Abstract
Background
Understanding the proportion and correlates of self-rated oral health (SROH) can assist in prioritising interventions. The aim of this study was to assess the prevalence of poor SROH and associated factors in a national community survey amongst adults in Algeria.
Methods
This World Health Organisation (WHO) STEPS cross-sectional survey in Algeria in 2016 and 2017 included 6989 people (18–69 years; median age, 37 years) selected by multistage cluster sampling. The assessment included questionnaire information, physical measures, and biochemistry tests. The measures included questions on SROH, oral conditions, oral health behaviour, general health behaviour, and measures of health status.
Results
The sample included 6989 people aged 18 to 69 years. Of the total sample, 17.1% had removable dentures, 35.5% had 0 to 19 natural teeth, 43.9% had dental pain in the past year, 40.5% had impaired oral health–related quality of life (OHRQoL), 26.9% cleaned their teeth 2 times/d or more, 79.6% used toothpaste, and 41.2% had visited a dentist in the past year. The prevalence of poor SROH was 37.3%. In the final logistic regression model, older age (45–69 years) (adjusted odds ratio [AOR], 1.34; 95% confidence interval [CI], 1.09–1.65), having removable dentures (AOR, 1.46; 95% CI, 1.14–1.87), dental pain (AOR, 2.16; 95% CI, 1.82–2.57), impaired OHRQoL (AOR, 2.69; 95% CI, 2.26–3.20), current smokeless tobacco use (AOR, 1.45; 95% CI, 1.12–1.89), and inadequate fruit and vegetable intake (AOR, 2.69; 95% CI, 2.26–3.20) increased the odds of poor SROH. Men (AOR, 0.76; 95% CI, 0.65–0.90), having 20 or more teeth (AOR, 0.35; 95% CI, 0.28–0.42), twice or more a day teeth cleaning (AOR, 0.72; 95% CI, 0.60–0.86), and using toothpaste (AOR, 0.67; 95% CI, 0.55–0.82) were protective against poor SROH.
Conclusions
Adults in Algeria reported a high prevalence of poor SROH, and several associated factors (sociodemographic, oral conditions, oral and general health–compromising behaviour) were found that can guide in oral health promotion strategies in Algeria.
Key words: Health status, Health behaviour, Oral health, Oral hygiene, Algeria
Oral diseases are a major public health concern, including in lower-resource countries.1 Worldwide, more than 2.2 billion people have dental caries, and almost 10% have severe periodontal diseases.1 Other oral health conditions include oral cancers, cleft lip and palate, orodental trauma, noma, and oral manifestations of HIV.1 Poor oral health status negatively affects general health and well-being.2 A broader concept of biopsychosocial oral health needs to take self-rated perceptions about oral health (SROH) into account3 because SROH may influence oral health behaviour, such as dental care utilisation.4 Understanding the concept of SROH may assist in improving dental care provision and has been shown to correlate with examined oral health status.5 There is a lack of information on SROH and its determinants amongst samples from the adult general population in North African countries, including Algeria.6,7 The age-standardised (rate per capita) prevalence and incidence of all oral conditions in Algeria in 2015 were 0.530 and 0.873, respectively. The prevalence and incidence of untreated caries in permanent teeth in Algeria in 2015 were 0.080 and 0.144, respectively, and the prevalence and incidence of severe periodontal disease in Algeria in 2015 were 0.392 and 0.703, respectively.8 The prevalence of severe periodontal disease in people 15 years and older in Algeria in 2019 was 15.9%, and the prevalence of edentulism in persons 20 years and older was 8.5% in 2019 in Algeria.9 The oral health workforce included 3.7% dentists, 0.2% dental prosthetic technicians, and 0.0% dental assistants and therapists per 10,000 population (2014–2019) in Algeria.9
In Sudan, a country in the eastern Mediterranean region, the prevalence of poor SROH in the general adult population was 8.0%,10 and amongst adults in Qatar 5.9% to 4.6% had poor SROH.11 In Kenya, the prevalence of poor SROH was 13.7%12; in Nigeria, 9%13; in Ecuador, 9.7%14; in Brazil, 5.9%15; and in rural India, 15.2%.16
Sociodemographic indicators associated with poor SROH consist of older age,10,12,17,18 female gender,10,11 such as Amerindian,14 lower educational and economic status,10,11,17,19, 20, 21, 22 and urban residence.10 Oral conditions associated with poor SROH include dentures,12 a lower number of teeth,12,23 pain in the teeth, gums, or mouth,10,12,14,24,25 impaired oral health–related quality of life (OHRQoL),10,11,14 and dental caries.16
Oral health behaviour reducing the risk of poor SROH include adequate toothbrushing,13 oral hygiene behaviours,18 and routine dental checkups.25 General health risk behaviour associated with poor SROH includes current smoking,13,16,17,22,26 smokeless tobacco use,11,27 hazardous alcohol use,17 poor diet,26 soft drink consumption,12,28 inadequate fruit and vegetable intake,29 and physical inactivity.30 General health status factors associated with poor SROH include chronic diseases,22 overweight and obesity,31,32 elevated total cholesterol,10 diabetes,11 and heart attack or stroke.14 The aim of the study was to assess the prevalence of poor SROH and associated factors in a sample of the national general adult population in Algeria.
