{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,21]],"date-time":"2026-07-21T14:04:22Z","timestamp":1784642662877,"version":"3.55.0"},"reference-count":53,"publisher":"BMJ","issue":"7","license":[{"start":{"date-parts":[[2026,7,21]],"date-time":"2026-07-21T00:00:00Z","timestamp":1784592000000},"content-version":"unspecified","delay-in-days":20,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"name":"The Science &Technology Department of Jiangsu Province","award":["BE2023778"],"award-info":[{"award-number":["BE2023778"]}]},{"name":"Liyang City\u2019s 2023 Annual research and development Plan Follows Nanjing Project","award":["LC2024001"],"award-info":[{"award-number":["LC2024001"]}]},{"name":"Jiangsu Provincial Medical Innovation Center","award":["Rehabilitation Medical Innovation Center CXZX20222"],"award-info":[{"award-number":["Rehabilitation Medical Innovation Center CXZX20222"]}]},{"name":"The National Key R&D Program of China","award":["2023YFC3603605"],"award-info":[{"award-number":["2023YFC3603605"]}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,7,7]]},"published-print":{"date-parts":[[2026,7]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Social isolation may have adverse effects on incidence and severity of cognitive impairment including subjective cognitive decline (SCD). An increase of environmental variety and social interactions may furthermore reduce progression from SCD to dementia. Research evaluating respective interventions is limited, particularly as regards studies comparing different degrees of social engagement interventions. We thus developed a clinical trial protocol to determine the efficacy of social interventions with different intensities in protecting cognitive function and white matter integrity in socially isolated adults aged 45\u201385 with SCD.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and analysis<\/jats:title>\n                    <jats:p>This is a single-centre, three-arm randomised controlled trial with a 1:1:1 randomisation ratio, conducted from 1 December 2023 to 30 December 2026. The trial evaluates three study arms over a 12-week period: two social intervention arms (a social group intervention and a one-to-one social interaction intervention), both of which adopt a comprehensive model centred on social interaction and integrated with structured aerobic exercise and cognitive training; and a usual care arm in which participants receive only weekly health education. The sample size is estimated at 132 participants with SCD aged 45\u201385 years residing in Nanjing communities, China. Participants will be assigned to one of the three study groups via block randomisation stratified by gender. The principal outcome is improvement in mnemonic performance with delayed recall in the HuaShan version of the auditory verbal learning test between baseline and week 12. Secondary outcomes include improvement in white matter integrity measured by fractional anisotropy, along with changes in executive function, behavioural indicators and serum biomarkers assessed at baseline and week 12. Furthermore, follow-up evaluations with cognitive scales and serological data will take place at 3\u2009months post-intervention.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Ethics and dissemination<\/jats:title>\n                    <jats:p>Ethical approval for this trial has been obtained from the Ethics Committee of the First Affiliated Hospital of Nanjing Medical University (approval No. 2023-SR-726.A1). Written informed consent will be secured from all participants before they are enrolled in the study. Findings from the trial will be submitted for publication in peer-reviewed academic journals.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration number<\/jats:title>\n                    <jats:p>ChiCTR2400080312.