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Donald M, Beanlands H, Straus S, Smekal M, Gil S, Elliott MJ, Harwood L, Waldvogel B, Delgado M, Sparkes D, Tong A, Grill A, Novak M, James MT, Brimble KS, Tu K, Hemmelgarn BR. An eHealth self-management intervention for adults with chronic kidney disease, My Kidneys My Health: a mixed-methods study. CMAJ Open 2022; 10:E746-E754. [PMID: 35973709 PMCID: PMC9388218 DOI: 10.9778/cmajo.20210332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND There is limited research of electronic tools for self-management for patients with chronic kidney disease (CKD). We sought to evaluate participant engagement, perceived self-efficacy and website usage in a preliminary evaluation of My Kidneys My Health, a patient-facing eHealth tool in Canada. METHODS We conducted an explanatory sequential mixed-methods study of adults with CKD who were not on kidney replacement therapy and who had access to My Kidneys My Health for 8 weeks. Outcomes included acceptance (measured by the Technology Acceptance Model), self-efficacy (measured by the Chronic Disease Self-Efficacy Scale [CDSES]) and website usage patterns (captured using Google Analytics). We analyzed participant interviews using qualitative content analysis. RESULTS Twenty-nine participants with CKD completed baseline questionnaires, of whom 22 completed end-of-study questionnaires; data saturation was achieved with 15 telephone interviews. Acceptance was high, with more than 70% of participants agreeing or strongly agreeing that the website was easy to use and useful. Of the 22 who completed end-of-study questionnaires, 18 (82%) indicated they would recommend its use to others and 16 (73%) stated they would use the website in the future. Average scores for website satisfaction and look and feel were 7.7 (standard deviation [SD] 2.0) and 8.2 (SD 2.0) out of 10, respectively. The CDSES indicated that participants gained an increase in CKD information. Interviewed participants reported that the website offered valuable information and interactive tools for patients with early or newly diagnosed CKD, or for those experiencing changes in health status. Popular website pages and interactive features included Food and Diet, What is CKD, My Question List and the Depression Screener. INTERPRETATION Participants indicated that the My Kidneys My Health website provided accessible content and tools that may improve self-efficacy and support in CKD self-management. Further evaluation of the website's effectiveness in supporting self-management among a larger, more heterogenous population is warranted.
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Affiliation(s)
- Maoliosa Donald
- Department of Medicine (Donald, Smekal, Gil, Elliott, James, Hemmelgarn), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Daphne Cockwell School of Nursing (Beanlands), Ryerson University; Department of Medicine (Straus), University of Toronto; Li Ka Shing Knowledge Institute (Straus), St. Michael's Hospital, Toronto, Ont.; London Health Sciences Centre (Harwood), London, Ont.; Can-SOLVE CKD Patient Partner (Waldvogel, Delgado, Sparkes), Vancouver, BC; Sydney School of Public Health (Tong), The University of Sydney, Sydney, New South Wales, Australia; Department of Family & Community Medicine (Grill, Tu) University of Toronto, Ont.; Centre for Mental Health (Novak), University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ont.; Department of Medicine (Brimble), McMaster University, Hamilton, Ont.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta.
