Determining Filipinos’ Preferences for Colorectal Cancer Screening Tests: Insights From a Choice-Based Conjoint Analysis

Abstract

Introduction

Filipinos in the U.S. have worse colorectal cancer screening rates and outcomes than non-Hispanic Whites, despite 85% of Filipinos being proficient in English and having insurance rates, education, and incomes that exceed those of the general population. To begin to address this disparity, the authors used conjoint analysis—a method that assesses complex decision making—to better understand Filipinos’ preferences for the different colorectal cancer screening test options.

Methods

The authors conducted a conjoint analysis survey among unscreened Filipinos aged ≥40 years at average risk for colorectal cancer to determine the relative importance of screening test attributes in their decision making (e.g., modality, effectiveness at reducing colorectal cancer risk, bowel prep). The authors also performed simulations to estimate the proportion of people who would prefer to do an annual fecal immunochemical test or colonoscopy every 10 years for their screening.

Results

Overall, 105 Filipinos completed the survey; most respondents were female (74.3%) and aged 40–49 years (84.8%). The authors observed that test modality was the most important factor in respondents’ decision making. After conducting simulations using the conjoint analysis data, the authors noted that 70 (66.7%) Filipinos preferred to do an annual fecal immunochemical test for their screening, whereas 35 (33.3%) wanted to do a colonoscopy every 10 years.

Conclusions

The authors found that 2 in 3 Filipinos prefer fecal immunochemical test to colonoscopy for their colorectal cancer screening. To address colorectal cancer disparities in the Filipino community, investigators, health systems, public health agencies, and community organizations need to develop culturally tailored, sustainable interventions, and such programs may want to focus on improving education on and access to fecal immunochemical test.

HIGHLIGHTS

• •Filipinos have lower colorectal cancer screening rates than Whites.
• •Test modality is key in Filipinos’ selection of a colorectal cancer screening test.
• •Most Filipinos prefer an annual fecal immunochemical test to colonoscopy.
• •Filipino community interventions may want to focus on fecal immunochemical test education and access.

INTRODUCTION

Colorectal cancer (CRC) is a major public health issue because it is the third most prevalent and deadly malignancy in the U.S.¹ Importantly, CRC is preventable through screening with stool, imaging, and endoscopy tests, and the U.S. Preventive Services Task Force recommends that all Americans at average risk for CRC start screening at age 45 years.²

Notably, Filipinos in the U.S. have significantly lower CRC screening rates and worse outcomes than non-Hispanic Whites.3, 4, 5, 6, 7, 8, 9 Sy et al.⁸ summarized data from studies comparing CRC screening rates between Whites and Filipinos and found that 57.7%–75.4% of Whites were screened versus only 41.7%–65.9% of Filipinos. Moreover, Lin and colleagues⁷ discovered that Filipinos were significantly more likely to be diagnosed with CRC at higher stages than Whites. These disparities exist even though Filipinos do not face some challenges encountered by other racial/ethnic minorities; nearly 85% of Filipinos are proficient in English and have insurance rates, education levels, and incomes that exceed those of the general U.S. population.10, 11, 12 This is problematic because Asian Americans are the fastest growing major racial/ethnic group in the U.S., with Filipinos comprising the third largest cohort with over 4.2 million people.^10,13

Before developing interventions aimed at increasing CRC screening uptake among Filipinos, it is first critical to understand how they choose among the different testing options. In a previous study, the authors qualitatively examined Filipinos’ perceptions on the various CRC screening tests and found that they considered many factors when selecting a test such as accuracy, frequency, convenience, insurance coverage, and out-of-pocket costs, among other factors.¹⁴ As part of this study, the authors aimed to quantify Filipinos’ decision making on CRC screening tests using conjoint analysis—a method that assesses how people make complex decisions. In addition, simulations were performed using the conjoint analysis data to determine the proportion of respondents who preferred to do an annual fecal immunochemical test (FIT) or colonoscopy every 10 years for their screening.¹⁵

METHODS

Study Population

This study was approved by the Cedars-Sinai IRB (Study599). The authors recruited a sample of Filipinos aged ≥40 years at average risk for CRC (i.e., no personal history of colon polyps, family history of CRC, or inflammatory bowel disease [Crohn's disease, ulcerative colitis]¹⁶) and who had not been previously screened to participate in a cross-sectional, self-administered, online survey. The survey was administered only in English.

