Oral glucose tolerance test-The imperfect gold standard for gestational diabetes screening: A qualitative study involving clinicians in regional, rural and remote areas of Western Australia.

ISSUE ADDRESSED: The oral glucose tolerance test is the 'gold standard' for detecting gestational diabetes in Australian and International guidelines. Test completion in regional, rural and remote regions may be as low as 50%. We explored challenges and enablers for regional, rural and remote antenatal clinicians providing gestational diabetes screening to better understand low oral glucose tolerance test completion. METHODS: We conducted a qualitative descriptive study using semi-structured interviews. Participants eligible for the study were doctors or midwives providing antenatal care in regional, rural and remote Western Australia, between August 2019 and November 2020. Interviews were recorded digitally and transcribed into a Word document. We conducted a thematic analysis after initial categorisation and deduction of themes through workshops involving the research team. RESULTS: We found a diversity of viewpoints on oral glucose tolerance test reliability for detecting gestational diabetes. Themes that emerged were; good collaboration between antenatal clinicians is required for successful screening; screening occurs throughout pregnancy using various tests; clinicians make significant efforts to address barriers; clinicians prioritise therapeutic relationships. CONCLUSIONS: Effective universal screening for gestational diabetes in regional, rural and remote Western Australia is difficult and more complex in practice than guidelines imply. Detecting gestational diabetes requires creative solutions, early identification of at risk women and trust and collaboration between clinicians and women. SO WHAT?: Detection of gestational diabetes in regional, rural and remote Western Australia remains poorly completed. New strategies are required to adequately identify women at risk of adverse birth outcomes relating to hyperglycaemia in pregnancy.

Early childhood development practices in a remote Aboriginal Community Controlled Health Services setting.

OBJECTIVE: Supporting Early Childhood Development (ECD) is an Australian national priority. Aboriginal children in Western Australia's Kimberley region have much higher rates of developmental concerns at school entry than non-Aboriginal children. We aimed to describe ECD practices in the participating service; document follow-up of identified developmental concerns; and identify barriers and enablers to incorporating ECD practices into clinic activity. DESIGN: Mixed-method design incorporating clinical audit and staff interviews. SETTING: An Aboriginal Community Controlled Health Service (ACCHS) in the Kimberley region. PARTICIPANTS: A total of 176 children receiving primary health care through the participating ACCHS; interviews with five ACCHS staff members. MAIN OUTCOME MEASURES: Frequency of developmental enquiry by age and domain; follow-up of identified developmental concerns; and barriers and enablers to ECD practices. RESULTS: Developmental enquiry was documented for 114 of 176 eligible children (65%), including in 80% of ACCHS child health assessments. Standardised ECD assessments were less common. Staff were aware of the importance of developmental enquiry, however, barriers to increasing ECD practices included a lack of resources and structured staff education, time pressures and a lack of role clarity between the ACCHS and government community health clinic. CONCLUSIONS: This study provides insight into ECD practices in an ACCHS setting, highlighting the potential of primary health care to have an enhanced role in ECD if appropriate systems, training and tools are provided. A lack of role clarity across services, combined with poor communication between services, creates a potential risk for missed opportunities to support ECD.

Risk and resilience: a mixed methods investigation of Aboriginal Australian women's perinatal mental health screening assessments.

PURPOSE: To describe the psychosocial protective and risk factors for perinatal mental health identified in a sample of Aboriginal women's Kimberley Mum's Mood Scale (KMMS) assessments and explore the role of these factors in their screening assessment and diagnostic outcome. METHODS: We used a mixed methods approach to retrospectively analyse a cross-sectional study dataset of 91 completed KMMS assessments. This included: categorising the clinical notes from the KMMS psychosocial yarn into 'risk' and 'protective' factors and describing these categories, describing the number and type of risk and protective factors associated with different KMMS risk assessment categories (no, low, medium, high), and exploring relationships between these risk and protective factors and diagnosis of perinatal depression and/or anxiety. RESULTS: Protective factors were recorded for the vast majority of the women; the most prominent was positive family relationships. When protective and risk factors were stratified by KMMS risk category, women in the higher risk group less commonly had specific protective factors (11-33% high vs 61-100% no risk) and more commonly had risk factors (22-67% high vs 6-28% no risk) than women with lower KMMS assessed risk. The average number of protective factors decreased with increasing KMMS risk category (4.9 ± 1.1 to 1.6 ± 1.3), with the inverse pattern for risk factors (1.1 ± 1.1 to 3.8 ± 1.0). Having protective factors also appeared to reduce the risk of developing clinical depression or anxiety. CONCLUSION: Assessing protective factors in mental health screening for perinatal Aboriginal women increases the effectiveness of screening and provides a foundation for the delivery of local structured psychosocial care.

