{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,9]],"date-time":"2026-07-09T09:18:03Z","timestamp":1783588683490,"version":"3.55.0"},"reference-count":58,"publisher":"BMJ","issue":"4","license":[{"start":{"date-parts":[[2026,4,6]],"date-time":"2026-04-06T00:00:00Z","timestamp":1775433600000},"content-version":"unspecified","delay-in-days":5,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000049","name":"National Institute on Aging","doi-asserted-by":"publisher","award":["R01AG069016"],"award-info":[{"award-number":["R01AG069016"]}],"id":[{"id":"10.13039\/100000049","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,3,2]]},"published-print":{"date-parts":[[2026,4]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>While adverse childhood experiences (ACEs) have been consistently linked to poorer cognitive outcomes in later life, far less is known about ACEs\u2019 contribution to dementia and cognitive ageing risk in low-income and middle-income countries (LMICs), despite their growing and disproportionate share of global Alzheimer\u2019s disease and related dementias (ADRD) burden. This study aimed to systematically review existing evidence on the association between individual ACEs and cognitive outcomes among adults aged 40 years and older in LMIC settings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Systematic review and narrative synthesis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Data source<\/jats:title>\n                    <jats:p>We searched Medline, Embase, PsycINFO and CINAHL from the inception of each database to January 2026.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Eligibility criteria<\/jats:title>\n                    <jats:p>Observational studies examining the association between individual ACEs and cognitive outcomes among adults aged 40 and older in LMICs.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Data extraction and synthesis<\/jats:title>\n                    <jats:p>Two reviewers independently screened each record, assessed risk of bias using the Joanna Briggs Institute critical appraisal tool and extracted data. Results were illustrated using descriptive forest plots and a narrative synthesis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Our systematic review included 14 studies, primarily from upper-middle-income countries, that assessed the relationship between individual ACEs and cognitive impairment (n=4) and function (n=10). 10 studies reported significant associations between ACEs and poorer cognitive function and increased risk of cognitive impairment. No study assessed the association between ACEs and ADRD. Parental death, neglect and mental health issues in the family showed consistent associations with cognitive outcomes, whereas experiencing hunger and poor health in childhood showed inconsistent associations.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Our review corroborated evidence from high-income countries that exposure to ACEs is associated with a long-term risk of poorer cognitive outcomes among older populations in LMICs. However, the available literature remains limited, with most studies originating from upper-middle-income countries, few examining cognitive impairment and none assessing ADRD. These findings underscore substantial gaps in knowledge and highlight the need for research across diverse LMIC settings to clarify the role of broader psychosocial and contextual childhood experiences in shaping cognitive ageing and dementia risk.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>PROSPERO registration number<\/jats:title>\n                    <jats:p>CRD42024501816.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-112648","type":"journal-article","created":{"date-parts":[[2026,4,6]],"date-time":"2026-04-06T14:10:18Z","timestamp":1775484618000},"page":"e112648","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Adverse childhood experiences and cognitive outcomes among older adults in low-income and middle-income countries: a systematic review"],"prefix":"10.1136","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1984-7909","authenticated-orcid":false,"given":"Che Henry","family":"Ngwa","sequence":"first","affiliation":[{"name":"Department of Epidemiology and Biostatistics,American University of Beirut, Beirut, Lebanon"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sawsan","family":"Abdulrahim","sequence":"additional","affiliation":[{"name":"Department