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. 2025 Sep 25;12(1):2563395. doi: 10.1080/20018525.2025.2563395

The prevalence and risk factors of respiratory symptoms in Finland: a comparative analysis

Heikki V T Pautola a,b,✉, Heikki O Koskela a,b, Minna K Purokivi a, Johanna T Kaulamo b, Anne M Lätti a,b
PMCID: PMC12466186  PMID: 41020184

ABSTRACT

Background

Knowledge about the local prevalence and risk factors of respiratory symptoms helps to address healthcare resources. Furthermore, no studies have compared the prevalence and risk factors of several respiratory symptoms within the same population.

Objective

We conducted two cross-sectional email surveys in 2017 and 2021 for public service employees in two Finnish towns and Finnish Pensioners’ Federation members. The questionnaires were sent to 40,185 subjects; 9,865 (24.6%) responded, 72.5% were female, and the mean age was 63 (range 18–94 years). Validated symptom questionnaires were included for each respiratory symptom. The questionnaire on sleep apnea symptoms was only included in the survey of retirees.

Results

Prevalence of current asthma was 8.9%, wheezing with dyspnea 12.5%, chronic rhinosinusitis 11.9%, chronic cough 12.8%, TBQ phenotype cough 9.6%, chronic bronchitis 17.6% and gastroesophageal reflux symptoms 15.6%. In the retired group, the prevalence of sleep apnea symptoms was 32,8%. More than one respiratory symptom was present in 27.1% of subjects. A higher body mass index (BMI), smoking, and allergy increased the risk of most symptoms, while high household income protected against some symptoms. Increased age was associated with an increased risk of chronic cough, chronic bronchitis, and gastroesophageal reflux symptoms. In contrast, decreased age was associated with an increased risk of wheezing with dyspnea and chronic rhinosinusitis. The male gender increased the risk of chronic bronchitis and sleep apnea symptoms. All respiratory symptoms were associated with multiple non-respiratory symptoms.

Conclusions

We gathered updated information on the prevalence of respiratory symptoms in Finland. Age, higher BMI, smoking, low household income, and allergy were significant risk factors for most respiratory symptoms.

ClinicalTrials.Gov identifier: NCT03639727.

KEYWORDS: Asthma; bronchitis, chronic; chronic cough; epidemiology; gastroesophageal reflux; prevalence; rhinosinusitis; risk factors; sleep apnea syndromes

Introduction

Respiratory symptoms are among the most common reasons for patients to consult a doctor [1]. Therefore, they constitute a significant burden on the healthcare system, and their management is of paramount importance. The prevalence of respiratory symptoms and diseases varies widely between countries. The prevalence of asthma varies between 4.3% and 10.6% [2–4], chronic rhinosinusitis 1.8% − 27.1% [5–8], chronic cough 2.1% − 18.1% [9–14], chronic bronchitis 0% − 10.8% [15–19], sleep apnea 6% − 38% [20,21], and gastroesophageal reflux disease 9.4% − 14.8% [22,23]. Many risk factors contribute to these symptoms, either reducing or increasing the risk. Ageing, higher body mass index (BMI) and smoking increase the risk of most of these symptoms [2,3,5,6,9–11,15–18,22–29]. However, prevalence rates and the significance of risk factors vary considerably between studies.

The first explanation for these variances is the different conditions between countries, i.e. the actual variance. For example, cold air is a typical trigger for rhinitis, asthma and cough, and the cold climate in Finland may overestimate the prevalence of these symptoms compared with countries in more temperate regions [30]. Also, according to WHO statistics in 2018, Finland’s air quality is among the best in the world, which may contribute to the prevalence of respiratory symptoms compared to polluted metropolises [31]. The second explanation is the methodological differences between the studies. The latter includes, for example, differences in the demographic properties of the populations and the different definitions of the symptoms and diseases affecting the outcome [32,33].

The outcomes in many studies focus on one symptom or disease in a selected population. This makes it difficult to compare the significance of the risk factors between symptoms. To our knowledge, no studies have compared the prevalence and risk factors of several respiratory symptoms within the same population. Furthermore, in various studies, not all age groups of the adult population have been included, and retired and older adults are often underrepresented [5,34–43].

Our primary objective was to determine the prevalence of respiratory symptoms in a Finnish population, utilising definitions recommended for epidemiological studies. Gastroesophageal reflux symptoms was included in the study due to its association with many respiratory disorders. The second objective was to compare the risk factors for these respiratory symptoms.

