Abstract
Background and objective
With the increasing prevalence of sedentary work life, misalignments in postural alignment and psychosocial health problems have become common among office workers. This study aimed to evaluate the effects of a reformer Pilates exercise program on postural alignment, body appreciation, and social appearance anxiety in sedentary office employees.
Methods
A one-group pretest-posttest experimental design was used. The sample consisted of 22 desk-based office workers (14 females, 8 males) selected through convenience sampling. Postural alignment, body appreciation, and social appearance anxiety were assessed using the New York Posture Rating Scale, the Body Appreciation Scale, and the Social Appearance Anxiety Scale, respectively. Participants completed 60-minute reformer Pilates sessions twice a week for 8 weeks. Pre- and post-intervention measurements were compared using paired samples t-tests. Effect sizes (Cohen’s d) were also calculated to assess the magnitude of changes.
Results
The 8-week reformer Pilates program led to significant improvements in postural alignment (p < 0.001, large effect), increased body appreciation (p < 0.01, moderate effect), and reduced social appearance anxiety (p < 0.001, large effect) among participants.
Conclusion
Reformer Pilates appears to improve postural alignment, body appreciation, and social appearance anxiety in sedentary office workers. Incorporating such programs into workplace wellness initiatives may help enhance physical and psychosocial well-being.
Keywords: Posture, Reformer pilates, Office workers, Body appreciation, Social appearance anxiety
Background
Desk-based office workers spend the majority of their day sitting in a sedentary position. When combined with factors such as ergonomically inadequate office furniture, psychological stress, and insufficient physical activity, this condition negatively impacts posture and the musculoskeletal system [1]. Posture is defined as the alignment of body parts while standing upright, and the spine plays a fundamental role as the core structure of the skeletal system in maintaining this alignment [2, 3]. In desk-based occupations, the spine’s inability to maintain upright alignment over prolonged periods has become a widespread health concern. Repetitive loads placed on the body unconsciously during work may lead to serious physiological problems such as muscle imbalances, fatigue, joint misalignment, and degenerative changes [4, 5] – [6]. Because of the interconnectedness of muscle chains in the spinal area, postural misalignments in the craniocervical region lead to compensatory changes in other parts of the spine. These biomechanical problems can result in local symptoms, including reduced cervical joint mobility, muscle strength imbalances, fatigue, muscle shortening, pain, and degenerative joint changes [7]. In addition, it causes negative socioeconomic effects and a decrease in quality of life with a decrease in the individual’s work performance [8, 9].
Spinal structures allow the upper body to move in different directions and reduce stress on the vertebrae. However, incorrect movement habits can cause the vertebrae to deviate from their normal position, resulting in deformities such as dorsal kyphosis and lumbar lordosis [10]. The postural regulation mechanism is often compared to a simple reflex arc Scoppa et al., [11]; however, unlike reflexes, Postural control mechanisms are constantly evolving and changing through learning and exercise [12]. Corrective exercises are one of the most common methods used to correct abnormal spinal curvatures, strengthen muscles, improve abnormal alignment, trunk balance and stability [13, 14]. Pilates exercises are also among the methods used to correct postural misalignments such as kyphosis and lordosis [15] and can be applied as a stand-alone intervention method for such abnormalities [6]. Pilates exercises are a specific exercise program designed to improve body strength, endurance and flexibility [16], as well as focusing on muscle function, balance, improving muscle control in the pelvis, shoulder girdle and lower extremities, providing correct body biomechanics, improving spinal health [14–17] and increasing stability [18]. Beyond its physical benefits, posture also has strong psychological implications, particularly in shaping one’s perception of their body and social presence.