of Health Promotion and Community Health, American University of Beirut, Beirut, Lebanon"},{"name":"FXB Center for Health and Human Rights, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts, U.S.A"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rim","family":"Nehme","sequence":"additional","affiliation":[{"name":"Department of Health Promotion and Community Health, American University of Beirut, Beirut, Lebanon"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Meiya","family":"Saad","sequence":"additional","affiliation":[{"name":"Department of Health Promotion and Community Health, American University of Beirut, Beirut, Lebanon"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mayssan","family":"Kabalan","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Biostatistics,American University of Beirut, Beirut, Lebanon"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-4424-8968","authenticated-orcid":false,"given":"Maria Rita","family":"Lteif","sequence":"additional","affiliation":[{"name":"Department of Health Promotion and Community Health, American University of Beirut, Beirut, Lebanon"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yara","family":"Yazbek","sequence":"additional","affiliation":[{"name":"Department of Health Promotion and Community Health, American University of Beirut, Beirut, Lebanon"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Monique","family":"Chaaya","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Biostatistics,American University of Beirut, Beirut, Lebanon"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5035-0370","authenticated-orcid":false,"given":"Martine","family":"Elbejjani","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Biostatistics,American University of Beirut, Beirut, Lebanon"},{"name":"Clinical Research Institute, Faculty of Medicine, American University of Beirut, Beirut, Lebanon"},{"name":"Department of Internal Medicine, Faculty of Medicine, American University of Beirut, Beirut, Lebanon"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,4,6]]},"reference":[{"key":"2026070902000897000_16.4.e112648.1","unstructured":"Alzheimer\u2019s Disease International . World Alzheimer Report 2024: Global Changes in Attitudes to Dementia. London, England: Alzheimer\u2019s Disease International, 2024."},{"key":"2026070902000897000_16.4.e112648.2","unstructured":"Long S , Benoist C , Weidner W . World-alzheimer-report-2023: reducing dementia risk: never too early, never too late. 2023."},{"key":"2026070902000897000_16.4.e112648.3","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(20)30367-6"},{"key":"2026070902000897000_16.4.e112648.4","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2019.20740","article-title":"Association Between Adverse Childhood Experiences and Dementia in Older Japanese Adults","volume":"3","author":"Tani","year":"2020","journal-title":"JAMA Netw Open"},{"key":"2026070902000897000_16.4.e112648.5","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2022.41714","article-title":"Association of Adverse Childhood Experiences and Social Isolation With Later-Life Cognitive Function Among Adults in China","volume":"5","author":"Lin","year":"2022","journal-title":"JAMA Netw Open"},{"key":"2026070902000897000_16.4.e112648.6","doi-asserted-by":"crossref","first-page":"1489","DOI":"10.1111\/jan.12329","article-title":"Adverse childhood experiences: towards a clear conceptual meaning","volume":"70","author":"Kalmakis","year":"2014","journal-title":"J Adv Nurs"},{"key":"2026070902000897000_16.4.e112648.7","doi-asserted-by":"publisher","DOI":"10.1016\/S2468-2667(17)30118-4"},{"key":"2026070902000897000_16.4.e112648.8","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2023-072916","article-title":"Comparing relationships between single types of adverse childhood experiences and health-related outcomes: a combined primary data study of eight cross-sectional surveys in England and Wales","volume":"13","author":"Bellis","year":"2023","journal-title":"BMJ Open"},{"key":"2026070902000897000_16.4.e112648.9","doi-asserted-by":"publisher","DOI":"10.1007\/s00127-024-02676-4"},{"key":"2026070902000897000_16.4.e112648.10","doi-asserted-by":"crossref","first-page":"1087","DOI":"10.1093\/geront\/gnac041","article-title":"The Association Between Adverse Childhood Experiences and Late-Life Cognition: A Systematic Review of Cross-Sectional and Case-Control