Digital Transformation and Sustainable Healthcare: Exploring Cancer Patients’ Interaction with Health Applications Open Access

Globally, the number of new cancer cases is projected to rise by approximately 50% over the next two decades [1]. In Saudi Arabia (SA), both cancer incidence and related mortality have shown significant increases from 1990 to 2016 [2]. New cases are expected to escalate from 27,885 in 2020 to 60,429 by 2040 [3]. In addition to the rise in incidence and mortality, healthcare expenditures for cancer care are increasing rapidly, with costs significantly higher than those for non-cancer patients [4]. Compounding these challenges, the healthcare system faces ongoing overuse and misuse of medical resources in cancer treatment [5].

A sustainable healthcare system delivers high-quality health services that are environmentally, socially, and economically responsible. The term “digital transformation” (DT) refers to technological advancements in digital media that improve society and the healthcare sector. Healthcare systems must utilize digital technology to find innovative solutions to medical issues and enhance healthcare delivery [6]. In this context, SA’s Vision 2030 focuses on healthcare sustainability by promoting DT through initiatives like the “Health Sector Transformation Program,” aimed at building an efficient and modern healthcare system [7].

According to a prior study, telemedicine and eHealth can serve as practical, safe, flexible, efficient, and environmentally friendly methods for delivering clinical care during medical emergencies [8]. DT, through health applications (apps), promises sustainability in healthcare. Particularly during the COVID-19 pandemic, health apps assisted patients in communicating with physicians and facilitated the provision of medical services [9]. Telemedicine plays a vital role in advancing sustainable healthcare by minimizing carbon emissions linked to travel and lowering costs associated with hospital visits. Economically, it also reduces the expenses related to medical equipment required for in-person appointments [10, 11].

Since the start of the COVID-19 pandemic, many individuals with cancer have turned to telemedicine for consultations with their doctors. A recent study suggests that, compared to in-person visits, telemedicine can save cancer patients’ time, travel, and money, making it an increasingly viable option for managing their care [12].

A systematic literature review revealed that digital health plays a vital role in supporting cancer patients through continuous care and outpatient treatment. The review found that health information technologies, such as telemedicine and mobile health applications, empower patients by enhancing communication with healthcare providers, fostering support networks, and improving access to health information. These tools effectively manage side effects and promote medication adherence, ultimately reducing disparities in cancer care and strengthening the patient-provider relationship [13].

Furthermore, another study indicated that for psychological follow-up, telephone interventions or tele-visits are convenient for patients, their families, and healthcare providers, as they help alleviate distress and anxiety while encouraging proactive behavior. This highlights the significance of telemedicine not only in physical healthcare but also in addressing the psychological needs of cancer patients [14].

A notable example of a successful telemedicine application in oncology care is the use of real-time video technology to improve access for rural populations. Initially investigated by Doolittle and colleagues at the University of Kansas Medical Center, this approach connected rural sites to oncology specialists remotely, eliminating the need for oncologists to travel. The study demonstrated both clinical and cost-effectiveness, with subsequent research confirming high patient satisfaction, improved access to cancer services, and enhanced cost efficiency, making it a sustainable solution for underserved areas [15].

However, limited research has been conducted regarding the utilization of telemedicine in relation to patients’ perspectives, emotions, and patient-physician communication in routine oncology practice, especially in SA [16]. Addressing this research objective is crucial because, while telemedicine has the potential to improve healthcare sustainability, it is important not to implement it blindly among sensitive patient groups, such as cancer patients. Therefore, we aimed to investigate how cancer patients maintained vital health-related communication during the COVID-19 pandemic and the role of health-related apps in order to facilitate the safe implementation of telemedicine for cancer patients in SA, aiming to address the challenges that cancer care presents to the development of a sustainable healthcare system.

This is a qualitative study conducted between June 2021 and August 2022, following ethical approval from the Institutional Review Board (IRB). A qualitative methodology was chosen to facilitate an in-depth exploration of our participants’ attitudes, behaviors, and experiences. Twenty-seven participants were interviewed through semistructured individual interviews and focus group discussions (FGDs), including key informants (KIs). Informed consent was obtained from participants by clearly communicating the study’s objectives, potential contributions to healthcare improvements, data protection measures, and their right to withdraw at any time. No monetary compensation was offered; however, participants valued the opportunity to express their thoughts and emotions during the interviews. Participants’ information and study data were treated with utmost confidentiality, strictly limited to the authors’ access due to the sensitive nature of cancer and its impact on patients.

