Occupational therapy contribution to the management of chronic pain in primary care: a qualitative descriptive study

Abstract

Background

People living with chronic pain (CP) face many daily challenges. Although occupational therapists (OTs) have the expertise to help these individuals regain a meaningful life, their services are not widely available in primary care settings. This study aimed to identify the needs of people with CP who seek primary care and to propose OT interventions in this context.

Methods

A qualitative descriptive study was conducted. Twenty-three semi-structured interviews were carried out with OTs (n = 5), nurses (n = 4), physicians (n = 4), and individuals with CP (n = 10) regarding CP needs and OT practice in primary care teams. After the interviews, mixed thematic analysis was conducted using an iterative approach. McColl and Law’s classification of occupational therapy interventions was used to organize the results.

Results

Fourteen needs were identified by people with CP when seeking primary care: four were related to service organization (accessibility, comprehensiveness, multidisciplinary care, and support for navigating the system), four were related to the therapeutic relationship (recognition of experience, support, active listening, and partnership), and six were related to pain management (occupational participation, education, medication management, pain relief, psychological support, and group participation). Regarding occupational therapy, nine occupational therapy interventions were identified: four were oriented toward the person (physical training, self-management and posture skills development, and education), four were oriented toward the environment (environmental modifications, service orientation, and psychological and emotional support), and one was oriented toward the occupation (support to perform various occupations).

Conclusion

This study presents multiple specific primary care needs of people with CP and highlights how these needs closely align with the scope of occupational therapy practice. The study findings contribute to knowledge about occupational therapy clinical pain management activities in the context of primary care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-025-03103-6.

Background

Chronic pain (CP) is defined as pain that persists for more than three months and is associated with significant emotional distress and/or functional disability [1, 2]. In Canada, as in the United States and other countries worldwide, CP affects one in five people [3–5]. Those living with CP often experience a reduced quality of life; a decline in mental, emotional, and cognitive health; and reduced functioning [4, 5]. CP is also associated with high healthcare utilization [5–7]. In addition to the negative impact of CP on daily life, people face challenges accessing health services due to waiting times and a fragmented approach [8–10]. Experts agree that people with CP should have access to interdisciplinary primary care services to meet their complex needs [10]. However, this remains an issue for both the Canadian and Quebec (a Canadian province) ministries of health, who are addressing it in their action plans [9, 11].

Since 2000, primary care teams called Family Medicine Groups (FMGs) have been established in Quebec to provide accessible primary care services to the population. Since the mid-2010s, the provincial government has provided financial support to integrate various healthcare professionals into FMG teams, including pharmacists, social workers, nurses, nutritionists, kinesiologists, physiotherapists, occupational therapists (OTs), respiratory therapists, and psychologists [12]. The amount awarded depends on the number of registered users, and family physicians select health professionals whose expertise matches their needs. A recent report on the healthcare experiences of people with CP showed that 56% of them have access to a family physician [9]. However, respondents indicated that they did not receive interdisciplinary services, even when non-physician healthcare professionals were present in their clinic.

Some OTs are involved in FMG, and their practice could benefit people with CP who face functional challenges [13]. A recent scoping review demonstrated OTs’ expertise in managing CP[14]. The main role of OTs working with people with CP, according to the included studies, is to improve activities and participation, focusing on addressing the occupational consequences of CP and self-management. They may provide interventions in accordance to McColl and Law classification of occupational therapy interventions [15] and focusing on the individual (e.g., postural advice, self-management strategies, exercises, and education), the environment (e.g., ergonomics and environmental modifications), and the occupation (e.g., task adaptation, graded activity, and sleep hygiene) and many of these interventions may be relevant to individuals with CP. Overall, OTs focus on helping individuals live fulfilling lives despite experiencing pain [16].

A recent qualitative descriptive study of physicians’ views on the role of OTs in primary care teams revealed a range of roles for OTs in the management of CP, including supporting return to work, promoting occupation participation, teaching pain management strategies, and managing work schedules [17]. The study also highlighted the advantages of integrating OTs, including providing a more holistic approach, improving service quality, ensuring timely access to care, and enhancing users’ health and quality of life [17]. However, disadvantages were also considered, such as the financial implications and possible duplication of work with professionals inside or outside the FMG.