Methods
Sample and procedure
National cross-sectional secondary data from participants (N = 6989) of the 2016–2017 Algeria STEPS household survey33 were analysed; the overall response rate to the study was 93.8%.34 A multistage cluster sampling design was applied to generate representative national data for 18- to 69-year-olds in Algeria. At the household level, an adult (18–69 years) was randomly selected.34 Inclusion criteria were being a household member aged 18 to 69 years and provision of informed consent. The household survey was conducted via trained interviewers who undertake face-to-face interviews at households.34 A pilot test was conducted with the translated versions of the Algeria-specific questionnaire and all other interview materials on a community sample.34
According to the STEPS survey procedures, “Socio-demographic, behavioural, including oral health information was collected in Step 1. Physical measurements such as height, weight, and blood pressure were collected in Step 2. Biochemical measurements were collected to assess blood glucose and cholesterol levels in Step 3.”35 The study was approved by the Ethics Committee of the Algerian Ministry of Health. Participants provided written informed consent.
All methods were performed in accordance with the relevant guidelines and regulations. All methods were carried out in accordance with the Declaration of Helsinki. The data on which this analysis was based are publicly available at the World Health Organisation NCD Microdata Repository: https://extranet.who.int/ncdsmicrodata/index.php/catalog.
Measures
SROH was measured with 2 items: (1) “How would you describe the state of your teeth and (2) gums?” Response options were 1 = excellent, 2 = very good, 3 = good, 4 = average, 5 = poor, 6 = very poor34 (Cronbach alpha, 0.70). The poor SROH was “classified as having poor or very poor status of teeth and/or gums, and good oral health as having average to excellent status of teeth and/or gums,” as in previous studies.10,12,14,36
Oral conditions
Participants were asked the following: “How many natural teeth do you have?”34 The responses were grouped into ≥20 teeth and 0 to 19 teeth. “Do you have any removable dentures?” (yes, no).34 “During the past 12 months, did your teeth or mouth cause any pain or discomfort?” (yes, no).34
OHRQoL was obtained from 10 items, for example, “Difficulty in chewing foods?” (yes, no)34 (Cronbach alpha, 0.84). Impaired OHRQoL was defined as any affirmative response to the 10 questions. OHRQoL measures “people's perception of the impact of oral disorders on their well-being, that is, the dysfunction, discomfort, disability, and handicap caused by oral conditions.”37
Oral health behaviours included 3 items34: (1) “How often do you clean your teeth?” (1 = never to 7 = twice or more a day); (2) “Do you use toothpaste containing fluoride?”(yes or no); (3) “How long has it been since you last saw a dentist?” (1 = less than 6 months to 6 = never received dental care), and (4) “What was the main reason for your last visit to the dentist?” (response options were (1) consultation/advice, (2) pain or trouble with teeth, gums, or mouth, (3) treatment/follow-up treatment, (4) routine checkup treatment, (5) other).
