Public health interventions successfully mitigated multiple incursions of SARS-CoV-2 Delta variant in the Australian Capital Territory.

The COVID-19 pandemic has presented a unique opportunity to understand how real-time pathogen genomics can be used for large-scale outbreak investigations. On 12 August 2021, the Australian Capital Territory (ACT) detected an incursion of the SARS-CoV-2 Delta (B.1.617.2) variant. Prior to this date, SARS-CoV-2 had been eliminated locally since 7 July 2020. Several public health interventions were rapidly implemented in response to the incursion, including a territory-wide lockdown and comprehensive contact tracing. The ACT has not previously used pathogen genomics at a population level in an outbreak response; therefore, this incursion also presented an opportunity to investigate the utility of genomic sequencing to support contact tracing efforts in the ACT. Sequencing of >75% of the 1793 laboratory-confirmed cases during the 3 months following the initial notification identified at least 13 independent incursions with onwards spread in the community. Stratification of cases by genomic cluster revealed that distinct cohorts were affected by the different incursions. Two incursions resulted in most of the community transmission during the study period, with persistent transmission in vulnerable sections of the community. Ultimately, both major incursions were successfully mitigated through public health interventions, including COVID-19 vaccines. The high rates of SARS-CoV-2 sequencing in the ACT and the relatively small population size facilitated detailed investigations of the patterns of virus transmission, revealing insights beyond those gathered from traditional contact tracing alone. Genomic sequencing was critical to disentangling complex transmission chains to target interventions appropriately.

Transition to adult care for Aboriginal children with rheumatic fever: a review informed by a focussed ethnography in northern Australia.

Aboriginal children in northern Australia have high rates of rheumatic fever and rheumatic heart disease, which are chronic conditions because of the need for long-term treatment and monitoring. This article critically reviews the literature on transition to adult care for children with chronic conditions and considers applicability to the care of these children. The review was merged with findings from a focussed ethnography conducted in four remote Aboriginal communities with young people who have these conditions. Transition care aims to support adolescents on a healthcare trajectory to facilitate best long-term health and personal outcomes. Characteristics of the two medical conditions, the children and their local health services in northern Australia were generalised and merged with principles from the transition care literature, including policies governing transition clinics in urban locations. In this setting, the challenge is to transition Aboriginal children safely through to adulthood without rheumatic heart damage rather than to a separate health service on reaching adulthood. Recommended tailoring of transition care involves engaging and valuing local navigators who can address language and cultural barriers to provide a sustainable alternative to transition coordinators in mainstream programs. This has potential to improve care without further burdening overstretched clinical resources.

The epidemiology of tuberculosis in the Australia Capital Territory, 2006-2015.

AIM: To review the epidemiology of tuberculosis (TB) in the Australian Capital Territory (ACT) over a 10 year period. Methods: A retrospective analysis of the ACT TB notification data from 1 January 2006 to 31 December 2015 was conducted. RESULTS: Over the 10 year study period there were 171 TB notifications in the ACT, with an increasing trend in the number of notifications over time. The median age of cases was 36 years (range 14 to 91 years) and 53.8% of cases were male. Most TB cases (84.2%) were born overseas. Among Australian-born cases the most common risk factor for acquiring TB was close/household contact with a known case of TB (30.8%). The most common risk factor in the overseas-born population was past travel or residence in a high-risk country (86.9%). Of all the TB cases notified, 82.4% successfully completed treatment. CONCLUSION: There was an increasing trend in the number of TB notifications in the ACT over the study period. The highest rate of TB notifications remained in the overseas-born population; with other studies suggesting this is commonly due to reactivation of latent tuberculosis infection (LTBI). As Australia starts working towards TB elimination, options for the screening and management of LTBI, especially in high risk populations, need to be explored.

Influenza vaccination coverage among pregnant Indigenous women in the Northern Territory of Australia.

