Rural healthy people 2030: New decade, new challenges

Highlights

• •Mental health was the most commonly selected rural health priority.
• •Addiction was the second most commonly selected rural health priority.
• •Health care access was ranked as the most important rural health priority.
• •Economic stability debuted as a top 10 rural health priority.

Abstract

Rural Healthy People is a companion piece to the federal Healthy People initiative released once a decade to identify the most important Healthy People priorities for rural America, as identified by rural stakeholders, for the current decade. This study reports on the findings of Rural Healthy People 2030. The study relied on a survey of rural health stakeholders collected from July 12, 2021, to February 14, 2022, and: 1) identified the 20 Healthy People priorities most frequently selected as priorities for rural America, 2) studied the priorities that were most frequently selected as a “top 3” priority within each Healthy People 2030 category, and 3) investigated Healthy People 2030 priorities in terms of ranked importance for rural Americans. The analysis finds that for the first time across 3 decades of Rural Healthy People, a greater proportion of respondents selected “Mental Health and Mental Disorders” and “Addiction” as Healthy People priorities for rural America, than did “Health Care Access and Quality”. Even still, respondents ranked “Health Care Access and Quality” as the single-most important rural priority. “Economic Stability,” a new priority within the Social Determinant of Health category, debuted within the 10 most frequently selected priorities for rural America for the coming decade. As public health practitioners, researchers, and policymakers work toward closing the urban–rural divide, the most important rural priorities to address in the coming decade are mental health and substance use disorders, access to high quality health care services, and social determinants of health, such as economic stability.

1. Introduction

Healthy People is a collaborative, multi-purpose initiative led by the U.S. Department of Health and Human Services (HHS) that establishes public health priorities in the United States (Office of Disease Prevention, 2030). Every ten years, HHS publishes public health objectives, sets targets for health improvement, and tracks the nation’s progress toward achieving its stated goals (Office of Disease Prevention, 2030). Rural Healthy People is a companion piece to the broader Healthy People initiative that seeks to identify and address the priority health concerns of rural America (Gamm et al., 2010). Rural Healthy People was first commissioned by the Federal Office of Rural Health Policy in 2002. The key source of data for Rural Healthy People is generated from a national survey of rural stakeholders. The survey gathers information directly from rural stakeholders about which of the national Healthy People priorities they deem to be most important for rural Americans (Bolin et al., 2015).

Healthy People objectives and targets are set for the nation as a whole, rather than for specific population groups (Office of Disease Prevention, 2021). Yet while the Healthy People initiative has been seen as successful at driving improvement toward national goals, studies have shown that progress toward Healthy People targets has been slower in rural areas (Callaghan et al., 2020, Yaemsiri et al., 2019, Office of the Assistant Secretary for Health. Healthy People, 2020). For example, in urban areas, 31.4% of the Healthy People 2020 objectives with trackable data had targets that were met or exceeded by the end of the decade. In rural areas, only 24.3% of trackable targets had been met or exceeded (Office of the Assistant Secretary for Health. Healthy People, 2020). Persistent geographic health disparities may explain this phenomenon. People living in rural areas are older, sicker, and poorer than people living in urban areas (National Healthcare Quality, 2017, Cromartie et al., 2020). They face limited access to health care providers, are more likely to be obese, smoke, be uninsured, and to have activity limitations due to chronic conditions (National Healthcare Quality, 2017, Cromartie et al., 2020, Bureau of Health Workforce, 2021). Of course, rural America is not a monolith and persistent disparities exist within rural communities, especially across race, nationality, and region. Notably, racial and ethnic minority groups in rural America face more barriers to health access and higher morbidity and mortality (Gamm et al., 2010, Bolin et al., 2015, Callaghan et al., 2020, Yaemsiri et al., 2019). Altogether, the distinct needs and unique barriers experienced by rural Americans likely shape a very different list of public health priorities than those relevant to the urban population majority. In light of the passage of time since the last national survey of rural stakeholders for Rural Healthy People 2020 and the new iteration of Healthy People (Healthy People 2030), the extent to which health priorities among rural stakeholders may have shifted is unknown.

Therefore, the purpose of this study is to identify and share the most important Healthy People priorities for rural America, as identified by rural stakeholders, for the current decade. With the combined dissemination efforts and promotion support of the National Rural Health Association, the American Hospital Association, the National Association of Rural Health Clinics, and numerous other organizations and individuals, this national study sought to gather the feedback of what is, to our knowledge, amongst the largest samples of rural public health stakeholders ever surveyed.

