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Practical tips and/or guidelines Open Access
Twelve tips for designing an inclusive curriculum in
medical education using Universal Design for
Learning (UDL) principles
Corresponding author: Mr Karl Luke lukek1@cardiﬀ.ac.uk
Institution: 1. Cardiﬀ University
Categories: Curriculum Planning, Educational Strategies, Teaching and Learning, Technology
An inclusive curriculum anticipates and provides strategies to support a diverse range of learners. Universal Design
for Learning (UDL) oﬀers medical educators three core principles, which can be used to design curriculum
objectives, activities, instructional materials, and assessments with embedded ﬂexibility, equitability, and
representation to support diverse learners. Drawing on the available literature and author experience, this article
presents twelve tips based on UDL principles for designing and implementing an inclusive curriculum in medical
education. This article also questions the purpose of medical curricula and makes recommendations for fostering
inclusivity within and beyond the curriculum setting.
Keywords: Universal Design for Learning; inclusive curriculum; curriculum design; inclusivity; medical education;
Widening access initiatives seek to increase the diversity of learners studying medicine and subsequently
diversifying the medical profession (Patterson and Price, 2017). With such diversiﬁcation it is essential that
measures are introduced to ensure that curriculum design does not produce unnecessary barriers or discriminate
against learners with diverse characteristics, backgrounds, circumstances, and preferences. Moreover, designing
inclusive and equitable learning experiences is critical to mitigating the predicted global worsening of equity gaps in
higher education as a result of the COVID-19 pandemic (Marinoni, van’t Land and Jensen, 2020; Montacute, 2020).
Curriculum refers to the body of knowledge-content, subjects and/or skills taught in a particular programme, often
informed by government, societal, regulatory, and institutional requirements. Curriculum is also concerned with
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‘when’ and ‘how’ the overall content will be transmitted or ‘delivered’ to learners (Smith, 2000). Various
interdependent components are involved in the curriculum design process, including the development of learning
outcomes, alignment to competence standards, and implementation through teaching, learning and assessment
activities (Morgan and Houghton, 2011). An inclusive curriculum anticipates the diverse needs of learners and aims
to provide all learners, regardless of their background and immutable characteristics, with equal opportunities to
participate fully and achieve the learning outcomes of a programme. Designing an inclusive curriculum should be
grounded by the principles of anticipatory, ﬂexibility, collaboration, transparency, and equitability (McLoughlin,
2001; Morgan and Houghton, 2011).
Principles from Universal Design for Learning (UDL) (CAST, 2018) provide a useful framework for assisting
medical educators in designing programmes with integrated scaﬀolding of support for learners and ﬂexibility of
access to learning with regards to space-time conﬁgurations and modality (Dickinson and Gronseth, 2020).
Curriculum designed in conjunction with UDL principles provides ﬂexibility and allows learners to customise their
learning experiences to meet their individual needs.
The tips outlined in this article are not presented in any hierarchical order but provide a framework for designing
and implementing an inclusive curriculum in medical education. The guidance also explores the important issue of
social inequality in relation to curriculum design and makes recommendations for fostering inclusivity using UDL
Tip 1: Embed inclusive design from the start
Many countries have equality legislation in place which requires educators to make reasonable accommodations or
adjustments to ensure that learners are not discriminated in relation to disability and protected characteristics.
However, inclusive curriculum design should anticipate and reduce the need for individual adjustments (Bunbury,
2020). Where individual accommodations remain necessary, it is recommended they are designed and implemented
in partnership with the learner. Moreover, engaging learners throughout the curriculum design process can help
educators anticipate potential adjustments and help evaluate whether such accommodations could beneﬁt a larger
population of learners and become mainstreamed (Morgan and Houghton, 2011).
Universal Design for Learning (UDL) (CAST, 2018) is a set of principles, grounded by cognitive neuroscience, for
designing curriculum that aims to provide all individuals with equal learning opportunities, regardless of (dis)ability,
gender, age, or cultural background. The three principles of UDL are:
Multiple means of representation: Using a variety of strategies to present information; providing a1.
range of methods to support perception and comprehension.
Multiple means of action and expression: Providing diverse learners with alternative ways to act2.
competently; providing alternatives for demonstrating what learners have learned.