The participants were recruited from the eastern, western, central, and northern regions of SA to distribute the sample as wide as possible in order to achieve national coverage. Despite numerous efforts to recruit participants from the southern region, no individuals were ultimately enrolled from that area due to difficulties in accessing cancer patients and charitable organizations, posed challenges to the generalizability of our study findings. Purposive sampling was employed to recruit a diverse range of participants, including cancer patients, survivors, and relatives, spanning various age groups, cancer stages, and regions, with differing experiences. Recruitment was done through multiple methods including contacting participants via multiple cancer charities from different regions, searching keywords in X (previously twitter) platform and recruiting participants who shared their diagnosis of cancer in their profiles, sending text messages to participants via mobile numbers retrieved from hospital records, after obtaining institution IRB approval, and searching for telegram channels dedicated for cancer patients and inviting them to participate in the study. The diverse recruitment methodology, which encompassed participants with varied demographic characteristics, also facilitated the exploration of a broad spectrum of perspectives. The IRB approval encompassed outreach to charities, and thus, initial ethical approval was submitted to these organizations, followed by a link facilitating voluntary participation in our study. Criteria of inclusion were: male and females, aged above 18 years old, participants diagnosed with cancer and their caregivers, and having a cancer status of either recovered (cancer survivor) or currently receiving treatment. Specific inclusion criteria for KIs were participants previously diagnosed with cancer and are supporting other cancer patients in the society, those who are members of cancer charities, and those who have platforms on social media to support cancer patients. We excluded individuals who had no follow-up appointments during the pandemic or after it and those who had received all their cancer care outside the Kingdom. Recruitment was stopped when data saturation was noted.

The participants were interviewed in Arabic via Zoom meetings platform or through a phone call. All interviewers underwent comprehensive training on qualitative interviews, received detailed instructions, observed multiple sessions, and were supervised during their initial interviews before conducting, independently, full interviews. The interviewers received explicit instructions to maintain neutrality throughout the interviews, adhering strictly to open-ended questions to minimize the introduction of potential biases and ensure the preservation of participants’ unbiased perspectives. A total of 27 participants were interviewed, comprising 19 individual interviews, each lasting approximately 1 h, and four FGDs, each comprising two participants and lasting approximately 2 h. Among these, five participants were designated as key informants, with three interviewed individually and two participating together in an FGD. Both individual interviews and FGDs facilitated an in-depth exploration of participants’ opinions and perspectives, highlighting shared experiences, and encompassing a broader spectrum of opinions. During interviews, participants were asked about their use of healthcare applications issued prior and during the COVID-19 pandemic, role of health apps in participants’ diagnosis, treatment, consultations and inquiring about matters related to the pandemic, how they heard about health apps, their advantages and disadvantages, the feasibility of using such applications, the satisfaction of receiving medical care services through such application versus seeking care directly from a hospital, and whether they would advise other cancer patients to use such applications.

Upon obtaining participants’ approval, most interviews were audio-recorded in Arabic. The authors, who also served as interviewers, subsequently transcribed all interviews into English. To ensure accuracy and credibility of the findings, member checking and reverse translation into Arabic were conducted by authors who were not involved in the initial translation. The data were organized and presented as themes and subthemes following inductive thematic analysis. After transcription and translation, color-coding was applied to identify meanings and patterns in the participants’ statements. Subsequently, the created codes were supported by quotes from the transcribed and translated interviews. The relevant codes were then grouped into major themes and further divided into subthemes. The themes and subthemes were reviewed through discussions among the entire team of authors, resulting in the merging of similar themes and the promotion of some subthemes to major themes by team consensus. Finally, the results were presented as two main themes and six subthemes. The patterns of responses that were coded and subsequently organized into themes and subthemes were regarded as significant findings. Ensuring reliability and consensus during the coding and theme development processes was facilitated by the significant contribution of team discussions.

A total of 27 participants, both males (n = 9) and females (n = 18), were recruited from various regions of SA including the eastern, western, central, and northern regions. A total of 16 individual interviews, 4 FGDs, and 5 KI interviews were conducted. The age range of interviewees was as follows: 22–30 (n = 6), 31–40 (n = 9), 41–50 (n = 7), 51–60 (n = 4), 61–70 (n = 0), and 71–80 (n = 1). Table 1 demonstrates the cancer-related characteristics of our interviewees.

