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Abstract

Introduction/Objectives:

Health equity is increasingly being recognized as an important aspect of healthcare. A focus on health equity allows everyone to reach their full potential. Yet there are gaps in healthcare to address health equity. The aim of this Canadian study was to assess how policy facilitates and hinders health equity within team-based primary healthcare settings in 3 provinces: British Columbia (BC), Ontario (ON), and Nova Scotia (NS), identify the similarities and differences across the Canadian provinces, and provide recommendations and actions to advance health equity at policy and systems levels.

Methods:

We used the OPTIC-PHC conceptual framework developed by the study team to better understand the implementation of primary healthcare teams. The Systemic Equity Action-Analysis Framework was used as the theoretical foundation for the work. The study used a policy scan approach to identify, review, and analyze primary healthcare policy documents in the 3 participating provinces. Sixty-two documents were included in the study.

Results:

Health equity did not appear in policy documents consistently until 2018. Four key themes were identified in the policy scan: partner engagement; Community Health Centres, Indigenous health, and equity initiatives.

Conclusions:

Health equity is now much more prevalent in policy documents. What is unknown, is whether equity approaches/initiatives have been implemented and/or evaluated. There is significant opportunity for collaboration between patients, caregivers, community members, healthcare providers, decision-makers, and policy-makers to develop health equity initiatives, to implement clearly articulated principles and initiatives to drive health equity, and to measure outcomes of these initiatives in primary healthcare settings.

Keywords

primary care health equity health policy primary health care policy analysis Canada

Introduction

The increasing recognition of health equity is leading to its integration across different areas of the primary health care (PHC) system. There is a growing body of literature that supports equity in PHC systems.^1-15 The Government of Canada¹⁶ defines health equity as “the absence of unfair systems and policies that cause health inequalities” and “seeks to reduce inequalities and to increase access to opportunities and conditions conducive to health for all” (Health Inequalities in Canada). The lack of focus on health equity contributes to gaps in quality of care and outcomes among equity-deserving groups (eg, Black, 2SLGBTQIA+, newcomers, women, and individuals living with disabilities and other racialized groups) and Indigenous (First Nations, Métis, and Inuit) Peoples.^3,9,10

Despite efforts to advance PHC, evidence suggests that health policies and reforms are often counterproductive or misaligned.^1,3,5 Policies play a critical role in the organization, quality, and delivery of care therefore having a major impact on the reduction of health inequities through their design and implementation, allowing the promotion of equitable resource allocation, attainment of cultural competence and culturally safe care, access to, and quality of care. Research highlights the consequences of the lack of direction on the organization and implementation of policy content.^1,7 Still, there is little literature that identifies health inequities within Canada and the role of policies in facilitating responses that are meaningful and conducive to reducing health inequities. This study aimed to assess how policy facilitates and hinders health equity within team-based PHC settings in 3 Canadian provinces: British Columbia (BC), Ontario (ON), and Nova Scotia (NS), identify the similarities and differences across the Canadian provinces, and provide recommendations and actions to advance health equity at policy and systems levels. This study was conducted as part of a larger study, Optimizing Teams for Interprofessional Care in PHC (OPTIC-PHC), to explore how (intra and inter-organizational) teams are formed, how they evolve and adapt over time, to address the challenges of implementing, and sustaining team-based PHC models.¹⁷ Teams vary in size, include a variety of providers (eg, primary care physician, nurses, and social work) and serve a variety of populations.

Methods

Research Design

We used a policy scan approach¹⁸ to identify, review, and analyze how PHC policy documents in NS, ON, and BC referenced and incorporated health equity. NS, ON, and BC represent diverse regional approaches to PHC delivery. These provinces differ significantly in terms of population size, geographic distribution, policy frameworks, and health outcomes, allowing for comparison across different provincial contexts. Our policy analysis used a structured approach to identify and assess policies, defined as “a set of statements of principles, values and intent that outlines expectations and provides a basis for consistent decision-making and resource allocation in respect to a specific issue,”¹⁹ (para 1) in this case PHC. We included provincial policies related to PHC and health equity, strategic direction documents, evaluations, and annual reports to understand their scope, content, and implications for policy and practice in PHC and health equity. This approach provided a comprehensive overview of existing policies and assisted in identifying gaps in health equity within PHC.

