Topics

The convergence of excessive heat, poor housing, energy insecurity and chronic disease has reached critical levels

Most Australians take safe housing and uninterrupted electricity for granted. Yet in remote Indigenous communities, low quality poorly insulated housing and energy instability are common.1 Most houses require prepaid power cards, resources are meagre, financial literacy is low, and people often have to choose between power and food. New evidence reveals extreme rates of prepaid electricity meters’ disconnection in these communities,2 making people with chronic diseases who depend on cool storage and electrical equipment particularly vulnerable. The convergence of excessive heat, poor housing, energy insecurity and chronic disease has reached critical levels in many parts of northern Australia, and a multisectoral response is needed to avert catastrophe. Medical professionals have a key role to play.

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1 Australian National University, Canberra, ACT
2 Julalikari Council Aboriginal Corporation, Tennant, Creek, NT
3 University Centre for Rural Health, Lismore, NSW

Correspondence: simon.quilty@anu.edu.au

Open access

Open access publishing facilitated by Australian National University, as part of the Wiley ‐ Australian National University agreement via the Council of Australian University Librarians.

Acknowledgements:

We thank Pandora Hope (Bureau of Meteorology) for her work on the climate maps.

Competing interests:

No relevant disclosures.

1. Lea T, Grealy L, Moskos M, et al. Sustainable Indigenous housing in regional and remote Australia — final report No. 368. Melbourne: Australian Housing and Urban Research Institute, 2021. https://www.ahuri.edu.au/research/final‐reports/368 (viewed Oct 2021).
2. Longden T, Quilty S, Riley B, et al. Energy insecurity during temperature extremes in remote Australia. Nature Energy 2022; 7: 43‐54.
3. Bureau of Meteorology. Annual Climate Summary for Northern Territory — Northern Territory in 2019: a very warm and dry year [9 Jan 2020]. http://www.bom.gov.au/climate/current/annual/nt/archive/2019.summary.shtml (viewed Oct 2021).
4. Abram M, Garrick M. Outback town smashes temperature records with 28 days above 40°C in one month. ABC News 2018; 27 Dec. https://www.abc.net.au/news/2018‐12‐27/bureau‐of‐meteorology‐says‐heat‐records‐broken‐in‐outback/10670438 (viewed Oct 2021).
5. Alice has hottest day on record. Alice Springs News 2018; 31 Dec. https://alicespringsnews.com.au/2018/12/31/alice‐has‐hottest‐day‐on‐record/ (viewed Oct 2021).
6. Layton JB, Li W, Yuan J, et al. Heatwaves, medications, and heat‐related hospitalization in older Medicare beneficiaries with chronic conditions. PLoS One 2020; 15: e0243665.
7. Gasparrini A, Armstrong B, Kovats S, Wilkinson P. The effect of high temperatures on cause‐specific mortality in England and Wales. Occup Environ Med 2012; 69: 56‐61.
8. Foster T, Hall NL. Housing conditions and health in Indigenous Australian communities: current status and recent trends. Int J Environ Health Res 2019; 31: 325‐343.
9. Bailie N, Main N. Environmental health survey year 2 evaluation. Indigenous housing authority of the Northern Territory. Casuarina: Cooperative Research Centre for Aboriginal and Tropical Health, 2002.
10. Northern Territory Government. Building outside of building control areas [website]. https://nt.gov.au/property/building/build‐in‐a‐controlled‐area/building‐control‐areas/building‐outside‐of‐building‐control‐areas (viewed Oct 2021).
11. Northern Territory Government, Department of Housing and Community Development. Property management — policy [reference No. 059; file HSG2016/01872‐5‐001]; 28 Sept 2018.
12. Australian Energy Regulator. Our role [website]. https://www.aer.gov.au/about‐us/our‐role (viewed Oct 2021).
13. Romero Rodríguez L, Sánchez Ramos J, Guerrero Delgado M, et al. Mitigating energy poverty: potential contributions of combining PV and building thermal mass storage in low‐income households. Energy Convers Manag 2018; 173: 65‐80.
14. World Health Organization. Accelerated stability studies of widely used pharmaceutical substances under simulated tropical conditions. WHO, 1986. https://apps.who.int/iris/handle/10665/61480 (viewed Oct 2021).
15. Yu J, Ouyang Q, Zhu Y, Shen H, Cao G, Cui W. A comparison of the thermal adaptability of people accustomed to air‐conditioned environments and naturally ventilated environments. Indoor Air 2012; 22: 110‐118.
16. Gruen RL. Evidence‐based advocacy: the public roles of health care professionals. Med J Aust 2008; 188: 684‐685. https://www.mja.com.au/journal/2008/188/12/evidence‐based‐advocacy‐public‐roles‐health‐care‐professionals
17. Evans EJ. The no‐wrong‐door approach: antidote to boundaries within the American welfare state. Health Soc Work 2019; 44: 8‐12.

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Perspectives

Birthing on Country for the best start in life: returning childbirth services to Yolŋu mothers, babies and communities in North East Arnhem, Northern Territory

Sarah Ireland, Yvette Roe, Suzanne Moore, Elaine Ḻäwurrpa Maypilama, Dorothy Yuŋgirrŋa Bukulatjpi, Evelyn Djota Bukulatjpi and Sue Kildea

Med J Aust 2022; 217 (1): . || doi: 10.5694/mja2.51586
Published online: 4 July 2022

Topics

Health occupations

Women's health

General medicine

First Nations Yolŋu women are speaking up to reclaim control and return of childbirth services

Over the millennia, First Nations women across Australia have given birth on their Country, supported by family and cultural caring practices, until recent disruption from European colonisation.1 Today, First Nations women, babies and families experience profound health inequities when comparing health outcomes to their Australian counterparts. A disproportionate number of First Nations women experience adverse outcomes in pregnancy and birth. For the past ten years, there has been little or no improvement in perinatal indicators. Maternal death for First Nations mothers is 3.7 times higher than for other Australian women,2 and perinatal deaths, largely driven by complications of pregnancy, are twice as high, although slightly improved between 2008 and 2018.3

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1 Molly Wardaguga Research Centre, Charles Darwin University, Darwin, NT
2 Molly Wardaguga Research Centre, Charles Darwin University, Brisbane, QLD
3 Yalu Aboriginal Corporation, Galiwin'ku, NT

Correspondence: sarah.ireland@cdu.edu.au

Open access

Open access publishing facilitated by Charles Darwin University, as part of the Wiley ‐ Charles Darwin University agreement via the Council of Australian University Librarians.

