Index

• Introduction
• Conceptual Framework and Research Questions
• Methodology
• Finding
• References

Abstract

At the end of the first quarter of the 21st century, when international arrivals were increasing, the COVID-19 pandemic occurred and turned into a major health crisis that affected the whole world. It has been emphasized that there is a linear relationship between the spread of the pandemic and travel movements from the time the pandemic started to the present day. In this context, the aim of this study is to determine whether there is a relationship between overtourism and pandemic, which has emerged because of increasing touristic travels in recent years. Another aim of the study is to consider demarketing as a solution proposal in the fight against overtourism to prevent health crises such as COVID-19. In this context, 586 news in which the keywords of COVID-19, overtourism and demarket were used together in a certain period were examined and the obtained data were analyzed with the help of MAXQDA (analysis program for qualitative research) qualitative research analysis program. According to the relations between the themes reflected in the results of the study, demarketing can be expressed as a solution proposal for overtourism in the post-COVID-19 period.

Keywords: COVID-19, Demarketing, Overtourism, Sustainability, Sustainable tourism, Tourism.

Received: 15 November 2022 / Revised: 29 December 2022 / Accepted: 13 January 2023 / Published: 2 February 2023

Contribution/ Originality

The relationship between overtourism and COVID-19 has been examined and what role demarketing strategies can have in solving the problem of overtourism has been discussed.

1. INTRODUCTION

As a result of the increasing improvements in human rights and developments in technology, the restrictions that characterize modern life have disappeared and more people have started to participate in travel mobility. As a result of these developments, one of the most accelerated industries in the world is tourism. Tourism is supported worldwide, especially because of the economic benefits it provides, and is becoming an important component of development plans (Cárdenas-García, Sánchez-Rivero, & Pulido-Fernández, 2015; Harrill, 2004; Rosentraub & Joo, 2009) . On the other hand, in the historical process, besides the economic benefits that tourism provides, it has been seen that it causes significant damage to the physical and social environment (GhulamRabbany, Afrin, Rahman, Islam, & Hoque, 2013; Liu, Sheldon, & Var, 1987). Therefore, despite all the economic benefits provided by tourism, concerns about sustainability are beginning to be seen in tourism as a result of exceeding the environmental carrying capacity (Green & Hunter, 1992). Since the mid-1970s, the sustainability of the tourism industry and concerns about this issue have started to take place in destination planning (Butler, 1999). However, it is seen that the concerns about the sustainability of tourism have not been resolved until today (Lu & Nepal, 2009).

Destinations where tourism develops, environmental concerns increase over time. Especially with the popularity of the destination, the increasing crowd and the use of environmental elements create problems at the point of sustainability. Along with the damage to the physical and socio-cultural environment, the local people also face economic difficulties. As a result of this situation, overtourism, one of the popular concepts of today, emerges (Çolak, Kiper, & Batman, 2020). Overtourism is an action-reaction problem that arises as a result of the local people's reactions to overcrowding as a result of exceeding their carrying capacity.

The concept of overtourism has become a phenomenon in the literature has led to an increase in the number of scientific studies on the subject. The relationship of the concept with close concepts such as sustainability and carrying capacity, the problems and protests of local people and tourists, the damage to the economic, physical and social environment have been examined in studies (Hughes, 2018; Mihalic, 2020; Milano, Novelli, & Cheer, 2019; Perkumienė & Pranskūnienė, 2019; Phi, 2020; Sengel, 2021; Wall, 2020) . However, with the COVID-19 process, it has emerged that this situation cannot be sustained and the need to find a solution to overtourism, which is one of the chronic problems of tourism.

Towards the end of the first quarter of the 21st century, when tourism and travel movements are increasing, a health crisis has occurred that has affected the whole world. Scientific debates that the increasing tourism and travel movements have a significant impact on the spread of the pandemic known as COVID-19 have increased day by day (Neuburger & Egger, 2021). Because it has been observed that the pandemic, which is transmitted from person to person through the respiratory tract, has increased in parallel with the increasing human mobility (Şengel et al., 2022a). The introduction of travel restrictions as the first solution strategy to prevent the spread of COVID-19 can be expressed as one of the important indicators of this. The COVID-19 process has revealed that overcrowded environments are an important problem in the health problems of this type of person due to their skin or left. In addition, the necessity of re-evaluating the sustainability and environmental impacts of tourism after the COVID-19 process has emerged (Higgins-Desbiolles, 2021; Tiwari & Chowdhary, 2021). For this reason, solution strategies for the overtourism problem experienced in many destinations, especially popular destinations in terms of the sustainability of tourism in the post-COVID-19 period, have begun to be realized (Amrhein, Hospers, & Reiser, 2022; Chaney & Seraphin, 2021; Fontanari & Traskevich, 2022; Koh, 2020) .

