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Kirke AB, Spry E, Atkinson D, Sinclair C, Marley JV. Oral glucose tolerance test-The imperfect gold standard for gestational diabetes screening: A qualitative study involving clinicians in regional, rural and remote areas of Western Australia. Health Promot J Austr 2024. [PMID: 38973209 DOI: 10.1002/hpja.899] [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: 09/17/2023] [Revised: 06/06/2024] [Accepted: 06/17/2024] [Indexed: 07/09/2024] Open
Abstract
ISSUE ADDRESSED The oral glucose tolerance test is the 'gold standard' for detecting gestational diabetes in Australian and International guidelines. Test completion in regional, rural and remote regions may be as low as 50%. We explored challenges and enablers for regional, rural and remote antenatal clinicians providing gestational diabetes screening to better understand low oral glucose tolerance test completion. METHODS We conducted a qualitative descriptive study using semi-structured interviews. Participants eligible for the study were doctors or midwives providing antenatal care in regional, rural and remote Western Australia, between August 2019 and November 2020. Interviews were recorded digitally and transcribed into a Word document. We conducted a thematic analysis after initial categorisation and deduction of themes through workshops involving the research team. RESULTS We found a diversity of viewpoints on oral glucose tolerance test reliability for detecting gestational diabetes. Themes that emerged were; good collaboration between antenatal clinicians is required for successful screening; screening occurs throughout pregnancy using various tests; clinicians make significant efforts to address barriers; clinicians prioritise therapeutic relationships. CONCLUSIONS Effective universal screening for gestational diabetes in regional, rural and remote Western Australia is difficult and more complex in practice than guidelines imply. Detecting gestational diabetes requires creative solutions, early identification of at risk women and trust and collaboration between clinicians and women. SO WHAT?: Detection of gestational diabetes in regional, rural and remote Western Australia remains poorly completed. New strategies are required to adequately identify women at risk of adverse birth outcomes relating to hyperglycaemia in pregnancy.
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Affiliation(s)
- Andrew B Kirke
- The Rural Clinical School of Western Australia, The University of Western Australia, Bunbury, Australia
| | - Erica Spry
- The Rural Clinical School of Western Australia, The University of Western Australia, Broome, Australia
- Kimberley Aboriginal Medical Services, Broome, Australia
| | - David Atkinson
- The Rural Clinical School of Western Australia, The University of Western Australia, Broome, Australia
| | - Craig Sinclair
- School of Psychology, The University of New South Wales, Kensington, Australia
| | - Julia V Marley
- The Rural Clinical School of Western Australia, The University of Western Australia, Broome, Australia
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Mullan L, Armstrong K, Job J. Barriers and enablers to structured care delivery in Australian rural primary care. Aust J Rural Health 2023. [PMID: 36639909 DOI: 10.1111/ajr.12963] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 10/04/2022] [Accepted: 01/01/2023] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE The primary aim of this study was to explore the barriers and enablers to structured care delivery in rural primary care, reflecting on Australian research findings. DESIGN CINAHL and Scopus databases were searched in August 2021. Inclusion criteria included English language, full-text studies, published since 2011, reporting on the barriers and enablers to the delivery of structured care within rural and remote primary care. Structured care was conceptualised as care that was organised, integrative and planned. FINDINGS A total of 435 studies were screened. Thirty-four met the inclusion criteria. Barriers to the provision of structured care related to workforce shortages, limited health care services and health care professional capacity, cultural safety and competency, limited resourcing, insufficient knowledge and education, geographical isolation, inadequate care coordination, unclear roles and responsibilities and poor health professional-patient relationships. DISCUSSION Health care system and geographical barriers and enablers encountered in rural areas are complex and multidimensional. Identification of the specific challenges to structured care delivery highlights the need for a focussed review of workforce supply and distribution challenges as well as the investigation of system integration, leadership, governance and funding reform that would be required to support rural primary care.
