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. 2022 Jul 1:10.1002/nml.21528. Online ahead of print. doi: 10.1002/nml.21528

Opportunities for organizational learning and innovation: A nonprofit case study during COVID‐19 in Hong Kong

Cheryl Hiu‐kwan Chui 1,✉
PMCID: PMC9350085  PMID: 35942274

Abstract

COVID‐19 has created unprecedented challenges and uncertainty for the nonprofit sector. Drawing from a case study of a community‐based service delivery nonprofit organization in Hong Kong, this research note examines the impact of COVID‐19 on this organization's daily operations, identifies its organizational coping strategies in response to the challenges it faced, and outlines key organizational learning resulting from its experience of dealing with the pandemic. With reference to the narrative development process framework, this study found that the customary social service delivery model was inadequate in meeting the emergent needs identified in the community. This realization served as a catalyst for the organization to employ socially innovative coping strategies to continue safeguarding the well‐being of vulnerable population groups. As a result, a new paradigm of service delivery leveraging on neighborhood support networks and cross‐sector collaborations was developed. Factors that would enable nonprofits to enhance their adaptive capacity in the face of future public health crises are discussed, with particular attention drawn to the usefulness of adopting a narrative development process in guiding organizations' collective actions.

Keywords: coping strategies, nonprofit organization, organizational learning, pandemic

1. INTRODUCTION

COVID‐19 has imposed unprecedented social, economic, and psychological costs that transcend geographic boundaries and proliferates across all sectors, organizations, and people worldwide. While public health measures such as border controls continue to take effect, we have also witnessed tremendous efforts by civil society actors to address a wide range of health, material, and psychosocial needs in the community resulting from the global pandemic (United Nations, 2020). As with any disasters, humanitarian and specialized nonprofit organizations (NPOs) have long played critical roles in disaster management, including, in the short term, emergency relief and recovery efforts, health care aid, and psychological support (Libal & Harding, 2011) and, in the medium‐ to longer‐term, post‐disaster reconstruction and rehabilitation efforts (Chui et al., 2014; Gajewski et al., 2010).

While COVID‐19 is not a natural disaster per se, it certainly constitutes a crisis, the novelty of which share similarities with disaster situations. Like other extreme events, especially prolonged disasters (e.g., drought), the pandemic has posed severe shocks to the political, financial, and social landscapes (Bryson, 2011), wherein NPOs have to contend with a highly uncertain external environment and to rapidly learn and adapt to minimize disruption resulting from the pandemic. However, unlike specialized NPOs, most NPOs in economically advanced societies, primarily social service delivery NPOs (SDNPOs), do not have the sets of knowledge, skills, and expertise (the know‐how) required for disaster management (Banks et al., 2020; Ling et al., 2021).

Against this backdrop, public health measures such as temporary closures of SDNPOs and mandatory social distancing have presented NPOs with challenges that bear little resemblance to the types of experiences that have occurred in the past (Kuenzi et al., 2021). These challenges are further exacerbated by rapidly emergent needs in the community; SDNPOs not only have to account for constituents' existing needs, they are also confronted with worsening social conditions such as rising rates of elderly depression (Meng et al., 2020), family violence (Zhang, 2020), and financial insecurity (Wilson et al., 2020) associated with the pandemic.

As with other organizations, how SDNPOs learn from and adapt to this experience carry significant implications on whether they “break down,” survive, or even prosper (Garud et al., 2011). Yet, there is little understanding and corresponding empirical data on how SDNPOs make meaning, learn, and adapt from such external shocks (Banks et al., 2020; Ling et al., 2021). This pilot study asks the following questions: How have SDNPOs been affected by COVID‐19? What coping strategies have been employed by SDNPOs to cope with these challenges? What organizational learning has taken place to better prepare for future crises?

Building upon the narrative development process framework proposed by Garud et al. (2011) within organizational learning literature, this research note addresses these questions by drawing on an SDNPO case study comprising both observational data and preliminary qualitative interviews (n = 7) in Hong Kong. Findings contribute to existing nonprofit studies by shedding light on the role SDNPOs play in safeguarding the well‐being of vulnerable population groups in the context of public health crises, and how organizational learning can take place amidst crises.

