Is ethnicity an appropriate measure of health care marginalization? A systematic review and meta-analysis of the outcomes of diabetic foot ulceration in Aboriginal populations.

BACKGROUND: Aboriginal people have higher prevalence rates of diabetes than non-Aboriginal people in the same geographic locations, and diabetic foot ulcer (DFU) complication rates are also presumed to be higher. The aim of this systematic review and meta-analysis was to compare DFU outcomes in Aboriginal and non-Aboriginal populations. METHODS: We searched PubMed, Embase, CINAHL and the Cochrane Library from inception to October 2018. Inclusion criteria were all types of studies comparing the outcomes of Aboriginal and non-Aboriginal patients with DFU, and studies from Canada, the United States, Australia and New Zealand. Exclusion criteria were patient age younger than 18 years, and studies in any language other than English. The primary outcome was the major amputation rate. We assessed the risk of bias using the ROBINS-I (Risk Of Bias In Non-randomized Studies - of Interventions) tool. Effect measures were reported as odds ratio (OR) with 95% confidence interval (CI). RESULTS: Six cohort studies with a total of 244 792 patients (2609 Aboriginal, 242 183 non-Aboriginal) with DFUs were included. The Aboriginal population was found to have a higher rate of major amputation than the non-Aboriginal population (OR 1.85, 95% CI 1.04-3.31). Four studies were deemed to have moderate risk of bias, and 2 were deemed to have serious risk of bias. CONCLUSION: Our analysis of the available studies supports the conclusion that DFU outcomes, particularly the major amputation rate, are worse in Aboriginal populations than in non-Aboriginal populations in the same geographic locations. Rurality was not uniformly accounted for in all included studies, which may affect how these outcome differences are interpreted. The effect of rurality may be closely intertwined with ethnicity, resulting in worse outcomes.

Is Cam Morphology Found in Ancient and Medieval Populations in Addition to Modern Populations?

BACKGROUND: Cam morphology is thought to originate near puberty and reflects a response of the peripheral aspect of the proximal femoral physis to increased local load. Participation in particular sports activities has been associated with cam morphology in contemporary patient populations; however, it is unclear whether cam is a recent phenomenon. There are limited data regarding the frequency of its occurrence and the general deviations in femoral anatomy in different historical populations. Such information may help to understand the possible influence of lifestyle and diet on cam morphology. QUESTIONS/PURPOSES: The purpose of this study was to evaluate femoral morphology in three historical populations. We asked: (1) Was cam morphology present in the three study populations, did those populations differ, and were there differences between sexes? (2) Were there differences in neck-shaft angle, version, or inclination between and among the examined populations? METHODS: We examined 204 adult femurs from the Neolithic population from Iran (n = 37, 3000 BC to 1631 BC), medieval population from Poland (n = 135, 10th to 13th centuries), and contemporary Australian aborigines (n = 32, early 20th century), provided by the Open Research Scan Archive, Museum of the First Piasts at Lednica and the University of Wroclaw, respectively. All three human populations represent different chronologic periods and lifestyles. All bones were scanned using CT and then measured on their three-dimensional (3-D) reconstructions in selected planes. Cam impingement was defined as an alpha angle > 55° measured on the inclination view. To evaluate the differences in anatomy between populations, we measured the true neck-shaft angle on the true AP view, apparent neck-shaft angle on the apparent AP view, the version angle on the version view, and the inclination angle on the inclination view. The prevalence of cam morphology and other anatomic parameters were compared among groups using chi-square test, one-way ANOVA with post hoc Tukey test, and paired t-test. RESULTS: Cam morphology was present in 5% of the Neolithic population from Iran, in 7% of the medieval population from Poland, and 3% of the contemporary Australian aborigine femurs (OR Neolithic population from Iran/the medieval population from Poland 0.7 [95% CI 0.2 to 3.4]; p = 0.67; OR Neolithic population from Iran/contemporary Australian aborigines 1.8 [95% CI 0.2 to 20.5]; p = 0.65; OR the medieval population from Poland/contemporary Australian aborigines 2.5 [95% CI 0.3 to 20.1]; p = 0.40). There were differences in the presence of cam morphology between the sexes in the medieval population from Poland with both femurs (females: 1% [1 of 76]; males: 15% [9 of 59]; p = 0.002). There was a difference in true neck-shaft angle between the Neolithic population from Iran (121° ± 6°) and contemporary Australian aborigines (131° ± 5°; mean difference 10° [95% CI 7° to 13°]; p < 0.001) and between the medieval population from Poland (124° ± 5°) and the contemporary Australian aborigines (mean difference 7° [95% CI 5° to 9°]; p < 0.001). Apparent neck-shaft angle differed between the Neolithic population from Iran (126° ± 6°) and the contemporary Australian aborigines (134° ± 5°; mean difference 8° [95% CI 6° to 11°]; p < 0.001), and between the medieval population from Poland (126° ± 6°) and the contemporary Australian aborigines (mean difference 9° [95% CI 7° to 11°]; p < 0.001). Moreover, we observed a difference in the version angle between the Neolithic population from Iran (19° ± 7°) and the medieval population from Poland (12° ± 9°; mean difference 7° [95% CI 4° to 10°]; p < 0.001] and in the inclination angle between aforementioned groups (18° ± 7° versus 11° ± 8°; mean difference 7° [95% CI 5° to 10°]; p < 0.001). CONCLUSION: This study found that cam morphology existed in historical populations at rates comparable with a contemporary population. CLINICAL RELEVANCE: The presence of cam morphology in historical populations suggests that cam morphology can develop outside of the intense sports activity seen in modern adolescents. Further study will help elucidate the etiology of cam morphology, which may be useful in the development of preventive strategies.

