Abstract
Objective:
We examined the effects of the family communication environment (conversation orientation) on adult child caregivers' burden and clinical interactions and if the effects are mediated by openness to communicate about cancer, avoidant cancer communication, and social support (SS).
Method:
Caregivers of a parent diagnosed with a blood cancer (N = 121) completed an online survey of validated measures of conversation orientation (i.e., the extent to which families openly communicate), SS, cancer openness, avoidance, caregiver burden, clinical communication skills, and quality of clinical interactions (QCI).
Results:
Conversation orientation had significant indirect effects on caregiver burden, mediated by SS (β = −0.11, p < 0.001), as well as cancer openness and avoidance (β = −0.07, p < 0.001). Conversation orientation also had significant indirect effects on caregivers' communication skills with a parent’s clinician, mediated by avoidance (β = 0.08, p < 0.01) and SS (β = 0.06, p < 0.001). Finally, conversation orientation had significant indirect effects on caregivers' QCI mediated by avoidance (β = 0.71, p < 0.05).
Conclusions:
Adult child caregivers whose families communicate more openly exhibit less caregiver burden and report better clinical interaction skills and perceived quality of the clinical interaction. Avoidance emerged as a key mediating factor. Caregivers from less open communication environments may benefit from interventions that help them navigate challenging but critical caregiving conversations.
Keywords: blood cancer, cancer, caregiver burden, caregiving, clinical communication, family communication, hematologic malignancy, oncology, openness, social support
1 |. BACKGROUND
Family caregivers face complex care-related tasks and emotions while juggling personal and professional demands,1,2 disrupted family dynamics and roles, varying communication needs, and uncertainty.3,4 Their place in the lifespan can shape the challenges they encounter,3–8 indicating the need for evidence-based interventions tailored to specific family caregiving contexts. Caregivers in midlife face additional challenges as they manage multiple roles9 and relational role shifts that require changes in family structure and responsibilities.4,8,10 Midlife adult children often become the caregiver for parents diagnosed with a blood cancer, given the median age at diagnosis for common types of blood cancer like leukemia and non-Hodgkin lymphoma is 67. These caregivers face extensive challenges regarding their parent’s cancer, including multiple treatments, extended hospitalizations, repeated emergency department visits, and difficult side effects.7,11–13 They may face additional caregiving challenges including moving geographically closer to their parent, becoming the decision maker, coordinating care with other family members, and managing emotional distress related to uncertainty and mortality.4 At the same time, caring for a parent involves a distinct relational role shift given the intergenerational dynamics of this bond that can spark tensions related to control, independence, and identity.4 How members of a family typically communicate with one another likely plays a role in how caregivers adjust to their caregiving load and new roles in both familial and clinical communication contexts.
1.1 |. Examining the family communication environment in caregiving
Families co-create an environment that shapes how they interact.14 The family communication environment (FCE) includes rules that facilitate or constrain interactions and contribute to communication patterns that persist across generations.15 The FCE also informs members' preferences for talking (or not) about certain topics.14 Thus, the FCE influences how families function both day-to-day and when they encounter stressful health-related experiences.
The FCE is shaped in part through members' conversation orientation, which refers to the extent to which families create an environment that encourages unrestrained interactions about a myriad of topics.14 Families with high conversation orientation value the open exchange of ideas, discussion of complex topics (i.e., health challenges), and shared family decision making. Such open communication dynamics are linked with better health outcomes (e.g., relational satisfaction, less depression) whereas avoidance or less openness is linked with unhealthy outcomes (e.g., poorer relational functioning or physical health).16,17 Conversation orientation may shape how caregivers approach blood cancer caregiving, their ability to assist with and coordinate care, and their ability to seek and receive social support (SS).
High conversation orientation is linked with active collection of family health history information18 as well as better relational health between mothers and daughters managing breast cancer.16 Family's conversation orientation represents the family's norms for the breadth, depth, and frequency of their communication, which can facilitate or limit communication specific to cancer caregiver. Regarding caregiving for a parent, the family's conversation orientation can facilitate or limit communication about critical caregiving issues like the parent’s prognosis, distress, and care needs. Avoiding such topics can confound caregivers' ability to help their parent as a co-decision-maker and add to feelings of emotional burden.4,10 Thus, we posit:
Hypothesis 1 (H1) The association between conversation orientation and caregiver burden will be mediated by the family's openness to communicate about cancer and the family's cancer topic avoidance.
