Leveraging community engagement for strengthening primary health care services: lessons from the 1^st international primary health care conference, Tanzania

¹School of Dentistry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, ²School of Public Administration and Management, Mzumbe University, Morogoro, Tanzania, ³President's Office Regional Administration and Local Government, Dodoma, Tanzania, ⁴Department of Public Health, University of Dodoma, Dodoma, Tanzania, ⁵University of Dar es Salaam, Dar es Salaam, Tanzania, ⁶School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania

^&Corresponding author
Kasusu Klint Nyamuryekung´e, School of Dentistry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania

Introduction    

Countries worldwide are working to achieve Universal Health Coverage (UHC) and the Sustainable Development Goals by 2030, Sustainable Development under Sustainable Development Goal Three (SDG3). The achievement of UHC and SGD3 relies heavily on effective Primary Health Care (PHC) that is well coordinated and integrated in providing essential health services to the entire population [1]. Given that half of the world's population lacks access to essential services [2], community participation is a critical component with the potential to strengthen PHC and thus address existing gaps in access to quality care, coverage, and financial protection. This is demonstrated by the Alma-Ata Declaration of 1978, which prioritized community participation in planning, implementing, delivering, and monitoring PHC services [3,4]. The World Health Organization (WHO) and its member states reaffirmed that community participation is an essential component of the framework for integrated and people-centered health services, which is critical to achieving UHC [5]. As evidence of this, the Astana Declaration of 2018 declared that the community should be strengthened and placed at the heart of PHC to progress toward UHC.

Empirical evidence shows that community-based programs and interventions hold great promise for achieving coverage, social protection, and access to high-quality healthcare for the entire population [2,6]. To establish a robust and efficient PHC that encompasses all levels, policies that offer precise procedures and directives for involving community members, individuals, and families as active participants in PHC service delivery are required. So, the secret to attaining UHC at the PHC is to forge a solid alliance with communities, businesses, and other stakeholders [7-9]. Indeed, there is a call to empower communities, families, and individuals so that they are fully integrated into health planning, implementation, delivery, and evaluation, as well as communities be able to support community resource persons, self-caregivers, and health workers as co-developers and designers of health, nutrition, and social welfare services [10-12]. This will contribute to responsive health and social welfare services with PHC services that meet the community's needs, tastes, and priorities. In Tanzania, community participation in primary health care dates back to 1967, when the Arusha Declaration placed communities at the center of service delivery [10]. This included community participation in establishing various local infrastructures such as healthcare facilities and schools [13,14]. In the context of health, community members were integrated into the delivery of community health programs such as health promotion and outreach [15]. As a result, by the time the Alma-Ata Declaration was issued in 1978, Tanzania had already implemented community participation and had well-structured primary health care at the grassroots level [10].

Since then, several policy initiatives have been implemented to strengthen PHC, which is strongly integrated with community interventions. The government's initiatives to strengthen community health care are not limited to the development of Tanzania's Health Policy 2007, which emphasizes community health service delivery participation, Community-Based Health Programs (CBHP), National Community-Based Care Policy Guideline (NCBCPG), and National Community-Based Health Program (NCBHP). These policy guidelines were critical in standardizing, coordinating, and formalizing community participation and engagement in primary health care. These policy guidelines acknowledge the existence of community governance structures and Community Health Workers as critical to empowering communities to design and control their health. The first International Primary Health Conference in Tanzania was conducted to provide a space for sharing scientifically proven pieces of evidence from policymakers, implementers, and researchers to inform decision-making within primary healthcare spheres [16]. As a part of the conference, experts, implementers, and researchers of community engagement had an opportunity to present empirical evidence of what works and how the situation regarding community engagement and participation. Therefore, this policy paper aims to determine key lessons and findings on applying community engagement for strengthened PHC services based on this seminal conference.

Methods     

Design and context:: data for this policy paper were collected from presentations at the International Primary Health Conference held in Dodoma, Tanzania, in March 2024. The conference featured keynote speeches, forum discussions, abstract presentations, and best practices on various aspects of primary health care services. These materials were supplemented by a desk review of existing policies and guidelines that direct the implementation of Community-Based Health Programs in Tanzania. Conference materials are available online [17], and accepted abstracts have been published in Pan African Medical Journal (PAMJ) as conference proceedings and are accessible online [18].