Lifetime alcohol intake, drinking patterns over time and risk of stomach cancer: A pooled analysis of data from two prospective cohort studies.

Alcohol consumption is causally linked to several cancers but the evidence for stomach cancer is inconclusive. In our study, the association between long-term alcohol intake and risk of stomach cancer and its subtypes was evaluated. We performed a pooled analysis of data collected at baseline from 491 714 participants in the European Prospective Investigation into Cancer and Nutrition and the Melbourne Collaborative Cohort Study. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for incident stomach cancer in relation to lifetime alcohol intake and group-based life course intake trajectories, adjusted for potential confounders including Helicobacter pylori infection. In all, 1225 incident stomach cancers (78% noncardia) were diagnosed over 7 094 637 person-years; 984 in 382 957 study participants with lifetime alcohol intake data (5 455 507 person-years). Although lifetime alcohol intake was not associated with overall stomach cancer risk, we observed a weak positive association with noncardia cancer (HR = 1.03, 95% CI: 1.00-1.06 per 10 g/d increment), with a HR of 1.50 (95% CI: 1.08-2.09) for ≥60 g/d compared to 0.1 to 4.9 g/d. A weak inverse association with cardia cancer (HR = 0.93, 95% CI: 0.87-1.00) was also observed. HRs of 1.48 (95% CI: 1.10-1.99) for noncardia and 0.51 (95% CI: 0.26-1.03) for cardia cancer were observed for a life course trajectory characterized by heavy decreasing intake compared to light stable intake (Phomogeneity = .02). These associations did not differ appreciably by smoking or H pylori infection status. Limiting alcohol use during lifetime, particularly avoiding heavy use during early adulthood, might help prevent noncardia stomach cancer. Heterogeneous associations observed for cardia and noncardia cancers may indicate etiologic differences.

Antioxidative and therapeutic potential of selected Australian plants: A review.

