Abstract
Background
Fatigue is one of the most important symptoms among patients receiving dialysis and is nominated as a core outcome to be reported in all clinical trials in this setting. However, few trials of interventions targeting fatigue have been conducted. Patients historically have rarely been involved in the design of interventions, which can limit acceptability and uptake. When asked, they have indicated a preference for lifestyle interventions, such as exercise, to improve fatigue. While some research has focussed on intradialytic exercise for patients receiving haemodialysis, patients have also indicated a preference for a convenient method of exercising with guidance, but on their own time outside of dialysis hours. In response to this, a mobile phone application was proposed as the method of delivery for a home-based exercise intervention targeting fatigue.
Methods
We convened a workshop with five breakout group sessions in Australia, with 24 patients on dialysis (16 haemodialysis and 8 peritoneal dialysis) and 8 caregivers to identify, prioritize and discuss exercise interventions for fatigue in patients receiving dialysis and the delivery of this through a mobile application.
Results
Of the 21 types of exercise identified, the top-ranked were walking outdoors, walking on a treadmill and cardio and resistance training. Six themes were identified: (i) ‘an expectation of tangible gains from exercise’, including strengthening and protecting against bodily deterioration related to dialysis; (ii) ‘overcoming physical limitations’, meaning that comorbidities, baseline fatigue and fluctuating health needed to be addressed to engage in exercise; (iii) ‘fear of risks’, which reinforced the importance of safety and compatibility of exercise with dialysis; (iv) ‘realistic and achievable’ exercise, which would ensure initial readiness for uptake; (v) ‘enhancing motivation and interest’ , which expected to support sustained use of the exercise intervention and (vi) ‘ensuring usability of the mobile application’ , which would require simplicity, convenience and comprehensibility.
Conclusion
Exercise interventions that are expected by patients to improve health outcomes and that are safe, realistic and easy to adopt may be more acceptable to patients on dialysis.
Keywords: clinical trials, dialysis, exercise, fatigue, patient perspectives
INTRODUCTION
Fatigue is one of the most debilitating symptoms in patients receiving dialysis [1–5] and ranked by patients on haemodialysis as a critically important outcome, even higher than death [1, 5]. The prevalence of fatigue ranges from 55% to 97% in adult patients on dialysis [6, 7] and is associated with increased mortality [8–10]. From the patient perspective, fatigue has a pervasive impact on their physical and social functioning [11]. Low levels of physical activity on dialysis can aggravate health issues and lead to physical disability, frailty and impaired quality of life [12]. Although the exact causes of fatigue are uncertain, it is likely to be multifactorial and thus a range of interventions may be considered [6, 13]. Despite such importance, the evidence to inform the management of fatigue in patients on dialysis remains very limited.
Patients on dialysis have consistently identified lifestyle interventions to improve symptoms, such as fatigue, as a top research priority [14, 15]. Furthermore, patients who feel in control or are involved in managing their symptoms also experience better health outcomes [16–18]. There is some evidence that regular exercise improves cardiovascular outcomes, physical functioning and quality of life in adults with kidney disease, including patients on dialysis [19].
The majority of the existing literature on exercise focuses on intradialytic exercises where patients participate in exercise programmes during dialysis [20, 21], however, patients on dialysis also have a preference for home-based exercise programmes [22]. In the recent Standardized Outcomes in Nephrology Haemodialysis (SONG-HD) workshop on fatigue, patients reported that exercise outside of dialysis hours, such as walking and team sports, improved fatigue and enabled them to better engage in activities and gain a sense of control over their condition [23].
There is increasing recognition that patient involvement across the full research cycle, from priority setting to implementation, strengthens participant recruitment, retention and acceptance and improves the quality and relevance of findings [24–26]. However, patients are seldom involved in the choice and design of interventions [27], which can limit the use and impact of the interventions assessed in trials. This report summarizes the discussions from a workshop with patients and their caregivers on dialysis that aimed to identify, prioritize and determine an exercise intervention to improve fatigue in patients receiving dialysis to inform a clinical trial of a mobile exercise application.
Context and scope
In response to the demand for exercise interventions that are easy, free and convenient, a group of nephrologists, exercise physiologists, physiotherapists, researchers and patients came together to examine the types of interventions and modes of delivery most suitable to address fatigue in the dialysis population. The current literature demonstrates inconclusive evidence for any one type of exercise as most beneficial for fatigue in patients receiving dialysis. The workshop was conducted as preliminary work for the Mobile exercise app to improve Fatigue In patients on dialysis: an adaptive Trial (M-FIT). There is mixed evidence regarding the types of exercise that are perceived to be effective and preferred by patients [27–30]. Therefore we aimed to identify patient priorities regarding the types of exercise in which patients would like to engage. Several exercise types chosen by patients in this workshop will be examined in M-FIT for effectiveness.
