This study investigated the English-only language-in-education policy in three primary schools in Ghana: University Primary, OLA Presby Primary and Apewusika Primary School in the Cape Coast Metropolitan in the Central Region of Ghana. The study employed Coulmas’s (2005) eight-step language planning model as a conceptual framework for the study. Nine teachers were randomly selected from Basic One to Basic Three to respond to the selection and supply items. The selected items were analysed and put into frequencies and percentages, while the supply items were coded into recurrent themes. Findings from data indicate that most teachers preferred using the local language (Fante) as a medium of instruction in the lower primary. The study also revealed that code missing is a significant feature in teacher-learner interaction. It was also observed that teachers encountered little problems when using Fante as a medium of instruction. Finally, most teachers express a lukewarm attitude towards using English as a medium of instruction in the lower primary school.

The English Language plays a vital role in Ghana. It is the nation's official language of business and commerce, law, Education, the learned professions, administration, governance, and politics [1]. For one to function well in such an English-speaking environment, one needs to acquire sufficient proficiency in the English language. It is also worth noting that the Ghanaian languages are also the vehicles of cultural transmission, and their value must be emphasised. They are access to our cultural heritage [2]. Historical evidence reveals that the Christian missionaries, notably the Bremen and the Basel missions, first attempted to develop the local languages in Ghanaian Education. Later, the British colonial government took over due to recommendations of various educational committees, namely the Educationist Committee of 1920, the Phelps-Stokes Commission's Report of 1922 and 1924 and the Advisory Committee in the Colonies [3]. All these committees stressed the importance of the L1 as a medium of instruction in the lower primary classes. Consequently, the twelfth educational principle of Governor Guggisberg pointed out that whilst an English education must be given, it must be based solidly on the vernacular [3, 4].

The various educational reforms in the post-independence era did not make any radical changes in the old recommendations or policies. An educational committee appointed by the National Liberation Council’s government in 1967 recommended that "A Ghanaian language be used as the medium of instruction for the first three years of the primary school course. The change to English as a medium of instruction should commence in the fourth year whilst the Ghanaian language continues to be studied as a subject in the metropolitan and other urban areas". [4]. In making the recommendation, the committee acknowledged that children learn more efficiently in their mother tongue and can express their ideas more clearly in that language. Psychologists agree that using the LI as a medium of instruction has excellent advantages. It facilitates concept formation and serves as a bridge between the school and home [5]. Surprisingly, however, the National Liberation Council’s government’s White Paper on this recommendation proposed that the mother tongue should be used as the medium of instruction for the first year only; the Dzobo committee’s Report in 1974 suggested “a gradual introduction of English as a medium of instruction after the third year of the primary school course” [4]. The previous language policy sought to make the local language the medium of instruction during the first three years of formal Education, while English is taught as a subject on the timetable. The expectation was that by the end of the third year, pupils would have learnt sufficient English to make for a smooth transfer to an English medium of instruction from primary four onwards [6].

However, upon assumption of office, the New Patriotic government appointed a committee to review the education structure in Ghana and advise the government appropriately. Before the committee could present its findings, the cabinet declared, “Henceforth, English Language should be used as the only medium of instruction at all levels of education” [7]. In October 2002, the President's Committee on Review of Education Reforms identified in its Report the limitation of the implementation of the policy of LI medium of instruction to be (a) multiplicity of local languages, (b) lack of teaching and learning materials in the local languages and (c) inadequate number of local language teachers [8]. It, therefore, made the following recommendations, among others:

• Either the local language or English language should be used as a medium of instruction at the kindergarten and lower primary as appropriate;
• Where teachers and teaching and learning materials are available, local languages must be used as the medium of instruction;
• Within five years, the Ministry of Education and the G.E.S. should prepare to implement L1 more effectively as a medium of instruction. This should include training more local language teachers and providing teaching and learning materials [8].

The committee acknowledged that using local languages as the medium of instruction at the lower level is significant, mainly because it facilitates pupil-teacher interactions.