Data collection: data to inform this policy paper were obtained from multiple sources. Official conference proceedings were acquired, including abstracts, presentation slides, and full-text papers where available. Additionally, recordings of keynote speeches and forum discussions were accessed through the conference´s digital archive. Relevant guidelines and policies that guide and inform the implementation of Community-Based Health Programs in Tanzania were also retrieved. These include the Policy Guideline for Community Based Health Programs (2020), National Operational Guideline for Community Based Health Programs (2021), Operational Guideline for Council Health Boards and Health Facility Governing Committees (2013), Guideline for Primary Health Care Committees in Tanzania (2022), Tanzania Health Policy (2017) and Health Sector Strategic Plan V 2021 -2025.

Data analysis: all collected conference proceedings, audio, and video recordings were subjected to content analysis to extract detailed descriptions of the emerging policy implications and recommendations, as well as their implementation contexts. Additionally, a narrative desk review was conducted to examine guidelines, policies, and reports related to the provision of community-based care and its linkages to primary healthcare facilities and service provision. The desk review informed on areas of alignment with evidence provided during the conferences and identified policy gaps regarding community participation in the provision of community-centered health services. A total of 16 abstracts that were peer-reviewed and submitted under the subheading “community engagement” were evaluated by the researchers. A rigorous qualitative content analysis was conducted to assess the relevance and quality of each abstract. Three abstracts were excluded from further analysis due to insufficient evidence (n=1) or unclear attribution of interventions to defined outcomes (n=2). The remaining 13 abstracts (Supplementary) underwent a hybrid content analysis, combining both deductive and inductive approaches to identify key emerging policy options. Initially, each researcher independently extracted policy themes from the abstracts. These themes were subsequently presented, discussed, and refined through a collaborative consensus process to ensure reliability and coherence in interpretation (Annex 1).

Ethical consideration: ethical approval was not required for this evaluation due to the nature of the evidence used. The evaluation team included scientists and researchers from Muhimbili University of Health and Allied Sciences, Mzumbe University, the University of Dodoma, the Ministry of Health, the President´s Office - Regional Administration and Local Government, and other implementing partners. The team members were also part of the Conference Scientific Committee.

Results     

The following are the main community engagement policy options emerging from the reviewed materials.

Integrated community health programs

Integrated community health programs play a pivotal role in enhancing outcomes within primary health care settings. These programs aim to bridge gaps in service delivery, particularly in underserved and hard-to-reach areas, by fostering collaboration among various stakeholders, including community members, community health workers (CHWs), local authorities, and health facilities. For instance, the Village Health and Nutrition Days (VHND+) in Kibondo District Council exemplifies how integrating nutritional services with malaria testing can effectively reduce child morbidity and mortality. Moreover, integrated community health programs have shown considerable success in engaging key and vulnerable populations, thereby enhancing the uptake and continuity of critical health interventions. The HIV Pre-Exposure Prophylaxis (PrEP) program in Chunya District highlights how community-based initiatives can significantly increase the reach and retention of HIV prevention services. By involving trained community service providers and conducting targeted outreach, the program not only improved PrEP uptake but also fostered a supportive environment for continuous health education and follow-up. Additionally, the deployment of CHWs in hard-to-reach areas, as demonstrated by the Amref USAID Afya Shirikishi Project, illustrates the vital role these workers play in enhancing integrated community health service delivery. Their contributions in identifying and notifying TB cases, for instance, significantly improved early detection and treatment outcomes. For example, the integrated family planning and TB services outreach program demonstrated significant reach and effectiveness, providing services to over 31,232 individuals. This evidence highlights significant improvements that can be obtained through integration of CHWs into the primary healthcare framework. By doing so, health systems can ensure that even the most marginalized populations receive timely and adequate care. Generally, current findings reveal that integrated community health programs are essential for optimizing health outcomes in primary care settings. They provide a comprehensive and inclusive approach to healthcare, addressing various health needs within the community simultaneously, engaging vulnerable populations, and ensuring the delivery of services in remote areas.

