Community-based peer education as a tool for the prevention of breast cancer: a narrative review

Rachael O Oduyemi^1a, Chizoma Millicent Ndikom^2b, Gloria Oluwakorede Alao^3,4c, Iyanuoluwa O Ojo^2d, Faith Ayomide Ajayi^5e, Damilola Ajibade^6f, Abdullahi Suleiman^7g, Hameedah Ayomide Gbadamosi^8h and Oluwadamilare Akingbade⁹ⁱ

¹Faculty of Nursing Sciences, Chrisland University, Abeokuta, 110104, Ogun State, Nigeria

²Faculty of Nursing, College of Medicine, University of Ibadan, Ibadan, 200001, Oyo State, Nigeria

³Institute of Nursing Research, Osogbo, 232111, Osun State, Nigeria

⁴Nursiscope Mentorship Academy, Nursiscope Inc., Edmonton, T5Y OW4, Canada

⁵Ahmadu Bello University, Zaria, 810001, Nigeria

⁶Chrisland University, Medical Centre, Abeokuta, 110104, Ogun State, Nigeria

⁷Bayero University Kano, Kano, 7000001, Kano State, Nigeria

⁸Olabisi Onabanjo University Teaching Hospital, Sagamu, 121101, Ogun State, Nigeria

⁹School of Nursing, Dalhousie University, Halifax, B3H 4R2, Canada

^ahttps://orcid.org/0000-0003-2451-7277

^bhttps://orcid.org/0000-0002-4036-156X

^chttps://orcid.org/0009-0009-9547-3831

^dhttps://orcid.org/0000-0002-2132-2987

^ehttps://orcid.org/0009-0006-9928-4294

^fhttps://orcid.org/0009-0004-7141-8030

^ghttps://orcid.org/0009-0002-0137-6977

^hhttps://orcid.org/0009-0002-5771-0559

ⁱhttps://orcid.org/0000-0003-1049-668X

Abstract

Background: Breast cancer remains a major threat to women, especially in low-resource settings like Nigeria, where awareness and screening are limited. Peer education may offer a practical way to improve early detection and prevention in these communities.

Objective: To examine how peer education supports breast cancer prevention in communities by exploring its delivery methods, impact on knowledge and behaviour and the cultural and practical factors that shape its effectiveness.

Methods: A narrative review was conducted to explore the role of community-based peer education in breast cancer prevention. Relevant studies published between 2010 and 2025 were identified through a systematic search of six databases (CINAHL, PubMed, Web of Science, Embase, Medline and APA PsycINFO) using specific keywords. After screening and applying inclusion and exclusion criteria, data were extracted from selected studies and thematically analysed to identify patterns, benefits and challenges of peer education interventions.

Result: Out of 818 studies initially retrieved, only 18 met the eligibility criteria and were reviewed, covering diverse locations and participant groups, mostly from high-income countries. The studies showed that peer education delivered through various methods and tailored to cultural contexts significantly improved breast cancer awareness, screening behaviours and community engagement, though challenges like role confusion, cultural barriers and logistical issues were also reported.

Conclusion: This review concludes that peer education is an effective, adaptable strategy for promoting breast cancer prevention in community settings, especially among underserved populations.

Keywords: breast, cancer, peer-based education, community

Correspondence to: Oluwadamilare Akingbade
Email: oakingbade@dal.ca

Published: 07/04/2026
Received: 11/09/2025

Publication costs for this article were supported by ecancer (UK Charity number 1176307).

Copyright: © the authors; licensee ecancermedicalscience. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background

Globally, cancer continues to rise at an alarming pace, affecting millions each year and placing an immense burden on individuals, families and healthcare systems. In 2022, the International Agency for Research on Cancer reported nearly 20 million new cancer cases worldwide, resulting in approximately 9.7 million deaths. Lung cancer was the most commonly diagnosed cancer, followed by breast cancer in women [1].

In Nigeria, the number of new cancer cases increased to 127,763, with 79,542 deaths and breast cancer emerged as the most prevalent, accounting for 25.3% of cases [2].

The uptake in Nigeria on the practice of breast self-examination (BSE), clinical breast examination and mammography remains low due to poor awareness, sociocultural beliefs, limited access and inadequate knowledge [3, 4].