Pregnant Aboriginal and Torres Strait Islander women are at particular risk of severe illness and high attack rates of influenza infection. In Australia, routine seasonal influenza vaccination is currently strongly recommended for all pregnant women and women planning pregnancy, and is provided free of charge for all pregnant women. We sought to determine vaccination coverage, describe the trends and characteristics associated with influenza vaccine uptake and determine the validity of self-reported influenza vaccination in a population of Indigenous pregnant women who were participants of a vaccine trial, prior to and during the 2009 H1N1 influenza pandemic. Vaccine coverage over the study period was 16% (35/214), increasing from 2.2% (3/136) in the period preceding the pandemic (2006-2009) to 41% (32/78) in the intra-pandemic period (2009-2010). Self-report was not a reliable estimate of verified vaccination status in the pre-pandemic period (κ=0.38) but was reliable in the intra-pandemic period (κ=0.91). None of the socio-demographic characteristics that we examined were associated with vaccine uptake. Whilst the increase in maternal influenza coverage rates are encouraging and indicate a willingness of pregnant Indigenous women to be vaccinated, the majority of women remained unvaccinated. Activities to improve influenza vaccination coverage for Indigenous pregnant women and monitor vaccine uptake remain a priority. Commun Dis Intell 2016;40(3):E340-E346.

Adaptation of the Ages and Stages Questionnaire for Remote Aboriginal Australia.

A key challenge to providing quality developmental care in remote Aboriginal primary health care (PHC) centers has been the absence of culturally appropriate developmental screening instruments. This study focused on the cross-cultural adaptation of the Ages and Stages Questionnaires, 3rd edition (ASQ-3), with careful attention to language and culture. We aimed to adapt the ASQ-3 for use with remote dwelling Australian Aboriginal children, and to investigate the cultural appropriateness and feasibility of the adapted ASQ-3 for use in this context. We undertook a qualitative study in two remote Australian Aboriginal communities, using a six-step collaborative adaptation process. Aboriginal Health Workers (AHWs) were trained to use the adapted ASQ-3, and follow-up interviews examined participants' views of the cultural acceptability and usefulness of the adapted instrument. The adapted ASQ-3 was found to have high face validity and to be culturally acceptable and relevant to parents, AHWs, and early childhood development experts.

Challenges in monitoring the development of young children in remote Aboriginal health services: clinical audit findings and recommendations for improving practice.

INTRODUCTION: Early detection of developmental difficulties is universally considered a necessary public health measure, with routine developmental monitoring an important function of primary healthcare services. This study aimed to describe the developmental monitoring practice in two remote Australian Aboriginal primary healthcare services and to identify gaps in the delivery of developmental monitoring services. METHODS: A cross-sectional baseline medical record audit of all resident children aged less than 5 years in two remote Aboriginal health centres in the Northern Territory (NT) in Australia was undertaken between December 2010 and November 2011. RESULTS: A total of 151 medical records were audited, 80 in Community A and 71 in Community B. Developmental checks were more likely among children who attended services more regularly. In Community A, 63 (79%) medical records had some evidence of a developmental check and in Community B there were 42 (59%) medical records with such evidence. However, there was little indication of how assessments were undertaken: only one record noted the use of a formal developmental screening measure. In Community A, 16 (16%) records documented parent report and 20 (20%) documented staff observations, while in Community B, the numbers were 2 (3%) and 11 (19%), respectively. The overall recorded prevalence of developmental difficulties was 21% in Community A and 6% in Community B. CONCLUSIONS: This is the first study to describe the quality of developmental monitoring practice in remote Australian Aboriginal health services. The audit findings suggest the need for a systems-wide approach to the delivery and recording of developmental monitoring services. This will require routine training of remote Aboriginal health workers and remote area nurses in developmental monitoring practice including the use of a culturally appropriate, structured developmental screening measure.

Effect of a family-centered, secondhand smoke intervention to reduce respiratory illness in indigenous infants in Australia and New Zealand: a randomized controlled trial.