The issue of language policy in Ghana, especially as it affects the lower primary school, has recently been the subject of public debate. Some object to the use of the mother tongue as the medium of instruction, especially in the lower primary schools, on the basis that the child knows his mother tongue before he/she comes to school; therefore, there is no need for the school to teach him/her again [9, 10]. This position is also precipitated by the argument that children in private schools who use the English language have higher academic achievement than those in public schools that use the LI (native language) as the medium of instruction. Even if the child is fluent in the local language, it is only the oral skills he has acquired. He must also acquire listening, reading, and writing skills in the local language. It is also argued that using the LI as the medium of instruction in the early stages eases concept formation and bridges the gap between home and school [5]. The new English medium policy in the lower level (primary 1-3) is, therefore, expected to reverse the low English proficiency of school children [9]. He argued that this would resolve the abysmal performance in examinations. The research problem, therefore, is to investigate the current language policy in three primary schools in the Cape Coast Metropolitan. The study sought to answer these research questions: (1) what language is used as the medium of instruction in the lower primary schools in the Cape Coast Metropolitan? (2) How well are schools prepared to use English or the local language as a medium of instruction in the Cape Coast Metropolitan? (3) How well are teachers prepared to use English or the local language as a medium of instruction? (4) What is teachers' attitude towards using English as a medium of instruction at the lower primary?

1.1. Conceptual Framework

Coulmas's (2005) eight-step language planning model was adopted as a framework for this study. Coulmas proposed an eight-step model of language planning as follows:

• an initial sociolinguistic situation (SLS₁) including speakers, languages and their functions;
• goals summarised as a projected situation SLS_2;
• a set of measures suitable to transform SLS₁ into SLS₂;
• an authority to determine and institutions to implement these measures;
• the actual implementation;
• monitoring the effectiveness of the measures over time;
• comparison of SLS₁ with SLS₂ and the actual outcome;
• Modification of measures if grave disparities between the actual outcome and SLS₂ are found [11].
• Language planning choices are undertaken with the expectation that they will affect future developments predictably. He pointed out that language planning requires a conditional model of language change of the form X→Y; if you do X, the outcome will be Y. In other words, changing a language policy is expected to bring about desirable goals within a speech community. It is significant to point out here that language policy is essential to language planning. Therefore, if language planning falters, language policy will inversely be affected [11].

Ghana's new language–in–education policy is currently being implemented. Therefore, where the elements of this conceptual framework will become handy and underpin the direction of this study is the last three elements. The choice of this model is informed by its relevance to the study. Besides, it is systematic because of the stages it involves. In other words, it gives a step-by-step direction to the study.

1.2. Language Policy

Language planning is defined as a deliberate and conscious effort to affect the structure and functions of language in society [12]. It involves linguistic research, diagnosis, forecasting, decision-making, budgeting, educational, administrative, legal and financial assessment. Language planning also involves designing and drafting an operational master plan on language use. Language planning is the responsibility of linguists and people with sound knowledge of language use. It is not the responsibility of politicians. Those involved in language planning:

Can carry out the basic research, describe the various

languages involve in a given situation, prepare

contrastive studies forecast the difficulties that speakers

of one language are likely to have in learning another,

and guide the preparation of teaching materials [13]

Language policy is a “conscious governmental effort to affect the structure and function of language varieties” [14]. One of the essential objectives of language policy is to give a clear status to the languages that exist in society. This is one of the best avenues for a country to manage multilingualism in its territory. However, the success of a language policy depends on thorough and strategic language planning. A writer asserts that:

Decisions about a national language policy are normally

made by politicians, not by linguists, and for political reasons

which may seem valid at one moment but may have lost much

of their force ten years later. If the people feel frustrated,

The policy is likely to fail. Therefore, an empirical and pragmatic approach

to the problem is desirable, and policies should be worked

out within the feasible limits [13].

It must be noted, therefore, that however laudable the aims of a language policy are, unless the people running it believe in it and agree with its dynamics, it will fail. Another writer identified four guiding principles that may serve as a reference point for formulating language policies in Ghana. One of these is the role and place of European languages in the child's development. He states that using English or French in Ghana is not a question of choice but of necessity. The French Teaching syllabus has this to say on this principle:

The pace of development in the present world makes it

essential to develop the capacity to communicate

in multiple languages. Communicating in

more than two of these (European) languages is a strategic

ally essential in areas such as commerce and industry, Science

and technology, telecommunication, diplomacy, and management [15].