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-108844","type":"journal-article","created":{"date-parts":[[2026,7,21]],"date-time":"2026-07-21T13:40:48Z","timestamp":1784641248000},"page":"e108844","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Impact of different degrees of social engagement interventions (DDSEIs) on cognitive performance and brain activity in community-dwelling adults with subjective cognitive decline in Nanjing, China: a randomised controlled trial protocol"],"prefix":"10.1136","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0009-0009-0831-5713","authenticated-orcid":false,"given":"Jiahuan","family":"Li","sequence":"first","affiliation":[{"name":"Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xi","family":"Yang","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hua","family":"Xu","sequence":"additional","affiliation":[{"name":"Nanjing Medical University Affiliated Geriatric Hospital, Nanjing, Jiangsu, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wei","family":"Pan","sequence":"additional","affiliation":[{"name":"Suzhou Ruiying Rehabilitation Hospital, Suzhou, Jiangsu, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chunxu","family":"Shi","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-4744-0421","authenticated-orcid":false,"given":"Nan","family":"Xia","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-2125-3172","authenticated-orcid":false,"given":"Yuqi","family":"Cheng","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fanfan","family":"Meng","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hanbo","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jin","family":"Liu","sequence":"additional","affiliation":[{"name":"Clinical Medicine Research Institution, Jiangsu Province People\u2019s Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing, Jiangsu, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ming","family":"Qi","sequence":"additional","affiliation":[{"name":"Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tong","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jan D","family":"Reinhardt","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China"},{"name":"Institute for Disaster Management and Reconstruction, Sichuan University, Chengdu, China"},{"name":"Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yi","family":"Zhu","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,7,21]]},"reference":[{"key":"2026072106402223000_16.7.e108844.1","first-page":"396","article-title":"Interpretation of subjective cognitive decline characteristics published in Lancet Neurology","volume":"53","author":"Sun","year":"2020","journal-title":"Chinese Journal of Neurology"},{"key":"2026072106402223000_16.7.e108844.2","first-page":"715","article-title":"Subjective cognitive decline at the pre-dementia stage in Alzheimer\u2019s disease","volume":"32","author":"Jessen","year":"2013","journal-title":"Nervenheilkunde"},{"key":"2026072106402223000_16.7.e108844.3","doi-asserted-by":"publisher","DOI":"10.1016\/S1474-4422(19)30368-0"},{"key":"2026072106402223000_16.7.e108844.4","doi-asserted-by":"crossref","first-page":"150","DOI":"10.5603\/pjnns.96286","article-title":"Updates on pharmacological treatment for Alzheimer\u2019s disease","volume":"58","author":"Tipton","year":"2024","journal-title":"Neurol Neurochir Pol"},{"key":"2026072106402223000_16.7.e108844.5","doi-asserted-by":"publisher","DOI":"10.1056\/NEJ-Moa2212948"},{"key":"2026072106402223000_16.7.e108844.6","doi-asserted-by":"crossref","first-page":"211","DOI":"10.1038\/s41392-024-01911-3","article-title":"Recent advances in Alzheimer\u2019s disease: mechanisms, clinical trials and new drug development strategies","volume":"9","author":"Zhang","year":"2024","journal-title":"Sig Transduct Target Ther"},{"key":"2026072106402223000_16.7.e108844.7","doi-asserted-by":"crossref","first-page":"753","DOI":"10.15585\/mmwr.mm6727a1","article-title":"Subjective Cognitive Decline Among Adults Aged \u226545 Years - United States, 2015-2016","volume":"67","author":"Taylor","year":"2018","journal-title":"MMWR Morb Mortal Wkly Rep"},{"key":"2026072106402223000_16.7.e108844.8","doi-asserted-by":"crossref","first-page":"4681","DOI":"10.1080\/09638288.2021.1916626","article-title":"Occupational performance issues in older adults with subjective cognitive decline","volume":"44","author":"Rotenberg","year":"2022","journal-title":"Disabil Rehabil"},{"key":"2026072106402223000_16.7.e108844.9","unstructured":"National Academies of Sciences EaM, Division of Behavioral and Social Sciences and Education, Division HaM . Social isolation and loneliness in older adults: Opportunities for the health care system. Washington (DC): National Academies Press (US), 2020."