Background
Primary health care systems around the world are going through reforms to adapt to the changing needs of the populations and their workforce [Macinko et al., Reference Macinko, de Fátima Marinho de Souza, Guanais and da Silva Simões2007; Canadian Institutes of Health Research (CIHR), 2013]. The term ‘community-based primary health care’ (CBPHC) emphasizes this important evolution to a more inclusive person-centered approach to primary health care delivered by multidisciplinary providers in diverse community-based settings. Research and innovation play a critical role in helping primary health care adapt to the increased need for complex management for chronic conditions and toward the vision of interdisciplinary team-based primary care homes. Effective training and mentorship for the next generation of CBPHC researchers are key for this movement to continue, and it is important for interdisciplinary and transdisciplinary research capacity (Choi and Pak, Reference Choi and Pak2006) to be developed strategically in the field of CBPHC.
Research mentoring programs and experiences have become increasingly recognized as important by those engaged in health research capacity building (Bennett et al., Reference Bennett, Paina, Kim, Agyepong, Chunharas, McIntyre and Nachuk2010; Stewart et al., Reference Stewart, Reid, Brown, Burge, Dicenso, Watt, McWilliam, Beaulieu and Meredith2010; Reference Stewart, Wuite, Ramsden, Burge, Beaulieu, Fortin, Godwin, Harris, Reid, Haggerty, Brown, Thomas and Wong2014). As a result, many studies have explored the role of mentorship in research training to learn about strategies for successful mentoring relationships, to understand the characteristics and actions of effective mentors and mentees, and to identify the characteristics of successful and failed mentoring relationships (Sambunjak et al., Reference Sambunjak, Straus and Marusic2006; Detsky and Baerlocher, Reference Detsky and Baerlocher2007; Straus et al., Reference Straus, Johnson, Marquez and Feldman2014). The findings demonstrate that successful mentoring relationships use a reciprocal model based on mutual respect and shared common values, with clear communication of needs, goals and expectations, and the planning of adequate time and methods for meaningful connection between mentor and mentee (Lach et al., Reference Lach, Hertz, Pomeroy, Resnick and Buckwalter2013). Whereas unsuccessful relationships are often characterized by poor communication, a lack of commitment to the mentorship, personality differences, conflicts of interest, and/or a mentor’s lack of experience (Straus et al., Reference Straus, Johnson, Marquez and Feldman2014). Incorporating these findings in the development and implementation of research training programs and initiatives to build CBPHC researchers’ capacity building programs is influential to their success.
Over the last 15 years, several important funding initiatives have been implemented to address the need to build primary health care researcher capacity. For example, the Transdisciplinary Understanding and Training on Research–Primary Health Care (TUTOR-PHC) program has been funded since 2003 to address this recognized need (Stewart et al., Reference Stewart, Reid, Brown, Burge, Dicenso, Watt, McWilliam, Beaulieu and Meredith2010). This transdisciplinary research capacity building program trains health care researchers and decision-makers from diverse disciplines and many geographic locations across Canada and abroad (Stewart et al., Reference Stewart, Reid, Brown, Burge, Dicenso, Watt, McWilliam, Beaulieu and Meredith2010) to develop interdisciplinary approaches to CBPHC research that actively integrate a variety of approaches to ensure positive outcomes (Choi and Pak, Reference Choi and Pak2006). Other organizations with a focus on health services and policy research have developed core competencies that have helped frame educational programs to prepare the next generation of leaders. Specifically, leaders in health services research have recommended a diverse array of competencies ranging from study design and data analysis to project management and knowledge translation (Bornstein et al., Reference Bornstein, Heritage, Chudak, Tamblyn, McMahon and Brown2018; Burgess et al., Reference Burgess, Menachemi and Maciejewski2018). Not as clear in such research mentorship programs are the roles to be played by the trainees themselves. While trainees receive guidance and teaching from their mentors, effective and meaningful capacity for responding adequately to the dynamic nature of CBPHC requires that trainees play a more active role in their education and preparation (Zea and Belgrave, Reference Zea and Belgrave2009). For example, peer-to-peer mentorship and advances in information technology provide suitable platforms for geographically dispersed trainees to be more connected and to form a supportive community.
