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J Geriatr Psychiatry Neurol. 2022 Mar; 35(2): 215–222.
PMCID: PMC8899829
PMID: 35130783
Guest Editor (s): Drs. Bao-Liang Zhong and Yu-Tao Xiang
Wen-Cai Chen, MD,1,2,* Si-Jing Chen, MD, PhD,1,2,* and Bao-Liang Zhong, MD, PhD
1,2
Author information Copyright and License information PMC Disclaimer
Abstract
Objective
To examine the epidemiology of sense of alienation (SoA) and its associationswith depressive symptoms and poor sleep quality (PSQ) in Chinese olderadults who experienced lockdown during the COVID-19 pandemic.
Background
There is a dearth of data on SoA in older adults during the COVID-19pandemic.
Methods
Altogether, 543 community-dwelling older adults (50+ years) were recruitedvia the three-tier mental health network in Wuhan, China, and completed anonline questionnaire in April 2020, the first month after the reopening ofWuhan. SoA, depressive symptoms, and sleep quality were measured by usingthe General Social Alienation Scale, Depression Anxiety and Stress Scale,and a single standardized question, respectively.
Results
The prevalence of SoA was 52.3% (95% confidence interval: 48.1–56.5%).Factors associated with higher levels of SoA were religious belief (β =1.960, P = .024), monthly family income<4000 RMB (β =1.405, P = .022), unemployment (β = 1.217,P = .039), fair or poor physical health (β = 2.202,P = .002), never and sometimes receiving communitysupport (β = 2.297, P < .001 and β = 3.417,P < .001), perceiving a low possibility of a curefor COVID-19 (β = 2.379, P < .001), and affirmative andunsure fear of COVID-19 patients (β = 2.025, P = .007 and β= 1.101, P = .027). After adjusting for sociodemographicand pandemic-related variables, a one-SD increment in the SoA score wassignificantly associated with depressive symptoms (Odd Ratio [OR] = 5.59,P < .001) and poor sleep quality (Odd Ratio = 2.00,P < .001).
Conclusion
Over half of the older adults who experienced lockdown felt alienated, andSoA was independently associated with their depressive symptoms and PSQ.Efforts are warranted to address SoA in older adults who experiencedlockdown during the pandemic.
Keywords: sense of alienation, depressive symptoms, sleep quality, elderly, COVID-19
Introduction
In social psychology, alienation refers to a sense of self-estrangement, an absenceof social support, or meaningful social connectedness.1 The sense of alienationgenerally consists of three dimensions: social isolation, powerlessness, andnormlessness.2 In China, social psychologists have defined it as analienated relationship with people, society, nature, and oneself or as arelationship of being dominated or controlled, typically exhibited as socialisolation, uncontrollability, meaninglessness, feelings of pressure, and a sense ofself-estrangement.3 Feelings of alienation are an important indicator of mentalwell-being and have been associated with depressed mood, anxiety symptoms, alcoholuse disorders, psychological distress, insomnia, post-traumatic stress disorder, andincreased risk of suicide.4-10
The ongoing coronavirus disease 2019 (COVID-19) pandemic has caused a worldwidepublic mental health crisis. In an attempt to curb the spread of the severe acuterespiratory syndrome coronavirus 2 (SARS-CoV-2), governments of various countrieshave imposed regulations such as lockdown restrictions, social distancing, massquarantine, self-quarantining, and home confinement. These restrictions, whilenecessary for infection control, reduce social contact among people and causedifficulties in maintaining traditional social connectedness.11 Moreover, thepandemic may also increase suspicion among people because of the invisibletransmission of SARS-CoV-2, asymptomatic COVID-19 infections, and fear of beinginfected, which in turn results in difficulties in developing quality relationshipsamong people. Consequently, people are more likely to feel alienated amid thepandemic. For example, researchers have observed the high prevalence of loneliness,a subjective feeling of social isolation, in Chinese residents affected by theCOVID-19 epidemic.12
The pandemic has disproportionately affected older adults, including higher casefatality and higher risk for severe complications in elderly patients with COVID-19,and concerns about disruptions in older adults’ access to routine healthcare andexacerbated mental health problems.13 Accordingly, empiricalstudies have reported a 32.0–35.8% prevalence of depressive symptoms and a57.0–64.3% prevalence of poor sleep quality among older adults during the COVID-19pandemic.14-16 Commonlyreported factors associated with depressive symptoms and poor sleep quality in theelderly population have included female sex, low socioeconomic status, poor physicalhealth, feeling lonely, fear of COVID-19, and history of exposure toSARS-CoV-2.14,16-20
In the context of rapid aging and urbanization in recent decades in China, the senseof social alienation had become a major psychosocial problem among Chinese olderadults before the pandemic.21-24 Because older adults arevulnerable to COVID-19, they are more likely to be recommended to stay at home andmaintain a social distance from others. Hence, feelings of alienation may have beenexacerbated in Chinese older adults, particularly those living in the COVID-19epicenter. Nevertheless, to our knowledge, few studies have examined the sense ofalienation in older adults amid the COVID-19 pandemic, as well as its associationwith poor mental health.
