COVID-19 Medicaid Continuous Enrollment Provision Yielded Gains In Postpartum Continuity Of Coverage.

The Medicaid continuous enrollment provision mandated by the Families First Coronavirus Response Act of 2020 effectively prohibited the termination of enrollees from Medicaid during the COVID-19 public health emergency, including people enrolled in Medicaid during pregnancy. Using data from the Transformed Medicaid Statistical Information System, we found that the rate of continuous Medicaid enrollment during the twelve months postpartum increased from 59.3 percent for births during March-December 2018 to 90.7 percent for births during March-December 2020, when the public health emergency was in effect. This corresponds to approximately 430,000 fewer people losing Medicaid coverage after pregnancy and an average of more than 2.5 months of additional postpartum enrollment. These findings indicate that states that have extended or that plan to extend pregnancy-related Medicaid eligibility in the postpartum year are likely to experience significant gains in continuity of coverage.

Association between racial iniquities and oral health status: a systematic review. / Associação entre iniquidades raciais e condição de saúde bucal: revisão sistemática.

The present study aimed to investigate the association between racial iniquities and oral health status. This is a systematic review with a protocol registered on the Prospero Platform (CRD42021228417), with searches carried out in electronic databases and in gray literature. Our study identified 3,028 publications. After applying the eligibility criteria and risk of bias analysis, 18 studies were selected. The results indicate that individuals of black/brown race/skin color have unfavorable oral health conditions, mainly represented by self-rated oral health, tooth loss, caries, and periodontitis. The results showed racial iniquities in oral health in different countries, for all analyzed indicators, with a greater vulnerability of the black population.

O objetivo deste estudo é investigar a associação entre iniquidades raciais e condição de saúde bucal. Trata-se de revisão sistemática com protocolo cadastrado na plataforma prospero (CRD42021228417), com buscas realizadas em bases de dados eletrônicas e na literatura cinzenta. Identificou-se 3.028 publicações e após aplicação dos critérios de elegibilidade e análise do risco de vieses, 18 estudos foram selecionados. Os resultados indicam que indivíduos de raça/cor da pele preta/parda apresentam condições de saúde bucal desfavorável, representada principalmente pela autoavaliação de saúde bucal, perda dentária, cárie e periodontite. Os resultados evidenciaram iniquidades raciais em saúde bucal em diferentes países, para todos os indicadores analisados, com maior vulnerabilidade da população negra.

Revisiting the lung cancer screening eligibility criteria to promote equity for Black individuals.

BACKGROUND: Early detection using low-dose computed tomography reduces lung-cancer-specific mortality by 20% among high-risk individuals. Blacks are less likely than Whites to meet lung cancer screening (LCS) criteria under both the former and the updated United States Preventive Services Task Force (USPSTF) guidelines. The purpose of this study was to assess racial disparities in LCS eligibility and to propose tailored eligibility criteria for Blacks to enable equitable screening rate between Whites and Blacks. METHODS: Data for this study were obtained from the Behavioral Risk Factor Surveillance System (2017-2021). 101,552 subjects were included in the final analysis. By employing a systematic approach, we sought cut-off points at which Blacks were equally likely as Whites to be eligible for LCS. We evaluated the minimum age and smoking pack-years for Blacks while we retained the 2021 USPSTF criteria for Whites. The final decision was based on the minimum Wald's Chi-square statistics. RESULTS: The model we employed identified cut-off points at which Blacks were equally likely as Whites to be eligible for LCS. Retaining the 2021 USPSTF criteria for Whites, the model discovered a new pair of points for Blacks by reducing the minimum age to 43 years and decreasing the cumulative number of cigarettes smoked to 15 pack-years. Based on these cut-off points, we created tailored criteria for Blacks. Under the tailored criteria, Blacks (OR: 1.00; 95 %CI: 0.88-1.14) had the same odds of eligibility for LCS as Whites. The odds of eligibility for LCS by sex under the tailored criteria did not differ significantly for Black men (OR: 1.02; 95 %CI: 0.85-1.24) and Black women (OR: 0.95; 95 %CI: 0.81-1.12) compared to their respective White counterparts. CONCLUSIONS: These tailored criteria for Blacks eliminate the disparities between Blacks and Whites in LCS eligibility. Future studies should test the sensitivity and specificity of these tailored criteria.