ETHNOPHARMACOLOGICAL RELEVANCE: Numerous common pharmaceuticals, including anti-cancer, antiviral and antidiabetic drugs, are derived from traditional plant-derived medicines. With approximately 25,000 species of flora occurring in Australia that are adapted to the harsh environment, there is a plethora of novel compounds awaiting research in the context of their medicinal properties. Anecdotal accounts of plant-based medicines used by the Australian Aboriginal and Torres Strait Islander peoples clearly illustrates high therapeutic activity. AIM: This review aims to demonstrate the medicinal potentials of selected native Australian plants based on scientific data. Furthermore, it is anticipated that work presented here will contribute towards enhancing our knowledge of native plants from Australia, particularly in the prevention and potential treatment of disease types such as cancer, microbial and viral infections, and diabetes. This is not meant to be a comprehensive study, rather it is meant as an overview to stimulate future research in this field. METHODS: The EBSCOhost platform which included PubMed, SciFinder, Web of Knowledge, Scopus, and ScienceDirect databases were searched for papers using the keywords: medicinal plants, antioxidative, antimicrobial, antibacterial, anticancer, anti-tumor, antiviral or antidiabetic, as well as Australian, native, traditional and plants. The selection criteria for including studies were restricted to articles on plants used in traditional remedies which showed antioxidative potential and therapeutic properties such as anticancer, antimicrobial, antiviral and antidiabetic activity. RESULTS: Some plants identified in this review which showed high Total Phenolic Content (TPC) and antioxidative capacity, and hence prominent bioactivity, included Tasmannia lanceolata (Poir.) A.C. Sm., Terminalia ferdinandiana Exell, Eucalyptus species, Syzygium species, Backhousia citriodora F.Muell., Petalostigma species, Acacia species, Melaleuca alternifolia (Maiden & Betche) Cheel, Eremophila species, Prostanthera rotundifolia R.Br., Scaevola spinescens R. Br. and Pittosporum angustifolium Lodd. The majority of studies found polar compounds such as caffeic acid, coumaric acid, chlorogenic acid, quercetin, anthocyanins, hesperidin, kaempferol, catechin, ellagic acid and saponins to be the active components responsible for the therapeutic effects. Additionally, mid to non-polar volatile organic compounds such as meroterpenes (serrulatanes and nerol cinnamates), monoterpenes (1,8-cineole and myodesert-1-ene), sesquiterpenes, diterpenes and triterpenes, that are known only in Australian plants, have also shown therapeutic properties related to traditional medicine. CONCLUSION: Australian plants express a diverse range of previously undescribed metabolites that have not been given full in vitro assessment for human health potential. This review has included a limited number of plant species of ethnomedicinal significance; hundreds of plants remain in need of exploration and detailed study. Future more elaborate studies are therefore required to screen out and purify lead bioactive compounds against numerous other disease types. This will not only improve our knowledge on the phytochemistry of Australian native flora, but also provide a platform to understand their health-promoting and bioactive effects for pharmaceutical interventions, nutraceuticals, cosmetics, and as functional foods. Finally, plant-derived natural compounds (phytochemicals), as well as plant-based traditional remedies, are significant sources for latent and novel drugs against diseases. Extensive investigation of native medicinal plants may well hold the key to novel drug discoveries.

"We're very much part of the team here": A culture of respect for Indigenous health workforce transforms Indigenous health care.

BACKGROUND: Improving health outcomes for Indigenous people by strengthening the cultural safety of care is a vital challenge for the health sector, both in Australia and internationally. Although Indigenous people have long requested to have Indigenous practitioners involved in their health care, many health services report difficulties with recruiting and retaining Indigenous staff. This article describes Indigenous workforce policies and strategies from two Australian health services, as well as cancer-service specific strategies. METHODS: Services were identified as part of a national study designed to identify and assess innovative services for Indigenous cancer patients and their families. In-depth interviews were conducted in a small number of identified services. The interviews from two services, which stood out as particularly high performing, were analysed through the lens of Indigenous health workforce. RESULTS: Twenty-four hospital staff (Indigenous and non-Indigenous), five Indigenous people with cancer and three family members shared their views and experiences. Eight themes were identified from the way that the two services supported their Indigenous workforce: strong executive leadership, a proactive employment strategy, the Indigenous Health Unit, the Indigenous Liaison Officer, multidisciplinary team inclusion, professional development, work environment and a culture of respect. Participants reported two positive outcomes resulting from the active implementation of the eight workforce themes: 'Improved Indigenous patient outcomes' and 'Improved staff outcomes'. CONCLUSIONS: These two cancer services and their affiliated hospitals show how positive patient outcomes and a strong Indigenous health workforce can be achieved when a health service has strong leadership, commits to an inclusive and enabling culture, facilitates two-way learning and develops specific support structures appropriate for Indigenous staff. It is hoped that the strategies captured in this study will be used by health services and cancer services to inform their own policies and programs to support building their Indigenous workforce.

Perceived barriers to cervical cancer screening among refugee women after resettlement: A qualitative study.

Background: Cervical cancer screening rates are low among refugee populations who have resettled in Australia, including among Bhutanese women who are at increased risk of cervical cancer. Understanding the barriers to accessing preventive health care is an important starting point to changing health behaviours. Objective: To identify perceived barriers to accessing cervical cancer screening programs among Bhutanese refugee women in Australia. Method: In-depth interviews with 30 Bhutanese refugee women resettled in Melbourne, Australia were analysed using an Interpretative Phenomenological Analysis (IPA) framework. Findings: A strong overarching theme was evident; health-seeking behaviour among the Bhutanese refugee women was strongly associated with symptoms and can be described as 'no symptoms- no check-up'. Three major contributors to health behaviour were: poor knowledge, cultural motivations and refugee experience. Poor knowledge was a consequence of low health literacy and lack of information. Cultural motivations included the notion of the sacred body and related stigmas, and strong faith in doctors. A set of latent themes associated with health professional behaviour was also identified in the experiences women recounted: screening was not offered; opportunistic screening occurred without education; and the use of interpreters was inappropriate and involved a mix of failure to use publicly available trained interpreters and informal use of family members. A contrary theme was also evident among younger educated women: changing awareness. Conclusion: Health professionals in the countries of resettlement need greater awareness of the barriers to health-seeking behaviours among refugee populations: cultural influences and norms; poor knowledge of health services and health systems; and poor practice by health professionals.

