Implementing 'Closing the Gap' policy through mainstream service provision: A South Australian case study.

ISSUE ADDRESSED: The Australian government's 'Closing the Gap' (CTG) strategy has been implemented via multiple strategies. We examined CTG policy in early childhood within Southern Adelaide during the first decade of implementation (2008-2018) and critiqued the complexity and challenges of policy that is designed to promote health and well-being of Aboriginal and Torres Strait Islander children but lacked Aboriginal control. METHODS: A qualitative case study was conducted in Southern Adelaide, and we interviewed 16 policy actors from health and early childhood education sectors. Thematic analysis revealed key themes to show how policy had been implemented through mainstream structures. RESULTS: The rapid roll out of the CTG strategy, the limitations of short-term funding, cuts to Aboriginal health services, tokenistic consultation, and the mainstreaming of service provision were key features of policy implementation. The influence of Aboriginal leaders varied across implementation contexts. Participants advocated for services in health and education that are culturally safe to improve health of children, families, and communities. CONCLUSIONS: The implementation of the CTG strategy in Southern Adelaide was rushed, complex, and lacking Aboriginal control. This contributed to the marginalisation of Aboriginal leaders, and disengagement of families and communities. A more collaborative and Aboriginal led process for policy implementation is essential to reform policy implementation and address health inequity. SO WHAT?: Findings from this study suggest that policy has continued to be implemented I ways that reflect colonial power imbalances. Alternative processes that promote the recognition of Indigenous rights must be considered if we are to achieve the targets set within the CTG strategy.

Experiences and impacts of out-of-pocket healthcare expenditure on remote Aboriginal families.

INTRODUCTION: Aboriginal Australians face significant health disparities, with hospitalisation rates 2.3 times greater, and longer hospital length of stay, than non-Indigenous Australians. This additional burden impacts families further through out-of-pocket healthcare expenditure (OOPHE), which includes additional healthcare expenses not covered by universal taxpayer insurance. Aboriginal patients traveling from remote locations are likely to be impacted further by OOPHE. The objective of this study was to examine the impacts and burden of OOPHE for rurally based Aboriginal individuals. METHODS: Participants were recruited through South Australian community networks to participate in this study. Decolonising methods of yarning and deep listening were used to centralise local narratives and language of OOPHE. Qualitative analysis software was used to thematically code transcripts and organise data. RESULTS: A total of seven yarning sessions were conducted with 10 participants. Seven themes were identified: travel, barriers to health care, personal and social loss, restricted autonomy, financial strain, support initiatives and protective factors. Sleeping rough, selling assets and not attending appointments were used to mitigate or avoid OOPHE. Government initiatives, such as the patient assistance transport scheme, did little to decrease OOPHE burden on participants. Family connections, Indigenous knowledges and engagement with cultural practices were protective against OOPHE burden. CONCLUSION: Aboriginal families are significantly burdened by OOPHE when needing to travel for health care. Radical change of government initiative and policies through to health professional awareness is needed to ensure equitable healthcare access that does not create additional financial hardship in communities already experiencing economic disadvantage.

"Listen with your ears and eyes and heart and your minds and your soul": Implications for decolonising consultation and occupational therapy from case studies on "Closing the Gap" policy implementation.