| | - Heather Beanlands
- Department of Medicine (Donald, Smekal, Gil, Elliott, James, Hemmelgarn), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Daphne Cockwell School of Nursing (Beanlands), Ryerson University; Department of Medicine (Straus), University of Toronto; Li Ka Shing Knowledge Institute (Straus), St. Michael's Hospital, Toronto, Ont.; London Health Sciences Centre (Harwood), London, Ont.; Can-SOLVE CKD Patient Partner (Waldvogel, Delgado, Sparkes), Vancouver, BC; Sydney School of Public Health (Tong), The University of Sydney, Sydney, New South Wales, Australia; Department of Family & Community Medicine (Grill, Tu) University of Toronto, Ont.; Centre for Mental Health (Novak), University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ont.; Department of Medicine (Brimble), McMaster University, Hamilton, Ont.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Sharon Straus
- Department of Medicine (Donald, Smekal, Gil, Elliott, James, Hemmelgarn), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Daphne Cockwell School of Nursing (Beanlands), Ryerson University; Department of Medicine (Straus), University of Toronto; Li Ka Shing Knowledge Institute (Straus), St. Michael's Hospital, Toronto, Ont.; London Health Sciences Centre (Harwood), London, Ont.; Can-SOLVE CKD Patient Partner (Waldvogel, Delgado, Sparkes), Vancouver, BC; Sydney School of Public Health (Tong), The University of Sydney, Sydney, New South Wales, Australia; Department of Family & Community Medicine (Grill, Tu) University of Toronto, Ont.; Centre for Mental Health (Novak), University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ont.; Department of Medicine (Brimble), McMaster University, Hamilton, Ont.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Michelle Smekal
- Department of Medicine (Donald, Smekal, Gil, Elliott, James, Hemmelgarn), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Daphne Cockwell School of Nursing (Beanlands), Ryerson University; Department of Medicine (Straus), University of Toronto; Li Ka Shing Knowledge Institute (Straus), St. Michael's Hospital, Toronto, Ont.; London Health Sciences Centre (Harwood), London, Ont.; Can-SOLVE CKD Patient Partner (Waldvogel, Delgado, Sparkes), Vancouver, BC; Sydney School of Public Health (Tong), The University of Sydney, Sydney, New South Wales, Australia; Department of Family & Community Medicine (Grill, Tu) University of Toronto, Ont.; Centre for Mental Health (Novak), University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ont.; Department of Medicine (Brimble), McMaster University, Hamilton, Ont.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Sarah Gil
- Department of Medicine (Donald, Smekal, Gil, Elliott, James, Hemmelgarn), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Daphne Cockwell School of Nursing (Beanlands), Ryerson University; Department of Medicine (Straus), University of Toronto; Li Ka Shing Knowledge Institute (Straus), St. Michael's Hospital, Toronto, Ont.; London Health Sciences Centre (Harwood), London, Ont.; Can-SOLVE CKD Patient Partner (Waldvogel, Delgado, Sparkes), Vancouver, BC; Sydney School of Public Health (Tong), The University of Sydney, Sydney, New South Wales, Australia; Department of Family & Community Medicine (Grill, Tu) University of Toronto, Ont.; Centre for Mental Health (Novak), University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ont.; Department of Medicine (Brimble), McMaster University, Hamilton, Ont.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Meghan J Elliott
- Department of Medicine (Donald, Smekal, Gil, Elliott, James, Hemmelgarn), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Daphne Cockwell School of Nursing (Beanlands), Ryerson University; Department of Medicine (Straus), University of Toronto; Li Ka Shing Knowledge Institute (Straus), St. Michael's Hospital, Toronto, Ont.; London Health Sciences Centre (Harwood), London, Ont.; Can-SOLVE CKD Patient Partner (Waldvogel, Delgado, Sparkes), Vancouver, BC; Sydney School of Public Health (Tong), The University of Sydney, Sydney, New South Wales, Australia; Department of Family & Community Medicine (Grill, Tu) University of Toronto, Ont.; Centre for Mental Health (Novak), University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ont.; Department of Medicine (Brimble), McMaster University, Hamilton, Ont.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Lori Harwood
