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Abstract Introduction: Reviewing factors that affect work challenges is crucial for any organization as it has an impact of organizational commitment for a better service delivery and job satisfaction. This study aimed to explore the perceptions of dental health professionals (DHPs) on work challenges and the impact it has on job satisfaction in Fiji. Materials and Methods: A descriptive, qualitative method approach (nationwide) was done commencing from August to November, 2021. DHPs who provide prosthetic services in Fiji were selected using purposive selection located at Nakasi Dental Clinic, Lautoka Dental Clinic, Labasa Dental Clinic, and Fiji National University. A total of 29 DHPs participated in the in-depth interview, and the responses were grouped into nine themes: working conditions, the location of practice, equipment and material, a lack of specialization, service delivery, organizational support, remuneration, career development, and promotions. A semi-structured open-ended questionnaire in the form of an interview via a virtual platform—Zoom was used for data collection. Thematic analysis was used to transcribe and analyze the audio recordings. Results: The findings from the study indicated that factors such as working conditions, the location of practice, equipment and material, a lack of specialization, service delivery, organizational support, remuneration, career development, and promotions were associated with work challenges. Conclusion: Gaps and areas for the improvement of work challenges and its impact on job satisfaction were identified for DHPs who provide prosthetic services in Fiji such as a need for more career and professional development pathways, improved infrastructure to support prosthetic service delivery, and better remuneration.
Keywords: Dental health professionals, Fiji, job satisfaction, perceptions, work challenges
Introduction 
Increasing trends in the global demand of dental healthcare professionals (DHPs) lead to an enormous amount of work pressure on DHPs to provide high-quality dental services. This can be a deterrent for dental health-care workers having a positive outlook on job satisfaction.[1] When members are satisfied with their work environment, they feel rewarded for the work they do, which leads to a more productive organization.[2] A number of studies found that common job stressors for DHPs have been time-related pressures, large workloads, financial burdens, anxious/difficult patients, human resources (HR) issues, resource limitations, poor working conditions, and the repetitive nature of the job.[3],[4],[5],[6],[7],[8],[9] Job satisfaction is an important aspect of any organizational life. The perception of job satisfaction is a reflection of one’s sense of fulfillment and expectations with the work they are doing, which should be challenging, interesting, and personally satisfying. It can be posed as an achievement indicator for the career development.[10]
Fiji is culturally a much diversified nation; thus, it has been mandated by government to provide acceptable levels of health care to its people.[6] The country is divided into three main administrative divisions, namely, Northern, Western, and Central/ Eastern divisions. Health facilities have been strategically placed in the areas of dense population.[11]
Fijian DHPs are employed by three sectors (government, private, and academic) where Ministry of Health and Medical Services (MoHMS) is the largest employer, followed by the private sector and Fiji National University (FNU). Dental prosthetics is a specialty dentistry field that provides rehabilitation for the lost or missing oral soft and hard tissues, to restore structural balance, functional efficiency, esthetic harmony, and oral health.[12] The fabrication of dental prosthesis requires great skill and extensive knowledge as each piece is unique and custom-made to accommodate individual patient’s needs.[8] Prosthetic dentistry requires the co-operation within the team of dental professionals and who provide this service are dentists and dental technicians (DTs).[9] Prosthodontists are dentists who specialize in prosthetics. Fiji currently has two registered prosthodontists who are employed at the School of Dentistry and Oral Health (SDOH) of FNU.
In Fiji, dental training for dental practitioners, therapists, technicians, hygienists, and dental assistants began in 1945 at the Central Medical School, which was later called Fiji School of Medicine and now falls under the FNU.[4] There are very limited postgraduate studies in the various fields of dentistry available in Fiji. Graduates who wish to further their qualifications have to travel to neighboring countries such as Australia and New Zealand that offer a wide range of postgraduate and specialist courses; however, not many intend to return as they feel frustrated because of the inability to fully apply their skills because of the lack of resources available locally.[7]
The rational for this study is to determine the perceptions of challenges that affect the work of DHPs and its associated factors and the emergence and present professional status of dental professionals who provide dental prosthetic services in Fiji and to possibly contribute to the literature on the factors affecting job satisfaction or dissatisfaction in the workplace. This group of DHPs was of particular interest as they seem to have been neglected as compared to other dental specialties. Prosthetic dentistry is a huge part of the dental health-care system in Fiji and thus it is important to find out factors that impact job satisfaction of these DHPs who provide this noble service. The findings of this study will be helpful to policymakers to design plans in order to increase the level of job satisfaction of DHPs by highlighting areas where there is a need for improvement in services and identifying the need for program development for dental academic institutes.
