Contextualizing Innovative Housing Models and Services Within the Age-Friendly Communities Framework

Abstract

This article compares and contrasts the characteristics of 3 models of housing and services for older adults, cohousing, Naturally Occurring Retirement Community Supportive Services Program, and villages, and links them to the domains of the age-friendly communities (AFCs) framework, specifically (a) services, supports, and information; (b) respect, inclusion, and diversity; (c) social and civic participation; and (d) affordability. We discuss key barriers and challenges of these models with respect to the AFC domains, as well as implementation and sustainability. Consideration of these models in age-friendly housing policy and practice could help expand and diversify the choices in the housing and services continuum. This aligns with AFC’s emphasis on the need for housing and services responsive to older adults’ diverse health and social needs, provides options that balance autonomy, choice, and support, and emphasizes older adults’ participation and involvement in tailoring these options.

Aging in place, Cohousing, NORC-SSP, Villages

A majority of older adults prefer to age in place, in their own homes, allowing them to remain connected to community life, access supports to compensate for changes in socioeconomic, functioning, and health status, and avoid relocating to care settings (Bigonnesse et al., 2014; World Health Organization [WHO], 2007). However, the lack of affordable rental housing and access to services and amenities, out-of-pocket expenses for health and housing maintenance, and unsuitable physical environments could challenge aging in place (Bigonnesse et al., 2014; Clark, 2005). Conventional housing also does not adequately serve the particular housing needs of those from minority ethnocultural backgrounds, the LGBTQ2S+ community, and those with physical and cognitive functional limitations. LGBTQ2S+ refers to Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, and Two-Spirit. (Addis et al., 2009; Somerville et al., 2011). Supportive housing interventions for older adults should ideally integrate the physical, social, technological dimensions, as well as the services and supports, necessary to promote aging in place (Forsyth et al., 2019; van Hoof et al., 2021). Cohousing, Naturally Occurring Retirement Community Supportive Services Program (NORC-SSP), and villages are promising integrated housing and/or service models for older adults.

Although these innovative models of housing and services address different age-friendly domains, they have not been formally discussed in relation to the age-friendly communities (AFCs) framework (Frochen & Pynoos, 2017). The goal of AFC is to enable older adults to achieve enhanced quality of life (QoL) through provision of appropriate city structures, programs, and policies that meet the needs of diverse groups (WHO, 2007). The interlinked domains of the AFC framework include outdoor spaces and buildings, transportation, housing, social participation, respect and social inclusion, civic participation and employment, communication and information, and community support and health services (WHO, 2007). Housing plays a key role in creating age-friendly environments and influencing health, independence, well-being, and the ability to age in place (WHO, 2007). Housing, viewed through the AFC lens, is considered to constitute three key interrelated components: (a) physical accessibility within the home and in the community, (b) services and supports, and (c) social participation and engagement (Menec et al., 2011). The AFC framework’s domains provide a platform to compare and contrast the merits, shortcomings, and challenges of these models and their potential contributions toward age-friendly housing policy and practice and environments. In applying this framework, the potential of “housing” can be reconceptualized to extend its conventional framing as “shelter,” and the principles and lessons can be adopted into mainstream housing models (e.g., assisted living), which may inspire other innovations capable of meeting the diverse needs of older adults.

Description of the Innovative Housing and Service Models

Table 1 gives a brief description and outline of the key features of cohousing, NORC-SSPs, and villages. Cohousing is a model of an intentional community that consists of private units for each resident/family and shared common spaces that are owned, developed, and governed by residents through collective and consensus-based decision making (Garland, 2018). A few cohousing projects (typically in Germany, the Netherlands, and Sweden) are owned and managed by nonprofit housing organizations (Fromm & de Jong, 2009; Labit, 2015). Intergenerational cohousing includes residents of all ages, including older adults (Labit & Dubost, 2016), while senior cohousing is exclusively inhabited by older adults (Rogers, 2014). Originating in Denmark in 1964, the cohousing model was adopted in the 1980s in the United States and has since steadily grown in prominence across North America and Europe (Garland, 2018). It is estimated there are 160 completed projects in the United Kingdom, 19 in the United States, and 16 in Canada (Canada Cohousing Network, 2021; Garland, 2018). An innovative example of senior cohousing is Harbourside in Sooke, British Columbia (Canadian Senior Cohousing [CSC], n.d.; Harbourside, n.d.). Located on a 2-acre site, the community has 31 households and spaces for gardening, exercise, and art, a workshop, and a common house containing dining and kitchen, two guest rooms, library, multipurpose rooms, and a care suite (CSC, n.d.; Harbourside, n.d.). The units are owned by residents (singles and couples) ranging in age from 50 to 85 years.

