Background
Tanzania, like many other low-income countries, is experiencing chronic shortages of facility-based healthcare providers. It has four health professionals, including physicians, nurses and midwives, for every 10 000 people [
1], in contrast to the 25 health professionals per 10 000 people recommended by WHO for achieving adequate coverage of critical maternal, newborn and child health (MNCH) interventions [
2]. This acute shortage of health workers in Tanzania is stalling improvements in MNCH outcomes and threatening the country’s potential for achieving the Millennium Development Goals (MDGs).
The extreme shortages in human resources for health and the need to rapidly increase access to services led to a reconsideration of cadres such as community health workers (CHWs) in health systems. A CHW can be defined as any health worker carrying out functions related to healthcare delivery, trained in some way to deliver an intervention and having no formal professional or paraprofessional certificate or tertiary education degree [
3]. CHWs can be deployed to create demand for health services, support linkages to facilities and in some instances provide basic health services. In countries where effective CHW programmes are in existence, studies show that CHWs are successful in improving health service coverage, continuity of care and health outcomes [
3‐
7].
Despite the positive effects of CHW programmes, sustainability of these programmes remains a concern. Attrition rates range from 3.2 % to 77 % across different settings [
8]. High CHW-attrition rates lead to discontinuity in service provision, increased costs to recruit and train new CHWs and lost opportunities to build on work experience, resulting in diminished effects on health outcomes [
8]. Key factors contributing to attrition are low health worker motivation and satisfaction [
9].
Motivation can be defined as the “willingness to exert and maintain an effort towards organizational goals” and is regarded to develop in individuals as a result of the interaction between individual, organizational and cultural determinants [
10]. Job satisfaction is highly interrelated but distinct from motivation and is referred to as “
a pleasurable or positive emotional state resulting from the appraisal of one’s job or job experience” [
11].
Several factors influence motivation and job satisfaction among healthcare providers. Provision of financial incentives (including the possibility of future paid employment) and non-financial incentives are important for CHWs [
8,
12]. Non-financial incentives include community recognition and respect, acquisition of valued skills, personal growth and development, accomplishment, peer support and community factors like relations with communities and leaders [
13]. Other supportive CHW programme factors include frequent supervision and continuous training [
12].
Motivation and satisfaction are key not only for retention but also for performance. Better workforce performance is positively associated with higher job satisfaction, and low levels of job satisfaction adversely affect employee commitment and sequentially affect achievement of organizational objectives and performance [
14].
National context
In Tanzania, the use of CHWs dates back to the mid-1960s when medical auxiliaries and village medical helpers were trained to run health posts. This emphasis on promoting access to health services was reinforced in 1978 after the Alma Ata declaration, and in 1983, the Ministry of Health and Social Welfare (MOHSW) developed a guideline for training primary healthcare workers in every village. Thereafter, a number of NGO-led vertical programmes resulted in heterogeneous CHWs often working in an uncoordinated manner. The lifetime of these CHW programmes was quite short, with a median of 4 years, though programmes with dedicated financial support and/or a narrow disease focus had more longevity [
15].
In recent efforts to accelerate progress towards achieving MDGs 4 and 5, the Government of Tanzania laid a greater emphasis on the role of CHWs as articulated in the Primary Health Care Services Development Programme (2007–2017) and the National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths (one plan) [
14,
15]. In 2012, national guidelines and training materials were approved for Integrated MNCH CHWs [
16], with a pilot in Morogoro Region initiated soon after.
CHWs in this Integrated MNCH Programme are selected by village leaders through village meetings in collaboration with government health facility personnel using the following criteria: (1) at least a form IV education level, (2) willingness to work and live at the community level, (3) willingness to work on a voluntary basis and (4) acceptability by communities. After 3 weeks of training, the selected CHWs undertake antenatal and postnatal home visits to women of child-bearing age for health and nutrition counselling, early detection of pregnancy, recognition of danger signs and support for seeking facility-based antenatal, delivery and postnatal care. They also follow up newborns and children under 5 years with health promotion and preventive healthcare.