INTRODUCTION: Secondhand smoke (SHS) is a significant cause of acute respiratory illness (ARI) and 5 times more common in indigenous children. A single-blind randomized trial was undertaken to determine the efficacy of a family centered SHS intervention to reduce ARI in indigenous infants in Australia and New Zealand. METHODS: Indigenous mothers/infants from homes with ≥ 1 smoker were randomized to a SHS intervention involving 3 home visits in the first 3 months of the infants' lives (plus usual care) or usual care. The primary outcome was number of ARI-related visits to a health provider in the first year of life. Secondary outcomes, assessed at 4 and 12 months of age, included ARI hospitalization rates and mothers' report of infants' SHS exposure (validated by urinary cotinine/creatinine ratios [CCRs]), smoking restrictions, and smoking cessation. RESULTS: Two hundred and ninety-three mother/infant dyads were randomized and followed up. Three quarters of mothers smoked during pregnancy and two thirds were smoking at baseline (as were their partners), with no change for more than 12 months. Reported infant exposure to SHS was low (≥ 95% had smoke-free homes/cars). Infant CCRs were higher if one or both parents were smokers and if mothers breast fed their infants. There was no effect of the intervention on ARI events [471 intervention vs. 438 usual care (reference); incidence rate ratio = 1.10, 95% confidence intervals (CI) = 0.88-1.37, p = .40]. CONCLUSIONS: Despite reporting smoke-free homes/cars, mothers and their partners continue to smoke in the first year of infants' lives, exposing them to SHS. Emphasis needs to be placed on supporting parents to stop smoking preconception, during pregnancy, and postnatal.

"Only your blood can tell the story"--a qualitative research study using semi-structured interviews to explore the hepatitis B related knowledge, perceptions and experiences of remote dwelling Indigenous Australians and their health care providers in northern Australia.

BACKGROUND: Hepatitis B is endemic in the Indigenous communities of the Northern Territory of Australia and significantly contributes to liver-related morbidity and mortality. It is recognised that low health literacy levels, different worldviews and English as a second language all contribute to the difficulties health workers often have in explaining biomedical health concepts, relevant to hepatitis B infection, to patients. The aim of this research project was to explore the knowledge, perceptions and experiences of remote dwelling Indigenous adults and their health care providers relating to hepatitis B infection with a view to using this as the evidence base to develop a culturally appropriate educational tool. METHODS: The impetus for this project came from health clinic staff at a remote community in Arnhem Land in the Northern Territory, in partnership with a visiting specialist liver clinic from the Royal Darwin Hospital. Participants were clinic patients with hepatitis B (n = 12), community members (n = 9) and key informants (n = 13); 25 were Indigenous individuals.A participatory action research project design was used with purposive sampling to identify participants. Semi-structured interviews were undertaken to explore: current understanding of hepatitis B, desire for knowledge, and perspectives on how people could acquire the information needed. All individuals were offered the use of an interpreter. The data were examined using deductive and inductive thematic analysis. RESULTS: Low levels of biomedical knowledge about Hepatitis B, negative perceptions of Hepatitis B, communication (particularly language) and culture were the major themes that emerged from the data. Accurate concepts grounded in Indigenous culture such as "only your blood can tell the story" were present but accompanied by a feeling of disempowerment due to perceived lack of "medical" understanding, and informed partnerships between caregiver and patient. Culturally appropriate discussions in a patient's first language using visual aids were identified as vital to improving communication. CONCLUSIONS: Having an educational tool in Indigenous patient's first language is crucial in developing treatment partnerships for Indigenous patients with hepatitis B. Using a culturally appropriate worldview as the foundation for development should help to reduce disempowerment and improve health literacy.

Impact and perceptions of tobacco tax increase in remote Australian Aboriginal communities.