Capacitation and engagement of CHWs

Capacitating and engaging community health workers (CHWs) are essential strategies for improving health outcomes in primary healthcare settings. The process of capacitation begins with comprehensive training and continuous skill development. For instance, the Amref USAID Afya Shirikishi Project demonstrated that trained CHWs significantly contributed to TB case notifications in hard-to-reach areas. This example illustrates that well-trained CHWs can effectively bridge gaps in healthcare delivery, improving health services and care even in underserved regions. Providing CHWs with the necessary resources and support is another crucial aspect of capacitation. The integration of CHWs in programs that combine family planning and TB services showcases the importance of equipping CHWs with the tools needed to deliver comprehensive health services. Ensuring that CHWs have access to the right resources not only enhances their ability to deliver care but also improves the overall reach and impact of health programs.

Engaging CHWs effectively also involves integrating them into the community health ecosystem and fostering collaboration with other health stakeholders. Community Health Workers (CHWs) act as vital links between the health facilitiesand the community, facilitating trust and communication. The success of CHWs in referral systems, as observed in the study across six districts in Tanzania, underscores the importance of their active involvement in community health programs. Increased referral completion rates and improved service uptake highlight the positive outcomes of effective CHW engagement. Integrating CHWs into the health system ensures that they are not only part of the service delivery process but also crucial contributors to health system strengthening. Regular supportive supervision and incentives are crucial for maintaining CHW motivation and performance. Supervision ensures that CHWs adhere to protocols and provides an opportunity for continuous learning and problem-solving. Moreover, providing incentives— financial or non-financial—helps to recognize and reward the valuable contributions of CHWs, thereby enhancing their job satisfaction and retention. The increased referral completion rates from 88% to 96%, and the increase of clients referred for family planning and maternal and child health services, illustrate the significant impact of supportive supervision in PHC setting.

Community participation in optimizing health services

Community participation allows health services to be tailored to the specific needs and contexts of the communities they serve. One study focused on the disposal of Long-Lasting Insecticidal Nets (LLINs) in rural southeastern Tanzania revealed that 97% of participants were unaware of WHO guidelines for proper disposal, leading to environmentally harmful practices such as burning and garbage pit disposal. This gap in knowledge highlights the necessity for comprehensive community education and engagement to ensure that health interventions are implemented effectively and sustainably. Empowering communities through feedback mechanisms is another critical aspect of optimizing health services. The study on community-led monitoring using the OneImpact TB Kiganjani mobile application among TB patients demonstrated how patient feedback can identify significant barriers to care, such as stigma, diagnostic quality, delayed test results, and facility-level issues like privacy concerns and accessibility. By addressing these barriers through stakeholder engagement, the intervention improved TB case finding and notification. This example illustrates the value of incorporating community feedback into health service planning and implementation, ensuring that services are responsive to the actual needs and challenges faced by the community. Community-driven initiatives also play a crucial role in optimizing health services. The construction of health care infrastructure (a radiology block) at the Misasi health center, driven by community involvement and collaboration with local leaders, achieved significant progress with 90% completion. This initiative demonstrates that community engagement can significantly accelerate health service improvements. By fostering community ownership and involvement in health facility development, health services can be more responsive, effective, and sustainable.

Partnership between healthcare providers and CBOs

The analysis highlights the importance of partnerships between healthcare providers and community-based organizations (CBOs) in improving outcomes in primary healthcare settings. These partnerships facilitate comprehensive and effective health service delivery, addressing multiple health needs and enhancing the reach and impact of health interventions, particularly for vulnerable populations. The inter-community facility approach in Dar es Salaam, Tanzania, exemplifies the benefits of partnerships between healthcare providers and community-based organizations (CBOs). By training peers as Community Adolescent Treatment Supporters (CATS) the program reached 779 beneficiaries and achieved a 90% viral load suppression rate among youth. CATS were strategically positioned within both the health facility and the community to ensure a continuum of dialogue in both formal (hospital) and informal (community) spaces. The partnership between healthcare providers and CBOs resulted in substantial gains and improved health outcomes for young populations by providing an avenue for leveraging the trust associated with health facilities and the relatability of peers. Similarly, the READY+ model, which integrates clinical services with CBOs to provide mental health and psychosocial support (MHPSS) for adolescents and young people living with HIV, emphasizes the importance of collaboration between health providers and CBOs. This collaborative model improved support and health outcomes for young people but also faced challenges related to inter-institutional communication, collaborative planning, and resource allocation.

