Abstract
The quality of psychiatric inpatient care is a pressing concern in Japan, where hospitalization is prolonged and coercive practices remain common. Incorporating patients’ perspectives is essential for evaluation and service improvement. The Views on Inpatient Care (VOICE) scale, originally developed in the United Kingdom through co-production between service users and researchers, assesses inpatients’ experiences. This study aimed to develop a Japanese version (VOICE-J) through rigorous translation and cross-cultural verification, and to evaluate its psychometric properties among psychiatric inpatients. People with lived experience contributed at every stage, from item review to questionnaire usability. The validation survey was conducted in a private psychiatric hospital in Tokyo, with 134 inpatients providing analyzable responses. VOICE-J demonstrated excellent internal consistency (Cronbach's α = 0.94), strong negative correlations with patient satisfaction (Japanese version of Client Satisfaction Questionnaire, 8-item, CSQ-8J) and recovery-oriented support (Brief INSPIRE-J), and good test-retest reliability (intraclass correlation coefficient = 0.85). Known-groups validity was partially supported, with more positive evaluations among voluntary and self-requested admissions. VOICE-J offers a reliable, patient-centered instrument for assessing psychiatric inpatient care in Japan and supports quality improvement through patients’ perspectives.
Keywords
Introduction
The quality of psychiatric care has emerged as a pressing global concern, and Japan faces particularly acute challenges, as its disproportionately high number of psychiatric inpatients reflects a hospital-centered system characterized by longer lengths of stay compared to other countries. 1 For individuals admitted to psychiatric wards, the quality of inpatient care is fundamental to their recovery, safety, and overall wellbeing. However, admission itself may constitute a distressing or even traumatic experience, especially when patients are subjected to, or witness, coercive measures such as seclusion or restraint, which undermine trust in services, exacerbate psychological distress, and diminish satisfaction with care.2,3 These concerns highlight the urgent need to evaluate and improve the quality of psychiatric inpatient care in ways that prioritize patients’ perspectives and experiences, while carefully considering cultural and contextual factors that may shape how patients interpret and respond to experience measures.
Systematic evaluation is fundamental to healthcare quality improvement, and incorporating patient perspectives—supported by evidence linking patient experience with clinical outcomes, and by approaches such as co-production and the integration of patient-reported outcomes—has increasingly been recognized as essential.4–6 This applies equally to psychiatric services: while evaluation has traditionally focused on clinical outcomes or staff-defined quality indicators, patients’ voices are critical for comprehensive assessment. In mental health contexts, co-production requires a paradigm shift to foster a culture that values consumer knowledge and expertise, engaging patients from the outset in problem definition, service design, delivery, and evaluation. 7 In Japan, however, no validated instrument currently exists to assess the quality of psychiatric inpatient care from patients’ perspectives, highlighting the need for robust tools that capture their evaluations.
The Views on Inpatient Care (VOICE) scale, 8 developed in the United Kingdom, is among the first patient-reported outcome measures in psychiatry to be generated directly by service users to capture perceptions of inpatient experiences, based on lived experience. Internationally, VOICE has been adapted into other languages; for example, the Portuguese version demonstrated strong internal consistency and acceptability among psychiatric inpatients in Portugal. 9 Such cross-cultural validation efforts are invaluable not only for enabling each country to evaluate and improve its own services but also for facilitating international comparisons of patient experience across diverse systems. Developing a Japanese version of VOICE would thus contribute to both local quality improvement and the broader global discourse on patient-centered psychiatric care. Furthermore, emerging evidence suggests that, because service users were directly involved in its development, VOICE may be particularly well-suited to capturing patients’ experiences compared with measures developed without patient input. 10
Accordingly, this study aimed to (i) develop the Japanese version of the VOICE scale (VOICE-J) through a rigorous process of translation and cross-cultural verification in collaboration with people with lived experience of psychiatric admission and (ii) evaluate its psychometric properties among psychiatric inpatients in Japan.
Methods
Study Design
This cross-sectional, self-administered questionnaire study was conducted to develop the Japanese version of the VOICE scale (VOICE-J) and to evaluate its validity and reliability among psychiatric inpatients in Japan.
