Academic literature on the topic 'Aboriginal and Torres Strait Islander public health and wellbeing'

Aboriginal and Torres Strait Islander people experience a greater range of health and social disadvantages compared to other Australians. Wellbeing is a culturally-bound construct, and to date, a national evidence base around the components of wellbeing for Aboriginal and Torres Strait Islander people is lacking. Understanding and measurement of wellbeing for this population is critical in achieving health equity. This paper aims to identify and describe the foundations of wellbeing for Aboriginal and Torres Strait Islander adults. This national qualitative study was underpinned by an Indigenist research approach which privileges the voices of Aboriginal and Torres Strait Islander people. Aboriginal and Torres Strait Islander adults were purposively recruited from around Australia between September 2017 and September 2018 to participate in Yarning Circles, led by Aboriginal and Torres Strait Islander researchers. Yarning Circles were audio recorded, transcribed and analyzed. A Collaborative Yarning Methodology was used, which incorporated reflexive thematic analysis to identify and describe the foundations of wellbeing reported by participants. A total of 359 Aboriginal and Torres Strait Islander adults participated. Our analysis revealed five foundations of wellbeing: belonging and connection; holistic health; purpose and control; dignity and respect; and basic needs. These foundations were deeply interwoven by three interconnected aspects of Aboriginal and Torres Strait Islander life: family, community and culture. The findings of this study will substantially aid our efforts to develop a new wellbeing measure for Aboriginal and Torres Strait Islander adults. The iterative Indigenist methods used in this study provide a robust research methodology for conducting large-scale, nationally-relevant qualitative research with Aboriginal and Torres Strait Islander people. Policies and practices that are informed by our results have the potential to address outcomes that are meaningful for Aboriginal and Torres Strait Islander people.

Wellbeing is culturally bound and is shaped by many aspects of life, including experiences, beliefs and values. As such, in order to accurately measure wellbeing for a specific cultural group, it is necessary to understand the experiences, beliefs and values that influence the conception and experience of wellbeing of that group. This paper presents a conceptual model of wellbeing for Aboriginal and Torres Strait Islander people, which was developed from a large national qualitative study that explored the views of 359 Aboriginal and Torres Strait Islander adults. An Aboriginal- and Torres Strait Islander-led research team used an Indigenist research approach to iteratively develop this conceptual model, called the Fabric of Aboriginal and Torres Strait Islander Wellbeing model, which takes inspiration from Aboriginal and Torres Strait Islander weaving traditions whereby individual strands are twined to create fabrics that are both beautiful and strong. This reflects our findings that the parts of life that are most important to wellbeing for many Aboriginal and Torres Strait Islander people are interwoven with their families, communities and culture.

The social and emotional wellbeing of young Aboriginal and Torres Strait Islander peoples should be supported through an Indigenous-led and community empowering approach. Applying systems thinking via participatory approaches is aligned with Aboriginal and Torres Strait Islander research paradigms and can be an effective method to deliver a decision support tool for mental health systems planning for Indigenous communities. Evaluations are necessary to understand the effectiveness and value of such methods, uncover protective and healing factors of social and emotional wellbeing, as well as to promote Aboriginal and Torres Strait Islander self-determination over allocation of funding and resources. This paper presents modifications to a published evaluation protocol for participatory systems modelling to align with critical Aboriginal and Torres Strait Islander guidelines and recommendations to support the social and emotional wellbeing of young people. This paper also presents a culturally relevant participatory systems modelling evaluation framework. Recognizing the reciprocity, strengths, and expertise Aboriginal and Torres Strait Islander methodologies can offer to broader research and evaluation practices, the amended framework presented in this paper facilitates empowering evaluation practices that should be adopted when working with Aboriginal and Torres Strait Islander peoples as well as when working with other diverse, non-Indigenous communities.

This Aboriginal-led study explores Aboriginal and Torres Strait Islander parents’ experiences of COVID-19. 110 Aboriginal and Torres Strait Islander parents were interviewed between October 2020 and March 2022. Participants were recruited through community networks and partner health services in South Australia, Victoria, and Northern Territory, Australia. Participants were predominantly female (89%) and based in Victoria (47%) or South Australia (45%). Inductive thematic analysis identified three themes: (1) Changes to daily living; (2) Impact on social and emotional wellbeing; and (3) Disconnection from family, community, and culture. COVID-19 impacted Aboriginal and Torres Strait Islander families. Disruption to cultural practice, and disconnection from country, family, and community was detrimental to wellbeing. These impacts aggravated pre-existing inequalities and may continue to have greater impact on Aboriginal and Torres Strait Islander parents and communities due to intergenerational trauma, stemming from colonisation, violence and dispossession and ongoing systemic racism. We advocate for the development of a framework that ensures an equitable approach to future public health responses for Aboriginal and Torres Strait Islander people.