Promotion of organizational capacity and gender diversity

Women are the majority of primary health services´ users, thus experiencing the full brunt of community, family and household burden when the services are poorly delivered or unresponsive. Ensuring the presence of gendered community decision-making platforms and structures is critical for addressing missing opportunities for women as well as having community health services that are inclusive and responsive. For instance, the study conducted by the GLASS project has revealed that the effective participation of women in voicing up in decision-making at primary health care, particularly the community level includes the presence of a conducive environment, organizational support to women as well as leadership style that give more opportunity for women to voice their opinion during decision making. It has been noted that organizational barriers in terms of a shortage of legal frameworks that favor the gendered community participation on one hand and failure to comply with guidelines to institute gendered decision-making on the other, are among some of the challenges. Other factors limiting gendered participation are cultural norms and values, and limited organizational capacity.

Discussion     

The aim of this work was to explore key lessons learnt on the application of community engagement for strengthened PHC services in the context of Tanzania and comparable countries. Our findings revealed five main community engagement issues of paramount importance namely; integration of community health programs, capacitating and engaging community health workers (CHWs), enhancing community participation, partnerships between healthcare providers and community-based organizations (CBOs) and promoting organizational capacity and gender diversity in decision-making platforms. We considered conference proceedings as valid sources of evidence to ensure comprehensive coverage of emerging data. Best-practice guidelines support this approach: for example, Cochrane and the US National Academy of Sciences recommend that systematic reviews “always” search for and include conference abstracts to capture unpublished studies to mitigate publication bias and information loss. Furthermore, incorporating conference abstract evidence is one way to accelerate the evidence-to-policy pipeline. It allows emerging research - including locally conducted studies first disseminated at conferences - to inform recommendations and practice without undue delay.

The evidence provided for strengthening community engagement underscores the need for policies and directives that integrate community-based health services across PHC levels. This integration needs to go hand in hand with CHWs empowerment and engagement, effective community participation as well as partnerships between healthcare providers and community-based organizations. This study is in line with the findings of the study conducted by Tani (2016) and recommended and a need for strengthening the integrated supportive supervision to the CHWs as means of empowering them [19]. These policies will need to be implemented within the context of organizations with enhanced capacity to realize their objectives while providing platforms for gendered decision-making.

Integrated community health programs have the key advantage of addressing multiple health needs simultaneously, providing a holistic approach to healthcare. This method reduces barriers such as distance, cost, and lack of awareness that often prevent community members from seeking care. These integrated programs have proven effective in engaging key and vulnerable populations, thereby enhancing equitable uptake and continuity of critical health interventions [20,21]. The current findings align with the Policy Guideline for Community-Based Health Program (PG-CBHP) of 2020 and the National Operational Guideline or Community-Based Health Program (NOG-CBHP) of 2021, both advocating for the integration of community health and social welfare services into existing systems and structures at the local level. This comprehensive and inclusive approach is envisioned to effectively address various health needs within the community. On the other hand studies have recommended that the government should take leading role of supply health commodities and supplies CHWs at the community level because they the backbone of the integrated community health programs [19].

Policies that develop and support the integration of various health services into routine community activities, such as Village Health and Nutrition Days, should be encouraged and prioritized. Advocacy is needed for policies that facilitate integrated outreach programs combining various health services, such as family planning and TB services, to reduce costs and increase access in remote and rural communities. Non-communicable diseases, particularly, are most amenable to this approach, considering the common risk factors shared across them [15,22]. The Tanzania Health Policy (2017) significantly focuses on addressing non-communicable diseases (NCDs) through community awareness, early detection, and integrating NCD management into primary healthcare. However, there was a lack of evidence illustrating NCD management integration in the PHC setting. The predominant focus was on managing and controlling communicable diseases. Peek et al. (2014) found that the integration of community health, particularly in non-communicable diseases such as diabetes, significantly helped to improve minority health at the community [23]. Thus, deliberate and concerted efforts are required to stimulate such integrations and reorient the focus to include NCDs, considering their heavy toll on the health system and rapidly increasing prevalence.

