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Yosep I, Hikmat R, Mardhiyah A, Hernawaty T. A Scoping Review of Digital-Based Intervention for Reducing Risk of Suicide Among Adults. J Multidiscip Healthc 2024; 17:3545-3556. [PMID: 39070693 PMCID: PMC11283240 DOI: 10.2147/jmdh.s472264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 07/10/2024] [Indexed: 07/30/2024] Open
Abstract
Suicide is a serious public health problem, especially among adults. Risk factors for suicide include the presence of mental health disorders, history of previous suicide attempts; substance or alcohol use and lack of social support. The impact of suicide risk includes psychological loss, as well as the trauma and emotional stress that can be felt by the families and communities left behind. Digital interventions have emerged as a promising alternative for suicide risk prevention. Previous research has focused on the findings of various designs, which did not provide clear intervention information to inform the implementation of the intervention. This study aims to describe a digital intervention to reduce the risk of suicidal behavior in adults. The design used in this study was a scoping review. The authors conducted a literature search from the Scopus, PubMed, and CINAHL databases. Inclusion criteria in this study were articles discussing digital interventions aimed at preventing suicide risk in adult populations, English language, full-text, RCT or quasi-experiment design, and publication period of the last 10 years (2014-2024). The major keywords used in the article search were suicide prevention, digital intervention, and adults. Data extraction used manual table and data analysis used descriptive qualitative with a content approach. The results showed that there were 9 articles that discussed digital-based interventions to reduce suicide risk in adults. The various types of digital interventions used were smartphone apps, online learning modules, and game-based interventions. These interventions offer significant potential in reducing the risk of suicidal behavior in adults. Digital interventions have an important role in reducing the risk of suicidal behavior in adults by considering aspects of suitability to individual needs and understanding digital literacy. Then, the development of mental health services and public health policies presented needs to be done with collaboration between stakeholders in suicide prevention efforts.
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Affiliation(s)
- Iyus Yosep
- Department of Mental Health, Faculty of Nursing, Universitas Padjadjaran, Sumedang, Jawa Barat, Indonesia
| | - Rohman Hikmat
- Master of Nursing Program, Faculty of Nursing, Universitas Padjadjaran, Sumedang, Jawa Barat, Indonesia
| | - Ai Mardhiyah
- Department of Pediatric Nursing, Faculty of Nursing, Universitas Padjadjaran, Sumedang, Jawa Barat, Indonesia
| | - Taty Hernawaty
- Department of Mental Health, Faculty of Nursing, Universitas Padjadjaran, Sumedang, Jawa Barat, Indonesia
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2
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Walsh AEL, Naughton G, Sharpe T, Zajkowska Z, Malys M, van Heerden A, Mondelli V. A collaborative realist review of remote measurement technologies for depression in young people. Nat Hum Behav 2024; 8:480-492. [PMID: 38225410 PMCID: PMC10963268 DOI: 10.1038/s41562-023-01793-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 11/20/2023] [Indexed: 01/17/2024]
Abstract
Digital mental health is becoming increasingly common. This includes use of smartphones and wearables to collect data in real time during day-to-day life (remote measurement technologies, RMT). Such data could capture changes relevant to depression for use in objective screening, symptom management and relapse prevention. This approach may be particularly accessible to young people of today as the smartphone generation. However, there is limited research on how such a complex intervention would work in the real world. We conducted a collaborative realist review of RMT for depression in young people. Here we describe how, why, for whom and in what contexts RMT appear to work or not work for depression in young people and make recommendations for future research and practice. Ethical, data protection and methodological issues need to be resolved and standardized; without this, RMT may be currently best used for self-monitoring and feedback to the healthcare professional where possible, to increase emotional self-awareness, enhance the therapeutic relationship and monitor the effectiveness of other interventions.
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Affiliation(s)
- Annabel E L Walsh
- The McPin Foundation, London, UK.
