Comparing oral health systems for children in six European countries to identify lessons learned for universal oral health coverage: A study protocol.

Background: Oral diseases have the highest global prevalence rate among all diseases, with dental caries being one of the most common conditions in childhood. A low political priority coupled with a failure to incorporate oral health within broader health systems has contributed to its neglect in previous decades. In response, calls are emerging for the inclusion of oral health within the universal healthcare domain (UHC). This protocol outlines the methodology for a cross-country comparative analysis of publicly funded oral health systems for children across six European countries, reporting on oral health status in line with the indicators for UHC. Methods: This study will follow Yin’s multiple case study approach and employ two strands of data collection, analysis, and triangulation: a systematic documentary analysis and semi-structured interviews with elite participants local to each country. The countries chosen for comparison and providing a representative sample of European dental systems are Denmark, Hungary, the Republic of Ireland, Germany, Scotland, and Spain. A systematic search of five electronic databases and four additional electronic resources will be undertaken, in addition to grey literature and other publicly available sources, with the outcomes verified and further informed by local experts. The WHO Universal Health Coverage Cube will be used to guide data collection and analysis. Conclusions: This research will provide policy makers with an in-depth analysis and comparison of publicly funded oral health systems for children in Europe, including consideration of effective preventive strategies, oral health system reform, and indicators of universal oral health coverage. It is anticipated that the outcomes may help in positioning oral health on governmental health agendas and support its integration into wider health systems’ reform in an accessible and affordable manner.


