| |

Received: 16 August 2019    Revised: 2 December 2019    Accepted: 4 December 2019

DOI: 10.1111/phn.12698

REVIEW SUMMARIES

Health education interventions for older adults with

hypertension: A systematic review and meta-analysis

Yajing Chen MD, Master's candidate1,2  | Xiuxia Li PhD, Associated Professor1,2 |

Guangzhuang Jing MD, Master's candidate1 | Bei Pan MD, Master's candidate1 |
Long Ge PhD, Lecture1,2,3,4 | Zhitong Bing PhD, Associated Researcher3,4 |
Kehu Yang PhD, Professor2,3,4 | Xuemei Han PhD, Professor1,2

1
Department of Social Medicine and Health
Management, School of Public Health, Abstract
Lanzhou University, Lanzhou, China Objective: The study aimed to evaluate the effectiveness of health education inter-
2
Evidence-Based Social Science Center,
vention for the control of blood pressure (BP) in older adults with hypertension.
School of Public Health, Lanzhou University,
Lanzhou Gansu, China Methods: Five databases were searched in March 2018 for randomized controlled
3
Evidence-Based Medicine Center, School of trials to manage hypertension in older adults by health education. The primary out-
Basic Medical Science, Lanzhou University,
Lanzhou Gansu, China
comes were changes in systolic and diastolic BP. RevMan5 was used for meta-analysis.
4
Key Laboratory of Evidence-Based Results: Seven articles with 1,105 participants were included. In them, 393 (35.56%)
Medicine and Knowledge Translation of older adults participated in health education interventions in the form of courses,
Gansu Province, Lanzhou, China
and 226 (20.45%), in health education sessions. The meta-analysis suggested an
Correspondence overall reduction in systolic BP after health education courses (SMD, standardized
Kehu Yang and Xuemei Han, Lanzhou
University, 199 Donggang West Road, mean difference = 4.80, 95% CI: 7.01–2.59, p < .05). Similar results were observed
Lanzhou, China. after health education sessions (SMD = 11.73, 95% CI: 17.63–5.82, p < .05). The
Email: kehuyangebm2006@126.com (K.Y.)
and xmhan@lzu.edu.cn (X.H.) diastolic BP reduction showed no difference after the health education course

Funding information
(p = .09). The random effects meta-analysis suggested an overall reduction in dias-
This work was supported by the China tolic BP after health education sessions (SMD = 5.39, 95% CI: 7.98–2.79, p < .05).
Medical Board (CMB 17-279); the
Fundamental Research Funds for the
Conclusion: Although different health education methods had different effects on
Central Universities (16LZUJBWTD013, hypertension control, overall, educational interventions can potentially lead to im-
18LZUJBWZX006, and lzujbky-2018-14);
and Gansu Soft science project
proved BP control.
(18CX1ZA043). The views expressed are
those of the authors and not necessarily KEYWORDS
those of Lanzhou University. The
funders had no role in the study design, health education, hypertension, meta-analysis, older adults
data collection, data synthesis, data
interpretation, or writing of the report.

1 |  BAC KG RO U N D
Elevated blood pressure (BP) is one of the most common health
problems in the older adult population and affects roughly one bil-
lion individuals worldwide (Park et al., 2011). If left uncontrolled,
high BP can lead to enlargement of the heart, and eventually, heart
Yajing Chen and Xiuxia Li are joint first authors.
failure; this health problem threatens quality of life, induces psycho-
social problems, limits activities of daily living, and increases overall
health care costs significantly (Desimone & Crowe, 2010; Irwan et
al., 2016). Without interventions for hypertension, we are unlikely
to achieve the goal of reducing premature mortality from noncom-
municable diseases by one third, as set in the 2015 UN Sustainable
Development Goals (Olaiya, 2015). The World Health Organization
documents that complications from elevated BP account for 9.4

Public Health Nurs. 2020;00:1–9. wileyonlinelibrary.com/journal/phn© 2020 Wiley Periodicals, Inc.     1 |