Materials and Methods Study design and setting
A descriptive, qualitative study design was adapted for this research DHPs of Fiji, which instituted a richer and comprehensive response.[13] This descriptive, qualitative study explained the situation and challenges DHPs were facing regarding the work situation in Fiji. This study was conducted among the DHPs based at the dental clinics of the MoHMS that provide prosthetic services located in Fiji, namely, Nakasi Dental Clinic, Lautoka Hospital, Labasa Hospital, and at the FNU Dental Clinic in Suva, which had been purposively selected.
Study sample
A homogeneous, purposive selection method was used for sampling.[14] A total of 32 DHPs were approached for the in-depth interviews from which only 29 DHPs participated. These included 18 DTs and 11 dentists (eight at FNU, eight at Nakasi Dental Clinic, seven at Lautoka Hospital, and six at Labasa Hospital). Dentists and DTs registered under the Fiji Dental Council, with a minimum work experience of 6 months, working at the selected clinics in the time of data collection and DHPs of both genders or any ethnicity were included in the study. Those who worked in the private dental clinics or were not willing to participate in this study were excluded. The final sample size was determined by data saturation.
Data collection tool
Data were collected using a semi-structured open-ended questionnaire. In-depth interview was conducted with participants via a virtual platform called Zoom that lasted between 30 and 40 min. The questionnaire comprised of two sections including: (1) five demographic questions based on age, race, gender, qualification, and years of work experience and dental specialty and (2) seven open-ended questions relating to job satisfaction in the English. All in-depth interviews were recorded, and the researcher transferred and documented the data exactly as expressed by the participants.
Study procedure
Ethical approval was sought prior to the commencement of the study. A list of suitable participants was made that met the inclusion/exclusion criteria and were contacted via the phone/email requesting their participation at a time convenient to them. An information sheet together with consent forms was emailed to them. On the day of interview, a guideline was explained, and verbal consent was recorded on the day of the interview prior to the commencement of the interview on Zoom. The participants were made aware that their identity would not be disclosed and confidentiality will be maintained, and they were asked to give their honest opinions. Each interview lasted about 20–30 min. The conversation was recorded and note-taking was done during the interview. The resulting audio was transcribed after each interview, and notes were reviewed to identify all references and contents that are related to job satisfaction.
Data management and analysis
The main researcher transcribed the content of interview and was then checked for sufficient quality and accuracy before major analysis was conducted. Backup files were created in the light of data management system and were updated as data preparation and analysis proceeded. A manual thematic analysis was used to analyze the data.[15] Field notes were arranged according to codes and themes, which were then combined into major categories and files (word documents). All interview transcripts were read and re-read to identify similar phrases and words for which numbers were assigned. The coded data with similar characteristics were grouped together. Once the grouping of similar data was completed, descriptive themes and codes were identified to reflect the perceptions of participants. The themes and subthemes were checked by the principal supervisor as well. In addition, the researcher received comments on the qualitative research analysis process and categorization process from a professor who is also the principal research superior with extensive experience in the qualitative research to enhance the feasibility and reliability of the research.
Study rigor
Four criteria were identified that contributed to the trustworthiness of this study:
Credibility was achieved through in-depth interviews that were conducted over the period of 1 month. Each interview lasted for at least 20–30 min. Interviews were recorded and transcribed by principal researcher on the same day.
Transferability was done using purposive sampling technique. In-depth interviews were carried out until data saturation was achieved, and no new knowledge was to be found. Although the sample size is limited, the depth of the interviews and data analysis provides rich information, which gave an insight into these particular participants’ work experiences.
Dependability: The study was developed from a systematic search of the existing literature. The review of transcriptions was done to correct errors. Data were coded and checked thoroughly.
Adherence to data collection tool strategies were maintained and the themes and codes were checked by the principal supervisor MM.
Ethical consideration
Ethical approval from the College Health Research Ethics Committee of FNU was obtained before the initiation of the study. Permission had been attained from the Office of the Dean and Head of SDOH, College of Medicine, Nursing, and Health Sciences, FNU and the MoHMS to allow for the participation of staff in this study. Verbal consent was given by participants, which was recorded prior to the commencement of interview.
