Abstract
In this study, domestic violence (DV) in five African refugee background communities post-settlement in Perth, Australia, is investigated—specifically, the interrelationship between experiences of DV, and changed and changing gender and family roles and responsibilities. The participatory qualitative design utilized in-depth interviews with 54 members of the Somalian, Sierra Leonean, Ethiopian, Liberian and Sudanese Communities, and focus groups with 24 professionals who support them. Three key dimensions of this interrelationship are discussed: “male loss of the breadwinner role and status,” “financial independence,” and “mismatch between formal response and expectations.” The importance of understanding experiences of DV within the context of cultural transition is highlighted here.
Introduction
Australia, including Perth in Western Australia, has a long history of settling immigrants, and individuals and families fleeing persecution, war, and violence. Among the more recent humanitarian arrivals in Perth are men, women, and children from the African continent, including from the countries involved in the research from which the findings of this article are drawn: Liberia, Somalia, Ethiopia, Sierra Leone, and Sudan.
Domestic violence (DV) has been an issue of concern in these five communities as well as in the African communities in general in Perth for a number of years. Despite a burgeoning literature examining DV in immigrant and other marginalized groups (Burman, Smailes, & Chantler, 2004; El-Mouelhy, 2004; Green, 1999; Grossman & Lundy, 2007; Kanuha, 2005; Mouzos & Makkai, 2004; Pratt & Sokoloff, 2005; Raj & Silverman, 2002; Sokoloff & Dupont, 2005), there is a dearth of research examining DV in communities from a refugee background, post-settlement, in Western countries (but see Fisher, 2009; Rees & Pease, 2007), including its nature and impact. The context in which it is experienced and perpetrated—specifically, changed and changing gender and family roles—is the focus of this article.
It is acknowledged that the term “community” is problematized in the literature and its meaning changes when used in different contexts by different people (Baum, 2008, p. 499). For the purposes of this research, “community” has spatial and nonspatial dimensions and the definition drawn from the understanding provided by Fielding and Anderson (2008) describing “community” in a refugee context. Thus, community is defined as “those individuals who share a common country or area of birth and/or extended residence in that country; and/or identify as such and are accepted as such, due to familial or other kinship or social ties” (Fisher, 2009, p. 4).
DV Research From the African Continent
DV is constructed differently internationally, as evidenced by the varying laws against the practice across nations and formal supports and responses, if any, available to address it (Heise, Ellsberg, & Gottemoeller, 1999). Thus, definitions of DV vary. That being said, it is most regularly constructed broadly to include physical, sexual, and emotional abuse (Department for Community Development, Family and Domestic Violence Unit, 2004; World Health Organization [WHO], 2005). This construction of DV underpins the present study and is commonly used for DV research undertaken on the African continent (El-Mouelhy, 2004; Koenig et al., 2003; McCloskey, Williams, & Larsen, 2005; Pelser et al., 2005). In research from that continent where the definition of DV is limited to physical violence, this is almost always due to methodological issues associated with the definition of nonphysical forms of violence, rather than advocating a narrow definition.
The body of literature reporting the aforementioned research reports high levels of victimization despite recognition that prevalence and incidence figures may be greatly underestimated (Fishman, Eisikovits, Mesch, & Gusinsky, 2001). Often the result is official figures that reflect a lower prevalence rate (Mouzos & Makkai, 2004). For example, a cross-sectional study undertaken by Jewkes, Levin, and Penn-Kekana (2002) in three provinces in South Africa involving 1,306 women found that 24.6% had a lifetime prevalence of experiencing physical violence. Similarly, in Uganda, results of a study with a representative sample of 5,109 women of reproductive age suggested that 30% of women had experienced physical abuse and/or threats from their current partner (Koenig et al., 2003). In Malawi, a national household survey involving 3,546 households suggested that 48% of Malawian women reported some form of DV, physical or nonphysical, in the survey (Pelser et al., 2005). In each of these studies, there was a similarly high prevalence of experiencing violence in the 12-month period prior to the survey.
