Advancing health equity amongst displaced persons through telehealth services: a retrospective cross-sectional study

The initiation of Russia’s military incursion of Ukraine on 24 February 2022 marked a significant escalation of the pre-existing Russo-Ukrainian conflict that traces back to 2014 (Sangal et al., 2022). This considerable military engagement prompted what is characterised as the most extensive refugee crisis in Europe since the end of World War II. Recent reports revealed that over 6.3 million Ukrainians have sought refuge in neighbouring countries, alongside approximately 3.7 million classified as internally displaced persons (IDPs), a figure reflecting more than one-third of the nation’s demographic (UNHCR, 2024).

The resulting extensive migration has worsened pre-existing disparities and concurrently introduced obstacles regarding the acquisition of health-care services. It is imperative to denote that these variances termed as health disparities, constitute inequitable discrepancies in health outcomes among various demographic groups, which are predominantly arising from discrepancies entrenched within social, economic or environmental conditions. Therewithal, during periods of military conflict, the health circumstances of certain demographic groups, typically characterised by heightened vulnerability including women, children and the aged tend to deteriorate (Holt, 2022). Analysing historical precedents elucidates the profound and extensive public health ramifications engendered by armed hostilities on susceptible segments of society. For instance, the ongoing armed engagement in Syria and the enduring conflict in Iraq serve as pertinent exemplars illustrating the considerable repercussions of warfare on health equity and the accessibility of medical interventions (Blanchet et al., 2017).

The analysis of a previous study showed that the health-care crisis ensuing from the Ukrainian conflict ushered in a myriad of complexities. A significant proportion, over 50%, of all forcibly displaced Ukrainians indicated a pronounced deficiency in accessibility to health-care provisions and vital medications (University of Southampton, 2022). With the temporal progression of hostilities, the obliteration of medical facilities escalated in magnitude, poised to incapacitate the pre-existing health-care system and exacerbating the humanitarian crisis (Dzhus and Golovach, 2022). In counteraction to this burgeoning health emergency, the World Health Organisation (WHO) engaged in prompt efforts, collaborating with assorted member states and global entities to facilitate the provision of imperative medicinal supplies and equipment to Ukrainian territories (Fletcher and Cullinan, 2022).

On a broader international spectrum, nations accommodating refugees undertook modifications within their health-care systems to manage the surge of refugees. Nonetheless, the dilemma surrounding Ukrainian refugees has unveiled certain vulnerabilities as well as rigidity inherent within public health strategies and health-care systems in certain countries within the European Union (EU) (Spiegel, 2022). Owing to the flawed responses, the European Commission (EC) created an online platform aimed at directing refugees towards attainable health-care services across various hosting countries (European Commission, 2023). Notwithstanding these initiatives, the preliminary responses to the Ukrainian displaced populace were insufficient, thereby underscoring ongoing inequalities in access to health care. Factors related to socio-political contexts, including barriers related to language, lack of familiarity with the health-care systems of host countries and uncertainties surrounding legal status, which are widely acknowledged obstacles for refugees across Europe, further elucidate the challenges encountered by Ukrainians (Lebano et al., 2020). Moreover, the psychological trauma prevalent among displaced individuals often culminated in issues related to mental health, which were habitually insufficiently addressed in contexts of crises (Silove, Ventevogel and Rees, 2017).

Comparably, in the aftermath of the Syrian refugee crisis originating in 2011, notable health-care discrepancies were brought to light, especially regarding displaced persons. An investigation surfaced the fact that a notably high percentage of this population (49.0%) experienced unmet medical needs, contrasting sharply with a mere 11.2% reported within the general populace. The predominant barriers identified included excessive wait times, lack of service availability and financial limitations. This disparity between perceived health status and tangible access to health-care services accentuates the intricate interrelation of determinants that foster health inequity in contexts of displacement (Oda et al., 2017).

