Consumer perspective from people with a diagnosis of Borderline Personality Disorder (BPD) on BPD management—How are the Australian NHMRC BPD guidelines faring in practice?

Accessible Summary What is known on the subject? Internationally, stigma towards people with mental illness has reduced due to greater understanding, education and advocacy in the community, and more focus on recovery‐oriented care within practice guidelines. However, many people with a diagnosis of BPD continue to experience stigma and difficulty accessing health services. Contributing factors include lack of understanding of BPD and effective management by health professionals, stigma from the general population and within healthcare services, and financial and geographical barriers. Mental health nurses comprise a large part of the healthcare workforce responsible for the day‐to‐day care of people diagnosed with BPD. What the paper adds to existing knowledge This paper investigates how Australian consumer perspectives on BPD management have changed over time. Comments from a large survey, delivered to consumers in 2011 (N = 153) and 2017 (N = 424), were analysed for common themes. Themes were broadly related to NHMRC BPD Guidelines sections released in 2013. These data sets therefore present an opportunity to evaluate changes in consumer perspectives pre‐ and post‐Guideline release. Although no direct causal relationship can be drawn, analysing these changes can potentially assist with understanding the impact of the Guidelines in practice. No such analysis of the Australian Guidelines has been conducted to date in the existing literature. What are the implications for practice? Many people diagnosed with BPD continue to experience stigma, barriers to treatment and difficulty accessing appropriate services. Widespread practical implementation of the Guidelines was not apparent; however, improved general awareness and understanding of BPD from consumers and health professionals were evident. Improved education and practice across each and all aspects of the Guidelines are indicated. The Guidelines need review to ensure they are in‐line with current evidence‐based practice, as well as effective health professional education, support and funding to embed the revised Guidelines into practice. Abstract Introduction Internationally, many individuals diagnosed with BPD continue to experience stigma within health care and are more likely to be viewed as manipulative and evoke negative responses from clinicians, compared with other mental health consumers. Aim/Question To understand Australian consumer perspectives regarding BPD management, and how these have changed between 2011 and 2017. To comment on how NHMRC BPD Guidelines, released 2013, are faring in practice. Method Individuals who identified a BPD diagnosis completed a 75‐question survey, delivered online Australia‐wide, in 2011 (N = 153) and 2017 (N = 424), providing comparative data sets to evaluate changes in consumer perspective on BPD management. Results Many people diagnosed with BPD experience difficulties when seeking help, stigma within health services and barriers to treatment. Improved general awareness, communication and understanding of BPD from consumers and health professionals were evident. Discussion Consumers demonstrated increased BPD‐literacy and help‐seeking behaviours in 2017, providing opportunity for health professionals to build stronger therapeutic relationships. Widespread practical implementation of the Guidelines does not appear to have been achieved. More health professional education, updated Guidelines, funding and strategies to embed these Guidelines into practice are needed. Implications for Practice Mental health nurses regularly provide care to people diagnosed with BPD; with practical education and support, they and other health professionals can improve their confidence in practice and provide better quality care to consumers.