The FCE affects families' SS capital and support-seeking behavior.19 For instance, a family's high conversation orientation positively predicts their ability to seek SS.20 Thus, in line with the buffering hypothesis, a family's ability to communicate openly could have a buffering effect by facilitating the exchange of support.21
Caregivers of a parent with a blood cancer have described coping with their burden by delegating caregiving tasks to - and receiving emotional support from - close family.4 However, when adult child caregivers had to ask family for help or felt unsupported, they expressed anger and frustration.4 Caregivers' FCE may predict the SS they receive in their role, which may impact caregiver burden. Thus, we proposed:
H1 The association between conversation orientation and caregiver burden will be mediated by the degree to which the caregiver receives social support.
Additionally, SS has been found to be a significant facilitator of patient participation in medical encounters.22 SS is associated with health information competence, which can improve patient participation in healthcare. Given previous research demonstrating the FCE's association with SS and recent research demonstrating SS's association with clinical involvement and interaction for patients, we pose the following question:
RQ 1 Does conversation orientation exhibit indirect effects via social support on (a) caregiver's clinical communication skills and (b) on caregiver's quality of clinical interactions?
The FCE may also influence how individuals relate to and trust clinicians.23,24 Previous research shows that caregivers who self-identified as “partners” with a patient and reported high conversation orientation had higher self-efficacy communicating with the patient’s physician, providing and collecting information, and verifying information.25 Conversation orientation is also linked with caregivers' comfort and competence talking with clinicians, such as requesting further explanation and sharing their parent’s health information and symptoms.17,26 Thus, conversation orientation may be associated with caregivers' clinical communication skills (CCS) and the quality of their clinical interactions. We predicted:
H3 The association between conversation orientation and caregivers' (a) clinical communication skills and (b) the quality of their clinical interactions will be mediated by the family's cancer topic avoidance.
2 |. METHOD
2.1 |. Participants
Participants were at least 18 years or older and caring for a living parent, stepparent, or parent-in-law with a blood cancer. Parents had to have been diagnosed within the 3 months prior to caregivers' survey start date or in treatment or completed treatment within the past year.
2.2 |. Procedures
Following IRB approval (IRB201902191), we recruited caregivers to complete an online survey between April and September 2020. The study was advertised through emails to The Leukemia & Lymphoma Society's (LLS) constituent database and through a post in its online community website for patients and caregivers. Participants completed eligibility screening questions to ensure they met criteria and gave consent before completing survey measures hosted by Qualtrics. Participants were compensated $25 upon completion.
2.3 |. Measures
We collected caregiver demographic characteristics including age, sex, educational attainment, employment status, number of children, and number of siblings. We also collected demographic variables relevant to the diagnosed relative receiving care, including age and blood cancer type.
2.3.1 |. Independent variable
Conversation orientation.
Conversation orientation was measured using the 6-item validated, short form Revised Family Communication Patterns Instrument.27 Higher scores indicated more family openness about multiple topics. The item, “My [parent with blood cancer] and I often have long, relaxed conversations about nothing in particular” was dropped to improve reliability (α = 0.86, M = 3.92, SD = 0.88).
2.3.2 |. Mediators
Cancer openness.
Participants responded to the 4-item Openness to Communicate about Cancer in the Nuclear Family scale.28 Higher scores indicated more openness to communicate about cancer between the caregiver and their parent. These items formed a reliable scale (α = 0.75, M = 3.12, SD = 0.92).
Avoidance.
Participants responded to the cancer Topic Avoidance scale,29 which was slightly modified for a parent-child relationship. Items were rated on a 5-point scale of (1) strongly disagree to (5) strongly agree. Higher scores indicated more topic avoidance. Scale reliability was good (α = 0.95, M = 2.86, SD = 0.83).
Social support.
Participants responded to the 8-item Functional SS Questionnaire.30 Items were rated on a 5-point scale of (1) Much less than I would like to (5) As much as I would like. Higher scores indicated more perceived SS. These items formed a reliable scale (α = 0.91, M = 3.68, SD = 1.03).
2.3.3 |. Dependent variables
Caregiver burden.