Similarly, the ongoing conflict in Afghanistan has revealed the enduring repercussions of warfare on health-care systems and public health outcomes. Prolonged periods of instability have resulted in a fragmented health-care infrastructure and constrained accessibility to vital services, alongside a substantial burden attributed to both communicable and non-communicable diseases (Acerra, Iskyan, Qureshi and Sharma, 2009). Such circumstances have emphasised the necessity for constructing health-care systems that exhibit resilience and adaptability, henceforth able to cater to the varied requirements of displaced persons. Within this context, telehealth has surfaced as a prospective intervention to address the barriers to health-care accessibility. By using digital technology for the delivery of remote health services, tackling health-care disparities particularly prevalent amongst a disadvantageous or inaccessible demographics became evident (Kichloo et al., 2020). Notably, the efficacy of telehealth has been further corroborated during the COVID-19 pandemic as it played a crucial role in ensuring remote access to critical health-care services (Ali and Khoja, 2020). Furthermore, telehealth services has provided a vital link in emergency events by allowing rapid operational capabilities. This operational framework enabled health-care practitioners who are geographically distanced from affected regions to provide supplementary support for local health-care systems under constraints (Xiong et al., 2012). However, the subsequent engagement with telemedicine following such cataclysmic events has frequently encountered hurdles stemming from infrastructural deficiencies alongside resource scarcity (Doarn and Merrell, 2014). Even so, the Ukrainian telecommunication infrastructure has retained its operational capabilities, which permitted a persistent internet connectivity in most regions (De Vynck, Allison and Pietsch, 2022).

Leveraging on the existent opportunity, several telemedicine coalitions were formed throughout 2022, aiming to improve health-care access for Ukrainian displaced persons and address the considerable surge in patient enquiries (GlobalData Thematic Intelligence, 2022). Amongst multiple initiatives, a prominent project called the Likarnya online project was created by Bionabu, a company that provides medical technology solutions tailored to health-care systems. This humanitarian initiative sought to proffer telehealth services specifically tailored for displaced individuals, thus fostering immediate communication channels between health-care providers and patients through various digital platforms (Likarnya Online, 2023). Notwithstanding the advantageous solutions offered by telehealth, some challenges related to equitable accessibility has been found. Issues surrounding digital literacy levels, the availability of necessary technological resources, along with concerns about privacy protection demand rigorous attention (Nouri, Khoong, Lyles and Karliner, 2020). Considering the complex nature of telehealth services provision within crisis contexts, this study examines data from the Likarnya online project, focusing on the health-related experiences of displaced Ukrainian individuals between March and September 2022. Hence, we aim to provide comprehensive insights into the usage and potential of telehealth services in addressing health disparities among displaced populations in conflict zones and to contribute to the growing body of knowledge on crisis health-care delivery and provide a foundation for future research and policy development.

The fundamental objectives that we principally seek to accomplish is to describe the demographic and clinical characteristics of people using telehealth services, examine patterns of health-care access barriers and its association to factors and to assess the distribution and various associations linking medical specialties, case statuses and illness conditions.

This research uses a retrospective cross-sectional design, using routinely collected data from the electronic health records (EHR) of the Likarnya online project between March and September 2022. The Likarnya online project stands as a prominent voluntary tele-consultation platform, offering medical advice and speciality-related consultations to Ukrainians who face barriers to accessing medical care due to the ongoing conflict. This study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines, as detailed in Supplementary File S1.

Since March 2022, the tele-consultation platform of the Likarnya project has been accessible to Ukrainian patients, delivering assessments across various clinical specialisations by a cadre of over 70 doctors and health-care experts from diverse global locations. The integration of data into the EHR follows a tripartite process. Initially, patients complete a streamlined electronic inquiry form via a secure mobile connection, wherein they select their preferred channel for contact; choices being email, Zoom or Telegram. In the next stage, a cadre of Ukrainian and Russian-speaking administrators filter, translate, refine and organise the data. In instances where essential data is lacking, the administrators reach out to the patients seeking additional information pertinent to the designated area of speciality.

The subsequent phase involves the incorporation of the structured data into the EHR for triage purposes. During this stage, physicians are allocated to consult or advise patients based on their expertise and area of speciality. In accordance with the project’s stringent data protection and security policy, access to the EHR is restricted exclusively to verified physicians and administrators.

This study examines information pertaining to displaced Ukrainian individuals due to the conflict from March to September 2022. The study population was defined based on specific inclusion and exclusion criteria to ensure a focused and relevant data set. Table 1 summarises these criteria.

