JMIR FORMATIVE RESEARCH

Rufus-Toye et al

Original Paper

Degenerative Cervical Myelopathy Awareness in Primary Care:UK National Cross-Sectional Survey of General Practitioners
Remi M Rufus-Toye1, MA, MBBCHIR; Amir Rafati Fard1, BA; Oliver D Mowforth1, MA, MBBCHIR, MST, MRCS;
Luke V McCarron1, MA, MBBCHIR; Kayen Chan1, BSc, MBBS, MRCS; Yuri Hirayama2, MA, MSci, MBBCHIR;
Emma K Smith3, MBBS; Munashe Veremu1, BSc, MBBS; Benjamin M Davies1, BSc, MBChB, MPhil, MRCS; Jamie
F M Brannigan4, MA, MBBCHIR
1Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom

2

University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom

3

School of General Practice, NHS Health Education East of England, Cambirdgeshire, United Kingdom

4

Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom

Corresponding Author:
Jamie F M Brannigan, MA, MBBCHIR
Nuffield Department of Clinical Neurosciences
University of Oxford
John Radcliffe Hospital
Headington
Oxford, OX3 9DU
United Kingdom
Phone: 44 7825545404
Email: Jamie.brannigan@medsci.ox.ac.uk

Abstract
Background: Degenerative cervical myelopathy (DCM) is a progressive neurological condition, characterized by spinal cord
injury secondary to degenerative changes in the spine. Misdiagnosis in primary care forms part of a complex picture leading to
an average diagnostic delay of 2 years. This leads to potentially preventable and permanent disability. A lack of awarenesssecondary to deficits in postgraduate education may contribute to these delays.
Objective: This study aims to assess the awareness of DCM in the setting of general practice.
Methods: General practitioners completed a quantitative web-based cross-sectional questionnaire. The 17-item questionnaire
captured data regarding demographics, subjective awareness, and objective knowledge. The questionnaire was disseminated via
professional networks, including via practice managers and senior practice partners. Incentivization was provided via a bespoke
DCM fact sheet for those that completed the survey.
Results: A total of 54 general practitioners representing all 4 UK nations responded to the survey. General practitioners mostcommonly self-assessed that they had “limited awareness” of DCM (n=24, 51%). General practitioners felt most commonly“moderately able” to recognize a case of DCM (n=21, 46%). In total, 13% (n=6) of respondents reported that they would not be
at all able to recognize a patient with DCM. Respondents most commonly reported that they were “moderately confident” in theirability to triage a patient with DCM (n=19, 41%). A quarter of respondents reported no prior introduction to DCM throughout
their medical training (n=13, 25%). The mean score for knowledge-based questions was 42.6% (SD 3.96%) with the lowest
performance observed in patient demographic and clinical recognition items.
Conclusions: General practitioners lack confidence in the recognition and management of DCM. These findings are consistent
with the diagnostic delays previously described in the literature at the primary care level. Further work to develop and implement
educational interventions to general practitioner practices is a crucial step to improving patient outcomes in DCM.
(JMIR Form Res 2024;8:e58802) doi: 10.2196/58802
KEYWORDS
cervical spine; degeneration; general practice; myelopathy; neurology; neurosurgery; medical education; cervical myelopathy;
primary care; misdiagnosis
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Introduction
Degenerative cervical myelopathy (DCM) is a common
progressive neurological condition, characterized bycompression of the cervical spinal cord secondary todegenerative changes in the spine [1-4]. Prevalence in thoseover the age of 40 years is estimated to be 5%, making it themost common cause of spinal cord pathology worldwide[1,2,5,6]. Disease progression has profound impacts upon thepatients’ quality of life [7-10], resulting in pain, functional
neurological decline, and disability.
The nature of pathology lends itself to favorable outcomes withearly diagnosis. While existing damage is irreversible, surgery
has been demonstrated to halt progression [11,12]. Despite thebenefits of surgical intervention, an average diagnostic delayof 2 years has been observed, typically requiring 5 clinic
appointments. Misdiagnosis in primary care plays a part in thecomplex picture leading to delays in the patient pathway [13,14].
Misdiagnosis likely arises due to a lack of awareness, driven
by inconsistent terminology [15], similarity with otherpresentations, and low levels of research activity. Most
significantly, recent studies have reported deficient teaching
and representation of DCM in medical education curricula [16].
It may be speculated that poor education at medical schools
translates to a lack of awareness of DCM among primary care
physicians.
To our knowledge, no study has yet characterized the awarenessof DCM in primary care. The objective of this study was
therefore to assess awareness of DCM in primary care,specifically among general practitioners in the United Kingdom.
The aim is to identify knowledge gaps, which may inform
initiatives to improve postgraduate knowledge, ultimately
improving efficiency of diagnosis and patient outcomes.
Improving DCM education is also an important component of
the number one research priority of the AO Spine
RECODE-DCM international research priority setting initiative:
improving awareness [15].

