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Richter R, Jansen J, Bongaerts I, Damman O, Rademakers J, van der Weijden T. Communication of benefits and harms in shared decision making with patients with limited health literacy: A systematic review of risk communication strategies. PATIENT EDUCATION AND COUNSELING 2023; 116:107944. [PMID: 37619376 DOI: 10.1016/j.pec.2023.107944] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 07/17/2023] [Accepted: 08/15/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVES Risk communication (RC), as part of shared decision making, is challenging with people with limited health literacy (LHL). We aim to provide an overview of strategies to communicate benefits and harms of diagnostic and treatment options to this group. METHODS We systematically searched PubMed, Embase, Cinahl and PsycInfo. We included 28 studies on RC in informed/shared decision making without restriction to a health setting or condition and using a broad conceptualization of health literacy. Two researchers independently selected studies and one researcher performed data extraction. We descriptively compared findings for people with LHL towards recommendations for RC. RESULTS Health literacy levels varied in the included studies. Most studies used experimental designs, primarily on visual RC. Findings show verbal RC alone should be avoided. Framing of risk information influences risk perception (less risky when positively framed, riskier when negatively framed). Most studies recommended the use of icon arrays. Graph literacy should be considered when using visual RC. CONCLUSIONS The limited available evidence suggests that recommended RC strategies seem mainly to be valid for people with LHL, but more research is required. PRACTICE IMPLICATIONS More qualitative research involving people with LHL is needed to gain further in-depth insights into optimal RC strategies. PROTOCOL REGISTRATION PROSPERO ID 275022.
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Affiliation(s)
- Romy Richter
- Department of Family Medicine, CAPHRI, Maastricht University, Maastricht, the Netherlands.
| | - Jesse Jansen
- Department of Family Medicine, CAPHRI, Maastricht University, Maastricht, the Netherlands
| | - Iris Bongaerts
- Department of Family Medicine, CAPHRI, Maastricht University, Maastricht, the Netherlands
| | - Olga Damman
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Free University of Amsterdam, Amsterdam, the Netherlands
| | - Jany Rademakers
- Department of Family Medicine, CAPHRI, Maastricht University, Maastricht, the Netherlands; Netherlands Institute for Health Services Research (Nivel), Utrecht, the Netherlands
| | - Trudy van der Weijden
- Department of Family Medicine, CAPHRI, Maastricht University, Maastricht, the Netherlands
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Wand H, Martschenko DO, Smitherman A, Michelson S, Pun T, Witte JS, Scott SA, Cho MK, Ashley EA. Re-envisioning community genetics: community empowerment in preventive genomics. J Community Genet 2023; 14:459-469. [PMID: 36765027 PMCID: PMC9918397 DOI: 10.1007/s12687-023-00638-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 02/04/2023] [Indexed: 02/12/2023] Open
Abstract
As genomic technologies rapidly develop, polygenic scores (PGS) are entering into a growing conversation on how to improve precision in public health and prevent chronic disease. While the integration of PGS into public health and clinical services raises potential benefits, it also introduces potential harms. In particular, there is a high level of uncertainty about how to incorporate PGS into clinical settings in a manner that is equitable, just, and aligned with the long-term goals of many healthcare systems to support person-centered and value-based care. This paper argues that any conversation about whether and how to design and implement PGS clinical services requires dynamic engagement with local communities, patients, and families. These parties often face the consequences, both positive and negative, of such uncertainties and should therefore drive clinical translation. As a collaborative effort between hospital stakeholders, community partners, and researchers, this paper describes a community-empowered co-design process for addressing uncertainty and making programmatic decisions about the implementation of PGS into clinical services. We provide a framework for others interested in designing clinical programs that are responsive to, and inclusive and respectful of, local communities.
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Affiliation(s)
- Hannah Wand
- Department of Cardiology, Stanford Medicine, Stanford, CA, USA.
