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Associate Professor Sophia Couzos
- 1. Associate Professor Sophia Couzos NACCHO Members’ Conference and Annual General Meeting 2017 Aboriginal health in Aboriginal hands | www.naccho.org.au Stay connected, engaged and informed with NACCHO www.naccho.org.au/connect ‘Our Health Counts: Yesterday, Today and Tomorrow’ National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people Third edition
- 2. A resource for primary health practitioners, supporting best practice preventive healthcare for Aboriginal and Torres Strait Islander people Easily accessible, accurate, current and relevant NACCHO and RACGP are preparing the third edition LAUNCH February 2018 The National Guide
- 3. Aboriginal health in Aboriginal hands | www.naccho.org.au Stay connected, engaged and informed with NACCHO www.naccho.org.au/connect A third edition of the National Guide is now being developed through a partnership between the National Aboriginal Community Controlled Health Organisation (NACCHO) and the Royal Australian College of General Practitioners (RACGP). A/Prof Sophia Couzos (QAIHC Consultant Public Health Physician) is leading the revision on behalf of the NACCHO. In partnership with Ms Kate Freeman (RACGP Project Coordinator), and Professor David Peiris (George Institute), and Dr Tim Senior (RACGP). NACCHO-RACGP partnership
- 4. National Guide Background • 2001, NACCHO commenced work with support coalition of non- government organisations. • 2003, NACCHO completed first version. • 2005, 1st edition published published with a NACCHO-RACGP partnership. • 2012, 2nd edition published with a NACCHO-RACGP partnership. • 2016, NACCHO-RACGP partnership formed again for the development of the 3rd Edition. Funded by the Australian Government Department of Health. Launch in Feb 2018. In 2000, National Guide conceived by Dr Sophia Couzos and the late Dr Puggy Hunter (on behalf of NACCHO).
- 5. Aim • Develop a national reference for evidence-based advice for primary health care providers to assist them to provide preventive care to Aboriginal and Torres Strait Islander people throughout their lifespan, and To assist health professionals to maximise the opportunity for the prevention/early detection of disease in each clinic visit.
- 6. Snapshot There are 17 chapters With ~23 subsections With 27 authors (mostly GP writers) With ~40 expert external reviewers And many reviews from peak bodies (pending)
- 7. Aboriginal health in Aboriginal hands | www.naccho.org.au Stay connected, engaged and informed with NACCHO www.naccho.org.au/connect We invited and selected authors with experience within the ACCHS sector or in Aboriginal health settings. David Thomas, David Peiris, Lea Merone, Jenny Hunt, Libby Hindmarsh, Kelsey Hegarty, Marguerite Tracy, Has Gunasekara, Mary Belfrage, James Fitzpatrick, Rebecca Pedruzzi, Annapurna Nori, Sandra Meihubers, Malcolm McDonald, Nitya Malhotra, Naomi Houston, Amanda Leach, Jacki Mein, Lea Merone, Tim Senior, Vicki Slinko, Penny Abbott, Anne Chang, Tim Usherwood, Justin Coleman, Nadia Lusis, Emma Fitzsimons. GP authors:
- 8. Aboriginal health in Aboriginal hands | www.naccho.org.au Stay connected, engaged and informed with NACCHO www.naccho.org.au/connect Each section was sent to an expert (and external person) to review the work: Rowena Ivers, Elizabeth Denney-Wilson, Ben Ewald, Kate Conigrave, Mark Harris, Malcolm Battersby, Marilyn Clarke, Frank Beard, David Atkinson, Patrick Patradoon-Ho, Jonathan Craig, Carmela Pestell, James Fitzpatrick, Salina Bernard, Sherry Saggers, Leon Flicker, Hugh Taylor, Kelvin Kong, Simon Wooley, Anne Chang, Paul Torzillo, Graeme Maguire, Jonathan Carapetis, Anthony Rodgers, Andrew Boyden, Lydia Scott, Alan Cass, Steven Skov, Lewis Marshall, Lisa Whop, Gail Garvey, Greg Dore, Jenny Reath, Bruce Armstrong, Kwun Fong, Summer May Finlay, Pat Dudgeon, Ernest Hunter. Expert reviewers:
- 9. How supportive were our contributors? REALLY REALLY
- 10. What are the topics? 1. Lifestyle Smoking Overweight/obesity Physical activity Alcohol Gambling Family abuse and violence 3. Child health Immunisation Anaemia Growth failure Childhood kidney disease Interventions to prevent child maltreatment Fetal Alcohol Spectrum Disorder 4. The health of young people Psychosocial assessment Unplanned pregnancy Illicit drug use 2. Antenatal care Assessment first antenatal visit Smoking cessation Genitourinary and BBV infections Alcohol consumption Nutritional assessment and supplementation Diabetes