Systemic delays within the health system such as fragmented delivery of health services, shortages in the health workforce, inadequate health financing, weak health information systems and limited access to essential medicines and technologies further worsen outcomes, as most Nigerian patients present at late disease stages. For example, a Northern Nigeria study found 99.4% presented with advanced disease [5], while a review reported symptom durations of 8–12 months before diagnosis [6]. These findings underscore the need for scalable interventions targeting awareness and behaviour at the community level.

Community-based peer education is an approach to health education and promotion in which trained community members known as peers educate and train others within the same community to improve attitude, knowledge and health-seeking behaviour to specific issues. Community-based peer education offers a promising solution. Peer-to-peer models leverage trust and shared experiences to deliver culturally relevant health messages. Successfully used in HIV prevention and adolescent health [7], peer education has also improved breast cancer screening uptake, as seen in Minnesota’s Breast Cancer Champions program [8]. However, evidence from Sub-Saharan Africa is limited. In Nigeria, few studies have applied peer-led models to breast cancer prevention. One study showed peer-led training improved BSE practices among students [9, 10], yet little is known about the cultural adaptation or outcomes of such interventions in rural and underserved communities.

This review will provide context-specific insights into how peer-led education can enhance breast cancer prevention in Nigeria. Findings will guide the design and scaling of culturally appropriate, community-driven programs that strengthen early detection and reduce mortality [7, 8, 10].

This review aims to:

1. To examine the structure, strategies and delivery methods of peer education programs used in community settings for breast cancer prevention.

2. To assess the impact of community-based peer education on knowledge, attitudes and screening behaviours related to breast cancer among women.

3. To identify contextual and cultural factors that influence the effectiveness of peer education interventions in rural and underserved communities.

4. To explore the challenges and facilitators associated with implementing peer-led breast cancer prevention programs.

5. To provide evidence-based recommendations for designing, adapting or scaling up peer education models for breast cancer prevention in similar contexts.

Methods

A narrative review approach was adopted to examine the role of community-based education in breast cancer prevention, as this approach enables a thorough understanding by synthesising a broad spectrum of literature [11]. The study aims to explore and synthesise existing evidence on the role of community-based peer education in the prevention of breast cancer . This narrative review was conducted and reported in accordance with the Scale for the Assessment of Narrative Review Articles (SANRAs). The quality of this narrative review was also assessed using the SANRA, a validated tool designed to improve the methodological rigor and reporting quality of narrative reviews [12]. SANRA consists of six criteria: (1) justification of the article’s importance, (2) clarity of aims, (3) description of the literature search, (4) quality and appropriateness of referencing, (5) scientific reasoning and (6) presentation of relevant data in an organised manner. Each criterion was rated on a 0–2 scale, where 0 indicates low quality, 1 indicates moderate quality and 2 indicates high quality, resulting in a maximum possible score of 12. The current review attained a SANRA score of 12, reflecting clarity of the review objectives, transparent description of the search process, appropriate and consistent referencing, logical synthesis of evidence and structured presentation of findings. The application of SANRA strengthened the overall rigor, transparency and reliability of this narrative review.

Search strategy

A systematic literature search was conducted to identify relevant studies that discussed the utilisation of community-based peer education in the prevention of breast cancer. Six databases were searched including CINAHL, PubMed, Web of Science, Embase,Medline and APA PsycINFO using keywords including ‘breast cancer,’ ‘breast carcinoma,’ ‘breast neoplasm’, ‘mammary cancer’, ‘Breast Neoplasms’, ‘prevention’, ‘risk reduction’, ‘screening’, ‘screen’, ‘breast self-exam’, ‘clinical breast exam’, ‘health promotion’, ‘Primary Prevention’, ‘Early Detection of Cancer’, ‘Mammography’, ‘Health Promotion’, ‘peer education’, ‘peer-led’, ‘peer to peer’, ‘peer support’, ‘lay health’, ‘worker’, ‘lay educator’, ‘community health volunteer’, ‘peer mentor’, ‘Peer Group/education’, ‘Community Health Workers’, ‘Health Education/methods’, ‘community-based’, ‘community setting’, ‘rural community’, ‘village’, ‘low-resource’, ‘underserved’, ‘grassroots’, ‘population-based’, ‘Nigeria’, ‘sub-Saharan Africa’, ‘Community Health Services’ and ‘Rural Health’. Results were exported to the Covidence software for de-duplication and screening.