BACKGROUND: Including Aboriginal and Torres Strait Islander people and communities through consultation has been a key feature of policy implementation throughout the Australian Government's "Closing the Gap" (CTG) strategy. However, consultation often reinforces power imbalances between government and local community and can undervalue or marginalise Indigenous knowledge and leadership. Occupational therapy has a short history of examining colonial power structures within the profession, but there has been limited progress to decolonise consultation and practice. METHODS: Drawing on decolonising research methodology and positioned at the interface of knowledge, comparative case studies were used to understand policy implementation in two regions. In Shepparton, Victoria, CTG policy was implemented predominately through an Aboriginal Community Controlled Health Organisation, and in Southern Adelaide, South Australia, CTG policy was implemented through mainstream state government and non-government providers in the absence of a local Aboriginal-controlled organisation. Findings were examined critically to identify implications for occupational therapy. RESULTS: Our case studies showed that policy stakeholders perceived consultation to be tokenistic and partnerships were viewed differently by Aboriginal and non-Indigenous participants. Participants identified the need to move beyond a rhetoric of "working with" Aboriginal and Torres Strait Islander people, to promote Aboriginal leadership and really listen to community so that policy can respond to local need. The findings of this research show that Aboriginal-controlled services are best positioned to conduct and respond to community consultation. CONCLUSION: A decolonising approach to consultation would shift the status quo in policy implementation in ways that realign power away from colonial structures towards collaboration with Indigenous leadership and the promotion of Aboriginal-controlled services. There are lessons for occupational therapy from this research on policy implementation on authentic, decolonised consultation as a key feature of policy implementation. Shifting power imbalances through prioritising Indigenous leadership and honouring what is shared can drive change in CTG policy implementation processes and outcomes.

A realist evaluation of a community of practice for dietitians and nutritionists working in Aboriginal and Torres Strait Islander health.

BACKGROUND: Communities of practice have been proposed as a workforce development strategy for developing dietitians, yet little is known about how they work and for whom, as well as under what circumstances. We aimed to understand the mechanisms by which dietitians working in Aboriginal and Torres Strait Islander health benefit from communities of practice. METHODS: A realist evaluation of 29 interviews with non-Indigenous dietitians and nutritionists was employed, which was conducted over the course of two communities of practice (2013 and 2014) and follow-up interviews in 2019. Programme theory was developed from analysis of initial interviews and used to recode all interviews and test theory. The identification of patterns refined the programme theory. RESULTS: Six refined theories were identified: (1) a community of practice fosters the relationships that support navigation of the many tasks required to become more responsive health professionals; (2) committed and open participants feel supported and guided to be reflexive; (3) sharing, reflexivity, feedback and support shift awareness to one's own practice to be able to manoeuvre in intercultural spaces; (4) through sharing, feedback, support and collaboration, participants feel assured and affirmed; (5) connection through feelings of understanding and being understood contributes to commitment to remain working in the area; and (6) through sharing, feedback, support and collaboration, participants with varied experience and roles see the value of and gain confidence in new perspectives, skills and practices. CONCLUSIONS: Further research is required to test this model on a much larger scale, with communities of practice inclusive of Aboriginal and non-Aboriginal health professionals together, and across a diverse group of dietitians.

Patient journey mapping to investigate quality and cultural safety in burn care for Aboriginal and Torres Strait Islander children and families - development, application and implications.

BACKGROUND: Quality and safety in Australian healthcare is inequitably distributed, highlighted by gaps in the provision of quality care for Aboriginal and Torres Strait Islander children. Burns have potential for long-term adverse outcomes, and quality care, including culturally safe care, is critical to recovery. This study aimed to develop and apply an Aboriginal Patient Journey Mapping (APJM) tool to investigate the quality of healthcare systems for burn care with Aboriginal and Torres Strait Islander children. STUDY DESIGN: Interface research methodology, using biomedical and cultural evidence, informed the modification of an existing APJM tool. The tool was then applied to the journey of one family accessing a paediatric tertiary burn care site. Data were collected through yarning with the family, case note review and clinician interviews. Data were analysed using Emden's core story and thematic analysis methods. Reflexivity informed consideration of the implications of the APJM tool, including its effectiveness and efficiency in eliciting information about quality and cultural safety. RESULTS: Through application of a modified APJM tool, gaps in quality care for Aboriginal and Torres Strait Islander children and families were identified at the individual, service and system levels. Engagement in innovative methodology incorporating more than biomedical standards of care, uncovered critical information about the experiences of culturally safe care in complex patient journeys. CONCLUSION: Based on our application of the tool, APJM can identify and evaluate specific aspects of culturally safe care as experienced by Aboriginal and Torres Strait Islander peoples and be used for quality improvement.

