Gotowa bibliografia na temat „Primary health services for Aboriginal Australians”

The aim of this study is to ascertain whether a simplified screening algorithm incorporating glycated haemoglobin (HbA1c) tests increases type 2 diabetes (T2D) screening in 10- to 14-year-old Aboriginal Australians presenting to primary healthcare (PHC) services. The study involved a 6-month pilot of a locally developed evidence-based screening algorithm in a remote Western Australian Kimberley town. A retrospective audit of electronic health records for the pilot period (27 June–26 December 2016) and a 6-month period before the screening algorithm was introduced (1 October 2015–31 March 2016) was conducted. Interviews were held with 30 PHC staff at participating PHC services, an Aboriginal Community Controlled Health Service (ACCHS) and a hospital-based general practice service. During the pilot, significantly more patients received an initial T2D screening test at the ACCHS (28/130 (22%) v. 50/139 (36%), P = 0.011), but there was no change at the hospital (0.02% v. 0.02%, P = 0.615). Staff feedback suggested measures to improve screening; these include simple guidelines, targeted screening, patient and staff education, point-of-care HbA1c tests and a whole-of-clinic approach to implementation. Implementing a screening algorithm for young-onset diabetes in Aboriginal Australians is challenging, but practical measures can be taken to improve screening.

Background. Cancer mortality among Indigenous Australians is higher compared to the non-Indigenous population and attributed to poor access to cancer detection, screening, treatment and support services. A large proportion of Indigenous Australians live in rural and remote areas which makes access to cancer treatment services more challenging. Factors, such as transport, accommodation, poor socio-economic status and cultural appropriateness of services also negatively affect health service access and, in turn, lead to poor cancer outcomes. Design, setting and participants. Qualitative research with 30 in-depth interviews was conducted with Aboriginal people affected by cancer from across WA, using a variety of recruitment approaches. Results. The infrastructure around the whole-of-treatment experience affected the decision-making and experiences of Aboriginal patients, particularly affecting rural residents. Issues raised included transport and accommodation problems, travel and service expenses, displacement from family, concerns about the hospital environment and lack of appropriate support persons. These factors are compounded by a range of disadvantages already experienced by Aboriginal Australians and are vital factors affecting treatment decision-making and access. Conclusion. To improve cancer outcomes for Aboriginal people, logistical, infrastructure and cultural safety issues must be addressed. One way of ensuring this could be by dedicated support to better coordinate cancer diagnostic and treatment services with primary healthcare services. What is known about the topic? Cancer is a major cause of death among Indigenous Australians who are generally diagnosed later with their disease, have poorer continuity of care and lower uptake and completion of cancer treatment. For cancer diagnosis at an equivalent stage of cancer, Aboriginal people have poorer outcomes. What does this paper add? This study documents Aboriginal perspectives on basic infrastructure and logistical problems which impede their accessing hospital-based cancer treatments: transport, accommodation, preparation for the experience of hospital and cancer treatment, service affordability and the certainty of support services. What are the implications for practitioners? There are difficulties for practitioners in addressing the geographic, socioeconomic and cultural differences that Aboriginal people face in accessing cancer treatment. System level changes to ensure cultural safety, social support and better coordination with primary healthcare are essential to improve outcomes of Aboriginal people with cancer.

Australians living in rural and remote areas have poorer access to dental care. This situation is attributed to workforce shortages, limited facilities and large distances to care centres. Against this backdrop, rural and remote Indigenous (Aboriginal) communities in Western Australia seem to be more disadvantaged because evidence suggests they have poorer oral health than non-Indigenous people. Hence, provision of dental care for Aboriginal populations in culturally appropriate settings in rural and remote Western Australia is an important public health issue. The aim of this research was to compare services between the Aboriginal Medical Services (AMS)-based clinics and a typical rural community clinic. A retrospective analysis of patient demographics and clinical treatment data was undertaken among patients who attended the dental clinics over a period of 6 years from 1999 to 2004. The majority of patients who received dental care at AMS dental clinics were Aboriginal (95.3%), compared with 8% at the non-AMS clinic. The rate of emergency at the non-AMS clinic was 33.5%, compared with 79.2% at the AMS clinics. The present study confirmed that more Indigenous patients were treated in AMS dental clinics and the mix of dental care provided was dominated by emergency care and oral surgery. This indicated a higher burden of oral disease and late utilisation of dental care services (more focus on tooth extraction) among rural and remote Indigenous people in Western Australia.