This study builds on prior qualitative research examining the motivation of CHWs in Morogoro Region [
17] before being selected and trained for the Integrated MNCH Programme. This study examines CHW motivation and satisfaction quantitatively across a larger number of CHWs and in light of a specific programme. The Government of Tanzania is in the process of developing a national cadre of CHWs who are expected to bridge the gap between communities and the health system. The results from this pilot programme aim to inform programme planners and their efforts to develop appropriate strategies to ensure sustainability of CHW programmes in Tanzania and beyond.
Results
MNCH CHW characteristics
A total of 228 of 238 (96 %) CHWs trained by the Integrated MNCH Programme prior to the study were interviewed with a median age of 32 (Table
1). Among respondents, 55 % were males, 51 % had completed secondary education and 60 % were married. The median household income among respondents was 50 000 TZS (US$ 29) per month, and the great majority (94 %) relied on farming as the main source of livelihood.
Table 1
Characteristics of 228 CHWs working for the Integrated MNCH Programme in Morogoro Region, Tanzania, in 2013
Sex |
Female | 45 % |
Age (years) |
Median (range) | 32 (19–61) |
<25 | 30 % |
25–35 | 33 % |
>35 | 37 % |
Marital status |
Married | 60 % |
Not married | 32 % |
Once married | 8 % |
Level of education |
Primary started but not completed | 2 % |
Primary education completed | 47 % |
Secondary education completed | 51 % |
Languages spoken |
Swahili | 100 % |
Tribal | 84 % |
English | 15 % |
Source of livelihood (not mutually exclusive) |
Agriculture (crops or livestock) | 94 % |
Non-agriculture | 14 % |
Wealth index mean (SD)a |
Lowest | −1.4 (0.47) |
Middle | −0.12 (0.41) |
Highest | 1.82 (1.15) |
Motivation
Exploratory factor analysis of motivational determinants scale (Table
2) yielded four factors labelled as i) extrinsic push; ii) skill utilization, respect and hope; iii) altruism; and iv) intrinsic needs, which together explained about 62 % of total variance.
Table 2
Exploratory factor analysis of motivational determinants for 228 CHWs working for the Integrated MNCH Programme in Morogoro Region, Tanzania, in 2013
I can continue working regardless of my age | 72 | 0.663 | | | |
Job gives greater autonomy | 66 | 0.828 | | | |
I can complete tasks without being told what to do | 65 | 0.519 | | | |
My family has asked me to volunteer | 40 | 0.657 | | | |
I am excused from shared community responsibility commitments | 35 | 0.553 | | | |
Financial incentives received | 4 | 0.553 | | | |
This work gives me respect in the community | 78 | | 0.405 | | |
This job gives me the opportunity to use my skills | 66 | | 0.536 | | |
For hoping to get more formal job from the government | 45 | | 0.511 | | |
There are no other employment opportunities | 37 | | 0.778 | | |
I am proud to work with the Integrated MNCH CHW Programme | 97 | | | 0.560 | |
I want to make my community better | 97 | | | 0.638 | |
This work gives me the opportunity to improve the health of others | 91 | | | 0.757 | |
I want to help my fellow neighbours | 82 | | | 0.565 | |
This work is focused on maternal and child health | 90 | | | | 0.475 |
By serving my community, I am serving God | 86 | | | | 0.593 |
I am a hard worker | 70 | | | | 0.790 |
% variance explained | | 21.95 | 16.08 | 13.01 | 10.66 |
Cronbach’s alpha | | 0.76 | 0.69 | 0.58 | 0.50 |
Mean out of 4 | | 1.89 | 2.11 | 3.31 | 3.12 |
SD | | 0.06 | 0.06 | 0.04 | 0.05 |
The first factor was a varied combination of extrinsic stimuli including incentives received, autonomy at work, influence of family and job security. With the exception of a very few, most respondents (96 %) did not consider becoming a CHW due to the financial incentives offered. Among extrinsic stimuli, CHWs valued autonomy and job security in terms of lack of an age criteria as key reasons for becoming a CHW. On the whole, a mean score of 1.89 out of 4 for this factor suggests that most CHWs were less likely to be motivated by external stimuli.
The second factor included items pertaining to opportunities to use skills, respect received from the community attributed to the job and the potential of employment prospects. While a large proportion of CHWs were motivated by receiving community respect (78 %) and the opportunities to use skills (66 %), fewer CHWs chose to become health workers in the hope of formal government positions (45 %) or due to lack of other employment options (37 %). A mean score of 2.11 out of 4 for this factor suggests that it was more important than external stimuli but still only moderate.
