The association between sociodemographic determinants and nomophobia among physiotherapists in the Kingdom of Saudi Arabia: a cross-sectional study

Abstract

Nomophobia is a psychological condition characterized by fear or anxiety resulting from being without access to a mobile phone. It is increasingly prevalent among healthcare professionals due to their high reliance on mobile technology. However, limited data exist regarding the prevalence and severity of nomophobia, specifically among physiotherapists in Saudi Arabia. The Nomophobia Questionnaire (NMP-Q) was administered via SurveyMonkey, targeting a convenience sample of physiotherapists between April 30 and June 27, 2023. Data were analyzed using IBM SPSS Statistics, Version 28.0. Categorical variables were summarized using frequencies and percentages. The Kruskal–Wallis H and Mann–Whitney U tests were employed to compare median NMP-Q scores across participant subgroups. A total of 1003 physiotherapists participated, with 579 (57.7%) females. The prevalence of nomophobia was 99.6%. The Kruskal–Wallis Test showed that the age group 51–60 years had the highest NMP-Q scores (Md = 99, x² (4, N = 1003) = 57.31, p < .001) in comparison to other age groups. The female group was higher in total scores on the NMP-Q questionnaire (Md = 94, x² (1, N = 1003) = 25.41, p < .001) compared to the male group (Md = 87, x² (1, N = 1003) = 25.41, p < .001). Physiotherapists with clinical experience between 16 and 20 years and night shift workers were the highest in total scores on the NMP-Q questionnaire (Md = 96, x² = 62.87; Md = 94, x² = 36.79, p < .001, respectively) compared to other groups with different levels of clinical experience and shift patterns. Being divorced, a current smoker, and living with roommates were highly scored levels of nomophobia compared with categorized sub-groups. Nomophobia is highly prevalent among physiotherapists, with most reporting moderate levels. Interventions to promote balanced mobile phone use and digital well-being are recommended to improve mental health, job satisfaction, and productivity, fostering a healthier work environment.

Introduction

The rapid advancement of technology has dramatically transformed modern life, with smartphones emerging as one of the most pervasive tools in daily activities. While smartphones offer numerous benefits, including enhanced connectivity and access to information, their excessive use has raised concerns about economic, physical, and psychological consequences^1,2. One such psychological outcome is nomophobia, short for “no mobile phone phobia”, which is characterized by anxiety or fear when an individual is unable to access or use their smartphone^3–5.

A growing body of research has linked nomophobia to a range of psychological and behavioral disorders, including anxiety, stress, narcissism, and social media addiction^6–8. Beyond mental health, nomophobia is also associated with negative physical and social consequences^9,10. Among healthcare professionals, the issue is particularly alarming, as smartphone overuse can impair clinical judgment, disrupt workflow, and compromise patient safety^11–13. Excessive phone use has been reported to contribute to distraction during patient care, leading to missed clinical signs, delayed decision-making, and a decline in therapeutic engagement^12–15. A clinical trial found that non-purposeful smartphone use during physiotherapy sessions significantly decreased patient satisfaction and perceived care quality¹⁴.

The relationship between sociodemographic factors and nomophobia is gaining increasing attention; however, findings across the literature remain inconsistent. Several studies have reported that women tend to experience higher levels of nomophobia, possibly due to greater emotional attachment to and more frequent use of smartphones for social connection^16–18. In contrast, other studies have found no significant association between gender and nomophobia^19,20, while some have reported higher levels among males^21,22. Similarly, marital status has been inconsistently associated with nomophobia. While some studies have shown that single individuals report higher nomophobia levels than their married counterparts^16,17, other research has found no statistically significant differences²³. Age is generally considered a significant predictor, with younger adults more vulnerable due to their developmental stage and the deeper integration of digital technology in their lives^24,25. Globally, nomophobia is notably prevalent among young adults aged 18–25, with rates as high as 99% reported in some countries^9,26. Among the general adult population, moderate nomophobia affects about 51%²⁷, while up to 21% report severe symptoms²⁸. In Saudi Arabia, the issue is especially pressing, with studies showing that 64% of adults experience nomophobia²⁹. Alarmingly high rates have been observed among healthcare professionals and students, with prevalence reaching 97.3% among respiratory therapy students¹⁷, 98.4% among physiotherapy students¹⁶, and 95% among working respiratory therapists³⁰.