Smoking prevalence among Indigenous Australians far exceeds that of non-Indigenous Australians and is considered the greatest contributor to burden of disease for Indigenous Australians. The Quitline is a primary intervention for facilitating smoking cessation and, given the health implications of tobacco use, maximising its effectiveness for Indigenous Australians is imperative. However, the utilisation and effectiveness of this service within the Indigenous Australian population has not been examined. This study explores the utilisation of the South Australian Quitline by smokers identifying as Indigenous Australian. Quitline counsellors collected data regarding demographic characteristics, and smoking and quitting behaviour from Quitline callers in 2010. Results indicated that the proportion of Indigenous and non-Indigenous smokers who registered for the service was comparable. Demographic variables and smoking addiction at time of registration with the Quitline were similar for Indigenous and non-Indigenous callers. However, results indicated that Indigenous callers received significantly fewer callbacks than non-Indigenous callers and were significantly less likely to set a quit date. Significantly fewer Indigenous callers reported that they were still successfully quit at 3 months. Thus, Indigenous Australian callers may be less engaged with the Quitline and further research is required exploring whether the service could be tailored to make it more engaging for Indigenous Australians who smoke.

Aboriginal community controlled PHC services have led the way in Australia in developing a model of PHC service that is able to address social issues and the underlying determinants of health alongside high quality medical care. This model is characterised by a comprehensive style rather than the selective PHC model that tends to be more common in mainstream services. Central to comprehensive PHC is community control, which is critical to the bottom up approach rather than the top down approach of selective PHC. The expansion of Aboriginal Community Controlled Health Services (ACCHSs) in Australia is a product of the colonial relationship that persists between Aboriginal and non-Aboriginal Australia. It is this relationship that explains why community control has been a feature of Aboriginal PHC services while similar attempts in the dominant society have tended to be incorporated into the mainstream. The mechanisms of control occur through community processes and should not be confused with day to day management processes, although the two are related. The Core Functions of PHC is a framework that reflects the experience of ACCHSs and allows for the development and assessment of comprehensive PHC. This framework is applied to a case study of the Central Australian Aboriginal Congress (Congress) which is the major Aboriginal health service in central Australia. The case study illustrates increasing utilisation of PHC services by Aboriginal people, and the capacity of community controlled organisations to respond to demographic and health pattern changes in their client populations.

Aboriginal and Torres Strait Islander people have high rates of cardiovascular disease (CVD). The National Vascular Disease Prevention Alliance (NVDPA) CVD risk assessment algorithm is used for all Australians. The Central Australian Rural Practitioners Association (CARPA) algorithm used in the Northern Territory adds five percentage points to all NVDPA risk scores for Indigenous Australians. Information was extracted from an Aboriginal Community-Controlled Health Service for all Aboriginal and Torres Strait Islander regular clients aged 35–74 years without known CVD (n=1057). CVD risk scores were calculated using both algorithms. Prescription of lipid-lowering medications was assessed. Clients with high-risk scores were reviewed and recalled if required. CVD risk scores were calculated for 362 (34.4%) clients. Clients with high CVD risk comprised 17.7% (NVDPA) or 23.8% (CARPA), with most determined clinically. Clients with low CVD risk comprised 73.7% (NVDPA) or 47.2% (CARPA). More than 30% of those with high risk were not on lipid-lowering medications. Significant health and social issues affected treatment uptake. It is unclear which algorithm is most applicable; however, this service has decided to continue to use the NVDPA algorithm. Use of CVD risk assessment and management of high-risk clients could be increased in primary care.

Tobacco smoking leads to one in five deaths of Aboriginal Australians and accounts for 17% of the reversible health gap. One in two Aboriginal women are reported to smoke during pregnancy, with no effective strategies currently available for health practitioners to utilise for supporting Aboriginal women. Aboriginal community participation in primary health research is crucial to implementing ethical research, with a clear benefit to the people and communities involved. However, currently there is little evidence on how Aboriginal programs and interventions are being developed in partnership with Aboriginal people and communities. ‘Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy’ aims to address the prevalence of smoking during pregnancy by enhancing health providers’ training in offering evidence-based smoking cessation care to Aboriginal mothers during pregnancy. This paper outlines the participatory research approach adopted for the developmental phase of the ‘ICAN QUIT in Pregnancy’ project developed in partnership with two Aboriginal Community-Controlled Health Services in NSW, and negotiation processes undertaken to implement a pilot intervention across NSW, SA and Qld.