The capacitation and engagement of community health workers (CHWs) are crucial strategies for improving health outcomes in PHC settings. Effective training programs equip CHWs with the knowledge and skills required to perform a variety of health services, allowing them to effectively bridge gaps in healthcare delivery, particularly in underserved regions [11,24,25]. Other empirical studies have found that leveraging the capabilities of CHWs to deliver different types of care, health systems can improve overall health outcomes and ensure that diverse health needs are met comprehensively and efficiently [26-28]. To ensure the realization of this potential, policies should support the development and implementation of comprehensive training programs for CHWs, ensuring they are well-equipped to address diverse health needs. This contention is supported by the Tanzanian Health Sector Strategic Plan V (HSSP V) 2021 -2025 which promises to build stronger and better-equipped community health structures including implementing the full-scale integrated and coordinated community health workers program. The integrated and coordinated CHW program will include standardized training, selection, and supervision of the CHWS. The government of Tanzania is currently reviewing the NOG-CBHP with the integrated and coordinated CHWs lens, which is expected to address the vertically based CHW programs that have been a major part of the community health services.

Equally important to effective CHW engagement is the provision of necessary resources and support. The ready availability of resources such as medical supplies, transportation means (e.g., motorcycles, bicycles), and communication tools enable them to perform their duties efficiently and reach more community members [15,29]. Another vital form of CHW's support is the provision of regular, effective, supportive supervision and incentives. Supervision ensures adherence to protocols and provides opportunities for continuous learning and problem-solving. By institutionalizing supportive supervision and creating sustainable incentive schemes, health systems can ensure sustained CHW engagement and high-quality service delivery [30,31]. These findings are also in line with the Tanzania Health Policy of 2017, HSSP V, PG-CBHP- 2020 and NOG-CBHP -2021 which all provide for bringing community health services closer to the community through introducing health workers at the hamlet level. Current policies should focus on ensuring that CHWs have access to the necessary resources to enhance their ability to deliver care and improve the overall reach and impact of health programs. Further, policies should institutionalize supportive supervision and create incentive schemes to ensure sustained CHW engagement and high-quality service delivery. Nevertheless, policies addressing the challenges of financial sustainability and the need for community-based solutions to reduce dependence on external support towards CHWs are proposed.

Community participation is essential for optimizing health services and improving outcomes in primary healthcare settings. It enhances the effectiveness and sustainability of health interventions and fosters a collaborative environment. It is the key ingredient in ensuring that the provided healthcare services are responsive to community needs [32]. To achieve this, community education and engagement are required to introduce a sense of agency to the communities, empowering them by emphasizing their active role in ensuring that interventions fit their demands and contexts. Health policies and guidelines in Tanzania have continually underscored the importance of community participation and engagement in PHC. The Tanzania Health Policy (2017) is committed to improving accountability and transparency in health services delivery through community engagement in designing, implementing, monitoring and evaluating health interventions. To ensure that the community gets space in decision-making about their health the Operation Guideline for Council Health Board and Health Facility Governing Committees has established community health governing structures composed of community members who govern and provide oversight in all levels of Tanzania health facilities. Indeed, the Revised Primary Health Care Committee Guideline (2022) has established primary health care committees from the village to the national levels which are also composed of community members that discuss and make decisions regarding PHC.

Support must be provided to community-driven initiatives, recognizing that local communities are often best positioned to identify their needs and mobilize resources to address them [33,34]. This aligns with the Tanzania HPPS V and Operational Guideline for Council Health Boards and Health Facility Governing Committees which insist that health problems at the community level must first be solved locally through engaging communities to find and propose their solutions. This calls for well-prepared and equipped communities that can identify, analyze, and suggest relevant interventions for addressing and improving health outcomes. Policies should encourage and facilitate community-driven health projects to foster community ownership and involvement in health facility development, ensuring that health services are more responsive, effective, and sustainable. By integrating these practices, health systems can leverage the strengths and insights of local communities to improve health outcomes comprehensively and efficiently.

Current findings underscore the critical importance of partnerships between healthcare providers and community-based organizations (CBOs) in improving PHC outcomes. This collaborative model improves and supports health outcomes in PHC across different contexts and population groups. However, challenges related to inter-institutional communication, collaborative planning, and resource allocation are frequently encountered due to structural and organizational dissimilarities [35]. These challenges underscore the critical need for robust partnerships and joint efforts between clinical services and community organizations to enhance the effectiveness and sustainability of health programs. Effective collaboration can address gaps in service delivery, streamline communication, and optimize resource allocation, thereby improving overall health outcomes. Policies should promote detailed and systematic joint planning sessions where healthcare providers and CBOs can strategize on service integration, patient outreach, and resource management. Additionally, policies should facilitate resource-sharing agreements that enable both parties to leverage each other's strengths, such as healthcare providers offering medical expertise and infrastructure, while CBOs contribute localized knowledge and community trust. By fostering such comprehensive collaboration, these partnerships can create a more cohesive, responsive, and efficient healthcare delivery system.

