Defensiveness in Cancer Screening and Prevention: A Scoping Review of Definitions, Measures and Profiles

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Emerging research highlights the role of cognitive processing, especially Defensive Information Processing (DIP), in influencing screening participation. This scoping review aims to 1) shed light on how Defensive Information Processing is defined and measured in cancer screening studies, 2) provide an overview of the use of theories and conceptual frameworks in such studies,3) describe defensive information processing profiles and outcomes, and 4) describe intervention strategies aimed at reducing defensiveness reactions to cancer screening. Methods This review will follow the Joanna Briggs Institute (JBI) guidelines and will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR). Inclusion/exclusion criteria and search strategy will be developed using the Population, Context, Concept (PCC) framework. Relevant studies will be retrieved via 6 databases (Scopus, Web of Science, EMBASE, Medline, CINAHL, PsychINFO and CENTRAL). Quantitative studies of cancer screening will be included if they report original research that defines, measures, and/or intervenes on any aspect of defensive information processing, consistent with the conceptualisations by McQueen et al (attention avoidance, blunting, suppression, and counterarguing). Two reviewers will independently screen published abstracts, full-text articles, and extract data from the final included studies using a standardised extraction form. Extracted data will be reported using narrative synthesis. Conclusion This scoping review will be the first to examine the range of literature on all or some domains of defensive information processing in cancer screening contexts since McQueen et al.’s conceptual model. By reviewing research beyond their work, it aims to provide an evidence base to inform future interventions addressing defensiveness in cancer screening. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://hrbopenresearch.org/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://hrbopenresearch.org/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://hrbopenresearch.org/articles/9-34/v1", "name": "Defensiveness in Cancer Screening and Prevention: A Scoping Review..." } } ] } Home Browse Defensiveness in Cancer Screening and Prevention: A Scoping Review... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Ahmed R, Ngo U, McQueen A et al. Defensiveness in Cancer Screening and Prevention: A Scoping Review of Definitions, Measures and Profiles [version 1; peer review: awaiting peer review] . HRB Open Res 2026, 9 :34 ( https://doi.org/10.12688/hrbopenres.14328.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Study Protocol Defensiveness in Cancer Screening and Prevention: A Scoping Review of Definitions, Measures and Profiles [version 1; peer review: awaiting peer review] Rana Ahmed https://orcid.org/0000-0003-4389-7084 1 , Uyen Ngo 1 , Amy McQueen 2 , [...] Linda Sharp 3 , Pamela Gallagher 4 , Christian Von Wagner 5 , Therese Mooney 6 , Nicholas Clarke 1 Rana Ahmed https://orcid.org/0000-0003-4389-7084 1 , Uyen Ngo 1 , [...] Amy McQueen 2 , Linda Sharp 3 , Pamela Gallagher 4 , Christian Von Wagner 5 , Therese Mooney 6 , Nicholas Clarke 1 PUBLISHED 16 Apr 2026 Author details Author details 1 Converge: Centre for Chronic Disease and Population Health Research,School Of Population Health, RCSI University of Medicine and Health, Dublin, Ireland 2 School of Public Health, Washington University in St. Louis, St. Louis, USA 3 Population Health Sciences Institute & NIHR Newcastle Patient Safety Research Collaboration, Newcastle University, Newcastle upon Tyne, England, UK 4 School of Psychology, Dublin City University, Dublin, Glasnevin, Ireland 5 Research Department of Behavioural Science and Health, University College London, London, England, UK 6 Program Evaluation, National Screening Service, Dublin, Ireland Rana Ahmed Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Validation, Writing – Review & Editing Uyen Ngo Roles: Data Curation, Investigation, Writing – Review & Editing Amy McQueen Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing Linda Sharp Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing Pamela Gallagher Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing Christian Von Wagner Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing Therese Mooney Roles: Funding Acquisition, Methodology, Writing – Review & Editing Nicholas Clarke Roles: Conceptualization, Funding Acquisition, Investigation, Methodology, Project Administration, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW REVIEWER STATUS AWAITING PEER REVIEW Abstract Introduction Organised population-based cancer screening invites identified populations to undergo a test, usually at regular intervals, to detect early-stage cancers or pre-cancerous lesions, to