Acknowledgements:

Our work was supported by the Birthing on Country Centre for Research Excellence at the Molly Wardaguga Research Centre, Charles Darwin University (APP 1197110), a Lowitja Institute Seeding Grant (20‐SG‐12), and Yalu Aboriginal Corporation. Funding contributed to researcher salaries and costs associated with traveling to and hosting the regional workshop. We acknowledge Raisa Brozalevskaia from Charles Darwin University and Alice McCarthy from Yalu Aboriginal Corporation for their dedication and support of Yolŋu researchers.

Competing interests:

No relevant disclosures.

1. Ireland S, Maypilama EL, Roe Y, et al. Caring for Mum on Country: exploring the transferability of the Birthing on Country RISE framework in a remote multilingual Northern Australian context. Women Birth 2020; 34: 487‐492.
2. Australian Institute of Health and Welfare. Maternal deaths in Australia 2009–2018. Canberra: Australian Institute of Health and Welfare, 2020. https://www.aihw.gov.au/reports/mothers‐babies/maternal‐deaths‐in‐australia/contents/maternal‐deaths‐in‐australia (viewed Dec 2021).
3. Commonwealth of Australia. Closing the Gap report 2020. Canberra: Australian Government, 2020. https://ctgreport.niaa.gov.au/ (viewed Dec 2021).
4. Msall ME, Sobotka SA, Dmowska A, et al. Life course health development outcomes after prematurity: developing a community, clinical, and translational research agenda to optimize health, behaviour, and functioning. In: Halfon N, Forrest CB, Lerner RM, Faustman EM, editors. Handbook of life course health development. Cham: Springer International Publishing, 2018: pp. 321‐348. https://doi.org/10.1007/978‐3‐319‐47143‐3_14 (viewed Oct 2020).
5. Li L, O’Neil L. Mothers and babies 2017: Northern Territory Midwives’ Collection. Darwin: Department of Health, 2020. https://digitallibrary.health.nt.gov.au/prodjspui/bitstream/10137/11647/1/Mothers%20and%20Babies%20Report_2017.pdf (viewed Dec 2021).
6. Longman J, Kornelsen J, Pilcher J, et al. Maternity services for rural and remote Australia: barriers to operationalising national policy. Health Policy 2017; 121: 1161‐1168.
7. Rolfe MI, Donoghue DA, Longman JM, et al. The distribution of maternity services across rural and remote Australia: does it reflect population need? BMC Health Serv Res 2017; 17: 163.
8. Barclay L, Kornelsen J, Longman J, et al. Reconceptualising risk: Perceptions of risk in rural and remote maternity service planning. Midwifery 2016; 38: 63‐70.
9. Kildea S, McGhie AC, Gao Y, et al. Babies born before arrival to hospital and maternity unit closures in Queensland and Australia. Women Birth 2015; 28: 236‐245.
10. Maypilama L, Josse P, Ireland S. Djäkamirr: caretaker of pregnancy and birth [documentary film]. ONE20 Productions, 2021. https://www.birthingoncountry.com/djakamirr (viewed Dec 2021).
11. Kildea S, Lockey R, Roberts J, et al. Guiding principles for developing a Birthing on Country service model and evaluation framework, phase 1. Brisbane: Mater Medical Research Unit and the University of Queensland on behalf of the Maternity Services Inter‐Jurisdictional Committee for the Australian Health Ministers’ Advisory Council, 2016. https://www.researchgate.net/publication/309584016_Guiding_Principles_for_Developing_a_Birthing_on_Country_Service_Model_and_Evaluation_Framework_Phase_1 (viewed July 2021).
12. Kildea S, Gao Y, Hickey S, et al. Effect of a Birthing on Country service redesign on maternal and neonatal health outcomes for First Nations Australians: a prospective, non‐randomised, interventional trial. Lancet Glob Health 2021; 9: e651‐e659.
13. Kildea S, Hickey S, Barclay L, et al. Implementing Birthing on Country services for Aboriginal and Torres Strait Islander families: RISE framework. Women Birth 2019; 32: 466‐475.
14. Roberts L. NT Health Minister Natasha Fyles on returning birthing to remote and regional locations. ABC News 2021; 3 June. https://www.abc.net.au/news/health/2021‐06‐03/health‐nt‐health‐minister‐commits‐to‐birthing‐on‐country/100180990 (viewed May 2022).
15. Molly Wardaguga Research Centre. To be born upon a pandanus mat. https://www.birthingoncountry.com/to‐be‐born‐upon‐a‐pandanus‐mat (viewed May 2022).
16. Charles Darwin University. Molly Wardaguga Research Centre secures $5 million to support First Nations maternal health. 6 Apr 2022. https://www.cdu.edu.au/news/molly‐wardaguga‐research‐centre‐secures‐5‐million‐support‐first‐nations‐maternal‐health (viewed May 2022).
17. Kildea S, Gao Y, Hickey S, et al. Reducing preterm birth amongst Aboriginal and Torres Strait Islander babies: a prospective cohort study, Brisbane, Australia. EClinicalMedicine 2019; 12: 43‐51.

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Narrative review

Management of atopic dermatitis: a narrative review

Michelle SY Goh, Jenny SW Yun and John C Su

Med J Aust 2022; 216 (11): . || doi: 10.5694/mja2.51560
Published online: 20 June 2022

Topics

Skin and connective tissue diseases

Summary

Atopic dermatitis (atopic eczema) is the most common inflammatory skin disease and has a significant burden on the quality of life of patients, families and caregivers.
Its pathogenesis is a complex interplay between genetics and environment, involving impaired skin barrier function, immune dysregulation primarily involving the Th2 inflammatory pathway, itch, and skin microbiome.
Restoration of skin barrier integrity with regular emollients and prompt topical anti‐inflammatory therapies are mainstays of treatment. Systemic therapy is considered for moderate to severe disease.
New understanding of inflammatory pathways and developments in targeted systemic immunotherapies have significantly advanced atopic dermatitis management. Dupilumab is a safe and effective treatment that is now available in Australia. Other promising agents for atopic dermatitis include Janus kinase, interleukin (IL)‐13 and IL‐31 inhibitors.