Background. Aboriginal and Torres Strait Islander peoples experience inferior outcomes following diagnosis of lung cancer. Aim. To examine the experience of lung cancer in this population and identify reasons for poorer outcomes and lower levels of treatment compared with non-Aboriginal and Torres Strait Islander peoples, and opportunities for early intervention. Method. Literature was sought via electronic database searches and journal hand-searching for the period from January 1995 to July 2010. Databases used included Indigenous HealthInfoNet, SCOPUS, PsycInfo, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, HealthInsite and Google Scholar. Findings. Exposure to risk factors, cultural and spiritual values, remoteness and geographic characteristics, entrenched socioeconomic inequalities and racism contribute to reduced service access and poor outcomes. The review highlighted a complex interplay of individual, social, health system and environmental factors that impact on optimal lung cancer care and lung cancer outcomes. Considering the burden of lung cancer within a framework of social determinants of health is necessary for policy-making and service planning and delivery. Conclusions. It is imperative that the disproportionate burden of lung cancer in Aboriginal and Torres Strait Islander peoples is addressed immediately. Whilst strategic interventions in lung cancer prevention and care are needed, service providers and policy makers must acknowledge the entrenched inequality that exists and consider the broad range of factors at the patient, provider and system level. Primary care strategies and health promotion activities to reduce risk factors, such as smoking, must also be implemented, with Aboriginal and Torres Strait Islander peoples’ engagement and control at the core of any strategy. This review has indicated that multifaceted interventions, supported by enabling policies that target individuals, communities and health professionals, are necessary to improve lung cancer outcomes and disparities. What is known about the topic? Aboriginal Australians suffer a disproportionate burden of ill health including poor outcomes from lung cancer. What does this paper add? This paper reports the outcomes of an integrative literature review. The paper identifies potential barriers to optimal lung cancer care and management for Aboriginal Australians. This paper describes barriers within the context of individual beliefs and behaviours, healthcare systems issues and environmental issues. The authors conclude that acknowledging entrenched inequality and addressing factors at the patient, provider and system level are needed to reduce the lung cancer burden in Aboriginal Australians. What are the implications for practitioners? This paper highlights the need for a greater focus on lung cancer care, awareness and diagnosis within the Aboriginal Australian population. Addressing culturally appropriate smoking-cessation initiatives is of particular importance. Primary care practitioners are key to reducing the burden of lung cancer in Aboriginal Australians.

IntroductionThe age-adjusted rate of potentially preventable hospitalisations for Aboriginal and Torres Strait Islander people is almost five times the rate of other Australians. Quality use of medicines has an important role in alleviating these differences. This requires strengthening existing medication reviewing services through collaboration between community pharmacists and health workers, and ensuring services are culturally appropriate. This Indigenous Medication Review Service (IMeRSe) study aims to develop and evaluate the feasibility of a culturally appropriate medication management service delivered by community pharmacists in collaboration with Aboriginal health workers.Methods and analysisThis study will be conducted in nine Aboriginal health services (AHSs) and their associated community pharmacies in three Australian states over 12 months. Community pharmacists will be trained to improve their awareness and understanding of Indigenous health and cultural issues, to communicate the quality use of medicines effectively, and to strengthen interprofessional relationships with AHSs and their staff. Sixty consumers (with a chronic condition/pregnant/within 2 years post partum and at risk of medication-related problems (MRPs) per site will be recruited, with data collection at baseline and 6 months. The primary outcome is the difference in cumulative incidence of serious MRPs in the 6 months after IMeRSe introduction compared with the 6 months prior. Secondary outcomes include potentially preventable medication-related hospitalisations, medication adherence, total MRPs, psychological and social empowerment, beliefs about medication, treatment satisfaction and health expenditure.Ethics and disseminationThe protocol received approval from Griffith University (HREC/2018/251), Queensland Health Metro South (HREC/18/QPAH/109), Aboriginal Health and Medical Research Council of New South Wales (1381/18), Far North Queensland (HREC/18/QCH/86-1256) and the Central Australian HREC (CA-18-3090). Dissemination to Indigenous people and communities will be a priority. Results will be available on the Australian Sixth Community Pharmacy Agreement website and published in peer-reviewed journals.Trial registration numberACTRN12618000188235; Pre-results.

