Endometrial cancer awareness as a public health blind spot: a cross-sectional survey study.

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Learn more: PMC Disclaimer | PMC Copyright Notice BMC Public Health . 2026 Apr 11;26:1785. doi: 10.1186/s12889-026-27152-3 Endometrial cancer awareness as a public health blind spot: a cross-sectional survey study Bar Levy 1, 2, ✉ , Nitsan Schwarz 1, 2 , Yael Maizels 1 , Orr Erlich 1, 2 , Zohar Magen 1 , Zvi Vaknin 1, 2, 3 Author information Article notes Copyright and License information 1 HaBait Shel Bar – Israel Women’s Cancer Association (RA), Tel Aviv, Israel 2 Gray Faculty of Medicine & Health Sciences, Tel Aviv University, Tel Aviv, Israel 3 Department of Obstetrics and Gynecology, Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel ✉ Corresponding author. Received 2026 Feb 16; Accepted 2026 Mar 23; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13235091  PMID: 41965582 Abstract Background Endometrial cancer is the most common gynecological cancer. With well-established risk factors and symptoms yet no early-detection screening test, patient-led symptom awareness is essential for early detection. With endometrial cancer rates rising, especially among younger populations, identifying gaps in public knowledge is essential for informing public health strategy. This study evaluates awareness of endometrial cancer symptoms and risk factors among healthy women to identify systemic disparities with global policy implications. Methods A cross-sectional online survey of Israeli women ( n = 1046 participants) was conducted using social media-based recruitment. The questionnaire assessed awareness of endometrial cancer symptoms, risk factors, and intended care-seeking behaviors. Descriptive statistics summarized awareness patterns across demographic cohorts. Results Despite high education levels and recent gynecological consultation (> 50% within the past year), only 26.3% of participants reported any awareness of endometrial cancer symptoms. This contrasts sharply with awareness of cervical (98.5%) and ovarian (77.5%) cancers. Most participants (72.6%) failed to recognize abnormal vaginal bleeding as an endometrial cancer warning sign and were unaware of identifiable risk factors (90.0%). While 86% reported they would consult a gynecologist for irregular bleeding, only 1% of the total cohort was classified as “fully aware” of endometrial cancer. Conclusion The profound deficit in endometrial cancer awareness within this highly educated cohort serves as a warning sign to global public health systems. These findings suggest an “awareness-access” paradox, where clinical access to health care does not equate to health literacy. In the absence of a standardized screening practice, these results from a high-resource population suggest a “high-water mark” indicator: if significant knowledge gaps persist here, they likely signal an even more severe, unmeasured crisis in less-advantaged populations. Policy interventions must rethink strategies to formalize symptom-based education within primary care as a standard of preventative care, to mitigate the rising global burden of endometrial cancer. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-026-27152-3. Keywords: Uterine neoplasms, Endometrial neoplasms, Endometrial cancer, Awareness, Risk factors, Vaginal bleeding Introduction Endometrial cancer (EC) is the most common gynecological malignancy in high-income countries and the second most common worldwide [ 1 ]. Globally, EC incidence has increased over the last few decades, and cases are projected to rise by nearly 50% by 2044 [ 2 ]. This rise is attributed to population aging and an increase in the prevalence of risk factors such as type 2 diabetes and obesity [ 3 , 4 ]. About 60% of ECs in the US are linked to obesity [ 5 ] and the upwards trend of obesity may partly account for the significant increase of EC diagnosis in pre-menopausal women [ 5 ], with an average of 20–25% of EC cases reported in pre-menopausal women[ 6 ]. Endometrial cancer has well established symptoms and risk factors, yet in contrast to cervical and breast cancers there is no screening test developed for early diagnosis [ 3 ]. While EC is highly curable when detected early, with five-year survival exceeding 95% for localized disease, survival falls below 20% at advanced stages [ 7 ]. Thus, in the absence of an established population-based screening strategy, early diagnosis relies heavily on patient awareness of symptoms