Abstract
We aimed to examine the prevalence of frailty in older adults with hypertension and its association with suboptimal blood pressure (BP), with a particular focus on differences by sex. The study was conducted at two major hospitals in Vietnam from 2023 to 2024. Frailty was defined by a Clinical Frailty Scale of ≥ 4. Suboptimal BP was defined as systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg. There were 1038 participants (326 female, mean age 73 years). The prevalence of frailty was 28.6%, higher in female (35.3%) than male participants (25.6%). The overall rate of suboptimal BP was 26.7%. In female participants, the frail had a significantly higher rate of suboptimal BP (33.9%) compared to the non-frail (20.9%), but no significant differences among male. In the logistic model adjusted for age, education, marital status, physical exercise, falls, coronary heart disease, diabetes, chronic kidney disease, osteoarthritis, heart failure, stroke, atrial fibrillation, osteoporosis, chronic obstructive pulmonary disease, duration of hypertension, monotherapy/combination therapy, and medication adherence score, the odds ratios of frailty on suboptimal BP were 2.01 (95% CI 1.08–3.76) in female participants, 0.92 (95% CI 0.59–1.44) in male, female-to-male ratio of odds ratios 2.18 (95% CI 1.01–4.70). These findings highlight the need for sex-specific approaches in managing hypertension in older populations.
Keywords: Frailty, Suboptimal blood pressure, Hypertension, Sex differences, Geriatric cardiology
Subject terms: Cardiology, Diseases, Health care, Medical research, Risk factors
Introduction
High blood pressure is a significant risk factor for the development of cardiovascular disease and a range of other chronic health conditions.1,2 The prevalence of hypertension increases with age, being 27% for people aged less than 60, but up to 74% for those aged 80 and older.3 Despite efforts to manage hypertension globally, poor blood pressure (BP) control continues to be a challenge, with approximately 20% of people with hypertension achieving optimal BP control.4,5 Uncontrolled hypertension can substantially increase the risk of stroke, heart failure, coronary heart disease, peripheral artery disease, renal failure, and dementia.1,2,6.
In Vietnam, a systematic review in 2019 reported an overall prevalence of hypertension of 21% in adults aged 18 or older.7 A recent 2024 community-based study in 2572 adults (mean age 51.5 ± 15.7) found that 36.1% had hypertension and, of individuals receiving antihypertensive treatment, 57.4% had suboptimal BP (≥ 140/90 mmHg).8 However, there is limited evidence of hypertension in older adults, particularly those with frailty, in Vietnam. The prevalence of frailty is very high in older adults in Vietnam, ranging from 11.2% to 21.7% in community-based studies and 18.5% to 54.9% in hospital-based studies.9–17 The treatment of hypertension in older adults is particularly challenging due to the complexity of their health needs and the presence of geriatric conditions, such as frailty, multimorbidity, polypharmacy, and cognitive impairment.18,19 In frail patients, various factors can contribute to suboptimal control of BP, such as low adherence to prescribed medications, changes in pharmacokinetics and pharmacodynamics and clinicians’ concerns about adverse side effects of antihypertensive treatment, such as dizziness and falls.2,20–22 In addition, sex differences related to frailty and cardiovascular physiology also contribute to the effective treatment of hypertension. There has been evidence that frailty occurs more frequently, and with greater severity, in women compared to men, which may be attributed to various biological, social, and environmental factors.23,24.
Therefore, this study aimed to examine the prevalence of frailty in older adults with hypertension and the association between frailty and suboptimal BP control, with a particular focus on sex disparities.
Methods
This was a cross-sectional analysis using routinely collected retrospective blood pressure data. The study was conducted at the outpatient clinics of two major hospitals in Vietnam (Thong Nhat Hospital in Ho Chi Minh City and University Medical Centre of Ho Chi Minh City) from June 2023 to June 2024. Consecutive patients aged ≥ 60 diagnosed with hypertension who visited the clinics during the study period were recruited. Hypertension was defined based on a documented physician diagnosis of hypertension in the medical record and/or the current use of antihypertensive medications. Patients with secondary hypertension, or not being able to provide consent, were excluded from the study.
The study was approved by the Ethics Committees of the University of Medicine and Pharmacy at Ho Chi Minh City (Reference Number 627/HDDD-DHYD, date 26/06/2023). Informed consent was obtained from all participants. The study was conducted in accordance with the Declaration of Helsinki.
