Implementation of the whole school, whole community, whole child model in Makkah schools, Saudi Arabia: association with students' body mass index and academic achievement

Abstract

Objective

To assess the implementation of the Whole School, Whole Community, Whole Child (WSCC) model in public elementary schools in Makkah, Saudi Arabia, and examine its association with students' body mass index (BMI) and academic achievement.

Methods

A cross-sectional study was conducted in 2022 across 20 elementary schools in Makkah using multistage cluster sampling. Participants included 385 students and 32 school staff from health-promoting schools (HPSs) and non-HPSs. Implementation of four WSCC domains; community involvement, family engagement, physical environment, and counseling services, was assessed using validated self-administered questionnaires. Academic scores, BMI, and sociodemographic data were collected. Data analysis utilized descriptive statistics, bivariate tests, Spearman correlations, and multivariable linear regression.

Results

Students in HPSs reported higher WSCC implementation and academic achievement than those in non-HPSs (median score: 687 vs. 665, p = 0.009). In multivariable models, WSCC implementation remained an independent predictor of academic achievement after adjustment (B = 1.63, 95 % CI: 0.90, 2.35), whereas its association with BMI was not significant (B = 0.36, 95 % CI: −0.32, 1.04). A dual burden of underweight and overweight was observed.

Conclusions

Strengthening WSCC implementation, especially mental health support, family and community engagement, and equitable policy adoption, may enhance students' learning and well-being.

Highlights

• •The Whole School, Whole Community, Whole Child model was evaluated in Makkah.
• •Implementation was higher in schools promoting student health.
• •Model implementation was linked to higher academic achievement.
• •No clear link was found with students' body mass index.
• •Undernutrition was more common in non–health-promoting schools.

1. Introduction

Traditionally, schools have focused on academic instruction and curriculum, placing responsibility for student success primarily on teachers and principals. This approach often overlooks the student as the central focus of educational policy. The Health-Promoting Schools (HPS) concept emerged to address this gap by engaging all members of the school community in promoting and protecting students' health and well-being through health services, supportive environments, and family and community engagement (Morse and Allensworth, 2015).

Globally, the World Health Organization (WHO) has endorsed HPS as a strategy to align education and public health goals, recognizing schools as key environments that shape lifelong behaviors and outcomes (World Health Organization, n.d.). Building on this, the Whole School, Whole Community, Whole Child (WSCC) model—developed in 2014 by the U.S. Centers for Disease Control and Prevention (CDC) and the Association for Supervision and Curriculum Development (ASCD)—integrates educational and health priorities through five guiding principles: that each child be healthy, safe, engaged, supported, and challenged (Centers for Disease Control and Prevention and ASCD, n.d.; Murray et al., 2015). The WSCC framework promotes academic and health equity through its ten interrelated components, including health education, physical activity, family engagement, and school climate (Lewallen et al., 2015; ASCD, n.d.).

Despite its comprehensive design, empirical research on WSCC remains limited. A scoping review (2014–2020) identified only eight studies directly evaluating WSCC implementation or outcomes, underscoring the need for further research to support its application and impact (Willgerodt et al., 2021).

In Saudi Arabia, the HPS initiative was introduced in 2002, implemented in 72 pilot schools, and focused on eight domains such as health services, environment, and counseling (Ministry of Education, Deputy Ministry for School Affairs, General Administration of School Health, 2020). National and regional evaluations reported improved student health awareness and infrastructure but persistent challenges in policy support, staff training, and funding (Bushara et al., 2017; Almusnad and Aldaghaem, 2015; Alziyad, 2018). Although these efforts laid an important foundation, WSCC-aligned approaches remain inconsistently implemented, particularly in elementary schools, where domains such as community involvement, family engagement, and counseling services appear underdeveloped (Ministry of Education, Deputy Ministry for School Affairs, General Administration of School Health, 2020).

To date, there is limited empirical evidence on WSCC implementation in the Middle East, and particularly within Saudi schools. While WSCC does not directly target body weight, its components addressing nutrition, physical activity, and family engagement influence determinants of healthy weight. Evidence from other countries suggests WSCC-aligned programs improve students' dietary behaviors, physical activity, and school climate (Murray et al., 2015; Lewallen et al., 2015; Alhelal et al., 2024).