Methods
Study Design
The survey was designed following the CHERRIES (Checklist
for Reporting Results of Internet E-Surveys) [17].

Study Partners
Myelopathy.org
Myelopathy.org is a global charity with the primary objectiveof advancing the health and well-being of individuals affectedby DCM. The charity places a strong emphasis on enhancing
medical education to effectively combat the prevailingchallenges of delayed or overlooked diagnosis. This research
is a component of a broader initiative that seeks to assess thelevel of DCM knowledge and awareness among medical
practitioners and create strategies to enhance it.

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Rufus-Toye et alStudent Society of Myelopathy.org
The student society of myelopathy.org works to promote thegoals of myelopathy.org. It coordinates teaching, student essay
prizes, and projects to promote awareness and improve thetreatment of DCM. It has designed and initiated this study tohelp serve these goals.

Survey Design
It was decided that the most efficient manner to cross-sectionallycapture the knowledge and awareness of general practitioners
regarding DCM across the United Kingdom was an electronic
survey. The survey entailed 2 parts. Part 1 obtained information
regarding the demographics of practitioners in addition to theirprevious experience of the condition. Part 2 provided amultifaceted assessment. First, the knowledge that would be
required of a practitioner to successfully recognize a potential
case of DCM was probed. Questions therein related tosymptomology and signs at presentation. Furthermore, part 2
evaluated a participant’s ability to ensure prompt treatment by
capturing knowledge of appropriate means of referral andinvestigation. Additional focus included questions regarding
patient experience of the disease, patient demographics, andpractitioner’s subjective assessment of their knowledge.
The survey was compiled using an iterative approach. Questions
were developed with input from a general practitioner (EKS)
and academic neurosurgeons with a subspecialist interest in
DCM (ODM and BMD). Part 1 was refined to the point at which
it was felt that enough practitioner related demographic
information was obtained to allow analysis of potential
confounders. Similarly, part 2 was developed to a point at which
it assessed the fundamental knowledge required by a generalpractitioner to provide appropriate primary care management
to a patient with DCM. This resulted in a 17-item questionnaire(Multimedia Appendix 1).

Survey Piloting
The piloting group consisted of general practitioners who were
not involved in study design. It was highlighted during thisphase that ambiguity arose in a question regarding referral due
to differences across regions regarding musculoskeletal referral
pathway (Multimedia Appendix 1). The question was
subsequently updated to remove ambiguity before wider
dissemination. It was reported that the format was readily
accessible on both desktop and laptop. Relevant responses fromthis pilot group were included in the final analysis wherequestion items were deemed appropriate for the final survey
dissemination.

Survey Administration
The survey was hosted by Momentive on their Survey Monkey
platform (Momentive), a commercial web-based survey
platform. The platform offers both desktop and smartphoneformatting making the survey readily accessible.
The survey contained 17 items, with the final item (being
optional) requesting contact details for those who wished toreceive a fact sheet regarding DCM for their future practice.

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Dissemination

Data Security

To achieve widespread dissemination of the survey across theUnited Kingdom, appropriate professional networks wereapproached to facilitate electronic distribution of the survey.
Practice managers and senior partners, who had no affiliation
with the survey, disseminated the survey throughout their
networks. While prompted to advertise the survey on one
occasion, it was left to the practice managers’ and senior
partners’ discretion as to whether follow-up prompts wereadministered.

The data remained solely on the secure, web-based Survey
Monkey platform until the survey closed. Subsequently, thesurvey data was transferred from the Survey Monkey platform
to a password-protected computer, using an Excel (Microsoft
Corp) spreadsheet. Access to this data was strictly limited tothe immediate research team on an as-needed basis. Once thedata analysis was completed, any unnecessary data waspermanently deleted. Importantly, no participant-identifiabledata was collected or stored.