Data were collected from patient interviews and medical records. Information obtained included demographic characteristics, lifestyles, height, weight, medical history, comorbidities, duration of having hypertension, frailty, medications, and medication adherence. Sex was categorized based on biological characteristics as either female or male. Body mass index (BMI) was calculated from measured weight and height. Smoking was defined as previous or current smoking. Regular exercise was defined as exercising at least five days per week. Multimorbidity was defined as having any other long term health conditions in addition to hypertension. Polypharmacy was defined as using 5 or more medications on a daily basis.25 Medication adherence was assessed using the 10-item Medication Adherence Rating Scale (MARS) and a MARS score > 5 was defined as adherence to medications.26,27.
Blood pressure measurement: Mean systolic BP and diastolic BP values were calculated from routine outpatient clinic measurements documented in participants’ medical records over the preceding six months. BP measurements were obtained during routine outpatient visits according to standard clinical practice at the participating hospitals. Multiple clinic BP measurements across visits were used when available. Home BP monitoring and ambulatory BP monitoring data were not systematically available and therefore were not included in the analysis. Suboptimal BP was defined as a mean systolic BP ≥ 140 mmHg or a mean diastolic BP ≥ 90 mmHg. These BP targets were chosen to align with the 2022 Vietnamese Society of Hypertension Guidelines.28.
Frailty was assessed using the Clinical Frailty Scale (CFS).29,30 The CFS score ranges from 1 to 9, and a score of 4 or greater indicates a frailty status.29,31(Fig. 1).
Fig. 1.
The Clinical Frailty Scale (CFS).
Sample size estimation
Based on the data from Vietnam and from a systematic review of studies worldwide on frailty and hypertension,9–17,32 we estimated a prevalence of frailty of 30% in older women and 20% in older men with hypertension. Therefore, at least 784 older adults with hypertension would be needed in this study to detect a significant difference in the prevalence of frailty between women and men (with a power of 90%, 2-sided test, alpha = 0.05).
Statistical analyses
Continuous variables are presented as means and standard deviations (SD), and categorical variables as frequencies and percentages. Comparisons between men and women were assessed using the Chi-square test or Fisher’s exact test for categorical variables and Student’s t-test or Mann-Whitney test for continuous variables.
To identify the association between frailty and suboptimal BP, multivariable logistic regression models were applied, with frailty as the predictive variable of interest and suboptimal BP as the outcome variable, adjusting for the covariates. Multiple adjusted models were fitted to evaluate the robustness of the association. Model 1 was adjusted for age. Model 2 was adjusted for socio-demographic variables (education, marital status). Model 3 was adjusted for lifestyles and comorbidities (physical exercise, falls, coronary heart disease, diabetes, chronic kidney disease, osteoarthritis, heart failure, stroke, atrial fibrillation, osteoporosis, chronic obstructive pulmonary disease [COPD]). Model 4 was adjusted for duration of hypertension, antihypertensive medications (monotherapy or combination therapy), and medication adherence (MARS score). Model 5 was fully adjusted (for age, education, marital status, physical exercise, falls, coronary heart disease, diabetes, chronic kidney disease, osteoarthritis, heart failure, stroke, atrial fibrillation, osteoporosis, COPD, duration of hypertension, monotherapy or combination therapy, and MARS score). Model 6 was the fully adjusted model without MARS score. The odds ratios (ORs) for suboptimal BP of each risk factor were estimated by sex, with interaction terms fitted between each risk factor and sex to obtain the female-to-male ratio of ORs (ROR), based on Woodward’s methodology33.
Multicollinearity among covariates was assessed using Pearson correlation coefficients, with high pairwise correlations indicating potential collinearity issues. Missing data were handled using complete-case analysis. All statistical tests were two-sided and a p value < 0.05 was considered as statistical significance.
Results
There were 1038 participants (326 female and 712 male). They had a mean age of 73.3 (SD 7.4) years (Table 1). Female participants were significantly older than male, with a mean age of 74.3 (SD 7.1) compared to 72.8 (SD 7.5) in male. Coronary heart disease was the most common comorbidity (49.3%), followed by type 2 diabetes (43.8%), and chronic kidney disease (23.0%). Female participants had significantly higher rates of osteoporosis and falls in the past 12 months. Male participants had a significantly higher prevalence of coronary heart disease.