Methods

Population

This was a cross-sectional study among two groups (Figure 1), described in detail in earlier publications [44,45]. Briefly, the first group consisted of all public service employees of two medium-sized towns in central Finland (Kuopio and Jyväskylä, altogether 13,980 employees, mean age of 46.6 years, 79.2% females) [44]. Invitations to the study and the questionnaire were emailed from March to April 2017. The second group consisted of members of the Finnish Pensioners’ Federation (26,205 members with an email address, mean age of 72.7 years, 63.5% females) [45]. The invitation to the study and the questionnaire were sent via email in April 2021.

Figure 1.

Figure 1.

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The flow chart.

Answers were collected via an electronic reply form. If a subject had not responded within 2 weeks, one reminder message was sent. Subjects were not involved in the design or conduct of this study. Permission to conduct the study was obtained from the Kuopio and Jyväskylä town officials and the Finnish Pensioners` Federation. The decision to respond was considered informed consent. Both surveys were approved by the Ethics Committee of Kuopio University Hospital (289/2015).

The questionnaires

The questionnaire for the working-age population in 2017 and that for the retired population in 2021 included the same questions about social background, working status, general and self-related health, doctors’ diagnoses and visits, depressive symptoms, exercise activity, medications, and cough. A questionnaire for sleep apnea symptoms (STOP-questionnaire) [46–48] was included only in the latter survey. Respondents with current cough answered additional cough-related questions, including the Leicester Cough Questionnaire.

Allergy was defined as a self-reported allergy to foods, pollen, and animals diagnosed or treated by a doctor in the past year. Current smoking was defined as a positive answer to the question, ‘Are you currently a smoker (on a daily basis)?’ Ever smoking was defined as daily smoking for at least a year during the lifetime. Household total income per year was defined as the household’s annual gross income: below 15,000, 15000–40,000, 40000–70,000, 70000–120,000, and over 120,000 €/year. The sum of somatic symptoms was calculated by summing all reported non-respiratory and non-mental somatic symptoms, giving a value of 0 to 12. These symptoms were: chest pain on exertion, aching joints, back problems and/or back pain, toothache, swollen feet, varicose veins, eczema, headache, constipation, other gut problems (flatulence, diarrhoea), sciatica (back pain that radiates to the leg), and urination disorders. Respiratory symptoms, like cough, and mental health symptoms like insomnia and depressive symptoms were excluded from this variable. English and Finnish versions of the questionnaires are provided as Supplementary Files.

Definitions of the symptoms

Current asthma

Doctor’s diagnosis of asthma and wheezing during the past year [33]. This symptom was the only one that required a doctor’s diagnosis in this study.

Wheezing with dyspnea

The simultaneous presence of dyspnea and wheezy or whistling breathing in the past year [33,49].

Chronic rhinosinusitis

The presence of two or more symptoms for at least 3 months during the past year, one of which should be either nasal blockage/obstruction/congestion OR nasal discharge (anterior/posterior nasal drip) AND facial pain/pressure OR reduction or loss of smell [50].

Chronic cough

Current cough that had lasted for more than 2 months [51,52].

TBQ phenotype cough

A phenotype of cough identified by cluster analyses of two large populations of cough patients, characterised by features of cough reflex hypersensitivity [53,54]. It was defined as a cough accompanied by at least two of the following features: Five or more cough triggers, at least one cough background disorder, or a Leicester Cough Questionnaire physical domain equal to or less than 4.9.

Chronic bronchitis

Cough with phlegm on most days or nights for ≥3 months of the year [55].

Sleep apnea symptoms

The presence of ≥ 2 features: loud snoring, daytime tiredness, observed apneas, and arterial hypertension [46–48].

Gastroesophageal reflux symptoms

Heartburn or regurgitation at least once a week in the past 3 months [56]. It was included in the analysis since it often accompanies and complicates common respiratory disorders such as asthma and chronic cough.

Statistical analysis

Unless otherwise stated, descriptive data are presented as means, percentages, and SDs. The bivariate associations of the symptoms with gender, age, body mass index (BMI), household income, smoking history, sum of somatic symptoms, and allergy were analysed by χ2 test and Mann-Whitney U test. The multivariate analyses were conducted using binary logistic regression with backward-directed stepwise exclusion. The dependent variable was the presence of each symptom, and the control group was the rest of the population. A p-value less than 0.05 was accepted as the level of statistical significance. All analyses were performed using SPSS version 29 software on a computer located at Kuopio University Hospital.