- 11. What are the topics? 6. Eye health Visual acuity Trachoma and trichiasis 7. Hearing loss 8. Oral and Dental health 10. Acute Rheumatic Fever and Rheumatic heart disease 9. Respiratory health Pneumococcal disease prevention Influenza Asthma Chronic obstructive pulmonary disease Bronchiectasis and chronic suppurative lung disease 5. The health of older people Osteoporosis Vit D and calcium supplementation Falls Dementia 11. Cardiovascular disease prevention For people without an established diagnosis of CVD For people with an established diagnosis of CVD
- 12. What are the topics? 12. Type 2 diabetes prevention and early detection 13. CKD prevention and management 14. Sexual health and blood- borne viruses 15. Prevention and early detection of cancer Prevention of cervical cancer Prevention and early detection of liver cancer Prevention and early detection of breast cancer Prevention and early detection of colorectal cancer Early detection of prostate cancer Lung cancer 17. Mental health Depression prevention Suicide prevention Screening for stress 16. Family abuse and violence
- 13. New topics in the third edition • Fetal alcohol spectrum disorder • Interventions to prevent child maltreatment – optimising health and wellbeing • Antenatal care section expanded • Family abuse and violence • Lung cancer • Young people lifecycle summary wall chart
- 14. Each topic explored these levels of prevention • avoids the development of a disease Primary • aims at early disease detection, (preventing progression and emergence of symptoms) Secondary • reduces the negative impact of an already established disease (eg preventing complications). Tertiary National Guide focussed on primary/seco ndary levels. X
- 15. Each topic categorised preventive interventions into 5 types • Immunisation • Screening • Behavioural • Chemoprophylaxis • Environmental Some interventions ‘universal’; some ‘selective’. Exploring social determinants
- 16. Methodology PROJECT REFERENCE GROUP Methodology Editorial committee reviewed recommendations & evidence-base (iterative) Authors searched for: evidence-based guidelines; then systematic reviews and meta-analyses; then primary research evidence. In the absence of this information, consensus- based guidelines, or expert opinion. External expert reviews External organisational reviews Categorised and critically appraised the information; Constructed recommendations to template NACCHO/RACGP- Reviewed/obtained GP feedback on first edition. Outlined new content; prepared clear literature review methodology for authors. Authors invited largely from ACCHS sector. Appointed clinical editor.
- 17. Aboriginal health in Aboriginal hands | www.naccho.org.au Stay connected, engaged and informed with NACCHO www.naccho.org.au/connect NACCHO representative (Ms Dawn Casey) RACGP Chair of the National Faculty Aboriginal and Torres Strait Islander Health (Peter O’Mara) RACGP representative (Nick Zwar) ACRRM representative (David Atkinson) NACCHO Affiliate representative (Nadia Lusis) NACCHO Project Lead (Sophia Couzos) Clinical Lead (David Peiris) RACGP Manager (Aboriginal and Torres Strait Islander Health- Michelle Gonsalvez) Project Reference Group:
- 18. Aboriginal health in Aboriginal hands | www.naccho.org.au Stay connected, engaged and informed with NACCHO www.naccho.org.au/connect Exploring the National Guide Fetal alcohol spectrum disorder
- 19. Aboriginal health in Aboriginal hands | www.naccho.org.au Stay connected, engaged and informed with NACCHO www.naccho.org.au/connect
- 20. Aboriginal health in Aboriginal hands | www.naccho.org.au Stay connected, engaged and informed with NACCHO www.naccho.org.au/connect
- 21. Screening: FASD (1) This is the most important strategy to prevent FASD
- 24. Screening: FASD (2) Fitzpatrick J, Pedruzzi R. Child health: Fetal alcohol spectrum disorder (chapter 3). In: National Guide, 3rd edn). DRAFT. Reviewed by: Craig J; Pestell C.DRAFT Screening/assessin g for child development is specialised! Reference to these tools are included, but require additional training and sometimes a fee.
