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Extending contact with participants after initial, intensive intervention may support maintenance of weight loss and related behaviors.
This community-wide trial evaluated a text message (short message service, SMS)-delivered, extended contact intervention (‘Get Healthy, Stay Healthy’ (GHSH)), which followed on from a population-level, behavioral telephone coaching program.
This study employed a parallel, randomized controlled trial: GHSH compared with no continued contact (standard practice). Participants (n=228) were recruited after completing a 6-month lifestyle telephone coaching program: mean age = 53.4 (standard deviation (SD)=12.3) years; 66.7% (152/228) female; mean body mass index (BMI) upon entering GHSH=29.5 kg/m2 (SD = 6.0). Participants received tailored text messages over a 6-month period. The message frequency, timing, and content of the messages was based on participant preference, ascertained during two tailoring telephone calls. Primary outcomes of body weight, waist circumference, physical activity (walking, moderate, and vigorous sessions/week), and dietary behaviors (fruit and vegetable serves/day, cups of sweetened drinks per day, takeaway meals per week; fat, fiber and total indices from the Fat and Fiber Behavior Questionnaire) were assessed via self-report before (baseline) and after (6-months) extended contact (with moderate-vigorous physical activity (MVPA) also assessed via accelerometry).
Significant intervention effects, all favoring the intervention group, were observed at 6-months for change in weight (-1.35 kg, 95% confidence interval (CI): -2.24, -0.46,
The GHSH extended care intervention led to significantly better anthropometric and physical activity outcomes than standard practice (no contact). This evidence is useful for scaling up the delivery of GHSH as standard practice following the population-level telephone coaching program.
Behavioral interventions can effectively promote weight loss [
Text messages (short message service, SMS) may be a suitable, low-cost delivery modality for extended contact. It can: deliver tailored, repeated contacts; be actively “pushed” to participants; prompt behaviors in real time; and maintain two-way communication with an interventionist using minimal resources. Two recent pilot studies reported maintained weight loss in participants receiving a text message-delivered extended contact intervention [
The Get Healthy Information and Coaching Service (GHS) is a population-wide telephone-delivered coaching program targeting weight loss, physical activity, and healthy eating in Australian adults [
The ‘Get Healthy, Stay Healthy’ (GHSH) randomized controlled trial compared a text message–delivered extended-contact intervention with standard practice (no contact) in GHS program completers. Primary outcomes for examining effectiveness of GHSH were: body anthropometry (weight, waist circumference), physical activity (self-reported walking, moderate and vigorous sessions/week, accelerometer-assessed moderate-vigorous physical activity minutes/week), and dietary behaviors (fruit and vegetable serves/day, cups of sweetened drinks/day, takeaway meals/week; fat, fiber, and total indices from the Fat and Fiber Behavior Questionnaire (FFBQ)). Secondary outcomes related to feasibility, acceptability, and costs of delivering GHSH.
Data were collected at baseline (at GHS completion), 6 (end of GHSH extended contact), and 12 months (6 months following GHSH completion). Recruitment began in August 2012 and 6-month follow-up data collection were collected until March 2014. This paper reports on the baseline and 6-month data. Ethical clearance was received from the Human Research Ethics Committee at The University of Sydney (Protocol No.: 03-2011/13523). A detailed description of the trial methods is published elsewhere [
Eligibility criteria were: lives in New South Wales, Australia; no intention of re-enrolling in GHS coaching; not involved in other GHS evaluations; and owns a mobile telephone. All eligible clients completing the GHS within the recruitment timeframe were invited to participate during their final coaching call. Interested participants were mailed an information sheet and consent form and then contacted via telephone to establish their eligibility and willingness to participate. Verbal consent to participation was audio recorded and participants returned a signed consent form via reply paid post.
Participants were randomized 1:1 to GHSH intervention and control conditions, in two strata (GHS weight loss ≥ or < median of 3-kg loss), via a randomization website. This was done by a research assistant with no involvement in participant recruitment.