Strong and healthy futures for Aboriginal and Torres Strait Islander people requires engagement in meaningful decision making which is supported by evidence-based approaches. While a significant number of research publications state the research is co-designed, few describe the research process in relation to Indigenous ethical values. Improving the health and wellbeing of Aboriginal and Torres Strait Islander mothers and babies is crucial to the continuation of the oldest living culture in the world. Developing meaningful supports to empower Aboriginal and Torres Strait Islander mothers to quit smoking during pregnancy is paramount to addressing a range of health and wellbeing outcomes. Aboriginal and Torres Strait Islander women have called for non-pharmacological approaches to smoking cessation during pregnancy. We describe a culturally responsive research protocol that has been co-designed and is co-owned with urban and regional Aboriginal communities in New South Wales. The project has been developed in line with the AH&MRC’s (Aboriginal Health & Medical Research Council) updated guidelines for ethical research with Aboriginal and Torres Strait Islander communities. Ethics approvals have been granted by AH&MRC #14541662 University of Newcastle HREC H-2020-0092 and the Local Health District ethics committee 2020/ETH02095. Results will be disseminated through peer reviewed articles, community reports, infographics, and online social media content.

As the world journeys towards the endemic phase that follows a pandemic, public health authorities are reviewing the efficacy of COVID-19 pandemic responses. The responses by Aboriginal and Torres Strait Islander communities in Australia have been heralded across the globe as an exemplary demonstration of how self-determination can achieve optimal health outcomes for Indigenous peoples. Despite this success, the impacts of pandemic stressors and public health responses on immediate and long-term mental health and wellbeing require examination. In December 2021, Aboriginal and Torres Strait Islander mental health and wellbeing leaders and allies (N = 50) attended a virtual roundtable to determine the key issues facing Aboriginal and Torres Strait Islander peoples and communities, and the actions required to address these issues. Roundtable attendees critically reviewed how the rapidly evolving pandemic context has impacted Aboriginal and Torres Strait Islander mental health and social and emotional wellbeing (SEWB). This paper presents an overview of this national collaborative consultation process, and a summary of the key issues and actions identified. These results build on evidence from other roundtables held in Australia during 2020, and the emerging consensus across the globe that Indigenous self-determination remains essential to Indigenous SEWB, especially during and following a pandemic.

The Coronavirus Disease 2019 (COVID-19) pandemic impacted peoples’ livelihoods and mental wellbeing. Aboriginal and Torres Strait Islander peoples in Australia continue to experience intergenerational trauma associated with colonization and may experience trauma-related distress in response to government responses to public health emergencies. We aimed to develop a culturally responsive trauma-informed public health emergency response framework for Aboriginal and Torres Strait Islander peoples. This Aboriginal and Torres Strait Islander-led study involved: (i) a review of trauma-informed public health emergency responses to develop a draft framework (ii) interviews with 110 Aboriginal and Torres Strait Islander parents about how COVID-19 impacted their lives, and (iii) a workshop with 36 stakeholders about pandemic experiences using framework analysis to refine a culturally responsive trauma-informed framework. The framework included: an overarching philosophy (cultural humility, safety and responsiveness); key enablers (local leadership and Eldership); supporting strategies (provision of basic needs and resources, well-functioning social systems, human rights, dignity, choice, justice and ethics, mutuality and collective responsibility, and strengthening of existing systems); interdependent core concepts (safety, transparency, and empowerment, holistic support, connectedness and collaboration, and compassion, protection and caring); and central goals (a sense of security, resilience, wellbeing, self- and collective-efficacy, hope, trust, resilience, and healing from grief and loss).

Informal carers provide an important role in supporting people with cancer. Aboriginal and Torres Strait Islander peoples experience higher cancer mortality than other Australians. To date, very little is known about the support needs of carers of Aboriginal and Torres Strait Islander adults with cancer. This article explored these needs through a qualitative study. Twenty-two semi-structured qualitative interviews and one focus group were conducted with carers of Aboriginal and Torres Strait Islander adults with cancer (n = 12) and Aboriginal and Torres Strait Islander cancer survivors (n = 15) from Queensland, Australia. Half of the carers interviewed were Aboriginal or Torres Strait Islander Australians. Interviews were transcribed, coded and thematically analysed following an interpretive phenomenological approach. Thematic analysis of carer and survivor interviews revealed four key themes relating to carers’ needs: managing multiple responsibilities; maintaining the carer’s own health and wellbeing; accessing practical support and information; and engaging with the health system. Within these overarching themes, multiple needs were identified including specific needs relevant for carers of Aboriginal and Torres Strait Islander peoples, such as advocating for the patient; accessing Indigenous support services and health workers; and ensuring that the cultural needs of the person are recognised and respected. Identifying the needs of informal carers of Aboriginal and Torres Strait Islander cancer patients will enable greater understanding of the support that carers require and inform the development of strategies to meet these areas of need.