In Spring 2013, the CIHR and its provincial partners funded a five-year Community-Based Primary Health Care Signature Initiative to support highly innovative approaches to improving the delivery of appropriate and high-quality CBPHC to Canadians (CIHR, 2013; Ben Charif et al., Reference Ben Charif, Hassani, Wong, Zomahoun, Fortin, Freitas, Katz, Kendall, Liddy, Nicholson, Petrovic, Ploeg and Légaré2018; Wong et al., Reference Wong, Langton, Katz, Fortin, Godwin, Green, Grunfeld, Hassani, Kendall, Liddy, Ploeg, Wodchis and Haggerty2018; Kendall et al., Reference Kendall, Fitzgerald, Kang, Wong, Katz, Fortin, Dionne, Kuluski, O’Brien, Ploeg, Crowe and Liddy2018). The CBPHC Signature Initiative supported 12 cross-jurisdictional and multidisciplinary research teams (12-Teams) with programs of research across Canada, which aimed to achieve four main objectives: (1) develop and compare innovative models for CBPHC delivery within Canada or internationally; (2) catalyze effective knowledge translation approaches to improve delivery of CBPHC in Canada or internationally; (3) evaluate and improve the impact of innovations for CBPHC; and (4) build interdisciplinary and interprofessional capacity for the generation, synthesis, and application of CBPHC research (CIHR, 2013). The 12-Teams were mandated to cross-collaborate and produce knowledge beyond what would be feasible by any one team, including collection of data and reporting on a set of agreed common indicators (Wong et al., Reference Wong, Langton, Katz, Fortin, Godwin, Green, Grunfeld, Hassani, Kendall, Liddy, Ploeg, Wodchis and Haggerty2018).
The 12-Teams included a large and diverse group of ‘trainees’, defined as individuals being trained at the undergraduate, graduate, postdoctoral, or professional level or individuals who were early career researchers. These individuals could also be completing their academic training, while assisting a CBPHC Team as a research coordinator, research assistant, or research associate. In line with their cross-team activities, the 12-Teams’ principal investigators initiated a capacity building committee and a trainee-led working group. The role of the capacity building committee was to provide mentorship for the working group as they organized activities, and this work took place within the broader context of the teams to which the trainees belonged (Figure 1). This paper specifically reports on the activities and outcomes of the capacity building strategy for CBPHC trainees.
Figure 1. The structure and relationship of the capacity building strategy by the 12-Teams capacity building committee and the trainee-led working group, within the broader context of the CBPHC Teams
Methods
Formation of the committee and the working group
Senior researchers from 11 of the 12 teams, as well as a 12-Teams trainee representative, formed the 12-Teams capacity building committee, beginning their activity immediately after the funding period began in 2013. One of the 12-Teams did not participate in trainee capacity building but instead focused on building capacity in the community in which their research was based. A principal investigator of 1 of the 12-Teams (M.S.) led the committee and requested participation of at least one senior researcher from the remaining teams interested in capacity building initiatives throughout the duration of the CBPHC funding period. The mandate of this committee was to organize educational events and activities for trainees, as well as to host trainee networking events at relevant academic conferences.
In early 2015, the 12-Teams capacity building committee recognized the need for a trainee-led working group for two main reasons: to assist with the development and implementation of events that were more relevant to the needs and interests of trainees and to provide opportunities for capacity building and leadership development among trainees during this process. The trainee representative who was a member of the capacity building committee (K.N.) assumed the leadership role in this new trainee-led working group. The capacity building committee then circulated an invitation email to a total of 85 CBPHC active trainees for them to join the working group. Twelve trainees from seven of the CBPHC Teams responded and formed the working group. These trainees represented diversity in disciplines, training levels, and geographic locations. With this membership, the working group functioned in parallel to the capacity building committee in planning, implementing, and evaluating its capacity building activities. The mandate of the working group was to facilitate educational activities for trainees: to encourage networking between trainees and other members of the 12-Teams; to share information relevant to trainees (e.g., CBPHC-related conferences, awards and career opportunities); and to increase trainee presence and involvement at conferences related to primary health care (e.g., North American Primary Care Research Group Annual Meeting, Canadian Association of Health Services and Policy Research Conference, and TUTOR-PHC Alumni Symposium). An online needs assessment survey of the trainees conducted in Summer 2015 guided the mandate of both the capacity building committee and the trainee-led working group to respond to the needs and interests of the CBPHC trainees (data available upon request). This needs assessment survey was used to determine interest in delivering an online webinar by the respondents about their research topics and preferred topics and formats of capacity building sessions. Respondents indicated an interest in the opportunity to share their research and a preference for online and recorded workshops about career building and advanced research methodologies.