The Get Healthy, Stay Healthy (GHSH) intervention was delivered via individually tailored text messages, with tailoring data collected during two telephone calls. Participants chose to focus on a weight loss or weight maintenance goal, and on physical activity or diet or both (with targets consistent with national guidelines) [
This telephone call was scripted, and conducted by a trained health coach (not a GHS coach). Participants set a goal for weight maintenance or further loss within 3 months, and then two goals for behavior change. For each behavioral goal, they were asked to identify: rewards for reaching their goal; expected benefits; preparatory behaviors for goal attainment; barriers and solutions; and a person who could support them to reach their goals. Participants selected their desired number of text messages (from 3-13 per fortnight), timing of texts (eg, 6 AM), and type of texts (from the four types described below). This information was recorded during the call and was used to tailor GHSH texts.
Four types of texts targeted different behavior change strategies, each with different permitted frequencies (an example of each text type has been previously published [
Prompts to self-monitor weight (once per fortnight).
Goal check text messages (from once per fortnight to once per week for each behavioral goal) that asked participants to reply “yes” or “no” to indicate their attainment of behavioral goals in the past week. Participants received a tailored goal check reply text message based on their yes/no response.
Real-time behavioral prompts (from none to four per fortnight for each behavioral goal) that remind participants of their goals, preparatory behaviors, and anticipated barriers and solutions.
Two goal reset text messages (one in week 6 and one in week 18) that prompt participants to consider their weight and behavioral goals and reset them appropriately. Participants were encouraged to tell their GHSH coach their new goals via reply text and these changes were reflected in subsequent texts.
Wording of the text messages (each ≤160 characters) was tailored to each individual’s name, gender, goals, identified barriers and strategies, preparatory behaviors to achieve their goals, expectations of behavioral change, and the first name of their identified support person. Texts were generated and sent by research staff, using a purpose-designed software package in which messages were preprogrammed in advance and scheduled to be sent at specific times. Replies to the goal check texts were stored and automatically triggered tailored responses whenever the participant replied with “yes,” “no,” or accepted variations of these. Whenever participants’ goal check reply contained additional words or an unrecognized variant of “yes” or “no” the program emailed research staff who manually decided which tailored reply to send. Unprompted reply text messages from participants did not receive a reply. At any stage participants, could change their text message preferences via text message or telephone call.
At 12 weeks, participants received a second telephone call from their coach to update their tailoring information. This call was made between weeks 12 and 14, and if contact was not made during this period, the existing tailoring information was used for the final 12 weeks.
To minimize trial attrition, control participants were posted brief written feedback of results following each assessment. The control group received no other contact.
The anthropometric and behavioral measurement tools used in this study were the same as those used in the GHS evaluation to enable comparison. More detailed data on MVPA and dietary behaviors were also collected at baseline and 6-months via: a computer-assisted telephone interview (CATI) conducted by a research assistant, a paper-based questionnaire, and a posted accelerometer. The research assistant was blinded to group allocation at baseline, but participants may have mentioned treatment during the 6-month CATI and so blinding was not guaranteed. Participants had previously provided demographic data and data on change in primary outcomes during the initial GHS.
During the CATI, participants reported their body weight in kilograms (while wearing light clothes and no shoes). They were encouraged to weigh themselves during the CATI if scales were present; otherwise, they were asked to report their most recent weighing. Participants were posted a measuring tape and instruction sheet on measuring waist circumference at baseline. The interviewer instructed participants to take the waist circumference measurement during the call. Body mass index (BMI) was calculated based on self-reported height at GHS baseline and self-reported weight at each assessment point. These self-report methods have been validated against objectively measured weight and waist circumference in a subsample of GHS users (n=38) [
During the CATI, participants completed a validated, 3-item assessment tool (3Q-PA) which asked about the number of weekly sessions spent: walking for ≥30 minutes; doing other moderate-intensity physical activity for ≥30 minutes (termed “moderate”); and, doing vigorous-intensity physical activity for ≥20 minutes [
Participants were also posted a belt-mounted dual-axis accelerometer (Actigraph model GT1M) initialized to collect data in 10-second epochs, a wear-time log, and a reply-paid envelope to return their materials. Participants were asked to wear the monitor on the hip for 7 consecutive days during all waking hours, and to remove the monitor only for sleep (if desired) and during times the monitor could be damaged (eg, during water-based activities). The wear log included monitor-fitting instructions and asked about any monitor removals, sleep time, and whether the monitor was worn or removed during sleep. Accelerometer data were downloaded in Actilife (v 6.6.2). Both 10- and 60-second epoch files were processed in SAS version 9.3. Nonwear time was excluded (ie, ≥60 minutes of 0 counts per minute (cpm), allowing for up to 2 minutes of 1 to 49 cpm [
During the CATI, participants reported the following: number of daily servings of fruit and of vegetables [
The text message software collected data on delivery (ie, number and type of text messages sent) and intervention engagement (ie, number of responses to goal check texts and achievement of weekly behavioral goals). The duration of the tailoring interviews and participant alterations to text preferences were tracked by research staff.
