The role of community pharmacies in the provision of human papillomavirus (HPV) self-testing: A range of delivery models and proof-of-concept study - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. 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Learn more: PMC Disclaimer | PMC Copyright Notice Explor Res Clin Soc Pharm . 2026 Mar 12;22:100729. doi: 10.1016/j.rcsop.2026.100729 Search in PMC Search in PubMed View in NLM Catalog Add to search The role of community pharmacies in the provision of human papillomavirus (HPV) self-testing: A range of delivery models and proof-of-concept study Karen Bartholomew Karen Bartholomew a Health Gain Development, Planning, Funding and Outcomes, Health New Zealand | Te Whatu Ora, Auckland, New Zealand Find articles by Karen Bartholomew a , Lily PH Yang Lily PH Yang a Health Gain Development, Planning, Funding and Outcomes, Health New Zealand | Te Whatu Ora, Auckland, New Zealand Find articles by Lily PH Yang a, ⁎ , Cleo Neville Cleo Neville a Health Gain Development, Planning, Funding and Outcomes, Health New Zealand | Te Whatu Ora, Auckland, New Zealand Find articles by Cleo Neville a , Anna Maxwell Anna Maxwell a Health Gain Development, Planning, Funding and Outcomes, Health New Zealand | Te Whatu Ora, Auckland, New Zealand Find articles by Anna Maxwell a , Joanna Hikaka Joanna Hikaka b Te Kupenga Hauora Māori University of Auckland, Auckland, New Zealand Find articles by Joanna Hikaka b , Jane Grant Jane Grant c Child, Youth and Women, Planning, Funding and Outcomes, Health New Zealand | Te Whatu Ora, Auckland, New Zealand Find articles by Jane Grant c , Collette Bromhead Collette Bromhead d Molecular Pathology, School of Health Sciences, Massey University, Palmerston North, New Zealand Find articles by Collette Bromhead d , Georgina McPherson Georgina McPherson e Women's Health, Waitematā District, Health New Zealand | Te Whatu Ora, Auckland, New Zealand Find articles by Georgina McPherson e , Kate Moodabe Kate Moodabe f Total Healthcare, Auckland, New Zealand Find articles by Kate Moodabe f , Richard Massey Richard Massey g Pathology Associates New Zealand, Tauranga, New Zealand Find articles by Richard Massey g , Sue Crengle Sue Crengle h Ngāi Tahi Māori Health Research Unit, University of Otago, Dunedin, New Zealand Find articles by Sue Crengle h , Susan M Sherman Susan M Sherman i School of Psychology, University of Sheffield, Sheffield, England, UK Find articles by Susan M Sherman i , Nina Scott Nina Scott j Hauora Māori Services, Health New Zealand | Te Whatu Ora, Waikato, New Zealand Find articles by Nina Scott j , Pania Coote Pania Coote k Māori Monitoring Equity Group (National Screening Programmes), AwhiMai Consultancy, Bluff, New Zealand Find articles by Pania Coote k , Wendy Burgess Wendy Burgess e Women's Health, Waitematā District, Health New Zealand | Te Whatu Ora, Auckland, New Zealand Find articles by Wendy Burgess e , Deralie Flower Deralie Flower l Obstetrics and Gynaecology, Te Toka Tumai Auckland District, Health New Zealand | Te Whatu Ora, Auckland, New Zealand Find articles by Deralie Flower l , Jyoti Kathuria Jyoti Kathuria m Women's Health, Counties Manukau District, Health New Zealand | Te Whatu Ora, Auckland, New Zealand Find articles by Jyoti Kathuria m Author information Article notes Copyright and License information a Health Gain Development, Planning, Funding and Outcomes, Health New Zealand | Te Whatu Ora, Auckland, New Zealand b Te Kupenga Hauora Māori University of Auckland, Auckland, New Zealand c Child, Youth and Women, Planning, Funding and Outcomes, Health New Zealand | Te Whatu Ora, Auckland, New Zealand d Molecular Pathology, School of Health Sciences, Massey University, Palmerston North, New Zealand e Women's Health, Waitematā District, Health New Zealand | Te Whatu Ora, Auckland, New Zealand f Total Healthcare, Auckland, New Zealand g Pathology Associates New Zealand, Tauranga, New Zealand h Ngāi Tahi Māori Health Research Unit, University of Otago, Dunedin, New Zealand i School of Psychology, University of Sheffield, Sheffield, England, UK j Hauora Māori Services, Health New Zealand | Te Whatu Ora, Waikato, New Zealand k Māori Monitoring Equity Group (National Screening Programmes), AwhiMai Consultancy, Bluff, New Zealand l Obstetrics and Gynaecology, Te Toka Tumai Auckland District, Health New Zealand | Te Whatu Ora, Auckland, New Zealand m Women's Health, Counties Manukau District, Health New Zealand | Te Whatu Ora, Auckland, New Zealand ⁎ Corresponding author at: Health Gain Development, Planning, Funding and Outcomes, Health New Zealand | Te Whatu Ora Q4 Building, Level 2, Smales Farm 74 Taharoto Road Takapuna, Auckland 0622, New Zealand. [email protected] Received 2025 Jun 25; Revised 2026 Mar 1; Accepted 2026 Mar 2; Collection date 2026 Jun. © 2026 The Authors This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). PMC Copyright notice PMCID: PMC13089177 PMID: 42007169 Abstract Background Cervical