Data collection
In Summer 2017, the committee administered an online semistructured survey to identify activities and outcomes of capacity building and mentorship efforts as part of the CBPHC Signature Initiative. The survey was developed by the trainee-led working group and included both open- and closed-ended questions. The survey was posted using Google Forms, and responses were anonymized to protect participant identity. The invitation included all active CBPHC trainees. The 12-Teams trainee membership (and therefore the sampling frame) changed over time, from 85 trainees in Summer 2015 to 65 trainees in Summer 2017 due to completion of education programs or completion of affiliation with CBPHC Team. The sampling frame included a range of disciplines, training levels (undergraduate, graduate, postdoctoral, and early career), geographic locations, and all CBPHC Teams. The working group members pretested the survey, and the final version was administered via personalized emails and reminder emails to increase response rates (Dillman et al., Reference Dillman, Smyth and Christian2014). To further encourage trainee participation, senior researchers or the principal investigators from the CBPHC Teams sent emails to their respective trainees. The online survey remained opened for a two-month period to allow sufficient time for completion by interested trainee respondents.
Data analysis
K.N. and Z.M. conducted the quantitative descriptive analyses for the closed-ended survey questions to explore trends pertaining to the characteristics of respondents and response distribution across questions. The thematic analysis of open-ended survey questions (conducted by A.I.K. and Z. M.) explored respondent perspectives on the perceived benefits of their involvement, unaddressed needs, and topics for future training sessions (Braun and Clarke, Reference Braun and Clarke2006; Green and Thorogood, Reference Green and Thorogood2009; Vaismoradi et al., Reference Vaismoradi, Turunen and Bondas2013). Coding of the data conducted by A.I.K. identified common ideas emerging from participant responses that were then categorized into themes as trends emerged (Braun and Clarke, Reference Braun and Clarke2006). A.I.K. and K.N. reviewed the themes to ensure appropriate categorization, mutual exclusion, and exhaustivity. All authors validated an overview of themes and key ideas under each emerging theme (Braun and Clarke, Reference Braun and Clarke2006). Due to the limited number of responses, no statistical software was needed for these analyses. Instead, the core competencies recently identified by the CIHR Canadian Health Services and Policy Research Alliance (Bornstein et al., Reference Bornstein, Heritage, Chudak, Tamblyn, McMahon and Brown2018; Burgess et al., Reference Burgess, Menachemi and Maciejewski2018) were used as a framework to contextualize the results from the thematic analysis. This was done by comparing the core competencies identified by the CIHR Canadian Health Services and Research Policy Alliance with the trainee responses.
Findings
Characteristics and capacity building activities
The characteristics of the trainee-led working group are presented in Table 1, and the details of the completed capacity building activities are presented in Table 2. Since 2015 when the working group was established, the membership of the working group included a total of seven CBPHC Teams and several disciplines, jurisdictions, and institutions. As seen in Figure 1, the capacity building activities were purposefully planned using three complementary dimensions: structure (e.g., formal webinars and workshops, virtual and in-person networking, and informal social media community); primary health care content (e.g., patient-centeredness, multimorbidity, home care, access, equity, and innovative research designs); and process (e.g., encouraging learning through explicit knowledge sharing and implicit mentorship opportunities). At the outset of this initiative, the working group determined that application of open-source virtual communication technology would be critical to build a meaningful network of colleagues, particularly because of the geographic distribution and the competing demands of completing graduate and postdoctoral training programs. As such, many of the capacity building activities (e.g., webinars and workshops) took place online, without any associated costs, and were recorded and available for trainees after the session.
