https://doi.org/10.1007/s00520-023-07640-7 RESEARCH
Walking activity and emotional distress among breast cancer survivors: the parallel mediating effects of posttraumatic growth and body image
Qiao Chu1 · Celia C. Y. Wong2 · Gan He1 · Jinhuan Yang1 · Chen Chen3 · Yaping He1,4
Received: 2 September 2022 / Accepted: 13 February 2023
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2023
Abstract
Purpose Although the antidepressant effects of physical activity have been well established, the underlying psychological mechanisms are understudied among cancer survivors. The present study aims to examine the parallel mediating effects of posttraumatic growth and body image on the association between walking activity and emotional distress (anxiety and depression) among Chinese breast cancer survivors.
Methods Chinese breast cancer survivors (n = 235) completed a cross-sectional questionnaire that assessed walking activ- ity, anxiety, depression, posttraumatic growth, and body image over the past week. Path analysis was conducted to test the hypothesized mediation model.
Results The hypothesized model was supported: walking activity was positively associated with posttraumatic growth and body image satisfaction, which were then negatively associated with anxiety and depression. After controlling for the media- tors, the direct effect of physical activity on depression was still significant, whereas the direct effect of physical activity on anxiety was no longer significant.
Conclusion Our findings suggest that posttraumatic growth and body image may be essential psychological pathways underly- ing the association between walking activity and emotional distress among Chinese breast cancer survivors. Researchers and health practitioners should consider supplementing physical activity interventions with mental health services that facilitate psychological growth and a positive body image to enhance the potential psychological benefits of physical activity.
Keywords Anxiety · Body image · Breast cancer · Depression · Posttraumatic growth · Psychological mechanism · Walking activity
Introduction
Despite the rising survival rate of breast cancer, long-term symptoms of anxiety and depression are prevalent among breast cancer survivors [1], which lead to poor treatment prognosis and poor quality of life. Although numerous stud- ies have demonstrated the benefits of physical activity (PA) in improving mental health [2], the underlying psychological mechanisms are understudied for cancer survivors. Under- standing the potential psychological pathways through which PA reduces emotional distress may guide the development of PA intervention strategies and supportive care services to facilitate mental health among cancer survivors. The present study examined the parallel mediating effects of posttrau- matic growth and body image on the association between walking activity and emotional distress (anxiety and depres- sion) in Chinese breast cancer survivors.
* Chen Chen
* Yaping He
1 School of Public Health, Shanghai Jiao Tong University School of Medicine, No.227 South Chongqing Rd, Shanghai 200025, China
2 College of Brockport, State University of New York, Brockport, NY, USA
3 Shanghai Jing’an District Jiangning Road Community Health Service Center, Shanghai 200040, China
4 Center for Health Technology Assessment, Shanghai Jiao Tong University China Hospital Development Institute, Shanghai Jiao Tong University, Shanghai, China
/ Published online: 23 February 2023
The emotional benefits of walking activity in cancer survivors
Current literature has well documented the psychological benefits of gym-based supervised PA interventions, such as resistance training and yoga [2]. However, recent studies suggest that breast cancer survivors face various physical and psychological barriers to performing PA, which impedes survivors’ adherence to regular PA training [3]. For exam- ple, the symptom burden coupled with the side effects of adjuvant therapy (e.g., physical weakness, bodily pain, and hair loss) have reduced survivors’ mobility and motivations to participate in group-based exercises [4, 5]. In addition, lymphedema associated with breast cancer surgery may impair arm and shoulder functioning, limiting survivors’
engagement in common gym-based exercises. Further- more, most PA interventions require regular coaching and supervision, and may restrict long-term compliance since cancer survivors undergoing adjuvant therapies have sched- uling difficulties and limited access to exercise facilities [6].
In contrast, walking is a more accessible form of exercise for breast cancer survivors, since it is flexible, and requires minimal facilities and supervision. A systematic review has indicated that walking was the most preferred mode of PA among cancer survivors [4]. In recognition of the accessi- bility of walking activity, an increasing number of walking- based intervention programs targeting cancer survivors have been conducted in the past decade, and have shown benefits in reducing anxiety and depression [7, 8].
