Abstract
Background
Individuals with disabilities are still legally allowed to be paid below the U.S. federal minimum wage through the use of 14(c) certificates. This practice overwhelmingly impacts individuals with intellectual and developmental disabilities and very few ever transition from subminimum wage work to competitive integrated employment. Efforts to reduce and eliminate subminimum wage practices continue at the state and federal levels to differing degrees of success.
Objective
The purpose of the article is to review the current state of 14(c) subminimum wage practices in the United States and identify steps to helping agencies providing subminimum wage work transform to fully integrated service models.
Methods
An interview panel of representatives from agencies that successfully transitioned from 14(c) certificates to competitive integrated services share insight into what is necessary to transition away from subminimum wage practices.
Results
The interview panel identifies important topics related to transformation efforts including how to address safety concerns, transportation barriers, and the decision to change.
Conclusion
Implications for how to successfully eliminate 14(c) certificates and help agencies transform into competitive integrated employment service models are discussed.
Keywords
Introduction
In the past 30 years, a series of policy initiatives and legal rulings have advanced the rights of individuals with disabilities to participate in the U.S. workforce. Notable examples include the Americans with Disabilities Act (ADA) of 1990, which prohibited job discrimination on the basis of disability; amendments to the Rehabilitation Act of (1973), hich required a presumption of employability for Vocational Rehabilitation (VR) recipients; the Individuals with Disabilities Education Act of 2004, which mandated transition planning for students with disabilities; and the watershed ruling in Olmstead vs. L.C., which determined that separation due to disability is a form of discrimination (Schwartz et al., 2020). While policy advancements have continued to open more doors for people with disabilities to secure employment, the emphasis has primarily been on increasing the number of people working and less on other critical factors that contribute to the quality of those employment outcomes (e.g., job satisfaction, desirable number of hours, upward mobility, etc.). Although the increased focus on elevating employment outcomes has been important and necessary, it is essential that we don’t lose sight of the fact that having any job is not the same as having a high-quality job.
Shifting The Focus to Quality Employment
All too often, employed people with disabilities end up working in positions that are below their potential or outside their area of interest (Qian et al., 2018). Unfortunately, individuals with disabilities are more likely than their non-disabled counterparts to be working in entry-level positions, working part-time rather than full-time, and employed in a more restricted range of professions (e.g., janitorial work, food service, etc.) with little opportunity for advancement (Qian et al., 2018; U.S. Bureau of Labor Statistics, 2024a, 2024b). On a granular level, what constitutes a “quality” employment outcome should be individualized to meet the needs of every individual with a disability. Generally, indicators of quality employment include competitive pay, access to fringe benefits, job satisfaction, inclusiveness, career development opportunities, and non-restrictive options with respect to type of business or industry (Krause et al., 2018). At the very minimum, a quality employment outcome assumes participation in competitive integrated employment (CIE). But, tens of thousands of workers with disabilities still earn below the federal minimum wage for work being performed in segregated settings (Avellone et al., 2023).
The Need to Eliminate the Subminimum Wage Program
Employers who obtain specialized 14(c) Certificates from the Wage and Hour Division of the U.S. Department of Labor are legally allowed to pay workers with disabilities below the federal minimum wage of $7.25 per hour (United States Department of Labor, 2024). Nearly 90% of those workers have an intellectual and developmental disability (IDD) and most of these workers make less than $3.50 per hour which is less than half of the federal minimum wage (Government Accountability Office, 2023). This practice was first made possible by the Fair Labor Standards Act of 1938 with the intent of encouraging employers to hire individuals with disabilities because they could pay them based on their relative productivity rather than a standard minimum wage (Avellone et al., 2023; Friedman & Rizzolo, 2020). The 14(c) program was also marketed as a theoretically necessary prerequisite to employment so individuals with significant barriers to employment could gain work skills before being able to pursue CIE (Friedman & Rizzolo, 2020). However, the Government Accountability Office (2023) found that as few as 17% of workers on 14(c) certificates ever transition to CIE. In addition, preparatory training has long since been rendered unnecessary and many people with complex support needs who were considered “too disabled to work” have successfully transitioned to CIE using a number of contemporary supports (Taylor et al., 2023; Wehman, 2023). These supports include the use of evidenced-based interventions (e.g., supported and customized employment), advantages made available to them via the ADA, progressions in technology, and increased efforts to embrace inclusivity by employers (U.S. Commission on Civil Rights, 2020). In addition, findings from an investigation conducted by the U.S. Commission on Civil Rights in 2020 concluded that the support needs of workers being paid subminimum wages were not substantially different than the support needs of those already successfully working in CIE (U.S. Commission on Civil Rights, 2020). Put plainly, we know much more about how to successfully support individuals with even the most complex support needs in CIE than we did when the Fair Labor Standards Act was established over 80 years ago.