Few studies provide information about OTs’ potential practice in FMGs, and, to our knowledge, none focus on CP management, despite the apparent match between occupational therapy practice and CP management in primary care. This study aimed to identify the healthcare needs of people with CP (Objective 1) and propose occupational therapy interventions for CP management in FMGs (Objective 2).

Methods

Study design

A qualitative descriptive study was conducted to specify the needs of people living with CP in terms of FMG services, and to propose occupational therapy interventions in FMG for the management of CP[18, 19]. For the purposes of this study, the term “need” refers to “what patients—and the population as a whole—want from health services to improve their overall health”[20](p.2).

Participants

Healthcare professionals

The research team identified French- or English-speaking healthcare professionals with expertise in CP, FMG, and/or occupational therapy to answer the research question from different perspectives (well-integrated FMG professionals, experts in occupational therapy practice, and expert in CP). The team used snowball sampling to identify key professionals initially in the Quebec Pain Research Network (https://qprn.ca/en/) based on their potential contribution to answering the study objectives. The research team used emails and phone calls to explain the project, assess eligibility, and invite potential participants.

People living with chronic pain

People living with CP were recruited using purposive sampling through announcements on the Quebec Pain Research Network’s recruitment portal and on the Facebook page of the Association de Soutien et d’Information Face à la Douleur (Support and Information Association for People with Pain). To participate, people living with CP had to be able to communicate in French or English, have CP according to the International Association for the Study of Pain (IASP) definition’[1], and be receiving FMG healthcare services. After contacting the research team by email, people living with CP were called to assess their eligibility and receive project information. Following this phone call, all willing participants were invited to read and complete the study consent form and choose a time for the interview. Due to the situation with the coronavirus, online video interviews were conducted to include participants across the province of Quebec. Ethical approval was obtained from the Lettres et Sciences Humaines Research Ethics Committee at the Université de Sherbrooke (#2021–3196).

Data collection and analysis

Data collection took place between December 2022 and May 2023. A questionnaire was used to collect sociodemographic information and describe the characteristics of the participants. The questionnaire was based on the work of Ariane Girard [21]. Andréa Dépelteau (AD) and Andréann Lamarre (AL) conducted qualitative, semi-structured interviews with physicians, OTs, nurses, and people living with CP using the Microsoft Teams platform. At this time, AD was an occupational therapist and AL a student in occupational therapy. The questions were developed by AD for this study and discussed with members of the research team prior to the interviews. The questions fell under two main themes: (1) healthcare needs in FMGs for CP management and (2) occupational therapy practices in FMGs. The researchers tested the interview guide with a person living with chronic pain (CP) (see Supplementary File A) and made improvements throughout the study as needed, to ensure it effectively addressed the research questions.

Since some people living with CP had not met with an OT during their healthcare journey, the participants were provided with a brief description of occupational therapy to ensure that everyone had a basic understanding of the profession. The average interview length was 47 min (54 min for people living with CP and 41 min for healthcare professionals). The research team conducted iterative and concurrent data collection and analysis. After a few interviews, they reviewed the interview guide to add probing questions as needed to answer the research questions. AD used a research journal to record useful information about the interview process, ideas for analysis, preconceptions, and decisions about the project. Potential biases were discussed with team members as necessary.

Each interview was recorded and transcribed by AD and AL. Then, each interview was analyzed using inductive thematic analysis [22] and DeDoose software. The first step, data condensation, involved listening to the interviews and reading the transcriptions to develop codes. AD and AL carried out this step independently. The second step was data display. AD and AL carried out this step as well and proposed the initial coding tree. Émilie Lagueux (EL) and Catherine Hudon (CH) then participated in step three (checking and drawing conclusions). Meetings were held to review the entire coding tree, and regular discussions were carried out throughout the analysis process to ensure the findings answered the research questions and represented the collected data.

For findings related to occupational therapy interventions, we used the classification of occupational therapy interventions [15]. This classification distinguishes three types of interventions: person-, environment-, and occupation-related. Person-related interventions include training, skills development, and education. Environment-related interventions include environmental modifications, support provision, and support enhancement. Occupation-related interventions include task adaptation and occupational development. To gain insight into the themes, the most discussed needs are further developed in the results.