Food insecurity adversely affects diet quality, physical, mental and social wellbeing and the capacity to act on health advice recommended by primary healthcare providers. In this article, an overview of the neglected issue of food insecurity in urban Aboriginal and Torres Strait Islander communities is provided. Policy and action on food security for urban Aboriginal and Torres Strait Islander people is reviewed, and it is argued that for primary health care to better address food insecurity, an evidence base is needed to understand the experiences of individuals and households and how to work effectively to support food insecure clients.

(1) Background: In healthcare settings, patient-reported outcome measures (PROMs) and surveys are accepted, patient-centered measures that provide qualitative information on dimensions of health and wellbeing. The level of psychometric assessment and engagement with end users for their design can vary significantly. This scoping review describes the psychometric and community engagement processes for PROMs and surveys developed for Aboriginal and Torres Strait Islander communities. (2) Methods: The PRISMA ScR guidelines for scoping reviews were followed, aimed at those PROMs and surveys that underwent psychometric assessment. The Aboriginal and Torres Strait Islander Quality Appraisal Tool and a narrative synthesis approach were used. (3) Results: Of 1080 articles, 14 were eligible for review. Most articles focused on a validity assessment of PROMs and surveys, with reliability being less common. Face validity with Aboriginal and Torres Strait Islander communities was reported in most studies, with construct validity through exploratory factor analyses. Methodological design risks were identified in the majority of studies, notably the absence of explicit Indigenous knowledges. Variability existed in the development of PROMs and surveys for Aboriginal and Torres Strait Islander communities. (4) Conclusions: Improvement in inclusion of Indigenous knowledges and research approaches is needed to ensure relevance and appropriate PROM structures. We provide suggestions for research teams to assist in future design.

Within Australia, data on the oral health and health-related quality of life experiences of Aboriginal and Torres Strait Islander children living in urban areas are lacking. This project utilised a mixed-methods approach to contribute new epidemiological and life experience data to the field of oral health and create a culturally specific, parent-proxy tool to measure the health-related quality of life of Aboriginal and Torres Strait Islander children. These findings provide contemporary oral health data to inform policy and a foundation for the development of other culturally specific health-related quality of life measures for Aboriginal and Torres Strait Islander peoples.

This study is a critical reflection on two music projects that I conducted in my home area of Ipswich, Australia, prior to undertaking this research. The music projects involved participatory action research to investigate the music heritage and culture of the rural Ipswich region. The purpose of this study is to review and analyse the creative processes that I used in the rural Ipswich music projects in order to develop suitable practice frameworks for similar projects in future. The first music project was a collaborative investigation of the music history of Purga in rural Ipswich (2003-2005). Local people and those who used to live in the area were invited to come back to share memories of the music from the area with one another. People collaborated creatively: This allowed me to write The Purga Music Story and Harold Blair (2005), an inter-generational community education package. In 2003, we established the Purga Music Museum as a meeting place where the music heritage and culture of our neighbourhood is performed and displayed. The second music project (2006) was a study of contemporary music in rural Ipswich that resulted in community consultation and the development of a Music Action Plan for the area. I continued facilitating community music in rural Ipswich, as the curator of the Purga Music Museum, until 2008. Both music projects presented different challenges in the establishment of processes that would be effective for the needs and interests of people from various cultural groups. The work was fraught with complex decisions and ethical dilemmas about representation and music cultural heritage management because our neighbourhood previously contained the Purga Aboriginal Mission (1915-1948). The findings therefore relate to the struggles of the ‘Stolen Generation’-- Aboriginal and Torres Strait Islander people who were taken away from their families and forced to live in government-controlled residential situations. New, respectful approaches had to be found, conducive to the health and well-being of all concerned. For this reason, participatory action research methods were developed and a ‘Community of Discovery’ approach was used. Throughout this study, I investigate issues that arose as people told their music stories, and passed on music heritage and culture from one generation to the next. The key question is “What are appropriate frameworks of culturally engaged community music practice for rural Ipswich?” This study also draws on findings from the music projects to address the sub-questions, “How did community music practice function in the past in rural Ipswich?” “What is the current situation regarding contemporary community music practice in rural Ipswich?” and “What can be done to enhance future community music practice for rural Ipswich?” Aspects of music and health practice complement each other in this study. As a dual qualified music and health professional, I draw on expertise from both of these areas. Ethnographic methods were used to record and review the findings from each music project. The analysis is grounded in review of literature and other sources, creative display and performance, analysis of music history, community consultation, and critical reflection on my own community music practice. Finally, this evidence-based process of professional reasoning leads to the development of appropriate practice frameworks that transform the way that I intend to deliver services in future, and will hopefully inspire others. The thesis has five parts. The context and rationale for the research are outlined in Part 1. This is followed by description of the two music projects in Part 2. Part 3 is an exploration of how my music practice is situated in relation to scholarly literature (and other sources) and outlines the chosen theoretical constructs or models. This prepares for critical analysis and discussion of specific issues that arose from reflection on practice in Part 4. The conclusions of the research, presented in chapter 9, outline the creative processes, underlying principles, and the philosophy of my practice. The study concludes with an epilogue, which is a consideration of the present situation and suggested future directions for service provision and research.