Participants responded to the 12-item Zarit Burden Questionnaire Short Form.31 Items were rated on a 5-point scale of (1) Never to (5) Nearly Always. Higher scores indicated more perceived caregiver burden. Scale reliability was acceptable (α = 0.91, M = 2.65, SD = 0.89).
Clinical communication skills.
Participants responded to the 11-item Patient Report of Communication Behavior,32 which was modified to be caregiver specific. Items were rated on a 5-point scale of (1) Never to (5) Always. Higher scores indicated higher assessment of the caregiver's CCS; the scale was reliable (α = 0.91, M = 4.20, SD = 0.68).
Quality of clinical interactions (QCI).
Participants responded to the 12-item Questionnaire on the Quality of the Physician-Patient Interaction.33 Items were modified to be cancer and caregiver specific and include all types of healthcare providers. Items were rated on a 5-point scale of (1) Strongly disagree to (5) Strongly agree. Higher scores indicated higher quality clinical interactions. Scale reliability was high (α = 0.95, M = 3.99, SD = 0.79).
2.4 |. Statistical analyses
Analyses were conducted using SPSS version 26. Missing data were handled listwise by including only participants with complete data on the primary variables in this analysis. Descriptive statistics were conducted to describe sample characteristics. Correlations among survey measures are in Table 1. A preliminary analysis using linear and multiple regressions was conducted before completing mediation analysis (results available in supplemental file).
TABLE 1.
Correlations among survey measures
| Variable | 1 | 2 | 3 | 4 | 5 | 6 | 7 |
|---|---|---|---|---|---|---|---|
| 1. Conversation orientation | |||||||
| 2. Cancer openness | 0.24** | ||||||
| 3. Avoidance | 0.33*** | −0.67*** | |||||
| 4. Social support | 0.28** | 0.10 | −0.26** | ||||
| 5. Caregiver burden | 0.32*** | −0.44*** | 0.53*** | −0.44*** | |||
| 6. Clinical communication skills | 0.13 | 0.22* | −0.35*** | 0.23* | −0.21* | ||
| 7. Quality of clinical interactions | 0.08 | 0.18 | −0.29** | 0.27** | −0.17 | 0.44*** |
p < 0.05
p < 0.01
p < 0.001.
When conducting the six mediation analyses, we controlled for a variety of factors including caregiver age, parent age, caregivers' number of children, caregivers' number of siblings, employment status, and educational attainment. Although the type of blood cancer diagnosis (e.g., acute, chronic, myeloma) can impact the caregiving experience,3 diagnosis type was not significantly related to the variables included in analysis and, therefore, was not included in analyses.
We used Hayes's PROCESS macro (Models 4 and 6) version 3.5 for SPSS to estimate mediation effects using bootstrapping.34 Bootstrap resampling was set to 5000 times for all analyses. PROCESS estimates model parameters via ordinary least squares regression and provides path coefficients for direct and indirect effects as unstandardized regression coefficients, as well as bootstrapped 95% confidence intervals (CI). If the CIs do not encompass 0, the indirect effect is significant and supports a mediating effect.
3 |. RESULTS
3.1 |. Participant characteristics
In total, 121 adult child caregivers participated. Demographics reported by the 121 caregivers this compares favorably to the caregiver demographics reported by LLS broadly. See Table 2 for characteristics.
TABLE 2.
Adult child caregiver participant demographics
| Age | 20–66 years old (M = 44.37, SD = 11.48) | |
|---|---|---|
| Parent’s age | 48–95 years old (M = 72.10, SD = 10.97) | |
| Diagnosis | Acute form of blood cancer (65.3%) | Myeloma (2.8%) |
| Chronic form of blood cancer (31.9%) | ||
| Caregiver sex | Female (79.3%) | Male (18.9%) |
| Other (1.8%) | ||
| Parent receiving care | Mother (57%) | Father (37.2%) |
| Stepfather (1.7%) | Mother-in-law (2.5%) | |
| Father-in-law (1.7%) | ||
| Parent’s marital status | Married/Domestic partner (49.5%) | Widowed (29.7%) |
| Divorced (17.1%) | Separated (3.6%) | |
| Race | Caucasian (71.9%) | Asian (9.1%) |
| Black/African American (9.1%) | American indian (2.5%) | |
| Native Hawaiian/Pacific islander (1.7%) | ||
| Ethnicity | Hispanic (17.1%) | Not hispanic (82.9%) |
| Education | High school graduate/GED (7.2%) | Some college (10.8%) |
| 2-year degree (8.1%) | 4-year degree (34.2%) | |
| Master’s degree (30.6%) | Professional degree (3.6%) | |
| Doctoral degree (5.4%) | ||
| Employment status | Employed full time (65.8%) | Employed part time (7.2%) |
| Self-employed (5.4%) | Not employed (12.6%) | |
| Retired (9%) | ||
| Relationship status | Married/Domestic partner (51.4%) | Single/Never married (29.7%) |
| Divorced (12.6%) | Widowed (2.7%) | |
| Separated (3.6%) |
Abbreviation: General Education Development.