and timely presentation to healthcare providers [ 8 ]. However, even in highly resourced countries, EC symptom and risk factor awareness is not yet integrated into standard primary care or community-based health education [ 9 , 10 ]. Previous studies conducted in specific populations in Germany, the US and Australia have shown that there is a lack of awareness of EC in the general population [ 8 , 11 – 14 ]. Yet no similar study has been conducted in Israel until now, a country presenting with a high education rate, gynecology as primary care, and unique universal healthcare system; factors expected to facilitate timely access to care and earlier presentation [ 15 ]. To evaluate awareness gaps in country that is representative of other global entities, we conducted a national survey assessing EC awareness among healthy women in Israel. The primary aim of this survey was to assess the level of awareness of EC among healthy women [ 16 ]. A secondary aim was to assess women’s practices of routine gynecological checkups and understand the various resources women would utilize in the presence of symptoms that could indicate EC. Materials and methods Participants In this cross-sectional study, a survey using convenience sampling was published on popular Israeli women’s social-media groups (over 20,000 users). To ensure data integrity against automated bots and multiple entries, the survey utilized Google Forms’ security features to limit responses to one per IP address. Digital consent was obtained from all participants and approval for this project was granted by the institutional review board of the Helsinki Committee of Israel (IRB #ASF-0248-24). In total, 1161 healthy adult women over the age of 18 responded to the survey voluntarily and anonymously in May 2023. Exclusion criteria spanned women with a past diagnosis of EC. Assessment of EC awareness As the Womb Cancer Awareness Measure (WCAM) [ 8 ] did not exist at the time of this study, the respondents were required to answer a Hebrew questionnaire with 22 questions built according to the Cancer Awareness Measure (CAM) [ 17 ] core questions. The questionnaire closely mirrored language of the WCAM, incorporating culturally relevant demographic variables such as religiosity and proximity to gynecological primary care (Supplementary document 1). This questionnaire had three main components, as follows: Demographic characteristics, including level of religion (7 questions). Open questionnaire evaluating participant-reported awareness of EC symptoms and risk factors (3 questions). Closed questionnaire measuring: awareness of gynecological cancers (i.e. cervical, endometrial and ovarian cancers), symptoms and risk factors of EC, and gynecological follow-up routine behavior (12 questions). These questions were aligned with the information available at the International Gynecologic Cancer Society (IGCS) website with regards to uterine cancer symptoms (“IGCS Rules”) [ 18 ]. Construct validity was demonstrated by comparing the knowledge of women with a medical background ( n = 308) to women without a medical background ( n = 848). To prevent priming bias, participants completed open-ended questions prior to questions listing possible gynecological cancer symptoms, and respondents could not go back from the closed-questionnaire to the open-questionnaire. We note that despite our use of the Hebrew term of EC in the survey, the terms “Uterine Cancer” and “Womb Cancer” refer to a single slang Hebrew term of EC. The open questionnaire measured objective awareness of EC by asking the respondents to list all the EC symptoms and risk factors they know, allowing participants to demonstrate uncertainty through writing or leaving their answer blank. The closed questionnaire measured subjective awareness by asking “yes or no” questions, with all symptoms and risk factors listed in accordance with the IGCS rules. Based on answers in the open questionnaire, an EC-awareness variable was operationalized with the following criteria: Grade 0: No response, or “I don’t know”. Grade 1: Identifying only vaginal bleeding as a symptom of EC. Grade 2: Identification of two out of the following symptoms: vaginal bleeding, pelvic pain, discharge, pain during urination or frequency of urination, or feeling a pelvic mass. Grade 3: Identification of at least three symptoms out of the five listed in Grade 2. Statistical analysis We evaluated EC-awareness between the different study populations using Pearson’s chi-square