Posttraumatic growth and body image as mediators Although the psychological mechanisms by which PA improves mental health among cancer survivors are relatively unclear, existing theoretical frameworks have underscored self-perception as an essential psychologi- cal pathway among the general population. Kandola et al.
presented a conceptual framework of the biological and psychosocial mechanisms underlying the antidepressant effects of PA [9]. According to this framework, participa- tion in PA reduces depressive symptoms through facilitat- ing positive changes in self-perception, such as a more positive body image, improved self-values, and growth in inner strength to cope with life challenges. Drawing upon Kandola’s framework, self-perception may be an impor- tant mediator linking PA and reduced emotional distress in cancer survivors. Two types of self-perception that are closely related to breast cancer survivors are posttraumatic growth and body image [10, 11].
Posttraumatic growth refers to positive psychological changes that emerge through coping with trauma [12].
Being diagnosed and treated for breast cancer is a life trau- matic event, as it shatters individuals’ core beliefs about themselves and the world. Nevertheless, psychological growth after trauma, such as a sense of personal strength to cope with life challenges, improved sense of control, and a greater appreciation for the value of one’s own life, have been observed among breast cancer survivors through coping with cancer [13]. Research has demonstrated that posttraumatic growth is associated with lower anxiety and depression, and improved hope and quality of life among cancer survivors [14, 15]. Moreover, existing quantitative and qualitative studies have demonstrated that participat- ing in PA facilitates posttraumatic growth among cancer survivors [16, 17]. In particular, performing exercises at leisure time provides opportunities for cancer survivors to develop a sense of control, to find new directions in life, and to obtain a new understanding of their strengths to overcome barriers [16]. Thus, it is likely that posttraumatic growth is a potential psychological mechanism underlying the relationship between walking activity and emotional distress among breast cancer survivors.
Surgery and adjuvant therapies for breast cancer can lead to temporary or permanent changes to survivors’ bod- ily appearance and functions, such as breast asymmetry, scarring, weight fluctuation, and shoulder morbidity. These changes can elicit negative body image among breast cancer survivors [18], which leads to anxiety and depression, and worse quality of life [19]. Kandola’s concept model has pos- ited that engaging in PA facilitates individuals’ self-accept- ance for bodily appearance and functions [9, 20]. Perform- ing walking activity may enable survivors to recognize their inner strength to overcome the physical and psychological obstacles of performing PA, which can gradually facilitate self-acceptance for the bodily changes, and contributes to body image satisfaction. Empirical evidence has supported this suggestion. A handful of interventions that employ physical activity have indicated efficacy in improving body image among breast cancer survivors [18, 21]. Hence, we expected that body image would mediate the association between walking activity and emotional distress among breast cancer survivors.
The present study
Using a cross-sectional design, the present study aims to investigate the potential psychological mechanisms underly- ing the association between walking activity and emotional distress (anxiety and depression) among Chinese breast can- cer survivors. Based on Kandola’s conceptual framework and empirical studies, we proposed a parallel mediation model. Specifically, we hypothesized that walking activity would be associated with greater posttraumatic growth and
body image satisfaction, which in turn, would be associ- ated with lower anxiety and depression (see Fig. 1 for the hypothesized model).
Method
Participants and procedure
Data collection was performed from April to July in 2019.
The recruitment and screening were conducted by staff of our research partner, the Peng Pu Xin Cun community health center (the PPXC health center). The PPXC health center man- ages follow-up visits for patients with cancer or chronic dis- eases who live in local communities, and has established trust and rapport with local cancer survivors. For the current study, physicians and nurses at PPXC health center firstly determined cancer survivors’ eligibility through their documented medical records, and then reached out to potential eligible survivors through phone calls to further determine eligibility and invite them to the study. For eligible survivors who are willing to participate, the staff at PPXC health center would schedule an in-person visit with the survivors to administer the paper-based informed consent and cross-sectional questionnaire.
The inclusion criteria included (a) a diagnosis of stage 0–IV breast cancer; (b) age of 18 years or older; and (c) female sex. The exclusion criteria included (a) severe mental or cognitive deficits and (b) poor language abilities with dif- ficulty understanding the study materials even after detailed explanation. The present study was approved by the Eth- ics Committee of Shanghai Jiao Tong University School of Medicine School of Public Health (protocol number:
SJUPN-201915). Informed consent was obtained from all enrolled participants.