Multiple means of engagement: Aligning to learners’ interests by oﬀering choices of modality,3.
content, and tools; optimising relevance, value, and authenticity; motivating learners by oﬀering
variable levels of challenge and eﬀective feedback.
UDL is signiﬁcantly diﬀerent from other curriculum design approaches as it encourages educators to undertake the
design process by expecting the curriculum to be accessed by diverse learners with varying abilities and skills. This
anticipatory design approach encourages educators to design curriculum that recognises and embraces diversity in
learners’ needs and preferences (Sanger, 2020).
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Tip 2: Deﬁne clear and achievable learning outcomes
In establishing curriculum objectives it is important that they are aligned to professional competence standards and
are also designed to allow learners multiple ways to demonstrate goal achievement. This advocated by the UDL
principle of multiple means of action and expression.
Eﬀective inclusive curriculum design, including the teaching strategies, materials, and assessment design, involves
ﬂexibility and strong constructive alignment with the intended learning outcomes (McLoughlin, 2001). Learning
outcomes should be non-discriminatory by design and reﬂect a genuine measure of achievable competence (Morgan
and Houghton, 2011). As an example, it is important to design goals and strategies within the medical curriculum
that will enable all learners to have equitable and ﬂexible opportunities to develop and express pre-clinical
knowledge, competencies, and attributes. Simulated, virtual, or augmented activities potentially provide a safe
environment for learners to practise, acquire, and enhance skills required during clinical practice (McLean and
Gibbs, 2010; Dickinson and Gronseth, 2020). Whilst such methods are likely to beneﬁt a range of learners, they may
be particularly helpful for the unconﬁdent learner or those with restricted opportunities to acquire skills before
practical training starts (Morgan and Houghton, 2011). This is a particularly important consideration given the
restrictions forced upon some training opportunities by the COVID-19 pandemic. Therefore, when designing
learning outcomes carefully consider how a diverse cohort of learners can achieve and express these.
Learning outcomes should be clearly presented to learners within the syllabus. A syllabus is typically presented as a
document which outlines the topic or concept areas that may be assessed and examined and is often developed by
the educator. It provides learners with the required elements of a course or programme and can shape learner
expectations (Harnish and Bridges, 2011). For educators, it serves as an instrument to help plan and organise the
content and activities that learners must engage with during a course (Slattery and Carlson, 2005). Language used
with the syllabus can inﬂuence learners’ initial impressions of educators. Incorporating friendly language and a
pleasant tone within the syllabus can foster learner motivation and positive relationships between faculty and
learners (Harnish and Bridges, 2011).
Tip 3: Diversify the curriculum
A goal of inclusive curriculum design is to recognise, value, and integrate the diverse identities within a programme,
which is supported by the UDL principles of multiple means of representation and engagement. Particularly
important when teaching diverse learners from diﬀerent backgrounds, countries, or cultural traditions, proactively
diversifying the curriculum will help learners feel that they belong, which can be a powerful motivator for
engagement and learning (Sanger, 2020).
Review the curriculum so it does not perpetuate stereotypes and explore if bias is evident within the content and
activities. Does the curriculum preference certain groups, contexts, mindsets, or cultures? For example, the UK
medical curriculum has been criticised for lacking cultural diversity and oﬀering traditionally white, androcentric,
Eurocentric content (Gishen and Lokugamage, 2019). Curriculum designers should actively explore unconscious
biases within the curriculum and prevailing forms of privilege (McIntosh, 1989).
Importantly, there is growing concern that the medical curricula oﬀered by UK Universities marginalises and
alienates minority learners. In recent years, calls have intensiﬁed for UK universities to "decolonise" the curriculum
and rebalance the dominance of western values and beliefs (Nazar et al., 2015; Lokugamage, Ahillan and Pathberiya,
2020). Educators should endeavour to remove colonial references and design a curriculum which allows learners to
see themselves and others exhibited in positive ways. There are recent examples of medical schools in the UK
actively widening the curriculum to include teaching on racial bias within medical trials and the historical
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exploitation of black people in medical research, and training on topics such as spotting unconscious bias and racism
(Mundasad, 2020). Verdonk and Janczukowicz (2018) observe that as patient populations become increasingly
varied and complex, educators need to equip medical students with the attributes, knowledge, and skills to treat
diverse patients fairly and non-judgmentally. Gishen and Lokugamage (2019) also argue that by introducing
diversity related topics into the medical curriculum increases medical students’ conﬁdence, communication skills,
and potentially improves future patient care.