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
| | | | - Thomas Sharpe
- Young People's Advisory Group, The McPin Foundation, London, UK
| | - Zuzanna Zajkowska
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Mantas Malys
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Alastair van Heerden
- Centre for Community-based Research, Human and Social Capabilities Department, Human Sciences Research Council, Johannesburg, South Africa
- MRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Valeria Mondelli
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust and King's College London, London, UK
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3
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Larkin C, Arensman E, Boudreaux ED. Preventing Suicide in Health Systems: How Can Implementation Science Help? Arch Suicide Res 2023; 27:1147-1162. [PMID: 36267036 DOI: 10.1080/13811118.2022.2131490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Suicide prevention is an emotive, complex goal for clinicians and health systems. Effective interventions for suicidality do exist; however, many patients do not receive them because implementation efforts tend to be time-limited and unsystematic. Implementation science is the study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice. This narrative review introduces implementation science to suicide researchers, with a special focus on healthcare settings. We outline prominent theories, methods, and measures, as well as examples of implementation research from suicidology. By embracing the principles of implementation science, suicidologists can help to close the gap between evidence-based practice and routine practice, thereby improving the delivery and uptake of suicide-related interventions and prevention programs.
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Van Goethem V, Dierickx S, Matthys O, Northouse L, Lund L, Jordan C, Turola E, van der Wel M, Scott D, Harding R, Deliens L, Lapeire L, Hudson P, De Vleminck A, Cohen J. A self-management psychoeducational eHealth program to support and empower people with advanced cancer and their family caregivers: Development using the scrum methodology. Internet Interv 2023; 33:100659. [PMID: 37593143 PMCID: PMC10428037 DOI: 10.1016/j.invent.2023.100659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 07/13/2023] [Accepted: 08/08/2023] [Indexed: 08/19/2023] Open
Abstract
Background eHealth programs could be a flexible and scalable resource to support and empower people with advanced cancer and their family caregivers. A face-to-face intervention that has demonstrated effectiveness is the "FOCUS" program, developed and tested in the USA. Recently the FOCUS program was translated and adapted to the European context as part of an international study in six European countries, resulting in the "FOCUS+" program. FOCUS+ served as the basis for development of the web-based iFOCUS program. Objective We aim to (1) describe the development process of the iFOCUS program, (2) outline the challenges we encountered and how they were overcome, and (3) present findings regarding the acceptability and usability of iFOCUS. Methods We used the four phased agile Scrum methodology to develop iFOCUS and applied set timeframes of rapid program development and evaluation (sprints). Five teams were involved in the development i.e. a core development group, a web development team, an international consortium, audio-visual experts, and potential end-users. Results Development followed seven steps, integrated across the four phases of Scrum: (1) concept design, (2) development of mock-ups, (3) Feedback from the international consortium, (4) technical development of iFOCUS, (5) creating versions for the six participating countries, (6) preliminary testing of iFOCUS and (7) implementing the final version in a randomized controlled trial. User testing included 42 participants (twenty patient-family caregiver dyads and two bereaved family caregivers) who reviewed the iFOCUS program. Users found the iFOCUS program to be acceptable and usable. Feedback mainly focused on text size and fonts. Minor changes to the content, tailoring, and program flow were required. During development we encountered program specific and general challenges. Using the Scrum methodology facilitated iterative development to address these issues. For some challenges, such as tailoring, we had to make pragmatic choices due to time and resource limitations. Conclusions/discussion The development of a tailored, self-managed psychoeducational eHealth program for people with advanced cancer and their family caregivers is an intense process and requires pragmatic choices. By keeping the emphasis on the target population during development, no specific remarks pertaining to advanced cancer were identified. Some challenges we encountered are common to eHealth development, others were related to program specific requirements. Using the Scrum methodology allows teams to efficiently collaborate during program development and increases the flexibility of the development process. Interpersonal contact between research staff and potential end-users is recommended during and after the development of eHealth programs.
