Abstract
Aim
To determine the association between urinary incontinence and primary caregiver burden (ZBI) in individuals aged ≥ 80, and to assess additional clinical and sociodemographic contributors.
Methods
In this cross-sectional study at Elazığ City Hospital (Oct–Nov 2025), 311 patient–caregiver dyads were evaluated using interviews and chart review. UI was assessed with ICIQ-SF and burden with the ZBI. We used descriptive statistics, Spearman correlation, and multiple linear regression (outcome: total ZBI).
Results
Mean patient age was 84.6 years; UI prevalence was 53.1% (n = 165). Mean caregiver ZBI = 47.08 ± 19.77. ZBI correlated strongly with ICIQ-SF (r = 0.536; p < 0.001). The regression model explained 31.5% of ZBI variance (F = 19.932, p < 0.001; adj R2 = 0.299); UI (B = 14.776; β = 0.374; p < 0.001) and BMI (B = 1.055; β = 0.194; p < 0.001) were the only significant predictors.
Conclusions
In geriatric patients, UI independently and substantially increases caregiver burden and may adversely affect quality of care. Prioritized strategies to reduce caregiver burden should include effective UI management, psychosocial support for caregivers, and control of modifiable risk factors such as obesity and falls.
Clinical trial number
Not applicable.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12912-026-04508-z.
Keywords: Geriatrics, Urinary incontinence, Caregiver burden, Zarit Burden Interview (ZBI)
Introduction
The rapid increase in the global older population places a substantial burden on health and social care systems and highlights the specific care needs of older adults. According to the United Nations’ 2022 report, the population aged 65 years and older is projected to reach approximately 1.5 billion by 2050, representing roughly 16% of the world population [1]. Turkey is experiencing a similar demographic transition: data from the Turkish Statistical Institute indicate that in 2024 the proportion of the population aged 65 and over was 10.6%, and this share is expected to rise in coming years [2]. Aging is accompanied by a higher prevalence of chronic diseases, functional decline, and cognitive impairment, which may reduce older adults’ independence in activities of daily living and increase their need for care. Thus, the growth of the older population constitutes a multifaceted social challenge that affects not only health services but also the burden borne by caregivers.
Providing care to older adults is demanding both physically and psychosocially. Caregivers may experience fatigue, stress, depression, social isolation, and financial difficulties as a result of prolonged and intensive caregiving responsibilities [3]. These challenges can reduce caregivers’ quality of life and negatively affect the quality of care provided. One of the most widely used and validated instruments for assessing multidimensional caregiver burden is the Zarit Burden Interview (ZBI). The ZBI is a 22-item questionnaire designed to measure caregivers’ perceived burden across physical, psychological, social, and economic domains; each item is scored from 0 (never) to 4 (nearly always) [4]. By quantifying the degree of burden experienced, the scale facilitates identification of support needs and planning of interventions for caregivers. The Turkish validity and reliability study of the scale was conducted by İnci and Erdem [5].
Urinary incontinence (UI) is one of the most common and challenging problems encountered in geriatric care. UI is a chronic condition that can substantially impair older adults’ quality of life and may lead to social isolation, depression, and adverse physical health outcomes [6]. Global prevalence estimates for UI in older populations range from 30% to 50%, and studies from Turkey report similar rates [7, 8]. UI is not only burdensome for patients but also represents a significant source of stress for caregivers: it can limit caregivers’ daily activities, increase their psychological burden, and complicate the caregiving process [9]. The International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) is a short, reliable instrument commonly used to assess UI severity and its impact on quality of life; it captures frequency, amount, and life-impact dimensions and is a useful tool for understanding the effect of incontinence on caregivers as well as patients [10, 11].
Factors that influence caregiver burden include the care recipient’s health status, number of chronic conditions, number of medications, body mass index (BMI), sociodemographic characteristics, and specific health problems such as urinary incontinence [12]. However, comparative studies examining the relative contribution of these factors to caregiver burden are limited. Therefore, a multidimensional assessment of caregiver burden and an analysis of the relative impact of UI on that burden are important for informing care strategies.
This study aims to examine the relationship between urinary incontinence and caregiver burden among geriatric individuals aged 80 years and older in eastern Turkey, and to compare the effects of other clinical and sociodemographic factors that may increase caregiver burden. Using validated instruments such as the ZBI and ICIQ-SF, we sought to quantify caregiver burden and elucidate the relative contribution of incontinence to that burden. The findings are expected to inform the development of geriatric care strategies, caregiver support interventions, and health policy.