Professional networks were engaged in a manner to capture
representation of general practitioners across a wide
geographical base. Representation of general practitioners was
obtained from all 4 nations. Responses were collected from theperiod of September 2022 to July 2023.

Statistical Analysis

As an incentive to complete the questionnaire, participants were
offered a fact sheet containing the key knowledge required at
the level of primary care about the condition, on completion of
the survey. It was felt that this was an appropriate incentive
which avoided compromising the integrity of the survey while
also helping to achieve one of the goals of Myelopathy.org in
improving awareness and treatment of DCM. This was agreed
by the study management group and the research ethics
committee.

Eligibility and Representation
Any general practitioner working within the United Kingdom
was eligible to complete the survey. We aimed to achieve
representation of all 4 UK nations.

Ethical Considerations
Ethical approval was granted by the University of Cambridge
Psychology Research Ethics Committee (application:
PRE.2022.115).

Consent and Confidentiality
The participant information sheet highlighted the importance,
objectives, and voluntary aspects of participation, while being
cautious in selecting background information about DCM toavoid biasing responses for the knowledge-based survey
questions. To ensure both anonymity and confidentiality,
participants created a distinctive identifier using specific details
from their mother’s maiden name and smartphone number,enabling the potential linkage of future surveys by the same
participant.

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Data analysis and visualization were performed using R (version
4.3.1, The R Foundation) and RStudio (version 2023.06.1,
RStudio Team).
Fisher exact test was used to assess for associations between
respondent characteristics and survey responses. This was usedin place of a chi-square statistic due to the small sample size ofthe data. Where comparisons between respondent characteristics
and responses expressed quantitatively as proportions of correct
answers were sought, the Kruskal-Wallis ANOVA wasemployed, as the data were nonparametric. Errors reported are
SEM.

Results
Summary of Respondent Characteristics
The survey captured the responses of 54 general practitioners,
representing all 4 nations of the United Kingdom (England:
30%, n=16; Northern Ireland: 65%, n=35; Scotland: 4%, n=2;
and Wales: 2%, n=1). Responses came mostly from experienced
general practitioners: 9 (17%) were still in training, 6 (11%)
were under 5 years post training, 7 (13%) were 5-10 years post
training, 20 (37%) were 11-20 years post training, and 12 (22%)
were more than 20 years post training. The full data set can befound in Multimedia Appendix 2.

Training and Exposure
The stage of training at which respondents were first introduced
to DCM varied. Respondents were most commonly introduced
to DCM in medical school (n=16, 30%), while 43% (n=23)
reported being introduced to DCM during training after medical
school (Table 1). A quarter of respondents reported no priorintroduction to DCM throughout their medical training (n=13,25%). Most general practitioners (n=27, 51%) reported at least
1 encounter with suspected DCM per month (Table 2). In total,
49% (n=26) respondents reported encountering 0 patients permonth with suspected DCM.

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Table 1. General practitioner responses to the question “At which stage of your training were you introduced to DCM, also historically known as
cervical spondylitic myelopathy?”
Training stage at introduction

Respondents, n (%)

Medical school

16 (30)Foundation years or house officer

4 (8)General practitioner trainee

12 (23)General practitioner post-training

7 (13)Never

13 (25)

Other

1 (2)

Table 2. General practitioner responses to the question “Approximately how many patients with suspected DCM do you encounter, per month, inclinical practice?”
Patients seen per month

Respondents, n (%)

0

26 (49)1

12 (23)2

8 (15)

3

3 (6)

4

1 (2)

5

1 (2)

Other

2 (4)

Subjective Awarenessof respondents and their subjectively rated awareness of DCM(P=.15).

Survey respondents were asked to subjectively assess their levelsof awareness of DCM. The most common response was “limited
awareness” (n=24, 51%; Table 3). A total of 3 respondents
reported “no awareness” (6%). No respondents reported having
an “excellent awareness” of the condition. There was no
significant association between the number of years of training

Respondents were also asked to subjectively rate their ability
to recognize DCM. The most common response was“moderately able” (n=21, 46%; Table 4). No respondents feltthat they were “extremely able”; however, 13% (n=6) reported
that they would be “not at all able” to recognize a patient with
DCM.