Despite growing awareness, much of the existing literature has focused on students or general healthcare populations, leaving a gap in understanding how nomophobia affects practicing physiotherapists in Saudi Arabia. Furthermore, while studies have identified demographic correlations, there is limited research exploring how multiple sociodemographic variables interact to predict nomophobia severity within a professional healthcare setting. Therefore, this study aims to address this gap by assessing the associations between sociodemographic determinants and the severity of nomophobia among physiotherapists in Saudi Arabia.

Methods

Study design

A cross-sectional survey was carried out between April 30 and June 27, 2023, utilizing Survey Monkey’s online survey platform.

Questionnaire

The survey consisted of 32 multiple-choice closed items divided into two parts. The first part consisted of 12 questions covering various demographic and professional factors, including gender, age, years of clinical experience, and the most frequently worked shifts. It also addressed marital status, smoking habits, living arrangements, and the hospital sector. Additionally, participants were asked about their academic qualifications, daily smartphone usage (in hours), primary reasons for smartphone use, and frequency of smartphone checks per day.

The second part featured the nomophobia questionnaire (NMP-Q), which involved 20 statements created and validated in English by Yildirim and Correia³¹. The NMP-Q comprised four main domains: the “not being able to access information” domain, which included four statements; the “giving up convenience” domain, which included five statements; the “not being able to communicate” domain, which included six statements; and the “losing connectedness” domain, which included five statements. The questionnaire used a seven-point Likert scale, with 1 denoting “strongly disagree” and 7 denoting "strongly agree." The NMP-Q scores ranged from 20 to 140, with higher scores indicating more severe nomophobia. A score of < 20 represents the absence of nomophobia, a score between 21 and 59 represents mild nomophobia, moderate nomophobia is represented by a score between 60 and 99, and severe nomophobia is represented by a score between 100 and 140³². The NMP-Q demonstrated strong reliability with high internal consistency (Cronbach’s alpha = 0.95). Regarding validity, the NMP-Q showed construct validity through exploratory factor analysis, revealing four dimensions of nomophobia, thereby confirming the theoretical framework underlying the questionnaire’s design. The NMP-Q demonstrated excellent internal consistency in this study, as evidenced by a Cronbach’s alpha coefficient of 0.93. This high value indicates that the items within the questionnaire are highly correlated and reliably measure the construct of nomophobia. Additionally, the exploratory factor analysis (EFA) produced a Kaiser-Meyer-Olkin (KMO) measure of 0.941 and a significant Bartlett’s Test of Sphericity (χ² = 4266.807, p < 0.01)³¹.

Sampling strategy and data collection

This study used a convenient sampling technique to reach all governmental and private physiotherapy personnel across the Kingdom of Saudi Arabia. To ensure participant eligibility, the survey was distributed through professional networks, including the Saudi Physical Therapy Association and heads of physiotherapy departments in hospitals. While the survey was anonymous, this controlled distribution method helped ensure that only licensed physiotherapists were reached. A total of 1600 invitations were distributed, and 1003 completed responses were received, resulting in an estimated response rate of approximately 62.7%. Before the participants began to fill out the questionnaire, they were given information about the study’s objectives, confidentiality agreements, and the principal investigator’s contact information in case any questions arose. Participants were asked if they would complete the survey to ensure voluntary participation. By responding “yes” to completing the survey questionnaire, participants willingly agreed to participate in the study and consented to use their anonymous data, as stated in the survey. Only fully completed questionnaires were included in the final analysis, and responses with missing data were excluded to ensure the accuracy and integrity of the results. The estimated time to complete the survey was three to five minutes. The survey used a validated instrument (NMP-Q) with clearly defined, recent-timeframe items to minimize recall bias. To mitigate social desirability bias, responses were collected anonymously through a self-administered online platform without interviewer influence. Participants were informed that their responses were confidential and would be used for research purposes only, which may have encouraged more honest reporting.

Sample size

With a 95% confidence interval, a standard deviation of 0.5, and a margin of error of 5%, we used the minimum sample size suggested by the WHO for a prevalence study of 385 respondents³³.