At 6 months, intervention participants rated satisfaction and usefulness in five categories (“not at all” to “extremely” satisfied/useful), of the GHSH intervention overall and specifically regarding support for achieving behavioral and weight loss goals. Intervention participants were invited to complete a telephone interview with research staff (approximately 10 minutes) involving open-ended questions regarding intervention usage, satisfaction, and potential program improvements. These interviews were audio-recorded, transcribed verbatim, and coded independently by two authors. Discrepancies between coding were discussed until consensus was reached and recruitment stopped once thematic saturation was reached.
Personnel time was tracked for delivering all intervention-related tasks. Coach time was costed at AU$37.56 per hour and research staff time was costed at AU$31.56 per hour. Average duration per participant (minutes) was multiplied by the relevant personnel cost. Direct costs of sending the texts (at AU$0.15 each) were tracked, totaled and then divided by the total number of intervention participants to provide a per participant cost.
The sample size was chosen a priori to provide ≥90% power to detect the following expected differences between groups in primary outcomes: two sessions/week of self-reported MVPA; one serving of fruit per day and one serving of vegetables per day; 2-kg body weight; and 4-cm waist circumference as previously reported [
Analyses were performed in SPSS version 22 and STATA version 13. Significance was set at
Intervention effects were re-examined using multiple imputation by chained equations in STATA (m=20 imputations), adjusting for the same covariates as the completers models as well as predictors of missing data (
It is complex to interpret results from extended contact interventions where “no change” in outcomes can be interpreted as a positive finding. Within-group changes (“worsened” or “improved”) and between-group differences (intervention “better” or “worse” than control) were only claimed when these were statistically significant. As nonsignificant findings can indicate either no change/difference or an insufficient sample size to yield a conclusive finding, we only described outcomes as “maintained” or as groups being “similar” if in addition to the finding being nonsignificant, the likely true effect size for the change/difference as indicated by the 95% confidence interval (CI) was also very small (<MDI).
There were 1071 clients invited to participate in this study, of whom 300 expressed verbal interest in participating in the trial, and 228 participants consented and were randomized (228/300, 76%;
The overall retention rate from baseline to 6 months was 95% (216/228) (103/114, 90% in intervention and 113/114, 99% in controls,
Participation in the Get Healthy, Stay Healthy (GHSH) trial.
Characteristics of ‘Get Healthy, Stay Healthy’ (GHSH) trial participants.
Mean (SD) or n (%) | |||
GHSH (n=114)a | Control (n=114)a | ||
Health and demographics at baseline | |||
Age (years) | 55.5 (12.3) | 51.2 (11.9) | |
BMI (kg/m2) | 29.3 (5.8) | 29.6 (6.3) | |
Weight (kg) | 82.8 (19.4) | 83.6 (18.9) | |
Waist circumference (cm) | 98.9 (15.4) | 99.6 (14.9) | |
Gender (% female) | 74 (64.9%) | 78 (68.4%) | |
In paid employment (% yes) | 69 (61.1%) | 68 (59.6%) | |
Education (% post-school qualification) | 73 (64.0%) | 77 (67.5%) | |
Indigenous Australian (%) | 1 (0.9%) | 5 (4.4%) | |
SEIFAb(% living in most advantaged 3 quintiles)c | 86 (75.4%) | 78 (68.4%) | |
Region (% living in major cities) | 71 (62.3%) | 82 (71.9%) | |
Physical activity at baseline | |||
Accelerometer PAd(minutes/week) | 196.9 (144.4) | 196.2 (143.6) | |
