Abstract
Background: Social accountability represents the social contract between medicine and society, encouraging healthcare professionals (HCPs) to address social and health-related issues. The importance of integrating social accountability into curricula is widely recognised, but there is a lack of comprehensive mapping of the specific elements that should be included.
Objectives: To identify the key elements of social accountability that should be integrated into undergraduate health sciences curricula to develop socially accountable HCPs.
Method: The scoping review was conducted following the Joanna Briggs Institute Reviewers’ Manual 2015 for scoping reviews. A comprehensive search was employed using various keyword combinations and search strings, inclusive of published and grey literature from the past 15 years. Studies were systematically charted and analysed.
Results: A rigorous screening process resulted in 47 studies being included in the review. Majority of the studies were qualitative, with the highest number of studies originating from Canada, South Africa, and the United States, as well as several multi-country studies. Equity emerged as the most frequently mentioned value, while cost-effectiveness was discussed the least.
Conclusion: The scoping review demonstrates that embedding equity-driven approaches, community engagement, interprofessional collaboration and transformative learning in healthcare systems and tertiary institutions is vital. Addressing these priorities through undergraduate health sciences training can foster more inclusive, responsive and effective healthcare delivery, and improve health outcomes.
Clinical implications: Integrating the identified elements of social accountability into undergraduate health sciences curricula may lead to improved patient outcomes, reduced health disparities, and more effective, patient-centred care.
Keywords: equity; community-oriented; curricula; relevance; cost-effectiveness.
Introduction
Socially accountable healthcare professionals (HCPs) understand their responsibility to the community they serve through training in population health and addressing health inequities (Clithero-Eridon, Albright & Ross 2020). Social accountability is the social contract between medicine and society, indicating that HCPs must ensure their services are equitable and responsive to the person, the community and population needs (Ventres, Boelen & Haq 2018). Historically, HCPs have been required not only to heal individuals ethically but also to improve society’s health (Abdalla 2012). Recognising social accountability encourages continuous learning, professional development, community engagement, advocacy and cultural competence (Preston et al. 2016).
Effective practice requires transformative education curricula that prepare HCPs to meet country-specific needs through decolonial and equitable approaches (Boelen & Woollard 2009; Rispel 2023). Transformative education addresses global challenges such as discrimination, poverty, inequality, environmental degradation, loss of biodiversity and climate change (Green-Thompson, McInerney & Woollard 2017), with social accountability as a core principle (Romano 2017). Transformative education is imperative in developing countries to develop HCPs who can provide equitable, effective and accessible healthcare (Preston et al. 2016). Thus, tertiary institutions should ensure that curricula cultivate HCPs who maximise societal impact and resource use (Armstrong & Rispel 2015).
Social accountability in tertiary institutions means aligning education, research and services to improve the health status of the communities served (Abdalla et al. 2022). Such curricula promote teamwork, effective communication, HCP readiness, self-confidence, empowerment (Boelen & Woollard 2009) and community engagement (Mahdavynia et al. 2022). True social accountability transcends clinical competence to include equity, inclusion, non-discrimination and responsiveness to community needs (Clithero-Eridon et al. 2020).
The World Health Organization (WHO) defines social accountability through four core values: relevance, quality, cost-effectiveness and equity (Boelen & Heckman 1995), with equity serving as both a guiding value and a desired outcome. Equity ensures that healthcare services and educational curricula address disparities and promote fairness in access and outcomes by ensuring that all individuals, particularly those from underserved or marginalised populations, have access to cost-effective, quality and culturally sensitive services. For healthcare services, relevance means prioritisation of the most essential problems of the population; while for curricula, it involves aligning educational content with community needs (Boelen & Heckman 1995). Quality refers to the delivery of health services based on good practice and established standards, in a manner that is respectful, effective and efficient (Brown & Grierson 2022). The concept of efficiency is about using resources cost-effectively. Hence, social accountability cannot exist without actively reducing health inequities and preparing graduates to serve all communities justly.
To improve curricula in social accountability, it is essential to understand the key elements and integrate them. This scoping review maps evidence on the key elements of social accountability that should be included in undergraduate health sciences curricula to prepare graduates to meet the needs of their country. Searches of the Cochrane Database of Systematic Reviews and the JBI Database of Systematic Reviews and Implementation Reports found no scoping reviews or systematic reviews on this specific topic.
