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Wagenius, C. M., San Sebastian, M., Gustafsson, P. E. & Goicolea, I. (2019). Access for all?: Assessing vertical and horizontal inequities in healthcare utilization among young people in northern Sweden. Scandinavian Journal of Public Health, 47
Open this publication in new window or tab >>Access for all?: Assessing vertical and horizontal inequities in healthcare utilization among young people in northern Sweden
2019 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 47Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Previous studies in Sweden have detected socioeconomic inequities in access to healthcare services. However, there is limited information regarding access in younger populations. The aim of this study was to explore vertical and horizontal inequities in access to healthcare services in young adults in the north of Sweden.

METHODS: The study used data from the Health on Equal Terms survey (age group 16-24 years, n = 2726) for the health and healthcare variables and from national registers for the sociodemographic characteristics. Self-rated healthcare utilization was measured as visits to general practitioners, youth clinics and nurses. Crude and multivariable binomial regression analysis, stratified by sex, was used to assess vertical equity, adjusting for sociodemographic characteristics, and horizontal equity, adjusting for need variables.

RESULTS: Vertical inequity was detected for all three healthcare services (youth clinics, general practitioners and nurses), with variations for men and women. Horizontal inequities were also found for both men and women in relation to all three healthcare services.

CONCLUSIONS: These findings suggest that both vertical and horizontal inequities in access exist for young people in northern Sweden and that the associations between sociodemographic characteristics and healthcare utilization are complex and need further investigation.

Keywords
Inequity, Sweden, access to healthcare, youth
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-150573 (URN)10.1177/1403494818774965 (DOI)000458888900001 ()29779450 (PubMedID)
Available from: 2018-08-13 Created: 2018-08-13 Last updated: 2019-04-16Bibliographically approved
Mathias, K., Kermode, M., San Sebastian, M., Davar, B. & Goicolea, I. (2019). An asymmetric burden: experiences of men and women as caregivers of people with psycho-social disabilities in rural North India. Transcultural Psychiatry, 56(1), 76-102
Open this publication in new window or tab >>An asymmetric burden: experiences of men and women as caregivers of people with psycho-social disabilities in rural North India
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2019 (English)In: Transcultural Psychiatry, ISSN 1363-4615, E-ISSN 1461-7471, Vol. 56, no 1, p. 76-102Article in journal (Refereed) Published
Abstract [en]

Caring for a family member with a psycho-social disability can be both rewarding and burdensome. This study analyses the experiences of caregivers of people with psychosocial disabilities (PPSDs) in rural communities in North India using relational gender theory. In-depth interviews with 18 female and male caregivers of PPSDs probed the social, emotional and health impacts of their caregiving role. Nine themes were identified that were grouped under three meta-themes: intra-personal, inter-personal and institutional impacts. Under the intra-personal meta-theme, all caregivers experienced high tension, with women describing almost overwhelming stress. Women minimised their role as caregivers, and felt negative and hopeless about their futures, while men had a more positive view of the future and themselves. Embodied experiences of psychological and social distress were consistently described by women, but not by men. Within the interpersonal meta-theme, men experienced opportunity for social connection and social support that was seldom available to women. Interpersonal violence with other household members was described by both men and women. Within the institutional meta-theme, both men and women described strength in unity, and gestures leading to the reordering of gender relations. These findings underline the significant and diffuse impacts of a gender order that values males and disadvantages females as caregivers of PPSDs, with the asymmetry of a greater burden for women. The findings point to the urgent need for global mental health policies that support and empower caregivers and that strengthen gender equality.