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Affiliation(s)
- Leanne Mullan
- Western Queensland Primary Health Network, Mount Isa, Queensland, Australia.,Australian Catholic University, Banyo, Queensland, Australia
| | | | - Jennifer Job
- Centre for Health System Reform and Integration, Mater Research Institute-University of Queensland, Brisbane, Queensland, Australia
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Hanks AJ, Hume C, Lim S, Grieger JA. The Perspectives of Diabetes Educators and Dietitians on Diet and Lifestyle Management for Gestational Diabetes Mellitus: A Qualitative Study. J Diabetes Res 2022; 2022:3542375. [PMID: 35782628 PMCID: PMC9242803 DOI: 10.1155/2022/3542375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 05/13/2022] [Accepted: 06/13/2022] [Indexed: 12/31/2022] Open
Abstract
This study explores the knowledge and practice of diabetes educators and dietitians on diet and lifestyle management in women with gestational diabetes mellitus (GDM). Diabetes educators and dietitians were recruited from three maternity hospitals in Adelaide (Australia), through snowball and purposive sampling. Thirteen semistructured interviews were conducted, audio recorded, transcribed verbatim, and analysed for codes and themes. Four themes emerged: guidelines and resources, dietary intervention, management delivery, and communication. Diabetes educators and dietitians demonstrated consistent knowledge of nutritional management for GDM and uniform delivery methods. However, a lack of culturally diverse resources was highlighted, along with a lack of continuity of care across the multidisciplinary team. Barriers towards uptake of dietary intervention were reflected by diabetes educators and dietitians as women showing signs of guilt and stress and disengaging from the service. Further exploration on the knowledge and practice of diabetes educators and dietitians for GDM to best inform implementation strategies for knowledge translation of nutritional management is needed. The indication of language and cultural barriers and resources highlight an ongoing key priority area to support the care of women of ethnic minorities.
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Affiliation(s)
- Amber J. Hanks
- School of Public Health, University of Adelaide, Adelaide 5000, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, SA 5005, Australia
| | - Clare Hume
- School of Public Health, University of Adelaide, Adelaide 5000, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, SA 5005, Australia
| | - Siew Lim
- Monash Centre for Health Research and Implementation, Monash University, Clayton 3168, Australia
| | - Jessica A. Grieger
- Adelaide Medical School, University of Adelaide, Adelaide, SA 5005, Australia
- Robinson Research Institute, University of Adelaide, Adelaide, SA 5005, Australia
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MacKay D, Freeman N, Boyle JA, Campbell S, McLean A, Peiris D, Corpus S, Connors C, Moore E, Wenitong M, Silver B, McIntyre HD, Shaw JE, Brown A, Kirkham R, Maple-Brown L. Improving systems of prenatal and postpartum care for hyperglycemia in pregnancy: A process evaluation. Int J Gynaecol Obstet 2021; 155:179-194. [PMID: 34331708 DOI: 10.1002/ijgo.13850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To identify successes to date and opportunities for improvement in the implementation of a complex health systems intervention aiming to improve prenatal and postpartum care and health outcomes for women with hyperglycemia in pregnancy in regional and remote Australia. METHODS A qualitative evaluation, underpinned by the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance), was conducted mid-intervention. Semi-structured interviews were conducted with the participants, who included clinicians, regional policymakers and managers, and study implementation staff. RESULTS Interviewees (n = 45) reported that the early phase of the intervention had resulted in the establishment of a clinician network, increased clinician awareness of hyperglycemia in pregnancy, and improvements in management, including earlier referral for specialist care and a focus on improving communication with women. Enablers of implementation included existing relationships with stakeholders and alignment of the intervention with health service priorities. Challenges included engaging remote clinicians and the labor-intensive nature of maintaining a clinical register of women with hyperglycemia in pregnancy. CONCLUSION The early phase of this health systems intervention has had a positive perceived impact on systems of care for women with hyperglycemia in pregnancy. Findings have informed modifications to the intervention, including the development of a communication and engagement strategy.
