Deliberative Dialogue Research Articles

Why Do Farmers Over-Extract Groundwater Resources? Assessing (Un)sustainable Behaviors Using an Integrated Agent-Centered Framework

This study uses an Integrated Agent-Centered (IAC) framework to investigate the socio-psychological drivers of Iranian farmers’ unsustainable groundwater management practices. Empirical land use change analysis of US Geological Survey Landsat satellite images of the Jaz-Murian wetland region for 1990, 2010, and 2022, is combined with community surveys conducted with randomly selected farmers in five townships within the region (n = 356). Visual analysis reveals dramatic increases in agricultural land coverage, diminished water bodies, and increased salt lands over the 32-year sampled period. We use survey data to explain the socio-psychological drivers of unsustainable groundwater use that lead to these adverse environmental changes. In the IAC survey analysis, we find that variables for “expectation” and “subjective culture” have a negative influence on pro-environmental “intention”. “Intention” and “habit” have a positive influence and “contextual factors” have a negative influence on the drivers of “unsustainable water use behavior”. We conclude that situational influences, habitual process, intentional process, and normative processes must be considered together to alleviate pressure on wetland ecosystems. Policy makers must provide effective agricultural extension training, deliberative dialogue amongst farmer networks, well-governed local water markets and financial support to shift farmer short-termist economic gain-thinking towards socially-supported pro-environmental habits over the longer term.

Representative Speech Acts of Chinese ESL Students in Deliberative Discussion

With the increasing proliferation of collaborative activities in English learning classes, deliberative discussions centered around achieving shared objectives are more likely to emerge during classroom conversations conducted in English. Through the lens of Speech Act Theory, this study examined and analyzed the English speech performance as second language of Chinese college students deliberative dialogues in groups. In discussion, the participants demonstrate sufficient pragmatic proficiency to reach a consensus on contentious issues through their deliberative speech acts, which involve four stages: proposing ideas, providing reasoning and arguments, responding to others viewpoints, and modifying or reformulating ideas. The analysis reveals that students can achieve an optimal deliberative dialogue through a congenial and supportive attitude. In their collaborative consultations, they diligently worked towards reaching a consensus that aligned with the collective interest, albeit failing to determine a feasible course of action. It is evident that students tend to overlook their communicative purposes amidst the process of test-oriented second language acquisition. Further English teaching should shift the focus from standard grammar and semantic accuracy to satisfying pragmatic functions.

Integrating Equity Considerations in an International Pandemic Instrument

Abstract Background The COVID-19 pandemic is widely regarded as a catastrophic failure of global governance with far-reaching consequences. Actions from wealthy countries severely limited access to essential medicines and supplies for the majority of the world's population. While the World Health Assembly has established an intergovernmental negotiating body (INB) to draft an instrument to strengthen pandemic prevention, preparedness and response, and equity considerations have been positioned as central to this process, there remains a danger that international power imbalances sabotage meaningful equity action. What priorities should an equity-centred pandemic instrument reflect? Methods Using a sequential deliberative dialogue (DD) methodology, international participants were purposefully selected for expertise, life experience, and spheres of influence. Two Fall 2022 dialogues were virtually convened to coincide with the study's official representation at the INB process and participants were engaged to respond specifically to the instrument's development. Dialogue findings were synthesized with a Systematic Equity Action-Analysis1 and participants were invited to review and respond. Results Alongside specific recommendations to prevent future inequitable pandemic responses, three overarching equity-centred approaches were identified as crucial: (1) consistently align stated intentions with operational proposals; (2) openly acknowledge causes and contexts of global inequity; and (3) create mechanisms for accountability and enforcement. Conclusions Achieving equity in international instruments is possible, but vague language threatens this potential. Beyond aspirational rhetoric, deliberate and coherent equity-promoting mechanisms are needed throughout the pandemic instrument in order to avoid the next catastrophic failure of global governance. 1. Plamondon et al. Turning the tide on inequity through systematic equity action-analysis. BMC Public Health. 2023;23(1):890. Key messages • Despite a rhetoric of ‘virtuous’ equity statements by the world's power and resource-wealthy countries, global contexts of inequity will continue or worsen without mitigation. • Given future pandemics are likely, the cost of not mitigating inequities through this treaty poses risks to global public health.