- Department of Medicine (Donald, Smekal, Gil, Elliott, James, Hemmelgarn), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Daphne Cockwell School of Nursing (Beanlands), Ryerson University; Department of Medicine (Straus), University of Toronto; Li Ka Shing Knowledge Institute (Straus), St. Michael's Hospital, Toronto, Ont.; London Health Sciences Centre (Harwood), London, Ont.; Can-SOLVE CKD Patient Partner (Waldvogel, Delgado, Sparkes), Vancouver, BC; Sydney School of Public Health (Tong), The University of Sydney, Sydney, New South Wales, Australia; Department of Family & Community Medicine (Grill, Tu) University of Toronto, Ont.; Centre for Mental Health (Novak), University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ont.; Department of Medicine (Brimble), McMaster University, Hamilton, Ont.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Blair Waldvogel
- Department of Medicine (Donald, Smekal, Gil, Elliott, James, Hemmelgarn), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Daphne Cockwell School of Nursing (Beanlands), Ryerson University; Department of Medicine (Straus), University of Toronto; Li Ka Shing Knowledge Institute (Straus), St. Michael's Hospital, Toronto, Ont.; London Health Sciences Centre (Harwood), London, Ont.; Can-SOLVE CKD Patient Partner (Waldvogel, Delgado, Sparkes), Vancouver, BC; Sydney School of Public Health (Tong), The University of Sydney, Sydney, New South Wales, Australia; Department of Family & Community Medicine (Grill, Tu) University of Toronto, Ont.; Centre for Mental Health (Novak), University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ont.; Department of Medicine (Brimble), McMaster University, Hamilton, Ont.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Maria Delgado
- Department of Medicine (Donald, Smekal, Gil, Elliott, James, Hemmelgarn), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Daphne Cockwell School of Nursing (Beanlands), Ryerson University; Department of Medicine (Straus), University of Toronto; Li Ka Shing Knowledge Institute (Straus), St. Michael's Hospital, Toronto, Ont.; London Health Sciences Centre (Harwood), London, Ont.; Can-SOLVE CKD Patient Partner (Waldvogel, Delgado, Sparkes), Vancouver, BC; Sydney School of Public Health (Tong), The University of Sydney, Sydney, New South Wales, Australia; Department of Family & Community Medicine (Grill, Tu) University of Toronto, Ont.; Centre for Mental Health (Novak), University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ont.; Department of Medicine (Brimble), McMaster University, Hamilton, Ont.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Dwight Sparkes
- Department of Medicine (Donald, Smekal, Gil, Elliott, James, Hemmelgarn), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Daphne Cockwell School of Nursing (Beanlands), Ryerson University; Department of Medicine (Straus), University of Toronto; Li Ka Shing Knowledge Institute (Straus), St. Michael's Hospital, Toronto, Ont.; London Health Sciences Centre (Harwood), London, Ont.; Can-SOLVE CKD Patient Partner (Waldvogel, Delgado, Sparkes), Vancouver, BC; Sydney School of Public Health (Tong), The University of Sydney, Sydney, New South Wales, Australia; Department of Family & Community Medicine (Grill, Tu) University of Toronto, Ont.; Centre for Mental Health (Novak), University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ont.; Department of Medicine (Brimble), McMaster University, Hamilton, Ont.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Allison Tong
- Department of Medicine (Donald, Smekal, Gil, Elliott, James, Hemmelgarn), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Daphne Cockwell School of Nursing (Beanlands), Ryerson University; Department of Medicine (Straus), University of Toronto; Li Ka Shing Knowledge Institute (Straus), St. Michael's Hospital, Toronto, Ont.; London Health Sciences Centre (Harwood), London, Ont.; Can-SOLVE CKD Patient Partner (Waldvogel, Delgado, Sparkes), Vancouver, BC; Sydney School of Public Health (Tong), The University of Sydney, Sydney, New South Wales, Australia; Department of Family & Community Medicine (Grill, Tu) University of Toronto, Ont.; Centre for Mental Health (Novak), University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ont.; Department of Medicine (Brimble), McMaster University, Hamilton, Ont.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Allan Grill
- Department of Medicine (Donald, Smekal, Gil, Elliott, James, Hemmelgarn), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Daphne Cockwell School of Nursing (Beanlands), Ryerson University; Department of Medicine (Straus), University of Toronto; Li Ka Shing Knowledge Institute (Straus), St. Michael's Hospital, Toronto, Ont.; London Health Sciences Centre (Harwood), London, Ont.; Can-SOLVE CKD Patient Partner (Waldvogel, Delgado, Sparkes), Vancouver, BC; Sydney School of Public Health (Tong), The University of Sydney, Sydney, New South Wales, Australia; Department of Family & Community Medicine (Grill, Tu) University of Toronto, Ont.; Centre for Mental Health (Novak), University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ont.; Department of Medicine (Brimble), McMaster University, Hamilton, Ont.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Marta Novak