cancer persists in Aotearoa New Zealand, mainly due to under-screening. Longstanding disparities in screening and cancer rates remain for Māori, Pacific and people not regularly screened. Community pharmacies are an important and accessible part of primary care. Objective To outline and provide potential models of pharmacy involvement in the provision of HPV self-testing. Of the three potential models proposed, our proof-of-concept study trialled two models: 1) promotion of human papillomavirus (HPV) self-testing by pharmacy staff, with mailed test kits from the centralised co-ordination team, and 2) on-site provision of at-home self-test kits by study nurses, both with telehealth support and results follow-up from the study team to expand self-test access. Methods Six Auckland community pharmacies with high proportions of female Māori and Pacific customers (based on dispensing data) participated in the study for 6 weeks from May to July 2024. All pharmacies participated in the promotion model and one participated in the on-site provision model. Results Although our numbers were small ( n = 45 participants), our sample return uptake was 69%, showing that pharmacy involvement can engage people with HPV self-testing. Self-tested participants ( n = 31) included 29% who were Māori (19%) or Pacific (10%), and 32% who were overdue for screening by ≥2 years. All surveyed pharmacy staff ( n = 16) supported pharmacy involvement in providing HPV self-tests. Conclusions Community pharmacies, supported by a centralised co-ordination team, appropriate infrastructure and resources, may be an additional setting for further research to increase access to HPV self-testing for Māori, Pacific, under-screened people, and those not enrolled with a primary care provider. Keywords: Cervical screening, Human papillomavirus (HPV), Self-sampling, At-home testing, Community pharmacy, Primary care, Māori health, Pacific health, Health inequity, Aotearoa New Zealand Highlights • Community pharmacies could be a new setting to increase access to HPV self-testing for priority populations. • Priority groups in Aotearoa New Zealand include Indigenous Māori, Pacific, and people who are under-screened (by ≥2 years). • This setting may also engage people who do not regularly access general practice. • To engage priority populations, pharmacies need centralised co-ordination support, appropriate infrastructure, and resources. • Large-scale implementation to expand access to HPV self-testing in community pharmacies needs further research. 1. Introduction Cervical cancer is highly preventable due to the availability of immunisation against human papillomavirus (HPV) and cervical screening. However, cervical cancer persists in Aotearoa New Zealand, largely due to under-screening. 1 Access to screening is inequitable, with Māori (the Indigenous population), Pacific (those with Pacific Island origins) and people living in areas associated with high socioeconomic deprivation being less well served. 1 These populations are priority groups for cervical screening in New Zealand. 2 In New Zealand, cervical screening is organised centrally through the National Cervical Screening Programme (NCSP) and delivered mainly through primary care by screen-taker nurses and general practitioners, with a small amount delivered by non-governmental organisation support-to-service providers. 2 Cervical screening is not generally free for participants, unlike the publicly funded national screening programmes for breast and bowel cancers. System-level barriers, such as inequitable access to primary care, more broadly impact some priority groups, particularly Māori. 3 , 4 Although cervical screens are funded for some targeted priority groups, 5 there are variable out-of-pocket costs for primary care visits and consumables. 6 A strategy anticipated to improve screening access was the introduction of human papillomavirus (HPV) primary screening with an initial choice of self-testing using a vaginal swab or clinician-taken HPV test by NCSP in September 2023. 2 Since then, the self-test has become the preferred option over the traditional and more invasive clinician-taken cervical sample using a speculum, accounting for 81% of screens completed. 7 HPV self-testing is associated with increased cervical screening coverage from 67.1% in August 2023 to 73.6% in March 2025. 8 While the preference for HPV self-testing is encouraging, the model of screening delivery was not altered with the programme change and therefore unlikely to overcome access barriers to primary care. Of note, a first-line, integrated and accessible community-based model was recommended by a Parliamentary Review 1 prior to the programme change. Research in New Zealand that explored the implementation of HPV-self testing has largely focused on delivering this to participants enrolled with primary care by offering self-testing in the clinic or at home. 9 , 10 , 11 , 12 , 13 Prior to the introduction of the HPV self-test, research with un- or under-screened wāhine Māori (Māori women) showed self-testing to be acceptable, and may improve uptake if delivered in a culturally safe manner. 