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Affiliation(s)
- Vincent Van Goethem
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-life Care Research Group, Laarbeeklaan 103, 1090 Brussels, Belgium
- Ghent University, Department of Public Health and Primary Care, C. Heymanslaan 10, 9000 Ghent, Belgium
- Vrije Universiteit Brussel (VUB), Department of Family Medicine and Chronic Care, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Sigrid Dierickx
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-life Care Research Group, Laarbeeklaan 103, 1090 Brussels, Belgium
- Ghent University, Department of Public Health and Primary Care, C. Heymanslaan 10, 9000 Ghent, Belgium
- Vrije Universiteit Brussel (VUB), Department of Family Medicine and Chronic Care, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Orphé Matthys
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-life Care Research Group, Laarbeeklaan 103, 1090 Brussels, Belgium
- Ghent University, Department of Public Health and Primary Care, C. Heymanslaan 10, 9000 Ghent, Belgium
- Vrije Universiteit Brussel (VUB), Department of Family Medicine and Chronic Care, Laarbeeklaan 103, 1090 Brussels, Belgium
| | | | - Line Lund
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Palliative Care Research Unit, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Catherine Jordan
- University College Dublin, National University of Ireland, Dublin, Ireland
| | - Elena Turola
- Scientific Directorate, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - David Scott
- The School of Nursing and Midwifery, Queen's University of Belfast, Belfast, United Kingdom
| | - Richard Harding
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
| | - Luc Deliens
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-life Care Research Group, Laarbeeklaan 103, 1090 Brussels, Belgium
- Ghent University, Department of Public Health and Primary Care, C. Heymanslaan 10, 9000 Ghent, Belgium
- Vrije Universiteit Brussel (VUB), Department of Family Medicine and Chronic Care, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Lore Lapeire
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-life Care Research Group, Laarbeeklaan 103, 1090 Brussels, Belgium
- Ghent University Hospital, Department of Medical Oncology, C. Heymanslaan 10, 9000 Ghent, Belgium
| | | | - Peter Hudson
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-life Care Research Group, Laarbeeklaan 103, 1090 Brussels, Belgium
- St Vincent's Hospital and the Univeristy of Melbourne, Centre of Palliative Care, Melbourne, Australia
| | - Aline De Vleminck
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-life Care Research Group, Laarbeeklaan 103, 1090 Brussels, Belgium
- Vrije Universiteit Brussel (VUB), Department of Family Medicine and Chronic Care, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Joachim Cohen
- Vrije Universiteit Brussel (VUB) & Ghent University, End-of-life Care Research Group, Laarbeeklaan 103, 1090 Brussels, Belgium
- Vrije Universiteit Brussel (VUB), Department of Family Medicine and Chronic Care, Laarbeeklaan 103, 1090 Brussels, Belgium
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Kriegshauser KD, Sexton CC, Bozsik FM, Blossom JB, Wiese AD, Adams Larsen M, Hale LR. The Feasibility of a Family-Focused CBT Skills Self-Help App. COGNITIVE AND BEHAVIORAL PRACTICE 2022. [DOI: 10.1016/j.cbpra.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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6
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Psihogios AM, Lane-Fall MB, Graham AK. Adolescents Are Still Waiting on a Digital Health Revolution: Accelerating Research-to-Practice Translation Through Design for Implementation. JAMA Pediatr 2022; 176:545-546. [PMID: 35404381 DOI: 10.1001/jamapediatrics.2022.0500] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Alexandra M Psihogios
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Meghan B Lane-Fall
- Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Andrea K Graham
- Center for Behavioral Intervention Technologies, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Sumner SA, Ferguson B, Bason B, Dink J, Yard E, Hertz M, Hilkert B, Holland K, Mercado-Crespo M, Tang S, Jones CM. Association of Online Risk Factors With Subsequent Youth Suicide-Related Behaviors in the US. JAMA Netw Open 2021; 4:e2125860. [PMID: 34542614 PMCID: PMC8453319 DOI: 10.1001/jamanetworkopen.2021.25860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE The association between online activities and youth suicide is an important issue for parents, clinicians, and policy makers. However, most information exploring potential associations is drawn from survey data and mainly focuses on risk related to overall screen time. OBJECTIVE To evaluate the association between a variety of online risk factors and youth suicide-related behavior using real-world online activity data. DESIGN, SETTING, AND PARTICIPANTS A matched case-control study was conducted from July 27, 2019, to May 26, 2020, with the sample drawn from more than 2600 US schools participating in an online safety monitoring program via the Bark online safety tool. For 