test. Then, we used the McNemar Test to evaluate awareness of the following cancer-related terms: HPV, cervical cancer, BRCA , ovarian cancer, Lynch Syndrome, and EC. The results of the survey were analyzed using R software (version 4.3.0) [ 19 ] SPSS v28.0 [ 20 ], and Excel. A two-sided P value ≤ 0.05 was considered significant. Open answers were reviewed manually to evaluate any variations in language. Results A total of n = 1161 women responded to the survey, with five women excluded because of past diagnosis of EC. The population’s characteristics are summarized in Table 1 . The age distribution of the study population consisted primarily of women aged 36 years or older (79.8%) (Table 1 ). Table 1. Demographic Characteristics ( N = 1056). Demographic characteristics of all study participants, including religion, medical background, age, and education. MA+ indicates an MA degree or higher Characteristic N (%) Age 18–25 21 (1.8%) 25–30 85 (7.4%) 30–35 129 (11.2%) 35–45 417 (36.1%) 45–55 304 (26.3%) 55–65 157 (13.6%) 65–75 35 (3.0%) 75+ 8 (0.7%) Education High School 84 (7.3%) Student 29 (2.5%) Technical Degree 12 (1.0%) BA 435 (37.6%) MA+ 596 (51.6%) Religion Jewish 1134 (98.1%) Christian 3 (0.3%) Muslim 3 (0.3%) Other 16  (1.4%) Religious affiliation Secular 974 (84.3%) Traditional 92 (8.0%) Religious 88 (7.6%) Orthodox 2 (0.2%) Sexual Orientation Straight 1098 (95.0%) LGBTQ+ 58 (5.0%) Medical or paramedical education No 851 (73.4%) Yes 308 (26.6%) Open in a new tab The educational background of the study population, as shown in Table 1 , indicated that the majority of respondents had a bachelor’s degree or higher (89.2%). The respondents were predominantly Jewish (98.1%), with most participants identifying as secular (84.3%). Approximately one-quarter (26.6%) of women answered yes to the question “Are you involved medical, para-medical or pharmaceutical field?”, affirming they had a medical or healthcare background (Table 1 ). The McNemar test evaluated awareness of gynecological cancer-related terms. 94.5% of participants reported general awareness of cervical cancer, 77.5% of ovarian cancer, and only 26.3% of EC. The relationship between cancer risk factor and cancer awareness was significant; 96.1% of participants were aware of the human papillomavirus (HPV) and 68.6% of the BRCA gene, while only 5.6% of participants were aware of Lynch syndrome (Fig. 1 ). Fig. 1. Open in a new tab Visual representation of gynecological cancer and risk factor awareness of endometrial cancer in Israeli women. In response to the question, “Which diseases, viruses or inherited conditions have you heard of before?” Cervical cancer awareness and HPV awareness were significantly correlated ( p < 0.001), as were ovarian cancer and BRCA ( p < 0.01). Additionally, EC awareness and awareness of Lynch syndrome were positively correlated ( p < 0.01). A total of 483 (41.8%) women answered that in their opinion, there are no signs or symptoms which require attention for any gynecological cancer. Gynecological healthcare behavior reported in the survey are summarized in Table 2 . 65.3% of participants reported a routine gynecological checkup at least once every year, 11.9% every two years, and 4.5% every three years. 12% reported gynecological visits only when concerned about an existing gynecological problem, with 6.3% reporting no routine checkups at all. There was no significant association between frequency of gynecological checkup routine and EC-awareness grade ( p = 0.15). Table 2. Level of awareness of gynecological cancer symptoms. Level of awareness of gynecological cancer symptoms in an open questionnaire, alongside multiple-choice questions evaluating specific symptoms and behaviors in a closed questionnaire N Awareness rate N (%) P Value* 0 1 2 3 Age 18–25 21 (1.8%) 19 (90.5%) 1 (4.8%) 1 (4.8%) 0 (0%) 0.078 26–30 85 (7.4%) 65 (76.5%) 11 (12.9%) 8 (9.4%) 1 (1.2%) 31–35 129 (11.2%) 106 (82.2%) 15 (11.6%) 7 (5.4%) 1 (0.78%) 36–45 417 (36.1%) 341 (81.8%) 42 (10.1%) 27 (6.5%) 5 (1.2%) 46–55 304 (26.3%) 212 (69.7%) 63 (20.7%) 27 (8.9%) 1 (0.3%) 56–65 157 (13.6%) 107 (68.2%) 36 (22.9%) 10 (6.4%) 1 (0.6%) 66–75 35 (3.0%) 26 (74.3%) 7 (20.0%) 2 (5.7%) 0 (0%) 76+ 8 (0.7%) 6 (75.0%) 2 (25.0%) 0 (0%) 0 (0%) Do you know if abnormal vaginal bleeding may be a symptom of endometrial cancer? No 839 (72.6%) 788 (93.9%) 26 (3.1%) 21(2.5%) 1 (0.1%) < 0.001 Yes 317 (27.4%) 94 (29.7%) 151 (47.6%) 61 (19.2%) 8 (2.5%) Do you know if pelvic pain may be a symptom of endometrial cancer? No 1035 (89.5%) 858 (82.9%) 134 (13.0%) 37 (3.6%) 1 (0.1%) < 0.001 Yes 121 (10.5%) 24 (19.8%) 43 (35.5%) 45 (37.2%) 8 (6.6%) How frequently do you visit your gynecologist? 