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Journal of Tourism & Hospitality

Journal of Tourism & Hospitality
Open Access

ISSN: 2167-0269

Research Article - (2023)Volume 12, Issue 5

Accessible Tourism and Sustainable Destination Development: The Case of the Border Region of Northern Greece

Dimitris Kourkouridis1* and Asimenia Salepaki2
 
*Correspondence: Dimitris Kourkouridis, School of Spatial Planning and Development, Aristotle University of Thessaloniki, Thessaloniki, Greece, Tel: +302310291550, Email:

Author info »

Abstract

The purpose of the present article is to present the results of a quantitative research about the accessibility of hotel businesses in the border region of Northern Greece, as a step towards the achievement of sustainable destination development. A quantitative survey was conducted with structured questionnaires in 69 hotel businesses in the border area of Northern Greece. The variables regarding the structured accessibility of hotel facilities (Accessibility Factor) derived from Greek legislation, while variables of staff behavior were also included (Staff Factor). The research revealed that there is a lot of room for improvement in the hotel sector of the study area, and identified the main factors that need to be improved. Also, spatial differences were found, as well as differences based on the category, capacity and years of operation of the hotels. This is an original approach to the accessibility status of tourism businesses in the study area, while there is also originality in the discussion about the connection of accessibility with sustainable destination development.

Keywords

Accessible tourism; Sustainability; Destination development

Introduction

Sustainability is primarily inspired by use with a commitment to transfer meaningful knowledge to social action [1]. As a seal of this significant ascertainment, in 2015 the United Nations General Assembly (UNGA) reached an important agreement that would affect everyone's lives: The 2030 Agenda for Sustainable Development and the adoption of 17 Sustainable Development Goals (SDGs), convey global issues to ensure that all countries deal with these problems properly [2,3]. Specifically in the field of tourism, the sustainable destination development is an important social action that is broadly recognized [4]. Approaching the issue anthropologically, sustainable tourism development aims to reshape societies and human behaviors so as to ultimately lead to an integrated path towards sustainable development [4,5].

The social dimension of sustainable development implies understanding the needs of the users of places and eliminating discrimination. Therefore, sustainability and accessibility of a destination are two interrelated concepts, as inclusive development is a basic principle of sustainability [4]. Accessibility is a very important aspect of sustainability because when an accessible environment is offered (buildings, transport, communication etc.) all people can live and develop on equal terms. Conversely, when accessibility in any area is missing, this creates social inequality [6].

Accessible tourism is an issue that has been extensively researched in recent decades, and its connection to the sustainability of tourism development is well known [7,8]. Sustainability and inclusiveness are strongly connected in a variety of ways [9], while the concept of social sustainability has arisen as a term that encompasses both inclusive and sustainable design [10]. The ascertainment of the accessibility status of the tourism industry is particularly important because, this helps to identify the points that require changes, but also helps in the future tourfism development of a destination [11]. In the present research we focus on the Greek area of the cross-border Region of Greece-Republic of Northern Macedonia, in order to investigate the accessibility of businesses in the hotel sector, focusing specifically on people with motor disabilities [9]. The research was carried out in the context of the wider research of the project ‘Alter Trip: Alternative Touristic Experience" which is implemented under the program Interreg Ipa Cbc Greece- Republic of Northern Macedonia 2014-2020’. The main goal of Alter Trip is to help transform the intervention area into a tourist destination accessible to all, without exclusions. In addition, the project seeks to support the sustainable tourism development of the cross-border region.

The present study is a continuation of the research, where it was found that tourism businesses in the specific area are at a moderate level regarding accessibility [12,13]. Here, our interest is specifically focused on accommodation businesses, due to their particular importance in the tourism development of a destination as they are the main element of the tourism product [14].

Given that Greece is a country with a significant tourism market, we believe that the accessibility of tourism businesses, especially in border regions, can contribute to achieving the Sustainable Development Goal (SDG) 11 of the 2030 Agenda about inclusive cities and settlements. The purpose of the research is to examine the accessibility status of tourism businesses in the study area, but also the factors that affect it. The accessibility of tourism businesses in the study area have not been studied in the past, therefore the present research is considered as a special contribution to the country's efforts to achieve the goal of accessibility.