In response to a call for exercise that offers the flexibility of location and time, a mobile application was chosen as the mode of delivery. Over the past decade there has been substantial growth in the body of evidence indicating the effectiveness of mobile health technology solutions in the management of chronic conditions [31, 32]. While the evidence remains unclear in some conditions due to a lack of high-quality, adequately powered trials, mobile applications are a powerful tool that can enable a convenient, acceptable and feasible method of delivering health interventions [33, 34]. Technical app features such as reminder messages and tracking may also be helpful in facilitating behaviour change [35].
We convened the workshop in a hotel meeting room in Sydney, NSW, Australia, in November 2018.
MATERIALS AND METHODS
Twenty-four patients on dialysis (16 haemodialysis and 8 peritoneal dialysis) and eight caregivers from four states across Australian (Victoria, Queensland, New South Wales and South Australia) attended the workshop. Invitations were sent to patients/caregivers by e-mail through the Better Evidence and Translation for chronic kidney disease, Kidney Health Australia and SONG networks. All attendees were involved as investigators. The full list of M-FIT workshop attendees and contributors is provided in the Acknowledgements.
The workshop programme is provided as Supplementary data, Item S1. The workshop commenced with a presentation on the proposal for M-FIT, a summary of research on exercise in dialysis and a presentation by a patient on the experiences of doing exercise to manage fatigue. To facilitate discussion, the participants were also provided with a summary table of the evidence on exercise in patients receiving dialysis.
For the breakout discussions, participants were allocated to one of five groups of six to seven patients and caregivers. The groups were facilitated by research team members (A.J., A.T., A.V.Z., K.M. and M.H.) who were trained and experienced in qualitative research. All facilitators used a standardized run sheet to guide the discussion (Supplementary data, Item S2). The questions were developed based on a literature review about fatigue, exercise and mobile applications and discussion among the multidisciplinary investigator team.
Breakout session 1: Participants discussed their experiences of fatigue, exercise and mobile phone applications. They generated a list of types of exercise that they would consider acceptable for patients on dialysis and might be effective for reducing fatigue. They also discussed the reasons for their choices. After this session, the facilitators collated a list of different types of exercises that participants had generated.
Breakout session 2: Participants reviewed the collated list of exercise types. They were provided with three sticker dots of different colours to vote for the top three exercise types that they thought were acceptable, effective and important for inclusion in the M-FIT trial. Exercises with ranking ‘1’ (most important) were given a weighting of 3 points, those ranking ‘2’ were given 2 points and those ranking ‘3’ were allocated 1 point. They discussed the reasons for their priorities. After the session, the scores for each exercise type were combined across the break-out groups and presented to all groups.
Breakout session 3: Participants reviewed the results of the voting exercise and discussed ways to optimize the delivery of these exercise interventions through a mobile phone application.
All discussions were audiotaped and transcribed verbatim. The transcripts were entered into Hyper RESEARCH version 3.0 (ResearchWare, Randolph, MA, USA) to facilitate coding and analysis of the data. All participants and contributors received a draft workshop report and were asked to provide feedback. Additional comments were integrated into the final report.
RESULTS
Rankings of exercise types
In total, 21 different types of exercises were generated. The top preferred exercises were walking in outdoor or natural settings (44 points), walking on a treadmill (21 points), mixed cardio and resistance exercise (13 points) and Pilates (11 points). Scores for each type of exercise are provided in Table 1.
Table 1.
Prioritization of the types of exercise interventions
| Exercise | n a | Pointsb |
|---|---|---|
| Walking—outside (shops, parks, etc.) | 15 | 44 |
| Walking—inside (treadmill) | 9 | 21 |
| Mixed cardio/resistance exercise (lunges, star jumps, body-bearing exercises, resistance bands and squats) | 7 | 13 |
| Pilates | 4 | 11 |
| Cycling—stationary (gym bike) | 4 | 10 |
| Cycling—outdoors | 3 | 7 |
| Aqua-aerobics | 3 | 7 |
| Gardening | 4 | 6 |
| Stretching | 3 | 5 |
| Yoga | 4 | 5 |
| Deep breathing | 3 | 5 |
| Swimming (for HD) | 2 | 4 |
| Weights | 2 | 4 |
| Tai chi | 2 | 4 |
| Zumba | 1 | 2 |
| Meditation | 1 | 2 |
| Musical instrument | 3 | 1 |
| Child-minding | 0 | – |
| Progressive muscle relaxation | 0 | – |
| Dancing | 0 | – |
| Running | 0 | – |
Number of participants who voted for the exercise.