INTRODUCTION: We sought to assess the impact of a 25% tax excise rise on tobacco sales in Aboriginal communities in remote Australia and to explore local perceptions about tobacco tax rises and their impact. METHODS: Tobacco sales data were collected from 18 stores in small remote Aboriginal communities from October 2009 to December 2010. Sales in the 7 months before and after the tax increase were compared. Interviews were conducted with 54 informants in 6 communities. RESULTS: There was a nonsignificant 2.2% average reduction (95% CI = -5 to 10) in total tobacco sold in a store in the 7 months after the price increase compared with the 7 months before the price increase, with a large variation across the 18 stores. The magnitude of this apparent impact may have been reduced by seasonal effects. There were increased demands to share cigarettes, with a perception that there was increased reliance on those with more disposable income to purchase cigarettes for other smokers. The main reasons given for not quitting or reducing smoking were dependence, the normative nature of smoking, and the lack of support to quit. All Aboriginal interviewees supported price increases as important in reducing smoking. CONCLUSIONS: The wide confidence interval around our estimated reduction in consumption means that the tax increase could have either been associated or not with a reduction in consumption. Future excise rises are supported but should be carefully monitored in Australian Indigenous populations.

Reducing smoking among indigenous populations: new evidence from a review of trials.

INTRODUCTION: Previous reviews have concluded that to be effective, evidence-based tobacco control interventions should be culturally adapted to indigenous populations. We undertook a systematic review to critically examine this hitherto conclusion. METHODS: We searched MEDLINE, PsychInfo, EMBASE, and Cochrane databases from 1980 to May 2012 for controlled trials. We included studies that recruited nonindigenous and indigenous participants to assess differences in impact of nonadapted interventions across ethnic groups and whether adapted interventions are more effective for indigenous participants. RESULTS: Five studies were included. Three tested the effectiveness of enhanced Quitline protocols with cessation products over usual Quitline care, and two trialed a culturally adapted cessation counseling intervention using mobile phones. Three studies did not demonstrate a significant effect of the intervention for both indigenous and nonindigenous participants; two were pharmacotherapy studies using nicotine replacement therapy and the third was a trial of a multimedia phone intervention. The fourth study found a significant effect of a behavioral intervention using text messaging for indigenous and nonindigenous participants. The final study found a significant effect in favor of very low nicotine cigarettes compared with usual care; results were similar across ethnic groups. DISCUSSION: There is likely no significant difference between indigenous and nonindigenous populations regarding the efficacy of smoking cessation products, and we provide some promising evidence on the efficacy of behavioral interventions delivered via mobile phone technology. We demonstrate that not all tobacco control interventions can or necessarily need to be culturally adapted for indigenous populations although there are circumstances when this is important.

Incentives for preventing smoking in children and adolescents.