Results

A total of twenty-three participants were interviewed. Ten of the participants had different types of CP (mostly musculoskeletal CP and fibromyalgia), and thirteen were healthcare professionals (five occupational therapists, four nurses, and four physicians) with expertise in primary care (61%) or CP (77%). Tables 1 and 2 show the participants’ additional demographic data.

Table 1.

Additional demographics of people with CP (n = 10)

Participant	Sex/ gender	Age range (years)	Marital status	Education	Economic situationa	Insurance for OT	Diagnosis	Range of years in FMG
1	F	50–59	Married	University	Comfortable	NR	Ehlers–Danlos syndrome	0–5
2	M	40–49	Single	University	Poor	Don’t know	Musculoskeletal and lower back pain	6–10
3	F	40–49	Common-law partner	University	Sufficient	Yes	Fibromyalgia	11–15
4	F	50–59	Common-law partner	Professional studies diploma	Sufficient	Yes	Musculoskeletal and fibromyalgia	21–25
5	M	50–59	Common-law partner	Secondary	NR	No	Musculoskeletal pain	21–25
6	M	60–69	Married	Post-secondary	Sufficient	No	Musculoskeletal pain	16–20
7	F	60–69	Single	Secondary	Poor	Yes	Fibromyalgia	11–15
8	F	60–69	Married	Post-secondary	Sufficient	No	Fibromyalgia, musculoskeletal	21–25
9	M	50–59	Married	University	Sufficient	Yes	Lower back pain	6–10
10	F	50–59	Single	Post-secondary	Sufficient	Don’t know	Fibromyalgia, musculoskeletal, neuropathic pain	0–5

F Female, M Male, NR No Response, OT Occupational Therapy, FMG Family Medicine Group

^aThe question addresses the participants’ perception of the financial situation compared to people of the same age and includes five answers: Comfortable, Sufficient, Poor, Very Poor, and Do Not Want To Answer

Table 2.

Additional demographics of healthcare professionals (n = 13)

Participant	Sex/ gender	Age range (years)	Job	Range of years of experience with CP	Range of years of experience in PC	Range of years of OT practice
1	F	30–39	OT	0–5	N/A	16–20
2	F	30–39	OT	6–10	6–10	6–10
3	F	30–39	OT	0–5	0–5	11–15
4	M	30–39	OT	6–10	N/A	6–10
5	F	30–39	OT	11–15	0–5	16–20
6	F	30–39	N	0–5	11–15	N/A
7	M	40–49	N	11–15	N/A	N/A
8	F	40–49	N	16–20	11–15	N/A
9	F	30–39	N	6–10	0–5	N/A
10	F	40–49	P	16–20	0–5	N/A
11	F	50–59	P	16–20	N/A	N/A
12	F	50–59	P	21–25	16–20	N/A
13	M	40–49	P	16–20	N/A	N/A

OT Occupational Therapist, P Physician, N Nurse, CP Chronic Pain, PC Primary Care, N/A Not Applicable

Primary care needs (obj. 1)

All of the participants were asked to identify the primary care needs of people with CP receiving care in FMG. There were only two differences in the needs identified by people with CP and those identified by healthcare professionals : only people living with CP mentioned the need for psychological support and pain relief. Therefore, when referring to participants, both people with CP and healthcare professionals are included. Fourteen needs were identified in three categories: Services Organization, Therapeutic Relationship, and Pain Management (see Table 3). These needs were sometimes met and sometimes not; often, they were simply discussed without specifying whether they were met.

Table 3.

Perceived FMG services needs for individuals with CP

Category	Theme	Theme explanation
Services Organization	Accessibility	Having easy access to primary health care (geographically, financially, timely)
	Comprehensiveness	Receiving services covering all aspects of the condition
	Multidisciplinary care	Having access to a team with various expertise (pharmacological, physical, psychological)
	Navigation support	Being oriented and informed about the care, receiving help to complete documents (where to go, what to do)
Therapeutic Relationship	Feeling of the legitimacy of the CP experience	Being welcomed, believed, and taken seriously
	Support	Being accompanied in the pain journey
	Listening	Being listened to
	Partnership	Feeling part of the team and collaborating with the team members
Pain Management	Occupational participation	Being able to perform activities
	Education	Receiving information to understand the pain experience (pain mechanism, pain consequence and course, available services)
	Medication management	Being guided and supported to take, test, sort, and stop medications
	Pain relief	Controlling and managing pain effectively
	Psychological support	Receiving services to address psychological aspects emerging from the pain experience
	Group participation	Participating in a group (peer or support group)