Conceptual and Theoretical Frameworks

The conceptual framework that guided the overall study was developed by the OPTIC-PHC project research team. Using concept mapping to inform longitudinal research on the development and performance of interprofessional primary care teams (PCTs),²⁰ the framework addresses domains such as partner engagement, efforts of internal and external collaborators, and PCTs structure and organizations with added policy questions for each domain (Supplemental Appendix A). Additionally, it considers the external factors that challenge PCTs (eg, geographic location, laws and regulations, and population groups). The framework’s concepts were addressed through a health equity lens.

Additionally, the Systemic Equity Action-Analysis (SEA) framework²¹ was utilized to analyze the data. This framework addresses key components of worldview, coherence, potential, and accountability that were integrated into the analysis of the policies. “Worldview” questions criticality and the understanding and representation of the world, including presumptions about how it functions and convictions about what is important and feasible. “Coherence” focuses on the process, the evidence of inequities and their causes, and the coherence and soundness of the reasoning behind anything put forth or done. “Potential” refers to choice and agency. The potential for advancing equity is the possibility that a decision, action, strategy, or choice will advance equity. Lastly, “accountability” addresses responsibility and how the consequences of power relations are addressed, such as accepting accountability and/or using privilege to address the root causes of social, geographical, and economic inequities.

Data Collection

Policy documents were retrieved from: (1) policymakers by researchers in each province; (2) Google search with keywords (equity, PHC, document/policy, health equity, and framework); and (3) reference lists from policies retrieved for additional related policies. Policies were included if: (1) published 2012 to present (based on 10 years from the start of the OPTIC-PHC study); (2) relevant to health equity, PHC/PCTs; (3) NS, ON, or BC; and (4) available in English.

Data Extraction and Analysis

Data were extracted using an extraction table (Supplemental Appendix B). The table was shared and discussed with 4 team members (GA, AR, PW, and NDO) engaged in analysis for verification and accuracy. Using inductive, deductive,²² and abductive analysis,²³ case descriptions were developed for each province and sent to the broader policy workstream group (n = 11), a subgroup of the full research team, for their feedback. Feedback was incorporated into the final analysis and results of the policy analysis.

Results

Our health equity policy analysis included 62 policy documents (BC = 21; ON = 24; and NS = 17) related to PHC (Supplemental Appendix C). Findings showed that the year in which documents were published may play a role in the recognition of health equity with very limited mention of health equity between the years 2012 and 2018. Documents from 2018 onwards were more likely to include health equity in policy objectives, goals, or expected outcomes and was more likely to be considered in health initiatives and frameworks across provinces (Table 1). Our results reflect the broader impact of COVID-19 pandemic, which exposed and amplified existing inequities (eg, increased hospitalization for black communities; overrepresentation of First Nations, Métis, and Inuit peoples in the healthcare system; increased exposure in people experiencing homelessness).^24-29 The widening of health inequities during the pandemic likely acted as a catalyst for provincial governments to prioritize equity in policy planning, resulting in policies focused on social determinants of health and more inclusive decision-making processes. Performance indicators were sometimes seen in documents but most pertained to broader policy goals and initiatives (NS = 4, BC = 8, and ON = 10) rather than specifically on health equity. Four key themes were identified in our policy analysis: partner engagement; Community Health Centres, Indigenous health, and equity initiatives.

Table 1.

Equity Comparison of Policy Documents.