Introduction
Oral diseases, despite being largely preventable, are among the most prevalent non-communicable diseases globally (World Health Organization, 2020).People are impacted from childhood to adolescence, adulthood and into later life with little improvement of the situation over the past two decades (World Health Organization, 2020).Furthermore, the burden of oral disease is hallmarked by significant inequality, disproportionately affecting marginalised populations and those in low socio-economic groups (Peres et al., 2019).
Dental caries (tooth decay) is an especially serious public health problem for children, affecting 60-90% of schoolchildren worldwide (Petersen & Lennon, 2004;Slade et al., 2018).In addition to causing pain and infection, caries significantly impact children's social and psychological wellbeing, along with their quality of life (BaniHani et al., 2018;Peres et al., 2019).It is associated with reduced school attendance, impaired speech development and can result in lower body weight and height (Jackson et al., 2011;Sheiham, 2006).
Dental caries not only impacts the affected child, but also the broader family, resulting in lost workdays with the added financial burden that may be associated with accessing dental services (Casamassimo et al., 2009).Furthermore, the management of dental caries in younger children may require hospitalisation for treatment under general anaesthesia with associated health, financial and health system implications (McAuliffe et al., 2017;Peres et al., 2019).This is a problem of global concern, with the management of oral diseases and extraction of carious (decayed) teeth previously cited as the number one reason for hospital admission of young children in Australia and England (Chrisopoulos, 2016;Levine, 2021).
Important risk factors for disease development in children have been identified, most notably high-sugar dietary habits (Watt et al., 2019) with parental behaviour being a 'significant predictor' (Östberg et al., 2017), while fluoride exposure is an important protective factor (Petersen & Lennon, 2004).Early availability and access to preventive oral healthcare has been proposed as fundamental to improving children's oral health, reducing costs, and establishing life-long practices (Irish Oral Health Services Guideline Initiative, 2012;World Health Organization, 2020).
In May 2021, the World Health Assembly adopted a historic resolution on oral health, strongly advocating for its inclusion under the Universal Healthcare (UHC) agenda (World Health Organization, 2021a).The WHO defines UHC as ensuring 'all people have access to services and do not suffer financial hardship for paying for them' (World Health Organization, 2021b).Evidence has suggested that UHC may be a global risk indicator for early childhood caries (ECC), i.e., dental caries diagnosed in children under age six (Anil & Anand, 2017) with a lower prevalence of ECC seen in countries with good UHC (El Tantawi et al., 2018).However, not all countries with UHC include entitlements to oral healthcare, particularly preventative oral healthcare, which is often considered a non-essential health service (Wang et al., 2020).
Historically, oral healthcare was relegated to the realm of personal responsibility (Wang et al., 2020) and currently remains a low priority across governments globally.This has led to a lack of political commitment, coverage, and a failure to resource disease prevention (World Health Organization, 2020).Responding to the 'global state of crisis' in oral health requires a shift in focus from the traditionally curative models of care to a more inclusive approach, where oral health services are fully integrated in universal health systems worldwide (Glick et al., 2021;Watt et al., 2019).
However, dental caries is a complex, multifactorial disease influenced by biological factors and the social determinants of health (Meyer & Enax, 2018;Watt et al., 2019).There have been conflicting results demonstrating the influence of access to oral healthcare on the prevalence of dental caries in very young children, with a reduction in disease severity evident in Nordic countries with universal oral health cover (Virtanen et al., 2007), yet a high disease prevalence remaining, or no impact seen, in countries with free access like Peru and Brazil (Azañedo et al., 2017;Pucca Jr et al., 2015).Recent research by Folayan et al. (2021), found that higher governmental health expenditure may be associated with a reduction in ECC and called for further research across individual countries to assess the impact of UHC on disease prevalence, and how UHC could be optimised to reduce the risk of dental caries.
In Europe, healthcare systems are publicly financed via general taxation or compulsory social health insurance and complemented by private contributions from either voluntary insurance and/or direct out of pocket payments (OPP) by individuals (Sinclair et al., 2019).Based on the method of administration and financing, six oral healthcare systems have been described, namely the Nordic, Bismarkian, Beveridgian, Southern European, Eastern European and Hybrid models (Widström & Eaton, 2004).However, the extent of public financing, universal coverage and the density and distribution of dentists working at the primary healthcare level varies within each system (Glick et al., 2021;Patel, 2012;The Platform for Better Oral Health in Europe, 2015).
In terms of publicly funded oral healthcare for children, the child population covered and the extent of cover also varies within and across systems (Table 1).For example, Denmark and Germany, representative of the Nordic and Bismarkian systems respectively, provide free basic oral healthcare services to pre-school and school children where even the youngest children are included in the system (Widström & Eaton, 2004).The Danish system is largely tax-financed, while Germany has a statutory health insurance system split into public social insurance (SHI) and private health insurance (Ziller et al., 2015).In the Beveridgian system, unique to the United Kingdom, the entire population is eligible to obtain treatment through the tax-financed National Health Service (NHS).In 2006, the NHS payment system changed in England, Wales, and Northern Ireland.However, it remained the same in Scotland, and oral healthcare treatment including orthodontics is free of charge to all patients under the age of 18 years as at time of writing (Sinclair et al., 2019).
In contrast, the Spanish health system, an example of a South European system, is primarily tax-financed and organised nationally and regionally, with health competencies transferred to the 17 Autonomous Communities (ACs) (Bravo et al., 2015).The level of oral health coverage for Spanish children strongly depends on regional location, with some oral healthcare available to children aged from seven to 15 years of age in certain areas yet little coverage in other regions (Sinclair et al., 2019).In most Eastern European countries, the provision of care has shifted from largely free public provision to the majority of care being delivered in the private sector (Widström & Eaton, 2004).Hungary, an example of an Eastern European system, is financed by contributions from employed persons and employers with children receiving free oral healthcare until the age of 18 (Kivovics & Csado, 2010).
In the Republic of Ireland (Ireland), representative of a hybrid system, children are targeted for comprehensive care at specific age groups, with restricted access other than emergency treatment for all other cohorts (Department of Health, 2019).Ireland's general health system is complex and predominantly funded through general taxation.However, more than half of the Irish population purchase private health insurance, predominantly to facilitate quicker access to hospital care and private healthcare (Johnston et al., 2020).In contrast to the general health system, two thirds of all dental expenditure in Ireland is privately financed with some, but little, publicly funded coverage for oral healthcare (Henry et al., 2021;Johnston et al., 2020).In any system when costs are high, children of limited means, who are also at increased risk, may not be able to afford care (Watt et al., 2019).This can result in inequalities in access to services and ultimately poorer oral health (Wang et al., 2020).
In addition to the range of differences between systems, including funding, there is a paucity of information on how the system is organised; for example, how services are delivered, the healthcare professionals responsible for providing care and access to services (Allin et al., 2020;Eaton et al., 2019;Glick et al., 2021).An in-depth understanding and comparison of how different oral care systems operate and their position within the UHC domain could provide a greater knowledge for healthcare planning and policy decision making (Eaton et al., 2019;Folayan et al., 2021).