Table 2 demonstrates the two major themes and subthemes identified in our thematic analyses of participants’ interviews. The pandemic accelerated the adoption of health apps by our participants, enabling them to conveniently manage their care, including scheduling appointments and accessing medical reports. These digital tools helped healthcare facilities maintain service delivery during the crisis. While usage patterns varied among our participants, the apps showed promise in facilitating early cancer detection, streamlining care, and overcoming pandemic-related obstacles.

Through health apps usage, especially during the pandemic, participants were able to ask about any concerns regarding their conditions quickly and conveniently, schedule appointments, seek sick leaves, obtain medical reports, and travel permits. These applications have enabled healthcare facilities to maintain the delivery of healthcare services to their patients during the unique circumstances of the pandemic. No significant correlations were found between participants’ demographic characteristics and their use of health applications, usage patterns, or experiences with these applications.

During interviews, the majority of participants stated that they have used Tawakalna and Sehaty applications to receive healthcare services, and others mentioned their usage of other applications such as Labayh, Altabbi, or applications provided by the treating hospitals. Tawakalna and Sehaty provided access to health services, vaccination status, travel permits, and medical appointments during the pandemic, with Tawakalna also offering a range of nonmedical services. On the other hand, Altabbi and Labayh focus on medical consultation services, with Labayh specializing in psychological care.

Some of our participants were aware of some healthcare applications like Sehaty and used it to inquire about their symptoms, schedule appointments, or obtain medical reports. Others were not interested in this method of delivering healthcare services; instead, they preferred to receive care directly from their doctor, through the doctor’s coordinator, or during hospital visits to maintain essential communication with their treating physicians. Likely, these patients were provided with their doctors’ contact numbers and permits to leave home for hospital visits, even amid pandemic restrictions.

Few participants have used these services for an inquiry regarding their cancer condition, some used it for inquiries regarding COVID-19 vaccination and its safety if taken during chemotherapy sessions and others needed consultations unrelated to their condition.

Some participants stated that they might have benefited from these services if they used them during their journey with cancer because a doctor can guide them to further investigate their complaint at a hospital.

Others wish they had known about these services prior to their diagnosis, as they did not know about them due to being diagnosed before the existence of these applications, before these services became popular, or due to lack of interest and popularity in their region. This indicates a lack of awareness among some cancer patients regarding health apps, which may be attributed to insufficient advertising and potential regional variations in awareness and utilizations.

Few believe that even though these applications could not have benefited them in their condition per se, they still could have aided them in inquiring about other health conditions.

While some participants did not use any applications during their journey of cancer, others did and shared their experience with regard to the role of such applications in cancer diagnosis and follow-up, its potential role in the detection of cancer at an early stage, and the feasibility of such digital communication route and how it assessed them in receiving care and aid them in maintaining communication during obstacles created by the pandemic.

Most of the participants felt that telemedicine has adequately replaced face-to-face hospital visits. Nevertheless, some participants believed that it cannot replace hospital visits completely because some situations require physical examination and further testing. Notably, participants who believed telemedicine adequately replaced face-to-face hospital visits were from the northern region, while those who felt it could not fully replace hospital visits were from the eastern province region.

Those groups of participants who received healthcare service remotely through such applications expressed that explaining their health complaint was not a big concern for them as some felt even more comfortable when explaining their symptoms.

Most participants used healthcare applications like Sehaty for consultations and the majority of them mentioned that no obstacles were faced while receiving their services and the application was easy to use, while few complained that the application was not easy to use.

Majority of participants were satisfied with the service they received even those who had some obstacles while using these services. On the other hand, a group of our participants believes that these types of virtual consultations are not the way to diagnose or inquire about cancer, as this disease requires clinical, in-person, diagnosis and examination, lab investigations, and biopsy.

Few stated that their presentation was too serious or atypical and these types of services could not have been the way to detect or diagnose their condition.

After some participants have experienced these services, their opinions varied on the possibility of using them again in the future, as some might use it in the future and others stated they were not interested to do so.

Even though some participants did not personally benefit or use these services, they still stated that they would recommend it to other cancer patients and few mentioned that they might not recommend it to others.

