919) and NHMRC CRE in Connected Health (reference: 1170937).
Ethical approval
Ethical approval for secondary analysis of the HaRI dataset was obtained from Macquarie University Human Research Ethics Committee for Medical Sciences (reference: 52020558018892) and the NHS (Research Ethics Committee [REC] reference: 19/LO/0364; Integrated Research Application System [IRAS] project ID: 257924). Ethical approval for the original HaRI project was obtained from the NHS (REC reference: 16/LO/1029; IRAS project ID: 197875).
Provenance
Freely submitted; externally peer reviewed.
Data
The data supporting this study are not publicly available due to ethical concerns regarding participant privacy. The data are only available on request if the relevant ethical approvals are provided.
Acknowledgements
The authors would like to express their sincere thanks to Fiona Stevenson and her team for conducting the 'Harnessing resources from the internet to maximise outcomes for GP consultations' (HaRI) project, and for sharing their data with us in order to facilitate this research. The HaRI project was funded by the National Institute for Health and Care Research (NIHR) School for Primary Care Research. The views expressed are those of the authors and not necessarily those of the NIHR, the NHS, or the Department of Health and Social Care. NHS costs were covered via the local clinical research network. The authors of this study would like to acknowledge the hard work of Andrew Lau, who worked to de-identify all video recordings of the GP–patient consultations; and Hannah Long Quan Wang, Veronica Chacty, Athshan Rahman, Danial Thirunrambi, Woohyuk Jang, Richard Ung, and Lauren Parbery for their role in assisting with coding consultations and group discussions in this study. Lastly, the authors would like to acknowledge the primary funders of this study.
Competing interests
The authors declare that no competing interests exist.
- Received June 18, 2025.
- Revision received October 28, 2025.
- Accepted November 24, 2025.
- Copyright © 2026, The Authors
This article is Open Access: CC BY license (https://creativecommons.org/licenses/by/4.0/)
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