Health Education Research Advance Access originally published online on July 31, 2006
Health Education Research 2007 22(2):261-271; doi:10.1093/her/cyl068
Baseline survey of sun-protection knowledge, practices and policy in early childhood settings in Queensland, Australia
Skin Cancer Research Group, North Queensland Center for Cancer Research, School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, Queensland, Australia 4811
* Correspondence to: S. L. Harrison. E-mail: Simone.Harrison{at}jcu.edu.au
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Abstract |
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Excessive exposure to sunlight during early childhood increases the risk of developing skin cancer. Self-administered questionnaires exploring sun-protection knowledge, practices and policy were mailed to the directors/co-ordinators/senior teachers of all known early childhood services in Queensland, Australia, in 2002 (n = 1383; 56.5% response). Most (73.7%) services had a written sun-protection policy (SPP). However, 40.6% of pre-schools and kindergartens had not developed a written SPP. Most directors had moderate knowledge about sun-protection (median score: 7/12 [IQR 6, 8]), but few understood the UV index, the sun-protection factor rating for sunscreens or the association between childhood sun-exposure, mole development and melanoma. Pre-school teachers had lower knowledge scores than directors of long day care centers and other services (P = 0.0005). Staff members reportedly wore sun-protective hats, clothing and sunglasses more often than children. However, sunscreen use was higher among children than staff. Directors' knowledge scores predicted reported hat, clothing, sunscreen and shade utilization among children. Remoteness impacted negatively on director's knowledge (P = 0.043) and written SPP development (P = 0.0005). Higher composite sun-protection scores were reported for children and staff from services with written sun-protection policies. SPP development and increased sun-protection knowledge of directors may improve reported sun-protective behaviors of children and staff of early childhood services.
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Introduction |
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Skin cancer is the most frequently diagnosed cancer in Caucasian populations, with incidence rates increasing worldwide [1, 2]. The incidence of these cancers in Queensland, Australia, is among the highest in the world [3–6]. Sun-exposure has long been regarded as the major environmental risk factor for non-melanoma skin cancer [7] and melanoma [8, 9].
The most important phenotypic risk marker for melanoma is an increased total number of melanocytic nevi (moles) [8], and children raised in Queensland develop common [10–12] and atypical nevi [13] earlier and in higher numbers than children who grow up elsewhere. Consequently, it has been suggested that minimizing sun-exposure in the early years of life is likely to have a greater impact on the incidence of skin cancer than strategies focussed on reducing sun-exposure later in life [14].
In recent years, the number of children attending child care in Australia has increased dramatically [15]. Likewise, the average amount of time Australian children spend in child care has also increased, with some young children spending up to 12 500 hours in child care before starting school (i.e. only 500 hours less than Australian children spend in lessons during 13 years of schooling) [15]. Because many children spend most of their daylight hours in child care, early childhood services play a major role in determining the amount of sunlight to which these children are exposed, which in turn influences their future risk of developing skin cancer. Thus, it is important that good sun-protection practices are adopted by early childhood services, particularly those situated in the ultraviolet radiation (UVR) intense environment of Queensland.
The duty of care of child care services includes adequately protecting children, staff and visitors from harm caused by the sun by developing and implementing appropriate sun-protection policies and practices [16]. The Child Care Act 2002 includes specific regulations regarding sun-protection, and represents minimum quality standards for licensed child care services in Queensland [16]. The act covers child care centers, kindergartens, occasional care centers, limited hours care centers and family day care schemes. In addition, long day care centers in Australia are accredited through the Quality Improvement and Accreditation System (QIAS) administered by the National Childcare Accreditation Council (NCAC) [16].
Children often attend child care services during the peak UVR period of 10.00 a.m. to 2.00 p.m., and as such, early childhood services play a major role in determining the amount of sunlight to which children in their care are exposed [16]. On average, Queensland children spend more time in child care, than children from other Australian states [17], thus it is particularly important that good sun-protection practices are adopted by services situated in this intense UVR environment.
