Alcohol screening in 22 Australian Aboriginal Community Controlled Health Organisations: Clinical context and who is screened.

INTRODUCTION: Alcohol screening among Indigenous Australians is important to identify individuals needing support to reduce their drinking. Understanding clinical contexts in which clients are screened, and which clients are more or less likely to be screened, could help identify areas of services and communities that might benefit from increased screening. METHODS: We analysed routinely collected data from 22 Aboriginal Community Controlled Health Organisations Australia-wide. Data collected between February 2016 and February 2021 were analysed using R, and aggregated to describe screening activity per client, within 2-monthly extraction periods. Descriptive analyses were performed to identify contexts in which clients received an Alcohol Use Disorders Identification Test consumption (AUDIT-C) screen. Multi-level logistic regression determined demographic factors associated with receiving an AUDIT-C screen. Three models are presented to examine if screening was predicted by: (i) age; (ii) age and gender; (iii) age, gender and service remoteness. RESULTS: We observed 83,931 occasions where AUDIT-C was performed at least once during a 2-monthly extraction period. Most common contexts were adult health check (55.0%), followed by pre-consult examination (18.4%) and standalone item (9.9%). For every 10 years' increase in client age, odds of being screened with AUDIT-C slightly decreased (odds ratio 0.98; 95% confidence interval [CI] 0.98, 0.99). Women were less likely to be screened with AUDIT-C (odds ratio 0.95; 95% CI 0.93, 0.96) than men. DISCUSSION AND CONCLUSIONS: This study identified areas where alcohol screening can be increased (e.g., among women). Increasing AUDIT-C screening across entire communities could help reduce or prevent alcohol-related harms. Future Indigenous-led research could help identify strategies to increase screening rates.

Rheumatology specialist care delivered at the Southern QLD Centre of Excellence in Aboriginal and Torres Strait Islander Primary Health Care.

BACKGROUND: There is limited literature on the prevalence of rheumatologic conditions in Australian First Nations people. Existing evidence suggests a high disease burden with poorer outcomes. In 2016 a rheumatology clinic was established at The Southern Queensland Centre of Excellence in Aboriginal and Torres Strait Islander Primary Health Care (CoE). AIMS: To improve knowledge of rheumatic diseases presentations in an urban First Nations cohort and to assess the effectiveness of the CoE clinic. METHODS: Data on attendance, diagnosis, treatment and demographics were obtained retrospectively from clinical records at the CoE from 2016 to 2020. Administrative attendance data for the largest public general rheumatology clinic in the region for the 4 years preceding the establishment of the CoE clinic were used as a historic cohort control. RESULTS: A cohort of 93 patients was seen at the CoE with 439 appointments compared to 207 in the historical control. Common diagnoses were osteoarthritis (24%), seropositive rheumatoid arthritis (17%), gout (13%) and spondyloarthropathies (10%). Forty per cent of the cohort at CoE were treated with at least one disease-modifying antirheumatic drug (DMARD) and 12% with a biologic or targeted synthetic DMARD. Seventy-five per cent of appointments were attended versus 71% in control group. Adjusted odds ratio of attendance was 1.35 (P = 0.07). CONCLUSIONS: Provision of rheumatology specialty care in an urban primary health setting aimed specifically at the needs of First Nations people led to increased uptake and engagement. A broad range of rheumatologic diagnoses was made and significant DMARD treatments commenced.

Unintended consequences: Alcohol screening at urban Aboriginal Community Controlled Health Services was suppressed during COVID-19 lockdowns.