Table 1. Characteristics of the trainee-led working group
Table 2. Capacity building activities of the trainee-led working group
Responses from survey
A total of 27 trainees responded to the survey (response rate: 41.5%). Among these respondents, 44.0% were doctoral students, 22.0% were postdoctoral fellows, 19.0% were research coordinators, 19.0% were research assistants or research associates, 15.0% were Master’s students, and 4.0% were undergraduate students. Based on our definition of trainee, respondents may have identified as both graduate student and research coordinator, research assistant, or research associate. These trainees represented various clinical (family medicine, nursing, and social work) and nonclinical (epidemiology and health policy) disciplines. As seen in Table 3, participants identified key forms of learning in their roles within their CBPHC Team: (1) tacit knowledge; (2) knowledge gained from engaging in research activities; and (3) knowledge gained through teamwork within and across the CBPHC Teams. Tacit knowledge consisted of knowledge that was gained through implicit learning and personal observation, as opposed to knowledge that was gained in didactic workshops and webinars.
Table 3. Summary of responses from survey participants (n = 27)
Among the three categories (tacit, research, and teamwork), research activities were experienced most by the respondents. More specifically, the majority of respondents indicated that they had learned the importance of context in research design, implementation, and reporting (96.3%); how to develop conference abstracts for submission (92.6%); and how to develop poster and oral conference presentations (92.6%). The trainees were then most likely to gain knowledge from teamwork activities including working with the contributions from different disciplines within a team (92.6%) and learning about effective team communication strategies (81.5%). Finally, the most common tacit learning was how to establish interdisciplinary research teams (85.2%) and how to lead and manage diverse teams (74.1%). In terms of the activities that the trainees would like to experience to build capacity, the top three activities were from each of the three categories (tacit, research, and teamwork). Respondents sought more experience in grant writing and submission (66.7%); effective approaches to conflict management (44.4%); and the opportunity to learn new teaching methods (40.7%). Trainees were also interested in learning more about academic career development or promotion (29.6%).
Based on the qualitative thematic analyses, both the competencies achieved during the CBPHC Signature Initiative and the areas for further capacity development are presented in Table 4. These competencies were aligned with the core competencies recommended by CIHR Canadian Health Services and Policy Research Alliance (Bornstein et al., Reference Bornstein, Heritage, Chudak, Tamblyn, McMahon and Brown2018). Competencies that were enhanced through the CBPHC capacity building initiatives included: analysis of data, evidence, and critical thinking; knowledge translation, communication, and brokerage; leadership, mentorship, and collaboration; interdisciplinary work; networking; research productivity; and peer-to-peer support and knowledge sharing. Overall, trainees indicated that they received advanced training in statistical or analysis software; learned skills for knowledge translation to different kinds of audiences; worked collaboratively with fellow trainees; developed and maintained productive relationships through virtual and in-person relationship building; presented and published completed and in-progress research; and participated in peer-to-peer support and knowledge sharing. In addition to advancing these competencies, trainees desired opportunities to expand skills in the leadership and management of an interdisciplinary research project. Trainees also expressed interest in developing experience and skills in group facilitation and to continue peer-to-peer support and knowledge sharing, importantly to address newly arising issues including career progression and establishing work–life balance.
Table 4. The core competencies recommended from the CIHR Canadian Health Services and Policy Research Alliance and acknowledged from the CBPHC trainee capacity building working group
CIHR = Canadian Institutes of Health Research; CBPHC = community-based primary health care; KTE = knowledge translation and exchange.
Throughout these capacity building initiatives, the working group experienced several process and data analysis challenges. The ongoing challenges included engaging all trainees from each of the 12-Teams (e.g., instead of a small group of already invested few); balancing information overload for busy trainees (e.g., emails, webinars, and workshops); and membership transition during the five-year funding program. Capacity building activities (particularly, webinars and workshops) needed to be accessible via internet or phone without any associated cost to the trainees and recorded and archived for those unable to participate in real time. Membership transition during this funding program impacted the total number of CBPHC trainees, the familiarity with the working group, and perhaps the response rate achieved for the final survey. The data analysis limitations were due to the small sample sizes as this did not allow for stratification of results by CBPHC Team, level of training, or academic discipline. Experiences from this capacity building initiative may have been different based on a trainee’s specific characteristics or affiliation with a specific CBPHC Team.
