Introduction

South Korea is projected to become a super-aged society by the year 2025, with projections indicating a sustained escalation in expenditures for long-term care, increasing to 4.2% of the Gross Domestic Product by the year 2050.1 The social cost of healthcare for older adults is a global health concern. Community-based care of older adults can be more cost effective than institutional care, as it allows them to receive care and support in their own homes or within their communities. Many older adults prefer to age in place and maintain their independence and connection to their communities. Community-based care allows them to receive the necessary support while remaining in familiar surroundings, promoting their overall well-being and quality of life.

This global shift toward community-based care and aging in place has prompted various healthcare system responses worldwide. In the United States, the transition from institution-centered to community-based care models has been driven by demographic changes and accelerated by the COVID-19 pandemic.2 The US experience highlights common challenges in implementing home care systems, including data fragmentation, workforce shortages, and regional resource disparities - challenges that resonate across different healthcare systems globally.

Similarly, countries like England, Australia, and Japan have implemented diverse models of home care services, offering valuable insights into how integrated and multidisciplinary approaches can enhance efficiency and accessibility. For instance, England has adopted a fully integrated system where nursing and social services are unified to optimize resources and ensure continuity of care.3 In Australia, the Aged Care Assessment Team (ACAT) employs a multidisciplinary framework to evaluate older adults’ needs and coordinate services, ensuring holistic and personalized care.4 Japan’s preventive care system, operating alongside long-term care insurance, highlights the importance of early interventions to delay frailty progression and maintain functional independence.5,6 These global practices underscore the necessity of bridging gaps between preventive and long-term care services, a challenge that South Korea also faces due to the current structural separation of these domains.

Embedded within South Korea’s broader healthcare strategy, the organizational structure of the public health center’s home care services in South Korea embodies a meticulously planned framework aimed at ensuring the delivery of comprehensive and accessible healthcare services directly to the homes of individuals. This initiative is especially crucial for those who find themselves unable to visit traditional healthcare facilities due to various barriers, including physical disabilities, chronic illnesses, or economic constraints. This project represents a significant governmental commitment to uphold the principle of universal healthcare access, ensuring that every citizen, irrespective of their social or economic status, can avail quality healthcare services.7

The World Health Organization (WHO) has introduced “The decade of healthy aging” as a slogan to address global aging challenges. This initiative emphasizes the concept of providing integrated management services for older adults focusing on enhancing their quality of life.8 Recognizing the importance of community-based care, the South Korean government has implemented policies to promote and support its development. These policies aim to enhance the accessibility and quality of community-based care services for the older adult population. The Seoul Metropolitan Government initiated the Outreach Community Center project in 2015, starting in 80 Dongs (a sub-municipal level administrative unit) across 13 autonomous districts.9 This project is currently being implemented in all districts across Seoul. This initiative reoriented the focus of community centers from handling civil complaints and general administration to prioritizing the welfare and health of citizens and fostering local community development. Since 2019, the project has expanded to all 25 autonomous districts and 426 Dongs. This shift represents a significant departure from traditional health and welfare services, which were primarily provided to those who applied for such services. It represents an innovative approach to identifying local issues and realizing resident-centered public services with the direct participation of the residents. Additionally, this project moves away from the conventional top-down service delivery model that views individuals as “beneficiaries”. Instead, it facilitates a resident-led ecosystem, supporting small resident groups and energizing self-help care groups, thereby enhancing resident participation and autonomy.10

With a growing number of seniors, there is a heightened need for effective home care services that can support their health and well-being in a familiar environment.11,12 Indeed, the healthcare system must adapt to meet new challenges posed by the changing demographic profile. In-depth research on these challenges can provide insights for integrating home care services into the existing healthcare infrastructure. This can help guide both policymakers and healthcare providers toward efficient allocation of resources. Moreover, evidence-based policies and practices can help establish a more robust, effective, and responsive healthcare system that caters to the evolving needs of the aging population. This approach can not only enhance the quality of care provided but also ensure that it aligns with best practices and the latest advancements in the field. However, in South Korea, no strategic analysis of the public health centers’ preventive home visit programs has been conducted in the past five years, despite their critical role in community health management. This lack of recent evaluation underscores the need for updated frameworks that align with the evolving demographic and healthcare landscape.13

This research aimed to identify the role of home care services within the public sector in South Korea and to develop a plan for restructuring these services in light of changing internal and external environments. The study was conducted in two main stages: (1) An analysis of the external and internal environments pertinent to the public sector’s home care services, leading to a comprehensive Strengths, Weaknesses, Opportunities, Threats (SWOT) analysis. (2) Using the insights gained from this analysis, the study then articulated key proposals for reforming the public sector’s home care services, offering diverse approaches to enhance and revitalize these services.