Compared to the numerous studies on the mental health of a variety of populationsduring the outbreak stage of COVID-19, fewer studies have focused on the mentalhealth of older adults after the outbreak.25,26 However, the negative mentalhealth impact of the COVID-19 pandemic is likely to be long-lasting and may persistfor several years.27 Given the importance of post-pandemic mental health, amunicipality-wide psychosocial services program was launched immediately after theeasing of the lockdown in Wuhan on 8 April, 2020, the initial COVID-19 epicenter inChina, which aimed to provide social work and mental health services to localresidents with a particular focus on older adults. To inform the planning anddevelopment of appropriate mental health services for older adults, the presentstudy investigated the sense of alienation and its associations with depressivesymptoms and poor sleep quality in older adults who experienced the lockdown inWuhan, China, between 12 and 21 April, 2020. The consideration for focusing onalienation was that since social distancing was still required and public gatheringwas still prohibited during the early post-outbreak stage, the sense of alienationwas still a psychosocial concern for older adults.
Methods
Sampling and Participants
Due to the potential risk of SARS-CoV-2 infection, household-based sampling andface-to-face interviews were not feasible. Instead, an online questionnaire wasadministered to a convenience sample of community-dwelling older adults livingin Wuhan, China. By using the preexisting three-tier mental health network inWuhan, ten community workers were purposively recruited as the seeds of oursampling. These seeds were required to send the link of our survey questionnaireto at least 50 older adults of the communities in which they were living.Eligible participants were community-dwelling older adults aged 50 years orolder living in Wuhan.28 We excluded older adults who had been infected withCOVID-19.
The study protocol was approved by the Ethics Committee of Wuhan Mental HealthCenter. Before completing the online questionnaire, a one-page letter was usedto display the content of the survey, declarations on the anonymity andconfidentiality principles, and instructions for completing the questionnaires.After that, the respondents were asked to press a “yes” button to indicate theirinformed consent to participate.
Assessments
Sociodemographic variables in the questionnaire were gender, age, education,marital status, employment status, monthly family income, living arrangement(alone or with others), and religious belief. The presence of religious beliefwas assessed by asking “Do you have any religious belief? Respondents whor*plied “yes” were classified as having religious belief.29
Self-rated physical health was assessed by using a single question: “In general,would you say your overall physical health is good, fair, or poor?”.
Pandemic-related factors included COVID-19 infection of family members orrelatives, frequency of receiving help from community workers for daily affairsduring the lockdown (never, sometimes, often), fear of COVID-19 patients (no,unsure, yes), and perceived possibility of a cure for COVID-19 if a person hadCOVID-19 (high vs low).
The Jessor and Jessor30 General Social Alienation Scale (GSAS) was used tomeasure feelings of alienation. The GSAS consists of 15 items with responsealternatives of “1=strongly disagree,” “2=disagree,” “3=agree,” and “4=stronglyagree”. The possible total scores range from 15 (low alienation) to 60 (highalienation). The Chinese GSAS has been proven to be reliable and valid inChinese older adults.31 Although there is no recommended cutoff score of theGSAS to dichotomize older adults into those with and without clinicallysignificant feelings of alienation, a preliminary study in China suggested 31and above to indicate the presence of at least some feelings ofalienation.32
Depressive symptoms over the past week were assessed with the depression subscaleof the validated Chinese Short Version of Depression Anxiety and Stress Scale(DASS).33 This subscale has seven items with all items beinganswered on a four-point Likert scale from “0=did not apply to me at all” to“3=applied to me very much or most of the time”. The possible total scores onthe depression subscale of the DASS range from 0 to 21, with 5 and abovedenoting clinically significant depressive symptoms.
