Women’s health and chiropractic: Educational audit and development of core competencies

Abstract

Objective

This study reviewed women’s health (WH) curricula at chiropractic colleges and developed core competencies for WH.

Methods

Instructors of chiropractic colleges who taught WH-related course(s) were contacted to complete a survey that gathered pertinent material, including course objectives and targeted competencies. Survey results were used to develop an initial set of WH competencies. These were presented at an international conference workshop, with feedback from attendees who chose to participate. An e-Delphi panel was convened to finalize the core competencies, which required greater than 80% consensus for approval of each statement.

Results

Based on surveys from 7 institutions and 13 courses, 11 individuals at the international conference workshop recommended 62 core competencies within 10 domains, which were subsequently evaluated by 42 Delphi panelists (DP). After one round, all competencies met consensus.

Conclusion

The study provided insight into the WH curriculum offered at participating chiropractic colleges. This resulted in a set of 10 domains and 62 core competencies to inform curricula that may be used by chiropractic training programs to enhance future chiropractors’ knowledge and skills around WH across the lifespan and for post-graduate courses to ensure that proficiency may continue to advance in practice. These competencies go beyond women’s reproductive health to include less considered milestones throughout the lifespan, including that gender is a social determinant of health, and the biological impact of social conditions, such as age in this population.

INTRODUCTION

Women’s health (WH), often paralleled with reproductive health,¹ encompasses a life-course approach to promoting wellness as well as preventing and managing a broad array of health concerns and challenges that affect women throughout their lifespan.² According to the Office of Women’s Health at the Centers for Disease Control and Prevention, WH involves mental and physical well-being from puberty through the elder years.³ Women, who comprise approximately half of the North American population,^4,5 experience greater barriers to optimal health,³ higher levels of morbidity, more chronic conditions, greater disability, and longer life expectancies compared to men.³ These factors highlight the need for greater awareness of the multidimensional health challenges women face throughout their lives.³

Despite recognizing the need to improve WH over 40 years ago,⁶ WH remains a neglected component of health professional education. It has not been uniformly incorporated into post-secondary curricula, including medical and public health schools in the United States (USA) and Canada.^2,3,7 A study has shown that undergraduate WH curricular materials from medical schools are often limited to a single course or seminar on a specific WH topic, such as domestic violence, or to didactic components of existing clerkships or clinical electives.³ Research further suggests gaps in physicians’ training, knowledge, and confidence in evaluating and managing WH concerns.¹ Health professional training programs should incorporate comprehensive education on WH to enable competency attainment and graduate practitioners who are proficient in the delivery of women’s health care. Unfortunately, some training programs may be outdated and focus on the acquisition of knowledge rather than competency, which is defined as a person’s ability to integrate knowledge, skills, and attitudes, demonstrated through behaviors, in the performance of a given task.⁸ To deepen knowledge gained during undergraduate training, colleges and associations should support ongoing or enhanced training not only in postgraduate education but also beyond graduation.⁹ As such, colleges and associations should support ongoing or enhanced training beyond graduation to support health professionals in maintaining competency in the care for women and individual practitioners to achieve expertise in WH. However, there are currently no defined WH competencies within undergraduate or postgraduate chiropractic education programs. The absence of standardized competencies leaves WH training dependent on individual program priorities, leading to variability and inconsistent knowledge and awareness.

To improve WH’s outcomes and equitable care,^8,10 gender-based competencies must be integrated into the education of future healthcare professionals. WH knowledge and confidence are critical across all healthcare fields,¹ including the chiropractic profession. A robust, well-integrated WH curriculum is essential to equip healthcare providers with the skills to address women’s unique health needs effectively. Chiropractic training programs around the world offer education regarding WH; however, little is known about their curricula and graduate competencies, which are quite diverse. Further investigation is required to better understand the level of training and the articulated competencies offered at chiropractic colleges, to identify gaps and potential inadequacies in chiropractic education on WH. The purpose of this study is to review the current WH curriculum across various chiropractic colleges, identify key topics and gaps, and employ an expert Delphi panel to develop consensus-based core competencies for an ideal chiropractic college and post-graduate education program, aligning them with current education standards and addressing the pressing need for standardized WH training.

METHODS

The study utilized a mixed methods approach to gathering information on WH education and included 4 major components (Figure 1): Part 1: Educational audit; Part 2: Development of the initial competency statements; Part 3: Workshop; and Part 4: Delphi consensus process.

Figure 1.

Study protocol.