Aim of this research
The primary aim of this research is to compare publicly funded oral health coverage for children under the age of eighteen years across six European countries, each of which is representative of a model for the provision of oral healthcare, and to report on oral health status in line with the indicators for universal oral healthcare.This protocol outlines the methodology for the collection, management, and analysis of data from a systematic documentary analysis and semi-structured interviews with local experts, pertaining to Denmark, Hungary, Ireland, Germany, Scotland, and Spain, to meet the primary study aim.
Objectives of this research 1.To describe and compare models of publicly funded oral health systems for children across the chosen six European countries including the financing arrangements associated with each system.
2. To collect and compare available and relevant indicators of universal coverage for oral health in the chosen countries.
3. To identify those national oral healthcare systems with effective oral health prevention and promotion programmes for children, as evidenced by low d 3 mft/D 3 MFT or ICDAS 0-3 and the percentage (%) with no obvious dental caries at age 12.

Study design
This is a cross-national comparative analysis of publicly funded oral health systems for children under the age of eighteen across six European countries.The study will follow Yin's multiple-case study approach (Yin, 2014).To strengthen study validity, two strands of data collection, analysis and triangulation will be undertaken: 1.A systematic documentary analysis.There are limitations associated with the DMFT, particularly the range of diagnostic criteria, sampling techniques and methods used to train and calibrate examiners across different countries.Nationally reported DMFT varies across countries, with some reports stemming from data generated almost 20 years apart (Patel et al., 2016).This will be recognised in the findings of this study by highlighting the year of reporting to facilitate appropriate interpretation of each country's D 3 MFT.

Participants
In-depth interviews will be undertaken with individuals selected as representatives of, and with expert knowledge local to, each country.Participants will be identified via (i) the outcomes of the documentary analysis, (ii) using purposive sampling based on the recommendations of participants and (iii) the researchers' understanding of individuals with expert knowledge of the oral health system in question.It is anticipated that two experts from each country, i.e., a total of twelve experts (n=12), will participate.

Data collection
Conceptual framework.To describe and compare publicly funded oral health systems for children under age 18 across the six chosen countries, each model will be described according to the three core features of the WHO Coverage Cube Framework (World Health Organization, 2010): (i) breadth, i.e., child populations (0-18 years) eligible for publicly funded oral health programs; (ii) depth, i.e., the share of the total costs that are borne by the government/public payer; and (iii) scope, i.e., the range of services covered under publicly funded oral healthcare programs (Figure 1).

Documentary analysis
A documentary analysis is a systematic procedure for reviewing documents, requiring data be examined and interpreted to elicit meaning and gain empirical understanding of a 1 Scotland is chosen for comparison due to the improvements in the oral health of children and the reduction in associated inequalities that have transpired following the successful implementation of the Childsmile programme.
given topic (Bowen, 2009).This systematic documentary analysis will aim to examine the relevant reports, policies, service documents, academic publications and other literature developed at local, regional, and national level for each country.

Information sources
The relevant documents will be identified in the following ways: 1.A literature search of the following databases: Medline (EBSCO), CINAHL (EBSCO), EMBASE, ProQuest and the Cochrane Library.The TRIP database will be searched for grey literature along with medRxiv (for health sciences preprints), while Google Scholar and Web of Science will also be utilised.
2. Manual reference checks of identified documents and studies.
3. Publicly available resources and documents will be searched to identify existing reviews, oral health policies and position papers regarding oral health coverage by national and international stakeholders e.g., governmental health departments of each country and international organisations including the World Health Organization, FDI World Dental Federation and the Council for European Chief Dental Officers.
Search strategy.The search strategy for this research will be developed with the assistance of a specialist medical librarian (SKB) based at Cork University Hospital, Cork, Ireland, in collaboration with the lead author, an academic dental researcher (UM).The search strategy will entail using a combination of keywords and subject headings, incorporating MeSH (PubMed/Medline), CINAHL Headings (CINAHL) and EMTREE headings (EMBASE).Search results will be filtered for items published in English since 2001 and will then be screened by title and abstract.If key documents are only available in the country's native language, these will be translated with verification of their critical elements sought from local experts.The search strategy presented in extended data (McAuliffe, 2021) is based on Medline and will be tested and adapted for all other databases and resources.An overview of the MeSH terms is presented in Table 2.