Materials and Methods Study Design

This study is a narrative review focusing on the current state and future challenges of Seoul’s policies regarding senior citizen healthcare and home care services. The research aimed to provide a comprehensive assessment of the existing strategies and identify key areas for development and improvement in these sectors.

Analytical Framework

South Korea’s home care services, directed by the Ministry of Health and Welfare (MOHW), operates through a systematically structured delivery system (Figure 1).14 At the national level, MOHW establishes policies and provides oversight, while Local Government Health Authorities adapt these guidelines to regional contexts. Public Health Centers serve as intermediate managers, coordinating between policy makers and service providers. The core service delivery is conducted by Home Care Service Teams, which consist primarily of visiting nurses. These teams operate through a collaborative network: they receive administrative support from Community Centers, work alongside other community health workers for comprehensive care delivery, and directly manage deployed visiting nurses.

Figure 1 Organizational structure of home care services in public health centers, Seoul, South Korea.

To systematically evaluate this complex healthcare delivery system and propose future directions, we employed SWOT analysis as our primary analytical framework. A SWOT analysis is a tool to help organizations identify problems and formulate basic strategies. Although the historical origins of the SWOT analysis are unclear, it was described by Learned15 and has been widely used for over 50 years in various fields, including healthcare, marketing, industry analysis, and policy formulation. SWOT is also used as an academic research tool.16 SWOT analysis enables the examination of the gaps and fit between the environment surrounding an organization and the organization’s policies and strategies as well as its capabilities and resources.17 On its own, a SWOT analysis is simply a list of problems but it can be a useful tool for systematic strategy formulation if it is followed by a plan for future actions.

The literature review was conducted between January 2023 and December 2023, with inclusion criteria encompassing documents related to Seoul Metropolitan Government’s home care services, official policies, program evaluations, and relevant academic literature in both Korean and English. Documents with unclear sources or unidentified authors were excluded, and only official documents and peer-reviewed literature were included in the analysis. Our comprehensive review included government documents (statutes, regulations, and official reports), academic sources (peer-reviewed journals and professional publications), gray literature (policy reports and program evaluations), and internal documents from the Expert Group on Health Promotion for Seoul Metropolitan Government.

The SWOT analysis was conducted through a systematic three-phase process (Figure 2), following the Organizational Diagnosis Manual for Scientific Organization Management.18 First, we analyzed the internal environment by examining organizational documents, operational data, and conducting interviews with field personnel. Second, we reviewed policy documents, demographic trends, and healthcare statistics for external environment analysis. Finally, we developed a SWOT matrix by cross-linking strengths, weaknesses, opportunities, and threats to derive strategic alternatives. The assessment was conducted by a research team that included one professor from the School of Preventive Medicine, three professors from the School of Nursing, and one doctor of nursing. It was also validated twice by an advisory group of 10 people that included the director of the health center, field personnel, and professors of medicine and nursing.

Figure 2 Framework for strategic analysis in home care services.

Results

SWOT analysis examined the internal and external environments pertaining to home care services in Seoul, South Korea, which is comprehensively summarized in Table 1.

Table 1 SWOT Analysis and Future Policy Strategy for Home Care Service in Seoul, South Korea

External Environment Analysis (1) Shift in the Policy Direction of Health and Welfare

Since 2018, the Government of South Korea has endeavored to improve the fragmented local community senior healthcare by announcing the implementation plan for “Community-Based Integrated Care”. This refers to a local government-led social service policy that ensures integrated support in housing, healthcare, nursing, care, and independent living, allowing residents to enjoy services tailored to their individual needs in their own homes or group homes.19 Furthermore, the government has strengthened its integrated and connected policies for medical and care services targeting older adults in the community, with the launch of initiative such as the medical care integration pilot project, home-based long-term care medical pilot project, and primary care chronic disease pilot project being launched.20,21