- Department of Medicine (Donald, Smekal, Gil, Elliott, James, Hemmelgarn), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Daphne Cockwell School of Nursing (Beanlands), Ryerson University; Department of Medicine (Straus), University of Toronto; Li Ka Shing Knowledge Institute (Straus), St. Michael's Hospital, Toronto, Ont.; London Health Sciences Centre (Harwood), London, Ont.; Can-SOLVE CKD Patient Partner (Waldvogel, Delgado, Sparkes), Vancouver, BC; Sydney School of Public Health (Tong), The University of Sydney, Sydney, New South Wales, Australia; Department of Family & Community Medicine (Grill, Tu) University of Toronto, Ont.; Centre for Mental Health (Novak), University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ont.; Department of Medicine (Brimble), McMaster University, Hamilton, Ont.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Matthew T James
- Department of Medicine (Donald, Smekal, Gil, Elliott, James, Hemmelgarn), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Daphne Cockwell School of Nursing (Beanlands), Ryerson University; Department of Medicine (Straus), University of Toronto; Li Ka Shing Knowledge Institute (Straus), St. Michael's Hospital, Toronto, Ont.; London Health Sciences Centre (Harwood), London, Ont.; Can-SOLVE CKD Patient Partner (Waldvogel, Delgado, Sparkes), Vancouver, BC; Sydney School of Public Health (Tong), The University of Sydney, Sydney, New South Wales, Australia; Department of Family & Community Medicine (Grill, Tu) University of Toronto, Ont.; Centre for Mental Health (Novak), University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ont.; Department of Medicine (Brimble), McMaster University, Hamilton, Ont.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - K Scott Brimble
- Department of Medicine (Donald, Smekal, Gil, Elliott, James, Hemmelgarn), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Daphne Cockwell School of Nursing (Beanlands), Ryerson University; Department of Medicine (Straus), University of Toronto; Li Ka Shing Knowledge Institute (Straus), St. Michael's Hospital, Toronto, Ont.; London Health Sciences Centre (Harwood), London, Ont.; Can-SOLVE CKD Patient Partner (Waldvogel, Delgado, Sparkes), Vancouver, BC; Sydney School of Public Health (Tong), The University of Sydney, Sydney, New South Wales, Australia; Department of Family & Community Medicine (Grill, Tu) University of Toronto, Ont.; Centre for Mental Health (Novak), University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ont.; Department of Medicine (Brimble), McMaster University, Hamilton, Ont.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Karen Tu
- Department of Medicine (Donald, Smekal, Gil, Elliott, James, Hemmelgarn), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Daphne Cockwell School of Nursing (Beanlands), Ryerson University; Department of Medicine (Straus), University of Toronto; Li Ka Shing Knowledge Institute (Straus), St. Michael's Hospital, Toronto, Ont.; London Health Sciences Centre (Harwood), London, Ont.; Can-SOLVE CKD Patient Partner (Waldvogel, Delgado, Sparkes), Vancouver, BC; Sydney School of Public Health (Tong), The University of Sydney, Sydney, New South Wales, Australia; Department of Family & Community Medicine (Grill, Tu) University of Toronto, Ont.; Centre for Mental Health (Novak), University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ont.; Department of Medicine (Brimble), McMaster University, Hamilton, Ont.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
| | - Brenda R Hemmelgarn
- Department of Medicine (Donald, Smekal, Gil, Elliott, James, Hemmelgarn), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Daphne Cockwell School of Nursing (Beanlands), Ryerson University; Department of Medicine (Straus), University of Toronto; Li Ka Shing Knowledge Institute (Straus), St. Michael's Hospital, Toronto, Ont.; London Health Sciences Centre (Harwood), London, Ont.; Can-SOLVE CKD Patient Partner (Waldvogel, Delgado, Sparkes), Vancouver, BC; Sydney School of Public Health (Tong), The University of Sydney, Sydney, New South Wales, Australia; Department of Family & Community Medicine (Grill, Tu) University of Toronto, Ont.; Centre for Mental Health (Novak), University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ont.; Department of Medicine (Brimble), McMaster University, Hamilton, Ont.; Faculty of Medicine and Dentistry (Hemmelgarn), University of Alberta, Edmonton, Alta