"When I got the news": Aboriginal fathers in the Kimberley region yarning about their experience of the antenatal period.

ISSUE ADDRESSED: Paternal involvement during the antenatal period is recognised as a positive contributor to a child's health and developmental outcomes. Little is known about Aboriginal Australian men's experiences and perceptions during their partner's antenatal period. METHODS: A qualitative yarning methodology was used to explore the experiences of ten Aboriginal Australian fathers during their partner's antenatal period, in a remote Northern Australian town. RESULTS: The study found the participants valued supporting their partners through pregnancy, making positive changes to their lifestyles, and having access to information on pregnancy. Participants described experiencing multiple stressors during the antenatal period that impacted on their social and emotional wellbeing. This is despite the range of protective factors identified by them. Participants had diverse experiences with health care providers during the antenatal period. CONCLUSIONS: This study demonstrated that these Aboriginal men valued engagement with antenatal care (ANC) services and highlighted strategies to improve Aboriginal paternal involvement with ANC services. SO WHAT?: Enhancing ANC to be inclusive of fathers, through a local co-design process, could strengthen and support Aboriginal families to achieve improved health and wellbeing outcomes across the family system.

Pregnancy intentions in a group of remote-dwelling Australian Aboriginal women: a qualitative exploration of formation, expression and implications for clinical practice.

BACKGROUND: Unintended pregnancies are associated with poorer obstetric outcomes and are sometimes measured at a population level as a surrogate marker for reproductive autonomy and access to health services, including contraception. Aboriginal Australians face many disparities in health outcomes, including in reproductive health and antenatal care. We aimed to explore the formation and expression of pregnancy intentions in an Aboriginal population to inform health service improvements. METHODS: Semi-structured interviews were conducted with 27 remote-dwelling Aboriginal women, aged 18-49 years. Content analysis was conducted; key themes were discussed with groups of women from participating communities to refine interpretation. RESULTS: Most (19/27) participants expressed pregnancy intentions congruent with reported contraceptive behaviour while eight expressed ambivalent or uncertain intentions. Intentions were shaped by traditional kinship practices, reproductive autonomy and desired family formation. Younger women tended to aspire to smaller family sizes than older women and support was expressed for the postponement of first pregnancy to achieve other life goals. Women in these communities hold strong traditional beliefs, including regarding conception, but did not use traditional methods of contraception in place of modern methods. Reproductive coercion, in the form of pressure to fall pregnant, was recognised as an important issue by women in the community. CONCLUSION: Consultation strategies that promote rapport, allow space for uncertainty and are inclusive of important personal and cultural contexts are likely to improve shared understanding of pregnancy intention. Universal screening for reproductive coercion and broad counselling on contraceptive options (including discrete methods) may reduce unmet need for contraception. Community approaches supporting reproductive autonomy that is inclusive of men, and enhanced educational and occupational opportunities for young women are needed.

Study protocol: a clinical trial for improving mental health screening for Aboriginal and Torres Strait Islander pregnant women and mothers of young children using the Kimberley Mum's Mood Scale.