Patient and public involvement

Subjects were not involved in the design or conduct of this study.

Results

In the working population and the pensioner population, the response rates were 26.4% (mean age of 47,8 years, 82.6% females) and 23.6% (mean age of 72.2 years, 66.4% females), respectively. The characteristics of the total population are expressed in Table 1 (column ‘All’). The proportion of missing values was < 1% in all other questions except for sleep apnea symptoms (3.1% − 3.7%) in the retired group, household income (2.7%), and chronic bronchitis-related questions (1.5%) in the total group.

Table 1.

Characteristics of the subjects in the total population and within different respiratory symptom groups. Figures are percentages, means, and standard deviations unless stated otherwise.

  All Current asthma
n a = 9773		 Wheezing with dyspnea
n = 9788		 Chronic rhinosinusitis
n = 9865		 Chronic cough
n = 9865		 TBQ phenotype cough
n = 9865		 Chronic bronchitis
n = 9717		 Sleep apnea symptoms
n = 5879		 Gastroesophageal reflux symptoms
n = 9810
All N (%) 9865 867
(8.9%)		 1221
(12.5%)		 1176
(11.9%)		 1264
(12.8%)		 950
(9.6%)		 1709
(17.6%)		 1928
(32.8%)		 1528
(15.6%)
Women (%) 72.5 78.4 80.2 75.6 73.1 79.5 68.7 57.0 79.0
Age, years 63.1 (14.2) 61.8 (14.5) 58.2
(15.4)		 60.6
(15.3)		 65.2 (12.8) 62.3
(14.2)		 65.5
(13.2)		 72.2
(5.6)		 65.0
(12.7)
BMI (kg/m2) 27.1 (4.8) 28.9
(5.7)		 28.9
(5.9)		 27.6
(5.2)		 27.9
(5.2)		 27.6
(5.0)		 27.8
(5.0)		 29.0
(5.1)		 28.0
(4.7)
Householdtotal income per year (k€)b 40–70 15–40 15–40 15–40 15–40 40–70 15–40 15–40 15–40
The mean sum of somatic symptomsc 2.00
(1.72)		 2.88
(1.99)		 3.07
(1.98)		 2.98
(2.00)		 2.65
(1.90)		 3.15
(2.04)		 2.63
(1.91)		 2.40
(1.81)		 2.85
(1.94)
Current daily smoking (%) 3.7 3.7 6.1 4.4 4.5 3.7 5.9 1.9 3.1
Ever-daily smokers (%)d 33.8 35.4 38.7 37.6 37.3 35.2 38.9 42.8 37.7
Allergy (%) 12.5 38.6 29.6 25.0 17.6 28.9 19.1 12.1 16.4
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a“n” describes the proportion of subjects from the entire population who answered all questions regarding the symptom in question.

bMedian value of the following alternatives: below 15,000, 15000–40,000, 40000–70,000, 70000–120,000, and over 120,000 €/year

cThe mean sum of somatic symptoms (non-respiratory, non-mental).

dEver smoker = smoking daily for a year or more during the lifetime.

The prevalence of current asthma was 8.9%, wheezing with dyspnea 12.5%, chronic rhinosinusitis 11.9%, chronic cough 12.8%, TBQ phenotype cough 9.6%, chronic bronchitis 17.6%, and gastroesophageal reflux symptoms 15.6%. In the retired group, the prevalence of sleep apnea symptoms was 32.8%.

Table 1 presents the characteristics of all subjects and those within the respiratory symptom groups. Most of the population (6163 subjects, 63.2%) were overweight (BMI ≥25). More than one respiratory symptom co-existed in 27.1% of subjects. Table 2 shows the co-existence of the symptoms; for example, 42,7% of the asthmatic group suffered from chronic bronchitis, but on the other hand, within the chronic bronchitis group, only 21,5% had current asthma symptoms. Among subjects with respiratory symptoms, 16.0–50.4% also had a TBQ phenotype cough; the most prominent of these symptoms was chronic cough.

Table 2.

Co-existing respiratory symptoms. The percentages express the proportion (%) of co-existing respiratory symptoms within the group mentioned on the horizontal axis.