Medicare Eligibility and Reported Support for Proposals to Expand Medicare.

This study estimates the association between Medicare eligibility and support for recent proposals to expand program participation and benefits.

Medicare Part D low-income subsidies expanded in January 2024, but more needs to be done to ensure that eligible beneficiaries enroll.

BACKGROUND: The Inflation Reduction Act of 2022 extended full low-income subsidies (LIS) to a small group of Medicare Part D recipients with limited assets and incomes between 135% and 150% of the Federal Poverty Level beginning in January 2024. This policy may result in small enrollment gains among beneficiaries eligible for the new benefits, but the biggest problem with the current LIS program is underenrollment across all eligibility groups. Prior research has shown that underenrollment has been a persistent problem since the LIS program began in 2006, yet little has been done to correct the situation. OBJECTIVE: To identify individual-level factors associated with failure to enroll among low-income beneficiaries eligible for both full subsidies and partial subsidies under the LIS program. METHODS: We used 2019 Medicare Current Beneficiary Survey data for the study. The Medicare Current Beneficiary Survey is uniquely suited for this work because it contains administrative data on LIS enrollment plus extensive survey information on financial resources necessary to establish program eligibility. We conducted descriptive and multivariate analyses to identify factors associated with failure to enroll when eligible for either full or partial subsidies. Explanatory variables included sociodemographic characteristics, economic resources, work status, health variables, and source of prescription coverage (for nonsubsidized beneficiaries). RESULTS: In 2019, 73% of beneficiaries eligible for full subsidies under pre-Inflation Reduction Act LIS provisions were enrolled, compared with only 25% eligible for partial subsidies. The number of those estimated to be eligible for full subsidies but not enrolled (N = 3.9 million) was more than double that of those eligible but not enrolled for partial subsidies (N = 1.5 million). Factors associated with failure to enroll (older age, male sex, White race, married, higher education, higher income and assets, and excellent/very good health status) were similar for both groups. In multivariate analyses, the single strongest predictor of failure to enroll was receipt of income from work (odds ratio = 5.50; P < 0.001). Among the nonenrolled, 64% eligible for full subsidies and 75% eligible for partial subsidies maintained unsubsidized Part D coverage. CONCLUSIONS: Significant numbers of low-income Medicare beneficiaries are eligible for Part D subsidies but fail to enroll. Common characteristics distinguishing nonenrollees from enrollees include older age with higher proportions of White individuals, married individuals, higher income and assets, and better overall health. Two promising targets for increasing LIS enrollment are evidence of work income and unsubsidized Part D coverage.

The effect of Medicare eligibility on diagnosis of chronic conditions.

OBJECTIVES: The near-universal access to Medicare coverage at age 65 years improves access to care. However, little is known about whether Medicare eligibility promotes the diagnosis of chronic diseases. We examined the effects of Medicare eligibility at age 65 years on the diagnosis of chronic conditions. STUDY DESIGN: Using data from the 2007-2019 Medical Expenditure Panel Survey, we employed a regression discontinuity design. METHODS: Our sample includes 43,620 individuals aged 59 to 71 years. Our primary outcomes were diagnoses of 19 chronic conditions. Using a regression discontinuity design, we exploited the discontinuity in eligibility for Medicare at age 65 years and compared individuals just before and after age 65 years. RESULTS: Medicare eligibility at age 65 years led to significant increases in having any coverage or Medicare coverage: 8.8 percentage points (95% CI, 8.4-9.2) and 78.1 percentage points (95% CI, 74.9-81.4), respectively. However, there were no or small changes in the diagnosis of chronic conditions at age 65 years. Specifically, there were no significant changes in the diagnoses of 17 chronic conditions, and the changes were minor in magnitude. Significant changes were observed only in the diagnosis of stroke and cancer, at -0.6 percentage points (95% CI, -1.0 to -0.2) and -1.7 percentage points (95% CI, -2.8 to -0.6), respectively. CONCLUSIONS: Our findings suggest that Medicare coverage did not necessarily lead to increased diagnosis of chronic conditions. Further research is necessary to explore the underlying mechanisms behind this observation.

The effects of medication therapy management on medication utilization among Medicare beneficiaries with HIV/AIDS.

