Asia-Pacific Context Research Articles

Thriving futures

This Special Issue of the journal Art, Design & Communication in Higher Education (ADCHE) revisits the purpose and potential of art and design from an Australian perspective. It draws on the November 2023 Australian Council of University Art & Design Schools (ACUADS) 43rd conference, co-convened by Thao Nguyen, School of Art, RMIT University and myself. This national forum sought to consider the following: (1) how can creative education and research embrace our unique Australian perspective and integrate First Nations knowledge to cultivate a ‘thriving future’? (2) What is the potential of creative research and pedagogy in responding to the climate crisis and other urgent societal concerns? (3) How has the global pandemic disrupted and catalysed innovation in creative art education, including the rapid uptake of digital media by traditionally haptic disciplines? What are the key technological agendas for art and design schools? Drawing on our unique perspective, with particular acknowledgement of First Nations knowledge and ways of being, our colonial history and Asia–Pacific context, this edition considers how creative education and research can contribute not only to economies but also to the array of pressing social, environmental and cultural issues necessary to enable thriving futures.

The role of internal communication on employee loyalty – a theoretical synthesis

PurposeThis paper aims to propose various theoretical lenses to explore the relationship between internal communication (IC) and its impact on employee loyalty.Design/methodology/approachA systematic review followed by a synthesis of the literature is adopted after identifying articles from various databases such as Scopus, Google Scholar and EBSCO and found that employee loyalty remains a significant gap in organisational IC research. The review will bring greater attention and focus for scholars to check how IC can help increase employee loyalty using the proposed theories – more so for IC in the Asia-Pacific.FindingsThe findings from this paper explicitly highlight that both individual/managerial theories (social cognitive, social identity, social exchange, expectancy and socio-analytic theories) and organisational theories (network, resource-based view and sensemaking theories) are close and relevant to study the IC and employee loyalty.Originality/valueThe value of this review is to move forward the debate on how IC can significantly contribute to developing employee outcomes (loyalty), how it can further enhance employee performance and commitment and what theories better explain this relationship. This review will inspire and inform future scholars to explore IC’s role in employee loyalty in the Asia-Pacific context.

Crossing borders

This issue builds on sociolinguistic research on indigenous languages, visual and auditory semiotics, material ethnography, and multicultural practices to develop a nuanced understanding of linguistic landscapes in the Asia Pacific context. The contributions to this issue, from Vanuatu to Hong Kong, disrupt the boundaries between the rural and the urban, the linguistic and the semiotic, the powerful and the marginal.

Asia-Pacific Consensus Recommendations on X-Linked Hypophosphatemia: Diagnosis, Multidisciplinary Management, and Transition From Pediatric to Adult Care.

X-linked hypophosphatemia (XLH) is a rare, inherited, multisystem disorder characterized by hypophosphatemia that occurs secondary to renal phosphate wasting. Mutations in PHEX gene (located at Xp22.1) in XLH alter bone mineral metabolism, resulting in diverse skeletal, dental, and other extraskeletal abnormalities that become evident in early childhood and persist into adolescence and adult life. XLH impacts physical function, mobility, and quality of life, and is associated with substantial socioeconomic burden and health care resource utilization. As the burden of illness varies with age, an appropriate transition of care from childhood and adolescence to adulthood is necessary to meet growth-related changes and minimize long-term sequelae of the condition. Previous XLH guidelines that encompassed transition of care have focused on Western experience. Regional differences in resource availability warrant tailoring of recommendations to the Asia-Pacific (APAC) context. Hence, a core expert panel of 15 pediatric and adult endocrinologists from nine countries/regions across APAC convened to formulate evidence-based recommendations for optimizing XLH care. A comprehensive literature search on PubMed using MeSH and free-text terms relevant to predetermined clinical questions on diagnosis, multidisciplinary management, and transition of care of XLH revealed 2171 abstracts. The abstracts were reviewed independently by two authors to shortlist a final of 164 articles. A total of 92 full-text articles were finally selected for data extraction and drafting the consensus statements. Sixteen guiding statements were developed based on review of evidence and real-world clinical experience. The GRADE criteria were used to appraise the quality of evidence supporting the statements. Subsequently, a Delphi technique was utilized to rate the agreement on statements; 38 XLH experts (15 core, 20 additional, 3 international) from 15 countries/regions (12 APAC, 3 EU) participated in the Delphi voting to further refine the statements. Statements 1-3 cover the screening and diagnosis of pediatric and adult XLH; we have defined the clinical, imaging, biochemical, and genetic criteria and raised red flags for the presumptive and confirmatory diagnosis of XLH. Statements 4-12 tackle elements of multidisciplinary management in XLH such as therapeutic goals and options, composition of the multidisciplinary team, follow-up assessments, required monitoring schedules, and the role of telemedicine. Treatment with active vitamin D, oral phosphate, and burosumab is discussed in terms of applicability to APAC settings. We also expound on multidisciplinary care for different age groups (children, adolescents, adults) and pregnant or lactating women. Statements 13-15 address facets of the transition from pediatric to adult care: targets and timelines, roles and responsibilities of stakeholders, and process flow. We explain the use of validated questionnaires, desirable characteristics of a transition care clinic, and important components of a transfer letter. Lastly, strategies to improve XLH education to the medical community are also elaborated in statement 16. Overall, optimized care for XLH patients requires prompt diagnosis, timely multidisciplinary care, and a seamless transfer of care through the coordinated effort of pediatric and adult health care providers, nurse practitioners, parents or caregivers, and patients. To achieve this end, we provide specific guidance for clinical practice in APAC settings. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Consumption, ongoingness and everyday-life embeddedness: Lifestyle experiences of Chinese transient migrants in Chiang Mai, Thailand