Equity Components	Nova Scotia	Ontario	British Columbia
Health equity definition	“Ensures that individuals have fair opportunities to achieve their full health potential and are not disadvantaged by the social, economic, environmental, and structural conditions in which people live”³⁰	“That all people can reach their full health potential and are not disadvantaged from attaining it because of their race, ethnicity, religion, gender, age, social class, socioeconomic status or other socially determined circumstance”³¹	“Health inequities . . . refers to unfair differences in health status and health outcomes between population groups as a result of social factors and structures shaping access to health care and other health-promoting resources. These structures include, but are not limited to, social exclusion based on race, ethnicity, sex, age, sexual orientation, gender identity, language and cultural identity, and other socio-demographic factors; and access to health care barriers informed by preventable social factors.”³²
Goals and objectives	• Increase accessible care and attachment • Increase recruitment and retention • Strengthen community-based PHC focused on equity, diversity, and inclusion • Improving coordination and collaboration • Enhance system performance • Address population needs with equity considerations	• Strengthen PHC (eg, enabling an equity lens across all domains) • Enhance coordination and collaboration • Shifting toward integrated services • Focus on education and strategic directions to achieve equitable care for all • Strengthen team-based care • Increase attachment	• Improve timely access to team-based care • Strengthen culturally safe care • Strengthen health system performance • Improve quality of care • Enhance collaboration and comprehensive care via PCTs and Primary care networks (PCNs). • Improve equity by enhancing evidence-based services via community engagement
Initiatives	• African Brotherhood and Sisterhood initiative • prideHealth • Tajikeimik • Kentville Gender • Affirming Care Clinic	• Rainbow Health • Indigenous Primary Health Care council (IPHCC) • Community Family Health Teams (CFHTs)	• First Nations Health Authority • Primary Care Networks (PCNs)
Tools/frameworks	• 2-Eyed-Seeing framework³³ • Equity Impact Assessment Tool for policy³⁴ • Health Equity Framework³³ • Equity and Anti-Racism Strategy³⁴ • The Provincial Diversity and Inclusion Framework³³	• Model of Wholistic Health and Wellbeing³⁵ • Ontario Health’s Equity Inclusion and Diversity Framework³⁶ • Implementing Health Equity for Change: A guide for policymakers and health system leaders in Ontario to take action³⁵ • Health Equity Guideline³⁷ • Health Quality Ontario’s Health Equity Plan³⁸ • Resource Guide to Ontario Health’s Social Determinants of Health Framework³⁹ • Health Equity Charter⁴⁰ • Black Health Strategy³⁶	• Gender-Based Analysis plus (GBA+) Framework⁴¹ • Anti-Racism Data Act⁴² • In Plain Sight Report⁴²

Patient, Caregiver, and Community Engagement

Nineteen of the policy documents (ON = 9; NS = 8; and BC = 2) were developed in partnership with community members/organizations, patients, and caregivers. NS was more likely to explicitly state who they referred to and defined as partners. For example, NS’s Health Equity Framework³³ (p. 5) identified the communities that were involved in the development, “These groups were included: Mi’kmaq and people of Indigenous descent, African Nova Scotians and people of African descent, 2SLGBTQIA+ communities, Newcomers (immigrants, refugees), Faith-based communities, Persons with disabilities and Acadian and Francophone communities).” NS and ON documents developed in partnership aimed to yield more effective and meaningful outcomes for the communities impacted. Engagement took place in many forms: NS used survey platforms (Engage4Health), Community Health Boards, In-person and online sessions, patient and family advisory, and the Speakupforhealthcare tour. ON utilized consultations, steering committees, working groups, and the Health Equity Summit to engage partners.

All provinces recognized the value of engaging with partners in service planning and implementation. The Ontario Health Teams: Guidance for Health Care Providers and Organizations document⁴³ (p. 19) states “Ontario Health Teams will be driven based on the needs of patients and communities. They will meaningfully engage and partner with patients, families, caregivers and communities, based on a robust patient partnership model and community engagement strategy.” Additionally, BC emphasized that collaborative service planning must include the perspectives of the communities in decision-making processes.⁴⁴ Findings showed significant variation in partner engagement in the development of policy across provinces, but each province highlighted engagement as a driver for equitable care delivery.

Community Health Centres (CHCs)

A common trend across provinces was the use of CHCs as a strategy to advance health equity, with community-based decision-making for equitable, meaningful, and relevant service delivery. BC has ~36 CHCs (32 community-governed), ON = 75, and NS = 9. CHCs are designed by community, for community, providing primary care, prevention, and health promotion services connecting underserved people to care.⁴⁵ Each province has developed documents outlining CHCs’ roles and responsibilities. In BC, “CHCs will ensure service delivery is health equity enhancing, with services developed based on population health needs in the community served by the CHC and in coordination with other primary and community care services and planning. CHCs will employ a community governances’ model with community-based decision-making to provide services based on the health needs of the community.”³² (p. 2) BC has also been expanded to support First Nations and Indigenous-governed centres.³² In ON, CHCs operate to provide care similar to BC and have added Aboriginal Health Access Centres and Aboriginal CHCs with leadership for Indigenous knowledge and services. NS utilized the CHC model to provide integrated services in primary care, health promotion, and community wellbeing, and actively address the social determinants of health.⁴⁶ (p. 2) CHCs in all provinces are expected to provide a grassroots solution to reducing inequities and addressing upstream determinants of health.