3.2 |. Indirect effects of conversation orientation on caregiver burden
3.2.1 |. Multiple mediation effect of cancer communication openness and cancer topic avoidance (H1)
We tested a multiple mediator model to examine the connections among conversation orientation, cancer openness, avoidance, and caregiver burden (H1). Conversation orientation had significant positive direct effects on cancer openness and significant, negative effects on avoidance. There were significant indirect effects between conversation orientation and caregiver burden through cancer openness and avoidance (Table 3 and Figure 1). However, cancer openness as a mediator did not have a significant direct effect on caregiver's burden. The total effect of conversation orientation on caregiver burden was negative (β = −0.31, df = 4,105, f = 5.04, p < 0.001). The indirect effects explained 16.1% of the variance in how conversation orientation related to caregiver burden. H1 was supported.
TABLE 3.
Results on direct and indirect effects from mediation models
| Paths | β | SE | 95% CI |
|---|---|---|---|
| Multiple mediating effect of open and avoid (H1) | |||
| Convo→Open | 0.26** | 0.09 | (0.08, 0.44) |
| Convo→Avoid | 0.07* | 0.07 | (−0.31, −0.04) |
| Open→Burden | −0.13 | 0.11 | (−0.35, 0.08) |
| Avoid→Burden | 0.46*** | 0.12 | (0.22, 0.69) |
| Open→Avoid | −0.56** | 0.07 | (−0.70, −0.42) |
| Convo→Burden | −0.31*** | 0.09 | (−0.49, −0.13) |
| Convo→Open→Avoid→Burden | −0.07*** | 0.03 | (−0.14, −0.01) |
| Mediating effect of SS (H2) | |||
| Convo→SS | 0.28** | 0.11 | (0.07, 0.49) |
| SS→Burden | −0.39*** | 0.08 | (−0.54, −0.23) |
| Convo→Burden | −0.31*** | 0.09 | (−0.50, −0.13) |
| Convo→SS→Burden | −0.11*** | 0.06 | (−0.23, −0.01) |
| Mediating effect of SS (RQ1) | |||
| Convo→SS | 0.30** | 0.11 | (0.08, 0.53) |
| SS→CCS | 0.21*** | 0.06 | (0.09, 0.33) |
| Convo→CCS | 0.04 | 0.07 | (−0.10, 0.19) |
| Convo→SS→CCS | 0.06*** | 0.04 | (0.01, 0.14) |
| Mediating effect of avoid (H3a) | |||
| Convo→Avoid | −0.32** | 0.09 | (−0.49, −0.14) |
| Avoid→CCS | −0.26*** | 0.08 | (−0.41, −0.11) |
| Convo→CCS | 0.04 | 0.07 | (−0.10, 0.18) |
| Convo→Avoid→CCS | 0.08** | 0.05 | (0.18, 0.20) |
| Mediating effect of avoid (H3b) | |||
| Convo→Avoid | −0.29* | 0.12 | (−0.52, −0.06) |
| Avoid→QCI | −0.25* | 0.09 | (−0.43, −0.06) |
| Convo→QCI | 0.17 | 0.10 | (−0.03, 0.37) |
| Convo→Avoid→QCI | 0.71* | 0.06 | (0.01, 0.21) |
Note: Controls are age of caregiver, age of the parent with blood cancer, number of children the caregiver reported, and caregiver employment status (omitted from table).