6 , 9 , 10 , 14 Culturally safe care places accountability on healthcare professionals to reflect on their own biases and assumptions, and to actively address these and existing power imbalances. 15 , 16 Only those receiving care, rather than health professionals, can determine whether the care was culturally safe. 15 , 16 Although mailed self-test kits are feasible internationally, 17 it has not been studied extensively in New Zealand 9 , 12 and this service is not currently offered in New Zealand outside of research; take-home self-test kits are not routinely offered in primary care. Novel ways to increase access to HPV self-testing that prioritise under-screened populations are needed. As part of a wider HPV self-test implementation research programme, 18 we explored access through community pharmacies. The general public is familiar with the expanding array of healthcare services available from community pharmacies, particularly since the COVID-19 pandemic. In New Zealand, community pharmacies are regarded as the most accessible primary care service. 19 While there is considerable regional and local variation in the services provided, in general, community pharmacists are an under-utilised healthcare provider, whose role continues to be perceived as, and funded for, services primarily related to dispensing. 19 Some community pharmacies in New Zealand offer a range of clinical services that require pharmacists to perform multiple steps to ensure safe and effective medicine use, such as warfarin point-of-care testing and dose titration, and throat swabbing and provision of antibiotics for strep throat. HPV self-testing is also a complex, multiple-step service, but is part of a national programme that requires input from responsible clinicians (experienced accredited cervical sample takers who are responsible for obtaining informed consent, result management and follow-up 20 ) and different services along the management pathway. Eligibility for self-testing must be confirmed either by credentialed clinicians or NCSP Register data check and clinical assessment, and a responsible clinician is needed to order the laboratory test, notify test results and provide clinical advice. People with an HPV not detected result need future screening advice and those with an HPV detected result need appropriate clinical management, ideally with continuity of care. Appropriate resources, either through a centralised support team or via the responsible clinician, are needed to facilitate the completion and return of samples. Few studies have involved pharmacies in the provision of HPV self-testing. A large Italian study 21 and its 3-year extension 22 compared uptake between mailed test kits with pharmacies as a test kit pick-up location and a letter reminder for in-clinic testing; completion of HPV self-tests did not differ significantly between the pharmacy and letter groups. In rural Canadian communities, a cervical cancer education campaign with the offer of HPV self-test kits from various public pick-up locations (that included pharmacies) or dropped off by a nurse significantly increased screening versus education alone. 23 Offering on-site HPV self-testing with telehealth support is being explored by some Australian pharmacies. 24 To our knowledge, no studies have directly approached potentially eligible people in community pharmacies to promote the availability of, or provide, at-home HPV self-testing. In consultation with commissioning colleagues and pharmacy staff, we developed models of the possible roles that New Zealand pharmacies could undertake in the provision of cervical screening, each requiring different levels of pharmacy infrastructure and resources. We outline three models of potential pharmacy involvement across a spectrum of increasing resource/involvement. The models described are: promotion of at-home testing, provision of at-home testing, and on-site testing ( Fig. 1 ). Pharmacies could adopt or adapt the models individually or in combination; these models could be useful for future research. We tested two of the three models to explore the involvement of pharmacies in the provision of HPV self-testing. Fig. 1. Open in a new tab Range of proposed healthcare intervention delivery models for community pharmacies in the provision of HPV self-testing. * Experienced accredited cervical sample takers who are responsible for obtaining informed consent, result management, and follow-up 20 . 