Indigenous Health

Policy documents indicated that all provinces were making efforts to integrate more collaborative approaches to enhance Indigenous health. In 2013, BC established the First Nations Health Authority supporting the health and wellness of First Nations people with responsibility for planning, management, service delivery, and funding of health programs, in partnership with First Nations communities.⁴⁷ (p. 6) BC recognizes the growing rate of Indigenous health inequities and in 2023, committed to “Continue to expand team-based primary care, providing people access to additional care through nurse practitioners, registered nurses and licensed practical nurses, and other allied health professionals such as pharmacists, mental health and substance use workers, dietitians, and more, as well as Indigenous cultural and health supports such as elders, and traditional healers.”⁴⁸ (pp. 8-9) Furthermore, BC plans to fully operationalize 15 First Nations Primary Care Centres.⁴⁷ In 2025, BC’s Service Plan outlines the Ministry’s commitment to “Continue to work with the Parliamentary Secretary for Rural Health, the Parliamentary Secretary for Mental Health and Addictions, FNHA, MNBC, and other key partners to improve health outcomes through equitable access and attachment to culturally safe primary care and public health services for people living in rural, remote, and Indigenous communities throughout our province, including innovative use of virtual technologies linked to in-person services, and more Indigenous led and/or focused primary care clinics and service providers”⁴⁸ (p. 9).

In ON, Indigenous Primary Health Care Organizations have been implemented and are Indigenous led and governed. The Indigenous Primary Health Care Council has impacted the design and delivery of Indigenous health.³⁵ (p. 11) ON outlines initiatives such as an updated First Nations, Inuit, Métis, and Urban Indigenous Cancer Strategy and the enhanced Indigenous Tobacco Program, expanding roles and scopes. Furthermore, the document commits to “Identify and work to address existing barriers to funding for First Nations, Inuit, Métis and Urban Indigenous-led organizations, including the creation of new Indigenous health service providers in alignment with MOH initiatives.”³⁶ (p. 11)

In NS, Indigenous health is addressed through the Tajikeimɨk, an organization created to transform health for Mi’kmaw communities. Tajikeimɨk guides NS Mi’kmaw communities to take ownership of designing and delivering health and well-being services including, “Nuji-Apopnmuet (Mi’kmaw Patient Helpers), Msɨt Mijua’ji’jk (All the Children), Mi’kmaq Cancer Care and Office of L’nu Nursing”⁴⁹ The Equity and Anti-Racism Strategy outlines the following: “Engage Mi’kmaw communities and Indigenous peoples to identify and address anti- Indigenous racism in specific health system facilities and collaborate with community partners to improve the availability of health system navigators and advocates among Mi’kmaw and Indigenous communities”³⁴ (p. 9) Furthermore, there is a commitment to support Mi’kmaw health directors, Elders, and knowledge keeps advocating for health and the healthcare system.

Equity Initiatives

Across provinces, initiatives addressing inequities for equity-deserving groups vary. NS’s Equity and Anti-Racism Strategy outlines initiatives aimed at advancing healthcare for African Nova Scotians through the Nova Scotia Brotherhood and Sisterhood model, prideHealth and establishment of a gender affirming care clinic: “Work with physicians and other care providers to improve access to safe, effective primary care services for the 2SLGBTQIA+ community (ie, developing a strategy for the provision of safe and culturally appropriate gender-affirming care/surgery).”³⁴ (p. 11) Another priority was collaborating with individuals living with disabilities to ensure equitable healthcare access and addressing barriers (eg, technology, transportation, and physical environment).