It has been observed that regular pilates exercises not only provide positive physical effects on individuals, but also have positive psychological effects. Postural alignment cause people to dislike their bodies and experience social appearance anxiety [19, 20]. Postural alignment serves as a key visual indicator of one’s bodily self-perception; therefore, distorted posture may heighten concerns about how one’s appearance is perceived in social contexts. Social appearance anxiety is a form of appearance-related concern that may be associated with postural misalignments and negative body image perceptions and negatively affects the daily social activities of the person [21]. At the same time, social appearance anxiety is defined as the anxiety and stress people feel when their physical appearance is evaluated by others [22]. When the literature is examined, Haase et al., [23] concluded that individuals experience physical anxiety and social appearance anxiety when they cannot control their bodies. Similarly, when the results of other studies [19–24] are examined, it is seen that social appearance anxiety is expressed as a negative result of a person’s dislike of his/her own body and physical appearance. Individuals with a positive physical self-perception tend to exhibit greater self-confidence in social relationships and are generally more successful in their professional lives. It has been shown in research that individuals with negative body image tend to have lower levels of self-confidence in social relationships and may experience decreased self-worth in association with increased social appearance anxiety [21]. In a study, it was stated that individuals with high levels of physical activity (such as mat pilates, reformer pilates) also had high levels of body appreciation [25]. Body appreciation is the evaluation of the positive or negative feelings that an individual develops towards the parts and functions of his/her own body or the definition of how the individual perceives his/her body by visualizing his/her appearance in his/her mind [26].
The primary aim of this research is to investigate the effectiveness of pilates exercise programs in individuals working at a desk and to evaluate their effects on postural improvement, body appreciation, and social appearance anxiety. Therefore, this study hypothesizes that participation in an 8-week reformer Pilates program will lead to significant improvements in postural alignment, body appreciation, and reductions in social appearance anxiety among desk-based office workers.
Method
Research model
In this study, a within-subject (one-group) experimental design was employed. This design involves administering a pretest to a group, implementing a treatment, and then assessing the effect of the treatment through a posttest conducted on the same group [27, 28].
The ethics committee approved the study methodology on February 24, 2022, under the reference number 2022/03–14. All methods were performed in accordance with applicable ethical guidelines and regulations.
Research group
The sample of this study consists of 22 individuals (14 female, 8 male) working at a desk in an office environment. The mean age of female participants was 33.71 (SD = 6.96), while the mean age for male participants was 35.50 (SD = 5.42). In this study, a purposive sampling approach was adopted, and participants were selected based on specific criteria releated to the research objectives.
The sample size was calculated using G*Power 3.1 software based on the effect size (Cohen’s d = 1.06) that was computed by the researcher from the pretest and posttest values reported in Polat [29] which examined the effects of posture exercises on social appearance anxiety using the same measurement tool. Assuming a significance level of 0.05 and a statistical power of 0.95 for a repeated-measures t-test, the minimum required sample size was determined to be 14. To account for potential dropouts, the target sample size was increased to 28 participants. Since 6 of the participants could not participate regularly in the exercise program, they were excluded from the study and the study was completed with 22 participants. Inclusion criteria for participation were as follows: being between 25 and 45 years of age, working at least 30 h per week in a desk-based office setting, having no acute orthopedic or neurological problems, and being medically fit to engage in exercise. Additionally, individuals who had not participated in regular pilates training in the past 6 months, who voluntarily agreed to join the study by signing informed consent, and who could commit to attending regular sessions throughout the 8-week program were included. Exclusion criteria involved having chronic systemic diseases (e.g., cardiovascular disease, uncontrolled hypertension, diabetes), musculoskeletal issues that could affect posture (e.g., herniated disc, severe scoliosis, rheumatic disorders), psychiatric diagnoses (e.g., anxiety disorders, major depression), pregnancy or pregnancy planning during the study period, and inability to regularly attend at least two sessions per week. Participants taking medications that could affect social anxiety, body image, or muscle tone were also excluded. During the participant selection process, individuals were informed about the study and were made aware that they could withdraw at any time if they chose to do so. The participants were informed about the purpose, procedures, and potential risks of the study, and their informed consent was obtained in writing. Participants who volunteered to participate in the eight (8) week exercise program were included in the study by signing a voluntary consent form.
Data collection tools
The study employed a personal information form, the Social Appearance Anxiety Scale, and the Body Appreciation Scale as instruments for data collection. In our study, postural changes were evaluated posteriorly - anteriorly (head, shoulders, back, hips, feet and arches of the feet) and laterally (neck, chest, shoulders, upper back, trunk, abdomen, waist) with the New York Posture Rating Scale.