Measures Walking activity
Walking activity was assessed using the Chinese version of the International Physical Activity Questionnaire-Long Form
[22, 23]. Three questions on the IPAQ were related to walk- ing activity. Participants reported the number of days and time spent per day engaging in walking activity for work, transportation, and leisure time over the past 7 days. Total minutes spent on walking for the past 7 days were calculated for each participant. The IPAQ has indicated good reliability and validity in measuring PA in cancer population [24].
Posttraumatic growth
Posttraumatic growth was assessed using the Posttraumatic Growth Inventory-Short Form [25]. The Chinese version has indicated good internal reliability among Chinese breast cancer survivors [26]. The 10-item questionnaire includes five subscales that measure the five facets of posttraumatic growth: meaningful interpersonal relationships, finding new possibilities in life, a sense of personal strength, spirituality, and appreciation of life. Participants indicated the degree to which they experienced the change described in each item related to cancer experience on a 6-point scale from 0 (I did not experience this change) to 5 (I experienced this change to a very great degree). A higher sum score indicates greater growth. The scale indicated good internal reliability in the current study (Cronbach’s 𝛼 = 0.72).
Body image satisfaction
Body image satisfaction was measured using the body image subscale of the EORTC Quality of Life Questionnaire-breast cancer module (QLQ-BR23) [27], which has been vali- dated in Chinese breast cancer survivors [28]. The subscale includes four items that measure survivors’ self-perceptions of their body. Example items were “Have you been dissatis- fied with your body?” and “Have you felt physically less attractive as a result of your disease or treatment?.” Partici- pants’ responses were made on a four-point scale from 1 (not at all) to 4 (very much). A linear transformation was applied to the raw sum score to compute a standardized score rang- ing from 0 to 100. A higher score indicates greater body image satisfaction. The four items indicated good internal reliability in the current study (Cronbach’s 𝛼 = 0.87).
Fig. 1 The parallel mediation model with standardized param- eter estimates. Solid lines indicate significant paths at p < 0.05.
Dashed lines indicate nonsignifi- cant paths. Controlled covariates (i.e., age, educational level, full-time employment, and having received chemotherapy) were omitted in the figure for simplic- ity. **p < 0.01, ***p < 0.001
Anxiety and depression
Anxiety and depression were assessed using the Chinese ver- sion of the Hospital Anxiety and Depression Scale (HADS) [29], which comprises two subscales that measure anxi- ety and depression, respectively. Each subscale includes 7 items. On a four-point scale from 0 to 3, participants rated the extent to which they experienced each symptom over the past week. A higher sum score of each subscale indi- cates greater anxiety or depressive symptoms. The present study indicated good internal reliabilities for the anxiety and depression subscale (Cronbach’s 𝛼 = 0.90 and 0.86, respec- tively). As recommended by a previous study of scale valida- tion in Chinese cancer survivors [30], sum scores of 9 and 8 were used as the cutoff points for probable diagnoses of anxiety and depressive disorders, respectively.
Data analysis plan
First, descriptive statistics and correlations were performed in SPSS 24.0. The associations of the outcome variables (i.e., anxiety and depression) with demographic and clinical characteristics were examined to identify potential covari- ates. To test the hypothesized model, path analysis was con- ducted in Mplus 7.0. Model fit was assessed using chi‐square goodness‐of‐fit statistic, the comparative fit index (CFI), the Tucker–Lewis index (TLI), and the root‐mean‐square error of approximation (RMSEA). A model with a CFI and TLI greater than 0.95 and an RMSEA less than 0.05 indicates a good fit with the data [31]. Indirect effects were assessed using the bootstrap procedure with bias‐corrected 95% CIs.
An absence of zero in the 95% CI suggests a significant indi- rect effect. Full information maximum likelihood (FIML) estimation was used to handle missing data.
Results
Descriptive statistics and correlations
In total, 256 female breast cancer survivors were approached, among whom 235 survivors consented and completed the questionnaire, resulting in a response rate of 91.8%. Par- ticipants were between 32 and 97 years old (M = 64.2, SD
= 10.9). Among the 235 enrolled participants, 91.9% were married, 47.2% had a senior high school educational level or above, and only 3.0% had a full-time job. Table 1 pre- sents the detailed sample characteristics. At time of data collection, participants’ stage of cancer ranged from stage 0 (28.1%), stage I (6.4%), stage II (24.7%), stage III (5.1%), and stage IV (1.3%). Time since initial diagnosis for breast cancer ranged from within 1 year through 41 years (M = 9.18, SD = 6.83). Based on the cutoff scores of 9 and 8
[30], 14.9% and 28.9% of the participants were above the thresholds for probable diagnoses of anxiety and depressive disorders, respectively.