Points calculated by adding the votes with their weighting where 1 = 3 points, 2 = 2 points and 3 = 1 point.
Workshop discussions
We identified six main themes that reflected patients’ and caregivers’ experiences with and perspectives on exercise, including the reasons for their choice and prioritization of exercise types, and priorities for implementation. These were expecting tangible gains, overcoming physical limitations, fear of risks, being realistic and achievable, enhancing motivation and interest and ensuring the usability of the mobile application. Illustrative quotations for each theme are presented in Table 2. The themes and respective subthemes are described below. Table 3 outlines the recommendations for developing and implementing exercise programmes in patients on dialysis.
Table 2.
Illustrative quotations for themes identified in the workshop discussions
| Themes | Quotations |
|---|---|
| Expecting tangible gains from exercise | Strengthening and protecting against bodily deterioration from end-stage kidney disease |
| |
| Pushing beyond the limits of dialysis | |
| |
| Eligibility and resilience for transplantation | |
| |
| Overcoming physical limitations | Managing disabling comorbidities |
| |
| Combating debilitating baseline fatigue | |
| |
| Fluctuating health constraining activity | |
| Part of it is rating how you felt on that day too. Some days I could do 20 000 steps no worries, and other days 5 is really tough.—P2 | |
| Building confidence in exercise | |
| |
| Fear of risks | Aggravating health |
| |
| Uncertainty about the compatibility of exercise with dialysis | |
| |
| Realistic and achievable | Affordable and feasible |
| |
| Flexibility around the dialysis schedule | |
| |
| Tailoring to individual capacity | |
| |
| Enhancing motivation and interest | Finding incentives |
| |
| Battling boredom | |
| |
| Tracking progress | |
| You can actually see, I’ve got to do this and this, then as you’re doing it you get that feedback of your progress.—P5 | |
| Ensuring usability of the mobile application | Simple and convenient to use |
| |
| Informative and comprehensible | |
|
Table 3.
Summary of recommendations to consider in developing exercise interventions for patients on dialysis
| Implications for exercise interventions in dialysis |
|---|
|
Expecting tangible gains
Strengthening and protecting against physical deconditioning from end-stage kidney disease
Patients and caregivers believed that exercise would slow or prevent bodily deterioration due to dialysis and end-stage kidney disease. Some patients reported that exercise enabled them to counteract the deleterious effects of dialysis on muscle mass and maintain their strength. Others also noted that exercise could prevent falls by improving strength and balance.
Pushing beyond the barriers of dialysis
Some patients were motivated to exercise to improve their health and physical activity, but this would require them to overcome health problems associated with dialysis that serve as limitations to exercise. They explained that ‘you need to push yourself a little bit more to get that little more fitter’. However, others were concerned that ‘pushing too hard’ until the ‘point of no return’ would aggravate their health.
Eligibility and resilience for transplantation
Some patients stated that exercise was important to improve their fitness and to reduce their weight so they would be eligible for deceased or living kidney donor transplantation. One patient was motivated to exercise after being told by a nephrologist—‘you have to lose five kilos, otherwise we won’t be able to do your transplant’. Thinking ahead, patients were determined to maintain strength and health enough to prevent deterioration even after their transplant because ‘life is dependent on it’.
Overcoming physical limitations
Managing disabling comorbidities
Some patients with comorbidities, including cardiovascular disease and neuropathy, were conscious of their limited capacity to exercise. The severe symptoms and complications associated with these comorbidities and kidney disease, such as pain, unstable blood pressure, cramps and muscle atrophy, were identified as major barriers to exercise—‘that’s the problem, because I go [walking] and my heart [rate] can go up very high all of a sudden’.
Combating debilitating baseline fatigue
Participants described having to endure extremely debilitating fatigue on a daily basis, which prevented them from doing exercise. For some, it was a ‘negotiation battle with your mind’, in which they forced themselves to push past the fatigue in order to exercise. It was seen as ‘a vicious cycle’ in that fatigue prevented them from exercising, but the physical inactivity also worsened their fatigue.