perceive this from treating health professionals, they can respond with self-harm and withdrawal from treatment (Aviram et al., 2006;Kling, 2014).
This complex set of circumstances has led to uncertainty and controversy amongst mental health professionals in disclosing a diagnosis of BPD to an individual, especially adolescents, due to concern for potential stigmatizing effects (Ring & Lawn, 2019;Wlodarczyk et al., 2018). However, recent research has shown that disclosing the diagnosis to the individual assists them in understanding their experiences and in receiving effective treatment (Courtney & Makinen, 2016;Kaess et al., 2014). Transparency regarding an individual's diagnosis of BPD can be positive for several reasons, including respecting their autonomy, avoiding misinformation via the Internet, ensuring they receive suitable treatment and reassuring them that their distress is due to a known illness, with effective treatments available (Lequesne & Hersh, 2004). Additionally, prompt and clear communication to the consumer regarding their diagnosis can avoid later disengagement with treatment, as demonstrated in a study by Sulzer et al. (2016), "patients who later discovered that their diagnosis had been withheld consistently left treatment." This research examined 32 patients and 32 clinicians, who were interviewed regarding communication of BPD diagnoses.
The majority of clinicians chose not to disclose a BPD diagnosis to a patient, even when they felt it was most appropriate, usually motivated by a desire to avoid the stigma associated with a BPD diagnosis. This is in direct contrast with most patients, who wanted to be told their diagnosis. Of note is that most patients in the sample wanted to specifically discuss the stigma they may face with their clinician. Patients in the sample overwhelmingly reported relief at being given their diagnosis, to the surprise of the clinicians in the sample. This research not only highlights the essential nature of open communication in a therapeutic relationship, but also highlights the extent to which stigma towards people with a diagnosis of BPD is manufactured from within mental health services. A study by Zanarini and Frankenburg (2008) also demonstrated that individuals who are educated about BPD with up-to-date information immediately after diagnosis experience significantly lower shortterm impulsivity and interpersonal relationship distress. The recent SANE report (Carrotte et al., 2019) further highlights the problems with stigma from within health services, and the negative effects of unclear or insensitive communication from health professionals in the Australian setting.
Placing trust in health professionals can be especially challenging for people with a diagnosis of BPD, for a multitude of reasons. Looking at Ward's (2017) paper on trust in public health, two different kinds of trust are outlined. He takes Sabel's (1993) definition of interpersonal trust; "the mutual confidence that no party will exploit another's vulnerability," and extends this to address the power differences that contribute to interpersonal relationships, adding, "to accept the risks associated with the type and depth of the interdependence inherent in a given relationship." This addition is particularly relevant when considering consumer-health professional interactions, due to the inherent power differential in the relationship. Institutional trust is defined as "the expected utility of institutions performing satisfactorily" (Mishler & Rose, 2001) and is influenced by personal experiences within the institution or its wider system, as well as social and cultural norms and public perception. Reflecting on the medical profession's volatile history with BPD and those given this diagnosis, in terms of stigma, dismissal and mistreatment, as well as directly or indirectly experienced stigma and misunderstanding from the wider community, it is understandable that consumers may be hesitant to trust health professionals or institutions, particularly psychiatrists and mental health nurses (MHNs) in an inpatient environment. With the current ease of sharing information via the Internet through platforms like social networking and forums, consumers are also able to connect more easily with one another, and share stories of lived experiences, which may also affect their views on the trustworthiness of healthcare systems and workers. Considering emotional instability and experiencing emotions intensely are characteristic and diagnostic features of BPD, it can be suggested that each interaction holds even more importance for that individual's overall trust in health care than people with other diagnoses.
The benefits of effective treatment for people diagnosed with BPD extend beyond the individual and their social network to reducing the economic burden associated with ineffective BPD management. Personality disorders in general account for a high economic cost to society, and people with a BPD diagnosis are significantly more likely to use all types of psychiatric services and see a greater number of specialists (Bender et al., 2001;Jackson & Burgess, 2004;Meuldijk et al., 2017;Soeteman et al., 2008). An Australian study by Lewis et al. (2018) on acute presentations to psychiatric services found that patients with personality disorders were 2.3 times more likely to re-present within 28 days of their first presentation than others and that personality disorders were second only to psychoses in increasing the rate of admission factor. This study also found that over a fifth of patients presenting to emergency, and a quarter of inpatients, had a personality disorder diagnosis. Equipping people diagnosed with BPD with the skills and support to successfully manage their emotions and engage in society through effective, evidence-based treatments leads to better quality of life for consumers, resulting in decreased need for emergency and hospital services, and offering a potential solution to the currently high economic cost of BPD management.
The National Health and Medical Research Council (NHMRC) released Guidelines for the management of people with a diagnosis of BPD in February 2013, with evidence-based recommendations relating to diagnosis, treatment options, ongoing management, utilization of healthcare services, support of carers and family, as well as general principles for care. In addition to the above sections, they contain management and crisis management plan templates. These Guidelines are of specific relevance to mental health professionals involved in regular care of people diagnosed with BPD, such as MHNs, in guiding their practice and decision-making. They also offer advice more broadly to other health professionals such as general practitioners (GPs) and allied health who may have responsibility for providing care to people diagnosed with BPD, with a condensed version of the Guidelines available for easy reference. Coincidentally, a survey investigating experiences of care by people with a BPD diagnosis was administered in 2011, before these Guidelines were released, and again in 2017 (Lawn et al., 2017;McMahon & Lawn, 2011). The term consumer is primarily used throughout this paper, to describe individuals diagnosed with BPD who seek care from health services.

