Abstract
Background
The relationship between social determinants of health (SDH) and negative health outcomes is well established, prompting undergraduate medical educators to teach students to recognize and address these SDH. However, current SDH resources like the Healthy People 2030 report and published curricula lack a targeted approach to best teach and learn pediatric-specific SDH.
Objective
To use medical students’ experiences working with patients affected by SDH on their pediatric clerkship as a targeted needs-assessment to drive pediatric-specific SDH curricula.
Methods
Qualitative analysis of the reflective journal entries of 94 medical students who rotated on the pediatrics clerkship from 2022–2023. Each student completed an entry on their experiences with pediatric SDH including identification of the SDH, perceptions of the impact of the SDH, and observed SDH navigation strategies. A team of three coders employed both deductive and inductive content analysis to the dataset. SDH codes were tabulated for frequency analysis.
Findings
Across the 94 entries, there were 205 reported SDH, with an average of 2.18 SDH per entry. Inductive content analysis resulted in six new pediatric-specific SDH in addition to those established by Healthy People 2030 report. Our analyses showed that students perceived SDH to impact pediatric patients and their families through five mechanisms; analyses of student entries also identified five strategies that the healthcare team used to facilitate SDH navigation. Finally, a frequency analysis showed that the three most common SDH clerkship students experienced were Language & literacy, Foster care / Department of Children and Families (DCF) system, and Insurance status.
Conclusion
Utilizing the medical student experience with SDH on the pediatric service can serve as a meaningful needs-assessment to drive pediatric-specific SDH curricular development. We identified a unique set of pediatric-specific SDH that may improve medical schools’ SDH curricula.
Introduction
Under the broadest definition, social determinants of health (SDH) are non-medical factors in an individual's physical and social environment that impact their health. 1 The Healthy People 2030 report, commissioned by the U.S. Department of Health and Human Services, outlines five overarching SDH domains, including economic stability; education access and quality; health care access and quality; neighborhood and built environment; and social and community context. 2 Importantly, SDH is implicated in both the emergence of disease pathology as well as its subsequent treatment, with extant literature indicating associations between unfavorable SDH and mortality. 3 This deleterious relationship between SDH and health outcomes has been found consistently across a host of pathologies including stroke, 4 diabetes, 5 cancer, 6 and cardiovascular disease. 7 Importantly, while literature most often highlights SDH in the context of adult populations, consideration of SDH in pediatric populations is equally important, given similar data on the consequential effects of SDH on unfavorable pediatric health outcomes. 8
Recently, the National Academies of Sciences, Engineering, and Medicine has called for medical schools to better equip their students with the knowledge and skills to address SDH at the community level. 9 In response, many medical institutions took distinct approaches to address their SDH curricula. Some focused on SDH training in graduate medical education with components both within and outside of the traditional classroom setting. 10 Others have started to introduce the concepts of SDH earlier in undergraduate medical education. 11 However, a review of 22 of these undergraduate medical education SDH curricula highlights significant heterogeneity with respect to faculty expertise, length of curricula, type of experiential learning, and accessibility to all students. 11 Of these 22 curricula, approximately 23% were <6 weeks long and occurred during orientation or clerkship; 32% were 6 weeks to 1 year long during the preclinical or clerkship periods; and 41% were >1 year in length. Additionally, less than half (45%) were geared for all medical students, while the majority were selective or elective courses. 11 To our knowledge, these curricula did not specifically target pediatric SDH and did not use the Healthy People 2030 report. More recently, medical schools have developed clerkship-specific SDH curricula in the family medicine 12 and emergency medicine 13 clerkships. Additionally, there has been increased focus on integrating pediatric SDH into clinical curricula. For example, Roth et al developed a pediatric-specific, case-based SDH curriculum administered to medical students during their pediatrics clerkship 14 and Marsh et al developed a lecture and assessment regarding pediatric SDH during a pediatric clerkship. 15
The reviewed undergraduate medical education SDH curricula, while well-intentioned, have not undertaken a robust needs-assessment to assess which SDH are most relevant (eg, most frequently encountered, most consequential to patient outcomes, etc) for students to learn. This type of needs-assessment is particularly important given that frequency and consequences of SDH may vary regionally 16 and based on patient demographics specific to each institution. Further, understanding the medical student's experience with SDH has wide-ranging implications. Notably, it can help design a student-driven curriculum serving as a targeted needs-assessment, consistent with Kern's 6 step model of curriculum development for medical education. 17
Therefore, a noticeable and important gap emerges within the literature – using the clerkship student experience with SDH as a targeted needs-assessment to better inform pediatric-specific SDH curricula.