Ethics

Two ethical applications were submitted and approved by the Canadian Memorial Chiropractic College Research Ethics Board; parts 1 and 2 (#2112X01) and parts 3 and 4 (#2301X01). Electronic informed consent was obtained from each Delphi panelist (DP) at the beginning of the process, and they could choose not to respond at any time. Written permission was obtained from the DP to share their names in the final manuscript.

When referring to the term “patient” or “lifespan,” unless otherwise explicitly stated, it will include “pediatric, adolescent, adult including nulliparous (women who do not have children), pregnant, postpartum, perimenopausal, menopausal and aging (or individuals on women’s hormones) patients.” In addition, when the terms “girl,” “female,” “woman,” or “women” are used, we are typically referring to individuals whose gender identity and expression align.

A steering committee (SC) was established to oversee the development of the competencies and ensure the inclusivity of stakeholder input. Members were carefully selected to provide diverse insights and ensure the representation of all healthcare provider stakeholder perspectives and consisted of nationally recognized chiropractic experts with extensive experience in WH, program administrators, practicing chiropractors, a clinical research coordinator, and a patient advocate. See Supplementary File Table 1 that summarizes the professional backgrounds and experience of the SC members for this project.

Part 1: Educational Audit

Deans or other equivalent representatives from 28 North American and international chiropractic colleges were contacted to identify the faculty member(s) responsible for their respective WH courses and to obtain approval to contact them. Deans or equivalent representatives were identified through institutional websites or word of mouth. Initial contact was made through email, with a follow-up email or phone call if no response was received. Once the appropriate individual, such as the primary WH course coordinator or lecturer, was identified, an introductory email was sent to determine their interest. Upon confirming their interest, the study package was sent.

The study package included an educational audit survey (See Supplementary File), which was developed based on previous work^11,12 and modified by the investigative team to address WH. The identified faculty member received a survey link within the study package informational letter, which outlined the available data collection options: submission of course syllabi, telephone conversation, and/or email discussions. The informed consent document was provided next, and once signed, the educational audit survey commenced. All collected information, including survey responses and submitted syllabi, was securely stored on a protected server. Data extracted from the educational audit survey were analyzed to establish the initial set of core competencies.

Part 2: Development of the Initial Competency Statements

The information gathered from the educational audit, combined with competencies established within the chiropractic profession⁹ and by other professions¹³ and the Councils on Chiropractic Education’s (CCE), including CCE-USA meta-competencies¹⁴ for undergraduate Doctor of Chiropractic degree programs and CCE-Canada¹⁵ entry-to-practice competency profile guided the SC members and investigative team in developing an initial draft of competencies. This draft was prepared for presentation at a workshop designed to attract clinicians, educators and researchers interested in WH who were attending the 2022 Association of Chiropractic College – Research Agenda Conference (ACC-RAC) in San Diego, California.

Part 3: ACC-RAC Workshop and Updates to the Competency Statements

Four SC members also served as facilitators for the ACC-RAC workshop. The workshop included an introduction to the topic, a summary of the audit findings, an introduction of the SC members, a presentation of the initial draft of the core competencies and how they were developed, small group discussions to refine the competencies, and a final full-group discussion to review all feedback from the small groups. The SC carefully reviewed and considered all attendee feedback, modified and edited as necessary to develop a set of core competency statements, which would be sent to the DP.

Three practicing chiropractors not associated with the study evaluated this revised version of the competencies for face validity. They were asked to assess the competencies for their suitability for clinical practice, readability, ease of implementation, and relevance to the chiropractic profession. Feedback from this review included grammatical corrections and suggestions for formatting to enhance readability. Additionally, they recommended aligning the competencies with the format used in the CanMEDS Competencies,¹³ which has been adopted by various healthcare academic institutions (including some chiropractic colleges). After incorporating this feedback, the updated competencies were finalized and prepared for the next stage of development.