It has emerged that human movement should be minimized in order to avoid health crises such as COVID-19. It has been started to be discussed that the decision-making stakeholders of the destinations should control the travel movements originating from tourism. Sengel (2021) defines this demand as the new normal tourism and states that COVID-19 may be an opportunity for the restructuring of tourism in this context. In this context, Demarketing strategies can come to the fore as an important marketing strategy used to reduce tourism demand so that tourism does not cause pandemics and similar health crises. In order to combat the problem of overtourism, demarketing practices are carried out in destinations (Butler & Dodds, 2022; Oklevik et al., 2019). For this reason, the aim of the study is to discuss whether demarketing strategies can be a solution for the problem of overtourism in the post-COVID-19 period. In the research carried out in this context, the relationship between overtourism and COVID-19 has been examined and what role demarketing strategies can have in solving the problem of overtourism has been discussed.

2. CONCEPTUAL FRAMEWORK AND RESEARCH QUESTIONS

2.1. Overtourism

The negative effects of tourism on the environment, the control of tourism and the view of local people on this situation have been discussed for many years (Johnston, 1997; King, Pizam, & Milman, 1993; Liu et al., 1987; Ross, 1992). With the negative effects experienced, the concept of sustainability in tourism has become popular since the 1980s (Liu, 2003). Theoretically, sustainable tourism is an understanding that includes all types of tourism, prioritizes the strengthening of local communities and increasing their environmental benefits, and supports the protection of the environment (Choi & Sirakaya, 2005; UNEP & UNWTO, 2005). However, there are question marks in the application of the sustainable tourism approach in popular destinations where mass tourism is intense. As a matter of fact, frequent examination of the problems caused by overcrowding in popular destinations is an important indicator of this Jin and Pearce (2011); Popp (2012); Sanz-Blas, Buzova, and Schlesinger (2019). Overcrowding in destinations has brought different problems along with it. In recent years, overcrowding, inappropriate tourist behavior, physical exertion, Airbnb, etc. The problems experienced by the homeowners due to the platforms and the increasing pressure on the local people have caused negative effects on the economic, ecological and social environment (Hospers, 2019; Koens, Postma, & Papp, 2018). Overtourism, which emerged to explain these negative effects, is a concept used to describe destinations where tourism mobility goes beyond acceptable limits, where the quality of life of local people or the quality of experience of tourists is negatively affected (Goodwin, 2017; UNWTO, 2018).

Although overtourism is a new concept, it has a long history, especially in destinations with high visitor density (Dodds & Butler, 2019; Milano, Cheer, & Novelli, 2018). Overtourism has become one of the most debated issues in world tourism, with frequent media coverage, increasing local protests in popular destinations, and academia's attention. Due to the fact that overtourism is a new phenomenon, studies have been intensively carried out to create the theoretical infrastructure of the concept. Among the studies, the determination of the main factors causing the problem, how the problem is approached, the predictions for the future, the relationship with the concept of carrying capacity and sustainability have been examined by researchers (Capocchi, Vallone, Pierotti, & Amaduzzi, 2019; Çolak et al., 2020; Koens et al., 2018; Mihalic, 2020; Veríssimo, Moraes, Breda, Guizi, & Costa, 2020). In the literature, there are studies that support the studies carried out in the theoretical field and contain more details. Studies that measure the attitudes of local people take an important place among them (Adie, Falk, & Savioli, 2020; Gössling, McCabe, & Chen, 2020; Pinke-Sziva, Smith, Olt, & Berezvai, 2019; Szromek, Kruczek, & Walas, 2019). On the other hand, there are field studies on the problems experienced in destinations where overtourism is intense (Álvarez Sousa, 2020; Atzori, 2020; Jover & Díaz-Parra, 2022; Seraphin, Sheeran, & Pilato, 2018).