Methods
Study design
A cross-sectional, descriptive study was conducted in Elazığ (eastern Turkey) at the Geriatric Unit of Elazığ City Hospital. The Geriatric Outpatient Clinic is the only center in Elazığ Province that registers individuals aged 80 years and older and provides regular follow-up; persons aged ≥ 80 may voluntarily register with the unit and receive periodic at-home checks. Data were collected from patient–caregiver dyads by face-to-face interviews and from medical records between October and November 2025. Clinical and demographic data for the older adults were obtained from the interviews and the medical records. Interviews were performed by the physicians who routinely follow the patients; interviewers were trained in questionnaire administration. Caregiver burden was measured using the Zarit Burden Interview (ZBI), and patient urinary incontinence (UI) status and its impact on quality of life were assessed with the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF). Turkish validity and reliability studies of these instruments were used to justify their application in this population.
Study population
All individuals aged 80 years and older registered at our geriatric unit were eligible to volunteer for the study. The unit’s registry included 1,000 individuals aged ≥ 80. Inclusion criteria were registration at the unit, age ≥ 80 years, voluntary participation, and having a primary caregiver. Exclusion criteria included severe baseline cognitive impairment, end-stage cancer or organ failure, and biological/psychological/neurological conditions that precluded communication. After applying these criteria, 452 patients were excluded. The caregivers of the remaining 548 patients were evaluated. Following commonly used definitions in the literature, a caregiver was defined as the unpaid person primarily responsible for the older adult’s daily care activities [4]. Caregivers were eligible for inclusion if they were the primary caregiver (responsible for tasks such as daily care, medication management, and mobilization support), had been providing care for at least the past 3 months, were aged ≥ 18 years, had sufficient cognitive capacity to understand and answer the questionnaire items, and provided informed consent. Exclusion criteria for caregivers were being a paid/professional caregiver (e.g., home-care service employee), providing care for less than 3 months, having a severe psychiatric disorder or cognitive impairment that would prevent questionnaire completion, or refusing participation. Applying these caregiver criteria resulted in exclusion of 237 caregiver–patient pairs, leaving a final sample of 311 dyads.
Sample size
We estimated the minimum sample required using the conventional formula for a single proportion, n0 = Z^2 × p × (1 − p) / d^2. A conservative prevalence estimate (p = 0.50), a two-sided 95% confidence level (Z = 1.96), and a margin of error of 0.05 produced an initial sample size of approximately 384. Because our sampling frame (the geriatric unit registry) is finite (N ≈ 1000), we applied the finite population correction, which reduced the required sample to about 278. Ultimately, 311 patient–caregiver dyads were included in the analysis, exceeding the calculated minimum sample and therefore providing adequate precision for prevalence estimates and multivariable modeling. The study complied with the Declaration of Helsinki. Prior to inclusion, written informed consent was collected from all participants and their companions. Ethical permission was issued by the Fethi Sekin City Hospital Ethics Committee for Non-Interventional Research on 16 October 2025 (Approval No.: 2025/17 − 05).
Data collection
Socioeconomic, demographic, and clinical data were collected via a structured questionnaire administered in face-to-face interviews. To minimize interviewer bias, interviews were conducted by the physician responsible for the patient’s routine follow-up and examination. The sociodemographic data form was developed based on a review of the relevant literature and reviewed by a clinical expert panel; it was revised according to recommendations to ensure content validity and appropriate terminology. The full questionnaire is provided as supplementary material.
Statistical analysis
Statistical analyses were performed with IBM SPSS Statistics for Windows (version 22.0). Continuous variables were inspected for distributional shape using the Kolmogorov–Smirnov test together with graphical checks (histograms and Q–Q plots); results are reported as mean ± standard deviation for approximately symmetric distributions and as median (minimum–maximum) for skewed variables. Categorical data are presented as counts and percentages. For comparisons between groups we used nonparametric methods: the Mann–Whitney U test for two independent groups and the Kruskal–Wallis H test for comparisons involving three or more groups (with post hoc pairwise comparisons where applicable). Associations among continuous or ordinal measures were evaluated with Spearman’s rank correlation coefficient. To examine independent predictors of caregiver burden (total ZBI score) we fitted a multiple linear regression model including prespecified covariates (body mass index, incontinence status coded 0 = no, 1 = yes, sex, number of chronic conditions, number of medications, education level, and history of falls). Model adequacy was assessed by inspecting residual plots for linearity and homoscedasticity and by checking multicollinearity using variance inflation factors (VIF); model performance is summarized using R^2 and adjusted R^2. Regression results are reported as unstandardized coefficients (B) with 95% confidence intervals, standardized β values to compare effect sizes, and two-sided p-values; statistical significance was set at p < 0.05.