Study invitation emails were sent to Filipinos who received care at an academic medical center (Cedars-Sinai Medical Center) in Los Angeles, California, as well as those who were members of national survey research panels between April 29, 2021 and November 7, 2021. For recruitment at Cedars-Sinai, the the Deep6 cohort builder was used to identify potentially eligible Filipinos. To recruit Filipinos who were members of national survey research panels, the authors collaborated with a research technology firm called Cint (Stockholm, Sweden). Cint and their remuneration policies are described in detail elsewhere.17, 18, 19, 20

All respondents who accessed the survey were informed that the study goal was “to learn how people make certain medical decisions,” and they were first presented with questions to confirm their eligibility. People who self-reported as being Filipino and aged at least 40 years were included. Of note, the authors used Filipinx in the survey as a gender-neutral alternative to Filipino. Since the initial development of the survey, there has been increasing debate regarding the appropriateness of Filipinx versus Filipino. For example, whereas Filipinx is intended to be more inclusive of nonbinary and gender-nonconforming individuals, others argue that Filipino is already gender neutral in the context of the Filipino language.21, 22, 23, 24 Given that this discussion remains ongoing and unresolved, the authors chose to use the term Filipino in the manuscript to align with its broader and more established usage.

Participants who had been previously screened for CRC were excluded because the study aimed to focus on individuals who have yet to engage in the screening process. Including those who were previously screened could have introduced bias because their past experiences might have influenced their current attitudes and behaviors toward CRC screening. The authors also excluded people who had been diagnosed with colon polyps, Crohn's disease, or ulcerative colitis by a physician or had a first-degree relative who was diagnosed with CRC; these individuals are at higher risk for CRC and require more intensive screening protocols with colonoscopy as the preferred test modality.¹⁶

Measures

The Appendix File (available online) includes the full survey instrument. All participants reviewed a study information page and provided consent before completing the survey. The authors used the same instrument that was used in a prior study assessing CRC screening test preferences among a nationally representative sample of 1,000 Americans.²⁰ Prior to deploying the survey, the authors pilot tested the instrument with 8 patients to ensure its understandability and usability. As further described below, the survey consisted of conjoint analysis exercises and multiple-choice questions.

Conjoint analysis is a method that quantifies how people make tradeoffs when considering competing factors. The development process for the conjoint analysis exercises used for this study is described in detail elsewhere.²⁰ In brief, the authors followed best practices endorsed by the International Society for Pharmacoeconomic and Outcomes Research.²⁵ Selection of the attributes and levels for the conjoint analysis were informed by findings from focus groups with 21 patients²⁶ and input from clinical experts on the research team. Table 1 presents the final attributes and levels that were tested in the survey.

Table 1.

Attributes and Levels Included in the Conjoint Analysis

CRC screening test attribute	Attribute levels
Way to look for colon cancer	Colonoscopy
	Colon video capsule
	Colon CT scan
	Stool test
Reduction in chance of getting colon cancer during your lifetime	Chance of getting colon cancer during your lifetime decreases by 20%
	Chance of getting colon cancer during your lifetime decreases by 40%
	Chance of getting colon cancer during your lifetime decreases by 60%
	Chance of getting colon cancer during your lifetime decreases by 80%
How often you perform the test	Repeat every 1 year
	Repeat every 3 years
	Repeat every 5 years
	Repeat every 10 years
Diet the day before the testa	Low fiber diet
	Clear liquid diet
Bowel preparation before the testa	Drink 1 liter of bowel prep both the night before and the morning of the test
	Drink 1.5 liters of bowel prep both the night before and the morning of the test
	Drink 2 liters of bowel prep both the night before and the morning of the test
Chance of a complication that requires you to go to the hospital a	0.1% (1 in 1,000) chance of a complication
	0.3% (3 in 1,000) chance of a complication
	0.5% (5 in 1,000) chance of a complication
	0.7% (7 in 1,000) chance of a complication
	0.9% (9 in 1,000) chance of a complication

Note: Whereas the original analysis focused on all MSTF-recommended CRC screening tests,²⁰ this study focused on examining those who preferred the MSTF Tier 1–recommended tests—annual FIT versus colonoscopy every 10 years.