Table 1.

Brief Descriptions of the Three Innovative Housing and Service Models for Older Adults

Name of model	Definition
Cohousing	• Founded and developed based on shared values and vision of residents • Two types of cohousing include intergenerational and senior • Consists of privately owned or rental units for each resident and shared common spaces for social activities • Governed through the consensus-based decision making and, in some cases, owned and managed by nonprofit organizations
NORC-SSP	• Supportive service programs developed in neighborhoods with a significant proportion of older residents • Coordinators help residents identify needs and access corresponding community health and social–recreational services • Funded through the government, grants, and membership fees
Village	• Membership organization of older residents within a neighborhood • Developed, governed, and funded by older residents • Services include social and educational activities, transportation, home maintenance, health care, and referrals • Services provided by paid staff and/or volunteers

Note: NORC-SSP = Naturally Occurring Retirement Community Supportive Services Program.

NORC-SSPs are models of supportive service programs, formed in neighborhoods or housing developments where older adults constitute 40%–50% of the population (Greenfield, 2014). The program offers flexible and integrated community-based health, social–recreational, and allied health services, establishing the infrastructure necessary to address older adults’ needs across the continuum of care (Vladeck, 2004). It is administered as part of the services provided by a parent organization (e.g., community nonprofit social service provider), which serves as the lead agency responsible for developing partnerships between residents and local service providers, coordinating service delivery, and managing finances (Greenfield, 2014). An advisory board consisting of NORC residents and local seniors’ groups guides the development and implementation of programs (Greenfield, 2014). The model is largely funded through grants and, in some cases, through membership and participation fees (Enguidanos et al., 2010; Vladeck, 2004). The first program originated in 1986, based out of a New York apartment building, and has since grown to over 100 programs throughout the United States (Greenfield, 2014, 2016). In Philadelphia, residents of several cooperative buildings formed the STAR NORC by partnering with a community service organization to initiate a self-generated service program supporting their aging-in-place needs (Ormond et al., 2004). Each building has its own resident-led board that pays to participate in the program (Ormond et al., 2004). Services include preventative health checks and education, social participation opportunities, and case management (Ormond et al., 2004). Member feedback is regularly sought regarding the services program, with the goal of aligning service provision with needs, and targeting those at risk of social isolation (Ormond et al., 2004).

The Village model consists of membership associations developed, governed, and funded by older residents and operated in collaboration with paid staff and volunteers, or solely by volunteers (Graham et al., 2014; Scharlach et al., 2014). Members of villages reside in their own homes within the catchment region specified as part of the village (Bookman, 2008). Villages provide social and educational activities and services linked to transportation, housing, health care, information and referrals, and companionship (Graham et al., 2018; Scharlach et al., 2014). There are over 250 operational villages and over 100 in development in the United States (Village to Village Network, 2021). Founded in 2001, Beacon Hill Village is a nonprofit membership organization that serves as the blueprint for the model (Scharlach et al., 2014). Older adults become members by paying membership fees of $600 for individuals or $850 for households. Services include exercise classes, discounted fitness center membership and home support/care, transportation services, home repairs, and computer assistance (“Case Study: Beacon Hill Village,” 2009).

In the following sections, the three housing and service models are discussed in the context of four AFC domains: (a) services, supports, and information; (b) respect, inclusion, and diversity; (c) social and civic participation; and (d) affordability. See Table 2 to get an overview of the similarities and differences of the three housing and service models according to these domains.

Table 2.