BACKGROUND: Adult smoking usually has its roots in adolescence. If individuals do not take up smoking during this period it is unlikely that they ever will. Further, once smoking becomes established, cessation is challenging; the probability of subsequently quitting is inversely proportional to the age of initiation. One novel approach to reducing the prevalence of youth smoking is the use of incentives. OBJECTIVES: To determine whether incentives prevent children and adolescents from starting to smoke. We also attempted to assess the dose-response of incentives, the costs of incentive programmes, whether incentives are more or less effective in combination with other interventions to prevent smoking initiation and any unintended consequences arising from the use of incentives. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE, EMBASE, CINAHL, CSA databases and PsycINFO for terms relating to incentives, in combination with terms for smoking and tobacco use, and children and adolescents. The most recent searches were in May 2012. SELECTION CRITERIA: We considered randomized controlled trials allocating children and adolescents (aged 5 to 18 years) as individuals, groups or communities to intervention or control conditions, where the intervention included an incentive aimed at preventing smoking uptake. We also considered controlled trials with baseline measures and post-intervention outcomes. DATA COLLECTION AND ANALYSIS: Data were extracted by two authors and assessed independently. The primary outcome was the smoking status of children or adolescents at follow-up who reported no smoking at baseline. We required a minimum follow-up of six months from baseline and assessed each included study for risk of bias. We used the most rigorous definition of abstinence in each trial; we did not require biochemical validation of self-reported tobacco use for study inclusion. Where possible we combined eligible studies to calculate pooled estimates at the longest follow-up using the Mantel-Haenszel fixed-effect method, grouping studies by study design. MAIN RESULTS: We identified seven controlled studies that met our inclusion criteria, including participants with an age range of 11 to 14 years. Of the seven trials identified, only five had analysable data relevant for this review and contributed to the meta-analysis (6362 participants in total who were non-smokers at baseline; 3466 in intervention and 2896 in control). All bar one of the studies was a trial of the so-called Smokefree Class Competition (SFC), which has been widely implemented throughout Europe. In this competition, classes with youth generally between the ages of 11 to 14 years commit to being smoke free for a six month period. They report regularly on their smoking status; if 90% or more of the class is non-smoking at the end of the six months, the class goes into a competition to win prizes. The one study that was not a trial of the SFC was a controlled trial in which schools in two communities were assigned to the intervention, with schools in a third community acting as controls. Students in the intervention community with lower smoking rates at the end of the project (one school year) received rewards.Only one study of the SFC competition, a non-randomized controlled trial, reported a significant effect of the competition on the prevention of smoking at the longest follow-up. However, this study had a risk of multiple biases, and when we calculated the adjusted RR we no longer detected a statistically significant difference. The pooled RR for the more robust RCTs (3 studies, n = 3056 participants) suggests that, from the available data, there is no statistically significant effect of incentives to prevent smoking initiation among children and adolescents in the long term (RR 1.00, 95% CI 0.84 to 1.19). Pooled results from non-randomized trials also did not detect a significant effect, and we were unable to extract data on our outcome of interest for the one trial that did not study the SFC. There is little robust evidence to suggest that unintended consequences (such as youth making false claims about their smoking status and bullying of smoking students) are consistently associated with such interventions, although this has not been the focus of much research. There was insufficient information to assess the dose-response relationship or to report costs. AUTHORS' CONCLUSIONS: To date, incentive programmes have not been shown to prevent smoking initiation among youth, although there are relatively few published studies and these are of variable quality. Trials included in this meta-analysis were all studies of the SFC competition, which distributed small to moderately sized prizes to whole classes, usually through a lottery system.Future studies might investigate the efficacy of incentives given to individual participants to prevent smoking uptake. Future research should consider the efficacy of incentives on smoking initiation, as well as progression of smoking, evaluate these in varying populations from different socioeconomic and ethnic backgrounds, and describe the intervention components in detail.

Starting to smoke: a qualitative study of the experiences of Australian indigenous youth.

BACKGROUND: Adult smoking has its roots in adolescence. If individuals do not initiate smoking during this period it is unlikely they ever will. In high income countries, smoking rates among Indigenous youth are disproportionately high. However, despite a wealth of literature in other populations, there is less evidence on the determinants of smoking initiation among Indigenous youth. The aim of this study was to explore the determinants of smoking among Australian Indigenous young people with a particular emphasis on the social and cultural processes that underlie tobacco use patterns among this group. METHODS: This project was undertaken in northern Australia. We undertook group interviews with 65 participants and individual in-depth interviews with 11 youth aged 13-20 years led by trained youth 'peer researchers.' We also used visual methods (photo-elicitation) with individual interviewees to investigate the social context in which young people do or do not smoke. Included in the sample were a smaller number of non-Indigenous youth to explore any significant differences between ethnic groups in determinants of early smoking experiences. The theory of triadic influence, an ecological model of health behaviour, was used as an organising theory for analysis. RESULTS: Family and peer influences play a central role in smoking uptake among Indigenous youth. Social influences to smoke are similar between Indigenous and non-Indigenous youth but are more pervasive (especially in the family domain) among Indigenous youth. While Indigenous youth report high levels of exposure to smoking role models and smoking socialisation practices among their family and social networks, this study provides some indication of a progressive denormalisation of smoking among some Indigenous youth. CONCLUSIONS: Future initiatives aimed at preventing smoking uptake in this population need to focus on changing social normative beliefs around smoking, both at a population level and within young peoples' immediate social environment. Such interventions could be effectively delivered in both the school and family environments. Specifically, health practitioners in contact with Indigenous families should be promoting smoke free homes and other anti-smoking socialisation behaviours.

The health of newly arrived refugees to the Top End of Australia: results of a clinical audit at the Darwin Refugee Health Service.

