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Abstract

Objectives:

The involvement of patient and family representatives in job interview panels is sparsely documented. This study was conducted at a newly established university hospital in Denmark. The aim was to identify different perspectives on attitudes and experiences associated with involving patient and family representatives in the recruitment process for senior staff. Furthermore, the aim was to highlight considerations and reservations related to the subsequent implementation process.

Methods:

Inspiration was drawn from formative evaluation research.

Data Sources:

Seventeen telephone interviews with applicants, 49 e-mail responses from staff, and unsolicited e-mails to the researcher.

Analysis Strategy:

Interpretive description.

Results:

Learnings from the study showed among other things that the participating staff experienced widespread skepticism before participation in the job interview panels, but their experience in the panels led them to consider the patients’ and families’ input to be beneficial to the entire recruitment process. The considerations and reservations raised were divided into 5 themes.

Conclusions:

The results provide a relevant starting point to negotiate and refine the aims of collective patient involvement related to a given situation—such as health-care recruitment processes.

Keywords

palliation rehabilitation practice development patientinvolvement

Introduction

Around the world, there is a move toward a patient-centered paradigm (1,2). The active involvement of patients and their families is considered to be a key factor in health-care quality development, including patient safety, better outcomes, and better use of resources (3,4). Patient involvement is an umbrella term for collaboration models (2) that have in common the concept of inviting patients and their families to work with health professionals. The purpose is to strengthen patients and families on health-care decisions related to 4 “levels” in health care—respectively, direct care, the collective or organizational level (eg, organizational decision-making processes—eg, as participants in various councils and panels), policy making (5 –10), and research (11). The evidence on the effects of patient involving interventions related to direct care is well-documented (3,12). However, a limitation seems to be the lack of guidance based on evidence regarding how patient and family representatives can be effectively involved in patient involvement on an organizational level (13). Research shows that implementation of effective patient involvement on the organizational level relay on several key elements—for instance, recruitment (eg, the identification and selection of legitimate groups), preparation (eg, supporting public representation role), moderation (eg, leveling power differences), and building a policy coalition supportive of public involvement (13). As greater attention to these elements may lead to more effective patient involvement interventions on the organizational level of health care (9,13), as well as support the development of measurements of what works, for who and in what circumstances (14), more research in the area is recommended (9,13,14).

In order to create the necessary cultural shift in beliefs, attitudes, and behaviors to support the worldwide change toward a patient-centered paradigm on all levels, new organizational structures, including more strategic approaches, are strongly recommended in the literature (8,13,15 –17). According to Coulter (16), such changes call for effective and strong leadership at all levels in the organization; a leadership that continuously promotes direct involvement of patients and carers. To foster a more patient-centered culture (16), it is necessary to experiment with new roles or new ways of relating patients and carers. One experimental role has involved including patient and family representatives in management recruitment processes, with the view that their perspectives could challenge and nuance the staff’s perspectives (8,9,16).

The involvement of patient and family representatives in recruitment processes is known from practice (18,19) but not well-documented in research studies. Systematic searches were conducted in June 2016 and April 2018 without time limits, using the search terms: Hiring process, recruitment process, staff interviews, patient involvement, patient participation, and public involvement, in the databases PubMed and PsycINFO. They did not yield relevant results. Through a chain search, one peer-reviewed, research-based Canadian study was found from 2015 (20).

The Canadian study described the development and evaluation of a recruitment process at a hospital, in which a patient- and family-centered interview tool was developed and patients and families were included in interview panels as interviewers. The study found the process to be valuable in relation to strengthening the organization’s overall strategy. The study recommended further research in the area (20), which is supported by other studies, which, from a more general perspective, recommend research that would assess the impact of patient and public participation in health care (14,21).

A newly established university hospital in Denmark has developed a vision that includes 3 strategic areas of action: organizational patient involvement, individual patient involvement, and reinforcement of co-operation with volunteers. In 2015, the hospital management decided to create a “Patient Forum” (PF) as part of the new patient involvement strategy. It was to be a forum for dialogue, in which patients and families would help the management to stay focused on the user perspective. To enhance new ways of relating patients and carers to the development of a more patient-centered culture at the hospital, the hospital management decided to invite patient and family representatives from the PF to participate in the recruitment process for senior staff. The senior positions involved were on 3 staff levels: hospital management, department management, and section management, including consultants (Table 1). On a par with employee representatives, their role was to advise management about the suitability of the prospective candidates, from a patient and family perspective. The hospital management invited 2 senior researcher to conduct an evaluation study in order to document the learnings from the initiative.