2. Methods

To identify the most important Healthy People priorities for rural America, we began by refining surveys administered nationally for Rural Healthy People 2010 and 2020 (Gamm et al., 2010, Bolin et al., 2015). We then included new Healthy People 2030 priorities as we developed the final instrument and ultimately administered the web-based survey to rural stakeholders across the United States. Rural stakeholders were defined as individuals who work in roles aimed at improving the lives and health of rural Americans. This includes medical professionals, government officials, academic researchers, and individuals in any other field of employment whose primary responsibility is to improve rural life and health.

Participants were recruited anonymously through three key mechanisms. First, we built dissemination partnerships with leading rural health organizations across the United States including the National Rural Health Association, the American Hospital Association, and the National Association of Rural Health Clinics (a full list of disseminating partners is available in Appendix A). These rural partners shared the survey via internal listservs, emails to members, and social media postings. Second, participants were recruited through snowball sampling. All participants taking the survey were asked to identify up to five other individuals that they considered to be rural health stakeholders and to provide contact information. We then used this information to reach out to those identified individuals. Finally, all individuals who have downloaded Rural Healthy People 2020 over the last decade have been asked for their contact information (Rural Healthy People, 2020). We used this information to recruit these individuals to participate in Rural Healthy People 2030. No incentive was provided for participating in the survey which was approved by the IRB at Texas A&M University.

Data collection occurred from July 12, 2021 – February 14, 2022, using Qualtrics, resulting in a final sample of 1,475 rural stakeholders in the United States. The survey took 30 min to complete and 66% of respondents who started the survey completed it. Importantly, as our Healthy People questions were asked at the beginning of the survey and questions about other issues such as the COVID-19 pandemic and Coronavirus Aid, Relief, and Economic Security (CARES) Act spending in rural America were asked later in the survey, the Healthy People questions had a much higher participation rate at 88%. Key demographic characteristics for the sample can be seen in Appendix D. There, we show that our sample included rural stakeholders from 49 states working in over 100 different professions, including rural health clinics (28.7%) and rural hospitals (21.8%). In our sample, 20.6% of stakeholders worked as health care administrators, 11.8% worked as nurses, and 5.9% worked as physicians. Our sample of rural stakeholders was predominantly female (77.3%), middle-aged (mean age of 42.7), lived in rural areas (57.6%), and well educated (64.4% with at least a master’s degree). Our sample is also overwhelmingly White (94.8%) as compared to the rural population where 24% of rural residents are people of color (Rowlands and Love, 2021). While these demographics differ considerably from those of rural America as a whole, it is critical to recognize that our population of interest is rural stakeholders who work to improve the lives and health of rural Americans which likely differs from rural residents themselves.

2.1. Key variable of interest

Multiple questions were used to evaluate which Healthy People 2030 priorities rural stakeholders believed were the most important for rural America. Each of these questions are included in Appendix B. In keeping with the format of surveys used in prior iterations of Rural Healthy People, respondents were first asked to select which of the 62 Healthy People 2030 priority areas they believed were a “top 10” priority for rural America. These 62 priority areas were listed alphabetically across two columns to reduce cognitive burden on survey respondents. This question was asked at the beginning of the survey to prevent the context of other survey questions shaping respondents’ top priorities.

Next, respondents were asked to rank, in order, the three Healthy People priorities that they perceived to be the most important. Finally, in response to the Healthy People initiative grouping the 62 priorities for 2030 into five topic areas/categories (Office of Disease Prevention, 2021), for the first time – Health Conditions, Health Behaviors, Populations, Settings and Systems, and Social Determinants of Health – we asked rural stakeholders to select their top 3 priorities in each category.

2.2. Data and Analysis

As in prior iterations of Rural Healthy People, a list of the top twenty Healthy People 2030 priorities for rural America was constructed by identifying the 20 Healthy People 2030 priorities that respondents selected as a “top 10” priority for rural America most often.

