{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,17]],"date-time":"2026-06-17T15:53:08Z","timestamp":1781711588210,"version":"3.54.5"},"reference-count":54,"publisher":"BMJ","issue":"2","license":[{"start":{"date-parts":[[2026,6,17]],"date-time":"2026-06-17T00:00:00Z","timestamp":1781654400000},"content-version":"unspecified","delay-in-days":77,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"name":"Special Project for the Development of Characteristic Disciplines of Fuwai Hospital, Chinese Academy of Medical Sciences","award":["2022-FWTS08"],"award-info":[{"award-number":["2022-FWTS08"]}]},{"name":"National High Level Hospital Clinical Research Funding","award":["2025-NHLHCRF-DLYJ-RCT-02"],"award-info":[{"award-number":["2025-NHLHCRF-DLYJ-RCT-02"]}]},{"name":"National High-Level Hospital Clinical Research Funding","award":["2023-GSP-GG-1"],"award-info":[{"award-number":["2023-GSP-GG-1"]}]},{"name":"CAMS Innovation Fund for Medical Sciences","award":["2024-I2M-C&T-B-092"],"award-info":[{"award-number":["2024-I2M-C&T-B-092"]}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["bmjph"],"accepted":{"date-parts":[[2026,6,1]]},"published-print":{"date-parts":[[2026,4]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Chronic obstructive pulmonary disease (COPD) represents a major public health challenge in China, with management delivered across all levels of the health system. Medication burden may undermine medication adherence and health-related quality of life (HRQoL), yet the pathways linking these factors remain unclear. This study evaluated the association between medication burden and HRQoL and examined whether medication adherence mediates this relationship from a multilevel health system perspective.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A multicentre cross-sectional study was conducted across healthcare institutions participating in the Cough and Wheeze Pharmaceutical Care Clinic network between September 2023 and September 2024. Medication burden was assessed using the total prescribed drugs and the Medication Regimen Complexity Index (MRCI). HRQoL was measured using the EuroQol 5-Dimension 5-Level Questionnaire, and adherence was evaluated with the Adherence to Refills and Medications Scale. Structural equation modelling assessed direct and indirect pathways, and mediation effects were estimated using percentile bootstrapping with 5000 resamples. Sensitivity analyses examined the robustness of the findings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>A total of 2125 patients with COPD were included. Participants had a median of 1 (IQR 0\u20132) prescribed medications and a median MRCI of 8.0 (range 0.0\u201313.5). A higher number of medications was significantly associated with poorer HRQoL both directly (estimate = \u20130.025, 95%\u2009CI \u20130.038 to \u20130.012) and indirectly via lower adherence (estimate = \u20130.007, 95%\u2009CI \u20130.010 to \u20130.003). While MRCI demonstrated no significant direct association with HRQoL, an indirect effect through adherence was observed (estimate = \u20130.001, 95%\u2009CI \u20130.002 to \u20130.001). All findings remained consistent across sensitivity analyses.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Across multiple levels of the healthcare system, medication adherence partially mediated the association between medication burden and HRQoL in patients with COPD. These findings highlight medication regimen optimisation and adherence support as important public health strategies for improving patient-centred COPD care.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjph-2025-004558","type":"journal-article","created":{"date-parts":[[2026,6,17]],"date-time":"2026-06-17T15:10:15Z","timestamp":1781709015000},"page":"e004558","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Medication burden, adherence and health-related quality of life in COPD in China: a multilevel health system study"],"prefix":"10.1136","volume":"4","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6289-7453","authenticated-orcid":false,"given":"Xuedi","family":"Ma","sequence":"first","affiliation":[{"name":"Medical Research and Biometrics Center, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9178-5971","authenticated-orcid":false,"given":"Xinyi","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China"},{"name":"China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Changcheng","family":"Shi","sequence":"additional","affiliation":[{"name":"China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China"},{"name":"Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People\u2019s