High levels of engagement with testing for HIV and sexually transmissible infection among gay Asian men in Sydney and Melbourne: an observational study.

Background Gay and other men who have sex with men of Asian background (GAM) have been identified as a key population in efforts to eradicate HIV in New South Wales. The aims of the present study were to evaluate current levels of engagement with HIV and sexually transmissible infection (STI) testing services, assess knowledge of pre- and post-exposure prophylaxis and to identify factors associated with service engagement in this group. METHODS: A survey of 604 GAM residing in Sydney and Melbourne was undertaken. RESULTS: The data identified that a significant proportion of non-HIV-positive men (i.e. HIV-negative men and men whose HIV status was unknown) surveyed (n = 567; 93.9%) had engaged in frequent HIV testing and comprehensive STI testing in the 12 months prior to the survey (n = 180; 31.7%). There were significant differences (P < 0.05) in sexual practices at the bivariate level between those who reported frequent and comprehensive HIV/STI testing and those who did not. Those who tested regularly were substantially more sexually active, were more likely to have multiple partners (P = 0.001) and were more likely to engage in condomless anal intercourse with both casual (P < 0.001) and regular (P = 0.002) partners. Those who engaged with testing initiatives were more likely to discuss HIV status with both regular (P = 0.008) and casual (P < 0.001) partners, and identified more reasons to test than their counterparts (P < 0.001). The data also highlighted key service venues, with gay men most likely to have used public sexual health clinics (46.9%) as their most recent testing venue. CONCLUSIONS: The data demonstrate an association between high levels of male-to-male sexual activity and engagement in frequent and comprehensive HIV and STI testing. This likely derives from both self-perceived notions of risk and current reliance on established gay community organisations to convey information around testing. Increasing engagement with testing initiatives beyond GAM who self-identify as being at high HIV and STI risk will require the use of novel routes by which to disseminate this information.

A decade on: Follow-up findings of indigenous children with bronchiectasis.

OBJECTIVE: The sole prospective longitudinal study of children with either chronic suppurative lung disease (CSLD) or bronchiectasis published in the current era was limited to a single center. We sought to extend this study by evaluating the longer-term clinical and lung function outcomes and their associated risk factors in Indigenous children of adolescents from Australia, Alaska, and New Zealand who participated in our previous CSLD or bronchiectasis studies during 2004-2010. METHODS: Between 2015 and 2018, we evaluated 131 out of 180 (72.8%) children of adolescents from the original studies at a single follow-up visit. We administered standardized questionnaires, reviewed medical records, undertook clinical examinations, performed spirometry, and scored available chest computed tomography scans. RESULTS: Participants were seen at a mean age of 12.3 years (standard deviation: 2.6) and a median of 9.0 years (range: 5.0-13.0) after their original recruitment. With increasing age, rates of acute lower respiratory infections (ALRI) declined, while lung function was mostly within population norms (median forced expiry volume in one-second = 90% predicted, interquartile range [IQR]: 81-105; forced vital capacity [FVC] = 98% predicted, IQR: 85-114). However, 43 out of 111 (38.7%) reported chronic cough episodes. Their overall global rating judged by symptoms, including ALRI frequency, examination findings, and spirometry was well (20.3%), stable (43.9%), or improved (35.8%). Multivariable regression identified household tobacco exposure and age at first ALRI-episode as independent risk factors associated with lower FVC% predicted values. CONCLUSION: Under our clinical care, the respiratory outcomes in late childhood or early adolescence are encouraging for these patient populations at high-risk of premature mortality. Prospective studies to further inform management throughout the life course into adulthood are now needed.

Chronic condition risk factor change over time in a remote Indigenous community.