reduce cancer-specific mortality rates, and, in some cases, cancer-specific incidence. Emerging research highlights the role of cognitive processing, especially Defensive Information Processing (DIP), in influencing screening participation. This scoping review aims to 1) shed light on how Defensive Information Processing is defined and measured in cancer screening studies, 2) provide an overview of the use of theories and conceptual frameworks in such studies,3) describe defensive information processing profiles and outcomes, and 4) describe intervention strategies aimed at reducing defensiveness reactions to cancer screening. Methods This review will follow the Joanna Briggs Institute (JBI) guidelines and will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR). Inclusion/exclusion criteria and search strategy will be developed using the Population, Context, Concept (PCC) framework. Relevant studies will be retrieved via 6 databases (Scopus, Web of Science, EMBASE, Medline, CINAHL, PsychINFO and CENTRAL). Quantitative studies of cancer screening will be included if they report original research that defines, measures, and/or intervenes on any aspect of defensive information processing, consistent with the conceptualisations by McQueen et al (attention avoidance, blunting, suppression, and counterarguing). Two reviewers will independently screen published abstracts, full-text articles, and extract data from the final included studies using a standardised extraction form. Extracted data will be reported using narrative synthesis. Conclusion This scoping review will be the first to examine the range of literature on all or some domains of defensive information processing in cancer screening contexts since McQueen et al.’s conceptual model. By reviewing research beyond their work, it aims to provide an evidence base to inform future interventions addressing defensiveness in cancer screening. READ ALL READ LESS Keywords Defensiveness, Cancer Screening, Avoidance, Suppression, Counterarguing, Blunting Corresponding Author(s) Rana Ahmed ( [email protected] ) Close Corresponding author: Rana Ahmed Competing interests: No competing interests were disclosed. Grant information: This research is funded by the Health Research Board (EIA-2022-012). Nicholas Clarke was supported in part by grants from the Health Research Board (EIA-2022-012) and Science Foundation Ireland (22/RP/10091). Linda Sharp is supported by the National Institute for Health and Care Research (NIHR) Newcastle Patient Safety Research Collaboration (PSRC). The views expressed are those of the authors and not necessarily those of the NIHR or Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2026 Ahmed R et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Ahmed R, Ngo U, McQueen A et al. Defensiveness in Cancer Screening and Prevention: A Scoping Review of Definitions, Measures and Profiles [version 1; peer review: awaiting peer review] . HRB Open Res 2026, 9 :34 ( https://doi.org/10.12688/hrbopenres.14328.1 ) First published: 16 Apr 2026, 9 :34 ( https://doi.org/10.12688/hrbopenres.14328.1 ) Latest published: 16 Apr 2026, 9 :34 ( https://doi.org/10.12688/hrbopenres.14328.1 ) Introduction Background and rationale Screening plays a crucial role in cancer prevention by detecting pre-cancer or early-stage cancer, when it is typically easier to treat, and where outcomes are more favourable. 1 In some cases, screening tests can prevent cancer from developing by identifying and removing abnormal cells before they become cancerous, such as polyps found during screening or diagnostic colonoscopy 2 (for colorectal cancer screening) or cervical intraepithelial neoplasia (CIN) detected through diagnostic colposcopy 3 (for cervical cancer screening). Studies indicate that implementing screening programmes and evidence-based prevention correctly, and at scale, can achieve substantial population benefits and reduce the burden of cancer on populations. 4 Organised population-based cancer screening involves inviting an identified population to undergo a screening test, usually at a defined interval, to identify early stage or precancerous lesions in order to reduce mortality, and where possible, incidence of those cancers in the population. 2 , 3 , 5 Population-based screening has been implemented in many countries for breast, cervical and colorectal cancer, particularly in Europe. 3 , 6 , 7 Lung cancer screening for defined high risk groups has also become available in several countries in the Europe 8 , 9 as well as the United States. 10 There is also growing potential and interest in screening for gastric, prostate, 11 oesophageal and ovarian cancers. 12 Multi cancer early detection (MCED) tests 13 also exist, although evidence on their use in asymptomatic populations is less solid. 14 The success of organised cancer screening programmes in maximising health benefits (reducing cancer mortality and incidence) depends in large part on achieving high uptake within the programme’s target population. 