To reduce the response burden, we used the subjective sleep quality question ofthe validated Chinese Pittsburgh Sleep Quality Index to evaluate the sleepquality: “During the past month, how would you rate your sleep qualityoverall?”.34 The question was answered on a four-point scale:“0=very good,” “1=fairly good,” “2=fairly bad,” and “3=bad”. Respondents whoanswered “fairly bad” and “bad” were considered to have poor sleep quality.
Statistical Analysis
The mean score (standard deviation [SD]) on the GSAS and prevalence rates ofdepressive symptoms and poor sleep quality were calculated. One-way ANOVA wasused to compare GSAS scores between/across different subgroups based onsociodemographic and pandemic-related characteristics. Multiple linearregression analysis with a backward stepwise entry of all significant variablesin one-way ANOVA was used to identify factors associated with feelings ofalienation.
The independent association of sense of alienation with depressive symptoms wasexamined with multiple logistic regression analysis, which included the presenceof depressive symptoms as the outcome variable, alienation as the predictor, andsociodemographic and pandemic-related variables together as covariates. Theassociation between alienation and poor sleep quality was examined in the samemanner. To facilitate the explanation of alienation-depression/sleepassociation, alienation was modeled as a continuous ordinal measure, per one-SDincrement in GSAS score, in the logistic regression analyses. Unstandardizedcoefficients (βs) and odds ratios (ORs) and their 95% confidence intervals (95%CIs) were used to quantify associations between factors and the outcomevariables in the linear and logistic regression analyses, respectively. Thestatistical significance level was set at P < .05(two-sided). SPSS software version 12.0 package (SPSS Inc, Chicago, IL, USA) wasused for all analyses.
Results
The final sample of this study was 543 older adults with an average age of 54.4years(SD: 4.5, range: 50–78) and 30.2% being men. Detailed sociodemographic andpandemic-related characteristics of the sample are displayed in Table 1.
Table1.
Characteristics of the Sample of Older Adults andGeneral Social Alienation Scale Scores According to Sociodemographic andPandemic-Related Variables.
| Variable | Number of Participants (Percentage Among theTotal Sample) | General Social AlienationScale Score | F | P | |
|---|---|---|---|---|---|
| Sex | Male | 164 (30.2%) | 30.9±5.6 | 1.479 | .225 |
| Female | 379 (69.8%) | 30.3±5.8 | |||
| Age (years) | 50–59 | 494 (91.0%) | 30.4±5.8 | 1.188 | .276 |
| 60+ | 49(9.0%) | 31.3±5.4 | |||
| Education | Senior middle school and below | 137(25.2%) | 31.6±5.5 | 7.468 | .006 |
| College andabove | 406 (74.8%) | 30.1±5.8 | |||
| Maritalstatus | Married | 479(88.2%) | 30.3±5.8 | 4.984 | .026 |
| Othersa | 64 (11.8%) | 32.0±5.3 | |||
| Monthly family income | <4000 RMB | 108 (19.9%) | 32.0±6.0 | 8.108 | <.001 |
| 4000–8000RMB | 271 (49.9%) | 30.6±5.4 | |||
| >8000 RMB | 164 (30.2%) | 29.2±5.9 | |||
| Employmentstatus | Employed | 425 (78.3%) | 30.0±5.8 | 10.768 | .001 |
| Unemployed | 118(21.7%) | 32.0±5.2 | |||
| Living alone | No | 506 (93.2%) | 30.4±5.6 | 2.135 | .145 |
| Yes | 37(6.8%) | 31.8±7.0 | |||
| Religious belief | No | 501 (92.3%) | 30.3±5.8 | 3.961 | .047 |
| Yes | 42 (7.7%) | 32.1±5.1 | |||
| Self-rated physical health | Good | 348 (64.1%) | 30.0±5.8 | 7.944 | <.001 |
| Fair | 169 (31.1%) | 31.4±5.6 | |||
| Poor | 26 (4.8%) | 33.4±4.8 | |||
| Familymembers or relatives diagnosed with COVID-19b | No | 523 (96.3%) | 30.4±5.7 | 1.709 | .192 |
| Yes | 20 (3.7%) | 32.1±6.4 | |||
| Receiving community support during the lockdown | Never | 91 (16.8%) | 31.0±5.1 | 11.162 | <.001 |
| Sometimes | 288 (53.0%) | 31.3±5.4 | |||
| Often | 164 (30.2%) | 28.7±6.3 | |||
| Possibilityof a cure for COVID-19b | High | 501 (92.3%) | 30.1±5.6 | 18.65 | <.001 |
| Low | 42 (7.7%) | 34.1±6.0 | |||
| Fear ofpatients with COVID-19b | No | 127 (23.4%) | 28.6±6.4 | 10.067 | <.001 |
| Unsure | 89 (16.4%) | 30.4±5.4 | |||
| Yes | 327 (60.2%) | 31.2±5.4 | |||
| Depressive symptoms | No | 427 (78.6%) | 29.0±5.0 | 152.822 | <.001 |
| Yes | 116 (21.4%) | 35.6±5.3 | |||
| Poor sleepquality | No | 415(76.4%) | 29.6±5.3 | 44.33 | <.001 |
| Yes | 128 (23.6%) | 33.3±6.2 |
aOthers includednever-married, divorced, separated, and widowed.