INTRODUCTION: This study sought to determine change in chronic condition risk factors in a remote Indigenous community following a 3-year period of community-led health promotion initiatives. METHODS: Data were compared between two cross-sectional surveys of Indigenous Australian community residents before and after health promotion activities, and longitudinal analysis of participants present at both surveys using multilevel mixed-effects regression. RESULTS: At baseline, 294 (53% women; mean age 35 years) participated and 218 attended the second survey (56% women, mean age 40 years), and 87 attended both. Body composition, blood pressure and urinary albumin-to-creatinine ratio remained stable between baseline and follow-up. After adjusting for age and sex, haemoglobin A1c significantly increased (from 57 to 63 mmol/mol (7.5% to 8.1%), p=0.021) for those with diabetes. Increases were also observed for total cholesterol (from 4.4 to 4.6 mmol/L, p=0.006) and triglycerides (from 1.5 to 1.6 mmol/L, p=0.019), and high-density lipoprotein cholesterol levels improved (from 0.98 to 1.02 mmol/L, p=0.018). Self-reported smoking prevalence was high but stable between baseline (57%) and follow-up (56%). Similar results were observed in the longitudinal analysis to the cross-sectional survey comparison. CONCLUSION: Community-led health promotion initiatives may have had some benefits on chronic condition risk factors, including stabilisation of body composition, in this remote Indigenous community. Given that less favourable trends were observed for diabetes and total cholesterol over a short time period and smoking prevalence remained high, policy initiatives that address social and economic disadvantage are needed alongside community-led health promotion initiatives.

What is the alcohol, tobacco, and other drug prevalence among culturally and linguistically diverse groups in the Australian population? A national study of prevalence, harms, and attitudes.

In Australia, one in three people are born overseas, and one in five households speak languages other than English. This study explores substance use prevalence, related harms, and attitudes among these large groups in the population. Analysis was conducted using cross-sectional data (N = 22, 696) from the 2013 National Drug Strategy Household Survey. General linear model and binary logistic regression were used to assess substance use and harms, using stabilized inverse propensity score weighting to control for potential confounding variables. Between culturally and linguistically diverse populations and the population born in Australia, United Kingdom, or New Zealand who speak only English at home, there is no statistically significant variation in the likelihood of current smoking; using analgesics, tranquilizers, or sleeping pills; or administering drugs via injection. Culturally diverse populations are less likely to drink alcohol or use cannabis or methamphetamines. No difference between these two major groups in the population is observed in substance-related abuse from strangers; but culturally diverse respondents are less likely to report substance-related abuse from known persons. Lower substance use prevalence is not observed among people from culturally diverse backgrounds who have mental health issues. Australian-, UK-, or New Zealand-born respondents who speak only English at home are more likely to oppose drug and tobacco policies, including a range of harm reduction policies. We discuss the practical and ethical limitations of this major Australian data set for examining the burden of drug-related harms experienced by specific migrant populations. Avenues for potential future research are outlined.

Aquí (en Sídney) estamos perdidos: estudio etnográfico de la satisfacción vital de aborígenes urbanos australianos participantes en un programa sociocomunitario / Here (in Sydney) we are lost: An ethnographic study of life satisfaction among urban aboriginal Australians participating in a community outreach program

RESUMEN Este estudio etnográfico fue diseñado para explorar las condiciones de vida de un grupo de familias aborígenes residentes en un contexto urbano, beneficiarias de un programa sociorecreativo en Sídney, Australia. El objetivo fue explorar la satisfacción vital mediante el análisis de sus condiciones de vida y del capital cultural inscrito en sus actitudes, percepciones y conocimientos establecidos. El trabajo de campo se estructuró en dos fases complementarias: en la fase 1, entre mayo de 2008 y diciembre de 2010, se inició con el ingreso del primer autor como voluntario en la asociación responsable del programa y, en la fase 2, entre enero de 2011 y febrero de 2013 se intensificó el proceso de observación participante y las entrevistas semiestructuradas. Los resultados muestran que el proceso de desarraigo cultural está en la base de las experiencias vitales de desigualdad social experimentadas y apunta a un efecto de cohorte que llega hasta nuestros días. Dicho proceso de (des)consonancia cultural debe ser tenido en cuenta como un factor clave a la hora de analizar las condiciones de vida y bienestar de estas minorías étnicas, así como a la hora de desarrollar programas e intervenciones.

