Commentary: Improving access to cardiac rehabilitation (Heart: Road for health) for Aboriginal and Torres Strait Islander peoples in rural and remote areas of North Queensland.

AIMS: To focus on the needs, challenges and opportunities to improve access to cardiac rehabilitation (CR) (Heart: Road to health [HRH]) for Aboriginal and Torres Strait Islander peoples in rural and remote (R&R) areas of North Queensland. CONTEXT: It is known that there is insufficient access to HRH for Aboriginal and Torres Strait Islander peoples in R&R areas of NQ, who have the highest rates of heart disease and socioeconomic disadvantage mainly due to poor social determinants of health. However, at least in part due to the impact of colonialism and predominantly western medicalised approach to health care, few gains have been made. APPROACH: This commentary draws on recent research and literature and reflects on cultural issues that impact on improving access to an HRH for Aboriginal and Torres Strait Islander peoples in R&R areas. The underutilisation of the skills of Aboriginal and Torres Strait Islander Health Workers (ATSIHW) and a lack of a defined process to ensure access to culturally responsive HRH are discussed. Finally, a way forward is proposed that includes the development of policies, pathways and guidelines to ensure that appropriate support is available in the client's home community. CONCLUSION: It is proposed that culturally responsive, accessible and effective HRH is achievable through the reorientation of current health systems that include a continuous client-centred pathway from hospital to home. In this model, ATSIHW will take a lead or partnership role in which their clinical, cultural brokerage and health promotion skills are fully utilised.

Cardiac rehabilitation in rural and remote areas of North Queensland: How well are we doing?

OBJECTIVE: To address access to cardiac rehabilitation (CR) for people in R&R areas, this research aimed to investigate: (1) post discharge systems and support for people returning home from hospital following treatment for heart disease (HD). (2) propose changes to improve access to CR in R&R areas of NQ. SETTING: Four focus communities in R&R areas of NQ. PARTICIPANTS: Focus communities' health staff (resident/visiting) (57), community leaders (10) and community residents (44), discharged from hospital in past 5 years following treatment for heart disease (purposeful sampling). DESIGN: A qualitative descriptive case study, with data collection via semi-structured interviews. Inductive/deductive thematic analysis was used to identify primary and secondary themes. Health service audit of selected communities. RESULTS: Health services in the focus communities included multipurpose health services, and primary health care centres staffed by resident and visiting staff that included nurses, Aboriginal and Torres Strait Islander Health Workers, medical officers, and allied health professionals. Post-discharge health care for people with HD was predominantly clinical. Barriers to CR included low referrals to community-based health professions by discharging hospitals; poorly defined referral pathways; lack of guidelines; inadequate understanding of holistic, multidisciplinary CR by health staff, community participants and leaders; limited centre-based CR services; lack of awareness, or acceptance of telephone support services. CONCLUSION: To address barriers identified for CR in R&R areas, health care systems' revision, including development of referral pathways to local health professionals, CR guidelines and in-service education, is required to developing a model of care that focuses on self-management and education: Heart: Road to Health.

Importance of cardiac rehabilitation in rural and remote areas of Australia.

OBJECTIVE: To assess implementation of in-patient cardiac rehabilitation (Phase-1-cardiac rehabilitation), impact on people in rural and remote areas of Australia and potential methods for addressing identified weaknesses. DESIGN: Exploratory case study methodology using qualitative and quantitative methods. Qualitative data collection via semi-structured interviews, using thematic analysis, augmented by quantitative data collection via a medical record audit. SETTING: Four regional hospitals (2 Queensland Health and 2 private) providing tertiary health care. PARTICIPANTS: (a) Hospital in-patients with heart disease ≥18 years. (b) Staff responsible for their care. OUTCOME MEASURES: Implementation of Phase-1-cardiac rehabilitation in tertiary hosptials in North Queensland and the impact on in-patients discharge planning and post discharge care. Recommentations and implications for practice are proposed to address deficits. RESULTS: Phase-1-cardiac rehabilitation implementation rates, in-patient understanding and multidisciplinary team involvement were low. The highest rates of Phase-1-cardiac rehabilitation were for in-patients with a length of stay three days or more  in cardiac units with cardiac educators. Rates were lower in cardiac units with no cardiac educators, and lowest for in-patients in all areas of all hospitals with length of stay of two days or less days. Low Phase-1-cardiac rehabilitation implementation rates resulted in poor in-patient understanding about their disease, treatment and post-discharge care. Further, medical discharge summaries rarely mentioned cardiac rehabilitation/secondary prevention or risk factor management resulting in a lack of information for health care providers on cardiac rehabilitation and holistic health care. CONCLUSION: Implementation of Phase-1-cardiac rehabilitation in regional hospitals in this study fell short of recommended best practice, resulting in patients' poor preparation for discharge, and insufficient information on holistic care for health care providers in rural and remote areas. These factors potentially impact on holistic care for people returning home following treatment for heart disease.