The widespread use of smartphones and devices has enabled the delivery of information and communication technology (ICT)-enabled services for older adults. During the COVID-19 pandemic in 2020, face-to-face home care services were largely suspended except for unavoidable cases, raising significant concerns about healthcare accessibility for vulnerable populations. In response to these challenges, the Ministry of Health and Welfare in Korea strategically expanded ICT-based home care services, implementing the “Artificial Intelligence-Internet of Things (AI-IoT) Older adults healthcare service” as a remote health management tool. This digital transformation of home care services was particularly crucial for vulnerable populations who faced heightened barriers to healthcare access during the pandemic. The initiative entails real-time monitoring of health status of older adults through the use of wearable devices to monitor blood pressure, blood sugar, and physical activity, ensuring continuity of care despite physical distancing requirements.22

Particularly in Seoul, unlike other regions, the role of community centers, which were primarily administrative and complaint-focused, has been strengthened to identify vulnerable groups and provide welfare services. Initially, universal services were provided with the goal of assessing the health status of those reaching the age of 65 years.23 However, from 2023, due to the limitations of manpower and resources, the priority for relatively self-capable individuals and older adults aged 65–74 years was lowered, focusing more on identifying and aiding middle to late-stage older adults’ crisis households and vulnerable groups.7

(2) Running a Backlog-Style Health Business

To prepare for an ultra-aging society, the government and local governments are implementing various programs to identify vulnerable people and manage their health. However, due to the overlapping tasks between each program, there is a need for careful role design. In addition, nurses in home care services are required to perform various tasks, such as managing vulnerable people, managing cancer patients at home, managing patients during heat waves and cold waves, and investigating infectious diseases.7 Therefore, it is necessary to narrow down their role to a clearly defined set of core services. In addition, it is imperative to optimize their workload through a quantitative analysis of business content and workload.

(3) Significant Changes in Population Structure

According to the National Statistical Office, as of 2022, the older adult population in Seoul was approximately 1.6 million, accounting for 16.5% of the total population, making it an aging society (more than 14%).24 Care of older adults requires the integrated provision of various medical, health, and welfare services. However, a rapid increase in the number of older adults is liable to constrain the service delivery.

(4) Changes in Health Status of Older Adults

According to the 2020 Seoul City Survey on the older adults, the average Tilburg Frailty Index score in Seoul was 4.1 out of 15, with 57% of older adults in the healthy group (0 to 4 points) and 43% in the frail group (5 to 15 points).25 This represented an 8.4% increase in the frail group compared to 2018. Individuals with lower levels of education, those living alone, and those with lower average monthly income were more likely to be in the frail group. In South Korea’s healthcare system, older adults with worsening frailty are registered in the long-term care system to receive care services. The annual number of people receiving care under the long-term care system continues to grow, from 920,000 in 2019 to 1.17 million in the first quarter of 2023 alone.26

Internal Environment Analysis (1) Strategy

The public health center’s home care service aims to increase accessibility to healthcare and welfare services for vulnerable older adults. Recently, there has been a focus on improving the self-management abilities of older adults using ICT. Those who do not necessarily need a home visit can be managed through app-based remote monitoring of indices such as blood pressure, blood sugar, walking practice, and medication compliance. Self-recording of these indices helped improve the efficiency of visiting services. A recent study of the AI-IoT senior healthcare projects revealed the effectiveness of healthy lifestyle habits and frailty prevention in older adults. Therefore, the provision of an appropriate mix of remote and face-to-face group intervention could be an effective strategy.22

(2) Personnel and Organization Efficiency of Organizational Structure

Despite the program’s ambitious scope, operational constraints, particularly in Seoul, have led multidisciplinary teams at public health centers to be predominantly staffed with nurses.27,28 This situation stems from a combination of factors, including the gradual scaling of the program from around 300 temporary workers in 2015 to approximately 750 visiting nurses by December 2023 who have been deployed across Dong Community Centers within Seoul.28 These nurses are tasked with providing community-based healthcare through a system that assigns around 1.8 nurses per community center, focusing on roughly 20–30 individuals per autonomous district public health center.28

Initially, these visiting nurses were integrated into neighborhood community centers in 2015 to enhance their connection with the community centers’ welfare services, marking a significant step toward delivering integrated healthcare services.10,13 Despite these efforts, challenges with regard to structure had emerged considering that each Dong office is typically staffed with 1–2 nurses without a dedicated manager to oversee health services. This lack of supervision complicates the management of patients with complex needs given that the distance from the central public health center makes coordinated team-based care difficult to achieve. Consequently, nurses often face challenges in providing comprehensive care by themselves, highlighting the need for a strategic structural overhaul to strengthen the system’s capacity for delivering holistic care.

