"It's hard for me to tell my story" the experiences of Aboriginal and Torres Strait Islander male clients at a residential drug and alcohol rehabilitation centre using primary health care.

ISSUE ADDRESSED: Aboriginal males who use drug and alcohol may experience unique barriers accessing primary health care. This study explores the perceptions of Aboriginal males in treatment for drug and alcohol use around their experiences accessing primary health care, and barriers to access. METHODS: Twenty male Aboriginal clients at a fee-paying residential drug and alcohol rehabilitation centre completed semi-structured interviews about their primary health care experiences before their stay. Interpretative phenomenological analysis was used to inductively develop themes. RESULTS: About half the males had regular General Practitioners at a mainstream primary health care service or Aboriginal Medical Service. Positive experiences included having medical needs met or understanding the health information provided; and negative experiences included inefficient health service or system processes or experiencing cultural bias or racism. Barriers included limited access to appointments or to the same GP regularly, long wait times, lack of access to transport, worry or fear about their health or the visit or their complex lives taking priority. CONCLUSION: This research showed that the participants sought out health care and identified barriers to accessing care and potential improvements. SO WHAT?: Access to a regular General Practitioner, continuity of care and culturally appropriate and comprehensive communication techniques are important to facilitate access to primary health care by Aboriginal males. Efforts to enhance access may focus on inherent strengths within Aboriginal communities including focusing on relationships between clinicians and families, providing a welcoming environment and encouraging clients to bring a trusted family member to appointments.

'We're here to listen and help them as well': a qualitative study of staff and Indigenous patient perceptions about participating in social and emotional wellbeing research at primary healthcare services.

BACKGROUND: Research can inform culturally-appropriate care to strengthen social and emotional wellbeing (SEWB) among Aboriginal and Torres Strait Islander (hereafter, the term 'Indigenous Peoples' is respectfully used and refers to all Aboriginal and/or Torres Strait Islander Peoples of Australia). We acknowledge the cultural diversity of Australia's Indigenous First Peoples and they do not represent a homogenous group.) (hereafter Indigenous) Peoples. We explore the perspectives of primary healthcare staff and Indigenous patients about their willingness to and experiences participating in SEWB research. METHOD: Process evaluation using grounded theory approaches of Getting it Right: The validation study, a national validation designed Indigenous SEWB research project (N = 500). Primary healthcare staff (n = 36) and community members (n = 4) from nine of ten primary healthcare services involved with the research project completed qualitative semi-structured interviews. Interview data were triangulated with participant feedback (responses to structured questions and free-text feedback collected during Getting it Right), study administrative data (participant screening logs, communication logs, study protocol, deviation logs and ethics correspondence) and interviewer field notes. RESULTS: Three themes about staff, patient and community perspectives concerning research participation developed: (1) considering the needs, risk, preferences and impact of participation in research for staff, patients and community; (2) building staff confidence speaking to patients about research and SEWB problems and (3) patients speaking openly about their SEWB. Some staff described pressure to ensure patients had a positive experience with the research, to respond appropriately if patients became upset or SEWB problems were identified during interviews, or due to their dual role as community member and researcher. Patients and staff reported that patients were more likely to participate if they knew the staff outside of the service, especially staff with a shared cultural background, and they perceived SEWB as a community priority. Staff reported their skills speaking to patients about the research and SEWB improved during the research, which built their confidence. Contrary to staff preconceptions, staff and patients reported that many patients appreciated the opportunity to speak about their SEWB and contributing to research that may eventually enhance SEWB in their community. CONCLUSION: Our research project was considered acceptable by most staff and patients. The positive outcomes reported by staff and feedback from patients highlights the importance of providing opportunities for people to speak about their SEWB and for research-informed SEWB PHC care. TRIAL REGISTRATION: Getting it Right is registered on ANZCTR12614000705684 .

Process evaluation of the Getting it Right study and acceptability and feasibility of screening for depression with the aPHQ-9.