227 youths having a severe suicide/self-harm alert requiring notification of school administrators, cases were matched 1:5 to 1135 controls on location, the amount of follow-up time, and general volume of online activity. EXPOSURES Eight potential online risk factors (cyberbullying, violence, drug-related, hate speech, profanity, sexual content, depression, and low-severity self-harm) through assessment of text, image, and video data. MAIN OUTCOMES AND MEASURES Severe suicide/self-harm alert requiring notification of school administrators; severe suicide alerts are statements by youths indicating imminent or recent suicide attempts and/or self-harm. RESULTS The 1362 participants had a mean (SD) age of 13.3 (2.41) years; 699 (51.3%) were male. All 8 online risk factors studied exhibited differences between case and control populations and were significantly associated with subsequent severe suicide/self-harm alerts when examining total direct and indirect pathways. These associations ranged from an adjusted odds ratio (aOR) of 1.17 (95% CI, 1.09-1.26) for drug-related content to an aOR of 1.82 (95% CI, 1.63-2.03) for depression-related content. When considering the total number of different types of online risk factors among the 8 measured, there was an exponentially larger risk of severe suicide/self-harm alerts; youths with 5 or more of the 8 risk factors present in their online activity had a more than 70-fold increased odds of subsequently having a severe suicide/self-harm alert (aOR, 78.64; 95% CI, 34.39-179.84). CONCLUSIONS AND RELEVANCE The findings of this study suggest that many discrete types of risk factors are identifiable from online data and associated with subsequent youth suicide-related behavior. Although each risk factor carries a specific association with suicide-related behavior, the greatest risk is evident for youths demonstrating multiple types of online risk factors.
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Affiliation(s)
- Steven A. Sumner
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | - Ellen Yard
- Division of Injury Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Marci Hertz
- Division of Adolescent and School Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Kristin Holland
- Division of Overdose Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Melissa Mercado-Crespo
- Division of Violence Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shichao Tang
- Division of Violence Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Christopher M. Jones
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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8
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Nathan N, Hall A, McCarthy N, Sutherland R, Wiggers J, Bauman AE, Rissel C, Naylor PJ, Cradock A, Lane C, Hope K, Elton B, Shoesmith A, Oldmeadow C, Reeves P, Gillham K, Duggan B, Boyer J, Lecathelinais C, Wolfenden L. Multi-strategy intervention increases school implementation and maintenance of a mandatory physical activity policy: outcomes of a cluster randomised controlled trial. Br J Sports Med 2021; 56:385-393. [PMID: 34039583 PMCID: PMC8938653 DOI: 10.1136/bjsports-2020-103764] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 02/06/2023]
Abstract
Objectives To assess if a multi-strategy intervention effectively increased weekly minutes of structured physical activity (PA) implemented by classroom teachers at 12 months and 18 months. Methods A cluster randomised controlled trial with 61 primary schools in New South Wales Australia. The 12-month multi-strategy intervention included; centralised technical assistance, ongoing consultation, principal’s mandated change, identifying and preparing school champions, development of implementation plans, educational outreach visits and provision of educational materials. Control schools received usual support (guidelines for policy development via education department website and telephone support). Weekly minutes of structured PA implemented by classroom teachers (primary outcome) was measured via teacher completion of a daily log-book at baseline (October–December 2017), 12-month (October–December 2018) and 18-month (April–June 2019). Data were analysed using linear mixed effects regression models. Results Overall, 400 class teachers at baseline, 403 at 12 months follow-up and 391 at 18 months follow-up provided valid primary outcome data. From baseline to 12-month follow-up, teachers at intervention schools recorded a greater increase in weekly minutes of PA implemented than teachers assigned to the control schools by approximately 44.2 min (95% CI 32.8 to 55.7; p<0.001) which remained at 18 months, however, the effect size was smaller at 27.1 min (95% CI 15.5 to 38.6; p≤0.001). Conclusion A multi-strategy intervention increased mandatory PA policy implementation. Some, but not all of this improvement was maintained after implementation support concluded. Further research should assess the impact of scale-up strategies on the sustainability of PA policy implementation over longer time periods. Trial registration number Australian New Zealand Clinical Trials Registry (ACTRN12617001265369).
