The CHIRO-Force peer-assisted learning program for manual therapy education

Abstract

Objective

Peer mentoring is increasingly valued in healthcare education for developing professional and clinical competencies. In the chiropractic program at our university, Force-Sensing Table Technology (FSTT®) was first integrated to enhance manual therapy training. After this, the CHIRO-Force Peer-Assisted Learning (PAL) program was launched as a collaborative learning process to further train students in practical skills related to chiropractic manual therapies. This paper introduces the program and reports findings from its first year.

Methods

The CHIRO-Force program was structured and evaluated using the PAL learning framework. After pilot funding approval, 2 fourth-year students were selected as mentors. Then, they and 2 faculty members completed intensive training from the developers of the FSTT® technology. Mentors then designed session protocols and organized a booking system. Mentees were invited to complete a short questionnaire after each session and a comprehensive one at the end of the pilot year. The program launched in September 2023 and the pilot year ended in April 2024.

Results

Mentors created 5 distinct session protocols and each dedicated about 5 hours weekly to mentoring. From September to April, more than 100 sessions were provided, involving over 100 students. Group mentoring was also integrated into clinical internships. Feedback was highly positive, with 97% of sessions rated as “highly appreciated”.

Conclusion

The CHIRO-Force PAL program shows promise in supporting students’ practice of spinal manipulative therapy outside class. Future steps include assessing its impact on clinical competency and self-efficacy.

INTRODUCTION

Peer-Assisted Learning (PAL) constitutes an education strategy used to support student learning in many healthcare professional training programs including pharmacy, medicine, physiotherapy, dentistry, midwifery, and nursing.^1–6 PAL takes place where a student (ie, the mentor), who is not yet a professional, takes on a teaching role with their fellow classmates.⁷ In PAL programs, the relationship may take the form of peer mentoring, when mentors and mentees are at the same stage of their curriculum, or near-peer mentoring, when they are at different stages.⁷

PAL has been shown to effectively support the acquisition of diverse concepts, ranging from theoretical knowledge (eg, pediatrics courses and pathophysiology) to technical, and procedural skills (eg, communication, patient interviews, physical exams, resuscitation skills, and anatomy surgical skills lab).^1–6,8 Overall, PAL is associated with a high level of satisfaction coming from both mentors and mentees.^8,9 The fact that mentors communicate in a manner more aligned with the language and perspective of mentees, a phenomenon referred to as social and cognitive congruence, is believed to enhance the learning observed with PAL.¹⁰ In addition to improvement in the skill or knowledge specifically targeted by the PAL, PAL education strategy often leads to the development of other professional or personal skills in both mentors and mentees, such as self-awareness, problem-solving competencies, team working, leadership, and communication skills.^8,11–13 Moreover, psychosocial support provided by peers in a PAL context has been shown to reduce academic stress.¹¹

Besides the potential benefits of PAL programs, there are several challenges to consider. In healthcare programs, students may be more exam-focused, meaning they often prioritize studying and preparing specifically for exams rather than developing their professional and clinical competencies.¹⁴ In a PAL setting, student motivation to integrate peer feedback may be lower compared to faculty feedback, which could result in a less effective learning experience.¹⁴ In near-peer mentoring, mentees may find themselves being mentored by a student less advanced in their curriculum, which can create an awkward learning environment and may lead to lower motivation in the skill development process.¹⁴ Finally, when learning a motor skill, timely and effective feedback is crucial to minimize the integration of motor errors and reinforce correct patterns to develop accurate motor skills.¹⁵ Although mentors may receive additional training to enhance their ability to provide accurate and timely feedback, they typically lack the experience of faculty, which may reduce the effectiveness of PAL.¹⁶

To our knowledge, a PAL within the context of manual therapy skills learning among students in healthcare degree programs has not yet been established, or at least, has not been published. Manual therapy proficiency typically develops over years of practice and refinement.^17,18 This progression has traditionally been supported through instruction based on faculty demonstration, followed by peer replication with feedback from both instructors and classmates.¹⁷ Recent integration of force-sensing technology into mandatory courses has enhanced training by providing visual and quantitative feedback on force–time application, improving student confidence, competence, and precision.^17,19,20 Advances in user-friendly devices (eg, instrumented treatment tables)^19,20 and human-like manikins now enable repetitive, independent practice, mitigating faculty availability limitations and facilitating large-cohort implementation. These innovations open the door to new pedagogical approaches, such as peer mentoring, which can extend practical learning opportunities beyond scheduled courses and without direct faculty supervision.