Interventions and comparisons

The review considered peer education programs aimed at increasing awareness, improving knowledge and enhancing uptake of breast cancer prevention and screening services. Interventions included home visits, group workshops, culturally tailored community education, storytelling, faith-based activities, health fairs and mobile health tools.

Inclusion and exclusion criteria

Studies were included in this narrative review if they focused on community-based or peer-led education interventions aimed at the prevention of breast cancer. Eligible studies targeted women of any age group and were conducted in community or rural settings. The review considered quantitative, qualitative and mixed-methods studies that provided relevant data. Only articles published in peer-reviewed journals, written in English and recently published within 2010–2025 were included to ensure the review captured recent developments and trends in the field.

Studies were excluded if they were hospital-based or focused on clinic-led interventions with no community or peer education component. Articles that addressed types of cancer other than breast cancer, or those that were editorials, reviews, commentaries or opinion pieces or non peer-reviewed studies were also excluded. In addition, studies not published in English or not available in full-text format were excluded from the review. Decisions for data inclusion and exclusion were documented using the PRISMA chart.

Data screening

Title and abstract screenings of relevant papers were conducted according to the established criteria, focusing on the role of community-based peer education in the prevention of breast cancer.

Figure 1. PRISMA flow chart.

Data extraction

Three authors independently extracted data from the selected articles using a data extraction form. This form was developed and pilot-tested on three articles, after which no further modifications were necessary. Extracted information included authors, publication year, study objectives, role of community-based education on breast cancer prevention, benefits, challenges and limitations of community-based education, as well as recommendations for their implementation. To ensure accuracy and completeness, a fourth reviewer verified the extracted data. The collected data were then synthesised thematically to identify patterns, trends and gaps within the literature.

Results

Search results

A total of 818 studies were retrieved from the database search. After removing 324 duplicates, 494 studies remained for title and abstract screening. Of these, 356 studies were excluded, leaving 138 studies for full-text review. Subsequently, 120 studies were excluded for reasons such as publication year, lack of full text, inappropriate setting or wrong target population. Ultimately, 18 studies were included in this review (Figure 1).

Study location

Thirteen (n = 13) of the included studies were conducted in the USA [12–24], while one study each was carried out in Canada [25], India [26], Malaysia [27], Mexico [28] and Nigeria [2]. According to World Bank [30], these studies were conducted in high-income countries, upper-middle income countries and lower-middle income countries.

Study characteristics

Table 1 provides a detailed description of the characteristics of the included studies. The majority (n = 13) were published between 2012 and 2019, while five (n = 5) were published between 2020 and 2023. All included studies are primary research and comprise qualitative studies (n = 4), quantitative studies (n = 2), mixed-methods studies (n = 4), surveys (n = 5) and pilot studies (n = 2).

Study participants

All participants in the included studies were female. The categories represented were African American (n = 5) [12, 13, 15, 19, 20], Chinese American (n = 2) [17, 21], Native American (n = 1) [16], Latin immigrant (n = 1) [24], Black and Latina women (n = 1) [23], Spanish-speaking Latinas (n = 1) [14] and immigrants (n = 1) [25].

Structure, strategy and delivery of peer education

Peer education in the studies included in this narrative review was implemented through a variety of structures, strategies and delivery systems (Table 2). The selection of peer leaders varied across studies: some were chosen through application and interview processes [25], while others emerged from community-led initiatives [18], community engagement and partnerships [22, 23] or volunteered for the role [26, 28]. In several studies, community health extension workers (CHWs) also served as peer leaders [17, 18, 24, 27]. Regardless of their selection method, all peer leaders received training to prepare them for their roles.

A range of educational materials and tools were utilised to support peer education. These included videos [13, 17, 18, 21], manuals [13, 24], PowerPoint presentations [14, 25] and demonstrations [16, 23, 26, 28].

The delivery methods were equally diverse. Group discussions [17, 21, 22, 23], virtual sessions [13, 27], focus groups [28], house-to-house visits [26] and teaching sessions [16, 22, 24] were all employed to engage participants and facilitate knowledge transfer. The studies demonstrate that peer education can be effectively adapted to different contexts through flexible selection processes, comprehensive training, varied educational resources and multiple delivery channels.