Evaluation of the ECOHIS and the CARIES-QC among an Australian "Aboriginal" population.

PURPOSE: An evaluation of the reliability and validity of two child oral health-related quality of life (COHRQoL) measures among Australian Aboriginal children who participated in a randomised trial was undertaken. METHODS: Study participants completed the Early Childhood Oral Health Impact Scale (ECOHIS) and the Caries Impacts and Experiences Questionnaire for Children (CARIES-QC). The questionnaires were completed a second time to test the scales' test-retest reliability. Internal consistency, convergent and discriminant validity were evaluated through Cronbach's alpha, correlation of the scale scores with the global oral health evaluation, and comparison of scale scores among children with varying levels of caries experience, respectively. RESULTS: Worse COHRQoL was reported by parents who rated their child's oral health as poor and by children who rated their teeth as being a lot of problem. Cronbach's alpha for the child impact section (CIS), family impact section (FIS), total ECOHIS score and the total CARIES-QC scale were 0.88, 0.81, 0.91 and 0.84, respectively. Spearman's correlations between scale scores and global oral health ratings of the CIS, FIS, total ECOHIS and the CARIES-QC were 0.42, 0.34, 0.45 and 0.70, respectively, p < 0.001. The Kruskal-Wallis test of scale scores with grouped caries experience was statistically significant, p < 0.005. Test-retest reliabilities for the ECOHIS were CIS ICC = 0.91, FIS ICC = 0.89, total ECOHIS ICC = 0.93 and for the CARIES-QC, ICC = 0.61. CONCLUSIONS: Both the ECOHIS and the CARIES-QC were reliable and valid scales for use among an Australian Aboriginal population for assessing COHRQoL of preschool children. TRIAL REGISTRATION: ACTRN12616001537448, date of registration-08 November 2016.

Understanding implementation factors and participant experiences of a cluster randomised controlled trial to prevent falls among older Aboriginal people: a process evaluation protocol.

INTRODUCTION: Process evaluations examining programme implementation are often conducted in conjunction with effectiveness studies. Their inclusion in studies with Aboriginal participants can give an understanding of programme delivery in Aboriginal community contexts. The Ironbark: Standing Strong and Tall programme was codesigned with Aboriginal communities and includes exercise and facilitated 'yarning' discussion about fall risk and prevention strategies. The programme pilot showed favourable outcomes and acceptability for Aboriginal people aged 45 years and over. The Ironbark: Standing Strong and Tall programme is now being compared with a 'Healthy Community' programme in a cluster randomised controlled trial within Aboriginal health and community services. An embedded process evaluation aims to explore relationships between participation and programme outcomes and the quality of programme implementation. METHODS AND ANALYSIS: The process evaluation will use a mixed methods design, guided by Indigenous research methodology. It will evaluate quantitative data (number of completed sessions, site coaching checklist tool, participant and facilitator questionnaire data and a participant habit formation scale), as well as qualitative data (open-ended responses from project and site staff and semistructured interviews using yarning with study participants and site managers). A programme logic model was developed to explain the intended inputs, activities, outputs and outcomes, which guided this process evaluation design. CONCLUSION: This process evaluation of a fall prevention programme for older Aboriginal people using a mixed methods design and data triangulation will allow for a comprehensive understanding of study findings. Multiple study sites allow for generalisability of findings and exploration of variation across sites. TRIAL REGISTRATION NUMBER: ACTRN12619000349145.

Theories of Indigenous and non-Indigenous wellbeing in Australian health policies.