Literature Review

Accessible tourism

People with disabilities have historically been a socially marginalized group of the population, who have encountered and continue to encounter significant obstacles to their inclusion in society. A typical example is their participation in tourist activities, which in the majority of cases are anything but inclusive [6]. In recent years, however, after focusing on the social model of disability where it is established that society creates the obstacles and not the disability itself [15]. Research has begun to focus on issues of equality and inclusiveness in tourism. Thus, the issue of accessible tourism was raised which ‘enables people with access requirements, including mobility, vision, hearing and cognitive dimensions of access, to function independently and with equity and dignity through the delivery of universally designed tourism products, services and environments’ (p. 34) [16].

Accessible tourism sector is a distinct market with significant future growth potential. It is a potentially major and profitable market [17] that is expected to be further developed in the future mostly due to population aging [6,18] while it is also expected to have an impact on the future competitiveness of tourism destinations [19,20]. According to United Nations World Tourism Organization (UNWTO) 15% of global population lives with some kind of disability, while more than 46% of people over the age of 60 have some form of disability. The tourism potential of this particular group of people is numerically established by the fact that, at least at EU level, 70% of people with disabilities have the financial and physical ability to travel [21].

Available data indicate that people with disabilities generally stay longer in the destinations, they have a higher average number of people accompanying them on their vacation (2 to 3 people) [21], they have more loyalty to the destinations and they travel in different seasons [22]. Thus, research shows that accessible tourism can contribute significantly to reducing the seasonality of tourism and to increasing occupancy [4,23]. Research also shows that even in the case of small tourist markets, accessibility contributes positively to the economic development and demographic resilience of the regions [24]. However, it should be noted that people with disabilities are faithful to destinations that offer accessibility [25]. Therefore, the aforementioned benefits can only be obtained if the destination meets their needs, that is, it is accessible.

From offering facilities or adjustments so that people with disabilities may be involved in tourism, accessible tourism has evolved into a notion of quality tourism for everyone, with the understanding that accessibility is an important qualitative element of the touristic experience. This broader view of accessibility incorporates sustainable and social tourism into a unified kind of tourism that includes everyone [26]. This approach indicates the complications of disability and the fact that it can arise at any time in one's life, whether temporarily or permanently [16]. Therefore, accessibility can be understood as a quality indication, a brand, and a competitive advantage [27]. Accessible tourism is based on inclusive design approaches found in the various terms, such as ‘universal design’ [7], ‘inclusive design’ [28] ‘design for all’ or ‘just design’ [29], which are essentially design strategies that prioritizes fairness and social justice [9]. The fundamental goal behind these concepts is to make products and services accessible to as many users of any age, gender or disability as possible [29]. Accessible destinations, and in particular accessible accommodations, are the defining condition for every travel experience for people with mobility difficulties. Studies show that people with disabilities they would participate in more trips if they felt comfortable in the accommodation, but also if they could more easily find accessible accommodation [30]. Moreover, travelers with disabilities may spend more on accessibility improvements such as room amenities and more helpful staff [31].

In particular, hotel facilities should include all assistive physical equipment necessary to ensure that all guests-with or without disabilities-can experience the hotel unhindered. As public buildings, i.e. buildings to which the public has access, hotels should be accessible to all people, regardless of functionality. The accessibility features of public buildings which have been mostly studied in the literature are: Parking area, entrance, and restroom/toilet [33]. Using the service provided in the building is also an important feature of accessibility, which in the case of hotels is accommodation, i.e. accessible rooms, but also an accessible route within the hotel. Some examples of requirements for the provision of accessible accommodation in hotels are as follows: Wheelchair accessibility, toilet with support handles, lower sink to be wheelchair accessible, toilet on a higher level, emergency cord, visual aids and audio guidance [34].

Many destination regions in the world have focused on accessible tourism not just as a part of the market, but in fact as part of every market [35]. There are many successful examples of accessible tourism, in many places around the world [36]. However, there are still some barriers and challenges, such as inadequate and unsuitable facilities as described above, but also insufficiently prepared and trained staff in the tourism industry [37,38]. The lack of physical access to tourism infrastructure is the biggest deterrent to the decision of people with disabilities to participate in travel, but also the staff attitudes, as they are the direct contacts of people with disabilities in their tourist experience [32,37,39,40]. Serving people with disabilities in hotels is a very challenging job and requires suitable information and training of the staff. Training should be aimed at cultivating appropriate skills so that employees are able to offer their services to each customer, including the different needs of each guest [32]. Thus, the issue of staff awareness has become particularly important in the field of accessible tourism [41]. As aptly state, in fact the culture of the business should be changed by adopting principles based on the elimination of discrimination [42].