Inclusion criteria
Types of study to be included No limitations will be placed on the study or document included if the study design and document address the research aim.Government documents such as national oral health policies along with clinical guidelines academic literature, oral health service reports, and other grey literature, in addition to international recommendations pertaining to evidence for improved oral health, will be eligible for inclusion.

Population, concept, and context
This research seeks to compare oral health systems for children across countries.To ensure most systems are eligible for consideration, an age range up to 18 years is proposed.It is beyond the scope of this research to consider oral health service reviews for special needs and other vulnerable populations.
Policies, guidance, and other literature that pertain to public oral healthcare systems, strategies for oral health promotion and prevention, universal oral health coverage, dental system reform and improved oral health status for children ≤ 18 years will be included.All included studies/documents must include two or more of the following outcomes: (1) publicly funded dental systems seeking to, or who have successfully, implemented universal oral health coverage in the last twenty years, (2) reduced oral health inequalities, (3) improved oral health system accessibility (4) reduced oral health system costs (5) caries rates as determined by d 3 mft/D 3 MFT and percentage with no obvious caries at 12 years, or (6) the International Caries Detection and Assessment System (ICDAS) and other indicators of oral health status including periodontal diseases and oral health-related quality of life measures (OHRQoL).Please see Table 3 for full inclusion criteria.

Download of title and abstract records
Titles and abstracts identified will be downloaded in file formats usable with our chosen reference management software (Zotero) with any additional information stored in Microsoft Excel.They will then be uploaded to Zotero and Rayaan, an online application supporting systematic review screening efficiency (Ouzzani et al., 2016), with any duplicate entries removed.

Reviewer calibration
A data charting form will be developed, guided by the inclusion criteria.The data selection process and form will be pilottested in 10% of randomly selected and included articles to assess reviewer calibration.Any discrepancies between reviewers will be discussed with amendments made to the data extraction form and further calibration as required to ensure near perfect (>80%) agreement.

Title and abstract reviews
Title and abstract reviewing will be performed by one reviewer (UM) and verified by another (JC).The verification process will entail an assessment of the original screening of the title and abstract to confirm whether the second reviewer agrees with the decision made.Any discrepancies will be discussed with a third researcher engaged (SB or KE) if a consensus fails to be reached.Titles and abstracts that fail to meet the eligibility criteria will be excluded from the next stage of assessment, while those that conform to the eligibility criteria will be included for full-text review.

Full-text review
Full-text material will be sourced using the resources provided by University College Cork.If the full text cannot be accessed, the team will investigate if they can be retrieved via any other library to which the broad team has access, via international experts local to each country or by contacting the relevant authors.

Data extraction
A data extraction form will be developed, guided by the WHO Coverage Cube, based on previous work by Allin et al., 2020, and further refined for this research.Full-text reviews will be completed by one reviewer (UM) with verification by another (JC).Any discrepancies will be resolved by discussion, and failure to reach consensus will require consultation with a third member of the research team (SB or KE).The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-S) will be applied in illustrating this approach (Rethlefsen et al., 2021).

Risk of bias (quality) assessment.
Risk of bias will be assessed by one researcher and verified by another with any discrepancies resolved in discussion with a third member of the research team (SB or KE).Each study will be assessed by a tool appropriate for its study design, particularly using the Critical Appraisal Skills Programme (CASP) checklists pertaining to the individual study type.However, considering the nature of the research question, not all items are applicable to every type of included document in this analysis and quality ratings will be determined in this instance.

Semi-structured interviews with elite participants
Following the outcomes of the documentary analysis and guided by the WHO Coverage Cube, a semi-structured interview guide will be developed for use with all participants (World Health Organization, 2010).This will be piloted and further reviewed in structured meetings with the research team.
The full list of participants will be regularly updated throughout the research process.In view of the wide geographic spread of participants, it is expected that all interviews will take place via tele-conferencing tools.