We also know that participation in subminimum wage work has an alarmingly negative socioeconomic impact on people with disabilities. Recent analyses show there are significant negative impacts for people receiving wages under section 14(c). In a study of the 2009–2019 Current Population Survey–Merged Outgoing Rotation Group, Maroto and Pettinicchio (2023) found that 3.7 percent of hourly workers were paid subminimum wages based on state minimum wage laws, and subminimum wages were associated with increases in family poverty by 1.4 percentage points. Poverty and low income are financial strains that lead to inadequate supports for people with disabilities (Zipperer, 2019). Families with household members with disabilities may also face added living expenses and additional earning penalties if non-disabled family members cannot work because they are providing care (Maroto & Pettinicchio, 2020). A person earning subminimum wages will never be able to afford basic necessities without the assistance of government programs or familial support. This highlights the necessity of securing quality employment outcomes for individuals with disabilities and the positive impact a quality job can have on their health, happiness, and financial well-being.
Current State of Advancing CIE and Reducing Subminimum Wage Practices
Ultimately, the 14(c) program has not lived up to its intentions to help people move from sheltered workshops to CIE. There is no evidence in support of segregated preparatory work training as a method of achieving a meaningful and competitive employment outcome (Taylor et al., 2023). Furthermore, integrated vocational service models lead to better employment outcomes in terms of job placement, stability and retention, benefits, independence, and several markers of individual health (Taylor et al., 2022). This fact has led many advocates across the U.S. to push a prioritization of CIE as the primary employment goal for all individuals with disabilities and for a simultaneous reduction and elimination of subminimum wage practices. These efforts comprise a number of cultural and policy efforts looking to move the needle on optimizing employment opportunities for all individuals, regardless of the type or severity of their disability. For instance, a number of states adhere to The Employment First Initiative, an inclusive movement which began in 1980s to ensure that individuals with disabilities have equal access to real community jobs and are compensated with fair pay (Association for People Supporting Employment First [APSE], 2022). To date, at least 31 states have successfully passed Employment First legislation, while another 16 have Employment First Executive Orders and 32 have State Agency Administrative Policies (APSE, 2022).
In addition to prioritizing CIE, efforts have also been made to limit and eliminate subminimum wage practices. The Workforce Innovation and Opportunity Act ([WIOA], 2014) stipulated restrictions on subminimum wage use, ensured better awareness of CIE as an option for individuals with disabilities, and provided better access to services which facilitate CIE (Kuo et al., 2020; WIOA, 2014). For instance, under Section 511 of WIOA, individuals of any age participating in subminimum wage work receive career counseling and other trainings (e.g., self-advocacy and self-determination) that promote CIE outcomes. These trainings must be provided by an entity other than the agency paying subminimum wage (U.S. Department of Labor, 2022). In addition, youth (age 24 or younger) are entitled to receive transition services under the IDEA and/or pre-employment transition services, career counseling and vocational rehabilitation services prior to being considered for subminimum wage work (U.S. Department of Labor, 2022). This safeguards against a pipeline of youth entering subminimum wage work directly out of secondary school without having sufficient opportunities to explore competitive work options.
Most recently, the Transformation to Competitive Integrated Employment Act (TCIEA) was introduced as a bill designed to phase out 14(c) certificate use and prioritize CIE (U.S. Senate Special Committee on Aging, 2024). If passed, it will direct the Department of Labor to award grants to states and certain eligible entities to help them transform their service models to support individuals with disabilities in obtaining CIE and provide funding to establish technical assistance centers that support agencies. The bill also prohibits the issuance of new certificates that allow payment of subminimum wages to individuals with disabilities and phases out existing certificates over a five-year period (TCIEA, 2023). In addition to federal efforts to address subminimum wage practices, at least 15 states have independently passed legislation to eliminate 14(c) certificate usage (APSE, 2024).
