Abstract
Background
Despite the benefits associated with participation in cancer clinical trials, participation rates in rural, regional and remote Victoria (Australia) are low. To address this issue, an $18.6 million funded project called ReViTALISE was established. One consumer representative for the project saw a need to establish a supportive network of consumers, and to provide a voice for rural, regional and remote people with lived experience of cancer. Many consumer advisory groups are established by organisations (top-down model) when the need arises and often focus on discrete projects. The Every Voice Consumer Advisory Network was established from the bottom up with its members enjoying the freedom to be involved in projects that align with their values. This case study commentary describes the journey of the Every Voice Consumer Advisory Network, their contributions to date, and their future directions. It also highlights what happens when a consumer advisory network is empowered to set the agenda. It is often difficult to discern the contribution of consumer co-authors in academic texts through editing that complies with the stylistic expectations and conventions of academia. This comes at the cost of disempowering consumer co-authors. To ensure power sharing, the text presented here is predominantly in the original form as written by the chair and co-chair of the group.
Main text
Members of the network represent five distinct regional health districts. They are providing their input from a lived cancer experience perspective to 18 separate organisations and programs across Victoria, Australia. Through the funded administrative support of the project they are embedded within, they are able to connect to complementary programs outside of the organisation. This has led to unintended and beneficial connections for the project. The Every Voice Consumer Advisory Network is investigating options to ensure its sustainability beyond the current funding period.
Conclusion
Every Voice Consumer Advisory Network has carved out a niche position of rural and regional voices of lived cancer experience in projects across the state. With the administrative support of a funded project office, the group has engaged with multiple organisations and projects, building unexpected connections for the project. This approach may benefit other organisations considering embedding consumer engagement into their own work.
Clinical trial number
Not applicable.
Keywords: Patient involvement, Rural and regional health, Power sharing, Lived experience, Cancer, Clinical trials
Plain language summary
There are benefits to taking part in cancer clinical trials that test new treatments in humans. Despite those benefits, not many people in regional and rural Australia take part in clinical trials. One organisation began a large five-year project to try and improve access to cancer clinical trials in regional and rural Victoria (Australia), called ReViTALISE. One woman who had experience of cancer and was working on the project saw an opportunity to support other people with experience of cancer who were also working on the project, while also helping the project and others like it. With the support of the project, she started a consumer advisory group called Every Voice Consumer Advisory Network (Every VoiceCAN). Groups of consumers providing input into projects and organisations are not unusual. However, many of them are brought together by the organisation with a specific task in mind. Every VoiceCAN is different in that respect. It was developed by consumers, for consumers, and group members get involved in multiple projects across a lot of organisations. This article presents the journey of the group in the words of the founding chair and co-chair. Allowing consumer representatives to use their own style of writing, rather than the specific language usually seen in academic publications, can help them feel they have just as much power and important knowledge as academics and clinicians.
Background
In 1954, Dr C. Gordon Zubrod introduced the randomised clinical trial to the American National Cancer Institute [1]. This sparked decades of systematic research globally and lead to numerous advances in the management of cancer. Seventy years later, despite the chance of improved outcomes for trial participants [2, 3], global estimates of cancer clinical trial (CCT) involvement suggest less than 5% of adults diagnosed with cancer are enrolled in a clinical trial [4]. In rural, regional and remote (RRR) Victoria, access to cancer clinical trials has traditionally been limited. McPhee et al. [5] note that of the 488 RRR-located participants joining clinical trials in 2018, 368 (75.4%) travelled to metropolitan trial sites.
The Regional Trials Network, Victoria (RTN-Vic) [6] was established in an effort to improve access to CCTs in RRR Victoria. The RTN-Vic, in partnership with universities, health services, and Cancer Trials Australia, secured $18.6 million in funding to conduct a 5-year, multi-pronged initiative to further their aim to bring clinical trials to priority populations. The Regional Victorian Trials Alliance: Linkages, Innovation, Special populations, equity (ReViTALISE) program contains seven distinct but interrelated initiatives including a regional research teaching hub, expansion of the trials network, palliative and supportive care research, registry trials, immunotherapy trials, Aboriginal and Torres Strait Islander clinical trial improvement, and geriatric oncology research.