Part 4: Delphi Consensus Process and Core Competency Statements

Delphi Panel Invitees

A call for chiropractors to volunteer as DP was issued to assist in curating the core competencies. Invitations were extended to respondents of the educational audit survey, attendees of the ACC-RAC workshop, WH clinical scientists, instructors of current postgraduate or undergraduate WH courses, holders of continuing education certificates in WH, and members of the American Chiropractic Association – WH Council. Once potential DPs were identified they were verified by the project manager to meet the study inclusion criteria. Eligibility criteria included chiropractors who have a special interest in WH including instructors in current postgraduate WH courses, scientists with clinical WH or in a subcategory of WH expertise, holders of continuing education certificates in WH or a subcategory of WH and undergraduate WH chiropractic instructors and members of the ACA WH. Once confirmation of their eligibility was obtained, they were sent a project information form, a consent form and a demographic and practice characteristic survey via email. Before participating in the Delphi process, all DPs were required to review the designated reading material.^9,13

Delphi Consensus Process

The Delphi consensus process was conducted to gather expert modifications and confirmations on the competencies, following the widely accepted RAND-UCLA (University of California, Los Angeles) methodology for Delphi studies.¹⁶ This process was carried out electronically using SurveyMonkey (San Mateo, California) (https://www.surveymonkey.com). DPs were asked to rate the “appropriateness” of each competency, defined as the extent to which the competency is expected to provide health benefits that outweigh potential negative consequences, exclusive of cost.¹⁶ Ratings were provided on a scale of 1 to 9 (highly inappropriate to highly appropriate), where the scale was then categorized with 1 to 3 indicating “inappropriate,” 4 to 6 indicating “undecided,” and 7 to 9 indicating “appropriate.”

DPs who rated a competency as “inappropriate” were required to provide a rationale and, if possible, a supporting reference. If no rationale was provided, the responses were marked as incomplete and recorded as missing. Competencies rated as “inappropriate” with accompanying rationale were revised accordingly. Tabulated results were reviewed, and competencies that did not reach 80% consensus as “appropriate” were edited based on DP feedback and recirculated for further review. This iterative process continued until an 80% consensus was achieved for each competency. All communications were conducted via email, and responses remained anonymous.

Once an 80% consensus was reached for all competencies, the Delphi consensus process was closed, and the results were compiled into a WH’s core competencies report, which was shared to the SC for final review and approval. The DPs were provided with a set of 9 competencies and given 2 weeks to return their feedback and suggested revisions. The competencies were accompanied by supporting citations, and reference materials were made available upon request. All information was kept confidential and securely stored on a server at the Canadian Memorial Chiropractic College.

RESULTS

Educational Audit

Of the 28 chiropractic educational deans/chairs (19 North American and 8 international) invited, 8 did not respond. The deans/chairs sent us 26 names of lecturers/coordinators who could fill out the survey. Five colleges submitted more than 1 contact name and 1 college, with 2 campuses, submitted only 1 coordinator’s name. Of the 26 lecturers/coordinators that we contacted, 14 responded to the initial invitation to fill out the survey and of those 5 failed to progress past the first question (Figure 2).

Figure 2.

Educational audit survey respondent results.

Four institutions had stand-alone courses on WH whereas in the other 5 institutions WH topics were interspersed in various courses or part of a larger course and therefore only some of the hours were allocated to WH. All courses were reported to be compulsory, and the majority of the content was delivered didactically. Most of the reported courses included labs and self-study components. At 3 institutions, a “hands-on technique component,” such as spinal manipulative therapy (SMT), mobilizations, or soft tissue technique, for WH was not included in the current course but was covered in another course, such as technique class and 2 institutions did not answer this question (Table 1).

Table 1.

Course Overview from Selected Chiropractic Colleges

College	Course (#)	Hours	Hands on (ie, Technique)	Didactic	Labs	Self-Study	Small Groups	Other
1	Stand-alone (1) & various (2)	30 30 30	Other	X	X	X	X	X
2	Stand-alone (1)	31	X	X	X	X	X	X
3	Various (3)	45 60 30	Other	X	X
4	Various (2)	30 30	Other	X		X
5a	Various (DNS)	50	X	X	X
6	Stand-alone	60	X	X	X	X
7	Stand-alone	60	DNS	X
8	In larger course	24	DNS	X
9b	Various (3)	36 36 36	X	X	X	X	X

All courses at each college were compulsory.

^aSent information from pediatrics course, very little on prenatal care; ^b sent only 1 syllabus out of 3.

Legend: DNS = did not state; Various = various courses; Other = taught in other courses.

After a review of the syllabus of the WH’s courses given, most common topics were in pregnancy, postpartum and to a lesser extent, menopause. Fewer academic institutions included information on reproductive physiology, menstrual cycle, uterine and ovarian conditions. (Table 2). Of the 9 institutions that responded, 4 institutions felt that they needed more topics included in their course on nutrition, sports, menopause, and pelvic floor dysfunction. Responses included (1) more focus on musculoskeletal (MSK) problems related to breastfeeding, nutrition, sports activities, menopause (hormonal); (2) more focus on labor and delivery, pelvic floor dysfunction and increase postpartum care; (3) more postpartum rehabilitation; and (4) perspectives from other medical and allied health professionals (ie, obstetrician, doula, midwife, etc) “Not enough time” and “better information found in many continuing education courses” were cited as the reasons they felt they were not offered.