Governments in Australia and internationally show growing interest in wellbeing as a policy goal; however, such interests raise questions about the theories or definitions of wellbeing they will apply. Choices about how wellbeing is defined for policy purposes are likely to delimit the strategies applied. Wholly individualized conceptualizations of wellbeing may lead to policy focused narrowly on 'improving' individuals rather than on creating favourable social conditions. Also, Indigenous theories of wellbeing may have much to offer policy for public wellbeing, but little research has examined whether this potential is considered in contemporary health policy. We report on research examining Indigenous and non-Indigenous theories of wellbeing in a representative sample of current Australian health policy documents. We examine what theories or definitions of wellbeing are present, whether policies recognize social determinants of health; if 'lifestyle drift' is present; how Indigenous and non-Indigenous theories of wellbeing are positioned; and whether policies propose strategies consistent with their definitions of wellbeing. We discuss implications of current approaches for effective policy to promote Indigenous and non-Indigenous wellbeing.

Responses to the primary health care needs of Aboriginal and Torres Strait Islander women experiencing violence: A scoping review of policy and practice guidelines.

ISSUE ADDRESSED: It is demonstrated that primary health care (PHC) providers are sought out by women who experience violence. Given the disproportionate burden of violence experienced by Aboriginal and Torres Strait Islander women, it is essential there is equitable access to appropriate PHC services. This review aimed to analyse whether Australian PHC policy accounts for the complex needs of Aboriginal and Torres Strait Islander women experiencing violence and the importance of PHC providers responding to violence in culturally safe ways. METHODS: Using the Arskey and O'Malley framework, an iterative scoping review determined the policies for analysis. The selected policies were analysed against concepts identified as key components in responding to the needs of Aboriginal and Torres Strait Islander women experiencing violence. The key components are Family Violence, Violence against Aboriginal and Torres Strait Islander Women, Social Determinants of Aboriginal and Torres Strait Islander Health and Wellbeing, Cultural Safety, Holistic Health, Trauma, Patient-Centred Care and Trauma-and-Violence-Informed Care. RESULTS: Following a search of Australian government websites, seven policies were selected for analysis. Principally, no policy embedded or described best practice across all key components. CONCLUSION: The review demonstrates the need for a specific National framework supporting Aboriginal and Torres Strait Islander women who seek support from PHC services, as well as further policy analysis and review. SO WHAT?: Aboriginal and Torres Strait Islander women disproportionately experience more severe violence, with complex impact, than other Australian women. PHC policy and practice frameworks must account for this, together with the intersection of contemporary manifestations of colonialism and historical and intergenerational trauma.

Assessing cultural safety in Aboriginal and Torres Strait Islander Health.

OBJECTIVE: The aim of this study was to explore how nurses and midwives (trained at Flinders University in Adelaide) from rural, remote and urban locations view the impact of cultural safety training on their practice and the extent to which they incorporated cultural safety principles into their practice. DESIGN: qualitative research study. SETTING: rural, remote and urban locations across Australia. PARTICIPANTS: Nurses and midwives who had undertaken cultural safety training at Flinders University as part of their undergraduate degree. METHODS: Participants were recruited for semi-structured interviews. Interviews were recorded and transcribed verbatim. Transcripts were coded independently by members of the research team. MAIN OUTCOME MEASURES: The use of cultural safety principles in participants' practice, and the extent to which they were applied, was determined. Barriers and enablers to enacting cultural safety in the workplace were also identified. RESULTS: 10 individuals participated in an interview (7 nurses and 3 midwives). The Modified Monash Model was used to classify participant location with the following observed: MM1, six; MM2, two; MM5, one; MM6, one. 3 participants were from the Northern Territory and 7 from South Australia. Participants were at varying stages in their journey of cultural safety, ranging from early stages to those able to embody the Cultural Safety Principles and negotiate barriers to provide culturally safe care. Educational strategies for participants to progress their cultural safety journey were also identified. CONCLUSION: The extent to which cultural safety principles are applied in practice is diverse amongst the nurses and midwives that participated in this study, demonstrating that cultural safety is a journey and ongoing support is needed.