Accurate data on the health of refugees in primary care is vital to inform clinical practice, monitor disease prevalence, influence policy and promote coordination. We undertook a retrospective clinical audit of newly arrived refugees attending the Darwin refugee primary health service in its first 12 months of operation. Data were collected from the clinic files of refugee patients who attended for their initial health assessment from 1 July 2009 to 30 June 2010 and were analysed descriptively. Among 187 refugees who attended in 2009-2010, ~60% were from Asia and 42% were female. The most common diagnoses confirmed by testing were vitamin D deficiency (23%), hepatitis B carrier status (22%), tuberculosis infection (18%), schistosomiasis (17%) and anaemia (17%). The most common documented health conditions recorded by the GPs were vitamin D deficiency or insufficiency (66%), followed by schistosomiasis (24%) and dental disease (23%). This clinical audit adds to a limited evidence base suggesting a high prevalence of infectious disease, nutrient deficiency and dental disease among refugees arriving to Australia. GPs involved in the care of refugees must be aware of the epidemiology of disease in this group, as some diseases are rare among the general Australian population. Our results also highlight the ongoing need for advocacy to address service constraints such as limited public dental access for this population.

Vaccine breakthrough infections in a highly-vaccinated Australian population during a SARS-CoV-2 Delta outbreak.

Abstract: Over 80% of residents in the Australian Capital Territory were fully vaccinated within 10 weeks of a SARS-CoV-2 Delta variant outbreak. Of the outbreak's 1,545 cases, 10% were breakthrough infections. The incidence of infections among fully- and partially-vaccinated people was 98.5% and 90% lower, respectively, than for unvaccinated people.

Maternal smoking and smoking in the household during pregnancy and postpartum: findings from an Indigenous cohort in the Northern Territory.

OBJECTIVE: To describe the trends in maternal smoking and smoking in the household for a cohort of Indigenous women followed from late pregnancy to 7 months postpartum. DESIGN AND SETTING: Prospective cohort study embedded within a randomised controlled trial (RCT) performed in the Northern Territory involving participants recruited between 30 June 2006 and 4 May 2010. PARTICIPANTS: 215 Indigenous women aged 17-39 years who had been recruited into the RCT, 162 of whom had completed their last study visit at 7 months postpartum by 1 June 2010. MAIN OUTCOME MEASURES: Smoking status of women, and smoking within their households, in their third trimester, and at 1 month, 2 months and 7 months postpartum. RESULTS: There were complete data on women's smoking status for 121 participants. Among these, the self-reported smoking rate was 45% (95% CI, 36%-55%) during pregnancy, increasing to 63% (95% CI, 54%-71%) at 7 months postpartum. Of the 66 women who were non-smokers at the antenatal visit, 23 (35%; 95% CI, 23%-47%) were smoking by the time their baby reached 7 months of age. Thirty-one per cent (95% CI, 23%-39%) of households included people who smoked inside during the antepartum period, whereas 16% (95% CI, 10%-23%) included people who smoked inside at 7 months postpartum. CONCLUSIONS: While an apparent reduction in indoor exposure to tobacco smoke during the postpartum period is encouraging, this is offset by an increase in the proportion of antenatal non-smokers who subsequently reported smoking after the birth of their child. More health care service delivery and research attention needs to be directed to smoking during pregnancy and to postpartum relapse in this population.

Wholesale data for surveillance of Australian Aboriginal tobacco consumption in the Northern Territory.