ON outlines the following current commitments to advancing health equity: “We will continue to prioritize partnerships with organizations that represent equity-deserving populations, to collaboratively implement our Equity, Inclusion, Diversity and Anti-Racism Framework. This will include continued collaboration with the public health system, the Black Health Plan Working Group and subgroups focused on prevention of chronic diseases, primary care and pediatrics, perinatal and newborn care. We will also work with partners to advance priorities focused on reducing disparities experienced by 2SLGBTQIA+ communities. In addition, we will develop partnerships to meet the needs of underserved communities, to reduce health inequities and create connections that address the social determinants of health.”³⁶ (p. 8)

In BC, less specific health initiatives aimed at equity-deserving groups are mentioned. However, the Service Plan states: “Support and promote the application of an equity lens for the design and delivery of health care services and programs to embed cultural safety, anti-racism, and equity for Indigenous Peoples, immigrants, racialized groups, persons with disabilities, the 2SLGBTQ+1 community, and other populations facing systemic inequities.”⁴⁸ (p. 18) There is also an emphasis on addressing systemic racism and discrimination through equity-based data collection. Additionally, the Primary Care Networks’ (PCNs) Planning Guide for Preventative Care emphasizes PCNs service attributes as “Monitoring and reporting on health inequities; ensuring that interventions are designed to support equitable health outcomes across population groups; working with others in the health system to ensure that all health services are designed and delivered in a way that reduces health inequity; working with other sectors to formulate policies and programs that will reduce health inequities and, collaborating with others beyond the health system to address the inequities among the broader environmental, social, economic and other health determinants.”⁴⁴ (p. 5)

Discussion

This study aimed to examine how policies facilitate or hinder the advancement of health equity within PHC settings. Sixty-two policy documents were reviewed from the 3 Canadian provinces engaged in the study. The composition of equity-deserving groups was similar across provinces, while the emphasis of a specific group differed slightly. A growing response to health equity and the use of equity-based terminology was seen from 2018 onwards as supported by the SEA framework’s context, structures, and worldview.²¹ As noted by Romanow,⁵⁰ equity in health care was important to Canadians, but not until this last decade have we seen the concept of health equity and its variation in definition and focus.⁵¹

Our results suggest that policies seeking to address health inequities for equity-deserving groups should strive for meaningful engagement of patients, caregivers, and community members at all policy levels including development, implementation, and evaluation^21,52 not only to produce relevant initiatives but also empower individuals to be drivers of their health. There is an opportunity for healthcare systems, organizations, and policymakers to collaborate, bridge gaps, and address the expressed need of healthcare providers, health decision-makers, and communities to develop principles and practices that allow for healthcare teams to implement health equity into practice aligned with the SEA framework’s coherence (process) and accountability (responsibility and power dynamics). Furthermore, the SEA framework²¹ talks about gathering and engaging 2 key components of engagement.

Our findings demonstrate an increasing effort in the realm of Indigenous health, however there is more work to be done. Policies aiming to address health inequities for Indigenous Peoples must acknowledge and uphold Indigenous communities’ inherent right to self-determination.⁵³ Striving to support Indigenous Peoples’ right to lead and govern their own health services and enabling Indigenous-led policy development, implementation, and evaluation. Policies should acknowledge the impacts of historic and ongoing colonialism, many tools/frameworks can be found across the 3 provinces to help guide decision-makers in their work to reduce inequities for Indigenous populations. For example, FNHA⁵⁴ has various frameworks (although not mentioned in the policies that were analyzed) that can be used to provide structure and direction for policy development, implementation, and evaluation.

CHCs can be found across NS, ON, and BC with common goals to address health inequities and provide care to equity-deserving groups and Indigenous communities. CHCs in Canada and internationally were developed to address the social determinants of health and are committed to health equity. They provide services needed by the communities they serve^55,56 and have had positive impacts on patients’ health. Research on ON CHCs has shown positive outcomes for CHC patients, particularly those of equity-deserving groups.⁵⁷ CHCs provide an opportunity for policymakers to collaborate and learn from organizations already doing the work on the ground. CHCs provide the potential for agency and choice as outlined in the SEA framework,²¹ as well as the components of process and responsibility.

Finally, we found that while documents recognized and mentioned health equity, and may have provided commitments, initiatives, or interventions, how and whether these initiatives are implemented or evaluated is relatively unknown. The lack of and/or unknown state of implementation and evaluation of health equity outlined in policies was highlighted by Spencer et al¹ and addressed in the SEA framework (process, accountability, and potential).²¹ An interesting finding in our analysis was that PHC focused policies often excluded initiatives and did not provide metrics or guidance around how these approaches should be implemented by relevant parties (eg, primary care teams, health providers, and family practices). Additionally, PHC focused policies often lacked depth in goals, objectives, and commitments. For example, policies could be seen stating equity or health equity as an expected outcome but fail to provide how that policy advances this goal, how that goal could be implemented by health providers/teams, and how outcomes can be measured. Collaboration between patients, community members, healthcare providers, decision-makers, and policy-makers is essential to develop health equity initiatives, to implement clearly articulated principles and initiatives to drive health equity, and to measure outcomes of these initiatives on health equity.