Therefore, the objective of this paper is to introduce the Chiropractic Hands-on Integration with Force-Sensing Technology (CHIRO-Force) PAL program and present the results from its first year of implementation within a chiropractic university program. The framework outlined by Balilah et al.¹⁴ for describing, implementing, and evaluating PAL educational programs was utilized to structure the presentation of the CHIRO-Force PAL program.

METHODS

Ethical Consideration

Although this data collection was granted an exemption from the need for ethical certification, the research team ensured adherence with the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS 2) guidelines.²¹

Context

The CHIRO-Force PAL program was developed as a supplementary teaching strategy within the five-year, competency-based Doctor of Chiropractic program at Université du Québec à Trois-Rivières (Québec, Canada). By the start of the PAL program pilot year, the chiropractic program had already incorporated Force-Sensing Table Technology (FSTT®) from the Canadian Memorial Chiropractic College (CMCC, Ontario, Canada) into practical spinal manipulative therapy (SMT) courses for 2 years. The PAL program was introduced to address the challenge of integrating additional hands-on practice with the FSTT® system into the existing curriculum and to alleviate faculty time constraints. Its overarching goal was to provide enhanced, practice-based learning opportunities as students progress through the chiropractic curriculum. Participation in the PAL program was expected to support students in developing the ability to deliver safe and effective SMT across a variety of patient types and populations. Mentors were responsible for understanding the challenges faced by mentees, analyzing their motor performance, interpreting force-time curves, and providing guidance to improve their skills.

Logistics

The PAL program operated within a secure environment, allowing students to perform repetitive SMT without involving living patients or colleagues, and integrated advanced learning technologies, including the FSTT® system (Figure 1). A full description of the FSTT® system is available elsewhere.²² The FSTT® system, which includes a chiropractic table equipped with a forceplate and accompanied by a small loadcell, may be used with either a Human Analog Manikin (HAM®, CMCC, Ontario, Canada) or a full-body dummy. The room is equipped with 3 large screens positioned on different walls, allowing visualization of the force-time curves recorded by the FSTT® system. Overall, this environment provided mentors with various ways to organize their mentoring sessions based on the mentees’ needs and preferences. The pilot testing of the PAL program was initiated in September 2023 and concluded in April 2024.

Figure 1.

Designated room setup and equipment used for the CHIRO-Force PAL sessions.

Program Content and Design

The PAL program content was tailored to specific subjects, concentrating on hands-on practice and guidance in SMT skills. Students could practice SMT techniques on any part of the spine using the FSTT® system, either with the HAM® or dummy, and could utilize both the table and the load cell. While one-on-one sessions are allowed, students were encouraged to form groups of 2 to 4, fostering a ludic environment that has been shown to enhance learning.¹⁵ Motor learning is also enhanced by observing other learners practicing the skill.¹⁵

Regardless of their academic year, all mentees had to first attend an introductory session. This session included a demonstration of the FSTT® system, an explanation of the expected SMT force-time curve, and a hands-on exercise to reach consensus on the preload force required for SMT on different surfaces (eg, directly on the table vs on the HAM®). The aim of the introductory session was to achieve the specified preload without emphasizing peak force or other aspects of the force-time curve. After completing the introductory session, mentees could select from various content options for subsequent sessions, including: “thoracic SMT,” “lumbopelvic SMT,” “cervical SMT,” “cervico-thoracic SMT,” and “free practice.” The CHIRO-Force team had developed content-specific protocols that emphasize practice variability and feedback, incorporating interactive and engaging practice elements. Sessions were tailored to the mentees’ learning levels, ranging from basic to advanced practice. Mentors were instructed not to introduce techniques or variations that had not already been covered in the mentees' mandatory curriculum. As the optimal force or rate of force application for treating neuromusculoskeletal conditions with SMT is not yet established,²³ the sessions’ objectives were not to achieve a specific peak force or rate. Instead, the emphasis was on enhancing the mentees’ ability to control their force-time characteristics and their self-efficacy. For example, mentees performed initial trials using their typical force, followed by practicing within low, typical, and high force ranges set on the FSTT® software. PAL sessions could last up to 90 minutes, and students were free to book as many sessions as they wished during the pilot testing year. Students were informed that participation in the program was voluntary and would not impact their course grades assigned by the faculty.