15 In Europe, screening uptake varies substantially; breast cancer screening uptake is between 23–84%, cervical cancer screening between 40–81% 16 and colorectal cancer screening between 23–71%. 7 Many cancer screening programmes have also observed disparities in uptake by sex, age and socioeconomic deprivation. 17 – 19 Reports from the National Screening Service (NSS) in Ireland on BreastCheck, CervicalCheck and BowelScreen (Ireland’s national population-based cancer screening programmes) indicated that screening uptake for these programmes was 70%, 75% and 46% respectively. However, the uptake rates were lower among older people in the three programmes (cervical, 60+ years: 30%; breast, 60+: <30%; colorectal, 65+: 10% (for initial invitees)) 20 – 22 which has also been observed in the UK. 23 Multiple strategies to improve cancer screening participation have been investigated and effectiveness varies. 24 – 28 Strategies that have been shown to increase uptake include general practitioner (GP) endorsements, telephone outreach, advance notifications, and offering simplified screening tests (HPV testing over pap smear for cervical cancer screening; Fecal Immunochemical test (FIT) over the guaiac Fecal Occult Blood Test (FOBT) for colorectal cancer screening), especially when paired with reminders, provider alerts, or vaccinations. 25 , 29 However, many uptake intervention studies show limited success, likely in part due to a lack of theoretical grounding or understanding of the determinants of screening behaviour. 24 , 30 , 31 The rationale for this scoping review emerged from previous theoretically informed research on colorectal cancer screening uptake in Ireland. 18 , 32 – 35 Previous studies have identified socio-demographic and socio-economic barriers to colorectal, breast and cervical cancer screening participation in Ireland. 32 , 36 Moreover, cancer fatalism, emotions (disgust about the screening test; a belief that screening is tempting fate), and attitudes (“cancer cannot be cured”) 33 have been reported to be independently associated with non-participation in colorectal cancer screening. 33 , 34 Growing evidence suggests that defensive reactions to health messages (messages which are primarily aimed at improving health and healthy behaviours) can lead to rejection of these messages (for instance, counterarguing: “I feel fine, I don’t need to be tested”). 37 McQueen and colleagues describe this phenomenon – known as defensive information processing - thus 38 : “Individuals do not always rationally process threatening information such as cancer risk, and they may engage in defensive information processing using a variety of strategies. The primary function of defences is to reduce negative psychological affect when individuals are faced with real or imagined threats, including information or behaviour that is inconsistent with one’s preferred view of the self.” McQueen et al.’s conceptual model and measure of defensive information processing for colorectal cancer screening includes four domains 37 : (1) attention avoidance (reducing awareness by avoidance); (2) blunting (active mental disengagement through avoidance and accepted denial); (3) suppression (acknowledging others’ risk but avoiding personal inferences through self-exemption beliefs); and (4) counter-argumentation (arguing against the evidence). Clarke et al. have reported that defensive information processing (message suppression) is independently associated with non-participation in colorectal cancer screening in Ireland. 34 The literature on Defensive Information Processing in cancer screening is diverse, spanning multiple theories, cancer types, and methodologies. Evidence on defensiveness in this context is fragmented across disciplines like health psychology, 39 , 40 behavioral medicine, 34 and communication science, 41 with inconsistent terminology, conceptual definitions, theoretical frameworks, and measurement tools. Establishing a comprehensive understanding of current research on factors and domains consistent with the defensive information processing conceptual framework and measure is critical for guiding the future design of cancer screening interventions. Studies conducted since the original model by Blumberg, 42 and following McQueen et al.’s development of the defensive information procesing conceptual model will act as the starting point for this review. Despite growing interest in defensive information processing within cancer screening contexts, no systematic or scoping reviews have synthesized this evidence base to date. Existing reviews on related constructs such as psychological distress or defensive reactions 43 , 44 to health messages do not specifically address these factors in cancer screening. A scoping review will therefore fill a critical gap by mapping existing research, clarifying conceptual definitions, identifying measurement tools, and describe intervention strategies aimed at reducing defensiveness. Review objective This scoping review will provide an overview of the current evidence on Defensive Information Processing and its domains, in cancer screening, within the context of McQueen et al.’s 37 , 38 conceptual model. Research question What is currently known about defensive information processing in cancer screening research? 