The VOICE Scale
The VOICE is a patient-reported outcome measure originally developed in the United Kingdom through co-production between service users and researchers. It was designed to systematically capture inpatients’ evaluations of psychiatric care across domains including communication, respect, autonomy, relationships with staff, and the ward environment. VOICE has demonstrated good psychometric properties in the UK validation study. 8 The scale contains one reverse-scored item, with lower total scores reflecting more positive experiences of care.
Development of the Japanese Version
Exploratory Phase
Prior to translation, semistructured interviews were conducted with 2 individuals who had experienced multiple psychiatric admissions across at least 2 hospitals. The purpose of this exploratory phase was not to generate new scale items, but to inform the selection of an existing instrument that has been used internationally, and to identify culturally relevant considerations for translation and adaptation, with particular attention to cross-cultural comparability.
Interviewees were purposively selected based on their ability to reflect on and compare different inpatient care environments, rather than solely to recount personal experiences. Both individuals had been admitted multiple times to different psychiatric wards and were able to articulate meaningful differences in care practices, staff interactions, and their perceived impact. During the interviews, interviewees were invited to reflect on both positive and negative aspects of their hospitalizations, including experiences that provided a sense of safety and those that caused distress.
The interviews revealed that interpersonal relationships with staff were central to interviewees’ evaluations of care. Positive experiences included feeling reassured when staff remembered them or initiated conversations, while negative experiences involved staff rarely leaving the nursing station or dismissing patients’ concerns. Detailed examples of patient-reported experiences from the interviews are provided in Supplemental Table S1.
Although the small number of interviewees limits the breadth of perspectives captured in this exploratory phase, the interviews were sufficient to identify key experiential domains relevant to the selection of an appropriate patient experience measure. These findings guided the selection of existing scales, leading to the identification of VOICE as the most comprehensive instrument.
To further support face validity, 2 additional individuals with lived experience of psychiatric admissions reviewed the VOICE items and confirmed that the instrument addressed important issues and was perceived as a meaningful and relevant tool.
Translation and Adaptation
The cross-cultural adaptation followed the ISPOR guidelines
11
:
Preparation: Permission to adapt VOICE into Japanese was obtained from the original developers. Forward translation: Two psychiatric nurses, both native Japanese speakers fluent in English, independently translated the VOICE items. Reconciliation: The translators and 2 authors produced a consensus draft, subsequently refined through iterative author discussions. Back translation: The consensus draft was back-translated into English by professional translators. Review by developers: The original VOICE developers confirmed conceptual equivalence. Cognitive debriefing: Cognitive interviews were conducted with 3 service users (2 with more than 10 admissions and 1 recently discharged after a short admission), who provided feedback on clarity, comprehensibility, and questionnaire layout. Finalization: Feedback was incorporated, the questionnaire was proofread, and the final version was approved by both the Japanese research team and the original developers.
Further details of the translation process are provided in Supplemental Table S2.
Patient and Public Involvement
People with lived experience of psychiatric admission were actively involved throughout the study.
Exploratory phase: Two individuals who have experience of multiple psychiatric admissions identified important domains for evaluating psychiatric inpatient care. Translation phase: Four individuals with lived experience (including 2 from the exploratory phase above) reviewed the provisional draft, in interviews and via email, providing feedback on clarity, acceptability, and questionnaire layout. The contributors were selected to reflect diversity in lived experience, including variation in the number of psychiatric admissions, types of inpatient facilities attended, gender, living arrangements, and geographic regions of residence. Cognitive debriefing phase: The same contributors assessed the comprehensibility of the items and suggested refinements. Practical feedback: These patient and public involvement (PPI) contributors also advised on questionnaire format to enhance usability in inpatient settings. Based on their input, all 19 items and the free-text box were printed on a single page to minimize fatigue. Explicit instructions were added to reassure patients that ward staff would not have access to their responses. The layout was further modified to use light green lines, following their suggestion that softer colors would be more approachable (see Supplemental Figure S1).
Although the number of PPI contributors was limited, their involvement was intensive and iterative, allowing for detailed review across multiple stages of scale development. This approach supported the understandability, relevance, and acceptability of the Japanese version of VOICE for patients currently hospitalized in psychiatric wards.
To acknowledge their time and expertise, individuals who contributed to the interviews during scale development received a 3000-yen (approximately US$25) gift card.