Substance use questions included current tobacco smoking (yes/no), current smokeless tobacco use such as snuff and chewing tobacco (yes/no), and alcohol use ever (yes/no). Daily vegetable/fruit intake was calculated from estimations of number of servings typically consumed per day. The levels of physical activity (low, moderate, and high) were assessed using the Global Physical Activity Questionnaire (GPAQ).38
Body mass index (BMI) was calculated from measured body weight and height, and overweight/obesity was classified as ≥25.0 kg/m2.35 Hypertension or elevated blood pressure (BP) was systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg or the participant currently being on antihypertensive medication.39 Diabetes was classified as fasting plasma glucose levels ≥7.0 mmol/L (≥126 mg/dL) or using insulin or oral hypoglycaemic drugs.35 Elevated total cholesterol was classified40 as being on antilipidemic medication or having elevated total cholesterol: ≥5.17 mmol/L (200 mg/dL). The history of a heart attack or chest pain due to heart disease (angina) or a stroke (cerebrovascular accident or incident) was evaluated by self-report.34
Statistical analysis
STATA software, version 13.0 (Stata Corporation) was used for statistical analyses. Frequencies and percentages were calculated to describe the data. Logistic regression was applied to model factors (social, oral conditions, oral health behaviour, health risk behaviour, and health status indicators) associated with poor SROH. Variables significant in univariable analysis were included in the multivariable model. Missing values (<4% of behavioural variables) were discarded, and P < .05 was considered significant. “Svy” commands in STATA were applied to adjust for the multistage sampling approach, including sampling weights. These weights were adjusted for differences in the age–sex composition of the sample population as compared to the target population.34
Results
Characteristics of the participants
The sample included 6989 people aged 18 to 69 years (median, 37 years; range 27–47 years), 55.9% were female, 67.5% lived in urban areas, and 33.8% had 12 or more years of education. In terms of oral conditions, 17.1% had removable dentures, 35.5% had 0 to 19 natural teeth, 43.9% had pain in the teeth, gum, or mouth in the past year, and 40.5% had impaired OHRQoL. Regarding oral health behaviour, 41.2% of participants had visited a dentist in the past year, 26.9% cleaned their teeth 2 or more times/d, and 79.6% used toothpaste. General health risk behaviour included 8.1% current smokeless tobacco use, 13.8% current tobacco smoking, 8.1% alcohol use ever, 85.1% insufficient fruit/vegetable consumption, and 34.5% had low physical activity. Almost 2 in 3 participants (60.0%) had overweight or obesity, 27.5% hypertension, 10.4% diabetes, 20.8% elevated total cholesterol, and 6.0% history of heart attack/stroke. The prevalence of poor SROH was 37.3%: 39.2% amongst women and 35.4% amongst men (see Table 1).
Table 1.
Sample and oral health characteristics, Algeria STEPS survey, 2016–2017.
| Variables | Subcategories | Sample | Self-rated poor oral health |
|---|---|---|---|
| No. (% unweighted) | % weighted | ||
| Sociodemographic variables | |||
| All | 6989 | 37.3 | |
| Age group (y) | 18–29 | 1508 (21.6) | 26.6 |
| 30–44 | 2747 (39.3) | 39.5 | |
| 45–59 | 1929 (27.6) | 47.3 | |
| 60–69 | 805 (11.5) | 50.0 | |
| Sex | Female | 3907 (55.9) | 39.2 |
| Male | 3082 (44.1) | 35.4 | |
| Education (y) | 0–5 | 1666 (23.9) | 48.7 |
| 6–11 | 2953 (42.3) | 38.8 | |
| ≥12 | 2356 (33.8) | 30.5 | |
| Residence | Rural | 2272 (32.5) | 38.8 |
| Urban | 4717 (67.5) | 36.5 | |
| Oral conditions | |||
| Number of natural teeth | 0–19 | 2442 (35.5) | 62.9 |
| 20 or more | 4434 (64.5) | 28.9 | |
| Dentures (removable) | Yes | 1186 (17.1) | 61.5 |