- Center for Inherited Cardiovascular Disease, Stanford Health Care, Palo Alto, CA, USA.
- Biomedical Data Science and Genetics (By Courtesy), Stanford Medicine, Stanford, CA, USA.
| | | | | | - Sheryl Michelson
- Patient and Family Partner Program, Stanford Health Care, Palo Alto, CA, USA
| | - Ting Pun
- Patient and Family Partner Program, Stanford Health Care, Palo Alto, CA, USA
| | - John S Witte
- Biomedical Data Science and Genetics (By Courtesy), Stanford Medicine, Stanford, CA, USA
- Department of Epidemiology and Population Health, Stanford Medicine, Stanford, CA, USA
- Stanford Medicine, Stanford Cancer Institute, Stanford, CA, USA
| | - Stuart A Scott
- Department of Pathology, Stanford University, Stanford, CA, USA
- Clinical Genomics Laboratory, Stanford Health Care, Palo Alto, CA, USA
| | - Mildred K Cho
- Stanford Center for Biomedical Ethics, Stanford Medicine, Stanford, CA, USA
| | - Euan A Ashley
- Department of Cardiology, Stanford Medicine, Stanford, CA, USA
- Center for Inherited Cardiovascular Disease, Stanford Health Care, Palo Alto, CA, USA
- Biomedical Data Science and Genetics (By Courtesy), Stanford Medicine, Stanford, CA, USA
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Wand H, Kalia SS, Helm BM, Suckiel SA, Brockman D, Vriesen N, Goudar RK, Austin J, Yanes T. Clinical genetic counseling and translation considerations for polygenic scores in personalized risk assessments: A Practice Resource from the National Society of Genetic Counselors. J Genet Couns 2023. [PMID: 36617640 DOI: 10.1002/jgc4.1668] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 12/06/2022] [Accepted: 12/09/2022] [Indexed: 01/10/2023]
Abstract
Polygenic scores (PGS) are primed for use in personalized risk assessments for common, complex conditions and population health screening. Although there is growing evidence supporting the clinical validity of these scores in certain diseases, presently, there is no consensus on best practices for constructing PGS or demonstrated clinical utility in practice. Despite these evidence gaps, individuals can access their PGS information through commercial entities, research programs, and clinical programs. This prompts the immediate need for educational resources for clinicians encountering PGS information in clinical practice. This practice resource is intended to increase genetic counselors' and other healthcare providers' understanding and comfort with PGS used in personalized risk assessments. Drawing on best practices in clinical genomics, we discuss the unique considerations for polygenic-based (1) testing, (2) clinical genetic counseling, and (3) translation to population health services. This practice resource outlines the emerging uses of PGS, as well as the critical limitations of this technology that need to be addressed before wide-scale implementation.
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Affiliation(s)
- Hannah Wand
- Department of Cardiology and Biomedical Data Sciences, Stanford Medicine, Stanford, California, USA
| | - Sarah S Kalia
- Department of Epidemiology, Harvard Chan School of Public Health, Boston, Massachusetts, USA
| | - Benjamin M Helm
- Department of Medical & Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Epidemiology, Indiana University Fairbanks School of Public Health, Indianapolis, Indiana, USA
| | - Sabrina A Suckiel
- Institute for Genomic Health & Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Natalie Vriesen
- Division of Medical Genetics, Department of Women's Health, Henry Ford Health, Detroit, Michigan, USA
| | - Ranjit K Goudar
- Division of Hematology & Oncology, Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA.,Virginia Oncology Associates, Hereditary Cancer Clinic, Norfolk, Virginia, USA
| | - Jehannine Austin
- Departments of Psychiatry & Medical Genitics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tatiane Yanes
- Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, Queensland, Australia
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Wallingford CK, Kovilpillai H, Jacobs C, Turbitt E, Primiero CA, Young MA, Brockman DG, Soyer HP, McInerney-Leo AM, Yanes T. Models of communication for polygenic scores and associated psychosocial and behavioral effects on recipients: A systematic review. Genet Med 2023; 25:1-11. [PMID: 36322150 DOI: 10.1016/j.gim.2022.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 09/14/2022] [Accepted: 09/17/2022] [Indexed: 11/13/2022] Open
Abstract