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2       CHEN et al.
million deaths worldwide every year. It is well-known that good
BP control is an effective approach to reducing the risk of hyper-
tension-related target organ damage (Olsen et al., 2016; Weber &
Lackland, 2016). Even modest reductions in systolic BP on a pop-
ulation-wide scale (e.g., 1 mm Hg) can have significant effects on
cardiovascular death prevention (Hardy et al., 2015). Nevertheless,
the cardiovascular complications of hypertension continue to cause
significant morbidity and mortality worldwide, largely due to inade-
quate strategies for the prevention, diagnosis, and control of hyper-
tension in an aging worldwide population (Olsen et al., 2016).
Epidemiological surveys have shown that with the aging of the
population, the prevalence of hypertension in older adults has not
decreased and that the ideal rate of control remains out of reach.
According to the China Patient-Centered Evaluative Assessment of
Cardiac Events (PEACE) 2017, the prevalence of hypertension was
44.7% among Chinese adults aged 35–75 years, of whom only 7.2%
had achieved control (Lu et al., 2017). The 2016 National Health
and Nutrition Survey (The Ministry of Health, Labour and Welfare
(JP) 2016) found that the prevalence of hypertension is 41% for
women and 60% for men for those aged 40–74 years, and 74% for
men and 77% for women in those aged ≥75 years. The 2015 Sixth
Korea National Health and Nutrition Examination Survey (Ministry
of health and welfare & Korea Centers for Disease Control and
Prevention, 2015) found the prevalence of hypertension to be
64.7% among older adults aged ≥65 years. One aim of the World
Health Organization (2016) is to achieve a 25% relative reduction
in the prevalence of elevated BP by 2025, reflecting studies on the
importance of prevention (Aung et al., 2012; Ng, Bo, Weinehall, &
Norberg, 2012; Ribeiro et al., 2011).
Healthy aging promotion strategies must be anchored in health
education that reduce premature cardiovascular morbidity, mortal-
ity, and burden of disease, while using minimal health resources
(Neupane et al., 2018). Educational interventions can not only in-
crease participants’ levels of knowledge about hypertension but can
also have a positive impact on their beliefs about medicines. Older
adults especially need to be cognizant of their health conditions
and the role of therapy, as well as enhanced awareness of disease
progression and complications (Ribeiro et al., 2015). Educational
interventions can positively change beliefs that older adults have
about their therapy and result in positive behavior changes, such as
medication adherence, adoption of a low-salt diet, and regular ex-
ercise (Saounatsou et al., 2010). In the long-term, health education
interventions can also affect disease progression and the preva-
lence of associated conditions related to high BP.
The effective control of hypertension has become a priority for
global health policy and, with growing interest in the prevention and
control of noncommunicable diseases, it is vital that health care sys-
tems deliver appropriate interventions for tackling hypertension. It is
well-known that well-conducted systematic reviews and meta-analyses
of randomized controlled trials (RCTs) provide the most valid research
evidence on effects of health care interventions (Ge et al., 2018; Murad
et al., 2014). Therefore, our present meta-analysis of RCTs was con-
ducted to perform comprehensive evaluation on the effectiveness of
educational interventions for improving hypertension control in older
adults with high BP, helping achieve policy guidance for hypertension
control potentially and thus providing high quality care for the elder.
2 | M ATE R I A L S A N D M E TH O DS
2.1 | Search and strategy
We searched PubMed, EMBASE, Web of Science, Campbell Library,
World Health Organization, and Cochrane Central Register of
Controlled Trials (CENTRAL) databases from the dates of their re-
spective inceptions until March 5, 2018. Two reviewers developed
the basic search strategy as follows: (“hypertension*” OR “blood
pressure” OR “blood pressure”) AND (“education” OR “self care” OR
“self concept” OR “self help” OR “health promotion” OR “social sup-
port” OR “lifestyle” OR “interpersonal communication” OR “patient
participation” OR “patient compliance” OR “counseling” OR “commu-
nity health nursing” OR “community care”) AND (“aged” OR “aging”
OR “elder*” OR “geriatric*” OR “older adult*” OR “senior citizen*” OR
“old person*” OR “late life*” OR “frail” OR “pensioner*”) AND “ran-
dom*”. The search strategy is shown comprehensively in Appendix
S1. We searched trial registry websites, including the Registry of
Clinical Trials and ClinicalTrials.gov, to find unpublished studies. We
also traced the references of included RCTs and relevant reviews
to identify potentially eligible studies. There were no restrictions in
terms of publication status and publication date.
2.2 | Inclusion and exclusion criteria
Studies that met the following criteria were included. (a) Type of
participants: We included studies that enrolled participants aged
≥60  years and who were diagnosed with hypertension based on
clinical and laboratory studies (systolic BP [SBP] ≥140  mmHg and
Diastolic BP [DBP] ≥90  mmHg. (b) Type of design: RCTs. (c) Type
of interventions: Health education (e.g., salt-reduction training, ef-
ficacy maintenance, group health education, individual counseling,
high BP advice, healthy lifestyle behavior counseling, self-monitor-
ing, and medication adherence). There were no limitations on the du-
ration and frequency of interventions. (d) Type of comparisons: usual
care (no intervention, standard care, routine monitor, or waiting list).
(e) Type of outcomes: SBP, DBP, body mass index (BMI), salt intake,
hypertension knowledge score, self-care behavior, self-efficacy for
exercise, regular use of medications, and regular physical activity.
Studies that did not provide specific data, such as study protocols,
abstracts, and commentaries, were excluded.
2.3 | Data extraction
Data from each study were independently extracted by two review-
ers. Information was extracted on study characteristics (i.e., first
CHEN et al. |
      3