This article examines recent Chinese migrants to Thailand, with a specific focus on those who migrate for education and remain in Thailand after graduation. It aims to drive the analytical theory from a methodological nationalism to a transient migration approach, and to capture the sense of “transience” of the new wave of Chinese migration in a broader Asia-Pacific context. A mixed-methods approach was adopted, with data collected from Chinese migrant website communities, questionnaires and in-depth interviews. The findings show that the Chinese migrants lead a consumption-oriented migration life that benefits from hypermobility by enjoying a “mobility surplus” in education as a family project. This article discusses the temporariness as a strategy that the Chinese use to bridge migratory resources in a permanent state of in-betweenness. The key issue that has been highlighted is the meaning of being transient in everyday life. As it articulates authenticity and the meaning of “self” in modern life, transient migration, thus, does not aim at its overcoming, but is rather a form of life in itself.

Centralization and prospective audit of cystectomy are necessary: a commentary on the case for centralization, supported by a contemporary series utilizing the ANZUP cystectomy database.

Bladder cancer (BC) outcomes are unacceptably poor. In Australia, BC survival is actually deteriorating. There is an urgent need to improve outcomes in BC patients, which requires a multipronged approach. One area deserving closer scrutiny is radical cystectomy. Audit is necessary to identify areas for improvement and without it, outcomes remain unknown. Evidence convincingly shows high-volume surgeons and centers improve cystectomy outcomes including overall survival, yet centralization has still not occurred. The Australia and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group cystectomy database has been established to facilitate cystectomy audit in Australia and New Zealand. We present initial data from the ANZUP cystectomy database from a single high-volume center, discuss the benefits of centralization and its challenges in the Asia-Pacific context.

The Role of the Built Environment on the Quality of Life for Residents in Long-Term Care Facilities in Asia: A Scoping Review.

Background and ObjectivesThe quality of the built environmental features in long-term care (LTC) homes significantly influences residents’ functioning (e.g., wayfinding, self-care, and social interaction) and well-being. There is limited research on the characteristics of the built environment of LTC and its influence on residents’ quality of life in countries in the Asia–Pacific region (e.g., East Asia and South Asia). The older adult population in this region is expected to increase significantly in the coming decades. There are distinctive perceptions of nursing home, nursing home environments, and sociocultural norms in this geographic region. Given this context, a better understanding of the built environment of LTC facilities in this region can inform design professionals and policymakers for evidence-based decision-making. The present study undertakes a scoping review of the empirical research on the characteristics and influence of the built environment of LTC facilities on residents’ quality of life in the Asia–Pacific context.Research Design and MethodsOnline relevant databases were used to identify articles published 2000–2021, from which we selected 33 publications.ResultsThree substantive themes were generated from the synthesis of the selected publications. These themes are (a) perceptions of nursing home, (b) impact of the built environment on residents’ quality of life, and (c) assessment of the LTC built environment.Discussion and ImplicationsWe identified research gaps in understanding the role of the built environment in nursing homes in the particular geographic context and future research directions. Five planning and design principles for LTC were derived from the synthesis of key findings to inform design professionals and policymakers.