Coordination of Functions Across Departments

There are various projects related to older adults in Seoul. The “Care SOS” project identifies vulnerable households in crisis at community centers and provides services, such as lunch box delivery, mobile services, and healthcare screening.29 The “Primary Medical Chronic Disease Project” provides health consultations and medication guidance at primary medical institutions to help seniors with chronic diseases, such as hypertension and diabetes, manage them at home.30 In addition, the “Senior Health Companion Project” is a service centered on doctors at public health centers that provides comprehensive healthcare for older adults through home visits.31 Although these projects differ in terms of their characteristics, screening tools, and targets, there is a considerable overlap in roles within the category of preventive services targeting older adults. Therefore, there is a need for periodic integrated linkage meetings wherein city hall department officials gather to calibrate and agree on service targets, contents, and performance indicators.

(3) Performance of Work Workflow Efficiency Strength of activating linkage with welfare: The arrangement at the community center level allows an effective linkage with welfare, which was previously done through written requests or phone calls. It is primarily implemented by a team of two, a visiting nurse and a welfare planner, at the community center. This arrangement offers a distinct advantage in enabling a smooth integration. This has been recognized as an innovative model for local community centers in Korea, and the role of local nurses is largely reflected in the Ministry of Interior and Safety’s “Resident Autonomy Public Service Construction Project” in 2018, spreading nationwide.32 Possibility of reduction in the role of healthcare services: Since there is an average of 1.8 nurses per unit, the absence of a practical manager who can qualitatively evaluate, manage, monitor, advise, and coordinate their healthcare work may affect the quality of service.7,28 Wide scope of the service list: The service content of the current home care service is very broad under the category of “healthcare”. Therefore, there is a lack of clarity regarding the essential services of this project. Moreover, the services provided should vary depending on the competency of the visiting nurse. Minimum service standards for new visiting nurses should be clearly delineated in the manual. From the service provider’s perspective, this will clearly outline the essential services of this business and set goals for service provision. From the service recipient’s perspective, this would enable them to receive standardized services based on algorithms. The contents of home care services should be based on the list of key health problems and interventions included in the “Community-Level Intervention Guidelines for Integrated Care of the Elderly” published by the WHO in 2017.8,33Work Quality Management

Visiting nurses in Seoul register and manage an average of approximately 400 older adults and vulnerable members of the community, and this number may vary widely from 250 to 780.28 The participants are classified according to the three automatic group classifications, Self-Empowerment Support Group, Routine Care Group, and Intensive Care Group, suggested by the Public Health Information System (PHIS) under criteria, such as blood pressure, blood sugar, frailty status, and health behavior.7,14 The distribution of counties is different for each autonomous district, making it difficult to maintain uniform workload and quality of nurses. To assess whether this difference is a difference in the health level of the autonomous district, it is necessary to analyze the target population. This would help manage appropriate county classification distribution and workload when planning the autonomous district’s business.

Evaluation and Performance Measurement

The lack of a data verification system in organizational and business operation management has been pointed out as a major problem. Currently, the person in charge of the public health center’s home care service is supposed to play this role, but since visiting nurses work at the community center, it is difficult to qualitatively monitor actual home care practices. The only mechanism of feedback is the monthly case meetings.

In addition, a longitudinal analysis of health outcome indicators should be conducted. However, the country’s business performance indicators are limited to “number of new registrations” and “number of cases managed in intensive management groups”, and a longitudinal analysis of health outcomes is not being conducted.34

One of the major challenges in analyzing health outcomes is the low information efficiency of the local healthcare system. The city hall manager who plans the entire project should be able to anonymize, download, and analyze the health information of older adults in Seoul. However, this is not possible due to privacy-related reasons. In terms of project performance management, it is essential to establish a monitoring and evaluation system for longitudinal tracking of health indicators.