Impact of peer education in the prevention of breast cancer for community-based peer education interventions

Findings from multiple studies consistently demonstrate that peer education significantly enhances breast cancer awareness, knowledge, screening uptake, positive health behaviours and empowerment particularly in underserved communities (Table 3). For example, study by Ahmad et al. [24] reported that 48% of immigrant women in Canada who were previously under- or never-screened underwent mammograms following peer-led education. Similarly, findings from a study observed a dramatic increase in breast cancer screening rates, rising from 4.4% to 67.6% after the intervention [29]. In Latino communities, it was found that promotores (community-based peer educators) effectively increased awareness and screening by addressing linguistic and cultural barriers [14]. Findings from a study noted that 72% of women educated by lay breast health educators completed recommended screenings [23].

Table 1. Geographic distribution, objectives and focus areas for community-based peer education interventions.

Table 2. Study design, target groups and delivery approaches for community-based peer education interventions.

Table 3. Outcomes, contextual influences, implementation barriers and enablers and key recommendations.

Culturally tailored peer-led interventions also yielded positive outcomes in Native American populations; findings reported an increase in the intention to undergo annual mammography from 81.1% to 94.6% [16]. Likewise, there was documented improvements in spiritual well-being, hope and patient-provider communication among African American breast cancer survivors who participated in peer support programs [15].

Regarding follow-up, studies by [23, 25, 26] monitored participants using phone calls, while [27] conducted a 4-month follow-up. These follow-up strategies likely contributed to the observed increases in screening uptake.

Challenges and facilitators associated with peer education approach

Despite promising outcomes, several challenges were identified across the studies. Rodriguez et al [25] reported tensions among peer educators as they struggled to balance their roles as both experts and community members. Baethge et al [13] found that although participants gained confidence in motivational interviewing (MI), mastering reflective listening and managing time constraints remained difficult. Barriers such as mistrust, lack of insurance and limited reach of educational resources were highlighted by [20, 24]. In rural India, [26] identified cultural taboos, low literacy levels and limited access to trained healthcare providers as significant obstacles. Similarly, [23] noted challenges in peer retention, transportation and screening attendance in the U.S., often linked to fear, undocumented status and systemic barriers.

Several facilitators enhanced the effectiveness of peer education programs. A key factor was cultural and linguistic alignment between educators and participants, which fostered trust and relatability, as reported by [14, 17]. Programs grounded in faith or cultural traditions, such as those described by [12, 22], benefited from community familiarity and moral authority. The use of culturally tailored tools including bilingual videos [21], storytelling and art [16] and breast models for demonstration [26] further supported effective learning. Additionally, comprehensive training and mentorship, as demonstrated by [24, 25], equipped peer educators with practical skills and structured educational materials, enhancing program delivery.

Factors influencing effectiveness of peer education

Community-based peer education interventions have proven highly effective in promoting breast cancer prevention among underserved women in diverse settings. A key factor was cultural and religious alignment between peer educators and participants, which fostered trust and helped overcome barriers like modesty, fatalism and stigma [15, 22, 23], Faith-based programs, such as mosque-centered education, notably increased women’s willingness and confidence to seek screening.

Language adaptation and literacy-sensitive approaches were also vital. [26] reached over 218,000 rural women using local languages, visual aids and storytelling, identifying numerous suspect cases. Similarly, [14, 25] found that materials tailored for low-literacy audiences improved understanding and retention.

Trust and community embeddedness consistently boosted participation. Engaging respected local figures, including breast cancer survivors and community health workers, led to substantial increases in screening uptake. For example, [29] reported cervical cancer screening rates rising from 3.2% to 67.6%, and clinical breast exams from 4.4% to 67.6%. Padela et al [23] found 72% mammography completion among women recommended by peer educators.

Effective training and ongoing mentorship enhanced peer educators’ knowledge and program adherence [17, 25]. Practical support, such as free screening, transport assistance and community-based sessions further increased participation, especially among low-income women [16, 29].