As required by the Master of Philosophy (Applied Epidemiology) program I completed a field placement in the Strategic Investment, Data and Evaluation Section in the Indigenous Health Division, Australian Government Department of Health. Following the introduction chapter (chapter 1), this thesis contains three projects, which aimed to: 1) explore the performance of health organisations providing social and emotional wellbeing (SEWB) services for Aboriginal and Torres Strait Islander peoples (chapter 2); 2) analyse the relationships between health organisations’ cultural safety policies and the uptake of Medicare Benefits Scheme (MBS) health assessments among Aboriginal and Torres Strait Islander clients (chapter 3); and 3) describe and the characteristics of inpatients who acquired vanA vancomycin-resistant enterococci and compare the characteristics of inpatients with vanA versus vanB sterile site infections at the John Hunter and Calvary Mater Newcastle hospitals in Newcastle, New South Wales (chapter 4). My first project was a national survey of SEWB service delivery in 2014-15 using a quantitative questionnaire, administrative data and qualitative case studies. Service delivery strengths included accessibility, capability, continuity, appropriateness, responsiveness and sustainability. Fifteen opportunities to strengthen SEWB service delivery were identified, including in the areas of: client access, perceptions and experiences of service delivery; strengthening the SEWB workforce; and facilities required to support service delivery. These opportunities represent potential approaches that could improve the SEWB of Aboriginal and Torres Strait Islander peoples. For my second project, I used logistic regression to model univariate relationships between seven cultural safety policies and low or high uptake of MBS health assessments in 2014-16 using existing administrative and service performance data. Data from 174 health organisations showed no associations between cultural safety policies and health assessment uptake, however this is likely due to study and data limitations. In my third project, I conducted two case series analyses. The first described numbers and proportions of 168 vanA and vanAB acquisitions in 2013-2015. It also examined potential contributing environmental exposures and other risk factors that might lead to infection or colonisation. The second case series used Wilcoxon rank-sum, Chi-squared or Fisher’s exact tests to compare morbidity and mortality outcomes between vanA and vanB for 42 inpatients with laboratory-confirmed sterile site infections in 2015. No specific environmental exposures or risk factors that likely contributed to acquisition, and no difference in morbidity and mortality outcomes between genotypes, were identified. This may suggest that vanA is endemic to the hospital environment, highlighting the importance of standard, enhanced and tailored infection prevention and control precautions. To meet the teaching requirements, I presented to my peers on logic models and confounding. Additional to the program requirements, I completed an internship in the Ebola Community Engagement Team at the World Health Organization, Geneva, Switzerland. Chapters 5 and 6, respectively, reflect on these experiences. I highly value the opportunities and the skills, experience and knowledge in epidemiology, public health research and practice I developed in the program. I applied my knowledge of logic models, skills in data analysis and interpretation, and knowledge of the importance of understanding and accommodating culture and belief systems when addressing public health issues in my paid employment in my field placement.

Research Doctorate - Doctor of Philosophy (PhD)
Aboriginal and Torres Strait Islander people, hereinafter respectfully referred to as Aboriginal people, a have a rich heritage and diverse cultures. They have a strong connection to their community and country. However, Aboriginal people have suffered long-lasting effects from colonisation, dispossession of land and racism with devasting impacts, particularly for health outcomes. In Australia, Aboriginal people have up to three-fold higher rates of chronic disease compared to non-Aboriginal people. Given the high risk of frequent avoidable admissions and unplanned hospital readmissions for people with chronic diseases, it is not surprising that Aboriginal people also have higher rates of these types of hospitalisations compared to non-Aboriginal people. High rates of avoidable admissions and unplanned readmissions reflect sub-optimal community healthcare and poor hospital care. However, little research has explored these types of potentially unnecessary hospitalisations for Aboriginal people with chronic disease in Australia’s most populous state of New South Wales (NSW). This thesis explores frequent avoidable admissions and unplanned readmissions among Aboriginal people by focusing on three key aims. The first was to examine the prevalence and trends of frequent avoidable admissions and unplanned readmissions of Aboriginal and non-Aboriginal people residing in NSW, utilising linked hospital administrative data. International research examining the factors associated with unplanned readmissions in general populations indicate the importance of factors such as chronic disease management, a regular general practitioner, good health literacy and medication adherence. Therefore, the second aim of this thesis was to identify perceptions of Aboriginal people regarding potential contributors to chronic-disease-related unplanned readmissions. In-depth interviews were conducted with a sample of Aboriginal people who had been readmitted to hospital. Telephone follow-up has been used alongside other intervention components, such as tailored discharge planning and patient education, with the aim of reducing unplanned readmissions in surgical and general medicine patients. The final aim of this thesis was to examine the potential impact of telephone follow-up in reducing unplanned readmissions rates for patients with chronic disease. This involved a systematic review of the research literature on the impact of telephone follow-up, and an evaluation of a program utilising telephone follow-up for Aboriginal people. The implications of the findings of this work are discussed in relation to hospital and community health service practices and state-wide data monitoring. Further explorative research and a community-led multicomponent telephone follow-up enhancement intervention are proposed.