Methods
Participants
Ninety-four (94) students, in groups of nine to sixteen students, rotated through the six-week long core pediatric clerkship between 2022 and 2023. Inclusion criteria included students who completed the pediatrics clerkship and rotated through the pediatrics inpatient units, pediatric intensive care units, pediatric emergency department, and pediatric outpatient sub-specialty clinics. As one of their clerkship passing requirements, medical students reflected on their experiences with pediatric SDH in the form of a journal entry. No student was excluded from the study, as all students completed the entirety of the pediatrics clerkship and submitted a journal entry. Student entries were graded on completion rather than according to a rubric. Consistent with the Health Equity Thread within the Yale School of Medicine's curriculum, all 94 students had longitudinal exposure to SDH during the preclinical phase of their training. Specifically, the Health Equity Thread covers eight domains of SDH including race & ethnicity, disability, climate change & environmental justice, immigration, carceral status, poverty, sex & gender, and sexual orientation & gender identity.
Data Collection
All 94 students who rotated through the pediatric clerkship submitted a journal entry. As outlined in Supplement 1, all students chose and described a real case in which SDH played a role and identified how the SDH may have impacted the patient's care. The journal entry instructions were designed jointly by the pediatric clerkship directors to increase medical student reflection and discourse regarding pediatric SDH. The first question was designed to help students recognize and understand pediatric SDH as part of patients’ medical presentation and the second and third were intended for students to meaningfully document navigation strategies and resources that could be shared among peers. The questions were intentionally designed to build on the content and themes pertaining to SDH that medical students were exposed to in the preclinical curriculum. Of note, this activity began in 2022, and the present study represents an analysis of data approximately one year after its onset. This activity was designed with the purpose of increasing student discourse regarding SDH in the pediatrics curriculum and to guide future SDH efforts.
Students were also encouraged to report both exemplary and ineffective strategies that the medical team used to navigate the identified SDH. These entries were checked for completion by the clerkship administrative team and some anecdotes were presented by students in an hour-long, conversational debriefing led by pediatric residents and faculty otherwise not involved in the current study during the final week of the clerkship. To promote discussion and protect confidentiality, these debriefing sessions were not recorded, and no formal data collection occurred during these debriefing sessions. Therefore, only the 94 submitted entries were used as the qualitative dataset.
Students were not re-contacted for any additional or clarifying information. Further, neither faculty nor families of patients were contacted to reflect on or triangulate on students’ entries. The study protocol was deemed exempt by the Yale University School of Medicine Institutional Review Board. The reporting of this study conforms to the consolidated criteria for reporting qualitative research 18 (Supplement 2).
Data Analysis
The research team comprised of a third-year medical student (SK), a house-staff liaison to the pediatrics clerkship (RJ), the pediatrics clerkship director (UP), and the inpatient and outpatient associate pediatric clerkship directors (MG & AF), representing a mix of gender identities, racial and ethnic backgrounds, clinical proficiency, and pedagogical expertise. While all authors interacted with the medical students in some capacity during their clerkship experience, data was analyzed by the coding team after entry of students’ grades.
Journal entries were anonymized and the date of submission was removed by an administrative assistant before loading the data into Dedoose, a cloud application for managing, analyzing and presenting qualitative research. 19 Both a deductive and inductive content analysis approach were applied to the coding effort. 20 First, when identifying SDH, a deductive coding approach used the Healthy People 2030 report as a reference for commonly encountered SDH. However, when a reported SDH did not neatly fit into the Healthy People 2030 structure, the coding team then applied inductive content analysis. To determine whether a reported SDH fit into the Healthy People 2030 structure, the coding team referred to the literature summaries, including related objectives and related evidence-based resources, included for each SDH included on the Healthy People 2030 website to derive an agreed-upon definition for each listed SDH.