In terms of service organization, accessibility and multidisciplinary care were the most frequently mentioned needs and were reported as unmet by 11 participants. Regarding accessibility, participants discussed three factors: proximity, cost, and the time required to access services. One individual living with CP reported needing access to rehabilitation services within the primary care team because he could no longer afford them:

People tell us to go to physiotherapy, go to occupational therapy, do this, do that, but it’s expensive, you can’t hide it, and the time I did that, those treatments, it felt good, but it’s because at some point the wallet doesn’t support it anymore, so we have to stop, […] that should be something in the clinics. (Person living with CP 4)

Both people living with CP and professionals reported the need for multidisciplinary care in CP management. This is evidenced by a person living with CP who reported that pain has both physical and psychological impacts:

I feel like it takes something with several professionals with different knowledge as much the psychological as the physical, because that’s it, the pain gets us, we get stiff physically, but in our head too. (Person living with CP 3)

However, even when professionals acknowledged the importance of multidisciplinary care, the clinical reality did not meet this: “Family doctors are the first to say, ‘We need multidisciplinary teams,’ but unfortunately, they don’t exist very often” (Physician 4).

In terms of the therapeutic relationship, the need to have a healthcare professional legitimize their CP experience was the most frequently reported (and perceived as unmet by eight participants). Feeling that one’s pain experience is legitimate means that the person with CP is welcomed with kindness, believed, and taken seriously. When asked about her needs in relation to FMG care, one person with CP reported: “To be believed, to feel like I’m being heard when I say something. I feel like I often have resistance” (Person living with CP 1).

Another person living with CP reinforced the importance of this need from a different perspective: “When I was assigned to the doctor who saw me, I explained what I had. That’s when I thought, ‘this is it, he’s going to tell me the same thing again, that I’m crazy.’ No. He took me seriously. It really feels good to be understood” (Person living with CP 5).

In terms of pain management, the most discussed needs were occupational participation, education, and medication management. Twelve participants perceived occupational participation as an unmet need. Many people put this need at the top of their list, whether it related to doing activities with their loved ones or carrying out daily tasks. Two people living with CP illustrated this need by saying: “To be able to do my daily tasks. That’s, that’s the number one priority. If I can’t do that, I can’t imagine doing anything else” (Person living with CP 9) and “I had asked the doctor, I had just given the mission: I just want you to, to meet my needs so that I can do activities with my children now that I’m retired, with my grandchildren” (Person living with CP 8).

In terms of education, 20 participants reported needing information about pain, including its mechanisms, consequences, and course. They also mentioned needing information about pain-related issues, such as sleep. Many participants also mentioned the need to be informed about services relevant to CP management. Training for healthcare professionals was another widely discussed topic. Many people with CP noted a lack of training for healthcare professionals. One participant reported: “There is certainly room for improvement in training, because sometimes I get the impression that they don’t know what to do with people suffering from CP” (Person living with CP 1). This sentiment, aligned with several healthcare professionals, reports that training is insufficient when it comes to CP. In fact, one professional explained that this lack of education leads to a variable quality of care depending on which professional is encountered: “It’s a bit like Russian roulette at the moment, because the knowledge is really not uniform” (OT 2).

Finally, medication management was the only need that was met for 13 participants. Several participants were satisfied and highlighted the presence and expertise of pharmacists at FMG. One participant said: “In general medicine, it’s fundamental […] the FMG pharmacists here are extremely competent and up to date in all aspects of medication” (Physician 3).

Occupational therapy practice (obj. 2)

Several areas of occupational therapy assessment and interventions were proposed for CP management in FMG practice (see Table 4).

Table 4.