Discussion
This paper describes the activities and outcomes of the capacity building activities for research trainees during the CBPHC Signature Initiative and facilitated by a capacity building committee and the trainee-led working group. The trainees within the working group had a diversity of characteristics (e.g., variety of disciplines, training levels, affiliations, and geographic locations) and included graduate students, postdoctoral fellows, early career researchers, and trainees who also worked as research staff. Activities included webinars and workshops delivered by both trainees and senior researchers to facilitate learning, as well as knowledge translation activities to share these capacity building efforts. In addition, each team provided experiences for the trainees to gain new research skills and experience. The completed surveys from trainees indicated the type of activities that either they had experienced or they would like to experience as part of the CBPHC Teams. The capacity building themes from these survey respondents indicated achievement in mandates of both the 12-Teams capacity building committee and the trainee-led working group aligned with the core competencies identified by the CIHR Canadian Health Services and Policy Research Alliance (Bornstein et al., Reference Bornstein, Heritage, Chudak, Tamblyn, McMahon and Brown2018).
Traditional models of mentorship consist of an experienced and established professional who provides support to a trainee in the form of guidance, encouragement, connections with appropriate networks, resources, and constructive feedback (Allen et al., Reference Allen, Eby, Poteet, Lentz and Lima2004; Berk et al., Reference Berk, Berg, Mortimer, Walton-Moss and Yeo2005). In the case of the 12-Teams, this capacity building initiative fostered and facilitated a mentor/mentee network in a nationwide initiative that brought together researchers and trainees with expertise across a broad array of disciplines. Interestingly, this novel approach enabled trainees to mentor one another in a reciprocal manner, optimized individual trainees’ skill sets, built research capacity, created research networks, and enabled junior researchers to enact a mentorship role. This complementary role of supervisors and peers added a horizontal relationship among trainees, strengthening their connections (Detsky and Baerlocher, Reference Detsky and Baerlocher2007). The survey findings also echo the mentorship literature on elements of successful relationships: reciprocity, respectful relationship with clear expectations, personal connection, and learner focused goals (Ploeg et al., Reference Ploeg, de Witt, Hutchison, Hayward and Grayson2008; Straus et al., Reference Straus, Johnson, Marquez and Feldman2014). As well, these findings reflect a recognized need for an enriched set of core competencies for trainees to ensure success for those with advanced education both inside and outside of academic careers (Bornstein et al., Reference Bornstein, Heritage, Chudak, Tamblyn, McMahon and Brown2018). We recommend that these enriched sets of core competencies are utilized in research funding proposals requiring a description of capacity development plans for trainees, particularly in the complex environment of CBPHC.
As described earlier, effective virtual communication was critical for building a meaningful network of colleagues in the context of geographic distance and competing demands. The working group had successes and challenges regarding activities for trainees. For example, the working group attempted to hold ‘virtual coffee or lunch breaks’ in which trainees would be able to join online for a chance to chat about their ongoing research work, career trajectories, or the shared experiences of being a trainee or early career researcher in primary health care. While there was some initial interest from trainees, this virtual strategy proved to be unsuccessful in terms of the number of attendees or ongoing interest in this opportunity. For example, this lack of success may have been due to the general nature of these get-togethers; the many competing demands of a trainee or early career researcher; or finding the right time for all interested trainees (although a poll was circulated to schedule the times with interested trainees and to account for time zone differences across the country). The bilingual nature of the CBPHC Signature Initiative meant that effective virtual communication was particularly important to ensure that bilingual trainees (whose first language was not English) had sufficient time to participate in discussions, as well as abstract and manuscript development. Indeed, this was a factor highlighted in facilitating the success of other mentorship initiatives (Byrne and Keefe, Reference Byrne and Keefe2002). As well, both virtual and in-person relationship building can be important for trainees to foster strong collegial bonds as they move forward in their careers. These findings are consistent with previous successful approaches among other research groups in primary health care and suggest that events such as conferences could be integrated into mentor/mentee models as a means of enhancing relationships, allowing for varied networking opportunities and building collegiality among trainees (Coates et al., Reference Coates, Ankel, Birnbaum, Kosiak, Broderick, Thomas, Leschke and Collings2004).
Although this CBPHC mentorship program has resulted in enhanced academic productivity (e.g., presentations and publications) and expanded collaborative networks of those trainees involved, these specific metrics have not been formally tracked during the process. Evaluating the number of peer-reviewed publications, government reports, and presentations at local, national, and international conferences led or co-authored by trainees, as a result of cross-team collaborations, could demonstrate the synergistic impacts of such approaches for other similar large multiteam training initiatives. In fact, a more formal evaluation could reinforce the value proposition for the career trajectories of academic trainees, such as through the expansion of networks of research collaborators, increased grant success, contributions to securing academic research positions, and practice or policy roles in CBPHC.