Place, publisher, year, edition, pages
Sage Publications, 2019
Keywords
India, caregiver burden, gender, gender inequality, global mental health, psycho-social disability, qualitative
National Category
Public Health, Global Health, Social Medicine and Epidemiology Psychiatry
Identifiers
urn:nbn:se:umu:diva-154005 (URN)10.1177/1363461518792728 (DOI)000454141000004 ()30141376 (PubMedID)
Note

Article first published online: August 24, 2018

Available from: 2018-12-11 Created: 2018-12-11 Last updated: 2019-01-15Bibliographically approved
Maquibar, A., Estalella, I., Vives-Cases, C., Hurtig, A.-K. & Goicolea, I. (2019). Analysing training in gender-based violence for undergraduate nursing students in Spain: A mixed-methods study. Nurse Education Today, 77, 71-76
Open this publication in new window or tab >>Analysing training in gender-based violence for undergraduate nursing students in Spain: A mixed-methods study
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2019 (English)In: Nurse Education Today, ISSN 0260-6917, E-ISSN 1532-2793, Vol. 77, p. 71-76Article in journal (Refereed) Published
Abstract [en]

Background: Health-care professionals, and nurses especially among them, play an essential role in the health sector's response to gender-based violence. To be able to successfully address this major public health issue they need specific training in the topic.

Objective: To analyse training on gender-based violence that nursing students receive at universities in Spain.

Design: Mixed-methods approach.

Setting: Spain.

Methods: Systematic review of public documents followed by in-depth interviews with university lecturers.

Results: Eighty per cent (92/115) of nursing training programmes included content regarding gender-based violence. There was great variability in the topics included in the training. Health consequences due to gender based violence exposure and the role of the health sector in addressing these health consequences were the most frequently included topics. Ethical issues and legislation were the least frequent ones, as these were only dealt with in one and 18 training programmes, respectively. In the qualitative analysis of the interviews, two categories were identified: 'Supportive legislation and supportive lecturers are essential for integrating gender-based violence training' and 'Approach to gender-based violence shapes the contents and the subject in which it is incorporated'. The first category refers to the main drivers for training integration, while the second category refers to how lecturers' perceptions influenced the way in which training was implemented.

Conclusions: As many as 80% of the nursing education programmes included specific training in gender-based violence, although with great variability in the contents among the universities. For this study's participants, enacted legislation, and lecturers interested in the topic and in decision-making positions were key drivers for this extensive implementation. The variability observed across universities might be explained by lecturers' different approaches to gender-based violence and the nursing profession.

Place, publisher, year, edition, pages
Elsevier, 2019
Keywords
Intimate partner violence, Nursing students, Curricula, Mixed methods
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-159588 (URN)10.1016/j.nedt.2019.01.017 (DOI)000467510200012 ()30999062 (PubMedID)
Available from: 2019-06-18 Created: 2019-06-18 Last updated: 2019-06-18Bibliographically approved
San Sebastian, M., Vives-Cases, C. & Goicolea, I. (2019). "Closer to the Unfair Reality": Magnitude and Spatial Analysis of Femicides in Ecuador. Journal of Interpersonal Violence, Article ID UNSP 0886260519863721.
Open this publication in new window or tab >>"Closer to the Unfair Reality": Magnitude and Spatial Analysis of Femicides in Ecuador
2019 (English)In: Journal of Interpersonal Violence, ISSN 0886-2605, E-ISSN 1552-6518, article id UNSP 0886260519863721Article in journal (Refereed) Epub ahead of print
Abstract [en]

During the last 5 years, Ecuador has published a series of progressive laws aiming to protect girls and women against any type of violence. While these efforts are of extreme importance, concerns were raised by national nongovernmental organizations that the official numbers might be biased due to the restricted definition of femicide applied. The main objective of this study was to assess the magnitude and spatial distribution of the femicide rate by province in Ecuador in 2017. Data on cases were collected by a national network of nongovernmental organizations. Age-specific population data were obtained from the National Institute of Statistics for the year 2017. Thematic maps of overall and age-specific femicide rates were also constructed. Moran's index was used to identify clusters of provinces with similar risks for the occurrence of the outcome. The total number of femicides during 2017 was 155, but age could not be recorded in 9 of those cases. More than one-third of the cases (36.99%) occurred in young women aged 15 to 24 years. The total rate was 1.99/100,000 women. When the femicide definition was restricted to women 15 years and above, the total rate increased to 2.41 cases/100,000. The femicide rate in Orellana boosted to 10.21 cases/100,000 in the age group of 15 years and older, the highest in the country. No pattern of spatial autocorrelation was observed. Femicides in Ecuador is a big public health problem, particularly in certain Amazon provinces. The observed rate for women above the age of 15 years (2.41) places Ecuador among the countries in the Latin American and the Caribbean region with the highest femicide rates. While progressive policies have been implemented in the last years, more educational interventions are needed at all societal levels to eradicate this kind of violence.