PURPOSE This study aimed to systematically review current models for communicating polygenic scores (PGS) and psycho-behavioral outcomes of receiving PGSs. METHODS Original research on communicating PGSs and reporting on psycho-behavioral outcomes was included. Search terms were applied to 5 databases and were limited by date (2009-2021). RESULTS In total, 28 articles, representing 17 studies in several disease settings were identified. There was limited consistency in PGS communication and evaluation/reporting of outcomes. Most studies (n = 14) presented risk in multiple ways (ie, numerically, verbally, and/or visually). Three studies provided personalized lifestyle advice and additional resources. Only 1 of 17 studies reported using behavior change theory to inform their PGS intervention. A total of 8 studies found no evidence of long-term negative psychosocial effects up to 12 months post result. Of 14 studies reporting on behavior, 9 found at least 1 favorable change after PGS receipt. When stratified by risk, 7 out of 9 studies found high PGS was associated with favorable changes including lifestyle, medication, and screening. Low-risk PGS was not associated with maladaptive behaviors (n = 4). CONCLUSION PGS has the potential to benefit health behavior. High variability among studies emphasizes the need for developing standardized guidelines for communicating PGSs and evaluating psycho-behavioral outcomes. Our findings call for development of best communication practices and evidence-based interventions informed by behavior change theories.
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Affiliation(s)
- Courtney K Wallingford
- Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Hannah Kovilpillai
- Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Chris Jacobs
- Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Erin Turbitt
- Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Clare A Primiero
- Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Mary-Anne Young
- Kinghorn Centre for Clinical Genomics, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia; St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | | | - H Peter Soyer
- Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, Queensland, Australia; Dermatology Department, The Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Aideen M McInerney-Leo
- Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Tatiane Yanes
- Dermatology Research Centre, The University of Queensland Diamantina Institute, The University of Queensland, Brisbane, Queensland, Australia.
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Recchia G, Lawrence AC, Freeman AL. Investigating the presentation of uncertainty in an icon array: A randomized trial. PEC INNOVATION 2022; 1:None. [PMID: 36518604 PMCID: PMC9731905 DOI: 10.1016/j.pecinn.2021.100003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/20/2021] [Accepted: 10/26/2021] [Indexed: 06/17/2023]
Abstract
BACKGROUND Clinicians are often advised to use pictographs to communicate risk, but whether they offer benefits when communicating risk imprecision (e.g., 65%-79%) is unknown. PURPOSE To test whether any of three approaches to visualizing imprecision would more effectively communicate breast and ovarian cancer risk for BRCA1 pathogenic variant carriers. METHODS 1,300 UK residents were presented with a genetic report with information about BRCA1-related risks, with random assignment to one of four formats: no visualization (text alone), or a pictograph using shaded icons, a gradient, or arrows marking range endpoints. We also tested pictographs in two layouts. Analysis of variance (ANOVA) and regression was employed. RESULTS There was no effect of format. Participants shown pictographs vs. text alone had better uptake of breast cancer risk messages (p < .05, η 2 = 0.003). Pictographs facilitated memory for the specific amount of risk (p < 0.001, η 2 = 0.019), as did the tabular layout. Individuals not having completed upper secondary education may benefit most. CONCLUSIONS We found weak evidence in favor of using simple pictographs with ranges to communicate BRCA risk (versus text alone), and of the tabular layout. INNOVATION Testing different ways of communicating imprecision within pictographs is a novel and promising line of research.
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Affiliation(s)
- Gabriel Recchia
- Corresponding author at: Centre for Mathematical Sciences, Wilberforce Rd, Cambridge CB3 0WA, UK.