BACKGROUND: Improving the rates of, and instruments used in, screening for perinatal depression and anxiety among Aboriginal and Torres Strait Islander women are important public health priorities. The Kimberley Mum's Mood Scale (KMMS) was developed and later validated as an effective and acceptable perinatal depression and anxiety screening tool for the Kimberley region under research conditions. Other regions have expressed interest in using the KMMS with perinatal Aboriginal and Torres Strait Islander women. It is, however, important to re-evaluate the KMMS in a larger Kimberley sample via a real world implementation study, and to test for applicability in other remote and regional environments before recommendations for wider use can be made. This paper outlines the protocol for evaluating the process of implementation and establishing the 'real world' validity and acceptability of the KMMS in the Kimberley, Pilbara and Far North Queensland in northern Australia. METHODS: The study will use a range of quantitative and qualitative methods across all sites. KMMS validation/revalidation internal consistency of Part 1 will be determined using Cronbach's alpha. Equivalence for identifying risk of depression and anxiety compared to a standard reference assessment will be determined from receiver operating characteristic curves. Sensitivity and specificity will be determined based on these cut-points. Qualitative methods of phenomenology will be used to explore concepts of KMMS user acceptability (women and health professionals). Additional process evaluation methods will collate, assess and report on KMMS quality review data, consultations with health service administrators and management, field notes, and other documentation from the research team. This information will be reported on using the Dynamic Sustainability Framework. DISCUSSION: This project is contributing to the important public health priority of screening Aboriginal and Torres Strait Islander women for perinatal depression and anxiety with tools that are meaningful and responsive to cultural and clinical needs. Identifying and addressing barriers to implementation contributes to our understanding of the complexity of improving routine clinical practie. TRIAL REGISTRATION: The study was registered retrospectively on 15/05/2019 with the Australian and New Zealand Clinical Trial registry (ACTRN12619000580178).

Diabetes screening in pregnancy failing women in rural Western Australia: An audit of oral glucose tolerance test completion rates.

OBJECTIVE: To quantify screening rate for gestational diabetes mellitus and completion of oral glucose tolerance test in rural and remote Western Australia. DESIGN AND PARTICIPANTS: Retrospective audit of 551 antenatal records from women of 16 years and older without pre-existing diabetes and with singleton pregnancies delivered in 2013. MAIN OUTCOME MEASURES: Number of women recorded screened for gestational diabetes mellitus in second or third trimester using oral glucose tolerance test or other tests; gestational diabetes mellitus rate. RESULTS: Only 278 (50.5%) women were screened with oral glucose tolerance test; 113 (20.5%) had no record of any screening related to gestational diabetes mellitus. In a nested mixed-effects logistic regression model, women with a previous gestational diabetes mellitus diagnosis, two or more risk factors (excluding ethnicity) or high-risk gestational diabetes mellitus ethnicity other than Australian Aboriginal were more likely to be screened, while Australian Aboriginal women were less likely to be screened with oral glucose tolerance test. Clinicians reported patient and clinician factors and logistical difficulties as reasons for the oral glucose tolerance test not being completed at their site. Of those screened with oral glucose tolerance test, a high rate of gestational diabetes mellitus was diagnosed (14.7% versus Western Australia state-wide average of 7.4%). CONCLUSION: Adherence to oral glucose tolerance test screening in rural Western Australia is inadequate for effective screening for gestational diabetes mellitus. Screening was not acceptable or available for a significant proportion of women at risk. Efforts to improve oral glucose tolerance test adherence and exploration of alternative gestational diabetes mellitus screening strategies are required.

Uptake of long-acting, reversible contraception in three remote Aboriginal communities: a population-based study.