Despite research studies adopting broad definitions of DV, it does not necessarily follow that a broad understanding is reflected in community attitudes (see, for example, Michau, 2007), nor do attitudes implicitly reflect the notion that DV is unacceptable (see, for example, Hajjar, 2004). For instance, more than half of the women participants in a study undertaken in Zimbabwe considered DV justifiable (Geneva Centre for the Democratic Control of Armed Forces, 2005). Similar results have been reported in the findings from the WHO (2005) multicountry DV study, in which three quarters of respondents from Ethiopia considered violence justified in some instances. The most widely accepted reason was female infidelity, with 80% of respondents agreeing with this justification. Other justifications for violence included disobeying a husband and refusing to have sex. Jewkes et al. (2002), in a study undertaken in South Africa, found a belief among women that being beaten by their husband was an expression of love.
Experiences of DV for Women From a Refugee or Immigrant Background
There is a growing body of research undertaken in Western countries exploring the experiences of DV among immigrant women. The experiences of DV among women from a refugee background, however, are often conflated with those of the former. This body of research similarly combines women from a range of countries or continents of origin into a single research study. Designing research in such ways makes delineating issues for refugee background women and from a particular geographical location difficult. Nonetheless, the literature is consistent when it points to women from immigrant and refugee backgrounds as being particularly at risk of experiencing DV (Perilla, 2003).
Research suggests that immigrant women experience similar forms of physical abuse to nonimmigrant women (Rees & Pease, 2007), but experience additional forms of emotional and sexual abuse (Raj & Silverman, 2002). For example, in research undertaken in the United States with immigrant women from Mexico and South Asian countries who have experienced DV, findings have revealed that women were subjected to rape in marriage (Abraham, 1998, 1999) and male control in decisions of a sexual and reproductive nature (Morash, Bui, & Santiago, 2000). In addition to control of these decisions, women also considered total male control in family decision making to constitute emotional abuse (Bui & Morash, 1999; Morash et al., 2000) and they were often humiliated by verbal abuse (Morash et al., 2000). Partners’ attacks on women’s “feminine” attributes, including their cooking ability and sexual modesty, have a particularly negative emotional impact on them (Morash et al., 2000). Stark (2007, 2009, 2010) also highlights the impact of such attacks on women’s feminine attributes in Western countries, but in cultures where there is an emphasis placed on defining women in such terms, Raj and Silverman (2002) suggest that such attacks can result in the denial of a woman’s value as a person.
Women from a refugee background are likely to experience a similarly broad range of violence. For some women from immigrant and refugee backgrounds, however, DV as a phenomenon is not named as such, and so “does not exist.” For example, in a study of DV among immigrants from Ethiopia in Israel, Kacen (2006) asked an Amharic-speaking man how to say “violence against women” or “domestic violence” in his language. She was told that there is no such term in Amharic (Kacen, 2006). When she asked how to describe situations in which a husband or partner assaults or insults his wife, she was told that there is no reason to speak about it. Kacen then questions, if there is no term for DV in Amharic, how do immigrants from Ethiopia understand this concept as used in Israeli society to describe situations of violence between husbands and wives? This could be equally applied to any immigrant woman or woman from a refugee background in any country. In a similar way, if women either do not want to, or do not like to talk about DV, or those experiencing it keep the secret of their circumstances well hidden (Immigrant Women’s Domestic Violence Service, 2006, p. 8), DV “does not exist” for those communities.
As noted before, research on the prevalence and experiences of DV, post-settlement, in Western countries among women from a refugee background is scarce. What we do know from the very limited available literature, however, is that factors contributing to DV in families from refugee backgrounds in Australia are almost all interrelated with refugee and settlement experiences (Rees & Pease, 2007). Experiences of trauma, loss, anger, sadness, depression, and anxiety have been shown to be associated with negative experiences of settlement and could be seen as inhibiting opportunities for successful settlement for men and women (Rees & Pease, 2007).
Traditional masculinities, evident among men in this study, exacerbate the risk of DV because men often react with violence should their sense of masculinity be threatened (Grzywacz, Rao, Gentry, Marin, & Arcury, 2009; Hyndman, 2000; Pittaway & Rees, 2006). Some men view violence against their wives and partners as their only option for the release of emotions and use it in an attempt to regain some power and control in their lives (Easteal, 1996). The predominance of patriarchy and power as factors in cases of DV against women from a refugee background is emphasized by the delineation between men’s often violent and women’s commonly nonviolent responses to trauma, persecution, and commensurate experiences of loss and change (Pittaway & Rees, 2006).