Tip 4: Co-design with learners
The UDL principle of providing multiple means of engagement centres around the concept of varying learner
motivations and educators should provide a variety of ways to focus and engage learners. To help foster learner
engagement, medical educators can actively involve learners in aspects of curriculum design by oﬀering
opportunities to inform the development of learning outcomes, the types of resources used, the subjects studied, or
the modalities of assessment.
Learners can act as powerful change agents through co-producing medial curricula (Burk-Rafel et al., 2020).
Engaging learners as authentic partners in the curriculum design process allows greater ownership, accountability,
and understanding about the purpose and context of the learning experience (Morgan and Houghton, 2011).
Engaging learners as curricula co-creators may produce more learner-centred and equitable educational programs,
whereby more diverse voices are represented (Burk-Rafel et al., 2020). There is evidence of medical educators
actively engaging learners as stakeholders in curricula reforms, whereby learners are provided opportunities to
critically question and challenge inequalities and gaps inherent in their curriculum and develop innovative
approaches to address such challenges (Krishnan et al., 2019; Moss et al., 2020). Within the curriculum, educators
could also explore principles of allyship (Ng, Ware and Greenberg, 2017) and encourage learners to co-design
practical strategies for enacting equitable relationships with peers inside and beyond the curriculum setting
(Ackerman-Barger et al., 2020; Roberts, 2020).
Tip 5: Present diverse voices and perspectives
Educators can promote a sense of belonging for learners by considering learner diversity and oﬀering
underrepresented scholarly perspectives. This could be achieved by ensuring diversity of perspectives within reading
lists, by promoting authors of diﬀerent gender identities, or incorporating case studies from a variety of regions and
countries (Sanger, 2020). Doing so supports the UDL principle of providing multiple means of engagement by
aligning to learners’ interests and motivations, as well as providing authentic experiences. If oﬀering broad and
diverse representation is challenging within a discipline, acknowledge imbalances and encourage critique. If a
seminal text only uses male pronouns, or stereotypical case studies, acknowledge this and give learners an
opportunity to discuss and critique. This can help learners see how and why particular materials or case scenarios are
selected. For example, if all essential texts are androcentric and produced in Europe or North America, discuss this
with the learners and explain the rationale behind their inclusion. Some key medical concepts may be strongly
associated with white males, which could be addressed by arranging seminar speakers from diverse backgrounds to
present content and to provide learners with positive role models from marginalised communities.
Where possible, underrepresented communities, such as the LGBT+ community and black, Asian and minority
ethnic (BAME) groups, should be visible within the curriculum, which will enable learners and educators to feel less
marginalised (Gishen and Lokugamage, 2019). Ensure a range of examples from diverse communities are provided
in lecture content, reading lists, and problem-based scenarios. For example, LGBT+ case inclusion and providing
illustrative photos of clinical signs on both light and dark skin tones. It is important to present diverse communities
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positively, equally, and avoid stereotyping; this is particularly important as stereotyping can have a profound
negative impact on learning and performance (Steele and Aronson, 1995). To promote an environment of belonging
and respectful inclusion, develop a mutually agreed charter - or ground rules - between learners and educators
outlining expected behaviours and responsibilities within all learning spaces (including virtual spaces). To further
support a sense of belonging, in discussions - whether online or in-person - apply the preferred names and pronouns
used by learners.
Tip 6: Review the timetable and delivery
When considering the UDL principle of action and expression, educators should provide learners with multiple
means to interact with the curriculum, including the resources, materials, tools, technologies, and peers. Review the
curriculum timetable and critically consider if the timing of the teaching and learning activities might negatively
impact some learners (e.g. religious or cultural holidays and celebrations). Using an online diversity and inclusion
calendar can be helpful in planning activities.