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1 Peter MacCallum Cancer Centre, Melbourne, VIC
2 St Vincent’s Hospital Melbourne, Melbourne, VIC
3 Royal Melbourne Hospital, Melbourne, VIC
4 Eastern Health, Monash University, Melbourne, VIC
5 Murdoch Children’s Research Institute, Melbourne, VIC

Correspondence: michelle.goh@petermac.org

Competing interests:

John Su has been a consultant/speaker/investigator for AbbVie, Amgen, Bioderma, Bristol Myers Squibb, Ego Pharmaceuticals, Eli‐Lilly, Janssen, LEO Pharma, L’Oreal, Mayne, Novartis, Pfizer, Pierre‐Fabre, and Sanofi.

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40. Kobayashi T, Ito T, Kawakami H, et al. Eighteen cases of wheat allergy and wheat‐dependent exercise‐induced urticarial/anaphylaxis sensitized by hydrolyzed wheat protein in soap. Int J Dermatol 2015; 54: e302‐305
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47. Majewski S, Bhattacharya T, Asztalos M, et al. Sodium hypochlorite body wash in the management of Staphylococcus aureus‐colonized moderate‐to‐severe atopic dermatitis in infants, children, and adolescents. Pediatr Dermatol 2019; 36: 442‐447.
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Research letters

Effect of a financial incentive on responses by Australian general practitioners to a postal survey: a randomised controlled trial

Alison C Zucca, Mariko Carey, Rob W Sanson‐Fisher, Joel Rhee, Balakrishnan (Kichu) R Nair, Christopher Oldmeadow, Tiffany‐Jane Evans and Simon Chiu

Med J Aust 2022; 216 (11): . || doi: 10.5694/mja2.51523
Published online: 20 June 2022

Topics

Statistics, epidemiology and research design

General medicine

General practitioners view health and medical research positively, but their participation in postal surveys is typically low.1 Poor response rates reduce the sample size and consequently the generalisability of survey results.

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1 College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, NSW
2 Hunter Medical Research Institute (HMRI), Newcastle, NSW
3 University of Wollongong, Wollongong, NSW
4 Illawarra Health and Medical Research Institute, Wollongong, NSW

Correspondence: alison.zucca@newcastle.edu.au

Trial registration

Open Science Framework, doi: 10.17605/OSF.IO/VZMWJ; 30 September 2021 (retrospective).

Open access

Open access publishing facilitated by The University of Newcastle, as part of the Wiley ‐ The University of Newcastle agreement via the Council of Australian University Librarians.

Acknowledgements:

This study was supported by the National Health and Medical Research Council (NHMRC) with a Dementia Research Team grant (APP1095078) and by infrastructure funding from the Hunter Medical Research Institute. Mariko Carey is supported by an NHMRC Boosting Dementia Research Leadership Fellowship (APP1136168). We acknowledge Grace Norton for research assistance and^, Sandra Dowley for data entry (both University of Newcastle and Hunter Medical Research Institute), and Lucy Leigh for statistical analysis (Hunter Medical Research Institute).

Competing interests:

No relevant disclosures.

1. Cook JV, Dickinson HO, Eccles MP. Response rates in postal surveys of healthcare professionals between 1996 and 2005: an observational study. BMC Health Serv Res 2009; 9: 160.
2. Parkinson A, Jorm L, Douglas KA, et al. Recruiting general practitioners for surveys: reflections on the difficulties and some lessons learned. Aust J Prim Health 2015; 21: 254‐258.
3. Carey M, Zucca A, Rhee, J, et al. Essential components of health assessment for older people in primary care: a cross‐sectional survey of Australian general practitioners. Aust N Z J Public Health 2021; 45: 506‐511.
4. Pit SW, Vo T, Pyakurel S. The effectiveness of recruitment strategies on general practitioner’s survey response rates: a systematic review. BMC Med Res Methodol 2014; 14: 76.
5. Edwards PJ, Roberts I, Clarke MJ, et al. Methods to increase response to postal and electronic questionnaires. Cochrane Database Syst Rev 2009; 2009:MR000008.
6. Campbell MK, Weijer C, Goldstein CE, Edwards SJ. Do doctors have a duty to take part in pragmatic randomised trials? BMJ 2017; 357: j2817.

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Editorials

Beyond rural clinical schools to “by rural, in rural, for rural”: immersive community engaged rural education and training pathways

Roger P Strasser

Med J Aust 2022; 216 (11): . || doi: 10.5694/mja2.51525
Published online: 20 June 2022

Topics

Medical education

General medicine

Health services administration

Cradle‐to‐grave regional programs featuring immersive community engaged education are needed to ensure a sustainable rural medical workforce

In this issue of the MJA, Seal and colleagues1 report a multi‐university investigation that found that extended rural clinical school (RCS) placements have a positive impact on rural workforce recruitment and the retention of both rural and metropolitan origin medical graduates. The authors examined the practice locations of medical graduates, as listed in the Australian Health Practitioner Regulation Agency (AHPRA) register, five and eight years after graduation; many doctors were probably still registrars in training locations five years after graduation. The authors considered a limited range of variables in their study, and did not adjust their analyses for registrars who had received bonded or other scholarships, nor for factors such as incentives to relocate and employment opportunities for partners. Nevertheless, there is merit in their conclusion that their “findings reinforce the importance of longitudinal rural and regional training pathways, and the role of RCSs, regional training hubs, and the rural generalist training program in coordinating these initiatives.”1

1 Northern Ontario School of Medicine University, Sudbury, ON, Canada
2 Te Huataki Waiora School of Health, University of Waikato, Hamilton, New Zealand

Correspondence: roger.strasser@nosm.ca

Competing interests:

No relevant disclosures.