^aThe choice-based conjoint employed an alternative specific design and levels for this attribute were only shown for colonoscopy, colon video capsule, and colon CT scan

CRC, colorectal cancer; CT, computed tomography; FIT, fecal immunochemical test; MSTF, Multi-Society Task Force.

Lighthouse Studio (Sawtooth Software, Version 9.11.0, North Orem, UT) was used to create the choice-based conjoint with alternative-specific design. Participants were shown a random set of 9 side-by-side profiles (Figure 1) drawn from 300 potential sets generated through a balanced overlap design. Participants were instructed to “choose which [screening test], if any, you would be most likely to do [for CRC screening]” and to “assume that medical insurance will cover each one and that you will not have any out-of-pocket costs.” Prior to completing the conjoint exercises, respondents were shown information on the testing modalities and their attributes (Appendix File, available online, provides these descriptions). The presentation order for the information on the various testing options was randomized among participants to prevent order bias.

Figure 1.

Sample conjoint exercise where participants consider hypothetical CRC screening tests side by side and decide which one, if any, they would be most likely to do.

Participants were shown a total of 9 vignettes, and they were able to hover their mouse over bolded text for further information. Note: whereas the original analyses focused on all MSTF-recommended CRC screening tests,²⁰ this study focused on examining those who preferred the MSTF Tier 1–recommended tests—annual FIT versus colonoscopy every 10 years.

CRC, colorectal cancer; CT, computed tomography; FIT, fecal immunochemical test; MSTF, Multi-Society Task Force.

The conjoint exercises were followed by questions on participants’ knowledge, attitudes, and beliefs on CRC screening. Specifically, respondents were asked whether they planned to get screened for CRC using a 5-point Likert scale. The CRC Knowledge, Perceptions, and Screening Survey was adapted to collect information on their self-perceived CRC susceptibility, impact of a CRC diagnosis, and benefits and barriers to screening; all items employed a 5-point Likert scale.²⁷

The survey collected self-reported sociodemographic information, including age, sex, education, marital status, total annual household income, and employment status. Participants were also asked about their self-reported health status,²⁸ comorbidities,²⁹ and any gastrointestinal symptoms that they experienced in the past 3 months.

Statistical Analysis

Hierarchical Bayes regression was used to estimate individual-level importance scores and part-worth utilities for each tested attribute and level, respectively; attributes and levels with higher scores were more highly valued in the decision-making process. The authors then performed simulations using the individual-level part-worth utilities for test modality and frequency to determine the proportion of individuals who would prefer the following U.S. Multi-Society Task Force (MSTF) Tier 1–recommended tests¹⁵: stool test every year (i.e., FIT) or colonoscopy every 10 years.

Statistical analyses were performed using SAS, Version 9.4 (Cary, NC). A 2-tailed p<0.05 was considered statistically significant. The authors used descriptive statistics for respondents’ conjoint analysis–derived importance scores and preferred CRC screening tests (annual FIT, colonoscopy every 10 years). Respondents’ sociodemographics, comorbidities, and CRC screening perceptions were summarized using frequencies and percentages or median and IQR, where appropriate. Multivariable logistic regression was performed to identify the factors associated with preferring an annual FIT to colonoscopy every 10 years. To adjust for confounding, the regression model included variables with a univariate p<0.20 as covariates. Results were reported as AORs with 95% CIs.

RESULTS

Among 1,172 individuals who accessed the survey, the following people were excluded: those who did not meet eligibility criteria (e.g., did not self-report as Filipino, aged <40 years, had prior CRC screening, not at average risk for CRC given a personal history of colon polyps or inflammatory bowel disease or family history of CRC) (n=945 [80.6%]), those who did not finish completing the survey (n=115 [9.8%]), and those who had implausible responses (e.g., straight-line responses or inconsistent responses³⁰ on the conjoint exercises, impossible answer combinations on multiselect multiple choice questions) (n=7 [0.6%]). Therefore, the final analytic set included 105 Filipinos, and Table 2 presents their demographics. Most participants were aged 40–49 years, female, college educated, and recruited from an academic medical center in Los Angeles, California.

Table 2.