Vigorous PA (sessions/week) | 1.56 (1.86) | 2.33 (2.53) | |
Moderate PA (sessions/week) | 1.11 (1.78) | 1.60 (1.97) | |
Walking PA (sessions/week) | 3.99 (3.04) | 3.30 (2.44) | |
Dietary behaviors at baseline | |||
Vegetables (servings/day) | 3.1 (1.4) | 3.4 (1.8) | |
Fruit (servings/day) | 2.0 (0.9) | 2.0 (1.0) | |
Sweetened drinks (cups/day) | 0.2 (0.5) | 0.4 (0.9) | |
Takeaway (meals/week) | 0.5 (0.8) | 0.5 (0.9) | |
FFBQ Total Index (Score (1-5) | 3.3 (0.4) | 3.3 (0.4) | |
FFBQ Fat Index (Score (1-5) | 3.5 (0.5) | 3.5 (0.5) | |
FFBQ Fiber Index (Score (1-5) | 2.9 (0.5) | 2.9 (0.5) | |
Prior changes during GHS | |||
Weight (kg) | −3.7 (4.0)e | −3.8 (4.3)e | |
Waist circumference (cm) | −5.5 (5.0)e | −6.3 (5.7)e | |
Vigorous PA (sessions/week) | 0.5 (1.4)e | 0.6 (1.7)e | |
Moderate PA (sessions/week) | 0.5 (2.1)e | 0.9 (2.2)e | |
Walking PA (sessions/week) | 1.7 (2.7)e | 1.1 (2.6)e | |
Vegetables (servings/day) | 1.2 (1.5)e | 1.2 (1.4)e | |
Fruit (servings/day) | 0.6 (1.2)e | 0.7 (1.1)e | |
Sweetened drinks (cups/day) | −0.2 (0.6)e | −0.3 (1.2)e | |
Takeaway (meals/week) | −0.5 (1.6)e | −0.5 (1.5)e |
aFigures exclude missing data: one GHSH intervention participant (employment, English spoken at home, referral source, accelerometer PA) and one control participant (waist circumference, Indigenous status).
bSocioeconomic Indexes for Areas.
cSpecifically the Index of Relative Socio-Economic Advantage and Disadvantage.
dPhysical activity.
eStatistically significant change during GHS (
32.7 ± 7.3 vs 29.1 ± 5.8 kg/m2,
Intervention participants showed significant reductions in both body weight (−0.89 kg, 95% CI: −1.53, −0.25) and waist circumference (−1.34 cm, 95% CI: −2.31, −0.36;
The intervention group maintained their accelerometer-assessed MVPA and self-reported vigorous activity, and changed significantly only in self-reported walking (−0.55, 95% CI: −0.99, −0.11 sessions/week;
In the intervention group, small, but statistically significant improvements in dietary outcomes were observed for the FFBQ Fiber and Total Indices, while remaining dietary outcomes, except takeaway meals per week, were all maintained (
Results from analyses using multiple imputation mostly supported the interpretations from the main analyses (
The mean (±SD) call duration was 34 ±8 minutes for the initial tailoring call and 18 ±8 minutes for the 12-week tailoring call. The median number of text messages requested during the initial tailoring call and at the 12-week tailoring call were both five per fortnight (25th-75thpercentiles =3-7 texts). During the initial tailoring call, 40% (46/111) of participants requested fortnightly goal checks for both behavioral goals; 35% (40/111) weekly for both goals; and, 22%(25/111) weekly for one goal and fortnightly for the other goal. Approximately one-half the participants (58/111, 52%) did not request any real-time behavioral prompts and 35% (39/111) requested between 2-4 prompts per fortnight. Almost all (89/95, 94%) intervention participants still enrolled at 12-weeks completed the 12-week tailoring interview. During the 12-week tailoring call, almost all (82/89, 92%) participants changed their preference for text message content, and 40% (36/89) changed their preferred text message schedule. Outside of the 12-week tailoring call, only 3% (3/90) of participants changed either of these preferences via text. The weight goal reset text received replies from 30% (33/111) of participants at week 6 and 26% (25/95) at week 18. At week 6, 40% (44/111) of participants reset at least one behavioral goal; 29% (28/95) did so in week 18. Intervention completers (n=90) replied to 84% of goal check texts sent in week 1 (152/180) and 69% (125/180) of goal check texts sent in the last week.