Ethical approval

The study, with reference number 435-22, received ethical approval from the Research Ethics Committee at King Abdulaziz University, Faculty of Medicine. Informed consent was obtained from all study participants before participating, ensuring they were fully aware of the study’s purpose and procedures. At the same time, measures were implemented to protect their anonymity throughout the research process. All methods were conducted in accordance with the principles of the Declaration of Helsinki

Statistical analysis

The Statistical Package for Social Sciences, version 28 (SPSS software, IBM Corp, Armonk, NY, USA) was used to gather and analyze the data. The Kolmogorov-Smirnov test and histogram were used to determine if the distributions of quantitative variables were normally distributed. The Mann-Whitney U-test and the Kruskal-Wallis test were employed to analyze variations in median nomophobia scores among individuals from various demographic groups, as the variables were not normally distributed. Categorical variables were reported and displayed using percentages and frequencies. Statistical significance was determined by a p-value of less than 0.05.

Results

A comprehensive survey involved 1003 physiotherapists enrolled in multi-center physical therapy programs. Most respondents were female (57.73%), worked night shifts (59.08%), were former smokers (42.47%), and had a marital status of separated (31.01%). The majority of respondents were 20–30 years old (28.22%), and had 11–15 years of clinical experience (29.74%). In addition, the percentage of respondents was higher among private sector workers (52.54%) and those with bachelor’s degrees (50.15%). Furthermore, 61.52% (617) dedicated 3–6 h per day using their smartphones, and 59.92% (601) checked their smartphones 3 to 6 times daily. The vast majority (23.83%) indicated using their smartphones for social networking (Table 1).

Table 1.

Demographic data of physiotherapists (N= 1003)

Demographics	Frequency (%), M ± SD
Age, n (%)
20–30 years	283 (28.22%)
31–40 years	279 (27.82%)
41–50 years	260 (25.92%)
51–60 years	160 (15.95%)
> 60 years	21 (2.09%)
Gender, n (%)
Male	424 (42.27%)
Female	579 (57.73%)
Years of clinical experience, n (%)
< 1 year	132 (13.17%)
1–5 years	170 (16.97%)
6–10 years	277 (27.64%)
11–15 years	298 (29.74%)
16–20 years	107 (10.68%)
> 20 years	18 (1.80%)
Most working shift, n (%)
Day shift	401 (40.92%)
Night shift	579 (59.08%)
Marital Status, n (%)
Single	214 (21.34%)
Married	238 (23.73%)
Separated	311 (31.01%)
Divorced	200 (19.94%)
Widowed	40 (3.99%)
Smoking Status, n (%)
Never smoke	296 (29.51%)
Former smoker	426 (42.47%)
Current smoker	281 (28.02%)
Living arrangement, n (%)
Living alone	97 (9.67%)
Living with family	621 (61.91%)
Living with roommate(s)	285 (28.41%)
Hospital sector, n (%)
Governmental	476 (47.46%)
Private	527 (52.54%)
Academic qualification, n (%)
Associate diploma	86 (8.57%)
Bachelor degree	503 (50.15%)
Master degree	356 (35.49%)
PhD degree	58 (5.78%)
Hours per day using the smartphone, n (%)
≤ 2 h per day	88 (8.77%)
3–6 h per day	617 (61.52%)
≥ 7 h per day	298 (29.71%)
Most common reason of using the smartphone, n (%)
Phone Calls	44 (4.39%)
Social Networking	239 (23.83%)
listening to Music	166 (16.55%)
Texting	127 (12.66%)
Watching movies	164 (16.35%)
Playing games	134 (13.36%)
Internet searches	111 (11.07%)
Other	18 (1.79%)
Frequent of checking the smartphone per day, n (%)
≤ 2 times per day	120 (11.96%)
3–6 times per day	601 (59.92%)
≥ 7 times per day	282 (28.12%)

Data are presented as frequency and percentage

The prevalence of nomophobia among physiotherapists

The survey results demonstrated that the prevalence of nomophobia among the participants was 99.6% (95% CI 99.2–99.9). Overall, all participants’ median total scores of the NMP-Q indicated moderate nomophobia (Md = 86, IQR 75-99). The data from this questionnaire revealed that 62 (6.2%) of the respondents had a mild level of nomophobia, while 607 (60.5%) had a moderate level of nomophobia, and 330 (32.9%) reported a severe level of nomophobia. However, only 4 (0.4%) showed an absence of nomophobia (Table 2). Additionally, the results of the NMP-Q indicated a range of scores among physiotherapy staff, with the highest score being 140 and the lowest score recorded at 20.

Table 2.