Proposed occupational therapy interventions for CP management in FMG

Type of intervention		Proposed interventions
Person-oriented	Training	• Developing physical capacities (strength, endurance)
	Skills development	• Helping people to learn and apply self-management strategies (particularly pacing) • Addressing postural hygiene, positioning, and load handling
	Education	• Educating about o Health conditions and their impact on daily life o Cognitive-affective factors o Pain-related issues, such as sleep
Environment- oriented	Environmental modifications	• Modifying or adapting the environment (at home, at work)
	Support provision and enhancement	• Helping people to grieve and accept their condition • Acting as a care navigator • Listening and emotional support
Occupation-oriented	Task adaptation and occupational development	• Accompanying the person in carrying out activities (ways of doing things, recovering, and integrating) such as work and return-to-work activities, domestic activities (making the bed, vacuuming, washing the bath, washing the dishes, running errands, mopping floors), physical activity, leisure, feeding, sexuality, sleep, travel

The structure is bsed on McColl and Law classification of OT interventions

The most frequently reported interventions in the interviews were: (1) helping people to learn and apply self-management strategies (n = 10/23, 43%), and (2) accompanying the person while they carry out activities (n = 20/23, 87%). Regarding self-management support, one OT said:

There are a lot of things that are general recommendations that any professional can give […] There’s a difference between knowing what I need to do to help my condition and being able to do it. I find that in occupational therapy, that’s where we’re often more successful, […] in translating these lessons into everyday life, in what it means, in relation to my roles, in relation to the demands I have in my tasks, in my environment, which makes it more concrete. […] I find that this little bit can make a difference. (OT 5)

Within accompanying the person while they carry out activities, activities included anything related to carrying out an activity, such as learning how to do it, thinking about it, resuming it, or integrating a new one. Thirteen participants (57%) addressed work-related activities in this category. As one OT put it: “Anything that makes it easier to return to work, from resuming activities to returning to work, an OT has all the skills needed to support not only the professional team, but also the individual” (OT4).

Following the interventions discussed above, addressing postural hygiene, positioning, and load handling (n = 6/23, 26%), education (n = 6/23, 26%) and environmental modifications (n = 8/23, 35%) were the most frequently reported interventions. About postural hygiene, positioning, and load handling, a person living with CP indicates the targets of occupational therapy intervention: « How to bend, how to work with your lower back, how to support yourself, abs and all, to put less strain on the joints than on the muscles. » (Person living with CP 2).

Education was discussed regarding the health condition, cognitive-affective factors and pain-related issues. A person living with chronic pain talked about health education in general, and underlined the need to improve this intervention for every healhcare professional :

I see the role of the occupational therapist and the role of the FMG nurse, or any other caregiver, who would have more time to educate the patient, but also give him other tools for when the patient is at home. It’s amazing how much is available online, the support is there, but doctors and healthcare professionals often aren’t even aware of associations like AQDC, there’s really a lot of help out there, and it’s often not the doctors who are going to lead patients to it, and I think there’s a lot of educational work to be done. (Person living with CP 1)

This same person living with CP precised about cognitive-affective education that « The occupational therapist will make us aware that there are so many other things we can do and so many ways of looking at things. For me, it’s all about education and saying that it’s about management and that it’s up to us. » (Person living with CP 1).

In terms of environmental modification, it was discussed that occupational therapist could intervene both at home and at work. A physician and a nurse mentioned :

I know there’s the whole issue of reorganizing the environment both at work and at home. Let’s say, you know, to go and assess whether it’s suitable for the person […] that his environment is going to be correct so that he can continue to live in that environment. (Physician 1)

It’s not just the assessment, it’s the technical aids, installing technical aids, making sure that the environment is safe, making sure that the person is going to be able to accomplish certain tasks by having the tools to help them get to the end of their tasks. (Nurse 4)

Discussion

The findings from this study demonstrate the strong alignment between needs of people with CP and OTs skills and knowledge. OTs have a relevant lens through which to view the complexity of the pain experience and the expertise to support people with CP in their self-management journey. They teach people with CP strategies for managing pain, activities, and time. They also help them learn self-analysis so they can apply self-management strategies according to their desired and necessary activities [16].

Regarding the needs of people with CP in primary care, the quality of the bond between these individuals and the professionals they encounter is important in terms of the therapeutic relationship. The literature defines a therapeutic relationship as an alliance “built on trust, empathy, collaboration, and mutual respect to create a safe environment for clients to delve into their experiences and foster personal growth”. [23] ^(p.1) The needs identified in our study align with a review of the literature on the key elements of therapeutic relationships in acute care by Kornhaber et al., [24] who point out that “therapeutic listening,” “responding to patient emotions and unmet needs,” and “patient-centeredness” are key elements for improving therapeutic interpersonal relationships.