Helping Agencies Transform from Subminimum Wage to CIE
It is extremely critical that advocates do not lose sight of the fact that eradicating 14(c) practices is not in and of itself enough to bolster CIE outcomes. Support for subminimum wage workers to transition to CIE is still essential. While the use of 14(c) practices has decreased overall during the past 20 years across employer types (e.g., hospitals and residential care facilities, schools, for-profit businesses, etc.), use by Community Rehabilitation Providers has shown the smallest decreases compared to other employer types, making them particularly in need of external support to facilitate change (Government Accountability Office, 2023). The reduction and elimination of 14(c) practices must be met with a plan for change that accounts for issues like funding, delivery of evidenced-based employment services, availability of training and technical assistance, solutions for transportation barriers, and information for families on how to address safety concerns in inclusive settings. The evidenced-based interventions that are successful in helping individuals with even the most complex support needs obtain and retain CIE have long since been established. Forty years of research has demonstrated the effectiveness of supported employment in helping individuals with a variety of disabilities become employed in their communities (Wehman, 2023). More recent research also points to the utility of customized employment in enhancing employment outcomes (Inge et al., 2024; Riesen et al., 2023). However, a template for entire agencies interested in transforming from subminimum wage models over to integrated service models is still being developed, and many variables can either facilitate or hinder success.
In 2021, the U.S. Government Accountability Office (GAO) released a report describing the findings from a study investigating factors the influence an individual's transition from subminimum wage to CIE. The GOA interviewed 17 disability employment experts from various states, 12 of which were disability advocates. Interviewees identified 32 factors within 4 main categories that impact successful transition (GAO, 2023). The first category pertained to characteristics of the employee with a disability, and included worries that CIE settings are less structured than facility-based settings, along with concerns about worker safety and fear of losing disability benefits. Secondly, factors about the characteristics of employers pertained to both employers holding 14(c) certificates (e.g., perceived ability of workers with disabilities, availability of technical assistance to provide adequate assistance, etc.) and community employers (e.g., employer flexibility to customize work-related activities). Thirdly, factors related to aspects of the local economy included the availability of transportation and amount of CIE positions within a community. Lastly, factors under the category of subminimum wage policy referred to the availability of state and federal funding for technical assistance efforts to help agencies during the transformation process, state implementation of Section 511, and adoption of Employment First policies (GAO, 2023).
Several initiatives have already been instituted to address factors within these categories. In 2022, the U.S. Department of Education's Rehabilitation Services Administration (RSA) invested $177 million into national demonstration projects known as Subminimum Wage to Competitive Integrated Employment (SWTCIEs). A total of 14 state Vocational Rehabilitation agencies were awarded 5 years of funding to assist youth and adults with disabilities who are either currently employed in subminimum wage jobs or at risk of entering such jobs transition to CIE (RSA, 2022). Demonstration projects are currently operating in the following states; California, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Minnesota, New York, North Carolina, Ohio, Pennsylvania, Texas, and Virginia (U.S. Department of Education, 2022). To assist in efforts to transition from subminimum wage to CIE, SWTCIE projects will help identify strategies for removing access barriers to CIE, use evidenced-based practices to promote employment participation that is integrated within the community, install wrap-around services to increase the support networks of individuals in CIE, and provide replicable templates for other agencies looking to transform (Luhr et al., 2023). Federal funding of SWTCIE grants highlights a significant investment in reducing subminimum wage employment while simultaneously increasing CIE outcomes.
Another notable example is the RSA funding of the Vocational Rehabilitation Technical Assistance Center for Quality Employment (VRTAC-QE), which was awarded to the University of Wisconsin - Madison in 2020. The purpose of VRTAC-QE is to improve the employment outcomes of people with disabilities by helping more people become employed and in higher quality, competitive work. In order to enhance employment outcomes, VRTAC-QE works with state VR agencies, Community Rehabilitation Providers and other partners to supply resources, trainings and support that enable service providers to deliver evidenced-based practices that promote CIE outcomes (VRTAC-QE, 2024). In addition to meeting the nationwide need for technical assistance on CIE, it also assembled a 14(c)-learning community comprised of 15 volunteers from 11 different states that convened over a 13-month period to develop a toolkit for assisting agencies who want to transform from subminimum wage practices to CIE. Collaborators in the learning community included a mixture of individuals representing a variety of professional and personal roles including self-advocates, state VR Counselors, and administrators. The toolkit, now published on the VRTAC-QE website, includes a number of fact sheets and infographics, along with interviews with representatives from four agencies in Pennsylvania, Alabama, and Minnesota who have successfully transitioned from offering subminimum wage work to offering fully integrated services. In this article, we share some of the insight offered from these interviews.