2. ORGANIZATIONAL LEARNING IN NONPROFITS AMIDST UNCERTAINTY

Existing organizational studies have often pinpointed “external shocks” or crises as the impetus for organizational learning and adaptation. Yet, external shocks may also debilitate an organization. Thus, an important question to ask is: why do some NPOs manage to adapt more effectively in times of crisis while others do not? As scholars argue, organizational learning takes place cumulatively (Argote & Miron‐Spektor, 2011; Bapuji & Crossan, 2004; Levitt & March, 1988). Knowledge is built upon previous experiences dealing with a particular phenomenon that in turn informs and shapes subsequent similar, well‐recognized, and recurring situations (Bowker & Star, 1999). Theoretically, under “normal circumstances,” implementing appropriate solutions and deploying critical resources including physical artifacts (e.g., equipment), work processes (e.g., standard operating protocols), and people (e.g., expertise) should become ever‐more efficient as organizations accumulate their experiences (Garud et al., 2011). But how can organizational adaptation and appropriate response be actualized when there is little prior knowledge or experiences that an organization can draw on?

To this end, Garud et al. (2011) offered a framework for organizational learning that describes the nature of learning when organizations are confronted with “unusual experiences,” and argue that a reflective, generative approach—alluding to the imperative to generate new solutions via constant organizational reflection— leading to novel solutions must take place in lieu of implementing responses informed by “predetermined templates.” Adapting from Riessman's (1993) narrative development process, Garud and associates (2011) further expanded this organizational learning process to explain how organizational actors confer shared meaning on these usual experiences that eventually lead to collective actions and novel solutions. This process involves people to “(a) attend to experiences, (b) tell others about these experiences, (c) transcribe these experiences into texts, (d) analyse these texts to clarify what may be learned; and (e) have others read these texts across culture and time” (p. 591). Expanding this original framework, Garud and associates further proposed (f) generating action, and (g) sustaining organizational learning to illustrate how organizations are able to leverage on their experiences to enhance their resilience and capacities.

Distinct from other scholars in organizational learning (Spector & Davidsen, 2006) that purport the progressive, “scientific” approach that builds knowledge upon prior known categories of knowledge, the narrative development process seeks to preserve rich contextual details to “assess the plausibility of an emerging explanation as the unusual event unfolds overtime” rather than building on previous known experiences or prior “knowledge templates” (Garud et al., 2011, p. 597). This framework allows for organizational actors to interpret and come to shared meanings of understanding pertinent to the unusual event rather than assessing the situations with objective indicators and measurements (Garud et al., 2011).

The narrative development process is particularly useful in examining organizational learning in novel situations, where no comparable prior experiences can shed light on how organizations can respond. However, no prior empirical studies have applied this framework to examine how NPOs responded to COVID‐19, which arguably is in itself a very unusual experience. Thus, situating the current study in the context of COVID‐19, I draw on Garud and associates' conceptual framework to illustrate how organizational learning and adaptation take place within an SDNPO in a way that addresses the emergent needs of the community and imbues the organization with better adaptive capacity, defined here as the social and technical skills and strategies of groups that are directed toward responding to environmental and socioeconomic changes.

3. STUDY CONTEXT: HONG KONG

With a population of over 7 million people living in an area of approximately 1100 km2, Hong Kong is one of the densest cities in the world. The city borders Mainland China, where COVID‐19 outbreak first occurred. SDNPOs in Hong Kong have long collaborated closely with the government to respond to the social needs of society and provide over 90% of social welfare services in Hong Kong (Jordan et al., 2020). Typically, Hong Kong's social service delivery model is center‐based and heavily professionally driven; welfare service users are typically seen as passive recipients of welfare (Cheng et al., 2013).

With regards to the COVID‐19 outbreak, Hong Kong reported its first two confirmed cases on January 22, 2020 (Cheung, 2020). By 28 January, the Hong Kong government announced that apart from residential care services (e.g., nursing homes), all center‐based and subsidized welfare services (SDNPOs) were to be suspended or significantly limited until further notice (Social Welfare Department, 2020). However, Hong Kong did not implement a total lockdown, although residents were strongly encouraged to stay home (Lum et al., 2020). While prudent public health measures were necessary to contain the spread of the virus, they rendered the traditional service delivery model almost dysfunctional. Thus, a dilemma arose: SDNPOs not only had to somehow ensure service continuity for existing beneficiaries but also had to contend with growing demands arising from the psychosocial and material challenges resulting from COVID‐19. The question was how these challenges could be met under Hong Kong's stringent public health containment measures.