| Pain in teeth/gum/mouth (past year) | Yes | 3055 (43.9) | 51.7 |
| Oral health impact | Yes | 2817 (40.5) | 57.5 |
| Oral health behaviour | |||
| Teeth cleaning | < Once/d | 2805 (40.3) | 47.3 |
| Once/d | 2275 (32.7) | 32.7 | |
| ≥ Twice/d | 1873 (26.9) | 27.5 | |
| Uses toothpaste | Yes | 5535 (79.6) | 34.3 |
| Dentist consultation | Never | 503 (7.2) | 20.0 |
| >12 months ago | 3585 (51.6) | 35.3 | |
| Past 12 months | 2865 (41.2) | 42.9 | |
| General health risk behaviour | |||
| Current smoking tobacco | Yes | 963 (13.8) | 40.2 |
| Current smokeless tobacco | Yes | 561 (8.1) | 46.3 |
| Ever alcohol use | Yes | 564 (8.1) | 46.7 |
| Inadequate fruit and vegetable intake | Yes | 5765 (85.1) | 38.1 |
| Physical activity | Low | 2327 (34.5) | 37.8 |
| Moderate | 1680 (24.9) | 36.6 | |
| High | 2738 (40.6) | 37.4 | |
| Health status | |||
| Overweight/obesity | Yes | 3970 (60.0) | 38.0 |
| Hypertension | Yes | 1851 (27.5) | 44.4 |
| Diabetes | Yes | 626 (10.4) | 43.7 |
| Elevated total cholesterol | Yes | 1307 (20.8) | 41.2 |
| Stroke or heart attack | Yes | 415 (6.0) | 45.2 |
OHRQoL and SROH
Participants with poor SROH had significantly higher (P < .001) impaired OHRQoL on all 10 items and overall. The most frequent impaired OHRQoL item was difficulty in chewing/biting (28.8%) followed by felt tense because of problems with teeth or mouth (17.2%) and sleep is often interrupted (16.1%) (see Table 2).
Table 2.
Oral health–related quality of life (OHRQoL) and self-rated oral health (SROH), Algeria 2016–2017.
| OHRQoL | Overall | Poor SROH | Average or good SROH |
|---|---|---|---|
| No. (%a) | %a | %a | |
| Difficulty in chewing/biting | 2113 (28.8) | 62.0 | 27.2 |
| Felt tense | 1227 (17.2) | 62.5 | 31.8 |
| Sleep often interrupted | 1108 (16.1) | 58.1 | 33.0 |
| Embarrassed about teeth | 765 (10.5) | 69.3 | 33.4 |
| Difficulty with speech | 651 (8.7) | 68.1 | 34.4 |
| Doing usual activities | 608 (8.6) | 60.4 | 35.0 |
| Avoid smiling | 625 (8.4) | 69.4 | 34.2 |
| Days taken off work | 484 (7.4) | 56.5 | 35.7 |
| Reduced social activities | 381 (5.5) | 61.3 | 35.8 |
| Less tolerant of spouse or someone close with | 374 (5.2) | 61.2 | 35.9 |
| Impaired OHRQoL | 6953 (39.3) | 57.5 | 23.9 |
Weighted percentage.
Dental visit and SROH
Asking for the motivation of the last dental visit, we find that people with acute treatment motivation had a significantly higher prevalence of poor SROH (41.0%) than those with preventive treatment motivations (26.4%) (see Table 3).
Table 3.
Reason for last dental visit and self-rated oral health (SROH), Algeria 2016–2017.
| Motivation for most recent dental visit | All | Average or good SROH | Poor SROH | Odds ratio (95% CI) |
|---|---|---|---|---|
| %a | %a | %a | ||
| Acute treatment | 76.8 | 59.0 | 41.0 | 2.23 (1.89–2.63)*** |
| Pain or trouble with teeth, gums, or mouth | 59.7 | 58.6 | 41.4 | |
| Treatment/follow-up treatment | 20.2 | 60.8 | 39.2 | |
| Other (mainly extraction) | 4.0 | 55.2 | 44.8 | |
| Preventive | 14.7 | 73.6 | 26.4 | 0.56 (0.45–0.69)*** |
| Consultation/advice | 12.3 | 71.9 | 28.1 | |
| Routine checkup treatment | 3.7 | 80.7 | 19.3 |
CI, confidence interval.
Weighted percentage.
P < .001.
Associations with poor SROH
In the final model, older age (45–69 years); having removable dentures; having pain in teeth, gum, or mouth; having impaired OHRQoL; current smokeless tobacco use; and inadequate fruit and vegetable intake increased the odds of poor SROH. Male gender, having 20 or more teeth, teeth cleaning twice or more a day, and using toothpaste decreased the odds of poor SROH. In addition, in unadjusted analysis, higher education decreased the odds and past-12-month dental consultation, alcohol use ever, hypertension, diabetes, elevated total cholesterol, and stroke or heart attack increased the odds of poor SROH (see Table 4).
Table 4.