Limitations in the study are acknowledged. The analysis relied on publicly available documents that may have excluded internal or unpublished policies, limiting the comprehensiveness of the findings. The coding approach, while structured, may be subject to researcher interpretation. Finally, external factors such as shifts in government leadership or emerging health crises were not considered that may influence policy. Despite these limitations, this study highlights critical gaps and opportunities for improving health equity through policy reforms in Canada.

Conclusion

We conducted a policy scan across 3 Canadian provinces with a specific focus on health equity. While many documents recognized and mentioned health equity within goals and objectives, findings revealed a disconnect between stated goals and practical application. Additional research is needed to better understand the implementation and evaluation of commitments to health equity within PHC policies.

Supplemental Material

sj-docx-1-jpc-10.1177_21501319251383598 – Supplemental material for The Intersection of Policy and Health Equity in Primary Health Care: A Policy Scan of 3 Canadian Provinces

Supplemental material, sj-docx-1-jpc-10.1177_21501319251383598 for The Intersection of Policy and Health Equity in Primary Health Care: A Policy Scan of 3 Canadian Provinces by Gabrielle Atkinson, Ashmita Rai, Paul Wankah, Ruth Lavergne, Emily Gard Marshall, Mark Embrett, Jennifer Rayner, Michael Reid, Valerie St. John, Deanna Beck, Catherine Aw and Nelly D. Oelke in Journal of Primary Care & Community Health

Supplemental Material

sj-xlsx-2-jpc-10.1177_21501319251383598 – Supplemental material for The Intersection of Policy and Health Equity in Primary Health Care: A Policy Scan of 3 Canadian Provinces

Supplemental material, sj-xlsx-2-jpc-10.1177_21501319251383598 for The Intersection of Policy and Health Equity in Primary Health Care: A Policy Scan of 3 Canadian Provinces by Gabrielle Atkinson, Ashmita Rai, Paul Wankah, Ruth Lavergne, Emily Gard Marshall, Mark Embrett, Jennifer Rayner, Michael Reid, Valerie St. John, Deanna Beck, Catherine Aw and Nelly D. Oelke in Journal of Primary Care & Community Health

Supplemental Material

sj-xlsx-3-jpc-10.1177_21501319251383598 – Supplemental material for The Intersection of Policy and Health Equity in Primary Health Care: A Policy Scan of 3 Canadian Provinces

Supplemental material, sj-xlsx-3-jpc-10.1177_21501319251383598 for The Intersection of Policy and Health Equity in Primary Health Care: A Policy Scan of 3 Canadian Provinces by Gabrielle Atkinson, Ashmita Rai, Paul Wankah, Ruth Lavergne, Emily Gard Marshall, Mark Embrett, Jennifer Rayner, Michael Reid, Valerie St. John, Deanna Beck, Catherine Aw and Nelly D. Oelke in Journal of Primary Care & Community Health

Footnotes

Acknowledgements

We would like to acknowledge the support of Walter Wodchis, Nominated Principal Investigator for the “Identifying strategies for successful implementation of primary healthcare teams: longitudinal case studies across three” (OPTIC-PHC Study) of which the Policy Workstream and its activities are a part of.

Author’s Note

Nelly D. Oelke is now affiliated with Rural Coordination Centre of BC, Vancouver, BC, Canada.

ORCID iDs

Ashmita Rai

Emily Gard Marshall

Michael Reid

Nelly D. Oelke

Ethical Considerations

All policy documents are publicly available therefore no ethics approval was needed.

Consent to Participate

There were no research participants included in the study.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this study was provided by the Canadian Institutes of Health Research, and Indigenous Research Mentorship Program, University of British Columbia, Okanagan.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

We have included our data extraction table as a supplemental file. Policy documents are publicly available.

Supplemental Material

Supplemental material for this article is available online.

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