Queensland's Skin Cancer Prevention Strategic Plan 2001–2005 was developed in 2001 through the partnership of government, non-government and community organizations with the aim of providing a framework for a co-ordinated, sustainable, statewide approach to skin cancer prevention [18]. The plan takes a settings approach to skin cancer prevention, and one of the six key settings identified in the plan is the early childhood setting. The anticipated outcomes of this strategic plan in relation to early childhood settings include ‘improving the sun-protective knowledge, awareness and behaviors of children, their parents and early childhood staff’ and ‘increasing the development and implementation of sun-protection policies within early childhood settings’ [18]. The present study was commissioned prior to implementing the educational strategies proposed in the strategic plan, to provide data about the sun-protection knowledge of early childhood directors/senior staff; the adequacy of sun-protective behaviors practiced by children and staff members at each service and the proportion of Queensland-based services with sun-protection policies. In addition, we sought to identify gaps in knowledge that could be addressed in future educational strategies targeting early childhood settings. These data will serve as a baseline from which, improvements in sun-protection knowledge, behavior and policy can be measured.
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Methods |
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Ethical approval was obtained from the James Cook University Ethics Review Committee prior to commencing a statewide (Queensland) survey of skin cancer prevention knowledge, policy and practice in the early childhood sector.
In consultation with the Queensland Skin Cancer Prevention Strategic Plan Early Childhood Implementation Group, we developed a self-administered questionnaire by adapting one used previously by the Cancer Council of New South Wales [19]. The survey was piloted in 25 early childhood services in Townsville during May 2002. The final 10-page questionnaire contained 67 questions seeking information about the sun-protection practices, strategies and written or unwritten (e.g. no hat no play rule) policies currently in use in each of these services. The questionnaire also sought information about the knowledge of skin cancer and sun-protection of the present director, co-ordinator or senior pre-school teacher in each of these services. Mailing lists were obtained for all licensed early childhood services operating in Queensland in 2002 with the assistance of the Department of Families, Queensland; the Queensland branch of the Creche and Kindergarten Association; Education, Queensland; the Association of Independent Schools, Queensland; Lutheran Education, Queensland and Catholic Education, Queensland (five diocesan offices, including Cairns, Townsville, Rockhampton, Toowoomba and Brisbane). The lists were checked for duplication before the questionnaires were dispatched. A total of 2450 early childhood services (including long day care centers, family day care schemes, state- and privately funded pre-schools, kindergartens, limited hours care facilities and occasional care facilities) were identified. In June 2002, the director, co-ordinator or senior pre-school teacher responsible for each of the services was sent a copy of the postal survey, a letter explaining the purpose of the survey and a reply paid envelope. Several weeks after the original mail-out, attempts were made to follow-up non-respondents by phone, fax or email as appropriate. At least two follow-up attempts were made to each non-respondent.
All data were treated as confidential. Paper-based records were stored in a locked filing cabinet and only de-identified data were entered into the password protected electronic database.
Statistical analysis
Categorical variables were expressed as proportions, while numerical variables [including director's knowledge and composite sun-protection scores (CSPSs)] were described using median values and inter-quartile ranges (IQRs) together with mean values and standard deviations (±SD). Bivariate analysis utilized chi-square tests (Chi2), Fisher's exact tests, t-tests and non-parametric Kruskal–Wallis (KW) tests as appropriate. Data analyses were performed using SPSS for Windows release 11.0.1 [20].
