Ethics guidelines use and Indigenous governance and participation in Aboriginal and Torres Strait Islander health research: a national survey.

OBJECTIVES: To assess the use of NHMRC Indigenous research guidelines by Australian researchers and the degree of Aboriginal and Torres Strait Islander governance and participation in Indigenous health research. DESIGN, SETTING, PARTICIPANTS: Cross-sectional survey of people engaged in Indigenous health research in Australia, comprising respondents to an open invitation (social media posts in general and Indigenous health research networks) and authors of primary Indigenous health research publications (2015-2019) directly invited by email. MAIN OUTCOME MEASURES: Reported use of NHMRC guidelines for Indigenous research; reported Indigenous governance and participation in Indigenous health research. RESULTS: Of 329 people who commenced the survey, 247 people (75%) provided responses to all questions, including 61 Indigenous researchers (25%) and 195 women (79%). The NHMRC guidelines were used "all the time" by 206 respondents (83%). Most respondents (205 of 247, 83%) reported that their research teams included Indigenous people, 139 reported dedicated Indigenous advisory boards (56%), 91 reported designated seats for Indigenous representatives on ethics committees (37%), and 43 reported Indigenous health research ethics committees (17%); each proportion was larger for respondents working in Indigenous community-controlled organisations than for those working elsewhere. More than half the respondents reported meaningful Indigenous participation during five of six research phases; the exception was data analysis (reported as apparent "none" or "some of the time" by 143 participants, 58%). CONCLUSIONS: Indigenous health research in Australia is largely informed by non-Indigenous world views, led by non-Indigenous people, and undertaken in non-Indigenous organisations. Re-orientation and investment are needed to give control of the framing, design, and conduct of Indigenous health research to Indigenous people.

Comment: Sedation as part of secondary prophylaxis to prevent recurrent rheumatic fever in Aboriginal and Torres Strait Islander peoples: time for a reset?

Australia's national clinical practice guidelines recommend intramuscular (IM) penicillin every 28 days for persons diagnosed with an initial episode of acute rheumatic fever (ARF). This antibiotic coverage is initiated to reduce recurrent ARF episodes by preventing repeat infections with the causative bacterium, group A Streptococcus. Because disease has already occurred, this regimen is known as secondary prophylaxis (SP), done in order to prevent more episodes of ARF (known as recurrences). In 2020, eight authors shared with readers of Rural and Remote Health their experience of introducing off-label an oral, centrally acting, alpha agonist sedative to the prescribed SP regimen of IM penicillin for each of three Aboriginal children previously diagnosed with ARF. The living environments of the three children increased their risk for repeat group A Streptococcus infections and subsequent recurrences of ARF. We find the clinical case report perpetuates a troubling academic tone about this singular priority for SP. Injecting a child with IM penicillin appears to supersede all other objectives. Off-label sedation in remote settings is legitimised in order to succeed in this imperative. Those articles that peer-reviewed medical journals choose to publish privilege directions for priorities, policy and practice. In this commentary, we present alternative perspectives and initiatives for consideration.

Clinic predictors of better syphilis testing in Aboriginal primary healthcare: a promising opportunity for primary healthcare service managers.

Integration of public health and primary healthcare (PHC) is a hallmark of comprehensive PHC to reduce inequitable rates of preventable diseases in communities at risk. In the context of a syphilis outbreak among Indigenous people in Northern Australia, the association between PHC clinic factors and syphilis testing performance (STP) was examined to produce empirical insights for service managers. Data from the Audit and Best Practice for Chronic Disease National Program (2012-14) were analysed to examine associations between clinic factors and STP (proportion of clients ≥15 years who were tested for or offered a test for syphilis in the prior 24 months). Univariate analyses were conducted for 77 clinics and a subset of 67 remote clinics. Multivariate linear regression models were used to determine independent predictors of STP. Syphilis testing performance across PHC clinics ranged from 0 to 93.8% (median 46.5%). In univariate analysis, Delivery system design, which refers to clinic infrastructure, staffing profile and allocation of roles and responsibilities, was significantly associated with higher STP in all clinics (P=0.004) and in the subset of remote clinics (P=0.008). Syphilis testing performance was higher in the Northern Territory compared to other states, in remote clinics and clinics serving smaller populations. In multivariate analysis, Delivery system design and jurisdiction remained associated with STP. To better realise the potential of comprehensive PHC, service managers should focus on PHC delivery system design to enhance the current syphilis outbreak response.