While cultural and behavioural factors are critical in shaping the effectiveness of peer education, system-level determinants also play a significant role in influencing outcomes. The availability and accessibility of early detection and diagnostic services, proximity of health facilities, cost of screening or treatment and trust in healthcare providers can all impact whether participants are able to act on the knowledge and motivation gained through peer-led interventions. Studies showed that even when peer education successfully increases awareness and intention to screen, structural barriers such as transportation challenges, financial constraints and limited healthcare infrastructure can limit actual uptake of services [23, 26, 28]. Integrating these system-level considerations into program design through strategies such as mobile clinics, subsidised screening, navigation support and partnerships with trusted healthcare providers can enhance the reach, uptake and sustainability of peer education interventions across diverse contexts.

Recommendations for designing peer education model

The studies included in this review offer several key recommendations for designing effective peer education models. First, lay health community-based programs should be integrated with strong collaborative partnerships within the community to enhance reach and acceptance [12, 23]. Peer education should incorporate multicomponent community education and navigation interventions to encourage positive health actions, often leveraging religious concepts to increase relevance and engagement [22, 27].

A train-the-trainer approach is recommended to build capacity, ensuring peer educators receive comprehensive training supported by appropriate educational materials and ongoing support [13, 14, 17, 24]. Additionally, delivering peer education through home visits or house-to-house outreach, coupled with the provision of preventive services at primary health care centers, can improve accessibility and uptake [29]. Overall, these recommendations emphasise the importance of community collaboration, culturally relevant content, capacity building and accessible delivery methods to maximise the impact of peer education programs.

Discussion

This paper provides a comprehensive analysis of studies employing peer education as a tool for community breast cancer prevention. The rising incidence of breast cancer among women has driven researchers to develop educational interventions aimed at improving knowledge, beliefs and screening uptake.

The first objective of this review was to examine the structure, strategies and delivery methods of peer education programs in community settings. Findings show that peer educators primarily deliver training through group discussions [17, 21–23], supported by videos [13, 17, 18, 21], practical demonstrations [16, 23, 26, 28] and PowerPoint presentations [14, 25]. This aligns with [31], who reported interventions delivered either one-to-one or in groups. The results confirm the transformative role of peer education, especially among marginalised populations. Peer-led models effectively overcome cultural, linguistic and socioeconomic barriers by leveraging trusted community members. The grade or level of English used in the included studies was not explicitly stated; however, all studies employed culturally tailored interpersonal education approaches. This may be because most of the studies were conducted in the United States and Canada, which are Western and high-income settings with relatively homogeneous English language proficiency. In contrast, within the Low- and- Middle Income Country context such as Nigeria, the use of indigenous languages is often more effective for community-based interventions. This is supported by the findings of [32], who reported that during the critical COVID-19 period, health communication delivered in indigenous languages significantly enhanced the population’s understanding and engagement. Dramatic increases in screening rates from under 5% to over 60% in some studies [23, 29] demonstrate its impact. Beyond behaviour change, peer education fosters empowerment and agency among both educators and participants [15, 25]. Effectiveness is enhanced when educators share ethnic, faith or linguistic backgrounds with their audiences, acting as trusted messengers and cultural interpreters [14, 22]. Embedding sessions in familiar settings like churches, mosques or tribal centers and incorporating local art, food and storytelling also increases participation [12, 16]. These findings are supported by [33], who showed peer education improves health-related knowledge, and [34] who found significant gains in adolescent knowledge and behaviours through peer education.

Despite their promise, peer education interventions face challenges. Role confusion among educators in close-knit communities can cause strain, necessitating training that addresses boundary management and ongoing support [25]. Logistical barriers such as transportation and lack of insurance limit participants’ ability to act on education, risking stagnation at awareness without behaviour change. Cultural sensitivities may also restrict discussion of breast health, especially if educators are unprepared [24, 26]. These issues highlight the need for adaptable, context-specific approaches rather than one-size-fits-all models. Successful programs emphasise cultural competence, community ownership and structural support. Also, it is crucial to involve men in the intervention. Studies by [35] revealed that involving men in the intervention produces better results as they provide emotional and psychological support.

Structured and ongoing training, along with mentorship, are essential to maintain program fidelity and educator confidence [17, 25]. This is echoed by [36], who emphasised that peer education and counselling succeed only when organisational factors are well managed and cultural contexts respected. Attention to program structure, management, training, supervision, support, monitoring and retention is critical for effective peer education initiatives. Community collaboration, culturally relevant content, capacity building and accessible delivery methods should be carefully considered when designing peer education models to maximise their impact. Co-creation of intervention materials with community involvement is a collaborative and democratic approach that recognises both community members and professionals as equal partners in developing community-based peer education [37]. This approach has been applied across a variety of healthcare settings and with diverse patient populations to design person-centered interventions that respond to patient-identified needs. Its application in community-based education is similarly expected to enhance relevance, acceptability and effectiveness.