Participants were asked to answer 12 knowledge questions (eight true/false/unsure questions and four multiple-choice questions) about skin cancer and sun-protection. Individual knowledge scores were generated by scoring one point for each correct answer and zero for each incorrect, unsure or missing response, to achieve a maximum possible score of 12. The median skin cancer risk and sun-protection knowledge scores achieved by the respondents were compared by the type of service (four categories: long day care center, family day care, pre-school/kindergarten and other), its governance (six categories: commercial/private, community-based, state pre-school, non-state pre-school, local government and other), license capacity (divided into quartiles: 1–25, 26–48, 49–74, 75–650 children) and remoteness, as defined by the Australian Standard Geographical Classification Remoteness Areas classification (ASGC) [21] using the KW test. A CSPS incorporating reported use of hats, sunscreen, sunglasses and clothing was calculated separately for the children and staff of participating centers by scoring 0 for using the item ‘none of the time when outside’, 100 for ‘all of the time when outside’ and using the mid-point for the categories ‘some’ (25%), ‘most’ (65%) and ‘nearly all’ (90%) of the time when outside, for each of the four sun-protection items. These scores were summed to produce a score out of 400 for all services that provided adequate information, and were considered in relation to type of service, governance, license capacity and remoteness using the KW test, and in relation to directors' skin cancer and sun-protection knowledge scores using linear regression.
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Results |
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Completed questionnaires were received from 1383 (56.5%) Queensland-based early childhood services, of which, more than half were pre-schools or kindergartens (Table I). The license capacity of these services ranged from 9 to 650 children, with a median of 50 [IQR 25, 74], and the majority (82.8%) provided care for pre-school age children (Range: 0–18 years; median: youngest 3 years [IQR 1 month, 4 years], oldest 5 years [IQR 5, 6]).
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Knowledge of skin cancer risk and sun-protection
Respondents' knowledge about the relationship between sun-exposure and skin cancer was generally good (Table II). However, their knowledge of the specific risk factors associated with melanoma was poor and the majority did not know that the most important risk determinant for melanoma is the number of moles. Their knowledge of the link between mole development and sun-exposure in early childhood was also poor. Most respondents (92.8%) had heard of the UV index, but only 79.2% thought they understood the term. When asked a multiple-choice question about a UV index of 13, only 20% of respondents answered correctly. Their knowledge of correct timing of application of sunscreens, and their understanding of the sun-protection factor (SPF) rating system used for sunscreens was also poor.
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Overall, the median skin cancer and sun-protection knowledge score was 7 out of 12 [IQR 6, 8] and the mean was 7.41 ± 1.67, with only nine respondents (<1%) achieving a perfect score. Median knowledge score did not vary with license capacity of the service (KW df 3, P = 0.369) or type of early childhood service (KW df 3, P = 0.092). However, the knowledge score of directors of commercial/private (median 8 [IQR 7, 9], mean 7.62), ‘other’ (median 8 [IQR 7.75, 9.25], mean 8.4) and community-based (median 7 [IQR 7, 9], mean 7.52) services was, on average, higher than that of senior teachers working in state (median 7 [IQR 6, 8], mean 7.12) and non-government pre-schools (median 7.5 [IQR 6, 8], mean 7.44) or local government centers (median 7 [IQR 7, 8], mean 7.33; KW df 5, P = 0.0005). Directors' knowledge scores tended to decrease with remoteness, ranging from a median of 7 [IQR 7, 9] and a mean of 7.58 ± 1.53 for services in major cities to a median of 7 [IQR 6, 8] and a mean of 6.75 ± 2.16 for those located in very remote areas (KW df 4, P = 0.043).
Reported sun-protection practices
The respondents were asked to estimate the proportion of children and staff who wore a broad-brimmed or legionnaire style hat, SPF 30+ sunscreen, sunglasses and clothing that offers protection from the sun when outdoors at the facility, year round, with the options being none of the time, some of the time (1–50%), most of the time (51–80%), nearly all the time (>80%) and all the time (Table III). A higher proportion of staff than children wore sun-protective hats, clothing and sunglasses most of the time when outdoors, whereas sunscreen use was slightly higher among children than staff. Apart from sunglasses (which are generally not encouraged in early childhood settings due to the risk of injury), suitable clothing was the least used form of personal sun-protection among children (Table III). Higher directors' knowledge scores were associated with higher rates of reported hat (P = 0.014), clothing (P = 0.043), sunscreen (P = 0.0005) and shade (P = 0.005) use among the children.