Provision of maternity care for women in remote Far West New South Wales: how far have we come?

BACKGROUND: The National Maternity Services Review in 2009 sought to address the ongoing issues of access, workforce capacity and inequalities in health outcomes for women and their babies in rural and remote Australia. The subsequent National Maternity Services Plan describes the type of care that should be offered to all women in Australia. OBJECTIVE: The aim of our study was to better understand the local context and progress in delivering recommendations of the National Plan to improve maternity services for women in remote communities of Far West New South Wales. DESIGN: Semistructured questionnaires. SETTING: Maternity care in Far West New South Wales involves long-standing partnerships between three service providers to provide antenatal and postnatal care to women in remote communities with birthing predominantly occurring at the Broken Hill Health Service. MAIN OUTCOME MEASURES: The degree of information sharing and communication, use of guidelines and policies, the effectiveness of workforce retention strategies and the current level of maternity care provided. PARTICIPANTS: Fourteen clinicians and policy makers. RESULTS: Participants reported clarity in roles and responsibilities of health staff, the appropriateness of antenatal care policies to the context, confidence in practising to their full professional scope and the existence of quality improvement initiatives across all providers. However, participants also reported being constrained by environmental and organisational factors in regards to risk assessment and referral of pregnant women. Key issues for local health service partners include adherence to antenatal care policies and a need to improve local workforce capacity. CONCLUSIONS: Local health service partners are demonstrably ready to address the modifiable factors of organisational capacity and interprofessional collaboration in accordance with the recommendations of the National Maternity Services Review.

Feasibility, acceptability and impact of a telephone support service initiated in primary medical care to help Arabic smokers quit.

Evidence-based tobacco control in ethnic minorities is compromised by the near absence of rigorous testing of interventions in either prevention or cessation. This randomised controlled trial was designed to evaluate the feasibility, acceptability and impact of a culturally specific cessation intervention delivered in the context of primary medical care in the most culturally diverse region of New South Wales. Adult Arabic smokers were recruited from practices of 29 general practitioners (GPs) in south-west Sydney and randomly allocated to usual care (n=194) or referred to six sessions of smoking cessation telephone support delivered by bilingual psychologists (n=213). Although 62.2% of participants indicated that telephone support would benefit Arabic smokers, there were no significant differences at 6 or 12 months between intervention and control groups in point prevalence abstinence rates (11.7% vs 12.9%, P=0.83; 8.4% vs 11.3%, P=0.68, respectively) or the mean shift in stage-of-change towards intention to quit. As participants and GPs found telephone support acceptable, we also discuss redesign and the unfulfilled obligation to expand the evidence base in tobacco control from which the ethnic majority already benefits.

Communicable disease outbreaks: Surveillance and infrastructure.

The sixth article in a series on communicable disease outbreaks looks beyond the acute epidemic to the rationale for surveillance systems, mandatory notification and social determinants.

Communicable disease outbreaks: The bigger picture.

This fourth article in a series on communicable disease outbreaks introduces the larger legislative, executive and social framework within which health protection takes place.

Communicable disease outbreaks: Describing an epidemic.

This first article in a series on communicable disease outbreaks explains terms used by public health authorities during epidemics.

Communicable disease outbreaks: Ethics in an outbreak.

This fifth article in a series on communicable disease outbreaks explores ethical aspects of public health action, information disclosure and research in an epidemic.

Communicable disease outbreaks: What is a case?

This second article in a series on communicable disease outbreaks focuses on case definitions, testing and early phases of a public health response.

Communicable disease outbreaks: Contact tracing.

This third article in a series on communicable disease outbreaks focuses on contact tracing, fondly known as 'shoe-leather epidemiology'.

Syphilis testing performance in Aboriginal primary health care: exploring impact of continuous quality improvement over time.