Table 3. General practitioner responses to the question “How would you currently rate your awareness of myelopathy/degenerative cervical myelopathy(DCM)?”
Self-assessed awarenessRespondents, n (%)

Excellent awareness0 (0)Very good awareness

4 (9)Average awareness16 (34)

Limited awareness24 (51)

No awareness

3 (6)Table 4. General practitioner responses to the question “How do you currently rate your ability to recognize myelopathy/degenerative cervical myelopathy(DCM)?”aSelf-assessed ability to recognize DCMa

Respondents, n (%)

Extremely able

0 (0)Very able

2 (4)Moderately able

21 (46)Slightly able

17 (37)

Not at all able

6 (13)

DCM: degenerative cervical myelopathy.

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Finally, respondents self-assessed their confidence in triaging
a patient with DCM. Few respondents felt “very confident”(n=4, 9%) or “extremely confident” (n=1, 2%) in triage (Table5). Respondents most reported that they were “moderately

Rufus-Toye et alconfident” in their ability to triage a patient with DCM (n=19,41%). There was no significant association between the numberof years of training of respondents and their subjectively rated
ability to recognize DCM (P=.53).

Table 5. General practitioner responses to the question “If you suspect a case of DCM, how confident are you currently at triaging that patient (i.e.,knowing where to refer them and how quickly)?”aSelf-assessed confidence to triage patients with DCMa

Respondents, n (%)

Extremely confident

1 (2)Very confident

4 (9)Moderately confident

19 (41)Slightly confident

14 (30)Not at all confident

8 (17)

DCM: degenerative cervical myelopathy.

Objective Awareness
When asked 6 objective questions to assess knowledge of DCM,
the mean score of respondents was 42.6% (SD 4%). There wasno statistically significant correlation between performance andyears of training (χ24=5.6; P=.23; Figure 1).
Performance varied by question item and topic area. The lowest
performance was observed in question items relating to patient
demographics and clinical recognition. A total of 19% (n=9)

correctly identified the prevalence of DCM in those aged over
40, while 50% of respondents (n=21) answered the correct
clinical sign to differentiate DCM from carpal tunnel syndrome(Multimedia Appendix 2).
In contrast, 78% of respondents (n=36) correctly identified themost important modality of imaging to diagnose DCM.
Furthermore, 74% of respondents (n=31) correctly identified
that referral to neurosurgery would be the most appropriate formof triage for a patient who has been diagnosed with DCM.

Figure 1. General practitioner performance in knowledge-based questions stratified by years of experience.

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Discussion

General Practitioners Report Low Confidence in theManagement of DCM

Principal Findings

General practitioners did not feel confident in appropriately
triaging patients with DCM. A total of 41 general practitioners(89%) felt at best “moderately confident” in triage, while 8(17%) felt “not confident at all” (Table 5). Despite low
confidence, respondents performed comparatively well onquestions relating to investigation and management of DCM,
where 31 respondents (74%) correctly identified appropriate
modes of referral (Multimedia Appendix 2).

One of the major challenges currently facing people with DCM
is delayed diagnosis. For a progressive, largely irreversible
condition with treatment available that can halt progression,
early diagnosis and specialist care is fundamentally importantfor good patient outcomes [18]. Misdiagnosis is part of acomplex picture leading to delayed diagnosis [13]. Our findings
suggest that a lack of awareness about DCM and a low ability
to recognize the condition may contribute to misdiagnosis in
primary care. General practitioners also reported a lack oftraining on DCM, with a substantial proportion of respondents
reporting that they had not encountered DCM at any point intheir training. Despite low confidence and awareness about
DCM, respondents demonstrated a reasonable level of
performance on questions related to disease management.

