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68 Chapter 4 METHODS The DA development process and usability testing among relevant user groups consisted of six stages and was based on the model described by Kushniruk 20 . This model describes the typical system development starting from initial analysis, prototype development and evaluation, but allows for more input and changes in every development step compared to more traditional methodologies that have a fixed order of steps. Each stage was worked on by a multidisciplinary development team of urologists, psychologists and engineers (N=6). This section will discuss the stages in the development process, the final DA as outcome is described in the results section. Stage 1: Translating the pre-existing DA The background and validation of the existing Canadian DA has been described thoroughly, with particular focus on the information needs of Pca patients whenmaking a treatment decision 15-19 . The validity of all topics covered by the original DA for Dutch patients was also confirmed by an earlier cross-country comparison (including The Netherlands) of information needs in prostate cancer patients 21 . Therefore, all content from the original DA was translated from English to Dutch. Stage 2: Evaluating Dutch clinical routine To investigate typical conversation flow in consultations about Pca treatment decision- making, all non-clinicianswithinthedevelopment teamobservedconsultationsbetween patients and urologist in the outpatient clinic of the initiating hospital. In addition to these observations of actual consultations, role playing was used to emphasize the steps clinicians usually take in treatment decision-making consultations with a patient. Role playing was performed by the two clinicians involved in the development team, with one of them simulating the patient role. Other members from the development team observed with special focus on the structure of the simulated consultations. Stage 3: DA re-design Following the observations from stage 2, the original DA was re-designed to fit with typical conversationflowas observed in stage 2. Moreover, the translated textual content from stage 1 was further adjusted to comply with Dutch and European treatment guidelines. All content was re-written according to standards for creating web-based text to ensure readability and comprehensibility for all literacy groups (e.g. maximum of 10-15 words per sentence and 5-10 sentences per paragraph, clear headings and