What is stressed here is the importance of studying English and French in Ghana. More significantly, the study of English is inextricably linked to our national development and Ghanaians' effective functioning and participation in society. The writer further stated that “the guiding principle of L1’s role is the child's affective, cognitive and cultural development”. That is, using L1 in school guarantees continuous affective, cognitive and cultural development of the Ghanaian child. He argues that “in the school, the child is cut off prematurely from his parental milieu and first language; this could lead him to a state of insecurity, affective, affective frustration and intellectual uncertainty” [15].

Therefore, the use of the L1 offers the child an opportunity to express himself freely and spontaneously. He added that the L1 will also serve as a mode of transmitting and inculcating cultural values into the child to ensure his total development. If we agree that language is inextricably linked with culture, then a child's L1 is essential in cultural development.

In addition, the effective integration of the school and the community requires the use of the local languages of the area by the school [15]. The writer explained that the intensive and premature use of foreign languages is a handicap that limits the involvement of the youth in their community's development; it is true that most highly educated Ghanaians cannot use their native languages competently in most social functions such as delivering a speech or a formalized discussion. While this could be attributed to their prolonged exposure to the English language, it is also a fact that most of these educated people need to be more competent in the English Language as expected [15]. The writer's final guiding principle was that “the harmonious development of the child can only be guaranteed by the Ghanaian language. Using the L1 will develop the child socially, culturally, psychologically, and morally” [15]. Another important guiding principle for language policies in Africa and Ghana is the position of international organisations, specifically, the Organization of African Unity (O.A.U., now African Union) and UNESCO. Both organisations stressed the importance of the L1 as a medium of instruction. As cited by Philipson (1996), The Language Plan of Action for Africa prepared by the A.O.U. and approved by African Heads of State in 1986 had the following among others as its aims:

• Liberate the African people from undue reliance on the utilisation of non-indigenous languages as the dominant, official language of the state in favour of the gradual takeover of appropriate and carefully selected Indigenous African languages in this domain;
• Ensure that African languages, by appropriate provision and practical promotions, assume their rightful role as a means of official communication in the public affairs of each member state in the placement of European languages, which has hitherto played this role;
• Encourage the increased use of African languages as instruction vehicles at all educational levels.

These aims will not be realistic when applied to most African countries, such as Ghana. Between Yaoundé, the capital of the Cameroon Republic, and Dakar, the capital of Senegal, 500-1000 different languages are spoken [17]. In Ghana, over fifty indigenous languages exist. Which of these is to be used as the official language or the language of instruction? If each society was to use her language, would it not destroy national unity and retard effective interaction? A UNESCO document responds to these questions in the following lines:

The use of African languages in teaching at the basic

level does not in any way contradict the importance

of non-African languages. This is because the

fastest and most steady means of education expansion

is when Africans have access to those languages.

They are not at variance with each other:

They may be less mutually exclusive, but they are very

Complementary [15].

It can be noted that while the OAU document stresses the importance of the local languages to the exclusion of the European languages, UNESCO recognizes their importance. Again, the OAU program proposes the use of African languages as vehicles of instruction at all educational levels (p.68). UNESCO, however, is concerned with the basic level. The point being made here is that Ghana is a multilingual country which has adopted English as an official language.

In principle, the language education policy has encouraged using local languages alongside English. Since colonial times, the issue of the appropriate medium of instruction in lower primary schools has been a heated argument among Europeans and Ghanaians alike. Policymakers, experts, parents and the public are torn between the use of L1 and the use of L2. A writer asserted that against this background, "Few aspects of education in Ghana can be more important than language policy and practice in the elementary school, few on which such differing views have been expressed, and few subject to such major changes in government policy” [18].

The primary school teaching syllabus enumerated the importance of English as the official language of government, administration, the learned professions, business, and the media. It is also the most widely used language for international communication, the dominant language of the internet, and the medium of formal Education at almost all levels in Ghana. It also contended that “success in any form of education training in work generally, depends upon the ability to understand and use English language effectively” [1]. It is against this background that the Ghanaian language syllabus considers the following to be the problems that retard the development of Ghanaian languages;

• The misconception is that Ghanaian languages need to be improved to treat certain subjects and issues.
• Ignorance of the potency of our traditional knowledge as a basis for advancement in Science and technology.
• The inferiority complex of Ghanaians when viewing Ghanaian things in the context of the external world [1].