General Practitioners Report Difficulties in
Recognizing DCM
A key finding from our survey was that general practitioners
have low self-assessed ability to recognize a case of DCM. Onlya small minority (n=2, 4%) felt they were “very able” or“extremely able” to recognize DCM, with 50% (n=23) feeling
either “slightly able” or “not able at all” (Table 4). This wasreflected in the results of questionnaire items objectively
assessing ability to recognize DCM. When asked to identify
features of patient presentation that may differentiate DCM
from carpal tunnel syndrome, only 50% (n=21) of respondents
responded correctly. These observations could not be explainedby respondents’ level of experience. Neither confidence inrecognition nor performance in knowledge-based questions
were statistically significantly correlated with the number ofyears of experience as a general practitioner.
Previous work has detailed the pathway to definitive
management of DCM, with delay secondary to misdiagnosis in
primary care being a factor [13,19]. Of note, the most common
diagnosis received was carpal tunnel syndrome [13]. We proposethat this delay may be due to a lack of knowledge regarding theclinical presentation of DCM.
Prior gap analysis has demonstrated a deficiency in references
to DCM in both educational curricula and study materials [20].
Our results corroborate these findings, with 25% (n=13) ofrespondents reporting never having been introduced to DCM
at any point in their training (Table 1). This large absence of
education may be an underlying cause for the difficulties thatgeneral practitioners have expressed and demonstrated in thisstudy.
It is of note that our respondents included general practitioner
trainees. Incomplete training from respondents introduces thepotential to confuse our results. However, of the respondents
who reported having never been introduced to DCM, only 1
respondent (8%) was a trainee.

This discrepancy between the confidence expressed by generalpractitioners to correctly triage patients, and their responses toknowledge-based questions may be explained by the cuing biasthat single best answer style questions may introduce to applied
medical knowledge assessments [21]. However, it is importantto highlight that a large proportion of respondents (n=11, 26%)
selected an inappropriate mode of referral which would lead todelays in management [19]. Moreover, the lack of DCM training
reported by respondents may have left general practitioners
feeling poorly equipped to provide appropriate management topatients with DCM.

General Practitioners Underestimate Prevalence andMisdiagnosis of DCM
Most respondents answered incorrectly to both the prevalenceof DCM (n=38, 81%) and the average time of diagnosis (n=30,
64%).
We believe that an underappreciation of the scale of the problem
regarding the delayed diagnosis of DCM may disincentivize
efforts among the general practitioner community to address
the issues identified. Additionally, an underestimate of thebase-rate of disease among the general population may
negatively affect probabilistic reasoning, leading tounderdiagnosis [22,23]. Efforts to increase understanding ofthese issues are aligned with the number 1 research priority
identified
by
the
AO
Spine
RECODE-DCM
initiative—improving awareness [15].

Deficits in General Practitioner Confidence andAwareness May Reflect Broader Issues in Neurological
Education
Diagnostic delay is not unique to DCM. Other neurologicalconditions, including dementia, amyotrophic lateral sclerosis,
and epilepsy face similar problems [24-26]. Although this ispartially attributable to the insidious progression thatcharacterizes many neurological conditions, educational
shortcomings have been well described in the literature [27,28].
The phenomenon of neurophobia is believed to be another oneof the factors contributing to such shortcomings. This describes
a disinclination of medical students and junior doctors to tackle
the task of understanding neurological disease [29,30]. This
may go some way to explain the consistent lack of confidence
revealed from the results of our survey, even when related
objective questions were answered more accurately.
Reviews of the literature have demonstrated that there iscurrently limited evidence regarding effective interventions forneurology education [31]. The development of a strong evidence

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base for effective interventions in neurology education of alllevels would be of great value not just to the prognostics of
DCM, but to neurological conditions.

Limitations and Future WorkTo our knowledge, this is the first study that attempts to identify
levels of confidence and awareness among general practitioners
pertaining to DCM. Our survey relied partially on generalpractitioners’ self-evaluation of their awareness of DCM,
potentially introducing response and recall biases. To enhance
the robustness of our findings and mitigate the effects of suchbias, we incorporated an objective assessment of awareness into
our survey.
Despite widespread dissemination with an appropriate incentive,
recruitment of general practitioners proved a challenge, resulting
in a relatively small sample size. Challenges in recruitment may
be partially attributed to unprecedented clinical pressures facing
general practitioners in the United Kingdom [32,33]. This
limitation restricts the generalizability of our findings to generalpractitioners across the United Kingdom and may introduce
selection bias. Furthermore, while our survey successfully
achieved representation from all nations in the United Kingdom,a significant proportion of this was from general practitioners
based in Northern Ireland, which further limits thegeneralizability of our results.
While our study highlights the relatively low awareness of DCM
among general practitioners in the United Kingdom, future work
should aim to validate our preliminary findings using a larger
and more diverse sample of primary care clinicians. Given our
difficulty in attaining even UK wide representation, futurestudies may benefit from focusing on individual UK regions,allowing targeted use of resources in underrepresented areas.
Literature regarding general practitioner awareness of DCM
internationally is sparse. However, previous work suggests thatlack of awareness exists in other health care systems in the
global north [13]. International surveys may offer valuable
insights and opportunities for learning from countries with acomparatively higher awareness of DCM.

