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Mughal F, Ougrin D, Stephens L, Vijayakumar L, Kapur N. Assessment and management of self-harm and suicide risk in young people. BMJ 2024; 386:e073515. [PMID: 39103171 DOI: 10.1136/bmj-2022-073515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Affiliation(s)
- Faraz Mughal
- School of Medicine, Keele University, Keele, UK; Department for General Practice and Primary Care, Melbourne Medical School, University of Melbourne
| | - Dennis Ougrin
- Youth Resilience Unit, Queen Mary University of London, London
| | | | | | - Nav Kapur
- Centre for Mental Health and Safety; Manchester Academic Health Sciences Centre; Mersey Care NHS Foundation Trust; NIHR Greater Manchester Patient Safety Research Collaboration, School of Health Sciences, University of Manchester
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Minian N, Gayapersad A, Coroiu A, Dragonetti R, Zawertailo L, Zaheer J, O’Neill B, Lange S, Thomson N, Crawford A, Kennedy SH, Selby P. Prototyping the implementation of a suicide prevention protocol in primary care settings using PDSA cycles: a mixed method study. Front Psychiatry 2024; 15:1286078. [PMID: 38333892 PMCID: PMC10850298 DOI: 10.3389/fpsyt.2024.1286078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/04/2024] [Indexed: 02/10/2024] Open
Abstract
Introduction In Canada, approximately 4,500 individuals die by suicide annually. Approximately 45% of suicide decedents had contact with their primary care provider within the month prior to their death. Current versus never smokers have an 81% increased risk of death by suicide. Those who smoke have additional risks for suicide such as depression, chronic pain, alcohol, and other substance use. They are more likely to experience adverse social determinants of health. Taken together, this suggests that smoking cessation programs in primary care could be facilitators of suicide prevention, but this has not been studied. Study objectives The objectives of the study are to understand barriers/facilitators to implementing a suicide prevention protocol within a smoking cessation program (STOP program), which is deployed by an academic mental health and addiction treatment hospital in primary care clinics and to develop and test implementation strategies to facilitate the uptake of suicide screening and assessment in primary care clinics across Ontario. Methods The study employed a three-phase sequential mixed-method design. Phase 1: Conducted interviews guided by the Consolidated Framework for Implementation Research exploring barriers to implementing a suicide prevention protocol. Phase 2: Performed consensus discussions to map barriers to implementation strategies using the Expert Recommendations for Implementing Change tool and rank barriers by relevance. Phase 3: Evaluated the feasibility and acceptability of implementation strategies using Plan Do Study Act cycles. Results Eleven healthcare providers and four research assistants identified lack of training and the need of better educational materials as implementation barriers. Participants endorsed and tested the top three ranked implementation strategies, namely, a webinar, adding a preamble before depression survey questions, and an infographic. After participating in the webinar and reviewing the educational materials, all participants endorsed the three strategies as acceptable/very acceptable and feasible/very feasible. Conclusion Although there are barriers to implementing a suicide prevention protocol within primary care, it is possible to overcome them with strategies deemed both acceptable and feasible. These results offer promising practice solutions to implement a suicide prevention protocol in smoking cessation programs delivered in primary care settings. Future efforts should track implementation of these strategies and measure outcomes, including provider confidence, self-efficacy, and knowledge, and patient outcomes.
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Affiliation(s)
- Nadia Minian
- INTREPID Lab, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Medical Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Allison Gayapersad
- INTREPID Lab, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Adina Coroiu
- INTREPID Lab, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Rosa Dragonetti
- INTREPID Lab, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Laurie Zawertailo
- INTREPID Lab, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Juveria Zaheer
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Braden O’Neill
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Shannon Lange
- Institute of Medical Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Nicole Thomson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Allison Crawford
- INTREPID Lab, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Sidney H. Kennedy
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Arthur Sommer Rotenberg Program in Suicide Studies, Unity Health Toronto, Toronto, ON, Canada
| | - Peter Selby
- INTREPID Lab, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Cleary M, West S, McLean L, Kornhaber R, Hungerford C. Two Halves of the Same Whole: A Framework to Integrate Autism and Mental Health Services. Issues Ment Health Nurs 2023; 44:93-103. [PMID: 36206026 DOI: 10.1080/01612840.2022.2126570] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2022]
Abstract
Given the higher rates of co-occurring mental health issues experienced by autistic people, there is a pressing need to implement an effective framework that integrates autism services with appropriate mental health services. This paper discusses the impact of mental illness on the person with autism and their families, and the current challenges they face when accessing mental health support. A framework for service providers is proposed to support the mental health needs and preferences of autistic people. The paper concludes by highlighting the importance of health professionals utilising mental health interventions appropriate for autistic people, including autism-specific suicide prevention and awareness programs.