OBJECTIVE: To assess the use, effectiveness and acceptance of prescribed contraception in three remote Western Australian Aboriginal communities. PARTICIPANTS AND DESIGN: Mixed method study, including retrospective file review of contraception methods for 566 regular female Aboriginal patients, 1 November 2010 - 1 September 2014, and semi-structured interviews with 20 Aboriginal women. SETTING: Primary care clinics in three remote Aboriginal communities. MAIN OUTCOME MEASURES: Number of episodes of contraceptive use, effectiveness and continuation rates of prescribed contraceptive use; personal experiences, attitudes towards and beliefs about contraception options. RESULTS: 34% of women had used contraception, ranging from 15% of women aged younger than 15 years to 55% of women aged 15-19 years. The most common forms of contraception at the census date were long-acting reversible contraceptives (LARCs): 77% of women using contraception had an etonogestrel implant and 7% had depot medroxyprogesterone. Etonogestrel continuation rates at 1, 2 and 3 years were 87% (95% CI, 81-92%), 72% (95% CI, 64-78%) and 51% (95% CI, 41-60%) respectively. Medroxyprogesterone depot continuation at one year was only 14% (95% CI, 8-22%). Social acceptance of the etonogestrel implant was high; no concerns were raised about stigma or unwanted attention related to implant use. CONCLUSION: The high uptake of LARCs in these communities is consistent with international recommendations about contraception use. High acceptability was reflected in excellent continuation rates. Service delivery models that use community engagement and capacity building are recommended for broadening the focus of sexual health beyond sexually transmitted disease detection and management, giving priority to the reproductive rights and unmet needs of Aboriginal women.

Using glycated haemoglobin testing to simplify diabetes screening in remote Aboriginal Australian health care settings.

OBJECTIVES: To determine whether a combination of point-of-care (POC) and laboratory glycated haemoglobin A (HbA1c) testing (HbA1c algorithm) is more effective in testing for diabetes in everyday practice in remote Australian Aboriginal primary health care, by providing a more rapid definitive result and diagnosing more cases than the standard glucose algorithm. DESIGN: Cross-sectional study that independently classified participants using both diagnostic algorithms and compared their outcomes. PARTICIPANTS: Two hundred and fifty-five Aboriginal Australians aged 15 years or more without confirmed diabetes and due for diabetes testing at participating clinics. SETTING: Six primary health care sites in the Kimberley region of Western Australia from 1 September 2011 to 30 November 2013. MAIN OUTCOME MEASURES: Number of participants with a definitive test result, a completed algorithm and a diagnosis of diabetes; time taken to deliver a test result. RESULTS: Participants were significantly more likely to have a definitive result within 7 days (249 v 199 of 255 participants; P < 0.001), be followed up if an initial laboratory measurement was abnormal (92 v 74 of 167 participants; P = 0.005), and be diagnosed with diabetes (15 v 4 of 255 participants; P = 0.003) using the HbA1c than with the glucose algorithm. Eight participants subsequently diagnosed with diabetes (four using the HbA1c test, four with additional oral glucose tolerance tests that would not normally have been requested) were incorrectly classified as normal by the glucose algorithm. No participants with normal HbA1c measurements were subsequently diagnosed with diabetes. CONCLUSIONS: Use of POC HbA1c testing and collection of venous blood on the same day for a confirmatory laboratory HbA1c testing if the POC HbA1c value is abnormal may simplify diabetes testing in remote areas, provide more timely diagnoses, and increase case detection.

Hepatitis B notifications in a vaccinated cohort of Aboriginal people in the Kimberley region.

OBJECTIVES: To identify cases of hepatitis B infection after vaccination in Kimberley residents and determine maternal serostatus as a potential indicator of mode of transmission. DESIGN AND PARTICIPANTS: Retrospective review of Kimberley residents with notified hepatitis B infection using records of vaccination history and child and maternal serology. MAIN OUTCOME MEASURES: Confirmed cases of hepatitis B infection after vaccination; chronic infection in cases of hepatitis B infection after vaccination; maternal serostatus in confirmed cases of hepatitis B infection after vaccination. RESULTS: From 1 January 1984 to 31 March 2011, we identified 17 cases of Aboriginal residents with hepatitis B infection after vaccination (10 chronic infections, five not defined and two cleared). In six patients, maternal chronic infection had been identified at some stage, raising the possibility of vertical transmission. In seven patients, maternal serology or evidence of subsequent acquisition suggested that horizontal transmission and therefore vaccination failure was likely. For four patients, there was inadequate information to assess possible mode of transmission. CONCLUSIONS: Hepatitis B infection after full vaccination is not limited to children of mothers with active infection. Further undiagnosed infections in the Kimberley are likely, and active monitoring to detect the extent and likely cause of hepatitis B infection in vaccinated children is needed. In children where vertical transmission is a risk, prospective follow-up is warranted.