1. How is Defensive information processing and it sub domains defined in cancer screening research and what theories or conceptual frameworks have been employed? 2. What tools have been utilised to measure defensiveness, as defined by the defensive information processing (and its sub domains) conceptual framework? 3. How do Defensive Information Processing domains vary by demographic factors (e.g., age, sex, socio-economic status)? 4. What are the characteristics and outcomes of cancer screening interventions that have focused on all or some of the domains of the defensive information processing conceptual framework? 5. What are the gaps in the literature on Defensive Information Processing in relation to cancer screening? Methods This review will follow the Joanna Briggs Institute (JBI) methodological guidance for scoping reviews and will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR). 45 The review has been registered on the Open Science Framework (Doi: https://doi.org/10.17605/OSF.IO/P6TJR ). Eligibility criteria Eligibility criteria for this study have been defined using the population, concept and context (PCC) framework described by JBI 46 ( Table 1 ). Quantitative studies that focus wholly or in part on measuring any Defensive Information Processing domains (attention avoidance, blunting; suppression; and counter-argumentation) in cancer screening research will be eligible for inclusion. Eligible studies will include randomized control trials, non-randomized control trials, uncontrolled studies, quasi-experimental studies, natural experiments of interventions and observational studies (cohort, case-control and cross-sectional designs). Qualitative studies will be excluded as they will not report quantitative defensiveness measures or intervention outcomes. English language full-text papers published in peer-reviewed journals will be eligible for inclusion. While we do not have the resources to assess studies in languages other than English, we will record and report on the number of these studies retrieved. 47 Table 1. Inclusion criteria and exclusion criteria using the PCC framework. Element Inclusion criteria Exclusion criteria P -Population • Asymptomatic adults (Males and Females) 18 years and older • Studies with participants under 18 years of age • Studies of adults with a current or previous cancer diagnosis C - Concept • Defensive Information Processing in cancer screening (as defined by McQueen et al.’s Defensive Information Processing conceptual framework) and how these studies define, measure and intervene in cancer screening • Studies that do not include any defensiveness factors/domains of the Defensive information processing conceptual framework • Studies not focusing on cancer screening research or interventions • Studies that do not use quantitative measures of defensiveness as defined by Amy McQueen • Studies solely focusing on other aspects of cancer prevention without addressing defensiveinfomration processing domains or interventions C -Context • Studies conducted in any community, healthcare setting or country • Studies including cancer screening • Defensiveness related to any of the top 15 most common cancers (classified by the international agency for cancer research) • Editorials, opinion pieces or reviews without original research findings • Dissertations, theses, other reports that are not peer-reviewed; including unpublished “Grey literature” • Qualitative studies • Studies published before year 2000 Information sources and search strategy The following electronic databases will be searched: Scopus, Web of Science, EMBASE, Medline, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials (CENTRAL). The search strategy will be developed in collaboration with an information specialist to ensure methodological rigor and comprehensive coverage. An initial limited search of EMBASE and Medline will be undertaken to identify key articles relevant to defensiveness in cancer screening (Appendix 1). The keywords and index terms extracted from these articles will inform the development of a refined and comprehensive search strategy. This strategy will then be reviewed and adapted for use across all target databases. A forward citation search will be performed and the reference lists of all included studies will be manually screened for additional relevant publications. Citation searches of relevant reviews also will be conducted. All databases