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Brockman DG, Petronio L, Dron JS, Kwon BC, Vosburg T, Nip L, Tang A, O'Reilly M, Lennon N, Wong B, Ng K, Huang KH, Fahed AC, Khera AV. Design and user experience testing of a polygenic score report: a qualitative study of prospective users. BMC Med Genomics 2021; 14:238. [PMID: 34598685 PMCID: PMC8485114 DOI: 10.1186/s12920-021-01056-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 08/12/2021] [Indexed: 12/28/2022] Open
Abstract
Background Polygenic scores—which quantify inherited risk by integrating information from many common sites of DNA variation—may enable a tailored approach to clinical medicine. However, alongside considerable enthusiasm, we and others have highlighted a lack of standardized approaches for score disclosure. Here, we review the landscape of polygenic score reporting and describe a generalizable approach for development of a polygenic score disclosure tool for coronary artery disease. Methods We assembled a working group of clinicians, geneticists, data visualization specialists, and software developers. The group reviewed existing polygenic score reports and then designed a two-page mock report for coronary artery disease. We then conducted a qualitative user-experience study with this report using an interview guide focused on comprehension, experience, and attitudes. Interviews were transcribed and analyzed for themes identification to inform report revision. Results Review of nine existing polygenic score reports from commercial and academic groups demonstrated significant heterogeneity, reinforcing the need for additional efforts to study and standardize score disclosure. Using a newly developed mock score report, we conducted interviews with ten adult individuals (50% females, 70% without prior genetic testing experience, age range 20–70 years) recruited via an online platform. We identified three themes from interviews: (1) visual elements, such as color and simple graphics, enable participants to interpret, relate to, and contextualize their polygenic score, (2) word-based descriptions of risk and polygenic scores presented as percentiles were the best recognized and understood, (3) participants had varying levels of interest in understanding complex genomic information and therefore would benefit from additional resources that can adapt to their individual needs in real time. In response to user feedback, colors used for communicating risk were modified to minimize unintended color associations and odds ratios were removed. All 10 participants expressed interest in receiving a polygenic score report based on their personal genomic information. Conclusions Our findings describe a generalizable approach to develop a polygenic score report understandable by potential patients. Although additional studies are needed across a wider spectrum of patient populations, these results are likely to inform ongoing efforts related to polygenic score disclosure within clinical practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12920-021-01056-0.
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Affiliation(s)
- Deanna G Brockman
- Center for Genomic Medicine, Department of Medicine, Massachusetts General Hospital, 185 Cambridge Street, Simches Research Building
- CPZN 6.256, Boston, MA, 02114, USA.,Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Lia Petronio
- Pattern Visualization Team, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Jacqueline S Dron
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Bum Chul Kwon
- Center for Computational Health, IBM Research, Cambridge, MA, USA
| | - Trish Vosburg
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Genomics Platform, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Lisa Nip
- Pattern Visualization Team, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Andrew Tang
- Pattern Visualization Team, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Mary O'Reilly
- Pattern Visualization Team, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Niall Lennon
- Genomics Platform, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Bang Wong
- Pattern Visualization Team, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Kenney Ng
- Center for Computational Health, IBM Research, Cambridge, MA, USA
| | - Katherine H Huang
- Pattern Visualization Team, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Akl C Fahed
- Center for Genomic Medicine, Department of Medicine, Massachusetts General Hospital, 185 Cambridge Street, Simches Research Building
- CPZN 6.256, Boston, MA, 02114, USA.,Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Amit V Khera
- Center for Genomic Medicine, Department of Medicine, Massachusetts General Hospital, 185 Cambridge Street, Simches Research Building
- CPZN 6.256, Boston, MA, 02114, USA. .,Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA. .,Department of Medicine, Harvard Medical School, Boston, MA, USA.