Table 1.
Participant characteristics, stratified by sex.
| Variables | All participants (N = 1038) | Female participants (N = 326) |
Male participants (N = 712) |
P |
|---|---|---|---|---|
| Frailty | 297 (28.6) | 115 (35.3) | 182 (25.6) | 0.001 |
| Age (years) | 73.3 (7.4) | 74.3 (7.1) | 72.8 (7.5) | 0.003 |
| Marital status | ||||
| Never married | 8 (0.8) | 4 (1.2) | 4 (0.6) | 0.003 |
| Married | 994 (95.8) | 301 (92.3) | 693 (97.3) | |
| Divorced/separated | 2 (0.2) | 1 (0.3) | 1 (0.1) | |
| Widow/widower | 34 (3.3) | 20 (6.1) | 14 (2.0) | |
| Education | ||||
| Primary school | 33 (3.2) | 17 (5.2) | 16 (2.2) | < 0.001 |
| Secondary school | 193 (18.6) | 86 (26.4) | 107 (15.0) | |
| High school | 363 (35.0) | 122 (37.4) | 241 (33.8) | |
| Higher education | 449 (43.3) | 101 (31.0) | 348 (48.9) | |
| Smoking | 97 (9.3) | 2 (0.6) | 95 (13.3) | < 0.001 |
| Regular exercise | 508 (48.9) | 91 (27.9) | 417 (58.6) | < 0.001 |
| Body mass index (kg/m2) | ||||
| <18.50 | 39 (3.8) | 17 (5.2) | 22 (3.1) | 0.196 |
| 18.50-24.99 | 703 (67.7) | 222 (68.1) | 481 (67.6) | |
| ≥ 25.0 | 296 (28.5) | 87 (26.7) | 209 (29.4) | |
| History of hospitalization in the past 12 months | 374 (36.0) | 131 (40.2) | 243 (34.1) | 0.059 |
| History of falls in the past 12 months | 89 (8.6) | 45 (13.8) | 44 (6.2) | < 0.001 |
| Polypharmacy | 955 (92.2) | 294 (90.5) | 661 (93.0) | 0.163 |
| Medication adherence | 859 (82.8) | 279 (85.6) | 580 (81.5) | 0.103 |
| Multimorbidity | 938 (90.5) | 291 (89.3) | 647 (91.0) | 0.377 |
| Coronary heart disease | 512 (49.3) | 145 (44.5) | 367 (51.5) | 0.035 |
| Type 2 diabetes | 455 (43.8) | 145 (44.5) | 310 (43.5) | 0.777 |
| Chronic kidney disease | 239 (23.0) | 79 (24.2) | 160 (22.5) | 0.532 |
| Osteoarthritis | 214 (20.6) | 64 (19.6) | 150 (21.1) | 0.596 |
| Heart failure | 95 (9.2) | 34 (10.4) | 61 (8.6) | 0.334 |
| Stroke | 85 (8.2) | 28 (8.6) | 57 (8.0) | 0.750 |
| Atrial fibrillation | 67 (6.5) | 22 (6.7) | 45 (6.3) | 0.794 |
| Osteoporosis | 39 (3.8) | 22 (6.7) | 17 (2.4) | < 0.001 |
| Chronic obstructive pulmonary disease | 23 (2.2) | 3 (0.9) | 20 (2.8) | 0.055 |
Summary statistics shown are n (%), except for age where mean (standard deviation) is given.
Data on antihypertensive therapy stratified by sex was presented in Table 2. There were no significant differences in the use of antihypertensive drug classes between female and male, except for renin-angiotensin-aldosterone system (RAAS) inhibitors, which were lower in female (85.6%) compared to male (91.7%). The mean number of antihypertensive medications was similar between female (2.42, SD 0.86) and male (2.46, SD 0.78). The percentage receiving combination antihypertensive therapy was significantly higher in male (91.2%) compared to female (86.5%), p = 0.022.
Table 2.