bCOVID-19: corona virusdisease 2019.
The mean GSAS score was 30.5 (SD: 5.7, range: 15–49). In total, 284 participants(52.3% [95% CI: 48.1–56.5%]) scored 31+. The results of one-way ANOVA showed thatthe participants who had an educational attainment of senior middle school and below(P = .006), had marital status of “others” (P= .026), had monthly family income <4000 RMB (P < .001), wereunemployed (P = .001), had religious beliefs (P =.047), had poor physical health (P < .001), “never” or“sometimes” received community support during the lockdown (P <.001), perceived a low possibility of a cure for COVID-19 (P <.001), and feared COVID-19 patients (P < .001) had significantlyhigher alienation scores than their counterparts in the same subgroups (Table 1).
In multiple linear regression, 6 factors were significantly associated with feelingsof alienation: religious belief (vs no; β = 1.960, P = .024),monthly family income <4000 RMB (vs. > 8000 RMB; β = 1.405, P= .022), unemployment (vs employment; β = 1.217, P = .039), fair orpoor physical health (vs good; β = 2.202, P = .002), never andsometimes receiving community support (vs often; β = 2.297, P <.001 and β = 3.417, P < .001), perceiving a low possibility of acure for COVID-19 (vs high; β = 2.379, P < .001), andaffirmative and unsure fear of COVID-19 patients (vs no; β = 2.025,P = .007 and β = 1.101, P = .027) (Table 2).
Table2.
Results of Multiple Linear Regression on FactorsAssociated With Feelings of Alienation in Chinese OlderAdults.
| Factor | β | Standard Error | t | P | |
|---|---|---|---|---|---|
| Monthlyfamily income | <4000 RMB vs > 8000RMB | 1.405 | .609 | 2.305 | .022 |
| Religious belief | Yes vs no | 1.960 | .865 | 2.267 | .024 |
| Employment status | Unemployed vs employed | 1.217 | .588 | 2.071 | .039 |
| Self-rated physical health | Fair or poor vs good | 2.202 | .705 | 3.125 | .002 |
| Receiving community support during thelockdown | Never vs often | 2.297 | .531 | 4.327 | <.001 |
| Sometimes vs often | 3.417 | .874 | 3.911 | <.001 | |
| Possibility of acure for COVID-19a | Low vs high | 2.379 | .563 | 4.225 | <.001 |
| Fear of patientswith COVID-19a | Yes vs no | 2.025 | .75 | 2.701 | .007 |
| Unsurevs no | 1.101 | .496 | 2.221 | .027 |
aCOVID-19: corona virusdisease 2019.
The prevalence rates of depressive symptoms and poor sleep quality were 21.4 and23.6%, respectively. GSAS scores were significantly higher in depressed thannon-depressed participants (35.6 ± 5.3 vs 29.0 ± 5.0, P < .001)and in participants with poor sleep quality than those without poor sleep quality(33.3 ± 6.2 vs 29.6 ± 5.3, P < .001) (Table 1). After adjusting forsociodemographic and pandemic-related variables, feelings of alienation (a one-SDincrement in GSAS score) were still significantly associated with depressivesymptoms (OR [95% CI]: 5.59 [3.76, 8.29], P < .001) and poorsleep quality (OR [95% CI]: 2.00 [1.54, 2.60], P < .001) (Table 3).
Table3.