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CSPSs incorporating hat, sunglasses, clothing and sunscreen use were lower for children (median 220 [IQR 166.5, 270.5], mean 215.3) than staff (median 290 [IQR 216, 345], mean 275.4; t-test P = 0.0005; Table IV), and remained so, even when frequency of use of sunglasses was excluded from the sun-protection score (t-test P = 0.0005). CSPS varied significantly according to the type of service, with long day care centers achieving the highest scores for both children and staff (Table IV). CSPS for children (P = 0.0005) and staff (P = 0.012) were also associated with higher directors' knowledge scores, and children's CSPS were also higher in large to very large services (license capacity in the upper half of distribution: KW df 3, P = 0.0005). However, license capacity had no bearing on the CSPS for staff (KW df 3, P = 0.844), and remoteness was not associated with CSPS for either group (children: KW df 4, P = 0.983; staff: KW df 4, P = 0.341).
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Sun-protection policy
Almost all (90.8%) of the 1366 services that answered the question reported that they had a sun-protection policy (SPP). Family day care services were the least likely to have developed and implemented a SPP, with only 53.7% having done so. In contrast, 99.2% of long day care centers reported having a SPP (Chi2 df 3, P = 0.0005). Most (81.2%) of the services that reported having a SPP had a written policy (overall 73.7% have a written policy). However, only 28.8% of those with a written SPP provided us with a copy, as requested in the questionnaire. A considerable proportion (40.6%) of pre-schools and kindergartens either had no SPP (12%) or only had an ‘unwritten’ policy (28.6%), with state pre-schools accounting for most (77.5%, 162 of 209) of these. In contrast, almost all (97.8%) long day care centers had a written SPP (Chi2 df 3, P = 0.0005).
Most of the services with written SPPs reported developing them around 1999 ([IQR 1996, 2000]; range 1970–2002). While the majority (70.1%) of SPPs had been subsequently reviewed, 26% had never been reviewed and 3.9% reported that their policy was due for review.
Remoteness had a significant negative impact on the development of a written SPP (Chi2 df 8, P = 0.0005) with 78.5% of services in major cities having written SPPs compared with 75.1 and 74.1%, respectively, in inner and outer regional areas, 58.5% in remote areas and only 48.8% for services located in very remote parts of Queensland. Directors' knowledge scores were also higher in services that had a written SPP (median 7 [IQR 7, 9], mean 7.5) than in services with an unwritten policy or no SPP (both median 7 [IQR 6, 8] means 7.2 and 7, respectively; KW df 2, P = 0.012).
CSPS for children increased significantly according to whether the service had no SPP (median 180.5 [IQR 116, 220], mean 173.9), an unwritten SPP (median 190.5 [IQR 130, 245], mean 187.1) or a written SPP (median 230 [IQR 181, 280], mean 226.4; KW df 2, P = 0.0005). The same trend was evident for CSPS for staff (no SPP, median 251 [IQR 181, 314.1], mean 249.9; unwritten SPP, median 280.5 [IQR 213.1, 330], mean 268.6 and written SPP, median 290.5 [IQR 220.5, 355], mean 279.3; KW df 2, P = 0.001).
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionConflict of interest statementAcknowledgementsReferences |
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The major findings of this study were that most directors had moderate knowledge about sun-protection, and that pre-school teachers had lower knowledge scores than directors of long day care centers and other services. Staff members reportedly wore hats, sun-protective clothing and sunglasses more often than children. However, sunscreen use was higher among children than staff. Sun-protective behavior was generally better in those centers where the directors had good sun-protection knowledge. Although services with written sun-protection policies reported better sun-protective behavior than centers without such policies, a disturbing number of pre-schools and kindergartens had not developed a written SPP.