In contrast to the first two factors, the other two factors generated from the motivational determinants scale had relatively high mean scale scores of 3.31 (altruism) and 3.12 (intrinsic needs) out of 4. Altruism corresponded with items on helping the community and improving its health, as well as pride in performing these services. Almost all respondents (82–97 %) reported to be motivated by altruism. The fourth factor included items pertaining to other intrinsic needs such as opportunity to serve God, working on maternal and child health and ability to perform tasks diligently, which was also reported as important by many CHWs (70–90 %).
Mean scale scores for motivation determinants were not significantly different between male and female CHWs. Similarly, no statistical difference was found between socio-demographic characteristics for the “extrinsic push” factor. On the other hand, mean scores for the remaining three factors (altruism; intrinsic needs; skill utilization, respect and hope) were found to be significantly higher for less educated and older CHWs. Mean score for the “skill utilization, respect and hope” factor was found to be greater for the relatively less wealthy respondents.
Satisfaction
Exploratory factor analysis of satisfaction according to the job attributes scale (Table
3) resulted in five factors being identified in positive and negative ways. These included the following: i) availability of job aides and registers, ii) capacity to provide services and support received, iii) training and relations at work, iv) availability of transportation and v) provision and quality of services, which altogether accounted for 63 % of total variance.
Table 3
Exploratory factor analysis of job satisfaction for 228 CHWs working for the Integrated MNCH Programme in Morogoro Region, Tanzania, in 2013
Monthly report register | 92 | 0.904 | | | | |
Mother, newborn and child health register | 91 | 0.876 | | | | |
Referral register | 91 | 0.902 | | | | |
Availability of the job aides | 90 | 0.400 | | | | |
Own capacity to meet the health services needs of the community | 81 | | 0.747 | | | |
Own knowledge competency to perform work | 71 | | 0.488 | | | |
Support provided by facility supervisor during visits to village | 65 | | 0.670 | | | |
Communication devices to communicate with health facilities | 41 | | 0.674 | | | |
Allowances and/or incentives received from the Integrated Programme | 14 | | 0.673 | | | |
Work relationships with health providers in the health centres | 97 | | | 0.710 | | |
Work relationships with health providers in dispensaries | 96 | | | 0.825 | | |
Relations as an Integrated Programme MNCH CHW with community leaders | 91 | | | 0.472 | | |
Level and quality of the training received from the Integrated Programme | 90 | | | 0.637 | | |
Own transport to provide services | 4 | | | | 0.871 | |
Own transport to the facility | 4 | | | | 0.882 | |
Quality of own work | 88 | | | | | 0.657 |
Services people receive in the referred health facilities | 79 | | | | | 0.711 |
Monthly meetings at the facility | 78 | | | | | 0.485 |
% Variance explained | | 16.93 | 14.06 | 12.51 | 10.35 | 9.98 |
Cronbach’s alpha | | 0.79 | 0.66 | 0.60 | 0.72 | 0.44 |
Mean out of 4 | | 3.27 | 2.18 | 3.29 | 0.38 | 3.00 |
SD | | 0.05 | 0.06 | 0.04 | 0.04 | 0.05 |
The first factor included the availability of a range of job aides and registers. It had a relatively high score of 3.27 out of 4, with a majority of respondents (over 90 %) satisfied with the availability of these tools. The second factor was a combination of capacity to perform at work and meet needs of the community, as well as support provided including communication devices, supervisory visits and allowances from the Integrated Programme. While a greater majority reported to be satisfied by their capacity to perform and meet community needs (71–81 %), they were dissatisfied by the support provided to them, especially in terms of allowances (14 %), resulting in a moderate mean score of 2.18 out of 4.
The third factor incorporated items on training received from the Integrated Programme and relations at work including those with healthcare providers working at dispensaries and health centres, as well as with community leaders. Almost all respondents were satisfied with work relations (91–97 %), and 90 % reported to be satisfied with the training received. This factor had the highest mean score of 3.29 out of 4, in contrast to the fourth factor related to the availability of transportation for travelling within their communities to provide services and to use when travelling to the health facilities. This fourth factor had a low score of 0.38 out of 4 suggesting a very high level of dissatisfaction among CHWs.