Prevalence of nomophobia among physiotherapists (N = 1003)

Level of nomophobia	Frequency (%)
Absence (≤ 20)	4 (0.4%)
Mild (21–59)	62 (6.2%)
Moderate (60–99)	607 (60.5%)
Severe (≥ 100)	330 (32.9%)

Data are presented as frequency and percentage

Nomophobia and sociodemographic variables among physiotherapists

As shown in Table 3, the Kruskal-Wallis Test revealed a statistically significant difference in age across the five groups, x² (4, N = 1,003)  = 57.31, p < 0.001. The age group of 51–60 years had the highest total scores on the NMP-Q questionnaire (Md = 99) compared to the lowest age group of 20–30 years (Md = 83). In addition, the female group had higher total scores on the NMP-Q questionnaire (Md = 94, x² (1, N = 1,003)  = 25.41, p < 0.001) than the male group (Md = 87, x² (1, N = 1,003)  = 25.41, p < 0.001), with both groups indicating moderate nomophobia. Physiotherapists with 16–20 years of clinical experience and those working night shifts had the highest total scores on the NMP-Q questionnaire (Md = 96, x² = 62.87; Md = 94, x² = 36.79, p < 0.001, respectively) compared to the lowest total scores for staff with more than 20 years of clinical experience and working during the day shift (Md = 79, x² = 62.87; Md = 86, x² = 36.79, p < 0.001, respectively). Divorced individuals, current smokers, and those living with roommates had higher levels of nomophobia (Md = 98, x² = 53.77; Md = 95, x² = 24.15; Md = 95, x² = 27.30, p < 0.001, respectively) compared to the lowest scores among single staff, who never smoke, and living alone (Md = 82, x² = 53.77; Md = 86, x² = 24.15; Md = 86, x² = 27.30, p < 0.001, respectively).

Table 3.

Comparison of the median total scores of the NMP-Q questionnaire among physiotherapists sub-groups (N= 1003)

Variables	df	X2	Median	P value
Age	4	57.31		< .001
20–30 years			83
31–40 years			90
41–50 years			94
51–60 years			99
> 60 years			94
Gender	1	25.41		< .001
Male			87
Female			94
Years of clinical experience	5	62.87		< .001
< 1 year			80
1–5 years			86
6–10 years			93
11–15 years			94
16–20 years			96
> 20 years			79
Most working shift	1	36.70		< .001
Day shift			86
Night shift			94
Marital status	4	53.77		< .001
Single			82
Married			88
Separated			91
Divorced			98
Widowed			94
Smoking status	2	24.15		< .001
Never smoke			86
Former smoker			90.5
Current smoker			95
Living arrangement	2	27.30		< .001
Living alone			86
Living with your family			89
Living with roommate(s)			95

Discussion

To the best of our knowledge, this is the first study to explore the association between sociodemographic determinants and nomophobia among physiotherapists in Saudi Arabia. Our findings suggest that nomophobia is a common psychological condition among physiotherapists, with most study participants experiencing moderate levels of nomophobia. Notably, higher nomophobia scores were observed in female physiotherapists, those with 16–20 years of clinical experience, divorced individuals, night shift workers, current smokers, and those living with roommates. Regarding smartphone use, social networking, communication, entertainment, and information retrieval were identified as the primary motivating factors.

The exceptionally high prevalence of nomophobia observed in our study (99.6%) is consistent with, but slightly exceeds, findings from other healthcare populations in Saudi Arabia. For instance, prior studies have reported nomophobia prevalence rates of 98.4% among physiotherapy students¹⁶, 97.3% among respiratory therapy students¹⁷, and 95.0% of respiratory therapists in Saudi Arabia³⁰. Such elevated rates may reflect the increasing integration of smartphones into clinical workflows, communication protocols, and patient management tools. Physiotherapists, in particular, often rely on mobile applications for exercise prescription, telehealth sessions, and professional networking, which may contribute to increased dependency and anxiety when disconnected^14,34. Furthermore, a study conducted in southern Italy among resident physicians specializing in clinical medicine, surgery, and emergency services found that 61.3% of participants exhibited moderate nomophobia³⁵. More importantly, a study conducted among hospital nurses in China further supports our findings, reporting that the highest percentage of participants showed moderate levels of nomophobia¹². The high prevalence of nomophobia could be attributed to the increasingly indispensable role of smartphones in healthcare, where they serve as essential tools for information retrieval and clinical decision-making¹². In such environments, this pattern may indicate that while mobile devices are crucial to professional functioning, they also contribute to anxiety that warrants attention³⁶.