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Extending Adjuvant Endocrine Therapy for 10 Years: A Mixed-Methods Analysis of Women's Decision Making in an Online Breast Cancer Forum. Healthcare (Basel) 2021; 9:healthcare9060688. [PMID: 34200326 PMCID: PMC8227818 DOI: 10.3390/healthcare9060688] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/01/2021] [Accepted: 06/02/2021] [Indexed: 11/21/2022] Open
Abstract
An additional 5 years of treatment with adjuvant hormonal therapy, to complete 10 years of medication, is recommended to reduce the risk of breast cancer recurrence. Yet professionals and patients should balance this benefit against side effects and toxicities. Little is known about women’s decision making regarding persistence with extended endocrine therapy. In this study, we collected data from a UK online breast cancer forum to analyse patterns of persistence and its associated factors. A mixed-methods exploratory sequential design was used, with a qualitative analysis of text (n = 61 individuals) informing the development of a quantitative instrument to statistically analyse the prevalence of the findings (n = 130). Our findings identified three different groups of women who had to make decisions regarding persistence with treatment: those about to complete 5 years of therapy, those who decided to extend treatment, and those who were initially prescribed 10 years. Factors affecting persistence were, lack of self-efficacy in managing side effects, lack of reassurance about individual risk of recurrence, and impact on quality of life. Interventions such as training of healthcare professionals including risk communication, medication reviews by clinical pharmacists, and re-planning of services in follow-up care, should better support women’s needs in extended hormonal therapy.
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Biesecker B, Lewis MA. Advancing genomic translation: Investigations in communication. A special series on communication research in the context of genomic medicine. PATIENT EDUCATION AND COUNSELING 2021; 104:933-934. [PMID: 33965008 DOI: 10.1016/j.pec.2021.03.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
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Trevena LJ, Bonner C, Okan Y, Peters E, Gaissmaier W, Han PKJ, Ozanne E, Timmermans D, Zikmund-Fisher BJ. Current Challenges When Using Numbers in Patient Decision Aids: Advanced Concepts. Med Decis Making 2021; 41:834-847. [PMID: 33660535 DOI: 10.1177/0272989x21996342] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Decision aid developers have to convey complex task-specific numeric information in a way that minimizes bias and promotes understanding of the options available within a particular decision. Whereas our companion paper summarizes fundamental issues, this article focuses on more complex, task-specific aspects of presenting numeric information in patient decision aids. METHODS As part of the International Patient Decision Aids Standards third evidence update, we gathered an expert panel of 9 international experts who revised and expanded the topics covered in the 2013 review working in groups of 2 to 3 to update the evidence, based on their expertise and targeted searches of the literature. The full panel then reviewed and provided additional revisions, reaching consensus on the final version. RESULTS Five of the 10 topics addressed more complex task-specific issues. We found strong evidence for using independent event rates and/or incremental absolute risk differences for the effect size of test and screening outcomes. Simple visual formats can help to reduce common judgment biases and enhance comprehension but can be misleading if not well designed. Graph literacy can moderate the effectiveness of visual formats and hence should be considered in tool design. There is less evidence supporting the inclusion of personalized and interactive risk estimates. DISCUSSION More complex numeric information. such as the size of the benefits and harms for decision options, can be better understood by using incremental absolute risk differences alongside well-designed visual formats that consider the graph literacy of the intended audience. More research is needed into when and how to use personalized and/or interactive risk estimates because their complexity and accessibility may affect their feasibility in clinical practice.
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Affiliation(s)
- Lyndal J Trevena
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Ask Share Know NHMRC Centre for Research Excellence, The University of Sydney, Australia
| | - Carissa Bonner
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Ask Share Know NHMRC Centre for Research Excellence, The University of Sydney, Australia
| | - Yasmina Okan
- Centre for Decision Research, University of Leeds, Leeds, UK
| | | | | | - Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA.,School of Medicine, Tufts University, Medford, MA, USA
| | | | - Danielle Timmermans
- Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, North Holland, The Netherlands
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