BACKGROUND: Medicare Part D plans are required to provide medication therapy management (MTM) programs to eligible beneficiaries to optimize medication utilization. MTM programs' effects on medication utilization among older persons living with HIV/AIDS (PLWHs) remain unclear. OBJECTIVE: This study examined the effects of the Medicare MTM programs on medication utilization among PLWHs. METHODS: This study analyzed 2017 Medicare databases linked to the Area Health Resources Files. Recipients and nonrecipients of the MTM services were compared on their medication utilization: adherence to antiretroviral medications, drug-drug interactions (DDI), and concurrent use of opioids and benzodiazepines. The intervention group comprised recipients of the MTM services, and the control group was nonrecipients meeting the eligibility criteria. A propensity score with a ratio of 1:2 between the intervention and control groups was used to identify study groups with balanced characteristics. A logistic regression was used to control for patient/community characteristics. RESULTS: After matching, the intervention and comparison groups comprised 3298 and 6596 beneficiaries for the antiretroviral adherence measure, 809 and 1618 for the DDI measure, and 691 and 1382 for the concurrent use of opioids and benzodiazepines measure. The intervention was associated with higher odds of adherence to antiretroviral medications (adjusted odds ratio = 1.15, 95% CI = 1.04-1.26), and no concurrent use of opioids and benzodiazepines (adjusted odds ratio = 1.255, 95% CI = 1.005-1.568). The study groups did not differ on no DDI (adjusted odds ratio = 0.95, 95% CI = 0.74-1.20). CONCLUSIONS: Medicare MTM programs effectively improved medication utilization among PLWHs. Future studies should explore the long-term effects of the program.

How Medicaid Financial Eligibility Rules Exclude Financially and Medically Vulnerable Older Adults.

Millions of older Americans rely on Medicaid because it is the largest payer of long-term services and supports. To qualify for the program, low-income individuals age 65 and over must meet income standards based on the dated Federal Poverty Level as well as asset tests that are often viewed as quite stringent. There has long been concern that current eligibility standards exclude many adults with significant health and financial vulnerabilities. We use updated household socio-demographic and financial information to simulate the impacts of five alternative financial eligibility standards on the number and profile of older adults that would gain Medicaid coverage. The study clearly demonstrates that a large number of financially- and health-vulnerable older adults are excluded from the Medicaid program under current policy. The study highlights the implications for policymakers of updating Medicaid financial eligibility standards to assure that Medicaid benefits are targeted to vulnerable older adults who need them.

What the Evolution of 1332 Waivers Tells Us about Their Innovative Potential.

Section 1332 of the Affordable Care Act (ACA) provides states unprecedented flexibility to alter federal health policy. The authors analyze state waiver activity from 2019 to 2023, applying a comparative approach to understand waivers proposed by Georgia, Colorado, Washington, Oregon, and Nevada. Much of the waiver activity during this period focused on reinsurance programs. During the Trump administration, the most innovative waiver application was from Georgia, which sought to restructure and decentralize its individual market, moving away from the framework established by the ACA. While the Biden administration suspended Georgia's efforts, Democratic-led states have focused implementing waiver programs supporting and expanding on the ACA. This has included adopting public-option insurance plans offered by private insurers and expanding eligibility for qualified health plans for previously ineligible groups. The authors' analysis offers insights into contemporary health politics, policy durability, and the role of the administrative presidency.

Special Education Assessment: Practices That Support Eligibility and Intervention.

PURPOSE: Federal special education requirements specify that information districts must gather and review during the process of finding a student eligible for special education and developing a student's Individualized Education Program (IEP). The purpose of this tutorial is to describe the federal requirements related to evaluation and assessment and to apply best practices in assessment to those expectations, thereby enhancing teams' ability to identify students' strengths and needs, determine eligibility for services, and create high-quality IEPs. METHOD: This tutorial includes a detailed review of the Individuals with Disabilities Education Act (IDEA) statute and regulations and the U.S. Department of Education guidance related to evaluation, assessment, and IEP development. The tutorial also reflects on an analysis of existing data regarding the identification of students with speech-language impairment in one state and a narrative review of the current literature related to assessment and its role in intervention planning. RESULTS: The results indicate that the IDEA requires rigorous evaluation and assessment practices to determine eligibility (evaluation) and identify students' unique strengths and needs for intervention (assessment). By adhering to these requirements and employing evidence-based assessment practices, speech-language pathologists (SLPs) can be assured that they are gathering accurate and useful information. This information is fundamental to developing an IEP that will support students' acquisition of the knowledge and skills needed to progress in the general curriculum. CONCLUSIONS: This tutorial reviews federal requirements related to assessment and links these with best practices in assessment, to facilitate compliance with federal evaluation requirements and IEP development in a manner that meets the needs of all students. SLPs can rely on the IDEA for guidance in completing their special education evaluations and assessments, using this as a framework for employing evidence-based assessment practices.