},{"key":"2026072106402223000_16.7.e108844.10","doi-asserted-by":"crossref","first-page":"5114","DOI":"10.1002\/alz.13072","article-title":"Social connections and risk of incident mild cognitive impairment, dementia, and mortality in 13 longitudinal cohort studies of ageing","volume":"19","author":"Mahalingam","year":"2023","journal-title":"Alzheimer's & Dementia"},{"key":"2026072106402223000_16.7.e108844.11","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(00)02113-9"},{"key":"2026072106402223000_16.7.e108844.12","doi-asserted-by":"publisher","DOI":"10.1002\/gps.5065"},{"key":"2026072106402223000_16.7.e108844.13","doi-asserted-by":"crossref","DOI":"10.1186\/s13643-017-0632-2","article-title":"The impact of social activities, social networks, social support and social relationships on the cognitive functioning of healthy older adults: a systematic review","volume":"6","author":"Kelly","year":"2017","journal-title":"Syst Rev"},{"key":"2026072106402223000_16.7.e108844.14","doi-asserted-by":"crossref","first-page":"218","DOI":"10.1016\/j.jad.2015.08.031","article-title":"Association of empty nest with depressive symptom in a Chinese elderly population: A cross-sectional study","volume":"187","author":"Zhai","year":"2015","journal-title":"J Affect Disord"},{"key":"2026072106402223000_16.7.e108844.15","doi-asserted-by":"crossref","first-page":"356","DOI":"10.1111\/ggi.12277","article-title":"Disparities in prevalence and risk indicators of loneliness between rural empty nest and non-empty nest older adults in Chizhou, China","volume":"15","author":"Cheng","year":"2015","journal-title":"Geriatr Gerontol Int"},{"key":"2026072106402223000_16.7.e108844.16","doi-asserted-by":"crossref","first-page":"1563","DOI":"10.1007\/s11357-022-00584-6","article-title":"Perceived social isolation is correlated with brain structure and cognitive trajectory in Alzheimer\u2019s disease","volume":"44","author":"Zhang","year":"2022","journal-title":"Geroscience"},{"key":"2026072106402223000_16.7.e108844.17","doi-asserted-by":"crossref","first-page":"e164","DOI":"10.1212\/WNL.0000000000201564","article-title":"Associations of Social Isolation and Loneliness With Later Dementia","volume":"99","author":"Shen","year":"2022","journal-title":"Neurology"},{"key":"2026072106402223000_16.7.e108844.18","doi-asserted-by":"publisher","DOI":"10.1016\/j.yfrne.2023.101061"},{"key":"2026072106402223000_16.7.e108844.19","doi-asserted-by":"crossref","DOI":"10.1186\/s12877-018-0897-x","article-title":"Interventions to address social connectedness and loneliness for older adults: a scoping review","volume":"18","author":"O\u2019Rourke","year":"2018","journal-title":"BMC Geriatr"},{"key":"2026072106402223000_16.7.e108844.20","doi-asserted-by":"crossref","first-page":"246","DOI":"10.1159\/000485616","article-title":"Is Social Network a Protective Factor for Cognitive Impairment in US Chinese Older Adults? Findings from the PINE Study","volume":"64","author":"Li","year":"2018","journal-title":"Gerontology"},{"key":"2026072106402223000_16.7.e108844.21","doi-asserted-by":"crossref","first-page":"1338665","DOI":"10.3389\/fpubh.2023.1338665","article-title":"Determinants of physical activity behavior among older adults with subjective cognitive decline based on the capability, opportunity, motivation, and behavior model: mediating and moderating effects","volume":"11","author":"Chen","year":"2023","journal-title":"Front Public Health"},{"key":"2026072106402223000_16.7.e108844.22","doi-asserted-by":"publisher","DOI":"10.1177\/0733464814537701"},{"key":"2026072106402223000_16.7.e108844.23","doi-asserted-by":"crossref","DOI":"10.1093\/geront\/gnad147","article-title":"Internet-Based Conversational Engagement Randomized Controlled Clinical Trial (I-CONECT) Among Socially Isolated Adults 75+ Years Old With Normal Cognition or Mild Cognitive Impairment: Topline Results","volume":"64","author":"Dodge","year":"2024","journal-title":"Gerontologist"},{"key":"2026072106402223000_16.7.e108844.24","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2022.36676","article-title":"Interventions Associated With Reduced Loneliness and Social Isolation in Older Adults: A Systematic Review and