Abbreviations: Avoid, avoidance; Burden, caregiver burden; CCS, clinical communication skills; Convo, conversation orientation; Open, cancer openness; SS, social support; QCI, quality of clinical interactions.
p < 0.05
p < 0.01
p < 0.001.
FIGURE 1.
Multiple mediator model for conversation orientation on caregiver burden. Note. Significant path = →; nonsignificant path = - - -. *p < 0.05, **p < 0.01, ***p < 0.001
3.2.2 |. The mediating effect of social support (H2)
There were significant indirect effects between conversation orientation and caregiver burden through SS (H2) (Table 3). The total effect of conversation orientation on caregiver burden was negative (β = −0.31, df = 4,10, f = 4.27, p < 0.001). The indirect effect explained 17% of the variance in how conversation orientation related to caregiver burden. H2 was supported.
3.3 |. Indirect effects of conversation orientation on caregivers' clinical communication
3.3.1 |. The mediating effect of social support (RQ1)
There were significant indirect effects between conversation orientation and caregivers' CCS with their parent’s doctor through SS (Table 3). Social support had significant direct effects on caregivers' CCS. The total effect of conversation orientation on CCS was positive (β = 0.20, df = 6,76, f = 3.25, p < 0.01). The indirect effects explained 13.4% of the variance in how conversation orientation related to caregiver communication skills.
Finally, there were no significant indirect effects between conversation orientation and QCI through SS (β = 0.04, SE = 0.04, CI = −0.01, −0.13).
3.3.2 |. The mediating effect of cancer topic avoidance (H3)
There were significant indirect effects between conversation orientation and CCS with a parent’s doctor through avoidance (Table 3). The total effect of conversation orientation on CCS was positive (β = 0.04, df = 1,100, F = 3.39, p < 0.01). The indirect effects explained 13.2% of the variance in how conversation orientation related to caregivers' communication skills with their parent’s doctors. H3a was supported.
There were also significant indirect effects between conversation orientation and QCI through avoidance (Table 3). The total effect of conversation orientation on QCI was positive (β = 0.17, df = 4,77, f = 3.05, p < 0.05). The indirect effects explained 14% of the variance in how conversation orientation related to QCI. H3b was supported.
4 |. DISCUSSION
Study findings highlight the importance of understanding caregivers' FCE to better identify their needs at home and in the clinical setting. Adult child caregivers whose family tends to communicate more openly reported less caregiver burden and better clinical interaction skills and perceived quality of the clinical interaction. More open FCEs may cultivate SS and cancer communication openness and may reduce cancer topic avoidance. Adult child caregivers whose family communicates less openly may benefit from tailored, family-centered communication skills intervention and support.
Caregivers from families that have more open communication reported receiving higher levels of SS, which reduced burden. Previous research found that high caregiver satisfaction with perceived SS buffered the effect of caring for an individual with greater functional impairment, which enhanced or maintained cancer caregivers' psychological well-being.35 SS has been found to have a positive effect on patients' and caregivers' self-reported health 12-months post cancer diagnosis.36 Our results may further explain this interdependence—the FCE can foster (or inhibit) SS exchange.19 Cultivating open FCEs can facilitate support exchange, which can buffer caregiver burden.
Findings also showed that participants whose family tended to communicate more openly reported better CCS mediated by SS. A recent study indicated family caregivers with open FCEs had more self-efficacy communicating with physicians about the patient’s needs.25 Previous research found that individuals from families high in conversation orientation were more adaptable and competent communicators, which facilitated their ability and motivation to seek SS.20 Caregivers from families high in conversation orientation might be more socialized (and comfortable) engaging in SS exchanges inside and outside of the family setting, which could promote their perceptions of their CCS.
Not surprisingly, results demonstrate that participants whose family tended to communicate more openly reported more openness and less avoidance when communicating about cancer. Interestingly, cancer topic avoidance was more strongly associated with caregiver's burden than cancer communication openness. Although positive behaviors like communicating openly about cancer can promote relational health,16 potentially negative communication behaviors like avoidance may have detrimental effects.37 Avoiding difficult health-related topics represent lost family support opportunities and inhibit caregivers' ability to provide care, which may heighten burden.10 Increased burden can interfere with effectively caring for a parent, which may impact patients' health.36,38 Caregivers from less open FCEs could benefit from interventions that help them develop skills to initiate challenging but critical caregiving conversations.