Enhancing effective healthcare communication in Australia and Aotearoa New Zealand: Considerations for research, teaching, policy, and practice

ObjectiveIn this article we present a conceptual framework for enhancing effective healthcare communication in Australia and Aotearoa New Zealand. MethodsThrough an iterative, deliberative dialogue approach, we, as experts from a variety of health professions and academic disciplines, worked together to identify core values and considerations for healthcare communication across numerous health professions and disciplines and within research, teaching, policy, and practice contexts. ResultsThe framework developed includes five core values at its centre: equitable, inclusive, evidence-based, collaborative, reflective. Around this are concentric circles showing key elements of collaborators, modality, context, and purpose. Each of these is explored. ConclusionThis work may support benchmarking for healthcare providers, researchers, policymakers, and educators across a breadth of professions to help improve communication in clinical practice. The framework will also help to identify areas across disciplines that are shared and potentially idiosyncratic for various professions to promote interprofessional recognition, education, and collaboration. InnovationThis framework is designed to start conversations, to form the foundation of a dialogue about the priorities and key considerations for developing teaching curricula, professional development, and research programs related to healthcare communication, providing a set of values specifically for the unique contexts of Australia and Aotearoa New Zealand. It can also be used to guide interdisciplinary healthcare professionals in advancing research, teaching, policy, and practice related to healthcare communication.

Relational practices for meaningful inclusion in health research: Results of a deliberative dialogue study.

The importance of including people affected by research (e.g., community members, citizens or patient partners) is increasingly recognized across the breadth of institutions involved in connecting research with action. Yet, the increasing rhetoric of inclusion remains situated in research systems that tend to reward traditional dissemination and uphold power dynamics in ways that centre particular (privileged) voices over others. In research explicitly interested in doing research with those most affected by the issue or outcomes, research teams need to know how to advance meaningful inclusion. This study focused on listening to voices often excluded from research processes to understand what meaningful inclusion looks and feels like, and asked what contributes to being or feeling tokenized. In this deliberative dialogue study, 16 participants with experience of navigating social exclusions and contributing to research activities reflected on what makes for meaningful experiences of inclusion. Using a co-production approach, with a diversely representative research team of 15 that included patient and community partners, we used critically reflective dialogue to guide an inclusive process to study design and implementation, from conceptualization of research questions through to writing. We heard that: research practices, partnerships and systems all contribute to experiences of inclusion or exclusion; the insufficiency or absence of standards for accountability amplifies the experience of exclusion; and inclusive practices require intention, planning, reflection and resources. We offer evidence-informed recommendations for the deeply relational work and practices for inclusivity, focused on promising practices for cultivating welcoming systems, spaces and relationships. This work reflects a co-production approach, where people who use and are affected by research results actively partnered in the research process, including study design, data-generating activities, analysis and interpretation, and writing. Several of these partners are authors of this manuscript.

The Influence of Leaders on the Quality of Citizen Deliberation: An Exploratory Assessment of Online Deliberation in New Zealand

Leaders can be essential in setting the tone of deliberation in the public sphere, but can their discursive style influence the wider public sphere? Mass communication usually mediates leader-citizen interactions, and the proliferation of social media has presented new, large-scale opportunities to support deliberation. Further, leaders using these platforms have widespread reach. Using deliberative discourse analysis, this exploratory research studies whether leaders influence the quality of citizen deliberation and whether this is dependent on the online arena. Two leaders with contrasting communication styles were chosen: New Zealand prime minister Jacinda Ardern and opposition leader Judith Collins. Two online arenas were included: a national news media Facebook page and the leaders’ respective Facebook pages. The results found that deliberative quality was variable within the news mass media arena; however, citizens displayed higher deliberative quality when the leader did so in the leaders-led online media arena. This study suggests that a leader’s use of deliberative dialogue to foster more deliberative discussion among citizens when they engage as both participants and facilitators in arenas with greater access to directly support deliberation. It presents theoretical arguments for leaders to participate in legitimation processes as part of the response ot the problem of scale and introduces a communication model for leaders to support deliberation in the public sphere. The model suggests that the leader's ability to affect the deliberative quality of citizens' discussions is mediated by their level of influence within that space. 