1. Seal AN, Playford D, McGrail MR, et al. Influence of rural clinical school experience and rural origin on practising in rural communities five and eight years after graduation. Med J Aust 2022; 216: 572‐577.
2. Australian Department of Health. National medical workforce strategy 2021–2031. 2021. https://www.health.gov.au/resources/publications/national‐medical‐workforce‐strategy‐2021‐2031 (viewed Apr 2022).
3. Strasser R. Will Australia have a fit‐for‐purpose medical workforce in 2025? Med J Aust 2018; 208: 198‐199. https://www.mja.com.au/journal/2018/208/5/will‐australia‐have‐fit‐purpose‐medical‐workforce‐2025
4. Strasser R, Strasser S. Reimagining primary health care workforce in rural and underserved settings [discussion paper: Health, Nutrition, and Population Global Practice of the World Bank]. Aug 2020. https://openknowledge.worldbank.org/handle/10986/34906 (viewed Apr 2022).
5. Strasser R. Immersive community engaged education: more community engaged learning than work‐integrated learning. In: Pretti J, Stirling A (ed). The practice of co‐op and work‐integrated learning in the Canadian context. Canada: World Association for Co‐op and Work‐Integrated Education (WACE), Co‐operative Education and Work‐Integrated Learning (CEWIL), 2021; pp. 72‐81.
6. Worley P, Couper I, Strasser R, et al; CLIC Research Collaborative. A typology of longitudinal integrated clerkships. Med Educ 2016; 50: 922‐932.
7. Strasser R. Students learning medicine in general practice in Canada and Australia. Aust Fam Physician 2016; 45: 22‐25.
8. Strasser R, Worley P, Cristobal F, et al. Putting communities in the driver’s seat: the realities of community engaged medical education. Acad Med 2015; 90: 1466‐1470.
9. Strasser R. Recruiting and retaining a rural medical workforce: the value of active community participation. Med J Aust 2017; 207: 154‐158. https://www.mja.com.au/journal/2017/207/4/recruiting‐and‐retaining‐rural‐medical‐workforce‐value‐active‐community
10. Abelsen B, Strasser R, Heaney D, et al. Plan, recruit, retain: a framework for local healthcare organizations to achieve a stable remote rural workforce. Hum Res Health 2020; 18: 63.

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Research

Selective personality‐targeted prevention of suicidal ideation in young adolescents: post hoc analysis of data collected in a cluster randomised controlled trial

Lucinda R Grummitt, Jennifer Debenham, Erin Kelly, Emma L Barrett, Katrina Champion, Patricia Conrod, Maree Teesson and Nicola Newton

Med J Aust 2022; 216 (10): . || doi: 10.5694/mja2.51536
Published online: 6 June 2022

Topics

Mental disorders

General medicine

Abstract

Objective: To assess the efficacy of a selective, personality‐targeted intervention for reducing suicidal ideation in adolescents.

Design: Post hoc analysis of survey data collected in the Climate and Preventure (CAP) study, a cluster randomised controlled trial that compared strategies for reducing alcohol misuse by adolescents, 2012–2015.

Setting, participants: Year 8 students at 16 New South Wales non‐government schools and one Victorian non‐government school.

Intervention: Preventure, a selective, personality‐targeted intervention designed to help adolescents with personality risk factors for alcohol misuse, comprising two 90‐minute sessions, one week apart. For our post hoc analysis, we combined data from the two CAP trial groups in which Preventure was offered (the Preventure and the Preventure/Climate Schools [a non‐selective prevention strategy] groups) as the intervention group; and data from the two groups in which Preventure was not offered (usual health education only [control] and Climate Schools groups) as the control group.

Main outcome measure: Difference between post hoc control and intervention groups in the change in proportions of students reporting suicidal ideation during the preceding six months (single item of Brief Symptom Inventory depression subscale) over three years.

Results: A total of 1636 students (mean age at baseline, 13.3 years; standard deviation, 0.5 years) were included in our analysis, of whom 1087 (66%) completed the suicidal ideation item in the three‐year follow‐up assessment. The post hoc control group included 755 students (nine schools), the intervention group 881 students (eight schools). After adjusting for nesting of students in schools and sex, reporting of suicidal ideation by students who had received Preventure had declined over three years, compared with the control group (per year: adjusted odds ratio, 0.80; 95% CI, 0.66–0.97).

Conclusion: Personality‐targeted selective prevention during early secondary school can have a lasting impact on suicidal ideation during adolescence.

Trial registration (CAP study only): Australian and New Zealand Clinical Trials Registry, ACTRN12612000026820 (prospective).

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1 The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, NSW
2 University of Montreal, Montreal, Canada
3 Sainte Justine Hospital Research Centre, University of Montreal, Montreal, Canada

Correspondence: lucinda.grummitt@sydney.edu.au

Acknowledgements:

The Climate and Preventure (CAP) study was funded by the National Health and Medical Research Council (APP1004744). We acknowledge the schools, students, teachers, and research assistants who were involved in the study. We also acknowledge the assistance of the New South Wales Department of Education and Communities for access to their schools (reference, SERAP 2011201).

Competing interests:

No relevant disclosures.

1. Australian Institute of Health and Welfare. Australian Burden of Disease Study: impact and causes of illness and death in Australia 2015 (Australian Burden of Disease series no. 19; Cat. no. BOD 22). Canberra: AIHW, 2019. https://www.aihw.gov.au/reports/burden‐of‐disease/burden‐disease‐study‐illness‐death‐2015 (viewed Sept 2021).
2. John A, Pirkis J, Gunnell D, et al. Trends in suicide during the COVID‐19 pandemic. BMJ 2020; 371: m4352.
3. Lifeline. More Australians than ever seeking crisis support [media release]. 4 Aug 2021. https://www.lifeline.org.au/media/yxab453i/20210804‐lifeline‐more‐australians‐than‐ever‐seeking‐support.pdf (viewed Sept 2021).
4. Tanaka T, Okamoto S. Increase in suicide following an initial decline during the COVID‐19 pandemic in Japan. Nat Hum Behav 2021; 5: 229‐238.
5. Michelmore L, Hindley P. Help‐seeking for suicidal thoughts and self‐harm in young people: a systematic review. Suicide Life Threat Behav 2012; 42: 507‐524.
6. Robinson J, Bailey E, Witt K, et al. What works in youth suicide prevention? A systematic review and meta‐analysis. EClinicalMedicine 2018; 4‐5: 52‐91.
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8. O’Connor RC, Nock MK. The psychology of suicidal behaviour. Lancet Psychiatry 2014; 1: 73‐85.
9. Gvion Y, Apter A. Suicide and suicidal behavior. Public Health Rev 2012; 34: 9.
10. Conrod PJ, Castellanos‐Ryan N, Mackie C. Personality‐targeted interventions delay the growth of adolescent drinking and binge drinking. J Child Psychol Psychiatry 2008; 49: 181‐190.
11. Conrod PJ. Personality‐targeted interventions for substance use and misuse. Curr Addict Rep 2016; 3: 426‐436.
12. Newton NC, Conrod PJ, Slade T, et al. The long‐term effectiveness of a selective, personality‐targeted prevention program in reducing alcohol use and related harms: a cluster randomized controlled trial. J Child Psychol Psychiatry 2016; 57: 1056‐1065.
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14. Kelly EV, Newton NC, Stapinski LA, et al. A novel approach to tackling bullying in schools: personality‐targeted intervention for adolescent victims and bullies in Australia. J Am Acad Child Adolesc Psychiatry 2020; 59: 508‐518.e2.
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16. Newton NC, Teesson M, Barrett EL, et al. The CAP study, evaluation of integrated universal and selective prevention strategies for youth alcohol misuse: study protocol of a cluster randomized controlled trial. BMC Psychiatry 2012; 12: 118.
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20. Woicik PB, Stewart SH, Pihl RO, Conrod P. The Substance Use Risk Profile Scale: a scale measuring traits linked to reinforcement‐specific substance use profiles. Addict Behav 2009; 32: 1042‐1055.
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23. Johnston AK, Pirkis JE, Burgess PM. Suicidal thoughts and behaviours among Australian Adults: findings from the 2007 National Survey of Mental Health and Wellbeing. Aust N Z J Psychiatry 2009; 43: 635‐643.
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27. Nock MK, Borges G, Bromet EJ, et al. Cross‐national prevalence and risk factors for suicidal ideation, plans and attempts. Br J Psychiatry 2008; 192: 98‐105.
28. Keyes KM, Gary D, O’Malley PM, et al. Recent increases in depressive symptoms among US adolescents: trends from 1991 to 2018. Soc Psychiatry Psychiatr Epidemiol 2019; 54: 987‐996.