Comparison of the Three Models Focusing on the Key Advantages and Disadvantages in Relation to the Four AFC Domains

AFC domains	Cohousing	NORC-SSP	Villages
Services, supports, and information	Advantages
	Facilitates choice and control in decision making Facilitates interdependence through mutual support Fosters a sense of responsibility for each other Lowers demand for professional care Increases awareness of health promotion and prevention	Facilitates choice and control in decision making Greater awareness of programs and services Coordinators help residents make informed choices Facilitates interdependence through mutual support Mutual support helps build positive relationships and a sense of community Proximity of resources in the region augments service delivery Leveraging community partnerships facilitates enhanced service provision over the long term	Helps older adults feel more comfortable seeking help from fellow residents Availability of informal mutual support has decreased older adults’ reliance on formal health care services Leverages members’ skills for the provision of voluntary services (known to be sustainable)
	Disadvantages
	Senior cohousing residents may not be able to provide adequate support for complex health needs	Stigma related to help-seeking could affect residents’ service utilization Services offered by resident volunteers may be insufficient to meet more complex needs Lack of resources in the region can disrupt service delivery resulting in fewer service options	Focuses on social needs rather than health-related needs Volunteer-based services cannot meet complex health-related and social needs
Respect, inclusion, and diversity	Advantages
	Promotes a sense of community and belonging In some cases, senior cohousing has been adapted to exclusively serve the needs of ethnic minority older adults Intergenerational cohousing promotes opportunities for generativity and generational solidarity	Provides culturally appropriate programs and services to augment social participation among ethnic minority older adults Facilitates intergenerational bonding Promotes opportunities for generativity and community contributions	Facilitates intergenerational bonding
	Disadvantages
	Intergenerational cohousing may exclude frail or low-income older adults Conflict with between tenants receiving residents and those not due to differences in priorities	Lack of resources for marketing, program distribution, and services for diverse groups of older adults Resource limitations negatively affect the provision of culturally appropriate programs and services Resource scarcity negatively affects the diversity of the resident population Staffing and funding issues reduce the ability of service providers to cater to complex- to high-level needs	Lack of racial, ethnic, or cultural diversity; villages fail to attract older adults with vulnerabilities in regard to age, race, ethnicity, and education Mostly located in affluent neighborhoods with financially stable residents; excludes low- to moderate-income older adults Lack of resources for recruitment strategies that target more diverse groups
Social and civic participation	Advantages   Fosters social interaction Augments community engagement Helps expand and sustain social networks Helps build cohesion within the housing and local neighborhood Facilitates open forum to increase awareness of others’ needs, preferences, and raise sensitivity	Fosters social interaction and reduces social isolation Augments social participation and engagement	Fosters social interaction and reduces social isolation Facilitates the expansion and maintenance of social networks Promotes meaningful opportunities for making significant community contributions Facilitates involvement in decision making and participation in a shared governance model
	Disadvantages
	Potential lack of consensus or imbalance between (a) privacy and social interaction and (b) personal and interpersonal space	Potential decrease in privacy	Overreliance on volunteer support; young-old members may be working and not be able to contribute
Affordability	Advantages
	Cost of unit lower than the market rate Sharing of costs of living Provision of rental subsidies	Provision of reduced membership fee and free or subsidized services	Provision of reduced membership fee and free or subsidized services
	Disadvantages
	The price of a cohousing unit is affordable only to financially stable older adults	Financial challenges associated with high rent and other living expenses may limit residents’ ability to pay fees for programs and services	Runs largely on membership fees, placing the onus of financial sustainability on members

Note: AFCs = age-friendly communities; NORC-SSP = Naturally Occurring Retirement Community Supportive Services Program.

Services, Supports, and Information

The three models are suggested to positively influence physical and mental health, lower the demand for formal health care, and advance residents’ knowledge of health promotion and disease prevention (HPDP; Cohen-Mansfield et al., 2010; Glass & Vander Plaats, 2013; Kehl & Then, 2013). NORC-SSPs facilitate access to formal health services through collaboration with local service providers (Bookman, 2008; Greenfield, 2014). Social workers (SWs) help NORC-SSP members with identifying health and social needs, becoming aware of service options, and accessing these services (Greenfield, 2014, 2016). Village services focus more on addressing the social needs (e.g., social events, classes, volunteer opportunities) rather than health needs (e.g., care coordination and case management, awareness and education of HPDP), which is identified as a priority area for change (Graham et al., 2018).