Meta-analysis","volume":"5","author":"Hoang","year":"2022","journal-title":"JAMA Netw Open"},{"key":"2026072106402223000_16.7.e108844.25","doi-asserted-by":"crossref","first-page":"23m15112","DOI":"10.4088\/JCP.23m15112","article-title":"Effects of a Multicomponent Intervention With Cognitive Training and Lifestyle Guidance for Older Adults at Risk of Dementia","volume":"85","author":"Wang","year":"2024","journal-title":"J Clin Psychiatry"},{"key":"2026072106402223000_16.7.e108844.26","doi-asserted-by":"crossref","first-page":"104701","DOI":"10.1016\/j.ijnurstu.2024.104701","article-title":"Multidomain interventions based on a life-course model to prevent dementia in at-risk Chinese older adults: A randomized controlled trial","volume":"152","author":"Meng","year":"2024","journal-title":"Int J Nurs Stud"},{"key":"2026072106402223000_16.7.e108844.27","doi-asserted-by":"crossref","first-page":"589","DOI":"10.14283\/jpad.2024.63","article-title":"China Initiative for Multi-Domain Intervention (CHINA-IN-MUDI) to Prevent Cognitive Decline: Study Design and Progress","volume":"11","author":"Li","year":"2024","journal-title":"J Prev Alzheimers Dis"},{"key":"2026072106402223000_16.7.e108844.28","doi-asserted-by":"crossref","DOI":"10.1186\/s13195-019-0484-1","article-title":"Effects of spermidine supplementation on cognition and biomarkers in older adults with subjective cognitive decline (SmartAge)-study protocol for a randomized controlled trial","volume":"11","author":"Wirth","year":"2019","journal-title":"Alzheimers Res Ther"},{"key":"2026072106402223000_16.7.e108844.29","doi-asserted-by":"crossref","first-page":"771413","DOI":"10.3389\/fnagi.2022.771413","article-title":"Effect of 3-Month Aerobic Dance on Hippocampal Volume and Cognition in Elderly People With Amnestic Mild Cognitive Impairment: A Randomized Controlled Trial","volume":"14","author":"Zhu","year":"2022","journal-title":"Front Aging Neurosci"},{"key":"2026072106402223000_16.7.e108844.30","first-page":"191","article-title":"Application of auditory verbal learning test-Huashan version in patients with subjective cognitive decline and mild cognitive impairment","volume":"39","author":"Zhou","year":"2024","journal-title":"Chinese Journal of Rehabilitation Medicine"},{"key":"2026072106402223000_16.7.e108844.31","unstructured":"Li Q , Miao Y , Zhong Y . Application of Huashan auditory word learning test in the diagnosis of forgotten mild cognitive impairment. Geriatrics & Health Care 2016;282\u20135."},{"key":"2026072106402223000_16.7.e108844.32","first-page":"2018","article-title":"Standardized Mini-Mental State Examination. Use and interpretation","volume":"47","author":"Vertesi","year":"2001","journal-title":"Can Fam Physician"},{"key":"2026072106402223000_16.7.e108844.33","doi-asserted-by":"publisher","DOI":"10.1891\/JNM-2021-0102"},{"key":"2026072106402223000_16.7.e108844.34","doi-asserted-by":"publisher","DOI":"10.1111\/j.1532-5415.2005.53221.x"},{"key":"2026072106402223000_16.7.e108844.35","doi-asserted-by":"crossref","first-page":"111","DOI":"10.2147\/CIA.S53645","article-title":"The Walking Trail-Making Test is an early detection tool for mild cognitive impairment","volume":"9","author":"Perrochon","year":"2014","journal-title":"Clin Interv Aging"},{"key":"2026072106402223000_16.7.e108844.36","first-page":"53","article-title":"Revision of the Wechsler memory scale-fourth edition of Chinese version (adult battery)","volume":"29","author":"Wang","year":"2015","journal-title":"Chinese Mental Health Journal"},{"key":"2026072106402223000_16.7.e108844.37","article-title":"Culture Effects on the Chinese Version Boston Naming Test Performance and the Normative Data in the Native Chinese-Speaking Elders in Mainland China","volume":"13","author":"Li","year":"2022","journal-title":"Front Neurol"},{"key":"2026072106402223000_16.7.e108844.38","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1016\/j.jpsychires.2023.07.004","article-title":"Effects of different interventions on insomnia in adults: Systematic review and network meta-analysis","volume":"165","author":"Wang","year":"2023","journal-title":"J Psychiatr Res"},{"key":"2026072106402223000_16.7.e108844.39","doi-asserted-by":"publisher","DOI":"10.1177\/0164027504268574"},{"key":"2026072106402223000_16.7.e108844.40","first-page":"2061","article-title":"A