Table 1.

Overview of the 10 Recruitment Cases.^a

Recruitment Cases	Position	Applicants Called for Interview/Interviewed for the Study	Staff In Interview Panel/From Whom Received E-Mail Reply	Job Interview Round No.
1	Vice Director	5/4	11/9	2
2	Consultant	2/1	4/3	1
3	Consultant	3/2	5/4	1
4	Consultant	2/1	6/5	1
5	Ward therapist	3/2	8/4	1
6	Chief consultant	3/1	12/7	1
7	Ward nurse	2/1	9/4	1
8	Head midwife	2/2	8/5	1
9	Ward nurse	2/2	4/4	1
10	Ward nurse	1/1	8/4	1
Total		25/17	75/49

^a Column 3 shows the number of applicants called to a job interview and applicants who wished to participate in the study interview(s). Column 4 shows the number of staff who participated in the panel and the number of staff who returned answers to the e-mailed questions.

Aims

From the perspectives of the applicants involved, the professionals employed, and the patient/family representatives, this evaluation study article aims to:

identify attitudes and experiences associated with involving patient and family representatives in the recruitment process for senior staff, and

highlight considerations and reservations related to the subsequent implementation process.

Methods

Recruitment Processes

From November 2015 to April 2016, 10 senior staff recruitment cases were chosen consecutively, taking into account that all 2 staff levels—hospital management, department management, and section management, including consultants—were represented. The 10 recruitment cases involved 25 individual job interviews (Table 1). The interviews took place in the departments involved, each of which had set up an interview panel.

Patient Forum Representatives

First, by e-mail, the PF-administrator invited all PF-representatives—which at the time consisted of 25 patient/family members—to take part in the project. Six PF-representatives responded (Table 2). They were all included without further selection procedures and all participated in a 3-hour briefing session to inform them about the formalized recruitment process and to discuss how to maintain a patient and family perspective in the recruitment process. An essential topic in the briefing session was to discuss how the PF-representatives were to gain access to the departments in which the job interviews would take place and how they should act, if unforeseen events occurred in the recruitment process. The Human Resource Director of the hospital, the PF-administrator and the researcher were present during the briefing. At the briefing, it was decided that an evaluation meeting would be held after 3 months, to discuss whether the procedures had proceeded as planned or needed to be revised. The PF-administrator was responsible for distributing the 10 recruitment cases between the representatives.

Table 2.

Overview of the Involvement of Patient Forum Representatives.

Gender	Age	Patient/Family	Experience of Participation in Interview Panels	No. of Interviews
Female	68	Family/former patient	Prior professional experience, including School head	2
Male	59	Patient and family	Prior professional experience, including Shop steward	2
Male	65	Family	Prior Professional experience, including Manager in several organizations	3
Male	79	Patient	Prior professional experience, including Employed in social services	2
Female	48	Family	Some experience, including Self-employed accountant	1
Female	50	Patient	Some experience, including Employed at socio-pedagogical facilities	0

Research Approach

Formative process evaluation inspired the overall methodological framework of the study. This is an evaluation method, in which the aim is to change the intervention during the evaluating process (22 –24). The researcher’s role is not only to generate results but also to support and guide the participants, if necessary (25,26). In this study, the researcher offered support and debriefing to the PF-representatives before and immediately after their participation in each interview panels. Furthermore, some administrative procedures were changed because it turned out that they were unsuitable and took too long time to carry out.

Data

The data came from 4 sources:

Applicants

Seventeen telephone interviews with job applicants. In the vacancy description, it was stated that a representative from the PF would attend the job interview, along with a researcher. When the applicants received the formal invitation from the department, they received detailed information about the study, including the informed consent form. Whenever possible, the interviews were conducted by the researcher a few hours after each applicant’s job interview. In a few cases, the telephone interview was conducted the following day. The interviews followed a structured guide (Table 3), and comprehensive notes were taken to document, what was said.

Table 3.

The Structured Questions That Were Put to the Applicants by Telephone—If Possible Within a Few Hours After the Job Interview or the Following Day.