Social determinants of alcohol-related traumatic injury in young adults: a scoping review protocol.

INTRODUCTION: Limited research examines alcohol-related injury in the context of social determinants of health (SDoH) to guide effective intervention and prevention programmes. SDoH are non-medical factors that impact health such as income, housing and childhood environment. This scoping review aims to explore the role SDoH in childhood have in alcohol-related injury in young adults. METHODS AND ANALYSIS: The scoping review process will be guided by the methodology framework of Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols Extension for Scoping Reviews Guidelines (PRISMA-ScR). The PubMed and SCOPUS databases will be systematically searched. Studies of various designs and methodologies (published in English since 1 January 2000) that examine certain SDoH of interest in relation to alcohol-related injury in adults aged 18-25 years old will be considered for inclusion in this review. Two reviewers will screen all articles identified from the databases independently. Titles and abstracts will be reviewed based on the initial search and included if eligibility criteria are met. Duplicate articles will be removed and full texts will be examined to create a final list of included studies. Any disagreements on the inclusion of any articles will be resolved through discussion and consultation with a third reviewer if necessary. ETHICS AND DISSEMINATION: As this research does not involve human subjects, ethics approval is not required. The results of this study will be summarised quantitatively through numerical counts and qualitatively through a narrative synthesis. The results from this review will address an important literature gap and inform the development of targeted prevention programmes for alcohol-related injury. REGISTRATION NUMBER: This protocol is registered with Open Science Framework (https://doi.org/10.17605/OSF.IO/MYEXA).

The Health And Social Needs Of Medicaid Beneficiaries In The Postpartum Year: Evidence From A Multistate Survey.

As of September 2023, thirty-seven states and Washington, D.C., had adopted the option in the American Rescue Plan Act of 2021 to extend pregnancy Medicaid eligibility to one year postpartum. To inform state initiatives to support this newly covered population, we conducted a representative survey of postpartum people in six states and New York City from January 2021 to March 2022. Compared with respondents who had commercial insurance at the time of childbirth, Medicaid respondents were less likely to have a usual source of care and reported less use of primary, specialty, and dental care in the postpartum year. Depression symptoms and social concerns such as food insecurity, intimate partner violence, and financial strain were significantly higher in the Medicaid population. Rates of anxiety symptoms, delaying or not getting needed care, and unsatisfactory child care were similar in both populations. Our findings suggest that postpartum Medicaid extensions should be coupled with state initiatives to address beneficiaries' health and social needs. National investments in data collection on postpartum people will be critical to support evidence-based policy making to improve maternal health and well-being.

Medicaid policy data for evaluating eligibility and programmatic changes.

OBJECTIVES: Medicaid and the Children's Health Insurance Program (CHIP) provide health insurance coverage to more than 90 million Americans as of early 2023. There is substantial variation in eligibility criteria, application procedures, premiums, and other programmatic characteristics across states and over time. Analyzing changes in Medicaid policies is important for state and federal agencies and other stakeholders, but such analysis requires data on historical programmatic characteristics that are often not available in a form ready for quantitative analysis. Our objective is to fill this gap by synthesizing existing qualitative policy data to create a new data resource that facilitates Medicaid policy research. DATA DESCRIPTION: Our source data were the 50-state surveys of Medicaid and CHIP eligibility, enrollment, and cost-sharing policies, and budgets conducted near annually by KFF since 2000, which we coded through 2020. These reports are a rich source of point-in-time information but not operationalized for quantitative analysis. Through a review of the measures captured in the KFF surveys, we developed five Medicaid policy domains with 122 measures in total, each coded by state-quarter-1) eligibility (28 measures), 2) enrollment and renewal processes (39 measures), 3) premiums (16 measures), 4) cost-sharing (26 measures), and 5) managed care (13 measures).