Studies","volume":"63","author":"Patel","year":"2023","journal-title":"Gerontologist"},{"key":"2026070902000897000_16.4.e112648.11","doi-asserted-by":"publisher","DOI":"10.1007\/S11606-021-07192-8\/FIGURES\/1"},{"key":"2026070902000897000_16.4.e112648.12","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2011-2663"},{"key":"2026070902000897000_16.4.e112648.13","doi-asserted-by":"publisher","DOI":"10.1016\/j.chiabu.2021.105456"},{"key":"2026070902000897000_16.4.e112648.14","doi-asserted-by":"crossref","first-page":"24751","DOI":"10.1007\/s12144-022-03523-y","article-title":"The relationship between cognitive reserve and cognition in healthy adults: a systematic review","volume":"42","author":"Panico","year":"2023","journal-title":"Curr Psychol"},{"key":"2026070902000897000_16.4.e112648.15","doi-asserted-by":"crossref","DOI":"10.3389\/fnins.2022.825811","article-title":"Are Brain and Cognitive Reserve Shaped by Early Life Circumstances?","volume":"16","author":"de Rooij","year":"2022","journal-title":"Front Neurosci"},{"key":"2026070902000897000_16.4.e112648.16","doi-asserted-by":"publisher","DOI":"10.1007\/s00127-022-02315-w"},{"key":"2026070902000897000_16.4.e112648.17","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2024.16305","article-title":"Bidirectional Associations of Depressive Symptoms and Cognitive Function Over Time","volume":"7","author":"Yin","year":"2024","journal-title":"JAMA Netw Open"},{"key":"2026070902000897000_16.4.e112648.18","doi-asserted-by":"crossref","first-page":"818","DOI":"10.1037\/pag0000552","article-title":"Adverse childhood experiences and domain-specific cognitive function in a population-based study of older adults in rural South Africa","volume":"35","author":"Kobayashi","year":"2020","journal-title":"Psychol Aging"},{"key":"2026070902000897000_16.4.e112648.19","doi-asserted-by":"crossref","DOI":"10.3389\/fpsyt.2018.00420","article-title":"Adverse Childhood Experiences and the Consequences on Neurobiological, Psychosocial, and Somatic Conditions Across the Lifespan","volume":"9","author":"Herzog","year":"2018","journal-title":"Front Psychiatry"},{"key":"2026070902000897000_16.4.e112648.20","doi-asserted-by":"publisher","DOI":"10.1177\/0898264315580122"},{"key":"2026070902000897000_16.4.e112648.21","doi-asserted-by":"crossref","DOI":"10.1038\/s41598-020-57490-0","article-title":"Influence of Severity of Type and Timing of Retrospectively Reported Childhood Maltreatment on Female Amygdala and Hippocampal Volume","volume":"10","author":"Herzog","year":"2020","journal-title":"Sci Rep"},{"key":"2026070902000897000_16.4.e112648.22","doi-asserted-by":"crossref","first-page":"29717","DOI":"10.1038\/s41598-024-79813-1","article-title":"The mediating role of frequent mental distress in the relationship between adverse childhood experiences and cognitive disability in emerging adults","volume":"14","author":"Sun","year":"2024","journal-title":"Sci Rep"},{"key":"2026070902000897000_16.4.e112648.23","doi-asserted-by":"publisher","DOI":"10.1016\/j.jad.2022.12.058"},{"key":"2026070902000897000_16.4.e112648.24","doi-asserted-by":"crossref","first-page":"2709","DOI":"10.1002\/hbm.23554","article-title":"Utility of the cumulative stress and mismatch hypotheses in understanding the neurobiological impacts of childhood abuse and recent stress in youth with emerging mental disorder","volume":"38","author":"Paquola","year":"2017","journal-title":"Hum Brain Mapp"},{"key":"2026070902000897000_16.4.e112648.25","doi-asserted-by":"crossref","DOI":"10.1016\/j.eclinm.2022.101784","article-title":"Cognitive variations following exposure to childhood adversity: Evidence from a pre-registered, longitudinal study","volume":"56","author":"Nweze","year":"2023","journal-title":"EClinicalMedicine"},{"key":"2026070902000897000_16.4.e112648.26","doi-asserted-by":"publisher","DOI":"10.1016\/j.tins.2020.01.002"},{"key":"2026070902000897000_16.4.e112648.27","doi-asserted-by":"publisher","DOI":"10.1016\/S2468-2667(21)00249-8"},{"key":"2026070902000897000_16.4.e112648.28","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0331204","article-title":"Global trends in Alzheimer\u2019s disease and other dementias in adults aged 55 and above (1992\u20132021): An age-period-cohort analysis based on the GBD 2021","volume":"20","author":"Zhang","year":"2025","journal-title":"PLoS One"},{"key":"2026070902000897000_16.4.e112648.29","doi-asserted-by":"publisher","DOI":"10.46234\/ccdcw2021.160"},{"key":"2026070902000897000_16.4.e112648.30","doi-asserted-by":"crossref","first-page":"1049","DOI":"10.1093\/heapol\/czx033","article-title":"Understanding the linkages between social safety nets and childhood violence: a review of the evidence from low- and middle-income countries","volume":"32","author":"Peterman","year":"2017","journal-title":"Health Policy Plan"},{"key":"2026070902000897000_16.4.e112648.31","unstructured":"The world bank . State of social protection report 2025. Washington, D.C., DC World Bank Publications; 2025."