Hospital, School of Medicine, Westlake University, Hangzhou, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yang","family":"Wang","sequence":"additional","affiliation":[{"name":"Medical Research and Biometrics Center, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wei","family":"Li","sequence":"additional","affiliation":[{"name":"Medical Research and Biometrics Center, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lihong","family":"Liu","sequence":"additional","affiliation":[{"name":"Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China"},{"name":"China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China"},{"name":"Clinical Trial Research Center, China-Japan Friendship Hospital, Beijing, China"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,6,17]]},"reference":[{"key":"2026061708100713000_4.2.e004558.1","doi-asserted-by":"crossref","DOI":"10.1136\/bmj-2021-069679","article-title":"Burden of chronic obstructive pulmonary disease and its attributable risk factors in 204 countries and territories, 1990-2019: results from the Global Burden of Disease Study 2019","volume":"378","author":"Safiri","year":"2022","journal-title":"BMJ"},{"key":"2026061708100713000_4.2.e004558.2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(18)30841-9"},{"key":"2026061708100713000_4.2.e004558.3","unstructured":"National Health Commission . Notice of the general office of the national health commission on issuing the health service standards for patients with chronic obstructive pulmonary disease. 2024. Available: https:\/\/www.gov.cn\/zhengce\/zhengceku\/202409\/content_6974437.htm [Accessed 13 Nov 2025]."},{"key":"2026061708100713000_4.2.e004558.4","doi-asserted-by":"crossref","DOI":"10.1186\/s12875-021-01583-w","article-title":"COPD - do the right thing","volume":"22","author":"Sandelowsky","year":"2021","journal-title":"BMC Fam Pract"},{"key":"2026061708100713000_4.2.e004558.5","doi-asserted-by":"crossref","DOI":"10.1186\/s12890-020-1116-z","article-title":"Validity of EQ-5D utility index and minimal clinically important difference estimation among patients with chronic obstructive pulmonary disease","volume":"20","author":"Bae","year":"2020","journal-title":"BMC Pulm Med"},{"key":"2026061708100713000_4.2.e004558.6","doi-asserted-by":"crossref","DOI":"10.1186\/s12955-015-0241-5","article-title":"Quality of life and its association with direct medical costs for COPD in urban China","volume":"13","author":"Wu","year":"2015","journal-title":"Health Qual Life Outcomes"},{"key":"2026061708100713000_4.2.e004558.7","doi-asserted-by":"crossref","DOI":"10.1136\/bmjph-2024-002489","article-title":"Burden of chronic obstructive pulmonary disease and its attributable risk factors in 204 countries and territories, 1990-2021: results from the Global Burden of Disease Study 2021","volume":"4","author":"Cao","year":"2026","journal-title":"BMJ Public Health"},{"key":"2026061708100713000_4.2.e004558.8","doi-asserted-by":"crossref","first-page":"102597","DOI":"10.1016\/j.eclinm.2024.102597","article-title":"The care cascade of chronic obstructive pulmonary disease in China: a cross-sectional study of individual-level data at enrolment into the national \u2018Happy Breathing\u2019 Programme","volume":"74","author":"Wang","year":"2024","journal-title":"eClinicalMedicine"},{"key":"2026061708100713000_4.2.e004558.9","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0321470","article-title":"Burden of Chronic obstructive pulmonary disease in China: an analysis based on the GBD 2021 compared with the United States","volume":"20","author":"Li","year":"2025","journal-title":"PLoS ONE"},{"key":"2026061708100713000_4.2.e004558.10","doi-asserted-by":"crossref","first-page":"105270","DOI":"10.1016\/j.ebiom.2024.105270","article-title":"Ambient particulate matter and chronic obstructive pulmonary disease mortality: a nationwide, individual-level, case-crossover study in China","volume":"107","author":"Jiang","year":"2024","journal-title":"EBioMedicine"},{"key":"2026061708100713000_4.2.e004558.11","unstructured":"Global Initiative for Chronic Obstructive Lung Disease (GOLD) . Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (2026 report). 