Accordingly, this study aims to assess the implementation of the WSCC model in public elementary schools in Makkah, Saudi Arabia, and examine its association with students' body mass index (BMI) and academic achievement.

2. Methods

2.1. Study design and population

A school-based, cross-sectional, self-administered web survey was conducted in 2022 to assess implementation of the WSCC model in public elementary schools in Makkah, Saudi Arabia. The study included male and female government schools across five geographic regions (Eastern, Western, Northern, Southern, and Central). Schools were categorized as HPS or non-HPS according to the national school health promotion guidelines of the Saudi Ministry of Education. These guidelines assess domains related to health education, physical and psychosocial environment, nutrition, physical activity, counseling services, and family and community participation (Ministry of Education, Deputy Ministry for School Affairs, General Administration of School Health, 2020). Although HPS framework does not cover all WSCC components, several domains overlap, allowing it to serve as a contextual proxy for WSCC implementation in the Saudi context.

Student eligibility included Saudi nationality, in the 5th and 6th grades, and independent completion of the questionnaire following parental electronic consent. Staff participants included health advisors, student counselors, administrative staff, and teachers directly involved in WSCC-related activities. Data were collected electronically via Google Forms, cleaned, and verified for completeness before analysis. No substantial missing, incomplete, or outlier data were identified, and all valid surveys were retained for statistical analysis.

2.2. Sampling and sample size

A multistage cluster random sampling approach was used (Fig. 1). In each of the five regions, four schools were randomly selected (one HPS boys' school, one non-HPS boys' school, one HPS girls' school, and one non-HPS girls' school), totaling 20 schools. Within each school, one class from the 5th grade and one from the 6th grade were randomly selected, and all students were invited to participate (response rate 66 % to 84 %). Staff were selected purposively to capture at least one key WSCC-related perspective per school, achieving balanced representation across schools (n = 32, response rate 40 %).

Fig. 1.

Flowchart of sampling strategy and recruitment of 5th–6th grade students and staff for the WSCC implementation study in Makkah, Saudi Arabia, 2022.

The minimum required student sample size (n = 385) was calculated using the formula n = Z²P(100–P)/d² with Z = 1.96, P = 50 %, and d = 5 %. Due to logistical limitations, the design effect (DEFF) was not applied, though regional coverage and high response rates enhanced representativeness.

2.3. Measures

Two structured, self-administered Arabic questionnaires—one for students and one for staff—were developed based on WSCC model literature (Morse and Allensworth, 2015; World Health Organization, n.d.; Centers for Disease Control and Prevention and ASCD, n.d.; Murray et al., 2015; Lewallen et al., 2015; ASCD, n.d.; Willgerodt et al., 2021) and expert input. Both were reviewed for content and cultural validity, and pilot tested among 20 students and 4 staff. Cronbach's alpha values were 0.78 and 0.81, respectively, indicating satisfactory reliability.

The student questionnaire collected sociodemographic data (age, sex, grade, number of siblings, birth order, parental education and employment, and housing type), four WSCC domains (community involvement, family engagement, physical environment, and counseling services) based on international WSCC guidelines (Morse and Allensworth, 2015; World Health Organization, n.d.; Centers for Disease Control and Prevention and ASCD, n.d.) and previously identified gaps in Saudi school health evaluations (Ministry of Education, Deputy Ministry for School Affairs, General Administration of School Health, 2020; Bushara et al., 2017; Almusnad and Aldaghaem, 2015; Alziyad, 2018; Alhelal et al., 2024; Alzahrani, 2022), academic achievement (self-reported as total grades out of 700 from the previous school year), and BMI calculated from self-reported or school-assisted height and weight. Similar proxies have been validated and widely adopted in previous studies linking school health to educational outcomes (Matingwina, 2018; Michael et al., 2015). The staff questionnaire included job title, school type, and the same WSCC domains adapted to their professional role.

Each WSCC item was rated on a five-point Likert scale (Strongly agree/Agree = two points, Neutral = one point, and Disagree/Strongly disagree = zero points), producing a total WSCC score (range: 0–38). Scores ≥29 indicated good implementation (≥75 % of total score).