Results
A total of 311 individuals aged 80 years and older were enrolled in the study. The mean age of participants was 84.61 ± 3.76 years. Of the participants, 61.4% were female (n = 191) and 38.6% were male (n = 120). The mean body mass index (BMI) was 23.18 ± 3.72. Participants’ sociodemographic and clinical characteristics are presented in Table 1.
Table 1.
Distribution of sociodemographic and clinical characteristics of geriatric participants
| Characteristics | Count (n) | % |
|---|---|---|
| Age | ||
| 80–84 | 154 | 49.5 |
| 85–89 | 125 | 40.2 |
| 90 and above | 32 | 10.3 |
| Gender | ||
| Female | 191 | 61.4 |
| Male | 120 | 38.6 |
| Education level | ||
| Illiterate (cannot read/write) | 184 | 59.2 |
| Primary school | 110 | 35.4 |
| Middle school | 16 | 5.1 |
| College/University | 1 | 0.3 |
| Family and social life (living arrangement) | ||
| Alone | 42 | 13.5 |
| With spouse | 106 | 34.1 |
| With spouse/children | 163 | 52.4 |
| Economic status | ||
| Poor | 52 | 16.7 |
| Moderate | 229 | 73.6 |
| Good | 30 | 9.6 |
| Type of residence | ||
| Detached house (single-family house) | 60 | 19.3 |
| Apartment | 251 | 80.7 |
| BMI | ||
| Underweight | 41 | 13.2 |
| Normal | 138 | 44.4 |
| Pre-obese (overweight) | 95 | 30.5 |
| Obese | 37 | 11.9 |
| History of falls | ||
| No | 229 | 73.6 |
| Yes | 82 | 26.4 |
| Forgetfulness (memory complaint) | ||
| No | 137 | 44.1 |
| Yes | 174 | 55.9 |
| Sleep disturbance | ||
| No | 167 | 53.7 |
| Yes | 144 | 46.3 |
| Hearing problem | ||
| No | 180 | 57.9 |
| Yes | 131 | 42.1 |
| Vision problem | ||
| No | 239 | 76.8 |
| Yes | 72 | 23.2 |
The prevalence of urinary incontinence in the study population was 53.1% (n = 165). The mean Zarit caregiver burden score was 47.08 ± 19.77. The median number of medications used by participants was 5.00 (range 0.00–12.00), and the median number of chronic diseases was 3.00 (range 0.00–8.00) (Table 2).
Table 2.
Clinical characteristics of participants
| Variable | Values |
|---|---|
| Number of medications used, Median (Min–Max) | 5.00 (0.00–12.00) |
| Number of chronic diseases, Median (Min–Max) | 3.00 (0.00–8.00) |
| Zarit Caregiver Burden Scale (ZBI), Mean ± SD | 47.08 ± 19.77 |
| Incontinence status (Yes), n (%) | 165 (53.1) |
| Incontinence Assessment Test (ICIQ-SF), Mean ± SD | 10.85 ± 3.45 |
When ZBI scores were examined according to sociodemographic and clinical variables, several significant differences emerged. Caregivers of female patients had significantly higher ZBI scores than caregivers of male patients (p = 0.007). Caregiver burden also differed significantly by education level (p = 0.012), with higher scores observed among caregivers of patients who were illiterate. There was a significant difference across BMI categories (p < 0.001), with higher caregiver burden in the pre-obese and obese groups. Caregivers of patients with a history of falls had higher ZBI scores compared with those without such a history (p = 0.025). Caregiver burden was markedly higher when patients had urinary incontinence (p < 0.001). No significant differences in ZBI scores were observed for patient age, type of residence, reported forgetfulness, sleep disturbance, hearing problems, or vision problems (Table 3).
Table 3.