Place, publisher, year, edition, pages
SAGE PUBLICATIONS INC, 2019
Keywords
femicide, domestic violence, violence exposure, Ecuador
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-162331 (URN)10.1177/0886260519863721 (DOI)000478286300001 ()31313622 (PubMedID)
Available from: 2019-08-16 Created: 2019-08-16 Last updated: 2019-08-16
Sirili, N., Frumence, G., Kiwara, A., Mwangu, M., Goicolea, I. & Hurtig, A.-K. (2019). "Doctors ready to be posted are jobless on the street…" the deployment process and shortage of doctors in Tanzania.. Human Resources for Health, 17(1), Article ID 11.
Open this publication in new window or tab >>"Doctors ready to be posted are jobless on the street…" the deployment process and shortage of doctors in Tanzania.
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2019 (English)In: Human Resources for Health, ISSN 1478-4491, E-ISSN 1478-4491, Vol. 17, no 1, article id 11Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The World Health Organization advocates that health workforce development is a continuum of three stages of entry, available workforce and exit. However, many studies have focused on addressing the shortage of numbers and the retention of doctors in rural and remote areas. The latter has left the contribution of the entry stage in particularly the deployment process on the shortage of health workforce less understood. This study therefore explored the experiences of medical doctors (MDs) on the deployment process after the internship period in Tanzania's health sector.

METHODS: A qualitative case study that adopted chain referral sampling was used to conduct 20 key informant interviews with MDs who graduated between 2003 and 2009 from two Medical Universities in Tanzania between February and April 2016. These MDs were working in hospitals at different levels and Medical Universities in eight regions and five geo-political zones in the country. Information gathered was analysed using a qualitative content analysis approach.

RESULTS: Experiences on the deployment process fall into three categories. First, "uncertainties around the first appointment" attributed to lack of effective strategies for identification of the pool of available MDs, indecision and limited vacancies for employment in the public sector and private sector and non-transparent and lengthy bureaucratic procedures in offering government employment. Second, "failure to respect individuals' preferences of work location" which were based on the influence of family ties, fear of the unknown rural environment among urbanized MDs and concern for career prospects. Third, "feelings of insecurity about being placed at a regional and district level" partly due to local government authorities being unprepared to receive and accommodate MDs and territorial protectionism among assistant medical officers.

CONCLUSIONS: Experiences of MDs on the deployment process in Tanzania reveal many challenges that need to be addressed for the deployment to contribute better in availability of equitably distributed health workforce in the country. Short-term, mid-term and long-term strategies are needed to address these challenges. These strategies should focus on linking of the internship with the first appointment, work place preferences, defining and supporting career paths to health workers working under the local government authorities, improving the working relationships and team building at the work places and fostering rural attachment to medical students during medical training.

Keywords
Africa, Deployment, Employment of doctors, Health sector, Health workforce, Internship, Physicians, Rural areas, Shortage of doctors, Tanzania
National Category
Public Health, Global Health, Social Medicine and Epidemiology Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-158185 (URN)10.1186/s12960-019-0346-8 (DOI)000457484100001 ()30709401 (PubMedID)2-s2.0-85060945358 (Scopus ID)
Available from: 2019-04-16 Created: 2019-04-16 Last updated: 2019-04-16Bibliographically approved
Linander, I., Alm, E., Goicolea, I. & Harryson, L. (2019). 'It was like I had to fit into a category': care-seekers' experiences of gender regulation in the Swedish trans-specific healthcare. Health, 23(1), 21-38
Open this publication in new window or tab >>'It was like I had to fit into a category': care-seekers' experiences of gender regulation in the Swedish trans-specific healthcare
2019 (English)In: Health, ISSN 1363-4593, E-ISSN 1461-7196, Vol. 23, no 1, p. 21-38Article in journal (Refereed) Published
Abstract [en]