This thesis is a compilation of applied epidemiological studies undertaken throughout the course of the Master of Philosophy in Applied Epidemiology (MAE) program. The focus of this thesis is on Aboriginal and Torres Strait Islander health and wellbeing and uses a strengths based, mixed methods approach. Community based participatory research methodologies were utilized in these studies. An outbreak investigation was also undertaken as part of the MAE competencies. This thesis includes the following studies: - The data analysis and major epidemiological studies explore the association between caring for country, through participation in a Ranger program, and wellbeing. A cross sectional analysis of data collected in Central Australia in 2017, comparing health and wellbeing (life satisfaction, general health, psychological wellbeing and family wellbeing) among Aboriginal and Torres Strait Islander people employed as Rangers (n=43) versus not employed as Rangers (n=160). - The Stronger Communities for Children (SCfC) program was evaluated through collection of cultural participation data (a key program outcome). Community based participatory research was utilised and community researchers were trained in delivering the survey through partnership with the Palngun Wurnangat Aboriginal Corporation, the Kardu Lurruth Ngala Purrungime Committee and the National Centre of Epidemiology and Population Health. - An outbreak investigation was undertaken of a cluster of Salmonella Typhimurium with a unique MLVA pattern in Canberra, ACT. Descriptive epidemiology and an environmental investigation was undertaken to identify the source of the pathogen, and implement public health measures to mitigate risk to the public of further infection. This thesis outlines additional activities undertaken during the MAE. Peer-reviewed articles, conference presentations, lesson plans and study proposals are included throughout.

I completed my Masters of Applied Epidemiology during 2017-18 with the NHMRC funded Centre for Research Excellence in Improving Health Services for Aboriginal and Torres Strait Islander Children (CRE ISAC) located at the University of Western Australia. My projects focussed mostly on social epidemiology, with the exception of my outbreak. Chapter two provides a case-control study of a point source outbreak of Salmonella Typhimurium, which occurred at a university residential college in April 2018. Epidemiological and environmental investigation identified the most likely source of the outbreak to be raw eggs used in coleslaw. Public health action was the provision of information on the safe handling of eggs to prevent further outbreaks. Chapter three, public health data analysis, was a population-based birth cohort study using linked datasets with information on a cohort of Aboriginal and Torres Strait Islander children, and their mothers and siblings. The 2009 and 2012 Australian Early Development Census was used to assess developmental vulnerability across five domains of development in Aboriginal children born in Western Australia. Latent class analysis was used identify and describe profiles of risk for developmental vulnerability. Six distinct classes were identified. My surveillance project, provided in chapter four, was the evaluation of the Western Australian population based data linkage Intellectual Disability Exploring Answers (IDEA) surveillance system. I evaluated the usefulness, simplicity, flexibility, data quality, acceptability, representativeness, timeliness, and stability of the IDEA system. This was completed by process observation, semi-structured interviews and data analysis. The IDEA system has successfully been used to understand prevalence rates and inform resource allocation. Advocacy organisations could play an important role in the sustainability of the system. Additional variables or enhanced surveillance for functional capacity could strengthen the system and provide information for people living with intellectual disability and their families. Chapter five is my epidemiology project which was a cross-sectional study of 1554 clinical child health audits and associated systems assessments from 74 primary care services from 2012-2014. Composite process of care indicators (PoCIs) were developed for social and emotional wellbeing, child neurodevelopment and anaemia. Crude and adjusted logistic regression models were fitted clustering for health services. 32.0% (449) of records had a social and emotional wellbeing PoCI, 56.6% (791) had an anaemia PoCI and 49.3% (430) had a child neurodevelopment PoCI. The study found that the need for young Indigenous children aged 24-59 months to receive quality care for important social and health indicators should be a priority. Processes of care and organisational systems within primary care services are important for the optimal management of anaemia in Indigenous children. The final chapter concludes with my lessons from the field. This provided me with an opportunity to deliver a count regression teaching opportunity to my peers.