Table 2.

Common Women’s Health Topics According to Participating Chiropractic Institutions

	Institutiona
Topic	1	2	3	6	7	8	9b
General female anatomy		X		X		X
Reproductive physiology (ie, hormonal changes)		X	X	X		X
Puberty		X
Routine preventive screening tests		X
Breast
Breast anatomy		X		X
Breast examination		X		X		X
Breast conditions (benign and malignant)		X		X		X
Menstrual cycle
Normal cycle		X		X
Cervical conditions (ie, human papillomavirus, cervical cancer)		X				X
History-specific questions		X
Physical exam		X
Management		X
Disorders of the menstrual cycle (ie, dysmenorrhea, premenstrual syndrome)		X		X
Ovarian conditions
Benign conditions				X		X
Germ cell tumor				X		X
Polycystic ovarian disease/syndrome		X		X		X
Malignant tumor				X		X
Uterine conditions
Uterine fibroids		X				X
Endometriosis		X		X		X
Heart disease		X
Infertility					X
Pelvic floor	X	X
Pelvic floor conditions (ie, urinary incontinence, pelvic organ prolapse, dyspareunia)				X		X	X
Pelvic floor examination				X
Management				X		X
Pregnancy
Contraception		X	X
Conception (including signs and symptoms, dating exam, terminology, etc)	X	X	X	X	X	X
History-specific questions	X	X				X
Physical exam	X	X
Complications of pregnancy (ie, placenta previa, hypertension)	X	X	X	X	X	X	X
Pregnancy-specific MSK conditions (ie, low back pain, pelvic girdle pain, osteitis condensan ilii, symphysis pubis dysfunction)	X	X		X		X	X
Labor & delivery	X	X	X	X	X	X
Chiropractic care (treatment of common conditions)	X	X		X	X
Management (ie, spinal manipulative therapy [SMT, including Webster], taping, rehab exercises)	X	X	X	X	X	X	X
Nutrition				X	X	X
Postpartum
History-specific questions	X	X				X
Physical exam	X	X
Postpartum-specific conditions (ie, diastasis recti)		X					X
Postpartum complications				X	X
Management (ie, SMT, taping, rehab exercises)	X			X
Lactation/breastfeeding	X			X			X
Maternal mental health			X	X
Menopause		X	X	X		X

^aTwo institutions did not submit their course syllabus; ^b only submitted 1 of 3 course outlines.

^cHPTN – hypertension; HPV – human papilloma virus; LBP – low back pain; OCI – osteitis condensans Illi; PGP – pelvic girdle pain; PMS – premenstrual syndrome; POP - pelvic organ prolapse; rehab – rehabilitation; SMT – spinal manipulative therapy; SPD – symphysis pubis dysfunction; UI – urinary incontinence.

Characteristics of the Delphi Panelists

Forty-seven DP (42 women and 5 men) gave their consent to be members of the Delphi panel. The Delphi panel consisted of 47 Doctors of Chiropractic (DC). In addition to their professional degree, 4 panelists had a PhD, 8 panelists had a Master’s degree other than Master of Chiropractic, 1 had both a Master’s and PhD, and 3 respondents completed a chiropractic residency (Supplementary File Table 2). One panelist chose not to disclose an education level. DP represented 5 countries: Canada had the highest number of DP at 20, followed by USA with 8 DP, Australia with 2 DP and New Zealand and Cyprus with 1 DP each. Twelve DP reported that they went through post-graduate training in WH. Twenty-eight DP were faculty at chiropractic college (21 full-time and 7 part time). The DP in active practice have been in practice for a median of 17 years (range: 0.5 – 50 years).

Panelist Responses

The Delphi process was conducted from February to April 2023. In accordance with the Delphi protocol, consensus was defined a priori at the start of the project as requiring at least 80% agreement (within 3 rounds) on appropriateness with a median rating of 7 or higher. Five DP failed to participate in the full consensus process, resulting in a total of 42 responses. A consensus was reached on all competencies after 1 round. Competencies were updated to incorporate the comments collected from the panelists via survey and individual emails to research coordinator. Subsequently these results were reviewed by the SC for their feedback and finalization. As a result of DP feedback, 62 competencies organized into 10 domains are suggested to support optimal female healthcare as delivered by chiropractors, across a woman’s lifespan. These domains are shown in Figure 3. A detailed list of the competencies under each domain can be found in Supplementary File Table 3.