Distribution of Zarit care burden scale scores by sociodemographic and clinical characteristics
| Variable | Groups | Mean Rank | Test | p |
|---|---|---|---|---|
| Gender | Male / Female | 138.66 / 166.89 | M–W U = 9379.5 | 0.007 |
| Age group | 80–84 / 85–89 / 90+ | 157.11 / 150.40 / 172.56 | K–W H = 1.596 | 0.450 |
| Literacy status | Illiterate / Primary school / Middle school | 167.85 / 138.89 / 127.63 | K–W H = 8.825 | 0.012 |
| BMI | Underweight / Normal / Pre-obese / Obese | 116.87 / 143.14 / 183.63 / 176.39 | K–W H = 21.471 | < 0.001 |
| Type of residence | Detached house / Apartment | 146.63 / 158.24 | M–W U = 6968.0 | 0.369 |
| History of falls | No / Yes | 149.14 / 175.15 | M–W U = 7818.5 | 0.025 |
| Forgetfulness (memory complaint) | No / Yes | 153.71 / 157.80 | M–W U = 11605,0 | 0.690 |
| Sleep disturbance | No / Yes | 149.73 / 163.27 | M–W U = 10977.0 | 0.185 |
| Hearing problem | No / Yes | 153.03 / 160.09 | M–W U = 11254.5 | 0.494 |
| Vision problem | No / Yes | 155.50 / 157.67 | M–W U = 8483.5 | 0.857 |
| Urinary incontinence | No / Yes | 105.49 / 200.70 | M–W U = 4670.0 | < 0.001 |
*M–W: Mann–Whitney U testi, K–W: Kruskal–Wallis H testi*
A statistically significant positive correlation was observed between the total ZBI score and ICIQ-SF score (Spearman’s rho = 0.536, p < 0.001), the number of chronic diseases (rho = 0.213, p < 0.001), and the number of medications (rho = 0.350, p < 0.001) (Table 4).
Table 4.
Correlation between the Zarit Caregiver Burden Scale (ZBI) and other measurement variables
| Variable | ZBI | |
|---|---|---|
| Incontinence Assessment Test (ICIQ-SF) | r | 0.536 |
| p | < 0.001 | |
| Number of chronic diseases | r | 0.213 |
| p | < 0.001 | |
| Number of medications used | r | 0.350 |
| p | < 0.001 |
Spearman correlation analysis. r: Correlation coefficient; p: Statistical significance (p < 0.05 considered significant)
Multiple linear regression analysis
A multiple linear regression analysis was performed to identify independent predictors of total Zarit Burden Interview (ZBI) score. The model included body mass index (BMI), incontinence status (0 = absent, 1 = present), sex, number of chronic diseases, number of medications, education level, and history of falls (Table 5). The overall model was statistically significant (F = 19.932, p < 0.001) and accounted for approximately 31.5% of the variance in caregiver burden (R2 = 0.315, Adjusted R² = 0.299).
Table 5.
Results of multiple linear regression analysis
| Variable | B | Std. Error | Standardized Beta (β) | p-value | 95% CI |
|---|---|---|---|---|---|
| BMI | 1.055 | 0.292 | 0.194 | < 0.001 | 0.479 − 1.630 |
| Incontinence (0 = no, 1 = yes) | 14.776 | 2.322 | 0.374 | < 0.001 | 10.207–19.345 |
| Gender (M/F) | 2.809 | 2.050 | 0.069 | 0.172 | -1.225–6.843 |
| Number of medications used | -0.300 | 0.694 | -0.024 | 0.665 | -1.666–1.065 |
| Number of chronic diseases | 0.582 | 0.387 | 0.091 | 0.133 | -0.179–1.343 |
| Education level | -0.044 | 1.646 | -0.001 | 0.979 | -3.283–3.194 |
| History of falls | 3.562 | 2.165 | 0.080 | 0.101 | -0.699–7.822 |
B: Regression coefficient; Std. Error: Standard error of the coefficient; Standardized Beta (β): Standardized regression coefficient indicating the relative effect size; 95% CI: 95% Confidence interval of the coefficient estimate; p: Statistical significance (p < 0.05 considered significant). Reference categories: Male for Gender, Illiterate for Education level, No for History of falls, and No for Incontinence
Examination of standardized beta coefficients indicated that urinary incontinence was the strongest independent predictor of caregiver burden (B = 14.776; β = 0.374; p < 0.001). BMI was also a significant positive predictor of ZBI score (B = 1.055; β = 0.194; p < 0.001). The remaining variables included in the model did not make statistically significant contributions. Variance inflation factor (VIF) values ranged from 1.0 to 1.6, indicating that multicollinearity was not a concern.