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Editorials

Achieving person‐centred primary health care through value co‐creation

Tina Janamian, Paresh Dawda and Walid Jammal

Med J Aust 2022; 216 (10): . || doi: 10.5694/mja2.51538
Published online: 6 June 2022

Topics

General medicine

Health services administration

Global health

Value co‐creation supports the delivery of optimal person‐centred care in an efficient way

Primary health care is the backbone of a high performing and efficient health system and is most people’s first contact with the health care system.1,2 The supplement accompanying this issue of the MJA reports on initiatives and approaches that strive to build high performing person‐centred primary health care that is critical to achieving the Quadruple Aim, a well regarded framework for optimising the health care system by simultaneously focusing on improving patient experience, improving population health, reducing costs, and improving the health care team experience.3

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1 Client Focused Evaluation Program (CFEP) Surveys, Brisbane, QLD
2 University of Canberra, Canberra, ACT
3 Hills Family General Practice, Sydney, NSW
4 University of Sydney, Sydney, NSW

Correspondence: tina.janamian@cfepsurveys.com.au

Competing interests:

No relevant disclosures.

1. Levine O, Gawande A, Lagomarsino G, et al. A safer world starts with strong primary healthcare. BMJ Opinion 2020; 26 Oct. https://blogs.bmj.com/bmj/2020/10/26/a‐safer‐world‐starts‐with‐strong‐primary‐healthcare/ (viewed Apr 2022).
2. World Health Organization. Primary health care: closing the gap between public health and primary care through integration. Geneva: WHO, 2018. https://www.who.int/docs/default‐source/primary‐health‐care‐conference/public‐health.pdf (viewed Apr 2022).
3. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med 2014; 12: 573‐576.
4. Ramaswamy V, Ozcan K. What is co‐creation? An interactional creation framework and its implications for value creation. J Bus Res 2018; 84: 196‐205.
5. Porter ME, Teisberg EO. Redefining health care: creating value‐based competition on results. Harvard Business School Press, 2006.
6. The Economist Intelligence Unit. Value‐based healthcare: a global assessment. London: The Economist Intelligence Unit, 2016. https://impact.economist.com/perspectives/sites/default/files/EIU_Medtronic_Findings‐and‐Methodology_1.pdf (viewed Apr 2022).
7. Dawda P, Janamian T, Wells L. Creating person‐centred health care value together. Med J Aust 2022; 216 (10 Suppl): S3‐S4.
8. The Health Foundation. Person‐centred care made simple: what everyone should know about person‐centred care. The Health Foundation, 2016. https://www.health.org.uk/publications/person‐centred‐care‐made‐simple.
9. Janamian T, Greco M, Cosgriff D, et al. Activating people to partner in health and self‐care: the use of the Patient Activation Measure. Med J Aust 2022; 216 (10 Suppl): S5‐S8.
10. Hibbard JH, Mahoney ER, Stock R, et al. Do increases in patient activation result in improved self‐management behaviors? Health Serv Res. 2007; 42: 1443‐1463.
11. Hibbard J, Gilburt H. Supporting people to manage their health: an introduction to patient activation. London: The King’s Fund, 2014. https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/supporting‐people‐manage‐health‐patient‐activation‐may14.pdf (viewed Apr 2022).
12. Janamian T, True A, Dawda P, et al. Co‐creating education and training programs to build workforce capacity to support the implementation of integrated health care initiatives. Med J Aust 2022; 216 (10 Suppl): S9‐S13.
13. Dopp AR, Parisi KE, Munson SA, et al. Integrating implementation and user‐centred design strategies to enhance the impact of health services: protocol from a concept mapping study. Health Res Policy Syst 2019; 17: 1.
14. Janamian T, Dawda P, Crawford G, et al. Building capacity in those who deliver palliative care services to Aboriginal and Torres Strait Islander peoples. Med J Aust 2022; 216 (10 Suppl): S14‐S18.
15. True A, Janamian T, Dawda P, et al. Lessons from the implementation of the Health Care Homes program. Med J Aust 2022; 216 (10 Suppl): S19‐S21.
16. Primary Health Reform Steering Group. Recommendations on the Australian Government’s Primary Health Care 10 Year Plan. Canberra: Australian Government, 2021. https://consultations.health.gov.au/primary‐care‐mental‐health‐division/draft‐primary‐health‐care‐10‐year‐plan/supporting_documents/Primary%20Health%20Reform%20Steering%20Group%20%20Recommendations%20September%202021.pdf (viewed Apr 2022).
17. Australian Government Department of Health. Future focused primary health care: Australia’s Primary Health 10 Year Plan 2022‐2032. Canberra: Australian Government, 2022. https://www.health.gov.au/resources/publications/australias‐primary‐health‐care‐10‐year‐plan‐2022‐2032 (viewed Apr 2022).
18. McColl‐Kennedy JR, Green T, van Driel ML, et al. Value in primary care clinics: a service ecosystem perspective. Med J Aust 2022; 216 (10 Suppl): S22‐S23.
19. Dawda P, True A, Dickinson H, et al. Value based primary care in Australia: how far have we travelled? Med J Aust 2022; 216 (10 Suppl): S24‐S27.
20. Australian Government Department of Health. Australia’s Long Term National Health Plan to build the world’s best health system. Canberra: Australian Government, 2019. https://www.health.gov.au/sites/default/files/australia‐s‐long‐term‐national‐health‐plan_0.pdf (viewed Apr 2022).
21. Australian Medical Association. Delivering better care for patients: the AMA 10‐Year Framework for Primary Health Care Reform. Canberra: AMA, 2020. https://www.ama.com.au/sites/default/files/documents/The_AMA_10_Year_Framework_for_Primary_Care_Reform.pdf (viewed Apr 2022).
22. Consumers Health Forum of Australia. Election platform 2022: community health and wellness in the 21st century. Canberra: CHF, 2022. https://chf.org.au/sites/default/files/chf_electionplatform_2022_v4b‐digital.pdf (viewed Apr 2022).