INTRODUCTION: Regular screening for risky drinking is important to improve the health of Aboriginal and Torres Strait Islander Australians. We explored whether the rate of screening for risky drinking using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questions was disrupted at Aboriginal Community Controlled Health Services (ACCHS) during state-wide and territory-wide COVID-19 lockdowns in 2020. METHODS: Retrospective analysis of screening data from 22 ACCHSs located in New South Wales, the Northern Territory, Queensland, South Australia, Victoria and Western Australia. These services provide holistic and culturally appropriate primary care. A multi-level Poisson regression, including AR(1) autocorrelation, was used to predict counts of AUDIT-C screening at ACCHSs. RESULTS: AUDIT-C screening was suppressed during state-wide and territory-wide lockdowns in 2020 (incident rate ratio [IRR] 0.42 [0.29, 0.61]). The effect of lockdowns differed by service remoteness. While there was a substantial reduction in AUDIT-C screening for urban and inner regional services (IRR 0.25 [95% confidence interval (CI) 0.15, 0.42]), there was not a statistically significant change in screening at outer regional and remote (IRR 0.60 [95% CI 0.33, 1.09]) or very remote services (IRR 0.67 [95% CI 0.40, 1.11]). DISCUSSION AND CONCLUSIONS: The COVID-19 lockdowns in Australia likely suppressed rates of screening for risky drinking in urban and inner regional regions. As harm from alcohol consumption may have increased during lockdowns, policymakers should consider implementing measures to enable screening for risky drinking to continue during future lockdowns.

Safeguarding against Dementia in Aboriginal and Torres Strait Islander Communities through the Optimisation of Primary Health Care: A Project Protocol.

This protocol describes the methodology and methods for a collaborative project with eight Aboriginal and Torres Strait Islander primary health care (PHC) organisations, across three Australian states and one territory, to increase clinical service performance and access to preventive health and health promotion services for preventing, identifying, treating, and managing dementia risk in Aboriginal and Torres Strait Islander communities. Aboriginal participatory action research (APAR) methodology will be the framework for this project, incorporating continuous quality improvement (CQI), informed by research yarning with stakeholder groups, comprising community members and PHC staff and service providers and data collected from the auditing of client health records and the mapping of existing clinical processes and health services at each partnering PHC organisation. The qualitative and quantitative data will be summarised and discussed with stakeholder groups. Priorities will be identified and broken down into tangible PHC organisation deliverable strategies and programs, which will be co-developed with stakeholder groups and implemented cyclically over 24 months using the Plan, Do, Study, Act model of change. Key project outcome measures include increased clinical service performance and availability of preventive health and health promotion services for safeguarding against dementia. Project implementation will be evaluated for quality and transparency from an Indigenous perspective using an appropriate appraisal tool. The project processes, impact, and sustainability will be evaluated using the RE-AIM framework. A dementia safeguarding framework and accompanying tool kit will be developed from this work to support Aboriginal and Torres Strait Islander PHC organisations to identify, implement, and evaluate dementia safeguarding practice and service improvements on a broader scale.

Walking side-by-side: Supporting Aboriginal and Torres Strait Islander Australians to lead the way in alcohol research.

Several initiatives have sought to increase the number of First Nations individuals with a higher degree in research (i.e., PhD or research masters)-in Australia and in similarly colonised countries. However, little has been written on day-to-day support structures and mechanisms that might help First Nations Australian candidates thrive in postgraduate research degrees and beyond. For sensitive research fields such as alcohol, emerging Aboriginal and Torres Strait Islander researchers must grapple with topics which are stigmatising and in some instances associated with traumatic associations. There is also a lack of studies internationally that describe optimal support for First Nations students undertaking a higher degree by research with a primary focus on alcohol. Here we discuss what we have learned from the support offered through the Centre of Research Excellence in Indigenous Health and Alcohol-from the perspective of academic staff, students, trainees and early career researchers. We consider what may be generalisable lessons from this experience.

'The Drug Survey App': a protocol for developing and validating an interactive population survey tool for drug use among Aboriginal and Torres Strait Islander Australians.