Fluctuating health constraining activity
Patients explained that the instability of their health, attributed to kidney disease and dialysis, was a deterrent to exercise. Their capacity for exercise was ‘very up and down’ because their health was unpredictable—‘some days I can do twenty thousand steps no worries, and other days five is really tough’. Some did not feel like they were seeing any ‘appreciable improvements’ in their health even with exercise, as the fluctuations were too severe.
Building confidence in exercise
Patients believed they would be more willing to exercise if they were better informed about how and what to do at home or at the gym. Patients were unsure about whom to ask for help, and there was limited guidance from their healthcare professionals, as they were told to ‘just do exercise’. Consequently, patients felt unable to exercise safely and effectively on their own.
Fear of health risks
Aggravating health problems
Due to the uncertainties around their own health and limitations, patients were afraid of inadvertently worsening their condition by doing exercise. They were concerned about safety and remained apprehensive about exercise, as they were unsure about when their ‘body’s just going to turn around and say no’. Even with simple exercises, such as walking, some patients were unsure if they were ‘going to be able to come back’ to where they had started.
Uncertainty about the compatibility of exercise with dialysis
Some patients felt they lacked knowledge about the type, duration and intensity of exercise that would be suitable given their physical limitations related to being on dialysis. Some were interested in resistance training using light weights, but some were concerned about the possible effects it may have on aspects of their dialysis treatment: ‘I’ve got the question mark of how does [exercise] impact your fistula’. Those who were on peritoneal dialysis were concerned more specifically about affecting their bags. Patients appreciated the option to exercise outside of their dialysis sessions because they had concerns about moving while being ‘hooked up’ to the dialysis machine and instigating cannulation and catheter compilations.
Realistic and achievable
Affordable and feasible
Patients and caregivers indicated that exercise needed to be affordable in terms of cost and time. Feasibility was crucial in ensuring that the patients were willing and able to participate. Some patients expressed preferences for types of exercise, such as walking outside, because they were free. Others preferred swimming, as it was something they could do with their children without having to find a babysitter.
Flexibility around the dialysis schedule
Having the exercises on a mobile phone application meant that patients could choose the day, time and location of their exercise. Patients believed this would improve flexibility around their dialysis days and allow them to exercise more frequently throughout the week as they were able to choose a time during which they were less fatigued.
Tailoring to individual capacity
Patients emphasized the importance of having options to increase or decrease the level of intensity and explained that patients receiving dialysis had different levels of fitness and capacity for exercise. Patients wanted to be able to make incremental progress at their own pace, taking into consideration their baseline fatigue, health status and overall well-being.
Enhancing motivation and interest
Finding incentives
Patients emphasized the need to find motivation and reasons to start and continue exercise to obtain long-term benefits for their health. Some mentioned that when they paid for a gym membership, it motivated them to use the facilities. Others were driven by their desire to stay healthy for their children and grandchildren. Social motivation, such as walking with friends and being able to see each other’s progress were also suggested to encourage patients receiving dialysis to exercise.
Battling boredom
Some patients preferred varying exercise routines over repetitive movements, as participants noted that exercise could get tedious, and maintaining interest was critical for sustained and long-term use. Some patients had tried different ways to entertain themselves, such as installing a television in front of their treadmill, playing different music or going to a different park every week.
Tracking progress
Participants suggested that the mobile application should include a feature that allows them to track their own progress. This feature would allow them to feel a sense of accomplishment because ‘you can see you’re getting fitter’. They believed it would keep them accountable because they would be able to see their progress or lack thereof, since it ‘is just there, you can’t get around it’.
Ensuring usability of the mobile application
Simple and convenient to use
For some patients, the discussion about the mobile applications raised concerns for those who were not familiar with the technology. To ensure usability across all levels of technology users, patients emphasized the need for a simple, ‘dummy-proof’ app that could be navigated with minimal clicks.
Informative and comprehensible
Patients preferred to have both videos and a written explanation for each type of exercise. It was critical for the videos to be easy to follow with minimal supervision. With each video, patients believed it would be helpful to have a written explanation of the muscle groups involved and an outline of the benefits that patients can expect from doing that particular exercise. One patient said that this would be ‘a good idea… because nine times out of ten, I don’t know why I’m doing [the exercise]. I just do what I’m told’.