Results General characteristics of participants
A total of 29 DHPs participated in the study. A majority of the participants were of the female gender (76%) and were mostly in the 30–40 age range (48%). Two ethnicities were noted: ITaukei (14%) and Indo Fijians (86%). Two-thirds (66%) of the DHPs had a minimum qualification in the field of dentistry, 31% postgraduate qualification, and 3% specialist. More than two-thirds (72%) of the participants were employed by the MoHMS. One-fourth (24%) had more than 20 years of experience. DHPs who are involved in the prosthetic services were 38% dentists and 62% DTs [Table 1].
Themes related to workplace challenges
Nine major themes had emerged from the thematic analysis, which included working conditions, the location of practice, equipment and material, a lack of specialization, service delivery, organizational support, remuneration, career development, and promotions.
Under these themes, codes were identified as summarized in [Table 2]. Participants’ quotations were referenced as P1–P29, DHPs-D (dentist) or DHPs-DT.
Theme 1: Working conditions
Participants describe the type of environment they are currently working in.
Most participants mentioned that space is an issue.
Currently we are based in Nakasi, it is a very confined area. We are having space issues there. We are unable to work on a single bench whole day; we have to share the work space. Our working environment needs to improve. Secondly is our equipment’s. They are very old and needs replacement. (P14 DHPs-DT)
Another participant compared how things are up to date and organized at home as compared to the provisions made available to them in their work space lowers their morale.
You know, we leave our beautiful homes and we come to work. At home in our kitchen, we got everything there, everything new to carry out our duties, but when we come to work place, there are leaking roofs, machines that don’t work, in the end there is defects in the denture, it lowers your morale. (P28, DHPs-D)
Some participants mentioned their scope of work is more compared with MoHMS.
We do teaching in the field of dental technology. We are considered as academics as well. And I am more satisfied at my current work in comparison to MOH, as we get to do more advanced procedures whereas at the ministry of health, the scope of work is very limited and very little availability of materials and equipment. (P02 DHPs-DT)
Theme 2: Location of practice
Some participants described how hectic work gets due to the location of practice and the community they serve.
It is very hectic, working for a government hospital it is very hectic and there are lot of limitations to the type of services we provide because we don’t all the resources that we would like to have. We see a lot of patients because we are the only clinic between the Nadi–Lautoka corridor and Lautoka–Ba, Tavua and Rakiraki corridor and population of Lautoka is really big. Most of the time patients complain that they have been waiting for so long and no one has tended to them. We are really understaffed and procedures take time. On average we see about 10 to 25 patients a day and sometimes even more per staff. (P16, DHPs-D)
Another added by saying that because of the number of patients they see daily, they understaffed and overworked.
Since this is the only hospital that provides prosthetic services to the people of Labasa, Savusavu, Taveuni and outer islands, sometimes we see 50 to 70 patients in a week which is very hard and we are very understaffed. The workload is very much, the pressure is so high and few staff. (P24, DHPs-D)
Theme 3: Equipment and material
Some described that they are not able to provide all services as they are limited because of resources available to them.
Prosthetic work as far as clinical is concerned I wouldn’t say that I really enjoy it. It’s just at one place and it becomes boring. Working within the ministry you are not really exposed to all services that come under prosthetics. We only do some of the work as what limits us is the resources. We are not supplied with the materials that we’d like for advanced procedures. (P28, DHPs-D)
They also expressed how inconvenienced they are, given the compromised situations they deal with at their current workplace.
When we were at the dental school, whatever we learnt and the materials that we used we don’t do it here at ministry. They tell us that we have to perform with whatever we have available. Most of the time we have to compromise. (P15, DHPs-DT)
Most participants expressed that because of the poor quality of materials, it affects the quality of services they provide.
It is high time that MoHMS starts providing some advanced prosthetic services as with new graduates, whatever they have learnt they are not able to utilize here in the ministry. We not given good quality materials and equipment we had at the dental school and that really affects the quality of prosthetics we make and offer. (P22, DHPs-DT)
Theme 4: Lack of specialization
They further add that the profession lacks specialization.