BACKGROUND: Disadvantage and transgenerational trauma contribute to Aboriginal and Torres Strait Islander (Indigenous) Australians being more likely to experience adverse health consequences from alcohol and other drug use than non-Indigenous peoples. Addressing these health inequities requires local monitoring of alcohol and other drug use. While culturally appropriate methods for measuring drinking patterns among Indigenous Australians have been established, no similar methods are available for measuring other drug use patterns (amount and frequency of consumption). This paper describes a protocol for creating and validating a tablet-based survey for alcohol and other drugs ("The Drug Survey App"). METHODS: The Drug Survey App will be co-designed with stakeholders including Indigenous Australian health professionals, addiction specialists, community leaders, and researchers. The App will allow participants to describe their drug use flexibly with an interactive, visual interface. The validity of estimated consumption patterns, and risk assessments will be tested against those made in clinical interviews conducted by Indigenous Australian health professionals. We will then trial the App as a population survey tool by using the App to determine the prevalence of substance use in two Indigenous communities. DISCUSSION: The App could empower Indigenous Australian communities to conduct independent research that informs local prevention and treatment efforts.

Effects of service-wide support on regularity of alcohol screening of clients in Australian Aboriginal and Torres Strait Islander Community Controlled Health Services: a cluster randomised trial.

BACKGROUND: We have previously shown that service-wide support can increase the odds of alcohol screening in any 2-month period in a cluster randomized trial of service-wide support to Aboriginal and Torres Strait Islander Community Controlled Health Services (ACCHS). Here we report an exploratory analysis on whether the resulting pattern of screening was appropriate. AIM: we assess whether that increase in screening was associated with: (i) increased first-time screening, (ii) increased annual screening, (iii) whether frequently screened clients fell into one of four risk categories as defined by national guidelines. METHODS: Setting and participants: 22 ACCHS; randomized to receive the support model in the treatment ('early-support') arm over 24-months or to the waitlist control arm. INTERVENTION: eight-component support, including training, sharing of experience, audit-and-feedback and resource support. ANALYSIS: records of clients with visits before and after start of implementation were included. Multilevel logistic modelling was used to compare (i) the odds of previously unscreened clients receiving an AUDIT-C screen, (ii) odds of clients being screened with AUDIT-C at least once annually. We describe the characteristics of a sub-cohort of clients who received four or more screens annually, including if they were in a high-risk category. RESULTS: Of the original trial sample, 43,054 met inclusion criteria, accounting for 81.7% of the screening events in the overall trial. The support did not significantly increase the odds of first-time screening (OR = 1.33, 95% CI 0.81-2.18, p = 0.25) or of annual screening (OR = 0.99, 95% CI 0.42-2.37, p = 0.98). Screening more than once annually occurred in 6240 clients. Of the 841 clients with four or more screens annually, over 50% did not fall into a high-risk category. Females were overrepresented. More males than females fell into high-risk categories. CONCLUSION: The significant increase in odds of screening observed in the main trial did not translate to significant improvement in first-time or annual screening following implementation of support. This appeared to be due to some clients being screened more frequently than annually, while more than half remained unscreened. Further strategies to improve alcohol screening should focus on appropriate screening regularity as well as overall rates, to ensure clinically useful information about alcohol consumption. Trial Registration ACTRN12618001892202, retrospectively registered 16 November 2018 https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12618001892202 .

Prevalence and correlates of alcohol dependence in an Australian Aboriginal and Torres Strait Islander representative sample: Using the Grog Survey App.

INTRODUCTION: Little is known about the prevalence of current alcohol dependence in Indigenous Australian communities. Here we identify the frequency of reported symptoms, estimate the prevalence and describe the correlates of current alcohol dependence. METHODS: A representative sample of Indigenous Australians (16+ years) was recruited from an urban and remote community in South Australia. Data were collected between July and October 2019 via a tablet computer-based application. Participants were likely dependent if they reported two or more dependence symptoms (ICD-11; in the last 12 -months), weekly or more frequently. Chi-square tests described the relationship between demographics, remoteness and alcohol dependence. Spearman correlations estimated the relationship between symptoms of dependence, consumption characteristics and demographics. RESULTS: A total of 775 Indigenous Australians participated. The most frequently reported symptoms were prioritising alcohol over other things and loss of control. Overall, 2.2% were likely dependent on alcohol (n = 17/775). Prevalence did not vary by remoteness. Participants who drank more and more frequently tended to report more frequent symptoms of dependence. In the urban site, men tended to report more frequent symptoms of dependence than women. Age, income and schooling were not linked to dependence. DISCUSSION AND CONCLUSIONS: The prevalence of current alcohol dependence in this representative sample was similar to that of the general Australian and international estimates. Understanding risk factors for current alcohol dependence will be useful to inform the allocation of funding and support. Accurate estimates of the prevalence of current alcohol dependence are important to better identify specialist treatment needs.