2.4. Ethical consideration

This study was conducted in accordance with institutional guidelines for the protection of human subjects, ensuring safety, confidentiality, and privacy. Ethical approval was obtained from the Biomedical Research Ethics Committee at Umm Al-Qura University (Reference No. HPDL280121) and the Makkah Education Department. Electronic informed consent was obtained from all participants or parents prior to data collection. Participants were clearly informed that their participation was voluntary, and that they could withdraw from the study at any time without providing a reason. All data collected were treated as confidential and were used solely for the purposes of academic research.

2.5. Statistical analysis

Shapiro–Wilk tests indicated non-normal distributions for key continuous variables; therefore, nonparametric methods were used for descriptive comparisons as applicable. Continuous variables were summarized using medians and interquartile ranges [IQRs] and compared using the Mann–Whitney U or Kruskal–Wallis tests. Categorical variables were summarized as frequencies and percentages and compared with the chi-square test. Bivariate associations between WSCC implementation and academic achievement were assessed using Spearman's rank correlation coefficient. A multivariable linear regression model was fitted with academic achievement as the dependent variable and total WSCC score as the main independent variable, adjusting a priori for potential confounders: BMI, school type, sex, and parental education. Adjusted β coefficients with 95 % confidence intervals (CI) are reported. All statistical tests were two-sided, and significance was set at p < 0.05. Analyses were performed using SPSS version 26 (IBM Corp., Armonk, NY, USA).

3. Results

A total of 385 students participated, of whom nearly 70 % attended non-HPS and two-thirds were in the 5th grade. The median age was 11 years [IQR: 11–12], and 59 % were female. Most students had 2–4 siblings and parents with at least a bachelor's degree. The median BMI was 21.6 kg/m² [18.6–24.8]; 23.4 % were underweight, 53.5 % normal weight, 17.9 % overweight, and 5.2 % obese (Table 1).

Table 1.

Sociodemographic and health-related characteristics of 5th–6th grade students in Makkah, Saudi Arabia, 2022 (N = 385).

Variable	Category	Frequency (n = 385)	Percentage (%)
Type of school	Health-promoting	119	30.9
	Non-health-promoting	266	69.1
Grade	5th	254	66.0
	6th	131	34.0
Age (years)	Median [IQR]	11 [11−12]
	Min – Max	10–13
Sex	Male	157	40.8
	Female	228	59.2
Number of brothers	0–2	85	22.1
	3–5	233	60.5
	>5	67	17.4
Birth order	First	102	26.5
	Middle	250	64.9
	Last	33	8.6
Father's employment	Government sector	220	57.1
	Private sector	85	22.1
	Not working	16	4.2
	Retired	64	16.6
Mother's employment	Government sector	84	21.8
	Private sector	100	26.0
	Housewife	201	52.2
Father's education	Primary	33	8.6
	Secondary	81	21.0
	Bachelor	203	52.7
	Postgraduate	68	17.7
Mother's education	Primary	66	17.1
	Secondary	17	4.4
	Bachelor	234	60.8
	Postgraduate	68	17.7
Lodging type	Rented house	181	47.0
	Owned house	102	26.5
	Private house	102	26.5
BMI (kg/m2)	Median [IQR]	21.6 [18.6–24.8]
	Min – Max	12.4–35.7
	Underweight (<18.5)	90	23.4
	Normal weight (18.5–24.9)	206	53.5
	Overweight (25–29.9)	69	17.9
	Obese (≥30)	20	5.2

Students' perceptions of WSCC domains indicated strongest agreement for the physical environment (91 % reported that schools were well located, 82 % with adequate safety tools). In contrast, satisfaction with bathroom facilities and laboratories was lower (about 60 %). Within family engagement, parental support and provision of school supplies were highly endorsed (74 %), whereas active school–home collaboration showed neutral trends. Community involvement and counseling services domains received moderate endorsement, with roughly 55–60 % agreement (Supplementary Table S1).

Among school staff (n = 32), the majority were student counselors or administrative staff; 56 % worked in non-HPS. Staff also reported higher satisfaction with physical environment (up to 88 %) but less with bathrooms and laboratories (∼20 % disagreement). Parental involvement beyond basic communication was limited. Community involvement appeared moderate overall, while perceptions of counseling services were largely positive (>75 % agreement) (Supplementary Table S2).