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Affiliation(s)
- Nicole Nathan
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia .,Hunter New England Population Health, Hunter New England Health, Wallsend, New South Wales, Australia.,Hunter Medical Research Institute (HMRI), New Lambton, New South Wales, Australia
| | - Alix Hall
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter Medical Research Institute (HMRI), New Lambton, New South Wales, Australia
| | - Nicole McCarthy
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter New England Population Health, Hunter New England Health, Wallsend, New South Wales, Australia.,Hunter Medical Research Institute (HMRI), New Lambton, New South Wales, Australia
| | - Rachel Sutherland
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter New England Population Health, Hunter New England Health, Wallsend, New South Wales, Australia.,Hunter Medical Research Institute (HMRI), New Lambton, New South Wales, Australia
| | - John Wiggers
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter New England Population Health, Hunter New England Health, Wallsend, New South Wales, Australia.,Hunter Medical Research Institute (HMRI), New Lambton, New South Wales, Australia
| | - Adrian E Bauman
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Chris Rissel
- Centre for Health Advancement, NSW Health, North Sydney, New South Wales, Australia
| | - Patt-Jean Naylor
- School of Exercise Science, Physical and Heal, University of Victoria, Victoria, British Columbia, Canada
| | - Angie Cradock
- Department of Social and Behavioral Sciences, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Cassandra Lane
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter New England Population Health, Hunter New England Health, Wallsend, New South Wales, Australia.,Hunter Medical Research Institute (HMRI), New Lambton, New South Wales, Australia
| | - Kirsty Hope
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter New England Population Health, Hunter New England Health, Wallsend, New South Wales, Australia
| | - Benjamin Elton
- Hunter New England Population Health, Hunter New England Health, Wallsend, New South Wales, Australia.,Hunter Medical Research Institute (HMRI), New Lambton, New South Wales, Australia
| | - Adam Shoesmith
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter New England Population Health, Hunter New England Health, Wallsend, New South Wales, Australia.,Hunter Medical Research Institute (HMRI), New Lambton, New South Wales, Australia
| | | | - Penny Reeves
- Hunter Medical Research Institute (HMRI), New Lambton, New South Wales, Australia
| | - Karen Gillham
- Hunter New England Population Health, Hunter New England Health, Wallsend, New South Wales, Australia
| | - Bernadette Duggan
- Catholic Schools Office Diocese of Maitland-Newcastle, Newcastle, New South Wales, Australia
| | - James Boyer
- School Sport Unit, NSW Department of Education, Turrella, New South Wales, Australia
| | - Christophe Lecathelinais
- Hunter New England Population Health, Hunter New England Health, Wallsend, New South Wales, Australia.,Hunter Medical Research Institute (HMRI), New Lambton, New South Wales, Australia
| | - Luke Wolfenden
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia.,Hunter New England Population Health, Hunter New England Health, Wallsend, New South Wales, Australia.,Hunter Medical Research Institute (HMRI), New Lambton, New South Wales, Australia
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