4. METHODS

This research used an exploratory case study approach (Yin, 2014) to address its three research questions. Given the research agenda, which is to explore what the response strategies were and how they came about, adopting an exploratory approach, the purpose of which is to further elaborate and explicate theoretical constructs, is appropriate. A community center, “NPO A” (a de facto SDNPO), 1 located in Hong Kong was purposefully selected due to its visibility during the COVID‐19 pandemic. NPO A has 27 full‐time staff and two project‐based staff. During the pandemic, it delivered material goods and services to approximately 800 households and also began several innovative projects in response to emergent needs. Its efforts were regularly reported on the news and on social media, which highlighted its innovativeness and impact during the pandemic (see for example: https://www.ln.edu.hk/lei/project-ultra-violite/).

As part of the case study, daily reports and announcements on the center's website were collected. This was supplemented by observational data, which were collected by the author during five site visits amidst the pandemic. In addition, the author also sat in NPO A's regular staff meetings thrice; during such time, she had taken extensive notes to document the process of the meetings. Dialogues between staff regarding personal reflections, “lessons learned,” idea generation, and formulation of response strategies were particularly highlighted. Furthermore, in‐depth interviews were conducted with social work supervisors and social workers (n = 7) who worked for NPO A. Informed by the narrative development process framework, interview questions revolved around COVID‐19 and its impact on NPO A, its corresponding organizational response strategies, and its organizational learning. Questions included: “How has COVID‐19 affected your organization?” “What have been the biggest challenges to your organization?” “How did your organization respond to these challenges?” “How did you make sense and meaning of the experience?” “How did you decide what collective action to take?” “What are the key lessons learned from this experience?” All data were collected between March and June 2020.

Interviews were audiotaped and transcribed verbatim. Data were analyzed using thematic analysis (Braun & Clarke, 2012). The analysis involved several steps. First, the author familiarized herself with the data and read the transcripts several times over. Words and phrases relevant to the three research questions were then highlighted to create an emergent coding framework where the remaining transcripts were coded accordingly and subsequently classified into different categories. Classifications of codes were made in reference to the key theoretical constructs within the narrative development process framework, and subsequently further sorted into emergent themes. For instance, one participant commented that “It became clear shortly after the outbreak that the way we normally do things, like simply expecting people to come to our center [for services],…was no longer an option…something else had to be done….” This quote was then categorized as “unusual experience” as an important emergent theme as purported by the narrative development framework. The same coding process was applied to the rest of the data. The last step involved a further distillation of the emergent themes and concepts in order to encapsulate their meanings. The emergent themes were (re)presented to participants in order to ensure data reliability.

Document materials obtained from websites were tallied in terms of frequency and analyzed using qualitative content analysis (Hsieh & Shannon, 2005). Texts that involved the words “pandemic” and/or “COVID‐19” were first identified, after which the posts or announcements were reviewed, and openly coded pertinent to the research objectives (e.g., “what coping strategies have been employed?”). These codes were further categorized and refined into meaningful themes substantiated by qualitative interviews.

This study was approved by the Human Research Ethics Committee of the University of Hong Kong.

5. RESULTS

5.1. Theme 1. Confronting an “unusual experience”: A disruptor to existing service delivery model

COVID‐19 constituted an unusual experience and created unprecedented organizational challenges for NPO A. Like any disaster or crisis situation, COVID‐19 affected the Hong Kong community unevenly. By mid‐February, there was a severe city‐wide shortage of personal protective equipment (PPE), such as masks, hand sanitizers, and other relevant products (Ng, 2020). Ordinary residents in Hong Kong queued up for hours to purchase PPE from local pharmacies, which hiked up product prices. Yet, the ability of low‐income families and/or other vulnerable population groups, such as older adults and people with disabilities, to purchase these products was comparatively much lower, rendering them at a significantly higher risk of infections and further exacerbating existing inequalities. Thus, it was evident that as the outbreak progressed, there were growing material and psychosocial needs within the community. Yet, participants recognized that NPO A's own organizational capacity to cope with these challenges in a timely manner was very much limited given its constrained manpower and financial resources.