| Rationale
Although this survey was not administered with the purpose of investigating the Guidelines in any way, and therefore no direct causal relationship can be drawn, the two time points at which it was delivered does provide an opportunity to assess changes in consumer experiences over this time. As such, this research can provide a useful insight into whether, given the release of the NHMRC Guidelines in this time, treatment has improved from the consumer perspective.
It also provides an exemplar to guideline developers, researchers, clinician services and clinicians, and consumer advocacy groups in other countries that may offer insights and therefore help support improvements in BPD care to practice, more broadly. As one of the primary aims of the Guidelines is to improve the delivery of BPD management, and therefore the consumer perspective on management, the authors believe it is reasonable to examine the changes in consumer opinion over this time as one way to assess the potential impact of the Guidelines in practice. The impact of the Guidelines on Australian consumers has not been addressed in the existing literature. The authors have analysed data from the Australian context, as their primary area of residence and practice, and acknowledge the potential for differences in other geographic locations. A study by Simonsen et al. (2019) comparing BPD guidelines across several European countries noted important contradictions between recommendations in relation to diagnosis, length and setting of treatment, and use of pharmacological treatments, but consensus on recommending the use of psychotherapy. Of note, these authors strongly recommended the inclusion of consumer perspectives in guideline development and review. The qualitative data from the Australian consumer surveys have not previously been analysed and as such is an important source of information on consumer perspectives on how they Australian guidelines are faring that deserves thematic analysis and discussion.

| Aims/Objectives
The aims of this paper were to understand consumer perspectives regarding BPD management, and how these have changed between 2011 and 2017, as well as commenting on how the NHMRC BPD Guidelines are faring in practice, given their release in 2013.

| Design
Data presented in this paper are drawn from two online surveys, one to people with a diagnosis of BPD and the other to their carers (predominantly family providing unpaid informal support), adminis-

| Ethics
Permission to access the data and conduct this study was granted by the PMHCCN. Participation in the surveys was open to anyone who identified as having a BPD diagnosis, and informed consent was assumed via participation in the voluntary online survey. Ethical considerations for the original 2011 survey were informed by consultation with the PMHCCN National Committee of consumers and carers, and BPD academics linked with the BPDERG. Ethics approval for the current study was granted by the Social and Behavioural Research Ethics Committee, Flinders University (No. 7613).

| Bias and reflexivity
The authors acknowledge the potential for bias in any interpretation of meaning from qualitative data, particularly given the mental health consumer systematic advocacy roles played by some of the authors.
We addressed this through the robust team discussion during the analysis processes described below and by presenting our preliminary findings for scrutiny to mental health peers at the Royal Australian and New Zealand College of Psychiatrists Annual Congress (2019). The audience at this presentation also included some individuals involved in the development of the Guidelines, who were given opportunity to comment and discuss their thoughts with some of the authors.

| Data analysis
Survey responses were analysed using summative content analysis, which involves subjective interpretation of the data through systematic classification and coding to identify themes or patterns (Hsieh & Shannon, 2005). The first author undertook data analysis by reading and re-reading respondents' qualitative responses, word by word. They then undertook formal analytic memo writing to begin formulating general impressions about participants' responses, checking back and forth across the data, highlighting phrases with similarities and differences in perspectives as part of preliminary organization of the data into themes. Two members of the research team met regularly to discuss and debate the tentative and final groupings, checking them against the original data sets, also to ensure accuracy of context was captured.
Specific examples of responses that exemplified each theme were discussed and agreed upon. The themes which emerged related broadly to the sections in the shortened version of the Guidelines-"Caring for People with Borderline Personality Disorder: A Reference Guide for Health Professionals" (NHMRC, 2013;NHMRC, 2013), and as such, the research team also agreed to present results under these subheadings.

| RE SULTS
De-identified direct qualitative quotes from survey respondents have been selected which best demonstrate the themes and reflect the dominant responses across the data. The terms "respondent," "consumer" and "patient" are used interchangeably, where appropriate, to denote people with a diagnosis of BPD who responded to the surveys, and when talking about the experiences of people with a BPD diagnosis generally.