My MAE was undertaken at the South Australian Health and Medical Research Institute (SAHMRI), during 2018-2019. My studies focussed on the health and wellbeing of adolescent and young Aboriginal and Torres Strait Islander peoples, with the exception of my outbreak project. My studies included: Analysis of public health dataset - A retrospective study of South Australian adolescents aged 10-24 years utilising data from the Integrated South Australian Activity Collection dataset. The aim of the study was to assess leading causes and trends in hospital separations among adolescents in South Australia (SA) between 2006 and 2015, by sex, age groups and Aboriginal status. Counts and proportions of leading causes of separation were calculated as age-standardised rates and negative binominal regression was used to assess trend over time. Epidemiological study - Let's Talk About It 2019, an online survey of sexual health, knowledge, behaviours and access to health services for sexually transmitted infections (STI) and bloodborne viruses (BBV), amongst young South Australians aged 16-29 years, both Aboriginal and Torres Strait Islander and non-Indigenous. Descriptive analysis, univariate and adjusted logistic regression models were used to determine whether socio-demographic characteristics and sexual risk behaviours were associated with specific behaviours. Evaluation of a public health surveillance system - The preliminary evaluation of the ATLAS Aboriginal and Torres Strait Islander Sexual Health Surveillance Network - a national sentinel surveillance system within Aboriginal community-controlled health services (ACCHS). The evaluation of ATLAS involved a document review, stakeholder interviews and analysis of ATLAS data using the Centers for Disease Control and Prevention (United States of America) Updated Guidelines for Evaluating Public Health Surveillance Systems. I assessed the following attributes: acceptability, simplicity, flexibility, data quality, representativeness, timeliness, stability, and usefulness. Outbreak investigation - An epidemiological investigation and a retrospective case-control study of an outbreak of Salmonella Havana in alfalfa sprouts, in Adelaide. The outbreak was conducted during June and July 2018 with colleagues from SA Health. Investigations identified the most likely source to be alfalfa sprouts. Public health action lead to a consumer level recall of all alfalfa sprout products and public health alert. Teaching - This chapter outlines two teaching sessions, (i) a teaching session to first year MAE scholars, on a Single Overarching Communication Outcome (SOCO) in relation to the communication of a public health message; and (ii) a Lessons From the Field to my fellow scholars, on 'Conducting research with Aboriginal and Torres Strait Islander communities'.

Aboriginal and Torres Strait Islander people are the first people of Australia. Consequences of colonisation and ongoing societal marginalisation and racism has led to significant health and wellbeing impacts on this population. Aboriginal and Torres Strait Islander people view health through a Social and Emotional Wellbeing (SEWB) framework. There are currently no measures of SEWB, with proxy measures used instead. The Kessler Psychological Distress Scale is a measure of psychological distress often used as a proxy for measuring SEWB. This thesis uses mixed-methods and best-practice approach to assess the reliability and validity of the culturally-modified, 5-item Kessler Psychological Distress Scale (K5) in the Aboriginal and Torres Strait Islander population. The results of this study found good internal consistency, construct validity, convergent validity, and divergent validity. The K5 was also found to have good clinical utility in indicating depressive and anxiety disorders at a cut-off of 10. Assessment of K5 face validity indicates that the measure achieved face validity for psychological distress but fails to accurately measure SEWB. Thus, the K5 is a valid measure of psychological distress for Aboriginal and Torres Strait Islander people, but the measure fails as a measure of SEWB.

AbstractConnection with Country, community, and culture lies at the heart of Aboriginal and Torres Strait Islander peoples’ health and wellbeing. Although there is some evidence on the role of cultural identity on the mental health of Indigenous adults, this relationship is relatively unexplored in the context of Indigenous Australian children. Robust empirical evidence on the role of cultural identity for social and emotional wellbeing is necessary to design and develop effective interventions and approaches for improving the mental health outcomes for Indigenous Australian children. Drawing on data from the Longitudinal Study of Indigenous Children (LSIC), we explore social and emotional wellbeing in Indigenous Australian children and assesses whether cultural identity protects against social-emotional problems in Indigenous children. The results show that Indigenous children with strong cultural identity and knowledge are less likely to experience social and emotional problems than their counterparts. Our work provides further evidence to support the change from a deficit narrative to a strengths-based discourse for improved health and wellbeing of Indigenous Australian children.

Abstract Race has been (re)constructed over time by those in power to oppress and regulate the lives of Indigenous Peoples and people of color. In settler-colonial states like Australia, race is weaponized to justify settler-colonial violence and to control Indigenous lives. The Indigenous Peoples of Australia have been racialized since first contact, which has resulted in racism and oppression, with present-day implications for health and well-being. To examine the health and well-being impacts of racism exposure, this chapter uses self-report exposure to interpersonal racism and health and well-being outcomes data from Mayi Kuwayu: The National Study of Aboriginal and Torres Strait Islander Wellbeing, an Indigenous designed, led, and governed Australian cohort study. The analysis shows that experiencing interpersonal racism has a range of negative consequences on health and well-being. Aboriginal and Torres Strait Islander People exposed to any level of interpersonal racism have poorer general health and mental health outcomes. Additionally, experiencing any level of interpersonal racism is linked to lower levels of cultural participation. Understanding the history of race and the impacts that racism has on health and well-being is necessary to improve the lives of Aboriginal and Torres Strait Islander Peoples.