6 months or less 78 (6.8%) 53 (68.0%) 14 (18%) 11 (14.1%) 0 (0%) 0.15 6–12 m 220 (19.0%) 169 (76.8%) 30 (13.6%) 17 (7.7%) 2 (0.9%) once a year 457 (39.5%) 339 (74.8%) 82 (18.0%) 33 (7.2%) 1 (0.7%) once every two years 137 (11.9%) 104 (75.9%) 20 (14.6%) 11 (8.0%) 1 (0.7%) once every three years 52 (4.5%) 39 (75.0%) 9 (17.3%) 2 (3.9%) 1 (1.9%) only when I feel something is wrong 139 (12.0%) 117 (84.2%) 15 (10.8%) 5 (3.6%) 2 (1.4%) do not have a routine 73 (6.3%) 61 (83.6%) 7 (9.6%) 3 (4.1%) 2 (2.7%) Are you involved medical, para-medical or pharmaceutical field? No 848 (73.4%) 725 (85.5%) 78 (9.2%) 38 (4.5%) 3 (0.4%) < 0.001 Yes 308 (26.6%) 157 (51.0%) 99 (32.1%) 44 (14.3%) 6 (1.9%) Open in a new tab *Derived using Pearson’s chi-square test Awareness of EC symptoms and risk factors, which were assessed using the closed questionnaire, is shown in Fig. 2 . Most women (72.6%) were unaware that vaginal bleeding, such as increased menstruation, intermenstrual bleeding, or post-menopausal bleeding, could be a symptom of EC. 89.5% were unaware of pelvic pain as an EC symptom, and most (90.0%) stated that they did not know any risk factors (Table 2 ; Fig. 2 ). Women with a medical or healthcare background were more knowledgeable about EC symptoms than those without any medical or healthcare background ( p < 0.01, Table 2 ), yet the majority were still unaware of vaginal bleeding or pelvic pain as endometrial cancer symptoms (47.1% and 24.4% awareness rates, respectively). Fig. 2. Open in a new tab Self-reported symptom and risk factor awareness of endometrial cancer across Israeli women, in response to a closed multiple-choice questionnaire In assessing open-ended question awareness (EC-Awareness variable, Fig. 3 ), 76.3% of women did not answer or wrote “I don’t know” (Grade 0), 15.3% were able to list only vaginal bleeding as a symptom of EC (Grade 1), 7.1% were able to list two out of five of the core symptoms of EC (Grade 2), and only 0.8% freely listed at least three out of the five core symptoms of EC (Grade 3). Fig. 3. Open in a new tab Endometrial cancer awareness levels across Israeli women, from Grade 0 (76.3%) to Grade 3 awareness (0.8%), in response to an open questionnaire Interestingly, age was not a significant measure predictive of awareness level, but a positive trend emerged where women in the age groups 45–65 were the most aware of EC symptoms among the sample population ( p = 0.078). 30% of the women in these age groups were defined as having an awareness level greater than or equal to one. Statistical analysis revealed no significant differences in endometrial cancer awareness or intended care-seeking behaviors across religious affiliations, including secular, traditional, and religious cohorts ( p = 0.63 to 0.98). When women were asked what they would do if they noticed irregular vaginal bleeding, 105 (9.1%) answered that they would ignore the symptom and 98 (8.5%) answered that they would not know how to recognize the symptom themselves (Table 3 ). The majority (84.1%) reported they would consult a gynecologist. When women were asked who they would confide in when experiencing symptoms, 972 women (84.1%) reported they would tell someone close to them (a friend or a family member). In contrast, 157 women (13.6%) would not tell anyone about their symptoms. Table 3. Response to Symptoms. Self-reported response to hypothetical endometrial cancer symptoms, in a closed questionnaire allowing more than one answer option to be selected What would you do if you noticed irregular vaginal bleeding (between periods or after menopause)? I would ignore the symptom. 105 (9.1%) I wouldn’t know how to recognize the symptom independently. 98 (8.5%) I would go to a gynecologist. 929 (80.4%) I would go to a GP. 90 (7.8%) Would you tell a close friend or relative if you experienced this symptom? I would tell a close friend or relative. 972 (84.1%) I wouldn’t tell, it’s a personal issue. 157 (13.6%) I don’t know or wouldn’t recognize the symptom. 