  Current asthma Wheezing with dyspnea Chronic rhinosinusitis Chronic cough TBQ phenotype cough Chronic bronchitis Sleep apnea symptoms Gastroesophageal reflux symptoms
Current asthma – 45.0 20.1 19.6 35.2 21.5 11.6 13.9
Wheezing with dyspnea 63.7 – 31.6 27.9 45.4 28.9 14.5 20.4
Chronic rhinosinusitis 27.0 30.1 – 27.0 41.7 28.3 15.3 19.0
Chronic cough 28.3 28.4 29.0 – 67.1 41.7 19.9 22.6
TBQ phenotype cough 38.3 34.9 33.7 50.4 – 34.4 16.0 21.3
Chronic bronchitis 42.7 40.3 41.7 56.9 62.6 – 27.9 29.2
Sleep apnea symptoms 47.5 53.3 51.8 47.3 61.4 48.1 – 43.1
Gastroesophageal reflux symptoms 24.4 25.5 24.8 27.6 34.3 25.9 23.6 –
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The risk factors for respiratory symptoms are described in Table 3. Decreased age increased the risk of wheezing with dyspnea and chronic rhinosinusitis. Increased age was associated with chronic cough, chronic bronchitis, and gastroesophageal reflux symptoms (Table 3, Figure 2). Male gender was a risk factor for chronic bronchitis and sleep apnea symptoms, and on the other hand, female gender was a risk factor for gastroesophageal reflux symptoms. Higher BMI, the sum of somatic symptoms, and allergy increased the risk of almost all respiratory symptoms. An increase in gross household income protected against wheezing with dyspnea, TBQ phenotype cough, and chronic bronchitis.

Table 3.

The risk factors of the respiratory symptoms analysed by multivariable binary logistic regression. Only the factors with statistically significant (p < 0.05) independent associations with the symptoms are presented. The figures represent adjusted odds ratios and 95% confidence intervals.

Characteristics Current asthma
n = 9773		 Wheezing with dyspnea
n = 9788		 Chronic rhinosinusitis
n = 9865		 Chronic cough
n = 9865		 TBQ-phenotype cough
n = 9865		 Chronic bronchitis
n = 9717		 Sleep apnea symptoms
n = 5879		 Gastroesophageal reflux symptoms
n = 9810
Gender (male) NS NS NS NS NS 1.38***
(1.22–1.57)		 2.26***
(1.99–2.56)		 0.69***
(0.60–0.79)
Age NS 0.74***
(0.70–0.79)		 0.94*
(0.89–0.99)		 1.19***
(1.13–1.26)		 NS 1.23***
(1.16–1.30)		 NS 1.20***
(1.14–1.26)
Body mass index 1.30***
(1.22–1.39)		 1.31***
(1.24–1.39)		 NS 1.09**
(1.04–1.16)		 1.08*
(1.02–1.15)		 1.05*
(1.00–1.11)		 1.52***
(1.43–1.60)		 1.17***
(1.11–1.23)
House income NS 0.88**
(0.81–0.95)		 NS NS 0.89**
(0.82–0.97)		 0.88***
(0.82–0.94)		 NS NS
The sum of somatic symptoms 1.23***
(1.18–1.28)		 1.35***
(1.30–1.39)		 1.35***
(1.31–1.40)		 1.25***
(1.21–1.29)		 1.40***
(1.34–1.45)		 1.27***
(1.23–1.31)		 1.35***
(1.31–1.41)		 1.35***
(1.30–1.39)
Ever smoker NS 1.18*
(1.03–1.34)		 1.17*
(1.03–1.33)		 NS NS 1.20**
(1.07–1.35)		 1.23***
(1.09–1.39)		 1.21**
(1.07–1.36)
Allergy 4.83***
(4.12–5.67)		 2.87***
(2.46–3.34)		 2.08***
(1.78–2.44)		 1.41***
(1.19–1.66)		 3.34***
(2.67–3.15)		 1.79***
(1.54–2.08)		 1.26*
(1.04–1.54)		 NS
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NS = Not significant.

Age OR is expressed in the following quartiles: < 56, 56–68, 69–73, and > 73 years.

Body mass index OR is expressed in the following quartiles: below 23.8, 23.8–26.4, 26.4–29.5, and over 29.5.

*p < 0.05, **p < 0.01, ***p < 0.001.

Figure 2.

Figure 2.