Aboriginal and Torres Strait Islander peoples’ (hereafter respectfully referred to as Indigenous Australians) experiences of health care are shaped by historical, social and cultural factors, with cultural security critical to effective care provision and engagement between services and community. Positive patient experiences are associated with better health outcomes. Consequently, it is an accreditation requirement that primary health care (PHC) services must formally gather and respond to patient feedback. However, currently available patient feedback tools were not developed with Indigenous Australians, and do not reflect their values and world views. Existing tools do not capture important experiences of care of Indigenous Australians in PHC settings, nor return information that assists services to improve care. Consistent with the principles of Indigenous Data Sovereignty, we will co-design and validate an Indigenous-specific Patient Reported Experience Measure (PREM) that produces data by and for community, suitable for use in quality improvement in comprehensive PHC services. This paper presents the protocol of the study, outlining the rationale, methodologies and associated activities that are being applied in developing the PREM. Briefly, guided by an Aboriginal and Torres Strait Islander Advisory Group, our team of Indigenous and non-Indigenous researchers, service providers and policy makers will use a combination of Indigenous methodologies, participatory, and traditional western techniques for scale development. We will engage PHC service staff and communities in eight selected sites across remote, regional, and metropolitan communities in Australia for iterative cycles of data collection and feedback throughout the research process. Yarning Circles with community members will identify core concepts to develop an “Experience of Care Framework”, which will be used to develop items for the PREM. Staff members will be interviewed regarding desirable characteristics and feasibility considerations for the PREM. The PREM will undergo cognitive and psychometric testing.

It is accepted protocol among Indigenous communities to identify one's link to land. I was born and raised in Brisbane. My birth grandmother is a Goreng Goreng woman, my birth grandfather is a Punthamara man. However, I was adopted by a Koombumberri man and an anglo-celtic mother after being removed at birth under the Queensland government policy of the day. The action of my removal and placement has had profound effects upon my growing and my place within my community today. For the last 15 years I have worked in the health sector. My current position is as a Lecturer within the Department of Nursing, Faculty of Science, University of Southern Queensland, Toowoomba. My areas of expertise are Indigenous Health and Primary Health Care. I have been employed in this capacity since January 2000. Prior to my full time employment as a nursing academic I have primarily been located within three areas of health which have directly impacted upon my current research. I was first positioned within health by undertaking my General Nurse Certificate through hospital-based training commenced in the late 1980s. For me this training meant being immersed within whiteness and specifically the white medical model. This meant learning a set of skills in a large institutionalised health care service with the provision of doctors, nurses, and allied medical staff through a hospital. Within this training there was no Indigenous health curriculum. The lectures provided on 'differing cultures' and health were on Muslim and Hindu beliefs about death. At that point I was painfully aware of the glaring omission of any representation of Indigenous health and of acknowledgment of the current outstanding health differentials between Indigenous and non-Indigenous Australians. I knew that the colonisation process inflicted upon Indigenous Australians was one of devastation. The decline in our health status at the time of colonisation had been felt immediately. Since this time our health has been in decline. While in the 1980s it was now no longer acceptable to shoot us, poison our waterholes, and incarcerate us on missions, we were still experiencing the influence of the colonisation process, which had strong repercussions for our current health status. Our communities were and remain rife with substance abuse, violence, unemployment, and much more. For Indigenous Australians these factors cannot be separated from our initial experience of the colonisation process but are seen as the continuation of it. However, there was no representation of this and I received my first health qualification.

It is accepted protocol among Indigenous communities to identify one's link to land. I was born and raised in Brisbane. My birth grandmother is a Goreng Goreng woman, my birth grandfather is a Punthamara man. However, I was adopted by a Koombumberri man and an anglo-celtic mother after being removed at birth under the Queensland government policy of the day. The action of my removal and placement has had profound effects upon my growing and my place within my community today. For the last 15 years I have worked in the health sector. My current position is as a Lecturer within the Department of Nursing, Faculty of Science, University of Southern Queensland, Toowoomba. My areas of expertise are Indigenous Health and Primary Health Care. I have been employed in this capacity since January 2000. Prior to my full time employment as a nursing academic I have primarily been located within three areas of health which have directly impacted upon my current research. I was first positioned within health by undertaking my General Nurse Certificate through hospital-based training commenced in the late 1980s. For me this training meant being immersed within whiteness and specifically the white medical model. This meant learning a set of skills in a large institutionalised health care service with the provision of doctors, nurses, and allied medical staff through a hospital. Within this training there was no Indigenous health curriculum. The lectures provided on 'differing cultures' and health were on Muslim and Hindu beliefs about death. At that point I was painfully aware of the glaring omission of any representation of Indigenous health and of acknowledgment of the current outstanding health differentials between Indigenous and non-Indigenous Australians. I knew that the colonisation process inflicted upon Indigenous Australians was one of devastation. The decline in our health status at the time of colonisation had been felt immediately. Since this time our health has been in decline. While in the 1980s it was now no longer acceptable to shoot us, poison our waterholes, and incarcerate us on missions, we were still experiencing the influence of the colonisation process, which had strong repercussions for our current health status. Our communities were and remain rife with substance abuse, violence, unemployment, and much more. For Indigenous Australians these factors cannot be separated from our initial experience of the colonisation process but are seen as the continuation of it. However, there was no representation of this and I received my first health qualification.
Thesis (Masters)
Master of Philosophy (MPhil)
School of Arts, Media and Culture
Full Text