ABSTRACT This ethnographic study was designed to explore living conditions among a group of aboriginal families residing in an urban context, who participated in a recreational social program. The aim of the study was to explore life satisfaction by analyzing their living conditions and cultural capital inscribed in established attitudes, perceptions, and lay knowledge. Fieldwork was carried out in two complementary phases: phase 1, between May 2008 and December 2010, began when the first listed author initiated volunteer work with the organization responsible for the program; in phase 2, which extended from January 2011 to February 2013, participant observation was intensified and semi-structured interviews were carried out. The results indicate that the process of cultural uprooting underscores the experience of social inequality, and suggest a cohort effect that continues to this day. This process of cultural (in)consonance must be taken into account as a key factor when analyzing the living conditions and well-being of ethnic minorities, as well as when developing programs and interventions.

Health outcomes for Australian Aboriginal and Torres Strait Islander children born preterm, low birthweight or small for gestational age: A nationwide cohort study.

OBJECTIVE: To examine health outcomes in Australian Aboriginal and Torres Strait Islander children experiencing perinatal risk and identify protective factors in the antenatal period. METHODS: Baby/Child cohorts of the Longitudinal Study of Indigenous Children, born 2001-2008, across four annual surveys (aged 0-8 years, N = 1483). Children with 'mild' and 'moderate-to-high' perinatal risk were compared to children born normal weight at term for maternal-rated global health and disability, and body-mass-index measured by the interviewer. RESULTS: Almost one third of children had experienced mild (22%) or moderate-to-high perinatal risk (8%). Perinatal risk was associated with lower body-mass-index z-scores (regression coefficients adjusted for pregnancy and environment factors: mild = -0.21, 95% CI = -0.34, -0.07; moderate-to-high = -0.42, 95% CI = -0.63, -0.21). Moderate-to-high perinatal risk was associated with poorer global health, with associations becoming less evident in models adjusted for pregnancy and environment factors; but not evident for disability. A range of protective factors, including cultural-based resilience and smoking cessation, were associated with lower risk of adverse outcomes. CONCLUSIONS: Perinatal risks are associated with Australian Aboriginal and Torres Strait children experiencing adverse health particularly lower body weight. Cultural-based resilience and smoking cessation may be two modifiable pathways to ameliorating health problems associated with perinatal risk.

The Intersections of Chronic Noncancer Pain: Culturally Diverse Perspectives on Disease Burden.

OBJECTIVE: This study highlights the burden of chronic non-cancer-related pain from the perspectives of three culturally and linguistically diverse communities, using an intersectionality analysis. Specifically, we identify how multiple social identities intersect to account for the unequal distribution of the burden of chronic pain. DESIGN AND METHODS: Six focus groups of 41 culturally and linguistically diverse participants (Mandaean, Assyrian, and Vietnamese) living with chronic noncancer pain were conducted in South-West Sydney, Australia, between February and July 2015. Data were analyzed using inductive and intersectional methodology. RESULTS: The interaction between a patient with chronic pain from a culturally and linguistically diverse background and the health system is influenced by four identified social identities that interact to create relative positions of disadvantage for the patient within the health system and with health care providers. The social identities identified were ethnoculture, social class, migration status, and gender. CONCLUSIONS: Health care providers must consider how the intersectionality of social identities related to ethnoculture, social class, migration status, and gender can factor into the creation and maintenance of chronic pain disparities. A greater, more thoughtful incorporation of intersectionality in chronic pain research and clinical practice will ensure that pain management approaches are designed and applied in a way that reflects the social context of affected communities and individuals from those communities.

Understanding Indigenous Australians' experiences of cancer care: stakeholders' views on what to measure and how to measure it.

BACKGROUND: Disparities in cancer outcomes amongst Indigenous Australians reflect a pattern of reduced access to and engagement with health services. A growing emphasis on patient-centred care has increased efforts to measure patient experiences, but it is unclear whether existing approaches: a) assess the most critical aspects of care that shape the experiences of Indigenous people with cancer; and b) facilitate the engagement and participation of Indigenous people with the measurement of care experiences. METHODS: Two rounds of semi-structured interviews and focus groups were used to elicit stakeholders' views on priorities for measuring the cancer care experiences of Indigenous cancer patients and on the acceptability of various methods for capturing such information. Participants included Indigenous people affected by cancer (n = 17), health professionals (n = 28) and individuals in both groups (n = 7). Recruitment occurred through a national web-based network and through four cancer services in urban and regional areas in three jurisdictions across Australia. RESULTS: Several aspects of cancer care were identified as critical in shaping Indigenous patients' experiences. Key themes included: feeling safe in the system; importance of Indigenous staff; barriers to care; the role of family and friends; effective communication and education; and coordination of care and transition between services. Those participants affected by carers' wellbeing and palliative care strongly advocated for the importance of these topics. Participants expressed support for a face-to-face interview with a trusted person as the most appropriate means of collecting cancer care experience information. CONCLUSIONS: While existing experience measurement tools would partially capture some important aspects of care, other critical areas would likely be missed. Appropriate tools and approaches, developed by and with Indigenous people, are urgently needed to determine the extent to which health services are meeting the needs of Indigenous people with cancer, and to identify areas for action to improve these services.