Comparative analysis showed that students in HPS had significantly higher median academic achievement scores (687 vs. 665; p = 0.009) and WSCC implementation scores (33 vs. 29; p < 0.001) than those in non-HPS. The proportion rating WSCC implementation as “good” was markedly higher in HPS (83.2 % vs. 50.8 %; p < 0.001), with female schools reporting slightly higher median implementation levels (31 vs. 29, p = 0.022). BMI did not differ significantly between groups (p = 0.430), but normal-weight status was more common in HPS (68.1 % vs. 47 %; p < 0.001), with notable rates of overweight and obesity in non-HPS (28.6 % vs. 10.9 %). Staff-reported scores followed a similar pattern, with significantly higher median scores among staff in HPS (36.5 vs. 26.5, p = 0.001). However, no significant differences were observed in WSCC implementation scores across staff job titles. (Table 2).

Table 2.

Association of school type with BMI, academic achievement, and WSCC implementation scores among 5th–6th grade students and staff in Makkah, Saudi Arabia, 2022 (N = 385 students, 32 staff).

Variable		Type of school		p-value
		Health promoting school (n = 119)	Non-health promoting school (n = 266)
BMI (kg/m2)		21.4 [18.2–26.5]	21.6 [18.7–24.1]	0.430
Underweight (<18.5)		25 (21.0)	65 (24.4)	<0.001
Normal weight (18.5–24.9)		81 (68.1)	125 (47.0)
Overweight (25–29.9)		11 (9.2)	58 (21.8)
Obese (≥30)		2 (1.7)	18 (6.8)
Academic achievement (out of 700)		687 [681.5–691]	665 [596–698]	0.009
WSCC implementation score for students (out of 38)		33 [29–37]	29 [23–35]	<0.001
Good implementation		99 (83.2)	135 (50.8)	<0.001
Fair/Poor implementation		20 (16.8)	131 (492)
Sex	Male	29 [24–33]		0.022
	Female	31 [26–36]
WSCC implementation score for staff (out of 38)		36.5 [26.7–38]	26.5 [20.7–31.2]	0.001
Job title of advisors	Health advisor	28 [20.7–35]		0.645
	Student advisor	36 [26.5–37]
	Administrative staff	29 [22.5–38]
	Teacher	27 [24–33]

Values present as Median [IQR] were analyzed by Mann-Whitney or Kruskal-Wallis tests.

Values present as numbers (percentages) were analyzed by Chi-square or Fisher exact tests.

Students perceiving good WSCC implementation also achieved higher median academic scores (681 vs. 642; p = 0.033), though BMI did not differ significantly by perception level (p = 0.235). (Fig. 2).

Fig. 2.

Association between WSCC implementation score and BMI and academic achievement among 5th–6th grade students in Makkah, Saudi Arabia, 2022. p-values were calculated using the Mann–Whitney U test to compare median BMI and academic achievement scores between groups reporting good versus fair/poor WSCC implementation.

WSCC implementation correlated moderately with academic achievement (ρ = 0.54; p < 0.001) but not with BMI (ρ = 0.09; p = 0.084). All WSCC domains, except family engagement, were positively correlated with academic achievement, most strongly counseling services (ρ = 0.29; p < 0.001), followed by physical environment (ρ = 0.26, p < 0.001) and community involvement (ρ = 0.23, p < 0.001). Analysis across BMI categories indicated that physical environment, family engagement, and community involvement scores decreased significantly with increasing BMI (all p < 0.05) (Supplementary Table S3).

In multivariable linear regression analyses, WSCC implementation remained a significant independent predictor of academic achievement (B = 1.63; 95 % CI: 0.90,2.35) after adjusting for BMI, school type, sex, and parental education. In contrast, the association between WSCC implementation and BMI was not significant (B = 0.36; 95 % CI: −0.32, 1.04). (Table 3).

Table 3.

Multivariable linear regression predicting academic achievement and BMI among 5th–6th grade students in Makkah, Saudi Arabia, 2022.

Dependent variable	Predictor variable	B (95 % CI)	β
Academic achievement	WSCC score	1.63 (0.90,2.35)	0.24
BMI	WSCC score	0.36 (−0.32,1.04)	0.05

B: Unstandardized coefficients, β: Standardized coefficients, CI: Confidence interval, WSCC: Whole school, whole community, whole child model, BMI: Body mass index.

All models were adjusted for school type (health-promoting vs. non-health-promoting), sex, and parental education. The academic achievement model also included BMI as a covariate because nutritional status may influence academic performance, allowing for a clearer estimation of the independent effect of WSCC implementation.