For dentistry it is very limited here in Fiji. There is hardly any specialization except for oral surgery and not everyone is interested in it. (P24, DHPs-D)
A few participants mentioned that because of the monotony of their work scope, the profession becomes boring.
It’s just monotonous what we are doing here. It will be great if we could be allowed to do a lot more advanced cases would be good. (P27, DHPs-DT)
Another participant stated that there is a lack of recognition of the need for specialization:
For dental professionals there are not much support except for oral surgery. I think they don’t recognize the need but there is a huge need for development for staff to specialize. There should be scholarships given and courses made available locally to specialize so that we can improve the services that we provide. (P15, DHPs-D)
Theme 5: Service delivery
Most of the participants are not happy with the type of work they are doing as they are underutilizing their skills and knowledge they graduated with.
I am not satisfied with the type of work that we do. We are not able to apply our skills that we graduated with. (P04, DHPs-DT)
A few participants mentioned the type of services they are providing at their current workplace is very limited.
Our work right now at the MoHMS is providing basic prosthetic services and simple orthodontics. Yes, I like it, we get to serve the lower income population but we are not able to offer a wider range of services. (P12, DHPs-D)
Some find their work disappointing as they feel confined to one area of dentistry.
We do removable prosthesis at MoHMS. I’m not satisfied with my work but its ok for the time being. At the moment we only focus on removable prosthetics only. So we are kind of confined to one part of prosthetics whereas the broader part we are not doing so it’s a bit disappointing not being able to practice all our skills that we graduate with. (P14, DHPs-DT)
Theme 6: Organizational support
Some participants felt that staff interest was not a priority at their organization for decision-making.
In terms of organization—I don’t think the organization has staff interest at heart, with the terms and conditions of our contract and the way in which they engage with us and the tone and language they use, all shows that we are not really valued as staff members. Just the fact that never consulted with us the terms and conditions of our contracts and are only beneficial for corporate managers is really disgusting. The management is very top down and all the decisions are made at top level and are influenced by a very few people in the senior management committee with advise from corporate staff and lack of employee consultation. (P11, DHPs-D)
A few participants mentioned that bringing about changes within the organization is difficult because of the resilient nature of older staff.
People do listen to us, but when it come to the resources that are available to them is quiet restricting. And working with older staff, they become very monotonous, no satisfaction or expectation of their work. Sometimes they become very resistance to change and have a very different attitude and all this affects decisions for bringing about changes. (P28, DHPs-DT)
Some felt that their views are pushed aside by their superiors.
Our supervisors do listen to us but when matters are escalated they don’t understand our point of view and things are usually push aside. (P03, DHPs-DT)
Theme 7: Remuneration
Most participants mentioned that they should be remunerated according to the qualifications they have.
Staff need to be remunerated fairly with the type of qualification they have and the amount time and investment that went into getting that qualification needs to be reflected. (P08, DHPs-D)
Here, participants expressed that the type of salary they are getting for the various roles they have is disappointing.
I think the remuneration aspect is a bit disappointing because I recently explored some time in acting position of head of school and also chair of teaching and learning and teaching in the higher level and that really takes up a lot of my time especially in the management level. So taking that into consideration, the remuneration needs to be a bit more justified as I am working at different levels and contribute a lot to the school. Also we invest a lot more into our studies so this needs to be also reflected in the type of pay we get. (P07, DHPs-D)
One participant described what their salary was like for the profession before job evaluation took place at their organization.
Actually it was a very good and pleasant, and positive thing to be a dentist since we graduated. We had very good feeling, pride until there was a job evaluation activity done whereby medical officers salary within the ministry went up significantly and dental salary did not go up as much as the medical officers. So looking at the number of years that we study and the fee that we pay, it brought about sadness and inferiority amongst the dental professionals which really has affected us. (P23, DHPs-D)
Theme 8: Career development
One participant felt their career ends at a diploma level.
For us dental technicians I don’t think so, our career ends at a diploma. We have talked to the bosses at MoHMS regarding our studies but they have not done anything about it. In Fiji a diploma is the highest qualification we can get in dental technology.(P18, DHPs-DT)
Some participants mentioned that they limited because of the lack of specialist courses available locally.
We don’t have much specialization locally in terms of career development. the working conditions at times there are lack of resources and man power, most of the time we have to do things do that is beyond our job description. (P15, DHPs-D)
One participant mentioned that because of dentistry being an expensive course to the study, they had to take up nonclinical courses.