Background Lung cancer is the number one cause of cancer death worldwide.(1) It is the fifth most commonly diagnosed cancer in Australia (12,741 cases diagnosed in 2018) and the leading cause of cancer death.(2) The number of years of potential life lost to lung cancer in Australia is estimated to be 58,450, similar to that of colorectal and breast cancer combined.(3) While tobacco control strategies are most effective for disease prevention in the general population, early detection via low dose computed tomography (LDCT) screening in high-risk populations is a viable option for detecting asymptomatic disease in current (13%) and former (24%) Australian smokers.(4) The purpose of this Evidence Check review is to identify and analyse existing and emerging evidence for LDCT lung cancer screening in high-risk individuals to guide future program and policy planning. Evidence Check questions This review aimed to address the following questions: 1. What is the evidence for the effectiveness of lung cancer screening for higher-risk individuals? 2. What is the evidence of potential harms from lung cancer screening for higher-risk individuals? 3. What are the main components of recent major lung cancer screening programs or trials? 4. What is the cost-effectiveness of lung cancer screening programs (include studies of cost–utility)? Summary of methods The authors searched the peer-reviewed literature across three databases (MEDLINE, PsycINFO and Embase) for existing systematic reviews and original studies published between 1 January 2009 and 8 August 2019. Fifteen systematic reviews (of which 8 were contemporary) and 64 original publications met the inclusion criteria set across the four questions. Key findings Question 1: What is the evidence for the effectiveness of lung cancer screening for higher-risk individuals? There is sufficient evidence from systematic reviews and meta-analyses of combined (pooled) data from screening trials (of high-risk individuals) to indicate that LDCT examination is clinically effective in reducing lung cancer mortality. In 2011, the landmark National Lung Cancer Screening Trial (NLST, a large-scale randomised controlled trial [RCT] conducted in the US) reported a 20% (95% CI 6.8% – 26.7%; P=0.004) relative reduction in mortality among long-term heavy smokers over three rounds of annual screening. High-risk eligibility criteria was defined as people aged 55–74 years with a smoking history of ≥30 pack-years (years in which a smoker has consumed 20-plus cigarettes each day) and, for former smokers, ≥30 pack-years and have quit within the past 15 years.(5) All-cause mortality was reduced by 6.7% (95% CI, 1.2% – 13.6%; P=0.02). Initial data from the second landmark RCT, the NEderlands-Leuvens Longkanker Screenings ONderzoek (known as the NELSON trial), have found an even greater reduction of 26% (95% CI, 9% – 41%) in lung cancer mortality, with full trial results yet to be published.(6, 7) Pooled analyses, including several smaller-scale European LDCT screening trials insufficiently powered in their own right, collectively demonstrate a statistically significant reduction in lung cancer mortality (RR 0.82, 95% CI 0.73–0.91).(8) Despite the reduction in all-cause mortality found in the NLST, pooled analyses of seven trials found no statistically significant difference in all-cause mortality (RR 0.95, 95% CI 0.90–1.00).(8) However, cancer-specific mortality is currently the most relevant outcome in cancer screening trials. These seven trials demonstrated a significantly greater proportion of early stage cancers in LDCT groups compared with controls (RR 2.08, 95% CI 1.43–3.03). Thus, when considering results across mortality outcomes and early stage cancers diagnosed, LDCT screening is considered to be clinically effective. Question 2: What is the evidence of potential harms from lung cancer screening for higher-risk individuals? The harms of LDCT lung cancer screening include false positive tests and the consequences of unnecessary invasive follow-up procedures for conditions that are eventually diagnosed as benign. While LDCT screening leads to an increased frequency of invasive procedures, it does not result in greater mortality soon after an invasive procedure (in trial settings when compared with the control arm).(8) Overdiagnosis, exposure to radiation, psychological distress and an impact on quality of life are other known harms. Systematic review evidence indicates the benefits of LDCT screening are likely to outweigh the harms. The potential harms are likely to be reduced as refinements are made to LDCT screening protocols through: i) the application of risk predication models (e.g. the PLCOm2012), which enable a more accurate selection of the high-risk population through the use of specific criteria (beyond age and smoking history); ii) the use of nodule management algorithms (e.g. Lung-RADS, PanCan), which assist in the diagnostic evaluation of screen-detected nodules and cancers (e.g. more precise volumetric assessment of nodules); and, iii) more judicious selection of patients for invasive procedures. Recent evidence suggests a positive LDCT result may transiently increase psychological distress but does not have long-term adverse effects on psychological distress or health-related quality of life (HRQoL). With regards to smoking cessation, there is no evidence to suggest screening participation invokes a false sense of assurance in smokers, nor a reduction in motivation to quit. The NELSON and Danish trials found no difference in smoking cessation rates between LDCT screening and control groups. Higher net cessation rates, compared with general population, suggest those who participate in screening trials may already be motivated to quit. Question 3: What are the main components of recent major lung cancer screening programs or trials? There are no systematic reviews that capture the main components of recent major lung cancer