- 25. Assess developmental milestones using a variety of simple methods.
- 26. Aboriginal health in Aboriginal hands | www.naccho.org.au Stay connected, engaged and informed with NACCHO www.naccho.org.au/connect Exploring the National Guide Screening for risky drinking. How should health professionals do this?
- 27. Merone L. Lifestyle: Alcohol (chapter 1). In: National Guide, 3rd edn). DRAFT. Reviewed by: Conigrave K; Harris M.DRAFT Recommendations unchanged from 2nd Edition. Exception is the scoring for AUDIT- C tool. “Screening can be performed via a simple patient history as part of routine consultation, or using brief questionnaires as an aid.”
- 28. Cut-off scores recommended for use with Aboriginal peoples and Torres Strait Islanders: • AT-RISK: >=5 • HIGH-RISK: >=6 • Likely to be dependant drinkers: >=9 (Validated in a 2014 report of a study comparing AUDIT scores with AUDIT-C in rural NSW and Sydney recruited patients from ACCHS and community-based ATODS). >=4>=5
- 29. Calabria et al. Identifying Aboriginal-specific AUDIT-C and AUDIT-3 cutoff scores for at- risk, high-risk, and likely dependent drinkers using measures of agreement with the 10- item Alcohol Use Disorders Identification Test. Addict Sci Clin Pract. 2014 Sep 1;9:17 This survey used plain language wording
- 30. Aboriginal health in Aboriginal hands | www.naccho.org.au Stay connected, engaged and informed with NACCHO www.naccho.org.au/connect National key performance indicator
- 31. Aboriginal health in Aboriginal hands | www.naccho.org.au Stay connected, engaged and informed with NACCHO www.naccho.org.au/connect Exploring the National Guide Assessment of absolute cardiovascular risk
- 32. Aboriginal health in Aboriginal hands | www.naccho.org.au Stay connected, engaged and informed with NACCHO www.naccho.org.au/connect Draft 3rd Edn- Recommendation: National Guide Peiris D. Cardiovascular disease prevention (chapter 11). In: National Guide, 3rd edn). DRAFT. Reviewed by Boyden A; Rodgers A.
- 33. Absolute CV risk assessment
- 34. Validation and recalibration of the Framingham cardiovascular disease risk models in an Australian Indigenous cohort (Hua, et al. Eur J Prev Cardio, 2017)
- 35. Aboriginal health in Aboriginal hands | www.naccho.org.au Stay connected, engaged and informed with NACCHO www.naccho.org.au/connect National key performance indicator
- 36. Aboriginal health in Aboriginal hands | www.naccho.org.au Stay connected, engaged and informed with NACCHO www.naccho.org.au/connect NKPIs should be evidence- based • The measures of performance of Aboriginal health services should at least reflect what is recommended as ‘best practice’. • nKPIs have implications for the funding of Aboriginal health services. • For example: the new proposed funding model for ACCHSs is to factor a proportion of the calculation of funding on how well the service has ‘performed’ based on nKPI indicators. • [Use of AUDIT-C is not one of the 7 nKPIs proposed, but it might be in the future]. • ‘Government policy’ should not be leading clinical practice and influencing clinical choices. • nKPI results are not accurate measures of morbidity. • The recommendations of the National Guide can help NACCHO and Affiliates to advocate for systems and resourcing to support best practice.
- 37. Launch Feb 2018 National Guide website – smartphone friendly Distribution of printed National Guide to all ACCHSs across Australia Workshops Podcasts, newsletters, social media promotion NACCHO Implementation Officer National Guide next steps
- 38. Implementing the National Guide We want your input!
- 39. Type ‘gosoapbox’ in google. Click on ‘join event’ as shown.