Strategy for data analysis
This research will follow Yin's multiple-case study methodology in employing two strands of data collection and analysis (Yin, 2014).
Document analysis requires superficial examination, thorough examination, and interpretation of documents combining content analysis and thematic analysis (Bowen, 2009).This analysis will follow a directed content analysis approach guided by the WHO framework and employ a deductive category application (Graneheim & Lundman, 2004).This research will follow the checklist to improve trustworthiness in content analysis developed by Elo et al. (2014).
Key initial concepts will be identified as coding categories using the WHO framework as guidance before operational definitions for each category are defined.Interviews will be transcribed verbatim and coded.All data will be managed and coded using qualitative data analysis software (NVivo 12 qualitative data analysis software).
The data from the documentary analysis will be analysed together with the data from interviews to ensure themes are triangulated across both datasets.A dedicated case study will then be drafted for each country individually before cross case analysis will be conducted to identify patterns of similarities and differences across the cases.All sub-themes and main themes will be tabulated and discussed among the research team, with a particular emphasis on the possible implications for policymakers.
The potential limitations of documentary analyses include: an absence of detail, low retrievability or biased selectivity (Yin, 1994).Additionally, interview data may be subjective and ambiguous (Pannucci & Wilkins, 2010).It is expected the data triangulation employed in this research will guard against the possible limitations of trustworthiness, researcher bias and respondent bias.Additional techniques including a documented systematic search, a 'thick' description of outcomes and an audit trail will further serve to ensure verification.

Dissemination
The findings will be presented to policymakers and governmental health departments in each country, in addition to professional networking conferences both nationally and internationally, such as the European Association of Dental Public Health congress.

Study status
The search strategy is under development with the support of a specialist medical librarian (SKB) at Cork University Hospital with initial searches of the MEDLINE database underway.

Conclusion
The challenges to meeting oral health needs of populations, and particularly vulnerable groups, is now receiving global attention, with policy makers being urged to appropriately position oral health within the emerging universal healthcare (UHC) agenda (Glick et al., 2021;Watt et al., 2019;World Health Organization, 2021a).However, there is conflicting support for the impact of improved access to oral health systems and the prevalence of dental caries in children (Pucca Jr et al., 2015;Virtanen et al., 2007).Recent evidence has confirmed that higher governmental health expenditure may be associated with lower prevalence of the disease among very young children; however, calls have been made for country-specific studies to determine how UHC may reduce the risk of dental caries (Folayan et al., 2021).This proposed research aims to compare publicly funded oral health systems for children throughout Europe and to report on oral health status in line with the indicators for UHC.By providing this evidence for oral health advocates internationally, this research may support the positioning of oral health on governmental agendas and ensure that essential oral health systems are integrated into broader healthcare in an accessible and affordable manner.
Is the rationale for, and objectives of, the study clearly described?Yes