Methods
Interview panelists included Jack Butler, the Director of Person-Centered Services at Achieva in Pennsylvania, Susan Klingel, the Executive Director at The ARC of Madison County Inc in Alabama, Tim Schmutzer, the CEO of PHASE-Industries in Minnesota, and Jen Skelly, the Director of Pennsylvania Operations at Penn-Mar Human Services. Additionally, Jason Jones, a Restaurant Employee and Achieva Participant in Pennsylvania discussed his experiences transitioning from subminimum wage work to CIE. Collectively, these individuals share their insight on how to address a number of common concerns and barriers that agencies and individuals with disabilities interested in transforming face during the process. In particular, the panel shared key information about; (a) what led to their decision to fully transform, (b) how to address concerns regarding safety in integrated settings, (c) the role of funding and how to solve transportation issues, and (d) the importance of working with community employers and other key individuals to secure and maintain jobs. Their insight and guidance can serve as a valuable tool for agencies interested in transforming to fully integrated employment services models. Highlights from the VRTAC-QE toolkit interviews are presented below.
Results
Committing to Transformation
The panelists all described their individual agency experiences in deciding to commit fully to a CIE model and eliminate subminimum wage practices. Each spoke to different elements required for making this commitment. Schmutzer spoke candidly about his agency's decision to transform because it was what clients wanted: “There were many years where I thought, you know, this is something that is an accommodation and needed because otherwise there are a group of human beings that aren't going to have very much of any opportunity to work. We had heard for years… our annual surveys for the folks we support. We heard very consistent themes and feedback for years…better job opportunities at a better rate of pay…and in the community…and so finally, around 2016 into 17… we began to deepen the conversations that we were having about if we can't overcome and meet the stated needs of the people that are entrusting us to support them, then we're doing something wrong. What needs to change? And it was at that time when we decided let's move away from just mechanically in the organization from subminimum wage piece-rated, segregated workshop work, and start developing more. And we closed the licensed segregated site in that time. This was all before this formalized transformation decision was made. And then in 2022, when those grants became available, transformation grants, we pursued it…Got it…And it was a race from there on” (Truths of Provider Transformation – Why, How, Then and Now?, 2024, 06:20; 07:00). “We started our transition and it wasn’t easy because the average age of the people that we were serving were between 50 to 55 years of age. So, we were dealing with a population who had been segregated all these years, many who had just been deinstitutionalized and trying to think ‘okay, how are we going to find a way to not have these people go back into day program-type of settings.’ So, we ended up getting the first grant in [our state] with the Office of Disability Employment Policy (ODEP)…we still loved our workshop and so we ended up with the next step working with [a University] …from there we not only transitioned our workshop, but we transitioned our day services as well so now we have no segregated settings within our organization” (Truths of Provider Transformation – Why, How, Then and Now?, 2024, 08:55). “There was a position that was made and agreed upon that we as an organization would start to divest our seven workshops…and part of that meant ending our 14(c). So, there were timelines that were developed, meetings that were scheduled with stakeholders, there was work with the communication department…to let everybody know…what the vision was, and there was a plan. So, we would have our workers that were once out on the workshop floor working with people and identifying…what types of work they would want to engage in…working on…those soft skills as well…It took us about seven years from start to end to shut all of those facilities and help everyone move out into a community [job] of their choice” (From Subminimum Wage to Competitive Integrated Employment: Provider and Participant Perspectives, 2024, 07:42). “Now, I polish silverware and I stand the whole time! I love everything at my job! They greet me with a hug! Every time I go to work, they all say “Jason, we love you, we love you!” They really do love me! And I love them!” (From Subminimum Wage to Competitive Integrated Employment: Provider and Participant Perspectives, 2024, 23:11).