Table 2 presents the means, standard deviations, and zero‐
order correlations among the variables of interest. Walking activity was positively associated with posttraumatic growth and body image satisfaction; the former three variables were all negatively associated with anxiety and depression.
To identify potential covariates, we tested the correlations between the sample characteristics, mediators, and outcome variables. The online supplement presents a full correlation table (Table s1). Depression was positively associated with age (r = 0.29), and negatively associated with educational level (r = −0.29), employment (full-time job vs. other; r =
−0.19), and having completed chemotherapy (r = −0.17);
Table 1 Demographic and clinical characteristics of participants (n = 235)
a Percentages may not add up to 100% because of missing data
b According to the WHO’s definition of catastrophic health expendi- ture [41], the healthcare-cost-to-income ratio was divided into three groups, using 10% and 25% as thresholds
Variable Mean (SD)/frequency
(%)a
Age (years) 64.20 (10.85)
Education
Elementary school or below 20 8.5%
Junior high school 104 44.3%
Senior high school 89 37.9%
College or above 22 9.4%
Marital status
Married 216 91.9%
Single/divorced/widowed 19 8.1%
Employment
Full-time job 7 3.0%
Other 228 97.0%
Years since initial diagnosis 9.18 (6.83) Cancer stage at time of data collection
0 66 28.1%
I 15 6.4%
II 58 24.7%
III 12 5.1%
IV 3 1.3%
Treatment received
Chemotherapy 121 51.5%
Surgery 167 71.1%
Radiotherapy 16 6.8%
Healthcare-cost-to-income ratiob
<10% 100 42.6%
10~25% 89 37.9%
>25% 37 15.7%
anxiety was negatively associated with educational level (r
= −0.16), full-time employment (r = −0.16), and having received chemotherapy (r = −0.14); posttraumatic growth was negatively associated with age (r = −0.14) and positively associated with educational level (r = 0.25), all p < 0.05.
Thus, age, educational level, full-time employment, and com- pletion of chemotherapy were controlled for in the path model as covariates. Although cancer stage and years since diagno- sis were not significantly related with the outcome variables or the mediators for our sample, we controlled for these two clinical variables in the path model, considering that previous literature has demonstrated the associations of cancer stage and time since diagnosis with emotional distress [32].
Path analysis
The hypothesized model indicated good fit, χ2(6) = 3.998, p
= 0.68; CFI = 1.000, TLI = 1.030, RMSEA = 0.000, 90% CI [0.000, 0.054]. As shown in Fig. 1, controlling for the covari- ates, walking activity was positively associated with posttrau- matic growth and body image satisfaction; both posttraumatic growth and body image satisfaction were negatively associ- ated with depression and anxiety. With posttraumatic growth and body image satisfaction included in the model, walking activity was negatively associated with depression, but no longer significantly associated with anxiety. The online sup- plement presents the path coefficients of controlled covariates predicting the major variables (Figure s1).
The total effects of walking activity on depression (stand- ardized estimate = −0.29, 95% CI = −0.39 to −0.19) and anxiety (standardized estimate = −0.24, 95% CI = −0.34 to −0.12) were both significant. There were also signifi- cant total indirect effects of walking activity on depression (standardized estimate = −0.15, 95% CI = −0.21 to −0.09) and anxiety (standardized estimate = −0.13, 95% CI =
−0.19 to −0.08). For depression, the specific indirect effects of walking activity through body image satisfaction (stand- ardized estimate = −0.07, 95% CI = −0.11 to −0.04) and posttraumatic growth (standardized estimate = −0.08, 95%
CI = −0.12 to −0.03) were both significant. For anxiety, the specific indirect effects of walking activity through body image satisfaction (standardized estimate = −0.07, 95% CI
= −0.12 to −0.04) and posttraumatic growth (−0.06, 95% CI
= −0.10 to −0.03) were both significant. Controlling for the mediators, the direct effect of walking activity on depression was still significant (standardized estimate = −0.14, 95%
CI = −0.24 to −0.04), whereas the direct effect of walk- ing activity on anxiety was no longer significant (standard- ized estimate = −0.10, 95% CI = −0.21 to 0.01). For the standardized regression coefficients of potential covariates predicting major variables, age was positively related to depression (β = 0.18, p = 0.003) and body image satisfac- tion (β = 0.20, p = 0.022). Education was positively related to posttraumatic growth (β = 0.21, p = 0.009). Employment was negatively related to anxiety (β = −0.11, p = 0.025).