Figure 3.

Summary of the key domains and competencies for women’s health curriculum.

DISCUSSION

This study successfully developed consensus-based core competencies for the chiropractic profession in WH. To achieve this, the current WH curriculum at various chiropractic institutions was audited, the profession’s meta-competencies were reviewed, other healthcare professions' WH competencies were analyzed, and expert input was gathered through a workshop and a Delphi consensus process. As a result of this process, a set of 10 domains with 62 core competencies was established. These competencies go beyond women’s reproductive health to include less-considered milestones throughout the lifespan (ie, puberty, peri- and post-menopause), the fact that gender is a social determinant of health, and the impact of biological factors on social conditions, such as age, in this population. These domains and competencies provide a framework that chiropractic colleges and continuing education programs can use to define the curricular content, standardize training, ensuring consistent knowledge and skills linked to practice activities of chiropractors while promoting transparency within the profession. Although the domains and competencies are presented as a list, the competencies may be interrelated and interdependent.

Much like in medicine, the results of the educational audit on WH reveal that the majority of WH topics are not well addressed² and those taught at chiropractic institutions focus predominantly on the reproductive years,¹ emphasizing pregnancy and postpartum. However, comprehensive WH knowledge and skills that extend beyond reproductive health are essential for clinicians across various specialties,¹⁷ including chiropractors, to provide optimal care for female patients. To address this, Sattari and colleagues advocate for a curriculum that includes substantial content outside the reproductive tract, emphasizing health promotion, disease prevention, and treatment across a woman’s lifespan.¹ Notably, some chiropractic institutions already integrate WH topics into various other courses, such as foundational sciences (ie, anatomy, physiology, pathology, etc) or combine them with pediatrics or geriatrics courses, reflecting an effort to broaden the scope of WH education.

To ensure that patients are protected and receive appropriate care from graduates of academic programs, accreditation authorities mandate that professional standards, delivered through competency-based education, are met during pre-professional training.¹⁸ These standards are critical in establishing a baseline for the knowledge, skills, and professionalism expected of chiropractic graduates. The CCE, aligned with their respective academic institutions, plays a pivotal role in defining and clarifying the necessary competencies. These include the essential knowledge, understanding, skills, attitudes, and behaviors students must demonstrate before graduation and entry into practice.¹⁸ Graduate competencies, in particular, serve as benchmarks for the abilities expected of new chiropractors, ensuring they are equipped to address society’s evolving healthcare needs.¹⁵

Chiropractic training and care can vary across regions. For example, CCE-Canada adopted the Canadian Medical Education Directives for Specialists (CanMEDS) framework, which describes the aspects of competence identified as fundamental for postgraduate training for healthcare professionals.¹⁹ The adopted framework included minor modifications to be specified to chiropractors’ scopes of practice (eg, Medical expert became Neuromusculoskeletal expert). The CanMEDs competency profile is founded on a ‘role’ framework, which is further broken into key competencies and enabling competencies. The 7 roles include: Neuromusculoskeletal Expert, Communicator, Collaborator, Health Advocate, Scholar, Professional, and Leader. In the United States, CCE-USA uses 8 meta-competencies including Assessment & Diagnosis, Management, Health Promotion and Disease Prevention, Communication and Record Keeping, Professional Ethics and Jurisprudence, Cultural Competency, Chiropractic Adjustment/Manipulation, and Inter-Professional Education. Although the domains and competencies are presented as a list, the competencies may be interrelated and interdependent, and possibly combined in a different manner, such as the differential and working diagnosis assimilated into the Musculoskeletal evaluation domain, as done by CCE- Competencies¹⁵ and CCE Meta-Competency.¹⁴ Additionally, jurisdictional culture and scope of practice are important factors to consider when implementing competencies into education and clinical practice. These variations necessitate a tailored approach to competency development and integration, ensuring they remain relevant and applicable within specific legal and cultural frameworks. With the competencies developed in this study, all programs can uniquely tailor them to meet the specific local needs or cultural factors, with documentation to justify the modifications.

Incorporating specific WH competencies into chiropractic curricula is essential to guide learning and student growth and improve WH worldwide.²⁰ Ultimately, these competencies achieve 2 critical goals. First, they ensure that academic institutions, regulatory bodies, and professional associations provide the support and framework necessary for chiropractors to deliver safe, effective, and evidence-informed care to women. Second, they aim to empower individual practitioners to develop expertise in WH, addressing both general and specialized needs in ways that enhance patient outcomes and align with societal healthcare priorities.