Parent perceptions of minimally invasive dental treatment of Australian Aboriginal pre-school children in rural and remote communities.

INTRODUCTION: Aboriginal* children in rural and remote communities in Australia have a higher burden of dental decay and poorer access to dental services than their non-Aboriginal counterparts. In the Kimberley region of Western Australia (WA), Aboriginal children experience six times the rate of untreated dental decay of non-Aboriginal children. Access to dental care is challenged by the availability and appropriate delivery of services in remote locations. This study elicited the experiences and perceptions of parents and carers who participated in a project that tested the minimally invasive atraumatic restorative treatment and the Hall technique approaches (ART-HT) to manage early childhood dental caries among Australian Aboriginal preschool children. METHODS: The core study design was a stepped-wedge, cluster-community-randomised controlled trial. Consenting communities in the Kimberley region of WA were randomised into early and delayed intervention groups. Children were clinically examined at study commencement; the early intervention group was offered dental treatment using the ART-HT approach, and the delayed group was advised to seek dental care from their usual service provider. At the 12-month follow-up, children in both groups were re-examined and offered care using the minimally invasive model of care, and parents and carers were invited to take part in focus group or one-to-one interviews. Semistructured interviews, guided by the yarning approach, were conducted with consenting parents and carers in community locations of convenience to participants. The same open-ended questions were asked of all participants, and the interviews were audio-recorded with permission and transcribed by an independent agency. Thematic analysis was undertaken, the transcripts were coded by NVivo software, and emergent themes were identified and developed. RESULTS: One-to-one interviews were conducted with 29 parents and carers (10 from five test communities; 19 from eight control communities). Interview participants consisted of 3 males and 26 females. Following thematic analysis, three main themes (and subthemes) were identified: (1) access to care (barriers, service availability, impact on family due to lack of access); (2) experience of care (cultural safety, child-centred care, comprehensiveness of care); (3) community engagement (service information, engagement, oral health education). Structural and system factors as well as geography were identified as barriers by parents and carers in accessing timely and affordable dental care in culturally safe environments; parents and carers also identified the impacts from lack of access to care. They valued comprehensive care delivered within community, underpinned by child- and family-centred care. Of equal importance was the holistic approach adopted through the building of community engagement and trusting relationships. CONCLUSION: A high level of satisfaction was reported by parents and carers with their experience of dental care for their children with the minimally invasive approach. Satisfaction was expressed around ease of accessing services delivered in a child- and family-centred manner, and that were well supported by appropriate engagement between service providers, communities and families. The findings from this study suggest a minimally invasive dental care model can be considered effective and culturally acceptable and should be considered in delivering oral health services for young children in rural and remote locations. * The term Aboriginal is inclusive of Aboriginal and Torres Strait Islander peoples.

Healthy ageing among older Aboriginal people: the Ironbark study protocol for a cluster randomised controlled trial.

INTRODUCTION: Older Aboriginal people have a strong leadership role in their community including passing on knowledge and teachings around culture and connections to Country. Falls significantly affect older people and are a growing concern for older Aboriginal people and their families. Regular participation in balance and strength exercise has been shown to be efficacious in reducing falls. A pilot study developed in partnership with Aboriginal communities, the Ironbark: Standing Strong and Tall programme, demonstrated high community acceptability and feasibility, and gains in balance and strength in Aboriginal participants. This cluster randomised controlled trial will assess the effectiveness of the programme in reducing the rate of falls in older Aboriginal people. METHODS: We will examine the effectiveness and cost-effectiveness of the Ironbark group-based fall prevention programme compared with a group-based social programme, with Aboriginal people aged 45 years and older in three Australian states. The primary outcome is fall rates over 12 months, measured using weekly self-reported data. Secondary outcomes measured at baseline and after 12 months include quality of life, psychological distress, activities of daily living, physical activity, functional mobility and central obesity. Differences between study groups in the primary and secondary outcomes at 12 months will be estimated. CONCLUSION: This is the first trial to investigate the effectiveness and cost-effectiveness of a fall prevention programme for Aboriginal peoples aged ≥45 years. The study has strong cultural and community governance, including Aboriginal investigators and staff, and is guided by a steering committee that includes representatives of Aboriginal community-controlled services. TRIAL REGISTRATION NUMBER: ACTRN12619000349145.