We immediately knew that there was a lot of inequality in the community… but we have limited manpower and resources like PPE supplies to meet all the needs of those in need. We were really stretching ourselves very thin…

Ordinarily, NPO A relies primarily on face‐to‐face contact to deliver its services, with social workers typically assuming the role of service providers, and clients as passive service users or recipients. COVID‐19 constituted an overwhelming and unprecedented external shock that completely disrupted this service delivery model given the containment measures. The actual physical location of NPO A that had for years been used as a key location for casework, group activities, and other social services could no longer be used. Yet, just because the physical location of the NPO A was closed, the needs of constituents were still very much present. As one participant recounted:

It became clear shortly after the outbreak that the way we normally do things, like simply expecting people to come to our center [for services],…was no longer an option…something else had to be done…I've never experienced anything like that in terms of scale and urgency…there was no protocol since not one of us have experienced this before.

There was no pre‐existing template that can inform NPO A's response strategy. The very modus operandi of NPO A was challenged. There was no pre‐existing template that can inform NPO A's response strategy.

5.2. Theme 2. Meaning‐making for collective action

By June 2020, COVID‐19 was largely contained in Hong Kong. COVID‐19 was and is nevertheless an overwhelming challenge to and disruptor of the traditional service delivery model. Yet, it is under this context where organizational learning occurred. Tsoukas and Hatch (2001) argue that under unusual circumstances, organizational actors must not only find ways to identify and make sense of these experiences but also to imbue them with meaning. This is akin to the “meaning‐making” necessary for collective action proposed by Garud and associates (2011). Echoing this notion, participants recounted how COVID‐19 had forced them to respond differently using innovative ways, which in turn had enhanced NPO A's adaptive capacity in face of future crises.

Internally, participants held weekly reflecting meetings with their staff to document key barriers and success factors in implementing their various services in response to the pandemic. It consciously adopted a “learning by doing approach,” brainstormed coping strategies, made extensive notes that were regularly revisited by center staff (Riessman, 1993), consolidated key lessons learned from their response to the pandemic, and ultimately created a crisis protocol (e.g., mobilizing emergency response networks) and training material for existing and new staff of NPO A to prepare them for future public health crises. One participant noted that the entire experience had been like a “capacity building process for [himself] and his staff in crisis management” and that, interestingly, “the experience of having to fight the virus as an organization had brought many of [his] staff closer together, akin to a team‐building experience.”

5.3. Theme 2.1. Mobilizing neighborhood social networks and technology

As observed by the author during staff meetings, it was evident that a marked departure from the traditional service delivery model had taken place. Despite the suspension of all center‐based services and activities, staff from NPO A continued to deliver its services by first, identifying key overlooked segments in society where neither the market or policies (government) are able to attend to; and second, by recalibrating its existing service model: departing from a center‐based, professionally driven model to one that mobilizes neigbhorhood social networks using technology. One participant recounted that NPO A “completely restructured [their] service delivery model, especially [their] services for older adults.”

Previously, older adults would go to NPO A to receive services or join activities. However, since February, NPO A assigned these older adults into three groups based on their location of residence and designated a social worker to manage each group. However, obviously, none of the social workers was able to cope with the needs of all older adults. As a result, a WhatsApp group was created for each of the three groups, and each social worker elicited volunteers from among their group to help carry out some of the services, such as the distribution of PPE materials. Young‐olds within the group were paired with several old‐olds to help respond to the needs of older adults (e.g., distribute PPE to homebound older adults). As indicated by participants, prior to COVID‐19, such mobilization of neighborhood support networks as an organizational coping strategy had never been done on such a scale, and thus constituted a novel service delivery approach:

Previously, our services were much more professionally or worker driven…[D]uring COVID‐19, it can be said that we co‐developed a collective response model that relies on community resources more ‐ I mean the older adults themselves.

Furthermore, content analysis revealed that NPO A utilized technology such as Zoom to continue providing counseling services and workshops online. To enhance the health literacy of the community, a series of educational videos was made and posted on social media platforms for the public's perusal. During the data collection period, NPO A had posted a total of 31 community engagement notifications. These include not only provisions of emergency services such as PPE distributions in neighbhorhoods, but also requests for neighborhood volunteers to participate in various pandemic‐related volunteering activities.