To ensure cohesion within the three members of the coding team (SK, RJ, MG), the deductive coding process began with the team reviewing and discussing the Healthy People 2030 report and its associated definitions. To begin the coding process, all three members of the coding team began by independently coding the same 10 student entries. Then, all three coders attended a coding meeting, which began with a review of memos, settling of coding discrepancies, and updating the code book with newly derived codes and/or more explicit definitions of established codes. 21 To resolve discrepancies, the coding team reviewed text segments and engaged in discussion to reach consensus. The coding team then independently returned to the same set of 10 entries and did not proceed to the next 10 entries until coders were completely aligned. This process continued until the point of thematic sufficiency, 22 which for our purposes was achieved when coders independently coded 10 codes in which no discrepancies existed between all three coders and no new codes emerged. Codes were iteratively expanded and revised as they were applied to subsequent data until a final code book emerged. 21 To enhance the rigor of our study, we maintained an audit trail of our code book adjustments.
Once thematic sufficiency and coding trustworthiness were achieved, indicating that each coder was coding text consistently in line with each other, the total dataset of 94 entries was split among the three coders and reviewed to ensure the most up-to-date code book was applied accurately and consistently to the entire dataset. Thus, each entry's final coding occurred by a single coder, which allowed for tabulating frequencies of the most common SDH reported by the students. Frequencies were coded once per student entry, even if one entry mentioned the same SDH multiple times. Additionally, for those entries identifying multiple SDH, frequencies were tabulated for each SDH within the entry. In addition to identifying and determining the most common SDH encountered, we utilized inductive content analysis to describe additional constructs such as SDH navigation strategies and the perceived impact of the SDH on the patient and family.
An “expert check” 23 step was integrated at two distinct timepoints. The first was midway through coding, when preliminary findings were reviewed with a faculty member with extensive experience with identifying, navigating and qualitatively reporting the impacts of SDH on patients and families (AF). This “expert check” added validity to the results and evolved our coding strategy from purely deductive to include the inductive coding approach to identify pediatric specific SDH outside of the Healthy People 2030 report. After this decision, all previously coded entries were re-coded to include both deductive and inductive analysis. A second “expert check” (AF) occurred after all entries were coded and resulted in changes to the wording of the pediatric-specific SDH.
Results
We reviewed SDH journal entries from 94 students, all of whom completed each component of the written assignment. The entries were relatively brief, with the average entry around 200 words. Thematic sufficiency was reached at entry 63, at which point no new codes were added by the coding team. Results of the deductive and inductive analyses are presented in Table 1.
SDH Classified by the Healthy People 2030 Report, Non-Pediatric-Specific SDH, and Pediatric-Specific SDH.
Numbers in parenthesis adjacent to the SDH represent the frequency of that SDH included within student entries.
SDH Frequency Analysis
Across the 94 entries, there were 205 reported SDH, with an average of 2.18 SDH per entry (Table 1). When collapsing across all SDH, the three most frequently coded SDH were: 1) language & literacy; 2) foster care / Department of Children and Families (DCF) system; and 3) insurance status. While the first and third most coded SDH fall under the Health People 2030 report, the second most frequent SDH was a pediatric-specific SDH.
Deductive & Inductive Content Analysis to Derive SDH
SDH topics not included in the Healthy People 2030 report were categorized into two broad categories: pediatric-specific SDH and non-pediatric-specific SDH. Overall, three prominent themes emerged from the analysis: 1) pediatric-specific SDH, 2) impact of SDH on patient and family, and 3) the healthcare team's navigation strategies to address the SDH. The inductive analysis specifically resulted in 10 new SDH that were not specifically captured in the Healthy People 2030 report.
Pediatric-Specific SDH
Six pediatric-specific SDH were derived (Table 1). Pediatric-specific SDH was further subdivided into child-focused pediatric-SDH, which include (1) foster care / DCF system, (2) peer social pressures, (3) adoption, and family-centered pediatric-SDH, which include (1) parental/caregiver–patient relationship, (2) family responsibilities, and (3) language heterogeneity within a family.
Students frequently documented patient cases where the presence of these SDH complicated and challenged care for their patients. In one example, a patient was adopted with unknown gestational and family histories, making it harder to assess for an underlying genetic condition. In other examples, students reported on a patient's unstable home environment resulting in DCF referrals being placed and the patient transitioning from home to foster care. In these situations, the medical team was tasked with addressing the patient's medical conditions as well as their rapidly changing home situations.