Although most directors who responded to the survey had a moderate level of knowledge about skin cancer risk and sun-protection (median knowledge score 7 out of 12), there were significant gaps in their understanding of the relationship between excessive sun-exposure during early childhood and mole development [11], and that of mole frequency and future risk of melanoma [8]. Furthermore, most directors had little understanding of the meaning of the SPF rating reported on Australian sunscreen products, and many did not understand the global solar UV index. This index was devised by the World Health Organization to provide a simple measure of the anticipated maximum intensity of UVR on a particular day, at a particular location, and was designed first to raise public awareness about the adverse health effects of excessive UV-exposure, second to educate the public about the variation in UV levels and third to encourage them to protect themselves accordingly [22, 23]. Since its publication in 1995, UV-index forecasts have increasingly been broadcast with weather bulletins in many countries [22, 23], including Australia [24]. In this survey, awareness of the UV index among directors of Queensland-based early childhood services was high (92.8%), but only 20% of them could interpret the index correctly. Blunden et al. [25] found similar evidence of underutilization of the UV index by Australians in a Perth study in 1999, in which 90% of the public had heard of the UV index, but only 5% took notice of the daily UV forecast. Although a mass media campaign to increase public awareness of the UV index in Australia is probably not warranted, the development of educational tools that link behavior change messages to UV index levels should be considered [25].
Remoteness impacted negatively on director's knowledge and written SPP development, indicating that it is important to provide educational resources for early childhood workers based in rural and remote areas. Remoteness represents poor access to services and may also reflect social inequality. The provision of on-line resources may reduce some of the disadvantages caused by remoteness.
Interestingly, despite their tertiary education, pre-school teachers had a lower mean sun-protection knowledge score than the directors of commercial or community-based early childhood services. In Australia, long day care centers (which account for the majority of commercial services and a considerable proportion of community-based services) are required to meet minimum quality assurance (QA) standards to achieve accreditation through the QIAS [16]. Directors may have higher sun-protection knowledge because sun safety is included in the minimum QA standards. Australia's QA system, which was established in 1993, was the first in the world to be linked to federal government child care funding, thus providing strong financial incentives for long day care centers to comply with the QIAS process [26]. In July 2001, the NCAC introduced a similar QA process for family day care schemes, and outside school hours care facilities were included in 2003 [26]. However, the QA process does not extend to pre-schools and kindergartens. The preparation of regular self-study reports for the QA review process may have motivated long day care center directors to seek further information in order to develop or update their service's SPP, resulting in improved knowledge of skin cancer and sun-protection. However, we are unable to substantiate this supposition, as there are no comparable data documenting the level of sun-protection knowledge held by long day care center directors in Queensland prior to the introduction of these QA systems.
SPP development was associated with better sun-protection knowledge of directors, and both variables were associated with better reported sun-protective behavior of children and staff. As this was a cross-sectional study, the directionality of the association is uncertain. It is possible that increased sun-protection knowledge among administrators may lead to the development of SPPs and better sun-protection practices. Alternatively, the process of developing a SPP (e.g. QA expectation) may be the stimulus that leads some directors to acquire information which improves their knowledge and influences their commitment to implementing sun-protective practices. Our findings are similar to those of Schofield and Walkom [27] who showed that sun-protection practices were more prevalent in child care centers when a comprehensive SPP was in place. Thus, encouraging the development of SPPs and improving the knowledge of administrators about sun-protection are strategies that employers could use to enhance sun-protection behavior in early childhood services.
The majority (73.7%) of the services that responded to our survey had a written SPP, and a further 17.1% had an ‘unwritten’ SPP (e.g. ‘no hat, no play’). Although research investigating SPP and sun-protective behavior across the whole early childhood sector is limited, the proportion of long day care centers in Queensland with a written SPP (97.8%) was similar to that reported for child care centers in New South Wales (97%) in 1999 [28], but substantially higher than that reported for child care centers in Colorado (56%) [29] and Michigan, USA (13%) [30].