OBJECTIVES: Effective monitoring of trends in tobacco use is an essential element of tobacco control policy. Monitoring tobacco consumption using tobacco wholesale data has advantages over other methods of surveillance. In the present work, a research project that monitored tobacco consumption in 25 remote Aboriginal communities and its translation to a policy to implement this monitoring routinely in the entire Northern Territory of Australia is described. METHODS: Tobacco consumption and trends were estimated using wholesale (or occasionally sales) data from all retail outlets in 25 remote Aboriginal communities. Self-reported consumption was estimated from the National Aboriginal and Torres Strait Islander Social Survey in 2008. Local consumption results were fed back in posters to local organisations and health staff. RESULTS: Estimates of consumption from wholesale data and self-report were similar (6.8 and 6.7 cigarettes/day/person aged 15 and over). Consumption was higher in the tropical Top End than in arid Central Australia, and 24% of tobacco was consumed as loose tobacco. The overall trend in monthly consumption was not significantly different from 0. Local communities could be ranked by their local trends in monthly consumption. CONCLUSIONS: Monitoring tobacco consumption using wholesale tobacco data is a practical and unobtrusive surveillance method that is being introduced as a new condition of tobacco retail licenses in the Northern Territory of Australia. It overcomes some problems with consumption estimates from routine surveys, enables rapid feedback and use of results and is particularly well suited for hard-to-reach discrete populations, such as remote Aboriginal communities in Australia. It has already been used to evaluate the impact of local tobacco control activities.

The study protocol for a randomized controlled trial of a family-centred tobacco control program about environmental tobacco smoke (ETS) to reduce respiratory illness in Indigenous infants.

BACKGROUND: Acute respiratory illness (ARI) is the most common cause of acute presentations and hospitalisations of young Indigenous children in Australia and New Zealand (NZ). Environmental tobacco smoke (ETS) from household smoking is a significant and preventable contributor to childhood ARI. This paper describes the protocol for a study which aims to test the efficacy of a family-centred tobacco control program about ETS to improve the respiratory health of Indigenous infants in Australia and New Zealand. For the purpose of this paper 'Indigenous' refers to Australia's Aboriginal and Torres Strait Islander peoples when referring to Australian Indigenous populations. In New Zealand, the term 'Indigenous' refers to Maori. METHODS/DESIGN: This study will be a parallel, randomized, controlled trial. Participants will be Indigenous women and their infants, half of whom will be randomly allocated to an 'intervention' group, who will receive the tobacco control program over three home visits in the first three months of the infant's life and half to a control group receiving 'usual care' (i.e. they will not receive the tobacco control program). Indigenous health workers will deliver the intervention, the goal of which is to reduce or eliminate infant exposure to ETS. Data collection will occur at baseline (shortly after birth) and when the infant is four months and one year of age. The primary outcome is a doctor-diagnosed, documented case of respiratory illness in participating infants. DISCUSSION: Interventions aimed at reducing exposure of Indigenous children to ETS have the potential for significant benefits for Indigenous communities. There is currently a dearth of evidence for the effect of tobacco control interventions to reduce children's exposure to ETS among Indigenous populations. This study will provide high-quality evidence of the efficacy of a family-centred tobacco control program on ETS to reduce respiratory illness. Outcomes of our study will be important and significant for Indigenous tobacco control in Australia and New Zealand and prevention of respiratory illness in children.

What works in Indigenous tobacco control? The perceptions of remote Indigenous community members and health staff.

ISSUES ADDRESSED: To explore the perceptions of remote Indigenous community members and health staff regarding the acceptability and effectiveness of different tobacco control health promotion interventions. METHODS: Qualitative methods were used for this exploratory study, including interviews with remote Indigenous community members and health staff, as well as observations of the delivery of different tobacco control activities in three remote communities in the Northern Territory (NT). RESULTS: Several tobacco control interventions for which there is strong evidence in other settings were generally perceived as acceptable and efficacious in the remote Indigenous setting. Primary care interventions, such as brief advice and pharmaceutical quitting aids, when available and accessible, were perceived as important and effective strategies to help people quit, as were the promotion of smokefree areas. By contrast unmodified Quit programs were perceived to have questionable application in this context and there were conflicting findings regarding taxation increases on tobacco and social marketing campaigns. CONCLUSIONS: Several evidence-based 'mainstream' activities are perceived to be acceptable to this population, but we may also need to address the concerns raised by health staff and community members about the acceptability of some unmodified activities. Additionally, organisational barriers within the health system may be contributing to the reduced effectiveness of tobacco control in this setting.