What facilitates or prevents academic fraud in a Colombian faculty of medicine-Protocol of a study using fuzzy cognitive mapping.

Academic fraud is any behavior that gives a student an undeserved advantage over another student. Few studies have explored the causes of and possible solutions to academic fraud in Latin America. We aim to map the knowledge of stakeholders in a Colombian faculty of medicine about the factors that facilitate and prevent academic fraud. Fuzzy cognitive mapping. We will use the approach proposed by Andersson and Silver to generate fuzzy cognitive maps representing stakeholder knowledge. This process consists of ten steps: (1) definition of the research question; (2) identification of participants; (3) generation of ideas; (4) rationalization of ideas; (5) organization and connection of ideas; (6) weighing; (7) pattern grouping; (8) list of links and digitization; (9) combination of maps and network analysis; and (10) deliberative dialogue. To draw the maps, we will invite medical students, interns, resident physicians, master's students, and professors in the faculty of medicine. Four medical students will receive training to facilitate the sessions. Participants will identify the factors contributing to academic fraud and their causal relationships. We will use a combination of network analysis and graph theory to identify the chains of factors with greatest influence on academic fraud. The maps will serve to discuss strategies to reduce academic fraud in the Faculty of Medicine and to identify factors that could be addressed in other contexts with similar problems. This research will allow the students who facilitate mapping sessions to learn about research techniques, fuzzy cognitive mapping and academic fraud. Study registration: Registered in OSF Registries on August 2nd, 2022. Registration number: osf.io/v4amz.

Phenomenological Views of Pancasila Perspectives about Democracy

As Indonesia navigates its complex path towards economic and political modernization, the transition to democracy has seen it evolve into an industrial society. However, this change has inadequately empowered vital economic sectors for public welfare. Additionally, the nation's unstable democratic politics stray from Pancasila, Indonesia's guiding philosophical principles advocating for deliberative dialogue. Over the past 15 years, developmental politics and political liberalization have clashed, undermining both the collective economy and cultural wisdom, and eroding Indonesia's unique cultural identity. This has stirred doubts about the fit of democracy within Indonesia's nation-state construct. The ensuing research aims to reevaluate indigenous wisdom and political ideologies ingrained in Indonesia's diverse ethnic landscape, focusing on untapped social capital to bolster the democratic framework. The study comprises two key research areas: one looks at ethnic communities like Wajo and Minang, and the second studies social dynamics in various Java city parks. Grounded in Consultative Democracy and examined through a phenomenological lens, the research sits within the broader arena of political anthropology. It uses a qualitative-interpretive methodology to delve into culture, economics, and politics, aspiring to enrich our understanding of their intricate interconnections in modern Indonesia and contribute to a nuanced dialogue on Indonesia's democratic viability

LOGOSOFIA: A platform for deliberative co‐construction of intersubjective consensual realities

AbstractIn this paper, we revisit lessons learned regarding the process of Structured Dialogic Design in the arena during the past 50 years. Thirteen Lessons are presented with the intent of helping stakeholders design a strategy for escaping the labyrinth (vicious cycle) produced by the strong interactions among three issues: (1) the critical role of inclusive deliberative dialogue; (2) the dependency of inclusive deliberative dialogue on the application of a systemic methodology for supporting its authentic implementation; and (3) the commitment by organizations to inclusive deliberative dialogue. This paper will also discuss the development and deployment of Logosifa, the latest software platform to support the process and the enhancements (including improved metrics and a facilitator dashboard) informed by the lessons learned.