As can be seen from the studies, many tourism destinations face the danger of overtourism. Strategies to combat overtourism are important for destinations to have a sustainable structure. When the strategies emerged in the researches are examined; The importance of environmental policies, increasing the benefits of local people, and the importance of a tourism management based on stakeholder cooperation and a common vision emerge under the lens of smart city (Jamieson & Jamieson, 2019; Nepal & Nepal, 2021; Pasquinelli & Trunfio, 2020; Plichta, 2019; Yuval, 2021).

The increasing number of international arrivals explaining tourism mobility makes the studies on the concept of overtourism even more meaningful. Because this increase in international travel movements may cause some social problems that are difficult to control in the future. As a matter of fact, the pandemic that emerged in China in late 2019 and spread all over the world is one of the clearest indicators of the situation (Lew, Cheer, Haywood, Brouder, & Salazar, 2020; Neuburger & Egger, 2021). The virus, which emerged in a certain part of the world, spread almost all over the world in a very short time due to the developments in transportation and communication technologies (Şengel et al., 2022). Because the spread of the virus is completely dependent on human mobility and passes from person to person in crowded environments. In fact, travel movements and the course of the pandemic are so interactive that travel restrictions are experienced between many destinations and this situation is encouraged (Burns et al., 2020; Chinazzi et al., 2020; Devi, 2020; Linka, Rahman, Goriely, & Kuhl, 2020). In the light of this information, it is thought that excessive tourism, which includes mass human mobility and crowded groups of people, is one of the factors that cause the spread of the pandemic. In the context of this interaction, the answer to the following research question was sought;

Q1: Are there effects of overtourism in the spread of COVID-19?

2.2. COVID-19

COVID-19 has been at the top of the world agenda since the first day it started. According to the data of the World Health Organization, as of July 26, 2022, 566.977.818 cases, 6.376.503 deaths and 12.219.375.500 vaccines have occurred (WHO, 2022). As can be seen from the figures, COVID-19 has caused more devastating damage than other epidemics and has turned all the economic and social balances upside down in the world since its beginning (Škare, Soriano, & Porada-Rochoń, 2021). One of the industries most affected by these negativities is tourism. The tourism industry is a highly sensitive industry to epidemics and environmental changes. The tourism industry has entered into a major crisis due to the priority of the desire for security in the destination choices of potential visitors (Uğur & Akbıyık, 2020). For this reason, the impact of the epidemic on tourism and crisis management strategies have come to the fore in studies on COVID-19.

In the Studies carried out regarding the pandemic, it has been determined that the number of tourists has decreased and tourism revenues have decreased due to factors such as the cancellation of travel by tourists, the inability to make flights due to travel restrictions, the cessation of activities of sporting events, festivals and entertainment centers. As a result, tourism businesses, especially hotels and travel agencies, stopped their activities (Foo, Chin, Tan, & Phuah, 2021; Kumar & Nafi, 2020; Qiu, Park, Li, & Song, 2020; Rogerson & Rogerson, 2020). On the other hand, due to the effects experienced, many different measures have been taken by both public administrations and businesses to alleviate the impact of the crisis and revitalize tourism, and it has been frequently examined in the literature that various strategies have been developed (Kreiner-Collins & Ram, 2021; McCartney, 2021; Musavengane, Leonard, & Mureyani, 2022; Şengel, Işkın, Çevrimkaya, & Genç, 2022b; Yeh, 2021).

With the COVID-19 pandemic, it has shown that there are things that need to be changed in the tourism industry not only today but also for the future. According to Higgins-Desbiolles (2021) COVID-19 is a game-changing challenge for the tourism industry. As a matter of fact, after the emergence of COVID-19, scientific studies on the restructuring of tourism began to be published. The issues to be restructured are the main problems of tourism such as carrying capacity, overtourism and sustainability (Chang, McAleer, & Ramos, 2020; Pardo & Ladeiras, 2020). These problems require solutions but are difficult to get results in the ordinary course of social life. In an extraordinary situation such as COVID-19, it creates an important opportunity to solve such problems and provides an opportunity for destination managements to implement radical strategies that would be difficult to implement under normal conditions (Chaney & Seraphin, 2021).