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Donald M, Beanlands H, Straus SE, Smekal M, Gil S, Elliott MJ, Herrington G, Harwood L, Waldvogel B, Delgado M, Sparkes D, Tong A, Grill A, Novak M, James MT, Brimble KS, Samuel S, Tu K, Farragher J, Hemmelgarn BR. A Web-Based Self-Management Support Prototype for Adults With Chronic Kidney Disease (My Kidneys My Health): Co-Design and Usability Testing. JMIR Form Res 2021; 5:e22220. [PMID: 33560245 PMCID: PMC7902181 DOI: 10.2196/22220] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 11/12/2020] [Accepted: 12/12/2020] [Indexed: 12/22/2022] Open
Abstract
Background Supporting patients to self-manage their chronic kidney disease (CKD) has been identified as a research priority by patients with CKD and those who care for them. Self-management has been shown to slow CKD progression and improve the quality of life of individuals living with the disease. Previous work has identified a need for a person-centered, theory-informed, web-based tool for CKD self-management that can be individualized to a patient’s unique situation, priorities, and preferences. We addressed this gap using an integrated knowledge translation method and patient engagement principles. Objective The aim of this study is to conduct systematic co-design and usability testing of a web-based self-management prototype for adults with CKD (nondialysis and nontransplant) and their caregivers to enhance self-management support. Methods A multistep, iterative system development cycle was used to co-design and test the My Kidneys My Health prototype. The 3-step process included creating website features and content using 2 sequential focus groups with patients with CKD and caregivers, heuristic testing using the 10 heuristic principles by Nielsen, and usability testing through in-person 60-minute interviews with patients with CKD and their caregivers. Patients with CKD, caregivers, clinicians, researchers, software developers, graphic designers, and policy makers were involved in all steps of this study. Results In step 1, 18 participants (14 patients and 4 caregivers) attended one of the 2 sequential focus groups. The participants provided specific suggestions for simplifying navigation as well as suggestions to incorporate video, text, audio, interactive components, and visuals to convey information. A total of 5 reviewers completed the heuristic analysis (step 2), identifying items mainly related to navigation and functionality. Furthermore, 5 participants completed usability testing (step 3) and provided feedback on video production, navigation, features and functionality, and branding. Participants reported visiting the website repeatedly for the following features: personalized food tool, my health care provider question list, symptom guidance based on CKD severity, and medication advice. Usability was high, with a mean system usability score of 90 out of 100. Conclusions The My Kidneys My Health prototype is a systematically developed, multifaceted, web-based CKD self-management support tool guided by the theory and preferences of patients with CKD and their caregivers. The website is user friendly and provides features that improve user experience by tailoring the content and resources to their needs. A feasibility study will provide insights into the acceptability of and engagement with the prototype and identify preliminary patient-reported outcomes (eg, self-efficacy) as well as potential factors related to implementation. This work is relevant given the shift to virtual care during the current pandemic times and provides patients with support when in-person care is restricted.
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Affiliation(s)
- Maoliosa Donald
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Heather Beanlands
- Daphne Cockwell School of Nursing, Ryerson University, Toronto, ON, Canada
| | - Sharon E Straus
- Department of Family & Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Michelle Smekal
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Sarah Gil
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Meghan J Elliott
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | | | - Lori Harwood
- London Health Sciences Centre, London, ON, Canada
| | | | | | | | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Allan Grill
- Department of Family & Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Marta Novak
- Department of Family & Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Matthew Thomas James
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - K Scott Brimble
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Susan Samuel
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Karen Tu
- Department of Family & Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Janine Farragher
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Brenda R Hemmelgarn
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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