Deliberative Dialogue as a Viable Instructional Method for Civic Learning Outcomes

Civic education aids students in acquiring the skills necessary to create a democratic society. The effectiveness of deliberative dialogue as an instructional method on civic learning outcomes was investigated in this study. A quasi-experimental design was used for the investigation. In Ilorin, two secondary schools were chosen at random and split into experimental and control groups. The sample for this study consisted of 73 students (control group: 38; experimental group: 35). An eight-week study was conducted. The Civic Learning Test (CLT), a fifty-item multiple-choice test with sufficient validation, served as the instrument for data collection. The Spearman-Brown Prophesy Formula yielded a reliability index of 0.78 using SPSS statistics (23.0). Mean and standard deviation were used to respond to research question 1, and ANCOVA was used to test the two research hypotheses at a 0.05 significance level. The results showed that students who participated in deliberative dialogue had significantly better civic learning outcomes. Additionally, there is no discernible gender difference in the civic learning outcomes of students who participated in deliberative dialogue. It was recommended that the Government, through NERDC, should include deliberative dialogue as a legitimate instructional method in the curriculum.

Building consensus in research partnerships: a scoping review of consensus methods

Background: Research partnership approaches that engage community members within the research team (for example, integrated knowledge translation, community-based participatory research) are typically used to enhance the relevance and usefulness of research findings. However, research outcomes generated through partnered research do not de facto address the priorities of those most affected nor take inclusion or power dynamics into consideration. Consensus methods (for example, Delphi, Deliberative Dialogue) can be used to develop evidence-based solutions by addressing the groups’ needs and priorities. Limited research has examined how consensus methods are used by research partnerships. Aims and objectives: Using the PRISMA-ScR checklist as a guide, this scoping review sought to better understand the use of consensus methods in research partnerships. Methods: The search strategy involved four databases (MEDLINE, PsycINFO, EMBASE and CINAHL Plus). A total of 6,654 citations were screened, 404 were advanced for full text review, and 34 studies met eligibility criteria. Data from the 34 studies were extracted and iteratively analysed by three members of our research team. Findings: At least 11 different consensus methods were used with variations of the Delphi being most common. Issues of inclusion and power dynamics were rarely discussed. Overall, there was limited reporting of consensus methods, partnership approaches, and/or power dynamics. Discussion and conclusions: This review extends the literature by providing an overview of consensus methods that have been conducted in research partnerships and how they have been executed. We offer initial considerations for conducting and reporting on the use of consensus methods in research co-production.

Understanding the impacts of the COVID-19 pandemic on the care experiences of people with mental-physical multimorbidity: protocol for a mixed methods study.

Primary care and other health services have been disrupted during the COVID-19 pandemic, yet the consequences of these service disruptions on patients' care experiences remain largely unstudied. People with mental-physical multimorbidity are vulnerable to the effects of the pandemic, and to sudden service disruptions. It is thus essential to better understand how their care experiences have been impacted by the current pandemic. This study aims to improve understanding of the care experiences of people with mental-physical multimorbidity during the pandemic and identify strategies to enhance these experiences. We will conduct a mixed-methods study with multi-phase approach involving four distinct phases. Phase 1 will be a qualitative descriptive study in which we interview individuals with mental-physical multimorbidity and health professionals in order to explore the impacts of the pandemic on care experiences, as well as their perspectives on how care can be improved. The results of this phase will inform the design of study phases 2 and 3. Phase 2 will involve journey mapping exercises with a sub-group of participants with mental-physical multimorbidity to visually map out their care interactions and experiences over time and the critical moments that shaped their experiences. Phase 3 will involve an online, cross-sectional survey of care experiences administered to a larger group of people with mental disorders and/or chronic physical conditions. In phase 4, deliberative dialogues will be held with key partners to discuss and plan strategies for improving the delivery of care to people with mental-physical multimorbidity. Pre-dialogue workshops will enable us to synthesize an prepare the results from the previous three study phases. Our study results will generate much needed evidence of the positive and negative impacts of the COVID-19 pandemic on the care experiences of people with mental-physical multimorbidity and shed light on strategies that could improve care quality and experiences.

Supporting occupational therapists to initiate conversations about sexuality with people with intellectual disability: Co-design by deliberative dialogue.