Moreover, the accessibility of information for people with disabilities is also particularly important. In recent years, the use of accessible websites and appropriate technologies Web Content Accessibility Guidelines (WCAG 2.0) is a practice that can be easily implemented [43-44]. However, their use is not widespread and as a result, an important obstacle for those with disabilities is still the shortage of access to information.

Border areas and cross-border cooperation

Borders typically refer to physical characteristics that might act as physical obstacles to communication and are frequently encountered in the outermost parts of countries [45]. This can be defined legally as: ‘An invisible vertical plane that separates two or more territories’ (p. 100647) [46]. Borders, however, are social creations that cause processes of marginalization [45]. Border areas are special spatial units as, in most cases, are peripheral areas characterized by local disadvantages. These disadvantages arise from their long distance from the political core [47] and from barriers created by national borders [48]. It is a fact that along state borders a special type of space is formed where various interactions between countries occur, such as cross-border flows [49]. Moreover, considering their geopolitical, historical, and symbolic importance, border regions have a great deal of potential as tourism destinations, an importance that is often an attractive feature for tourists [50].

The uniqueness of cross-border areas has been recognized, especially in Europe, where efforts are being made to turn the disadvantages of these areas into competitive advantages through cross-border relations and cooperation [48]. Due to the long-term demographic decrease brought on by urbanization, peripheral areas typically have a territorial capital of extraordinary value and diversity that is frequently underutilized [51]. In fact, border regions should not be considered solely in terms of their capacity to cause marginalization. In some circumstances, border regions can serve as a hub for social, economic, and cultural exchange. The Eu’ Interreg project that started in 1990 and has subsequently evolved through a number

of different phases is a direct recognition of these particular challenges. In this case, promoting cross-border cooperation was given a lot of attention, especially in areas of limited development that were shown unique economic obstacles [45]. Cross-border cooperation promotes border regions to work together as a tool for reducing disparities between them [52].

Materials and Methods

The study area

The purpose of the present paper is to examine the case of the Hospitality Businesses in Greek area that shares a border with the Republic of Northern Macedonia regarding the accessibility of their services. In order for Greece to achieve Sustainable Development Goals (SDG) 11 of the 2030 Agenda for Sustainable Development, accessible tourism is a particularly important means, given the country's high tourism market [44-48].

Greece is a country with significant tourism development. It is noteworthy that the total arrivals in the country in 2022 amounted to almost 28 million [53], and given that the country has about 10 million inhabitants [54], the size of the tourism market is confirmed. However, the distribution of tourism in the Regions of the country is characterized by significant inequality, with the island regions attracting the largest number of tourists [53]. Thus, the border regional areas of the country, which are the subject of the present research, have comparatively much less tourism development, which makes the need for differentiation and competitive advantage important.

The study area is a regional border area, which specifically includes five Regional Units as shown in Figure 1: Regional Unit of Thessaloniki inhabitants), Regional Unit of Serres, Regional Unit of Pella, Regional Unit of Kilkis (population: 80,419 inhabitants), and Regional Unit of Florina (population: 51,841 inhabitants) [55]. Regional Unit of Thessaloniki is an area with a metropolitan character, as it includes Thessaloniki, the country's second most populous city, while the other four include smaller peripheral cities [55]. Table 1 shows the hotel sector of the study area, where we see that there are a total of 288 hotel units. Understandably, Thessaloniki has the largest number of hotels by quite a margin from the other regional cities under study (Figure 1 and Table 1).

Region Region unit Population 5 stars 4 stars 3 stars 2 stars 1 star Total
Central Macedonia Thessaloniki 10,74,827 Units 15 31 42 24 31 143
Rooms 2,113 2,099 2,314 812 740 8,078
Beds 3,924 3,937 4,469 1,540 1,570 15,440
Central Macedonia Kilkis 80,419 Units - - 9 4 4 17
Rooms - - 252 133 55 440
Beds - - 515 388 127 1,030
Central Macedonia Serres 1,76,430 Units - 6 20 6 1 33
Rooms - 299 548 179 4 1,030
Beds - 706 1,142 392 9 2,249
Central Macedonia Pella 1,39,371 Units - 7 32 14 9 62
Rooms - 207 671 254 166 1,298
Beds - 430 1,422 564 337 2,753
West Macedonia Florina 51,841 Units 1 3 17 10 2 33
Rooms 38 59 343 136 43 619
Beds 82 132 715 281 14 1,334
Total units 288

Table 1: Hotels in the study area.

tourism-hospitality

Figure 1: Regional cities under study area.