Where possible, curricula should provide opportunities for ﬂexible delivery using both asynchronous and
synchronous online activities, which removes some of the barriers associated with developing a ﬁxed timetable and
conﬂicts with clinical responsibilities and rotas (McLean and Gibbs, 2010; Dickinson and Gronseth, 2020).
Synchronous learning refers to learner engagement with materials, instructors, and peers in real-time, although not
necessarily in the same place, such as through the use of virtual classroom technologies. This contrasts to
asynchronous learning, which does not involve learners in the same place or at the same time (e.g. a task to gather
information on a topic individually by a set date).
Tip 7: Design opportunities for cooperative learning
Creating peer learning opportunities helps exploit the advantages oﬀered by a diverse cohort of learners and supports
the UDL principles of providing multiple means of engagement and expression/action. Learners often value
opportunities to share their background and perspectives, therefore design activities and assessments that encourage
peer working and support. Design opportunities within the curriculum which allow learners to bring together their
unique voices for shared enterprise, for example through cooperative learning which prioritises collaboration to
achieve learning goals. Techniques, such as the Jigsaw method, can be a successful strategy in which small groups,
with mixed levels of ability, use a variety of activities to develop joint understandings of a topic area or subject
(Walker, Olvet and Chandran, 2015; Eachempati, KS and Ismail, 2017). Creating space within the curriculum for
learners to share personal experiences can support learner motivation and sets an inclusive tone by encouraging each
learner to share understandings. When designing small group work activities, ensure that the allocation of learners
enables the formation of ethnically diverse groups from various educational backgrounds.
Tip 8: Consider eﬀective teaching strategies
There is some evidence to suggest that learner-centred strategies may have a negative impact on learners from lower
socio-economic backgrounds and may perpetuate some inequalities in education (Andersen and Andersen, 2017).
Furthermore, as the majority of medical students may have relatively similar pre-entry qualiﬁcations, there can be an
implicit assumption that these learners will share similar learning experiences, approaches, and preferences (Morgan
and Houghton, 2011). However, this is unlikely to be the case and learners deploy a range of strategies depending on
their abilities, needs, and preferences. The UDL principle of representation advocates that educators should guide
information processing and engage learners by activating prior knowledge. Incorporating diﬀerent teaching
strategies and varying activities will oﬀer a more inclusive experience for learners with diﬀerent prior knowledge,
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experiences, and learning needs. Therefore, when designing opportunities for self-directed learning or collaborative
learning, medical educators have an important role in providing direct instruction, which involves providing clear and
detailed instructions, guiding learners as they begin independent practice, and oﬀering examples and explanations
(Kirschner and Hendrick, 2020).
UDL principles advocate that medical educators should avoid or explain culturally speciﬁc references, clarify
medical vocabulary and symbols, and provide cognitive supports in instruction. Giving learners organising clues can
be an eﬀective strategy, for example: "we have explored four risk factors associated with disease progression, which I
will now summarise." Provide background or framing information for new concepts using artefacts such as images,
articles, and videos, which can be explored independently outside of a teaching session. Scaﬀold learning (oﬀer
guidance to reduce the complexity of a task) by providing access to resources (e.g. syllabus, summaries, study
guides, PowerPoint slides) and tutor support (e.g. formative assessment feedback, tutorials) (Sanger, 2020). Clearly
segment teaching sessions and activities into chunks, which will help learners to organise content into coherent
cognitive structures (Mayer, 2010). Design learner activities that require retrieval practice and provide worked
examples, demonstrating how to solve a speciﬁc problem or modelling expected outcomes, which can be eﬀective
for optimising germane load (Collins et al., 2020).
Tip 9: Oﬀer multiple strategies to present information
The UDL principle of representation advocates that educators should provide instruction through multiple forms of
media and provide a variety of ways to interact with educational content to generate new understandings. Enhance
instruction through a range of activities, such as the use of case studies, poetry, patient stories, stimulations, role
play, practical activities, guest speakers, virtual communications, and educational software. Within the curriculum
oﬀer alternative learning contexts by designing opportunities for individual and collaborative working, as well as
distance learning, peer learning, and clinical work.