The fifth factor was an amalgamation of items pertaining to service provision and quality of work. CHWs reported being motivated by the services people received when referred to health facilities by them, the quality of their own work and their participation in monthly meetings at facilities. It had a relatively strong mean score of 3 out of 4.
Mean scale scores for each factor were not found to be significantly different between male and female CHWs. Mean scores for the fifth factor (service and quality) were found to be higher among older CHWs than younger CHWs although the difference was not statistically significant (Table
4). The mean score for the 5th factor were also significantly higher for CHWs who had completed primary education as compared to secondary education (Table
5). Findings also showed that satisfaction with availability of job aids was greater among CHWs in the highest asset thirtile (Table
5). No statistical difference was found between socio-demographic characteristics for other factors of job satisfaction.
Table 4
Differences between factors of job satisfaction and motivation determinants by sex and age for 228 CHWs working for the Integrated MNCH Programme in Morogoro Region, Tanzania, in 2013
Job satisfaction |
Job aides | 3.3 (0.6) | 3.2 (0.8) | 0.3417 | 3.3 (0.7) | 3.3 (0.6) | 3.3 (0.8) | 0.9931 |
Capacity and support | 2.2 (0.8) | 2.1 (0.9) | 0.2707 | 2.1 (0.9) | 2.3 (0.8) | 2.1 (0.9) | 0.3739 |
Job relations | 3.3 (0.5) | 3.2 (0.6) | 0.1792 | 3.3 (0.6) | 3.3 (0.5) | 3.3 (0.5) | 0.7880 |
Transport | 0.3 (0.6) | 0.4 (0.8) | 0.2068 | 0.5 (0.9) | 0.4 (0.5) | 0.3 (0.5) | 0.1061 |
Service and quality | 3.1 (0.7) | 2.9 (0.7) | 0.1927 | 2.9 (0.8) | 2.9 (0.7) | 3.2 (0.6) | 0.0211* |
Motivation determinants |
Extrinsic | 1.9 (0.9) | 1.9 (0.9) | 0.8678 | 1.8 (0.9) | 1.9 (0.9) | 2.0 (0.9) | 0.2711 |
Job availability | 2.2 (0.9) | 2.0 (0.9) | 0.3317 | 1.9 (0.9) | 2.0 (1.0) | 2.3 (0.9) | 0.0490* |
Altruism | 3.4 (0.6) | 3.2 (0.6) | 0.0924 | 3.2 (0.6) | 3.2 (0.6) | 3.5 (0.5) | 0.0002* |
Intrinsic needs | 3.2 (0.7) | 3.0 (0.7) | 0.1109 | 2.9 (0.8) | 3.2 (0.7) | 3.2 (0.7) | 0.0384* |
Table 5
Differences between factors of job satisfaction and motivation determinants by education and wealth status for 228 CHWs working for the Integrated MNCH Programme in Morogoro Region, Tanzania, in 2013
Job satisfaction |
Job aides | 3.2 (0.8) | 3.3 (0.6) | 0.323 | 3.0 (0.9) | 3.4 (0.6) | 3.4 (0.5) | 0.0026* |
Capacity and support | 2.1 (0.8) | 2.1 (0.9) | 0.9727 | 2.1 (0.8) | 2.1 (0.9) | 2.3 (0.7) | 0.1791 |
Job relations | 3.3 (0.5) | 3.3 (0.6) | 0.485 | 3.3 (0.5) | 3.3 (0.6) | 3.3 (0.5) | 0.8288 |
Transport | 0.4 (0.6) | 0.4 (0.7) | 0.6988 | 0.3 (0.5) | 0.4 (0.7) | 0.5 (0.6) | 0.1752 |
Service and quality | 3.1 (0.6) | 2.9 (0.8) | 0.0304* | 3.1 (0.7) | 2.9 (0.8) | 2.9 (0.6) | 0.0978 |
Motivation determinants |
Extrinsic | 1.9 (0.9) | 1.8 (0.9) | 0.1035 | 1.9 (0.9) | 1.8 (1.0) | 1.9 (0.9) | 0.8000 |
Job availability | 2.2 (0.9) | 1.9 (0.9) | 0.0317* | 2.4 (0.9) | 1.8 (1.0) | 2.1 (0.9) | 0.0015* |
Altruism | 3.4 (0.5) | 3.2 (0.6) | 0.0364* | 1.9 (0.8) | 1.8 (1.0) | 1.9 (0.9) | 0.1804 |
Intrinsic needs | 3.3 (0.6) | 2.9 (0.8) | 0.0041* | 2.4 (0.9) | 1.8 (1.0) | 2.2 (0.9) | 0.4067 |
Discussion
This study aimed to identify factors associated with motivation and satisfaction among a recently trained and deployed volunteer cadre of CHWs in Morogoro Region, Tanzania. CHWs were more likely to be motivated to become CHWs due to altruism (work on MNCH, desire to serve God, work hard) and intrinsic needs (help community, improve health, pride) than due to external stimuli (monetary incentives, skill utilization, community respect or lack of professional alternatives). Factors strongly associated with CHW satisfaction included relationships with health workers and communities, the availability of job aides and the capacity to provide services and with the training. On the other hand, CHWs were highly dissatisfied with the unavailability of transportation for carrying out their tasks and the lack of allowances or financial incentives. Factors associated with motivation and satisfaction did not substantially differ across socio-demographic CHW characteristics, although CHWs who were older and less educated were more likely to report motivation and job satisfaction.