From the beginning, ReViTALISE embedded lived experience involvement at both the initiative and executive levels, with a handful of experts-by-experience (people with lived experience of cancer or caring for someone diagnosed with cancer. Note: the term is used interchangeably here with the term consumer) being members of various committees. One such expert-by-experience, Kathleen, felt disconnected from the other lived experience members of the ReViTALISE initiatives and thought consumers could do more for the project. And so, the idea of Every Voice consumer advisory network (CAN) was conceived. Every VoiceCAN, therefore, began with a specific purpose: to provide mutual support and connection for experts-by-experience already involved in ReViTALISE. However, as the group grew, its scope expanded beyond this initial purpose to encompass broader regional consumer representation across cancer and palliative care research more widely, as described in the sections that follow. Due to members being located across different regions, the group meets bi-monthly online.
Anecdotally, many consumer advisory groups described in published articles are initiated and established by organisations or researchers (top down) when need arises, e.g. [7–10]. We refer here to ‘top-down’ as it relates to a consumer advisory group established and directed by an organisation or researcher to meet a defined need. A ‘bottom-up’ model, by contrast, originates with consumers themselves, who identify the need and drive the formation and direction of the group. Every VoiceCAN is relatively uncommon in being conceived within an organisation but not instigated at an executive or operational level. Rather, the group was developed from the bottom up. What follows is a narrative of Every VoiceCAN’s journey as described by the founding chair of the group (Kathleen Wilkins), and the co-chair (Harry Thomas). As the text highlights, while unintentional, the benefits to the ReViTALISE program are largely indirect, with its value lying in the relationships and inter-organisational links Every VoiceCAN has enabled.
The large body of evidence supporting the positive impact of lived experience involvement at both the personal and structural level [11, 12] is now familiar to academics, funders, policy makers and organisations alike. Much is said about the inclusion of the lived experience “voice” in research and healthcare. However, experts-by-experience are not always included as co-authors, and it is often difficult to discern when experts-by-experience have co-authored an article [13]. Rigid editorial format requirements can be a barrier to co-authoring academic articles for people with lived experience [14]. Rewriting the consumer experience to more closely align with academic style expectations risks disempowering people with lived experience and depriving the academic community of their unique perspective [15]. In this case study, preserving the unedited voice of expert-by-experience co-authors is therefore a deliberate methodological choice and is consistent with the principles of power sharing that underpin this work.
This commentary is a case study of involvement by experts-by-experience. It has two aims. The first is to describe the journey, contributions and future direction of Every VoiceCAN in the written words of its members. The second is to highlight what happens when a consumer advisory network is empowered to set the agenda.
Main text
The following text was written by Kathleen Wilkins and Harry Thomas, founding chair and co-chair of Every VoiceCAN. In line with the principles of power sharing, the text is deliberately preserved in its original “voice” and is unedited by academic co-authors, apart from spelling out acronyms in full and providing references to projects and organisations mentioned in the text for clarity. The discussion that follows was written collaboratively by all listed authors.
In our own words
For those just starting out in this community, we begin our journey as consumers with a simple desire to make a difference. We do our best to learn your language and adapt to new environments. We are always striving to fit in.
Eager to contribute, we often take on multiple projects. For example, we attend workshops on project improvement or sustainability. Through these activities, we hope to find our place and contribute meaningfully.
We genuinely want to add value, though at times we are unsure exactly how to do so. Sometimes, we hesitate to share our opinions, fearing they may not be relevant or helpful to the project. However, through these challenges, we gradually learn resilience and gain confidence in our contributions.”
Reflection of an every VoiceCAN consumer
Every VoiceCAN began with a simple but powerful idea: “Why can’t we, as consumers, get together to discuss the initiatives and support each other?”. This question sparked a movement for greater connection and collaboration. Many of us started out without knowing each other or having a clear sense of who else shared our experiences within these projects.
This enthusiasm led us to participate in a range of projects and workshops. At our core, we exist to share ideas, address concerns, and propose practical solutions. Supporting each other as lived experience advisors remains central to our mission.