Demographics of the Study Population (N=105)

Variable	n (%)
Age, years
40–49	89 (84.8)
≥50	16 (15.2)
Sex
Male	27 (25.7)
Female	78 (74.3)
Educational attainment
Some college education or less	16 (15.2)
College degree	89 (84.8)
Marital status
Married or living with a partner	85 (81.0)
Not married	20 (19.0)
Total household income
≤$100,000	43 (41.0)
>$100,000	50 (47.6)
Prefer not to say	12 (11.4)
Employment status
Unemployed, on disability, on leave of absence from work, retired, or a homemaker	23 (21.9)
Employed or student	82 (78.1)
Self-reported health status
Excellent or very good	50 (47.6)
Good or fair	55 (52.4)
Number of medical comorbiditiesa
0	25 (23.8)
≥1	80 (76.2)
Number of gastrointestinal comorbiditiesb
0	88 (83.8)
≥1	17 (16.2)
Number of gastrointestinal symptoms  experienced in past 3 monthsc
0	54 (51.4)
≥1	51 (48.6)
Recruitment source
Cedars-Sinai	71 (67.6)
Cint, national survey research firm	34 (32.4)

^aInclude migraines, heart disease, high blood pressure, lung disease, diabetes, kidney disease, anemia or other blood disease, cancer, depression, osteoarthritis or degenerative arthritis, back pain, rheumatoid arthritis, or other medical problems.

^bInclude irritable bowel syndrome, ulcer or stomach disease, liver disease, celiac disease, cirrhosis, diverticulitis, gallstones, gastroenteritis, gastroesophageal reflux disease, gastroparesis, or pancreatitis.

^cIncludes abdominal pain or discomfort, anal or rectal pain, bloating, bowel incontinence, constipation, diarrhea, dysphagia, heartburn, nausea/vomiting, or regurgitation.

Table 3 presents individuals’ intentions to undergo screening for CRC; 64.8% of respondents stated that they planned to be tested. Table 3 also shows participants’ responses regarding their self-perceived CRC susceptibility, impact of CRC diagnosis, benefits of CRC screening, and barriers to CRC screening.

Table 3.

Knowledge, Attitudes, and Beliefs on CRC and CRC Screening (N=105)

Variable	Total (N=105)
Plans to get screened for CRC	68 (64.8%)
Has non–first-degree relative or friend diagnosed with CRC	25 (23.8%)
Self-perceived CRC susceptibility (1–5 scale; higher=more susceptible)	2.6 (2.0–3.0)
Self-perceived impact of CRC diagnosis (1–5 scale; higher=more severe impact)	3.5 (3.1–3.8)
Self-perceived benefits of CRC screening (1–5 scale; higher=more beneficial)	4.4 (3.8–4.8)
Self-perceived barriers to CRC screening (1–5 scale; higher=more barriers)	2.5 (2.1–3.0)

Note: Data are presented as n (%) or median (IQR).

CRC, colorectal cancer.

Regarding colorectal cancer screening test preferences, the mean importance scores among Filipinos were test modality (33.0% [SD=15.5%]), reduction in chance of getting CRC (30.0% [SD=15.1%]), chances of a serious complication (14.4% [SD=6.1%]), test frequency (12.7% [SD=5.8%]), bowel preparation before the test (5.9% [SD=3.1%]), and diet changes before the test (4.0% [SD=2.6%]). Figure 2 shows results from the conjoint analysis–derived simulations determining the proportion of respondents who preferred to do either an annual FIT or colonoscopy every 10 years for their CRC screening. Most Filipinos preferred to do a yearly FIT (n=70, 66.7%), whereas fewer people (n=35, 33.3%) wanted to do a colonoscopy every 10 years.

Figure 2.

Data from simulations using conjoint analysis data assessing the proportion of respondents who would prefer each MSTF Tier 1–recommended test (N=105).

FIT, fecal immunochemical test; MSTF, Multi-Society Task Force.

Table 4 shows the results of the logistic regression on preferring to do a yearly FIT to colonoscopy every 10 years; the model included variables with a p<0.20 from univariate logistic regression analyses as covariates. The authors found that sex, marital status, total household income, employment status, recruitment source, and having a non–first-degree relative or friend diagnosed with CRC were not statistically associated with decision making.

Table 4.