5.4. Theme 2.2. Leveraging cross‐sector expertise to cocreate solutions

Leveraging cross‐sector collaborations constituted another major organizational coping strategy. Recognizing their own limitations in terms of organizational capacity, NPO A proactively reached out to stakeholders in different sectors to cocreate and implement solutions. NPO A partnered up with the private sector and universities to implement a series of projects in response to the different needs arising from the pandemic. For example, given that families in sub‐divided units 2 were highly susceptible to infection, NPO A quickly collaborated with engineers, corporations, and private funders to install ultraviolet lights in SDUs to conduct weekly disinfectant services, combining both technology and expertise from different fields for the provision of public goods (Chui & Ko, 2021). NPO A also collaborated with an IT company to provide online learning for children. Interestingly, participants contended that such depth of cross‐sector collaboration, and the speed to which they were established, was unprecedented and was the result of the pandemic situation. Compared with the “pre‐COVID era,” such cross‐sector collaborations were limited at best. One participant explained:

Ironically, this pandemic allowed us to grow our cross‐sector networks and collaborations. We had always wanted to do that but were pulled in many different directions. Many corporates actually wanted to do something for the community during the pandemic but didn't know where to turn to. We recognized this opportunity and took advantage of it for sure…I can foresee many more collaborative opportunities in the future.

Furthermore, participants shared that another key lesson learned was the importance of ensuring income diversification and maintaining healthy fiscal reserves. Participants recounted how despite being a subvented organization, their usual fee‐for‐service activities and projects had enabled them to garner healthy fiscal reserves. It is also noteworthy that the government did not allocate any additional funding for NPOs during the initial months of the outbreak. This indicates that diversification of income and having sufficient capital for emergency purposes enabled NPO A to exercise more flexibility and adaptability in times of crisis:

This experience really highlights how important it is to have a healthy reserve…to hedge ourselves in times of crisis. If we had just relied on the government's subsidies, we wouldn't have been able to do anything since everything was already tied up to existing services.

In many ways, COVID‐19 served as a catalyst and an opportunity for accelerated organizational learning and the establishment of corresponding organizational coping strategies.

5.5. Theme 3. Sustaining organizational learning: Establishing a crisis protocol

Garud and associates supplemented the narrative development process framework by highlighting the imperatives of action generation, and sustained organizational learning to illustrate how organizations are able to leverage on their experiences to enhance their resilience. In the context of this study, sustained organizational learning was crystallized when NPO A, through their weekly staff reflections, consolidated key lessons learned resulting from COVID‐19 and established a crisis protocol in the face of future public health challenges. The protocol marks the first step toward forming a “knowledge template” from which NPO A can draw on in face of similar crises in the future.

5.6. Theme 3.1. Embedding permanent changes: A paradigm shift

As espoused by participants, COVID‐19 had taught NPO A that neighborhood support networks are a critical resource in crisis management. Participants indicated that it was evident that further collaborations with community networks were imperative and that (over)reliance on the center‐based service delivery model (the traditional model) may hamper its ability to respond effectively to the multidimensional needs in the community in future public health crises. Certainly, center‐based service delivery is still very much needed. However, SDNPOs should at the same time identify, mobilize, and strengthen existing community resources (e.g., active citizen engagement) to better prepare itself for future crises. That NPO A was able to learn how to “restructure its entire older adult service” during this crisis is indicative of substantial organizational learning. As one participant recounted, neighborhood support networks were very much at the periphery and were not conceived as part of the “solution” or service delivery. This realization led another participant to remark:

As an organization, we really learned that previously we had underutilized and underestimated the power of community networks. I really had to rethink our whole service model…which was not sustainable or functional during the pandemic.

NPO A had since embedded its neighborhood support network as part of its core service delivery model.

6. DISCUSSION

This research note drew on the narrative development process as a basis framework to examine how an NPO responded to the challenges incurred by the pandemic despite having to operate under resource constraints and having no prior knowledge and experience managing large‐scale public health crises. Several additional insights can be generated from this pilot study.