Safety Management

According to the 2018 Visiting Workforce Working Conditions and Policy Support Measures study involving a workplace safety survey of 695 social workers and 163 visiting nurses, 48.8% of respondents reported experiencing various safety issues, including verbal, physical, and sexual violence.35

(4) Empowerment Training Programs

Approximately 800 personnel have been trained, including visiting nurses and government officials working at public health centers and community centers in Seoul. The Seoul Metropolitan Government separately trains privately contracted visiting nurses through the Expert Group on Health Promotion for Seoul Metropolitan Government.36,37 Like hospitals, communities should adopt the concept of preceptor-preceptee and utilize senior staff with practical expertise as trainers. On-The-job training should be strengthened in the community, as it is not at the same level as in hospitals.

Discussion

This study aimed to identify a strategic alignment between external opportunities and internal strengths. It explores the policy-level interventions to mitigate external threats and address internal weaknesses.

SO Strategies (Strengths and Opportunities)

According to the WHO report, “healthy aging” focuses on optimizing “intrinsic capacity” and “functional capacity” rather than the absence of disease.8 This effort underlines a paradigm shift in the concept of health from theoretical frameworks to practical applications, emphasizing the importance of prioritizing it within home care services for effective community health management.

In the United kingdom’s Integrated Care Pilot (ICP) program, the integration of nursing and social services within a unified system has proven effective in optimizing resources and ensuring continuity of care. Although South Korea has already implemented collaboration between nurses and social workers in community centers, this existing strength should be further leveraged and maintained to provide more seamless services to older adults.3 It entails a shift from individualized chronic disease case management to population-based health management with a key focus on maintaining the functioning and independent living of older adults. National and local governments should develop strategies for community-level interventions at the micro-, meso-, and macro-levels to promote integrated management of older adults. Since the ability to perform activities of daily living alone is the most important factor for independent living, preventing sarcopenic frailty should be a specific strategic goal. Increasing muscle strength through nutrition (protein) and exercise (aerobic, strength) can also improve depressive and social domain indicators.38 In line with Australia’s multidisciplinary approach through Aged Care Assessment Teams (ACAT), South Korea could establish multidisciplinary teams to address frailty prevention and management. These teams would integrate visiting nurses, physiotherapists, and dieticians to deliver tailored interventions in the community.4

Health centers should run frailty prevention programs on a full-time basis. They should formulate annual plans based on a comprehensive assessment of the health status of the community using community health surveys and healthcare utilization indicators. By comparing with the city average (cross-sectional comparison) and checking temporal changes (longitudinal comparison), they should focus on indicators that meet the needs of the local older adults and need improvement. In addition, since the ability to independently perform activities of daily living is the most important factor underlying independent living, all boroughs should incorporate sarcopenia prevention exercises into their programs. The relative handgrip strength, chair rise test (lower extremity muscle strength), and Short Physical Performance Battery are good indicators of physical frailty and should be assessed before and after the intervention.39,40

Compared with their counterparts stationed exclusively at public health centers, community center-based visiting nurses have a distinct geographical advantage because their positioning enables effective collaboration between social workers and administrative staff within the community centers. Seoul comprises 25 autonomous districts and 426 Dongs, with an average of 17 Dong Community Centers per autonomous district evenly distributed geographically.28 Thus, visiting nurses dispatched to community centers are extremely accessible to the target population. This distribution offers an excellent opportunity to leverage the unique strengths of these visiting nurses. Considering the presence of many seasoned nurses, some of whom have been in the field since 2015, there is a strong potential for the creation of an organization driven by these experienced individuals. The full utilization of these advantages will maximize the visiting nurses’ deep-rooted experience and their comprehensive understanding of community resources, offering substantial benefits to the community healthcare system.

ST Strategies (Strengths and Threats)

There should be a supervisory-level nurse manager in charge of the district and staff nurses. A weekly meeting or case conference of nurse managers can be organized to monitor the quality of healthcare practice and case management. To increase accessibility, the dispatch of visiting nurses to community centers was an important strategy to strengthen connectivity with welfare. Although it was successful in that regard, it led to a weakening of the management and supervision of healthcare work. As pilot projects of a similar nature continue to be implemented to prepare for an aging society, these health tasks must have a manager to ensure good co-ordination between each project.