Review question
What are the key elements of social accountability that should be included in undergraduate health science curricula to prepare graduates to meet the needs of their country?
Research methods and design
The scoping review followed ‘the Joanna Briggs Institute Reviewers’ Manual 2015: Methodology for JBI Scoping Reviews’ (Peters et al. 2015). The scoping review was directed by the population, concept and context (PCC) approach (Peters et al. 2015). The population was not applicable. The concept focused on key social accountability elements to include in undergraduate health sciences curricula to prepare graduates for their country’s needs. The context was undergraduate health sciences education curricula globally.
Inclusion criteria
The search included all published and grey literature describing social accountability elements for undergraduate health sciences curricula. It considered studies of all designs: quantitative, qualitative (narrative, phenomenological and grounded theory), mixed methods, observational studies (case-control studies, cohort studies, case series, cross-sectional studies, case reports), expert reviews and opinion pieces. No limitations were set on publication status.
Exclusion criteria
Studies were excluded if not published in English or older than 15 years, to ensure applicability, relevance and currency in relation to evolving social accountability elements in undergraduate health sciences education. Studies involving postgraduate curricula or non-health science curricula (‘wrong population’) were excluded, as were studies lacking key elements of social accountability for curricula (‘wrong outcomes’).
Search strategy
Table 1 outlines the characteristics of the database search for the scoping review.
Study selection
A comprehensive search was conducted using various keyword combinations and search strings, filtered by year (last 15 years) and English language. The results are noted in Table 2. Records were screened by title, with relevant records imported into a reference manager, Zotero, as well as Covidence, which is web-based software designed to organise the screening, data extraction and quality assessment processes in systematic and scoping reviews. However, when titles lacked sufficient information, abstracts were reviewed to avoid excluding relevant articles. The reviewer focused on titles related to social accountability in health sciences using keywords from Table 1.
Duplicates were removed using Covidence software and manual checking. The first and second authors independently screened abstracts against inclusion criteria and Table 1 keywords to identify relevant studies, excluding those that did not qualify. The third author was the third reviewer and resolved conflicts which were based on disagreements regarding the appropriateness of the studies to be included, or if the first two reviewers were undecided, as Covidence allows a ‘yes’, ‘no’ and ‘maybe’ option when reviewing. Subsequently, the first author conducted a full-text screening of all articles. The selection process, including the numbers of included and excluded studies, is illustrated in a Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) flow chart (Ramasamy 2022).
Data extraction
In scoping reviews, data extraction is referred to as ‘charting’, where a descriptive summary of the results is developed (Ghalibaf et al. 2017). Microsoft Excel charting forms were designed through team consultation to collect relevant data (Pollock et al. 2023). Extracted information included title, authors, publication date, study location and country in which the study was conducted, study setting (e.g. community or university), study design and population, and social accountability elements addressed. The first author completed charting through an iterative process with input from the co-authors (Pollock et al. 2023). The data are presented descriptively using figures and tables and synthesised narratively.
Ethical considerations
Ethical clearance was obtained from the University of the Witwatersrand Human Research Ethics Committee (Medical) (ethics clearance number: M240905).
Results
Study inclusion
The identification phase began with 183 studies selected by title screening based on inclusion criteria and keywords from Table 1, and were then imported into Covidence. After removing 21 duplicates, 162 studies underwent abstract screening by two reviewers, with a third reviewer resolving conflicts based on the appropriateness of the studies. A total of 124 studies were screened by full text, resulting in 47 studies included in the final review. The screening process by full text identified whether the study recommended various elements of social accountability that should be included in undergraduate health sciences curricula or not. The 47 included studies specifically recommended key elements of social accountability to be incorporated into undergraduate health sciences curricula. Figure 1 outlines this information through a PRISMA chart.