DISCUSSION
Patients and caregivers regarded exercise as necessary and beneficial to reduce their fatigue, protect against deterioration related to kidney disease and dialysis, access transplantation and maintain their health for their family. They recognized the value in exercises such as weight training and walking in improving their fatigue. However, major barriers to uptake and sustained exercise included lack of guidance and confidence in exercise, being without time and energy to exercise because of their dialysis schedule, limitations due to physical comorbidities and fear of unknown risks that may aggravate their health condition. Walking (in outdoor or natural settings) was the most preferred type of exercise, as it is free and easy for patients to do on their own terms. However, other exercise types, such as resistance training and Pilates, also had a high priority due to the protective benefits against falls and weak muscles. A mobile application with simple instructions and user-friendly interface was perceived to be an acceptable and feasible mode of delivery.
Many important features of mobile applications were raised during the workshop, which was considered crucial to optimize the mode of delivery. Patients and caregivers noted that they varied in terms of the level and type of technology that they felt confident in using. Thus a user-friendly interface that requires minimal navigation was deemed critical to ensure that the interventions were accessible for everyone. They suggested that exercise videos and text should be easy to follow. A feature that allows one to keep track of his/her own and/or others’ progress was suggested as a means to keep patients motivated in using the intervention.
Patients in studies conducted in other chronic conditions have also identified physical limitations and uncertainty about how to exercise as barriers to exercise [36, 37]. However, patients in our workshop articulated additional and specific concerns about the suitability of exercise related to their dialysis treatment. Patients wanted to know about exercises that they could do without causing harm to their fistula and peritoneal dialysis bags. It is well known that being aware of the benefits of exercise can motivate patients to engage with exercise [36, 37]. In this workshop, patients also mentioned that they were interested in exercise to improve quality of life, reduce fatigue and combat further deterioration caused by kidney disease and treatment, as well as to be eligible for a kidney transplant and maximize post-transplant outcomes. Dialysis-related fatigue and was noted as a ‘paradoxical’ barrier to exercise for patients on dialysis, in that it prohibited patients from doing exercise, which further exacerbated their fatigue.
Most trials of exercise interventions in patients receiving dialysis have been conducted in the haemodialysis population with a focus on intradialytic exercise programmes [20, 21]. In trials, intradialytic programmes have better adherence and lower dropout rates compared with exercise programmes that are implemented between dialysis sessions [38, 39], as it is easier to track adherence to the exercise interventions. However, during dialysis may not necessarily be a time that patients want to exercise. Some patients in this workshop preferred interdialysis exercises, for reasons including the need to rest while dialysing and concerns about the harms of being active while on dialysis. Further evidence is needed to determine the effectiveness of more flexible exercise programmes that patients prefer and to address potential challenges of adherence to exercise programmes that are not supervised. Having a flexible and convenient self-administered programme would allow them to decide where and when they want to exercise. Furthermore, providing a mechanism to monitor individual progress by giving patients flexibility to choose when to exercise and at what intensity according to their level of fitness will help to ensure they are not overwhelmed by the physical requirements of exercise. This highlights the need to involve patients in designing interventions to ensure they meet their individual needs. A summary of suggestions for developing exercise interventions identified from the workshop is provided in Table 3.
There is recognition that patients should be involved across the stages of research from priority-setting through to implementation [40], but examples of patient involvement in the identification, prioritization, selection and design of interventions are limited [41]. The discussion and ranking of exercise interventions and their optimal delivery from this workshop will directly inform the design of the interventions for the M-FIT trial. A multidisciplinary team of exercise physiologists, physiotherapists, nephrologists, researchers, information technology experts and patient partners will design the intervention (a range of different types of exercise), which will be embedded into a mobile application. The final set of exercises to be embedded into the mobile application will be reviewed and checked by exercise physiologists to ensure safety. We acknowledge that patients who were non-English speaking or with severe mobility limitations or cognitive impairment were not able to attend the workshop. Thus, to ensure maximum usability for a wide range of patients, we will seek feedback from patients of diverse backgrounds through focus groups and a pilot trial to assess its feasibility in a trial setting. Assessing interventions prioritized by patients is likely to help maximize the impact of the intervention by improving its acceptability, feasibility and sustainability.
We involved patients as named investigators in this workshop and for this reason we did not collect demographic characteristics from the attendees. While we can confirm that attendees were different ages and genders, received different dialysis modalities (HD and PD) and provided a broad range and breadth of perspectives, we are unable to provide specific demographic data. Thus the transferability of the findings to other patient populations may be difficult to ascertain. We also recognize that patients who attended the workshop may preclude those who have mobility limitations, severe cognitive impairment or are unable to participate in exercise.