Sampling

The current research's population of interest is the hotel establishments in the study region. At first, information and data for the research's population were gathered, and a database of the area's 288 hotels was constructed. An e-mail was sent to these hotel businesses outlining the study and its goal, and explaining the significance of their replies. The mail also provided a link to a survey questionnaire developed in Google Forms. Finally, 69 of these tourism businesses, which correspond to 29% of the hotels in the area, responded. The survey sample consisted of these 69 hotel businesses [59].

Data collection method

A questionnaire comprising 21 items was developed for the purposes of the current study. The questionnaire consists of 3 parts. Part A contains questions concerning the companies participating in the research's fundamental information, Part B contains questions concerning the accessibility (regarding motor disabilities and website accessibility) of the hotels, and Part C contains questions concerning staff training in servicing people with disabilities.

Specifically, for the mobility disabilities, the items of the questionnaire were based on the Greek legislation regarding the accessibility of public buildings [57,58] and in particular the items that are included are the following: (a) whether or not there are rooms special designed for people with disabilities; (b) existence of an accessible entrance (adequate width and if there are height differences appropriate configuration-ramp, mechanical means etc.); (c) whether or not a wheelchair can maneuver freely within the establishment; (d) whether or not there is a parking spot for people with disabilities; (e) elevator accessibility (appropriate size and the controls at the proper height); (f) whether or not there are toilets special designed for people with disabilities. In terms of accessibility for websites, the item used is the existence of a user-friendly for people with disabilities website (wcag 2.0 protocol). Finally, for staff awareness, the items of the questionnaire are the following: (a) awareness of the accessibility legislation for people with disabilities; (b) staff’s knowledge regarding the management of people with disabilities; (c) staff’s experience in managing people with disabilities.

Data analysis method

The tools of descriptive statistics were initially used to capture the results of the research, followed by inductive statistics tests. In particular, the Chi-square test of independence statistical hypothesis test was applied, which is non-parametric and is used to control two categorical (nominal) variables [59]. The p-value was calculated using the statistical package International Business Machines (IBM) Statistical Package for the Social Sciences (SPSS) Statistics.

Results and Discussion

Results of descriptive statistics

The descriptive statistics results are shown in Table 2. We utilized the following variables in order to assess the accessibility of the hotels: (a) special rooms for people with disabilities; (b) accessibility of the entrances of the hotels; (c) wheelchair free movement inside the hotels; (d) special parking spot(s) for people with disabilities; (e) elevators’ accessibility; (f) toilets for people with disabilities; and (g) accessibility of the websites. These considerations resulted in the 'Accessibility' factor. In cases where the accommodation is accessible in each of these variables, it receives a score of 1, while when it is not accessible it receives a score of 0. So, the 'Accessibility' score is on a scale from 0 (not accessible) to 1 (accessible) (Table 2).