Insights from the conference call for the need to go beyond participation approaches that are based on the number of women and men who are represented in decision-making platforms at the community level. Indeed, women's representation in decision-making platforms, whether in PHC or community-level structures, is very limited. For instance, global empirical evidence indicates that while 70% of the health workforce in PHC are women, only 25% hold leadership positions meaning that 75% of men occupy leadership positions. This is evidenced by the publication titled “delivered by women but led by men” [36]. Typically, men dominate all decision-making platforms even though women are the users of community-based health services. Sustained and targeted advocacy aimed at empowering socially and culturally disadvantaged groups such as women through organizational, legal frameworks, and other initiatives is recommended. Inclusive platforms to voice their opinion and influence decisions should be provided since that is the meaningful product in bringing about responsive health services. This gender issue is in line with the Tanzania Health policy which is committed to enhancing gender equality and women's empowerment integration in health service. On the other hand, the Operational Guideline for Council Health boards and facility government committees has specified that these boards must have a certain number of women. The revised primary health care committees have also specified that women should be a part of each committee formulated at different levels. However, policies should go further by directing women to be given opportunities to air out their opinions during the meeting.

Limitations: the methodology employed in this policy paper has strengths and weaknesses, affecting the robustness and reliability of the findings. A major strength is the comprehensive data collection strategy, leveraging multiple sources such as presentations, keynote speeches, forum discussions, and abstract presentations. This approach captures a wide range of expert insights and contemporary developments in primary health care. Supplementing these with a desk review of existing policies and guidelines ensures the findings are grounded in current regulatory frameworks, providing a robust contextual foundation. The use of content analysis to extract detailed descriptions and policy implications from the collected materials is another strength, enabling the identification of emerging themes and actionable recommendations. Additionally, the involvement of a diverse evaluation team from reputable institutions and government bodies adds credibility and a multidisciplinary perspective to the study. However, relying primarily on conference materials can introduce bias, as these may reflect the perspectives of a select group of experts, potentially overlooking broader community viewpoints and on-the-ground realities. While the desk review is comprehensive, it may not fully capture the dynamic nature of community-based health programs, as policies and guidelines can lag behind current practices and innovations. The lack of direct engagement with community members also raises questions about inclusivity. Nevertheless, the diversity of data sources, systematic approach to analysis, and expert insights provide reliable evidence of community engagement's role in strengthening primary health care.

Conclusion     

Five main community engagement levers critical for maximizing health services in PHC settings have been identified. First, integrated community health programs enhance outcomes by addressing multiple health needs and fostering stakeholder collaboration. Second, capacitating and engaging community health workers (CHWs) through training, resource provision, and supportive supervision is essential for effective healthcare delivery, especially in underserved areas. Third, community participation, including comprehensive education and feedback mechanisms, ensures effective and sustainable health interventions. Fourth, partnerships between healthcare providers and community-based organizations (CBOs) are crucial for comprehensive service delivery, despite communication and resource challenges. Finally, promoting organizational capacity and gender diversity in decision-making platforms is vital for responsive health services, ensuring that women's voices are included and valued in the health care system.

Competing interests     

The author declare no competing interest.

Authors' contributions     

Kasusu Klint Nyamuryekung´e conceived, designed, and conducted the study, data analysis and interpretation, and drafted the manuscript. Anosisye Mwandulusya Kesale, Pius Kagoma, Mageda Kihulya and James Tumaini Kengia participated in the design of the study, composition of the study tools, data analysis and interpretation, and critical revision of the manuscript. Paul Chaote, Rashid Mfaume, Grace Magembe, Wilson Mahera Charles and Bruno Fokas Sunguya participated in study design, composition of the study tool, supervision of the research process and critical review of the manuscript. All the authors have read and agreed to the final manuscript.

Acknowledgments     

We would like to extend our heartfelt gratitude to all the participants, presenters, and organizers of the conference. Their valuable contributions, insightful presentations, and active engagement have significantly enriched the results of this manuscript. Special thanks to our presenters for sharing their empirical evidence, research findings, and expertise, which have provided us with a wealth of knowledge and actionable insights.

Annex     

Annex 1: supplementary material (PDF 81KB)

References