Who we are
Every VoiceCAN is a consumer advisory network formed through the Regional Trials Network ReViTALISE project. The initiative was instigated, designed, and established by a consumer, driven by the desire to connect with others and build a supportive network.
Today, our group has grown to include ten consumer members and five non-consumer stakeholders. The membership includes individuals from regional and rural areas across Victoria, each bringing their lived experience of cancer from five distinct health regions. This diversity is one of our greatest strengths, allowing us to advocate for a wide range of perspectives and needs.
One example of the members advocacy is a member from Gippsland region shared how participating in Every VoiceCAN has given them a stronger voice in their community, while those from the Hume region have helped shape cancer care initiatives that address unique rural challenges.
Inclusivity and regional focus
Our approach is the commitment to be inclusive and amplify diverse voices.
We do this by fostering a network that prioritises regional representation. We are working to address persistent inequities and encourage wider participation.
Our contributions
Our members play vital roles within ReViTALISE project. We are actively embedded in more than four major initiatives and regularly participate in statewide governance and steering groups. Beyond this, Every VoiceCAN members contribute to over eighteen cancer and palliative care research projects and health service advisories across Victoria, including but not limited to “Consumers Leading Transformational Change in the Cancer Sector” a Victorian statewide project. Other examples include serving on the board of a regional health service and driving change in projects such as the Timely Referral to Palliative Care (Tropical Vic) project, Care Plus project [16].
For instance, one member shared how their lived experience helped researchers redesign patient information for clinical trials resources, making them clearer and more accessible for people in regional /rural areas. This collaborative effort resulted in improved patient understanding and satisfaction—a testament to the value of consumer input.
We also maintain a dedicated page on the @research website [16]. Researchers use this resource to identify consumers whose expertise aligns with their project needs, fostering effective partnerships from the outset.
The chair of Every VoiceCAN regularly represents regional and rural consumer interests on the VCCC CCAC [Victorian Comprehensive Cancer Centre cancer consumer advisory committee [17] ] and Hume RICS [Hume Regional Integrated Cancer Service [18] ], providing updates and advocating for improved health services.
Stories from members in different regions further highlight our commitment to inclusivity. For instance, a participant from Gippsland stated how Every VoiceCAN’s encouragement led them to join the statewide project and being one of the participants in the pilot project Lived experience leader’s masterclass, amplifying rural voices on a broader stage.
Progress and impact
Since launch, Every VoiceCAN has welcomed 12 new consumer members—each bringing unique perspectives and expertise to our network. Over the past year, our recruitment efforts have reached more than 350 health professionals through presentations at forums such as the Clinical Oncology Society of Australia (COSA) and the Victorian Association of Registered Nurses (VARN), Regional research round table as well as targeted flyer distribution and personal presentations within health sectors. Notably, our participation in regional and rural panels has helped us engage with communities throughout Australia, for example, a member from the Hume region recently shared their story at a local health forum, inspiring two new members to join and sparking broader interest in consumer advocacy.
Challenges faced
Life Changes: Our consumer members often face unexpected personal challenges. As a network, we must remain flexible and adapt when circumstances shift.
Membership Reach: The majority of Every VoiceCAN members are engaged in advocacy, research, or advisory roles outside of ReViTALISE. This breadth brings both opportunities and coordination challenges.
Administrative Growth: As our network has expanded, so too have the administrative responsibilities required to support and maintain our activities.
Organic Expansion: Since our inception, Every VoiceCAN has grown organically, broadening our scope and welcoming new members from organisations such as Cancer Council [Victoria [19] ] and Hume Regional Integrated Cancer Services [18].
Opportunities ahead
We have benefited from ongoing support from staff within Regional Trials Network-Vic and ReViTALISE project. Their dedication, support and encouragement help keep our initiative moving forward.
We are exploring collaboration with the Lotjpa Yapaneyepuk team—an Aboriginal and Torres Strait Islander group within the ReViTALISE project. This partnership could strengthen our commitment to cultural inclusivity and expand our reach to underrepresented communities. This would allow us to build on the collaboration already in existence where the acknowledgement of country was written expressly for this network by our past indigenous member.