Regression Analysis on Preferring FIT Test Every Year to Colonoscopy Every 10 Years for CRC Screening

Variable	Prefers FIT every year for CRC screening
	n (% of row)	AOR (95% CI)
Sex
Male	21 (77.8%)	ref
Female	49 (62.8%)	0.66 (0.21, 2.02]
Marital status
Married or living with a partner	53 (62.4%)	ref
Not married	17 (85.0%)	2.37 (0.54, 10.31]
Total household income
≤$100,000	34 (79.1%)	ref
>$100,000	31 (62.0%)	0.72 (0.25, 2.12)
Prefer not to say	5 (41.7%)	0.23 (0.05, 1.09)
Employment status
Unemployed, on disability, on leave of absence from work, retired, or a homemaker	19 (82.6%)	ref
Employed or student	51 (62.2%)	0.36 (0.10, 1.29)
Recruitment source
Cedars-Sinai	42 (59.2%)	ref
Cint, national survey research firm	28 (82.4%)	1.52 (0.47, 4.90)
Has non–first-degree relative or friend diagnosed with CRC	11 (44.0%)	0.42 (0.15, 1.16)

Note: Screening test preferences were determined through simulations from conjoint analysis–derived data (N=105). The logistic regression model included all variables in the table.

CRC, colorectal cancer; FIT, fecal immunochemical test.

DISCUSSION

To the authors’ knowledge, this is the first study to use conjoint analysis to quantitatively assess the tradeoffs that Filipinos make when selecting a CRC screening test. When participants’ conjoint analysis responses to the U.S. MSTF Tier 1 tests were mapped,¹⁵ 66.7% of Filipinos preferred to do an annual FIT for their CRC screening, whereas the remaining 33.3% of people wanted to do a colonoscopy every 10 years. This finding suggests that interventions aimed at improving CRC screening rates among Filipinos should consider either focusing on FIT or employ a sequential approach where FIT is offered first and, if declined, then colonoscopy. Notably, in prior focus groups with unscreened Filipinos, there were limited knowledge and awareness of FIT as an appropriate CRC screening option; most believed that colonoscopy was the only way to screen for CRC.¹⁴ This is consistent with findings from Tsoh et al.³¹ where they observed that only 22.6% of surveyed Filipinos were aware that fecal occult blood test should be performed annually.

Filipinos' marked preference for FIT to colonoscopy may be partially attributed to the greater ease of use associated with FIT. In previous focus groups with Filipinos, most barriers to CRC screening mentioned by participants were associated with colonoscopy, including concerns about safety, fear of anesthesia, and a desire to avoid out-of-pocket medical costs.¹⁴ In other non-Filipino focused studies, individuals reported aversion to the bowel preparation, lack of time, and parasexual sensitivities as barriers to undergoing colonoscopy.³² Moreover, Filipinos, particularly recent immigrants from the Philippines, where the healthcare system is largely cash based,³³ may be more inclined to choose FIT owing to its lower cost than colonoscopy. By developing interventions focused on FIT, it may improve screening rates and reduce CRC disparities among Filipinos3, 4, 5, 6, 7, 8, 9 because it is convenient to perform, is less costly, and does not have any safety concerns. Such an approach is supported by data from a community-based RCT conducted by Maxwell and colleagues³⁴ from 2005 to 2007; they found that 30.2% of Filipinos who attended an education session and received a free fecal occult blood test kit successfully underwent CRC screening compared with only 8.6% for controls. It is important to note that although FIT presents its own unique barriers, reported obstacles include discomfort with handling stool, forgetting to mail the test to the laboratory, and concerns about the test's accuracy, among others.³⁵ Thus, investigators may also consider interventions that employ a sequential approach (i.e., offering FIT first and, if declined, then offering colonoscopy) to minimize missed screening opportunities among individuals unwilling to undergo a stool-based test.

The strong preference for a yearly FIT to colonoscopy every 10 years among Filipinos is consistent with results from the authors’ initial study assessing CRC screening test preferences in a nationally representative sample of 1,000 Americans.²⁰ This again suggests that organized screening programs should strongly consider a sequential-based strategy to maximize screening uptake. This is further supported by data from a CRC screening program at Kaiser Permanente in Northern California that uses direct-to-patient annual FIT outreach but also makes colonoscopy available upon request^36,37; the percentage of patients up to date with screening increased from 38.9% in 2000 to 82.7% in 2015.³⁶ Notably, Ghai et al.³⁷ performed a separate analysis examining screening rates in 2016 among Asian American subgroups in the same healthcare system, and they did not find any differences in CRC screening rates between Filipinos (78.7%) and non-Hispanic Whites (77.6%). By enacting an organized screening program primarily focused on FIT, Kaiser Permanente in Northern California eliminated CRC screening disparities among Filipinos and other racial/ethnic minorities.^37,38 Because CRC screening in the U.S. is primarily opportunistic (i.e., screening recommendations are initiated by the primary care provider or by patient request during routine clinic visits),³⁹ healthcare systems should consider implementing organized CRC screening programs to increase screening uptake and reduce disparities.