2.3. Demarketing

Marketing strategies mean more than just getting more consumers to buy a good or service. It refers to temporarily or permanently deterring all consumers or a certain audience, which is one of the important strategies of marketing (Gerstner, Hess, & Chu, 1993). Strategies are basically used as a way to reduce the demand for a limited resource (Farquhar & Robson, 2016; Medway & Warnaby, 2008). Especially with the increasing concern about sustainability, the importance of strategies has increased. As a matter of fact, the emergence of the concept of green marketing, which encourages purchasing for the realization of production without concern for the environment, is an indicator of this Armstrong Soule and Reich (2015).

Sustainable environmental management is a priority for the realization of tourism activities in the future. However, one of the least paid attention to the historical process of tourism has been the management of the environment. One of the most serious consequences of not managing the environment is the emergence of overtourism. One of the debates that started with the emergence of the COVID-19 pandemic is the need to develop a solution for overtourism. Therefore, it is important to examine the relationship between COVID-19 and Overtourism. As a matter of fact, it has been discussed in the literature that the pandemic may offer some opportunities to combat excessive tourism (Higgins-Desbiolles, 2021; Koh, 2020). Within the scope of combating overtourism during the COVID-19 period, issues such as reducing pollution, giving importance to environmentally friendly infrastructure, controlling overcrowding, adopting climate-friendly practices in transportation, providing empty spaces, paying attention to accessibility, and developing a joint strategy of stakeholders were emphasized (Jiricka-Pürrer, Brandenburg, & Pröbstl-Haider, 2020; Koh, 2020; López & GONZÁLEZ, 2020) . However, it is thought that it is more important to implement strategies in a holistic way instead of these applications. For this reason, it is thought that demarketing practices can be used as a solution strategy in order to solve over-tourism, which is one of the main problems of tourism in the post-pandemic period. There are studies in the literature that evaluate this role of demarketing (Milano et al., 2019; Tiwari, Kainthola, & Chowdhary, 2020). In this context, an answer to the following research question was sought in the study;

Q2: Could demarketing be a solution strategy for overtourism in the post-COVID-19 period?

3. METHODOLOGY

The COVID-19 pandemic is emerging as a process that seriously affects all people, as it affects the tourism industry and other industries. For this reason, secondary data sources are used in research on this subject. Secondary data sources are important in terms of analyzing content and revealing information securely. This information, which is revealed through secondary data sources, should be processed in a systematic way. For this reason, it is beneficial to pass the data through a secure review system.

Qualitative research methods were used in the study and content analysis technique was used. Content analysis is a technique in which the quantity of the word is high and it is formed into classifications that have occurred within certain criteria. It is a technique that examines and infers in order to reveal the important aspects of the content (Krippendorff, 2004; Stemler, 2000). The benefit of this type of analysis is that it allows for a systematic simplification of large-scale sources of information.

The news content obtained in the research covers the period from March 11, 2020, the beginning of the COVID-19 pandemic, to February 15, 2022. This is because the World Health Organization (WHO) has declared COVID-19 as a pandemic since this date (WHO, 2022). Data were obtained online and analyzed with the MAXQDA qualitative research program. These contents were created with 652 news covering the words demarketing and overtourism. Some codes were determined in the analysis. Within these codes, media, destination, local people, business, policy, demarketing, sustainability, COVID-19 and overtourism factors are discussed. The words in each code were transferred to the MAXQDA program and analyzed according to this content (Kuckartz & Rädiker, 2019).

4. FINDING

Qualitative data analysis program was used to create a holistic perspective in the study. With the help of the relationship map, the connections between the themes were determined. The shape and intensity of the lines on this map show the strength of the inter-thematic relationships. In addition, the relations of each category are presented with the help of graphics with the analysis program. MAXQDA visual tools are preferred to define and classify ideas and to see the thematic relationships between themes (Azzopardi & Nash, 2016).

As seen in Figure 1 a total of four word clouds, one of which is general, were revealed within the scope of the news. These word clouds consisting of overtourism, COVID-19 and demarketing codes are examined. The frequency of the general category word cloud of this study was determined to be over 100 and the frequency of the word cloud of the other three themes was determined to be over 50. In the word cloud of the COVID-19 theme the words tourism, travel and overtourism were found intensively. In the word cloud of the demarketing theme, there are the words tax, tourism and COVID-19, and in the word cloud of the overtourism theme the words destination, tourist and tourism are concentrated.