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FIGURE 1: Preferred Reporting Items for Systematic Reviews and Meta-analysis chart for scoping review. |
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Characteristics of the studies
Information from the studies was extracted and populated into a charting form (Table 3). The countries or regions where the studies were conducted are grouped according to the World Bank income levels. Nineteen studies were from high-income countries, 11 from upper-middle-income, 5 from low-middle-income and 2 from low-income countries. Four studies were conducted across more than one country (studies involved multiple specific countries, often within a region with defined contexts) and another four were conducted globally (took a global perspective and was not limited to specific countries). Additionally, one study focused on Latin America and one on the Eastern Mediterranean region (exact countries included in these regions were not specified).
The review includes studies of various study designs. The majority of the studies were qualitative studies (n = 17), followed by reviews (n = 8), commentary and/or opinion pieces (n = 7), case study approaches (n = 6), mixed methods (n = 4), quantitative studies (n = 3), conference pieces (n = 1) and cross-sectional studies (n = 1). These are presented in Figure 2 as percentages.
Review of findings: Elements of social accountability
A total of 47 studies were included in the review, highlighting key elements of social accountability for undergraduate health sciences curricula. Figure 3 illustrates the number of studies addressing each element or combination of elements.
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FIGURE 3: Values of social accountability noted in studies (N = 47). |
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The scoping review identified that 26% of the studies reviewed (12 out of 47) addressed all values of social accountability. Other frequently mentioned values included the combination of relevance and equity, the combination of quality and equity, and the combination of relevance, quality and equity (each with eight studies), while fewer studies focused on individual values such as cost-effectiveness or equity alone. Figure 4 describes elements that should be covered within each value of social accountability, namely, cost-effectiveness, relevance, quality and equity.
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FIGURE 4: Elements of social accountability within each of the four core values: (a) cost effectiveness, (b) relevance, (c) quality of services and (d) equity. |
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Under the value of cost-effectiveness, the studies identified elements such as the efficient use of physical, financial and human resources, budgeting, responsible management, creativity and accountability. Interventions promoting cost-effectiveness and sustainability involved group-based rehabilitation, home-based rehabilitation and caregiver training.
The studies identified the value of relevance to include elements that ensure HCPs deliver services aligned with the needs of the communities that they serve. Key aspects included in the studies were community participation, community inclusivity, and active involvement of community members in programme planning and implementation. In addition, understanding national health needs and priorities, incorporating health promotion and disease prevention, decolonising healthcare, and addressing the needs of marginalised and underserved populations were emphasised.
Quality was associated with curricula that foster both clinical and cultural competence. The studies demonstrated that emphasis must be placed on continuous professional development, evidence-based practice and person-centred care. Person-centred care was linked to attributes such as professionalism, communication and interpersonal skills, empathy, and compassion. Additional elements included collaborative practices, stakeholder engagement and policy involvement aimed at building resilient health systems.
The studies identified the need for HCPs to engage with the social and structural determinants of health affecting both the individuals and the communities that they serve. Identified elements within the value of equity include diversity, inclusivity, advocacy and social justice. Equity was presented in the studies concerning a broader understanding of the political, socio-economic, racial and cultural realities of the communities that HCPs serve.
Several cross-cutting elements, not exclusive to one value, also emerged as relevant to fostering social accountability among HCPs. These included interdisciplinary teamwork, collaboration, networking, stakeholder involvement, including global partnerships and leadership skills. Curriculum elements such as the dismantling of hierarchies, transformative learning and decoloniality were also highlighted. Additional themes such as awareness of implicit biases, stereotypes, self-reflection, transparency, experiential learning, environmental accountability and professional identity formation were all emphasised to develop socially accountable HCPs.
Community orientation featured prominently across the reviewed studies. Community-based learning including community assessment and participation, as well as aligning clinical practice with community health needs, was recommended. The results of the studies indicated the importance of embedding partnerships, community empowerment and community-based collaborations within the curriculum.
Global health literacy, inclusive of knowledge related to population health, health policies and national targets, was also identified as a necessary component within undergraduate health sciences curricula. Some studies noted that collaboration and partnerships should extend to international partners, such that HCPs improve their networking skills. The development of skills related to one’s specific profession, communication skills, social and interpersonal skills, as well as the ability to work within an interdisciplinary team, were all emphasised. Finally, the results of the studies indicated that quality extends beyond clinical competence to include awareness of environmental circumstances. This included teaching on social contexts, socio-economic conditions, race, racism, diversity, ethics and advocacy.