Structured Questions to Applicants
When did it become clear to you that a patient/relative would participate in the interview?
Did knowing that a patient/relative would participate have an impact on your preparation for the interview?
Did the fact that a patient/relative participated make a difference in relation to other interviews in which you were an applicant? How?
Have you any comments on the questions put to you by the patient/relative?
Please elaborate, if you wish
What is your opinion of the idea of including patients or relatives in the recruitment process?
Have you any suggestions as to how one could optimally prepare patients/relatives to participate in similar job interviews?
Is there anything you would suggest that we could do differently in future in relation to the inclusion of patients/relatives in the recruitment process?
Have you any other comments that might inform patient/relative inclusion in the recruitment process?

Employees

Forty-nine e-mails from employees participating in the 10 recruitment cases. The employees came from professions that related to the job for which the interviews were being held. Prior to the job interviews, the participant employees were informed by their department management that a PF-representative and a researcher would take part in the job interviews. Furthermore, they received detailed information about the study from the researcher. After the recruitment interviews, 5 structured questions (see Table 4) were e-mailed to all participating employees, and they were requested to reply directly to the researcher.

Table 4.

Five Structured Questions, E-Mailed to Participating Employees After the Recruitment Interview.

When did you realize that a patient or a relative would participated in the recruitment interview?

What was your immediate reaction?

How did the participation of a patient/relative affect the interaction in the interview panel? Please come up with specific examples

What benefits and challenges are involved with involving patients/relatives in an interview panel at the hospital?

Do you have further comments about the value of involving patients/relatives in recruitment interviews?

PF-representatives

Ten debriefing conversations between the researcher and each PF-representatives. The debriefings took place immediately after the recruitment cases. The debriefings revolved around anything that had made an impression on the PF-representative during the interview. The representatives were also asked about their preparation process and about the teamwork and any challenges experienced related to administrative procedures. The researcher took notes during the debriefings, which were written to a coherent text immediately after the debriefings. Several PF-representatives subsequently sent unsolicited e-mails to the researcher. These were also included in the data.

Analysis Strategy

The empirical data were anonymized and analyzed in accordance with the Interpretive Description method (27), which is characterized by producing new knowledge that is both academically credible and clinically relevant (27,28). The approach is inspired by phenomenology, grounded theory, and ethnography. An inductively based conceptualization process is a key factor (29). According to recommendations embedded in Interpretive Description, all data from the 4 data sources (see Table 5) were analyzed using an approach that consisted of synthesizing meanings, theorizing relationships (using critical and reflecting questions as “why is this here?” “why not something else?” and “what does it mean?”), and recontextualizing data into findings (27,28). The analysis process was supported by creating integrative diagrams (29).

Table 5.

“The Reflective Study Overview” Documents the Researchers’ Methodological Considerations During the Evaluation Process.

Reflective Study Overview
Context: The hospital management at a newly established university hospital decided to invite patient and family representatives from the Patient Forum (PF) to participate in the recruitment process for senior staff. The aim was to enhance new ways of relating patients and carers to the individual and organizational development of a more patient-centered culture at the hospital. On a par with employee representatives, the PF representatives’ roles were to advise management about the suitability of the prospective candidates, from a patient and family perspective. Two senior researchers were invited to document and evaluate the process
Reviewing the literature: The researchers conducted a literature review showing that the evidence for inviting patient and family representatives in the recruitment process was sparse. Furthermore, comprehensive learnings from similar initiatives were lacking
Designing a research framework: Based on the results from the literature review, the researchers and the hospital management decided to conduct an evaluation study using a formative process approach. The argument was that this approach allows the inclusion of evidence from different perspectives documenting learning, which may strengthen the ongoing initiative as well as future initiatives. An important consideration was that following this approach, the researcher’s role is not only to generate results but also to support and guide the participants, if necessary. Thereby, the researcher may achieve an active role different from the traditional objective researcher role. Furthermore, the approach underpins the constructivist rather than the objective methodological framework, which in this context calls for ongoing methodological and organizational reflections between the researchers, the hospital management, and other study participants
Engaging the Patient Forum representatives: By e-mail, the PF-administrator invited all PF-representatives—which at the time consisted of 25 patient/family members—to take part in the project. Six PF-representatives responded. They were all included without further selection procedures and all participated in a 3-hour briefing session to inform them about the formalized recruitment process and to discuss how to maintain a patient and family perspective in the recruitment process
The evidence included: To support the decision to include evidence from different sources that may document learning, which may strengthen the ongoing initiative as well as future initiatives, the researchers included evidence from 4 sources: A. 17 telephone interviews with job applicants B. 49 e-mails from employees participating C. 10 debriefing conversations between the researcher and each PF-representatives D. unsolicited e-mails from the PF-representatives to the researcher
Analyzing the empirical evidence: The researchers decided to use interpretive description (ID) as the analysis strategy. ID was originally developed in recognition of the fact that the rigidity of traditional scientific approaches did not permit the solution of professional clinical problems in what is a complex practice. ID was therefore developed as a pragmatic, noncategorical, descriptive approach focusing both on academic rigor and on the need to find solutions that can be used in a clinical practice. This analysis process seemed adequate to support the chosen formative evaluation approach. As recommended in ID, the analysis process consisted of synthesizing meanings, theorizing relationships (using critical and reflecting questions as “why is this here?” “why not something else?” and “what does it mean?”), and recontextualizing data into findings/learnings
Learnings: From the analysis process learnings emerged, that on one hand seem useful in the further implementation process, and on the other hand may constitute the basement for similar future initiatives. This 2-fold learning perspective supports the aims of the evaluation study