This study has strengths. First, the study is one of very few CRC screening studies that focused solely on Filipinos; most previous studies studied Filipinos in aggregate or in addition to other Asian Americans.^31,40, 41, 42, 43, 44, 45, 46, 47, 48 Second, the study is the first to quantify Filipinos’ CRC screening test preferences using conjoint analysis. Because Filipinos strongly prefer FIT to colonoscopy, subsequent interventions may want to focus their efforts around educating and increasing access to FIT among those in the Filipino community. Of note, the authors plan to use findings from this study along with observations from their recent Filipino focus groups to inform the development and implementation of a sustainable, culturally tailored, community-based intervention to improve CRC screening uptake among Filipinos in Los Angeles, California.

Limitations

There were limitations to this study. First, although the study is the first to quantitatively assess CRC screening test preferences among Filipinos using conjoint analysis, it was based on data from 105 participants. Given the relatively small sample size, the authors focused on modeling the proportion of people who preferred either FIT every year or colonoscopy every 10 years; other available CRC screening modalities include FIT-fecal DNA, colon computed tomography scan, and colon video capsule. Notably, FIT and colonoscopy are Tier 1 tests according to the U.S. MSTF and the most used tests in the U.S.¹⁵ Second, the survey was administered only in English, which may limit the generalizability of the findings to Filipinos who are not proficient in English and prefer to communicate in languages such as Tagalog, Bisaya, Ilokano, or other regional languages. Third, the authors utilized the same conjoint instrument from a prior study focused on the general U.S. population,²⁰ which did not collect data on immigration status or country of birth. It is possible that CRC screening preferences may vary among Filipinos on the basis of whether they were born in the U.S., immigrated long ago, or recently immigrated; this is an area worthy of further study. Fourth, most respondents received care at an academic medical center in Los Angeles, California. Although Los Angeles is the top U.S. metropolitan area by Filipino population, these findings may not extend to other areas in the U.S. with a high prevalence of Filipinos such as San Francisco, California; New York, New York; and Honolulu, Hawaii, among other cities.¹⁰ In addition, most of study's participants were female, highly educated, and from high-income households; it is unclear whether the findings are generalizable to other Filipino groups not as well represented in this study. Further research in diverse settings and among broader Filipino populations is needed. Fifth, the survey did not include instruments for assessing specific Filipino cultural values, such as hiya (shame), bahala na (fatalism), and kapwa (shared identity), which can influence health-seeking behaviors in Filipinos.^49,50 Future research should consider assessing the impact of these cultural values on Filipinos’ decision making on CRC screening. Finally, the survey was conducted during the coronavirus disease 2019 (COVID-19) pandemic from April 2021 to November 2021. It is possible that hesitancy to seek care during the pandemic51, 52, 53 may have led more Filipinos to prefer FIT, which is performed at home, to colonoscopy, which requires presenting to a healthcare facility.

CONCLUSIONS

In conclusion, 2 in 3 Filipinos preferred to do an annual FIT to colonoscopy every 10 years for their CRC screening. Because Filipinos comprise a growing portion of the U.S. population and have lower CRC screening uptake and worse CRC outcomes than non-Hispanic Whites,3, 4, 5, 6, 7, 8, 9 it is imperative for investigators, health systems, public health agencies, and community organizations to develop culturally tailored, sustainable interventions to address these disparities. Given Filipinos’ strong preference for FIT, such interventions may want to primarily focus on FIT or employ a sequential approach where FIT is offered first and, if declined, then colonoscopy.

CRediT authorship contribution statement

Austin Crochetiere: Investigation, Methodology, Writing – original draft, Writing – review & editing. Marie Lauzon: Data curation, Formal analysis, Investigation, Visualization, Writing – original draft, Writing – review & editing. Antwon Chaplin: Data curation, Investigation, Methodology, Project administration, Writing – review & editing. Christopher V. Almario: Conceptualization, Data curation, Funding acquisition, Investigation, Methodology, Resources, Supervision, Writing – original draft, Writing – review & editing.