Clinical trials in a remote Aboriginal setting: lessons from the BOABS smoking cessation study.

BACKGROUND: There is limited evidence regarding the best approaches to helping Indigenous Australians to stop smoking. The composite analysis of the only two smoking cessation randomised controlled trials (RCTs) investigating this suggests that one-on-one extra support delivered by and provided to Indigenous Australians in a primary health care setting appears to be more effective than usual care in encouraging smoking cessation. This paper describes the lessons learnt from one of these studies, the Be Our Ally Beat Smoking (BOABS) Study, and how to develop and implement an integrated smoking cessation program. METHODS: Qualitative study using data collected from multiple documentary sources related to the BOABS Study. As the project neared completion the research team participated in four workshops to review and conduct thematic analyses of these documents. RESULTS: Challenges we encountered during the relatively complex BOABS Study included recruiting sufficient number of participants; managing the project in two distant locations and ensuring high quality work across both sites; providing appropriate training and support to Aboriginal researchers; significant staff absences, staff shortages and high workforce turnover; determining where and how the project fitted in the clinics and consequent siloing of the Aboriginal researchers relating to the requirements of RCTs; resistance to change, and maintaining organisational commitment and priority for the project. The results of this study also demonstrated the importance of local Aboriginal ownership, commitment, participation and control. This included knowledge of local communities, the flexibility to adapt interventions to local settings and circumstances, and taking sufficient time to allow this to occur. CONCLUSIONS: The keys to the success of the BOABS Study were local development, ownership and participation, worker professional development and support, and operating within a framework of cultural safety. There were difficulties associated with the BOABS Study being an RCT, and many of these are shared with stand-alone programs. Interventions targeted at particular health problems are best integrated with usual primary health care. Research to investigate complex interventions in Indigenous health should not be limited to randomised clinical trials and funding needs to reflect the additional, but necessary, cost of providing for local control of planning and implementation.

The Be Our Ally Beat Smoking (BOABS) study, a randomised controlled trial of an intensive smoking cessation intervention in a remote aboriginal Australian health care setting.

BACKGROUND: Australian Aboriginal and Torres Strait Islander peoples (Indigenous Australians) smoke at much higher rates than non-Indigenous people and smoking is an important contributor to increased disease, hospital admissions and deaths in Indigenous Australian populations. Smoking cessation programs in Australia have not had the same impact on Indigenous smokers as on non-Indigenous smokers. This paper describes the outcome of a study that aimed to test the efficacy of a locally-tailored, intensive, multidimensional smoking cessation program. METHODS: A randomised controlled trial of Aboriginal researcher delivered tailored smoking cessation counselling during face-to-face visits, aiming for weekly for the first four weeks, monthly to six months and two monthly to 12 months. The control ("usual care") group received routine care relating to smoking cessation at their local primary health care service. Data collection occurred at enrolment, six and 12 months. The primary outcome was self-reported smoking cessation with urinary cotinine confirmation at final follow-up (median 13 (interquartile range 12-15) months after enrolment). RESULTS: Participants in the intervention (n = 55) and usual care (n = 108) groups were similar in baseline characteristics, except the intervention group was slightly older. At final follow-up the smoking cessation rate for participants assigned to the intervention group (n = 6; 11%), while not statistically significant, was double that of usual care (n = 5; 5%; p = 0.131). A meta-analysis of these findings and a similarly underpowered but comparable study of pregnant Indigenous Australian women showed that Indigenous Australian participants assigned to the intervention groups were 2.4 times (95% CI, 1.01-5.5) as likely to quit as participants assigned to usual care. CONCLUSIONS: Culturally appropriate, multi-dimensional Indigenous quit smoking programs can be successfully implemented in remote primary health care. Intensive one-on-one interventions with substantial involvement from Aboriginal and Torres Strait Islander workers are likely to be effective in these settings. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12608000604303).

Quality improvement in practice: improving diabetes care and patient outcomes in Aboriginal Community Controlled Health Services.

