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McCormack H, Wand H, Bourne C, Ward J, Bradley C, Mak D, Guy R. Integrating testing for sexually transmissible infections into annual health assessments for Aboriginal and Torres Strait Islander young people: a cross-sectional analysis. Sex Health 2023; 20:488-496. [PMID: 37690512 DOI: 10.1071/sh23107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/23/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND In the context of an expanding syphilis epidemic, we assessed the integration of sexually transmissible infection (STI) testing within annual health assessments for Aboriginal and Torres Strait Islander young people aged 16-29years in Aboriginal Community Controlled Health Services between 2018 and 2020. METHODS Using routinely collected electronic medical record data from a national sentinel surveillance system (ATLAS), we performed a cross-sectional analysis to calculate the proportion of assessments that integrated any or all of the tests for chlamydia, gonorrhoea, syphilis, and HIV. We used logistic regression to identify correlates of integration of any STI test. RESULTS Of the 13 892 assessments, 23.8% (95% CI 23.1, 24.6) integrated a test for any STI and 11.5% (95% CI 10.9, 12.0) included all four STIs. Of assessments that included a chlamydia/gonorrhoea test, 66.9% concurrently included a syphilis test. Integration of any STI test was associated with patients aged 20-24years (OR 1.2, 95% CI 1.1-1.4) and 25-29years (OR 1.1, 95% CI 1.0-1.2) compared to 16-19years and patients residing in very remote (OR 4.2, 95% CI 3.7-4.8), remote (OR 2.4, 95% CI 2.1-2.8), and regional areas (OR 2.5, 95% CI 2.2-2.8) compared to metropolitan areas. There was no association with patient sex. CONCLUSIONS Integration of STI testing into annual health assessments for Aboriginal and Torres Strait Islander young people was higher in remote areas where disease burden is greatest. Integration is similar in men and women, which contrasts with most studies that have found higher testing in women.
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Affiliation(s)
- Heather McCormack
- Kirby Institute, UNSW, Sydney, NSW, Australia; and NSW STI Programs Unit, Centre for Population Health, NSW Ministry of Health, Sydney, NSW, Australia
| | - Handan Wand
- Kirby Institute, UNSW, Sydney, NSW, Australia
| | - Christopher Bourne
- Kirby Institute, UNSW, Sydney, NSW, Australia; and NSW STI Programs Unit, Centre for Population Health, NSW Ministry of Health, Sydney, NSW, Australia; and Sydney Sexual Health Centre, Sydney, NSW, Australia
| | - James Ward
- UQ Poche Centre for Indigenous Health, University of Queensland, Brisbane, Qld, Australia
| | - Clare Bradley
- UQ Poche Centre for Indigenous Health, University of Queensland, Brisbane, Qld, Australia
| | - Donna Mak
- Department of Health, East Perth, WA, Australia; and School of Medicine, University of Notre Dame Australia, Fremantle, WA, Australia
| | - Rebecca Guy
- Kirby Institute, UNSW, Sydney, NSW, Australia
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McCormack H, Wand H, Newman CE, Bourne C, Kennedy C, Guy R. Exploring Whether the Electronic Optimization of Routine Health Assessments Can Increase Testing for Sexually Transmitted Infections and Provider Acceptability at an Aboriginal Community Controlled Health Service: Mixed Methods Evaluation. JMIR Med Inform 2023; 11:e51387. [PMID: 38032729 PMCID: PMC10722379 DOI: 10.2196/51387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 10/22/2023] [Accepted: 11/13/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND In the context of a syphilis outbreak in neighboring states, a multifaceted systems change to increase testing for sexually transmitted infections (STIs) among young Aboriginal people aged 15 to 29 years was implemented at an Aboriginal Community Controlled Health Service (ACCHS) in New South Wales, Australia. The components included electronic medical record prompts and automated pathology test sets to increase STI testing in annual routine health assessments, the credentialing of nurses and Aboriginal health practitioners to conduct STI tests independently, pathology request forms presigned by a physician, and improved data reporting. OBJECTIVE We aimed to determine whether the systems change increased the integration of STI testing into routine health assessments by clinicians between April 2019 and March 2020, the inclusion of syphilis tests in STI testing, and STI testing uptake overall. We also explored the understandings of factors contributing to the acceptability and normalization of the systems change among staff. METHODS We used a mixed methods design to evaluate the effectiveness and acceptability of the systems change implemented in 2019. We calculated the annual proportion of health assessments that included tests for chlamydia, gonorrhea, and syphilis, as well as an internal control (blood glucose level). We conducted an interrupted time series analysis of quarterly proportions 24 months before and 12 months after the systems change and in-depth semistructured interviews with ACCHS staff using normalization process theory. RESULTS Among 2461 patients, the annual proportion of health assessments that included any STI test increased from 16% (38/237) in the first year of the study period to 42.9% (94/219) after the implementation of the systems change. There was an immediate and large increase when the systems change occurred (coefficient=0.22; P=.003) with no decline for 12 months thereafter. The increase was greater for male individuals, with no change for the internal control. Qualitative data indicated that nurse- and Aboriginal health practitioner-led testing and presigned pathology forms proved more difficult to normalize than electronic prompts and shortcuts. The interviews identified that staff understood the modifications to have encouraged cultural change around the role of sexual health care in routine practice. CONCLUSIONS This study provides evidence for the first time that optimizing health assessments electronically is an effective and acceptable strategy to increase and sustain clinician integration and the completeness of STI testing among young Aboriginal people attending an ACCHS. Future strategies should focus on increasing the uptake of health assessments and promote whole-of-service engagement and accountability.