In addition, we asked survey respondents to identify, in order, which three Healthy People priorities they believed were the most important for rural America. We utilized this data in two ways. First, we looked at which priorities were most frequently identified by respondents as their first choice, second choice, and third choice. Second, by assigning respondents’ first choices a value of 3 points, second choices a value of 2 points, and third choices a value of 1 point, we were able to generate a list of priorities in ranked order of importance. The ten priorities that were awarded the greatest total number of points by the sample were organized into an overall “top 10” ranked list of priorities.

Finally, we were interested in identifying what respondents perceived to be the most important Healthy People priorities within each of the five new categories. The top priorities within each category were identified in a similar process as for “top 10” priorities, where the priorities selected most often in respondents’ “top 3” lists were identified as those most important for rural America in each category.

3. Results

Fig. 1 shows the 20 Healthy People 2030 priorities that were most often selected by rural stakeholders as a “top 10” priority for rural America. “Mental Health and Mental Disorders” was the most oft-cited priority, with just over three-quarters of respondents (75.2%), including it in their top 10 list. The second-most often selected priority was “Addiction”, which 63.5% of respondents identified as a “top 10” priority. About half of the sample included “Health Care Access and Quality” (50.1%), “Overweight and Obesity” (48.4%), and “Drug and Alcohol Use” (45.6%) in their “top 10” lists for rural America, placing these priorities in the third, fourth, and fifth positions, respectively. The remainder of the top 10 most commonly selected priorities for rural America were “Nutrition and Healthy Eating” (38.3%), “Older Adults” (32.5%), “Preventive Care” (32.5%), “Diabetes” (32.2%), and “Economic Stability” (29.7%).

Fig. 1.

Top Twenty Healthy People 2030 Priorities for Rural America.

The margin separating priorities 11 through 20 was smaller, with less than 9 percentage points separating the former from the latter. These priorities, in order, were “Transportation” (26.3%), “Cancer” (25.3%), “Public Health Infrastructure” (24.5%,), Housing and Homes” (23.0%), “Workforce” (22.2%), “Education Access and Quality” (21.2%), “Health Insurance” (20.9%), “Child and Adolescent Development” (20.6%), “Hospital and Emergency Services” (19.0%), and “Chronic Pain” (17.7%). As seen in Table A5 of Appendix D, we find no evidence of a primacy effect, with priorities at both the top and the bottom of our list falling into the top 20 most often selected.

While the results depicted in Fig. 1 help to identify the priorities most often included in respondents’ top 10 priorities, it does not depict which priorities stakeholders viewed as most important. For that reason, we explored results from a question asking respondents to rank which Healthy People 2030 priorities are most important for rural America (Table 1). “Health Care Access and Quality” was most frequently ranked as the single most important Healthy People priority for rural America, with 20.9% of respondents placing it in first position. Another 8.7% and 6.1% of the sample ranked “Health Care Access and Quality” as the second or third most important Healthy People priority, respectively, earning it 1,063 total points in our coding scheme. While “Mental Health and Mental Disorders” was most often ranked as a top 10 priority, Table 1 shows that it is the second most important Healthy People priority for rural America in terms of points. Notably, it was also the priority that was most often selected as both the second-most and third-most important Healthy People priorities for rural America. Rounding out the list of ten ranked priorities were: 3) “Addiction”, 4) “Overweight and Obesity”, 5) “Economic Stability”, 6) “Drug and Alcohol Use”, 7) “Workforce”, 8) “Preventive Care”, 9) “Diabetes”, and 10) “Nutrition and Healthy Eating”.

Table 1.

Top Ten Healthy People 2030 Priorities for Rural America in Ranked Order.

Ranked Order	Priority	Total Points	Pct. Ranking #1	Pct. Ranking #2	Pct. Ranking #3
1	Health Care Access and Quality	1,063	20.9%	8.7%	6.1%
2	Mental Health and Mental Disorders	978	15.0%	12.5%	10.6%
3	Addiction	631	8.3%	9.8%	7.8%
4	Overweight and Obesity	378	5.0%	5.3%	5.7%
5	Economic Stability	348	5.2%	4.5%	4.2%
6	Drug and Alcohol Use	308	2.9%	6.0%	4.9%
7	Workforce	235	3.5%	3.1%	2.6%
8	Preventive Care	228	3.4%	3.2%	2.1%
9	Diabetes	206	2.1%	3.9%	3.2%
10	Nutrition and Healthy Eating	185	2.7%	2.2%	2.8%

Notes: 1.) Total Points = (Number of respondents ranking the priority as the #1 most important for rural America × 3 points) + (Number of respondents ranking the priority as the #2 most important for rural America × 2 points) + (Number of respondents ranking the priority as the #3 most important for rural America × 1 points); 2.) Ranked order was determined by sorting the Healthy People 2030 priorities earning the greatest number of “Total Points” to the least.