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Affiliation(s)
- Michelle Cleary
- School of Nursing, Midwifery & Social Sciences, CQUniversity, Sydney, New South Wales, Australia
| | - Sancia West
- School of Nursing, Midwifery & Social Sciences, CQUniversity, Sydney, New South Wales, Australia
| | - Loyola McLean
- Brain and Mind Centre, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia.,Westmead Psychotherapy Program for Complex Traumatic Disorders, Cumberland Campus, WSLHD, North Parramatta, New South Wales Australia
| | - Rachel Kornhaber
- College of Health and Medicine, University of Tasmania, Sydney, New South Wales, Australia
| | - Catherine Hungerford
- School of Nursing, Midwifery & Social Sciences, CQUniversity, Sydney, New South Wales, Australia.,Faculty of Health, Federation University, Melbourne, Victoria, Australia
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The mediator role of perceived social support in the relationship between difficulties in emotion regulation and suicide tendency. CURRENT PSYCHOLOGY 2022. [DOI: 10.1007/s12144-022-03347-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
OBJECTIVE Suicide is a complex phenomenon, with numerous factors contributing to an individual's risk of suicide. The aim of the present study was to explore how risk and protective factors for suicide interact with one another in a network sense and to determine which factors were most central to a network of these factors. METHOD Using an online survey, cross-sectional data were collected from a sample of 515 individuals who lived in New Zealand, Australia, the United Kingdom, and the United States of America. Participants were recruited through either social media or Prolific Academic. A network of 18 risk and protective factors for suicide was estimated using network analysis. Analyses were preregistered on the Open Science Framework. RESULTS Factors that had the highest strength centrality were feeling depressed, feeling hopeless, perceived burdensomeness, self-esteem, and social support. Factors that were directly associated with suicidal ideation included feeling depressed, perceived burdensomeness, feeling hopeless, self-esteem, resilience, access to mental health services and a positive attitude toward these services. CONCLUSION This research demonstrates the importance of examining protective factors as well as risk factors when estimating an individual's suicide risk. The results suggest that interventions targeting depression may be particularly beneficial in reducing suicide risk, but further longitudinal research is required.HIGHLIGHTSThe network analyses estimated depression to be the most central risk factor.Depression and perceived burdensomeness were risk factors for suicidal ideation.Self-esteem and resilience were protective against suicidal ideation.
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Abstract
Suicide is significant public health concern within the United States. Research results are mixed about the effectiveness of universal screening and interventions with patients who are at-risk for suicide. Primary care is a logical intervention point to mitigate risk among patients in each of these areas. The Department of Veterans Affairs and Department of Defense have developed comprehensive guidelines for the assessment and management of suicidal patients. This approach involves specific screening tools, risk stratification by categories and interventions used by clinicians to help reduce risk levels in their patients. This article aims to provide a model, built on the principles of these guidelines, which primary care physicians can use to identify, assess and intervene with patients who are at-risk for suicide.
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Szilassy E, Roy J, Williamson E, Pitt K, Man MS, Feder G. Reaching everyone in general practice? Feasibility of an integrated domestic violence training and support intervention in primary care. BMC FAMILY PRACTICE 2021; 22:19. [PMID: 33435891 PMCID: PMC7802315 DOI: 10.1186/s12875-020-01297-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 10/25/2020] [Indexed: 12/16/2022]
Abstract
Background Primary care needs to respond effectively to patients experiencing or perpetrating domestic violence and abuse (DVA) and their children, but there is uncertainty about the value of integrated programmes. The aim of the study was to develop and test the feasibility of an integrated primary care system-level training and support intervention, called IRIS+ (Enhanced Identification and Referral to Improve Safety), for all patients affected by DVA. IRIS+ was an adaptation of the original IRIS (Identification and Referral to Improve Safety) model designed to reach female survivors of DVA. Methods Observation of training; pre/post intervention questionnaires with clinicians and patients; data extracted from medical records and DVA agency; semi-structured interviews with clinicians, service providers and referred adults and children. Data collection took place between May 2017 and April 2018. Mixed method analysis was undertaken to triangulate data from various sources to assess the feasibility and acceptability of the intervention. Results Clinicians and service providers believed that the IRIS+ intervention had filled a service gap and was a valuable resource in identifying and referring women, men and children affected by DVA. Despite increased levels of preparedness reported by clinicians after training in managing the complexity of DVA in their practice, the intervention proved to be insufficient to catalyse identification and specialist referral of men and direct identification and referral (without their non-abusive parents) of children and young people. The study also revealed that reports provided to general practice by other agencies are important sources of information about adult and children patients affected by DVA. However, in the absence of guidance about how to use this information in patient care, there are uncertainties and variation in practice. Conclusions The study demonstrates that the IRIS+ intervention is not feasible in the form and timeframe we evaluated. Further adaptation is required to achieve identification and referral of men and children in primary care: an enhanced focus on engagement with men, direct engagement with children, and improved guidance and training on responding to reports of DVA received from other agencies. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-020-01297-5.