Across models, at least one or more home and community service, essential to aging in place is offered, such as meal preparation, housekeeping chores and maintenance, salon services, shopping, gardening, accompanied walks, and funding (Fromm & de Jong, 2009; Graham et al., 2018; Ivery, 2014). In villages, subsidized or volunteer-based transportation services are widely requested/used, particularly for health care visits, and help augment social engagement and out-of-home mobility (Graham et al., 2017; Scharlach et al., 2014). Research on NORC-SSPs highlights inaccessible transportation as a barrier to service use and social participation among members with mobility disabilities/frailty, suggesting transportation as a high-priority area for improvement (Davitt et al., 2017).

Senior cohousing is known to reduce reliance on formal health services by fostering exchange of mutual support, interdependence, and collective responsibility among residents (Ahn et al., 2018; Critchlow et al., 2016; Glass, 2013). Mutual support is also found in NORC-SSPs and villages to foster reciprocity, trust, and reliability (Bookman, 2008; Graham et al., 2017). However, sustained provision and reliance on mutual support in cohousing and villages can be challenged by age-related decline in health (Glass, 2013; Rogers, 2014). To augment the provision of informal support, some senior cohousing communities are inviting younger residents (Glass, 2013), while villages are recruiting more young-old adults (Lehning et al., 2015). Villages are also building partnerships with service providers in the community to facilitate discounted access to services and meet the growing needs of aging members with complex needs that may not be met by volunteers (Graham et al., 2017; Lehning et al., 2015). SWs in NORC-SSPs are known to be instrumental in addressing advancing care needs that may not be met through informal supports (e.g., neighbors; Greenfield, 2016). Although the senior cohousing model does not integrate access to formal health services or supports, some projects include a dedicated care suite in the common house of the cohousing environment, to accommodate for the care needs of members (Harbourside, n.d.).

Respect, Social Inclusion, and Diversity

Some cohousing projects and NORC-SSPs are known to be inclusive of older adults from different ethnic minority groups and lower socioeconomic status, through tailored programming and recruitment of culturally diverse individuals (Bookman, 2008; Fromm & de Jong, 2009). NORC-SSPs are particularly noteworthy in that they tend to target communities of moderate-to-low income older adults (Ivery et al., 2010). Villages have not been found to facilitate the inclusion of members from diverse backgrounds, with most members being White, of middle-to-high or high socioeconomic status, and living with a low level of disability (Graham et al., 2014, 2017; Hinze, 2016; Scharlach et al., 2014). However, efforts are being made to reframe villages as a “middle-class concept” to attract a wider audience and recruit members from diverse cultural, racial, ethnic, and socioeconomic backgrounds (Lehning et al., 2015, p. 695). Strategies proven to be successful in recruiting new village members (e.g., word of mouth) are unlikely to target diverse individuals, necessitating more targeted approaches (Lehning et al., 2015).

Although a minority, village members with disabilities or health conditions show greater improvement of QoL and health due to programs and services than other members (Graham et al., 2017). However, this group is also less likely to experience social connectedness as a result of their village membership, hinting at the inaccessibility of social activities and lack of social support for this group (Graham et al., 2017). More young-old members of villages are aging in place and subsequently developing more complex care and social needs, demonstrating why providing intentional supports for this group is increasingly relevant (Graham et al., 2017).

While intergenerational cohousing facilitates bonding and solidarity across generations, helping counter ageist attitudes and social exclusion (Garland, 2018; Labit, 2015), younger members are known to exclude older members with complex personal and functional care requirements, framing them through a deficit-focused lens (Hinze, 2016; Riseborough, 2013). Nonetheless, the built-in social activities in intergenerational cohousing offer a higher possibility of informal interactions among different age groups compared to senior-specific housing; hence, it is likely to enhance awareness about the diversity of interests in various age groups. These interactions can give older adults an enhanced sense of purpose and self-efficacy, particularly when they are able to guide, mentor, and even offer practical support to younger residents (Baker, 2014; Garland, 2018). On the other hand, senior cohousing fosters an inclusive environment for older adults to collectively reconcile with aging-related losses, learn from diverse experiences of aging, and acknowledge, accept, and support members with wide-ranging abilities and needs (Glass & Vander Plaats, 2013).