Findings on the indirect effects of conversation orientation on caregivers' CCS and quality of clinician interactions expand previous research on the FCE's impact on patient perceptions and outcomes.24 Open FCEs may reduce cancer topic avoidance and promote better clinical communication, which could explain the positive effect of conversation orientation on caregivers' CCS and their perception of the QCI. Open FCE and reduced avoidance may also enhance caregivers' ability to take on the role as a co-decision-maker and support a collaborative approach to managing cancer.39 The ability to adopt a collaborative orientation to cancer is impeded when caregivers avoid cancer-related topics or are physically absent. Moreover, when families use active, problem-focused coping strategies they experience better illness outcomes compared to families engaging in avoidance or conflict.17 The FCE may help explain why some families are better able to take a collaborative care approach and which caregivers need supportive interventions with clinical communication.
4.1 |. Clinical implications
The FCE is an important factor in psycho-oncology and palliative care. Our findings connect caregivers' conversation orientation to burden, communication skills with a parent’s doctor, and QCI. Given the FCE is a relatively stable, pervasive mechanism,14,15 conversation orientation may be used as a screening tool to identify families less likely to communicate openly who may benefit from assistance with navigating critical conversations with clinicians and family members to promote psychosocial coping and health outcomes. Currently, authors are pilot testing an online training for caregivers of a parent with a blood cancer informed by results on the indirect effects of FCE to reduce caregiver burden and improve clinical communication. This training models how caregivers can approach cancer care collaboratively as a co-decision-maker, navigate triadic (i.e., clinician-parent-caregiver) communication, demonstrate healthier family communication approaches to facilitate difficult cancer conversations, and how to seek support.
Clinicians may benefit from understanding the impact of FCE on caregivers' psychosocial and clinical communication outcomes, heightening their awareness of avoidant communication from caregivers and their ability to identify those needing supportive resources. Clinicians can also tailor their communication to more effectively interact with caregivers based on their FCE. Caregivers from less open families may need clinicians to invite their participation by asking questions as they set the agenda, inviting questions about their caregiving role, providing psycho-educational resources, and continuing to check in on their well-being across the cancer trajectory. Furthermore, findings highlight the importance of integrating psychologists and social workers into the clinical setting to assist with healthy communication practice. Appreciating the FCE and its impact on patient-caregiver outcomes can facilitate a family-centered care approach.40
4.2 |. Limitations
Data were collected during the COVID-19 pandemic, which could affect how caregivers report burden, communication behaviors, and perceived QCI. In using survey collection from the perspective of caregivers, results are subject to response bias. Additionally, the sample reported high educational attainment and largely identified as Caucasian and female, which may limit generalizability. Future research should explore the FCE of more diverse family caregivers as ethnicity, race, and gender may have important moderating effects on conversation orientation, burden, and clinical communication. Given the stability of FCE across the lifespan,14,15 a cross-sectional approach was appropriate to explore mediation effects between conversation orientation and caregivers' burden and clinical interactions. However, future research utilizing longitudinal data would be useful to examine the persistent effects of FCE across the cancer and caregiving continuum and inter-generational perspectives within family. Finally, future research should gather reports from multiple family members and analyze actor-partner interdependence effects to further illuminate the interrelationships among the FCE and caregiver and patient psychosocial and health outcomes for intervention development.
5 |. CONCLUSIONS
This study enhances our understanding of the effects of the FCE when caregiving for a parent with a blood cancer. Open FCEs may facilitate open communication about cancer, reduce cancer topic avoidance, and promote SS, which is positively associated with reduced caregiver burden and improved CCS and QCI. Findings can be used to tailor interventions to the FCE to better support caregivers as they aid a parent with a blood cancer.
Supplementary Material
ACKNOWLEDGMENTS
This article is dedicated to the memory of Dr. Geraldine Fennell, whose work articulated the importance of effectively developing and delivering tailored support and information to caregivers, especially to subgroups of caregivers with distinct needs. This study was funded by the Carolan Research Institute and The Leukemia & Lymphoma Society.
Footnotes
SUPPORTING INFORMATION
Additional supporting information may be found in the online version of the article at the publisher's website.
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.
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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
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.