The review of literature identified transformative learning, decoloniality, leadership development and self-reflection as important elements to develop socially accountable HCPs. Experiential learning with active work in the community, as well as outreach activities, was emphasised to bridge the gap between theory and practice. Overall, the findings demonstrate that each of the four values of social accountability, namely, cost-effectiveness, relevance, quality and equity, encompasses multiple elements as presented in Figure 4.
Discussion
The scoping review identifies a comprehensive range of themes as outlined in Figure 4 for integrating social accountability into undergraduate health sciences curricula. The findings underscore that embedding social accountability enhances the commitment of HCPs to population health. Integrating community-oriented, equity-driven, and interdisciplinary approaches into education, practice, and policy ensures that HCPs are equipped to address the needs of marginalised populations as well as advocate for social conditions that impact health outcomes. The review also demonstrated that a socially accountable HCP collaborates with partners and policymakers to create a truly accountable and resilient healthcare system.
Professional development and competency frameworks
Ensuring high-quality health services requires a strong foundation in clinical competencies and evidence-based medicine. Accreditation bodies such as the Health Care Professional Council of South Africa (HPCSA) emphasise professionalism, good communication skills, lifelong learning, advocacy, scholarship and teamwork (HPCSA 2023). Frameworks such as the Canadian Medical Education Directives for Specialists Framework (CanMEDS) provide structured guidance on competencies for graduates, grouping abilities into roles; namely, medical expert, professional, communicator, collaborator, leader, health advocate and scholar (eds. Frank, Snell & Sherbino 2015; Royal College of Physicians and Surgeons, Canada 2024). Healthcare Professionals must be clinically competent and socially accountable to address complex and evolving health needs. A key finding of the review relates to the importance of continuous learning, flexibility and a reflective mindset to align practice with societal needs. However, this is achievable only if health sciences education standards set by accreditation bodies and developed in curricula by tertiary institutions, explicitly incorporate social accountability as a core concern rather than an optional addition. Curriculum developers should collaborate with professional bodies to determine specific core social accountability competencies required across healthcare professions and clinical settings. Consistent with professional development, professional identity formation (DeMatteo & Reeves 2013) should include technical skills plus a commitment to ethical practice, community needs and the ability to work collaboratively across diverse teams (Matthews, Bialocerkowski & Molineux 2019). Healthcare professionals should advocate for their profession and improve the quality of services and patient care by understanding the roles of other HCPs, making referrals and fostering interpersonal collaboration (Du Toit et al. 2019).
Interdisciplinary teamwork is a cornerstone for improving healthcare outcomes and promotes holistic care by leveraging diverse expertise (Bates et al. 2023). Interdisciplinary teamwork also aligns with the goals of global health initiatives that emphasise ‘health for all’ through shared responsibility and collective action (Liu et al. 2015). Interprofessional and stakeholder collaboration cultivates mutual respect, interdisciplinary problem-solving and joint accountability for patient and population outcomes (Clithero et al. 2017). Professional development related to social accountability prepares health sciences graduates for competent and effective service delivery and leadership in policy, equity, advocacy and justice.
Equity, advocacy and social determinants of health
The inclusion of equity-focused content related to the social determinants of health (SDH), human rights and sustainability (Armstrong & Rispel 2015; Van Wyk et al. 2016; Velardo 2018) addresses primary drivers that produce health disparities rather than focusing on symptoms at an individual level. Curricula can prepare HCPs to be agents of change (Sekome et al. 2023) who advocate for marginalised populations and challenge health systems that perpetuate disparities and inequities by cultivating an understanding of systemic inequities such as those related to race, socio-economic status and culture (Sharma & Kuper 2017). Reflexivity, anti-racism and cultural competence are vital to navigate complex social dynamics and advocate effectively for marginalised groups (Ramsay et al. 2020). Health science education and training that models advocacy, community responsiveness, and engages with priority health concerns of the population is essential (Liu et al. 2015). The shift supports quality service delivery and ethical clinical practice alongside improved population health outcomes. Global health initiatives further recognise the importance of reorienting health services towards prevention and primary healthcare through the growing recognition of interconnected health challenges. However, awareness alone is insufficient. The incorporation of the health inequities and advocacy into curricula requires transformative pedagogies that facilitate critical self-reflection and practical advocacy skills (Chiutsi, Suleman & Perumal-Pillay 2022). Curriculum developers should ensure that theoretical content is supported by experiential learning, which meaningfully engages students with complex social realities.