Discussion
This study comprehensively examined the impact of urinary incontinence (UI) on caregiver burden among geriatric individuals aged ≥ 80 years and demonstrated that UI is a significant and strong determinant of caregiver burden. The observed UI prevalence of 53.1% supports the high frequency of incontinence reported in older populations and falls within prevalence ranges reported in the literature [13]. The effect of UI on caregivers was reflected by significantly higher Zarit Burden Interview (ZBI) scores, a finding that is consistent with prior studies reporting that UI increases caregivers’ physical, psychological, and social burden [14].
In multiple linear regression, UI was the strongest predictor of caregiver burden (standardized β = 0.374, p < 0.001), indicating an independent and substantial impact on caregivers’ quality of life and psychosocial well-being. The model accounted for approximately 30% of the variance in caregiver burden (adjusted R² = 0.299). Given the multifactorial nature of psychosocial outcomes like caregiver burden, a moderate R² is not unexpected; the remaining unexplained variance likely reflects other individual or contextual factors and measurement limitations. Consequently, further and more comprehensive studies are warranted. The literature similarly reports that UI raises the risk of caregiver stress, anxiety, and depression, and that increasing incontinence severity is associated with greater caregiver burden [15]. The extra hygiene and care tasks required to manage UI raise caregivers’ daily responsibilities and physical workload, increasing the risk of burnout and potentially reducing care quality. The potential mechanisms by which urinary incontinence (UI) increases caregiver burden are multifaceted. Physically, managing incontinence adds tasks such as frequent pad and linen changes, routine skin care, and, when necessary, assistance with transfers and mobility; these activities directly increase the time and energy demanded of caregivers. In addition, nocturia or the need for nighttime care fragments sleep, undermines restorative rest, and over time raises the risk of fatigue and burnout. At the psychosocial level, the unpleasant odor, embarrassment, and social restriction associated with incontinence can strain family dynamics and deepen caregivers’ social isolation and psychological stress [16].
Although many studies address the effect of the caregiver’s sex on burden, few investigate the relationship between the care recipient’s sex and caregiver burden, and results have been inconsistent [17, 18]. In our cohort, caregivers of female patients had significantly higher burden scores than caregivers of male patients. This finding may reflect differences in care needs or expectations, whereby female patients may require or elicit more assistance and attention. Lower education level was also associated with higher caregiver burden, which aligns with prior research suggesting that limited education adversely affects caregivers’ coping skills, stress management, and help-seeking behaviors [15].
The positive association between body mass index (BMI) and caregiver burden highlights obesity as an important risk factor in geriatric care. Obese patients often require more time, effort, and specialized equipment for mobilization, personal care, and transfers, increasing caregivers’ musculoskeletal strain and workload [19]. The significant effect of a history of falls on caregiver burden underscores that falls contribute to functional decline and complications in older adults, thereby increasing care needs and caregiver stress [20].
Positive correlations between ZBI scores and both the number of chronic diseases and the number of medications are consistent with the literature. Patients with multiple chronic conditions often require more frequent medical visits and complex management, which places additional demands on both patients and caregivers [21]. The lack of statistical significance of these variables in the regression model suggests that specific factors such as UI and BMI may exert a stronger and more direct influence on caregiver burden in this population.
The absence of a significant effect of age, type of residence, forgetfulness, sleep disturbance, and hearing problems on caregiver burden reflects the complex, multidimensional nature of factors that determine caregiver burden. Findings on age and caregiver burden are inconsistent. Some studies report increased burden with advancing age [22], while others suggest that burden is more closely related to functional status and specific health problems than to age itself [23, 24]. The lack of an age effect in our study may be attributable to the narrow age range (all participants were ≥ 80 years) and to the possibility that age effects are overshadowed by other clinical variables.