Data was extracted from the EHR database using a standardised template based on the study’s objectives and eligibility criteria. The EHR contains a comprehensive pool of demographic, clinical and triage assessment information, from which certain variables were extracted for analysis: age, sex, language, location, enquiry category, case status, medical speciality, health-care access barriers, case severity, displacement status and illness condition. The data was subsequently transferred into separate analysis file for further processing and validation executed by the corresponding author. When a specialist needed more information about a patient’s complaint during the triage phase, patients were contacted. To ensure the entry of validated data, clinicians were required to complete a case summary section after consulting with patients. In due course, subsequent checks for completeness of data were performed by the lead administrator to uphold the structural integrity of data sets.

The statistical analysis used both descriptive and inferential methods. Descriptive statistics included a comprehensive table of participant characteristics. Visual representations comprised three charts: a stacked bar chart illustrating clinical specialty referrals by sex, a clustered bar chart depicting case status stratified by health-care access barriers and age and a stacked bar chart showing illness condition by case status.

Inferential analyses encompassed a series of statistical tests. Chi-square tests of independence were conducted to examine associations between four pairs of variables: medical specialty referral and sex, case status and health-care access barriers, illness condition and case status and case severity and health-care access barriers. These tests were used to ascertain the presence of statistically significant relationships between categorical variables.

For those associations that yielded significant results in the chi-square tests, odds ratio (OR) analyses were subsequently performed. Whilst chi-square tests provide information about the existence of an association, OR offers a measure of the strength and direction of that association. This dual approach allows for a more nuanced understanding of the relationships between variables.

A logistic regression analysis was conducted with health-care access barriers as the dependent variable, and age, sex and displacement status as independent variables. This multivariate approach enables the exploration of how multiple factors simultaneously influence the likelihood of experiencing health-care access barriers.

All analyses were conducted using R version 3.0. The threshold for statistical significance was set at p < 0.05, and 95% confidence intervals were calculated where appropriate, providing a measure of the precision of our estimates. The contingency tables underpinning all statistical analyses are presented in Supplementary File S2, offering a comprehensive view of the data distribution across variables of interest.

This study used de-identified data from the Bionabu Likarnya project, a telehealth initiative serving displaced Ukrainians. The data set contained no direct or indirect identifiers, precluding any means of linking data to subjects’ identities. A thorough review of Bionabu’s data collection and management processes was conducted to ensure data integrity. Given the nature of the data and the absence of identifiable information, this research falls under the category of exempt research as per institutional review board (IRB) guidelines. Nonetheless, the study adhered to stringent ethical standards throughout the analysis and reporting process, maintaining the principles of beneficence and non-maleficence in research involving crisis-affected populations.

The demographic and clinical characteristics of the study cohort are presented in Table 2. The study encompassed a sample of 314 Ukrainians who used the Likarnya online tele-consultation services from March to September 2022. A significant majority of the users were females, accounting for 77.1% (n = 242) of all users. The median age of users was 33 years with a mean age of 33.21 ± 19.09. The dominant language used by the participants was Ukrainian 59.62% (n = 186), succeeded by Russian, which constituted 35.58%, while a mere fraction of 4.81% used English as their primary language of communication.

The majority of the population was considered as refugees (74.19%, n = 233), while 25.81% were identified as internally displaced. A total of 69.7% (n = 219) of the population indicated the presence of barriers to health-care access. The most common illness condition was chronic cases, accounting for 80.6% (n = 253) of all cases, and a total of 19.4% of patients had acute illness conditions. An examination of case severity showed an equitable distribution across mild and moderate categories, each comprising an approximate equal share of cases at around 47.45% (n = 149), while cases classified as severe accounted for a small percentage amounting to just 5.10% (n = 16). As for cases status, most cases were closed; the remaining 21.34% have been lost to follow-up. As for the questions, consultation constituted 73.84% of cases, and advice was demanded in 26.11% of all cases.

Analysis of clinical speciality referrals, as illustrated in Figure 1, revealed a predominance of general practice (GP)/internal medicine consultations (72.93%, n = 229), followed by paediatrics (10.19%, n = 32) and obstetrics and gynaecology (5.10%, n = 16). Further analysis of the gender distribution within specialities elucidated notable patterns (S2,1). Accordingly, GP/internal medicine, the most frequently required speciality, demonstrated a significant female majority (79%, n = 181). Paediatrics emerged as the sole speciality with a slight male preponderance (53.1%, n = 17). Certain specialities, namely, cardiology, obstetrics and gynaecology and psychology, exhibited exclusive female representation, albeit with smaller sample sizes.