Based on the 2 research questions, the analysis process was divided into 2 steps. The first step focused on attitudes and experiences associated with involving patient and family representatives in the recruitment processes for senior employees. These were considered from the perspectives of the applicants, the employees, and the PF-representatives, respectively. The second step focused on considerations and reservations related to the participation of PF-representatives in interview panels.

The analysis was conducted collaboratively between the 2 authors, who are both experienced researchers. Furthermore, the results were continuously discussed with the PF-representatives, the administrator of the PF-forum and the Human Resource Director. Hereby, communicative validity was achieved (30). Ongoing field notes and methodological reflections between the 2 researchers documented the research process. Inspired by Caracary (31), the overall evaluation process is documented in a reflective study overview (Table 5).

Ethical Considerations

To ensure that the applicants’ participation in the evaluation study would not affect the ongoing recruitment process, all communications about participation were conducted solely between the researcher and the applicants. All participants gave informed consent and the project was approved by the Danish Data Protection Agency, no.: 2008-58-0020. Formal approval by the local ethics committee was not required, in accordance with Danish directives.

Results

First, 3 different perspectives on attitudes and experiences associated with involving patient and family representatives in the recruitment processes for senior employees are presented. Then, considerations and reservations related to the implementation of PF-representatives in interview panels are detailed.

The Applicant Perspective

Almost all applicants regarded it as positive that representatives were to take part in the interview panel. One applicant said: “My reaction was that it was a new way of thinking about patient involvement, but that’s why we are there, so it’s quite ok’. It forces us to reflect on the perspective.” Many saw it as a consequence of the hospital’s overall strategy. Others considered it as a necessary and courageous step toward a paradigm shift in health care.

All applicants found that the interaction with PF-representatives was positive and that the representatives were well prepared and asked good questions, for instance: “Do you think you could support the development of a department that can promote the ambitious vision of patient involvement at the hospital?” It made a huge impression on the applicant that the question came from a PF-representative. Others had barely registered the representative’s presence but rather perceived the person and their question(s) as “one out of many” (applicant). Several candidates highlighted how the involvement of the representative signaled that the focus in the interview was not only on professional skills but also on general personal values.

The Employee Perspective

In general, the employees—apart from hospital and ward management—expressed that, prior to the job interviews, they had been skeptical toward the participation of PF-representative. For example, there was ambiguity about the purpose of involving representatives and concerns that the process would be impeded or about how much the representatives “would interfere” (doctor) in the recruitment process.

However, after participating in the interview panels, a transformation seemed to take place, in that the majority of the staff assessed the participation of the PF-representatives as a surprisingly positive experience. A nurse wrote: “My immediate reaction when I first heard about it was that it did not make sense. How can a patient contribute when hiring managers? But I was very positively surprised. The representative asked some highly relevant questions. These questions gave other participants inspiration for questions in the same direction.” One direction turned out to be questions that brought to the fore aspects of the applicants’ qualities other than their purely professional competencies.