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Perspectives

Should clinicians and the general population be concerned about seasonal affective disorder in Australia?

Adriana G Nevarez Flores, Emmanuelle CS Bostock and Amanda L Neil

Med J Aust 2022; 216 (10): . || doi: 10.5694/mja2.51518
Published online: 6 June 2022

Topics

Mental disorders

Anatomy and physiology

Seasonal affective disorder, a well documented syndrome in northern latitudes, has limited credence in Australia

Seasonal affective disorder (SAD), also known as “winter depression”, refers to the recurrence of major depressive episodes (for a minimum of 2 consecutive years) during a particular season, typically winter.1 While the construct is widely acknowledged,1,2,3 the condition is not recognised as a stand‐alone mental disorder by current classification systems. Rather, the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM‐5) includes “seasonal pattern” as a specifier for recurrent major depressive disorder,4 and the International Classification of Diseases, 11th revision (ICD‐11) has included “seasonal depressive disorder” under the category of “recurrent depressive disorder”.5 As such, the validity of the construct as an individual mental disorder remains debatable,6,7 with some suggesting the syndrome is a “temporary expression of a mood disorder rather than a specific disorder”.8 However, the condition’s potential as a stand‐alone disorder remains extant given both its continuous identification2,3,9,10 and the ongoing inclusion of seasonal pattern specifiers in diagnostic classification systems.

1 Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS
2 University of Tasmania, Hobart, TAS

Correspondence: adriana.nevarezflores@utas.edu.au

Competing interests:

No relevant disclosures.

1. Galima SV, Vogel SR, Kowalski AW. Seasonal affective disorder: common questions and answers. Am Fam Physician 2020; 102: 668‐672.
2. Meesters Y, Gordijn MC. Seasonal affective disorder, winter type: current insights and treatment options. Psychol Research Behav Manag 2016; 9: 317‐327.
3. Melrose S. Seasonal affective disorder: an overview of assessment and treatment approaches. Depress Res Treat 2015; 2015: 178564.
4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed. Arlington, VA: American Psychiatric Association, 2013; p 947.
5. World Health Organization. ICD‐11 International Classification of Diseases, 11th revision [website]. https://icd.who.int/ (viewed Apr 2022).
6. Murray G. SAD schmad: is seasonal affective disorder a valid construct? Aust N Z J Psychiatry 2017; 51: 18‐19.
7. Øverland S, Woicik W, Sikora L, et al. Seasonality and symptoms of depression: a systematic review of the literature. Epidemiol Psychiatr Sci 2020; 29: e31.
8. Cléry‐Melin ML, Gorwood P, Friedman S, Even C. Stability of the diagnosis of seasonal affective disorder in a long‐term prospective study. J Affect Disord 2018; 227: 353‐357.
9. Hobeika E, Haddad C, Akel M, et al. Factors associated with seasonal affective disorders in Lebanese adults. Perspect Psychiatr Care 2021; https://doi.org/10.1111/ppc.12933 [Epub ahead of print].
10. Fonte A, Coutinho B. Seasonal sensitivity and psychiatric morbidity: study about seasonal affective disorder. BMC Psychiatry 2021; 21: 317.
11. National Institute of Mental Health. Seasonal affective disorder [website]. https://www.nimh.nih.gov/health/publications/seasonal‐affective‐disorder (viewed Apr 2022).
12. National Health Service. Treatment — Seasonal affective disorder (SAD) [website]. https://www.nhs.uk/mental‐health/conditions/seasonal‐affective‐disorder‐sad/treatment/ (viewed Apr 2022).
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16. Hunt M. Are some people more at risk of getting SAD in winter? ABC Everyday 2020; 4 Aug. https://www.abc.net.au/everyday/are‐some‐people‐more‐at‐risk‐of‐getting‐sad‐in‐winter/12478178?msclkid=73a52507a67c11ec82452ed2f07c07bf (viewed Apr 2022).
17. Titov N, Thomas S. Please explain: what is seasonal affective disorder? The Lighthouse 2021; 10 June. https://lighthouse.mq.edu.au/article/please‐explain/june‐2021/Please‐explain‐What‐is‐seasonal‐affective‐disorder (viewed Apr 2022).
18. Healthdirect. Seasonal affective disorder (SAD) [website]. https://www.healthdirect.gov.au/seasonal‐affective‐disorder?msclkid=f4270065a67a11ec9f2ee097807e89d3 (viewed Apr 2022).
19. Beyond Blue. Feeling SAD (seasonal affective disorder) [website]. https://www.beyondblue.org.au/personal‐best/pillar/in‐focus/feeling‐sad‐seasonal‐affective‐disorder (viewed Apr 2022).
20. Danilenko KV, Levitan RD. Chapter 17: seasonal affective disorder. In: Shlaepfer TE, Nemeroff CB; editors. Handbook of clinical neurology; Vol. 106, Neurobiology of psychiatric disorders. Amsterdam: Elsevier, 2012; pp. 279‐289.
21. Lewy AJ, Rough JN, Songer JB, et al. The phase shift hypothesis for the circadian component of winter depression. Dialogues Clin Neurosci 2007; 9: 291‐300.
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23. Parslow RA, Jorm AF, Butterworth P, et al. An examination of seasonality experienced by Australians living in a continental temperate climate zone. J Affect Disord 2004; 80: 181‐190.
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25. Austen ML. Autonomic arousal and cognitive performance in seasonal affective disorder [PhD’s thesis]. Hobart: University of Tasmania, 2003; p 349.
26. Murray G. The Seasonal Pattern Assessment Questionnaire as a measure of mood seasonality: a prospective validation study. Psychiatry Res 2003; 120: 53‐59.