Although most of the studies included in this review were conducted in high- or middle-income countries, their findings can be adapted to lower-resource settings, such as Nigeria. Translation of these interventions requires culturally relevant content, accessible delivery methods and strong community collaboration. Additionally, local health system constraints, resource limitations and factors such as availability of early detection services, transportation challenges and trust in healthcare providers must be considered to ensure program feasibility, acceptability and effectiveness. Incorporating these adaptations can help bridge the gap between evidence from higher-income settings and practical implementation in Nigerian communities, enhancing the relevance and impact of community peer education interventions.

Implications for practice and recommendations

Based on the findings of this review, the following recommendations are proposed:

1. Integrate peer education into community structures. Leveraging women’s groups, religious networks, cooperatives and other established community organisations enhances credibility and participation [23, 25]. Implementation should engage community-embedded peer educators, CHWs, local survivor-led groups, faith-based educators, and existing health structures.

2. Provide structured training, mentorship and supervision. Clear guidance and support reduce role ambiguity and strengthen program delivery [17, 25]. Training should be delivered by program supervisors, research teams, health-education institutions and advisoryboard-guided trainers.

3. Mitigate logistical and cultural barriers. Transportation challenges, stigma, and other contextual barriers [24, 26] can be addressed through flexible, community-based program designs. CHWs, local health facilities and community educators can manage operational challenges, while policymakers address financial and systemic constraints.

4. Adapt evidence-based models to local contexts. Successful interventions from high-income settings should be tailored to align with local health systems and cultural norms. Researchers and program designers should collaborate with local health authorities, community stakeholders and grassroots health workers to ensure feasibility and acceptability.

Limitations

This review was limited by the predominance of studies conducted in high-income countries and methodological constraints such as small sample sizes and cross-sectional designs. These limitations reduce the direct generalizability of findings to low-resource settings. Nonetheless, by synthesising global findings and contextualising their relevance for Sub-Saharan Africa, this review contributes practical insights for adapting peer education locally. Future research should prioritise longitudinal and mixed-method designs in African and other resource-constrained settings to evaluate sustainability, scalability and long-term health outcomes.

Conclusion

This review adopted a narrative approach to examine the role of community-based peer education in breast cancer prevention. Through a systematic search of six databases, studies published between 2010 and 2025 were identified and screened using strict inclusion and exclusion criteria, ensuring a clear focus on peer-led interventions in culturally diverse and low-resource community settings. By incorporating qualitative, quantitative and mixed-methods studies, the review captured a nuanced understanding of strategies, challenges and contextual factors influencing intervention outcomes. Data extraction and thematic analysis enabled the identification of recurring patterns and effective practices. Findings highlight peer education as a culturally adaptable, cost-effective and community-driven approach to improving breast cancer awareness and early detection, particularly among underserved populations. This review also emphasises the importance of system-level considerations, including access to early detection and diagnostic services, proximity of healthcare facilities, affordability and trust in healthcare providers, as these factors influence the success of peer-led interventions. Based on the evidence, several recommendations emerge for policymakers and healthcare professionals: integrating peer programs into primary care and community health structures, establishing structured training and mentorship frameworks for peer educators, providing mechanisms to sustain engagement over time and ensuring adequate funding to maintain program reach and quality. Collectively, these strategies can enhance the effectiveness, scalability and sustainability of community-based peer education programs, ultimately contributing to improved breast cancer outcomes in diverse populations.

Author contributions

Conceptualisation and design: ROO, CMN, GOA, IOO, OA. Literature search: OA, ROO, CMN, IOO, GOA. Manuscript writing and editing: ROO, GOA, FAA, DA, SA, HAG, DA, IOO, CMN. Data Extraction and Synthesis: ROO, GOA, FAA, DA, SA, HAG, DA. Supervision: CMN, OA. Final approval of manuscript: All authors.

Conflicts of interest

The authors declared no conflicts of interest.

Funding

There was no external funding available for this study.

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