Relevance: Community engagement and experiential learning
Community engagement and experiential learning consistently emerge as critical approaches that emphasise the active partnerships of community members in health initiatives. Active community participation not only empowers communities but also promotes health and well-being, directly aligning with the five action areas of health promotion as outlined in the 1986 Ottawa charter (WHO 1986). Curricula should encourage community engagement and active community participation through experiential learning to bridge the gap between theory and practice. Wang (2024) emphasises that curricula should encompass not only theoretical frameworks but also their practical applications within real-world contexts. Similarly, Schwab (2013) highlights that curricula should address tangible, context-specific challenges, encountered in teaching and learning. The practical engagement immerses students in the cultural context of the communities that they serve, which requires an understanding of how race, culture, health systems, policies and global influencing factors such as refugee health, climate change, wars and political discourse shape health outcomes (Kelly et al. 2022).
Experiential learning, particularly when conducted in partnership with empowered communities, creates reflective spaces where students recognise how context-specific challenges, such as subtle manifestations of racism, shape access to care, patient experience and health outcomes. Practically and openly engaging with communities moves beyond abstract concepts of racial awareness and cultural sensitivity towards fostering deep race consciousness and an explicit understanding of how racism operates institutionally and interpersonally to produce health inequities. Race consciousness goes beyond mere cultural differences towards an explicit understanding of how race and racism impact the experience of communities and their health outcomes (Sharma & Kuper 2017). An important aspect of experiential learning involves empowering students to address these tensions without feeling threatened. In practice, this means curricula should not only teach cultural competence but also develop students’ abilities to identify, analyse and challenge racial inequities within healthcare systems.
A key recommendation for curriculum developers includes designing experiential learning modules that include direct engagement with marginalised groups such as communities of colour, people with disabilities, refugees and underprivileged populations. The modules should integrate guided reflection on the history and ongoing impact of social determinants of health, such as racism in healthcare, supported by active community participation in all initiatives. Such approaches, exemplified by rural immersion and service learning projects (Emadzadeh et al. 2016), centre the voices and lived experiences of those affected by health disparities, equipping students with practical skills to confront inequities and contribute to inclusive health practices.
Equity: Social justice and transformative education
Social justice emerges as a unifying element and is grounded in the belief that every individual and group within a given society has a right to civil liberties, equal opportunities, fairness, and participation in the educational, economic, social and moral freedoms and responsibilities valued by the community. Social justice plays a crucial role in addressing health inequities, guiding how interventions are identified and implemented towards health issues within populations. The element of social justice shapes curricula by guiding what is taught as well as preparing HCPs to ethically respond to systemic barriers resulting in health disparities.
The review highlights that curricula grounded in social justice focus on transformative education strategies, such as experiential learning and critical self-reflection, which are essential to developing HCPs who challenge health disparities and system-level barriers (Mlambo et al. 2018). Social justice strategies are pivotal in shaping HCPs who are empathetic, socially conscious and adaptable to evolving healthcare challenges. Social justice in the curricula also encompasses the development of skills like compassion, leadership, resilience and a commitment to the advancement and protection of human rights within clinical and community settings.
The integration of social justice in curricula will develop HCPs who not only deliver competent and effective healthcare but who actively work to reshape health systems. Embedding social justice in undergraduate health sciences curricula equips HCPs to be accountable to the communities that they serve, aligning with the global agenda for health equity and sustainable healthcare systems.
Implementation strategies and barriers
Social accountability can be operationalised by integrating courses in anthropology, epidemiology and public health with a focus on poverty and health disparities (Abdalla et al. 2022). Partnerships must be formed between health science schools and key stakeholders such as policy-makers and community representatives to promote community-oriented strategies and experiential learning (Shrivastava, Shrivastava & Wanjari 2024). Education institution accreditation standards should align with social accountability goals, ensuring that graduates are competent in population health and working with marginalised populations.