Addressing Safety Concerns
The perceived safety of an individual with complex support needs in an integrated setting is a commonly cited concern among agencies, families, and other invested parties when discussing employment goals. Safety concerns generally pertain to fear of worked-related injury on-the-job, injury resulting from existing medical conditions, physical harm, or legal ramifications of challenging behavior in a work setting (e.g., aggression, self-injury, theft, etc.). All panelists agreed that they do not see more safety issues in the community than they had in facility-based settings and point to various reasons for this phenomenon. For instance, Klingel spoke about how an emphasis on individualized workplace safety training for each employee with a disability has facilitated success with clients at her agency: “We do a lot of training. We do have mentors at some of the places…We’ve not seen more safety types of issues and most of the places that we are working with, especially in manufacturing…they have their own training courses so the person who's going into the job is learning a lot of their safety measures specific to that company…that was a concern that families always talk about, but from our perspective we have not seen any types of concerns there” (Truths of Provider Transformation – Safety, 2024, 02:55). “We most certainly had safety concerns at the beginning…[our jobseekers had] a high degree of physical assaults, police involvement and so on and so forth… When we were fully segregated, our focus was on physical safety a lot and because our expectation was that there were going to be physical incidences and then all of a sudden when we transitioned…then all of a sudden the expectation became, even subconsciously…‘well, we're not going to help somebody work a job in the community and look at physical safety…but the expectation is that they're not going to assault somebody’… it is laid out that expectation is there…and lo and behold, once the expectation changed…incidents reduced…it's amazing how people rise to the level of belief and expectation that others have in them” (Truths of Provider Transformation – Safety, 2024, 05:54). “People just had more choice and control in their life, less stress, being able to go out and do things. We have not had any situations in all of these years we've been doing it where somebody has been injured at work because of work safety issues…it isn't an issue because you take that stuff into consideration through what we do - the exploration and Discovery process - so you understand what that person needs and you work with the businesses…Regarding medical issues and that sort of thing, it is all about building that relationship and we don't expect our employers to necessarily know how to provide the supports that each individual might need, but they do have that information…they're getting on the phone with us immediately so we can go out and help support that” (Truths of Provider Transformation – Safety, 2024, 04:07). “Kids are excited to get their driver's licenses, and it's a big celebration…I think ‘what could possibly be more dangerous that we are all just accepting of…than putting a kid into a steel box on four small rubber wheels and having him zip down the highway at 70, 75 miles an hour’ and somehow we're okay with it, but we're really nervous about somebody going to work in the community because there's risk in the world” (Truths of Provider Transformation – Safety, 2024, 04:07).
Addressing Transportation Issues
The availability of affordable and reliable transportation is a pervasive barrier to work for many individuals with complex support needs (Sabella & Bezyak, 2019). Successfully transitioning to fully integrated work models is not just about helping individuals with disabilities get jobs, but also getting those individuals to those jobs. The panel all spoke about the necessity of securing funding in order to provide transportation to clients as a way to overcome this hurdle. For example, Klingel said: “[Transportation is] one of the biggest barriers we find in [our state] because we have so many rural areas…When we started our transformation that was one of the biggest pieces of our plan…we leveraged a lot of 5310 grants…we ended up…purchasing vehicles, we started working on getting your own license [programs], we do boot camps on city transportation, and we put together flyers on transportation options” (Truths of Provider Transformation – Opportunities and Supports, 2024, 22:52). “We have a fleet of around 60 vehicles, and we have made the decision that we will support and try to get fully integrated public transportation to support our CIE outcomes, but we fully know we're going to have to be the transportation provider in a whole different way than we have been…it's just not out there yet, but we’re willing to spend the next decade doing it, as long as its paid for…and thank goodness in [our state] it's one of the very few services that's reimbursed at market rate so that we can negotiate transportation rates…and that's on the transportation waiver” (Truths of Provider Transformation – Opportunities and Supports, 2024, 26:58).