Data from 110 primary healthcare clinics participating in two or more continuous quality improvement (CQI) cycles in preventive care, which included syphilis testing performance (STP) for Aboriginal and Torres Strait Islander people aged between 15 and 54 years, were used to examine whether the number of audit cycles including syphilis testing was associated over time with STP improvement at clinic level in this specific measure of public health importance. The number of cycles per clinic ranged from two to nine (mode 3). As shown by medical record audit at entry to CQI, only 42 (38%) clinics had tested or approached 50% or more of their eligible clients for syphilis in the prior 24 months. Using mixed effects logistic regression, it was found that the odds of a clinic's STP relative to its first cycle increased only modestly. Counterintuitively, clinics undertaking the most preventive health CQI cycles tended to have the lowest STP throughout. Participation in a general preventive care CQI tool was insufficient to achieve and sustain high rates of STP for Aboriginal and Torres Strait Islander people required for public health benefit. Improving STP requires dedicated effort and greater understanding of barriers to effective CQI within and beyond clinic control.

Research engagement and outcomes in public health and health services research in Australia.

OBJECTIVES: To retrospectively explore research outcomes in Australian public health research and their relationship to full engagement with potential research users during the research process. METHODS: A self-administered survey of all principal investigators (PIs) receiving research funds from one of three well-known research funding agencies. 'Research value' and 'research utility' were self-reported using fixed response sets. Associations between outcomes and 'full engagement' were examined. RESULTS: Our response rate (75.1%) yielded data for 187 research projects. For just over one-quarter (26.7%), 'research value' was rated 'very important' in terms of knowledge generation. The most common 'research utility' was 'continuing education' (27.3%) followed by 'policy formulation' (25.7%). While 66 (35.3%) projects engaged at least one potential research user group throughout 'full engagement', such an intertwined relationship between researchers and research users was not associated with research value (chi(2)=0.46, 1df, p=0.5) or research utility (chi(2)=2.19, 1df, p=0.14). There were no predictors of 'full engagement'. In just over a third of projects (34.8%), both part of the awarded grant and additional funding had been spent to promote research use. CONCLUSIONS AND IMPLICATIONS: This snapshot demonstrates patchy research engagement between researchers and research users. Other academic groups were the most common partner for full engagement. In an evidence-based era, innovation in health research funding policy should be evaluated. As NHMRC embarks upon its 'Partnerships initiative' in 2009, we recommend a prospective approach to evaluation.

Smoking patterns and readiness to quit--a study of the Australian Arabic community.

BACKGROUND: Smoking cessation interventions have typically focused on majority populations who, in Australia, are English speaking. There has been an overall decline in the prevalence of smoking in the Australian community. However, there remains a relative paucity of useful information about tobacco use and the effectiveness of tobacco interventions among specific ethnic minorities. OBJECTIVE: To determine associations of tobacco use and tobacco control indicators for Arabic speakers seen in the Australian general practice setting. METHODS: A cross sectional study in a consecutive sample of Arabic patients (n=1371) attending the practices of 29 Arabic speaking general practitioners in Sydney, New South Wales. RESULTS: Twenty-nine (53.7%) of 54 eligible Arabic speaking GPs in southwest Sydney participated in this study. Of 1371 patients seen, 29.7% were smokers. Smokers were more likely to report poorer health (chi2=21.7, df=1, p<0.001); 35.7% reported high nicotine dependence. Dependence was more in men (chi2=11.7, df=1, p<001) and those who reported poorer health (chi2=4.9, df=1, p<0.03); 35.9% had attempted to quit in the previous year; 17% were in preparation stage of change; 42.7% recalled quit advice. Poorer self reported health status (AOR=2.13, 95% CI: 1.14-3.97, p=0.017) and unemployment (AOR=1.69, 95% CI: 1.51-4.90, p=0.033) were independent predictors of advice from a health professional, most often a GP (71%). CONCLUSION: Our study confirms previous reports that the proportion of self reported current smokers among the Arabic community is higher than for the Anglo-European majority. There is a need for ethno specific campaigns in tobacco control.

Clinic factors associated with better delivery of secondary prophylaxis in acute rheumatic fever management.