BACKGROUND: Management of chronic disease, including diabetes, is a central focus of most Aboriginal Community Controlled Health Services (ACCHSs) in Australia. We have previously demonstrated that diabetes monitoring and outcomes can be improved and maintained over a 10-year period at Derby Aboriginal Health Service (DAHS). While continuous quality improvement (CQI) has been shown to improve service delivery rates and clinical outcome measures, the process of interpreting audit results and developing strategies for improvement is less well described. This paper describes the evaluation of care of patients with type 2 diabetes mellitus (T2DM) and features of effective CQI in ACCHSs in the remote Kimberley region of north Western Australia. METHODS: Retrospective audit of records for Aboriginal and Torres Strait Islander primary care patients aged ≥15 years with a confirmed diagnosis of T2DM at four Kimberley ACCHSs from 1 July 2011 to 30 June 2012. Interviews with health service staff and focus group discussions with patients post audit. MAIN OUTCOME MEASURES: diabetes care related activities, clinical outcome measures and factors influencing good diabetes related care and effective CQI. RESULTS: A total of 348 patients from the four ACCHSs were included in the study. Clinical care activities were generally high across three of the four health services (at least 71% of patients had cholesterol recorded, 89% blood pressure, 84% HbA1c). Patients from DAHS had lower median cholesterol levels (4.4 mmol/L) and the highest proportion of patients meeting clinical targets for HbA1c (31% v 16% ACCHS-3; P = 0.02). Features that facilitated good care included clearly defined staff roles for diabetes management, support and involvement of Aboriginal Health Workers, efficient recall systems, and well-coordinated allied health services. Effective CQI features included seamless and timely data collection, local ownership of the process, openness to admitting deficiencies and willingness to embrace change. CONCLUSIONS: Well-designed health care delivery and CQI systems, with a strong sense of ownership over diabetes management led to increased service delivery rates and improved clinical outcome measures in ACCHSs. Locally run CQI processes may be more responsive to individual health services and more sustainable than externally driven systems.

Aboriginal health research in the remote Kimberley: an exploration of perceptions, attitudes and concerns of stakeholders.

BACKGROUND: For decades Indigenous peoples have argued for health research reform claiming methods used and results obtained often reflect the exploitative history of colonisation. In 2006 the Kimberley Aboriginal Health Planning Forum (KAHPF) Research Subcommittee (hereafter, the Subcommittee) was formed to improve research processes in the remote Kimberley region of north Western Australia. This paper explores the major perceptions, attitudes and concerns of stakeholders in the Subcommittee. METHODS: Qualitative analysis was carried out on data retrospectively collected from multiple evidentiary sources linked to the Subcommittee i.e. database, documents, interviews, review forms and emails from 1 January 2007 to 31 October 2013. RESULTS: From 1 January 2007 to 30 June 2013 the Subcommittee received 95 proposals, 57 (60%) driven by researchers based outside the region. Local stakeholders (22 from 12 different Kimberley organisations) raised concerns about 36 (38%) projects, 30 (83%) of which were driven by external researchers. Major concerns of local stakeholders were inadequate community consultation and engagement; burden of research on the region; negative impact of research practices; lack of demonstrable community benefit; and power and control of research. Major themes identified by external stakeholders (25 external researchers who completed the review form) were unanticipated difficulties with consultation processes; barriers to travel; perceiving research as a competing priority for health services and time-consuming ethics processes. External stakeholders also identified strategies for improving research practices in the Kimberley: importance of community support in building good relationships; employing local people; flexibility in research approaches; and importance of allocating sufficient time for consultation and data collection. CONCLUSIONS: Health research in the Kimberley has improved in recent years, however significant problems remain. Prioritising research addressing genuine local needs is essential in closing the gap in Indigenous life expectancy. The long-term aim is for local health service connected researchers to identify priorities, lead, conduct and participate in the majority of local health research. For this to occur, a more radical move involving reconceptualising the research process is needed. Changes to institutional timeframes and funding processes could improve Indigenous and community-based research.