A key priority for Every VoiceCAN is clearly defining who we are and what we do. Through clarifying our identity, the focus of our work and activities to support our objectives and goals we hope to better promote our network and broaden our influence and scope.
Looking forward
Looking ahead, we are looking to the possibility and benefit of becoming a regional arm of a university or larger organisation. We would like to initiate partnership discussions in early 2026, with the goal of establishing a formal agreement by December 2027. This transition would involve formalising a partnership that supports infrastructure, administrative resources, and expert assistance—enabling us to sustain growth and deepen our impact, especially in regional and rural areas. Aligning with Every VoiceCAN’s mission, such a partnership would help expand our advocacy reach, build capacity, and ensure that consumer voices continue to shape health policy and practice across Victoria.
Becoming a national organisation by 2028 is another direction the group is working towards. To achieve national status, we will focus on building partnerships with organisations in other states, expanding our advocacy programs, and increasing our operational capacity over the next four years.
We recognise that securing sustainable funding and managing organisational change are potential challenges; therefore, we will explore stakeholder engagement and seek diversified funding sources throughout this process.
We plan to showcase member testimonials and stories in future updates by way of social media, this would highlight how real experiences are driving meaningful change within the health landscape. This ongoing reflection will strengthen our narrative and reinforce the value of consumer-led advocacy in improving outcomes for Victorians and in future regional and rural Australians.
Discussion
Every VoiceCAN is distinct in that it is a consumer-initiated, grassroots network within a regional cancer trials initiative. Arguably, this aspect of the network enables true empowerment of regionally-located people, a group often associated with lower levels of power [20]. Group members have the freedom to determine their own priorities, select their areas of involvement, and shape the group’s direction. In doing so, the network can reconfigure power structures to place the health service consumer at the heart of regional cancer care. Further, consumer networks are important to helping people feel supported in their engagement work [21], providing a safe space for consumers to speak out and learn from other consumers.
Preserving the unedited text of experts-by-experience in scholarly articles is in itself an enactment of power sharing between scholars, and people with lived experience. The text contained within this commentary highlights the importance of maintaining the voice of consumers. The act of writing the text allowed the authors to reflect on and feel pride in their achievements to date. Arguably, rewriting the text into a format more aligned with academia would be detrimental to the message conveyed and to the authors’ sense of ownership. Here the experts-by-training can step aside and hand over the power of information dissemination to the experts-by-experience.
Because Every VoiceCAN has the freedom to decide on their direction, the group can pursue connections, engagements and ways of working that align with the values of its members alongside the objectives of the ReViTALISE project. Far from being problematic, this has been a boon to both the project and to Every VoiceCAN. As highlighted in the Our Contributions section of the text, where once there was a void of regional voices in important projects and organisations, there are now 18 projects benefiting from their perspective.
These projects exist both within ReViTALISE, and external to it, effectively creating a bridge between ReViTALISE and other complementary programs. It is this aspect of Every VoiceCAN that we believe is of benefit to organisations considering incorporating lived experience in their own operations. Rather than bringing experts-by-experience into discrete projects, empowering them to connect to other groups and organisations creates a system of knowledge sharing that arguably is more beneficial to all stakeholders involved. This is particularly important in regional and rural areas, where health-related resources are spread across large geographical areas, and networking is crucial to building the critical mass of voices needed to enact change. Having links into different communities and organisations allows organisations and researchers to ensure interventions are pragmatic, appropriate, and most important of all, meet the priorities of those communities [20].
While the bottom-up approach that led to Every VoiceCAN has proven fruitful, that does not mean it has been easy. As highlighted in the text, there are challenges to overcome. Grassroots consumer advocacy groups such as Every VoiceCAN require the same resources that any fully funded organisation would require but often operate through the good will of volunteers. By being embedded within the broader ReViTALISE program, the group has been able to access the administrative support of the program office. This model has allowed the group to grow beyond ReViTALISE and continue to self-govern while not relying on volunteers to maintain operations. However, as the funding period ends, Every VoiceCAN must adapt and evolve to ensure its continuation. A key opportunity for Every VoiceCAN’s continued growth is the incorporation of dedicated administrative and expert assistance. This could be in the form of a non-consumer stakeholder or staff member embedded within the network as an integrated network partner. This would enable the group to sustain momentum, foster growth, and maximise its advocacy impact.