2025. Available: https:\/\/goldcopd.org\/2026-gold-report-and-pocket-guide\/ [Accessed 05 Feb 2026]."},{"key":"2026061708100713000_4.2.e004558.12","doi-asserted-by":"crossref","DOI":"10.1038\/s41533-017-0016-z","article-title":"Device errors in asthma and COPD: systematic literature review and meta-analysis","volume":"27","author":"Chrystyn","year":"2017","journal-title":"NPJ Prim Care Respir Med"},{"key":"2026061708100713000_4.2.e004558.13","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1007\/s11606-023-08378-y","article-title":"Errors and Adherence to Inhaled Medications in Chinese Adults with COPD","volume":"39","author":"Wu","year":"2024","journal-title":"J Gen Intern Med"},{"key":"2026061708100713000_4.2.e004558.14","first-page":"440","article-title":"Polypharmacy in Patients With COPD: A Scoping Review","volume":"12","author":"Upadhyay","year":"2025","journal-title":"Chronic Obstr Pulm Dis"},{"key":"2026061708100713000_4.2.e004558.15","doi-asserted-by":"crossref","first-page":"1713","DOI":"10.1007\/s41999-024-01036-4","article-title":"The association between medication use and health-related quality of life in multimorbid older patients with polypharmacy","volume":"15","author":"Falke","year":"2024","journal-title":"Eur Geriatr Med"},{"key":"2026061708100713000_4.2.e004558.16","first-page":"1531","article-title":"Examining the Effect of Polypharmacy on Quality of Life and Frailty in Older Adults from the Perspective of Community-Based Rehabilitation","volume":"13","author":"Cemali","year":"2025","journal-title":"Health Care (Don Mills)"},{"key":"2026061708100713000_4.2.e004558.17","doi-asserted-by":"crossref","DOI":"10.1038\/s41533-025-00413-1","article-title":"The availability of drugs for stable COPD treatment in China: a cross-sectional survey","volume":"35","author":"Du","year":"2025","journal-title":"NPJ Prim Care Respir Med"},{"key":"2026061708100713000_4.2.e004558.18","doi-asserted-by":"crossref","first-page":"2466215","DOI":"10.1080\/20523211.2025.2466215","article-title":"Access to single-inhaler triple medicines for chronic obstructive pulmonary disease in China: a national survey on accessibility and utilisation","volume":"18","author":"Li","year":"2025","journal-title":"J Pharm Policy Pract"},{"key":"2026061708100713000_4.2.e004558.19","doi-asserted-by":"crossref","unstructured":"Wang J , Feng Z , Dong Z . Does Having a Usual Primary Care Provider Reduce Polypharmacy Behaviors of Patients With Chronic Disease? A Retrospective Study in Hubei Province, China. Front Pharmacol 2021;12. doi:10.3389\/fphar.2021.802097","DOI":"10.3389\/fphar.2021.802097"},{"key":"2026061708100713000_4.2.e004558.20","doi-asserted-by":"crossref","first-page":"1567","DOI":"10.2147\/COPD.S509949","article-title":"The Association Between Medication Adherence and Health-Related Quality of Life in Patients with COPD: A Cross-Sectional Study","volume":"20","author":"Saja","year":"2025","journal-title":"Int J Chron Obstruct Pulmon Dis"},{"key":"2026061708100713000_4.2.e004558.21","doi-asserted-by":"crossref","first-page":"1636806","DOI":"10.3389\/fphar.2025.1636806","article-title":"Clinicians\u2019 view on non-adherence: sharing expert opinion","volume":"16","author":"Tan","year":"2025","journal-title":"Front Pharmacol"},{"key":"2026061708100713000_4.2.e004558.22","doi-asserted-by":"crossref","DOI":"10.1186\/s12890-024-03274-5","article-title":"Prevalence and predictors of polypharmacy and comorbidities among patients with chronic obstructive pulmonary disease: a cross-sectional retrospective study in a tertiary hospital in Saudi Arabia","volume":"24","author":"Alwafi","year":"2024","journal-title":"BMC Pulm Med"},{"key":"2026061708100713000_4.2.e004558.23","doi-asserted-by":"crossref","first-page":"1009","DOI":"10.2147\/COPD.S498302","article-title":"Identification of Psychosocial and Sociodemographic Factors Associated with Low Medication Awareness in COPD Subjects: A Cross-Sectional Study, Findings from the Indonesian Family Life Survey 5","volume":"20","author":"Jannah","year":"2025","journal-title":"Int J Chron Obstruct Pulmon Dis"},{"key":"2026061708100713000_4.2.e004558.24","doi-asserted-by":"crossref","first-page":"2500","DOI":"10.1111\/ggi.13115","article-title":"Poor adherence to chronic obstructive pulmonary disease medications in primary care: Role of age, disease burden and polypharmacy","volume":"17","author":"Vetrano","year":"2017","journal-title":"Geriatr