To enhance continuity in care, it is essential to link the currently separate long-term care assessment system and public health center-based preventive home care services. This integration would ensure seamless transitions from prevention to long-term management, addressing gaps in service continuity. Japan’s long-term care insurance system, which incorporates preventive services for individuals with mild functional impairment through its “yo-shien” category, offers a valuable framework for aligning these systems.6 By integrating frailty prevention programs into the assessment process, individuals at risk could receive targeted interventions earlier, reducing the likelihood of rapid functional decline. Establishing a unified platform for sharing data between these systems could further improve operational efficiency and provide more seamless support to older adults.

As the older adult population continues to increase, human resources are becoming inadequate for one-on-one care and efficient management. Since Korea has a well-established ICT-based healthcare infrastructure, it should be utilized more actively in remote access and group intervention strategies.

WO Strategies (Weaknesses and Opportunities)

Now that awareness of the crisis in the aging society is increasing throughout the general population, this may be an ideal opportunity to implement innovative changes to the current framework of the home care services that have been in place for over 30 years in South Korea.9,10

Drawing insights from international best practices, particularly the United Kingdom’s integrated care model, systematic reforms in assessment and service delivery should be prioritized. Effective reform of assessment and service delivery requires a comprehensive understanding of health status among Korean older adults. To achieve this goal, a longitudinal analysis utilizing national population surveys, such as the Korean Longitudinal Study of Aging41 or the National Survey of Older Koreans, should be conducted.42 These nationwide periodic assessments enable regional and international comparisons. Following the UK’s single access process (SAP) model, these assessments should be streamlined through a unified evaluation tool, eliminating redundant assessments while ensuring comprehensive information sharing among healthcare providers.43

This systematic analysis would enable identification of groups requiring intensive management and frequent health problems, which can then serve as key performance indicators for home care services projects, allowing continuous analysis of longitudinal trends. Furthermore, to prevent institutionalization, stronger integration with the current home medical care pilot project is essential. A priority action item is securing and utilizing a list of individuals in the preliminary stages of long-term care as potential beneficiaries of home care services.

WT Strategies (Weaknesses and Threats)

Each borough should aim to incorporate visiting nurses into neighborhood-level healthcare teams,44 comprising doctors, nurses, nutritionists, exercise trainers, and dental hygienists as essential personnel. Australia’s success with visiting nurse-led multidisciplinary teams highlights the potential for strengthening team-based care in South Korea. By building on the experience of seasoned nurses, such teams could provide high-quality, coordinated care at the community level.4

Quantitative research on the workload associated with the health level of older adults is necessary to determine how much work the current workforce can handle and the scope of their roles. Currently, approximately 25–30 hours annually are dedicated to specialized new visiting nurse training and continuing education for visiting nurses, but there is a lack of practice-oriented training.36,37 Simulation-based training programs, modeled after Australia’s team-building approaches, could be introduced to enhance practical skills and team collaboration.4 These programs would enable nurses and other team members to address real-world scenarios effectively in community settings.

Conclusion

The progressive population aging, preferences for aging in place, policy-driven reforms, and concerns around COVID-19 transmission in institutional care settings have led to a surge in the demand for home-based care. However, sociopolitical and infrastructural contexts often do not align with the operational needs of home care service organizations, presenting challenges to healthcare equity.2 Insights obtained from this study can help inform the development of more effective, equitable, and sustainable home care services.

There is a lack of strategic solutions to prepare for an aging society. Home care services are expected to play a pivotal role in preventing older adults from entering the long-term care system, and therefore, we performed a SWOT analysis to identify strategic solutions. Home care services must change their core offerings from those focused on chronic disease to frailty prevention programs in older adults via a multidisciplinary team approach. Additionally, it is imperative that a new position of nursing manager be created to lead cooperation between various health and welfare projects and to foster professional instructors to manage the quality of services.

Abbreviations

ICOPE, Integrated care for older people; MOHW, Ministry of Health and Welfare; PHIS, Public Health Information System; SWOT, Strengths, Weaknesses, Opportunities, Threats; WHO, World Health Organization; ICT, Information and Communication Technology; SOS, Save Our Souls; SAP, Single Access Process.

Data Sharing Statement

There are no new data associated with this article.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Funding

There is no funding to report.

Disclosure

The authors declare that they have no competing interests.

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