Roadmap to recovery: Reporting on a research taskforce supporting Indigenous responses to COVID-19 in Australia.

In April 2020 a Group of Eight Taskforce was convened, consisting of over 100 researchers, to provide independent, research-based recommendations to the Commonwealth Government on a "Roadmap to Recovery" from COVID-19. The report covered issues ranging from pandemic control and relaxation of social distancing measures, to well-being and special considerations for vulnerable populations. Our work focused on the critical needs of Aboriginal and Torres Strait Islander communities; this paper presents an overview of our recommendations to the Roadmap report. In addressing the global challenges posed by pandemics for citizens around the world, Indigenous people are recognised as highly vulnerable. At the time of writing Australia's First Nations Peoples have been largely spared from COVID-19 in comparison to other Indigenous populations globally. Our recommendations emphasise self-determination and equitable needs-based funding to support Indigenous communities to recover from COVID-19, addressing persistent overcrowded housing, and a focus on workforce, especially for regional and remote communities. These latter two issues have been highlighted as major issues of risk for Indigenous communities in Australia It remains to be seen how governments across Australia take up these recommendations to support Indigenous peoples' health and healing journey through yet another, potentially catastrophic, health crisis.

Heart disease, hospitalisation and referral: Coaching to Achieving Cardiovascular Health through cardiac rehabilitation in Queensland.

OBJECTIVES: To describe rates of hospitalisation and Coaching on Achieving Cardiovascular Health referral, for Queensland's adults with heart and related disease, and comparisons between Aboriginal and Torres Strait Islander and non-Indigenous peoples in northern Queensland. DESIGN: Descriptive retrospective epidemiological study of Queensland Health Patient Admission Data Collection for adults with heart and related disease, and Coaching on Achieving Cardiovascular Health referral data. Relative risk and age standardisation were calculated for Aboriginal and Torres Strait Islander and non-Indigenous peoples. PARTICIPANTS: Queensland's adults ≥20 years, hospitalised with heart and related disease (1 January 2012-31 December 2016). SETTING: Queensland, Australia. MAIN OUTCOME MEASURES: Queensland Health Hospital and Health Services' hospitalisation and Coaching on Achieving Cardiovascular Health referral rates for heart and related disease. RESULTS: Queensland's Aboriginal and Torres Strait Islander peoples have a higher hospitalisation rate for heart and related disease, with higher rates for northern Queensland. Queensland's overall Coaching on Achieving Cardiovascular Health referral rates were low, but higher for Aboriginal and Torres Strait Islander peoples. Deficiencies in documentation of Aboriginal and Torres Strait Islander people's status affected results in some areas. CONCLUSION: Queensland's Aboriginal and Torres Strait Islander peoples were more likely to be admitted to hospital for heart and related disease and referred to Coaching on Achieving Cardiovascular Health than non-Indigenous peoples. However, hospitalisation and Coaching on Achieving Cardiovascular Health referral rates are unlikely to reflect the needs of Aboriginal and Torres Strait Islander peoples especially in rural and very remote areas given their higher mortality and morbidity rates and fewer services.

Cardiac rehabilitation services for people in rural and remote areas: an integrative literature review.