Accessibility Frequency Percent Valid percent Cumulative percent
Rooms for PwD not accessible 30 43.5 43.5 43.5
accessible 39 56.5 56.5 100
Total 69 100 100
Accessible entrance not accessible 14 20.3 20.3 20.3
accessible 55 79.7 79.7 100
Total 69 100 100
Wheelchair free movement not accessible 24 34.8 34.8 34.8
accessible 45 65.2 65.2 100
Total 69 100 100
Parking for PwD not accessible 46 66.7 66.7 66.7
accessible 23 33.3 33.3 100
Total 69 100 100
Accessible elevator not accessible 42 60.9 60.9 60.9
accessible 27 39.1 39.1 100
Total 69 100 100
Toilet for PwD not accessible 34 49.3 49.3 49.3
accessible 35 50.7 50.7 100
Total 69 100 100
Website accessibility not accessible 57 82.6 82.6 82.6
accessible 12 17.4 17.4 100
Total 69 100 100
Accessibility factor N Range Minimum Maximum Mean
69 1 0 1 0.4886
Staff
Legislation awareness I do not know if anyone knows the law 4 5.8 5.8 5.8
yes, very well 8 11.6 11.6 17.4
yes, moderate 22 31.9 31.9 49.3
yes, a little 16 23.2 23.2 72.5
no 19 27.5 27.5 100
Total 69 100 100
Staff knowledge excellent 2 2.9 2.9 2.9
very good 18 26.1 26.1 29
moderate 27 39.1 39.1 68.1
a little good 12 17.4 17.4 85.5
not at all good 10 14.5 14.5 100
Total 69 100 100
Staff experience excellent 2 2.9 2.9 2.9
very good 20 29 29 31.9
moderate 27 39.1 39.1 71
a little good 8 11.6 11.6 82.6
not at all good 12 17.4 17.4 100
Total 69 100 100
Staff factor N Range Minimum Maximum Mean
69 3.67 1.33 5 3.2512

Table 2: Descriptive statistics results.

The factors that we used in order to assess the employees training for the care of individuals with disabilities are the following: (a) knowledge of the relevant legislation; (b) employee expertise; and (c) employee experience. These considerations resulted in the not at all good (39.1% moderate) (Table 3).

Pearson Chi-square Value df Asymptotic significance (2-sided)
Accessibility
Accessibility regional unit 66,623 28 ,000
Accessibility years of operation 45,460 21 ,002
Accessibility category 68,549 35 ,001
Accessibility capacity 1,06,135 28 ,000
Staff
Staff regional unit 97,223 40 ,000
Staff years of operation 65,738 30 ,000
Staff category 1,22,972 50 ,000
Staff capacity 74,134 40 ,001

Table 3: Chi-square test results.

Results of inductive statistics

The findings of the Chi-square test of independence statistical 'Staff' factor. As shown in Table 2, these variables are on a 5- point scale, so the score results as 1 being the lowest and 5 being the highest, for each variable. Therefore, the ‘Staff’ variable is on a scale from 1 (excellent) to 5 (not at all good) .

The mean score for ‘Accessibility’ factor is 0.4886, meaning that the hotels in the study area are in average condition in terms of their accessibility. From the sub-factors of accessibility, we observe at average levels the factors of rooms for people with disabilities (43.5% not accessible, 56.5% accessible) and toilet for people with disabilities (49.3% not accessible, 50.7%accessible). Most hotels have accessible entrances (79.7%), and also wheelchair free movement is achieved in most of them (65.2%). On the other hand, there are significant barriers in the case of special parking spots (66.7% not accessible and 33.3%accessible); elevators (60.9% not accessible and 39.1%accessible); and websites (82.6% not accessible and 17.4%accessible).

The mean score for ‘Staff’ factor is 3.2512 out of 5, which means that hotel staff should be better informed and trained in serving people with disabilities. In particular, 27.5% of the participants claimed that they are not aware of the legislation (31.9% moderate aware), 14.5% that the staff knowledge is not at all good (39.1% moderate), and 17.4% that the staff experience is hypothesis for the variables 'Accessibility' and 'Staff' are displayed in Table 3. The analysis is related to the association of these factors with the following four variables: a) regional unit, b) years of operation, c) hotel category, and d) hotel capacity. We see that both factors are related to all four variables.

Statistical analysis gave some further useful information about these relationships Figure 2. In particular, we found that Regional Unit of Thessaloniki has more accessible hotels: 81.8%of the hotels that scored 0.75-1, and 63% that scored 0.5-0.75 are in this Region (recall that the score is on a scale from 0: not accessible to 1: accessible). Instead, 50% of the hotels with a score of 0-0.25 are in the Regional Unit of Florina. Regarding the years of operation, we found that 72.7% of the hotels with a score of 0.75-1 have been operating more than 15 years. Moreover, hotels categorized as 3 stars and those as 5 stars seem to be more accessible: 45.5% of those scored 0.75-1 are 3 stars, and 54.5% of them are 5 stars. Finally, bigger hotels are more accessible, as we found that 54.5% of those scored 0.75-1 have more than 40 rooms, while 70% of those scored 0-0.25 have less than 10 rooms (Figure 2).