Social and Civic Participation

Villages and cohousing are initiated and developed by older adults based on self-directed needs assessments, while NORC-SSPs are initiated by community-based agencies. NORC-SSPs and villages enable older adults to play an active role in planning and implementing programs and services through the creation of volunteer opportunities (Graham et al., 2017; Vladeck, 2004). NORC-SSP members’ involvement in the advisory board is also helpful for outreach and identifying new (overlooked) members with a high need for services (Greenfield, 2014). Villages further enable members to participate in shared governance and have an active voice in decision making (Graham et al., 2014). However, member recruitment, involvement, and retention in regular ongoing volunteer roles in NORC-SSPs can be challenging due to evolving health issues, caregiving responsibilities, and, in the case of young-old members, employment (Enguidanos et al., 2010). Designing flexible volunteer positions (e.g., setting one’s own schedule) amenable to individual abilities and preferences can better facilitate volunteer participation in NORC-SSPs (Enguidanos et al., 2010).

In cohousing, communal spaces, shared activities (e.g., meal preparation), and group discussion forums help promote spontaneous social interaction, social engagement, and social cohesion (Ahn et al., 2018; Glass, 2013). NORC-SSPs increase residents’ participation in social activities, augment social interaction, and foster the development of social connections, which in turn encourages members’ continued patronage of services/activities (Enguidanos et al., 2010). Social and civic participation in these models can be challenged by the social fabric of the community. Consensus-based decision making in cohousing and villages could be strained by the lack of social cohesion or ongoing conflict between residents (Riseborough, 2013; Sandstedt & Westin, 2015). Furthermore, social participation in cohousing can sometimes compromise older adults’ privacy or autonomy, which is likely why the model is considered more suitable for those who desire social interaction and active participation in the community (Ahn et al., 2018; Killock, 2014). Maintaining a balance between social interaction and privacy is essential to ensuring members’ satisfaction with cohousing (Glass, 2013).

Affordability

The average cost per unit in cohousing has been found to be 15%–20% lower than market value (CSC, n.d.). Because most cohousing projects are self-developed, there are no additional costs associated with profit margin and marketing, as is the case with external housing developers. These savings help offset the costs of building the common house and augmenting the energy efficiency of buildings (CSC, n.d.). The cost of living in cohousing is affordable due to the sharing of costs (e.g., buying supplies as a group), as well as higher energy efficiency of buildings (i.e., resulting in lower utility bills; Riseborough, 2013). However, it can be difficult for many older adults to purchase a cohousing unit and pay membership/strata fees if they do not have sufficient savings or home equity (Critchlow et al., 2016; Fromm & de Jong, 2009). Unlike the privately funded model of cohousing in the United States, the European alternative shows how housing nonprofit organizations can own, construct, and rent senior cohousing for older adults, including those with moderate-to-low incomes (Killock, 2014; Labit, 2015). In some cases, government-subsidized low-income older renters are included in regular senior cohousing; however, this is known to cause conflict with homeowners in the community due to a mismatch of priorities (i.e., financial need prioritized over the intention of communal living; Glass, 2013). This points to the challenge of providing financial support, while maintaining the integrity and ethos of the model. Provision of subsidized membership and discounted/free services in NORC-SSPs and villages helps include low-income older adults who cannot dedicate funds toward membership and service fees (Aging in Place Committee, 2013; Vladeck, 2004).

While NORC-SSPs largely run on government funding and grants, villages rely primarily on membership dues, with some unstable secondary sources (e.g., individual donations and, to a smaller extent, grants and government funds), thus placing the onus on members to maintain financial sustainability (Ivery, 2014; Lehning et al., 2015). Unlike the mostly volunteer-led nature of villages, the availability of external funding allows NORC-SSPs to be staffed by SWs, who play a crucial role in identifying members’ financial needs and connecting them with service providers who can offer subsidized services (Ivery, 2014). Securing long-term funding has been identified as a challenge for NORC-SSPs and villages, rendering their sustainability uncertain when short-term grant funding expires (Enguidanos et al., 2010; Lehning et al., 2015). To address funding issues and maintain membership rates without hikes that could jeopardize renewal, some villages are expanding member recruitment to increase membership-based funding (Lehning et al., 2015).