Table 2 shows each of the five categories that were introduced in Healthy People 2030 to better organize priorities, along with what our sample of rural stakeholders selected as the three most important priorities for rural America within each. Within “Health Conditions” (n = 20 priorities), “Mental Health and Mental Disorders”, “Addiction”, and “Overweight and Obesity”, were most frequently included in respondents’ top 3 lists, with more than half of respondents including each of them (68.3%, 52.6%, and 52.0%, respectively). Within “Health Behaviors” (n = 14 priorities), “Drug and Alcohol Use”, “Preventive Care”, and “Nutrition and Healthy Eating” emerged as most important for rural America (61.0%, 47.1%, and 46.4%, respectively). Within “Populations” (n = 10 priorities), 70.1% of respondents included “Older Adults” in their top 3 lists, followed by “Children” (54.3%), and “Adolescents” (40.9%). The category with the least consistency in responses was “Settings and Systems” (n = 13 priorities), within which the most frequently cited priority, “Health Care”, was selected by just 47.9% of the sample, “Community” was selected by 40.7%, and “Hospital and Emergency Services” were selected by 31.9%. “Social Determinants of Health”, the smallest of the 5 categories (n = 5 priorities), saw “Health Care Access and Quality” included by 86.1% of respondents, “Economic Stability” included by 83.0%, and “Education Access and Quality” included by 64.3% of respondents.

Table 2.

Top Three Healthy People 2030 Priorities for Rural America Within Each Healthy People 2030 Category.

Healthy People 2030 Category	Most Frequently Selected Healthy People 2030 Priorities		No. Selecting in Top 3	Pct. Selecting in Top 3
Health Conditions (20 priorities)	1.	Mental Health and Mental Disorders	749	68.3%
	2.	Addiction	577	52.6%
	3.	Overweight and Obesity	570	52.0%
Health Behaviors (14 priorities)	1.	Drug and Alcohol Use	663	61.0%
	2.	Preventive Care	511	47.1%
	3.	Nutrition and Healthy Eating	504	46.4%
Populations (10 priorities)	1.	Older Adults	766	70.1%
	2.	Children	594	54.3%
	3.	Adolescents	447	40.9%
Settings and Systems (13 priorities)	1.	Health Care	526	47.9%
	2.	Community	447	40.7%
	3.	Hospital and Emergency Services	350	31.9%
Social Determinants of Health (5 priorities)	1.	Health Care Access and Quality	945	86.1%
	2.	Economic Stability	910	83.0%
	3.	Education Access and Quality	705	64.3%

Note: A full list of the Healthy People 2030 priorities that fall within each Healthy People 2030 Category may be found in Appendix C.

4. Discussion

For the first time across three decades of research, a greater proportion of Rural Healthy People respondents selected “Mental Health and Mental Disorders” and “Addiction” in their lists of top 10 Healthy People priorities for rural America, than did “Health Care Access and Quality” (Gamm et al., 2010, Bolin et al., 2015). Critically however, given the reliance on convenience samples in all iterations of Rural Healthy People, we cannot say definitively that the rise of mental health and addiction (substance abuse) from 4th and 5th in Rural Healthy People 2020 to 1st and 2nd in Rural Healthy People 2030 reflects genuine intensification in the importance of these topics over the past decade among rural health stakeholders more broadly. Nevertheless, evidence over the past decade gives us strong reason to believe that the elevation of “Mental Health and Mental Disorders” and “Addiction” reflect a real increase in the importance of these topics to rural America.