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Affiliation(s)
- Heather McCormack
- Kirby Institute, University of New South Wales, Kensington, Australia
- Centre for Population Health, New South Wales Ministry of Health, Sydney, Australia
| | - Handan Wand
- Kirby Institute, University of New South Wales, Kensington, Australia
| | - Christy E Newman
- Centre for Social Research in Health, University of New South Wales, Kensington, Australia
| | - Christopher Bourne
- Kirby Institute, University of New South Wales, Kensington, Australia
- Centre for Population Health, New South Wales Ministry of Health, Sydney, Australia
- Sydney Sexual Health Centre, Sydney, Australia
| | | | - Rebecca Guy
- Kirby Institute, University of New South Wales, Kensington, Australia
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Ward J, Guy RJ, Rumbold AR, McGregor S, Wand H, McManus H, Dyda A, Garton L, Hengel B, Silver BJ, Taylor-Thomson D, Knox J, Donovan B, Law M, Maher L, Fairley CK, Skov S, Ryder N, Moore E, Mein J, Reeve C, Ah Chee D, Boffa J, Kaldor JM. Strategies to improve control of sexually transmissible infections in remote Australian Aboriginal communities: a stepped-wedge, cluster-randomised trial. LANCET GLOBAL HEALTH 2020; 7:e1553-e1563. [PMID: 31607467 DOI: 10.1016/s2214-109x(19)30411-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 08/02/2019] [Accepted: 08/06/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Remote Australian Aboriginal communities have among the highest diagnosed rates of sexually transmissible infections (STIs) in the world. We did a trial to assess whether continuous improvement strategies related to sexual health could reduce infection rates. METHODS In this stepped-wedge, cluster-randomised trial (STIs in remote communities: improved and enhanced primary health care [STRIVE]), we recruited primary health-care centres serving Aboriginal communities in remote areas of Australia. Communities were eligible to participate if they were classified as very remote, had a population predominantly of Aboriginal people, and only had one primary health-care centre serving the population. The health-care centres were grouped into clusters on the basis of geographical proximity to each other, population size, and Aboriginal cultural ties including language connections. Clusters were randomly assigned into three blocks (year 1, year 2, and year 3 clusters) using a computer-generated randomisation algorithm, with minimisation to balance geographical region, population size, and baseline STI testing level. Each year for 3 years, one block of clusters was transitioned into the intervention phase, while those not transitioned continued usual care (control clusters). The intervention phase comprised cycles of reviewing clinical data and modifying systems to support improved STI clinical practice. All investigators and participants were unmasked to the intervention. Primary endpoints were community prevalence and testing coverage in residents aged 16-34 years for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. We used Poisson regression analyses on the final dataset and compared STI prevalences and testing coverage between control and intervention clusters. All analyses were by intention to treat and models were adjusted for time as an independent covariate in overall analyses. This study was registered with the Australia and New Zealand Clinical Trials Registry, ACTRN12610000358044. FINDINGS Between April, 2010, and April, 2011, we recruited 68 primary care centres and grouped them into 24 clusters, which were randomly assigned into year 1 clusters (estimated population aged 16-34 years, n=11 286), year 2 clusters (n=10 288), or year 3 clusters (n=13 304). One primary health-care centre withdrew from the study due to restricted capacity to participate. We detected no difference in the relative prevalence of STIs between intervention and control clusters (adjusted relative risk [RR] 0·97, 95% CI 0·84-1·12; p=0·66). However, testing coverage was substantially higher in intervention clusters (22%) than in control clusters (16%; RR 1·38; 95% CI 1·15-1·65; p=0·0006). INTERPRETATION Our intervention increased STI testing coverage but did not have an effect on prevalence. Additional interventions that will provide increased access to both testing and treatment are required to reduce persistently high prevalences of STIs in remote communities. FUNDING Australian National Health and Medical Research Council.