The experience of Every VoiceCAN offers some practical lessons for organisations and consumers considering establishing a consumer-led advisory network (refer Table 1).
Table 1.
Lessons learned through the Every VoiceCAN development process
| Lesson | What this means in practice |
|---|---|
| Start with consumers | Allow the group to self-organise from the outset around a consumer-identified need rather than an organisational directive |
| Provide infrastructure without taking control | Access to administrative support enabled the group to grow without placing operational burden on volunteers |
| Allow the direction to be consumer-driven | Granting the group freedom to pursue connections beyond the immediate organisation created unexpected benefits for all stakeholders |
| Build in sustainability planning early | Dependence on a single funding source is a vulnerability. Exploring partnership and independence options should begin well before the funding period ends |
| Embrace organic growth | Expansion into external organisations and projects was unplanned but proved to be one of Every VoiceCAN’s greatest strengths. |
Limitations
This case study has several limitations worth acknowledging. First, as a co-produced reflective narrative, it is descriptive rather than evaluative in nature. The contributions and impacts described reflect the lived experience and observations of network members rather than formally measured outcomes. Second, as an account produced by those within the network, it is subject to the inherent subjectivity of insider perspectives. Finally, the sustainability of Every VoiceCAN beyond the current ReViTALISE funding period remains uncertain, and the long-term impact of the network’s contributions has yet to be established. These limitations do not diminish the value of the case study as a record of consumer-led innovation in regional cancer research, but they do suggest that independent evaluation of the model would be a worthwhile future direction.
Conclusion
This case study commentary had two aims. The first, to describe the journey, contributions and future direction of Every VoiceCAN in the written words of its members. The second, to highlight what happens when a consumer advisory network is empowered to set their own agenda. By actively seeking out connections and selecting opportunities presented to the group, Every VoiceCAN has carved out a niche position of rural and regional voices of lived cancer experience in projects across the state. With the administrative support of a funded project office, the group has engaged with multiple organisations and projects, building unexpected connections for the ReViTALISE program.
Although this account is purely descriptive and reflects the experience of those within the network, it offers a record of consumer-led innovation in regional cancer research. The “bottom-up” Every VoiceCAN approach and experience may prove fruitful to other organisations considering embedding consumer engagement into their own work.
Acknowledgements
The authors would like to acknowledge and thank the members of the Every VoiceCAN network, and the support of Stacey Panozzo (Consumer Liaison Coordinator, RTN-Vic), Donna Long (Network Manager, RTN-Vic) and Damon Parker (project officer, RTN-Vic).
Author contributions
KW wrote the text presented in the “In our words” section, HT provided edits and comments on this section of the text. SR drafted the background and discussion sections, with further input and editing from SC and CU. KW and HT provided input and editing on the discussion section. All authors read and approved the final manuscript.