Nationally, the prevalence of mental health conditions and substance use disorders (Substance USE and Co-Occurring, 2022), is such that roughly half of all Americans will meet the diagnosable criteria for at least one of them within their lifetime (Mental Health America, 2021, Kessler et al., 2005). Mental health disorders and substance use disorders are often co-occurring and an estimated one in two people who experience one of these types of disorders also experiences the other (Substance USE and Co-Occurring, 2022). While studies have suggested that the burden of mental health disorders is similar in urban and rural areas, the availability, accessibility, affordability, and acceptability of treatment is more limited in rural communities (Wilson et al., 2015). These unique barriers to treatment of mental health disorders in rural areas, include a lack of providers (Over one-third of Americans, 2021), a larger portion of the resident population that is uninsured (National Healthcare Quality, 2017, Cromartie et al., 2020), and the increased deterrence that stigma has on treatment-seeking due to the lack of anonymity that accompanies residing in a more sparsely populated area (U. S. Department of Health and Human Services, 2021).

These barriers are equally impactful in the context of substance use disorders, wherein research has shown that rural Americans are less likely to seek treatment (Hoeg, 2021). Exacerbating matters, recent data suggests that increased social isolation, perceived vulnerability of infection, job loss, lack of childcare, and other stressors secondary to the COVID-19 pandemic have substantially increased the percent of the population reporting mental health disorders and/or substance use (Panchal et al., 2021, USAFacts, 2021). Given that our Rural Healthy People 2030 survey dissemination period coincided with the COVID-19 pandemic, it is likely that the increased burden of mental health conditions and substance use disorders that it has engendered contributed to the increase in importance of these issues relative to decades prior (Murthy and Narasimha, 2021, Marel et al., 2021, Xiong et al., 2020).

While “Health Care Access and Quality” was not included in Rural Healthy People 2030 survey respondents’ identification of top 10 Healthy People priorities as often as “Mental Health and Mental Disorders” and “Addiction”, respondents ranked “Health Care Access and Quality as the single most important priority for rural America. This suggests that while mental health and substance use disorders have become increasingly widespread, health care access and quality remains the single most serious public health concern in the eyes of many rural stakeholders. Despite the passage of time and the enactment and implementation of national legislation such as the Affordable Care Act over the past decade, rural populations continue to lag behind urban populations in health care access. Rural America has yet to realize substantial improvements in key measures of health care access including local availability of providers and health care facilities. Instead, an unmet demand for nearly 7,000 primary health care practitioners exists in wholly or partially rural areas and 140 rural hospitals have closed since 2010 (Bureau of Health Workforce, 2021, Rural hospital closures, 2021).

Notably, amendments and new priorities added to Healthy People 2030 have also created opportunities to expand our understanding of rural health priorities beyond our understanding from Rural Healthy People 2010 and 2020. Healthy People 2030′s organization of priorities into five categories (shown in Appendix C) provided a window into which of the broader aspects of health and well-being rural stakeholders consider most important for rural America. Interestingly, we found that the 20 most important priorities for rural America for the coming decade spanned all 5 of the new Healthy People categories. This underscores the importance of maintaining a holistic view of health and well-being and pursuing cooperation across sectors and professions when working toward rural health goals in the coming decade.

An additional change made to the 2030 iteration of Healthy People was the elevation of “Social Determinants of Health”, which was included as single priority in Healthy People 2020, to a category containing 5 priorities (Rural Healthy People, 2020, Giroir, 2021). One of these priorities, “Economic Stability”, emerged as the 10th most frequently cited “top 10” priority for rural America and was ranked 5th in terms of ranked importance by our sample. While this important issue is being illuminated for the first time in the context of the Healthy People initiative, it is not a new problem in rural America. In fact, the rural poverty rate has been higher than that in urban areas since the 1960 s when this information was first officially recorded (Well-Being, 2021). By ranking “Economic Stability” so highly, it is apparent that Rural Healthy People 2030 respondents recognize that a lack of financial resources is foundational to other downstream rural health challenges including lack of access to health insurance and rural hospital closures (Hospital closings likely to increase, 2017, Tolbert et al., 2020).

Finally, even as this survey was fielded amid the COVID-19 pandemic, neither “Infectious Disease” nor “Vaccination” were among the 20 priorities most frequently chosen by respondents. One possible explanation for this phenomenon is that respondents were cognizant of some of the recent significant and specific investments that federal and state governments have made with the intention of increasing vaccination in rural areas (Rural Health Funding, 2021, HHS Press Office, 2021). If so, they may have opted to, instead, select priorities that they felt were more in need of attention and resources. Even still, this finding is surprising given that the COVID-19 vaccination rate in rural areas has lagged behind urban areas and COVID-19 deaths have disproportionately affected rural communities (The Daily Yonder, 2021, Ullrich and Mueller, 2021).