INTRODUCTION: Morbidity and mortality from heart disease continues to be high in Australia with cardiac rehabilitation (CR) recognised as best practice for people with heart disease. CR is known to reduce mortality, reoccurrence of heart disease, hospital readmissions and costs, and to improve quality of life. Australian Aboriginal and Torres Strait Islanders (Australian First Peoples or Indigenous peoples) have a greater need for CR due to their higher burden of disease. However, CR referral, access and attendance remain low for all people who live in rural and remote areas. The aim of this integrative review was to identify barriers, enablers and pathways to CR for adults living independently in rural and remote areas of high-income countries, including Australia. METHODS: Studies were identified through five online data bases, plus reference lists of the selected studies. The studies focused on barriers and enablers of CR for adults in rural and remote areas of Australia and other high-income countries, in English peer-reviewed journals (2007-2016). A mix of qualitative, quantitative and mixed method studies were reviewed through a modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), followed by a critical review and thematic analysis. RESULTS: Sixteen studies were selected: seven qualitative, four quantitative and five mixed method. Five themes that influence CR attendance were identified: referral, health services pathways and planning; cultural and geographic factors necessitating alternative and flexible programs; professional roles and influence; knowing, valuing, and psychosocial factors; and financial costs - personal and health services. Factors identified that impact on referral and access to CR were hospital inpatient education programs on heart disease and risk factors; discharge processes including CR eligibility criteria and referral to ensure continuum and transition of care; need for improved accessibility of services, both geographically and through alternative programs, including home based with IT and/or telephone support. Also, the need to ensure that health professionals understand, value and support CR; the impact of mental health, coping with change and competing priorities; costs including travel, medications and health professional consultations; as well as low levels of involvement of Australian First Peoples in their own care and poor cultural understanding by non-Australian First Peoples staff all negatively impact on CR access and attendance. CONCLUSION: This study found weak systems with low referral rates and poor access to CR in rural and remote areas. Underlying factors include lack of health professional and public support, often based on poor perception of benefits of CR, compounded by scarce and inflexible services. Low levels of involvement of Australian First Peoples, as well as a lack of cultural understanding by non-Australian First Peoples staff, is evident. Overall, the findings demonstrate the need for improved models of referral and access, greater flexibility of programs and professional roles, with management support. Further, increased education and involvement of Australian First Peoples, including Indigenous health workers taking a lead in their own people's care, supported by improved education and greater cultural awareness of non-Australian First Peoples staff, is required.

Indigenous mortality (revealed): the invisible illuminated.

Inaccuracies in the identification of Indigenous status and the collection of and access to vital statistics data impede the strategic implementation of evidence-based public health initiatives to reduce avoidable deaths. The impact of colonization and subsequent government initiatives has been commonly observed among the Indigenous peoples of Australia, Canada, New Zealand, and the United States. The quality of Indigenous data that informs mortality statistics are similarly connected to these distal processes, which began with colonization. We discuss the methodological and technical challenges in measuring mortality for Indigenous populations within a historical and political context, and identify strategies for the accurate ascertainment and inclusion of Indigenous people in mortality statistics.

Aboriginal community controlled health services: leading the way in primary care.

The national Closing the Gap framework commits to reducing persisting disadvantage in the health of Aboriginal and Torres Strait Islander people in Australia, with cross-government-sector initiatives and investment. Central to efforts to build healthier communities is the Aboriginal community controlled health service (ACCHS) sector; its focus on prevention, early intervention and comprehensive care has reduced barriers to access and unintentional racism, progressively improving individual health outcomes for Aboriginal people. There is now a broad range of primary health care data that provides a sound evidence base for comparing the health outcomes for Indigenous people in ACCHSs with the outcomes achieved through mainstream services, and these data show: models of comprehensive primary health care consistent with the patient-centred medical home model; coverage of the Aboriginal population higher than 60% outside major metropolitan centres; consistently improving performance in key performance on best-practice care indicators; and superior performance to mainstream general practice. ACCHSs play a significant role in training the medical workforce and employing Aboriginal people. ACCHSs have risen to the challenge of delivering best-practice care and there is a case for expanding ACCHSs into new areas. To achieve the best returns, the current mainstream Closing the Gap investment should be shifted to the community controlled health sector.

Health systems model for chronic disease secondary prevention in rural and remote areas - Chronic disease: Road to health.