Social appearance anxiety scale
The Social Appearance Anxiety Scale, developed by Hart et al., [20] evaluates the social anxiety related to appearance in individuals. Doğan [19] adapted this scale for Turkish culture. It consists of 16 items, with the first item being reverse scored. Respondents evaluate these items using a 5-point Likert-type scale that ranges from “Not at All Appropriate” to “Fully Appropriate.” The scale demonstrates a unidimensional structure, where higher scores indicate greater appearance anxiety. Factor analysis confirmed that the scale retains its unidimensionality, similar to the original version. The Cronbach’s alpha internal consistency coefficient for the Social Appearance Anxiety Scale was reported as 0.93, with a test-retest reliability coefficient of 0.85 and a split-half reliability coefficient of 0.88. In our research, the internal consistency reliability coefficient was determined to be 0.89.
Body appreciation scale
The Body Appreciation Scale, developed by Tylka and Wood-Barcalow [30], was culturally adapted for Turkey by Anlı, Akın, Eker & Özçelik [31]. This scale uses a 5-point Likert-type format, where responses range from “never” to “always.” It comprises 10 items, and participants indicate their level of agreement with each statement. The overall Body Appreciation score is calculated by summing the responses from all items. There are no reverse-coded items on this scale, and scores range from 10 to 50. Higher scores reflect a greater level of body appreciation. The internal consistency reliability coefficient for the Body Appreciation Scale was reported to be 0.90, while in our study, we found the Cronbach’s alpha internal consistency coefficient to be 0.95.
New York posture rating scale
The New York Posture Rating Scale was developed to assess the correct and incorrect alignment of various body parts in anatomical position. The New York Posture Rating Scale is a rating scale that provides a pictorial assessment of possible alignment scores that may occur in 13 body parts, including the head, neck, shoulders, waist and back, hips, knees and ankles. Each body part is scored from “good posture” to “bad posture” (5-3-1) and the person receives a total score between 13 and 65. A high score means the closest to ideal posture [32].
Data collection process
Before starting the study, posture evaluations of the individuals were made with the New York Posture Rating Scale and the measurements were recorded. Then, preliminary measurements were taken by applying the Social Appearance Anxiety and Body Appreciation Scales to the individuals. Participants who completed the initial assessments engaged in supervised reformer Pilates sessions twice weekly for eight weeks. One week after the end of the exercise program, posture was re-evaluated using the same criteria from the New York Posture Rating Scale. In addition, the Social Appearance Anxiety and Body Appreciation Scales were administered again and final measurements were made. All data were digitally recorded and entered into statistical software for analysis.
Exercise protocol
Before starting the planned exercises, the participants were informed about the equipment to be used and how to use it. After posture analysis, information about their current posture was given and the points to be considered to ensure postural improvement with exercises were explained. Each participant received individualized instruction and supervision during the exercise sessions. The exercise program, presented in Table 1 was divided into two 4-week phases. In the first phase (weeks 1–4), the focus was on mobility and flexibility exercises using the reformer and mat-based movements. In the second phase (weeks 5–8), progression was ensured by adding core stabilization (plank and side plank), resistance-based shoulder mobility, and postural control exercises. Repetitions and static hold durations were adjusted accordingly (e.g., plank for 1 min, foam roller SMR for 3 min). At the beginning of the second phase, participants were re-informed about the updated exercises and equipment use.
Table 1.
Reformer pilates exercise program applied for eight weeks
| Week | Session | Exercise Name | Repetitions | Sets |
|---|---|---|---|---|
| 1-2-3-4 | 1 |
1. Catcow 2. Thoracic extansion with foam roller 3. Shoulder mobility 4. Iliopsoas strech 5. Hamstring strech 6. Leg circles 7. Reformer priformis strech 8. Footwork |
15 Repetitions 15 Repetitions 15 Repetitions 15 Repetitions 15 Repetitions 15 Repetitions 15 Repetitions 15 Repetitions |
1 |
| 2 | Same as session 1 | 15 Repetitions each | 1 | |
| 5-6-7-8. | 1 |
1. Catcow 2. Footwork 3. Foam roller smr 4. Chintuck 5. Thoracic mobilty 6. Shoulder mobilty with band 7. Shoulder exercise 8. Back series 9. Arm series 10. Core series 11. Plank and Side plank 12. Foam roller smr 13. Plank and side plank |
15 Repetitions 15 Repetitions 15 Repetitions 15 Repetitions 15 Repetitions 15 Repetitions 15 Repetitions 15 Repetitions 15 Repetitions 15 Repetitions 15 Repetitions 3 min 1 min |
1 |
| 2 | Same as session 1 | Same as above | 1 |
Analysis of data
Before the data analysis, missing data analysis was performed and the normality assumption of the data was tested. Normality was assessed using skewness and kurtosis values. Values within the range of -1 to + 1 were considered indicative of normal distribution [33]. To assess whether there is a statistically significant difference between the pre-test and post-test scores of postural alignment, body appreciation and social appearance anxiety, a paired samples t-test was conducted. Statistical analyses were performed using IBM SPSS Statistics, Version 25.0.