Pixies in a windstorm: Tracing Australian gymnasts’ stories of athlete maltreatment through media data

ABSTRACT The media have reported stories of a toxic sport culture in elite gymnastics. Our interdisciplinary research team, through the lens of cultural relativism, sought to present athlete maltreatment as culturally constructed across individual, organizational and national cultural layers in Olympic development contexts. Tracing storied media data from elite Australian gymnasts, we tailored our sociocultural interpretation of athlete maltreatment within an Asia-Pacific context. We engaged in a reflexive thematic analysis to analyze and recognize our interpretations of the media data. We use a polyphonic vignette to highlight multiple storylines of Olympic athlete maltreatment across five temporal phases: (1) defining an Australian gymnast, (2) grooming an Australian gymnast, (3) living as an Australian gymnast, (4) questioning gymnastics and (5) what happens to Australian gymnasts now? Utilizing Asia-Pacific media data facilitated our nuanced interpretation of infacing and outfacing athlete maltreatment as media sources project athlete narratives in alignment with cultural agendas.

Policy experimentation with impact financing: a systematic review of research on social impact bonds

ABSTRACT Social impact bonds (SIB) have become a novel and attractive policy tool to assist with service delivery to vulnerable groups. Since the first SIB in 2010 in the United Kingdom, hundreds of projects have been adopted, implemented, and continue to be developed around the world. A broad observation from current research concludes that there is a lack of consistent evidence on research foci and orientations with regard to this innovative policy tool. In the context of the Asia-Pacific region, research on SIBs is largely non-existent. Moreover, research from Asia-Pacific contexts is primarily focused on the (financial) product features of impact financing, at the expense of studying the process innovation aspect of SIBs in service delivery. This contrasts with research from European and North American SIBs, which exhibit a relatively heightened interest on issues in service delivery process and their impact on performance measurement, evidence auditing and evaluation, and accountability to service recipients versus investor returns. As policy experimentation continues with SIBs in the Asia-Pacific region, several key considerations remain vital and require future scholarly attention.

Challenges and Opportunities for Academic Journals to Serve the Older Population in Western Pacific Region.

Annals of Geriatric Medicine and Research held its inaugural international editorial board virtual meeting on September 16, 2021, to brainstorm ideas for sustainable growth. This special article summarizes the key concepts obtained from the webinar proceedings, with further development of ideas from ensuing discussions occurring after the meeting. From the initial discussion points provided by eight editorial board members, including six presenters, email discussions further enriched these ideas to construct the current special article. The key points discussed were: impactful research and impact factors, international and Asian perspectives, and challenges to sustainable growth. The editors noted the existing gap between the impact factor and research impact as a challenge for the growth paths of regional journals. However, they agreed that persevering with impactful research would ultimately translate into parallel and gradual gains in impact, which is, therefore, consistent with the organic growth of the journal. Acknowledging challenges in navigating between unique Asian perspectives and international outlooks, the editors encouraged academic journals to serve as bridges linking international evidence with the richness of local perspectives. For sustainable growth, the editors suggested that journals may be forged into the academic ecosystems of the region, diversify value streams, and establish themselves as reputable brands in disciplines. By combining these discussions, we proposed the “IMPACT” strategy for journals on the growth path in the region, which stands for IMmersive user experience encompassing authors, reviewers, and readers; Pasteur’s quadrant use-inspired research; Asia-Pacific context; Collaborative; and Translation to practice and policy.