BACKGROUND: The Getting it Right study determined the validity, sensitivity, specificity and acceptability of the culturally adapted 9-item Patient Health Questionnaire (aPHQ-9) as a screening tool for depression in Aboriginal and Torres Strait Islander (hereafter referred to as Indigenous) people. In this process evaluation we aimed to explore staff perceptions about whether Getting it Right was conducted per protocol, and if the aPHQ-9 was considered an acceptable and feasible screening tool for depression in primary healthcare. This process evaluation will provide information for clinicians and policy makers about the experiences of staff and patients with Getting it Right and what they thought about using the aPHQ-9. METHODS: Process evaluation using grounded theory approaches. Semi-structured interviews with primary healthcare staff from services participating in Getting it Right were triangulated with feedback (free-text and elicited) from participants collected during the validation study and field notes. Data were thematically analysed according to the Getting it Right study protocol to identify the acceptability and feasibility of the aPHQ-9. RESULTS: Primary healthcare staff (n = 36) and community members (n = 4) from nine of the ten participating Getting it Right services and Indigenous participants (n = 500) from the ten services that took part. Most staff reported that the research was conducted according to the study protocol. Staff from two services reported sometimes recruiting opportunistically (rather than recruiting consecutive patients attending the service as outlined in the main study protocol), when they spoke to patients who they knew from previous interactions, because they perceived their previous relationship may increase the likelihood of patients participating. All Getting it Right participants responded to at least six of the seven feedback questions and 20% provided free-text feedback. Most staff said they would use the aPHQ-9 and most participants said that the questions were easy to understand (87%), the response categories made sense (89%) and that they felt comfortable answering the questions (91%). CONCLUSION: Getting it Right was predominantly conducted according to the study protocol. The aPHQ-9, the first culturally adapted, nationally validated, freely available depression screening tool for use by Indigenous people, appears to be acceptable and feasible to use. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry ANZCTR12614000705684 , 03/07/2014.

"I tried to get help about my addiction but he just gave me tablets:" male Aboriginal drug and alcohol rehabilitation clients' experiences and preferences speaking about substance use in primary care.

BACKGROUND: Primary healthcare (PHC) services are crucial in supporting people who use substances. The aims of this study were to explore the experiences of Aboriginal males in NSW in treatment for substance use about speaking about their substance use with PHC staff, and their preferences for accessing PHC about their substance use. METHODS: Semi-structured interviews with residential drug and alcohol rehabilitation treatment service clients. Thematic analysis was used to develop themes inductively and deductively. Two interviews were independently double coded by an Aboriginal researcher and the project was supported by an Aboriginal Advisory Group. RESULTS: Twenty male adults who self-identified as Aboriginal participated (mean age 27 years). Half reported visiting PHC and talking about their substance use before their residential service stay. Two major themes developed: (1) speaking up about substance use or mental health problems linked with substance use, (2) ways to improve access to PHC about substance use. Although some males were offered treatment, some were not, and others had concerns about the treatments offered. CONCLUSION: This research highlights opportunities to improve access and to better support Aboriginal males who use substances in PHC. Focus on culturally appropriate PHC and providing staff with training around substance use and treatment options may improve access. It is important to foster culturally appropriate services, develop PHC staff knowledge around substance use, focus on therapeutic relationships and have a range of treatment options available that can be tailored to individual circumstances.

What are the resourcing requirements for an Aboriginal and Torres Strait Islander primary health care research project?

OBJECTIVE AND IMPORTANCE: To explore the role of resourcing during an Aboriginal and Torres Strait Islander primary health care research project. STUDY TYPE: Process evaluation using grounded theory approaches of a national Aboriginal and Torres Strait Islander research project (N = 500) named Getting it Right: the validation study. METHODS: Qualitative semistructured interviews with 36 primary health care staff and 4 community members from 9 of 10 primary health care services involved in the research project. Interviews included questions about the resources needed to conduct the research project, including flexible reimbursement to participating services (allocated within services), human resources and reimbursement to research participants (vouchers). Qualitative data were triangulated with participant feedback, study administrative data and field notes kept by the interviewer. RESULTS: Three themes were identified: 1) the influence of reimbursement on participating services and the research project; 2) the influence of human resources on the research project at participating services; and 3) the consequences of offering vouchers to reimburse research participants. Reimbursement was allocated to research expenses (human resources and logistics) or non-research expenses (service operations, equipment and conference attendance costs). Most services opted to offer vouchers to compensate participants for their time, which staff considered was appropriate recognition of participants' contributions and facilitated recruitment. Some staff described some potential unintended negative consequences from offering vouchers, including creating a welfare mentality or creating problematic expectations. CONCLUSION: Primary health care research should have sufficient resourcing available, including human resource capacity, to achieve research targets. Research planning should include consideration of the existing commitments, priorities and human capacity needs of services and patients.