Limitations

Although the intent was to create competencies with an international scope, most of the representation came from the United States and Canada. As a result, the competencies may be better tailored to training programs in these regions and to those whose curricula are competency-based. International, regional, and national organizations interested in adopting these competencies should ensure they are reviewed and validated by experts within their respective region before implementation to ensure relevance and applicability. Additionally, future studies should include a greater number of chiropractic colleges outside North America. Furthermore, we do not know if some of the WH topics that were considered missing in the initial audit could be found in other courses within the curriculum. For example, at 1 institution, osteoporosis is not taught in the WH course but is in the older adult course, so it is not necessarily missing from the curriculum.

Future studies should include asking about WH topics in all courses throughout the curriculum and the hours dedicated to each topic. Additionally, since the initial set of competencies was not created directly by the Delphi panel, there is a possibility that it overly influenced panelists. Although the initial competencies were modeled on the current curricula garnered from the academic institutions included, panelists were given opportunities to provide qualitative feedback on the core set of competencies. This approach may not have fully addressed all potential issues or gaps in the WH curriculum. To address this, it is recommended that the application of competencies be iterative, that is, be revisited and revised after a period and practical application to identify and address any shortcomings. Moreover, while establishing competencies is a critical first step, it is not sufficient on its own. Future efforts should prioritize the development of robust practice activities, similar to those developed by the World Health Organization’s Global Competency Framework for Universal Health Coverage8, which will represent the integration and application of knowledge, skills, and attitudes to practice (including references and resources), and the development of assessment tools to evaluate whether the established competencies are being effectively achieved.

CONCLUSIONS

This study successfully developed a consensus-based set of core competencies for WH within the chiropractic profession, addressing the longstanding gaps in standardized WH education. By auditing the current curricula, analyzing the profession’s competencies and meta-competencies, reviewing WH competencies from other healthcare fields, and incorporating expert input through a workshop and Delphi process, the study established 10 foundational domains and 62 competencies. These competencies provide a framework to standardize WH training across chiropractic colleges and continuing education programs, promoting consistent knowledge, skills, and professionalism among practitioners. Importantly, the competencies emphasize a life-course approach to WH, extending beyond reproductive health to address the multidimensional health challenges faced by women throughout their lives. Although these competencies were designed with an international perspective, the predominance of input from the United States and Canada underscores the need for region-specific validation to ensure global applicability. By equipping chiropractors with comprehensive WH knowledge and skills, these competencies aim to enhance the quality of care delivered to women, empowering practitioners to meet both general and specialized health needs while addressing societal healthcare priorities.

SUPPLEMENTARY FILE

Supplementary material associated with this article can be found online at doi: 10.7899/JCE-25-7.

DECLARATIONS

Acknowledgments

Thank you to the Delphi panelists: Kathryn Brown; Katie Burn Ryan; Kristy Carbonelli-Cloutier; Karen Chrobak; Sophia da Silva-Oolup; Lara deGraauw; Katie de Luca; Paul Dougherty; Crystal Draper; Ana Facchinato; Katelyn Foster; Rosemary Giuriato; Brian Gleberzon; Tanja Glucina; Karin Hammerich; Cheryl Hawk; Ceara Higgins; Heather Hollman; Emily Howell; Karen Hudes; Erin Kempt-Sutherland; Jaclyn Kissel; Aurelie Marchand; Sarah Mickeler; Kelsey Nissen; Tolu Oyelowo; Nakiesha Pearson; Sarah Radabaugh; Katherine Reckelhoff; Kathryn Vardy; Jeana L. Voorhies; Jennifer L. Ward; Debbie Wright.

Funding

No funding was received for this study.

Competing Interests

The authors have no conflicts of interest to declare relevant to this work.

Data Availability

Deidentified data can be provided by the corresponding author upon reasonable request.

Artificial Intelligence

Artificial intelligence was not used to prepare this paper.

Contributorship

Concept development: CAW, CD, CB, DB. Design: CAW, CB, DB, KP. Supervision: CAW, CB. Data collection/processing: CAW DKG, CB, JL, KP, FW. Analysis/interpretation: CAW, CD DKG, CB, DB, NG, JL, KP, FW. Literature search: CAW, CB. Writing: CAW, DKG, CB, BDL, KP. Critical review: CAW, CD, CB, DB, BDL, NG, JL, KP, FW.