Occupational therapists routinely report low levels of confidence in addressing needs related to sexuality and intimacy. These issues are compounded when supporting clients with intellectual disability, due to prevailing assumptions about capacity and few practical support resources. At a disciplinary level, there is ongoing discourse around how to best conceptualise and support sexual and gender identities generally, within models of human occupation. Leveraging interdisciplinarity, where sexuality overlaps as a sphere of interest, can aid the development of practical support resources. Engagement with sociology (focussed on relationality) and disability studies (focussed on embodiment) offers a generative path forward. The deliberative dialogues framework was used to develop a co-designed resource by occupational therapists for occupational therapists. Six Australian occupational therapists with experience working with clients with intellectual disability and/or sexuality were purposively recruited to participate in co-design groups. Using the eight features of deliberative dialogue, data was collected and analysed by an interdisciplinary research team to collaboratively produce a practical support resource. Participants agreed the greatest need was to develop a resource for clinicians, to support conversations with clients about sexuality. Five key themes emerged: (1) Theoretical explanations addressing why sexuality is important must be paired with practical advice; (2) make a conversational call to action from 'OTs' for 'OTs' by locating sexuality within the domain of occupational therapy; (3) make explicit that people with intellectual disability are sexual beings; (4) need for self-reflection; and (5) demonstrate how existing understandings of occupation apply to sexuality. A resource in the form of a brochure was developed, intended to be used as a conversation primer. The process used to develop the resource demonstrated the value of interdisciplinary collaboration and the utility of deliberative dialogue as a co-design method.

Social justice implications of smart urban technologies: an intersectional approach

Techno-optimistic visions around smart buildings, homes, cities, grids, healthcare, etc. have become ubiquitous over the past decade. Using variations of machine learning and artificial intelligence, smart urbanism (SU) envisions an efficient, digital society. However, research shows that smart technologies reinscribe inequalities by prioritising the interests of the free market, technology-centric governance and data monetisation. Although there has been a growing concern over the injustices SU perpetuates, there is a lack of systematic engagement with power systems such as capitalism or heterosexism that underpin SU visions. A novel framework is presented that situates intersectional justice at the heart of SU. A mapping of 70 cases of ‘trouble’ with the promises of SU is used to address three core research questions: What are the ‘troubles’ with SU? To what extent are they intersectional? What can intersectionality add to the development of a just SU? The analysis shows how SU politics play out in relation to how users are understood and engaged, how different actors institutionalise SU and how dominant power systems are challenged. The presented strategy contributes to understanding not just the data politics in urban spaces, but also how they can be renegotiated and re-evaluated to solve multiple and interconnected urban crises without compromising on social justice. Practice relevance Citizen-led initiatives against SU should commit to intersectionality’s radical core to dismantle power structures to ensure local smart urban projects do not entrench global business-as-usual neoliberal agendas. Intersectional thinking can create spaces for deliberative dialogues between civil society groups and build alliances across groups that seek to challenge the hegemony of exclusionary urban policies. Urban planners and local governments, which are at the forefront of SU applications, should decentre technologies and rather focus efforts on working out how smart technologies can work in conjunction with other kinds of urban interventions, such as social, economic and environmental policy changes, collaborative planning, community development, etc. to herald more just urban futures. Designers of smart urban technologies should apply intersectional approaches to further challenge ‘Homo economicus’ (rational, White, technophilic, able-bodied) as the primary user type and to replace it with diverse user archetypes that express humanity, justice and generosity.

Evaluating the quality of research co-production: Research Quality Plus for Co-Production (RQ + 4 Co-Pro)