Objectives Cardiac rehabilitation (CR) provides evidence-based secondary prevention for people with heart disease (HD) (clients). Despite HD being the leading cause of mortality and morbidity, CR is under-utilised in Australia. This research investigated healthcare systems required to improve access to CR in rural and remote areas of North Queensland (NQ). Methods A qualitatively dominant case study series to review management systems for CR in rural and remote areas of NQ was undertaken. Data collection was via semi-structured interviews in four tertiary hospitals and four rural or remote communities. An audit of discharge planning and CR referral, plus a review of community-based health services, was completed. An iterative and co-design process including consultation with healthcare staff and community members culminated in a systems-based model for improving access to CR in rural and remote areas. Results Poorly organised CR systems, poor client/staff understanding of discharge planning and low referral rates for secondary prevention, resulted in the majority of clients not accessing secondary prevention, despite resources being available. Revised health systems and management processes were recommended for the proposed Heart: Road to health model, and given common chronic diseases risk factors it was recommended to be broadened into Chronic disease: Road to health . Conclusion A Chronic disease: Road to health model could provide effective and efficient secondary prevention for people with chronic diseases in rural and remote areas. It is proposed that this approach could reduce gaps and duplication in current healthcare services and provide flexible, client-centred, holistic, culturally responsive services, and improve client outcomes.

Building better systems of care for Aboriginal and Torres Strait Islander people: findings from the Kanyini health systems assessment.

BACKGROUND: Australian federal and jurisdictional governments are implementing ambitious policy initiatives intended to improve health care access and outcomes for Aboriginal and Torres Strait Islander people. In this qualitative study we explored Aboriginal Medical Service (AMS) staff views on factors needed to improve chronic care systems and assessed their relevance to the new policy environment. METHODS: Two theories informed the study: (1) 'candidacy', which explores "the ways in which people's eligibility for care is jointly negotiated between individuals and health services"; and (2) kanyini or 'holding', a Central Australian philosophy which describes the principle and obligations of nurturing and protecting others. A structured health systems assessment, locally adapted from Chronic Care Model domains, was administered via group interviews with 37 health staff in six AMSs and one government Indigenous-led health service. Data were thematically analysed. RESULTS: Staff emphasised AMS health care was different to private general practices. Consistent with kanyini, community governance and leadership, community representation among staff, and commitment to community development were important organisational features to retain and nurture both staff and patients. This was undermined, however, by constant fear of government funding for AMSs being withheld. Staff resourcing, information systems and high-level leadership were perceived to be key drivers of health care quality. On-site specialist services, managed by AMS staff, were considered an enabling strategy to increase specialist access. Candidacy theory suggests the above factors influence whether a service is 'tractable' and 'navigable' to its users. Staff also described entrenched patient discrimination in hospitals and the need to expend considerable effort to reinstate care. This suggests that Aboriginal and Torres Strait Islander people are still constructed as 'non-ideal users' and are denied from being 'held' by hospital staff. CONCLUSIONS: Some new policy initiatives (workforce capacity strengthening, improving chronic care delivery systems and increasing specialist access) have potential to address barriers highlighted in this study. Few of these initiatives, however, capitalise on the unique mechanisms by which AMSs 'hold' their users and enhance their candidacy to health care. Kanyini and candidacy are promising and complementary theories for conceptualising health care access and provide a potential framework for improving systems of care.

Australian Aboriginal and Torres Strait Islander Health Information: Progress, Pitfalls, and Prospects.

Despite significant developments in Aboriginal and Torres Strait Islander Health information over the last 25 years, many challenges remain. There are still uncertainties about the accuracy of estimates of the summary measure of life expectancy, and methods to estimate changes in life expectancy over time are unreliable because of changing patterns of identification. Far too little use is made of the wealth of information that is available, and formal systems for systematically using that information are often vestigial to non-existent. Available information has focussed largely on traditional biomedical topics and too little on access to, expenditure on, and availability of services required to improve health outcomes, and on the underpinning issues of social and emotional wellbeing. It is of concern that statistical artefacts may have been misrepresented as indicating real progress in key health indices. Challenges and opportunities for the future include improving the accuracy of estimation of life expectancy, provision of community level data, information on the availability and effectiveness of health services, measurement of the underpinning issues of racism, culture and social and emotional wellbeing (SEWB), enhancing the interoperability of data systems, and capacity building and mechanisms for Indigenous data governance. There is little point in having information unless it is used, and formal mechanisms for making full use of information in a proper policy/planning cycle are urgently required.

Rationale and design of the Kanyini guidelines adherence with the polypill (Kanyini-GAP) study: a randomised controlled trial of a polypill-based strategy amongst indigenous and non indigenous people at high cardiovascular risk.