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Perspectives

The impact of COVID‐19 on chronic disease management in primary care: lessons for Australia from the international experience

Anne Parkinson, Sethunya Matenge, Jane Desborough, Sally Hall Dykgraaf, Lauren Ball, Michael Wright, Elizabeth A Sturgiss and Michael Kidd

Med J Aust 2022; 216 (9): . || doi: 10.5694/mja2.51497
Published online: 16 May 2022

Topics

Infectious diseases

General medicine

The continuation of chronic disease management in primary care remains essential during the COVID‐19 pandemic

International primary care responses to the coronavirus disease 2019 (COVID‐19) pandemic have seen the prioritisation of acute and urgent services for people with COVID‐19 as well as seeing many practitioners involved in COVID‐19 vaccination counselling and delivery.1,2 This prioritisation has often resulted in partial or complete disruption to chronic disease management (CDM),1 including care for conditions such as hypertension, diabetes and cancer.2 CDM in Australian primary care has been similarly disrupted, with reports of decreased time spent on CDM activities and preventive care,3 particularly for elements of care that require in‐person examination or testing,4 and delays in investigation, diagnosis, referred appointments and elective procedures, resulting in prolonged pain, anxiety and deterioration for patients.5 The introduction of telehealth items under the Medicare Benefits Schedule (MBS) may have both alleviated and contributed to disruption.5,6,7 Although early data suggested that there was little reduction in the total volume of services provided against the MBS, when accounting for telehealth services, and little change in medications used to manage chronic diseases,8 these data paint a complex and dynamic picture with differential changes in certain service types, such as allied health and referred and non‐referred services. A recent study from the United Kingdom has suggested that few studies have reported the impact of increases in COVID‐19‐related respiratory consultations in primary care and that these consultations might mask other reductions in service volume.9

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1 National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT
2 Australian National University, Canberra, ACT
3 Centre for Health Practice Innovation, Griffith University, Brisbane, QLD
4 Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, NSW
5 Monash University, Melbourne, VIC
6 COVID‐19 Primary Care Response Group, Australian Government Department of Health, Canberra, ACT

Correspondence: anne.parkinson@anu.edu.au

Competing interests:

No relevant disclosures.

1. Matenge S, Sturgiss E, Desborough J, et al. Ensuring the continuation of routine primary care during the COVID‐19 pandemic: a review of the international literature. Fam Pract 2021; doi: https://doi.org/10.1093/fampra/cmab115 [Epub ahead of print].
2. World Health Organization. Rapid assessment of service delivery for NCDs during the COVID‐19 pandemic 2020 https://www.who.int/publications/m/item/rapid‐assessment‐of‐service‐delivery‐for‐ncds‐during‐the‐covid‐19‐pandemic (viewed Dec 2021).
3. Halcomb E, McInnes S, Williams A, et al. The experiences of primary healthcare nurses during the COVID‐19 pandemic in Australia. J Nurs Scholarsh 2020; 52: 553‐563.
4. Dimopoulos‐Bick T, Walsh L, Sutherland K. Indirect impacts of COVID‐19: a case study of evidence, advice and representation from consumer and community members in New South Wales Australia. J Patient Exp 2021; 8: 2374373521998628.
5. Douglas K, O’Brien, Hall S, et al. Quick COVID Clinician Survey Summary (Australia), Series 9‐13 [preprint]. Ann Fam Med 2021; https://doi.org/10.7302/385.
6. Royal Australian College of General Practitioners. General practice: health of the nation 2020. https://www.racgp.org.au/health‐of‐the‐nation/health‐of‐the‐nation (viewed Dec 2021).
7. Javanparast S, Roeger L, Reed RL. Experiences of patients with chronic diseases of access to multidisciplinary care during COVID‐19 in South Australia. Aust Health Rev 2021; https://doi.org/10.1071/AH20328 [Epub ahead of print].
8. Australian Institute of Health and Welfare. Impacts of COVID‐19 on Medicare Benefits Scheme and Pharmaceutical Benefits Scheme service use [updated 17 Dec 2021]. https://www.aihw.gov.au/reports/health‐care‐quality‐performance/covid‐impacts‐on‐mbs‐and‐pbs/contents/impact‐on‐mbs‐service‐use (viewed Dec 2021).
9. Dambha‐Miller H, Hounkpatin HO, Morgan‐Harrisskitt J, et al. Primary care consultations for respiratory tract symptoms during the COVID‐19 pandemic: a cohort study including 70 000 people in South West England. Fam Pract 2021; https://doi.org/10.1093/fampra/cmab127 [Epub ahead of print].
10. Beran D, Aebischer Perone S, Castellsague Perolini M, et al. Beyond the virus: ensuring continuity of care for people with diabetes during COVID‐19. Prim Care Diabetes 2021; 15: 16‐7.
11. Mobula LM, Heller DJ, Commodore‐Mensah Y, et al. Protecting the vulnerable during COVID‐19: treating and preventing chronic disease disparities. Gates Open Res 2020; 4: 125.
12. Brey Z, Mash R, Goliath C, Roman D. Home delivery of medication during coronavirus disease 2019, Cape Town, South Africa: short report. Afr J Prim Health Care Fam Med 2020; 12: e1‐e4.
13. Haldane V, Zhang Z, Abbas RF, et al. National primary care responses to COVID‐19: a rapid review of the literature. BMJ Open 2020; 10: e041622.
14. Desborough J, Hall Dykgraaf S, de Toca L, et al. Australia’s national COVID‐19 primary care response. Med J Aust 2020; 213: 104‐106. https://www.mja.com.au/journal/2020/213/3/australias‐national‐covid‐19‐primary‐care‐response
15. Danhieux K, Buffel V, Pairon A, et al. The impact of COVID‐19 on chronic care according to providers: a qualitative study among primary care practices in Belgium. BMC Fam Pract 2020; 21: 255.
16. van Weert H. After the first wave: what effects did the COVID‐19 measures have on regular care and how can general practitioners respond to this? Eur J Gen Pract 2020; 26: 126‐128.
17. Franzosa E, Gorbenko K, Brody AA, et al. “At home, with care”: lessons from New York City home‐based primary care practices managing COVID‐19. J Am Geriatr Soc 2020; 69: 300‐306.
18. Williams R, Jenkins DA, Ashcroft DM, et al. Diagnosis of physical and mental health conditions in primary care during the COVID‐19 pandemic: a retrospective cohort study. Lancet Public Health 2020; 5: 543‐550.
19. Donohue D. A primary care answer to a pandemic: keeping a population of patients safe at home through chronic care management and remote patient monitoring. Am J Lifestyle Med 2020; 14: 595‐601.
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Perspectives