Results of Multiple Logistic Regression Analyses onAssociations Between Sense of Alienation and Depressive Symptoms andPoor Sleep Quality in Chinese Older Adults, Controlling forSociodemographic and Pandemic-RelatedFactors.
| Variable | Depressive Symptoms | P | Poor SleepQuality | P |
|---|---|---|---|---|
| Alienation score: Per standarddeviation increment | 5.59 (3.76,8.29) | <.001 | 2.00 (1.54, 2.60) | <.001 |
| Gender:Female vs male | .74 (.42, 1.30) | .293 | 1.42 (.84, 2.39) | .190 |
| Age (years): 60+ vs50–59 | .97 (.38, 2.48) | .952 | .46(.17, 1.23) | .124 |
| Education: College andabove vs senior middle school and below | 1.10 (.57, 2.12) | .780 | 1.46 (.79, 2.70) | .228 |
| Marital status:Othersa vsmarried | 1.06 (.49, 2.28) | .883 | 1.32 (.69, 2.54) | .401 |
| Monthly family income: <4000 RMB vs >8000 RMB | .73 (.32,1.64) | .442 | 1.34 (.64, 2.77) | .437 |
| Monthly familyincome: 4000–8000 RMB vs >8000 RMB | .91 (.49, 1.69) | .764 | 1.51 (.88, 2.58) | .134 |
| Employed: No vsyes | 1.65 (.81, 3.37) | .169 | 1.21 (.64, 2.30) | .562 |
| Living alone: Yes vsno | 1.43 (.52, 3.95) | .492 | 1.12 (.46, 2.74) | .799 |
| Religious belief: Yes vsno | 1.10 (.47, 2.60) | .830 | .61(.26, 1.42) | .253 |
| Self-rated physicalhealth: Poor or fair vs good | 1.57 (.93,2.64) | .093 | 2.00 (1.27, 3.14) | .003 |
| Family membersor relatives diagnosed with COVID-19b:yes vs no | 2.15 (.62, 7.41) | .226 | 2.94 (1.04, 8.36) | .043 |
| Receiving community supportduring the lockdown: Never vs often | .80(.40, 1.61) | .530 | 1.00 (.53, 1.88) | .999 |
| Receivingcommunity support during the lockdown: Sometimes vsoften | 1.08 (.49, 2.35) | .856 | 1.44 (.72, 2.85) | .301 |
| Possibility of a cure forCOVID-19b:Low vs high | 2.00 (.86, 4.62) | .107 | 2.24 (1.09, 4.60) | .029 |
| Fear of patients withCOVID-19b:Unsure vs no | 1.50 (.75, 2.99) | .253 | 1.05 (.60, 1.84) | .860 |
| Fear of patients withCOVID-19b:Yes vs no | 1.15 (.48, 2.79) | .751 | .77(.36, 1.65) | .502 |
aOthers includednever-married, divorced, separated, and widowed.
bCOVID-19: corona virusdisease 2019.
Discussion
To the best of our knowledge, this is the first study investigating the sense ofalienation in an older adult population amid the COVID-19 pandemic. In addition, thesignificant associations of feelings of alienation with depressive symptoms and poorsleep quality were also replicated in older adults who experienced thelockdown.
The main finding of this study is the mean GSAS score of 30.5 and 52.3% prevalence ofat least some feelings of alienation in the elderly population living in theCOVID-19 epicenter after the reopening of Wuhan. In 2014, Gu andcolleagues22 reported a mean GSAS score of 31.0 in a representativesample of 733 Chinese older adults aged 60years and over. Compared to this meanlevel of sense of alienation during the pre-pandemic period, our study found asimilar level of sense of alienation in Chinese older adults amid the pandemic.However, because the average age of our sample was much lower than that of the abovestudy (54.4 vs 70.4years) and because levels of sense of alienation were shown tobe higher in the oldest old and old–old adults than young–old adults,35 our studywould likely have a higher level and prevalence of sense of alienation if we hadrecruited a sample of similar age.
Nevertheless, it is expected to find that as high as 52.3% of the Wuhan older adultshad a sense of alienation during the first month after the reopening. Older adultshave reduced social connections with others due to their low socioeconomic status,physical illnesses, disability, and frailty, and limited access to technologyaids.36,37 The mass quarantine in Wuhan worsened this situation, becauseChinese older adults were not able to maintain social connectedness in aface-to-face manner, which they have been shown to prefer.11 Furthermore, it is not easyfor this population to re-establish connections with others after the easing of massquarantine because of the restrictions caused by social distancing. The highprevalence of a sense of alienation in our study suggests that feelings ofalienation in older adults may not be a transient phenomenon during the outbreak;rather, it could persist for a long time after the successful containment of theCOVID-19 outbreak.