There is no doubt that the English language is needed by any Ghanaian "for full participation in the political and economic life of the nation’’ [19]. Nevertheless, the Ghanaian languages are crucial for integrating Ghanaians into their society. A cord is needed to link the educated with his people, not to talk about culture as the bedrock of development. These two equally essential phenomena have been the most recurrent source of conflict regarding whether the L1 or the L2 should be the medium of instruction in the lower primary school course. Adherents of the L1 medium of instruction, notably linguists and psychologists, argue that the L1 facilitates concept formation and classroom interaction in the early stages. A writer contended that "there is no evidence that six-year-old children who have no speaking knowledge in English derive maximum benefit from instruction in English” [20]. It, he said, is against this background that "there is no denying the fact those most Ghanaian children comprising the urban poor….. Moreover, the rural children enter school knowing (only) their mother tongue" [20]. The writer further observed that “children taught the basic concepts in the L1 and English Language by competent teachers in the early stages do better in all subjects including English Language, adding that the L1 helps the child to adjust to the school environment” [20].

Again, teaching these children in English alone will mean denying them “access to their cultural heritage” [20]. A writer posits that “English should be the medium of instruction at all educational levels. The fear is that the child enters class one and is confronted by a teacher who speaks English throughout the class to teach other subjects. If the child does not speak English at home, he will be completely lost and may even lose interest in school; this is more dangerous, taking into account that the majority of Ghanaian children are those referred to as “urban poor” and “rural children” [5]. A similar study also reveals, “Humans build the foundations of language communication, comprehension, thinking, imagination, creativity and more profound cognitive abilities through their first language. The writer continued, “These are cognitive and linguistic foundations that we bring to subsequent learning [21]. It is, therefore, important that children are taught their mother tongue to give them the foundation for learning English and other disciplines.

On the other hand, in his declaration of the L2 medium of instruction policy, the minister of Education contended that the policy had become necessary to improve the pupil's comprehension of the English language [7]. Longstanding in the mother tongue builds concepts in that language and internalizes in children. That language makes it "second nature to him". The child thus can think clearly in the Vernacular. The writer argued that “when the child had left the lower primary school for a long time, he/she would always have to think in the vernacular and translate what he wants to say in his/her mind to English before he/she speaks if the translation is not smoother, errors occur” [10]. ‘Lack of communicative competence in English by most Ghanaians is due to their inability to directly organise what they want to say in English. An early exposure to English will be a solution to this problem [10].

The prominence of the L2 medium of instruction is always supported by the fact that children in private schools, who are exposed to English earlier, perform better than those in public schools, where the policy mandates an L1 medium of instruction. In a writer's words, however, this perception is based on "introspective logic". There has not been any scientific research to prove that an early introduction to English gives the child a chance to excel academically. It is most probable that other factors in private schools give children such a chance of academic excellence rather than the language factor [21]. In Ghana, English is perceived as a civilized language, and parents use it with their children as a show-off. This is well captured in the following assertion:

They (parents) do not teach their little children the native

language. Rather, they teach English

to these poor, little children in public to show how

Civilized they are and how they even have 'civilized

little children [21]

These parents always want to send their children to schools where English is used as a medium of instruction. Thus, they naturally kick against using the Ghanaian language as a medium of instruction in the lower primary schools. A writer indicates, “Ghana promulgated an English-only policy during Kwami Nkrumah’s era 1957-1966 because students' English language proficiency fell below the adopted threshold. Therefore, the English-only policy at that time was justifiable. On the other hand, the problem is not with the policy but its implementation. He posits that we have not provided our teachers and learners with the needed resources to teach and learn the English language. The writer goes on to assert that a programme which ensures success in L2 provides quality instruction and enough opportunities for learning the language, which includes adequate time”. The instructor's constant use of the target language in the teaching and learning process enhances their proficiency. As a nation, we have not trained teachers to teach English as a foreign language meaningfully and use it for academic purposes in a way that could lead to maximum returns” [22].

Using the child's first language in Education has enhanced learners' academic, linguistic and cognitive achievement. The first language proficiency level directly influences second language development and cognitive academic growth [22]. The writer further admits that "the cause of students' underachievement, despite starting their Education in L1, to the type of bilingual education model practised. He believes that the type of bilingual Education practised in Ghana before the policy change was the early exit transition model [22]. As a policy, the Ghanaian language was used as the medium of instruction at the lower primary level (p1-3), and English as the medium of instruction from class four. At the lower primary level, English was taught as a subject. The writer acknowledged the teacher factor, lack of supervision and lack of exposure to the target language as factors responsible for the abysmal performance of students; he also believes that two main factors worked against the model. One, learners were prematurely transitioned into using English as a medium of instruction, and two, the transitional process was abrupt [22]. L1 directly influences the development of proficiency in the second language. In some cases, a disruption in first language development has been found to inhibit second language proficiency and cognitive growth [22].