Logistic regression with poor oral health status, Algeria 2016–2017.
| Variable | Subcategory | COR (95% CI) | AOR (95% CI) |
|---|---|---|---|
| Sociodemographic factors | |||
| Age group (y) | 18–29 | 1 (Reference) | 1 (Reference) |
| 30–44 | 1.80 (1.56–2.08)*** | 1.29 (1.08–1.53)** | |
| 45–69 | 2.48 (2.08–2.96)*** | 1.34 (1.09–1.65)** | |
| Sex | Female | 1 (Reference) | 1 (Reference) |
| Male | 0.85 (0.76–0.96)** | 0.76 (0.65–0.90)*** | |
| Education (y) | 0–9 | 1 (Reference) | 1 (Reference) |
| ≥10 | 0.68 (0.60–0.77)*** | 0.98 (0.84–1.15) | |
| Residence | Rural | 1 (Reference) | — |
| Urban | 0.90 (0.76–1.07) | ||
| Oral conditions | |||
| Number of natural teeth | 0–19 | 1 (Reference) | 1 (Reference) |
| 20 or more | 0.24 (0.20–0.28)*** | 0.35 (0.28–0.42)*** | |
| Dentures (removable) | Yes | 2.94 (2.43–3.56)*** | 1.46 (1.14–1.87)** |
| Pain in teeth/gum/mouth (past year) | Yes | 3.19 (2.81–3.62)*** | 2.16 (1.82–2.57)*** |
| Oral health impact | Yes | 4.31 (3.74–4.96)*** | 2.69 (2.26–3.20)*** |
| Oral health behaviour | |||
| Teeth cleaning | < Twice/d | 1 (Reference) | 1 (Reference) |
| ≥ Twice/d | 0.42 (0.36–0.49)*** | 0.72 (0.60–0.86)*** | |
| Uses toothpaste | Yes | 0.50 (0.43–0.59)*** | 0.67 (0.55–0.82)*** |
| Dentist consultation | Never/≥12 months | 1 (Reference) | 1 (Reference) |
| ≤12 months | 1.53 (1.35–1.72)*** | 0.86 (0.74–1.01) | |
| General health risk behaviour | |||
| Current smoking tobacco | Yes | 1.16 (0.99–1.37) | — |
| Current smokeless tobacco | Yes | 1.51 (1.24–1.85)*** | 1.45 (1.12–1.89)** |
| Ever alcohol use | Yes | 1.53 (1.25–1.88)** | 1.24 (0.95–1.62) |
| Inadequate fruit/vegetable intake | Yes | 1.30 (1.07–1.57)** | 1.33 (1.06–1.67)* |
| Physical activity | Low | 1 (Reference) | — |
| Moderate | 0.95 (0.81–1.11) | ||
| High | 0.98 (0.85–1.14) | ||
| Health status | |||
| Overweight/obesity | Yes | 1.04 (0.93–1.17) | — |
| Hypertension | Yes | 1.43 (1.25–1.63)*** | 1.11 (0.93–1.31) |
| Diabetes | Yes | 1.30 (1.10–1.55)** | 1.06 (0.85–1.32) |
| Elevated total cholesterol | Yes | 1.18 (1.02–1.37)* | 0.98 (0.82–1.18) |
| Stroke or heart attack | Yes | 1.42 (1.09–1.84)** | 0.97 (0.71–1.34) |
COR, crude odds ratio; AOR, adjusted odds ratio; CI, confidence interval.
Discussion
We found a high prevalence of poor SROH (37.3%) in the general adult population in Algeria, which seems much higher than in previous studies using similar measures of poor SROH. The very high prevalence of poor SROH may mirror a high prevalence of oral conditions needing treatment in Algeria.8,9,41 This may also be reflected in the high proportion (76.8%) of the population attending the last dental consultation for reasons of acute treatment. Some of the country differences in the prevalence of poor SROH may be explained by the use of different measurements of poor SROH.