The Representative Perspective

The PF-representatives related especially well to the way they were perceived as “external” participants in the interview panels and to the influence they felt they had. They all found that they were regarded as equal participants, who, on a par with everyone else on the panel, had a chance to influence who was appointed to the vacant positions. It was important to all representatives that they were aware of their role on the panel. One representative said: “It is essential that we represent the patient perspective and understand that while we don’t have power, we do have influence.” Also, several expressed that participation had given them a unique insight into a complex world, and a greater understanding and tolerance of the challenges faced by the organization.

Considerations and Reservations

Across the 3 groups, a number of considerations and reservations were expressed, which relate to the subsequent implementation process. They have been conceptualized into 5 overall themes and are detailed hereunder.

Concerns related to participating in decision-making

Several staff members expressed doubts about the authority of patients and relatives in relation to the final decision about who should be appointed, especially in cases of panel disagreement. There were particular concerns about whether patients and relatives should have a decisive influence on appointments without having the necessary medical qualifications to assess candidates. One consultant wrote: “If there is a major disagreement in the recruitment group, I have difficulty assessing what this [the participation of the PF-representative] might mean for the outcome and how much influence such a representative will have.”

Furthermore, the applicants, staff, and representatives alike emphasized the importance of representatives not being known to the department because that would significantly increase the risk of confusing one’s own and the department’s interests.

Management of confidentiality

Some staff members expressed great concern about whether professional confidentiality could be maintained when patients and relatives were involved. One doctor wrote: “My biggest concern was whether confidentiality could be enforced well enough. Is it reasonable to expect this from a patient?” A similar concern was expressed by some applicants. As an example, one applicant asked for confirmation that, prior to participating, the representatives had signed confidentiality agreements, both in terms of what the applicant had written in his application and in relation to the personal information that emerged during the interview.

The significance of experience and relevant competencies

Several staff members, representatives, and applicants pointed to the importance of the representatives having experience from other recruitment processes because it could be a challenging situation, made more complex by the fact that, apparently, each department followed slightly different procedures and norms.

Furthermore, they all highlighted the need for the representatives to possess competencies such as maturity, tact, and the ability to rise above their own disease and understand the need to choose the person best suited to the department’s needs, rather than being steered by personal preferences. One PF-representative said:

Not everyone can easily join an interviewing panel. It is not only necessary to have relevant experience and competencies in terms of recruitment. It also involves personal skills, including assessment of the situation to see how it would be most appropriate to react in this situation.

Development of the participant role

All representatives said that they were positively surprised by the way they were treated by the department managers and that they had a level of influence that was equal to that of everyone else on the panel. At the same time, several felt during the process like “a rare bird in unfamiliar surroundings” (representative).

Most PF-representatives were invited to a preliminary meeting in the relevant department immediately before the job interviews. This gave them a chance to clarify role expectations, review the procedure, and ask questions that had emerged during the preparatory phase. Furthermore, several representatives expressed that it had been of enormous significance that, in advance of the interview, they had been in ongoing contact with the management of the department by e-mail—or telephone—in order to clarify any practical questions.

Administrative challenges

All representatives expressed that the introduction to the evaluation study had provided a good overview of the scope of the task. Unfortunately, there were administrative challenges during the process, which included, in some cases, the arrival of the selected applications as late as the day before the scheduled interview. This meant that preparations were more rushed than anticipated.

Several staff members expressed concern that the administrative work created by involving patients and relatives outweighed the value of the initiative. For example, fixing dates where the representatives could participate and taking the time to call and e-mail PF-representatives meant that the process became protracted. One department manager wrote: “It was as if it was more important that the patient could come to the interview than the applicant!”