Rapid review of five years of Aboriginal and Torres Strait Islander health research in Australia - persisting under-representation of urban populations.

OBJECTIVE: To review how published Aboriginal and Torres Strait Islander health research reflects the geographical distribution of the Indigenous population of Australia. METHODS: Rapid review using Lowitja Institute Lit.search tool for PubMed indexed Indigenous health research papers (January 2013 to January 2018). Geographic location, participant age, study type and recruitment site were identified for each paper. RESULTS: A total of 1,258 research papers were identified: 190 (15%) focused exclusively on Indigenous people living in urban areas; 563 (45%) in rural/remote areas; and 505 (40%) spanned urban and rural/remote areas. Despite similar burdens of disease, three times as many papers were published per 1,000 DALYs for rural/remote areas than urban areas. CONCLUSIONS: Indigenous health research publications have more than doubled since 2010. However, research focusing on the health needs of urban Indigenous people remains low relative to disease burden and population. Implications for public health: More research to address the health needs of Indigenous people living in urban areas is required although this should not be at the expense of research for rural and remote areas. Increased funding quarantined for Indigenous health research, coupled with self-determination of the research agenda and reporting on the geographic representativeness of research, may help address geographical inequities in research outputs.

Support can increase use of the AUDIT-C in Australian Aboriginal Community Controlled Health Services: a cluster randomized trial.

BACKGROUND AND AIMS: Unhealthy alcohol consumption is a key concern for Aboriginal and Torres Strait Islander ('Indigenous') communities. It is important to identify and treat at-risk drinkers, to prevent harms to physical or social wellbeing. We aimed to test whether training and support for Aboriginal Community Controlled Health Service (ACCHS) staff would increase rates of alcohol screening and brief intervention. DESIGN: Cluster randomized trial. SETTING: Australia. Cases/Intervention/Measurements Twenty-two ACCHSs that see at least 1000 clients per year and use Communicare as practice management software. The study included data on 70 419 clients, training, regular data feedback, collaborative support and funding for resources ($9000). Blinding was not used. The comparator was waiting-list control (equal allocation). Alcohol Use Disorder Identification Test (AUDIT-C) screening and records of brief interventions were extracted from practice management software at 2-monthly intervals. Observations described the clinical actions taken for clients over each 2-month interval. The baseline period (28 August 2016-28 August 2017) was compared with the post-implementation period (29 August 2017-28 August 2018). We used multi-level logistic regression to test the hypotheses that clients attending a service receiving active support would be more likely to be screened with AUDIT-C (primary outcome) or to receive a brief intervention (secondary outcome). FINDINGS: We observed an increase in the odds of screening with AUDIT-C for both groups, but the increase was 5.52 [95% confidence interval (CI) = 4.31, 7.07] times larger at services receiving support. We found little evidence that the support programme increased the odds of a recorded brief intervention relative to control services (odds ratio = 2.06; 95% CI = 0.90, 4.69). Differences in baseline screening activity between treatment and control reduce the certainty of our findings. CONCLUSIONS: Providing Aboriginal Community Controlled Health Services with training and support can improve alcohol (AUDIT-C) screening rates.

Factors Associated with Thoughts of Self-Harm or Suicide among Aboriginal and Torres Strait Islander People Presenting to Urban Primary Care: An Analysis of De-Identified Clinical Data.