Consistent with some previous research,10,11,14,18, 19, 20, 21, 22, 23 we found that older age (45–69 years, 47.9%), female gender (39.2%) and, in unadjusted analysis, lower education levels (48.7%) increased the odds of poor SROH. Whilst a previous study found an association between urban residence and poor SROH,10 we did not find significant urban (36.5%)–rural (36.8%) differences. Lower general education levels may also impact lower oral health behaviour, increasing poor SROH.14 Women may be more likely than men to report dental or oral symptoms and may have less access to dental care than men.19
In agreement with former research,23,24 the survey showed that oral conditions (impaired OHRQoL, dentures, tooth loss, and dental pain) increased the odds of poor SROH. Of concern is that the prevalence of oral conditions was high, for example, <20 teeth, 35.5%, compared to Kenya at 2.2%12 and Sudan at 10.8%10; removable dentures, 17.1%, compared to Kenya at 4.6%12 and Sudan at 1.3%10; past-12-month pain in teeth, gums, or mouth, 43.9%, compared to Kenya at 31.6%12 and Sudan at 23.1%10; and impaired OHRQoL, 40.5%, compared to Kenya at 28.2%12 and Sudan at 30.5%.10 The higher prevalence of oral conditions in this study may in part explain the higher prevalence of poor SROH.
Furthermore, several oral health behaviours (teeth cleaning ≥2 times/d, using toothpaste, and preventive dental care) decreased the odds of poor SROH, which is consistent with previous research.24 However, there is a concern that only 26.9% of the participants cleaned their teeth ≥2 times/d, 79.6% used toothpaste, and 26.4% had preventive dental care. In comparison, for example, in Sudan,10 63.2% cleaned their teeth ≥2 times/d and 87.5% used toothpaste, and in Ecuador,14 85.1% cleaned their teeth ≥2 times/d, and 98.6% used toothpaste with fluoride. This could imply that special efforts should be made in Algeria to promote oral health behaviours to improve oral health.
In terms of general health risk behaviours, we found—in agreement with previous research11,26,27,29—that smokeless tobacco use (and not smoking) and inadequate fruit and vegetable intake were positively associated with poor SROH. However, unlike some previous results,17,30 alcohol use and physical inactivity were not significantly associated with poor SROH. These results seem to partially confirm that oral health risk behaviours cluster with general health–compromising behaviours.42 Smokeless tobacco use can cause sensory irritation27,43 and possibly be used to reduce dental pain or caries.27,44
Some previous research found an association between general health status (overweight/obesity, elevated total cholesterol, diabetes, and heart attack or stroke) and poor SROH,10,11,14,31,32 which we only found in unadjusted analysis for diabetes, elevated total cholesterol, stroke or heart attack, and hypertension.
Oral health promotion strategies in Algeria may want to target older women, those with poor oral conditions (having <20 teeth, removable dentures, impaired OHRQoL, and dental pain), poor oral health behaviour (<2 times/d teeth cleaning and not using toothpaste), and general health–compromising behaviour (current smokeless tobacco use and inadequate fruit and vegetable intake) in order to improve SROH.
Study limitations
Oral health and some other variables were assessed by self-report, which may have led to biased responses, and due to the cross-sectional study design no causal inferences can be made. We did not assess the associations between SROH and clinical parameters to evaluate the validity of SROH. However, studies in various cultural contexts have consistently shown the validity and reliability of SROH, including self-reported dental conditions, for population health assessment and monitoring.16,26,45, 46, 47, 48 Future research may include both objective and subjective oral health status assessments. Household income could not be calculated due to many missing values. In addition, additional dietary questions, such as consumption of sugar-sweetened beverages and sugar, were not included and should form part of future research.
Conclusions
Almost 2 in 5 adults in Algeria reported poor SROH and several associated factors were identified, including sociodemographic factors (older age and female gender), poor oral conditions (having <20 teeth, removable dentures, impaired OHRQoL, and dental pain), poor oral health behaviour (<twice/d teeth cleaning and not using toothpaste), and general health–compromising behaviour (current smokeless tobacco use and inadequate fruit and vegetable intake), which can guide oral health promotion strategies in Algeria.
Conflict of interest
None disclosed.
Acknowledgments
Acknowledgements
This paper uses data from the 2016-2017 Algeria STEPS survey, implemented by the Ministry of Health with the support of the World Health Organisation.
Author contributions
All authors fulfill the criteria for authorship. SP and KP conceived and designed the research, performed statistical analysis, drafted the manuscript, and made critical revisions to the manuscript for key intellectual content. All authors read and approved the final version of the manuscript and have agreed to authorship and order of authorship for this manuscript.
Funding
No funding was received.
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