4. Discussion

This study offers a novel contribution to school health research in Saudi Arabia by empirically examining implementation of WSCC model in public elementary schools in Makkah. Findings suggest a modest but meaningful link between WSCC implementation and better outcomes, with significantly higher implementation scores and academic achievement in HPS compared to non-HPS, although BMI outcomes did not differ significantly between the two groups.

The coexistence of underweight and overweight/obesity among students reflects a dual burden of malnutrition that likely reflect broader socio-environmental influences which may not be fully addressed by WSCC implementation alone in the short term, and consistent with national trends. For instance, Al Shaikh et al. reported overweight and obesity rates of 14.4 % and 7.1 %, respectively, among Saudi schoolchildren, with prevalence increasing with age (p = 0.006) (Al Shaikh et al., 2020). A recent systematic review reported wide variation in obesity prevalence across regions, ranging from 3.8 % to 49.7 %, with the Makkah region reporting rates of 17.3 %–19.2 % (Adam et al., 2024). This suggests that while schools may provide supportive environments, broader socioeconomic and behavioral factors continue to influence children's weight status. These findings underscore the importance of context-specific, multi-level interventions that integrate WSCC implementation with family and community health promotion initiatives.

WSCC implementation was positively correlated with academic achievement, and the model remained a significant independent predictor of academic performance after adjusting for confounders. This supports the central WSCC premise that a supportive, health-oriented school climate enhances learning and student engagement (Centers for Disease Control and Prevention and ASCD, n.d.), potentially mitigating the effects of household or individual factors such as parental education. The stronger and more immediate responsiveness of academic outcomes, compared to BMI, may reflect the greater short-term influence of psychosocial and educational supports versus the slower-changing determinants of physical health.

They also align with international evidence. For instance, a WHO multi-country intervention demonstrated that comprehensive school-based health programs led to better student engagement, learning outcomes, and school connectedness (Langford et al., 2014). Similarly, a 2018 systematic review reported that school-based interventions with strong parental components had favorable effects on children's physical activity (81.1 %), sedentary behavior (75 %), and, to a lesser extent, BMI (61.1 %), although nutrition behavior outcomes were mixed (Verjans-Janssen et al., 2018).

Students and staff reported relative strengths in the school's physical environment, such as school location, ventilation, and lighting, but weaknesses were noted in bathrooms and laboratory facilities, echoing previous national studies that highlighted persistent infrastructure concerns (Bushara et al., 2017; Alzahrani, 2023).

Staff in HPSs reported significantly higher WSCC implementation scores, suggesting stronger institutional commitment to health promotion, though gaps remained in mental health services, community partnerships, and family engagement. No significant differences were found across job titles, pointing to the need for clearer role definition and interdepartmental collaboration. These observations underscore the persistent gap between the ideal vision of a HPS and the current state of implementation. For example, a study in Hong Kong identified 20 core indicators across key domains of the HPS framework, each significantly correlated with student health outcomes (Lee et al., 2019). Adopting similar performance-based approaches could help bridge existing implementation gaps in Saudi schools and advance WSCC objectives more systematically.

A national survey by Alzahrani (Alzahrani, 2022) indicated an expanding adoption of the HPS framework, particularly in primary schools with enhanced student health awareness and improvements in the physical environment, though limitations were noted in financial support, professional training, and the evaluation of core HPS components. A city-level study in Makkah by Bushara et al (Bushara et al., 2017). noted substantial activity in health education and environmental improvements, but also documented shortcomings in canteen services, healthcare provision, and community partnership development. Regional studies in Qassim and Aseer echoed these challenges, especially pointing to limited staff training, poor financial incentives, and weak policy support as barriers to full implementation (Almusnad and Aldaghaem, 2015; Alziyad, 2018).

The domain of family engagement showed relatively positive results in terms of parental provision of supplies and communication via notes. However, deeper engagement was less consistently reported. This aligns with findings from prior research, which emphasized a need for stronger parental roles in educational development (Chiang et al., 2015).