A Prescription for Americans Dually Eligible for Medicare and Medicaid.

This Viewpoint discusses the lack of coordination of care that individuals who are eligible for both Medicare and Medicaid services face.

Medicare Advantage Enrollment and Disenrollment Among Persons With Alzheimer Disease and Related Dementias.

Importance: Large enrollment growth has been observed in the Medicare Advantage program, but less is known about enrollment patterns among persons with Alzheimer disease and related dementias (ADRD). Objective: To evaluate patterns in Medicare Advantage enrollment and disenrollment among beneficiaries with or without ADRD. Design, Setting, and Participants: This cross-sectional study used 6 national data sources between January 1, 2011, and December 31, 2018. Analyses were performed between June 2021 and August 2022. The cohort comprised US Medicare beneficiaries with acute or postacute care utilization between 2013 and 2018. Exposure: ADRD diagnosis from an acute or postacute care encounter Medicare data source. Main Outcomes and Measures: Enrollment in Medicare Advantage, disenrollment from Medicare Advantage to traditional Medicare, and contract exit (leaving a Medicare Advantage contract for traditional Medicare or a different Medicare Advantage contract). Results: The 32 796 872 Medicare beneficiaries in the cohort had a mean (SD) age of 74.0 (12.5) years and included 18 228 513 females (55.6%). Enrollment in Medicare Advantage among beneficiaries with ADRD increased from 24.7% (95% CI, 24.7%-24.8%) in 2013 to 33.0% (95% CI, 32.9%-33.1%) in 2018, an absolute increase of 8.3 percentage points and a 33.4% relative increase after adjusting for demographic characteristics, comorbid conditions, and utilization and including county fixed effects. Among beneficiaries without ADRD, enrollment in Medicare Advantage increased by 8.2 percentage points from 27.6% (95% CI, 27.6%-27.6%) in 2013 to 35.8% (95% CI, 35.8%-35.8%) in 2018, a 29.7% relative increase over the study period. Beneficiaries with ADRD were 1.4 times as likely to disenroll from their Medicare Advantage contract to traditional Medicare (4.4% vs 3.2% in 2017-2018; P < .001) in adjusted analyses. Regardless of ADRD status, beneficiaries had similar rates of switching to a new Medicare Advantage contract. Differences in contract exit rates were associated with higher rates of disenrollment from Medicare Advantage to traditional Medicare among beneficiaries with ADRD vs those without ADRD (16.3% [95% CI, 16.2%-16.3%] vs 15.1% [95% CI, 15.1%-15.1%]). Beneficiaries with ADRD and dual eligibility for Medicaid enrollment had higher rates of contract exit than those without dual eligibility (19.7% [95% CI, 19.6%-19.7%] vs 14.9% [95% CI, 14.8%-14.9%]), and these differences were even greater than those among beneficiaries without ADRD and with and without dual-eligibility status, respectively (18.3% [95% CI, 18.2%-18.3%] vs 13.8% [95% CI, 13.7%-13.8%]). Conclusions and Relevance: In this cross-sectional study of the Medicare population with acute and postacute care use, beneficiaries with ADRD had increasing enrollment in the Medicare Advantage program, proportional to the growth in overall enrollment, but their disenrollment from Medicare Advantage in the following year remained higher compared with beneficiaries without ADRD. The findings highlight the need to understand the factors associated with higher disenrollment rates and determine whether such rates reflect access or quality challenges for beneficiaries with ADRD.

The Effect of COVID-19 on Dual-Eligible Beneficiaries: A Scoping Review.