tourism-hospitality-capacity

Figure 2: Crosstab factor accessibility-regional unit, years of operation, category, capacity. Note: 4,00; 3,00; 2,00; 1,00

Also, the factor ‘Staff’ shows some interesting relationships with the variables Figure 3. Regional Unit of Thessaloniki seems to have more trained staff: 50% of those scored 1-1.5, and 40% of those scored 1.5-2.5 are in this Region (recall that the score is on a scale from 1: Excellent to 5: not at all good). Regional Unit of Florina has the worst scores in this factor as well: 75% of those scored 4.5-5 are from this Region. Years of operation have the same effect as previously: 100% of the hotels that scored 1-1.5 have been operating more than 15 years and 75% of those scored 4.5-5 have been operating from 5 to 10 years. Hotel category in this case has a bit different relationship than in Accessibility factor: 50% of the hotels that scored 1-1.5 belongs to 2 stars category and 50% to 3 stars category. Finally, 50% of the hotels with a score of 1-1.5 have more than 40 rooms, and 100% of those scored 4.5-5 have less than 10 rooms (Figure 3).

tourism-hospitality-factor

Figure 3: Crosstab factor staff-regional unit, years of operation, category, capacity. Note: 5,00; 4,00; 3,00; 2,00; 1,00

The most important obstacles faced by people with disabilities in their tourism experiences are related to the accessibility of the built environment, and also to the attitude of the staff [37-40]. The present research focused on these two factors, in order to investigate the accessibility of the hotels in the Greek side of the Greece Republic of Northern Macedonia border region. The findings revealed that the research area's hotels are in average status in terms of their accessibility, and that the main factors that need to be improved are: the provision of special parking spot(s), accessible elevators, and accessible websites. Staff training is also found to be in moderate condition when it comes to serving those with disabilities.

The problem seems to be worse for both factors examined (accessibility of built environment and staff training) in the peripheral areas, and mostly in the Regional Unit of Florina, rather than in the Regional Unit of Thessaloniki which is a metropolitan area. Moreover, hotels that have been operating for more years are more accessible and have more trained staff. Hotels from category 3 stars and 5 stars are more accessible, while those from categories 2 stars and 3 stars have the most trained staff. Finally, the hotels with a larger capacity are more accessible and have more trained staff.

Considering the lack of relevant data for the area, the specific results are an important starting point for the future development of an accessible destination. The significant future growth potential of accessible tourism [4,6,17-24], combined with its dynamic relationship with sustainable destination development, is a challenge but at the same time an important opportunity for disadvantaged border regions.

Conclusion

This study's goal is to examine how easily accessible hotel businesses are in the border region of Northern Greece, as a step towards the achievement of Sustainable Destination Development. Given the fact that border regions are disadvantaged due to their geographical location, their touristic development is a great challenge. The research results showed that there is a lot of room for improvement in the hotel sector of the study area and we believe that this research can contribute in this direction, as it identifies the areas that need the most attention. This improvement will be an important step towards the achievement of Sustainable Development Goals, thus contributing to the efforts to effectively respond to global challenges.

As a limitation of the research, we could mention that it includes only one category of tourism businesses (hotels). The research should be expanded in the future, to include equally important categories of tourism businesses, such as food and beverage businesses and sports activities, and also tourist attractions and sights in the area. Moreover, we focused almost exclusively on motor disabilities, while there are many more aspects of accessibility that need to be researched.

References

Author Info

Dimitris Kourkouridis1* and Asimenia Salepaki2
 
1School of Spatial Planning and Development, Aristotle University of Thessaloniki, Thessaloniki, Greece
2School of Urban Regional Planning and Development Engineering, Aristotle University of Thessaloniki, Thessaloniki, Greece
 

Citation: Kourkouridis D, Salepaki A (2023) Accessible Tourism and Sustainable Destination Development: The Case of the Border Region of Northern Greece. J Tourism Hospit. 12:533.

Received: 13-Oct-2023, Manuscript No. JTH-23-27555; Editor assigned: 16-Sep-2023, Pre QC No. JTH-23-27555 (PQ); Reviewed: 30-Oct-2023, QC No. JTH-23-27555; Revised: 06-Nov-2023, Manuscript No. JTH-23-27555 (R); Published: 13-Nov-2023 , DOI: 10.35248/2167-0269.23.12.533

Copyright: © 2023 Kourkouridis D, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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