The Development of Sub-Regional Institutions in Southeast Asia: The Case of BIMP-EAGA

The relationship between economics and sub-regionalism remains relatively unexplored, particularly in the Asia-Pacific context. This article seeks to broaden the comprehension of various dimensions of this relationship. One of the focuses is to understand the circumstances in which sub-regional institutions have come to be defined as components of economic development in Southeast Asia. Another is to develop a more nuanced approach to regional studies, one that recognizes that institutional changes can occur in many forms, like Historical Institutionalism. This paper’s starting point is on the emphasis that institution is a social construction: political contestations between the social forces in the domestic often influences how state shaped regional institutions that would serve their interest. It uses the critical juncture framework championed by the Historical Institutionalist approach during that particular period to produce divergent outcomes. This study uses BIMP-EAGA to provide some grounds for optimism on the relationship between institutional changes and economic development in the region. Keywords: Historical Institutionalism, critical juncture, economic development, institutional changes, sub-regional institutions, and BIMP-EAGA

An introduction to the special issue on cyberbullying in Asia and Pacific: its nature and impact

ABSTRACT Recently research on cyberbullying has been extensive, but mostly in Western societies. Cyberbullying is a new and unique form of bullying behaviour, which is affected by several protective and risk factors as well as is associated with behavioural, psychological and health outcomes. This introduction provides a background of cyberbullying in the Asia-Pacific context, summarises seven studies included in this special issue, and suggests a direction for cyberbullying prevention and the young’s well-being.

Improving the Effectiveness of the Consumer Product Safety System: Australian Law Reform in Asia-Pacific Context.

The Australian government is undertaking public consultations over possible improvements to the 2010 Australian Consumer Law (ACL) regime, including again the idea of adding a European-style general safety provision (GSP). To bolster the case for such reform, Part 2 of this paper analyses 2017–2019 data trends from the OECD Global Recalls Portal for Australia compared with several comparable economies, especially in the Asia-Pacific region where Australia now has most of its trade and investment links. The analysis finds a persistently high per capita recall rate for Australia, compared with several jurisdictions including Korea, Japan, and especially the USA. However, the analysis identifies various legal and other factors across the jurisdictions that impact on interpreting such data. Part 3 therefore begins by highlighting some more specific patterns uncovered from an ongoing joint research project comparing child product safety trends particularly in Australia and the USA. It highlights various concerns regarding recalls in Australia, as well as weaknesses in Australia’s ACL regime (in addition to the lack of a GSP), in coordinating with sector-specific regulation, and in private law mechanisms that could more indirectly promote consumer product safety. Some estimated economic costs from current levels of reported injuries, as well as of many recalls, further reinforce the case for adding a GSP. Part 4 concludes that this improvement to the ACL could be combined with some of the other reform options outlined by the Australian government’s Consultation Regulatory Impact Statement, as well as the introduction of a novel “product safety substantiation order” power. The conclusions and analysis should be helpful for other jurisdictions considering product safety law reforms in an increasingly globalized and digital economy, and draw already on comparisons with regulatory regimes and issues particularly in the Asia-Pacific region.

Environmental assessment of domestic water supply options for remote communities

Access to clean water is one of the targets in the UN Sustainable Development Goals. However, millions of people are still without basic water services, predominantly in rural areas in developing nations. Previous studies have investigated the environmental impacts of water provision, but they mostly focused on large-scale urban systems. This paper considers for the first time the life cycle environmental impacts of different water supply options applicable to remote communities in developing countries. Focusing on the Southeast Asia-Pacific (SEAP) context, a cradle-to-grave approach is followed to estimate the impacts of locally-sourced groundwater, surface water and desalinated seawater as well as externally-sourced bottled water. The results reveal that surface water is environmentally the most sustainable alternative. Locally desalinated water, powered by diesel electricity, has two orders of magnitude higher impacts than surface water. However, externally-sourced water in plastic bottles is the worst option with 4–155 times higher impacts than desalinated water and up to three orders of magnitude higher impacts than surface water. This is largely due to the impacts related to the production of bottles. Doubling their recycling would reduce the impacts by 7–23% but bottled water would still be environmentally the least sustainable option. Although water in single-use bottles currently provides only 3% of the water supply of a representative remote community in the SEAP region considered in this study, it accounts on average for more than 50% of the total impacts from water consumption. By 2030, population increase could lead to greater reliance of remote communities on bottled water and 60–73% higher impacts of water consumption per household. Relying solely on local surface, ground and water desalinated using solar power and avoiding bottled water would reduce the impacts by 33–99% relative to the current situation. This would also improve considerably water availability and security in remote communities. The findings of this study will be of interest to national and local governments developing future policies aimed at increasing access of remote communities to clean water.