Participants who completed the self-administered questionnaire survey received a 500-yen (approximately US$5) gift card.
Setting and Participants
The validation study was conducted in a private psychiatric hospital in Tokyo between June and October 2021. With hospital approval, patients in 5 wards (excluding one ward predominantly serving elderly individuals unable to complete self-report questionnaires) were invited to participate. Hospital staff distributed information sheets, anonymous self-report questionnaires, and return envelopes to all eligible inpatients. Of the 244 eligible patients, 141 returned questionnaires, and 134 provided sufficient data to calculate the VOICE-J total score; these individuals were included in the main analyses.
Measures
VOICE-J: The Japanese version of the VOICE scale developed as described above.
Japanese version of Client Satisfaction Questionnaire, 8-item (CSQ-8J): A validated 8-item measure of client/patient satisfaction, scored on a 4-point Likert scale (range 8-32), with higher scores indicating greater satisfaction.12,13
Brief INSPIRE-J: A 5-item patient-rated experience measure assessing staff support for recovery, scored on a 5-point Likert scale (0-4 per item). Higher scores reflect greater perceived recovery-oriented support from care workers.14,15
Demographic and clinical variables included gender, age, self-reported psychiatric diagnosis, type of admission (voluntary vs involuntary), and experiences of seclusion or restraint.
Hypotheses
We hypothesized that:
Individuals with voluntary or self-requested admissions would report more positive ward experiences (lower VOICE-J scores). Individuals who had experienced seclusion or restraint would report more negative ward experiences (higher VOICE-J scores).
Procedures and Statistical Analysis
Internal consistency was assessed using Cronbach's α for the VOICE-J total score and item-deleted models.
Concurrent validity was examined through Pearson's correlations among VOICE-J, CSQ-8J, and Brief INSPIRE-J.
Known-groups validity was tested using independent-samples t-tests for predefined subgroups (voluntary vs involuntary admission; with vs without seclusion; with vs without restraint; male vs female).
Test-retest reliability was assessed in a subsample who consented to repeat participation approximately 1 month later. Twenty-eight participants completed both assessments, and intraclass correlation coefficients, ICC (2,1), were calculated.
Analyses included only participants with sufficient data to compute the VOICE-J total score. Missing data were not imputed. All analyses were performed using STATA version 16 (StataCorp LLC), with statistical significance set at P < .05.
Ethics
The study was approved by the Ethics Committee of the Graduate Schoolf of Medicine, the University of Tokyo. Participation was voluntary, and informed consent was indicated by returning the questionnaire. Confidentiality was maintained using anonymous, sealed envelopes. Address slips for honorarium delivery were handled separately from survey responses to ensure anonymity. The final questionnaire layout incorporated feedback from people with lived experience regarding usability and confidentiality (see Supplemental Figure S1).
Results
Participants
Of the 244 eligible inpatients, 141 returned questionnaires, yielding a response rate of 57.8%. Among these, 134 provided sufficient data to calculate the VOICE-J total score and were included in the analyses. The demographic and clinical characteristics of the participants are summarized in Table 1.
Participant Characteristics (N = 134).
Multiple responses were possible for seclusion, restraint, and diagnoses; therefore, totals exceed 100%.
*Details of the distribution of the number of previous admissions are provided in Supplemental Table S3.
Internal Consistency
Item-total statistics are presented in Table 2. Most items demonstrated adequate item-rest correlations (>0.50), and the overall scale showed excellent internal consistency (Cronbach's α = 0.94), indicating that the items coherently capture a common construct related to inpatient care experience. Inter-item correlations generally ranged from 0.35 to 0.70 (see Supplemental Table S4). The reversed item (voice6r) showed weaker correlations with the other items, and removing it slightly increased α to 0.95.
Item-Total and Item-Rest Statistics for the Japanese Version of VOICE (N = 134).
Overall scale: Average inter-item correlation = 0.453; Cronbach's α = 0.940.
Concurrent Validity
As shown in Table 3, VOICE-J total scores were strongly and negatively correlated with both CSQ-8J (r = –0.77, P < .001) and Brief INSPIRE-J (r = –0.70, P < .001). These results indicate that lower VOICE-J scores, reflecting more positive ward experiences, were associated with higher patient satisfaction and higher perceived recovery-oriented support, supporting the validity of VOICE-J as an indicator of patients’ overall inpatient care experience.