However, barriers exist to the inclusion of social accountability in the curriculum as well as the practical implementation of the elements. Barriers relate to limited curricula exposure, a lack of time to teach all of the identified elements, and the lack of staff expertise and enthusiasm for elements of social accountability (Benrimoh et al. 2016). Practical implementation of social accountability may be hindered by overworked and overwhelmed HCPs, resource constraints (Anawati et al. 2023), inadequate capacity building, a shortfall in community participation, safety concerns within the communities and a lack of community-oriented programmes (Clithero-Eridon et al. 2020).
Furthermore, a critical concern in implementing social accountability within curricula relates to who delivers the content. Evidence has demonstrated that the method of instruction (Schwab 2013; Schwab et al. 2022; Wang 2024) as well as the educators themselves (Mlambo et al. 2018; Sharma & Kuper 2017) influences how social accountability is internalised by students.
Implications for practice
The results from the scoping review lay the foundation for curriculum re-design by emphasising that undergraduate health sciences curricula must incorporate experiential, service-learning opportunities together with theoretical teaching that emphasise primary healthcare principles, SDH, and equity-focused interventions. In addition, educators and those training health sciences students should be from diverse backgrounds and have knowledge around both health and social sciences, which can enrich learning experiences. It also highlighted that continuous development in areas such as communication skills, diversity, cultural humility, inclusivity, advocacy and interdisciplinary teamwork is essential for fostering lifelong learning among HCPs. Lastly, HCPs should be empowered to understand policies within their health system and work towards advocating for healthy public policies.
Limitations of current literature
The scoping review provides valuable insights, but several gaps remain, such as limited focus on evaluating the long-term impact of student-led community-based interventions on patient outcomes, insufficient exploration of structural barriers to implementing equity-focused curricula in diverse geographic contexts and a lack of standardised frameworks for assessing competencies related to SDH and interdisciplinary collaboration. Furthermore, most of the studies focused on medical students or nursing students, with only a few relating to rehabilitation professionals.
Conclusion
The scoping review highlights the multifaceted nature of social accountability in undergraduate health sciences curricula, encompassing the core values of relevance, cost-effectiveness, quality and equity. Key elements such as community engagement, culturally and clinically competent service delivery, advocacy for social justice and efficient use of resources are critical to prepare HCPs to meet the needs of the communities that they serve. The review underscores the need for equity-driven approaches in healthcare systems and tertiary institutions, emphasising interprofessional collaboration, transformative and decolonial learning, leadership development and self-reflection to foster socially accountable HCPs. Additionally, including community-oriented and global health literacies within curricula improves alignment with national and international health priorities. Emphasising experiential learning through active community involvement bridges the gap between theory and practice, while addressing the broader socio-political and environmental determinants of health. Together, the elements provide a comprehensive framework to develop HCPs who deliver equitable, relevant, cost-effective and quality services that are responsive to the evolving health needs of populations served.
Acknowledgements
This article includes content that overlaps with research originally conducted as part of phase one of Laeeqa Sujee’s doctoral thesis titled ‘Social accountability in South African physiotherapy education: Preparing physiotherapists to respond to the health needs of their country, ‘Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand. The thesis is supervised by Hellen Myezwa and Vaneshveri Naidoo. Portions of the data, analysis and/or discussion have been revised, updated, and adapted for journal publication. The author affirms that this submission complies with ethical standards for secondary publication, and appropriate acknowledgement has been made of the original work.
Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. The author, Hellen Myezwa, serves as an editorial board member of this journal.
CRediT authorship contribution
Laeeqa Sujee: Conceptualisation, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualisation, Writing – original draft, Writing – review & editing. Vaneshveri Naidoo: Conceptualisation, Supervision, Writing – review & editing. Hellen Myezwa: Conceptualisation, Supervision, Writing – review & editing. All authors reviewed the article, contributed to the discussion of results, approved the final version for submission and publication, and take responsibility for the integrity of its findings.
Funding information
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data availability
The authors confirm that the data supporting the findings of this study are available within the article and its references.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. The article does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.
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