The journey of aftercare for Australia's First Nations families whose child had sustained a burn injury: a qualitative study.

BACKGROUND: Access to ongoing multidisciplinary healthcare services for children who have sustained a burn injury is critical for optimal recovery. This paper reports on barriers and facilitators to culturally safe and appropriate burn aftercare for Australia's First Nations children. The voices of First Nations families whose child had sustained a serious burn are central to this paper. METHODS: Eighteen families, which consisted of 59 family members, of children younger than 16 years who had sustained a burn injury were asked to describe their own journey in accessing appropriate burn aftercare. Interviews were conducted in the families' homes using yarning (dialogue) and Dadirri (deep listening) as Indigenous research methods. Data was gathered in South Australia, the Northern Territory, Queensland and New South Wales, Australia. Using a cyclic process, transcripts and emerging themes were sent back to participants, and a collaborative approach was used to conduct the final analysis. RESULTS: Lack of culturally safe communication between service providers and family members, in addition to institutionalised racism, were found to be the major barriers to accessing healthcare services. Distance to medical treatment also impacted children's access to aftercare. Involvement of First Nations Health Workers and/or Liaison Officers working with health providers, the child and family members, was found to be an important facilitator in reducing miscommunication and alleviating fear and anxiety in the children and families. CONCLUSION: There are significant barriers to access to aftercare following a serious burn including miscommunication, lack of cultural safety, distance to medical treatment and racism. However, these can be largely mitigated when First Nations families have input into the care received and the care needed for ongoing burn care to be effective and are supported by First Nations Health/Liaison Officers support.

A framework to assess cultural safety in Australian public policy.

The concept of cultural safety (CS) has been developed as a critical perspective on healthcare provided to Indigenous service users in neo-colonial countries such as New Zealand, Australia and Canada. Unlike other frameworks for culturally competent healthcare, a CS approach recognizes impacts of colonization and power inequalities on Indigenous peoples and asks how these may manifest in healthcare settings. It has been argued that CS thinking is suited to critical analysis of public policy, but there has been limited work in this direction. Drawing on literature on CS in Australian healthcare, we defined a CS framework consisting of five concepts: reflexivity, dialogue, reducing power differences, decolonization and regardful care. Our research examined whether and in what terms this framework could be adapted as a tool for critical analysis of Australian public policy as it affects Aboriginal and Torres Strait Islander peoples. We used a collaborative inquiry process combining perspectives of an Aboriginal researcher and a non-Indigenous researcher. We developed a thematic analysis framework to examine how the five concepts might be reflected in contemporary writings on policy by leading Aboriginal or Torres Strait Islander thinkers. We found the framework is applicable as a tool for policy analysis; bringing together key concerns raised by Aboriginal and Torres Strait Islander leaders and critical concepts such as sovereignty and interface thinking. We concluded the framework is likely to be a useful tool for critical, systemic thinking about public policy as it affects Indigenous peoples and for specifying areas where performance can be improved to achieve culturally safe policy.

How institutional forces, ideas and actors shaped population health planning in Australian regional primary health care organisations.