| Transparency and communication regarding BPD diagnosis
The Guidelines recommend that people diagnosed with BPD should be told their diagnosis, have the diagnosis and symptoms explained to them and related to their own experiences, with emphasis on the fact it is not their fault, and that effective treatments are available.
The data highlighted two main problems consumers faced when being diagnosed with BPD: the health professional making the diagnosis withholding this information from the consumer and poor explanations of BPD at the time of diagnosis (Table 1).
Respondents in 2017, in general, appeared to be given their BPD diagnosis earlier than was the experience of 2011 respondents;

TA B L E 1 Transparency and communication regarding BPD diagnosis 2011
1. "…I got hospital files and found out they said I had BPD when I was 18 I had no idea!! I feel really angry about this. People MUST explain diagnosis not just hand them out. I didn't find out what BPD was until I was 38 years old and a therapist explained it…" 2. "I had a hospital stay 16 years ago and was diagnosed with BPD -this has never been explained to me and I have been treated for depression ever since." 2017 3. "If I had been properly assessed when I was first diagnosed with a mental health condition, I wouldn't be in this situation now, people might take me seriously, and I could have started ACT and DBT much sooner. I was 17 at the time, and no psychiatrist would have diagnosed me with BPD." 4. "I was diagnosed with BPD at age 19 but had already brought up the possibilities to several psychologists and the school counsellor I had during my 15-18 years of age. I was diagnosed with depression at age 14 but felt there was much more so I did my own research to gain some understanding. I brought up my concerns with these professionals but they didn't consider the possibilities (due to stigma, lack of knowledge or that I was good at masking my problems) and as a result I received inadequate treatment. It was only until I was admitted to hospital for BPD-related issues at 18 and was referred to another psychologist that the possibility of me having BPD was taken seriously." 5. "Psychiatrist diagnosed BPD but didn't tell me -only found out when she made a report to AHPRA re suicide attempt/alcohol use, still see her but will never trust her again (didn't tell me about the report either, that was left to my psychologist)." 6. "Given a diagnosis of BPD in 1975 by a psychiatrist, I was 12. Since then I have not received any information and didn't know what was the point of the label." however, comments regarding the negative impact of not receiving their diagnosis early enough prevailed across both samples.
In 2017, there was a sense that respondents were more aware of their own behaviour as likely to be a mental health problem. They also seemed more health literate about the characteristics of BPD, leading them to suggest the diagnosis to health professionals, but unfortunately, they often felt that these thoughts were not considered or taken seriously, leading to delay in diagnosis and treatment.
Comments about younger respondents not being taken seriously due to their age were also prevalent in both data sets, despite the Guidelines stating that although the diagnosis is not recommended for prepubescent children, assessment for BPD should be considered in people presenting with the relevant signs from age twelve.
Only 50

| Interpersonal approach demonstrated by health professionals in BPD management
The Guidelines state that health professionals working with people diagnosed with BPD should listen to the person's experiences and take their feelings seriously, whilst being respectful, caring, compassionate, consistent, reliable and non-judgemental. Comment 8 (Table 2) highlights the negative effects on consumers when they perceive they are not being treated respectfully. The psychiatrist explicitly addressing the power imbalance in the therapeutic relationship resulted in increased trust and understanding in comment 7, and comments 9 and 11 show the positive impact of the psychologist listening and making efforts to understand the respondent's experience. However, it was still apparent in 2017 that many consumers felt dismissed, misunderstood and in some cases demonized, by their health professionals, and many still expressed that they felt they were not taken seriously. The idea of BPD not being a "real" mental illness was present, and continued to be so in 2017, despite the Guidelines specifically addressing the need to understand BPD as a legitimate use of health services. This was especially reported by respondents regarding hospital admission and in crisis situations, scenarios in which MHNs play an integral role in face-to-face service delivery.

| Managing crises, self-harm and suicidal behaviour
The harm or has a co-occurring mental illness. It seems that distinguishing the level of immediate risk to the consumer in emergency presentations causes significant problems for health professionals and consumers (Table 3). Many comments from 2011 and 2017 describe respondents feeling as if they were at imminent risk of self-harm and unable to manage on their own, but assessment from health professionals, particularly paramedics, MHNs and psychiatrists, did not align with the respondent's own beliefs at the time.
Comment 13 points to the importance of stable management, when this person transitioned to a new psychiatrist and experienced suicidal thoughts, the support of the new psychiatrist meant they avoided hospitalization and confidence in their ability to control their own emotions increased. A recommendation of the Guidelines includes explaining to the respondent that it is not feasible to depend on the mental health service or GP to be available at all times, and to help them use a problem-solving approach to identify practical alternatives in a crisis. From these data, it is evident that there continues to be significant use of hospital emergency departments for individuals diagnosed with BPD in a crisis, rarely resulting in positive therapeutic outcomes. MHNs are well placed to provide consistent and routine care to enhance stability in the consumers' BPD management. Nurses are also able to undertake training in a wide range of areas, including in providing psychoeducation to patients, helping to build consumers' capacity and autonomy regarding day-to-day management of distress and BPD symptoms.