BackgroundCo-production is an umbrella term used to describe the process of generating knowledge through partnerships between researchers and those who will use or benefit from research. Multiple advantages of research co-production have been hypothesized, and in some cases documented, in both the academic and practice record. However, there are significant gaps in understanding how to evaluate the quality of co-production. This gap in rigorous evaluation undermines the potential of both co-production and co-producers.MethodsThis research tests the relevance and utility of a novel evaluation framework: Research Quality Plus for Co-Production (RQ + 4 Co-Pro). Following a co-production approach ourselves, our team collaborated to develop study objectives, questions, analysis, and results sharing strategies. We used a dyadic field-test design to execute RQ + 4 Co-Pro evaluations amongst 18 independently recruited subject matter experts. We used standardized reporting templates and qualitative interviews to collect data from field-test participants, and thematic assessment and deliberative dialogue for analysis. Main limitations include that field-test participation included only health research projects and health researchers and this will limit perspective included in the study, and, that our own co-production team does not include all potential perspectives that may add value to this work.ResultsThe field test surfaced strong support for the relevance and utility of RQ + 4 Co-Pro as an evaluation approach and framework. Research participants shared opportunities for fine-tuning language and criteria within the prototype version, but also, for alternative uses and users of RQ + 4 Co-Pro. All research participants suggested RQ + 4 Co-Pro offered an opportunity for improving how co-production is evaluated and advanced. This facilitated our revision and publication herein of a field-tested RQ + 4 Co-Pro Framework and Assessment Instrument.ConclusionEvaluation is necessary for understanding and improving co-production, and, for ensuring co-production delivers on its promise of better health.. RQ + 4 Co-Pro provides a practical evaluation approach and framework that we invite co-producers and stewards of co-production—including the funders, publishers, and universities who increasingly encourage socially relevant research—to study, adapt, and apply.

Evidence synthesis to policy: development and implementation of an impact-oriented approach from the Eastern Mediterranean Region

BackgroundDespite the importance of evidence syntheses in informing policymaking, their production and use remain limited in the Eastern Mediterranean region (EMR). There is a lack of empirical research on approaches to promote and use policy-relevant evidence syntheses to inform policymaking processes in the EMR.ObjectiveThis study sought to describe the development of an impact-oriented approach to link evidence synthesis to policy, and its implementation through selected case studies in Lebanon, a middle-income country in the EMR.MethodsThis study followed a multifaceted and iterative process that included (i) a review of the literature, (ii) input from international experts in evidence synthesis and evidence-informed health policymaking, and (iii) application in a real-world setting (implementation). We describe four selected case studies of implementation. Surveys were used to assess policy briefs, deliberative dialogues, and post-dialogue activities. Additionally, Kingdon’s stream theory was adopted to further explain how and why the selected policy issues rose to the decision agenda.ResultsThe approach incorporates three interrelated phases: (1) priority setting, (2) evidence synthesis, and (3) uptake. Policy-relevant priorities are generated through formal priority setting exercises, direct requests by policymakers and stakeholders, or a focusing event. Identified priorities are translated into focused questions that can be addressed via evidence synthesis (phase 1). Next, a scoping of the literature is conducted to identify existing evidence syntheses addressing the question of interest. Unless the team identifies relevant, up-to-date and high-quality evidence syntheses, it proceeds to conducting SRs addressing the priority questions of interest (phase 2). Next, the team prepares knowledge translation products (e.g., policy briefs) for undertaking knowledge uptake activities, followed by monitoring and evaluation (phase 3). There are two prerequisites to the application of the approach: enhancing contextual awareness and capacity strengthening. The four case studies illustrate how evidence produced from the suites of activities was used to inform health policies and practices.ConclusionsTo our knowledge, this is the first study to describe both the development and implementation of an approach to link evidence synthesis to policy in the EMR. We believe the approach will be useful for researchers, knowledge translation platforms, governments, and funders seeking to promote evidence-informed policymaking and practice.

Benefits and harms of fibrate therapy in patients with type 2 diabetes: a systematic review and meta-analysis.