2. Methods We conducted a small, proof-of-concept study to test pharmacy promotion of mailed self-test kits (the first model outlined in Fig. 1 ) and provision of self-test kits for at-home testing by on-site study nurses (a modified version of the second model). In the promotion model, pharmacy staff approached people who appeared to be of the eligible age range (25–69 years) 2 for cervical screening and encouraged self-registration through a QR code/online form or by calling the study team (no charge to call). Study nurses confirmed eligibility against the NCSP Register data and entered eligible participants into the study data management system; self-test kits were mailed to eligible participants. One set of training materials was provided to all pharmacies prior to the study with information on the HPV self-test and a guide to approaching potentially eligible people. In the provision model, study nurses approached and interacted directly with interested individuals, checked eligibility, recorded consent, confirmed eligibility with the NCSP Register data and clinical assessment, and registered participants. The nurses completed laboratory forms, and labelled and provided test kits. In both models, participants completed self-tests at home and returned their samples via free courier or to community laboratory collection centres. Our centralised co-ordination team, set up as part of our wider research programme, 18 allowed for centralised eligibility checking, provision of self-test kits, telehealth information support for participants to complete the test, sample return reminders, HPV result notification, and overseeing follow-up test requirements ( Fig. 1 ); this function is not currently available in New Zealand outside of research. The co-ordination team minimised the need for participating pharmacies to set up new processes and technology. Another advantage of our co-ordination team was that, as our nurses were the designated clinicians ordering the laboratory tests, participants not enrolled with a primary care provider could access the self-test and be supported through results management. Our wider study team also included Māori kaiawhina (holistic, practical and cultural support), Māori engagement staff (guided the development of our participant communication strategy), and Māori and Pacific call centre staff. 18 Study-specific materials (e.g. the self-registration and consent online form, the Participant Information Sheet) are available on request. Six community pharmacies in Auckland with high proportions of female Māori and Pacific customers (based on dispensing data) participated in the study for 6 weeks from May to July 2024. Each pharmacy was offered a small payment in acknowledgement of their time and participation. After the study period, pharmacy staff were invited to a survey (Supplementary material 1). All pharmacies participated in the promotion model, and one pharmacy, in a rural location, also participated in the provision model two days per week. We recruited people aged 25–69 years who were due for HPV self-testing (according to NCSP Standards 25 ) and did not have any of the exclusion criteria after answering clinical assessment questions online or with a study nurse. Exclusion criteria were total hysterectomy, history of cervical cancer, previous high-grade lesion and no test of cure, symptomatic (e.g. abnormal bleeding or discharge), or never been sexually active. People interested in the study could ask the nurse questions prior to consent. Ethnicity data in New Zealand is self-identified and people can identify with multiple ethnic groups; where participants identified more than one ethnic group, ethnicity was prioritised according to the New Zealand Health and Disability Ethnicity Data Standards: Māori > Pacific > Asian > European/Other (European/Other includes New Zealand European, Other European, Middle eastern Latin American and African (MELAA)). 26 3. Results Sixty-three people consented to participate in the study and 45 (71%) were eligible for HPV self-testing; 31 (69%) returned a self-test sample ( Table 1 ). Of the 31 self-tested participants, 29% were Māori and Pacific (19% Māori, 10% Pacific), 32% were people overdue for screening by ≥2 years, and 39% lived in areas associated with the two highest (of five) levels of socioeconomic deprivation (Supplementary material 2a). Some people who were interested in participation were ineligible for screening ( n = 18); 31% of those who were eligible and consented to participate did not return their sample. More people were recruited ( n = 29 vs. 16) and a higher proportion returned samples (79% vs. 50%) in the provision model than in the promotion model. Table 1. Uptake of HPV self-tests from community pharmacies. Model Consented to be screened for eligibility Eligible for HPV self-testing (proportion of those consented) Sample returned (proportion of eligible participants) n n (%) n (%) Provision 44 29 (66) 23 (79) Promotion 19 16 (85) 8 (50) Total 63 45 (71) 31 (69) Open in a new tab All pharmacy staff who responded to our post-study survey ( n = 16) supported pharmacy involvement in providing HPV self-tests. Respondents were predominantly female (63%), aged 20–39 years old (62%) and of Asian ethnicity (63%) (Supplementary material 2b). They identified challenges to approaching customers, such as time constraints of both staff and customers, a perceived lack of privacy to conduct a health-related conversation, and gender-related discomfort when discussing women's health (raised by male staff). They also identified enablers to promoting HPV self-testing, including having female staff approach customers, explaining the self-test in the participants' native language (other than English), and discussing the self-test in the context of relevant consultations (e.g. emergency contraception). 