Antihypertensive therapy, stratified by sex.
| Variables | All participants (N = 1038) | Female participants (N = 326) |
Male participants (N = 712) |
P |
|---|---|---|---|---|
| Number of antihypertensive medications | 2.45 (0.80) | 2.42 (0.86) | 2.46 (0.78) | 0.505 |
| Antihypertensive drug classes | ||||
| RAAS inhibitors | 932 (89.8%) | 279 (85.6%) | 653 (91.7%) | 0.002 |
| Beta-blockers | 718 (69.2%) | 224 (68.7%) | 494 (69.4%) | 0.828 |
| CCB | 670 (64.5%) | 206 (63.2%) | 464 (65.2%) | 0.536 |
| Thiazides | 147 (14.2%) | 48 (14.7%) | 99 (13.9%) | 0.725 |
| MRA | 42 (4.0%) | 16 (4.9%) | 26 (3.7%) | 0.340 |
| Loop diuretics | 23 (2.2%) | 10 (3.1%) | 13 (1.8%) | 0.207 |
| Antihypertensive therapy | ||||
| Monotherapy | 107 (10.3) | 44 (13.5) | 63 (8.8) | 0.022 |
| Combination therapy | 931 (89.7) | 282 (86.5) | 649 (91.2) | |
Summary statistics shown are n (%), except for number of antihypertensive medications where mean (standard deviation) is given. CCB: calcium channel blockers; MRA: mineralocorticoid receptor antagonist; RAAS: renin-angiotensin-aldosterone system.
In both female and male participants, the CFS ranged from 2 to 6, with CFS 3 being the most common category (Fig. 2). The percentages with CFS 5 and CFS 6 were higher in female than in male participants. The prevalence of frailty overall was 28.6% (297/1038), higher in female (35.3%) than male participants (25.6%), p = 0.001. The distribution of the Clinical Frailty Scale categories by blood pressure control status among 1038 participants was presented in Fig. 3.
Fig. 2.
The distribution of the Clinical Frailty Scale categories by sex among 1038 participants.
Fig. 3.
The distribution of the Clinical Frailty Scale categories by blood pressure control status among 1038 participants.
The mean SBP values were 132.19 (SD 11.87) mmHg overall, 131.75 (SD 12.11) mmHg in female vs. 132.39 (SD 11.76) mmHg in male (p = 0.418), and 132.40 (SD 12.54) mmHg in frail participants vs. 132.11 (SD 11.60) mmHg in non-frail participants (p = 0.721).
The mean DBP values were 74.76 (SD 7.62) mmHg overall, 74.44 (SD 7.52) mmHg in female vs. 74.91 (SD 7.67) mmHg in male (p = 0.366), and 74.22 (SD 8.08) mmHg in frail participants vs. 74.98 (SD 7.43) mmHg in non-frail participants (p = 0.151).
Overall, 26.7% (277/1038) of the participants had suboptimal BP, 29.3% (87/297) in the frail vs. 25.6% (190/741) in the non-frail (p = 0.229), and 25.5% (83/326) in female vs. 27.2% (194/712) in male participants (p = 0.546).
Figure 4 presents the rates of suboptimal BP stratified by sex and frailty status. Among 326 female participants, the frail had a significantly higher rate of suboptimal BP (39/115, 33.9%) compared to the non-frail (44/211, 20.9%), p = 0.010. Among 712 male participants, there was no significant differences in suboptimal BP rates between the frail (48/182, 26.4%) and the non-frail (146/530, 27.5%), p = 0.759.
Fig. 4.
The percentages of participants with blood pressure ≥ 140/90 mmHg by sex and frailty status (CFS ≥ 4 vs. CFS < 4).
In the various adjusted logistic regression models presented in Table 3, , there was a consistent trend of increased odds of frailty on suboptimal BP control in female compared to male participants. In the model adjusted for age, education, marital status, physical exercise, falls, coronary heart disease, diabetes, chronic kidney disease, osteoarthritis, heart failure, stroke, atrial fibrillation, osteoporosis, chronic obstructive pulmonary disease, duration of hypertension, monotherapy/combination therapy, and MARS score, the odds ratios of frailty on suboptimal BP were 2.01 (95% CI 1.08–3.76) in female, 0.92 (95% CI 0.59–1.44) in male, female-to-male ratio of odds ratios 2.18 (95% CI 1.01–4.70).
Table 3.