Both groups highlighted weak community involvement, limited parental participation in school activities, and a lack of structured mental health programs—findings consistent with prior Saudi studies that cite work conflicts, inadequate communication, desire to promote student independence, and limited training as barriers to engagement. Addressing these challenges requires institutional and policy-level solutions such as childcare services, flexible meeting times, expanded mental health staffing, and integration of school–community partnerships (Alzahrani, 2022; Alharbi, 2017).

Supporting this, a systematic review of school-based interventions with direct parental involvement found that such approaches can significantly improve children's BMI, physical activity, and sedentary behavior outcomes, particularly when interventions are implemented over a longer duration and address both the school and family environments (Verjans-Janssen et al., 2018).

The national Jeeluna study provides further context, showing that one in four Saudi adolescents reported difficulties accessing health services, often due to limited provider engagement and weak communication. These systemic issues underscore the broader challenges in addressing adolescent mental health within schools and communities (AlBuhairan et al., 2015). Our findings thus reinforce the need for comprehensive, equitable, and well-resourced implementation of WSCC domains—particularly in mental health, family engagement, and community integration.

The strongest domain-specific association was observed between counseling services and academic achievement, suggesting that psychosocial support plays a pivotal role in enhancing learning outcomes. Conversely, higher BMI was linked to lower scores in physical environment, family engagement, and community involvement, implying that overweight or obese students may be less engaged or have limited access to WSCC components. These patterns warrant further investigation in larger, longitudinal studies to clarify causal pathways and identify which domains exert the greatest impact on academic and health outcomes.

4.1. Limitations and strengths

This study provides valuable baseline evidence on WSCC implementation in Saudi elementary schools; however, several limitations should be considered. The student questionnaire's length and the use of web-based data collection may have introduced comprehension and selection biases. BMI and academic achievement were self-reported, which may have introduced recall and social desirability biases despite partial verification by school records. BMI was not treated as a direct confounder, as it theoretically represents a downstream outcome of WSCC implementation; however, sensitivity analysis showed that including BMI did not materially change the associations, supporting the robustness of findings. Exclusion of private and special needs schools may limit generalizability. Additionally, the study relied on perceived rather than objective indicators of WSCC implementation, and formal construct validation of the adapted tool was not conducted. Such perceptions may not fully reflect actual policy enactment or service availability and could be influenced by overall school climate or satisfaction with student outcomes. This halo effect may have led high-achieving schools to rate WSCC implementation more favorably. Future research should triangulate perception surveys with objective school-level data to provide a more comprehensive evaluation of WSCC implementation. Although the sample was sufficient for primary analyses, the design effect of cluster sampling was not accounted for, and the modest staff sample size may introduce selection bias and affect representativeness. Finally, as a cross-sectional design, causal inference cannot be established, and unmeasured confounding may persist. Despite these limitations, this study provides foundational evidence for WSCC implementation in Saudi schools and highlights critical methodological and contextual considerations to guide future research and evidence-based school health policies. Strengths include the inclusion of both student and staff perspectives, the use of validated and contextually adapted WSCC-based questionnaires, and the assessment of both health and educational outcomes, offering a multidimensional view of school health implementation.

5. Conclusions

This study provides empirical evidence that WSCC model implementation is significantly associated with higher academic achievement among elementary school students in Makkah. HPSs demonstrated higher WSCC implementation scores and better academic performance than non-HPSs. WSCC implementation remained an independent predictor of academic achievement even after adjusting for confounders, underscoring its potential to enhance learning outcomes beyond individual or household-level factors. Although no significant association was observed between WSCC implementation and BMI, or between BMI and academic achievement, the coexistence of underweight and overweight, especially in non-HPSs, signals a dual burden of malnutrition requiring targeted interventions.

Strengthening mental health support, enhancing family and community engagement, and ensuring equitable implementation across regions are essential to realizing the WSCC model's full potential in improving both academic and health outcomes. National adoption of WSCC principles should prioritize training for school health personnel, integration of counseling services, and stronger partnerships with families and communities, particularly in underserved areas. Future research should employ longitudinal and mixed-methods designs using objective indicators, evaluate cost-effectiveness and sustainability, and include all ten WSCC domains to capture a comprehensive picture of school health implementation in Saudi Arabia.

CRediT authorship contribution statement

Mohamed O. Nour: Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.

Funding

This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.

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.

Data availability

The datasets used and analyzed in this study are available from the corresponding author on reasonable request. Confidentiality and security of data and materials were ensured through all stages of the study.