},{"key":"2026070902000897000_16.4.e112648.32","unstructured":"Quality health services, Available: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/quality-health-services [Accessed 21 Jan 2026]."},{"key":"2026070902000897000_16.4.e112648.33","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.g7647","article-title":"Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation","volume":"350","author":"Shamseer","year":"2015","journal-title":"BMJ"},{"key":"2026070902000897000_16.4.e112648.34","unstructured":"Hamadeh N , Rompaey C , Metreau E , et al . New world bank country classifications by income level: 2022-2023. World Bank Blogs; 2022. Available: https:\/\/blogs.worldbank.org\/en\/opendata\/new-world-bank-country-classifications-income-level-2022-2023 [Accessed 25 Sep 2024]."},{"key":"2026070902000897000_16.4.e112648.35","doi-asserted-by":"crossref","DOI":"10.3390\/ijerph22081219","article-title":"The Association Between Physical Activity and Frailty: China Health and Retirement Longitudinal Study (CHARLS)","volume":"22","author":"Yin","year":"2025","journal-title":"Int J Environ Res Public Health"},{"key":"2026070902000897000_16.4.e112648.36","doi-asserted-by":"crossref","unstructured":"Mao Y , Zhang Z , Yan Z . From digital cities to smart homes: how does smart older adults care affect the life satisfaction of older adults?\u2014Evidence from CLASS 2020. Humanit Soc Sci Commun 2024;11. doi:10.1057\/s41599-024-04243-3","DOI":"10.1057\/s41599-024-04243-3"},{"key":"2026070902000897000_16.4.e112648.37","doi-asserted-by":"crossref","DOI":"10.3390\/ijerph182010642","article-title":"Vulnerable Older Adults\u2019 Identification, Geographic Distribution, and Policy Implications in China","volume":"18","author":"Jin","year":"2021","journal-title":"Int J Environ Res Public Health"},{"key":"2026070902000897000_16.4.e112648.38","doi-asserted-by":"crossref","unstructured":"Moola S , Munn Z , Tufanaru C , et al . Chapter 7: Systematic reviews of etiology and risk. JBI 2020. doi:10.46658\/JBIRM-17-06","DOI":"10.46658\/JBIRM-17-06"},{"key":"2026070902000897000_16.4.e112648.39","doi-asserted-by":"crossref","first-page":"2158244019879135","DOI":"10.1177\/2158244019879135","article-title":"Early Parental Death and Cognitive Impairment in Late Life: A Cohort Study","volume":"9","author":"Fu","year":"2019","journal-title":"Sage Open"},{"key":"2026070902000897000_16.4.e112648.40","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2017.08.009"},{"key":"2026070902000897000_16.4.e112648.41","doi-asserted-by":"crossref","first-page":"116800","DOI":"10.1016\/j.socscimed.2024.116800","article-title":"Cognitive function following early life war-time stress exposure in a cohort of Vietnamese older adults","volume":"349","author":"Korinek","year":"2024","journal-title":"Soc Sci Med"},{"key":"2026070902000897000_16.4.e112648.42","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1080\/07481187.2024.2306471","article-title":"Does childhood parental death impact late life health directly and indirectly? Evidence from a National Survey in China","volume":"49","author":"Li","year":"2025","journal-title":"Death Stud"},{"key":"2026070902000897000_16.4.e112648.43","doi-asserted-by":"crossref","first-page":"214","DOI":"10.1177\/0891988719874120","article-title":"Childhood socioeconomic status and cognitive function later in life: Evidence from a national survey in Indonesia","volume":"33","author":"Maharani","year":"2020","journal-title":"J Geriatr Psychiatry Neurol"},{"key":"2026070902000897000_16.4.e112648.44","doi-asserted-by":"crossref","first-page":"12786","DOI":"10.1038\/s41598-022-16652-y","article-title":"Childhood deprivations predict late-life cognitive impairment among older adults in India","volume":"12","author":"Muhammad","year":"2022","journal-title":"Sci Rep"},{"key":"2026070902000897000_16.4.e112648.45","doi-asserted-by":"publisher","DOI":"10.1016\/j.psychres.2016.04.090"},{"key":"2026070902000897000_16.4.e112648.46","doi-asserted-by":"crossref","first-page":"828","DOI":"10.1177\/08862605231198245","article-title":"Childhood