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Affiliation(s)
- James Ward
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia; Flinders University, Adelaide, SA, Australia.
| | - Rebecca J Guy
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Alice R Rumbold
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia; Samson Institute, Adelaide University, Adelaide, SA, Australia; Menzies School of Health Research, Darwin, NT, Australia
| | - Skye McGregor
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Handan Wand
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | | | - Amalie Dyda
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; Macquarie University, Sydney, NSW, Australia
| | - Linda Garton
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; Northern Territory Department of Health, Darwin, NT, Australia
| | - Belinda Hengel
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; Apunipima Cape York Health Council, Cairns, QLD, Australia
| | - Bronwyn J Silver
- Central Australian Aboriginal Congress, Alice Springs, NT, Australia
| | | | - Janet Knox
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Basil Donovan
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; Sydney Sexual Health Centre, Sydney, NSW, Australia
| | - Matthew Law
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Lisa Maher
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Christopher K Fairley
- Melbourne Sexual Health Centre, Melbourne, VIC, Australia; Central Clinical School Monash University, Melbourne, VIC, Australia
| | - Steven Skov
- Northern Territory Department of Health, Darwin, NT, Australia
| | - Nathan Ryder
- Northern Territory Department of Health, Darwin, NT, Australia; Hunter New England Health Service, Newcastle, NSW, Australia
| | | | - Jacqueline Mein
- Wuchopperen Aboriginal Health Service, Cairns, QLD, Australia
| | | | - Donna Ah Chee
- Central Australian Aboriginal Congress, Alice Springs, NT, Australia
| | - John Boffa
- Central Australian Aboriginal Congress, Alice Springs, NT, Australia
| | - John M Kaldor
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
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Graham S, Smith LW, Fairley CK, Hocking J. Prevalence of chlamydia, gonorrhoea, syphilis and trichomonas in Aboriginal and Torres Strait Islander Australians: a systematic review and meta-analysis. Sex Health 2018; 13:99-113. [PMID: 26775118 DOI: 10.1071/sh15171] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 11/05/2015] [Indexed: 11/23/2022]
Abstract
Higher notification rates of sexually transmissible infections (STIs) are reported among Aboriginal and Torres Strait Islander (Aboriginal) compared with non-Aboriginal people in Australia. The aim of this study is to estimate the pooled prevalence of chlamydia, gonorrhoea, syphilis and trichomonas among Aboriginal people in Australia by sex, age-group, setting (clinic vs population/community-based) and population group [adults, pregnant females, young people (12-29 years) and prisoners]. The databases Medline, PubMed and Web of Science were searched in May 2015. A meta-analysis was conducted to estimate the pooled prevalence of the four STIs in Aboriginal people and if possible, by gender, age-group, setting and population group. A total of 46 studies were included. The pooled prevalence was 11.2% (95%CI: 9.4-13.0%) for chlamydia (36 studies), 12.5% (95%CI: 10.5-14.6%) for gonorrhoea (28 studies), 16.8% (95%CI: 11.0-22.6%) for syphilis (13 studies) and 22.6% (95%CI: 18.5-26.7%) for trichomonas (11 studies); however, there was significant heterogeneity between studies (I(2) <97.5%, P<0.01). In the subgroup analysis, a higher pooled prevalence occurred in females than males for chlamydia (12.7% vs 7.7%) and gonorrhoea (10.7% vs 8.1%). The prevalence of chlamydia was 12.4% in clinic-based compared with 4.3% in population-based studies. The highest pooled prevalence by population group was among pregnant females (16.8%) and young people (16.2%) for chlamydia, pregnant females (25.2%) for trichomonas; and young people for gonorrhoea (11.9%). This review highlights the need to decrease the prevalence of STIs among Aboriginal people through community-based programs that target asymptomatic young people.