- 41. For more information contact: Assoc Prof Sophia Couzos, General Practice and Rural Medicine, James Cook University Email: sophia.couzos@jcu.edu.au Kate Freeman, Project Coordinator, RACGP Aboriginal and Torres Strait Islander Health Email: kate.freeman@racgp.org.au Lauren Trask, NACCHO National Guide Implementation Officer Email: ltrask@qaihc.com.au
Editor's Notes
- Methods Development of the National Guide comprised three stages: Review of the second edition online survey & key informant interviews 2a) Evidence review project reference group defined scope new topics tbc through stakeholder consultation/user review 2b) Formulation of recommendations by authors with experience within Aboriginal and Torres Strait Islander health services 3) Editorial review, expert review and stakeholder consultation clinical editor review draft topics draft topics to independent expert reviewers editorial team project reference group drafts to peak organisations Practical User-friendly Best-practice in preventive healthcare for Aboriginal and Torres Strait Islander people Clinical guidelines - can also be utilised in strategic planning, curriculum planning, education and policy making
- Survey: A diverse sample was sought to include representatives from Aboriginal Community Controlled Health Services (ACCHSs), other Aboriginal health services, general practices and government departments working in urban, rural and remote settings. Use of the National Guide varied considerably, with staff from ACCHSs reporting greatest usage. A range of health professionals accessed the National Guide including general practitioners, public health medical officers, practice nurses and Aboriginal and Torres Strait Islander Health Workers. The National Guide was used for clinical care, teaching, developing policies and guidelines for best practice, general information, designing health practice protocols, and developing research and quality improvement questions. Whilst most respondents considered it important to have a separate preventive health guide for Aboriginal peoples and Torres Strait Islanders, a number of people recommended greater consistency in recommendations between it and the RACGP Guidelines for preventive activities in general practice (Red Book)
- Maybe one or two people said that they couldn’t contribute. This demonstrates the level of support for this product.
- To provide oversight, approval and strategic guidance – including feedback, expert advice and diverse perspectives to guide NACCHO and RACGP in fulfilling the update to the National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander people. The responsibilities of the Project Reference Group include: provide advice and expertise to guide decision making on the delivery of the project plan provide diverse perspectives, input and feedback into the project at key stages contribute to the identification of barriers and solutions pertaining to project dilemmas, risks and issues provide representation of the perspectives, views and interests of the departments and organisations represented champion the project outside the Project Reference Group raise the profile of Aboriginal and Torres Strait Islander health issues commit to attending all meetings as required and reading agenda papers prior to attending meeting maintain a high level of understanding in relation to Aboriginal and Torres Strait Islander health issues confirm project outcomes align with NACCHO and RACGP strategic objectives confirm project closure
- Consistent with first edition, authors were advise to think systematically. Otherwise you will miss a variety of options and restrict your scope. Immunisation involves the administration of vaccines to prevent the onset of infectious disease. • Screening involves the systematic detection and management of disease before symptoms develop. Screening is warranted when management of the disease in the preclinical phase confers benefits beyond those from when the person becomes symptomatic and seeks clinical help. Examples include screening for diabetes, cancer, osteoporosis and high cardiovascular risk. • Behavioural interventions involve any interventions that target the actionsa person may take for the purpose of promoting or maintaining health (eg. physical activity), or brief interventions, for example, to support smoking cessation or safe sex. • Chemoprophylaxis involves the use of medication to prevent the onsetof disease or reduce the risk of acquiring disease: for example, use ofangiotensin converting enzyme inhibitors to prevent kidney disease and the use of antiviral drugs to prevent influenza. • Environmental influences include community and public health focused structural interventions that are considered relevant to primary care practitioners either via direct implementation or via involvement in peripheral activities such as advocacy and liaison with other agencies. It also includes systems based interventions conducted in the health service. Examples include community based programs to ensure improved food supply, school based interventions, implementation of systematic recall and reminder system, advocacy to government stakeholders for local/regional liquor licencing regulations, and involvement of the health service in social marketing activities.
- Screening for facial features for children is not an effective strategy to prevent FASD. Screening for problem drinking and drinking in pregnancy is. Reminder: What is risky drinking? Drinking that exceeds guidelines. Screening for alcohol use in pregnancy, and offering appropriate intervention or referral to a specialist alcohol treatment service is an important strategy to prevent FASD Alcohol consumption is common among Australian women, including women of childbearing age. National survey data suggests that about 50–60% of Australian women drink in pregnancy.(21, 22) Most pregnant women report ceasing drinking alcohol once they find out that they are pregnant. However one in four continue to drink even once they know they are pregnant. Of those who continue to drink, 96% report drinking 1–2 standard drinks on a typical drinking occasion. Although data from a large national survey indicate that only 20% of Aboriginal and Torres Strait Islander women drink in pregnancy,(23) it has also been reported that a greater proportion of Aboriginal and Torres Strait Islander women (compared to non-Aboriginal women) drink alcohol at high-risk levels. Some communities have identified problem drinking in pregnant women and taken action. Safe drinking in pregnancy is no drinking. (the NG does not state that).