Familial responsibilities also emerged as a frequently reported pediatric-specific SDH, with students reflecting on the challenges associated with patient care when the patient's caregiver was a single parent, had other children to take care of, or had a job that did not permit them to take substantial time off. These factors, as students report, limited the ability of the parent or caregiver to serve as a bedside advocate for the patient.
Other students reflected on the parental/caregiver–patient relationship as another pediatric-specific SDH. In one specific example, a student documented a case of a teenage football player who was hospitalized for disordered eating, whose care was complicated by, among others, a challenging parental/caregiver–patient relationship: “[His] course was affected by educational and financial constraints. He attends a private high school on a football scholarship, and many of his weight fluctuations were preceded by directives from his coach . . . Since his scholarship depended on his football participation, being barred from playing due to weight was a significant concern for him . . . Further, his parents are separated, meaning that supervision and miscommunication between households represented challenges in ensuring consistent care. His mother was unable to get him to health appointments . . . Additionally, lack of consistent oversight meant that [the patient] was able to continue to purge without arousing suspicion in either of his parents . . . his parents were often not on the same page and his father would bring outside food to the hospital room, making calorie control more difficult.”
Additionally, these pediatric-specific SDH often co-occurred, rather than existing in a silo. One student described a case of a patient hospitalized with recurrent anorexia nervosa where the patient's care was complicated by both language heterogeneity within a family and family responsibilities: “Her stay was significantly complicated by her family/culture not recognizing mental health as a legitimate disorder/condition. Additionally, [her] mother (the primary caretaker) did not speak English as [her] primary language and also had a 4 year-old autistic boy . . . Due to the mother's busy caretaking schedule with other kids, family education [regarding anorexia nervosa] initially happened via Zoom (and in English) where it was clear we weren’t making any progress.”
Impact of SDH on Patient & Family
Students reflected on the direct impact of SDH on their patients (Table 2). Increased morbidity was commonly reported; for example, food insecurity impacted a patient's diabetic control and loss of parental custody led to confusion about the patient's medical history and contributed to a hospital admission. Delayed diagnosis was another perceived effect of SDH. Students noticed a disparity in length of stay for patients with access to different financial and social resources: “She stayed in the hospital for 15 [days], even after being medically cleared, due to difficulty securing affordable behavioral health care. In contrast, another patient who had also been admitted for restrictive eating around the same time came from a wealthy family and was shipped off to an inpatient rehab facility in Missouri after only a 5 [day] hospital admission. This other patient's family had both the time and resources to be able to expeditiously set up her outpatient care.”
Impact of SDH on Patient and Family.
In addition, students witnessed, firsthand, the consequences of inappropriate handling of SDH by clinicians. Especially for families with a language barrier, physicians were perceived to communicate poorly: “Due to [a] language barrier, the mother was not contacted until 45 min after the patient was brought in. The mother presented when the baby was being imaged and was told she would be allowed to see her child shortly. [The mother waited] for over 2 [hours] without anyone from the floor speaking with her. [The nurses] told me that this is not an uncommon experience for young parents who don't speak English because they are unable to advocate for themselves.” “The inability to effectively communicate the pathogenesis of the disease, disease course, treatments, etc created a black box environment for the family which further aggravated [their] fear[s]. Additionally, it created an environment in which shared decision making processes took a backseat, with paternalistic medicine becoming the driver of care.”
Healthcare Team's Navigation Strategies
Students identified five different strategies for navigating social determinants of health: identifying the SDH; building trust and understanding with clear, frequent, non-judgmental communication; utilizing short term resources; eliminating SDH; and prioritizing aspects of care (Table 3). One strategy was simply to identify the SDH; students commented frequently on the importance of asking the family and investigating which SDH they were currently facing.
Healthcare Team's Strategy in Addressing the SDH.
Next, and most commonly, students described observing the healthcare team build trust and understanding by using clear and frequent communication. The specific strategies described by students ranged from very informal–“sitting down, eye to eye, and discussing [the mother's] concerns, listening to her, and explaining the strategy of her daughter's care”–to very structured, such as the LEARN model for patient communication 24 or weekly family meetings.