author's name, country where the study was conducted, and year
of publication), participants (i.e., inclusion criteria, numbers of indi-
viduals in two groups, age of participants, and baseline comparisons),
interventions (i.e., type, frequency, and duration), outcomes (i.e.,
SBP, DBP, BMI, hypertension knowledge score, and self-efficacy
for BP control), and other confounding factors from eligible studies.
Disagreements in extracted data were resolved by discussion among
the reviewers.
used to indicate the merger effect, with a statistical significance of
p ≤ .05. The heterogeneity between results was assessed using the
χ2 and I2 statistics (Higgins et al., 2011a, 2011b). If significant (p < .05
or I2 > 50%), a random effects model was used. Otherwise, a fixed
effect model was used. RevMan5 was used for the statistical calcula-
tions of all data.
3 | R E S U LT S

2.4 | Quality assessment 3.1 | Study section

The Cochrane collaboration tool was used to assess risk of bias in the
studies to be included for review (Higgins et al., 2011a, 2011b). For
each study, the following items were evaluated: (a) random sequence
generation; (b) allocation concealment; (c) blinding of participants
and personnel; (d) blinding of outcome assessment; (e) incomplete
outcome data; (f) selective reporting; (g) other bias, including com-
parison of baseline characteristics, reporting of power calculations,
and risk of vested financial interests. Each of the above domains
was classified into one of three levels: low, unclear, and high risk of
bias. Studies that explicitly specified the method and description for
each of the domains were considered to have a low risk of bias. Two
researchers independently evaluated all seven studies; differences
were resolved by consensus.
2.5 | Statistical analysis
In view of the inconsistency of measurement standards, standard-
ized mean difference (SMD) with 95% confidence interval (CI) was
The initial search yielded 776 potentially relevant references; after re-
moving duplicate articles, 697 articles remained. Using the inclusion
and exclusion criteria, and a screening of the title and abstract, 46 re-
cords remained for further screening by reading of the full text. Finally,
seven eligible RCTs were included in this meta-analysis (Figure 1).
3.2 | Study characteristics
The seven articles were published between 1990 and 2018. All the stud-
ies were published in Science Citation Indexed journals; the impact fac-
tor of these journals ranged from 1.89 to 17.686. The participants were
older adults with a mean age of 65 years from, Australia, Indonesia, Iran,
Nepal, South Korea, the United States, and Turkey and 51.3% (1,105)
of them were male. Interventions varied in type included, frequency,
and duration. Health education type included salt-reduction training,
efficacy maintenance, group health education, individual counseling,
high BP advice, healthy lifestyle behavior counseling, self-monitoring,
and medication adherence. The median duration of exercise was two

Cochrane PubMed Web of Campbell EMBASE

Iden

Library (n=1602) science Library (n=1607)

Idteifnictaiftiicoanti

(n=893) (n=1050) (n=22)

Records after duplications (770) removed (n=4404)

Screening

Records screened Records excluded after title and abstract

(n=4404) evaluation (n=4313)

Records excluded (n=84)

Eligibility

Full-text articles · Studies were irrelevant to topics (n=28)

assessed for eligibility · Studies were not original research (n=36)
(n=91) · Reporting only as abstracts (n=4)
·Theoretical systems were not clearly
Identified (n=16)
Included