Correlations among VOICE-J, CSQ-8J, and Brief INSPIRE-J Scores (N = 134).
Values are Pearson's correlation coefficients (2-tailed). ***P < .001. Sample sizes vary slightly due to missing data.
Abbreviations: Brief INSPIRE-J, Japanese version of the Brief INSPIRE, higher scores indicate greater perceived support for recovery from care workers; CSQ-8J, Japanese version of the Client Satisfaction Questionnaire-8, higher scores indicate higher satisfaction; VOICE-J, Japanese version of the Views on Inpatient Care, higher scores indicate more negative perceptions of inpatient care.
Known-Groups Validity
Known-groups validity was examined by comparing mean VOICE-J scores across subgroups (Table 4). Patients who self-requested admission reported significantly more positive ward experiences (lower VOICE-J scores; P < .001). Similarly, patients admitted voluntarily showed more positive experiences than those admitted involuntarily for medical care and protection (P = .041). No significant differences in VOICE-J scores were observed by sex or by whether patients had experienced seclusion or restraint, either during the current or past hospitalizations (Table 4).
Group Comparisons of VOICE-J Scores (Known-Groups Validity) (N = 134).
“Involuntary hospitalization for medical care and protection” refers to compulsory admission under the Japanese Mental Health and Welfare Act.
Abbreviation: VOICE-J: Japanese version of the Views on Inpatient Care; higher scores indicate more negative perceptions of inpatient care.
Test-Retest Reliability
Test-retest reliability was examined in a subsample of 28 participants who agreed to complete VOICE-J twice, approximately 1 month apart. The ICC(2,1) was 0.85 (95% confidence interval [CI]: 0.71-0.93), indicating good reliability, suggesting that VOICE-J produces stable scores when patients’ experiences are unchanged. The ICC for average measures was 0.92 (95% CI: 0.83-0.96), indicating excellent reliability.
Free-Text Comments
Seventeen participants provided comments. These included strong objections to compulsory admission, dissatisfaction with specific staff members, complaints or gratitude regarding treatment and care within the ward, additional explanation regarding the response, and broader opinions (eg, “please also study God and spirits”).
Discussion
This study developed the VOICE-J and examined its psychometric properties among psychiatric inpatients. Overall, the findings indicate that VOICE-J is a sound and reliable instrument for assessing how patients experience care during psychiatric hospitalization. Specifically, VOICE-J demonstrated excellent internal consistency, strong correlations with patient satisfaction and recovery-oriented support, good test-retest reliability, and partial support for known-groups validity. These results suggest that VOICE-J consistently captures meaningful differences in patients’ inpatient care experiences. A key strength of this study is the emphasis on PPI, with individuals who had lived experience of psychiatric admission actively contributing to the development and adaptation of the VOICE-J.
The VOICE-J showed excellent internal consistency, with a Cronbach's α of 0.94, which is comparable to previous studies of the original UK version (α = 0.92). 8 Most items had adequate item-rest correlations (>0.50), indicating that they contributed meaningfully to the overall construct.
One notable finding was the inconsistent performance of the reversed score item (“Staff give me medication instead of talking to me.”). This item showed very low item-rest correlations, and removing it slightly improved the overall α. Caution in the use of reversed items has been emphasized in prior research. 16 However, in VOICE, each item describes a specific situation and asks respondents to indicate the degree to which they agree with the statement, and only item 6 addresses an undesirable situation, making it the sole reversed item. Importantly, this item is not phrased as a negated statement, but rather captures a clinically relevant phenomenon without the use of explicit negation. During the adaptation process, people with lived experience consistently emphasized that this experience—being offered medication in place of meaningful communication with staff—was a common and important aspect of psychiatric inpatient care. From a clinical perspective, this phenomenon is also well-recognized by practitioners as a key factor influencing patients’ sense of being heard and respected during hospitalization. Because of the nature of this experience, rephrasing the item into a positively framed or negated form to align its scoring direction with other items would risk altering its meaning and diminishing its experiential relevance. For this reason, we decided to retain the item in VOICE-J. At the same time, we acknowledge that the performance of this item warrants further examination. Future validation studies with larger and more diverse samples may explore alternative ways of modeling or refining this item while preserving its conceptual and experiential significance, including the use of more advanced approaches such as ordinal modeling or item response theory.