Our knowledge, however, is incomplete and further study of experiences and perceptions of DV and the context in which it is perpetrated and experienced is clearly warranted. This article reports findings on the interrelationships between changed and changing cultural norms and expectations around gender and family roles and responsibilities, and DV following settlement in Perth, Australia. The findings form part of a broader study examining understandings, experiences, and impacts of DV (Fisher, 2009). Prior to the presentation of these findings and discussion, however, a brief overview of the conceptual framework underpinning the study and the methodology will be discussed.
Conceptual Framework: Intersectionality
Recently, the concept of “intersectionality” (Crenshaw, 1994) has been used to explain the experiences of victims of DV from diverse backgrounds and marginalized communities. Intersectionality is seen as a powerful explanatory framework as it overcomes what is seen as the inadequacy (Kanuha, 2005) of Western feminist perspectives that place preeminence on gender inequality as the most salient factor in explaining DV or addressing the needs of diverse women (Rees & Pease, 2007). This is important as women from a refugee background do not experience DV in isolation from social or cultural factors (Sokoloff & Dupont, 2005). Trauma resulting from experiencing DV is amplified by other victimization outside the intimate relationship including racism, class oppression (Bograd, 2005), and, for women from refugee backgrounds, culture. As such, DV may not be the only or primary violence shaping family life and does not impact singularly on all families.
Commensurate with this theorizing about experiences of DV among marginalized women and women from diverse backgrounds, intersectionality provides a useful and sound framework and underpins the interpretation of data in this study.
Method
A qualitative research design involving in-depth interviews with members of five African communities—Liberia, Sierra Leone, Ethiopia, Sudan, and Somalia—and focus groups with staff from health and social service agencies that provide support to members of the five communities, was utilized for this project. In-depth interviews were undertaken by bilingual, bicultural members of the respective communities. Bilingual, bicultural community members were fluent in their community languages as well as English, and had awareness and understanding of both mainstream and community cultural practices and beliefs. Importantly, they were trusted members of the community, making it much more likely that community member research participants would openly discuss sensitive and personal issues in an interview situation with them. The bilingual, bicultural community members were trained in qualitative research and exposed to a wide range of research on DV by the author. The author undertook the focus groups.
Data were collected over a period of 11 months from May 2008 to March 2009. A total of 78 individuals participated in the research: 54 members (24 male and 30 female), aged 18 to 56 years from the five communities (13 from both Liberia and Sierra Leone, 12 from Ethiopia, and 8 from both Somalia and Sudan); and 24 staff (5 male and 19 female) from five support agencies. To enable broad participation and to limit distress, community member interviews were undertaken in Krio, Amharic, Somali, Madi, Arabic, and Dinka, as well as in English.
Interviews and focus groups were audio-recorded with participants’ consent. For those interviews in which consent to record was not given, lengthy notes were made by the interviewer. Audiotapes from each of the focus groups and recorded interviews in English were transcribed verbatim and imported into the qualitative computer-based data analysis program QSR Nvivo8, along with electronic copies of notes taken during nonaudio-recorded interviews, to facilitate analysis. To protect the anonymity of participants, interviews in a language other than English were translated either locally by the interviewer, or in a different Australian state by professional translators, and likewise imported into NVivo8.
Analysis of the data was facilitated by the use of the constant comparison method described by Glaser and Strauss (1967) and Glaser (1978), and operationally refined by Lincoln and Guba (1985). As such, each transcript or set of notes was read line by line, and units of meaning were identified and coded. As the data analysis proceeded, the units were coded onto major categories of meaning. All the categories were then reexamined and refined. The aim of this refinement process was to maximize internal homogeneity and external heterogeneity. Once this had been completed, the relationships between the categories were examined and data reviewed to confirm associations (Ezzy, 2002).
Ethical approval for the research documentation and to undertake the study was obtained from the author’s university. To protect the identity of those community members who participated in the study, quotes are not attributed to any particular individual or community; instead, the participant is merely identified as a man or a woman. Rigor for the data analysis was ensured using the criteria recommended by Sandelowski (1993).