Regarding the sociodemographic determinants, our study found that female physiotherapists had significantly higher median NMP-Q scores compared to their male counterparts. This finding aligns with previous research conducted among healthcare workers^25,37, as well as a systematic review of 108 studies by León-Mejía et al.³⁸, which reported that women predominantly exhibit symptoms of nomophobia. However, it is important to note that some investigations have reported higher nomophobia levels among males^21,22. These inconsistencies may reflect variations in cultural expectations regarding technology use, differences in the purpose and frequency of smartphone usage between genders. For instance, studies suggest that women tend to score higher on nomophobia scales, which is attributed to the fact that men are more likely to use smartphones for non-social purposes, such as work, while women may use smartphones to avoid feelings of loneliness and exhibit a stronger preference for online social interactions^26,39. These variations underscore the complexity of the gender–nomophobia relationship and highlight the need for further cross-cultural and occupational studies to clarify this association.

Additionally, our analysis revealed that those with 11–15 years and 16–20 years of clinical experience demonstrated significantly higher scores than those with over 20 years of experience. This observation aligns with previous studies indicating that assistant healthcare professionals in Turkey with 10–19 years of experience reported the highest NMP-Q scores compared to their more experienced counterparts^30,40. Conversely, research conducted by Giuseppe et al. among nursing students and nurses found that younger nurses with less than two years of experience spent more time on their phones, while mobile phone usage significantly decreased with increased work experience⁴¹. Additionally, a survey among Italian nurses revealed that junior staff with less than one year of clinical experience were more susceptible to nomophobia³⁹. These findings may result from the changing demands of the workplace and a growing dependence on smartphones for communication. Junior staff may struggle to navigate traditional practices alongside modern digital expectations, contributing to nomophobia. In contrast, more experienced professionals are likely to have developed better-coping strategies and a healthier relationship with technology, resulting in lower levels of nomophobia.

In our study, divorced and widowed physiotherapists exhibited the highest scores on the NMP-Q compared to their single and married counterparts. Several studies have demonstrated a correlation between moderate levels of nomophobia and various aspects of life, including work and social relationships^42,43. For instance, Ozdemir et al.⁴⁴ conducted a study comparing the prevalence of nomophobia among Pakistani and Turkish undergraduate students, revealing a positive correlation between nomophobia and loneliness, alongside a negative correlation with self-reported happiness. Similarly, a study by Alwafi et al. involving around 5191 participants from Saudi Arabia and Jordan found that divorced and widowed individuals had a higher risk of experiencing nomophobia. The research concluded that married individuals were less likely to exhibit mobile phone dependence, with divorced participants facing a 46% increased risk factor for nomophobia²⁷. These outcomes can be understood through the lens of social and emotional support dynamics, where divorce and widowhood can lead to feelings of loneliness and isolation, which may drive individuals to rely more heavily on smartphones for social interaction and emotional connection²⁵.

In terms of work shifts, night-shift physiotherapists were found to have significantly higher NMP-Q scores than day-shift workers. Previous studies among nurses have found that night shifts are associated with increased stress due to poor sleep, heavy workloads, and high demands, leading healthcare professionals to use smartphones as a coping mechanism^45,46. Wang et al. investigated the impact of nomophobia on work-related outcomes in Canada. They discovered that while engagement with smartphones may enhance perceived productivity, it is also linked to negative emotional states such as anxiety and stress, which can be related to emotional exhaustion⁴⁷. Nonetheless, integrating smartphones into professional environments has transformed communication dynamics, enabling real-time interaction among colleagues and facilitating more efficient information sharing and collaboration^48,49. This communication style has been associated with reduced patient wait times, higher satisfaction rates, and overall better health outcomes⁵⁰.

Concerning smoking, it was found that current smokers exhibited higher scores on the NMP-Q. This finding is consistent with subsequent literature that demonstrated a notable association between tobacco smoking and nomophobia^30,51. Additionally, a Lebanese national survey by Dip et al.⁷ indicated a correlation between smoking water pipes (hookah) and nomophobia, while cigarette smoking showed a different pattern. However, some studies have reported no relationship between smoking and nomophobia^52,53. These results may reflect varying cultural attitudes towards smoking and smartphone use, suggesting that smokers might use smartphones as a coping mechanism for stress or social interaction, thereby exacerbating nomophobia.