Mentor’s Recruitment and Preparation

For the pilot year of the PAL program, 2 highly engaged students were selected to serve as mentors. Recognizing the importance of equipping students with the skills required to effectively mentor their peers, the 2 mentors and 2 co-directors (IP and SR) participated in a comprehensive 2.5-day intensive training session at CMCC in June 2023, which provided the mentors with valuable insights, strategies, and practical techniques to enhance their mentoring roles.

Faculty Role

To create a secure environment where mentees feel comfortable sharing their challenges, no faculty members were permitted to attend mentoring sessions unless explicitly requested by the mentees and mentors. Mentors were informed that they could contact one of the 2 co-directors at any time if needed.

Outcomes and Processes

Mentors were asked to keep a record of the number of different students who participated in at least one mentoring session they conducted during the pilot year of the program, as well as the number of group sessions involving interns and clinicians from the University Outpatient Chiropractic (UOC) clinic. In April 2024, the mentors were asked to share their feedback on participating in the PAL program as mentors and whether they had suggestions to improve the PAL program.

Each student booking an introductory session received an email explaining their opportunity to participate in the evaluation of the PAL program, which included completing an online initial questionnaire, a post-session questionnaire that could be completed after each PAL session attended, and a final questionnaire administered at the end of the academic year. Students were informed that participation in the program evaluation was voluntary. The initial questionnaire collected demographic information about the mentees, including gender, age, and academic year. The post-session questionnaire could be assessed by scanning a QR code displayed in the mentoring room. This questionnaire recorded the content of the session as well as the session duration. Mentees also evaluated their appreciation with the session using a 6-point Likert scale (1-not at all appreciated to 6–strongly appreciated). The questionnaire concluded with 2 open-ended questions asking participants which aspects of the session they particularly appreciated and whether they had any suggestions for improvement. At the end of the pilot year, all mentees who had consented to participate in the evaluation received an email with a link to the final questionnaire. This survey asked how many mentoring sessions were attended and included 7 items adapted from Elhadi et al.²⁴ to assess the overall appreciation of the program. Responses were rated on a 4-point Likert scale (1-strongly disagree to 4-strongly agree). Mentees were also asked if they would recommend the program to others and were invited to propose suggestions for improvement. All questionnaires were anonymized.

RESULTS

Program Utilization and Participant Characteristics

During the pilot year, mentors estimated that they conducted approximately 100 sessions involving over 100 different chiropractic students, representing about 45% of the total student population. From all students who attended the PAL program, 77 students (53.2% female, n = 41; 46.8% male, n = 36) consented to participate in the data collection for the evaluation of the PAL program (mean age = 22.8 years, SD = 1.2 years). Among them, none (0/77) were Year 1 students, 18.2% (14/77) were Year 2 students, 37.7% (29/77) were Year 3 students, 22.1% (17/77) were Year 4 students (junior internship), and 22.1% (17/77) were Year 5 students (senior internship). Overall, 6.5% (5/77) of students reported having already participated in weekend seminars offered by external programs, while 61.0% (47/77) reported having participated in at least 1 out-of-class session offered by a faculty member to practice their SMT skills.

In addition to the sessions booked directly by students, mentors reported providing 10 mentoring sessions requested by clinicians from the UOC for their intern subgroups. Moreover, 10 interns (12% of all interns) were directly referred to the PAL program by their clinicians to address deficiencies or low self-efficacy in SMT skills.

Post-Session Evaluation

A total of 88 post-session questionnaires were completed, of which 60 followed the introductory session. This means that only 28 post-session questionnaires were completed by students who participated in the PAL program multiple times. Most sessions were held in small groups of 2 or 3 students, with one-on-one sessions being relatively rare. Regardless of the session content, the most common session duration was 60 minutes (76% of the sessions).

The appreciation results showed that 97% (84/88) of the sessions were rated as “strongly appreciated” by the mentees (Table 1). Due to the distribution of the results, where responses were concentrated in one extreme category whereas other categories had a frequency of zero, it was not possible to perform a chi-square goodness-of-fit test. The 4 students who did not rate their session as “strongly appreciated” evaluated their appreciation with the next highest rating on a scale of 0 to 6.