Students also appreciated the team's efforts to remain non-judgmental, for example by supporting a parent's need to go to work instead of staying at the bedside or only mentioning a family's prior involvement with DCF when directly relevant to the patient's clinical concern. Additionally, students reported that medical teams frequently used community resources to decrease the impact of the SDH, including free care programs, transportation resources, or interpreter services. However, there were significant limitations seen for many of these resources. One student astutely commented: “While following this patient for almost 2 weeks, I learned that at the community level, there exists a multitude of resources, and with effective collaboration, these resources can be made accessible to patients. However, it's essential to recognize that these resources may not always be readily available or easily accessible to patients who lack a dedicated team of advocates. Patients often find themselves in situations where they are unable to actively advocate for themselves or address the social determinants of health independently.”
Discussion
Consistent with our primary aim, this study employs both deductive and inductive content analysis to serve as a targeted needs-assessment for a student-driven approach to pediatric SDH curriculum development. The deductive component of our analysis allowed SDH detailed within the student entries to be mapped on to five broad SDH domains included in the Healthy People 2030 report. At the same time, inductive analysis led to the emergence of several prominent themes: pediatric-specific SDH that were not otherwise sufficiently captured in the Healthy People 2030 report, impact of SDH on patient and family, and the healthcare team's navigation strategies. Our frequency analysis highlights that the most canonical SDH listed in the Healthy People 2030 report (eg, language, health literacy, low socioeconomic status) are also among the most witnessed SDH for students rotating through our pediatric clerkship. Our frequency analysis also indicates that some of these pediatric-specific SDH (eg, child involvement in the foster care and DCF systems) were just as frequently observed by clerkship students as other SDH contained within the Healthy People 2030 report. Finally, the frequency analysis indicates that the average student entry contained 2.18 SDH, operationalizing the intersectionality inherent to SDH discourse.
Taken together, our results can help guide SDH curriculum development. For one, future SDH curricula should address certain pediatric-specific SDH that occur in high frequencies, which are often omitted from published SDH pedagogy. Additionally, curricula should emphasize the co-occurring nature of SDH and recognize that pediatric-specific and non-pediatric-specific SDH can occur in unison and uniquely complicate a child's disease presentation, workup, and management.
Consistent with prior studies, we report the deleterious impacts of negative SDH on children and families as they grow and mature. Our analysis additionally summarizes healthcare team-based approaches for addressing SDH that may improve patient outcomes. Some helpful strategies emerging from our data may be integrated into future SDH curricula to equip students with tangible skills to better address SDH. For example, SDH curricula may benefit from experiential learning experiences involving practicing in-person and virtual communication skills (eg, LEARN model and teach-back method in patient scenarios with pertinent SDH) as well as effective administration of educational tools specifically designed to address pediatric-specific SDH.
At the same time, certain student reflections force us to think about how to best define the contours of future SDH curricula. We recognize that it is impossible to integrate didactics regarding all pertinent SDH in sufficient detail in the confines of current medical education. In fact, prior research on barriers stymieing medical schools from better prioritizing SDH indicate that 82% of survey respondents identified insufficient space for new content in their curricula. 25 The natural next question becomes which SDH should be prioritized within this limited space. The frequency analysis may help address which SDH should be preferentially included in SDH curricula. For example, a child's experience with foster care / DCF system was a frequently witnessed SDH that might be prioritized in future curricula over the less frequent pediatric-specific SDH.
Recognition of pediatric-specific SDH and subsequent curricular improvements are especially important given their unique nature. For example, Viner et al's “Adolescent Health” Lancet series highlights the unique mechanisms such as socialization, new behaviors, and identity formation that gives rise to SDH in early childhood and adolescence. 26 Additionally, Brooks-Gunn's Family and Community Resource Framework 27 suggests that certain parents are better equipped to deal with the challenges associated with having a chronically ill child than others. Third, our findings complement extant literature on adverse childhood experiences (ACEs), which are tightly interconnected with pediatric-specific SDH. SDH and ACEs not only co-exist, but often work cumulatively, and substantially increase a risk of negative health outcomes in children, including childhood obesity. 28 Given the unique nature of pediatric-specific SDH, including their emergence, their effect on the family unit, and their overlapping nature with ACEs, identifying and addressing pediatric-specific SDH may warrant different skill sets and strategies, which we hope future pediatric curricula will continue to address.