Most (69/99, 70%) participants rated GHSH as “useful” or “extremely useful” in supporting their weight goal, and 75% (74/99) reported that they were “satisfied” or “extremely satisfied” with the intervention. Follow-up interviews with 62 intervention participants revealed that: experience with text messaging prior to GHSH impacted on participants’ experience during the intervention; the GHSH program often exceeded participants’ expectations; and participants generally perceived the GHS and GHSH intervention to be one program. Reasons for liking GHSH focused on: the reminders provided by the text messages to reinforce what participants wanted to do; maintaining accountability; and increased awareness of behaviors in real time. The few participants who did not like aspects of the GHSH nominated text messages being too repetitive or automated as key reasons.
Health coach staff spent, on average, 35 minutes per participant conducting and preparing for the initial tailoring interview and 30 minutes for the 12-week tailoring interview. Research staff spent on average 31 minutes per participant entering tailoring data into the software following the initial tailoring call and 15 minutes per participant after the 12-week tailoring call. Research staff had to manually trigger responses to 813 goal check replies not recognized by the software (813/2071, 39%) of responses received), which took approximately 1 minute per response. During the intervention, 8518 text messages were sent to participants (at AU$0.15 each) totaling AU$1278 (averaging AU$11.21 per participant). Overall, it cost approximately AU$80.00 per participant to deliver the GHSH extended contact intervention.
Mean changes within the ‘Get Healthy, Stay Healthy’ (GHSH) intervention group (I; n=104) and the control group (C; n=114)
MDI | Group | Mean Change |
Within−group |
||||
Mean (95% CI) | |||||||
Anthropometry | |||||||
Weight (kg) | 1 kg | I | − |
Improved | |||
C | 0.30 (−0.35, 0.95) | .357 | Maintained | ||||
Waist circumferencec(cm) | 1 cm | I | − |
Improved | |||
C | −0.32 (−1.47, 0.82) | .578 | Inconclusive | ||||
Physical activity (PA) | |||||||
Vigorous PA (sessions/week) | 0.5 session | I | 0.20 (−0.10, 0.50) | .183 | Maintained | ||
C | −0.40 (−0.86, 0.05) | .084 | Inconclusive | ||||
Moderate PA (sessions/week) | 0.5 session | I | 0.19 (−0.16, 0.54) | .277 | Inconclusive | ||
C | − |
Worsened | |||||
Walking PA (sessions/week) | 0.5 session | I | − |
Worsened | |||
C | 0.31 (−0.40, 1.01) | .392 | Inconclusive | ||||
Accelerometer PAd(minutes/week) | 30 minutes | I | 7.41 (−5.61, 20.44) | .265 | Maintained | ||
C | − |
Worsened | |||||
Dietary behaviors | |||||||
Vegetables (servings/day) | 0.5 serves | I | −0.17 (−0.46, 0.12) | .237 | Maintained | ||
C | − |
Worsened | |||||
Fruit (servings/day) | 0.5 serves | I | −0.06 (−0.22, 0.10) | .482 | Maintained | ||
C | − |
Worsened | |||||
Sweetened drinks (cups/ day) | 0.25 cups | I | −0.00 (−0.08, 0.08) | .982 | Maintained | ||
C | −0.04 (−0.19, 0.11) | .602 | Maintained | ||||
Takeaway (meals/week) | 0.25 meal | I | −0.13 (−0.28, 0.02) | .379 | Inconclusive | ||
C | −0.06 (−0.19, 0.07) | .079 | Maintained | ||||
FFBQ Total Index Score (1–5) | 0.2 units | I | Improved | ||||
C | 0.01 (−0.05, 0.07) | .781 | Maintained | ||||
FFBQ Fat Index Score (1–5) | 0.2 units | I | 0.06 (−0.01, 0.13) | .082 | Maintained | ||
C | 0.03 (−0.04, 0.11) | .368 | Maintained | ||||
FFBQ Fiber IndexScore (1–5) | 0.2 units | I | Improved | ||||
C | −0.03 (−0.12, 0.06) | .493 | Maintained |
aMean changes estimated by paired
bItalic values indicate statistical significance at P˂.05.
cn=103 GHSH group; n=112 control group (item missing data for waist circumference).
dn=99 GHSH group; n=108 control group; some participants did not wear the accelerometer.
Mean differences in changes between the ‘Get Healthy, Stay Healthy’ (GHSH) intervention (I; n=104) and control groups (C; n=114).