A chi-square test of independence was conducted to test the association between medical speciality referrals and sex variables. The analysis yielded a chi-square statistic (χ²) of 24.02, with a corresponding p-value of 0.0011. This p-value, being less than the conventional significance threshold of 0.05, indicates a statistically significant association between sex and medical speciality referrals.

Given the significant association between medical speciality referrals and sex, OR was not calculated due to key methodological considerations. Primarily, the limited data availability within particular specialties, exemplified by cardiology and psychology, which poses a challenge due to the lack of reliability and robustness of OR estimates. Furthermore, the intrinsic nature of specific specialties, particularly those such as obstetrics and gynaecology, which are decidedly sex-specific, gives rise to scenarios involving structural zeros for male patients; this circumstance contravenes foundational assumptions requisite for the interpretation of OR- in a meaningful capacity.

Analysis of case status and healthcare access barriers, as depicted in Figure 2, reveals noteworthy results. A significant majority (55.09%, n = 173) of individuals encountering health-care access barriers ultimately achieved case closure. Conversely, 14.64% (n = 46) were lost to follow-up. Among those without reported access barriers, 23.57% (n = 74) had their cases closed and 6.69% (n = 21) were lost to follow-up (S2,2).

The age-stratified analysis revealed that in the group of patients who aged 16 years and older, 44.90% (n = 141) of those facing health-care access barriers had closed cases, compared to 17.83% (n = 56) of those without such barriers. The case closure proportion of patients under 16 years old was 10.19% (n = 32) for those with health-care access barriers and 5.73% (n = 18) for those without barriers. The proportion of lost to follow-up cases was consistently lower than closed cases in both age groups, with the largest proportion (12.10%, n = 38) identified in the group of patients over 16 years old who reported health-care access barriers (S2,3).

To test the association between case status and health-care access barriers, a chi-square test was performed. The results showed a chi-square statistic (χ²) of 0.0047 with a p-value of 0.9452, suggesting no statistically significant association between these variables when stratified by age.

Figure 3 illustrates the distribution of illness conditions in relation to case status. Of the acute cases, 12.42% (n = 39) were closed, whilst 7.0% (n = 22) were lost to follow-up. Among chronic cases, 66.24% (n = 208) were closed, and 14.33% (n = 45) were lost to follow-up (S2,4).

A chi-square test was conducted to assess the association between illness condition and case status. The test yielded a χ² value of 8.7252, with a p-value of 0.0031. This result indicates a statistically significant association between illness condition and case status, with the significance level set at 0.05.

Consequently, an OR analysis was performed to quantify the strength and direction of the association. The analysis yielded an OR of 0.384 (95% CI: 0.203–0.725) for illness condition against case status was observed, indicating that the odds of a case being closed are virtually 61.6% lower for acute conditions than chronic conditions. Simply put, displaced Ukrainians with chronic conditions were more likely to have their cases closed compared to those with acute conditions.

The association between case severity and health-care access barriers was tested (S2,5). Among mild cases, 41.61% (n = 62) of patients did not encounter health-care access barriers, whilst 58.39% (n = 87) faced such barriers. In the group of moderate cases, 20.13% (n = 30) encountered no barriers, compared to 79.87% (n = 119) who did. In severe cases, only 18.75% (n = 3) reported no barriers, whilst 81.25% (n = 13) experienced health-care access barriers.

To test the statistical significance of this association, a chi-square test was conducted. The test yielded a chi-square statistic of 17.34, with a corresponding p-value of 0.00017, which indicates a highly significant association between case severity and health-care access barriers variables at the 0.05 significance level. Given the significant results of the chi-square test, OR analyses were performed to quantify the strength of these associations. Accordingly, moderate severity cases were 2.58 times more likely to face health-care access barriers compared to other severity levels. Severe cases follow with a 1.94 times higher odds of encountering health-care access barriers, while mild cases showed lower odds (0.35) of experiencing such barriers.

To expound upon the various factors that impede access to health-care services, a logistic regression analysis was performed (S2,6). This analysis included age, sex and displacement status as independent variables, with health-care access barriers as the dependent variable.

The results showed that age is the sole statistically significant predictor, which implies an associated increase in the odds of experiencing impediments to health-care access by an approximation of 1.5% (OR = 1.015, 95% CI: 1.001–1.030) for each increment in year.