Numerous approaches have been proposed to effectively implement sustainability in the healthcare sector. Marimuthu et al. [17] have classified these approaches into four dimensions: environmental-oriented, customer-oriented, employee-oriented, and community-oriented sustainability [17]. The utilization of telemedicine and health apps as part of the DT in healthcare systems has been examined in many studies as a sustainable healthcare method [10, 18‒20]. The application of these technologies in the care of oncology patients has been termed as teleoncology [21]. We aimed to present some “case studies” highlighting the potential of these technologies in healthcare delivery in general and for cancer care in particular, as these promise personalized healthcare, thus serving an important goal of the Saudi healthcare system transformation toward value-based care. Our findings showed that the pandemic played a pivotal role in expediting the adoption of health apps by our participants, enabling them to conveniently manage their care, including scheduling appointments and accessing medical reports. These digital tools helped healthcare facilities maintain continuity of service delivery during the crisis. While usage patterns varied among our participants, the apps demonstrated significant potential in facilitating early cancer detection, streamlining care pathways, and mitigating pandemic-related obstacles. Our study findings discuss the effectiveness of DT and telemedicine in implementing sustainable healthcare, while also exploring the diverse applications developed for these purposes from the perspective of cancer patients. Thus, our results are among very few in SA describing use of health applications by cancer patients and survivors, throughout their journey from symptoms, through management, and further follow-up.

The utilization of telemedicine has experienced a significant upsurge during the COVID-19 pandemic as a means to control the spread of infection [9]. This circumstance has presented a valuable opportunity to further evaluate the appropriateness of this DT in managing diverse patient groups. Regarding infection control, the effectiveness of telemedicine in mitigating the transmission of infections has been firmly established [9]. A study conducted at the Princess Noorah Oncology Center, a tertiary care cancer facility in Jeddah, SA, demonstrated the efficacy of palliative tele-clinic services and virtual visits in reducing the risk of COVID-19 transmission [22]. Moreover, compelling evidence supports the pivotal role of telemedicine in promoting healthcare sustainability. Telemedicine has been shown to be effective in reducing carbon emissions generated by travel, as well as cutting down on expenses associated with hospital visits and procurement of medical instruments and devices required for in-person consultations [10, 11]. Our interviewees agreed that telemedicine significantly reduced their need for in-person hospital visits.

Nonetheless, it is essential for those responsible for the implementation of telemedicine in healthcare to recognize that this DT tool and its proven role in healthcare sustainability should not come at the expense of compromising the quality of patient care. It is important to note that studies assessing the effectiveness of telemedicine in providing sustainable healthcare did not encompass crucial factors such as patient suitability and the potential for missed diagnoses, resulting from virtual consultations, which could necessitate subsequent hospital visits and admissions [18]. Fortunately, the majority of our participants affirmed that teleconsultations adequately substituted in-person hospital visits, although a minority still preferred attending appointments physically. These findings are reassuring, as they were derived from in-depth individual interviews and FGDs conducted with participants from various regions in SA, ensuring comprehensive national coverage. These findings align with a study conducted by Nasser et al. [23], aiming to assess general outpatients’ experiences with telemedicine during the COVID-19 pandemic in SA. The study revealed a considerable level of patient satisfaction, with 84.9% expressing that healthcare was easier through telemedicine, with 43.4% of participants reporting feeling more comfortable expressing themselves during telemedicine encounters [23]. These sentiments are echoed by our interviewees who experienced no difficulty in expressing their symptoms; in fact, they felt even more comfortable explaining their symptoms through their chosen telemedicine modality, further emphasizing the effectiveness of telemedicine.

While the majority of our study cohort acknowledged the adequacy of telemedicine compared to face-to-face consultations, a minority held the view that it could not fully replace hospital visits due to the potential need for physical examinations and laboratory investigations. Similarly, two separate studies revealed that approximately 70% of virtual visit users actually preferred in-person visits over virtual consultations [24, 25]. Although the application of telemedicine as a sole option could enhance healthcare sustainability, it is important to consider its potential impact on patients’ health-seeking behavior, as some individuals still favor in-person hospital visits. Addressing this issue becomes a target for those responsible for developing and maintaining health apps used for teleconsultations, who should strive to understand the reasons behind patients’ preference for hospital visits and work toward resolving these concerns. As a suggested solution, offering teleconsultations as an optional and/or complimentary, rather than mandatory, communication modality may be considered.