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Affiliation(s)
- Eszter Szilassy
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Jessica Roy
- School for Policy Studies, University of Bristol, Bristol, UK
| | - Emma Williamson
- School for Policy Studies, University of Bristol, Bristol, UK
| | - Katherine Pitt
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Mei-See Man
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Gene Feder
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
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Frick MG, Butler SA, deBoer DS. Universal suicide screening in college primary care. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2021; 69:17-22. [PMID: 31381487 DOI: 10.1080/07448481.2019.1645677] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 03/14/2019] [Accepted: 07/16/2019] [Indexed: 06/10/2023]
Abstract
Implementation of a universal primary care (PC) suicide-screening program in a college student health center to heighten awareness, provide support and enhance education of staff and students served. Program feasibility, data collection, electronic medical record (EMR) adaptations and staff learning outcomes were examined. Participants: 1,607 students with PC visits during Spring 2018 semester. Methods: Annual Suicide Behaviors Questionnaire (SBQ-R), EMR template, safety alert, referral tracking and simulated staff training were employed. Chi-square tests assessed documentation, safety alerts and mental health referral changes. Paired t-tests evaluated staff learning outcomes. Results: 12.8% of students screened positively for suicide risk during implementation. Documentation consistency, EMR safety alert utilization, mental health referrals and subsequent appointments increased significantly. Staff learning outcomes yielded growth in knowledge and comfort with suicide screening and brief intervention. Conclusion: A comprehensive suicide-screening program is feasible for identifying students at-risk and promoting positive clinical changes in college PC practice settings.
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Affiliation(s)
| | - Shirley Ann Butler
- Loyola University Chicago Marcella Neihoff School of Nursing, Chicago, IL, USA
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Bellairs-Walsh I, Perry Y, Krysinska K, Byrne SJ, Boland A, Michail M, Lamblin M, Gibson KL, Lin A, Li TY, Hetrick S, Robinson J. Best practice when working with suicidal behaviour and self-harm in primary care: a qualitative exploration of young people's perspectives. BMJ Open 2020; 10:e038855. [PMID: 33115897 PMCID: PMC7594366 DOI: 10.1136/bmjopen-2020-038855] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 09/09/2020] [Accepted: 09/24/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES General practitioners (GPs) have a key role in supporting young people who present with suicidal behaviour/self-harm. However, little is known about young people's opinions and experiences related to GPs' practices for such presentations, and their decisions to disclose suicidal behaviour/self-harm to GPs. Additionally, existing guidelines for the management of suicide risk and/or self-harm have not incorporated young people's perspectives. This study aimed to explore young people's views and experiences related to the identification, assessment and care of suicidal behaviour and self-harm in primary care settings with GPs. DESIGN, SETTING AND PARTICIPANTS Two qualitative focus groups were conducted in Perth, Western Australia, with 10 young people in total (Mage = 20.67 years; range: 16-24). Data were collected using a semistructured, open-ended interview schedule and analysed using thematic analysis. RESULTS Five major themes were identified from the focus groups. (1) Young people wanted a collaborative dialogue with GPs, which included being asked about suicidal behaviour/self-harm, informed of treatment processes and having autonomy in decision making; (2) young people were concerned with a loss of privacy when disclosing suicidal behaviour/self-harm; (3) young people viewed labels and assessments as problematic and reductionist-disliking the terms 'risk' and 'risk assessment', and assessment approaches that are binary and non-holistic; (4) young people highlighted the importance of GPs' attitudes, with a genuine connection, attentiveness and a non-judgemental demeanour seen as paramount; and (5) young people wanted to be provided with practical support and resources, followed-up, and for GPs to be competent when working with suicidal behaviour/self-harm presentations. CONCLUSIONS Our study identified several concerns and recommendations young people have regarding the identification, assessment and care of suicidal behaviour/self-harm in primary care settings. Taken together, these findings may inform the development of resources for GPs, and support progress in youth-oriented best practice.