Background: Australia‟s Aboriginal and Torres Strait Islanders are over represented in poor health and education outcomes. Little is known about the bullying experiences of Aboriginal school age children and young people. This Master's study aimed to investigate the policies and practises school principals use for bullying prevention and management in primary schools located in the Yamaji region or Midwest Education District of Western Australia.This study was conducted in conjunction with the Child Health Promotion Research Centre‟s Solid Kids, Solid Schools project. Solid Kids, Solid Schools is a four-year study that aimed to contextualise the bullying experiences of Yamaji school-age children and young people; and develop a locally relevant and culturally secure bullying prevention and management resource. Method: Thirty-one principals and four deputy principals of primary school aged students participated in either a semi-structured telephone interview or survey. Instrument items asked principals: how often staff at their school used 12 bullying management strategies; to describe and rate the effectiveness of 25 bullying prevention guidelines and strategies; and to describe enablers and barriers to working with Aboriginal students who are bullied or who bully others.Participant responses were matched for compliance with evidence-based recommendations (Cross, Pintabona, Hall, Hamilton, & Erceg, 2004, p. 11) and national policy as set out in the National Safe Schools Framework (NSSF) (Department of Education Science and Training; DEST, 2003) for school bullying prevention and management. Participant responses were also compared to a culturally secure bullying prevention and management model to determine if their guidelines and strategies are culturally secure and could respond to the strengths and needs of Aboriginal students.

The bureaucratic measure of health service, health performance indicators, suggest that we are not effective in our legislative responsibility to deliver suitable health care to some of the populations we are meant to serve. Debate has raged over the years as to the reasons for this, with no credible explanation accepted by those considered stakeholders. One thing is clear though, we have gone from being a culture believing that the needs of the many far outweigh those of the few, to one where we are barely serving the needs of the 'any'. This is most evident in the care delivered to the Aboriginal and Torres Strait Islander people of Australia.

This study concerned a primary health care approach to trachoma control in two Central Australian Aboriginal communities. The World Health Organization (WHO) has advocated that the best method to control trachoma is the SAFE strategy (Surgery, Antibiotics, Facial hygiene, and Environmental improvements), and this approach was adopted.
The communities, Pipalyatjara and Mimili, with populations slightly less than 300 each, are located in the Anangu Pitjantjatjara (AP) lands of Central Australia, in the northwest corner of the South Australia territory. At Pipalyatjara, a full SAFE-type intervention was undertaken, with the ‘E’ component designed and implemented by the NHC (Nganampa Health Council Inc.). At Mimili, only a SAF-type of intervention was implemented.
Baseline data was gathered for 18 months from March 1999 through September 2000 (five visits to Pipalyatjara and four at Mimili), and included determining trachoma prevalence levels using the WHO system, facial cleanliness, and nasal discharge parameters. A trachoma health program was implemented at the end of this period and a one-time dose of azithromycin was given in September of 2000. The chief focus of the study was children under 15 years of age.
Improvements in road sealing, landscaping, and the creation of mounds were started to improve dust control. Concurrently, efforts were made in the houses of the residents to improve the nine healthy living practices, which were scored in two surveys, in March 1999 and August 2001. Trachoma prevalence, and levels of facial cleanliness and nasal discharge were determined at 3, 6, and 12 months following antibiotic administration.
In children less than 15 years of age, the pre-intervention prevalence level of TF (Trachoma Follicular) was 42% at Pipalyatjara, and 44% at Mimili. For the 1-9 year age group, the TF prevalence was 47% and 54% respectively. For TI (Trachoma Intense), the pre-intervention prevalence was 8% for Pipalyatjara, and 9% for Mimili. The TF prevalence, adjusted for clustering, and using only individuals present at baseline and follow-up (3, 6, and 12 months post-intervention), was 41.5%, 21.2%, 20.0%, and 20.0% at Pipalyatjara respectively. For Mimili, the corresponding prevalence figures were 43.5%, 18.2%, 18.2%, and 30%.
In the 1-9 year age group, a lower TF prevalence existed between the pre-intervention and 12-month post-intervention points at Pipalyatjara compared to Mimili. The TF prevalence after the intervention was also lower for males compared to females, when the cohorts were grouped by gender, rather than community. It is posited that reinfection was much higher at Mimili within this age group, however, in both communities, there appeared to be a core of females whose trachoma status did not change. This is speculated as mainly being caused by prolonged inflammation, though persistent infection C. Trachomatis cannot be ruled out.
Facial cleanliness and nasal discharge continued to improve throughout the intervention at both communities, but at the 3-month post-intervention point no longer became a good predictor of trachoma.
It is not known whether the improvements in the environment at Pipalyatjara were responsible for the reduction in trachoma prevalence 12 months after the intervention, relative to Mimili.