Majority of the above findings and patients’ perspectives primarily pertain to the concept of telemedicine as a whole. However, it is worth noting that patients’ satisfaction and perception, regarding specific modalities employed to accomplish DT and telemedicine, have been examined separately in other studies further explored below.

In order to prevent the spread of COVID-19, various precautions such as quarantine, sterilization procedures, and cautious contact tracing were implemented. Therefore, telemedicine and mobile health apps emerged as pivotal measures to minimize the risk of disease transmission and prevent overwhelming the healthcare system during this challenging period [26]. Recognizing the significance of these technologies, the Saudi Ministry of Health (MOH) promptly released three mobile applications, Tetamman, Tawakalna, and Tabaud, specifically in response to the COVID-19 pandemic. These applications were part of a larger collection of 12 mobile apps created between 2012 and 2019, each serving a distinct purpose. Notable examples include Tawakalna, Sehaty, Tabaud, Tataman, Seha, Mawid, Qareebon, Anaat, Asafny, Eshar, and Wasfaty [27].

Sehaty was the most popular health application among our participants. They used it to inquire about their symptoms, schedule appointments, and access reports about their health condition. This reduced their need to visit hospitals and facilitated receiving healthcare services from home, saving both time and effort while helping prevent COVID-19 transmission. A study evaluating the usability of the Sehaty app, used in SA during the COVID-19 pandemic, found that 33% of participants agreed with the statement, “Sehaty application provides everything a patient wants to do regarding their healthcare,” 23.6% disagreed, while the rest expressed a neutral opinion [24].

A large group of our participants relied on the Sehaty and Tawakalna apps. However, it is important to note that the widespread use of the Tawakalna app does not necessarily indicate complete user satisfaction. Its mandatory implementation during the COVID-19 pandemic for accessing government or private establishments, commercial facilities, and obtaining travel permits during curfew periods may have influenced its adoption. Our participants primarily used Tawakalna for obtaining travel permits and booking COVID-19 vaccine appointments, reflecting the predominant themes that emerged from the open-ended questions in the semistructured interviews. A case study focusing on official healthcare informatics programs and applications developed in SA before and during the pandemic confirmed that residents and citizens were required to activate the Tawakalna app whenever visiting companies or other entities. The app offered various services, including obtaining travel permissions during curfews, personal permits, gathering permits, checking COVID-19 test status, accessing education services, and dependent services [28].

Several studies have examined the satisfaction levels and encountered obstacles associated with the use of Saudi mobile health applications (mHealth apps) during the COVID-19 pandemic. These studies encompassed a range of applications, including Seha, Mawid, Sehaty, Tetamman, Tawakalna, and Tabaud [24, 27‒30]. However, it is worth noting that most of these studies focused on the general population and did not specifically target cancer patients. Only one study investigated the use of mHealth apps among patients with chronic diseases such as hypertension and diabetes, but its scope was limited to assessing the prevalence of application use rather than exploring patient satisfaction and encountered obstacles [31].

In our study, participants expressed a high level of satisfaction with the use of health apps, particularly Sehaty and Tawakalna. They reported no significant obstacles or disadvantages, and the majority found the apps easy to use. Some participants believed that these applications could continue to be beneficial even after the pandemic, and they would recommend them to other cancer patients, although not all interviewees agreed on this point. In contrast, a questionnaire-based study [30] found mixed responses regarding satisfaction with Tawakalna, with 43% expressing positive satisfaction and −47% expressing dissatisfaction. Similarly, Sehaty had an even worse total usability score of −107%. Another study, analyzing posts discussing health apps on platform X (previously known as twitter), reported that Tawakalna received more negative sentiments than positive ones, while Sehaty had 31.8% positive sentiments and 28.5% negative sentiments [27]. However, a study by Dawood et al. [24] had consistent findings with our results, showing an overall satisfaction rate of 76.36% among Sehaty app users.

The wide variation in satisfaction levels among these latter studies could be attributed to several factors. First, the studies were conducted on the general population, whereas our study specifically focused on cancer patients who may have different needs and expectations, suggesting the need for a more targeted approach for cancer patients. Second, the studies were conducted at different time frames, which may have been influenced by these applications’ overload during periods of COVID-19 restrictions and subsequent updates. Therefore, we emphasize the importance of continuous assessment by app developers to evaluate user satisfaction and identify obstacles, with a particular focus on different populations and patient groups. Regular updates for these applications should be provided based on current assessment findings.