will be searched from 2000 (the year Blumbergs 42 information processing model was published) to the commencement date of the scoping review. Study selection Search results will be uploaded to the web-based Covidence platform to manage each stage of the scoping review including de-duplication, title and abstract screening, full-text review and data extraction. To determine eligibility, two reviewers will independently screen titles and abstracts for inclusion and exclusion criteria, with disagreements resolved through discussion and, where required, a third reviewer to ensure consensus. Among eligible abstracts, all full-text articles will then be reviewed independently by both reviewers with disagreements resolved through discussion and, where required, a third reviewer. Reasons for excluding at full text screening stage, along with the final numbers of included and excluded studies at each stage of the review, will be documented and reported in a PRISMA flow diagram. 38 Data charting/Collection/Extraction A standardised data extraction template will be designed and piloted to extract and code relevant data ( Table 2 ). Data will be extracted on cancer type, use of theory and conceptual frameworks, defensiveness definitions and measures (related to Defensive Information Processing domains; attention avoidance, blunting, suppression and counter-arguing) and interventions utilised within included studies (charted using the TIDiER framework 48 and including rationale, theory or goal of the intervention, intervention type, delivery mode, intervention provider and intervention materials). In addition, sociodemographic characteristics of study participants, the nature and setting of the behaviour under study, and outcomes related to defensive information processing domains will also be extracted. Where information is missing or unclear, study authors will be contacted. Any missing, redundant or unclear information will be discussed with all co-authors. Table 2. Example data extraction form. Category Data items Citation details Title, Year of publication, First/corresponding author details, Journal full name Study characteristics Aim of the study, Study type, country, target population, study focus, cancer type Defensiveness Defensiveness description/definition, Theory or conceptual framework used, Defensive Information Processing measurement tool Defensive Information Processing domain under study Defensiveness , defensive information processing, Psychological reactance, Dispositional psychological reactance defensive reactions, psychological reactance, reactance, identity salience, Avoidance, Cancer information avoidance, Cancer information overload, Fear control, Opting out (informational/behavioural), Suppression, Self exemption, Deny immediacy, Denial, Blunting, Discarding, Rejecting, Ignoring, Threat, Counterarguing, Message rejection, Risk Normalisation, Cognitive reappraisal, Emotion regulation, Biased processing Other frameworks Other framework mentioned besides Defensive Information Processing Study methodology and settings Study design, Settings, duration, Study participants (population and partcipanst description (opt-in, opt out, random selection, etc.)), sampling techniques, recruitmenst, incluion and exclusion criteria, consents, Total number of invitd, enrolled, followedup and analyses partcipants, participants demographics (age, gender, marital status, ethnicity, socio economic status (education, employmnet, income, health insurance)), comobidites Intervention Is this an interevention study, details of interevention (tools, rationale/theory, materials used, procedures/activities used, mode of deleviry, times of deleivery, assesmnet of the interevention) Screening related variables Behavior, intention/readiness, self-efficacy, social norms/influence, perceived risk, unrealistic optimism, other Type of screening included Mammogram, Breast examination, Colonoscopy (or other endoscopy), Home stool blood test (FIT, Cologuard, FOBT), Pap test, HPV, PSA test, Low dose CT scan Statistical measures used Sample sise, descriptive statitsics (means per groups, standard deviation), Statistical methods applied (e.g., regression, correlation, etc.), Effect measures (e.g., odds ratio, relative risk, beta coefficient), Adjustment for confounders, Statistical significance reported (p-values, confidence intervals) Main results Summary of the study findings, Direction and size of effects of the defensive measure used, Outcomes Limitations Study limitations noted by authors Notes from coder Notes and comments from the coder Synthesis and presentation of results The review will use a narrative synthesis approach according to SWiM guidance. 