The SunSmart Early Childhood Center Program offered by the Queensland Cancer Fund (launched November 2000) assists early childhood services to develop and implement a SPP (Queensland Cancer Fund, 2003). As only 59.4% of pre-schools and kindergartens (compared with 97.8% of long day care centers) had developed a written SPP by mid-2002, providing incentives for teachers to obtain ‘SunSmart’ accreditation for their pre-school may increase the number who develop SPPs. Given that state pre-schools accounted for 77.5% of the pre-schools/kindergartens with ‘unwritten’ SPPs, Education, Queensland, could encourage participation in this program and thus enhance sun-protection knowledge and SPP development, and ultimately improve the sun-protective behavior of pre-school children and staff in Queensland. The SunSmart Program could also be used as a model to encourage the development and implementation of SPPs in early childhood services in other countries with a high incidence of skin cancer.
An important issue not considered here in detail was the availability and use of shade structures. It has been suggested that a more careful design of shade structures in schools may decrease the UV exposure of adolescents [31] and we have observed that attractive shady environments encourage shade use in outdoor pre-school settings (A. F. Moise and S. L. Harrison, unpublished data). Furthermore, recent studies suggest that the attractiveness of the outdoor physical environment, and purposeful architecture such as welcoming shade and strategic positioning of attractive play constructions are important moderators of shade utilization by children [32]. As shade provision is such an important issue in shaping sun-protective behavior in early childhood settings, key individuals within these settings should be aware of the role of built environments in improving sun-protection.
The results presented here are based on self-reported data and were not confirmed by direct observation, as this was not feasible in such a large, statewide survey. Therefore, some respondents, particularly those with greater knowledge about sun-protection, may have over-reported the sun-protective practices of staff and children at their service because they were aware of our interest in sun-exposure, giving rise to an ‘observer-expectancy’ effect. Given that sun-protective behaviors are valued in our society, the possibility of social desirability bias cannot be discounted. In addition, the response rate (56.5%) was less than optimal due to the short timeframe available (driven by the need to begin implementing strategies identified in the strategic plan), and because there were few opportunities for personalized follow-up for some types of early childhood services. Thus, the possibility of selection bias cannot be excluded. There were no apparent differences in known demographic characteristics, such as the remoteness of those who returned the completed questionnaire, and those who did not, other than type of service. The response from family day care services was lower than for other ‘center-based’ services, and feedback from family day care co-ordinators revealed that the questionnaire was difficult for them to complete because they manage multiple home-based care situations and are not in constant contact with, nor regularly observing carers in the way that a center-based director managing a single facility can. Thus, family day care services are under-represented in this sample and the results for this group should be interpreted with caution. If such a bias were in effect, services with SPPs and greater confidence in their sun-protection habits would tend to be more likely to participate, thus resulting in an overestimate the true proportion of services with a SPP and good sun-protection practices, and demonstrating that there is still room for improvement in SPP development (particularly in pre-schools, kindergartens and family day care settings) and sun-protection behavior (particularly in relation to the proportion of children who wear clothing that offers reasonable protection) in Queensland-based early childhood services.
In conclusion, early childhood services can help protect children by educating them about sun-protective habits, serving as role models, providing supportive environments and encouraging sun-protective behavior. The SunSmart Early Childhood Centers Program [16] and a QA program specifying minimum standards for sun-protection in early childhood services are two successful models which could be used to encourage SPP development and improve the sun-protection knowledge and habits of staff and children in early childhood services elsewhere. Our results also suggest that novel educational tools, whose reach extends into metropolitan, regional, rural and remote areas, are required to increase the public's understanding of the UV index, sunscreen SPF ratings and the relationship between sun-exposure, mole development and melanoma.
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Conflict of interest statement |
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None declared.
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Acknowledgements |
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TopAbstractIntroductionMethodsResultsDiscussionConflict of interest statementAcknowledgementsReferences |
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The authors thank Rosemary Sallway, Dianne Clee, Judy Woosnam and Jenny Darr for research assistance; the members of the Queensland Early Childhood Implementation Group for helping to adapt the questionnaire and Louise Baldwin for her assistance in acquiring funding for this project from Queensland Health. This research was supported by Queensland Health and the Parkes Bequest to James Cook University.
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References |
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Received on July 12, 2005; accepted on June 5, 2006
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