All other path coefficients were nonsignificant (p > 0.05).
The parallel mediation model accounted for 40.1% of the variance in depression and 24.8% of the variance in anxiety.
Although our path model is based on an established theoretical framework, the cross‐sectional design makes alternative causal models plausible. Therefore, follow- ing the recommendation of Fiedler et al. [33], we tested the reverse mediation models, by switching the outcome variables and the mediators. Specifically, four reverse mediation models were tested individually: (a) walk- ing activity→anxiety→posttraumatic growth; (b) walk- ing activity→anxiety→body image; (c) waking act ivity→depression→posttraumatic growth; and (d) walking→depression→body image. Results indicated good fit with the two models with posttraumatic growth as the outcome variable, and with anxiety or depression as the mediator (for the model with anxiety as the mediator, χ2(2)
= 0.041, p = 0.98; CFI = 1.000, RMSEA = 0.000; for the model with depression as the mediator, χ2(2) = 0.589, p = 0.74; CFI = 1.000, RMSEA = 0.000). The other two mod- els with body image satisfaction as the outcome variable indicated poor fit (for both models, TLI < 0.80, RMSEA >
0.05). The online supplement presents the figures and model fit indices of the reverse models (Figure s2a-s2d).
Discussion
The present study examined the parallel mediating effects of posttraumatic growth and body image on the association between walking activity and emotional distress (anxiety and
Table 2 Descriptive statistics and correlations of variables
**p < 0.01
M SD Range 1 2 3 4 5
1. Walking minutes 215.83 215.32 0.00–1300.00 1 0.23** 0.20** −0.28** −0.38**
2. Posttraumatic growth 30.23 7.42 9.00–50.00 1 −0.03 −0.35** −0.47**
3. Body image satisfaction 92.48 13.68 33.33–100.00 1 −0.30** −0.29**
4. Anxiety 3.99 3.69 0.00–18.00 1 0.73**
5. Depression 5.44 3.76 0.00–19.00 1
depression) among Chinese breast cancer survivors. Consist- ent with our hypotheses, the findings indicated that post- traumatic growth and body image satisfaction were parallel mediators for the relationship between walking activity and emotional distress among Chinese breast cancer survivors.
Specifically, with relevant demographic and clinical covari- ates controlled for, walking activity facilitates the develop- ment of posttraumatic growth and body image satisfaction, which are then associated with lower levels of anxiety and depression. Previous studies have demonstrated that PA was associated with posttraumatic growth and a positive body image among cancer survivors [16, 18]. The present study adds to the existing literature by illuminating posttraumatic growth and body image as parallel psychological mecha- nisms underlying the association of walking activity with anxiety and depression among breast cancer survivors.
Through the lens of posttraumatic growth and body image, our findings offer support for Kandola’s concep- tual framework [9] that underscores self-perception as an essential psychological mechanism by which PA facilitates mental health. The shock of a breast cancer diagnosis may shatter individuals’ prior assumptions of personal invulner- ability and control [34]. The traumatic experience of coping with the symptom burden and the uncertainty of life may diminish individuals’ self-values and perceived control over life, leading to emotional distress and poor quality of life [35]. Participation in walking activity during work, trans- portation, or leisure time provides opportunities to develop a sense of accomplishment and self-empowerment, which can rebuild positive self-perceptions in other areas of their lives. Specifically, through walking, breast cancer survivors may gain a renewed understanding of their personal strength to overcome the many physical (e.g., limited mobility and fatigue) and psychological (e.g., lack of motivation and self-confidence) obstacles of performing exercises, which promotes a sense of mastery and self-accomplishment [36].
Being able to step out of home and resume social life may also foster a new sense of possibility and appreciation for life [37]. Moreover, through walking, survivors may also learn to gradually accept and adapt to their bodily changes, regain control of their body, and thus develop a more positive body image [21, 38]. These positive self-perceptions may then contribute to decreased anxiety and depression.