Findings and Discussion
Overwhelmingly, when participants from the five communities discussed DV, they incorporated lengthy discussion of changing and changed gender and family roles and expectations into their narrative. Thus, the inherent interrelationship between these postsettlement changes and the perpetration and experiencing of DV was very apparent. Three key dimensions of this interrelationship emerged from the analysis: “male loss of the breadwinner role and status,” “financial independence,” and “mismatch between formal response and expectations.” Although these three dimensions are inherently intertwined, they are discussed separately here for purposes of clarity.
Male Loss of the Breadwinner Role and Status
Australia is socially, economically, and culturally different from the five countries from which community member participants in this study came. As such, it would be expected that they would experience some sense of cultural dissonance as they adapted to a different social, political, and economic environment. It is also inevitable on resettlement and against this backdrop that changes in gender and family roles would occur.
Many men in this study were not employed or were employed in positions that were of a much lower status than those they were qualified for and held in their home country. Prior to resettlement, men also occupied a traditional role of “breadwinner” for their family and enjoyed its concomitant status as “head of the house” within a traditional, hierarchical family structure. The perceived loss of status of the man when he was no longer the breadwinner and household head was an integral facet of changing and changed gender and family roles. Both men and women in this study reflected on these changes and their impact; for example, a woman said,
My husband is not happy here in Australia for several reasons. He has not any job to do. The new cultural change and the new language that he need to learn. He is not any longer someone who look after and support his family, especially financially. My husband’s role has changed totally in his own family and in society as well.
The dual role that men in this study had previously held—breadwinner and head of the household—were integral to their sense of identity and integrity (see also Green, 1999; Grzywacz et al., 2009; Kang, Kahler, & Tesar, 1998; Rees & Pease, 2007). These traditional roles were lost on resettlement, with often negative impacts, including perpetration of DV:
Back home [country of origin] the husband works, the wife stays home, you know, so automatically the man is in charge. He’s got all the financial issues under his belt, he takes care of that, it’s up to him, you know. . . . I think it can contribute to domestic violence because, I mean men . . . are the dominant ones, men are the powerful ones, you know, and once that’s taken away from them, you can imagine how that could feel. (Woman)
Perpetration of DV, then, was often seen as a response by men as a means of reestablishing their control as head of the family in a changed social and cultural environment. Both male and female community member participants talked about men “being in control” as they supported their families financially, while the women’s role was supporting their families emotionally. Thus, the importance of the breadwinner role was culturally determined for community member participants in this study, and failure of the man to find employment commensurate with his knowledge and skills led, in part, to men talking about being “depressed” and “worthless”:
Here in Australia no one respect men, specially if you are not working. In other words men’s role has been changed totally, and we worth nothing. (Man)
Unemployed or underemployed men in this study felt disempowered. If they perceived their wives and/or children as the disempowering agents, albeit as a result of changed and changing roles for them as well as women and children, while not implying causation, it appears that this may manifest in women and children becoming victims of DV.
This observation has precedence in the literature. Pittaway and Rees (2006) argued that women’s gender roles and traditional notions of masculinity are rigorously defended when cultures feel under threat from external pressures as is the case for gender and familial roles in the communities in this study, particularly for men. The result can be an increase in rigidity of cultural practices and increased gender inequality.
Employment and culture appear to be intricately intertwined in the narratives of community member participants in this study. Thus, rather than being seen as patriarchal beliefs and practices mediated through culture, these gendered beliefs and practices around employment and, thus, male dominance in families were seen by men as pertaining to “our culture.”
Such struggles and tensions around change in status for men were noted also by support agency staff:
They [men] still try to hold that role of powerful ones, probably more important within the community and I think there’s that struggle as an outsider watching and listening to conversations in certain forums that they do struggle with it because the women are starting to have a voice. Getting a better understanding, I guess . . . They [women] are becoming better at standing up for themselves and speaking. So I think it’s [women having a voice] causing them [men] a bit of unrest.
Masculinity, expressed through power and status in the family and economic independence, appears to create the context for vulnerability of women to DV in this study. Women, however, are exposed to a “double whammy” because the erosion of masculinity, evident in the breakdown of the traditional male breadwinner role, and men’s struggle to retain it also creates the context for women’s vulnerability to DV.
Financial Independence
Australia has a social security system that provides ongoing financial support for individuals and families who have no, or very low, private income. In addition, payments are made to families to assist with the cost of raising their children. Payments for the woman and the children go directly to her bank account. The agency administering and controlling this support allocation is Centrelink, a department of the Australian federal government.