It was recommended that “the reinforcement of Ghanaian language use in schools as the medium of instruction be implemented by the late-exit transitional bilingual Education to redress the controversy surrounding the language-in-education policy. More needs to be done to train highly motivated teachers, provide effective supervision, provide educational materials, provide parental and community involvement, and formulate sound language and educational policies. In late-exit transitional bilingual Education, according to him, Ghanaian language (L1) should be used as a medium of instruction from primary 1- 4, and English (L2) should be introduced from primary five onwards. Children might have acquired enough proficiency in their mother tongue to transfer concepts into the L2 better" [22].

Quantitatively, the study adopted a multiple case study research design. The study population comprised language teachers in the three selected primary schools in the Cape Coast metropolis. The main instrument used in the data collection is the questionnaire. A purposeful sample design was employed to select the three schools: Apewusika M/A Primary School, University Primary School and Ola Presby Primary School. The study was conducted with the Basic three classes of these three schools. This choice was informed by the fact that after this stage in their schooling, pupils are said to have acquired sufficient English language to ensure a smooth transition from L1 to L2 as media of instruction [4, 23]. Three teachers in each school were used as respondents though each school has four classes for the Basic three levels. This was because not all the teachers were willing to answer the questionnaire. Nine teachers from all three schools were used as respondents for the study. Respondents were asked to respond to both supply and selection items. The selected items were analyzed and put into frequencies and percentages while the supply items were coded into categories

Table 1 indicated that most respondents were males since 80 % were males, while 20 % were females.

Table 2 shows that the educational qualifications of respondents were quite high: 60 % of them are first-degree holders, while 40 % are Cert ‘A’ holders.

Table 3 illustrates the teaching experience of respondents. While 70 % of the teachers have been teaching from 0- 5 years, 30 % have taught from 6- 10 years. This shows that the respondents' level of experience is relatively high.

Table 4 shows that 70% of the respondents teach in class three. Only 20 % indicate that they have ever taught in all three classes. Therefore, the respondents are expected to be familiar with events in the lower primary.

Table 5 shows that 50 % of the respondents have been handling their classes for one year, 30 % have been handling theirs for 2-3 years, and 20 % have also been handling theirs for 4-5 years.

Table 6 shows that 60 % of the respondents have had in-service training, while 40 % never had any in-service training.

Table 7 analyses the number of in-service training sessions respondents have had. 66.7 % indicated that they have had in-service training once, while 33.3 % have had it twice. This shows that more in-service training needs to be provided to equip teachers with the requisite skills to perform better.

Table 8 shows respondents' ratings as regards their proficiency in the English language. 60 % rated themselves as average, while 40 % rated themselves as high. This means that the level of proficiency among the teachers leaves much to be desired. This, therefore, has the potential to negatively affect the learners in the classroom since teachers are supposed to be models for learners to emulate.

Table 9 shows that only 10 % of Ghanaian language teachers have ever had in-service training in the Ghanaian language, while 90% have had no in-service training at all. This shows severe constraints on the part of the Ghana Education Service to organise periodic in-service training for teachers.

Table 10 indicates the literacy level of teachers in the Ghanaian language. 60 % indicated that they could read and write, while 40 % indicated they could neither read nor write. These statistics show that some respondents are non-natives and, therefore, cannot teach in the local language.

Table 11 indicates that there needs to be more teacher/learner materials for using English as a medium of instruction. 70 % of the respondents indicated there are not enough, while 30 % indicated the contrary.

Table 12 also shows an insufficient need for more teacher-learner materials for using the Ghanaian language as a medium of instruction.

Table 13 indicates that code-missing and code-switching are prevalent in the classroom. Responses from the respondents show that only 40 % used English as a medium of instruction, while 60% of them indicated they use both English and vernacular.

Table 14 shows respondents' choice of language as a medium of instruction. While some favour the use of both media, others favour only English.