Thesis (Ph. D.)--University of Sydney, 2009.
Degree awarded 2009; thesis submitted 2008. Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy to the Dept.of History, Faculty of Arts. Title from title screen (viewed 3 December, 2009). Includes graphs and tables. List of tables: leaf 9. List of illustrations: leaves 10-12. Includes bibliographical references. Also available in print form.

Thesis (M.P.H.)--Dept. of Public Health & Community Medicine, Faculty of Medicine, University of Sydney, 1999.
"An historical exploration of poor aboriginal health and the continuities of the colonial relationship as an explanation of the persistence of poor aboriginal health " Includes bibliographical references (leaves 334-349).

Self determination has been recognised as a basic human right both internationally and, to an extent, locally, but it is yet to be fully realised for Aboriginal Peoples in Australia. The assertion of Aboriginal community control in Aboriginal health has been at the forefront of Aboriginal peoples' advocacy for self determination for more than thirty years. Aboriginal Community Controlled Health Services and their representative organisations have been the site of considerable resistance and contestation in the struggles involved in trying to improve Aboriginal health experiences. Drawing on some of these experiences I explore the apparent inability of policy and decision makers to listen to systematic voices calling for change from the Aboriginal Community Controlled Health sector. It is government inability to act more fully on clear and repeated messages that is a source of much disquiet within representative Aboriginal organisations. Such disquiet is grounded in a belief that colonial notions continue to influence decision making at policy, practice and research levels resulting in a significant impediment to the realisation of self determination and associated human rights in Aboriginal health matters and Aboriginal Affairs more broadly.

Human health is multidimensional: apart from physical, mental, and social aspects, it also incorporates subjective perceptions of health, and functional status (FS). Given that elderly persons have very distinctive health and social needs, multidimensional assessment (MA) of health proves particularly useful in this age group.¶ Aboriginal populations suffer poor health, and there are relatively few studies addressing the health problems of older Aboriginal Australians, mainly because of their distinctive demographic structure, and the low proportion of their elderly. Also, there is no prior information available on MA of health in this Australian population group.¶ This thesis offers a MA of health in older Aboriginal persons from two, urban and rural/isolated, locations in the NT, Katherine and Lajamanu (the NT survey).¶ This thesis specifically addresses the following questions: - what is the physical health, FS, subjective perception of health, and social functioning amongst the NT survey participants? - what are the possible similarities and differences in various dimensions of health between the two major survey locations, what age and gender patterns are observed, and what are the reasons for these patterns, similarities and differences? - how do various dimensions of health relate to each other, and why? - how do current findings relate to broader Aboriginal and non-Aboriginal populations, and why? - what can MA add to a better understanding of various aspects of morbidity and health care use? - what are its possible implications for health planning?¶ Findings from this work indicate poor physical health amongst participants in almost all investigated aspects, comparable to information available from other Aboriginal populations. These are accompanied by low levels of ability for physical functioning. Despite this, subjective perception of health is rather optimistic amongst participants, and levels of social functioning high. Use of health services is mainly related to available health infrastructure. Important health differences exist between Katherine and Lajamanu, and they became particularly visible when all dimensions of health are considered together.¶ The Main conclusions from the current work are that 1) poor physical health is not necessarily accompanied by similar level of deterioration in other dimensions of health: even though participants from the isolated community of Lajamanu experience most chronic diseases, their ability for physical functioning is better, self-perceived health (SPH) more optimistic and levels of social functioning highest 2) institutionalised participants from Katherine suffer by far the worst health of all sample segments in this study; at least some of the poor health outcomes are potentially avoidable, and could be improved by more appropriate residential choices for Aboriginal elderly 3) better health infrastructure does not necessarily bring better health in all its dimensions, suggesting that other factors (primarily socio-economic and cultural) should be addressed in conjunction with this in solving complex health problems of Aboriginal Australians, and 4) it provides strong support that MA can become a useful tool in comprehensive health assessment of older Aboriginals.