During discussions with community member participants about DV, the impact of Western legal and social systems on changed and changing gender and family roles was dominant, most notably the role of Centrelink. It is important to note that the community member participants in this study came from societies where such payments did not exist, or did not exist to the same extent. Thus, for many participants, a social security system and its underlying ideologies are completely alien.
Payment being made directly to women was a cause for great angst for many men in the study as it was seen as undermining and usurping their “provider” role and handing it to the woman. This, they argued, was leading to a breakdown of the traditional family structure. The tension that this created as men struggled to retain their traditional role and status was seen as manifesting in DV in many families:
This Centrelink payment causes in my opinion some problems because, let’s say if the husband gets Centrelink payment and the wife gets Centrelink payment and also gets a child support there is no dependence between each other. The husband is not depending on his wife or the wife is not depending on her husband. So this kind of welfare assistance will create the independence between couples, will create a lot of independence in families. (Man)
Hence, tensions around financial issues and loss of status of the male and DV become intertwined:
Everyone here [in Australia] is equal rights; nobody is higher than any other person—we are all equal, the children, the man, the woman and eventually through the system here, it’s like the women, ah, have more responsibilities because, like Centrelink with the income, the kid’s money is always deposited into the ladies’ accounts, the ladies have her own account and the man has his own account and this has not been happening where they come from. So these, these are some of the things, you know, that bring these problems [domestic violence]. (Woman) The factors that cause the loss of leadership role of the husband include financial problems. The wife likes to manage the family’s financial affairs. Similarly, the husband thinks he has to manage it as this is his traditional role in their home country. (Man)
There is evidence in the above quotes, which were typical of many, of the tension that exists between the man and the woman: The woman often does not want to let go of newfound freedom in managing finances, and the man does not want to relinquish his traditional role.
The Australian government was often seen as a “de facto father” to the children as it now provides financially for the family, the role the male traditionally performed pre-settlement. Because their status was bound up in their roles as providers, as this status diminished, women perceived that men felt there was no need to continue their responsibility for caring for their family in any form. This resulted in women, as receivers of Centrelink payments for children, having to assume this additional provider role:
One of the difference in men these days, I mean for my partner he doesn’t care to do anything in the home because he say that because me and the kids’ [money] come on . . . me so, I mean, he just don’t care about doing anything . . . So I mean I’m forced to pay the rent, I’m forced to . . . pay the bills and . . . he doesn’t much care for the kids as he used to be in Africa because he says that the government gives the kids money, and I mean it’s not a bad thing for government to give us money, but that doesn’t mean that men should not take their responsibility as they used to. (Woman)
From the data, it appears that complex dynamics are occurring in families around receipt of Centrelink money. The man may feel disempowered because Centrelink makes payment for the woman and any child directly to the woman. Issues are thought to arise as there is no information given about, and there is limited understanding of, the reasons why payments are made in this way. This lack of knowledge is thought to build up tension as there is no context through which men can understand the payment system that operates in Australia. For many women, this may be the first time in their lives that they have had access to money and they may not want to give it to the man. The situation becomes further complicated if one of the partners obtains employment and the other loses Centrelink money, and/or children reach the age of 16 are eligible to receive their own benefits. Tensions thus develop and remain over the receiving, controlling, and expenditure of finances.
Underpinning this is the belief that increased access to and expenditure of economic resources is breaking down traditional family structures and detrimentally impacting traditional family and gender roles. The traditional family structure, with authority vested in the male as head and the consequent dependence on him by other family members, is being supplanted by a Western individualist structure that challenges the notion of a head. Individuals are considered important and power is divested to them. Ostensibly, Australia’s individualism is at odds with worldviews emphasizing collective well-being (McMichael & Manderson, 2004; see also Kacen, 2006).