Findings of this study pertaining to motivation behind becoming a CHW corroborate those previously reported from Morogoro. Qualitative research found that strong altruistic motivation was not incompatible with the importance of financial compensation of some kind, particularly considering the vulnerable livelihoods among these communities [
25]. In other settings, for example, in Bangladesh, the reasons respondents chose to become CHWs included a desire to improve community health and to serve women and children and not aspirations for financial independence [
26]. Trust-based relationships with rural communities, an altruistic motivation to serve rural people and sound health knowledge and skills were reported to facilitate successful implementation of CHW programmes in Iran [
27].
The strongest satisfaction factor for CHWs was related to work relations with varied CHW stakeholders and training. Similarly, a study conducted in Nepal found that one of the most enabling factors for the sustainability and scaling up of CHW programmes was integration of CHWs with the health system and existing healthcare providers [
28]. Community support has been found to be critical for making CHWs feel welcome, acceptable and appreciated in the communities where they provide services in various settings [
8,
29]. With regard to training, technically strong and relevant training valued by CHWs and respected by communities has been reported to be an important factor for satisfaction, retention and motivation of CHWs in other low- and middle-income countries as well [
8,
30‐
32]. Increased training corresponding to a broader scope of work and, in particular, having more curative tasks may too increase motivation, service delivery time and time spent working [
12].
Another strong factor for satisfaction, the availability of job aids and registers, indicated the importance CHWs attach to having necessary supplies to carry out their tasks effectively. Other studies have also reported the availability of job aids as critical, whether in improving the efficiency of their tasks and in supporting communication with beneficiaries [
8,
17,
33]. The capacity to provide services and receive support was also a strong satisfaction factor. Studies have documented similar findings reflecting “personal satisfaction about their contribution to the work”, self-efficacy (able to handle tough situations, solve problems, feel emotionally and physically perfect on work) and self-esteem as factors influencing satisfaction [
25,
30,
31,
34].
While CHWs reported to be highly satisfied by their capacity to meet needs of the community, they were dissatisfied by the specific types of support that had not been adequately provided to them (allowances, supply of communication devices and transportation). Dissatisfaction with support received, particularly financial compensation, has been found in other low-resource settings [
25,
33‐
37] as well as in the same region in Tanzania in a prior study [
38]. Financial incentives have also been reported as dominant motivating factors for retention of these providers [
26,
39].
Similar to other settings [
39], lack of availability of transport for travelling to households and health facilities also appeared to have caused discontentment among CHWs. This can be attributed to the fact that CHWs in Morogoro Region have to travel across an expansive and difficult terrain, making it both strenuous and time-consuming to complete scheduled household visits without readily available transportation. The programme had promised to give the CHW bicycles to facilitate movement during care provision. However, it was not possible to follow through on this promise in a timely manner, and the survey was conducted before they received them.