The quality of Australian Indigenous primary health care research focusing on social and emotional wellbeing: a systematic review.

Objectives and importance of the study: Primary health care research focused on Aboriginal and Torres Strait Islander (Indigenous) people is needed to ensure that key frontline services provide evidence based and culturally appropriate care. We systematically reviewed the published primary health care literature to identify research designs, processes and outcomes, and assess the scientific quality of research focused on social and emotional wellbeing. This will inform future research to improve evidence based, culturally appropriate primary health care. STUDY TYPE: Systematic review in accordance with PRISMA and MOOSE guidelines. METHODS: Four databases and one Indigenous-specific project website were searched for qualitative, quantitative and mixed-method published research. Studies that were conducted in primary health care services and focused on the social and emotional wellbeing of Indigenous people were included. Scientific quality was assessed using risk-of-bias assessment tools that were modified to meet our aims. We assessed community acceptance by identifying the involvement of community governance structures and representation during research development, conduct and reporting. Data were extracted using standard forms developed for this review. RESULTS: We included 32 articles, which reported on 25 studies. Qualitative and mixed methods were used in 18 studies. Twelve articles were judged as high or unclear risk of bias, four as moderate and five as low risk of bias. Another four studies were not able to be assessed as they did not align with the risk-of-bias tools. Of the five articles judged as low risk of bias, two also had high community acceptance and both of these were qualitative. One used a phenomenological approach and the other combined participatory action research with a social-ecological perspective and incorporated 'two-way learning' principles. Of the 16 studies where a primary outcome was identified, eight aimed to identify perceptions or experiences. The remaining studies assessed resources, or evaluated services, interventions, programs or policies. We were unable to identify primary outcomes in eight studies. CONCLUSION: Conducting Indigenous-focused primary health care research that is scientifically robust, culturally appropriate and produces community-level outcomes is challenging. We suggest that research teams use participatory, culturally sensitive approaches and collaborate closely to plan and implement high-quality research that incorporates local perspectives. Research should result in beneficial outcomes for the communities involved.

Process evaluation of a primary healthcare validation study of a culturally adapted depression screening tool for use by Aboriginal and Torres Strait Islander people: study protocol.

INTRODUCTION: Process evaluations are conducted alongside research projects to identify the context, impact and consequences of research, determine whether it was conducted per protocol and to understand how, why and for whom an intervention is effective. We present a process evaluation protocol for the Getting it Right research project, which aims to determine validity of a culturally adapted depression screening tool for use by Aboriginal and Torres Strait Islander people. In this process evaluation, we aim to: (1) explore the context, impact and consequences of conducting Getting It Right, (2) explore primary healthcare staff and community representatives' experiences with the research project, (3) determine if it was conducted per protocol and (4) explore experiences with the depression screening tool, including perceptions about how it could be implemented into practice (if found to be valid). We also describe the partnerships established to conduct this process evaluation and how the national Values and Ethics: Guidelines for Ethical Conduct in Aboriginal and Torres Strait Islander Health Research is met. METHODS AND ANALYSIS: Realist and grounded theory approaches are used. Qualitative data include semistructured interviews with primary healthcare staff and community representatives involved with Getting it Right. Iterative data collection and analysis will inform a coding framework. Interviews will continue until saturation of themes is reached, or all participants are considered. Data will be triangulated against administrative data and patient feedback. An Aboriginal and Torres Strait Islander Advisory Group guides this research. Researchers will be blinded from validation data outcomes for as long as is feasible. ETHICS AND DISSEMINATION: The University of Sydney Human Research Ethics Committee, Aboriginal Health and Medical Research Council of New South Wales and six state ethics committees have approved this research. Findings will be submitted to academic journals and presented at conferences. TRIAL REGISTRATION NUMBER: ACTRN12614000705684.