This systematic review aimed to evaluate the benefits and harms of fibrate therapy, alone or in combination with statins, in adult patients with type 2 diabetes (T2D). A comprehensive search was conducted in six databases, from inception to January 27, 2022. Clinical trials that compared fibrate therapy with other lipid-lowering interventions or placebo were included. Outcomes of interest comprised cardiovascular (CV) events, complications of T2D, metabolic profile, and adverse events. Random-effects meta-analyses were performed to estimate mean differences (MD) and risk ratios (RR), alongside 95% confidence intervals (CI). A total of 25 studies were included, six comparing fibrates against statins, 11 against placebo, and eight evaluating the combination of fibrates with statins. Overall risk of bias was rated as moderate, and most outcomes rendered low confidence per GRADE approach. Fibrates showed reduction of serum triglycerides (TGs) (MD -17.81, CI -33.92 to -1.69) and a marginal increase of high-density lipoprotein cholesterol (HDL-c) (MD: 1.60, CI 0.29 to 2.90) in adults with T2D, but no differences were found in CV events when compared to statin therapy (RR 0.99, CI 0.76 to 1.09). When used in combination with statins, no major differences were exhibited regarding lipid profile and CV outcomes. Adverse events were comparable between fibrate and statin monotherapies (e.g., RR of 1.03 for rhabdomyolysis, and 0.90 for gastrointestinal events). Fibrate therapy in patients with T2D results in a marginal improvement of TGs and HDL-c but without reducing the risk of CV events and mortality. Their use should be reserved for very specific scenarios after a deliberative dialogue between patients and clinicians regarding their benefits and harms.

Physical Activity Preferences of People Living with Brain Injury: Formative Qualitative Research to Develop a Discrete Choice Experiment.

The World Health Organization physical activity guidelines for people living with disability do not consider the needs of people living with moderate-to-severe traumatic brain injury. This paper describes the qualitative co-development of a discrete choice experiment survey to inform the adaption of these guidelines by identifying the physical activity preferences of people living with moderate-to-severe traumatic brain injury in Australia. The research team comprised researchers, people with lived experience of traumatic brain injury and health professionals with expertise in traumatic brain injury. We followed a four-stage process: (1) identification of key constructs and initial expression of attributes, (2) critique and refinement of attributes, (3) prioritisation of attributes and refinement of levels and (4) testing and refining language, format and comprehensibility. Data collection included deliberative dialogue, focus groups and think-aloud interviews with 22 purposively sampled people living with moderate-to-severe traumatic brain injury. Strategies were used to support inclusive participation. Analysis employed qualitative description and framework methods. This formative process resulted in discarding, merging, renaming and reconceptualising attributes and levels. Attributes were reduced from an initial list of 17 to six: (1) Type of activity, (2) Out-of-pocket cost, (3) Travel time, (4) Who with, (5) Facilitated by and (6) Accessibility of setting. Confusing terminology and cumbersome features of the survey instrument were also revised. Challenges included purposive recruitment, reducing diverse stakeholder views to a few attributes, finding the right language and navigating the complexity of discrete choice experiment scenarios. This formative co-development process significantly improved the relevance and comprehensibility of the discrete choice experiment survey tool. This process may be applicable in other discrete choice experiment studies.

How to Account for Asymmetries in Deliberative Dialogues Comment on "Evaluating Public Participation in a Deliberative Dialogue: A Single Case Study".

In health policy-making, various deliberative mechanisms can be used to engage the members of the public in exploring what might be a reasonable course of action. Scurr et al take power dynamics into consideration to analyse a deliberative dialogue involving stakeholders with diverse points of view. Given such asymmetries at play, the conclusions of deliberations could be biased. Scholars would benefit from guidance on designing and evaluating deliberative processes. This commentary aims to broadly reflect on the possible sources of power and information asymmetries in deliberative dialogues, and to bring the biographical resources approach to deal with such asymmetries.

A North Star Vision: Results from a Deliberative Dialogue to Identify Policy Strategies to Improve Value in Healthcare.

We hosted a deliberative dialogue with citizens (n = 3), policy researchers (n = 3), government decision makers (n = 3) and health system leaders (n = 3) to identify evidence-informed policy options to improve the value of Canadian healthcare. The analysis resulted in three themes: (1) the need for a vision to guide reforms, (2) community-based care and (3) community-engaged care. Results suggest the need for a new paradigm: community-focused health systems. Such a paradigm could serve as a North Star guiding healthcare transformation, improving value by aligning citizen and healthcare system goals, prioritizing spending on services that address the social determinants of health and improving quality and equity.