Examining the Pulse of the Tourism Industry in the Asia-Pacific Region: A Systematic Review of Social Media

Purpose – Social media continues to be the major influencer in the lives of the millennial and generation-z in many regions of the world; especially in influencing their travel decisions. In order to validate such relationship, a systematic literature review with an end goal of closing the current gaps in knowledge with regard to the impact of social media on tourism in the Asia-Pacific region has been conducted. Design/Methodology – We performed a systematic search of relevant literature through various databases including Scopus, ScienceDirect and ProQuest. In total, 25 articles were taken into consideration in which the review protocol made use of specific techniques such as PRISMA. Approach – We conceptualized the differences and similarities in the Asia-Pacific tourism industry influenced by social media. Findings – As a contribution to knowledge and practice, we found that the usage of social media for tourism marketing purposes is strongly correlated to the tourism industry in many countries of the APAC region. However, it has not yet been generalized as a popular tool in other nations in the region. Originality of the research – This study provides practical and future recommendations concerning the influence of social media in the Asia-Pacific context that has become increasingly popular. Asia-Pacific governments need to introduce social media inclusive tourism marketing to capture the full potential of their tourism industry.

Implementing practitioner research as a teacher professional development strategy in an Asia-Pacific context

ABSTRACTThis paper draws on the experiences of nine secondary school teachers in Hong Kong who conducted practitioner research (PR) in their Liberal Studies classrooms. The purpose of the study is to 1) investigate the impact and effectiveness of PR as a teacher professional development strategy and 2) identify effective support from the university team addressing the challenges relevant to an Asia-Pacific context. The study employed a qualitative design. Data were drawn from teacher interviews, meetings between the research team and the teachers, school documents and field notes. Findings suggest that while contextual challenges exist, PR is an effective approach for teacher professional development. Teachers perceived the direct impact of PR as observing the improvement of pupil performance and engagement, and a readiness to adopt new teaching strategies. Teachers also reflected on the benefits of professional development as related to the use of evidence to support reflection on pupil learning and teaching, and redefining teachers’ roles. The findings provide insight into designing effective support and collaborative strategies for PR. With the support of the findings, a feasible approach to PR as a teacher professional development strategy relevant to an Asia-Pacific context is proposed.

Ancestors in the Asia-Pacific Context

Ancestors in the Asia-Pacific Context

Secondary prevention of fragility fractures in Asia Pacific: an educational initiative.

The Asia -Pacific Bone Academy (APBA) Fracture Liaison Service (FLS) Focus Group educational initiative has stimulated activity across the Asia -Pacific region with the intention of supporting widespread implementation of new FLS. In 2017, the APBA FLS Focus Group developed a suite of tools to support implementation of FLS across the Asia-Pacific region as a component of a multi-faceted educational initiative. This article puts this initiative into context with a narrative review describing the burden of fragility fractures in the region, the current secondary fracture prevention care gap and a summary of emerging best practice. The results of a survey to evaluate the impact of the APBA educational initiative is presented, in addition to commentary on recent activities intended to improve the care of individuals who sustain fragility fractures across the Asia -Pacific. A FLS Toolbox for Asia-Pacific was developed which included the following sections:1. The burden of fragility fractures in the Asia-Pacific region.2. A summary of evidence for FLS in the Asia-Pacific.3. A generic, fully referenced FLS business plan template.4. Potential cost savings accrued by each country, based on a country-specific FLS Benefits Calculator.5. How to start and expand FLS programmes in the Asia-Pacific context.6. A step-by-step guide to setting up FLS in countries in the Asia-Pacific region.7. Other practical tools to support FLS establishment.8. FLS online resources and publications.The FLS Toolbox was provided as a resource to support FLS workshops immediately following the 5th Scientific Meeting of the Asian Federation of Osteoporosis Societies (AFOS) held in Kuala Lumpur in October 2017. The FLS workshops addressed three key themes:• The FLS business case.• Planning the FLS patient pathway.• The role of the FLS coordinator in fragility fracture care management.A follow-up survey of 142 FLS workshop participants was conducted in August-September 2018. The survey included questions regarding how FLS were developed, funded, the scope of service provision and the support provided by the educational initiative. Almost one-third (30.3%) of FLS workshop participants completed the survey. Survey responses were reported for those who had established a FLS at the time the survey was conducted and, separately, for those who had not established a FLS. Findings for those who had established a FLS included:• 78.3% of respondents established a multidisciplinary team to develop the business case for their FLS.• 87.0% of respondents stated that a multidisciplinary team was established to design the patient pathway for their FLS.• 26.1% of respondents stated that their FLS has sustainable funding.• The primary source of funding for FLS was from public hospitals (83.3%) as compared with private hospitals (16.7%).Most hospitals that had not established a FLS at the time the survey was conducted were either in the process of setting-up a FLS (47%) or had plans in place to establish a FLS for which approval is being sought (29%). The primary barrier to establishing a new FLS was lack of sustainable funding. The APBA FLS Focus Group educational initiative has stimulated activity across the Asia-Pacific region with the intention of supporting widespread implementation of new FLS. A second edition of the FLS Toolbox is in development which is intended to complement ongoing efforts throughout the region to expedite widespread implementation of FLS.