Rufus-Toye et al
Our results suggest a discrepancy between general practitioners’
confidence of primary care management of DCM andperformance in objective assessments. To gain a deeper
understanding of this phenomenon and the wider factors
influencing DCM awareness in the primary care setting, it would
be beneficial to supplement questionnaire data with qualitative
research methods, including interviews and focus groups. These
could be used to define the learning needs of the population.
This understanding provides a clear rationale for educational
intervention at the primary care level. Such education must
provide clarity and simplification to recognition andmanagement of DCM. No diagnostic criteria currently exist for
DCM. It is only recently that DCM was defined [34,35]. We
plan to develop diagnostic criteria for DCM, following which
we would reassess confidence and awareness of DCM.
Considering the limitations in generalizability of this study andits cross-sectional nature, validation of such approaches may
require focused assessment of general practitioner awarenessand confidence both before and after intervention.
Previous work has noted the significant difference between theneurological examination of specialists versus non specialists,
with the former often targeting examination to rule out specificdifferentials [36,37]. A clear reference tool for generalpractitioners may aid prompt and streamlined referral onto
secondary care, reducing subsequent disability [38-40]. Thisaligns with the number 3 research priority identified by the AO
Spine RECODE-DCM initiative—establishing diagnostic
criteria for DCM [38].

Conclusions
DCM is a rising health concern [41,42] for which generalpractitioners lack confidence in the recognition and managementof DCM. This lack of awareness has clear implications forprompt diagnosis and referral onto specialist care. Addressing
the education deficits highlighted by this study is an essential
step to resolving these issues.

Acknowledgments
This article is independent research. The views expressed in this publication are those of the authors and not necessarily those of
the NHS, the National Institute for Health Research or the Department of Health.
BMD is supported by an NIHR Clinical Doctoral Research Fellowship. ODM is supported by an NIHR Academic Clinical
Fellowship.

Data Availability
The majority of data generated or analyzed during this study are included in this article. The remaining data sets generated during
and/or analyzed during this study are available from the corresponding author on reasonable request.

Conflicts of Interest
JFMB reports consulting fees for Synchron Inc.

Multimedia Appendix 1
Final survey design.

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Rufus-Toye et al[PNG File , 113 KB-Multimedia Appendix 1]

Multimedia Appendix 2
Full data set.
[PDF File (Adobe PDF File), 111 KB-Multimedia Appendix 2]

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Abbreviations
CHERRIES: Checklist for Reporting Results of Internet E-Surveys
DCM: degenerative cervical myelopathy

Edited by A Mavragani; submitted 29.03.24; peer-reviewed by M Fehlings, JA Gilani; comments to author 27.05.24; revised version
received 11.06.24; accepted 26.06.24; published 19.08.24
Please cite as:
Rufus-Toye RM, Rafati Fard A, Mowforth OD, McCarron LV, Chan K, Hirayama Y, Smith EK, Veremu M, Davies BM, Brannigan
JFM
Degenerative Cervical Myelopathy Awareness in Primary Care: UK National Cross-Sectional Survey of General Practitioners
JMIR Form Res 2024;8:e58802
URL: https://formative.jmir.org/2024/1/e58802
doi: 10.2196/58802
PMID: 39158957©Remi M Rufus-Toye, Amir Rafati Fard, Oliver D Mowforth, Luke V McCarron, Kayen Chan, Yuri Hirayama, Emma K Smith,
Munashe Veremu, Benjamin M Davies, Jamie F M Brannigan. Originally published in JMIR Formative Research(https://formative.jmir.org), 19.08.2024. This is an open-access article distributed under the terms of the Creative Commons
Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete
bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright and license
information must be included.

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