Associations between frailty and suboptimal blood pressure.
| Odds ratios (95% confidence interval) | Ratio of odds ratios (95% confidence interval) | ||
|---|---|---|---|
| Female participants | Male participants | Female: male | |
| Unadjusted | 1.95 (1.17–3.24) | 0.94 (0.64–1.38) | 2.07 (1.10–3.93) |
| Adjusted for age | 1.82 (1.03–3.21) | 0.99 (0.65–1.50) | 1.84 (0.91–3.72) |
| Adjusted for socio-demographic variables (education, marital status) | 1.98 (1.17–3.33) | 0.95 (0.65–1.39) | 2.08 (1.09–3.98) |
| Adjusted for lifestyles and comorbidities (physical exercise, falls, coronary heart disease, diabetes, chronic kidney disease, osteoarthritis, heart failure, stroke, atrial fibrillation, osteoporosis, COPD) | 2.30 (1.33–3.99) | 0.90 (0.60–1.36) | 2.56 (1.29–5.07) |
| Adjusted for duration of hypertension, monotherapy/combination therapy, and adherence (MARS score) | 1.77 (1.03–3.02) | 0.89 (0.60–1.32) | 1.99 (1.02–3.87) |
| Fully adjusted (age, education, marital status, physical exercise, falls, coronary heart disease, diabetes, chronic kidney disease, osteoarthritis, heart failure, stroke, atrial fibrillation, osteoporosis, COPD, duration of hypertension, monotherapy/combination therapy, and MARS score) | 2.01 (1.08–3.76) | 0.92 (0.59–1.44) | 2.18 (1.01–4.70) |
| Fully adjusted model without medication adherence | 2.11 (1.14–3.90) | 0.94 (0.60–1.45) | 2.24 (1.05–4.70) |
COPD: Chronic obstructive pulmonary disease; MARS: Medication Adherence Rating Scale.
Discussion
In this study in participants with hypertension, we found that frailty was present in 28.6% of the participants and female participants had a significantly higher prevalence of frailty than male participants. Frailty was associated with an increased risk of having uncontrolled BP in women, with the effect being twice as strong in female compared to male participants.
Frailty is a common condition in older adults with cardiovascular disease and is associated with various adverse health outcomes.34,35 For older adults with hypertension, there is a greater risk of developing frailty which can impact overall care.35 The prevalence of frailty in our study population is similar to other studies in Vietnam in older adults with type 2 diabetes and coronary heart disease.9,14 However, there is limited evidence on sex differences in frailty in Vietnam. In a study of 638 older patients with diabetes (median age 71 years) attending outpatient clinics in Vietnam during 2019–2020, the prevalence of frailty defined by Fried’s frailty phenotype was 28.2% and there was no significant difference in frailty prevalence among women and men (29.9% vs. 26.8%, respectively, p = 0.388). Differences in frailty definitions may explain this discrepancy.
There have been many studies on the prevalence of frailty in older people with hypertension, but limited studies have evaluated blood pressure control in older adults with frailty.35,36 Our findings are in line with a study on the association between frailty and hypertension treatment in Korea.36 In a study of 4352 older Koreans (mean age 72.6 years, SD 5.4), the proportion of participants with uncontrolled BP was higher in the frail (20%) compared to those who were prefrail (18%) and non-frail (15%), p = 0.005.36
In our study, female participants with frailty had the highest rate of suboptimal hypertension. Frailty may have a greater impact on poor control of hypertension in women than in men due to reasons specific to gender, rather than sex.37 Unfortunately, the available data precludes separation of sex and gender, so we have restricted to labels used in data collection. When comparing male and female participants in our study, we found that female participants were less likely to have higher education (31.0% of female vs. 48.9% of male). The influence of educational background warrants further examination, particularly regarding its impact on health literacy, awareness of hypertension and medication adherence. The female participants in our study were also less likely to take part in regular exercise (27.9% vs. 58.6% in men). While frailty can contribute to more sedentary lifestyles, the significant differences between women and men indicate a potential area for further investigation. Other comorbidities such as osteoporosis and falls can also impact the treatment of hypertension. In our study, the prevalence of falls and osteoporosis was higher in female participants compared to men. Since low blood pressure can sometimes increase the risk of falls and fracture, it is possible that physicians preferred higher BP targets for women to help manage this risk. In addition, sex differences in pharmacokinetics and pharmacodynamics can affect the efficacy of antihypertensive medications.39,40 For example, subgroup analysis by sex from the ACCOMPLISH (Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension) trial, showed that compared to benazepril-hydrochlorothiazide combination, benazepril-amlodipine combination significantly reduced the primary outcome of cardiovascular events and cardiovascular death for men but not women (hazard ratios were 0.83, 95%CI 0.68–1.01, p = 0.06 in women vs. 0.80, 95%CI 0.69–0.91 in men, p = 0.001)41.