The few previous studies investigating regulation of gender in trans-specific healthcare are mainly based on text material and interviews with care-providers or consist solely of theoretical analyses. There is a lack of studies analysing how the regulation of gender is expressed in the care-seeker's own experiences, especially in a Nordic context. The aim of this study is to analyse narratives of individuals with trans experiences (sometimes called transgender people) to examine how gender performances can be regulated in trans-specific care in Sweden. The conceptual framework is inspired by trans studies, a Foucauldian analysis of power, queer phenomenology and the concept of cisnormativity. Fourteen interviews with people with trans experiences are analysed with constructivist grounded theory. The participants' experiences indicate that gender is constructed as norm-conforming, binary and stable in trans-specific healthcare. This gendered position is resisted, negotiated and embraced by the care-seekers. Norms and discourses both inside and outside trans-specific care contribute to the regulation and limit the room for action for care-users. We conclude that a trans-specific care that has a confirming approach to its care-users, instead of the current focus on gender norm conformity, has the potential to increase the self-determination of gender performance and increase the quality of care.

Place, publisher, year, edition, pages
Sage Publications, 2019
Keywords
gender and health, grounded theory, patient–physician relationships, phenomenological approaches, post-structuralism/postmodernism
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-141444 (URN)10.1177/1363459317708824 (DOI)000454118500002 ()28523938 (PubMedID)
Note

Article first published online: May 19, 2017

Available from: 2017-11-03 Created: 2017-11-03 Last updated: 2019-01-18Bibliographically approved
Eid, D., San Sebastian, M., Hurtig, A.-K. & Goicolea, I. (2019). Leishmaniasis patients' pilgrimage to access health care in rural Bolivia: a qualitative study using human rights to health approach. BMC International Health and Human Rights, 19(1), Article ID 12.
Open this publication in new window or tab >>Leishmaniasis patients' pilgrimage to access health care in rural Bolivia: a qualitative study using human rights to health approach
2019 (English)In: BMC International Health and Human Rights, ISSN 1472-698X, E-ISSN 1472-698X, Vol. 19, no 1, article id 12Article in journal (Refereed) Published
Abstract [en]

Background: Leishmaniasis is a neglected tropical disease endemic in Bolivia that disproportionately affects people with little social and political capital. Although the treatment is provided free of charge by the Bolivian government, there is an under-utilization of treatments in relation to the estimated affected population. This study explores the experiences of patients with leishmaniasis and the challenges faced when searching for diagnosis and treatment in Bolivia using a human rights approach.

Methods: We conducted open-ended interviews with 14 participants diagnosed with leishmaniasis. The qualitative data were analysed using thematic analysis and were interpreted under a human rights approach to health care.

Results: Four themes emerged during data analysis: (1) the decision for seeking a cure takes time; (2) the severity of symptoms and disruption of functioning drives the search for Western medicine; (3) the therapeutic journey between Western and traditional medicine; and (4) accessibility barriers to receive adequate medical treatment. This study showed that access to health care limitations were the most important factors that prevented patients from receiving timely diagnosis and treatment. Cultural factors played a secondary role in their decision to seek medical care.

Conclusions: Accessibility barriers resulted in a large pilgrimage between public health care and traditional medicinal treatments for patients with leishmaniasis. This pilgrimage and the related costs are important factors that determine the decision to seek health care. This study contributes to the understanding of the under-utilisation problems of medical services in leishmaniasis and other similar diseases in remote and poor populations.