| Managing trauma
The potential link between trauma and BPD is addressed in the Guidelines, and the high prevalence of comorbidities (such as PTSD) linked to previously reported trauma in both data sets highlights this (Lawn et al., 2017). The Guidelines specify that clinicians should avoid re-traumatizing patients and that questions about past adverse experiences should be handled sensitively. Comments 17-18 (see Table 4) highlight the distress caused by a health professional exposing trauma without patient guidance and sensitivity.

| Management plans
The Guidelines specify that every individual with BPD should have a tailored management plan, developed in collaboration with them, and that their family/carer/partner should be involved if the individual consents and this is in their best interest. This should also include a brief and clear crisis plan, and these plans should be shared with all health professionals involved in the person's care. Access to a management plan could be of huge assistance to health professionals working with people diagnosed with BPD, especially in crisis or with health professionals new to the patient. However, comments 19-20 (see Table 5) demonstrate that these respondents perceived 18. "Psychiatrist did help with medication and has done her best in other ways -but if anything is more likely to trigger distress than to help resolve it as she goes in too hard. Psychologist is much better at dealing with childhood trauma and has been willing to learn how best to assist me."

TA B L E 5 Management plans 2011
19. "I think that if my hospital plan was removed then I would be more happy to attend a hospital or get the help I need when it's needed. At the moment, they put a plan in place that if I turn up before acting then I will have access to a mental health nurse. If I turn up after then they will treat me medically but will not be allowed to get the emotional help, which means I leave in the same headspace and do the same thing over again. their management plans as more harmful than helpful, and they were not invited to collaborate on how they wanted to be treated.
The damage caused by plans made without their consultation was explicitly stated in these comments, including one respondent stating that their plan increased their desire to self-harm (comment 20).
Interestingly, there were very few comments explicitly mentioning care plans in either data set, and no mention of any BPD-specific plans.

| Barriers to treatment
There were many comments from both 2011 and 2017 regarding barriers to treatment, most of which related to a lack of available specialized services. Although there was a sense that appropriate services were more plentiful in 2017, they were still either too far away, too expensive or the wait list was too long for respondents to utilize those services ( TA B L E 6 Barriers to treatment indicated that individuals were seeking out more of these evidencebased psychological treatments. Comparison of the quantitative data clearly showed a shift towards psychologists as primary treatment providers, with 76.2% (N = 80) of respondents primarily seeking support from a psychiatrist in 2011, to 2017 where psychologists were the primary support professional for 84.19% (N = 245) of respondents (Lawn et al., 2017;McMahon & Lawn, 2011). Respondents to the 2017 survey also appeared to have great awareness and use of DBT group therapy, though there were many comments about long waiting times for access to these services.