22 (1.9%) Open in a new tab Discussion Principal findings This study demonstrates that awareness of EC symptoms and risk factors among healthy Israeli women is strikingly low, with only 26.3% of participants reporting any awareness. These findings highlight a substantial gap in public knowledge regarding the most common gynecologic malignancy, even within a population characterized by high educational attainment and frequent engagement with gynecologic care. Although a trend toward greater awareness was observed among women aged 45 years and older, overall awareness remained limited across age groups. Notably, awareness of EC was markedly lower than awareness of less common gynecologic cancers such as cervical and ovarian cancer (26.3% vs. 98.5% and 77.5%, respectively; p < 0.001). Despite limited awareness, many women in age groups at higher risk for the disease reported regular gynecologic follow-up. In Israel, gynecologists often function as primary care for women, in contrast to other medical systems like the UK where they are considered specialists [ 21 ]. Indeed, most participants indicated that they would seek medical evaluation, primarily from a gynecologist, if they experienced abnormal vaginal bleeding. These findings suggest an “awareness-access” paradox, where clinical access to health care does not equate to health literacy. While EC is associated with cure rates exceeding 90% 3 when detected early, the observed lack of symptom recognition suggests that routine gynecological encounters are not being consistently utilized as opportunities for preventative counseling. This points to primary care education as vital for symptom and risk factor education, particularly in countries where gynecology is not considered primary care. Implications from early detection guidelines The clinical implications of this knowledge gap are further magnified by the updated ESGO-ESTRO-ESP guidelines [ 22 ], which have moved towards a “molecular-first” risk stratification. We now recognize that early-stage detection does not always guarantee a low-risk clinical course. For example, some stage II tumors that were once thought to be low-risk are now known to harbor aggressive molecular features (i.e. p53-abnormal) that require intensive adjuvant therapy [ 22 ]. The window for effective intervention, therefore, is even more narrow than previously thought. Comparison with global context and policy gaps The substantially higher awareness of ovarian and cervical cancer observed in this study likely reflects long-standing public health, policy, and industry engagement surrounding these diseases. In Israel, ovarian cancer awareness has been strongly influenced by the high prevalence of BRCA mutations and population-based BRCA screening, while HPV initiatives have led to near-universal awareness of cervical cancer. However, the absence of a comparable risk-factor–driven public health framework for EC is reflected by the low awareness of Lynch syndrome, which correlated with EC awareness. This represents a notable global disparity: while coordinated efforts target cervical cancer (primarily in low-middle income countries), no comparable program exists for EC, which primarily burdens high-middle income countries. Our findings are consistent with global data from Germany, Australia, the United States, and the United Kingdom, where only 24–35% of women have been reported to identify key symptoms [ 11 , 13 , 14 ]. Together, these findings suggest that Israel is not an outlier, but rather serves as a warning sign; if significant knowledge gaps persists in a population with high education and universal healthcare access, they likely signal an even more severe crisis in less-advantaged populations. Furthermore, the fact that knowledge gaps persist even in the subgroup of women with medical backgrounds emphasizes the systemic nature of the awareness deficit. Strengths and limitations Limitations include selection bias, as participants were recruited through online social media groups and therefore result in the overrepresentation of highly educated women. Future research could utilize clinic-based recruitment or random sampling to better capture the average population. Nevertheless, given the strong association between education and cancer awareness reported in prior studies, this cohort likely represents an upper-bound estimate. It is likely that awareness levels in other demographic groups may be even lower. Recall bias is also possible; however, consistency between open- and closed-questionnaire responses supports the internal validity of the findings. Additionally, while online recruitment methods broaden reach, this also introduces risks that can compromise data quality [ 23 , 24 ]. We mitigated these risks by using platform-specific security features and manual screening of response