4.1. Directions for future research

To our knowledge, no comparable urban-focused counterpart to the Rural Healthy People initiative currently exists. Such a project would be a useful means of highlighting how the needs of urban and rural communities differ, as well as to better target funding and improvement efforts to maximize progress toward public health goals. Thus, future research should explore which Healthy People priorities urban stakeholders deem most important. In addition, while the top-line results of Rural Healthy People 2030, as presented in this paper, are valuable alone, there is potential for additional information to be gleaned by exploring how these results vary across geographic regions, respondents’ sociodemographic characteristics, and across Rural Healthy People iterations. This detailed information, coupled with additional research about the top priorities and which interventions for tackling them have proved most successful, may hold additional power to ensure that progress toward Healthy People goals does not lag behind in rural America for yet another decade. In addition, while we focus our analysis on rural stakeholders given our interest in informed population-level priorities, future research would benefit from learning the perspectives of regular rural residents about the most important health priorities for rural America.

4.2. Limitations

Several limitations of this study are worth note. First, Healthy People 2030 expanded the number of priority areas from previous decades and organized the new list of priorities into 5 categories. In some instances, these changes may have led to what respondents may have seen as overlapping or duplicate response options. For example, it is possible that some respondents were indifferent between “Child and Adolescent Development” (an established priority), “Children” (a new priority), “Education Access and Quality” (established) and “Schools” (new). If these priorities were not seen as unique and respondents split votes between them, then the true importance of these issues could be understated in our results. In addition, although all participants were notified in the consent documents that we were interested in speaking with rural stakeholders and consented under those conditions, it is possible that some of our participants would not meet our definition of a rural stakeholder. Finally, despite relying on varied recruiting mechanisms, certain states are over- or under-represented. For example, a disproportionate percent of our stakeholders come from Texas.

In addition, it is critical to recognize our use of a convenience sample as a limitation. While this was necessary due to the lack of population benchmarks for rural stakeholders, we could be underrepresenting portions of the rural stakeholder population. Our results in Appendix D do suggest broad participation across states, professions, and health care settings, and that the sample for Rural Healthy People 2030 is more diverse than Rural Healthy People 2020 (Bolin et al., 2015). Still, it remains possible that certain groups are under-represented and that differences in priorities observed across decades are more reflective of sample differences as opposed to priority change. Relatedly, while we included snowball sampling as part of our recruitment strategy, asking participants to identify other participants could lead them to identify other individuals who are like them, potentially reducing sample diversity. Finally, in administering this survey over the internet, we could have missed potential rural stakeholders who lack internet access.

5. Conclusion

The urban–rural divide continues to expand in health access and outcomes. With more than 65-million Americans living in rural regions of the United States, we must persist in our efforts to invest in rural communities, with a particular focus on improving infrastructure, workforce availability, prevention, and attention to the social determinants of health in rural areas. The challenges faced by rural governments and public health officials are enormous, with widening disparities across race, ethnicity, age, and gender.

The results of our study shed light on which health priorities rural stakeholders deem the most important for rural America over the next decade. This information holds the potential to accelerate health improvements in rural areas, which have lagged behind urban areas in achieving Healthy People goals. Among the most important priorities to address in the coming decade are mental health and substance use disorders, access to high quality health care services, and social determinants of health, such as economic stability. As we usher in a new decade with a new set of Healthy People priorities, providers, policy makers, public health professionals, and other stakeholders may use these data to accelerate progress on public health priorities that will benefit Americans who reside in rural areas.

CRediT authorship contribution statement

TC: conceptualization, data curation, funding acquisition, investigation, methodology, project administration, supervision, writing – original draft, writing – reviewing and editing. MK: conceptualization, data curation, investigation, methodology, writing – original draft, writing – reviewing and editing. NJ: conceptualization, funding acquisition, project administration, writing – reviewing and editing. AS: investigation, methodology, writing – reviewing and editing. JH: Conceptualization, data curation, project administration. SH: conceptualization, data curation, investigation, methodology, project administration, writing – reviewing and editing. JB: conceptualization, methodology, writing – reviewing and editing. AF: conceptualization, data curation, funding acquisition, investigation, methodology, project administration, supervision, writing – original draft, writing – reviewing and editing.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

The following are the Supplementary data to this article:

Data availability

Data will be made available on request.