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Prevalence of various respiratory symptoms by age group. Sleep apnea symptoms was excluded because the STOP questionnaire was only included in the survey for the retired in 2021.

Discussion

In this sizeable community-based population with a wide age range, the prevalence of respiratory symptoms ranged from 8.9% to 32.8%. The relative importance of various risk factors differed significantly between the respiratory symptoms.

The prevalence of chronic rhinosinusitis (11.9%), chronic cough (12.8%), and gastroesophageal reflux symptoms (15.6%) was in line with previous results [5–7,9,22,23,34,57–59]. The prevalence of current asthma (8.9%) and wheezing with dyspnea (12.5%) also corresponded quite well with both previous Finnish [39,43,60] and international [58] results. Interestingly, much lower prevalence figures for asthma can also be found in the literature [2,3,37,61,62].

Among the total population, the most common symptom was chronic bronchitis (17.6%). The prevalence of chronic bronchitis was higher than globally [15–19,63] and in Finland [64]. This is noteworthy, especially given our study population’s low proportion of current smokers (3.7%) compared to 11% in Finland in 2022 [65]. Chronic bronchitis was often associated with other symptoms. Therefore, undiagnosed background diseases (e.g. asthma and bronchiectasis) may explain the high prevalence of chronic bronchitis in the present study.

Among the retired population, the prevalence of sleep apnea symptoms (32.8%) was higher than in previous Finnish [66–69] and American [20] studies, but the methodologies vary significantly. Using the STOP questionnaire, the prevalence of sleep apnea symptoms has varied between 27.5% [46] and 49.7% [70] in previous studies, which aligns with our research. The high prevalence of sleep apnea symptoms and its clinical significance in our study remains open due to the lack of data on the entire population. In addition, the STOP questionnaire used in screening for sleep apnea is very sensitive but not very specific [46,47,70]. Normal polysomnography parameters vary between gender and age groups [,71], and using polysomnography, up to 90% of prevalence figures for sleep apnea have been found among people over 60 years old [72]. Therefore, determining the true prevalence of sleep apnea at a population level is challenging.

The prevalence of TBQ phenotype cough was 9.6%, but no comparable studies exist. TBQ phenotype cough probably represents cough associated with cough reflex hypersensitivity [53,54].

Most previous population-based studies focus on one or a few symptoms within the same population. To the best of our knowledge, a comparison of the prevalence between several different symptoms at the same time within the same population has not been previously published. In our study, some respiratory symptoms were associated with each other more than others. About every fourth of current asthma and wheezing with dyspnea subjects also had gastroesophageal reflux symptoms, and 27% of current asthma subjects had chronic rhinosinusitis, which is in line with previous results [73–75]. Chronic bronchitis co-existed most often (27.9% − 62.6%) with other symptoms, and the co-existence of other symptoms varied between 11.6% and 63.7%. Therefore, careful investigation of underlying disorders is essential in chronic bronchitis and other respiratory symptoms so that the patient receives comprehensive treatment. TBQ phenotype cough probably represents hypersensitivity of the cough reflex arc [53,54]. TBQ phenotype cough was quite prevalent (21.3% − 50.4%) with other symptoms, referring to cough sensitisation in approximately every third person who suffers from a respiratory symptom.

The importance of gender as a risk factor for respiratory symptoms in this population was relatively small. This may be due to including the sum of somatic symptoms in the multivariate analysis. It describes the overall sensitivity to experience and report bodily sensations [76], which is higher in the female gender [77]. In this study, the male gender was associated with both chronic bronchitis and sleep apnea symptoms, and the female gender with gastroesophageal reflux symptoms. These results are in line with previous results [15,18,21–23]. No statistically significant difference between genders was seen with chronic rhinosinusitis, which contradicts the research by Hastan et al. [5]

The population is ageing in Finland [78] and other Western countries [79]. In this study, age was associated with many symptoms, either positively or negatively. Chronic cough, chronic bronchitis, and gastroesophageal reflux symptoms were associated with increased age. On the contrary, decreased age was associated with wheezing with dyspnea and chronic rhinosinusitis. Previous studies have also observed the negative association of ageing with chronic rhinosinusitis [5,6].

Interestingly, allergy was a risk factor for almost all respiratory symptoms. However, the possibility of error must be considered because the allergy was based on the subject’s self-report. Allergy as a risk factor for chronic cough was in line with previous results [80–82], contradicting our previous subgroup results [44,45] or results from longitudinal studies [83,84].