Suicide amongst Aboriginal and Torres Strait Islander people is a major cause of premature mortality and a significant contributor to the health and life expectancy gap. This study aimed to estimate the prevalence of thoughts of self-harm or suicide in Aboriginal and Torres Strait Islander people attending an urban primary health care service and identify factors associated with these thoughts. Multilevel mixed-effects modified Poisson regression models were employed to analyse three years of data gathered during the annual Aboriginal and Torres Strait Islander health assessments. At their first health assessment, 11.5% (191/1664) of people reported thoughts of suicide or self-harm in the prior two weeks. Having children, participating in sport or community activities or being employed full-time decreased the risk of such thoughts. Conversely, factors relating to social exclusion including homelessness, drug use, unemployment and job insecurity increased the risk of thoughts of self-harm or suicide. Individual clinicians, health services, and policy-makers all have a role in suicide prevention. Clinicians need appropriate training to be able to respond to people expressing these thoughts. Aboriginal and Torres Strait Islander community organisations need sovereignty and self-determination over resources to provide programs that promote cultural connectivity and address social exclusion, thereby saving lives.

Acceptability and feasibility of a computer-based application to help Aboriginal and Torres Strait Islander Australians describe their alcohol consumption.

We examined acceptability and feasibility of a tablet application ("App") to record self-reported alcohol consumption among Aboriginal and Torres Strait Islander Australians. Four communities (1 urban; 3 regional/remote) tested the App, with 246 adult participants (132 males, 114 females). The App collected (a) completion time; (b) participant feedback; (c) staff observations. Three research assistants were interviewed. Only six (1.4%) participants reported that the App was "hard" to use. Participants appeared to be engaged and to require minimal assistance; nearly half verbally reflected on their drinking or drinking of others. The App has potential for surveys, screening, or health promotion.

Quantitative evaluation of an outreach case management model of care for urban Aboriginal and Torres Strait Islander adults living with complex chronic disease: a longitudinal study.

BACKGROUND: Chronic diseases are the leading contributor to the excess morbidity and mortality burden experienced by Aboriginal and Torres Strait Islander (hereafter, respectfully, Indigenous) people, compared to their non-Indigenous counterparts. The Home-based Outreach case Management of chronic disease Exploratory (HOME) Study provided person-centred, multidisciplinary care for Indigenous people with chronic disease. This model of care, aligned to Indigenous peoples' conceptions of health and wellbeing, was integrated within an urban Indigenous primary health care service. We aimed to determine the impact of this model of care on participants' health and wellbeing at 12 months. METHODS: HOME Study participants were Indigenous, regular patients of the primary health care service, with a diagnosis of at least one chronic disease, and complex health and social care needs. Data were collected directly from participants and from their medical records at baseline, and 3, 6 and 12 months thereafter. Variables included self-rated health status, depression, utilisation of health services, and key clinical outcomes. Participants' baseline characteristics were described using frequencies and percentages. Generalized estimating equation (GEE) models were employed to evaluate participant attrition and changes in outcome measures over time. RESULTS: 60 participants were enrolled into the study and 37 (62%) completed the 12-month assessment. After receiving outreach case management for 12 months, 73% of participants had good, very good or excellent self-rated health status compared with 33% at baseline (p < 0.001) and 19% of participants had depression compared with 44% at baseline (p = 0.03). Significant increases in appointments with allied health professionals (p < 0.001) and medical specialists other than general practitioners (p = 0.001) were observed at 12-months compared with baseline rates. Mean systolic blood pressure decreased over time (p = 0.02), but there were no significant changes in mean HbA1c, body mass index, or diastolic blood pressure. CONCLUSIONS: The HOME Study model of care was predicated on a holistic conception of health and aimed to address participants' health and social care needs. The positive changes in self-rated health and rates of depression evinced that this aim was met, and that participants received the necessary care to support and improve their health and wellbeing.

A digital health intervention for cardiovascular disease management in primary care (CONNECT) randomized controlled trial.