CONCLUSION
Patients on dialysis have interest and motivation in being physically active to combat dialysis-related fatigue and protect against further bodily deterioration. However, they experience many barriers to exercise, including baseline fatigue, comorbidities, fear of uncertainties and risks and lack of time. These factors need to be considered in identifying and developing exercise interventions to help maximize acceptability, uptake and sustainability, which in turn may help to enhance overall patient outcomes.
SUPPLEMENTARY DATA
Supplementary data are available at ckj online.
The M-FIT workshop investigators:
| First name | Last name | Affiliation (organization/institute)a | Country |
|---|---|---|---|
| Allison | Tong | University of Sydney | Australia |
| Amelie | Bernier-Jean | University of Sydney | Australia |
| Andrea | Viecelli | University of Queensland | Australia |
| Angela | Charalambous | – | – |
| Angela | Ju | University of Sydney | Australia |
| Anita | van Zwieten | University of Sydney | Australia |
| Barrymore | Beach | – | – |
| Bernard | Larkin | – | – |
| Carmel | Hawley | University of Queensland | Australia |
| Carol | Beach | – | – |
| Cornish | Clive | – | – |
| Danilo | Dingle | – | – |
| Danny | Thomas | – | – |
| David | Blake | – | – |
| David | Johnson | University of Queensland | Australia |
| Deane | Baker | – | Australia |
| Debbie | Underwood | – | Australia |
| Dianne | McLaren | – | Australia |
| Faye | Demagante | – | Australia |
| Gaye | Jennings | – | Australia |
| Helen | Jeff | – | Australia |
| Irene | Mewburn | – | Australia |
| Jonathan | Craig | Flinders University | Australia |
| Joy | Wooldridge | – | Australia |
| Julianne | Ellis | – | Australia |
| Karine | Manera | University of Sydney | Australia |
| Kass | Widders | – | Australia |
| Kay | Young | – | Australia |
| Ken | McLaren | – | Australia |
| Ken | Yew | – | Australia |
| Kevan | Polkinghorne | Monash University | Australia |
| Martin | Howell | University of Sydney | Australia |
| Melinda | Ellis | – | Australia |
| Michelle | Blake | – | Australia |
| Neil | Boudville | – | Australia |
| Neil | Scholes-Robertson | – | Australia |
| Nicki | Scholes-Robertson | University of Sydney | Australia |
| Nicole | Evangelidis | University of Sydney | Australia |
| Paul | Grant | – | Australia |
| Paul | Kennedy | – | Australia |
| Pauline | Walter | – | Australia |
| Pauline | Yew | – | Australia |
| Raymond | Jeff | – | Australia |
| Shilpa | Jesudason | University of Adelaide | Australia |
| Talia | Gutman | University of Sydney | Australia |
| William | Wooldridge | – | Australia |
| Yeoungjee | Cho | University of Queensland | Australia |
No affiliation specified for patients/caregivers.
Supplementary Material
ACKNOWLEDGEMENTS
We acknowledge, with permission, all the patients and caregivers who contributed to the M-FIT workshop: Angela Charalambous, Barrymore Beach, Bernard Larkin, Carol Beach, Cornish Clive, Danilo Dingle, Danny Thomas, David Blake, Deane Baker, Debbie Underwood, Dianne McLaren, Faye Demagante, Gaye Jennings, Helen Jeff, Irene Mewburn, Joy Wooldridge, Julianne Ellis, Kass Widders, Kay Young, Ken McLaren, Ken Yew, Melinda Ellis, Michelle Blake, Nicole Scholes-Robertson, Neil Scholes-Robertson, Paul Grant, Paul Kennedy, Pauline Walter, Pauline Yew, Raymond Jeff and William Wooldridge.
CONFLICT OF INTEREST STATEMENT
None declared.
Contributor Information
for the M-FIT workshop investigators:
Angela Charalambous, Barrymore Beach, Bernard Larkin, Carol Beach, Cornish Clive, Danilo Dingle, Danny Thomas, David Blake, Deane Baker, Debbie Underwood, Dianne McLaren, Faye Demagante, Gaye Jennings, Helen Jeff, Irene Mewburn, Joy Wooldridge, Julianne Ellis, Kass Widders, Kay Young, Ken McLaren, Ken Yew, Melinda Ellis, Michelle Blake, Nicole Scholes-Robertson, Neil Scholes-Robertson, Paul Grant, Paul Kennedy, Pauline Walter, Pauline Yew, Raymond Jeff, and William Wooldridge
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