In addition, although not statistically significant, the results suggested that males had 24.1% higher odds of facing access barriers compared to females (OR = 1.241, p = 0.485), and refugees had 12.9% higher odds of experiencing barriers compared to IDPs (OR = 1.129, p = 0.694).

The Russian–Ukrainian conflict has precipitated a humanitarian crisis of unprecedented scale that has exacerbated pre-existing health inequities and created new challenges in health-care access. The resulting mass displacement has significantly disrupted healthcare provision, leading Ukrainians to face substantial barriers to accessing essential medical services. Consonantly, a study showed that 72% of displaced Ukrainians encountered barriers to accessing health-care services owing to issues such as language barriers, unfamiliarity with host country health-care systems and limited access to specialised care. These challenges highlight the pressing need for innovative solutions to address health disparities among displaced populations (Ivanova, Kovalenko and Smith, 2023).

Our findings contribute to understanding health-care accessibility within health inequities, revealing a significant gender disparity among telehealth users, with females constituting 77.1% of the cohort. This imbalance likely reflects the demographic shift caused by the conflict, with many men of military age remaining in Ukraine (Carpenter, 2022). The predominance of female users underscores the importance of gender-sensitive approaches in telehealth service design and delivery, particularly in addressing women’s health needs in displacement contexts.

The high prevalence of health-care access barriers (69.7%) amongst our study population emphasises the critical role of telehealth in bridging gaps in care provision for displaced individuals. This finding aligns with previous research indicating that more than half of displaced Ukrainians face significant barriers to accessing health services (Head, 2022). The transnational nature of this health-care challenge is further highlighted by the substantial proportion of refugees (74.19%) in our study population.

Additionally, the analysis of clinical specialty referrals revealed a striking predominance of GP/internal medicine consultations (72.93%). This finding underscores the crucial role of primary care in addressing the health needs of displaced populations. A seminal study on rebuilding health systems in conflict-affected states emphasises the importance of strengthening primary health-care systems in such regions, noting that robust primary care can provide a foundation for health system resilience and responsiveness during crises (Martineau et al., 2017). These insights align closely with our findings, reinforcing the need to prioritise primary care services in telehealth platforms for displaced populations.

Moreover, our data revealed a significant association between medical specialty referrals and sex variables, particularly in specialities such as obstetrics and gynaecology. This observation highlights the need to incorporate tailored, gender-specific health services within telehealth platforms to address the unique needs of both men and women in crisis situations. Alongside demographic factors, our results show a significant case closure (78.66%), which may imply the potential effectiveness of telehealth platforms in mitigating health-related challenges. However, the lower odds of case closure for acute conditions compared to chronic conditions (OR = 0.384), requires further investigation. This discrepancy could potentially indicate limitations in the ability of telehealth to address acute conditions, or more broadly, manage acute cases, particularly in displacement contexts. Hence, further research is needed to identify the factors contributing to this discrepancy and conceptualise strategies aimed at bolstering the management of acute conditions through telehealth modalities.

Our findings regarding the association between case severity levels and health-care access barriers provide valuable insights pertaining to the role of health-care accessibility as a pivotal social determinant within conflicted regions. Both moderate and severe cases have higher odds of facing health-care access barriers, with an OR equating (OR = 2.58) and (OR = 1.94), respectively, in comparison to mild cases. These results illustrate how the severity of health conditions may evidently impact social determinants through perpetuating pre-existing disparities intrinsic to health equity frameworks.

The association between case severity and health access barriers elucidates a rather multifaceted scenario inherent within contexts of displacement. This observation accentuates the pressing necessity for interventions that are precisely calibrated for enhancing available pathways toward adequate health care for moderate or severe cases. This could be achieved through enhanced telehealth programmes or specifically designed outreach programmes.

The logistic regression analysis brings forth age as a paramount predictive variable concerning health-care access barriers, in which each additional year of age associated with a 1.5% increase in the odds of encountering such barriers. This finding underscores the specific adversities faced by older displaced individuals and emphasises the need for age-sensitive approaches in telehealth service provision. Notably, this observation aligns with and expands upon previous research that has shed light on the unique challenges faced by older adults in accessing health care during humanitarian crises (Karunakara and Stevenson, 2012). Our results corroborate and build upon these prior findings, highlighting the persistent nature of age-related health-care disparities in displacement contexts, thus reaffirming the imperative for targeted interventions tailored to the specific needs of this demographic in telehealth implementation strategies.