Similarly, the obstacles and disadvantages associated with the above apps were not consistent across studies. While our interviewees reported minimal or no obstacles, other studies identified limitations in clinic appointments’ availability as a weakness of Sehaty [24]. Another study highlighted issues such as increased battery consumption and potential breaches of location privacy with Tawakalna, and challenges with accurately detecting healthcare center locations on Sehaty [30]. Additionally, a study reported that Sehaty requires an account with the Mawid app and highlighted the unavailability of tele-consultation and COVID-19 testing, whereas Tawakalna encountered multiple issues with permits [27].

These obstacles may have contributed to some users expressing reservations about the utility of these apps for future appointments, as observed in the study conducted by Dawood and Alkadi [24], where 27.36% of Sehaty users disagreed about its usefulness. To ensure that these applications effectively contribute to healthcare sustainability through DT, it is crucial to promptly address obstacles encountered by users. This would ensure a higher level of user satisfaction, fostering greater enthusiasm for future use of such applications among the target population. To overcome obstacles such as navigation challenges and limited awareness, health apps must be designed with a user-centered approach.

Our study is not without its limitations. Notably, regional representation was restricted due to the lack of participants from the southern region. The reliance on virtual interviews may have also limited our ability to capture nuanced nonverbal insights. Furthermore, potential biases may have arisen from self-reported data, while the qualitative design constraints may have compromised the generalizability of our findings. To address these limitations, we advocate for further research in this domain. Longitudinal studies could provide valuable insights into app usage and outcomes over time. Quantitative investigations could rigorously assess the impact of health apps on clinical outcomes. Additionally, exploring health app adoption among diverse patient populations or in rural settings could further enrich our understanding of the use of health apps as a sustainable modality.

In conclusion, and amidst the challenges posed by the pandemic, the adoption of DT, exemplified by health apps and the implementation of telemedicine, has proven crucial in keeping vulnerable patient populations, such as cancer patients, connected with healthcare providers. This highlights the need to enhance and promote the sustainability of healthcare services through these technologies and communication modalities. While users may face challenges, these applications present an opportunity to preserve hospital resources and reduce greenhouse gas emissions and waste production associated with each hospital visit. Despite the strong consensus among our participants in favor of continued usage, it is important to acknowledge that these apps have not been extensively investigated for different patient groups. Additionally, there is clear evidence of lower satisfaction among the general population regarding the use of these applications, emphasizing the importance for developers to strategically focus on comprehensive testing and regular updates in order to facilitate further adoption of these promising digital health transformation modalities. We expect that the aspects described in our current manuscript would be useful for many stakeholders, including policy makers, health services’ managers and researchers, physicians, healthcare IT professionals, and sustainability advocates, among many others.

We wish to extend our thanks and appreciation to all those cancer patients, cancer survivors, and related key persons who gave of their time to join our research and share with us their valuable insights.

The study was held in accordance with the World Medical Association Declaration of Helsinki 1975 (revised in 2000). Ethical approval for this study was obtained from the Institutional Review Board (IRB). Written informed consent was obtained from all study participants prior to data collection, and they were reassured that all data will be kept confidential and they have the right to withdraw from the study at any time.

The authors have no conflicts of interest to declare.

This study was not supported by any sponsor or funder.

Dalia Yahia M. El Kheir conceived the concept and design choice for the study and has a role in implementing the study, data collection, analysis, and interpretation of data and contributed substantially to the writing of this article, read, edited, and approved its final version and is the corresponding author. Alnouf Z. Alghamdi and Hasan M. Alswiket have similar roles in data collection, analysis, and interpretation of data, and contributed substantially to the writing of this article, read, edited, and approved its final version. Fatimah M. Alalwiat and Hoor M. AlSaffar have similar roles in data analysis and interpretation, and contributed substantially to the writing of this article, read, edited, and approved its final version. Alaa M. Alaali has a role in data collection, analysis, and interpretation of data, and has read, edited, and approved this article’s final version. All authors approved the final manuscript and are responsible for the content and similarity index of the manuscript.

The data that support the findings of this study are not publicly available due to their containing information that could compromise the privacy of research participants but are available from the corresponding author upon reasonable request.