Place, publisher, year, edition, pages
BioMed Central, 2019
Keywords
Cutaneous leishmaniasis, human rights, health care, seeking behavior, Bolivia
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-156786 (URN)10.1186/s12914-019-0196-4 (DOI)000460652900002 ()30837001 (PubMedID)
Funder
Sida - Swedish International Development Cooperation Agency, 75000554
Available from: 2019-02-28 Created: 2019-02-28 Last updated: 2019-04-08Bibliographically approved
Hernandez, A., Lorena Ruano, A., Hurtig, A.-K., Goicolea, I., San Sebastian, M. & Flores, W. (2019). Pathways to accountability in rural Guatemala: a qualitative comparative analysis of citizen-led initiatives for the right to health of indigenous populations. World Development, 113, 392-401
Open this publication in new window or tab >>Pathways to accountability in rural Guatemala: a qualitative comparative analysis of citizen-led initiatives for the right to health of indigenous populations
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2019 (English)In: World Development, ISSN 0305-750X, E-ISSN 1873-5991, Vol. 113, p. 392-401Article in journal (Refereed) Published
Abstract [en]

Strengthening citizen-led accountability initiatives is a critical rights-based strategy for improving health services for indigenous and other marginalized populations. As these initiatives have gained prominence in health and other sectors, there is great interest in how they operate and what makes them effective. Scholarly focus is shifting from measuring the efficacy of their tools and tactics to deepening understanding of the context-sensitive pathways through which change occurs. This paper examines how citizen-led initiatives' actions to strengthen grassroots networks, monitor health services and engage with authorities interact with local sociopolitical conditions and contribute to accountability achievements for indigenous populations in rural Guatemala. We used qualitative comparative analysis to first systematize and score structured qualitative monitoring data gathered in 29 municipal-level initiatives, and then analyze patterns in the presence of different forms of citizen action, contextual conditions and accountability outcomes across cases. Our study identifies pathways of collective action through which citizen-led initiatives bolster their power to engage and negotiate with authorities and bring about solutions to some of the health system deficiencies that they face. While constructive engagement is widely advocated as the most effective approach to interaction with authorities, our study indicates that success depends on wider processes of community mobilization. To overcome the power asymmetries that marginalized groups face when engaging with authorities, iterative processes of network building and participatory monitoring as well as persistence in their demands are critical. These processes further provide an enabling environment for moving beyond the local and projecting indigenous voices to engage with authorities at higher governance levels. Initiatives also applied adversarial legal action as an alternative engagement strategy that contributed to bolster citizen power. Our findings indicate the potential of collective power generated by the actions of citizen-led initiatives to enable marginalized populations to hold authorities accountable for health system failures. 

Place, publisher, year, edition, pages
Elsevier, 2019
Keywords
Accountability, Health system, Indigenous peoples, Qualitative comparative analysis, Guatemala
National Category
Social Sciences Interdisciplinary
Identifiers
urn:nbn:se:umu:diva-153629 (URN)10.1016/j.worlddev.2018.09.020 (DOI)000449310800029 ()
Funder
Swedish Research Council, 2015-05898
Available from: 2018-11-27 Created: 2018-11-27 Last updated: 2018-11-27Bibliographically approved
Sirili, N., Frumence, G., Kiwara, A., Mwangu, M., Goicolea, I. & Hurtig, A.-K. (2019). Public private partnership in training of doctors after the 1990s' health sector reforms: the case of Tanzania. Human Resources for Health, 17, Article ID 33.
Open this publication in new window or tab >>Public private partnership in training of doctors after the 1990s' health sector reforms: the case of Tanzania
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2019 (English)In: Human Resources for Health, ISSN 1478-4491, E-ISSN 1478-4491, Vol. 17, article id 33Article in journal (Refereed) Published
Abstract [en]