Funding
The ReViTALISE project is the recipient of $18.6 million under the Australian Governments Medical Research Future Fund: Rural, Regional and Remote Clinical Trial Enabling Infrastructure Fund. The Regional Trials Network – Victoria is supported by the Victorian State Government.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Gehan EA, Schneiderman MA. Historical and methodological developments in clinical trials at the National Cancer Institute. Stat Med. 1990;9(8):871–80. discussion 903-6. [DOI] [PubMed] [Google Scholar]
- 2.Duenas JAC, Sanchez PN, Bonilla CE. Comparison of clinical outcomes among cancer patients treated in and out of clinical trials. BMC Cancer. 2023;23(1):786. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Iskander R, Moyer H, Vigneault K, Mahmud SM, Kimmelman J. Survival Benefit Associated With Participation in Clinical Trials of Anticancer Drugs: A Systematic Review and Meta-Analysis. JAMA. 2024;331(24):2105–13. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Unger JM, Cook E, Tai E, Bleyer A. The Role of Clinical Trial Participation in Cancer Research: Barriers, Evidence, and Strategies. Am Soc Clin Oncol Educ Book. 2016;35:185–98. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.McPhee NJ, Leach M, Nightingale CE, Harris SJ, Segelov E, Ristevski E. Differences in cancer clinical trial activity and trial characteristics at metropolitan and rural trial sites in Victoria, Australia. Aust J Rural Health. 2024;32(3):569–81. [DOI] [PubMed] [Google Scholar]
- 6.Muthusamy A, Long D, Underhill CR. Improving recruitment to clinical trials for regional and rural cancer patients through a regionally based clinical trials network. Med J Aust. 2021;214(10):453–e41. [DOI] [PubMed] [Google Scholar]
- 7.Quetsch L, Shah E, Kiefer J, Family. Community Intervention Lab: Autism Community Advisory B. Collaborating with an autism community advisory board to develop a family-based, neurodiversity-affirming intervention. PCIT-Autism. Research Involvement and Engagement; 2025. [DOI] [PMC free article] [PubMed]
- 8.Penfold M, Gorayski P, Green J, Skelton K. Establishing a consumer advisory group at the Australian Bragg Centre for Proton Therapy and Research. J Med Radiat Sci. 2024;71(S2):77–81. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Lepage S, Whelan B, Flight L, Totton N, Devane D. Lessons learned from building the kid’s trial with an online children’s and parents’ research advisory group: a descriptive, qualitative study. Res Involv Engagem. 2025;11(1):72. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Arelingaiah M, Navaneetham J, Lakshman KA, Podiya JK, Prabhu SG, Kandeparker P, et al. Progressing participatory research with young people in India: how a youth advisory board supported a large mental health project in Bengaluru. Res Involv Engagem. 2025;11(1):116. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Wiles LK, Kay D, Luker JA, Worley A, Austin J, Ball A, et al. Consumer engagement in health care policy, research and services: A systematic review and meta-analysis of methods and effects. PLoS ONE. 2022;17(1):e0261808. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Mah H, Dobson R, Thomson A. The Importance of Lived Experience: A Scoping Review on the Value of Patient and Public Involvement in Health Research. Health Expect. 2025;28(2):e70205. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Oliver J, Lobban D, Dormer L, Walker J, Stephens R, Woolley K. Hidden in plain sight? Identifying patient-authored publications. Res Involv Engagem. 2022;8(1):12. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Savarese M, Usta D, Bozzoli F, Fanning V, Molinari F, Graffigna G, et al. Enhancing patients’ role in scientific writing: insights from a global participatory approach with people with multiple sclerosis. Res Involv Engagem. 2025;11(1):14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Rudnick A, Rofè T, Virtzberg-Rofè D, Scotti P. Supported reporting of first person accounts: assisting people who have mental health challenges in writing and publishing reports about their lived experience. Schizophr Bull. 2011;37(5):879–81. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Every VoiceCAN. Every VoiceCAN 2025 [Available from: https://www.research.regionaltrialsnetwork.org/regional-network/every-voicecan/
- 17.Victorian Comprehensive Cancer Centre Alliance. Elevating consumer experience into consumer leadership. 2021 [Available from: https://vcccalliance.org.au/news-and-events/news/elevating-consumer-experience-into-consumer-leadership
- 18.Victorian Integrated Cancer Services. Hume Regional Integrated Cancer Service ND [Available from: https://vics.org.au/hrics
- 19.Cancer Council Victoria. Cancer Council Victoria ND [Available from: https://www.cancervic.org.au/
- 20.Broadhurst T, Cha YJ, Bartlett C, Van Heerden J, Smith L, Lizarondo L et al. Mixed methods systematic review of consumer engagement in rural health practice, research, and education. Health Promot Int. 2025;40(4). [DOI] [PMC free article] [PubMed]
- 21.Adams C, Brown AJ. Partnering with healthcare: The experiences of consumer representatives. Patient Experience J. 2023;10(1):4–9. [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
No datasets were generated or analysed during the current study.