It is time to reinvest in quality improvement collaboratives to support Australian general practice

Andrew W Knight, John Fraser and C Dimity Pond

Med J Aust 2022; 216 (9): . || doi: 10.5694/mja2.51502
Published online: 16 May 2022

Topics

General medicine

Health occupations

Health services administration

Supporting improved general practice is urgent, and quality improvement collaboratives are an effective Australian strategy

Australia faces serious challenges to the effectiveness and sustainability of its health system, including barriers to access, rising costs, chronic disease rates, an ageing population, and overstretched hospitals.1,2 High quality primary care is recognised to underpin effective and efficient health systems.2,3,4 The coronavirus disease 2019 (COVID‐19) pandemic has starkly illuminated the problems and demonstrated the importance of supporting general practice for health care delivery in Australia.

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1 South Western Sydney Local Health District, Sydney, NSW
2 UNSW Sydney, Sydney, NSW
3 University of New England, Armidale, NSW
4 University of Newcastle, Newcastle, NSW

Correspondence: awknight@aapt.net.au

Acknowledgements:

Andrew Knight is a general practitioner who has written about the Australian Primary Care Collaboratives (APCC) as a participant, academic and leader. He is completing a PhD on the impact of the APCC. Dimity Pond is a GP researcher and educator with a special interest in dementia. John Fraser is a rural GP researcher and educator with a special interest in public health. We thank Michael Tam for providing advice on this manuscript.

Open access: Open access publishing facilitated by University of New South Wales, as part of the Wiley ‐ University of New South Wales agreement via the Council of Australian University Librarians.

Competing interests:

Andrew Knight received payment from the Improvement Foundation Australia in his role as Chair of the Expert Reference Panel on Access during the Australian Primary Care Collaboratives Program.

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2. Primary Health Reform Steering Group. Recommendations on the Australian Government’s Primary Health Care 10 Year Plan, September 2021. https://consultations.health.gov.au/primary‐care‐mental‐health‐division/draft‐primary‐health‐care‐10‐year‐plan/supporting_documents/Primary%20Health%20Reform%20Steering%20Group%20%20Recommendations%20September%202021.pdf (viewed Dec 2021).
3. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005; 83: 457‐502.
4. World Health Organization. Framework on integrated, people‐centred health services [15 Apr 2016]. http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_39‐en.pdf?ua=1&ua=1 (viewed Dec 2021).
5. Schneider EC, Shah A, Doty MM, et al. Mirror, Mirror 2021. Reflecting poorly: health care in the US compared to other high‐income countries. https://www.commonwealthfund.org/sites/default/files/2021‐08/Schneider_Mirror_Mirror_2021.pdf (viewed Dec 2021).
6. Australian Government Department of Health. Consultation draft. Future focused primary health care: Australia’s Primary Health Care 10 Year Plan 2022–2032. https://consultations.health.gov.au/primary‐care‐mental‐health‐division/draft‐primary‐health‐care‐10‐year‐plan/supporting_documents/PHC%2010%20Year%20Plan%20%20Consultation%20Draft%20%20October%202021.pdf (viewed Dec 2021).
7. Institute for Healthcare Improvement. The Breakthrough Series: IHI’s collaborative model for achieving breakthrough improvement — IHI Innovation Series white paper. Boston: IHI, 2003. http://www.ihi.org/resources/pages/ihiwhitepapers/thebreakthroughseriesihiscollaborativemodelforachievingbreakthroughimprovement.aspx (viewed Dec 2021).
8. Hulscher MEJL, Schouten LMT, Grol RPTM, Buchan H. Determinants of success of quality improvement collaboratives: what does the literature show? BMJ Qual Saf 2013; 22: 19‐31.
9. Nadeem E, Olin SS, Hill LC, et al. Understanding the components of quality improvement collaboratives: a systematic literature review. Milbank Q 2013; 91: 354‐394.
10. Schouten LMT, Hulscher MEJL, van Everdingen JJE, et al. Evidence for the impact of quality improvement collaboratives: systematic review. BMJ 2008; 336: 1491‐1494.
11. Wells S, Tamir O, Gray J, et al. Are quality improvement collaboratives effective? A systematic review. BMJ Qual Saf 2018; 27: 226‐240.
12. Zamboni K, Baker U, Tyagi M, et al. How and under what circumstances do quality improvement collaboratives lead to better outcomes? A systematic review. Implement Sci 2020; 15: 27.
13. Brown V, Fuller JD, Dunbar JA, Ford D. The enablers and barriers for the uptake, use and spread of primary health care collaboratives in Australia. APHCRI Centre of Research Excellence in Primary Health Care Microsystems, University of Queensland; 2014.
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15. Knight AW, Caesar C, Ford D, et al. Improving primary care in Australia through the Australian Primary Care Collaboratives program: a quality improvement report. BMJ Qual Saf 2012; 21: 948‐955.
16. Knight AW, Ford D, Audehm R, Colagiuri S, Best J. The Australian Primary Care Collaboratives program: improving diabetes care. BMJ Qual Saf 2012; 21: 956‐963.
17. Knight AW, Szucs C, Dhillon M, et al. The eCollaborative: using a quality improvement collaborative to implement the National eHealth Record System in Australian primary care practices. Int J Qual Health Care 2014; 26: 411‐417.
18. Knight AW, Dhillon M, Smith C, Johnson J. A quality improvement collaborative to build improvement capacity in regional primary care support organisations. BMJ Open Qual 2019; 8: e000684.

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