Similar to many other low- and middle-income countries, public private partnership (PPP) in the training of the health workforce has been emphasized since the launch of the 1990s’ health sector reforms in Tanzania. PPP in training aims to contribute to addressing the critical shortage of health workforce in these countries. This study aimed to analyse the policy process and experienced outcomes of PPP for the training of doctors in Tanzania two decades after the 1990s’ health sector reforms. We reviewed documents and interviewed key informants to collect data from training institutions and umbrella organizations that train and employ doctors in both the public and private sectors. We adopted a hybrid thematic approach to analyse the data while guided by the policy analysis framework by Gagnon and Labonté. PPP in training has contributed significantly to the increasing number of graduating doctors in Tanzania. In tandem, undermining of universities’ autonomy and the massive enrolment of medical students unfavourably affect the quality of graduating doctors. Although PPP has proven successful in increasing the number of doctors graduating, unemployment of the graduates and lack of database to inform the training needs and capacity to absorb the graduates have left the country with a health workforce shortage and maldistribution at service delivery points, just as before the introduction of the PPP. This study recommends that Tanzania revisit its PPP approach to ensure the health workforce crisis is addressed in its totality. A comprehensive plan is needed to address issues of training within the framework of PPP by engaging all stakeholders in training and deployment starting from the planning of the number of medical students, and when and how they will be trained while taking into account the quality of the training.

Place, publisher, year, edition, pages
BioMed Central, 2019
Keywords
: Health sector reforms, Training of doctors, Policy analysis, Public private partnership, Tanzania, Health workforce shortage
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-150635 (URN)10.1186/s12960-019-0372-6 (DOI)000468753800002 ()31118038 (PubMedID)
Note

Originally included in thesis in manuscript form.

Available from: 2018-08-15 Created: 2018-08-15 Last updated: 2019-06-11Bibliographically approved
Jonsson, F., Goicolea, I. & San Sebastian, M. (2019). Rural-urban differences in health among youth in northern Sweden: an outcome-wide epidemiological approach. International Journal of Circumpolar Health, 78, Article ID 1640015.
Open this publication in new window or tab >>Rural-urban differences in health among youth in northern Sweden: an outcome-wide epidemiological approach
2019 (English)In: International Journal of Circumpolar Health, ISSN 1239-9736, E-ISSN 2242-3982, Vol. 78, article id 1640015Article in journal (Refereed) Epub ahead of print
Abstract [en]

The aim of this research was to contribute knowledge about rural-urban differences in health among young northern Swedish women and men. This study was based on the 2014 "Health on Equal Terms" survey, distributed in the four northernmost counties of Sweden, with complementary information on areas of residence classified as rural, semi-urban and urban from total population registers. The analytical sample included 2,691 individuals who were selected using a probabilistic sampling method. Prevalence ratios were calculated in multivariable log-binomial regression analyses to measure the association between place of residence and nine outcomes covering three health dimensions (general, mental and lifestyle behaviours). The results indicated that daily smoking and being overweight were more common, while feelings of stress and psychological distress were less prevalent, among youths in rural as compared to urban areas. After including covariates, this pattern appeared stronger for young women, although the direction of the results also applied to young men, albeit without revealing significant differences. In conclusion, the findings from this study indicate that for youths - particularly young women - the rural setting may imply an increased risk of poor general health and lifestyle behaviours, while simultaneously playing a partially protective role for mental health.

Place, publisher, year, edition, pages
Taylor & Francis, 2019
Keywords
Northern Sweden, general health, lifestyle behaviours, mental health, rural–urban differences, youth
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-161563 (URN)10.1080/22423982.2019.1640015 (DOI)31282296 (PubMedID)
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare
Available from: 2019-07-11 Created: 2019-07-11 Last updated: 2019-07-12
Projects
How, why and under what circumstances are Swedish Youth Clinics youth friendly? A realist evaluation [2014-00235_Forte]; Umeå University Health care access for rural youth on equal terms? Identifying needs and proposing actions using mixed-methods research [2016-00434_Forte]; Umeå University Stärka ungdomars motståndskraft (resilience) och mentala hälsa i norra Indien [2017-05421_VR]; Umeå UniversityHow can mental health care services be integrated in youth clinics? A health policy and systems study [2018-00364_Forte]; Umeå University
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-8114-4705

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