- How much alcohol does it take to cause FASD? Unknown, conclusion is that no amount is safe. *Alcohol is a teratogen. Effect of explosure may vary from person to person. Higher quality- greater risk.
- Doctors are often untrained in making a FASD diagnosis. The diagnosis is not just based on facial features. Facial features are not always present. FASD is often diagnosed in middle childhood as the learning and behavioural difficulties become more apparent as children enter early schooling. This is especially the case for children with milder impairments, and those without the characteristic facial features Diagnosis requires referral to a peadistrician. GPs often worried about raising this issue. There may be concerns amongst clinicians that a label of FASD will stigmatise the mother and affected individual. Clinicians may also have the belief that there is little that can be done to alleviate the effects of FASD. For these reasons there may be a reluctance to ask about prenatal alcohol exposure.
- The NG recommends this: Early pick-up – early referral for interventions. Sophie comments to James and Rebecca: Given that all the resources listed are specialised tools for developmental assessment by trained personnel (PEDS, etc), it is impractical to recommend that 'all children exposed" to prenatal alcohol be referred to specialist assessment. I therefore wonder about modifying this rec to read: "All children exposed to alcohol in the prenatal period (AUDIT-C score >0 in any trimester, with parental or clinician concern about not meeting normal developmental milestones". [we might need to modify it to say that]. The chapter could also benefit from a brief snapshot of normal developmental milestones. Do you have one we could use?
- Denver develpmental scale and CDC resources (new). Australian Government document for Early Years Learning Framework Practice Based Resources - Developmental Milestones. [Undated]. Qld Health FACTsheets from about 10 years ago- different ages per sheet. The Australian Early Development Census (AEDC) is a nationwide data collection of early childhood development at the time children commence their first year of full-time school. The AEDC highlights what is working well and what needs to be improved or developed to support children and their families by providing evidence to support health, education and community policy and planning. The AEDC is held every three years, with the 2015 AEDC data collection being the third collection. The census involves teachers of children in their first year of full-time school completing a research tool, the Australian version of the Early Development Instrument. The Instrument collects data relating to five key areas of early childhood development referred to as ‘domains’, these include: Physical health and well being Social competence Emotional maturity Language and cognitive skills Communication skills and general knowledge The AEDC domains have been shown to predict later health, wellbeing and academic success.
- Text states the above. The actual recs state to ‘use’. Mmm… ambiguous. Should state- consider using… (like the 2nd edn). The Alcohol Use Disorders Identification Test (AUDIT) was developed by the World Health Organization as a cross-cultural screening instrument for problematic alcohol use [10,11]. AUDIT has high internal consistency across diverse samples and settings (median alpha = 0.83) “The AUDIT-C tool provides a shorter version for circumstances where time is limited. Neither tool has been specifically, nor reliably, validated in the Aboriginal and Torres Strait Islander populations. However, some studies have demonstrated their value (32,33) and currently they are the most commonly used tools in this population.(34) Using AUDIT-C, it is recommended that those who reach a cut-off score of equal to or greater than 5 are deemed to be ‘at risk’, those with a score equal to or greater than 6 ‘high risk’, and those with a score equal to or greater than 9 are potentially alcohol dependent.(32) Alternatively, the Indigenous Risk Impact Screen (IRIS; see ‘Resources’) tool can be used. It comprises 13 questions designed to assist in identifying drug and alcohol problems, along with mental health risks, in Aboriginal and Torres Strait Islander people.(35) The IRIS tool has proven to be consistent with other screening tools such as AUDIT and is recommended as a brief screening tool for use with the Aboriginal and Torres Strait Islander people.(27,36) The CAGE tool has been used in many Aboriginal health settings to screen for hazardous drinking, but has been reported to have very low sensitivity for detecting risky or hazardous drinking. According to the Agency for Healthcare Research and Quality in the US, it is not recommended as a screening test for identifying risky or hazardous drinking or for screening for the full spectrum of alcohol misuse.(31) Measures such as liver function tests should not be relied on as a primary screen for alcohol dependency and should only be used as adjuncts owing to their low sensitivity and specificity.(17)”