While developed nations search for solutions to pay for the increasing financial burden of healthcare, developing nations provide a way forward in the deployment of innovative healthcare. Mobile SMS programs are low-cost and effective in supporting health services. Having been successfully used to address lifestyle factors directly affecting maternal outcomes, such as: smoking, physical activity, nutrition, substance use and psychological stressors. Of primary importance in the development of SMS behavior change programs to support the maternal healthcare of Indigenous Australian women, is cultural appropriateness; specifically, the cultural notion of ‘women's business'. In traditional Indigenous Australian culture, it is senior women who teach young women about maternal health and it is considered offensive for anyone other than a senior woman to instruct women on such matters. This discussion will consider the challenges in developing maternal healthcare SMS messages that aim to satisfy both the culturally sensitive requirements in addition to the medical requirements.

Temporary telehealth initiatives during COVID-19 have been life-changing for many people in Australia; for the first time Frail, Homebound, and Bedridden Persons (FHBP) equitably received primary healthcare services, like Australians without a disability. However, government changes to telehealth funding mean that since July 2020 telehealth is only available for those who have attended a face-to-face appointment in the last 12 months, thus excluding FHBP. This paper illustrates the reported health exclusion and marginalisation of FHBP. We reviewed the literature and surveyed 164 Australian adults (27% homebound people and 73% affiliated persons) to ascertain their opinions and thoughts on potential strategies to tackle issues associated with FHBP’s current circumstances. Results demonstrate that digital technologies and telehealth services are ethical imperatives. Policymakers, clinicians, and health researchers must work with end-users (community-based participation) to create an inclusive healthcare service.

The MHEC-RAP project involves the innovative application of video conferencing to mental health assessment in rural NSW. The preliminary evaluation findings of the project are presented. Mental health emergencies in rural and remote settings cause particular problems and are not amenable to conventional health service solutions. Patients and local health care staff may be isolated from specialist mental health staff and from acute inpatient services. Decisions to transport patients for specialist assessments or treatment may be required at night or at weekends and may involve families, police, ambulance services and local health staff. Such decisions need to be made promptly but carefully and the ability to obtain a specialist assessment may assist in making a decision about how best to care for the patient bearing in mind the need to provide a responsive, high quality and safe service to patients and local clinicians. In this chapter we examine a novel approach which uses audio-visual technology to conduct remote emergency mental health patient assessment interviews and provide consultations to local clinicians in rural communities in western NSW. The Mental Health Emergency Care – Rural Access Project or ‘MHEC-RAP’ was developed in 2007 following a series of consultations held in rural towns and implemented in 2008 within the Greater Western Area Health Service (GWAHS), New South Wales, Australia. GWAHS is a primary example of a rural and remote health service. It serves 287,481 people (8.3% of whom are Indigenous Australians) in an area that is 445,197sq km or 55% of the state of New South Wales (Australian Bureau of Statistics, 2001; Greater Western Area Health Service, 2007, 2009). The communities within GWAHS are mostly small, the towns are widely dispersed and local services are “limited by distance, expense, transport, and the difficulty of recruiting health professionals to these areas” (Dunbar, 2007 page 587). The chapter focuses on the design of the service, its implementation and its performance in the first year. We conclude with a discussion about the service, its broader relevance, transferability and its sustainability.