First, echoing existing studies (Dierkes et al., 2001; Herrero & Kraemer, 2022), the findings of this study indicate that external shocks can serve as an impetus and opportunity for actualizing organizational learning. Arguably, NPO A was able to demonstrate its reflective, generative approach—an underlying premise of the narrative development process (Garud et al., 2011)—in the face of emergent challenges in the community, which had ultimately led them to enhance its adaptive capacity by implementing novel solutions collectively (Strichman et al., 2007). Primarily, it realized that its existing service delivery model, which had for a long time been worker and professionally driven and center‐based, was insufficient in responding to public health crises. Thus, it revamped its service model by mobilizing existing community assets (e.g., neighborhood networks) as critical service partners.

Second, and relatedly, despite being only one organization with limited resources, NPO A was able to consolidate key lessons learned from the pandemic, including the importance of having a healthy fiscal reserve accrued through its various income streams (Hung & Hager, 2018), and harnessing cross‐sector collaborations (Shier & Handy, 2016) to deliver novel services. These collaborations engendered socially innovative projects that would not have been possible had NPO A been working alone. This finding carries important practice implications for other nonprofits in cultivating continuous engagement and collaborations with other stakeholders in the community, including but not limited to service constituents (among whom nonprofits can mobilize as service partners), the private sector, and local governments. Doing so appears to enable organizations to respond to such crises more effectively.

Third, by consciously reflecting upon the lessons learned during the pandemic among its staff, NPO A had “grown” and enhanced its adaptive capacity, as evidenced by their creation of a crisis protocol. As Garud and associates (2011) argued, conventional organizational learning can be supplemented and enriched by consciously drawing lessons from “unusual experiences” that fall outside of known categories or experiences. In this light, the narrative development framework is a useful tool to analyze organizational learning resulting from unusual experiences. Other nonprofits may consider adapting this reflective process in order to optimize lessons learned during unusual experiences, which in turn can be turned into organizational practices via establishing protocols in such a way that enhances their resilience in the face of future crises.

This study is not without its limitations. Only one SDNPO was included due to feasibility issues and the urgency of the pandemic, and thus the findings may not be generalizable to other SDNPOs. Future studies may consider using a comparative case study approach to examine how different organizational coping strategies and subsequent organizational took place, and whether various approaches may be linked to varying levels of innovation conducive to organizational growth. Nevertheless, this case study demonstrates that despite being an SDNPO without prior training on disaster management, NPO A was able to adopt a flexible and innovative approach to tackling and addressing a range of community needs. Future nonprofit studies could examine how these novel approaches may potentially develop into longer‐term sustainable service models. Nevertheless, the findings generated from this study are relevant to other SDNPOs struggling to cope with COVID‐19 and its associated challenges.

To conclude, this research note highlighted the various organizational challenges posed by COVID‐19. In particular, I highlight how despite having to contend with a highly uncertain environment and despite having no prior training on disaster preparedness, SDNPOs are able to employ a series of innovative organizational coping strategies to continue safeguarding the vulnerable in the community. In the case of NPO A, significant organizational learning and subsequent growth also took place. The lessons learned amidst this pandemic will enhance its adaptive capacity to respond to crises in the future.

CONFLICT OF INTEREST

There is no conflict of interest.

ACKNOWLEDGMENTS

I thank the community‐based nonprofit organization for their participation in this study.

Biography

Dr Chui's research examines the role of civil society actors including nonprofits, social enterprises, social businesses and other hybrid organizations in facilitating positive change at the individual, community, and policy levels. Her works on nonprofit management, social innovation and entrepreneurship, community development, and age‐friendly cities have been extensively published in peer reviewed journals. More recently, she is leading several projects investigating the interface between social entrepreneurship and inclusion of people with differences. As both a researcher and a registered social worker, Dr Chui advocates for cross‐sector, socially innovative, and community‐based solutions in face of increasingly complex societal challenges.

Chui, C. H. (2022). Opportunities for organizational learning and innovation: A nonprofit case study during COVID‐19 in Hong Kong. Nonprofit Management and Leadership, 1–12. 10.1002/nml.21528

Endnotes

1

The community center, referred to as NPO A to ensure confidentiality, provides a large range of social services to the local community, including child care services, services for older adults, ad hoc programmes and services for students with learning disabilities and ethnic minorities, outreach programmes for youths, and community development projects.

2

Subdivided units are existing flats (apartments) that have been (often illegally) divided into two or more separate units to rent. The median per capita floor area in such SDUs is only 5.3 square meters (Legislative Council Secretariat, 2018). SDUs compromise and violate many building safety and hygiene standards.

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.

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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