The strong negative correlations between VOICE-J and both CSQ-8J and Brief INSPIRE-J indicate that more positive ward experiences (lower VOICE-J scores) were associated with greater patient satisfaction and higher levels of perceived recovery-oriented support. These findings support the concurrent validity of VOICE-J and are consistent with the original VOICE study in the United Kingdom. 8
As hypothesized, patients admitted voluntarily, including those who self-requested admission, reported significantly more positive experiences than those admitted involuntarily, and this was consistent with the study by Evans et al. 8 However, contrary to expectations, no significant differences were observed according to experiences of seclusion or restraint. Although patients who had experienced seclusion or restraint during the current hospitalization tended to report higher mean VOICE-J scores (ie, less positive ward experiences), the standard deviations were also large, and these differences did not reach statistical significance. This may reflect insufficient statistical power, due to the modest sample size, or it may indicate that the evaluation of ward experience may be influenced by broader aspects of care that are not fully captured by the presence or absence of these interventions. Further research with larger samples is warranted to clarify this issue.
Test-retest reliability was good to excellent, with ICC values ranging from 0.85 to 0.92, suggesting that VOICE-J produces stable results over time. Although the retest subsample was relatively small (n = 28), the estimates were consistent with accepted standards and support the reliability of the instrument. 17
Taken together, these findings indicate that VOICE-J can be used not only for research purposes but also as a practical tool to identify strengths and areas for improvement in psychiatric inpatient care from the patient's perspective.
Patient and Public Involvement
A distinctive feature of this study was the active involvement of people with lived experience of psychiatric admission throughout the scale development process. People with lived experience of multiple psychiatric admissions contributed to the identification of relevant content, refinement of wording, cognitive debriefing, and even practical aspects of survey implementation. Their input shaped the questionnaire layout to make it easier to complete and led to the inclusion of explicit instructions reassuring patients that their responses would not be accessible to ward staff. This partnership ensured that the Japanese version of VOICE was understandable, acceptable, and meaningful for patients, and highlights the importance of patient and public involvement in the development of patient-reported outcome measures.
Cultural context may also influence how patients interpret and respond to experience measures. During the adaptation process, individuals with lived experience emphasized the importance of clearly communicating that questionnaire responses would not be accessible to ward staff, reflecting concerns about expressing honest views within hierarchical care environments. In response, explicit instructions regarding confidentiality were added to the questionnaire layout.
In addition, although many respondents in Japan may not identify strongly with religious or distinct ethnic backgrounds, consultation with people with lived experience supported retaining items related to respect for religious and cultural background. These items were considered important for inclusivity and for acknowledging the experiences of patients for whom such considerations are salient, even if some respondents perceived them as less personally relevant.
Clinical and Research Implications
The findings suggest that VOICE-J is a reliable and valid tool for capturing psychiatric inpatients’ experiences of inpatient care. It should also be noted that the VOICE-J validation primarily reflects the experiences of inpatients able to complete self-report questionnaires, as one ward predominantly serving older patients with limited capacity for self-report was excluded from recruitment. Clinically, it can be used to monitor and improve care practices, such as communication, respect, and environment. In research, VOICE-J offers a standardized way to incorporate patient perspectives into evaluations of psychiatric inpatient care, which may inform service development and policy. 6 Future studies should apply VOICE-J in larger and more diverse inpatient populations and examine its sensitivity to change over time or following service improvements.
Limitations
Several limitations should be noted. First, because this study was conducted at a single psychiatric hospital, the findings may reflect characteristics of the patient population, care practices, or organizational culture specific to that setting. As such, the generalizability of the psychometric properties of VOICE-J to other psychiatric inpatient settings or regions in Japan cannot be assumed and requires further examination. At the same time, the development and adaptation of VOICE-J were informed by people with lived experience of multiple psychiatric admissions across different hospitals. Through iterative discussion, contributors reflected not only on their own experiences but also on shared and commonly observed aspects of inpatient care. This process may partially mitigate concerns about site-specificity by grounding the instrument in experiences that extend beyond a single institution. Nevertheless, future multi-site validation studies involving diverse psychiatric hospitals and regions will be essential to strengthen the applicability and generalizability of VOICE-J and to examine its performance across different service contexts.