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Affiliation(s)
- Simon Graham
- Centre for Epidemiology and Biostatistics, School of Population and Global Health, University of Melbourne, 207 Bouverie Street, Parkville, Vic. 3052, Australia
| | | | - Christopher K Fairley
- Melbourne Sexual Health Centre and Central Clinical School, Monash University, 580 Swanston Street, Carlton, Vic. 3053, Australia
| | - Jane Hocking
- Centre for Epidemiology and Biostatistics, School of Population and Global Health, University of Melbourne, 207 Bouverie Street, Parkville, Vic. 3052, Australia
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Graham S, Guy RJ, Ward JS, Kaldor J, Donovan B, Knox J, McCowen D, Bullen P, Booker J, O'Brien C, Garrett K, Wand HC. Incidence and predictors of annual chlamydia testing among 15-29 year olds attending Aboriginal primary health care services in New South Wales, Australia. BMC Health Serv Res 2015; 15:437. [PMID: 26424655 PMCID: PMC4588905 DOI: 10.1186/s12913-015-1116-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 09/24/2015] [Indexed: 11/10/2022] Open
Abstract
Background For the past two decades, chlamydia has been the most commonly notified infectious disease among young people (15–29 year olds) in Australia, the United States of America and the United Kingdom and rates have increased annually in these three countries. In Australia, rates of chlamydia are three times higher in Aboriginal compared with non-Aboriginal people. Australian sexually transmissible infection guidelines recommend annual chlamydia testing for 15–29 year old females and males. This analysis will examine the incidence and predictors of annual chlamydia testing in 15–29 year olds attending four Aboriginal Community Controlled Health Services (ACCHS) in Australia. Methods From 2009–2011, attendance and chlamydia testing data were extracted from the patient system to calculate the number and proportion of 15–29 year olds that were tested for chlamydia and that tested positive for chlamydia by gender (male, female), age-group (15–19, 20–24, 25–29 years), Aboriginal status (Aboriginal, non-Aboriginal people) and by the four ACCHSs sites (1, 2, 3 and 4). A cohort was created to calculate the incidence rate per 100 person-years (PY) and predictors of an annual chlamydia test (a test within 12-months of a previous test/visit) by the above factors using Cox regression. Unadjusted and adjusted hazard ratios (AHR) and their 95 % confidence intervals (CIs) and p-values were calculated with significance at p < 0.05. Results From 2009–2011, there were 2896 individuals who attended the four ACCHSs. Overall , 17 % (22 % of females and 10 % of males) were tested for chlamydia and 9 % tested positive (8 % of females and 14 % of males). The median time to an annual chlamydia test was 10.7 months. The cohort included 2318 individuals. Overall the incidence rate of an annual chlamydia test was 9.1 per 100 PY (11.6 in females and 5.8 in males). Predictors of an annual chlamydia test were being female (AHR: 1.7, 95 % CI: 1.2-2.2, p < 0.01), being 15–19 years old (AHR: 1.6, 95 % CI: 1.1-2.3, p < 0.01) and attending ACCHS site 2 (AHR: 3.8, 95 % CI: 1.8-8.0, p < 0.01). Conclusions This analysis highlights that opportunistic STI testing strategies are needed to increase annual chlamydia testing in young people; especially males.
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Affiliation(s)
- Simon Graham
- Kirby Institute, UNSW Australia, Sydney, NSW, 2052, Australia. .,Centre for Epidemiology and Biostatistics, School of Population and Global Health, University of Melbourne, Melbourne, VIC, 3052, Australia.
| | - Rebecca J Guy
- Kirby Institute, UNSW Australia, Sydney, NSW, 2052, Australia.
| | - James S Ward
- South Australian Health and Medical Research Institute, Adelaide, SA, 5000, Australia.
| | - John Kaldor
- Kirby Institute, UNSW Australia, Sydney, NSW, 2052, Australia.
| | - Basil Donovan
- Kirby Institute, UNSW Australia, Sydney, NSW, 2052, Australia. .,Sydney Sexual Health Centre, Sydney Hospital, Sydney, NSW, 2000, Australia.
| | - Janet Knox
- Kirby Institute, UNSW Australia, Sydney, NSW, 2052, Australia.
| | - Debbie McCowen
- Aboriginal Community Controlled Health Service, New South Wales, NSW, Australia.
| | - Patricia Bullen
- Aboriginal Community Controlled Health Service, New South Wales, NSW, Australia.
| | - Julie Booker
- Aboriginal Community Controlled Health Service, New South Wales, NSW, Australia.
| | - Chris O'Brien
- Aboriginal Community Controlled Health Service, New South Wales, NSW, Australia.
| | - Kristine Garrett
- Aboriginal Community Controlled Health Service, New South Wales, NSW, Australia.
| | - Handan C Wand
- Kirby Institute, UNSW Australia, Sydney, NSW, 2052, Australia.