7 articles included in

F I G U R E 1   Flow chart of study qualitative synthesis

identification process
TA B L E 1   Characteristics of studies included in meta‑analysis
|

Experimental Group
4      

Sample Gender Mean SBP/DBP (SD) Age distribution Control Outcomes

First author (year) Country size (male%) BMI at baseline (X ± S ) Type Frequency Duration Group assessed

Irwan et al. (2016) Indonesia 45 37.8 EX1, 22.6 ± 3.3 SBP EX1, 147.5 (17.3) EX1, 67.90 ± 6.90 Salt-reduction Salt-reduction 1 week No SBP, DBP, BMI,
EX 2, 23.5 ± 3.3 EX2, 145.5 (30.5) EX2, training + Efficacy training: intervention salt intake,
CON, 21.6 ± 3.9 CON, 144.8 (21.1) 65.80 ± 5.90 maintenance 2 days Hypertension
DBP EX1, 88.0 (12.8) CON, a week; knowledge
EX2, 87.5 (15.5) 66.10 ± 5.70 Efficacy score
CON, 85.2 (10.2) maintenance:
each session
90 min
Wang and Li (2003) Australia 272 72.3 N/A SBP EX, 169.6 (14.9) EX, 62.70 ± 7.90 Education course Two times 2 months No SBP/DBP
CON, 170.0 (12.3) CON, monthly; intervention
DBP EX, 95.6 (8.7) 63.20 ± 10.70 each session
CON, 96.0 (10.4) 120 min
Park et al. (2011) South 40 32.5 N/A SBP EX, 134.6 (14.6) EX, 71.40 ± 5.70 Group health Health 12 weeks No SBP, DBP, Self-
Korea CON, 130.3(15.4) CON, education + Individual education: 1 intervention care behavior,
DBP EX, 77.9 (11.5) 69.70 ± 5.60 counseling + Exercise time a week; Self-efficacy
CON, 84.3 (10.0) Counseling: for exercise
1 time at the
4th week;
Exercise: 2
times per
week
González- USA 47 44.7 N/A SBP EX, 151 (23) EX, 60 ± 10 Education session Each session 8 weeks No SBP/DBP
Fernández, Rivera, CON, 144(13) CON, 58 ± 12 15–20 min, in intervention
Torres, Quiles, and DBP EX, 100 (13) 2 days
Jackson, (1990) CON,101 (13)
Hacihasanoglu et al. Turkey 120 48.3 EX1, SBP EX1, 159.25 EX1, 58 ± 8.90 Education session: EX1, Four times 2 months Routinely SBP, DBP, BMI,
(2011) 25.27 ± 2.87 (12.48) EX2, medication adherence; during clinic monitored: Regular use of
EX 2, EX2, 158.62 (12.85) 56.92 ± 8.04 EX2, medication visits; 2 times 4 times medications
25.62 ± 2.87 CON, 158.50 (14.24) CON, adherence + healthy home visits monthly in
CON, DBP EX1, 95.75 (5.00) 55.62 ± 8.46 lifestyle behaviors health care
26.07 ± 4.09 EX2, 95.50 (5.03) facilities;
CON, 94.75 ( 5.05) 2 times
monthly at
home

(Continues)
CHEN et al.
 CHEN et al. |
      5

months. In five studies that reported having health education sessions

control, healthy
regular physical

efficacy for BP

intake, alcohol
smokers、 salt

regular use of
of more than one time a week, each session lasted from 15 to 150 min.

Body weight,

activity, self-

medication,
Outcomes More specific details on each trial are given in Table 1.

nutrition

drinkers,
SBP, DBP,

SBP, DBP,

physical
assessed

Regular

activity
care: 1 time
3.3 | Risk of bias within studies
health care
weekly in

Usual care
centers
Routine
Control
Group

Figure 2 shows the risk of bias for the seven included studies. No
study was judged to be of low risk of bias in all six domains. Only two
studies explicitly demonstrated a randomized sequence generation
12 months
Duration

6 weeks

method (Daniali, Eslami, Maracy, Shahabi, & Mostafavidarani, 2017;

Neupane et al., 2018), and only two indicated the allocation conceal-

Abbreviations: BP, blood pressure; CON, control; DBP, diastolic blood pressure.; EX, experimental; N/A, information not available; SBP, systolic blood pressure.
ment method (Irwan et al., 2016; Neupane et al., 2018). Two trials
course: 5 days
a year; Home
monitoring + Promotion 120−150 min

visit: 3 times
each session

did not explicitly report the blinding of participants and personnel

Frequency

One time

(Daniali et al., 2017; Wang & Li, 2003). Moreover, two trials did not
weekly;