Working with the Families and the Community
Successful transformation requires help from a number of different supporters. In particular, Butler discussed the importance of cooperative support from VR, Board Members, and families, in addition to establishing internal agency support by making sure everyone is effectively working together toward a common goal. In addition, Butler discussed the essential role of businesses and establishing good relationships with businesses in order to increase CIE outcomes. All panelists acknowledged that the work landscape has changed in the twenty-first century (e.g., more flexible schedules, additional options for remote work, increased initiatives to embrace diversity, etc.) and also agreed that this has worked in the favor of agencies supporting clients moving to CIE. For instance, Schmutzer said: “The market changed. Employers are desperate for talent and help and labor and employees and all of a sudden we are almost like this employment agency resource for our community…if we frame ourselves that way. And employers…I don't think I've met one that loves the human resources component of recruiting, speeding up, hiring, disciplining, performance battles, and if the person is supported and the employer wants it…we as providers can provide support around that” (Truths of Provider Transformation – Opportunities and Supports, 2024, 04:25). “Things have changed dramatically. You know, we are able to customize jobs so much easier. Employers are willing to listen to that more because they don't have the workforce to fill their need. And so, although we might not have a job seeker who can plug directly into one of their current jobs, they are far more likely to listen and to help and work with our job developer to create an opportunity that is going to help their organization and advance their organization and their business” (Truths of Provider Transformation – Opportunities and Supports, 2024, 06:14). “We're able to access a lot of younger people who are wanting to be employed…and people who have started WIOA training a little bit early. We have [internship] sites, so many of the people we are seeing coming to us have some skills where they did not have that before. Also, they're very technology savvy. You know, when we were transitioning, our 50 to 55-year old's [they] didn't even know very much about a computer because, you know, they were working on this contract or that contract… And they're coming with a lot more skills. And that is helping a lot in the employment process” (Truths of Provider Transformation – Opportunities and Supports, 2024, 08:23). “Absolutely. We embrace the idea that if you want to work, there's a job for you in the community. It's up to us to figure out what that is and to integrate that with the environment through a customized approach. The reality is it sometimes takes longer. It just does. And so that is where those resources need to be in place. We found the reality is that sometimes folks need that one-on-one support a little bit longer, maybe for a really long time. But that doesn't negate the fact that they are working and that they are advancing in a job and in a career” (Truths of Provider Transformation – Opportunities and Supports, 2024, 11:18).
Discussion
Next Steps in Reducing and Eliminating 14(c) Practices
Whether agencies choose to abandon 14(c) practices in favor of CIE, or are forced to eliminate subminimum wage practices for people with disabilities through state or federal policy changes, they are often faced with a scarcity of resources and assistance on how to effectively make the change. In the future, agencies interested in transforming need better roadmaps from successful demonstration projects and insight from agencies who have already been able to effectively move into exclusively CIE service models. Interested agencies also need greater opportunities to connect with, and learn from, existing agencies who have already made the change via educational conferences, interactive webinars, and other networking opportunities. Continued national technical assistance efforts are critical in helping agencies provide evidence-based community employment services and offering guidance on how to navigate the transformation process. In addition, family outreach and training efforts are needed to help educate support systems about the benefits of choosing CIE, and the safety nets in place to reduce risks and support individuals with disabilities in CIE settings.
Conclusion
In the future, businesses could serve a greater role in transformation efforts and could benefit from greater awareness regarding their part and responsibilities in the process. Employed persons with disabilities need access to routine benefits counseling to ensure their CIE earnings don’t impact disability benefits. Employed persons with disabilities also need greater opportunities to participate in postsecondary education and other career-focused training. Youth with disabilities need exposure to work opportunities prior to leaving secondary school in order to be better positioned to enter the world of competitive work. Lastly, and perhaps most importantly, continued policy initiatives are needed that support the elimination of subminimum wage practices and provide funding to help agencies address obstacles to converting such as transportation, staffing capacity, and the provision of ongoing support services for job retention and upward mobility. As agencies continue to identify working strategies to transform from subminimum wage practices to CIE, it is essential that they be given a platform to share their methods of success.
Footnotes
Acknowledgements
The authors have no acknowledgements to report.
Ethics Statement
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Informed Consent
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Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This paper is funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) (grant number #90RTEM0013) and the Vocational Rehabilitation Technical Assistance Center for Quality Employment (grant number #H264K200003) from the U.S. Department of Education. The contents do not necessarily represent the policy of the U.S. Department of Health and Human Services, and you should not assume endorsement by the Federal government.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.