BACKGROUND: Worldwide, there are competing norms driving health system changes and reorganisation. One such norm is that of health systems' responsibilities for population health as distinct from a focus on clinical services. In this paper we report on a case study of population health planning in Australian primary health care (PHC) organisations (Medicare Locals, 2011-2015). Drawing on institutional theory, we describe how institutional forces, ideas and actors shaped such planning. METHODS: We reviewed the planning documents of the 61 Medicare Locals and rated population health activities in each Medicare Local. We also conducted an online survey and 50 interviews with Medicare Local senior staff, and an interview and focus group with Federal Department of Health staff. RESULTS: Despite policy emphasis on population health, Medicare Locals reported higher levels of effort and capacity in providing clinical services. Health promotion and social determinants of health activities were undertaken on an ad hoc basis. Regulatory conditions imposed by the federal government including funding priorities and time schedules, were the predominant forces constraining population health planning. In some Medicare Locals, this was in conflict with the normative values and what Medicare Locals felt ought to be done. The alignment between the governmental and the cultural-cognitive forces of a narrow biomedical approach privileged clinical practice and ascribed less legitimacy to action on social determinants of health. Our study also shed light on the range of PHC actors and how their agency influenced Medicare Locals' performance in population health. The presence of senior staff or community boards with a strong commitment to population health were important in directing action towards population health and equity. CONCLUSIONS: There are numerous institutional, normative and cultural factors influencing population health planning. The experience of Australian Medicare Locals highlights the difficulties of planning in such a way that the impact of the social determinants on health and health equity are taken into account. The policy environment favours a focus on clinical services to the detriment of health promotion informed by a social determinants focus.

Factors that impact access to ongoing health care for First Nation children with a chronic condition.

BACKGROUND: Access to multidisciplinary health care services for First Nation children with a chronic condition is critical for the child's health and well-being, but disparities and inequality in health care systems have been almost impossible to eradicate for First Nation people globally. The objective of this review is to identify the factors that impact access and ongoing care for First Nation children globally with a chronic condition. METHODS: An extensive systematic search was conducted of nine electronic databases to identify primary studies that explored factors affecting access to ongoing services for First Nation children with a chronic disease or injury. Due to the heterogeneity of included studies the Mixed Method Appraisal Tool (MMAT) was used to assess study quality. RESULTS: A total of six studies from Australia, New Zealand and Canada were identified and included in this review. Four studies applied qualitative approaches using in-depth semi structured interviews, focus groups and community fora. Two of the six studies used quantitative approaches. Facilitators included the utilisation of First Nation liaison workers or First Nation Health workers. Key barriers that emerged included lack of culturally appropriate health care, distance, language and cultural barriers, racism, the lack of incorporation of First Nation workers in services, financial difficulties and transport issues. CONCLUSION: There are few studies that have identified positive factors that facilitate access to health care for First Nation children. There is an urgent need to develop programs and processes to facilitate access to appropriate health care that are inclusive of the cultural needs of First Nation children.

The Ironbark program: Implementation and impact of a community-based fall prevention pilot program for older Aboriginal and Torres Strait Islander people.

AIM: To document the implementation and investigate within-group impact of The Ironbark Program: a community-based, Aboriginal-specific fall prevention program, in New South Wales, Australia. METHODS: The Ironbark Program was trialled in six Aboriginal communities over a three- to six-month period. A mixed methods approach was used for program evaluation: strength, balance and gait were assessed to measure participant physical function and BMI was monitored. Semi-structured participant interviews investigated program suitability, relevance and impact. RESULTS: Ninety-eight Aboriginal people aged 40+ years registered for the pilot program, 77 (79%) of whom were present at all assessment time points. There were significant improvements in participant leg strength (average time to complete five repetition sit-to-stand: 14 seconds to 11 seconds), balance (timed single-leg stance: 5.6 seconds to 7.8 seconds), gait (timed 4 m walk: 0.51 m/s to 0.94 m/s) and a significant decrease in BMI (32.0 to 31.6) was observed. Participants reported enjoying the program and stated they would recommend it to others. CONCLUSION: The evaluation of the Ironbark Program demonstrated acceptability, and showed significant improvements in physical function. If proven to be effective in a definitive trial, this program could be used widely to prevent falls in older Aboriginal people. IMPLICATIONS: Key features of the Ironbark Program were local Aboriginal management, culturally relevant resources, ongoing availability and enabling program use for people aged less than 65 years. These features should be retained on the program's upscale, and may be incorporated into other healthy ageing programs developed for the Aboriginal population.