Dentistry is quiet an expensive field to begin with, so when it comes to clinical training or post grad training, there is a lot of money that is required so financially, the organization is not very supportive and this is one thing that has hindered my development and so I had to take up a non-clinical masters. (P07, DHPs-D)
Theme 9: Promotions
For most participants, the upgrading of qualification is a requirement for getting a promotion in their organization.
Our HR considers promotions based on qualification upgrades. There are difficult criteria that cannot be met as there are no post graduate courses available locally and this makes it difficult to getting promotion. (P01, DHPs-DT)
Most participants felt that getting a promotion has been made a difficult process.
Opportunities are not very good, FNU as an organization has put in too many processes and a lot of filtrations so getting to level of promotion is there but it is very difficult to attain. (P07, DHPs-D)
Most participants mentioned that because of the limited number of positions, opportunities for getting a promotion are difficult.
There are hardly any opportunities for getting a promotion. There are staff who have waited more than 15 years to get a promotion. Until and unless a staff retires, it is very rare to get promoted. There needs to be more positions created and more labs made to get an opportunity to get promoted. (P04, DHPs-DT)
Discussion Overall, participants found that the profession is challenging and work situations differed on a daily basis. Similar finding was made by Epari et al. (2017) stating that practicing DHPs who were also academics were happier than those who were either fully engaged in the teaching profession or who were doing only private practice.[16] However, a study by Pandita et al. (2015) reported that full-time clinicians were more satisfied than part-time practitioners.[17]
Work environment plays a huge role in job satisfaction, and its importance cannot be underestimated. The working environment is one of the most crucial factors, which influence the level of satisfaction as well as the motivation of its employees. Agbozo et al. (2017) found a direct correlation between work environment and job satisfaction. His findings concluded that work environment has a significant effect on employees’ satisfaction and emphasized the need for management to improve the work environment of employees to boost productivity.[18]
The centralized location of the prosthetic clinics in the country has become a limiting factor as it limits the opportunities for more job establishments. This leads to a higher volume of patients being tended to, which in turn causes overcrowding, overworked, and burnout staff.[19]
Participants expressed their dissatisfaction because of the monotonous nature of their work. Theoretical and empirical evidence has long suggested that monotonous work has a negative effect on employee task performance, which leads to boredom.[18] Job satisfaction and psychological distress were mainly related to subjective monotony as is evident in this study.
A majority of participants felt that this profession is neglected and not recognized as a specialist field. Although the levels of job satisfaction are satisfactory, many DTs feel insufficiently valued in the dental team. These finding are parallel to a study conducted in the United Kingdom where many DTs did not feel sufficiently valued and most perceived their professional group to be inadequately valued in the dental team.[20] Other studies in the United Kingdom indicated that job satisfaction was relatively low among DTs and was dissatisfied with working conditions, colleagues, remunerations, working hours, autonomy, recognition of work, and continuous professional development, with many intending to leave the profession, which may be linked with the relative isolation of DTs compared with other members of the dental team. It was also highlighted that there were a number of real and potential problems in the field of education in dental technology.[21],[22] These finding are further enforced by Murariu et al. (2017) indicating that factors such as a lack of motivation for continuing education and ongoing professional development training were elements of low satisfaction levels.[23]
A majority of participants, in particular DTs, were not happy in the work environment they were in. They found it was not an ideal environment because of many reasons such as overcrowdedness due to space constrains, working with the poor-quality materials and outdated machines and equipments, a lack of resources available to them that inhibits a good quality service delivery. Because of the lack of infrastructure, the ability to fully utilize one’s skills and knowledge is limited. Participants felt that because of poor working conditions, it lowered their morale for going to work. A study in the United States reinforces this finding based on staff morale having a linear and positive relationship with organizational productivity.[24]
Some DHPs who also have an academic role said that they were more satisfied with their work environment as they have the advantage of working with better technology, resources, and opportunities. Similar finding was made in a study conducted by Shepherd et al. (2001) where dental educators were more satisfied with their work environment compared with DHPs who were nonfaculty.[25]
The participation of workers in the decision-making plays an important role in any organization and has an impact on the satisfaction level of staff.[19] In this study, participants reported being dissatisfied with the lack of staff engagement being considered by their organization in important decision-making that directly affects staff. It was also mentioned that because of the resilient nature of older staff who have hold positions of influence, there is no improvement, and fresh ideas get push aside.