Mismatch Between Formal Response and Expectations
In addition to the freedom that financial independence accrued by receiving individual Centrelink support payment is perceived to allow women, the Western legal system (the police and judiciary) and social support systems that respond on behalf of victims of DV were likewise seen as complicit in changing gender roles. Community member participants spoke from a personal perspective about the impact of these systems—largely the “freedoms” that provision of services and support afforded women and children. It was felt, predominantly by community men, and also by some women (particularly where freedom for children was concerned), that the formal systemic response to DV that adopts a stance that DV is not acceptable, not a private family issue, will not be tolerated, and will be taken seriously, was very “pro women and children” at men’s expense and to men’s detriment. The Australian formal response to DV is very different from the response, or nonresponse, most were familiar with prior to settlement in Australia:
They [legal and social system staff] always look at one side, at the side of the woman. So this has been going on and it’s been affecting our relationship and our family. I’m quite sure it is not just me, it is many Africans as a whole. (Man)
Essentially, the system was threatening patriarchal norms that position women as subordinate to men in the family, through supporting them by taking the issue of DV seriously and responding to it accordingly.
An interrelated and interwoven issue with DV is that of “discipline.” Despite the behaviors involved often constituting physical assault, “discipline” was described by community member participants in this study as a way of “guiding” and “providing direction” to another individual and, therefore, was not considered “domestic violence.” Indeed “discipline” was often seen as a duty. Community member participants felt that they were no longer able to discipline children as they had in Africa. This was seen to lead to a lack of respect for, and loss of, parental authority. This view was expressed by men and women. For example,
In the first place in Australia there are whole lot of influences in dealing with your family, yes, because, you know, when you reach here, you know, the way you can’t take control [of] your family [as in] Africa . . . your child does wrong and you smack them to discipline them, which they do in Africa, you do it here the government will come in, the community people will come in, the school will come in and it’s a whole lot of interference here. So it’s hard to bring up family here as in Africa. In Africa they [children] listen to you at least, because you are the breadwinner, but here they don’t. It’s like in [name of country] you know, where I come from, they listen to you as a father but coming here in the Western world is different. (Man)
Just as alarming, however, some men saw it as their right and responsibility to “discipline” their wives:
When we were living in [name of suburb] she [wife] came home late with my daughter in the pram, so I said, “Look, where you coming from?” “Oh, I can do anything, I can do anything.” So I had to discipline her because I know my woman. (Man)
Not everyone, however, considered the impact of the legal and social systems negatively. Some women in particular were thankful for a system that they believed treated everyone equally, provided a voice for them, supported them, and provided a positive response to DV:
Well in Africa women have not much to say, but we, the women, say “thanks God” because here women are given priority by being able to talk to your husband and giving him your opinions and they can listen to us . . . here there is access and independence. (Woman)
There was a sense that women were becoming stronger, felt more able to speak up about the violence in their lives, and seek support for it because they know that violence is unacceptable, that it will be taken seriously and there are options for them:
The fighting which has been happening between myself and my husband has changed a bit. He can no longer fight me because he can smell the problem if he fights me. Now, whenever we quarrel, he will make a remark that “Oh, if we were in Africa, like your mouth is bleeding.” In fact we are now living in separate rooms because this is an English country so there will be no bleeding from my mouth. Now if I want, I can greet him, but if I don’t want, I will not . . . Now I am a strong woman so these issues [domestic violence] does not always affect me because he no longer punish me as he use to do, so most times when we have issues, I will tell him that this is not Africa. (Woman)
The challenge for service providers is to ensure that their services are culturally relevant and secure, that locally recruited staff are aware of the context of women’s lives prior to settlement, and that staff have the skills and knowledge to understand DV within the context of cultural transition.
Conclusion
There is a complex interrelationship between gender and family roles that has been changed or is in a state of flux by virtue of the refugee experience and settlement in Australia, and the perpetration and experiencing of DV. This, coupled with Australian social and legal systems that reflect Western individualist ideologies in contrast to the collectivist structures apparent in participants’ countries of origin, appears to create tensions within families. The community member participants in this study came from countries where there was a limited or no formal response to DV, and so it could be expected that they would experience the formal legal and social responses to DV in Australia as dissonant. The manifestation in DV of the struggle of many men to maintain traditional gender and family roles and understand and adapt to the Australian response to DV is a challenge for service providers, researchers, and community members alike who are working for its prevention. The resulting cultural dissonance and often increased gender inequality, cultural rigidity, and a sense of loss experienced as a result of the changing roles as well as their intersectionality with socially structured systems of inequality including refugee status must be acknowledged and accounted for in all efforts to address DV in communities from a refugee background in Western countries including Australia.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by Lotterywest.