A comparison of Australian and French families affected by sarcoma: perceptions of genetics and incidental findings.

AIM: To compare Australian and French perceptions of genetics and preferences regarding the return of incidental findings. METHODS: Participants from the International Sarcoma Kindred Study received a survey at intake to cancer referral units. A total of 1442 Australian and 479 French individuals affected by sarcoma and their unaffected family members responded to four hypothetical scenarios depicting hereditary conditions of varying treatability and severity. RESULTS: Australians' preference for the return of incidental findings was consistently higher than French for all scenarios. Country group differences were significant for two scenarios when individual characteristics were controlled through multivariable analyses. CONCLUSION: Findings support the need for guidelines that are sensitive to sociocultural context and promote autonomous decision-making.

Fear of cancer recurrence and psychological well-being in women with breast cancer: The role of causal cancer attributions and optimism.

This study aims to examine the association between cancer causal attributions, fear of cancer recurrence (FCR) and psychological well-being and the possible moderating effect of optimism among women with a previous diagnosis of breast cancer. Participants (N = 314) completed an online self-report assessment of causal attributions for their own breast cancer, FCR, psychological well-being and optimism. Simultaneous multiple regression analyses were conducted to explore the overall contribution of causal attributions to FCR and psychological well-being separately. Hierarchical multiple regression analyses were also utilised to examine the potential moderating influence of dispositional optimism on the relationship between causal attributions and FCR and psychological well-being. Causal attributions of environmental exposures, family history and stress were significantly associated with higher FCR. The attribution of stress was also significantly associated with lower psychological well-being. Optimism did not moderate the relationship between causal attributions and FCR or well-being. The observed relationships between causal attributions for breast cancer and FCR and psychological well-being suggest that the inclusion of causal attributions in screening for FCR is potentially important. Health professionals may need to provide greater psychological support to women who attribute their cancer to non-modifiable causes and consequently continue to experience distress.

Testing for type 2 diabetes in Indigenous Australians: guideline recommendations and current practice.

OBJECTIVES: To determine the proportion of Aboriginal Controlled Community Health Service (ACCHS) patients tested according to three national diabetes testing guidelines; to investigate whether specific patient characteristics were associated with being tested. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional study of 20 978 adult Indigenous Australians not diagnosed with diabetes attending 18 ACCHSs across Australia. De-identified electronic whole service data for July 2010 - June 2013 were analysed. MAIN OUTCOMES MEASURES: Proportions of patients appropriately screened for diabetes according to three national guidelines for Indigenous Australians: National Health and Medical Research Council (at least once every 3 years for those aged 35 years or more); Royal Australian College of General Practitioners and Diabetes Australia (at least once every 3 years for those aged 18 years or more); National Aboriginal Community Controlled Health Organisation (annual testing of those aged 18 years or more at high risk of diabetes). RESULTS: 74% (95% CI, 74-75%) of Indigenous adults and 77% (95% CI, 76-78%) of 10 760 patients aged 35 or more had been tested for diabetes at least once in the past 3 years. The proportions of patients tested varied between services (range: all adults, 16-90%; people aged 35 years or more, 23-92%). 18% (95% CI, 18-19%) of patients aged 18 or more were tested for diabetes annually (range, 0.1-43%). Patients were less likely to be tested if they were under 50 years of age, were transient rather than current patients of the ACCHS, or attended the service less frequently. CONCLUSIONS: Some services achieved high rates of 3-yearly testing of Indigenous Australians for diabetes, but recommended rates of annual testing were rarely attained. ACCHSs may need assistance to achieve desirable levels of testing.

Childhood Stress and Adversity is Associated with Late-Life Dementia in Aboriginal Australians.