OBJECTIVES: To examine the impact of COVID-19 on clinical health outcomes and health-related social needs among Medicaid-Medicare dual-eligible beneficiaries. DESIGN: Scoping review. SETTING AND PARTICIPANTS: Dual eligibles during COVID-19. METHODS: We performed a comprehensive scoping review including observational studies, clinical trials, and original empirical research studies of PubMed and CINAHL. We generated a list of terms related to programs that both serve dual eligibles and address our desired outcomes. With the assistance of a medical librarian, we identified relevant abstracts published during COVID-19 meeting our inclusion criteria. We performed full-text reviews of relevant abstracts and selected the final studies. We extracted the study population, design, and major findings, then conducted thematic analysis. RESULTS: 1100 articles were identified, with 439 deemed relevant. On full text-review, 15 articles met inclusion criteria representing more than 86 million Medicare beneficiaries. No studies were specific only to dual eligibles. Topic areas included in this review include COVID-19 case counts (2 articles), mortality (8 articles), hospitalizations (7 articles), food insecurity (1 article), self-reported mental health (1 article), and social connectedness (2 articles). Dual eligibles had disparate COVID-19-related outcomes from Medicare-only enrollees in 12 of 15 studies. Studies show higher mortality for dual eligibles overall, but this was not true for dual eligibles in nursing homes and assisted living communities. Dual eligibles were more likely to experience food insecurity. More favorably, dual eligibles reported greater social connectedness. CONCLUSIONS AND IMPLICATIONS: Dual eligibles had different outcomes from Medicare-only recipients in multiple health outcomes and health-related social needs during COVID-19, but studies are limited, particularly in terms of health-related social needs. Future work focusing on outcomes only among dual-eligible beneficiaries, integrated care programs, and fiscal alignment between Medicare and Medicaid plans may help stakeholders address health needs specific to dual eligibles.

Is extending eligibility for adult social care better than investing more in existing users in England? A cross-sectional evidence for multiple financial years.

OBJECTIVES: Publicly funded adult social care (ASC) in England aims to improve quality of life through the provision of services for individuals with care needs due to physical and/or mental impairment or illness. Access to these services, however, is often restricted to contain public expenditure. With a fast-growing care need, information on whether extending eligibility is good value for money becomes policy-relevant. PRIMARY AND SECONDARY OUTCOME MEASURES: This study investigates the effect of extending ASC eligibility on user care-related quality of life (CRQoL), a policy-relevant measure of quality of life. DESIGN: We use English cross-sectional survey data from 2017/2018 to 2019/2020 on users receiving publicly funded long-term support including domiciliary and other community-based social care, as well as residential and nursing care from local authorities responsible for ASC. We employ the two-stage least square method to estimate the impact of ASC expenditure on CRQoL at various levels of ASC expenditure in each financial year. This includes the CRQoL effect of increasing expenditure from zero to some level, which captures the effect of extending ASC eligibility to new users. RESULTS: We find that publicly funded ASC improves the CRQoL of both existing and newly eligible users, although the latter are likely to experience greater CRQoL gains. Moreover, from 2017/2018 to 2019/2020, spending as much as an average user for a newly eligible user costs between £54 224 and £77 778 per social care-quality-adjusted life year (SC-QALY) gained. These results are statistically significant at the 5% level. Compared with this finding, increasing expenditure for an existing user has always a higher cost per SC-QALY gained. CONCLUSIONS: Extending ASC eligibility to new users is likely to be more cost-effective compared with using the same resources to increase expenditure for existing users.

Population health differences in cross-border regions within the European Union and Schengen area: a protocol for a scoping review.

INTRODUCTION: Along with European integration and the harmonisation of living conditions, improvements in health have been observed over the past decades. However, sociospatial inequalities within and across member states still exist today. While drivers of these health inequalities have been widely researched on a national and regional scale, cross-border regions remain understudied. The removal of border controls within the European Union (EU) member states has facilitated economic convergence and created new opportunities, including cross-border cooperation in the healthcare systems. However, whether and how these developments have influenced the population health in the respective cross-border regions is unclear. Hence, this scoping review aims to examine the empirical literature on the changes in health outcomes over time at the population level in EU cross-border areas. Additionally, we aim to identify the type of evidence and available data sources in those studies. Finally, we will determine the research gaps in the literature. METHODS AND ANALYSIS: We will follow the Joanna Briggs Institute methodology for this scoping review. The 'Population-Concept-Context' framework will be used to identify the eligibility criteria. A three-step search strategy will be conducted to find relevant studies in the databases of PubMed, Web of Science, Scopus and EBSCOhost (SocIndex). Additionally, we will search on websites of international governmental institutions for further reports and articles. The finalisation of the search is planned for August 2023. The extracted data from the scoping review will be presented in a tabular form. A narrative summary of the selected studies will accompany the tabulated results and describe how they answer the research questions. ETHICS AND DISSEMINATION: We will exclusively use secondary data from available studies for our analysis. Therefore, this review does not require ethical approval. We aim to publish our findings at (inter-)national conferences and as an open-access, peer-reviewed journal article.