Digital health applications (apps) have the potential to improve health behaviors and outcomes. We aimed to examine the effectiveness of a consumer web-based app linked to primary care electronic health records (EHRs). CONNECT was a multicenter randomized controlled trial involving patients with or at risk of cardiovascular disease (CVD) recruited from primary care (Clinical Trial registration ACTRN12613000715774). Intervention participants received an interactive app which was pre-populated and refreshed with EHR risk factor data, diagnoses and, medications. Interactive risk calculators, motivational messages and lifestyle goal tracking were also included. Control group received usual health care. Primary outcome was adherence to guideline-recommended medications (≥80% of days covered for blood pressure (BP) and statin medications). Secondary outcomes included attainment of risk factor targets and eHealth literacy. In total, 934 patients were recruited; mean age 67.6 (±8.1) years. At 12 months, the proportion with >80% days covered with recommended medicines was low overall and there was no difference between the groups (32.8% vs. 29.9%; relative risk [RR] 1.07 [95% CI, 0.88-1.20] p = 0.49). There was borderline improvement in the proportion meeting BP and LDL targets in intervention vs. control (17.1% vs. 12.1% RR 1.40 [95% CI, 0.97-2.03] p = 0.07). The intervention was associated with increased attainment of physical activity targets (87.0% intervention vs. 79.7% control, p = 0.02) and e-health literacy scores (72.6% intervention vs. 64.0% control, p = 0.02). In conclusion, a consumer app integrated with primary health care EHRs was not effective in increasing medication adherence. Borderline improvements in risk factors and modest behavior changes were observed.

Visual impairment among Aboriginal and Torres Strait Islander patients attending an Australian Indigenous primary health service: a cross-sectional study.

This cross-sectional study aimed to identify the period prevalence of visual impairment (VI) and blindness among Aboriginal and Torres Strait Islander people attending an Indigenous urban primary healthcare service, eye care practitioner referrals for those with VI and any opportunities to improve care delivery. Visual acuity (VA) examinations, using a Snellen chart, are performed as part of routine annual health assessments offered to children and adults. This study included patients aged ≥5 years (n=1442) who had a health assessment conducted between 1 January 2015 and 31 December 2016 and provided consent for the use of their health assessment information for research. Of patients with available data, 2.4% (33/1374) experienced VI, defined as presenting VA worse than 6/12 to 6/60 in the better-seeing eye. VI was more common in those aged ≥60 years (14/136; 10.3%) and was significantly associated with increasing age (P<0.001). No patients experienced blindness, defined as presenting VA worse than 6/60 in the better-seeing eye. All patients with VI were aged ≥16 years. Nine (27%) of the 33 patients with VI in the better-seeing eye were referred to an optometrist or an ophthalmologist. The low period prevalence of VI and no blindness in this study are positive findings. The findings also indicate that routine VA testing of older adults, especially those aged ≥60 years, should be conducted to avoid missing those not having an annual health assessment.

How can mobile applications support suicide prevention gatekeepers in Australian Indigenous communities?

RATIONALE: Suicide prevention training in Aboriginal and Torres Strait Islander communities is a national health priority in Australia. OBJECTIVE: This paper describes a qualitative study to increase understanding of how a mobile application (app) could be used to support suicide prevention gatekeepers in Indigenous communities. We respectfully use the term Indigenous to refer to Australian peoples of Aboriginal and/or Torres Strait Islander descent. METHOD: Two participatory design workshops were held with 12 participants who were either Indigenous health workers or community members. The workshops first explored what knowledge, skills, and support suicide prevention gatekeepers in Indigenous communities may require, as well as how technology, specifically mobile apps, could be used to support these needs. RESULTS: Qualitative analysis identified four themes related to perceptions of who gatekeepers are, their role requirements, technology and supporting resources, as well as broader community issues. Participants thought training programs should target key, accessible, and respected people from diverse, designated, and emergent groups in Indigenous communities to act as gatekeepers, but requested an alternative, more culturally appropriate term to 'gatekeeper' (e.g., responder). Training should prepare gatekeepers for multifaceted suicide prevention roles, including the identification and management of at-risk Indigenous persons, the provision of psychoeducation and ongoing support, as well as facilitate integrated care in collaboration with community services. A combination of multiple support resources was recommended, including multi-platform options in the technology (e.g., mobile applications, social media) and physical domains (e.g., wallet cards, regular meetings). Recommended app features included culturally appropriate refresher content on suicide intervention, training recall, integrated care, how to access gatekeeper peer support, and debriefing. Broader community concerns on gatekeeper support needs were also considered.