OBJECTIVES: High rates of dementia have been observed in Aboriginal Australians. This study aimed to describe childhood stress in older Aboriginal Australians and to examine associations with late-life health and dementia. DESIGN: A cross-sectional study with a representative sample of community-dwelling older Aboriginal Australians. SETTING: Urban and regional communities in New South Wales, Australia. PARTICIPANTS: 336 Aboriginal and/or Torres Strait Islander Australians aged 60-92 years, of whom 296 were included in the current analyses. MEASUREMENTS: Participants completed a life course survey of health, well-being, cognition, and social history including the Childhood Trauma Questionnaire (CTQ), with consensus diagnosis of dementia and Alzheimer disease. RESULTS: CTQ scores ranged from 25-117 (median: 29) and were associated with several adverse childhood indicators including separation from family, poor childhood health, frequent relocation, and growing up in a major city. Controlling for age, higher CTQ scores were associated with depression, anxiety, suicide attempt, dementia diagnosis, and, specifically, Alzheimer disease. The association between CTQ scores and dementia remained significant after controlling for depression and anxiety variables (OR: 1.61, 95% CI: 1.05-2.45). In contrast, there were no significant associations between CTQ scores and smoking, alcohol abuse, diabetes, or cardiovascular risk factors. CONCLUSIONS: Childhood stress appears to have a significant impact on emotional health and dementia for older Aboriginal Australians. The ongoing effects of childhood stress need to be recognized as people grow older, particularly in terms of dementia prevention and care, as well as in populations with greater exposure to childhood adversity, such as Aboriginal Australians.

Chronological narratives from smoking initiation through to pregnancy of Indigenous Australian women: A qualitative study.

OBJECTIVE: One in two Indigenous Australian pregnant women smoke, yet little is known about their trajectory of smoking. This study aimed to explore Aboriginal women's narratives from starting smoking through to pregnancy. METHODS: A female Aboriginal Researcher conducted individual face-to-face interviews with 20 Aboriginal women from New South Wales, Australia. Recruitment, through Aboriginal services and community networks, continued until saturation was reached. Audio-recorded transcripts were independently open coded by two researchers, inductively analysed and reported using a three-dimensional structure of looking backwards, forwards, inwards, outwards and a sense of place, to elucidate the chronology of events, life stages, characters, environments, and turning points of the stories. RESULTS: A chronology emerged from smoking initiation in childhood, coming of age, becoming pregnant, through to attempts at quitting, and relapse post-partum. Several new themes emerged: the role mothers play in women's smoking and quitting; the contribution of nausea to spontaneous quitting; depression as a barrier to quitting; and the hopes of women for their own and their children's future. The epiphany of pregnancy was a key turning point for many - including the interplay of successive pregnancies; and the intensity of expressed regret. CONCLUSIONS: Aboriginal women report multiple influences in the progression of early smoking to pregnancy and beyond. Potential opportunities to intervene include: a) childhood, coming of age, pregnancy, post-natal, in-between births; b) key influencers; c) environments, and d) targeting concurrent substance use. Morning sickness appears to be a natural deterrent to continued smoking. Depression, and its relationship to smoking and quitting in Australian Indigenous pregnant women, requires further research.

The burden and implications of preoperative atrial fibrillation in Australian heart valve surgery patients.

BACKGROUND: Atrial fibrillation (AF) is the most common preoperative arrhythmia in heart valve surgery patients and its prevalence is rising. This study aims to investigate the impact of AF on valve surgery early complications and survival and on valve disease of different aetiologies and populations with particular reference to Indigenous Australians with rheumatic heart disease (RHD). METHODS: The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database was analysed to determine the association between preoperative AF and valve surgery outcome. Its association with demographics, co-morbidities, preoperative status and short and long term outcome was assessed. RESULTS: Outcome of 1594 RHD and 19,029 non-RHD-related surgical procedures was analysed. Patients with preoperative AF were more likely to be older, female, Indigenous, to have RHD and to bear a greater burden of comorbidities. Patients with RHD and preoperative AF had a longer hospital stay and were more likely to require reoperation. Adjusted short (OR 1.4, 95% CI 1.2-1.7) and long term (HR 1.5, 95% CI 1.3-1.7) survival was inferior for patients with non-RHD preoperative AF but was no different for Indigenous and non-Indigenous Australians with RHD. CONCLUSIONS: In this prospective Australian study, patients with valve disease and preoperative AF had inferior short and long term survival. This was particularly the case for patients with non-RHD valve disease. Earlier intervention or more aggressive AF management should be investigated as mechanisms for enhancing postoperative outcomes. This may influence treatment choice and the need for ongoing anticoagulation.