Table 1.

Frequency of Mentees Responses to the Post-Session Questionnaires per Content Session

Content Session	No. (n, %)	Duration (n, %)	Level of Appreciation (n, %)
			Not at all (1)	(2)	(3)	(4)	(5)	Strongly (6)
Introduction	60 (68.2%)	15 min: 3 (5.0%) 30 min: 1 (1.7%) 45 min: 8 (13.3%) 60 min: 42 (70.0%) 75 min: 5 (8.3%) 90 min: 1 (1.7%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	3 (5.0%)	57 (95.0%)
Cervical SMT	4 (4.6%)	15 min: 0 (0.0%) 30 min: 0 (0.0%) 45 min: 0 (0.0%) 60 min: 4 (100%) 75 min: 0 (0.0%) 90 min: 0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	4 (100%)
Cervico-thoracic SMT	1 (1.1%)	15 min: 0 (0.0%) 30 min: 0 (0.0%) 45 min: 0 (0.0%) 60 min: 1 (100%) 75 min: 0 (0.0%) 90 min: 0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (100%)
Thoracic SMT	4 (4.6%)	15 min: 0 (0.0%) 30 min: 0 (0.0%) 45 min: 0 (0.0%) 60 min: 4 (100%) 75 min: 0 (0.0%) 90 min: 0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (25.0%)	3 (75.0%)
Lumbo-pelvic SMT	14 (15.9%)	15 min: 0 (0.0%) 30 min: 0 (0.0%) 45 min: 0 (0.0%) 60 min: 13 (92.9%) 75 min: 1 (7.1%) 90 min: 0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	14 (100%)
Free practice	5 (5.7%)	15 min: 0 (0.0%) 30 min: 0 (0.0%) 45 min: 0 (0.0%) 60 min: 3 (60.0%) 75 min: 0 (0.0%) 90 min: 2 (40.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	5 (100%)
All	88 (100%)	15 min: 3 (34.1%) 30 min: 1 (1.1%) 45 min: 8 (9.1%) 60 min: 67 (76.1%) 75 min: 6 (6.8%) 90 min: 3 (3.4%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	4 (4.6%)	84 (95.6%)

SMT, spinal manipulative therapy.

Final-Year Evaluation

A total of 33 of the 77 initial students who agreed to participate in the data collection (42.9%) completed a final-year questionnaire (Table 2). Those respondents reported participating in an average of 2.9 sessions (SD = 2.01 sessions, range: 1 to 9 sessions) and all of them stated that they would recommend other students to participate in mentoring sessions. Six of the 7 items were rated as “agree” or “strongly agree” by more than 90% of respondents. The remaining item was judged as not applicable by 9 of the 33 respondents and concerned the availability and usefulness of preparatory materials. As was the case for the post-session evaluation, it was not possible to perform a chi-square goodness-of-fit test.

Table 2.

Frequency of Mentees Responses to the End-of-Pilot Testing Appreciation Questionnaire

Item	Level of Agreement (n/33, %)
	Not Applicable	Strongly Disagree 1	Disagree 2	Agree 3	Strongly Agree 4
The mentor was enthusiastic.	0 (0%)	0 (0%)	0 (0%)	2 (6.1%)	31 (93.9%)
The mentor was well-prepared.	0 (0%)	0 (0%)	0 (0%)	5 (15.2%)	28 (84.9%)
The techniques or procedures taught were appropriate for a student of my academic level.	0 (0%)	0 (0%)	0 (0%)	2 (6.1%)	31 (93.9%)
The preparatory materials (videos, documents) helped me prepare to perform the techniques or procedures.	9 (27.3%)	0 (0%)	1 (3.03%)	4 (12.1%)	19 (57.6%)
The feedback on my performance during sessions was very helpful.	0 (0%)	0 (0%)	2 (6.1%)	5 (15.2%)	26 (78.8%)
I believe these mentoring sessions will be beneficial for developing my competency in performing joint adjustments or manipulations on patients while ensuring their safety.	0 (0%)	0 (0%)	0 (0%)	2 (6.1%)	31 (93.9%)
Overall, this mentoring experience has been beneficial educationally.	0 (0%)	0 (0%)	0 (0%)	2 (6.1%)	31 (93.9%)