The trainee working group successfully engaged trainees from multiple CBPHC research teams across Canada, but there were some limitations. The working group leadership had trainees from seven of the CBPHC Teams, which provided a solid foundation for interdisciplinary peer mentorship and cross-institution networking. In addition, trainees from 7 of the 12-Teams participated at least one activity offered by the working group. However, despite providing diverse trainee activities and opportunities, there was no engagement from trainees on the remaining four teams (including the survey described herein). As mentioned earlier, 1 of the 12-Teams had opted to conduct their own trainee capacity building specific to their indigenous context and not participate in the larger trainee working group activities, so it has been excluded from this count. Since there were no survey responses from trainees on the other four teams, it is unknown what may have been the contributing factors to this lack of participation. For example, trainees working in larger research programs may have had ample opportunities for peer mentorship and feedback may have felt less compelled to engage with this initiative. Therefore, the working group was successful in achieving its trainee capacity building and mentorship mandate for trainees on the majority of the teams, but there is still opportunity to improve in future endeavors.
Conclusions
This paper describes capacity building and mentorship activities developed and implemented for trainees during the CBPHC Signature Initiative and presents key insights from trainees on the mentorship that they received in a large, multiyear funding program in CBPHC. Importantly, this initiative fostered learning and collaboration across the 12-Teams. Building from the core competencies already identified in the existing literature, similar capacity building efforts should include the enriched set of competencies described herein to ensure that trainee needs and interests are represented during a research program.
The CBPHC Signature Initiative provided and facilitated trainees’ exposure to innovative research, expanded collaborative networks, and fostered synergies among junior researchers in primary health care. The combination of the advanced core competencies in trainee development, as well as the lessons learned from the trainee feedback, can inform dynamic and enhanced learning opportunities for early career researchers. To sustainably build primary health care research capacity, the research community must continue to develop and implement effective opportunities for capacity development and mentorship, as well as interdisciplinary, transdisciplinary, and cross-jurisdictional collaborations to support emerging researchers.
Acknowledgements
The authors thank the 12-Teams: ACCESS-MH (Atlantic Canada Children’s Effective Service & Strategies in Mental Health), ACHRU (Aging Community and Health Research Unit), CanIMPACT (Canadian Team to Improve Community-Based Cancer Care Along the Continuum), C-ChAMP (Canadian Chronic Disease Awareness and Management Program), CircHSIT (Circumpolar Health System Innovation Team), FORGE-AHEAD (Transformation of Indigenous Primary Healthcare Delivery), iCOACH (Implementing Integrated Care for Older Adults with Complex Health), IMPACT (Innovative Models Promoting Access-to-Care Transformation), iPHIT (Innovation in Community Based Primary Healthcare Supporting Transformation in the Health of First Nations and Rural/Remote Manitoba Communities), LHIV (Living with HIV Innovation Team), PACE in MM (Patient-Centred Innovations for Persons with Multimorbidity), and TRANSFORMATION (Improving the Science and Reporting of Performance in Primary Care). Dr. Moira Stewart was funded by the Dr. Brian W. Gilbert Canada Research Chair in Primary Health Care Research (2003–2017).
Authors’ contribution
All authors designed the study and contributed to data collection. K.N., S.B.B., L.G.B., A.G., A.I.K., and Z.M. contributed to data collection and analysis. All authors drafted the manuscript and K.N. is the guarantor. All authors revised the final manuscript for important intellectual content and approved its final version for publication. This study was overseen by M.S.
Financial support
This study has been supported by Community-Based Primary Health Care Signature Initiative grants from the CIHR. The funder did not play a role in study design, data collection, analysis, and interpretations of the data. Only the authors have responsibility for the information provided in this article.
Dr. Moira Stewart was funded by the Dr. Brian W. Gilbert Canada Research Chair in Primary Health Care Research (2003–2017).
Conflicts of interest
None.
Ethical standards
Using guidance from the Tri-Council Statement and the ARECCI Tool and through consultation with the institutional Research Ethics Board for the corresponding author, it was determined that formal ethics approval and formal consent to participate were not needed for the mentorship survey as the information obtained from the trainees was descriptive and this quality improvement project was conducted within the context of the CBPHC Signature Initiative.
Open access