'Yarning up with Koori kids' - hearing the voices of Australian urban Indigenous children about their health and well-being.

OBJECTIVE: Australian Indigenous children experience some of the most substantial health inequalities globally. In this context, research regarding their health and well-being has overemphasised physical illnesses with limited exploration of a diverse range of dimensions and determinants, particularly those based on Indigenous holistic understandings of health and well-being. This deficit-based approach has thus missed many strengths and assets of Indigenous children. This research aimed to gain insight into the perspectives of Indigenous children about their health and well-being in an urban setting in Australia. It joins a limited international literature examining views and experiences of non-majority children. DESIGN: Participatory and qualitative child-friendly research methods were utilised. The project was developed in partnership with Indigenous community organisations and members. Photo-elicitation activities and focus groups were conducted with 31 Indigenous children aged 8-12 years. Qualitative data were analysed thematically, combining focus group and interview data. RESULTS: It was evident an urban Indigenous child perspective of health and well-being includes rich understandings of the interconnectedness of physical, social-emotional and cultural dimensions of holism, as well as the integral importance of family and community relationships. The study also found that specific worries regarding loss of loved ones and racism were highly salient in Indigenous children's lives. CONCLUSION: The overwhelming conclusion to be drawn from this research is that Indigenous children in urban areas need ongoing recognition of both their agency and resilience in the face of adversity, within a wider context of historical and contemporary racialisation and racism.

Coproducing Aboriginal patient journey mapping tools for improved quality and coordination of care.

This paper describes the rationale and process for developing a set of Aboriginal patient journey mapping tools with Aboriginal patients, health professionals, support workers, educators and researchers in the Managing Two Worlds Together project between 2008 and 2015. Aboriginal patients and their families from rural and remote areas, and healthcare providers in urban, rural and remote settings, shared their perceptions of the barriers and enablers to quality care in interviews and focus groups, and individual patient journey case studies were documented. Data were thematically analysed. In the absence of suitable existing tools, a new analytical framework and mapping approach was developed. The utility of the tools in other settings was then tested with health professionals, and the tools were further modified for use in quality improvement in health and education settings in South Australia and the Northern Territory. A central set of patient journey mapping tools with flexible adaptations, a workbook, and five sets of case studies describing how staff adapted and used the tools at different sites are available for wider use.

Use of telehealth for health care of Indigenous peoples with chronic conditions: a systematic review.

INTRODUCTION: Telehealth may be a cost effective modality in healthcare delivery, but how well used or how appropriate it is for the care of Indigenous peoples is unclear. This review examines the evidence for telehealth in facilitating chronic conditions management with Indigenous peoples. METHODS: Databases were systematically searched for qualitative or quantitative primary research studies that investigated telehealth use for chronic conditions management with Indigenous peoples worldwide. Evidence of effectiveness was by consumer health outcomes, evidence of acceptability was through consumer and user perception, and health service feasibility was evident by service impact. Data were assessed for quality and data extracted using pre-defined tools. RESULTS: Articles (n=32) examined effectiveness (n=11), critiqued telehealth from the perspectives of the client (n=10) and healthcare professionals (n=8), and examined feasibility (n=12). Studies reported Indigenous people tend to be satisfied with telehealth, but are sceptical about its cultural safety. Evidence for the effectiveness of telehealth from a western biomedical perspective was found. CONCLUSIONS: Telehealth is promising; however, a lack of robust studies in this review make tangible conclusions difficult. A better overall understanding of telehealth use with Indigenous peoples, including delivery of culturally competent health care, true consultation and cultural competency of the professionals involved, would be helpful. Telehealth may have the potential to improve health care for Indigenous people, however the modality needs to be culturally competent and the care received must be culturally safe.