Gerontol Int"},{"key":"2026061708100713000_4.2.e004558.25","doi-asserted-by":"publisher","DOI":"10.4104\/pcrj.2011.00029"},{"key":"2026061708100713000_4.2.e004558.26","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2017-018404","article-title":"Examining patterns of multimorbidity, polypharmacy and risk of adverse drug reactions in chronic obstructive pulmonary disease: a cross-sectional UK Biobank study","volume":"8","author":"Hanlon","year":"2018","journal-title":"BMJ Open"},{"key":"2026061708100713000_4.2.e004558.27","doi-asserted-by":"crossref","first-page":"535","DOI":"10.1016\/j.jamda.2015.03.003","article-title":"Prevalence and factors associated with polypharmacy in long-term care facilities: a systematic review","volume":"16","author":"Jokanovic","year":"2015","journal-title":"J Am Med Dir Assoc"},{"key":"2026061708100713000_4.2.e004558.28","doi-asserted-by":"crossref","first-page":"844","DOI":"10.1038\/s41598-024-85010-x","article-title":"Treatment patterns for chronic obstructive pulmonary disease under the tiered medical system","volume":"15","author":"Wang","year":"2025","journal-title":"Sci Rep"},{"key":"2026061708100713000_4.2.e004558.29","unstructured":"Chinese Pharmaceutical Association . Specifications on cough and wheeze pharmaceutical care clinic construction. 2024. Available: https:\/\/www.cpa.org.cn\/\/?do=info&cid=76795 [Accessed 11 Sep 2025]."},{"key":"2026061708100713000_4.2.e004558.30","doi-asserted-by":"publisher","DOI":"10.1016\/j.jval.2016.11.016"},{"key":"2026061708100713000_4.2.e004558.31","doi-asserted-by":"crossref","first-page":"1020","DOI":"10.1016\/S2213-2600(23)00261-8","article-title":"COPD and multimorbidity: recognising and addressing a syndemic occurrence","volume":"11","author":"Fabbri","year":"2023","journal-title":"Lancet Respir Med"},{"key":"2026061708100713000_4.2.e004558.32","doi-asserted-by":"publisher","DOI":"10.1345\/aph.1D479"},{"key":"2026061708100713000_4.2.e004558.33","doi-asserted-by":"crossref","first-page":"384","DOI":"10.1513\/AnnalsATS.202211-975OC","article-title":"Predictors of Patient-reported and Pharmacy Refill Measures of Maintenance Inhaler Adherence in Veterans with Chronic Obstructive Pulmonary Disease","volume":"21","author":"Pattock","year":"2024","journal-title":"Ann Am Thorac Soc"},{"key":"2026061708100713000_4.2.e004558.34","doi-asserted-by":"publisher","DOI":"10.1111\/j.1524-4733.2008.00400.x"},{"key":"2026061708100713000_4.2.e004558.35","doi-asserted-by":"crossref","first-page":"379","DOI":"10.1177\/1948550617715068","article-title":"Determining Power and Sample Size for Simple and Complex Mediation Models","volume":"8","author":"Schoemann","year":"2017","journal-title":"Soc Psychol Personal Sci"},{"key":"2026061708100713000_4.2.e004558.36","doi-asserted-by":"publisher","DOI":"10.2307\/271084"},{"key":"2026061708100713000_4.2.e004558.37","doi-asserted-by":"publisher","DOI":"10.1183\/09031936.00102509"},{"key":"2026061708100713000_4.2.e004558.38","doi-asserted-by":"crossref","first-page":"1310","DOI":"10.1111\/crj.13434","article-title":"Clinical characteristics and outcomes of polypharmacy in chronic obstructive pulmonary disease patients: A cross-sectional study from Crete, Greece","volume":"15","author":"Ierodiakonou","year":"2021","journal-title":"Clin Respir J"},{"key":"2026061708100713000_4.2.e004558.39","doi-asserted-by":"crossref","DOI":"10.5888\/pcd19.220062","article-title":"Polypharmacy and Health-Related Quality of Life\/Psychological Distress Among Patients With Chronic Disease","volume":"19","author":"Van Wilder","year":"2022","journal-title":"Prev Chronic Dis"},{"key":"2026061708100713000_4.2.e004558.40","doi-asserted-by":"crossref","first-page":"2385","DOI":"10.2147\/COPD.S310630","article-title":"Associations of Medication Regimen Complexity with COPD Medication Adherence and Control","volume":"16","author":"Federman","year":"2021","journal-title":"Int J Chron Obstruct Pulmon Dis"},{"key":"2026061708100713000_4.2.e004558.41","doi-asserted-by":"crossref","first-page":"104553","DOI":"10.1016\/j.archger.2021.104553","article-title":"Associations between polypharmacy and physical performance measures in older adults","volume":"98","author":"Ozkok","year":"2022","journal-title":"Arch Gerontol Geriatr"},{"key":"2026061708100713000_4.2.e004558.42","doi-asserted-by":"crossref","first-page":"93","DOI":"10.37201\/req\/097.2020","article-title":"High