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Graham S, Guy RJ, Wand HC, Kaldor JM, Donovan B, Knox J, McCowen D, Bullen P, Booker J, O'Brien C, Garrett K, Ward JS. A sexual health quality improvement program (SHIMMER) triples chlamydia and gonorrhoea testing rates among young people attending Aboriginal primary health care services in Australia. BMC Infect Dis 2015; 15:370. [PMID: 26329123 PMCID: PMC4557217 DOI: 10.1186/s12879-015-1107-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 08/19/2015] [Indexed: 11/18/2022] Open
Abstract
Background In Australia, chlamydia is the most commonly notifiable infection and over the past ten years chlamydia and gonorrhoea notification rates have increased. Aboriginal compared with non-Aboriginal Australians have the highest notifications rates of chlamydia and gonorrhoea. Regular testing of young people for chlamydia and gonorrhoea is a key prevention strategy to identify asymptomatic infections early, provide treatment and safe sex education. This study evaluated if a sexual health quality improvement program (QIP) known as SHIMMER could increase chlamydia and gonorrhoea testing among young people attending four Aboriginal primary health care services in regional areas of New South Wales, Australia. Methods We calculated the proportion of 15–29 year olds tested and tested positivity for chlamydia and gonorrhoea in a 12-month before period (March 2010-February 2011) compared with a 12-month QIP period (March 2012-February 2013). Logistic regression was used to assess the difference in the proportion tested for chlamydia and gonorrhoea between study periods by gender, age group, Aboriginal status and Aboriginal primary health service. Odds ratios (OR) and their 95 % confidence intervals (CIs) were calculated with significance at p < 0.05. Results In the before period, 9 % of the 1881 individuals were tested for chlamydia, compared to 22 % of the 2259 individuals in the QIP period (OR): 1.43, 95 % CI: 1.22-1.67). From the before period to the QIP period, increases were observed in females (13 % to 25 %, OR: 1.32, 95 % CI: 1.10-1.59) and males (3 % to 17 %, OR: 1.85, 95 % CI: 1.36-2.52). The highest testing rate in the QIP period was in 15–19 year old females (16 % to 29 %, OR: 1.02, 95 % CI: 0.75-1.37), yet the greatest increase was in 20–24 year olds males (3 % to 19 %, OR: 1.65, 95 % CI: 1.01-2.69). Similar increases were seen in gonorrhoea testing. Overall, there were 70 (11 %) chlamydia diagnoses, increasing from 24 in the before to 46 in the QIP period. Overall, 4 (0.7 %) gonorrhoea tests were positive. Conclusions The QIP used in SHIMMER almost tripled chlamydia and gonorrhoea testing in young people and found more than twice as many chlamydia infections. The QIP could be used by other primary health care centres to increase testing among young people.
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Affiliation(s)
- Simon Graham
- Kirby Institute, UNSW Australia, Sydney, Australia. .,Centre for Epidemiology and Biostatistics, School of Population and Global Health, University of Melbourne, Melbourne, Australia.
| | | | | | | | - Basil Donovan
- Kirby Institute, UNSW Australia, Sydney, Australia. .,Sydney Sexual Health Centre, Sydney Hospital, Sydney, Australia.
| | - Janet Knox
- Kirby Institute, UNSW Australia, Sydney, Australia.
| | - Debbie McCowen
- Aboriginal Community Controlled Health Service, Sydney, New South Wales, Australia.
| | - Patricia Bullen
- Aboriginal Community Controlled Health Service, Sydney, New South Wales, Australia.
| | - Julie Booker
- Aboriginal Community Controlled Health Service, Sydney, New South Wales, Australia.
| | - Chris O'Brien
- Aboriginal Community Controlled Health Service, Sydney, New South Wales, Australia.
| | - Kristine Garrett
- Aboriginal Community Controlled Health Service, Sydney, New South Wales, Australia.
| | - James S Ward
- South Australian Health and Medical Research Institute, Adelaide, Australia.
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