Peritoneal dialysis outcomes of Indigenous Australian patients of remote Kimberley origin.

OBJECTIVES: To compare clinical outcomes and mortality rates between Kimberley Indigenous, other Indigenous and non-Indigenous Australian patients on peritoneal dialysis (PD). DESIGN AND PARTICIPANTS: Patients commencing renal replacement therapy (RRT) with PD for the first time from 1 January 2003 to 31 December 2009 were retrospectively identified. Secondary data from medical records and the Australian and New Zealand Dialysis and Transplant Registry from 1 January 2003 to 31 December 2010 were used to compare outcomes between patients. MAIN OUTCOME MEASURES: Time to first peritonitis; failure and death rates per 100 patient-years, hazard ratios, unadjusted and adjusted (for age, sex, comorbid conditions, PD not the first RRT modality used). Comparison of the two PD systems used in the Kimberley. RESULTS: Kimberley patients had significantly shorter median time to first peritonitis (11.2 versus 21.5 months), higher technique failure (46.0 versus 25.2 per 100 patient-years) and shorter median survival on PD (17.5 versus 22.4 months) but similar adjusted mortality (hazard ratio 1.32; 95% CI, 0.76-2.29) as non-Indigenous patients. They also had a significantly higher technique failure rate than other Indigenous patients (46.0 versus 31.4 per 100 patient-years) and nearly double the average peritonitis episodes previously reported for Indigenous Australians (2.0 versus 1.15 per patient-year). CONCLUSIONS: PD can bring patients closer to home; however, it is relatively short term and potentially hazardous. PD remains an important therapy for suitable remote patients to get closer to home, providing they are fully informed of the options. The current expansion of safer Kimberley haemodialysis options needs to continue.

Quality indicators of diabetes care: an example of remote-area Aboriginal primary health care over 10 years.

OBJECTIVES: To describe service characteristics of Derby Aboriginal Health Service (DAHS) and document diabetes management activities and intermediate clinical outcomes for Aboriginal patients with type 2 diabetes. DESIGN, SETTING AND PATIENTS: Retrospective audit of records for patients ≥ 15 years old who had a confirmed diagnosis of type 2 diabetes, received primary health care from DAHS for at least 6 continuous months between 1 July 1999 and 30 June 2009, resided in the Derby area and were not on renal replacement therapy. MAIN OUTCOME MEASURES: Electronic records of blood pressure (BP), glycated haemoglobin (HbA(1c)) level, weight, albumin-creatinine ratio, creatinine level or estimated glomerular filtration rate, lipid levels and smoking status during each audit year; and proportions of patients who met clinical targets for HbA(1c), BP and cholesterol. RESULTS: Over the 10 years, the proportion of clinical care activities undertaken according to regional protocols increased significantly, with very high levels recorded in the last 3 years (at least 70% of patients had each activity recorded). There were significant improvements in systolic BP, diastolic BP and cholesterol levels over the 10 years (P < 0.001 for all). In the final year, 69% of patients had at least half their BP measurements ≤ 130/80 mmHg and 83% had median annual cholesterol levels of < 5.5 mmol/L. There were small improvements in HbA(1c) levels that approached statistical significance (P = 0.05). In the final year, 34% of patients had median annual HbA(1c) levels of ≤ 7.0%. CONCLUSIONS: This study shows that diabetes monitoring and outcomes can be improved and maintained over a 10-year period in a well supported remote Aboriginal community-controlled health service setting.

The protocol for the Be Our Ally Beat Smoking (BOABS) study, a randomised controlled trial of an intensive smoking cessation intervention in a remote Aboriginal Australian health care setting.