Teaching and learning materials should be presented in a range of modalities, such as online resources, digital
learning objects, videos, articles, podcasts, PowerPoint presentations, and e-books. When designing multimedia
artefacts and presentations critically consider eﬀective design principles (Pate and Posey, 2016). Mayer’s (2010)
multimedia design principles oﬀer practical guidance for reducing extraneous information, such as decorative
images, and optimising the presentation of multimodal aspects for eﬃcient cognitive processing and learning.
Where possible, provide instructional material in alternative formats. For example, provide access to both physical
and electronic versions of key textbooks, capture lectures using recording software, and provide a digital document
version of online learning packages (e.g. a downloadable PDF ﬁle). Providing captions to videos and podcasts, or
enabling live captions within online synchronous tools (e.g. Microsoft Teams), serves the dual purpose of enhancing
accessibility for learners with hearing impairments and supporting multiple options for perception, which aligns with
the UDL principle of representation and can be particularly beneﬁcial for second language learners (Dickinson and
Gronseth, 2020). This oﬀers an example of how adjustments can become mainstreamed to beneﬁt a wider group of
Tip 10: Use technology appropriately
Whilst not an inherent solution, if used appropriately technology can be used to facilitate enhancements within
inclusive curriculum design and is highlighted throughout the three core principles of UDL. For example, the use of
touch-sense haptic technologies and stimulations can replicate learning experiences that might otherwise be
inappropriate for learners to undertake on real patients, for example based on training stage or issues with access to
assessors for appraisal (Morgan and Houghton, 2011). Such technologies also allow greater ﬂexibility with regards to
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the space-time dimensions of learning. UDL principles have also been successfully deployed in clinical practice with
the support of technologies (Martyn, Pace and Gee, 2015). In practice environments, mobile technologies and
assistive applications have been used to provide feedback (e.g. mini-CEX) and electronic note-taking whilst on ward
rounds (Morgan and Houghton, 2011). Developing clear policies and processes (e.g. data protection and
conﬁdentiality) that break down the barriers to using technology, including the use of mobile devices and assistive
applications in clinical environments, helps foster an enabling learning experience (Martyn, Pace and Gee, 2015).
To ensure the inclusive use of technology, potential barriers - such as skills, ability, equipment access, ﬁnancial, and
accessibility - need consideration prior to implementation. Importantly, the use of technology should not be a barrier
for learners with disabilities (Hersh and Mouroutsou, 2019). For example, medical educators can make simple
adjustments when designing resources and multimedia content by using consistent page titles and headings, and
images should be relevant to the content and include alt text (alternative text descriptions). This is crucial for
learners who rely on assistive technologies, such as screen readers, to interact with content. Consistent and clear page
titles provides clarity and structure to assist learners with orientation and navigation, and alt text within images are
used by applications to describe images to learners with visual impairments.
Tip 11: Provide ﬂexible opportunities for assessment and feedback
UDL principles advocate that the curriculum should provide multiple means of learner action and expression,
whereby learners are oﬀered alternative means to demonstrate what they have learned (Sanger, 2020). Medical
educators should design diﬀerent assessment options to demonstrate learning, such as oral presentations (individual
or team-based), written assignments (e.g. essays, ﬁctional, creative), or visual representations (e.g. posters, videos).
Where summative assessments, such as traditional essays or exams, are obligatory due to professional body
requirements, diﬀerent formative assessment options should be oﬀered, such as more personalised submissions (e.g.
reﬂective commentaries, online discussion forums, blogs) (Morgan and Houghton, 2011).
Feedback is an essential component of learning and its value is widely recognised within medical education (Bing-
You et al., 2017; Kornegay et al., 2017). Within the curriculum, design opportunities for formative feedback based
on group and individual activity. When considering eﬀective feedback in diverse contexts, ensure feedback is
timely, honest, direct, and constructive. Recommend concrete steps for improvement and signpost additional
resources and services which can be accessed ﬂexibly. Support learner motivation by providing feedback, setting
goals, and providing rewards for completing tasks. Importantly, the UDL engagement principle also recommends that
educators support learners in developing self-regulatory skills and provide opportunities for learner self-assessment
Tip 12: Evaluate curricula using an inclusive design checklist
As discussed, an inclusive curriculum anticipates and provides strategies to support a diverse range of learners.