The obesity epidemic is a global problem [85–87]. In this study, higher BMI increased the risk of almost all symptoms. Low household income increased the risk of some respiratory symptoms, and globally, poorer populations tend to have more health problems [88]. Smoking status (ever smoking) increased the risk of many symptoms, but no significant conclusions can be drawn due to the relatively small proportion of smokers in our data.

The present study has several shortcomings. The participation rate was relatively low, a typical finding for academic email surveys [89]. It can be suspected that more active retired or those who suffer from respiratory symptoms were more likely to answer the survey than asymptomatic/less symptomatic subjects or those retired with problems with their daily functioning. Our study population was older and more female-dominated than the general Finnish population, therefore being not fully representative. This higher proportion of older women may lead to some distortion in prevalence figures and smoking habits. However, this has less impact on the significance of risk factors, and the age and gender distribution did not differ between the target population and the responders. The unemployed are underrepresented, and the low proportion of smokers may underestimate its effect on symptoms. Questionnaire-based information is more fragile than information obtained through a patient’s clinical examination. Because this was a cross-sectional study, verifying a causal relationship between different symptoms and risk factors is impossible.

The strengths of the current study included a wide age range, with older adults and the retired population well represented. Symptoms were defined using commonly agreed definitions; therefore, a reliable comparison with other similar studies is straightforward. To the best of our knowledge, our current study was the first in Finland and globally to compare the prevalence and characteristics between several respiratory symptoms within the same population.

In conclusion, the present study brings updated information about the prevalence of respiratory symptoms in a country with a subarctic climate. Higher BMI, smoking, low household income, and allergy were significant risk factors for most respiratory symptoms. Some risk factors, like ageing and gender, associated with the symptoms in opposite ways and many subjects suffered from several different symptoms. The climate is changing, especially in Northern Europe and Scandinavia [90]. Therefore, it would be sensible to continue conducting epidemiological research on various respiratory symptoms and their risk factors in the future.

Supplementary Material

STROBE checklist cross sectional.docx
ZECR_A_2563395_SM1567.docx (33.2KB, docx)

Acknowledgments

We thank Seppo Hartikainen for his assistance in creating the electronic questionnaire.

Funding Statement

This study was supported by Foundation of the Finnish Anti-Tuberculosis Association, Vaino and Laina Kivi Foundation, Research Foundation of the Pulmonary Diseases, and Respiratory Foundation of the Kuopio Region. The foundations had no role in the study’s design, data collection, analysis, interpretation, or manuscript writing.

Disclosure statement

HVTP reports grants from the Foundation of the Finnish Anti-Tuberculosis Association, the Vaino and Laina Kivi Foundation, the Research Foundation of the Pulmonary Diseases, and The Respiratory Foundation of the Kuopio Region. During the conduct of the study, congress travel costs from AstraZeneca Oy and Sanofi Oy Finland, and a personal fee from the University of Eastern Finland as payment for giving a scientific lecture. HOK reports support from Orion Ltd to visit an international scientific meeting, and from owning shares of Orion Pharma, outside the submitted work. MKP reports grants from the Foundation of the Finnish Anti-Tuberculosis Association, Jalmari and Rauha Ahokas Foundation, and The Respiratory Foundation of the Kuopio Region, and a payment from Boehringer-Ingelheim Finland Ltd for participating in the advisory board. JTK reports grants from the Foundation of the Finnish Anti-Tuberculosis Association, the Vaino and Laina Kivi Foundation, the Research Foundation of the Pulmonary Diseases, The Respiratory Foundation of the Kuopio Region and the Finnish Cultural Foundation. AML reports personal fees from Chiesi, GSK, and AstraZeneca Finland as payments for lectures or educational events and support from Chiesi and GSK for attending scientific meetings.

Contributors

All authors contributed to the study’s conception and design. HOK, AML and JTK performed data collection. HVTP and HOK performed the analysis. HVTP wrote the first draft of the manuscript, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Patient consent

The decision to respond to the questionnaire was considered informed consent.

Ethics approval

The study was approved by the Ethics Committee of Kuopio University Hospital (289/2015).

Provenance and peer review

Not commissioned; externally peer-reviewed.

Data sharing statement

There is no additional unpublished data.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/20018525.2025.2563395

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