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Article History

Received: 26 April 2025

Accepted: 2 March 2026

First Online: 17 April 2026

Ethical approval

: This study was conducted in accordance with the Declaration of Helsinki on ethical principles for research involving human participants, with particular reference to Article 23 (paragraph 3) concerning prior approval by a research ethics committee. As an international collaborative project involving participants from Indonesia, Malaysia, the Philippines, and Taiwan, ethical clearance was obtained from the competent review boards in each participating country. In Taiwan, the sponsoring country, approval was granted by the Institutional Review Board of National Cheng Kung University (NCKU) on 17 May 2022 (Approval No. NCKU HREC-E-111-096-2). In Indonesia, ethical approval was secured from the Ethics Committee of STIKES PEMKAB Jombang on 6 June 2022 (Approval No. 0522060004/KEPK/STIKES-PEMKAB/JBG/VI/2022). In the Philippines, the study was approved by the University of Makati Research Ethics Committee on 22 May 2023 (Approval No. 8/UMREC/2023). In Malaysia, approval was obtained from the Ethics Committee for Research Involving Human Subjects at Universiti Putra Malaysia on 17 June 2022 (Approval No. JKEUPM-2022-314). The scope of these approvals encompasses the study protocol, participant recruitment procedures, informed consent process, data collection instruments, cross-national data transfer arrangements, and safeguards for confidentiality and data protection.

: All participants were provided with an informed consent form embedded within the online survey platform. In Taiwan, Indonesia, and Malaysia, consent was obtained beginning on 20 June 2022. Following completion of data collection in these three countries, the study continued in the Philippines, where participants provided consent starting on 25 May 2023. In all cases, consent was obtained only after formal ethical approval had been granted by the respective review committees in each participating country. Participation was entirely voluntary. Respondents were informed of their right to decline participation or withdraw at any stage without penalty. The consent form outlined the study’s objectives, potential risks and anticipated benefits, and ensured that participants received sufficient information prior to enrolment. It further specified that personal data would be treated confidentially, used exclusively for research purposes, and could be withdrawn upon request without adverse consequences.

: The authors declare no competing interests.