Mean difference |
Between-group interpretation | |||
Mean (95% CI) | ||||
Anthropometry | ||||
Weight (kg) | − |
significantly better | ||
Waist circumferencec(cm) | −1.18 (−2.65, 0.29) | .116 | inconclusive | |
Physical activity (PA) | ||||
Vigorous PA (sessions/week)d | 0.15 (−0.34, 0.63) | .547 | inconclusive | |
Moderate PA (sessions/week)d | significantly better | |||
Walking PA (sessions/week) | −0.69 (−1.46, 0.08) | .077 | inconclusive | |
Accelerometer PA (mins/week)e | significantly better | |||
Dietary behaviors | ||||
Vegetables (servings/day) | 0.15 (−0.21, 0.50) | .408 | inconclusive | |
Fruit (servings/day)d | 0.16 (−0.05, 0.37) | .133 | similar | |
Sweetened drinks (cups/day) | −0.05 (−0.19, 0.10) | .537 | similar | |
Takeaways (meals/week) | 0.01 (−0.15, 0.18) | .864 | similar | |
FFBQ Total Index Score (1–5) | 0.05 (−0.03,0.13) | .195 | similar | |
FFBQ Fat Index Score (1–5) | 0.02 (−0.07, 0.12) | .615 | similar | |
FFBQ Fiber Index Score (1–5) | 0.08 (−0.03, 0.19) | .147 | similar |
aMean difference (β) with 95% CI, and
bItalic values indicate statistical significance at P˂.05.
cn=102 GHSH group; n=112 control group (item missing data for waist circumference).
dn=103 GHSH group; n=114 control group (item missing data for vigorous PA, moderate PA and Fruit).
eEstimated using marginal means from GEE models of log-transformed daily MVPA (repeated term for “day”), adjusting for confounders, and correcting for regression to the mean using the method [
Overall, the GHSH intervention was feasible to deliver and acceptable to participants. It led to significantly better outcomes compared with the control group in weight loss and some forms of physical activity, but not in dietary behaviors. For most dietary outcomes, meaningful intervention effects were also unlikely, based on the CIs. The study findings were inconclusive due to insufficient sample size for vegetable intake, walking, vigorous activity and waist circumference.
The GHSH weight loss of 0.89 kg (95% CI: −1.53, −0.25) during extended care was better than or consistent with comparable extended contact interventions. Spark and colleagues [
The GHSH intervention was designed to follow on from a telephone coaching program, in which participants developed a rapport with a health coach. It is positive to note that a semiautomated text message program (with two brief telephone contacts) maintained the perception of accountability and that most participants felt personal engagement with their coach. It is encouraging that participants updated their text message preferences throughout the trial, given that continued engagement is a known facilitator of maintenance [
Strengths of this trial include: the range of outcomes evaluated to inform service delivery; the high retention rate (216/228, 95%); its conduct in partnership with the service delivery agents and funders; and, the rigorous research design embedded within real-world delivery [
While self-report of anthropometric outcomes was a limitation, the measures showed acceptable validity against objective measures in a GHS subsample [
The GHSH extended contact intervention was feasible to deliver, acceptable to GHS clients and led to significantly better outcomes than standard practice in weight loss and physical activity. Supporting individuals to maintain positive lifestyle changes through cost-effective programs is paramount to the success of the GHS and more broadly to public health in Australia.
Confounders considered and adjusted for in main and sensitivity analyses.
Odds of being in the ‘Get Healthy, Stay Healthy’ (GHSH) trial (n=228) within those completing the Get Healthy Service (GHS) during the GHSH trial recruitment period (n=1071).
Characteristics of ‘Get Healthy, Stay Healthy’ (GHSH) trial participants at baseline with and without missing data
Mean changes within the ‘Get Healthy, Stay Healthy’ (GHSH) intervention group (I; n=114) and the control group (C; n=114) using multiple imputation for missing data.
CONSORT-EHEALTH Checklist.
CONSORT-EHEALTH Checklist.
body mass index
computer-assisted telephone interview
confidence interval
counts per minute
Fat and Fiber Behavior Questionnaire
generalized estimation equations
Get Healthy Information and Coaching Service
‘Get Healthy, Stay Healthy’
minimum differences of interest
moderate-vigorous physical activity
Socioeconomic Indexes for Areas
standard deviation
We would like to acknowledge the participants, GHS coaches, Medibank Health Solutions staff and GHSH project staff. This trial was funded by the New South Wales Ministry of Health and an Early Career Researcher grant from The University of Queensland.
None declared.