screening trials and programs. We extracted evidence from original studies and clinical guidance documents and organised this into key groups to form a concise set of components for potential implementation of a national lung cancer screening program in Australia: 1. Identifying the high-risk population: recruitment, eligibility, selection and referral 2. Educating the public, people at high risk and healthcare providers; this includes creating awareness of lung cancer, the benefits and harms of LDCT screening, and shared decision-making 3. Components necessary for health services to deliver a screening program: a. Planning phase: e.g. human resources to coordinate the program, electronic data systems that integrate medical records information and link to an established national registry b. Implementation phase: e.g. human and technological resources required to conduct LDCT examinations, interpretation of reports and communication of results to participants c. Monitoring and evaluation phase: e.g. monitoring outcomes across patients, radiological reporting, compliance with established standards and a quality assurance program 4. Data reporting and research, e.g. audit and feedback to multidisciplinary teams, reporting outcomes to enhance international research into LDCT screening 5. Incorporation of smoking cessation interventions, e.g. specific programs designed for LDCT screening or referral to existing community or hospital-based services that deliver cessation interventions. Most original studies are single-institution evaluations that contain descriptive data about the processes required to establish and implement a high-risk population-based screening program. Across all studies there is a consistent message as to the challenges and complexities of establishing LDCT screening programs to attract people at high risk who will receive the greatest benefits from participation. With regards to smoking cessation, evidence from one systematic review indicates the optimal strategy for incorporating smoking cessation interventions into a LDCT screening program is unclear. There is widespread agreement that LDCT screening attendance presents a ‘teachable moment’ for cessation advice, especially among those people who receive a positive scan result. Smoking cessation is an area of significant research investment; for instance, eight US-based clinical trials are now underway that aim to address how best to design and deliver cessation programs within large-scale LDCT screening programs.(9) Question 4: What is the cost-effectiveness of lung cancer screening programs (include studies of cost–utility)? Assessing the value or cost-effectiveness of LDCT screening involves a complex interplay of factors including data on effectiveness and costs, and institutional context. A key input is data about the effectiveness of potential and current screening programs with respect to case detection, and the likely outcomes of treating those cases sooner (in the presence of LDCT screening) as opposed to later (in the absence of LDCT screening). Evidence about the cost-effectiveness of LDCT screening programs has been summarised in two systematic reviews. We identified a further 13 studies—five modelling studies, one discrete choice experiment and seven articles—that used a variety of methods to assess cost-effectiveness. Three modelling studies indicated LDCT screening was cost-effective in the settings of the US and Europe. Two studies—one from Australia and one from New Zealand—reported LDCT screening would not be cost-effective using NLST-like protocols. We anticipate that, following the full publication of the NELSON trial, cost-effectiveness studies will likely be updated with new data that reduce uncertainty about factors that influence modelling outcomes, including the findings of indeterminate nodules. Gaps in the evidence There is a large and accessible body of evidence as to the effectiveness (Q1) and harms (Q2) of LDCT screening for lung cancer. Nevertheless, there are significant gaps in the evidence about the program components that are required to implement an effective LDCT screening program (Q3). Questions about LDCT screening acceptability and feasibility were not explicitly included in the scope. However, as the evidence is based primarily on US programs and UK pilot studies, the relevance to the local setting requires careful consideration. The Queensland Lung Cancer Screening Study provides feasibility data about clinical aspects of LDCT screening but little about program design. The International Lung Screening Trial is still in the recruitment phase and findings are not yet available for inclusion in this Evidence Check. The Australian Population Based Screening Framework was developed to “inform decision-makers on the key issues to be considered when assessing potential screening programs in Australia”.(10) As the Framework is specific to population-based, rather than high-risk, screening programs, there is a lack of clarity about transferability of criteria. However, the Framework criteria do stipulate that a screening program must be acceptable to “important subgroups such as target participants who are from culturally and linguistically diverse backgrounds, Aboriginal and Torres Strait Islander people, people from disadvantaged groups and people with a disability”.(10) An extensive search of the literature highlighted that there is very little information about the acceptability of LDCT screening to these population groups in Australia. Yet they are part of the high-risk population.(10) There are also considerable gaps in the evidence about the cost-effectiveness of LDCT screening in different settings, including Australia. The evidence base in this area is rapidly evolving and is likely to include new data from the NELSON trial and incorporate data about the costs of targeted- and immuno-therapies as these treatments become more widely available in Australia.