Next steps involve the didactic and clinical pediatric faculty discussing these findings and working closely with institutional leadership to determine curriculum improvements relating to SDH. Specifically, they should consider the ways in which SDH and ACEs, which are also taught in the pediatrics curriculum, may be better integrated. In some ways, we view this as an iterative process–using the clerkship student experience to drive curricular improvements and then re-assessing the student clerkship experience with SDH in the setting of the updated curriculum to continue to drive meaningful SDH curricular adaptations.
As previously mentioned, medical educators have undertaken recent efforts to implement pediatric SDH medical school curricula.14,15 While these important and well-executed pediatric SDH curricula begin to fill the current gap, to our knowledge, they do not leverage the medical student experience to derive the specific content encountered in local pediatric clinical environments. We believe our qualitative study, focusing on a student-driven approach, can identify specific, relevant SDH to foster learning and confidence to identify and address pediatric-specific SDH in local clinical environments.
However, these findings need to be considered in the context of several limitations. First, while 63 codes to reach inter-coder consensus may be relatively high compared to other qualitative efforts, this is likely due to the brevity of each student entry as well as the wide range of possible SDH described within each entry. Secondly, our qualitative assessment of student entries occurred in only a single institution and primarily in the inpatient setting. The results of our study may not be entirely generalizable to different pediatric practice settings (eg, inpatient, primary care, specialty outpatient clinics) or other institutions located in other geographies where students interface with different demographics than that of a midsize, urbanized city in the Northeast. We encourage other institutions to perform a similar needs assessment within their own locations to drive SDH curriculum modifications that may be most specific and impactful for their students. Third, while our study involved a cohort of 94 students rotating through the pediatric clerkship in a single year (2022-2023), future research could trend results longitudinally. Finally, we acknowledge that students may have written their submissions on the most easily-recognizable and least controversial SDH (ie, language & literacy). While this does not detract from the prevalence of language-related SDH witnessed by students, student entries may not perfectly represent the true range or frequency of SDH which children and families face. Similarly, we recognize that Question 1 in the SDH Self Directed Learning assignment (Supplement 1) lists specific SDH as examples that students can reflect on in their written entries. Several of these listed SDH, including language, insurance status, and the DCF system are among the most frequently reported SDH in our dataset. However, other listed SDH in the assignment, including experiences of racism, had relatively lower frequencies; also, the average student entry contained 2.18 SDH, indicating that students reflected on complex patient presentations who experienced more SDH other than those just listed in the assignment. Nevertheless, future iterations of this work may benefit from not providing examples of SDH in the assignment, so that the frequency analysis is a more accurate representation of the pediatric SDH students experience.
Conclusion
To our knowledge, the current study is one of the first to use a student-driven approach to drive improved pediatric-specific SDH curricula. Improving approaches to recognizing and addressing SDH is paramount to better pediatric patient outcomes.
Supplemental Material
sj-docx-1-mde-10.1177_23821205251342079 - Supplemental material for Leveraging Medical Students’ Experiences with Social Determinants of Health During Their Pediatric Clerkship to Drive Curriculum
Supplemental material, sj-docx-1-mde-10.1177_23821205251342079 for Leveraging Medical Students’ Experiences with Social Determinants of Health During Their Pediatric Clerkship to Drive Curriculum by Shashwat Kala, Rachel Johnson, Uma Phatak, Ada Fenick and Michael Goldman in Journal of Medical Education and Curricular Development
Supplemental Material
sj-pdf-2-mde-10.1177_23821205251342079 - Supplemental material for Leveraging Medical Students’ Experiences with Social Determinants of Health During Their Pediatric Clerkship to Drive Curriculum
Supplemental material, sj-pdf-2-mde-10.1177_23821205251342079 for Leveraging Medical Students’ Experiences with Social Determinants of Health During Their Pediatric Clerkship to Drive Curriculum by Shashwat Kala, Rachel Johnson, Uma Phatak, Ada Fenick and Michael Goldman in Journal of Medical Education and Curricular Development
Footnotes
Ethical Considerations
The study protocol was deemed exempt by the
Consent to Participate
The requirement for informed consent to participate in this study was waived by the
Author Contributions
All authors made substantial contributions to the study meriting formal authorship. SK, MG, UP, and AF conceived and designed the study analysis. SK and MG collected the data and contributed data/analysis tools. SK, MG, UP, and RJ performed the analysis. SK, MG, and RJ wrote the paper.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
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