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Affiliation(s)
- India Bellairs-Walsh
- Orygen, Parkville, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Yael Perry
- Telethon Kids Institute, The University of Western Australia, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Karolina Krysinska
- Orygen, Parkville, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Sadhbh J Byrne
- Orygen, Parkville, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Alexandra Boland
- Orygen, Parkville, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Maria Michail
- School of Psychology, Institute for Mental Health, University of Birmingham, Birmingham, UK
| | - Michelle Lamblin
- Orygen, Parkville, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Kerry L Gibson
- School of Psychology, Faculty of Science, The University of Auckland, Auckland, New Zealand
| | - Ashleigh Lin
- Telethon Kids Institute, The University of Western Australia, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Tina Yutong Li
- Orygen, Parkville, Victoria, Australia
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Sarah Hetrick
- Orygen, Parkville, Victoria, Australia
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Jo Robinson
- Orygen, Parkville, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
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Tham SG, Ibrahim S, Hunt IM, Kapur N, Gooding P. Examining the mechanisms by which adverse life events affect having a history of self-harm, and the protective effect of social support. J Affect Disord 2020; 263:621-628. [PMID: 31744741 DOI: 10.1016/j.jad.2019.11.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/05/2019] [Accepted: 11/09/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Psychological models of suicide emphasize perceptions of negative stressors, hopelessness and self-harm as key antecedents to suicidal thoughts/acts. Such models also emphasize the potential protective role of social support in these pathways. However, such pathways have not been tested using population level data. Hence, this study aimed to redress this gap. METHODS Questionnaire data regarding 24,444 patient suicide deaths were analysed. All individuals died between 1996 and 2015 and were seen by secondary mental health services in England within 12 months before their death. Mediation analyses, using fitted logistic regression models, investigated direct and indirect pathways between negative stressors, hopelessness and a proxy measure of suicide, namely, self-harm history. In addition, the buffering effects of social support were examined in these pathways. RESULTS There was a direct effect of negative life events on suicidal behaviors. Supporting contemporary psychological models of suicide, a mediated effect via hopelessness and a protective effect of social support were identified. Social support buffered the pathway between stressful life events and hopelessness, with hopelessness decreasing as social support increased. LIMITATIONS Causal inferences are inappropriate as the design was cross-sectional. A proxy measure of suicidality was utilized (history of self-harm) as all individuals had died by suicide. CONCLUSIONS This is the first time that population data has been used to test psychological pathways to suicidal acts involving negative stressors, hopelessness and social support. Psychological interventions should focus on increasing social support following negative life events together with ameliorating perceptions of hopelessness.
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Affiliation(s)
- Su-Gwan Tham
- The National Confidential Inquiry into Suicide and Safety in Mental Health, Centre for Mental Health and Safety, University of Manchester, UK; Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, UK
| | - Saied Ibrahim
- The National Confidential Inquiry into Suicide and Safety in Mental Health, Centre for Mental Health and Safety, University of Manchester, UK; Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, UK
| | - Isabelle M Hunt
- The National Confidential Inquiry into Suicide and Safety in Mental Health, Centre for Mental Health and Safety, University of Manchester, UK; Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, UK
| | - Nav Kapur
- The National Confidential Inquiry into Suicide and Safety in Mental Health, Centre for Mental Health and Safety, University of Manchester, UK; Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, UK; Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, UK; Greater Manchester Mental Health NHS Foundation Trust, UK; NIHR Greater Manchester Patient Safety Translational Research Centre, UK
| | - Patricia Gooding
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, UK; Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, UK.
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Abstract
It is widely believed that suicide prevention involves the consideration of risk and protective factors and related interventions. Preventative interventions can be classified as “universal” (targeting whole populations), “selective” (targeting higher-risk groups), and “indicated” (protecting individuals). This review explores the range of preventative measures that might be used commensurately with different types of suicide prediction. The author concludes that the best prospects for suicide prevention lie in universal prevention strategies. While risk assessments do generate some information about future suicide, suicide risk categorization results in an unacceptably high false positive rate, misses many fatalities, and therefore, is unable to usefully guide prevention strategies. The assessment of suicidal patients should focus on contemporaneous factors and the needs of the patient, rather than probabilistic notions of suicide risk.
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Affiliation(s)
- Matthew Michael Large
- Mental Health Services, The Prince of Wales Hospitals, Barker Street, Randwick, NSW, 2031, Australia
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Heng A, Heal C, Banks J, Preston R. Transgender peoples’ experiences and perspectives about general healthcare: A systematic review. Int J Transgend 2018. [DOI: 10.1080/15532739.2018.1502711] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Audrey Heng
- College of Medicine and Dentistry, Division of Tropical Health and Medicine, James Cook University, Townsville, Australia
| | - Clare Heal
- College of Medicine and Dentistry, Division of Tropical Health and Medicine, James Cook University, Townsville, Australia
| | - Jennifer Banks
- College of Medicine and Dentistry, Division of Tropical Health and Medicine, James Cook University, Townsville, Australia
| | - Robyn Preston
- College of Medicine and Dentistry, Division of Tropical Health and Medicine, James Cook University, Townsville, Australia
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