Discussion and Conclusion

The key challenges of the models discussed here include addressing wide-ranging health and social needs of members, facilitating their access to relevant services, and sustained delivery of programs. NORC-SSPs demonstrate how SWs play a key role in addressing these challenges by (a) securing ongoing funding, (b) managing partnerships with service providers, (c) maintaining volunteer base, and (d) facilitating ongoing needs assessments (Enguidanos et al., 2010; Ivery, 2014; Ivery et al., 2010). It is suggested that appointing SWs could also help villages in these areas, particularly in relation to providing individualized services for members with diverse and complex needs (Graham et al., 2017; Lehning et al., 2015). Additionally, integrating SWs into cohousing could help facilitate consensus building, conflict resolution (particularly between members who have different social locations and where issues of stereotyping or discrimination may be of concern), and co-caring (Glass, 2016). Appointed SWs should receive comprehensive training to provide person-centered case work and coordinate multisectoral community partnerships (Graham et al., 2017; Vladeck & Altman, 2015). However, it is important that the appointment of SWs does not undermine the aspect of self-governance in villages and cohousing, so as to maintain the uniqueness and strengths of these models.

Federal and state backing for these models could help (a) address the issues with procuring long-term funding (particularly for villages and some NORC-SSPs); (b) support nonprofit housing organizations in providing affordable and tailored housing and services for older adults who are disproportionately affected by structural factors; (c) develop context-specific guidelines for initiation, development, operation, and evaluation; and (d) strengthen and diversify communities’ assets and capabilities to better support aging in place. These models offer preventive or proactive and health-promotive housing/service approaches for older adults who are not in immediate need of high-level care and support, potentially delaying relocation to formal care settings (Graham et al., 2018). The integrated delivery of housing and services offered by these models could have implications for rebalancing initiatives advocating for scaling back dependency on institutional care and prioritizing user preference and choice to age in place (Woodcock et al., 2011, p. 1). However, given the limited empirical evidence and reliance on cross-sectional study designs, these models should be systematically evaluated through longitudinal research for health-related outcomes to gain wider adoption in housing policy and programs (Graham et al., 2017).

Wide-scale implementation of the models discussed here could help expand the range of options in the continuum of housing and services for older adults, providing them with more choices for aging in place. These models are based on deliberative development rather than a speculative approach based on assumptions of residents’ needs and preferences, financial aspects, and market demands (Wynne et al., 2018). By giving credence and primacy to older adults’ voices, these models highlight resident preferences so as to be most responsive to their needs (Wynne et al., 2018). This approach helps “maintain [older adults’] individual agency at the micro (interpersonal) level in the face of macro-level hindrances” linked to societal stigma and deficit-focused lens surrounding aging (Glass & Vander Plaats, 2013, p. 440), thus addressing important ethical principles that underlie the AFC framework (WHO, 2007).

Lessons learned from these models also hold relevance for traditional housing. For instance, cohousing demonstrates the potential for an intentionally designed and developed community to foster social connectedness among residents through shared and jointly developed/maintained spaces and activities. This is particularly salient in the current context of the global coronavirus disease 2019 pandemic, which has been linked to a greater risk of social isolation and loneliness among older adults (Wu, 2020). Villages and NORC-SSP models add a critical piece missing in fragmented public health care systems by incorporating and facilitating older adults’ access to health care services and supports (Abendstern et al., 2018). These two models also demonstrate how partnerships between local government, regional health authorities, and third sector organizations could help provide coordinated services and supports to older residents.

Conceptually, the literature focused on the three models covers the key principles that constitute the AFC framework, namely equity, accessibility, and inclusiveness (WHO, 2015). The AFC input/output/outcome indicators (WHO, 2015) can be used to appraise and compare communities based on traditional and innovative housing/service models to help us understand which model is more relevant for a particular context. While the AFC framework provides the basis for appraising age-friendliness and supportiveness for aging in place at the broader scale of the community/neighborhood/city, there is scope for more microlevel analysis of age-friendly attributes specific to housing. Luciano et al. (2020) have developed a framework for age-friendly housing which includes the following eight domains: (a) affordability, (b) community connection, (c) access to services, (d) safety and security, (e) essential services, (f) design, (g) modification, and (h) maintenance. These domains could prove advantageous in assessing the extent to which these innovative models are able to facilitate aging in place. This article compares and contrasts these models to highlight their comparative strengths and weaknesses. Empirical evaluations in the future, based on Luciano’s domains, would provide a systematic understanding of the value of these innovative models relative to more traditional models. Findings from these systematic evaluations can help accordingly plan and prioritize interventions that draw upon these models based on their effectiveness and appropriateness for certain contexts and groups of older adults aging in place.

Funding

None declared.

Conflict of Interest

None declared.