While UDL itself is not a list of strategies that must be implemented, the UDL Guidelines (CAST, 2018) oﬀer a set
of practical suggestions that can be applied to any discipline and provides ideas for UDL implementation. To help
with the implementation of UDL principles, many UDL checklists can be found online, such as those designed by
Iowa State University (2019) and West Virginia Department of Education (Unknown). Such UDL checklists can be
a useful starting point in evaluating the current level of inclusively with programmes or for planning curriculum
changes (Bartholomew and Griﬃn, 2018).
Many UK Universities have also designed general inclusive curriculum checklists. Whilst not explicitly aligned to
the UDL principles, many of the checklists oﬀer important aspects covered by UDL. Examples of inclusive
curriculum checklists can be found from University of Dundee (2017), University College London (2018), and
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Manchester Metropolitan University (2020). Importantly, inclusive curriculum checklists can be completed as part
of the development and design of new programmes and the periodic review of existing programmes.
Medical curricula are not static and continues to evolve to reﬂect new ideas, practices, and knowledge. Designing an
inclusive curriculum extends to critically exploring the ideological assumptions underpinning the purpose of the
curricula (Smith, 2000). Within medical education, outcomes‐based curricula, which is heavily dependent on the
setting of behavioural objectives, has been challenged by educators who argue that learning outcomes are unable to
accurately specify educational achievements and the true eﬀects of learning (Rees, 2004). Scholars have advocated a
paradigm shift from curriculum as product to emancipatory models, known as curriculum as praxis, which focuses on
the domains of knowledge, critical reﬂection, and committed action (Ford and Profetto-McGrath, 1994). The
curriculum as praxis model is concerned with the development of a critical consciousness, and actively seeks to
challenge inequalities through action. For example, Shahvisi (2019) reports on teaching UK medical students of the
signiﬁcant social status and privilege they will have as doctors, and the importance of collective action against
damaging agendas and social injustices. Moreover, it is essential that medical curricula attend to the current political,
economic, and societal issues we face, including global pandemics, social injustices, technological advances, and
climate change (Verdonk and Janczukowicz, 2018; Finkel, 2019; Goh and Sandars, 2020).
Implementing curriculum changes poses numerous challenges such as stakeholder resistance, lack of skills and
knowledge, time pressures, lack of desire or damaging conﬂicts, and issues with communication and planning (Luke,
2021). Adopting a methodological approach to managing curriculum change is essential and awareness of the need
for change is a key foundation in the change process (Luke, 2021). This paper has aimed to raise awareness of the
importance of inclusivity within medical education and explored how UDL principles can be used to develop a
ﬂexible curriculum, which embeds opportunities for learners to be active participants in the curriculum design and
delivery. The three core UDL principles oﬀer medical educators opportunities to design curriculum outcomes,
activities, instructional materials, and assessments with embedded ﬂexibility, equitability, and representation to
support diverse learners in any context. In turn, an inclusive curriculum may help in tackling systemic barriers that
produce inequitable learning opportunities and outcomes. Inclusive curriculum design may also provide learners with
the critical skills and competencies to positively contribute to diverse workplaces and wider society.
Take Home Messages
Use UDL principles when (re)designing curriculum. Flexibility, variation, and engagement are key principles
for universal design.
Recognise, incorporate, and celebrate diversity in the curriculum. Demonstrate the cultural and social
relevance of course concepts.
Design opportunities for personalising activities and allow learners to co-design elements of the curriculum.
Use technology appropriately and digitise resources. Present content in alternative formats (text, audio, and/or
visual). For example, record lectures where possible.
Use varied teaching methods and provide learners with active learning opportunities. Use alternative
strategies for assessing learning.
Notes On Contributors
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Karl Luke is a lecturer in Medical Education at Cardiﬀ University, United Kingdom. Karl is a Senior Fellow of the
Higher Education Academy (SFHEA) and Certiﬁed Member of the Association of Learning Technology (CMALT).
Karl's research interests include digital education, multimodality and sociomateriality. ORCiD:
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The author has declared that there are no conﬂicts of interest.
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