After controlling for the mediating effects of posttrau- matic growth and body image satisfaction, the direct effect of walking activity on anxiety was no longer significant.
This finding indicates the essential roles of posttraumatic growth and body image in accounting for the relationship between walking activity and emotional distress. Meanwhile, the nonsignificant direct effect needs to be interpreted with caution, since other biological and psychosocial mechanisms might exist [9]. For example, studies have indicated that engaging in PA may broaden individuals’ social network,
and provides opportunities to obtain social support for stress coping, which may then reduce emotional distress [16].
Unfortunately, the present study did not collect information about whether participants performed walking activity alone or with social partners. It calls for more studies to elucidate the psychological processes through which PA may reduce emotional distress.
Although the parallel mediation model is drawn upon theoretical frameworks and empirical evidence, the cross- sectional design precludes drawing conclusions of causal relationships or temporal precedence. In particular, we found adequate fit of alternative mediation models with anxiety or depression mediating the association of walking activity with posttraumatic growth. These findings suggest the pos- sibility of bidirectional relationships between posttraumatic growth and emotional distress among breast cancer survi- vors. Future studies with longitudinal or experimental design are needed to test this suggestion.
This study has important implications for clinical practice and intervention studies. Our findings point to the possibility that PA interventions may yield greater benefits for breast cancer survivors’ mental health when they are supplemented with psychological interventions that facilitate posttraumatic growth and a positive body image. It has been found that supervised exercise interventions coupled with psychologi- cal counseling that covered self-efficacy, overcoming barri- ers and stress coping indicated good adherence to PA train- ings and significantly improved anxiety and depression for breast cancer survivors [39]. Moreover, our findings suggest that unsupervised walking activity during work, transporta- tion, or leisure time may potentially benefit mental health of cancer survivors. In contrast to most gym-based PA interventions that require regular supervision, space, and facilities, walking is simpler and more flexible, which can be easily tailored to cancer survivors’ physical condition and time schedule. Thus, special consideration should be given to offering trainings or guidance for performing walking activity, tailored to survivors’ recovery stage.
Study limitations
The present study has limitations that point to future research. First, as mentioned before, our findings are based on a cross-sectional design, and thus no conclusions can be made for causal relationships. It calls for experimental studies to further test our findings. Second, the assessment of walking activity relied on participants’ self-reports, which may be subject to response bias. Future studies should con- sider supplementing the subjective responses with objective measurement tools, such as pedometers or activity trackers [40]. Third, our sample was restricted to Chinese breast can- cer survivors; thus, it calls for future research to test whether our findings can be generalized to survivors of other cancer
types and other ethnicities. Moreover, the majority (59.2%) of the participants in our study had a stage II or earlier stage of breast cancer. The generalizability of our findings to sur- vivors with late stage of cancer warrants future research.
Conclusions
In conclusion, the present study adds to the literature about the association between PA and emotional distress among breast cancer survivors by demonstrating the potential psy- chological mechanisms. Our findings suggest that walking activity may be associated with reduced anxiety and depres- sion through improved posttraumatic growth and a positive body image. Clinical practitioners may consider integrating psychological services about posttraumatic growth and body image into PA interventions to improve breast cancer survi- vors’ mental health.
Supplementary Information The online version contains supplemen- tary material available at https:// doi. org/ 10. 1007/ s00520- 023- 07640-7.
Author contribution Qiao Chu, Yaping He, and Chen Chen contrib- uted to the study conception and design. Chen Chen supervised the study implementation. Material preparation and data collection were conducted by Gan He and Jinhuan Yang. Analysis was performed by Qiao Chu and Celia Wong. The first draft of the manuscript was writ- ten by Qiao Chu and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding This work was supported by the National Natural Science Foundation of China (grant numbers: 72004133, 71874111), Shang- hai Pujiang Program (grant number: 2020PJC080), Shanghai Jiao Tong University Research Fund for Young Scholars (grant number:
20X100040013), and Shanghai Public Health System Construction Three-Year Action Plan (GWV-10.1-XK15).
Data availability The data that support the findings of this study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate The present study was approved by the ethics committee at School of Public Health at Shanghai Jiao Tong University School of Medicine (SJUPN-201915).
Informed consent was obtained from all individual participants included in the study.
Consent for publication Not applicable.
Competing interests The authors declare no competing interests.
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