Results
The descriptive statistics of the desk-based office workers who participated in the study for the duration of working sitting at a desk and age variables are given in Table 2.
Table 2.
Participants’ age and sitting working time
| Variable | N |
|
SD | Min | Max | |
|---|---|---|---|---|---|---|
| Mean sitting time (years) | 22 | 7.55 | 1.95 | 5.00 | 12.00 | |
| Mean age (years) | 34.36 | 6.37 | 23.00 | 44.00 | ||
Findings related to the participants’ posture measurements are presented in Table 3.
Table 3.
Results of participants’ posture measurement Pre - exercise and Post - exercise
| Participants | Pre-exercise posture assessment | Post-exercise posture assessment | ||
|---|---|---|---|---|
| P1 | 24.00 | Weak | 50.00 | Good |
| P2 | 32.00 | Medium | 56.00 | Very good |
| P3 | 31.00 | Medium | 55.00 | Very good |
| P4 | 30.00 | Medium | 60.00 | Very good |
| P5 | 34.00 | Medium | 60.00 | Very good |
| P6 | 37.00 | Medium | 49.00 | Good |
| P7 | 33.00 | Medium | 43.00 | Good |
| P8 | 38.00 | Medium | 46.00 | Good |
| P9 | 37.00 | Medium | 47.00 | Good |
| P10 | 35.00 | Medium | 43.00 | Good |
| P11 | 27.00 | Weak | 56.00 | Very good |
| P12 | 39.00 | Medium | 51.00 | Very good |
| P13 | 39.00 | Medium | 45.00 | Good |
| P14 | 33.00 | Medium | 35.00 | Medium |
| P15 | 39.00 | Medium | 43.00 | Good |
| P16 | 31.00 | Medium | 45.00 | Good |
| P17 | 31.00 | Medium | 35.00 | Medium |
| P18 | 32.00 | Medium | 50.00 | Good |
| P19 | 33.00 | Medium | 49.00 | Good |
| P20 | 33.00 | Medium | 47.00 | Good |
| P21 | 37.00 | Medium | 38.00 | Medium |
| P22 | 38.00 | Medium | 50.00 | Good |
Note: The score ranges are interpreted as follows: 13–27 = Weak, 28–39 = Medium, 40–52 = Good, 53–65 = Very Good
In Table 3, it can be seen that the participants’ alignment score measurements were at a medium level before the pilates exercises and improved towards a good level after the exercises.
The results of the paired samples t-test to examine whether there is a significant difference in alignment scores of desk-based office workers depending on reformer pilates exercises are given in Table 4.
Table 4.
t-Test results of posture measurement pre-test and post-test mean scores
| Posture | N | Mean | SD | df | t | p | Cohen’s d |
|---|---|---|---|---|---|---|---|
| Pre-test | 22 | 33.82 | 3.94 | 21 | -7.426 | < 0.05* | 1.32 |
| Post-test | 47.86 | 6.99 | 21 |
*p < 0.05
In Table 4, there was a significant decrease in the participants’ alignment scores after the 8-week reformer pilates exercise program, t(21)= -7.426, p < 0.05. The mean pre-test score was 33.82, which increased to 47.86 post-test. These results indicate that the Pilates intervention substantially improved postural alignment, with a large effect size. Moreover, the effect size was positive and large (Cohen’s d = 1.32), indicating that the intervention had a strong practical impact on improving posture alignment among participants.
The results of the paired samples t-test to examine whether there is a significant difference in body appreciation levels of desk-based office workers depending on reformer pilates exercises are given in Table 5.