Several comments were provided by the mentees in the open-ended questions. They consistently praised the clarity and effectiveness of the feedback provided by the mentors, emphasizing how it helped them refine their techniques, particularly in areas such as force application, speed (ie, rate of force application) control, and lumbar techniques. The small group format and one-on-one interactions were frequently mentioned as beneficial, allowing for personalized guidance and repeated practice, which led to significant improvements in their motor patterns and overall techniques. Many mentees also appreciated the use of visual aids, such as force-time curves, which facilitated their understanding and allowed for immediate correction of errors. The sessions were described as enjoyable and educational, with mentees valuing the opportunity to develop their skills in a supportive and less stressful environment. However, some mentees noted that the sessions could be stressful, and there were suggestions to increase the structure and productivity of the sessions. Some requested more flexible scheduling options. Additionally, some mentioned wrist discomfort while practicing certain techniques.

Mentors’ Experience

Both mentors expressed that they loved their experience as mentors and sincerely believed that the use of force detection technology, such as the FSTT® system, would improve the quality of teaching and the intrinsic motivation of students to invest in their SMT skills. They also reported that their own skills had improved, making them more comfortable and confident in SMT delivery. One mentor added that this experience had been an inspiration to aim for a career involving a teaching component. The other mentor highlighted that this experience allowed to meet new people as well as to enhance teaching, collaboration, and communication skills.

Mentors recommended adding another treatment table in the mentoring room to accommodate larger groups of students or to allow SMT practice when feedback through the FSST® system is not required. They noted that practicing cervical SMT was challenging with the current HAM® due to stiffness of the manikin neck and as the force vectors are not accurately directed to the table's force platform. Mentors also suggested that the co-directors schedule practice sessions with future mentors to update them on the specific SMT subjects taught in mandatory courses, ensuring they practice the appropriate SMT techniques with the mentees. Additional training pertaining to communication skills and motor learning principles was also recommended to complement the initial training received with the CMCC team.

DISCUSSION

This paper aims to report on a PAL program focused on developing students’ skills and self-efficacy in delivering SMT within a chiropractic curriculum. The results of the pilot program, the relevance of the technology, and the next steps for program development are discussed below in context with the current literature.

The development of force-sensing technology applications in the health sciences has enabled several researchers to measure the force–time characteristics of SMT, leading to an exponential increase in the number of publications on SMT biomechanics in recent years.^25–27 Although SMT force-time characteristics vary greatly among clinicians, techniques, and patients, studies have revealed that maturation of these characteristics can be observed throughout student learning and even until their first years of practice.^17,18,20 These studies, however, have mostly been conducted in situations where the chiropractic curricula were based on traditional methods of teaching SMT, which involve observing a clinician perform a technique, followed by practice among students. The use of force-sensing technology, such as the FSTT® system, to provide feedback on force-time characteristics has shown promising results as it may facilitate student learning and improvement of SMT as well as student confidence or self-efficacy.²⁰ Although it remains to be seen whether our PAL program had any impact on the maturation of students' SMT force-time characteristics, both mentors and mentees positively evaluated the program and considered that their participation improved their learning and their confidence in their SMT competency.

Available literature on PAL programs supports their use in both practical and theoretical competencies, with reported benefits for both mentees and mentors.^8–13 The results from mentors and mentees who participated in the pilot year of the CHIRO-Force program align with previous literature. Indeed, participation as a mentor has been shown to enhance knowledge acquisition and retention, foster self-confidence and leadership skills, be beneficial for future job applications, increase the ability to admit uncertainty, improve communication skills, and enhance examination performance.^8,11,13 For mentees, participation has been shown to provide a better understanding of difficulties, ease the learning process due to relaxed and cooperative settings, facilitate deeper learning, and improve academic performance.^8,9,11–13 Nevertheless, some studies evaluating PAL programs have also suggested that participation as mentees can result in no difference or even a reduced academic performance.¹⁴ The use of force-sensing systems has already been shown to improve chiropractic students' self-efficacy and control of their force-time characteristics when delivering SMT.²⁰ However, it remains essential to evaluate whether the use of this technology within a PAL environment, such as the CHIRO-Force program, has the same benefits for students.