Discussion and Conclusion

Discussion

The evaluation study was conducted with the purpose of learning from and adapting similar future initiatives. The results support and nuance the existent literature highlighting key elements important to implement more effective patient involvement on the collective and organizational level. Furthermore, the results add new knowledge and learnings about involving patient and family representatives in the recruitment process for senior staff. One principal area of learning related to the fact that, even though some health-care professionals felt a certain skepticism toward the initiative before the job interview took place, most of them changed to a more positive attitude based on their experience in the job interview. Several studies have pointed to professionals’ skepticism toward patient involvement (4,7,32,33). Longtin et al (4) showed that one of the major obstacles to patient involvement in decision-making processes is the refusal of health-care workers to abandon their traditional roles and share power, as well as insufficient training in patient involvement. The same mechanisms could explain the initial professional skepticism in our study. However, in one review, the aim of which was to identify the impact of patient and public involvement on health-care services, it was shown that working with service users contributed to changing health professionals’ attitudes and beliefs about the value of user involvement (14). The learning from the current study, as well as the results from the review, indicate the need to bring health-care professionals and patients together as early as possible in the development process of new patient involvement initiatives, in order to reach a common understanding of mutual expectations and clear communication.

Another principal learning point related to role of the interview panel, including the role of the PF-representatives. According to the strategy of the university hospital in which the current study took place, the role of interview panels is advisory in nature and the departmental management team make the final decision. It remains unclear whether the staff had been informed about their advising rather than deciding role. Nevertheless, most staff expressed their expectation of having a more active role in the decision-making. Such lack of prior clarity could influence the development of a transparent, collective patient involvement, which requires active participation by all those involved, in order to create the basis for reciprocal learning (13).

The current study showed the need for the representatives to have relevant experience. Other studies report similar findings (13,34) without defining what characterizes relevant experience. Collins and Evans (34) distinguish between 3 levels of public expertise (a) a basic level, at which members of the public have no expertise at all in a specific domain; (b) an intermediate level, at which members of the public have developed knowledge that allows them to interact meaningfully with the professionals; and (c) the highest level, where some members of the public have developed contributory expertise in a specific domain. The learning gained from the current study highlights that relevant experience in this context relate to maintaining a user perspective and to being able to express opinions in a way that generates responsiveness to and interaction with the professionals in the interview panel—corresponding to level (b), above (34). This indicates that a structured selection process ahead of the job interview is required (9).

Furthermore, the study points to a dilemma between feeling like a “rare bird” and being an equal participant in the interview. A similar ambiguity is shown by Renedo and Marston (9), who point out that entering into the context of collective patient involvement entails participating in elite systems in which the representatives have to develop a new position as social actors. However, they must also engage with the ways of thinking and norms of the environment, including being able to deal with possible reluctance toward their presence. This points to the fact that the responsibility for constructing identity should not lie solely with the public representatives. It also lies in the social setting, including the attitudes of the professionals and the local managers’ abilities to facilitate and support mutual understanding and influence among professionals and members of the public (13).

The research approach chosen, which was inspired by formative process evaluation, enabled us to uncover and document important information about challenges to the implementation of the initiative (22,24). A limitation might be that such knowledge is, by its nature, context-sensitive, which means that the transfer of the results into similar contexts would require local adaptation (25).

Conclusion

Learning gained from this evaluation study showed that the experience of taking part in an interview panel alongside representatives from the local PF changed staff members’ attitudes—from skepticism to an acknowledgment of the benefits of the patient involvement approach. Both applicants and representatives were positive toward the initiative, but all participants involved expressed several considerations and reservations. It is important to include these in the ongoing process. The results provide a relevant starting point to negotiate and refine the aims of collective patient involvement in a given situation—such as health-care recruitment processes. Furthermore, the results highlight the need to further address the benefits of organizational patient and family involvement.

Footnotes

Acknowledgments

The authors would like to thank the Research Foundation in Region Zealand, Denmark, for their financial support. The authors would also like to thank the applicants, health-care professionals, as well as patients and families who participated in the evaluation research study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Involvement of Patient and Family Representatives in Health-Care Job Interview Panels

Abstract

Objectives:

Methods:

Data Sources:

Analysis Strategy:

Results:

Conclusions:

Keywords

Introduction

Aims

Methods

Recruitment Processes

Patient Forum Representatives

Research Approach

Data

Applicants

Employees

PF-representatives

Analysis Strategy

Ethical Considerations

Results

The Applicant Perspective

The Employee Perspective

The Representative Perspective

Considerations and Reservations

Concerns related to participating in decision-making

Management of confidentiality

The significance of experience and relevant competencies

Development of the participant role

Administrative challenges

Discussion and Conclusion

Discussion

Conclusion

Footnotes

Acknowledgments

Declaration of Conflicting Interests

Funding

References