Table 5.
t-Test results of the mean scores of the pre-test and post-test of body appreciation
| Body Appreciation | N | Mean | SD | df | t | p | Cohen’s d | |||
|---|---|---|---|---|---|---|---|---|---|---|
| Pre-test | 22 | 3.56 | 0.86 | 21 | -2.92 | 0.008* | 0.62 | |||
| Post-test | 4.14 | 0.61 | 21 | |||||||
*p < 0.05
In Table 5, it was found that there was a significant increase in the body appreciation scores of the participants after the 8-week reformer pilates exercise program, t(21)= -2.92, p < 0.05. The mean pre-test score was 3.56, which increased to 4.14 post-test. This finding shows that the reformer pilates exercise program had a significant effect on increasing the body appreciation scores of the participants. Furthermore, the effect size was positive and moderate (Cohen’s d = 0.62), indicating that the program had a meaningful impact on increasing participants’ body appreciation levels.
The results of the paired samples t-test to examine whether there is a significant difference in social appearance levels of desk-based office workers depending on reformer pilates exercises are given in Table 6.
Table 6.
t-Test results of social appearance anxiety pre-test and post-test mean scores
| Social Appearance Anxiety |
N | Mean | SD | df | t | p | Cohen’s d |
|---|---|---|---|---|---|---|---|
| Pre-test | 22 | 1.75 | 0.52 | 21 | 4.98 | < 0.05* | -1.06 |
| Post-test | 1.47 | 0.41 | 21 |
*p < 0.05
In Table 6 it was found that there was a significant decrease in the social appearance anxiety scores of the participants after the 8-week reformer pilates exercise program, t(21) = 4.98, p < 0.05. The mean pre-test score was 1.75, which decreased to 1.47 post-test. This finding shows that the reformer pilates exercise program had a significant effect on reducing the social appearance anxiety of the participants. Although negative due to score direction, the magnitude of the effect was large (Cohen’s d = -1.06). Moreover, the effect size indicating that the program had a strong practical impact on alleviating participants’ concerns related to their social appearance.
Discussion
The primary objective of this study was to examine the effects of reformer pilates exercises, implemented over a period of eight weeks, on alignment score, body image, and social appearance anxiety in individuals engaged in desk-based office workers office-related work. Reformer Pilates significantly improved posture, body appreciation, and social appearance anxiety.
The initial finding of the study indicates that the eight-week reformer pilates program resulted in a statistically significant improvement in the postural alignment of the participants. As stated in the extant literature, insufficient physical activity can result in weakening and shortening, particularly in postural muscle groups. This phenomenon can lead to distortions in body symmetry and impaired function of the musculoskeletal system [34, 35]. In individuals who engage in sedentary occupations, such as office work, prolonged sitting and ergonomic inadequacies are identified as primary risk factors contributing to postural decline. The American Medical Association [36] emphasizes that exercise-based approaches should be considered as the primary intervention in the non-surgical, low-risk, and effective management of such postural alignment. Pilates practices have been a subject of extensive discourse within the scholarly community. These practices have been incorporated into a range of health approaches, including both preventive and corrective measures. They have been demonstrated to offer a multitude of benefits to the musculoskeletal system [37, 38, 39, 40, 41, 42, 43, 44, 45, 46]. A substantial body of research has demonstrated that pilates exercises enhance strength, particularly in the abdominal and spinal muscle groups. These exercises have also been shown to improve range of motion and increase mobility in the spine and peripheral joints. Furthermore, these gains have a positive effect on motor coordination [34–47, 48, 49]. A systematic review of 119 articles by Wellset et al. [50] demonstrates that pilates exerts a holistic effect on key elements such as muscle strength, core stability, flexibility, motor control, posture, and breath awareness. As posited by Emery et al. [18], the 12-week twice-weekly pilates program has been demonstrated to have a positive effect on posture. Furthermore, Kuo et al. [39] have demonstrated the program’s effectiveness in reducing thoracic spine curvature. Researchers such as Karavelioğlu et al. [43] and Günendi [50] have also reported similar positive effects on sedentary women and office workers. The present study’s findings are largely consistent with those of the aforementioned study, thereby lending support to the notion that reformer pilates is an effective intervention for postural correction, particularly among groups exhibiting low levels of physical activity.