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Affiliation(s)
- Diana MacKay
- Division of Wellbeing and Preventable Chronic Disease, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.,Department of Endocrinology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Natasha Freeman
- Division of Wellbeing and Preventable Chronic Disease, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Jacqueline A Boyle
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Sandra Campbell
- College of Nursing and Midwifery, Charles Darwin University, Cairns, Queensland, Australia
| | - Anna McLean
- Division of Wellbeing and Preventable Chronic Disease, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.,Department of Diabetes and Endocrinology, Cairns and Hinterland Hospital and Health Service, Cairns, Queensland, Australia
| | - David Peiris
- Centre for Health Systems Science, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Sumaria Corpus
- Danila Dilba Health Service, Darwin, Northern Territory, Australia
| | - Christine Connors
- Population & Primary Health Care, Top End Health Service, Northern Territory Department of Health, Darwin, Northern Territory, Australia
| | - Elizabeth Moore
- Aboriginal Medical Services Alliance Northern Territory, Darwin, Northern Territory, Australia
| | - Mark Wenitong
- School of Exercise and Nutrition Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Bronwyn Silver
- Central Australian Aboriginal Congress, Alice Springs, Northern Territory, Australia
| | - H David McIntyre
- Clinical Unit, Mater Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Jonathan E Shaw
- Aboriginal Health Domain, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Alex Brown
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Faculty of Health and Medical Science, University of Adelaide, Adelaide, South Australia, Australia
| | - Renae Kirkham
- Division of Wellbeing and Preventable Chronic Disease, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Louise Maple-Brown
- Division of Wellbeing and Preventable Chronic Disease, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.,Department of Endocrinology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
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Dyson J, Cowdell F. How is the Theoretical Domains Framework applied in designing interventions to support healthcare practitioner behaviour change? A systematic review. Int J Qual Health Care 2021; 33:6324052. [PMID: 34279637 DOI: 10.1093/intqhc/mzab106] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/21/2021] [Accepted: 07/19/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The use of theory is recommended to support interventions to promote implementation of evidence-based practices. However, there are multiple models of behaviour change which can be complex and lack comprehensiveness and are therefore difficult to understand and operationalize. The Theoretical Domains Framework sought to address these problems by synthesizing 33 models of behaviour or behaviour change. Given that it is 15 years since the first publication of the Theoretical Domains Framework (TDF), it is timely to reflect on how the framework has been applied in practice. OBJECTIVE The objective of this review is to identify and narratively synthesize papers in which the TDF, (including frameworks that incorporate the TDF) have been used have been used to develop implementation interventions. METHODS We searched MEDLINE, PsychINFO, CINAHL and the Cochrane databases using the terms: 'theoretical domains framework*' or TDF or Capability, Opportunity, Motivation to Behaviour (COM-B) or 'behav* change wheel' or 'BCW' AND implement* or improv* or quality or guideline* or intervention* or practice* or EBP or 'evidence based practice' and conducted citation and key author searches. The included papers were those that used any version of the TDF published from 2005 onwards. The included papers were subject to narrative synthesis. RESULTS A total of 3540 papers were identified and 60 were included. Thirty-two papers reported intervention design only and 28 reported intervention design and testing. Despite over 3000 citations there has been limited application to the point of designing interventions to support the best practice. In particular use of the framework has not been tried or tested in non-western countries and barely used in non-primary or acute care settings. Authors have applied the framework to assess barriers and facilitators successfully but reporting of the process of selection of behaviour change techniques and intervention design thereafter was variable. CONCLUSION Despite over three thousand citations of the framework there has been limited application to the point of designing interventions to support best practice. The framework is barely used in non-western countries or beyond primary or acute care settings. A stated purpose of the framework was to make psychological theory accessible to researchers and practitioners alike; if this is to be fully achieved, further guidance is needed on the application of the framework beyond the point of assessment of barriers and facilitators.