Emotional Neglect and Cognitive Function Among Middle-Aged and Older Adults: Mediating Role of Social Engagement","volume":"39","author":"Wang","year":"2024","journal-title":"J Interpers Violence"},{"key":"2026070902000897000_16.4.e112648.47","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2021-060477","article-title":"Heterogeneous adverse childhood experiences and cognitive function in an elderly Chinese population: a cohort study","volume":"12","author":"Yuan","year":"2022","journal-title":"BMJ Open"},{"key":"2026070902000897000_16.4.e112648.48","first-page":"1106","article-title":"Association between lack of care in childhood and cognitive impairment in middle-aged and elderly population","volume":"39","author":"Zhang","year":"2018","journal-title":"Zhonghua Liu Xing Bing Xue Za Zhi"},{"key":"2026070902000897000_16.4.e112648.49","doi-asserted-by":"crossref","first-page":"941","DOI":"10.1016\/j.socscimed.2010.05.013","article-title":"Childhood nutritional deprivation and cognitive impairment among older Chinese people","volume":"71","author":"Zhang","year":"2010","journal-title":"Soc Sci Med"},{"key":"2026070902000897000_16.4.e112648.50","doi-asserted-by":"crossref","first-page":"1319","DOI":"10.1177\/0898264317715975","article-title":"The Long Arm of Childhood in China: Early-Life Conditions and Cognitive Function Among Middle-Aged and Older Adults","volume":"30","author":"Zhang","year":"2018","journal-title":"J Aging Health"},{"key":"2026070902000897000_16.4.e112648.51","doi-asserted-by":"crossref","DOI":"10.1186\/s12889-025-21345-y","article-title":"The association between childhood hunger experiences and health in middle and old age: a longitudinal study over 10 years","volume":"25","author":"Li","year":"2025","journal-title":"BMC Public Health"},{"key":"2026070902000897000_16.4.e112648.52","doi-asserted-by":"crossref","first-page":"3362","DOI":"10.1007\/s11606-023-08252-x","article-title":"Adverse Childhood Experiences and Aging-Associated Functional Impairment in a National Sample of Older Community-Dwelling Adults","volume":"38","author":"Lee","year":"2023","journal-title":"J Gen Intern Med"},{"key":"2026070902000897000_16.4.e112648.53","doi-asserted-by":"crossref","first-page":"1164","DOI":"10.1093\/geronb\/gbab125","article-title":"Parental Death and Cognitive Impairment: An Examination by Gender and Race\u2013Ethnicity","volume":"77","author":"Liu","year":"2022","journal-title":"J Gerontol B Psychol Sci Soc Sci"},{"key":"2026070902000897000_16.4.e112648.54","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1111\/jcpp.12507","article-title":"Annual Research Review: Enduring neurobiological effects of childhood abuse and neglect","volume":"57","author":"Teicher","year":"2016","journal-title":"Child Psychology Psychiatry"},{"key":"2026070902000897000_16.4.e112648.55","doi-asserted-by":"publisher","DOI":"10.1177\/0898264315585504"},{"key":"2026070902000897000_16.4.e112648.56","doi-asserted-by":"publisher","DOI":"10.1093\/ageing\/afp023"},{"key":"2026070902000897000_16.4.e112648.57","doi-asserted-by":"crossref","unstructured":"Xie Z , Sun H , Zhou C , et al . Childhood, adulthood, and cumulative traumatic events experienced from childhood to adulthood and dementia risk: a population-based cohort study. In Review [Preprint] 2023. doi:10.21203\/rs.3.rs-2726742\/v1","DOI":"10.21203\/rs.3.rs-2726742\/v1"},{"key":"2026070902000897000_16.4.e112648.58","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1159\/000375462","article-title":"Association between Stressful Life Events and Cognitive Disorders in Central Africa: Results from the EPIDEMCA Program","volume":"44","author":"Pilleron","year":"2015","journal-title":"Neuroepidemiology"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2025-112648","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,9]],"date-time":"2026-07-09T09:00:38Z","timestamp":1783587638000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2025-112648"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4]]},"references-count":58,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,4,6]]},"published-print":{"date-parts":[[2026,4]]}},"alternative-id":["10.1136\/bmjopen-2025-112648"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2025-112648","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4]]}}}