Limitations of the study
The study was conducted as part of a larger study to evaluate the Integrated Programme and the CHWs who worked with it. There is therefore a possibility of desirability bias in the responses received, particularly around altruistic motivations for being a CHW. Attempts were made to reduce this by assuring respondents of confidentiality and by using investigators external to the programme. The study did not interview community members to share their experiences about the performance of CHWs. This could have helped to better understand community perceptions of CHWs’ performance and hence assess strengths and weaknesses of the Integrated Programme. Although scale items for both job satisfaction and motivation were selected based on discussions with key stakeholders and an extensive literature review, additional qualitative approaches to check face and content validity were not carried out. Although these results closely match those obtained from a qualitative study conducted in the same setting previously [
38], concurrent qualitative research or further field testing of the items could have resulted in increasing the total variance explained by the scale.
In addition, a global or overall item of motivation or satisfaction was not included in the scale, limiting the ability to measure correlations between different facets of these constructs with an overall score. The grouping of a few items resulting from factor analysis, for example, the fifth factor for job satisfaction, included heterogeneous items, which collectively did not necessarily represent a composite factor. This could provide a possible explanation for the low value of Cronbach’s alpha for this particular factor. Similarly, the fourth factor of motivation (intrinsic needs) determinants also includes unrelated factors. Testing the psychometric properties of the reduced scales obtained for both job satisfaction and motivation in this study could improve further research inquiry in similar settings.
Implications
This study has significant policy and programmatic implications for the current CHW programme in Morogoro Region, as well as its scale up to other parts of Tanzania and other low- and middle-income countries. The fact that the CHWs were selected from and by their own communities may have contributed to high levels of satisfaction with relations with co-workers and community members. The importance of interpersonal relations with health workers for CHWs is also an important finding, pointing to the importance of elements such as trust in health worker performance [
40,
41].
The CHWs interviewed during this study were from a government programme supported by external technical assistance and had access to essential working tools such as job aides and registers to record patient information. The importance CHWs attached to training in this programme, by highly qualified trainers, instilled performance confidence among the trainees. Sustained availability of working tools and training will ensure high satisfaction among the current cadre of CHWs and is likely to attract others into the workforce in the future.
On the other hand, this study suggests that the current programme did not at the time of the survey provide adequate transportation and monetary compensation to CHWs. In order to improve coverage of visits to target households as per the recommended schedule, given the large catchment area under each CHW, the current and future programmes should strive towards ensuring means of transport or equivalent monetary resources to CHWs. While findings suggest that CHWs were more likely to join this profession due to altruism and to meet their intrinsic needs, they became dissatisfied by the lack of financial incentives offered to them. This result could be due to the growing demands on their time, comparisons that may be drawn with other community level cadres that are paid and/or the desire to contribute to their household income – an activity that programme engagement may detract from. Thus, CHW programmes should also advocate for financial incentives for this cadre either in the form of a salary or stipends to influence both job satisfaction and motivation and consequently the attrition rate [
38,
42].
Further research
In 2015, it is anticipated that the government of Tanzania will initiate a national CHW programme. While this study highlights several key determinants of motivation and satisfaction that need to be considered, additional research is warranted to better understand nuances regarding intrinsic vs extrinsic motivations to enlist as a CHW and levels of monetary compensation to ensure their job satisfaction. The relationship between job satisfaction and performance should also be studied in greater detail for this specific context. Future research should also consider further scale refinement and larger sample sizes to support subgroup analyses of interest.
Acknowledgements
This study was supported by USAID through the Health Research Challenge for Impact (HRC) Cooperative Agreement (#GHS-A-00-09-00004-00). The contents are the responsibility of JHSPH and MUHAS and do not necessarily reflect the views of USAID or the United States Government.
The following are acknowledged for their contribution in one way or another during the planning, data collection and data management and during the development of this manuscript.
JHSPH: Gupta Shivam, Joy Chebet
MUHAS: Aisha Omary, Patrick Kazonda and the data collectors,
Jhpiego: Giulia Besana, Elaine Charurat, Dunstan Bishanga, Maryjane Lacoste, Chrisostom Lipingu
MOHSW: Neema Rusibamayila, Georgina Msemo
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
AB and JK are the principal investigators of the Morogoro Evaluation Project from which data were collected. AL, DC, JK, RM, DU, CK, PW and AB developed data collection instruments. RM, DC, CK, AL, JK and PW supervised data collection. RM, AB and AL wrote the first draft of the paper with contributions from AG and inputs from RMdee, HS and all other authors. All authors reviewed the manuscript and approved it for submission.