BACKGROUND: Australian Aboriginal peoples and Torres Strait Islanders (Indigenous Australians) smoke at much higher rates than non-Indigenous people and smoking is an important contributor to increased disease, hospital admissions and deaths in Indigenous Australian populations. Smoking cessation programs in Australia have not had the same impact on Indigenous smokers as on non-Indigenous smokers. This paper describes the protocol for a study that aims to test the efficacy of a locally-tailored, intensive, multidimensional smoking cessation program. METHODS/DESIGN: This study is a parallel, randomised, controlled trial. Participants are Aboriginal and Torres Strait Islander smokers aged 16 years and over, who are randomly allocated to a 'control' or 'intervention' group in a 2:1 ratio. Those assigned to the 'intervention' group receive smoking cessation counselling at face-to-face visits, weekly for the first four weeks, monthly to six months and two monthly to 12 months. They are also encouraged to attend a monthly smoking cessation support group. The 'control' group receive 'usual care' (i.e. they do not receive the smoking cessation program). Aboriginal researchers deliver the intervention, the goal of which is to help Aboriginal peoples and Torres Strait Islanders quit smoking. Data collection occurs at baseline (when they enrol) and at six and 12 months after enrolling. The primary outcome is self-reported smoking cessation with urinary cotinine confirmation at 12 months. DISCUSSION: Stopping smoking has been described as the single most important individual change Aboriginal and Torres Strait Islander smokers could make to improve their health. Smoking cessation programs are a major priority in Aboriginal and Torres Strait Islander health and evidence for effective approaches is essential for policy development and resourcing. A range of strategies have been used to encourage Aboriginal peoples and Torres Strait Islanders to quit smoking however there have been few good quality studies that show what approaches work best. More evidence of strategies that could work more widely in Indigenous primary health care settings is needed if effective policy is to be developed and implemented. Our project will make an important contribution in this area. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12608000604303).

Culture and rural health.

This paper considers the role of culture in rural health, suggesting that the concept and its impacts are insufficiently understood and studied. It reviews some of the ways that culture has been considered in (rural) health, and states that culture is either used ambiguously and broadly - for example, suggesting that there is a rural culture, or narrowly - indeed perhaps interchangeably with ethnicity, for example Aboriginal culture as a unity. The paper notes that, although culture is a dynamic social concept, it has been adopted into a biomedical research paradigm as though it is fixed. Culture is often treated as though it is something that can be addressed simplistically, for example, through cultural sensitivity education. Authors suggest that culture is an unaddressed 'elephant in the room' in rural health, and that exploring cultural differences and beliefs and facing up to cultural differences are vital in understanding and addressing rural health and health system challenges.

Implementation of the 'Kimberley Mum's Mood Scale' across primary health care services in the Kimberley region of Western Australia: A mixed methods assessment.

The Kimberley Mum's Mood Scale (KMMS) was co-designed with Aboriginal women and healthcare professionals to improve culturally appropriate screening practices for perinatal depression and anxiety. This paper describes the implementation of the KMMS across the remote Kimberley region of Western Australia from January 2018 to December 2021. We used the Dynamic Sustainability Framework to progress the implementation and assess at the intervention, practice setting and ecological system level using a mixed methods approach to analyse implementation. Rates of administration and results of screening were described using a retrospective audit of electronic medical records. Analyses of KMMS training registry, stakeholder engagement and sustainability initiatives were descriptive. KMMS acceptability was assessed using qualitative descriptive approaches to analyse patient feedback forms (n = 39), healthcare professional surveys (n = 15) and qualitative interviews with healthcare professionals (n = 6). We found a significant increase in overall recorded perinatal screening (pre-implementation: 30.4% v Year 3: 46.5%, P < 0.001) and use of the KMMS (pre-implementation: 16.4% v Year 3: 46.4%, P < 0.001). There was improved fidelity in completing the KMMS (from 2.3% to 61.8%, P < 0.001), with 23.6% of women screened recorded as being at increased risk of depression and anxiety. Most healthcare professionals noted the high levels of perinatal mental health concerns, stress, and trauma that their patients experienced, and identified the KMMS as the most appropriate perinatal screening tool. Aboriginal women reported that it was important for clinics to ask about mood and feelings during the perinatal period, and that the KMMS was appropriate. Aboriginal women consistently reported that it was good to have someone to talk to. This study demonstrates that innovation in perinatal depression and anxiety screening for Aboriginal women is possible and can be implemented into routine clinical care with the support of a sustained multi-year investment and strong partnerships.