Paulo Frazão
University of São Paulo, São Paulo, Brazil The authors present a study protocol that aims to compare publicly funded oral health coverage for children under the age of eighteen years across six European countries.The countries will be selected according to diversity of oral healthcare model that they deliver.Based on the management and financing strategy, six oral healthcare systems will be described, namely the Nordic, Bismarkian, Beveridgian, Southern European, Eastern European and Hybrid models.The rationale of the study is well formulated but some points deserve consideration.The literature shows that the magnitude of dental caries prevalence is strongly associated to sugar and fluoride exposures.
Then it is important to clarify that the focus is untreated dental caries prevalence.This point is clearer in the Methods (use of 'd3 level' in deciduous teeth and the 'D3 level' in permanent teeth) than in the Introduction.This is particularly relevant because previous studies that sought to explore relationship between Universal Health Coverage (see that the manuscript reports incorrectly UHC as Universal Healthcare in the fifth paragraph, in the conclusion and in the abstract) and early childhood caries (ECC) have some major limitations.For example, the supporting studies (El Tantawi et al., 2018;Folayan et al. 2021) of the justification did not included indicators related to sugar and fluoride exposure.ECC's definition requires the presence of one or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth.The conflicting results cited by the authors in the 7th paragraph can be related to methodological characteristics of the studies as the observed outcome and included variables.The presented study protocol will investigate dental caries determined by 'd3 and D3 levels' indicators.
The study design will be based on multiple-case study approach in which a cross-national comparative analysis will be undertaken using documentary research and semi-structured interviews with local experts.Forward the authors stated that they will undertake in-depth interviews.So they will undertake semi-structured in-depth interviews.Each delivery model of oral healthcare will be described according WHO Coverage Cube Framework.Systematic documentary analysis will be performed examining scientific documents and technical reports.It was not justified why the authors will select local and regional reports.
For the purpose of the protocol I think that national-level documents would be more appropriated.The procedures for searching and selecting of the documents were well described.The researchers will assess risk of bias using a tool appropriate for each study design.The presented protocol is well designed for producing evidence on publicly funded oral health systems for children throughout Europe and on oral health status in line with the indicators for Universal Health Coverage.It is important to highlight that UHC means Universal Health Coverage instead of Universal Health Care.The UHC strategy sponsored by WHO is not necessarily the same strategy implemented by some countries where the access to health services does not depend on the user's ability to pay.I agree with the authors that the current protocol may support the positioning of oral health on governmental agendas and ensure that essential oral health systems are integrated into broader healthcare in an accessible and affordable manner.
Is the rationale for, and objectives of, the study clearly described?Yes

Is the study design appropriate for the research question? Yes
Are sufficient details of the methods provided to allow replication by others?Yes Are the datasets clearly presented in a useable and accessible format?

Not applicable
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Oral health policy and epidemiology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Risk of bias:
Since you include all types of articles, the CASP checklist cannot be performed in all included documents.In that case, what tools or checklist will you use?
It would be better to state the research questions you want to answer in this review because study selection and data extraction will depend on it.The risk of bias assessment will be unclear without considering each research question.

Conclusion:
Since there were four objectives mentioned in this study, it would have been better if each objective was addressed in the conclusion.Future study recommendations could also be mentioned (e.g., can be used for reform).
Beside the above mentioned comments, I may suggest you to add the sections such as "Expected results", "Study period and study protocol".
In addition, when you described the outcomes, it is better to specify which is primary outcome, then which are the secondary outcomes.
Is the rationale for, and objectives of, the study clearly described?Partly

Is the study design appropriate for the research question? Yes
Are sufficient details of the methods provided to allow replication by others?Partly Are the datasets clearly presented in a useable and accessible format?Partly Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Oral health and general health, oral health promotion, dental public health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Figure 1 .
Figure 1.Dimensions of coverage for public oral healthcare models based on the World Health Organization Coverage cube framework.Adapted from Allin et al., 2020.

Table 1 . An overview of oral health systems coverage for children in six European countries. Country Main source of general healthcare financing, model and percentage of current expenditure financed in 2019. TF = Tax financed, SHI= Social health insurance. Oral healthcare model Children's oral health cover
*The

figure for the UK is for England, Scotland and Wales. The table saying the focus of this analysis is Scotland. Source: Sinclair et al. (2019) and Eurostat (2021). *Office for National Statistics, 2021, UK Health Accounts 2019, UK https
To learn from successful examples of oral health systems for children internationally, in terms of outcomes and costs, that can be applied to other countries.
approval Ethical approval for the study was obtained from the Clinical Research Ethics Committee of the Cork Teaching Hospitals at University College Cork (Reference number: ECM 4 (J)12/11/2019).Written informed consent to participate will be sought from each participant prior to interview.tics.The ICDAS scores range from zero to six for coronal caries, with zero representing a sound tooth and six an extensive distinct cavity with visible dentin(Shivakumar et al., 2009).

Table 3 . Documentary analysis related inclusion criteria. Criterion Inclusion Population
Community dwelling children aged less than 18 years of age.Document/study type No limitations on document type provided research aim is addressed.

the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests:
No competing interests were disclosed.Oral epidemiology, Oral health promotion, Oral health related quality of life, Common risk factor on Oral disease and ChronicNon-communicable Diseases (NCD), Oral health policy, Diet and Oral health, Oral heath inequality I

confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
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