A further significant finding of the study was that reformer pilates exercises had a substantial impact on the participants’ perceptions of body appreciation. Body appreciation is a multidimensional construct encompassing an individual’s evaluation of their physical appearance. It is associated not only with aesthetic appreciation, but also with self-esteem, self-efficacy, perception and psychological resilience. A substantial body of research has indicated that regular participation in physical activities has a favourable impact on body perception [50, 51, 52, 53, 54]. Civan [55] posited that physical activity enhances the sense of bodily control and ownership. In addition, Güven and Solmaz [56] identified a substantial positive correlation between body perception and physical activity levels. It is evident that mind-body-oriented practices, such as pilates and yoga, offer holistic approaches that have a direct effect on an individual’s body image. This is achieved by improving muscle mass, metabolic balance and body awareness [57, 58]. Vaquero-Cristóbal et al. [59] revealed that regular pilates practice increased body appreciation, while Wood-Barcalow et al. [60] state that individuals with positive body image turn exercise into a health investment. In this context, the findings of our study suggest that pilates practices may positively affect body appreciation not only in physical but also in cognitive and affective dimensions.
The third and final main finding of the study was that reformer pilates exercises led to a significant decrease in social appearance anxiety. Social appearance anxiety is defined as an individual’s concern about the evaluation of their physical appearance by others and is closely related to body perception. Such concerns are shaped by social expectations and have the capacity to limit the individual’s behaviour in social environments. As demonstrated by Alemdağ and Öncü [61], an enhancement in physical activity levels has been shown to result in a reduction in social appearance anxiety. Duyan et al. [62] stated that pilates exercises supported psychological well-being by reducing social appearance anxiety; Akkuş et al. [63] demonstrated that appreciation with physical appearance alleviated social evaluation anxiety. An evaluation of the present study’s findings from this perspective demonstrates that reformer pilates practices promote individuals’ self-acceptance of their physical appearance, thereby reducing anxiety in social environments.
Limitations of the study and recommendations for future research
Although this study presents important findings, it also includes several methodological limitations. First, the absence of a control group limits the ability to determine whether the observed effects can be solely attributed to the reformer Pilates intervention or influenced by other external factors. Normality was assessed only through skewness and kurtosis values, which constitutes a limitation in terms of not employing more comprehensive tests for the assumption of normality. Additionally, the relatively small sample size restricts the statistical power and reduces the generalizability of the findings. Future studies should be conducted with larger and more diverse samples using controlled and long-term intervention designs to enhance the validity of the results. Moreover, incorporating objective physical indicators such as body mass index could provide a more comprehensive evaluation of the effects of exercise interventions.
Conclusıon
In conclusion, the findings of the present study demonstrated that reformer pilates practices provide multifaceted contributions to enhancing the physical and psychological well-being levels of individuals working in an office environment. Reformer Pilates may serve as a promising strategy for improving posture and psychosocial well-being among sedentary office workers. Problems common in modern work life, such as prolonged sitting, lack of physical activity and ergonomic inadequacy [64] have been shown to be associated with both postural deformations and negative body image. In this context, it can be posited that controlled and systematic movement systems such as the reformer pilates apparatus constitute an accessible and sustainable intervention tool with high applicability in sedentary individuals, such as office workers. However, it should be noted that the conclusion is limited to the short-term effects evaluated in the current study. The findings suggest that reformer pilates interventions may serve as a feasible and effective individual-level strategy within workplace-based health promotion programs. Employers are encouraged to support accessible, structured exercise opportunities—such as reformer Pilates—within workplace wellness programs.
Acknowledgements
The authors would like to express their sincere gratitude to all participants who voluntarily took part in this study. Their time, effort, and willingness to contribute were essential to the successful completion of the research.
Author contributions
Z.T., C.A. and A.D. conceptualized the study and designed the methodology. N.S. and B.G. were responsible for data collection and participant coordination. Z.T. and Y.D. performed the statistical analysis and interpreted the data. B.A. and S.G. contributed to literature review and assisted in manuscript formatting. Z.T. and A.D. wrote the main draft of the manuscript. All authors reviewed and approved the final version of the manuscript.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Data availability
All data generated or analyzed during this study are included in this published article.
Declarations
Ethics approval and consent to participate
The study was conducted in accordance with the Declaration of Helsinki and approved by the Istanbul Esenyurt University Ethics Committee (Approval No: 2022/03–14). Written informed consent was obtained from all participants prior to their inclusion in the study.
Consent for publication
Not applicable. This protocol does not contain any individual person’s data in any form.
Competing interests
The authors declare no competing interests.
Trial status
This study has been completed and all findings are reported in this manuscript.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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