Similarly, the lack of an independent effect of housing type is in line with reports that housing alone does not sufficiently capture the social support, economic conditions, and care environment that influence burden [25]. Although the lack of a significant effect of forgetfulness and sleep disturbance on caregiver burden is partly consistent with the literature, some studies report that these factors increase caregiver stress and burden [26, 27]. This discrepancy may arise from differences in measurement methods, sample characteristics, or the severity of forgetfulness and sleep disturbance in our cohort. Patients with advanced underlying cognitive impairment, that is, those with severe forgetfulness or sleep disorders, were excluded from our study, which may have contributed to these factors not reaching statistical significance. Furthermore, the impact of these factors on caregiver burden may be relatively less pronounced compared with more prominent stressors such as UI and chronic multimorbidity.
Findings on hearing and vision problems are mixed. Some studies report increased caregiver burden due to social isolation and communication difficulties [28, 29]. Others find smaller effects, especially when effective interventions (e.g., hearing aids, cataract surgery, rehabilitation) are available [30]. In our sample, the lack of a significant association for hearing problems may reflect caregiver adaptation or the relatively lower direct caregiving demands imposed by sensory loss compared with other conditions.
In summary, factors that did not show significant independent effects in our analyses have heterogeneous and context-dependent relationships with caregiver burden. Caregiver burden is a multifaceted phenomenon shaped by individual differences and interacting factors, underscoring the need for personalized care strategies. By evaluating these variables alongside strong determinants such as UI and BMI, our study contributes an important perspective to the literature.
Strengths of this study include a relatively large sample size, use of validated and reliable instruments, and multivariable analyses that accounted for several potential confounders. Furthermore, our focus on individuals aged 80 and over represents an important contribution. Older adults are more likely to have multiple chronic conditions, physical weakness, and mild cognitive problems, which increase care needs that often require continuous, direct assistance such as limited mobility, getting up at night to urinate, transfers, and skin or urinary care. This situation changes the pattern of caregiving and caregiver burden compared with younger older adult groups. Caregivers in this age group are frequently elderly spouses or older children, and reduced social support makes it harder to share duties, which increases both the duration and intensity of care. For these reasons, our findings provide specific and actionable implications not only for the general older population but especially for care strategies and health policies targeting the most vulnerable adults aged 80 and over. Limitations include the cross-sectional design, which precludes causal inference, and recruitment from a single geographic region, which may limit generalizability. The study is based on a single-center sample of voluntary participants registered at the Elazığ City Hospital Geriatrics Unit; therefore, the findings may not be fully representative of all individuals aged 80 and over in the community. Moreover, local factors such as access to health services, follow-up practices, family structure, and cultural caregiving norms (e.g., the role of family caregivers, rural–urban differences) may affect the relationships between prevalence and caregiver burden; thus, confirmation of these findings in other settings is important. Future longitudinal and multi-center studies across different regions are warranted to further elucidate determinants of caregiver burden and to guide targeted interventions.
Conclusion
This study demonstrates that urinary incontinence (UI) in geriatric patients is associated with a significantly increased caregiver burden and may adversely affect the quality of care. Consequently, effective management of UI and strengthening caregivers through psychosocial support should be prioritized in geriatric care services. Control of modifiable risk factors—such as obesity and falls—should also be considered key strategies for reducing caregiver burden. Improving caregiver education and developing gender-sensitive support programs are critical to ensuring the sustainability of care provision.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
None.
Author contributions
M.B and A.A.O contributed substantially to the conception or design of the manuscript; M.B, A.A.O contributed substantially to the acquisition, analysis, and interpretation of the data. All authors participated in drafting the manuscript M.B and A.A.O revised the manuscript critically. All authors contributed equally to the manuscript and read and approved the fnal version of the manuscript.
Funding
The authors report no involvement in the research by the sponsor that could have infuenced the outcome of this work.
Data availability
Data is provided within the manuscript or supplementary information fles. The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Ethical permission was issued by the Fethi Sekin City Hospital Ethics Committee for Non-Interventional Research on 16 October 2025 (Approval No.:2025/1705). Written informed consent was obtained from all participants prior to their inclusion in the study. All procedures performed in this study involving human participants and/or human data were conducted in accordance with the principles of the Declaration of Helsinki.
Consent for publication
Not applicable. No identifiable personal data from participants are included in this manuscript.
Prior publication
The study has not been presented and/or published in whole or in part anywhere else.
Abbreviations
Abbreviations used in this manuscript are defined at first mention in the text.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data is provided within the manuscript or supplementary information fles. The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.