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Affiliation(s)
- Judith Dyson
- Healthcare Research and Implementation Science, Faculty of Health, Education and Life Sciences, Birmingham City University, Westbourne Road, Edgbaston, Birmingham B15 3TN, UK
| | - Fiona Cowdell
- Faculty of Health, Education and Life Sciences, Nursing and Healthcare Research, Birmingham City University, Westbourne Road, Birmingham B15 3TN, UK
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MacKay D, Kirkham R, Freeman N, Murtha K, Van Dokkum P, Boyle J, Campbell S, Barzi F, Connors C, O'Dea K, Oats J, Zimmet P, Wenitong M, Sinha A, Hanley AJ, Moore E, Peiris D, McLean A, Davis B, Whitbread C, McIntyre HD, Mein J, McDermott R, Corpus S, Canuto K, Shaw JE, Brown A, Maple-Brown L. Improving systems of care during and after a pregnancy complicated by hyperglycaemia: A protocol for a complex health systems intervention. BMC Health Serv Res 2020; 20:814. [PMID: 32867837 PMCID: PMC7461356 DOI: 10.1186/s12913-020-05680-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 08/21/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Many women with hyperglycaemia in pregnancy do not receive care during and after pregnancy according to standards recommended in international guidelines. The burden of hyperglycaemia in pregnancy falls disproportionately upon Indigenous peoples worldwide, including Aboriginal and Torres Strait Islander women in Australia. The remote and regional Australian context poses additional barriers to delivering healthcare, including high staff turnover and a socially disadvantaged population with a high prevalence of diabetes. METHODS A complex health systems intervention to improve care for women during and after a pregnancy complicated by hyperglycaemia will be implemented in remote and regional Australia (the Northern Territory and Far North Queensland). The Theoretical Domains Framework was used during formative work with stakeholders to identify intervention components: (1) increasing workforce capacity, skills and knowledge and improving health literacy of health professionals and women; (2) improving access to healthcare through culturally and clinically appropriate pathways; (3) improving information management and communication; (4) enhancing policies and guidelines; (5) embedding use of a clinical register as a quality improvement tool. The intervention will be evaluated utilising the RE-AIM framework at two timepoints: firstly, a qualitative interim evaluation involving interviews with stakeholders (health professionals, champions and project implementers); and subsequently a mixed-methods final evaluation of outcomes and processes: interviews with stakeholders; survey of health professionals; an audit of electronic health records and clinical register; and a review of operational documents. Outcome measures include changes between pre- and post-intervention in: proportion of high risk women receiving recommended glucose screening in early pregnancy; diabetes-related birth outcomes; proportion of women receiving recommended postpartum care including glucose testing; health practitioner confidence in providing care, knowledge and use of relevant guidelines and referral pathways, and perception of care coordination and communication systems; changes to health systems including referral pathways and clinical guidelines. DISCUSSION This study will provide insights into the impact of health systems changes in improving care for women with hyperglycaemia during and after pregnancy in a challenging setting. It will also provide detailed information on process measures in the implementation of such health system changes.
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Affiliation(s)
- D MacKay
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- Royal Darwin Hospital, Darwin, Australia
| | - R Kirkham
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - N Freeman
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - K Murtha
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - P Van Dokkum
- Baker Heart & Diabetes Institute Central Australia, Alice Springs, Australia
| | - J Boyle
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - S Campbell
- College of Nursing and Midwifery, Charles Darwin University, Cairns, Australia
| | - F Barzi
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - C Connors
- Top End Health Service, Northern Territory Department of Health, Darwin, Australia
| | - K O'Dea
- Population School of Health Research, University of South Australia, Adelaide, Australia
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - J Oats
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - P Zimmet
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia
| | - M Wenitong
- Apunipima Cape York Health Council, Bungalow, Australia
| | - A Sinha
- Cairns and Hinterland Hospital and Health Service, Cairns, Australia
| | - A J Hanley
- Department of Nutritional Sciences, Faculty of Medicine and the Dalla Lana School of Public Health, The University of Toronto, Toronto, Canada
| | - E Moore
- Aboriginal Medical Services Alliance Northern Territory, Darwin, Australia
| | - D Peiris
- The George Institute for Global Health, Sydney, Australia
| | - A McLean
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- Cairns and Hinterland Hospital and Health Service, Cairns, Australia
| | - B Davis
- Cairns and Hinterland Hospital and Health Service, Cairns, Australia
| | - C Whitbread
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- Royal Darwin Hospital, Darwin, Australia
| | - H D McIntyre
- Mater Medical Research Institute, University of Queensland, Brisbane, Australia
| | - J Mein
- Wuchopperen Health Service, Cairns, Australia
| | - R McDermott
- Centre for Chronic Disease Prevention, Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, Australia
| | - S Corpus
- Danila Dilba Health Service, Darwin, Australia
| | - K Canuto
- South Australian Health and Medical Research Institute, Adelaide, Australia
| | - J E Shaw
- Aboriginal Health Domain, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - A Brown
- South Australian Health and Medical Research Institute, Adelaide, Australia
- Faculty of Health and Medical Science, University of Adelaide, Adelaide, Australia
| | - L Maple-Brown
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
- Royal Darwin Hospital, Darwin, Australia.