Because of these reasons, there are implications on the type of remuneration they are receiving and the development of the profession. There is so much time devoted in developing practical prosthetic skills, and therefore recognition in terms of remuneration and career progression should be made available to those who elect to enter this profession.[26] According to many studies, income is a major determinant for job satisfaction.[1],[27],[28] Income has been identified as one of the major dissatisfying aspects of this profession.
There is a significant difference in job satisfaction levels experienced by participants based on their qualification levels and the type of remuneration they are receiving. Satisfaction is likely to result when one’s income is seen as fair based on job demands and individual skill level and in accordance with community pay standards.[29] Results from the study reveal that respondents who have upgraded their qualifications are significantly less satisfied than respondents in possession of baseline qualification. This is mainly due to not being compensated in monetary value in accordance to the qualification they hold and comparison with the private sector and the international market. Similarly, in Iran, Khalighi et al. (2018) found that dental specialists, namely prosthodontists, were the most dissatisfied among other faculty members due to the great income gap between academic and private practice in dentistry, which is a reason of low job satisfaction level especially in the salary domain.[30] Contrary to the findings of the current study, Maharjan and Mathema (2018) found that in Nepal, highly educated DHPs experienced higher levels of job satisfaction.[31]
Promoting employees from a lower to a higher position brings about a feeling of satisfaction.[32] It improves their job satisfaction and motivation by providing greater income, status and responsibilities.[33] According to Janakiram et al. (2017), the career advancement through promotion is a key element for employee satisfaction and retention. This could be due to different perceptions of the term professional advancement among persons. It could be through gaining experience in their professional fields and creating a unique and versatile role for oneself or attaining a senior position.[34] In this study, the upgrading of qualification was identified as a requirement for getting a promotion in their organization. Most felt the process of getting a promotion was difficult due to many policies in place, which hurdled their chances. Some even mentioned that despite upgrading their qualification, they still were not promoted. For others, due to the limited number of positions, opportunities for getting a promotion were difficult. Some participant mentioned waiting for many years until senior positions become available, and that is only made possible when someone’s retires or passes on. Given these reasons, a majority of participants felt that dentistry in Fiji has become stagnated, which is a major dissatisfying factor for DHPs.
Limitations
Because of the qualitative design of this study, findings of this research must be interpreted within the context of its limitations and is limited to DHPs providing prosthetic services in Fiji, only DHPs working at MoHMS and FNU were included. For future researchers, it would be ideal to include DHPs who offer prosthetic services in the private sector. The timing of data collection was limited because of the setting of the study and the nature of the study participants.
Conclusion The principal aim of this study was to establish the perceptions of variables associated with work challenges among DHPs who provide prosthetic services in Fiji. To date, this has been the only study conducted exploring the perceptions of work challenges among DHPs in Fiji using the qualitative analysis. The results of this study will be useful in informing DHPs, their employers, and the academic institutes about the current work challenges that affect job satisfaction of individuals working within the dental profession. The empirical findings from the study indicated that factors such as working conditions, the location of practice, equipment and material, a lack of specialization, service delivery, organizational support, remuneration, career development, and promotions were associated with work challenges.
Acknowledgement
We express our sincere thanks to the DHPs who participated in this study.
Financial support and sponsorship
Nil.
Conflicts of interest
The authors declare that there are no conflicts of interest in this work.
Authors contributions
SK: Conceptualization; data collection; formal analysis; methodology; project administration; writing – original draft preparation; writing – review and editing. MM: Conceptualization; data analysis; supervising; writing –review and editing.
Ethical policy and institutional review board statement
Ethical approval from the College Health Research Ethics Committee (CHREC) of FNU with ID#032.21 was obtained before commencement of the study. Permission had been sought from the Office of the Dean and Head of School of School of Dentistry and Oral Health (SDOH), College of Medicine, Nursing, and Health Sciences (CMNHS), FNU and the MoHMS to allow for the participation of staff in this study. All participants were given the informed consent form to sign before conducting interview. All methods were carried out in accordance with relevant guidelines and regulations.
Patient declaration of consent
Patients were not part of the study.
Data availability statement
The data that supports the findings of this study are available on request from the corresponding author.
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