Training

a year

explicitly report the blinding of outcomes assessment (González-

Fernández et al., 1990; Irwan et al., 2016). As we could not obtain
the published protocols, the risk of bias in selective reporting for
control + Medication
Experimental Group

three studies was considered unclear (González-Fernández et al.,

course + Lifestyle
adherence + Self-
Exercise + Weight

counselling + BP
of self-efficacy

1990; Park et al., 2011; Wang & Li, 2003).

monitoring
Training
Type

3.4 | Meta-analysis
EX, 54.14 ± 6.50

EX, 50.12 ± 8.99
Age distribution

Figure 3 shows the forest plots for SBP after a single session or
50.28 ± 8.14
52.11 ± 6.50

course of health education. A statistically significant heterogene-

ity was identified across studies (I2 = 85%, p < .0001). The random
(X ± S )

CON,

CON,

effects meta-analysis suggested an overall reduction in SBP after

health education courses (SMD = 4.80, 95% CI: 7.01–2.59, p < .05),
DBP EX, 82.40 (8.47)

DBP EX, 91.83 (9.57)

Mean SBP/DBP (SD)

CON, 139.08 (13.84)

and similar results were observed after health education sessions

CON, 144.19 (19.19)

CON, 93.08 (10.83)

CON, 84.43 ( 8.80)

(SMD = 11.73, 95% CI: 17.63–5.82, p < .05).

SBP EX, 135.53

SBP EX, 142.71

Figure 4 gives the forest plots for DBP after a single session or
at baseline

(15.54)

(16.96)

course of health education. The DBP in intervention groups was sta-

tistically significantly lower compared with the control groups. DBP
reduction was not different after health education courses (p = .09).
The random effects meta-analysis suggested an overall reduction in
DBP after health education sessions (SMD = 5.39, 95% CI: 7.98–2.79,
p < .05). Meanwhile, heterogeneity across studies was statistically
BMI

N/A

N/A

significant (I2 = 84%, p < .001).

(male%)
Sample Gender

42.8

4 | D I S CU S S I O N
0
146

435
size

Seven available studies involving a total of 1,105 older adults from

Australia, Indonesia, Iran, Nepal, South Korea, the United States, and
Country

Turkey were included in this systematic review and meta-analysis.

Nepal
Iran
TA B L E 1   (Continued)

Among them, 707 (63.98%) older adults with hypertension were en-
rolled in health education courses. The effects of the health educa-
Daniali et al. (2017)
First author (year)

tion intervention were shown to be significantly greater compared

Neupane et al.

with usual care. The results are in line with previous reports (Daniali
et al., 2017; Miyamatsu et al., 2012; Wang & Li, 2003).
(2018)

Subgroup analyses of BP further demonstrated that structured

educational sessions involving large studies induced greater SBP and
 |
6       CHEN et al.

F I G U R E 2   Risk of bias

F I G U R E 3   Forest plot of the mean difference in systolic blood pressure with health education compared with usual care group