Overview Skin cancer prevention is a component of the new Cancer Plan 2022–27, which guides the work of the Cancer Institute NSW. To lessen the impact of skin cancer on the community, the Cancer Institute NSW works closely with the NSW Skin Cancer Prevention Advisory Committee, comprising governmental and non-governmental organisation representatives, to develop and implement the NSW Skin Cancer Prevention Strategy. Primary Health Networks and primary care providers are seen as important stakeholders in this work. To guide improvements in skin cancer prevention and inform the development of the next NSW Skin Cancer Prevention Strategy, an up-to-date review of the evidence on the effectiveness and feasibility of skin cancer prevention activities in primary care is required. A research team led by the Daffodil Centre, a joint venture between the University of Sydney and Cancer Council NSW, was contracted to undertake an Evidence Check review to address the questions below. Evidence Check questions This Evidence Check aimed to address the following questions: Question 1: What skin cancer primary prevention activities can be effectively administered in primary care settings? As part of this, identify the key components of such messages, strategies, programs or initiatives that have been effectively implemented and their feasibility in the NSW/Australian context. Question 2: What are the main barriers and enablers for primary care providers in delivering skin cancer primary prevention activities within their setting? Summary of methods The research team conducted a detailed analysis of the published and grey literature, based on a comprehensive search. We developed the search strategy in consultation with a medical librarian at the University of Sydney and the Cancer Institute NSW team, and implemented it across the databases Embase, MEDLINE, PsycInfo, Scopus, Cochrane Central and CINAHL. Results were exported and uploaded to Covidence for screening and further selection. The search strategy was designed according to the SPIDER tool for Qualitative and Mixed-Methods Evidence Synthesis, which is a systematic strategy for searching qualitative and mixed-methods research studies. The SPIDER tool facilitates rigour in research by defining key elements of non-quantitative research questions. We included peer-reviewed and grey literature that included skin cancer primary prevention strategies/ interventions/ techniques/ programs within primary care settings, e.g. involving general practitioners and primary care nurses. The literature was limited to publications since 2014, and for studies or programs conducted in Australia, the UK, New Zealand, Canada, Ireland, Western Europe and Scandinavia. We also included relevant systematic reviews and evidence syntheses based on a range of international evidence where also relevant to the Australian context. To address Question 1, about the effectiveness of skin cancer prevention activities in primary care settings, we summarised findings from the Evidence Check according to different skin cancer prevention activities. To address Question 2, about the barriers and enablers of skin cancer prevention activities in primary care settings, we summarised findings according to the Consolidated Framework for Implementation Research (CFIR). The CFIR is a framework for identifying important implementation considerations for novel interventions in healthcare settings and provides a practical guide for systematically assessing potential barriers and facilitators in preparation for implementing a new activity or program. We assessed study quality using the National Health and Medical Research Council (NHMRC) levels of evidence. Key findings We identified 25 peer-reviewed journal articles that met the eligibility criteria and we included these in the Evidence Check. Eight of the studies were conducted in Australia, six in the UK, and the others elsewhere (mainly other European countries). In addition, the grey literature search identified four relevant guidelines, 12 education/training resources, two Cancer Care pathways, two position statements, three reports and five other resources that we included in the Evidence Check. Question 1 (related to effectiveness) We categorised the studies into different types of skin cancer prevention activities: behavioural counselling (n=3); risk assessment and delivering risk-tailored information (n=10); new technologies for early detection and accompanying prevention advice (n=4); and education and training programs for general practitioners (GPs) and primary care nurses regarding skin cancer prevention (n=3). There was good evidence that behavioural counselling interventions can result in a small improvement in sun protection behaviours among adults with fair skin types (defined as ivory or pale skin, light hair and eye colour, freckles, or those who sunburn easily), which would include the majority of Australians. It was found that clinicians play an important role in counselling patients about sun-protective behaviours, and recommended tailoring messages to the age and demographics of target groups (e.g. high-risk groups) to have maximal influence on behaviours. Several web-based melanoma risk prediction tools are now available in Australia, mainly designed for health professionals to identify patients’ risk of a new or subsequent primary melanoma and guide discussions with patients about primary prevention and early detection. Intervention studies have demonstrated that use of these melanoma risk prediction tools is feasible and acceptable to participants in primary care settings, and there is some evidence, including from Australian studies, that using these risk prediction tools to tailor primary prevention and early detection messages can improve sun-related behaviours. Some studies examined novel technologies, such as apps, to support early detection through skin examinations, including a very limited focus on the provision of preventive advice. These novel technologies are still largely in the research domain rather than recommended for routine use but provide a potential future opportunity to incorporate more primary prevention tailored advice. There are a number of online short courses available for primary healthcare professionals specifically focusing on skin cancer prevention. Most education and training programs for GPs and primary care nurses in the field of skin cancer focus on treatment and early detection, though some programs have specifically incorporated primary prevention education and training. A notable example is the Dermoscopy for Victorian General Practice Program, in which 93% of participating GPs reported that they had increased preventive information provided to high-risk patients and during skin examinations. Question 2 (related to barriers and enablers) Key enablers of performing skin cancer prevention activities in primary care settings included: • Easy access and availability of guidelines and point-of-care tools and resources • A fit with existing workflows and systems, so there is minimal disruption to flow of care • Easy-to-understand patient information • Using the waiting room for collection of risk assessment information on an electronic device such as an iPad/tablet where possible • Pairing with early detection activities • Sharing of successful programs across jurisdictions. Key barriers to performing skin cancer prevention activities in primary care settings included: • Unclear requirements and lack of confidence (self-efficacy) about prevention counselling • Limited availability of GP services especially in regional and remote areas • Competing demands, low priority, lack of time • Lack of incentives.

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.