BACKGROUND: The Kanyini Guidelines Adherence with the Polypill (Kanyini-GAP) Study aims to examine whether a polypill-based strategy (using a single capsule containing aspirin, a statin and two blood pressure-lowering agents) amongst Indigenous and non-Indigenous people at high risk of experiencing a cardiovascular event will improve adherence to guideline-indicated therapies, and lower blood pressure and cholesterol levels. METHODS/DESIGN: The study is an open, randomised, controlled, multi-centre trial involving 1000 participants at high risk of cardiovascular events recruited from mainstream general practices and Aboriginal Medical Services, followed for an average of 18 months. The participants will be randomised to one of two versions of the polypill, the version chosen by the treating health professional according to clinical features of the patient, or to usual care. The primary study outcomes will be changes, from baseline measures, in serum cholesterol and systolic blood pressure and self-reported current use of aspirin, a statin and at least two blood pressure lowering agents. Secondary study outcomes include cardiovascular events, renal outcomes, self-reported barriers to indicated therapy, prescription of indicated therapy, occurrence of serious adverse events and changes in quality-of-life. The trial will be supplemented by formal economic and process evaluations. DISCUSSION: The Kanyini-GAP trial will provide new evidence as to whether or not a polypill-based strategy improves adherence to effective cardiovascular medications amongst individuals in whom these treatments are indicated. TRIAL REGISTRATION: This trial is registered with the Australian New Zealand Clinical Trial Registry ACTRN126080005833347.

Strengthening the link between policy formulation and implementation of Indigenous health policy directions.

This study aimed to understand the problems within the Indigenous health policy process in Australia and how weaknesses in the process impact on policy implementation. Using semi-structured questions, 23 key stakeholders in the policy-making process were interviewed. Three main themes dominated; a need for increased Indigenous involvement in policy formulation at the senior Australian Government level, increased participation of Indigenous community-controlled health organisations in the policy-making process and, most importantly, ensuring that policies have the necessary resources for their implementation. The emergence of these specific themes demonstrated weaknesses in policy process from the formulation stage onward. Tackling these would, according to our informants, significantly enhance the effectiveness of the policy process and contribute to further improvement of the health of Indigenous Australians.

Diagnosis and management costs of suspicious skin lesions from a population-based melanoma screening programme.

BACKGROUND: Recently, massive increases in health-care costs for the diagnosis and management of skin lesions have been observed (2000-05). The aim of this study was to describe the health system costs attributed to the diagnosis and management of suspicious skin lesions detected during a trial of a population melanoma screening programme (1998-2001). SETTING: Queensland, Australia. METHODS: Data from the trial and Medicare Australia were used to categorize and cost all suspicious skin lesions arising from the trial, which included general practitioner consultations, diagnosis/management and pathology. Comparisons were made with other screened and unscreened populations. RESULTS: Overall, 2982 lesions were treated within the trial producing a mean cost of Aus$118 per lesion. Excisions for benign lesions contributed the greatest proportion of total costs (45%). The total cost burden was approximately 10% higher for men than women, and 63% of overall costs were for persons aged >or=50 years. For diagnosis and management procedures, the estimated average cost per 1000 individuals was Aus$23,560 for men aged >or=50 years from the skin cancer screening trial, compared with Aus$26,967 for BreastScreen Australia and Aus$3042 for the National Cervical Screening Program. CONCLUSIONS: The proportion of costs for benign skin lesions and biopsies arising from the screening programme were no higher than in the two-year period outside the trial. While comparisons are difficult, it appears that diagnostic and management costs for skin cancer as a result of screening may be comparable with those for BreastScreen Australia, if screening is targeted at men aged >or=50 years.

Clinical outcomes from skin screening clinics within a community-based melanoma screening program.

BACKGROUND: Within a randomized trial of population screening for melanoma, primary care physicians conducted whole-body skin examinations and referred all patients with suspect lesions to their own doctor for further treatment. OBJECTIVE: Our aim was to describe characteristics of skin screening participants, clinical screening diagnoses, management following referral, and specificity and yield of screening examinations. METHODS: Information collected from consent forms, referral forms, and histopathological reports of lesions that had been excised or undergone biopsy was analyzed by means of descriptive statistics. RESULTS: A total of 16,383 whole-body skin examinations resulted in 2302 referrals (14.1% overall; 15.5% men, 18.2% > or = 50 years of age) for 4129 suspect lesions (including 222 suspected melanoma, 1101 suspected basal cell carcinomas [BCCs], 265 suspected squamous cell carcinomas [SCCs]). Histopathologic results were available for 94.8% of 1417 lesions excised and confirmed 33 melanomas (23 in men; 24 in participants > or = 50 years of age), 259 BCCs, and 97 SCCs. The probability of detecting skin cancer of any type within the program was 2.4%. The estimated specificity of whole-body skin examinations for melanoma was 86.1% (95% confidence interval = 85.6-86.6). The positive predictive value (number of confirmed/number of lesions excised or biopsied x 100) for melanoma was 2.5%, 19.3% for BCC, and 7.2% for SCC (overall positive predictive value for skin cancer, 28.9%). LIMITATIONS: Follow-up of participants with a negative screening examination has not been conducted for the present investigation. CONCLUSIONS: The rate of skin cancer detected per 100 patients screened was higher than previously reported and men and attendees older than 50 years more frequently received a referral and diagnosis of melanoma. The specificity for detection of melanoma through whole-body skin examination by a primary care physician was comparable to that of other screening tests, including mammography.