Second, the test-retest reliability subsample was relatively small, and results should be interpreted with caution. Third, cultural and contextual factors specific to psychiatric inpatient care in Japan may influence responses, and further cross-cultural validation is recommended.
In addition, the study excluded patients who were unable to complete self-report questionnaires independently. This decision was made to prioritize patient autonomy and psychological safety, as responses were completed privately, sealed, and submitted without access by ward staff. In line with this approach, one ward predominantly serving elderly patients who were generally unable to complete self-report questionnaires was excluded from recruitment. As a result, the study may have underrepresented the experiences of older inpatients and those with greater cognitive or functional impairments. Because no data were collected from patients unable to self-complete the questionnaire, we cannot determine whether their experiences would systematically differ in terms of satisfaction or dissatisfaction with care. As such, the findings should not be interpreted as representative of all psychiatric inpatients, but rather of those who were able to engage in self-report at the time of the survey. Future research may consider ethically appropriate methods to include a broader range of inpatient voices, such as supported self-report facilitated by peer supporters or independent volunteers who are not part of the hospital staff. Such approaches may help balance inclusivity with the protection of autonomy and confidentiality in psychiatric inpatient settings.
Conclusion
VOICE-J demonstrated strong psychometric properties and provides a useful tool for assessing psychiatric inpatients’ experiences of care in Japan. By incorporating the voices of patients themselves in its development, VOICE-J offers a meaningful way to evaluate and improve psychiatric inpatient services.
Supplemental Material
sj-docx-1-jpx-10.1177_23743735261439462 - Supplemental material for Development of the Japanese Version of the Views on Inpatient Care (VOICE-J): Service Users’ Perspectives on Psychiatric Inpatient Care
Supplemental material, sj-docx-1-jpx-10.1177_23743735261439462 for Development of the Japanese Version of the Views on Inpatient Care (VOICE-J): Service Users’ Perspectives on Psychiatric Inpatient Care by Yuki Miyamoto, Risa Kotake, Emiko Otsu-Mitsui, Manami Tsunemoto, Tomoko Shinmura, Utako Sawada, Kaori Tsuzuki, Neteru Masukawa, Jo Evans and Daisuke Nishi in Journal of Patient Experience
Supplemental Material
sj-docx-2-jpx-10.1177_23743735261439462 - Supplemental material for Development of the Japanese Version of the Views on Inpatient Care (VOICE-J): Service Users’ Perspectives on Psychiatric Inpatient Care
Supplemental material, sj-docx-2-jpx-10.1177_23743735261439462 for Development of the Japanese Version of the Views on Inpatient Care (VOICE-J): Service Users’ Perspectives on Psychiatric Inpatient Care by Yuki Miyamoto, Risa Kotake, Emiko Otsu-Mitsui, Manami Tsunemoto, Tomoko Shinmura, Utako Sawada, Kaori Tsuzuki, Neteru Masukawa, Jo Evans and Daisuke Nishi in Journal of Patient Experience
Footnotes
Acknowledgments
We wish to thank the participants and staff involved in this research for their cooperation. We also thank all those who supported this study for their valuable input.
Authors’ Contributions
YM and RK contributed equally to the conceptualization and design of the study. YM, RK, MT, TS, US, KT, NM, and DN participated in interviews. All authors contributed to the translation process and the implementation of the survey. YM performed the data analysis and drafted the manuscript. All authors reviewed and approved the final version.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Declaration of Conflicting Interests
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: YM, RK, EO, MT, TS, US, KT, NM, and JE report there are no competing interests to declare. DN received personal fees outside the submitted work from MD.net, and an honorarium from Takeda Pharmaceutical Co. and Otsuka Medical Devices Co., Ltd.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Health and Labor Sciences Research Grants (20GC1021), JSPS KAKENHI (JP 22K10779), and RISTEX Research Institute of Science and Technology for Society (JPMJRS24K1).
Ethics Approval
The Research Ethics Review Board of the Graduate School of Medicine, University of Tokyo, approved this study (2020237NI-(1)).
Informed consent
Informed consent was obtained from all individual participants included in the study.
Statement of Human and Animal Rights
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study did not involve animals.
Supplemental Material
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