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Wood A, MacKay D, Fitzsimmons D, Derkenne R, Kirkham R, Boyle JA, Connors C, Whitbread C, Welsh A, Brown A, Shaw JE, Maple-Brown L. Primary Health Care for Aboriginal Australian Women in Remote Communities after a Pregnancy with Hyperglycaemia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17030720. [PMID: 31979123 PMCID: PMC7037226 DOI: 10.3390/ijerph17030720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 01/20/2020] [Accepted: 01/20/2020] [Indexed: 01/24/2023]
Abstract
Background: Hyperglycaemia in pregnancy contributes to adverse outcomes for women and their children. The postpartum period is an opportune time to support women to reduce cardiometabolic and diabetes risk in subsequent pregnancies. Aims: To identify strengths and gaps in current care for Aboriginal women after a pregnancy complicated by hyperglycaemia. Methods: A retrospective review of the 12 month postpartum care provided by primary health centres in remote Australia in 2013–2014 identified 195 women who experienced hyperglycaemia in pregnancy (gestational diabetes (GDM) (n = 147), type 2 diabetes (T2D) (n = 39), and unclear diabetes status (n = 9)). Results: Only 80 women (54%) with GDM had postpartum glycaemic checks. Of these, 32 women were diagnosed with prediabetes (n = 24) or diabetes (n = 8). Compared to women with GDM, women with T2D were more likely to have their weight measured (75% vs. 52%, p <0.01), and smoking status documented as “discussed” (65% vs. 34%, p < 0.01). Most women (97%) accessed the health centre at least once in the 12 month postpartum period but, during these visits, only 52% of women had service provision, either structured or opportunistic, related to diabetes. Conclusion: High rates of dysglycaemia among women screened for T2D after GDM in the 12 month postpartum period highlight the need for increased screening and early intervention to prevent the development of T2D and its complications. Whilst a clear strength was high postpartum attendance, many women did not attend health services for diabetes screening or management.
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Affiliation(s)
- Anna Wood
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0810, Australia; (A.W.)
- Endocrinology Department, Division of Medicine, Royal Darwin Hospital, Darwin, NT 0810, Australia
| | - Diana MacKay
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0810, Australia; (A.W.)
- Endocrinology Department, Division of Medicine, Royal Darwin Hospital, Darwin, NT 0810, Australia
| | - Dana Fitzsimmons
- Northern Territory Department of Health, Darwin, NT 8000, Australia
| | - Ruth Derkenne
- Northern Territory Department of Health, Darwin, NT 8000, Australia
| | - Renae Kirkham
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0810, Australia; (A.W.)
| | - Jacqueline A. Boyle
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0810, Australia; (A.W.)
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3800, Australia
| | | | - Cherie Whitbread
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0810, Australia; (A.W.)
| | - Alison Welsh
- Northern Territory Department of Health, Darwin, NT 8000, Australia
| | - Alex Brown
- South Australia Health and Medical Research Institute, Adelaide, SA 5000, Australia
- Faculty of Health and Medical Science, University of Adelaide, Adelaide, SA 5005, Australia
| | - Jonathan E. Shaw
- Aboriginal Health Domain, Baker Heart and Diabetes Institute, Melbourne, VIC 3004, Australia;
| | - Louise Maple-Brown
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0810, Australia; (A.W.)
- Endocrinology Department, Division of Medicine, Royal Darwin Hospital, Darwin, NT 0810, Australia
- Correspondence:
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