These findings contribute significantly to our understanding of health equity in conflict settings and the potential role of digital health solutions in addressing disparities. The considerable engagement with telehealth services, particularly for primary care needs, suggests that such platforms may fulfil an essential role in providing accessible health care to displaced populations. Nevertheless, the enduring obstacles associated with health-care accessibility, predominantly impacting individuals with more severe conditions and older individuals, highlight the need for continued efforts to enhance the reach and effectiveness of telehealth services.

This study presents multiple significant strengths concerning telehealth services provision to displaced Ukrainians. A key advantage is our use of a comprehensive data set from the Likarnya online project.

The collection of real-time data amidst the crisis facilitates a timely and relevant analysis of health-care needs and existing access barriers in a rapidly evolving humanitarian situation. Furthermore, the study’s rigorous statistical analyses, encompassing both descriptive and inferential analyses, offers a nuanced understanding of the complex interplay between demographic factors, health conditions and health-care access in the context of displacement.

Nevertheless, it remains essential to acknowledge various constraints inherent within this research. While using a retrospective cross-sectional design suits the urgent conditions of this study, it impedes the establishment of causal relationships and limits our ability to track changes in health-care access and outcomes over time.

Furthermore, the study’s reliance on secondary data derived from EHR, whilst providing a wealth of information, restricts our ability to investigate potential confounding variables or engage in a more profound exploration of the qualitative dimensions of patients’ experiences with telehealth services.

Additionally, the lack of a control group alongside the absence of comparisons with traditional health-care delivery models serve to significantly hinder our ability to decisively assess the efficacy of telehealth services within this specific context. Despite these aforementioned limitations, this study offers important insights into the prospective role of telehealth in mitigating health disparities among displaced populations. Moreover, it lays down an initial foundation for future research in this crucial area of global health research.

This study illuminates the pivotal role of telehealth in addressing health inequities amongst displaced Ukrainians amidst an unprecedented humanitarian crisis. The findings underscore the potential of digital health solutions to bridge significant gaps in health-care access, particularly for vulnerable populations in conflict zones. The high proportion of reported health-care access barriers and the substantial rate of case closure through telehealth consultations, makes it evident that telehealth services are critically needed during crisis situations. Moreover, the prevalence of primary care consultations through the telehealth platform emphasises the critical need for robust, accessible general medical services for displaced populations. This insight suggests that future telehealth initiatives should prioritise the integration of primary care services, potentially reshaping health-care delivery strategies in humanitarian contexts.

Our analysis reveals important disparities in health-care access and utilisation across different demographic groups and health conditions. The higher odds of encountering health-care access barriers for older individuals and those with severe health conditions highlights the need for targeted interventions to support these vulnerable groups. These findings might guide the development of more equitable and effective telehealth interventions, tailored to address the specific needs of women, older adults and those with complex health conditions.

The insights garnered from this study have significant implications for global health policy as well as implementation strategies. Building on these findings, policymakers and health-care providers can develop targeted interventions which specifically address the needs of displaced persons, ultimately contributing to increased equity in health-care provision in areas affected by conflict and displacement.

In contemplating future initiatives, it is imperative to build upon this foundation to further enhance the efficacy and reach of telehealth services in humanitarian emergencies. Upcoming research endeavours ought to focus on probing the prolonged repercussions of telehealth services on health outcomes, alongside paradigms of access pertinent to displaced groups. Furthermore, exploring innovative approaches to navigate around detected barriers such as challenges stemming from age-related digital literacy and acute conditions management through telehealth platforms will prove vital in this domain moving forward.

The authors would like to thank the CEO of Bionabu and creator of the Likranya online project, Ina Burgstaller for granting permission to use the Likarnya online database to conduct this research. The authors’ gratitude also goes to the administrators of Likarnya Online for their collaboration and support in obtaining the required information.

Funding: The authors declare no relevant financial interests and affirm that no promises of future financial support were received in relation to this work.

Conflict of interest: The authors have no conflicts of interest to declare for this study.

Data availability: This study used the Likarnya online project’s database, which was collected and refined by the Bionabu MedTech company. The company restricts public data dissemination due to privacy considerations. However, de-identified data is available for researchers who meet the criteria of access by contacting the corresponding author.

The supplementary material for this article can be found online.

S1 file includes the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for reporting a cross-sectional study.