Urban-rural differences in survival from cutaneous melanoma in Queensland.

OBJECTIVE: To assess how much of the urban-rural disparity in melanoma survival in Queensland is due to later diagnosis. METHODS: Data were obtained from the population-based Queensland Cancer Registry. We used incident cases for the six years 1996 to 2001 with follow-up to the end of 2002, so that all patients were followed for at least 12 months with a median follow-up time of 41 months. Cox regression models were used to compare urban versus rural case-fatality rates, after adjusting for thickness, level, subsite, age and sex. RESULTS: The adjusted case-fatality rate was 20% higher in rural versus urban areas (hazard ratio 1.20, 95% CI 1.02-1.43). CONCLUSIONS: There is some characteristic of living in an urban area, other than earlier diagnosis, that improves melanoma survival. In the first instance, differences in access to services and variation in management practices deserve investigation and exclusion.

Using linkage between hospital and ABS mortality data to enhance reporting of deaths among Aboriginal and Torres Strait Islander peoples.

OBJECTIVE: To investigate the potential of record linkage between the Australian Bureau of Statistics (ABS) mortality data and the NSW Admitted Patient Data Collection (APDC) to improve reporting of deaths among Aboriginal and Torres Strait Islander peoples. METHODS: ABS mortality data for 2002 to 2006 were linked with APDC records for 2001 to 2006. Six algorithms were developed to enumerate deaths. Possible biases by age, sex and geographic remoteness were investigated. RESULTS: Levels of reporting ranged from baseline reporting on the ABS mortality data to the largest enhancement with the 'ever reported as Aboriginal or Torres Strait Islander' algorithm. Enhancement was more likely in females, older people and residents of major cities. CONCLUSIONS: Data linkage substantially improved reporting of Aboriginal and Torres Strait Islander deaths. An algorithm that includes both the number of APDC records and the number of facilities reporting a person as Aboriginal or Torres Strait Islander was considered most promising. IMPLICATIONS: Inclusion of other datasets in the enhancement process is warranted to further improve reporting and address possible bias produced by using APDC records only. Further work should take into account the possibility that a person may be falsely reported as Aboriginal or Torres Strait Islander or not reported in either hospital or death records.

Our hearts and minds--what would it take for Australia to become the healthiest country in the world?

OBJECTIVE: To highlight recent reductions in mortality rates in Australia and identify conditions and population groups with the greatest potential for further reduction in mortality rates. DESIGN: International benchmarking and intranational comparisons of mortality rates were used to identify areas with the greatest potential for improvement. RESULTS: Latest data from Organisation for Economic Cooperation and Development (OECD) countries confirm that, while Japan's death rates remain the lowest in the world, Australia's are decreasing rapidly and we now rival Switzerland for second overall ranking. When the contributions of specific conditions are compared, the areas with the greatest potential for reductions are circulatory diseases (especially ischaemic heart disease); suicide; injury and violence; smoking-related conditions; and cancers amenable to prevention/early detection. Intranational comparisons show considerable scope for reduction in inequalities, especially those between Aboriginal and Torres Strait Islander peoples and other Australians, between males and females, and between low and high socioeconomic groups. These conditions and inequalities are highly interrelated, as differentials in health status are often mediated through broader societal inequalities. CONCLUSIONS: Australia should aim to become the country with the lowest mortality rate in the world. This could realistically be achieved by benchmarking performance nationally and internationally, applying current knowledge and available interventions, matching policies with funding, and implementing systemic national programs and activities to promote health and prevent "illth".