The Duterte method: A neoclassical realist guide to understanding a small power’s foreign policy and strategic behaviour in the Asia-Pacific

In the contemporary Asia-Pacific context, the fault lines leading to the Thucydides trap can be attributed to the continuing strategic competition between a seemingly declining United States and a rising China. Failure to circumvent this trap can ultimately result in a war of all against all. Against this backdrop, this article investigates how a small power re-evaluates its foreign policy and strategic behaviour using neoclassical realism theory. In particular, I examine President Rodrigo Duterte’s method which is characterized by four key elements: cultivating a more favourable image for China; moderating the country’s American-influenced strategic culture; mobilizing state-society relations supportive of ‘Sinicization’; and reorienting the country’s Western-based institutions to better accommodate Chinese pressures and incentives. Does a China-centric approach give a small power an indispensable strategic capital to successfully navigate and exploit both the challenges and opportunities of the impending new order? Do the Philippines’ shifting rules of engagement under the Duterte administration represent a forward-thinking strategic outlook rather than a defeatist and naïve stance? The article answers these questions by examining the factors and dynamics underpinning the conception and construction of the Duterte method, as well as its implications vis-a-vis a small power’s foreign policy and strategic behaviour.

2205-PUB: Temporal Patterns of Inpatient Hypoglycemia and Predictors of Recurrent Hypoglycemia in a Singapore Tertiary Medical Center

Background: Inpatients hypoglycemia has adverse impacts on patient outcomes and healthcare resources use. While recurrent hypoglycemia is largely preventable, limited studies were done within the Asia-Pacific context. We sought to determine whether temporal distributions of hypoglycemia exist between insulin and/or sulfonylureas (SU) treated patients and identify predictors of recurrent hypoglycemia at a tertiary medical center in Singapore. Methods: We analyzed data of 420 hypoglycemic episodes (capillary blood glucose (CBG) ≤ 70mg/dL) in 207 diabetes patients at general medical wards over a 2-month period from 1st May 2017. This was analyzed by 4 time frames coincided with blood glucose monitoring times. Time periods associated with hypoglycemia were compared using the Chi-square test. Multivariate logistic regression estimated risk factors of recurrent hypoglycemia. Results: Most frequent hypoglycemia episodes occurred between 04:00 and 09:59 (41.7%). Greater frequency was seen in insulin- and SU-treated than insulin-treated patients between 04:00 to 09:59 (58.3% vs.37.9% of readings for respective treatments, p<0.05). It was also more frequent in insulin-treated than SU-treated patients between 10:00 to 15:59 (19.2% vs. 10.9%, p<0.05). Nearly a third of patients had recurrent hypoglycemia (32.9%). Longer length of stay, treated with premixed insulin, age < 65 years, HbA1C > 7% and repeated CBG checking > 30 minutes interval emerged as predictors of recurrent hypoglycemia with odds ratio of 1.07 (95% CI 1.03-1.11), 8.07 (95% CI 2.82-23.08), 3.71 (95% CI 1.59-8.65), 3.12 (95% CI 1.26-7.74) and 3.54 (95% CI 1.59-7.91), respectively. Conclusions: Hypoglycemic episodes were more frequent in the early hours of the day in insulin and SU-treated inpatients. This may have implications for the continuing use of SU at inpatients. Recurrent hypoglycemia can be prevented by developing strategies targeting the modifiable iatrogenic risk factors. Disclosure P. Lim: None. S. Goh: None. Y. Bee: None. X. Xin: None. L. Ang: None. N.A. Salleha: None. M.M. Teh: None.