level of medication regimen complexity index correlate with worse quality of life in people living with HIV","volume":"34","author":"Contreras-Mac\u00edas","year":"2021","journal-title":"Rev Esp Quimioter"},{"key":"2026061708100713000_4.2.e004558.43","doi-asserted-by":"crossref","DOI":"10.3390\/jcm14176034","article-title":"Understanding Treatment Adherence in Chronic Diseases: Challenges, Consequences, and Strategies for Improvement","volume":"14","author":"Patel","year":"2025","journal-title":"J Clin Med"},{"key":"2026061708100713000_4.2.e004558.44","doi-asserted-by":"crossref","DOI":"10.1183\/20734735.0039-2021","article-title":"The clinical impact of adherence to therapy in airways disease","volume":"17","author":"Brennan","year":"2021","journal-title":"Breathe (Sheff)"},{"key":"2026061708100713000_4.2.e004558.45","doi-asserted-by":"crossref","first-page":"559","DOI":"10.1007\/s11606-019-04837-7","article-title":"Associations Between Polypharmacy, Symptom Burden, and Quality of Life in Patients with Advanced, Life-Limiting Illness","volume":"34","author":"Schenker","year":"2019","journal-title":"J Gen Intern Med"},{"key":"2026061708100713000_4.2.e004558.46","doi-asserted-by":"crossref","first-page":"369","DOI":"10.1007\/s41999-020-00313-2","article-title":"Medication adherence in the older adults with chronic multimorbidity: a systematic review of qualitative studies on patient\u2019s experience","volume":"11","author":"Maffoni","year":"2020","journal-title":"Eur Geriatr Med"},{"key":"2026061708100713000_4.2.e004558.47","doi-asserted-by":"crossref","DOI":"10.1186\/s12890-022-01892-5","article-title":"Understanding barriers to and strategies for medication adherence in COPD: a qualitative study","volume":"22","author":"O\u2019Toole","year":"2022","journal-title":"BMC Pulm Med"},{"key":"2026061708100713000_4.2.e004558.48","doi-asserted-by":"publisher","DOI":"10.1007\/s00228-012-1279-5"},{"key":"2026061708100713000_4.2.e004558.49","doi-asserted-by":"publisher","DOI":"10.1016\/j.jaci.2013.02.014"},{"key":"2026061708100713000_4.2.e004558.50","doi-asserted-by":"publisher","DOI":"10.1016\/j.chest.2016.03.041"},{"key":"2026061708100713000_4.2.e004558.51","doi-asserted-by":"crossref","first-page":"2135","DOI":"10.2147\/PPA.S268499","article-title":"Impact of Medication Regimen Simplification on Medication Adherence and Clinical Outcomes in Patients with Long-Term Medical Conditions","volume":"14","author":"Elnaem","year":"2020","journal-title":"Patient Prefer Adherence"},{"key":"2026061708100713000_4.2.e004558.52","doi-asserted-by":"crossref","first-page":"904","DOI":"10.1111\/jcpt.13126","article-title":"Effect of pharmacist-led interventions on medication adherence and inhalation technique in adult patients with asthma or COPD: A systematic review and meta-analysis","volume":"45","author":"Jia","year":"2020","journal-title":"J Clin Pharm Ther"},{"key":"2026061708100713000_4.2.e004558.53","doi-asserted-by":"crossref","DOI":"10.2196\/82806","article-title":"Evaluation of a Tailored Multifaceted Pharmaceutical Care Intervention to Optimize Chronic Obstructive Pulmonary Disease Management: Protocol for a Cluster Randomized Controlled Trial","volume":"15","author":"Ma","year":"2026","journal-title":"JMIR Res Protoc"},{"key":"2026061708100713000_4.2.e004558.54","doi-asserted-by":"crossref","first-page":"591","DOI":"10.1016\/S2213-2600(22)00534-3","article-title":"Use of digital measurement of medication adherence and lung function to guide the management of uncontrolled asthma (INCA Sun): a multicentre, single-blinded, randomised clinical trial","volume":"11","author":"Hale","year":"2023","journal-title":"Lancet Respir Med"}],"container-title":["BMJ Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjph-2025-004558","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,17]],"date-time":"2026-06-17T15:10:22Z","timestamp":1781709022000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjpublichealth.bmj.com\/lookup\/doi\/10.1136\/bmjph-2025-004558"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4]]},"references-count":54,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,6,17]]},"published-print":{"date-parts":[[2026,4]]}},"alternative-id":["10.1136\/bmjph-2025-004558"],"URL":"https:\/\/doi.org\/10.1136\/bmjph-2025-004558","relation":{},"ISSN":["2753-4294"],"issn-type":[{"value":"2753-4294","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4]]}}}