patterns, but acknowledge that cyber-attacks on digital research remains a systemic limitation. Strengths include this being the first large-scale assessment of EC awareness conducted in Israel to our knowledge. Additionally, the study population consists of healthy women who were not interacting with the healthcare system while answering the survey, possibly reflecting the general population better than studies cited above who recruited participants from healthcare clinics [ 11 , 13 , 14 , 25 , 26 ]. The study also has a large number of participants compared to other EC awareness studies. In the absence of an established population-based screening program for EC, symptom and risk factor awareness remains an essential component of early detection. The finding that most women would first discuss symptoms with family members or friends before seeking medical care highlights the importance of disseminating accurate information beyond clinical settings alone. Integrating EC education into routine primary care, alongside broader public health initiatives modeled after the successful cervical cancer elimination strategy and efforts [ 27 ], may represent a scalable strategy to reduce diagnostic delay and improve outcomes; as such interventions have been proven to be supportive of any strategic imperatives of the healthcare system [ 28 , 29 ]. Additionally, while specialized post-menopausal bleeding clinics have been established in countries like the UK [ 30 ], the increasing rise of EC in younger women (pre- or peri-menopausal) requires a modern education in primary care that is not reliant on post-menopausal bleeding symptoms for gynecological referral. Conclusions Our study shows that awareness of endometrial cancer, the most common gynecologic malignancy in industrialized nations, is strikingly low in Israel among highly educated women. This knowledge gap represents a public-health blind spot with potential consequences for delayed diagnosis and preventable morbidity, and should serve as a “wake-up call” to policymakers. In absence of a screening program, symptoms awareness is the primary defense. We conclude that there is an urgent need to formalize symptom-based education within primary care as a standard of preventative care to mitigate the rising global burden of endometrial cancer. Supplementary Information Supplementary Material 1. (18.6KB, docx) Acknowledgements The authors would like to thank Dr. Eliya Shachar for her much-appreciated comments, and Amit Jaffe for the statistical analysis. Abbreviations EC Endometrial cancer IGCS International Gynecologic Cancer Society Authors’ contributions Conceptualization: BL, ZM, ZV, NS. Methodology: BL, ZM. Validation: BL, ZM, ZV. Formal analysis and Investigation: OE, BL, ZM, ZV. Writing – original draft preparation: BL, YM, NS, ZV. Writing – review and editing: NS, BL, ZM, ZV, OE, YM. Resources: BL, ZM. Supervision: ZV, BL, ZM. All authors approved the final version of the manuscript. Funding The authors have not declared a specific grant for this research from any funding agency in the commercial, public or non-profit sectors. Data availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Declarations Ethics approval and consent to participate This study adhered to the Declaration of Helsinki, with approval granted by the institutional review board of the Helsinki Committee of Israel (IRB #ASF-0258-24). Informed consent was obtained from all participants. Consent for publication Not applicable. Competing interests ZV received honoraria for lectures from MSD, AstraZeneca and GSK, unrelated to this work. ZV has participated in an Advisory Board for MSD, Astra-Zenica and GSK, unrelated to this work. Footnotes Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References 1. SEER. Cancer of the Endometrium - Cancer Stat Facts. Available from: https://seer.cancer.gov/statfacts/html/corp.html . Cited 2025 Aug 14. 2. Onstad MA, Schmandt RE, Lu KH. Addressing the Role of Obesity in Endometrial Cancer Risk, Prevention, and Treatment. 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(18.6KB, docx) Data Availability Statement The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Articles from BMC Public Health are provided here courtesy of BMC ACTIONS View on publisher site PDF (1.2 MB) Cite Collections Permalink RESOURCES Similar articles Cited by other articles Links to NCBI Databases Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top

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