Reanalysis of Cognitive-Functional Performance in Older Adults: Investigating the Interaction Between Normal Aging, Mild Cognitive Impairment, Mild Alzheimer\u2019s Disease Dementia, and Depression","volume":"6","author":"de Paula","year":"2015","journal-title":"Front Psychol"},{"key":"2026072106402223000_16.7.e108844.41","first-page":"961","article-title":"Chinese guidelines for data processing and analysis concerning the International Physical Activity Questionnaire","volume":"35","author":"Fan","year":"2014","journal-title":"Zhonghua Liu Xing Bing Xue Za Zhi"},{"key":"2026072106402223000_16.7.e108844.42","doi-asserted-by":"publisher","DOI":"10.1093\/geronj\/37.3.323"},{"key":"2026072106402223000_16.7.e108844.43","doi-asserted-by":"crossref","first-page":"2495","DOI":"10.1002\/acn3.70190","article-title":"Plasma p-tau181 as a Marker of Conversion to Alzheimer\u2019s Disease Dementia and Worsening in Cognitive Functions in Subjective Cognitive Decline and Mild Cognitive Impairment: A Longitudinal Study","volume":"12","author":"Giacomucci","year":"2025","journal-title":"Ann Clin Transl Neurol"},{"key":"2026072106402223000_16.7.e108844.44","doi-asserted-by":"publisher","DOI":"10.1016\/S1474-4422(20)30071-5"},{"key":"2026072106402223000_16.7.e108844.45","doi-asserted-by":"publisher","DOI":"10.21037\/qims-23-808"},{"key":"2026072106402223000_16.7.e108844.46","doi-asserted-by":"publisher","DOI":"10.1177\/0733464814560468"},{"key":"2026072106402223000_16.7.e108844.47","doi-asserted-by":"crossref","first-page":"683","DOI":"10.1111\/ajag.13214","article-title":"The psychometric properties of the Lubben Social Network Scale (LSNS-6) and its associations with well-being indicators in Hong Kong older adults","volume":"42","author":"Chan","year":"2023","journal-title":"Australas J Ageing"},{"key":"2026072106402223000_16.7.e108844.48","doi-asserted-by":"crossref","DOI":"10.1186\/s12874-021-01261-6","article-title":"A review of the use of controlled multiple imputation in randomised controlled trials with missing outcome data","volume":"21","author":"Tan","year":"2021","journal-title":"BMC Med Res Methodol"},{"key":"2026072106402223000_16.7.e108844.49","doi-asserted-by":"crossref","first-page":"492","DOI":"10.1080\/01634372.2024.2338066","article-title":"Multicomponent Intervention on Improving the Cognitive Ability of Older Adults with Mild Cognitive Impairment: A Pilot Randomized Controlled Trial","volume":"67","author":"Young","year":"2024","journal-title":"J Gerontol Soc Work"},{"key":"2026072106402223000_16.7.e108844.50","doi-asserted-by":"publisher","DOI":"10.1002\/1522-2594(200101)45:1<29::AID-MRM1005>3.0.CO;2-Z"},{"key":"2026072106402223000_16.7.e108844.51","doi-asserted-by":"crossref","first-page":"296","DOI":"10.1016\/j.jalz.2016.09.012","article-title":"Implementation of subjective cognitive decline criteria in research studies","volume":"13","author":"Molinuevo","year":"2017","journal-title":"Alzheimer's & Dementia"},{"key":"2026072106402223000_16.7.e108844.52","doi-asserted-by":"crossref","first-page":"270","DOI":"10.1016\/j.jalz.2011.03.008","article-title":"The diagnosis of mild cognitive impairment due to Alzheimer\u2019s disease: Recommendations from the National Institute on Aging\u2010Alzheimer\u2019s Association workgroups on diagnostic guidelines for Alzheimer\u2019s disease","volume":"7","author":"Albert","year":"2011","journal-title":"Alzheimer's & Dementia"},{"key":"2026072106402223000_16.7.e108844.53","unstructured":"American Psychiatric Association . Diagnostic and statistical manual of mental disorders. 4th edn. Washington, DC: American Medical Association, 1994."}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2025-108844","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,21]],"date-time":"2026-07-21T13:40:59Z","timestamp":1784641259000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2025-108844"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7]]},"references-count":53,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2026,7,21]]},"published-print":{"date-parts":[[2026,7]]}},"alternative-id":["10.1136\/bmjopen-2025-108844"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2025-108844","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7]]}}}