In the literature, male sex, older age, marital status of never-married, indicatorsof low socioeconomic status such as low monthly income and unemployment, livingalone, and poor physical health have been significant factors associated with thesense of alienation in the elderly population.22,24,38 Correlates of a sense ofalienation identified in our study were consistent with some, not all, previousstudies. The association of alienation with religious belief was unexpected, becauseit is generally believed that religious belief and attendance can promote socialconnectedness.39 We speculate that this may be explained by the suspensionof religious activities during the COVID-19 pandemic, which disrupted socialconnections among those with religious beliefs and makes them feel alienated. Thefinding of a higher sense of alienation in older adults who never and sometimesreceived community support than those who often received support was interesting andsuggested the importance of support from community workers for maintaining thepsychosocial well-being of older adults during the pandemic. For example, during thelockdown days in Wuhan, community workers and volunteers played a critical role inmeeting older adults’ needs for daily necessities, care, and social interactionsbecause most of them either lacked access to social technologies or had limitedskills to use social media.11
The significant associations of perceiving a low possibility of a cure for COVID-19and fear of COVID-19 patients with a sense of alienation suggested that olderadults’ knowledge and attitudes toward COVID-19 may have influenced the risk offeeling alienated. The excessive fear of COVID-19 infection may have limited olderadults’ willingness to go out and interact with others and participate in communityactivities, increasing the risk of feelings of alienation.
The 21.4% prevalence of depressive symptoms and 23.6% prevalence of poor sleepquality demonstrated in this study were lower than those of the aforementionedstudies,14-16 which may beattributed to the time point of our mental health assessment, which was during thepost-outbreak period, not the outbreak period itself. However, the finding that overone-fifth of the Wuhan older adults suffered from depressive symptoms and poor sleepquality after the reopening of Wuhan still suggests that reducing and preventingmental health problems should still be a focus of the psychosocial services forolder adults who experienced the outbreak and mass quarantine. The elevated risk ofdepressive symptoms and poor sleep quality in alienated older adults was consistentwith earlier studies.10,22 There might be direct and indirect pathways to explain thealienation-depression/sleep relationship; for example, people may feel depressed andexperience insomnia due to lack of meaningful social connectedness, and the risk ofdepression and poor sleep quality may be heightened in stressed older adults wholack of social support.
The current study has some limitations. First, the sample of older adults wasrelatively young and recruited by convenience sampling, so the samplerepresentativeness was limited. We must be cautious when generalizing the findings.Second, sense of alienation is a culturally specific subjective feeling, soqualitative data from Wuhan older adults who experienced the mass quarantine wouldprovide more insights to understand their feelings of alienation. Due to our limitedresearch budget, we did not perform in-depth interviews with them. Third, olderadults’ attitudes toward psychosocial services are also important for planning theservices, but we did not collect data on these variables in the questionnaire.Finally, since this was a cross-sectional study, the causality between identifiedfactors and sense of alienation needs to be further examined in longitudinalstudies.
In conclusion, over half of the older adults who experienced the lockdown in theCOVID-19 epicenter had feelings of alienation after the outbreak, and the sense ofalienation was independently associated with their high risk of depressive symptomsand poor sleep quality. Addressing the sense of alienation should be considered afocus of the post-outbreak psychosocial and mental health services for older adults,which may be beneficial for reducing depressive symptoms and improving their sleepquality. Efforts to prevent or reduce feelings of alienation in older adults may bemore useful if targeted at those with a low socioeconomic status, poor physicalhealth, and excessive fear of COVID-19. In addition, providing community support tothose in need is promising for relieving the feelings of alienation.
Acknowledgments
The authors thank all the research staff for their team collaboration work andparticipants involved in this study for their cooperation and support.
Footnotes
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to theresearch, authorship, and/or publication of this article.
Funding: The author(s) disclosed receipt of the following financial support for theresearch, authorship, and/or publication of this article: This work wassupported by the National Natural Science Foundation of China (grant number:71774060) and 2015 Irma and Paul Milstein Program for Senior Health Awards fromthe Milstein Medical Asian American Partnership Foundation.
ORCID iD
Bao-Liang Zhong https://orcid.org/0000-0002-7229-1519
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