Looking at the findings of the study from a general perspective, it has been revealed that there is a strong connection between overtourism and destination, policy and destination, and sustainability and destination. Figure 2 shows MAXQDA's Code Matrix Scanner. Here the themes are displayed as a table. Nine codes are displayed on both the x-axis and y-axis. In this context, it is seen that destinations try to increase sustainability by trying to prevent overtourism with preventive policies. It can be said that especially the destinations that host a large number of tourists follow such preventive policies in order not to wear out their tourism supply resources and to meet the tourism demand that will occur in the future. Apart from this, it is thought that the locals theme will create a strong connection with sustainability, destination and overtourism, and the local people can support the destination managers.

Figure 3 shows the code co-occurrence pattern used to reveal the relationships found between different themes. Thanks to this technique, by looking at the thickness of the lines, it is revealed whether the strength of the relations is strong or weak. In this context, within the scope of the study, the relationship strength of 3 main themes with sub-codes was examined. While the strongest relationship of COVID-19 was with destination, the weakest relationship was with media. It has also been revealed here that it is an undeniable fact that COVID-19 heavily affects crowded environments. Looking at overtourism, it is seen that there is a strong relationship with destination. It is thought that the strong relationship between COVID-19 and overtourism with the destination negatively affects the tourism supplies in the destination. In the Demarketing theme, this situation changed and a strong relationship emerged between politics. It can be said that it is planned to create demarketing together with the policies implemented by the administrations and thus to increase the sustainability of tourism supplies.

The model in Figure 4 shows the relations and connections of the themes of COVID-19, overtourism and demarketing, which constitute the main frame of the study, with sub-codes. The other codes that intersect with the selected codes are shown with a line and connected to each other. This model, which was created using codes, actually constitutes the entire summary of the research. When the relationship between overtourism, COVID-19 and demarketing themes in the model is examined, it is seen that the strongest relationship is between overtourism and COVID-19. Following this, it can be said that the weakest relationship is between COVID-19 and demarketing. It is thought that the reason for this is that with the emergence of COVID-19, the phenomenon of overtourism has been eliminated and thus demarketing policies are not needed in this process.

4.1. Discussion and Theoretical Implications

This research discusses the effects of overtourism on the spread of COVID-19 and whether demarketing can be a strategy for the solution of overtourism in the post-pandemic period. Overcrowding and increasing international arrivals, which are the source of the discussion of the phenomenon of overtourism, are one of the crucial factors that accelerate the spread of COVID-19 all over the world in a brief time (Neuburger & Egger, 2021). This is also supported by the results of the study. According to the results of the study, the theme of COVID-19 is heavily related to the codes such as sustainability, policy and destination that make up overtourism. Studies emphasize that COVID-19 interacts with tourism and travel movements from the first day it first appeared until the last moment when its effects will decrease (Gössling et al., 2020; Şengel et al., 2022; Sigala, 2020).

In addition to the impact of COVID-19 on tourism activities, it has been observed that tourism activities also affect the course of COVID-19. It is known that international tourist arrivals have a large share in this regard. Moosa and Khatatbeh (2021) reached conclusions that support this situation in their study. It can be said that overtourism, caused by the increasing international arrivals, has a significant role in the spread of COVID-19. The literature reveals the existence of the current situation and reveals that the pandemic is an important opportunity to show the current situation of overtourism (Kainthola, Tiwari, & Chowdhary, 2021; Mohanty, Tiwari, & Chowdhary, 2022). Sengel (2021) who made similar evaluations, reveals that it is necessary to restructure tourism by making a new normal tourism evaluation for the post-COVID-19 period. In this new restructuring process, it is necessary to control overtourism in order to ensure sustainable tourism and not exceed the carrying capacity. In many studies, it is emphasized that demarketing is one of the important factors in controlling overtourism (Lindberg & Seeler, 2021; Tiwari et al., 2020).

As resuls, one of the focal points of the evaluations made on three main topics is sustainability. Overtourism must be brought under control in order to ensure that tourism is sustainable and to prevent similar crises such pandemics. Many studies in the literature consider drivability as the most important factor to combat overtourism. However, sustainable tourism is an older phenomenon than overtourism. This situation moves sustainability away from being a solution tool for the issue (Öztor & Şengel, 2022). Sustainable tourism is a result that can emerge when successful solutions are found, rather than being a solution to overtourism. Instead, applications such as demarketing, which are related to sustainability as well as overtourism, can be a solution.