BACKGROUND AND OBJECTIVES: Acute rheumatic fever (ARF) is a complication of infection with group A streptococcus. ARF is treated with a long-term regimen of antibiotic secondary prophylaxis. Recent data have shown that only 36% of clients receive >80% of their regimen. The aim of this study was to determine clinic-level factors independently associated with the performance of primary healthcare clinics in delivering secondary prophylaxis to patients with ARF. METHOD: Cross-sectional de-identified data from clinics agreeing to data retention through the Audit and Best Practice for Chronic Disease National Research Partnership were accessed to calculate secondary prophylaxis performance scores and clinic-level factors associated with secondary prophylaxis performance using regression analysis. RESULTS: Thirty-six clinics and 496 client records met eligibility criteria for analysis. Clinic secondary prophylaxis performance was significantly associated with 'systematic processes of follow-up'. Every one unit increase in 'systematic approach to follow-up' increased the median level of secondary prophylaxis performance by 30% (95% confidence interval: 2, 66). Clinic accreditation status, location or workforce were not associated with secondary prophylaxis performance. DISCUSSION: General practitioners as clinical leaders are well placed to support managers to critically review follow-up and electronic reminder systems for secondary prophylaxis delivery at clinic level.

Acceptability and effectiveness of opportunistic referral of smokers to telephone cessation advice from a nurse: a randomised trial in Australian general practice.

BACKGROUND: GPs often lack time to provide intensive cessation advice for patients who smoke. This study aimed to determine the effectiveness of opportunistic referral of smokers by their GP for telephone cessation counselling by a trained nurse. METHODS: Adult smokers (n = 318) attending 30 GPs in South Western Sydney, Australia were randomly allocated to usual care or referral to a telephone-based program comprising assessment and stage-based behavioural advice, written information and follow-up delivered by a nurse. Self-reported point prevalence abstinence at six and 12 months was compared between groups. Characteristics of patients who accepted and completed the intervention were investigated. RESULTS: Of 169 smokers randomised to the intervention, 76 (45%) consented to referral. Compared with smokers in 'pre-contemplation', those further along the stage-of-change continuum were significantly more likely to consent (p = 0.003). Those further along the continuum also were significantly more likely to complete all four calls of the intervention (OR 2.6, 95% CI: 0.8-8.1 and OR 8.6, 95% CI: 1.7-44.4 for 'contemplation' and 'preparation' respectively). At six months, there was no significant difference between groups in point prevalence abstinence (intention to treat) (9% versus 8%, p = 0.7). There was no evidence of differential intervention effectiveness by baseline stage-of-change (p = 0.6) or patient sex (p = 0.5). At 12 months, point prevalence abstinence in the intervention and control groups was 8% and 6% respectively (p = 0.6). CONCLUSION: Acceptance of opportunistic referral for nurse delivered telephone cessation advice was low. This trial did not demonstrate improved quit rates following the intervention. Future research efforts might better focus support for those patients who are motivated to quit. AUSTRALIAN CLINICAL TRIALS REGISTRY NUMBER: ACTRN012607000091404.

Pre-operative screening for excessive alcohol consumption among patients scheduled for elective surgery.

Pre-operative intervention for excessive alcohol consumption among patients scheduled for elective surgery has been shown to reduce complications of surgery. However, successful intervention depends upon an effective and practical screening procedure. This study examines current screening practices for excessive alcohol consumption amongst patients scheduled for elective surgery in general hospitals. It also examines the appropriateness of potential sites and staff for pre-operative screening. Forms used routinely to assess alcohol consumption in the pre-admission clinics (PAC) of eight Sydney hospitals were examined. In addition, the appropriateness of six staff categories (surgeons, surgeons' secretaries, junior medical officer, anaesthetists, nurses and a research assistant) and of two sites (surgeons' office and PAC) in conducting additional screening was assessed at two hospitals. Outcomes included observed advantages and disadvantages of sites and personnel, and number of cases with excessive drinking identified. There was duplication in information collected routinely on alcohol use in the PACs in eight Sydney Hospitals. Questions on alcohol consumption in patient self-completion forms were not validated. The PAC provided for efficient screening but time to surgery was typically too short for successful intervention in many cases. A validated tool and efficient screening procedure is required to detect excessive drinking before elective surgery. Patients often present to the PAC too close to the time of surgery for any change in drinking to reverse alcohol's effects. The role of the referring general practitioner and of printed advice from the surgeon in preparing patients for surgery needs further investigation.