Implications
These findings support further investigation into whether frailty screening and tailored interventions may improve BP control, particularly among older women. Given the significance of sex differences on frailty and BP control, personalized treatment strategies should be explored when designing future strategies for improving BP management in the older population. A one-size-fits-all approach to hypertension management may not be effective because of the heterogeneity of this population. With the prefrail category (CFS 3) being the most common frailty category in both female and male participants in our study, it suggests that older adults with hypertension should be routinely screened for frailty to enable early detection of frailty. Timely intervention can help prevent the progression of frailty and its adverse effects on BP control, especially in older women.
Strengths and limitations
To the best of our knowledge, this is the first study examining sex differences in how frailty may affect BP control in older adults with hypertension. Our study provides important insights into the relationship between sex differences, frailty and BP control in older adults with hypertension. Despite the strength, there are potential limitations to consider. Because frailty was assessed at a single time point while BP control was determined using retrospectively collected clinical BP data, the temporal relationship between frailty and BP control could not be established, and causal inferences should be avoided. Blood pressure data were derived from routinely collected outpatient clinical records rather than from a fully standardized research measurement protocol. Variability in the number of clinic visits, measurement procedures, and devices used across routine clinical practice may have influenced BP classification. The smaller number of female participants may have reduced the precision of some subgroup analyses, which could partly explain the wider confidence intervals in this group . We did not collect data on socioeconomic status or nutrition intake, factors that may serve as potential confounders for the relationship between frailty and BP control. Future studies would benefit from including these parameters to provide a more comprehensive analysis and to enhance the robustness of the findings. Previous studies in adults with cardiovascular diseases in Vietnam reported that women had lower income compared to men.42,43 This disparity may lead to reduced access to healthcare and antihypertensive medications for women. Women may have caregiving roles, which might have limited their ability to engage in activities that promote physical activities and self-care. Furthermore, sex differences related to dietary intakes were not assessed in our study. In a study in 2203 community-dwelling adults in Vietnam, the authors found a stronger association between salt intake and hypertension in women compared to men.44 Since participants were recruited from hospital-based outpatient clinics, the study population may not be representative of community-dwelling older adults with hypertension in Vietnam. The high prevalence of multimorbidity, polypharmacy, and cardiovascular comorbidities suggests that the findings are most applicable to clinically complex older adults receiving specialist outpatient care. Therefore, selection bias and limited external generalizability should be considered when interpreting the findings. Finally, since the data collected in our study was tied to clinical care, future research involving laboratory data could deepen our understanding on sex differences in the impact of frailty on health outcomes in older adults. This knowledge could also aid in developing future care strategies that are sex-specific.
Conclusion
In this study in older adults with hypertension, frailty was more common in female participants and was associated with an increased odds of having suboptimal BP among female participants alone. This study contributes to the understanding of how frailty and sex influence BP control in older adults with hypertension, and informs the development of targeted interventions to improve health outcomes for this population. These findings highlight the need for sex-specific approaches in managing BP in older populations. Future studies in Vietnam should also examine sex differences in the impact of BP control on cardiovascular outcomes in older adults.
Author contributions
TVN and TNN conceived the study. TVN and VTN designed the study protocol, led the ethics application and conducted recruitment. TNN conducted the statistical analyses. TVN and TNN wrote the manuscript. All authors were involved in data interpretation. The manuscript was revised for important scientific content by all authors. All authors approved the final version of the manuscript.
Funding
This paper was funded by the University of Medicine and Pharmacy at Ho Chi Minh City under Contract No. 003-NNC/2026/HÐ-ÐHYD, signed on January 30, 2026, in support of the Comprehensive Geriatrics and Older Adults Leading Research Group (Code: 003.TCM2026).
Data availability
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
Declarations
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.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.