- I have not been able to source a reference for the score of >=4!!! USPSTF report on screening to reduce alcohol misuse: “For the AUDIT-C, the appropriate cut-points for balancing sensitivity and specificity appear to be ≥ 2 or 3 for women and >= 4 for men”.64 64. Bradley KA, DeBenedetti AF, Volk RJ, et al. AUDIT-C as a brief screen for alcohol misuse in primary care. Alcohol Clin Exp Res. 2007 Jul; 31(7):1208-17. PMID: 17451397. This is for screening adults for the full spectrum of alcohol misuse in primary care. (as opposed to ‘risky/hazardous drinking’ and alcohol abuse/dependance). These are the three categories referred to in the USPSTF report. In the Australian review, the categories were: ‘at risk, high-risk and likely dependant drinkers’. Addict Sci Clin Pract. 2014 Sep 1;9:17. doi: 10.1186/1940-0640-9-17. Identifying Aboriginal-specific AUDIT-C and AUDIT-3 cutoff scores for at-risk, high-risk, and likely dependent drinkers using measures of agreement with the 10-item Alcohol Use Disorders Identification Test. Calabria B1, Clifford A, Shakeshaft AP, Conigrave KM, Simpson L, Bliss D, Allan J. AUDIT-C score of risky alcohol consumption cluster (dischargee) Note: Meteor: http://meteor.aihw.gov.au/content/index.phtml/itemId/483163 Responses to each question on the AUDIT are scored from 0 to 4, with a maximum possible score over the three questions being 12. A score of 6 or more on the AUDIT may indicate a risk of alcohol-related harm. [So the AIHW state this!!!].
- Aboriginal adaptation- FYI. These (136) participants were recruited through existing community-based groups run by the ACCHS (58% of the sample) or clients of the drug and alcohol treatment agency who were seeking treatment (11% of the sample). Participants were also recruited through existing Aboriginal community-based groups in metropolitan Sydney. [Basically some came from rural NSW, and others from metro Sydney). AUDIT-C scores were calcuated relative to cutoff scores on the 10-item AUDIT for at-risk, high-risk, and likely dependent drinkers. [ie there is no gold-standard comparison). “The optimal combination of sensitivity and specificity for at-risk drinkers was reached using a cutoff score of ≥ 5 for AUDIT-C. This cutoff score identified 85 percent of at-risk drinkers, as classified by the 10-item AUDIT, and 81 percent of those identified as not being at increased risk. The positive and negative predictive values were both greater than 0.80.” “ Further study is required to determine if the current recommended AUDIT cutoff scores (and hence AUDIT-C and AUDIT-3 cutoff scores) should be revised downward, to allow detection of anyone drinking over current recommended limits (e.g., 20 g daily or 40 g on any one occasion in Australia)” AUDIT-3 is the 3rd Q in this list and is a single question. The authors state this can be used with a cut-off score: >=1 (for at risk) >= 2 for high risk, and >= 3 for likely dependant drinkers.
- Example of tables.
- FRE- recalibration and validation in north Qld Aboriginal and TSI peoples. Created new chart- followed for median of 10 years and compared actual CV events (probability) with risk estimates. The recalibrated version of the FRE chart shows no SS difference in risk estimates from that observed (5 years). This chart does not have the same effect as a 5%increment. Ie adding 5% overestimates CV risk in those younger but seems to be more reflective of risk with a 5% increase for those 55 years and over. This shows that the issues is complex. On the one hand, as a GP you might be overestimating CV risk in your patients and putting them on medication when they don’t need it it yet, depending on which assessment tool you use. This also has implications for the nKPI reporting as some ACCHSs are using the CARPA increment and others are not. This wlll affect reporting on the NKPI CV risk RESULT. Study findings are not applicable to urban populations (only Notth Qld) also may not be appliable to all Qld. Select group of patients in a survey. , Validation and recalibration of the Framingham cardiovascular disease risk models in an Australian Indigenous cohort European journal of Preve;;;nd~w;..,...., CardioiCII)' ‘ Xinyang Hua 1, Robyn McDermott2, Thomas Lung4Mark Wenitong5 An Tran-Duy1, Ming Li3 and Philip Clarke1
- Gosoapbox activities and discussion