F I G U R E 4   Forest plot of the mean difference in diastolic blood pressure with health education compared with usual care group
CHEN et al.
DBP reduction compared with small studies. Structured educational
courses and sessions on hypertension have been related to substan-
tial improvements in older adults’ understanding of the nature and
treatment of hypertension (Cuspidi et al., 2001). Health education
and behavioral interventions for older adults with hypertension,
coupled with close BP monitoring, may result in better management
of hypertension. Several studies have demonstrated that struc-
tured training in hypertensive patients result in increased number
of weekly self BP measurements, weight loss, and decreased SBP
and DBP (Bernard, Townsend, & Sylvestri, 1998; Cuspidi et al., 2000;
Hartmann, 1997). Svetkey et al. and Reid et al. showed that edu-
cational interventions, as part of antihypertension therapy, improve
healthy lifestyle behaviors, increase medication adherence, and
significantly decrease BP levels. Wang and Li (2003) also reported
that the short-term favorable effects of educational interventions
on SBP may last up to five years. The improved BP management in
the educational group may be attributed to the interaction of many
factors, such as a significant reduction in BMI, healthy lifestyle be-
haviors, better medication compliance and self-care behavior, and
increased level of physical exercise.
Included trials were conducted in developed and developing
countries (Australia, Indonesia, Iran, Nepal, South Korea, the United
States, and Turkey), suggesting that structured health education in-
terventions are suitable for promotion across a wide range of health
systems (McLean et al., 2016). Health education intervention is cost
effective in terms of design and logistics, and can improve knowl-
edge and cognition, change behaviors, and improve physical condi-
tions (Albert & Davia, 2011). Gruman et al. (2010) reported that the
main purposes of health education are to cultivate health-related
and autonomous responsibilities, encourage realistic health-related
perceptions, improve public self-care capabilities, promote the ef-
fective use of health facilities, and promote the quality of health care
services. These interventions also have positive effects on preven-
tive health services. Therefore, the application of health education
can help older adults with hypertension obtain adequate and accu-
rate knowledge of hypertension, thereby improving their awareness
regarding seeking medical help when symptoms occur.
The methodological quality assessment of the RCTs identified
that the majority were at high or unclear risk for selection bias
because of inadequate concealment of allocation to the interven-
tion and random sequence generation. Although all presently re-
ported studies demonstrated randomization, only three reported
the use of stochastic grouping methods without providing details
(González-Fernández et al., 1990; Hacihasanoglu & Gozum, 2011;
Park et al., 2011). Only one RCT (Irwan et al., 2016) provided infor-
mation on using sealed envelopes as allocation concealment. Five
trials did not use any blinding method, which reflects the symp-
tom-based nature of the endpoints measured, thereby precluding
the blinding of the outcome reporting as well. All seven studies
provided information regarding dropouts, which was not enough
to influence the intervention effects. Four trials (Daniali et al.,
2017; Hacihasanoglu & Gozum, 2011; Irwan et al., 2016; Neupane
et al., 2018) were also considered to be at low risk of reporting
|
      7
bias, as they reported all the outcomes prespecified in their stud-
ies. Larger, adequately powered RCTs that are designed to assess
the impact of health education on hypertension are required to
confirm our positive finding.
This study has a number of limitations that need to be consid-
ered. First, some studies were not included owing to the limitations
in data availability, although we searched for accessible database
resources and references to the best of our ability. Second, we
found only a few studies involving hypertensive older adults and
implementing health education, which limited the generalizability
of our results. Third, our meta-analysis detected significant hetero-
geneity, including differences in type of intervention, participants’
living environment, and strategies used to confirm the research ob-
jectives. Systematic reviews bring together studies that are both
clinically and methodologically diverse; as such, heterogeneity in
the results is to be expected. A random effects model was used
to pool the results of the captured studies to estimate BP. Fourth,
the results of this meta-analysis are dependent on the quantity and
quality of the available literature, which may change in the future.
Fifth, to compare with other meta-analyses in this field, we have
limited the inclusion criteria for this meta-analysis to completed
publications in peer-reviewed journals because data from unpub-
lished abstracts may be unreliable and usually contain incomplete
information.
5 | CO N C LU S I O N
The results of this systematic review and meta-analysis showed that
the level of BP in older adults with hypertension in the health educa-
tion group, in terms of SBP and DBP, was significantly lower com-
pared with those in the usual care group.
AC K N OW L E D G E M E N T S
We thank all members of our study team for their whole-hearted
cooperation and the original authors of the included studies for their
wonderful work. We also thank Evidence-Based Medicine Center of
Lanzhou University for methodological support.
C O N FL I C T O F I N T E R E S T
None declared.
AU T H O R C O N T R I B U T I O N S
XXL and XMH planned and designed the research; KHY and XMH
provided methodological support/advice; YJC and LG tested the fea-
sibility of the study; YJC, GZJ, BP, and ZTB extracted data; YJC and
XXL performed the statistical analysis; YJC wrote the manuscript;
YJC, XMH, and KHT revised the manuscript; all authors approved
the final version of the manuscript.
E T H I C S A P P R OVA L
Ethics approval and participants’ consent were not required because
this study is a meta-analysis based on the published studies.
 |
8       CHEN et al.
DATA AVA I L A B I L I T Y S TAT E M E N T
The datasets and any other materials of our study are available from
the corresponding author on request.
ORCID
Yajing Chen  https://orcid.org/0000-0001-9862-4863
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