49 Extracted data will be coded, categorised and a descriptive analysis will be conducted. Where data is available and appropriate, we will explore how interventions in cancer screening, which have targeted defensive information processing domains, are implemented and targeted at sub-groups (e.g., sex, age, socio-economic status). Data will be presented in aggregate formats such as tables and appropriate visual representations. Ethics and dissemination This study is based on a review of existing published and publicly available reports and no ethical approval is required. Registration of this review on OSF will enhance transparency and reproducibility. Stakeholders, including public and patient representatives, healthcare professionals and the National Screening Service will be consulted throughout the review process and will ensure our findings are relevant and appropriate for the development of future interventions. Dissemination of findings will be conducted through various methods such as peer review publications, national and international conferences and seminars, and within other stakeholder forums. Discussion This scoping review will contribute to the emerging international evidence base on defensive information processing in cancer screening. It will provide a current description of the evidence on Defensive Information Processing measures and interventions in cancer screening, thereby contributing and assisting in the development of future interventions to increase uptake across organised cancer screening programmes. Data availability statement Underlying data No data are associated with this article. Extended data Open Science Framework Repository – Defensiveness in Cancer Screening and Prevention: A Scoping Review of Definitions, Measures and Profiles. DOI: 10.17605/OSF.IO/P6TJR . 50 This OSF project contains the following extended data: • Extended data_Appendix 1_Search strategy.docx Data are available under the terms of the Creative Commons Attribution 4.0 International Public License . References 1. WHO Health Organisation: A Short Guide to Cancer Screening Increase Effectiveness. Maximize Benefits and Minimize Harm. 2022. Reference Source 2. Senore C, Lansdorp-Vogelaar I, de Jonge L , et al. : Rationale for organized Colorectal cancer screening programs. Best Pract. Res. Clin. Gastroenterol. 2023; 66 . Publisher Full Text 3. Maver PJ, Poljak M: Primary HPV-based cervical cancer screening in Europe: implementation status, challenges, and future plans. Clin. Microbiol. Infect. 2020; 26 : 579–583. Publisher Full Text 4. Emmons KM, Colditz GA: Realizing the Potential of Cancer Prevention — The Role of Implementation Science. N. Engl. J. Med. 2017; 376 : 986–990. PubMed Abstract | Publisher Full Text | Free Full Text 5. 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Ahmed R, Ngo U, McQueen A, et al. : Defensiveness in Cancer Screening and Prevention: A Scoping Review of Definitions, Measures and Profiles.2026, March 23. Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 16 Apr 2026 ADD YOUR COMMENT Comment Author details Author details 1 Converge: Centre for Chronic Disease and Population Health Research,School Of Population Health, RCSI University of Medicine and Health, Dublin, Ireland 2 School of Public Health, Washington University in St. Louis, St. Louis, USA 3 Population Health Sciences Institute & NIHR Newcastle Patient Safety Research Collaboration, Newcastle University, Newcastle upon Tyne, England, UK 4 School of Psychology, Dublin City University, Dublin, Glasnevin, Ireland 5 Research Department of Behavioural Science and Health, University College London, London, England, UK 6 Program Evaluation, National Screening Service, Dublin, Ireland Rana Ahmed Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Validation, Writing – Review & Editing Uyen Ngo Roles: Data Curation, Investigation, Writing – Review & Editing Amy McQueen Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing Linda Sharp Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing Pamela Gallagher Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing Christian Von Wagner Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing Therese Mooney Roles: Funding Acquisition, Methodology, Writing – Review & Editing Nicholas Clarke Roles: Conceptualization, Funding Acquisition, Investigation, Methodology, Project Administration, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information This research is funded by the Health Research Board (EIA-2022-012). Nicholas Clarke was supported in part by grants from the Health Research Board (EIA-2022-012) and Science Foundation Ireland (22/RP/10091). Linda Sharp is supported by the National Institute for Health and Care Research (NIHR) Newcastle Patient Safety Research Collaboration (PSRC). The views expressed are those of the authors and not necessarily those of the NIHR or Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (1) version 1 Published: 16 Apr 2026, 9:34 https://doi.org/10.12688/hrbopenres.14328.1 Copyright © 2026 Ahmed R et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 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