Table 15 shows that 70% of the respondents preferred both English and vernacular to be used as a medium of instruction, while 30% preferred English only. This high preference for both media shows that teachers favour code missing as a medium of interaction.

Table 16 shows the preferences of respondents and the reasons assigned for these choices. The words in the brackets indicate the choices of the respondents.

Table 17 shows that 70% of the respondents indicate that pupils use the native language as a medium of interaction in school, while 30% of them indicate that the English language is used as a medium of interaction.

Table 18 shows that when English is used as a medium of instruction, pupils contribute better to lessons. 60% of the respondents testified to this, while 30% indicated the opposite. This, however, depends on the type of school.

Table 19 shows that the overwhelming majority of the respondents (7believe that using the Ghanaian language as a medium of instruction in the lower primary use should, therefore, be a simple language-in-education cation policy.

Table 20 illustrates the reasons why media of instruction is useful. Most of the respondents favour the local language.

Table 21 shows that 60 %of the respondents disagree that English should be used as the medium of instruction in the lower primary and secondary schools, while 40% agree.

Table 22 indicates the reasons assigned to respondents' preferences as to which language should be used as the medium of instruction.

Table 23 shows that most of the respondents (70%) indicated that they encounter problems when using English as a medium of instruction in the lower primary. However, 30% of them indicated the opposite.

Table 24 indicates some of the problems teachers encounter when using English as a medium of instruction.

Table 25 shows that most respondents (60%) are okay with using the local language as a medium of instruction in the lower primary. This indicates that the use of the local language as a medium of instruction at the primary level is appropriate.

Table 26 presupposes that some of the teachers and students are non-natives and, therefore, cannot speak or understand concepts when the local language (Fante) is used as a medium of instruction.

Results from the data indicated that using the local language facilitates concept formation. In other words, pupils comprehend concepts better when the local language is used as the medium of instruction. These results align with previous studies that “teachers encounter little problem when the local language is used as a medium of instruction”. The use of the child’s first language enhances the academic, linguistic and cognitive achievement of learners” [5, 21]. It was also found that the medium of interaction among pupils in the school environment is the local language. This gives belief that “the use of the child’s first language helps him or her to adjust to the school environment. In other words, using the native language in school bridges the child's home environment and the school” [20]. There are possibilities where the medium of instruction in the child’s home may be English; however, it is not out of place to say that it may be on a small scale since English is not our native language.

It is also significant to note that there needed to be more teacher-learner materials to facilitate the use of both English and Ghanaian languages as media of instruction. It is also sad to observe from the analysis that some teachers (though a small percentage) could not speak or write in the local language [8]. It is also observed from the analysis that most teachers in all three schools employ code missing in the classroom interaction. This, of course, is a novelty which should be encouraged since it facilitates the comprehension of concepts. It can also facilitate the involvement of the learner in the classroom discourse. From the results of the data, the answers that were found to the research questions are the following:

• The medium of instruction adopted in the three schools is either the local language or a mixture of both the Fante and English language (code missing).
• The schools still need both human and material resources to equip them adequately to use either the local language or English as the medium of instruction.
• The analysis generally shows that teachers are better equipped to instruct in the local language.
• Most teachers have a lukewarm attitude towards using English as the medium of instruction.

The local language should be used as the medium of instruction in the lower primary, as Anamua Mensah’s 2000 Report suggested. Trained teachers should be posted to areas where they can speak and write in the local language. Code-missing and code-switching should be encouraged in the lower primary. The Ministry of Education, Science and Sports, in conjunction with Ghana Education Service, should make a frantic effort to organise periodic in-service training to equip teachers with the requisite skills to use the local language as a medium of instruction. Ghana Education Service must also ensure that teacher-learner materials are provided to ensure effective teaching in the local language. More research should be done to compare the performance of pupils to determine which of these languages, when used as a medium of instruction, help pupils comprehend concepts better.

Author Contributions: Conceptualisation; methodology; formal analysis; investigation; Resources; data curation; writing-original draft preparation; writing-review and editing; visualisation; supervision; project administration; Author has read and agreed to the published version of the manuscript.

Funding: "This research received no external funding."

Data Availability Statement: Data is available on request from the corresponding author.

Acknowledgements: I acknowledge respondents for their time with me.

Conflicts of Interest: “The author has declared no conflict of interest.” “No funders had any role in the study's design; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results”.