Our data analysis revealed that physiotherapists living with roommates had the highest NMP-Q scores. This finding is supported by a related study conducted among respiratory therapy students in Saudi Arabia. It revealed that individuals residing away from their families experienced greater nomophobia than those living with family members¹⁷. Living apart from family can contribute to loneliness, which may adversely affect physical and mental health, potentially fostering increased reliance on mobile devices to mitigate these feelings^54,55. As noted by Aslan et al., individuals may engage more with smartphones to create virtual connections to cope with loneliness⁵⁶.

Based on these findings, it is recommended that healthcare organizations implement strategies to promote responsible smartphone use among physiotherapists. This may include training programs on digital well-being, setting guidelines for smartphone use during work hours, and offering support for individuals experiencing high levels of nomophobia. To mitigate the potential negative impacts of smartphone overuse on professional performance and well-being, stakeholders should consider developing targeted interventions for vulnerable groups, such as night-shift workers, mid-career professionals, and divorced or widowed individuals. Although the study includes a large and diverse sample, convenience sampling may limit the external validity of the findings.

Strength and limitations

This study is significant as it is the first to investigate the association between sociodemographic determinants and nomophobia among physiotherapists in Saudi Arabia. Additionally, it encompasses a robust sample size drawn from diverse geographical regions, aiming to enhance the generalizability of the findings across the nation. Nevertheless, certain limitations are acknowledged, including using a convenience sampling technique, which may introduce selection bias, and relying on self-reported questionnaires, which may be subject to recall and social desirability biases. Also, due to the cross-sectional nature of this study, the findings reflect associations observed at a single point in time and do not permit conclusions about causality or the direction of relationships between variables. Moreover, the multifaceted nature of nomophobia suggests the potential influence of various contributing factors, impeding the establishment of causal relationships within our study design. Additionally, this study is limited by the inability to confirm the participants’ identities, despite our efforts to distribute the survey electronically solely through the directors of physical therapy departments and the Saudi Physical Therapy Association. Therefore, addressing these potential confounding variables of nomophobia can alter the interpretation of our findings. Further studies are imperative to delve into the etiology of nomophobia and develop preventive strategies to improve the well-being of physiotherapists in Saudi Arabia.

Conclusion

This study highlights the high prevalence of nomophobia among physiotherapists in Saudi Arabia, with nearly all participants reporting some level of this condition. Several sociodemographic and occupational factors, including age, gender, clinical experience, work shifts, marital status, smoking habits, and living arrangements were significantly associated with higher nomophobia scores. These associations suggest that certain subgroups of physiotherapists may be more vulnerable to smartphone-related anxiety. The findings underscore the importance of considering digital well-being within the professional environment. Interventions such as awareness campaigns, digital literacy training, and workplace support programs may help promote healthier smartphone use among physiotherapists. However, given the use of convenience sampling and the cross-sectional design, these results should be interpreted with caution and are not generalizable to all physiotherapy professionals. Future research should include longitudinal or interventional studies to better understand the potential consequences of nomophobia on job performance, mental health, and quality of care, as well as to evaluate effective strategies for mitigating its impact in healthcare settings.

Author contributions

Conceptualization, AMA, JSA, AAA, AHA, MMA; Data curation, OAA, HA, MMA; Formal analysis, MSM, RRS, KB; Investigation, HIA, SAA; Methodology, HA, AYN; Project administration; AAA, JSA, MMA; Supervision, AMA, MMA; Validation, OAA, HIA; Writing original draft, AHA, MAZ, GIH, AAR, RAA, KNA; Writing – review & editing, All authors. The authors read and approved the final manuscript.

Funding

This project was funded by the Deanship of Scientific Research (DSR) at King Abdulaziz University, Jeddah, under grant no. (GPIP: 1199-883-M 2024). The authors, therefore, acknowledge with thanks DSR for technical and financial support.

Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.

Declarations

Conflict of interest

The authors declare no competing interests.

Ethics approval and consent to participate

This study was approved by the Research Ethics Committee at King Abdulaziz University, Faculty of Medicine, under reference number 435-22. All participants provided informed consent prior to participation. All methods were carried out in accordance with the principles of the Declaration of Helsinki.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-025-09042-7.