A systematic review of approaches to improve practice, detection and treatment of unhealthy alcohol use in primary health care: a role for continuous quality improvement.

BACKGROUND: Unhealthy alcohol use involves a spectrum from hazardous use (exceeding guidelines but no harms) through to alcohol dependence. Evidence-based management of unhealthy alcohol use in primary health care has been recommended since 1979. However, sustained and systematic implementation has proven challenging. The Continuing Quality Improvement (CQI) process is designed to enable services to detect barriers, then devise and implement changes, resulting in service improvements. METHODS: We conducted a systematic review of literature reporting on strategies to improve implementation of screening and interventions for unhealthy alcohol use in primary care (MEDLINE EMBASE, PsycINFO, CINAHL, the Australian Indigenous Health InfoNet). Additional inclusion criteria were: (1) pragmatic setting; (2) reporting original data; (3) quantitative outcomes related to provision of service or change in practice. We investigate the extent to which the three essential elements of CQI are being used (data-guided activities, considering local conditions; iterative development). We compare characteristics of programs that include these three elements with those that do not. We describe the types, organizational levels (e.g. health service, practice, clinician), duration of strategies, and their outcomes. RESULTS: Fifty-six papers representing 45 projects were included. Of these, 24 papers were randomized controlled trials, 12 controlled studies and 20 before/after and other designs. Most reported on strategies for improving implementation of screening and brief intervention. Only six addressed relapse prevention pharmacotherapies. Only five reported on patient outcomes and none showed significant improvement. The three essential CQI elements were clearly identifiable in 12 reports. More studies with three essential CQI elements had implementation and follow-up durations above the median; utilised multifaceted designs; targeted both practice and health system levels; improved screening and brief intervention than studies without the CQI elements. CONCLUSION: Utilizing CQI methods in implementation research would appear to be well-suited to drive improvements in service delivery for unhealthy alcohol use. However, the body of literature describing such studies is still small. More well-designed research, including hybrid studies of both implementation and patient outcomes, will be needed to draw clearer conclusions on the optimal approach for implementing screening and treatment for unhealthy alcohol use. (PROSPERO registration ID: CRD42018110475).

Drinking risk varies within and between Australian Aboriginal and Torres Strait Islander samples: a meta-analysis to identify sources of heterogeneity.

BACKGROUND AND AIMS: To reduce health and social inequities, it is important to understand how drinking patterns vary within and between Indigenous peoples. We aimed to assess variability in estimates of Indigenous Australian drinking patterns and to identify demographic and methodological factors associated with this. DESIGN: A three-level meta-analysis of Australian Aboriginal and Torres Strait Islander ('Indigenous') drinking patterns [International Prospective Register of Systematic Reviews (PROSPERO) no. CRD42018103209]. SETTING: Australia. PARTICIPANTS: Indigenous Australians. MEASUREMENTS: The primary outcomes extracted were drinking status, single-occasion risk and life-time risk. Moderation analysis was performed to identify potential sources of heterogeneity. Moderators included gender, age, socio-economic status, local alcohol restrictions, sample population, remoteness, Australian state or territory, publication year, Indigenous involvement in survey design or delivery and cultural adaptations. FINDINGS: A systematic review of the literature revealed 41 eligible studies. For all primary outcomes, considerable heterogeneity was identified within ( I22 = 51.39-68.80%) and between ( I32 = 29.27-47.36%) samples. The pooled proportions (P) of current drinkers [P = 0.59, 95% confidence interval (CI) = 0.53-0.65], single-occasion (P = 0.34, 95% CI = 0.24-0.44) and life-time (P = 0.21, 95% CI = 0.15-0.29) risk were all moderated by gender, age, remoteness and measurement tool. Reference period moderated proportions of participants at single-occasion risk. CONCLUSIONS: Indigenous Australian drinking patterns vary within and between communities. Initiatives to reduce high-risk drinking should take account of this variability.