Renée R. Taylor developed the Intentional Relationship Model in 2008, believing that the therapeutic relationship is an integral part of the occupational therapy practice process. This model provides a conceptual framework for the therapeutic relationship in occupational therapy [25]. The model aims to enhance therapists’ use of self to promote occupational engagement and positive therapy outcomes by teaching interpersonal skills, therapeutic modes, and interpersonal reasoning. Currently, the relationship is the heart of contemporary occupational therapy practice [26]. OTs should leverage this expertise to foster deeper relationships and enhance their practice in CP management. Furthermore, a study by Jónsdóttir et al.[27] highlighted that the greater the pain’s impact on quality of life, the more time and support people need to express how their condition affects their daily lives. People living with chronic pain need access to qualified primary care professionals who take the time to build therapeutic relationships with them and OTs have the expertise to do so.

In terms of occupational therapy practice, the most cited interventions were supporting the person to perform activities and to learn and use self-management strategies with the ultimate outcome of doing activities in the way they aspire to. This aligns with a scoping review on occupational therapy in pain management that found improving activity and participation to be the focus [14]. Self-management is widely recommended for CP management[28–31], and primary care is an ideal setting for supporting self-management [32].

However, the literature has identified barriers to the use of self-management in primary care. A qualitative study involving people living with CP and primary care professionals identified four main barriers to self-management: the practice is discussed too late, if at all, between people living with CP and professionals; people living with CP do not feel supported in their pain experience; treatment options are perceived as limited and overly medicalized; and there are multiple organizational issues, such as short appointments, long waiting times, and fragmented care [33]. Healthcare professionals acknowledge the importance of building a partnership with people living with CP to support self-management. However, they find it difficult to do so, revealing that people with CP are often perceived as challenging, particularly for general practitioners, as CP often has no cure [33]. On the other hand, occupational therapy practice addresses both physical and psychological health, and does not aim to cure but rather to improve health and function by enabling occupation and support self-management [16]. This expertise must be recognized and widely integrated into primary care since CP does not typically follow a linear progression over the course of a lifetime, meaning that self-management is a complex but necessary skill to develop.

Strengths and limitations of the study.

To our knowledge, this is the first study to focus specifically on the needs of people with CP in FMGs. Several elements demonstrate the rigor of this project[34]. The iterative approach, the data transcription, the use of a logbook and the initial independent coding demonstrate its credibility. The review of analyses by several team members, the frequent meetings to discuss analyses, the use of a logbook, and the research process description demonstrate its reliability. Like any other study, this one has limitations. The transferability of the results is limited to similar contexts, such as primary care people living with CP who are treated in FMGs. Like any other study, this one has limitations. The transferability of the results is limited to similar contexts, such as primary care people living with CP who are treated in FMGs. Thus, the results represent only one subset of the population living with CP, and some participants did not have first-hand experience with OT. Whether the findings apply to healthcare systems other than the one in Quebec merits further investigation. Social desirability bias may have been present, since the interviewers were an occupational therapy student and an OT.

Conclusions

This study presents multiple specific needs of people living with CP in the primary care setting and underlined how these needs align closely with the scope of occupational therapy practice. OTs should promote their abilities in self-management support and in addressing both the physical and psychological aspects of CP to enhance their presence in primary care teams. Further research on OTs’ pain management practices in FMGs is essential in the coming years to clarify the interventions used and to document their effects.

Abbreviations

CP

Chronic Pain 

FMG

Family Medicine Group 

OT

Occupational therapist 

Authors’ contributions

AD and AL did the interviews. AD, AL, ÉL, and CH analyzed and interpreted the data to answer the research questions. All authors are major contributors in writing and reviewing the manuscript. All authors read and approved the final manuscript. DeepL translator (2024 advanced version) was used for traduction from French to English.

Funding

Andréa Dépelteau’s doctoral training grant from the Fonds de Recherche du Québec en Santé made the project possible.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The research Ethical approval of the present study was obtained in November 2021 from the Research Ethics Committee - Lettres et sciences humaines of the Université de Sherbrooke (Project #2021–3196). All participants gave an informed consent to participate by completing a written consent form. This study was conducted in accordance with the Énoncé de politique des trois Conseils (for Ethical Conduct for Research Involving Humans), as required by Canadian research ethics standards and is in compliance with Helsinki Declaration.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.