Although the current literature lacks descriptions of PAL programs within chiropractic educational institutions, it would be surprising that a similar path would not have been pursued in this profession. PAL programs are often implemented for practical reasons, such as addressing resource limitations in accommodating a growing student population and seeking cost-effective teaching methods.^13,14 As a result, they are typically viewed as a complement to the traditional curriculum rather than a replacement for in-course teaching. Evaluating the benefits of a PAL program is crucial during its early implementation or after a curriculum review to assess its necessity and identify areas for improvement. However, the primary goal of a PAL program is to meet specific intra-program needs, rather than to generate knowledge about student learning processes for dissemination to other institutions, clinicians, or researchers.^13,14 Consequently, the existing literature likely represents only the beginning in terms of PAL program implementation worldwide. To bridge this gap, institutions should be encouraged to share their PAL programs with the broader academic community.

Future Studies

We currently do not know if the perceived improvements reported by the mentees and mentors will translate into quantifiable outcomes. Additionally, although the program was designed to enhance students' manual therapy skills, the results were obtained from practice performed on manikins. Therefore, there remains uncertainty regarding how these skills, developed in a simulated environment, will transfer to real clinical situations with actual patients. Future research on these topics can provide further insight into training techniques for these manual skills. The next step will be to evaluate the impact of the PAL program on student competency in delivering SMT and their self-efficacy in clinical skills. Additionally, content sessions for other SMT techniques should be developed to further enhance the program's scope and effectiveness.

Strengths

To our knowledge, the CHIRO-Force program is the first PAL program based on the use of force-sensing technology. It provides an initial report demonstrating feasibility. This report may assist others in developing similar programs.

Limitations

Although the results obtained during the first year of the CHIRO-Force program are promising, some limitations must be considered. Firstly, it is important to note that the data collection was based solely on qualitative data gathered over a 1-year period. We currently do not know if the perceived improvements reported by the mentees and mentors will translate into quantifiable outcomes. In addition, most of the questionnaires used to assess participant satisfaction were developed specifically for this study, while only one was adapted from a previously validated instrument. It is also not possible to determine whether the reported satisfaction and perceived improvements among mentees will be sustained over time. Finally, due to the anonymity of the post-session questionnaires and voluntary participation, evaluation bias may have occurred, as highly satisfied mentees may have participated in multiple sessions and completed multiple questionnaires, whereas less satisfied students may have been less likely to complete post-session questionnaires.

CONCLUSIONS

The CHIRO-Force PAL program appears to be a promising approach for supporting out-of-class practice of SMT among chiropractic students. The program’s 1-year pilot project was well received by faculty and students, achieving self-sustainability by the end of the testing period. Feedback from mentors and mentees was overwhelmingly positive, with only a few suggestions for improvement.

DECLARATIONS

Acknowledgments

The authors would like to express their sincere gratitude to the Director of Education of the Canadian Memorial Chiropractic College that oversees the Chiropractic Technique Department, and David Starmer BSc(Hons), DC, MHS, for his unwavering support and availability in training the mentors, as well as throughout the pilot year. The authors would also like to extend their thanks to the department directors, David Hayes and Julie O’Shaughnessy, and to the clinic director, Chantale Doucet, for their invaluable support.

Funding

Isabelle Pagé acknowledges financial support from the Québec Chiropractic Foundation. The 1-year pilot CHIRO-Force PAL program was supported by internal research funding aligned with UQTR's strategic plan (CA$24,000). The funding sources had no involvement in the study design, data collection, analysis, or interpretation, nor in the writing of the report or the decision to submit the article for publication.

Competing Interests

The authors declare no competing interests.

Data Availability

The data underlying this study are not publicly available due to ethical restrictions. Participants did not agree to open access sharing. To ensure participant confidentiality and privacy, access to the data is restricted. The dataset is securely stored on Borealis, the Canadian Dataverse Repository, a bilingual, multidisciplinary, and secure platform for research data management and sharing (https://doi.org/10.5683/SP3/PHQAVD). Access may be granted upon reasonable request.

Artificial Intelligence

During the preparation of this work the authors used the language model ChatGPT (version 3.5) developed by OpenAI to improve readability and language. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

Contributorship

Concept development: DB, JLG, SR, IP. Design: MJW, JG, DB, JLG, FP, SR, IP. Supervision: JLG, SR, IP. Data collection/processing: MJW, JG, FP, IP. Analysis/interpretation: MJW, IP. Literature search: MJW, DB, IP. Writing: MJW, DB, IP. Critical review: JG, JLG, FP, SR.