| D ISCUSS I ON
Effective, evidence-based treatments are available which assist people with a diagnosis of BPD to recovery, so they can succeed in Consumers across both data sets frequently reported distress when seeking help in crisis, such as self-harming, suicidal thoughts or attempts. Inappropriately slow responses to physical injuries and psychological distress, lack of empathy and poor listening skills seemed to be amplified in the emergency department and acute inpatient setting. Respondents most often referred to paramedics, MHNs and emergency department staff as particularly unhelpful, more so than psychiatrists; however, respondents are aware of the control that psychiatrists have over the decision of whether they will be admitted or not (Ring & Lawn, 2019). Considering the concepts of interpersonal and institutional trust discussed earlier, the negative effects of such an experience on the individual's recovery, and implications for future interactions with healthcare services can be appreciated. It is clear from the data that many respondents, when seeking help by presenting to an acute health service in crisis, felt that they did not receive the help they required, or were actively ignored and/ or mistreated by health staff at the time. A key recommendation of the Guidelines is that all individuals diagnosed with BPD have a person-centred management plan, developed collaboratively between consumer, carer/family and health professionals. BPD-specific management plan and crisis management plan templates are provided in both versions of the Guidelines, and the finalized plans are designed to assist health professionals who are unfamiliar with the consumer to access information about the consumer's needs and preferences, so they can provide appropriate treatment and support to the individual and their family/carers. Respondents rarely referred to management plans in either data set, which may reflect the survey itself, as it was not designed to gain data specifically relating to management plans. However, where references to plans were made, it was in an overwhelmingly negative way, with multiple respondents highlighting that their plans were not developed with them collaboratively and were instead forced upon them as control measures.
The importance of collaboratively developed management plans is noted in the Guidelines, and specialist BPD services like Spectrum, Victoria, Australia, use methods such as co-authoring to ensure consumers feel involved and in control of their BPD and its management (Mental Health Professionals' Network, 2018). These data show that consumers did not feel involved in the development of their management plans and did not see them implemented in a way that contributed to their recovery. Respondents described limitations to treatment access dependent on their actions and expressed fear of detainment if they presented to an emergency department with selfharm injuries. The exact nature of these plans cannot be determined from these data, and it is possible that some of the plans mentioned refer to Involuntary Treatment Orders (ITOs), informal "contracts" with their regular doctor, or other circumstances, which serve a different purpose than the plan templates in the Guidelines.
What is clear from the data is that management plans, for many consumers, are not present in the way in which the Guidelines recommend-in that a collaboratively written guiding document is available to the consumer, their family/carers, and all health professionals and services they interact with, which outlines how to address their needs and manage distress or crisis. Accessible, well-made manage-  and clinicians, as well as collaborating with universities and others in a research role, to further inform evidence-based practice and continue to improve service delivery. BPD Co also has a training and education programme, aiming to upskill health professionals and staff involved in service delivery, carers and families, and eventually the wider general community (SA Health, 2019). BPD is a complex and often debilitating health condition for individuals and their families, but with awareness, education and accessible, evidence-based, effective treatments, better outcomes for individuals with this manageable condition can be achieved.

| LI M ITATI O N S
It is not possible to determine how many consumers the invitation was forwarded to, therefore making it impossible to determine an overall response rate. Additionally, survey respondents were not a random sample of the population of people with a diagnosis of BPD, as they self-selected by virtue of choosing to respond to the survey; therefore, the extent to which the conclusions drawn from these surveys represent the wider population of Australians with a BPD diagnosis depends on whether response bias exists and its influence. The surveys did not specifically ask about knowledge or use of NHMRC BPD Management Guidelines, and therefore, no direct causal relationship can be attributed to the Guidelines for changes observed. There was no way to identify and match responses for respondents who completed the survey in 2011 and 2017, as they were completely anonymous. This was done to encourage participation and minimize potential stigma. It was also not ascertained if 2017 respondents had received their diagnosis since 2011, or were responding to experiences prior to 2011. However, original researchers did their best to convey and ensure survey questions were asked with the intention that participants would recall their "current" experi-

| RELE VAN CE TO MENTAL HE ALTH N U R S I N G S TATE M E NT
Caring for people with a BPD diagnosis is an important part of mental health nursing. This paper analyses consumer-reported qualitative survey data from 2011 and 2017. These comparative data sets offered an opportunity to examine the impact of the National Health and Medical Research Council BPD Management Guidelines, released in February 2013, on practice. Although a direct causal relationship between the Guidelines and changes observed in the data is not clear, these time points provided an opportunity to consider the Guidelines influence, for improved practice by mental health nurses and other health professionals, and outcomes for people diagnosed with BPD.

ACK N OWLED G M ENTS
The authors would like to thank Ms Janne McMahon for her integral role in collecting the original data analysed in this paper and for her ongoing work in advocating for people with BPD and other mental illnesses. The authors also wish to thank Lived Experience Australia (formerly PMHCCN) for permission to access these data.

CO N FLI C T O F I NTE R E S T
The authors declare that there is no conflict of interest.

Miss Proctor and Professor Lawn formulated the study design; Miss
Proctor then undertook the analysis, with input from Professor Lawn and critical comment from Ms McMahon.

Approval granted by the Social and Behavioural Research Ethics
Committee, Flinders University (no. 7613).

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from