4.2. Practical Implications

Based on the relationship between the spread of COVID-19 and overtourism, the study focuses on solving the problem of overtourism in order to avoid such health crises. For this reason, it considers demarketing studies as a solution strategy to combat overtourism for the post-pandemic period. Önder and Zekan (2020) used demarketing for a similar purpose in their study and discussed it as a means of combating overtourism. In this context, some suggestions can be made to certain stakeholder groups related to tourism based on the results of the study. All three concepts covered in the study were strongly related to the destination. Overtourism, COVID-19 and demarketing practices are all among the issues that concern destinations. For this reason, public authorities, private sector representatives and NGOs (Non-governmental organization) in the destination should act jointly and create a mechanism that will control overtourism to avoid crises with great social impact (Mohanty et al., 2022). Fontanari and Traskevich (2022). It reveals that it is necessary to deal with overtourism and that it is necessary to develop the resilience of destinations in the post-COVID-19 period, which they see as an opportunity for this. In fact, in case of failure in the organization of the stakeholders, destination management organizations that can produce professional solutions can be established. Especially popular and overcrowded destinations need to spend more effort to establish DMOs. (Destination Management Organization) While Gowreesunkar and Vo Thanh (2020) state that DMOs will play a key role in solving the problem, Lindberg and Seeler (2021) consider that DMOs alone will not be sufficient, instead, effective participation and strategic work of all stakeholders is necessary. Successful implementation of demarketing activities depends on successful policies. All its stakeholders and professional DMOs can play an active role at this point.

Businesses have great duties for demarketing strategies. Tourism businesses are generally among the stakeholders who do not complain about overtourism. As a matter of fact, in this study, no relationship was found between the overtourism theme and the business sub-code. Tourism businesses should be a part of the demarketing process and should act jointly with public authorities. Çakar and Uzut (2020) state that a downsizing model adopted by all tourism stakeholders to be implemented will create a lack of effectiveness against overtourism. Otherwise, it is not possible for the efforts to yield positive results. Businesses struggling with the seasonality problem should be directed to alternative tourism types, they should be directed to demarketing applications for crowded periods, and they should apply to marketing mix elements for periods when the number of tourists is low (Arora & Sharma, 2021; Dhiraj & Kumar, 2021). Practices such as demarketing, which will be applied to combat overtourism, are critical elements for the adoption of quality tourism, ensuring coordination between different components of tourism in the destination, re-analyzing trends in the markets, restructuring existing marketing strategies, and adopting innovative products. The pandemic is also an opportunity for these, and they can be easy to implement in the post-COVID-19 era (Hall & Wood, 2021; Kumar & Garg, 2021; Tiwari & Chowdhary, 2021) .

The negative societal effects of excessive tourism have become more pronounced with the pandemic. Therefore, it is important to solve the overtourism problem. Such crisis periods offer important opportunities for the solution of chronic social problems. As a matter of fact, Renaud (2020) states that radical solutions should be adopted to ensure the transition from “growth for development” to “downsizing for livability”. Making similar evaluations, Kainthola et al. (2021) states that the crowd perception in tourism should be changed in the post-COVID-19 period. It handles the situation with the slogan from extreme tourism to zero tourism. This process offers some opportunities to popular destinations where tourism activities exceed their carrying capacity. Kodaş and Kodaş (2021) describe similar opportunities for popular destinations. The strong relationship between demarketing and policy shows that demarketing can be used to solve post-COVID-19 overtourism (Hall & Wood, 2021; Happonen, Rasmusson, Elofsson, & Kamb, 2022). The study is based on a strong theoretical background while offering alternative practical implications for the solution of this important problem.

4.3. Limitations and Future Studies

Although the study reveals the relationship between overtourism and COVID-19 and the importance of demarketing activities in the post-pandemic period in the fight against overtourism, it contains some limitations. The study is based on online news data and covers only a certain time period. For this reason, this study can be renewed by obtaining data in different periods in future studies. In addition, studies involving quantitative, qualitative or mixed models can be conducted to obtain data from primary data sources with stakeholder participation.

Funding: This study received no specific financial support.

Competing Interests: The authors declare that they have no competing interests.

Authors’ Contributions: All authors contributed equally to the conception and design of the study.

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