4. Discussion Although our numbers were small ( n = 45), we showed that promotion and provision of HPV self-tests in community pharmacies can engage people due for cervical screening, including groups typically less well served by standard national screening strategies. The provision model was associated with more recruited participants and a higher rate of sample return than the promotion model. This may be due to the favourable influence of face-to-face interactions between participants and nurses, with more opportunity for immediate discussion and questions, although it required substantially more resources (including clinician availability and pharmacy space) to implement. The promotion model required more active involvement from interested participants to self-register, which may have decreased participation. However, this model required the lowest level of pharmacy resource and, if promoted more widely (such as by a national campaign, if adopted), could ultimately have greater reach. While the promotion model showed a positive impact on participant recruitment and sample return, we anticipate on-site test kit provision to be highly resource intensive and require investment in additional infrastructure that is likely to be prohibitive. Further study is needed to determine the feasibility, workforce, infrastructure and education support requirements and cost effectiveness at each level of pharmacy involvement in cervical screening. Our three-level model of potential pharmacy involvement in supporting cervical screening could be useful to locate future research on adaptations to, and relative effectiveness of, the different models in this novel setting. Considerations should be given to mitigate some of the challenges identified by participating pharmacy staff, such as upskilling staff to discuss sensitive health issues and providing private spaces in pharmacies to hold discussions 27 , 28 ; such improvements would have benefits beyond the provision of HPV self-tests, particularly when health equity is a concern. 29 Future implementation studies could also assess whether any pharmacy staff do not wish to participate. A recent New Zealand study showed that while 85% of 218 surveyed pharmacists understood the rationale for ethnicity-based eligibility criteria (for minor ailment services), 50% identified a need for further training and resources 30 ; these findings are also relevant to cultural safety considerations in developing pharmacy-based cervical screening strategies. Regardless of the service delivery model, we anticipate that community pharmacies will need the support of a centralised co-ordination team with cervical sample-taker expertise. To adopt the self-test provision or on-site testing models, pharmacies will require new investment in infrastructure, resources and support, including collaboration with mail-out and centralised results management services. The promotion model would be most beneficial if a mail-out service was already in operation as part of the NCSP. Culturally appropriate community engagement is an important consideration to encourage and improve screening uptake in priority groups, such as Māori and Pacific. 31 5. Conclusion Our proof-of-concept study showed that community pharmacies, with support from a centralised co-ordination team, appropriate infrastructure and resources, could be an additional primary care setting to help increase access to HPV self-testing for Māori and Pacific, under-screened populations, and people not enrolled with a primary care provider. Large-scale implementation studies are needed to inform the feasiblity, acceptability, and resource considerations, and to explore underlying mechanisms for relative effectiveness of implementing the proposed models of pharmacy involvement in HPV self-testing. CRediT authorship contribution statement Karen Bartholomew: Writing – review & editing, Writing – original draft, Visualisation, Supervision, Resources, Project administration, Methodology, Funding acquisition, Conceptualisation. Lily P.H. Yang: Writing – review & editing, Writing – original draft, Visualisation, Validation, Software, Formal analysis, Data curation. Cleo Neville: Writing – review & editing, Writing – original draft, Visualisation, Validation, Software, Resources, Methodology, Formal analysis, Data curation. Anna Maxwell: Writing – review & editing, Writing – original draft, Visualisation, Supervision, Software, Resources, Project administration, Methodology, Formal analysis, Data curation, Conceptualisation. Joanna Hikaka: Writing – review & editing, Writing – original draft, Visualisation, Conceptualisation. Jane Grant: Writing – review & editing, Supervision, Software, Investigation, Conceptualisation. Collette Bromhead: Writing – review & editing, Supervision, Investigation, Conceptualisation. Georgina McPherson: Writing – review & editing, Supervision, Investigation. Kate Moodabe: Writing – review & editing, Supervision, Conceptualisation. Richard Massey: Writing – review & editing, Supervision, Investigation. Sue Crengle: Writing – review & editing, Supervision, Investigation. Susan M. Sherman: Writing – review & editing, Supervision. Nina Scott: Writing – review & editing, Supervision. Pania Coote: Writing – review & editing, Supervision. Wendy Burgess: Writing – review & editing, Supervision. Deralie Flower: Writing – review & editing, Supervision, Investigation. Jyoti Kathuria: Writing – review & editing, Supervision. Consent for publication Not applicable. Ethics approval This study was approved by the New Zealand Health and Disability Ethics Committee (HDEC), reference number 21/STH/141. Data access was approved by the NCSP and the National Kaitiaki Group, which oversees the use of data from wāhine Māori (Māori women) from the NCSP Register. The study was approved through localities research office approvals in the three Auckland districts where the study was conducted. A Māori data sovereignty assessment was conducted and approved as part of ethics and localities approval. A privacy and security assessment was conducted and approved. All individuals in the study provided informed consent. This study adhered to the Declaration of Helskinki. Funding This study was funded by Health New Zealand | Te Whatu Ora's Te Toka Tumai Auckland district, Waitematā district, and Counties Manukau district, Tamaki Health, and Health New Zealand | Te Whatu Ora's National Screening Unit (formerly the Ministry of Health, New Zealand). The funding sources had no involvement or restrictions regarding publication. Declaration of competing interest The authors declare that there are no conflicts of interest. Acknowledgements We would like to thank the study participants for their contribution to informing the access to HPV self-tests through community pharmacies in Aotearoa New Zealand. We would like to thank the staff at the participating pharmacies. We thank Melissa Bentley and Daniel Tsai from the Pharmacy Commissioning team for their contribution and support. We would like to acknowledge the leadership and dedication of the nurse-led co-ordination team (Seshnee Pillay, Fiona Gillet, Frances Kendall, Isha Gaikwad, Natacha Toledo Yanez), the HPV call centre and mail-out staff (Paris Fale, Eden Wharerau, Faenza Williams-Fonohema, Brooke Crawford, Louise Swann, Angelina Taungahihifo) and kaiawhina (cultural support; Marara Metekingi, Melissa Murray). We would like to thank the Group Manager of the Māori Health Pipeline team Scott Abbot, the Māori engagement team, including manager Erin Stirling, and Yvonne Timaloa for their ongoing support. We acknowledge the support of a range of laboratory staff at Pathlab. We thank the National Kaitiaki Group and NCSP for their feedback on the initial proposal, the project in-flight and this manuscript. We thank the colposcopy teams in the Auckland region who participated in this study. We thank the Equity, Scientific and Technical team for their support with data processes, including Group Manager Wendy Bennett, analysts Michael Walsh and Jean Wignall. We thank Ken Leech, Arthur Mate and Malcolm Fletcher for technical data support. We thank Dr Phyu Sin Aye for proofreading. Footnotes Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.rcsop.2026.100729 . Appendix A. Supplementary data Supplementary material 1 mmc1.pdf (253.8KB, pdf) Supplementary material 2 mmc2.docx (23.6KB, docx) Data availability The data used and analysed during the current study contain identifiable individual patient information, including that of Māori. The data are not publicly available due to the data confidentiality and privacy restrictions and Māori data sovereignty considerations, but are available from the corresponding author on reasonable request and corresponding approvals. References 1. 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Supplementary Materials Supplementary material 1 mmc1.pdf (253.8KB, pdf) Supplementary material 2 mmc2.docx (23.6KB, docx) Data Availability Statement The data used and analysed during the current study contain identifiable individual patient information, including that of Māori. The data are not publicly available due to the data confidentiality and privacy restrictions and Māori data sovereignty considerations, but are available from the corresponding author on reasonable request and corresponding approvals. 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