A comparison of rural Australian First Nations and Non-First Nations survey responses to COVID-19 risks and impacts: implications for health communications.

INTRODUCTION: This study investigated differences between rural Australian First Nations and non-First Nations survey respondents' perceptions of COVID-19-related risks and analysed other variables that could predict an exacerbation of anxiety related to COVID-19 harms. METHODS: A cross-sectional online and paper survey of rural residents from the western regions of NSW, Australia, was conducted. Descriptive and multivariate statistical analyses were used to assess links between First Nations status and demographic measures including postcode, age, gender, education, rural or town/village location, proximity to medical services and living situation. The analysis included five items related to perceptions about COVID-19: perceived likelihood of contracting COVID-19 in the next 12 months, perceived harmfulness of the virus, how often people felt afraid, perception about respondents' ability to do something about the virus and perceived economic impacts of the pandemic. RESULTS: There were significant differences between First Nations (n=60) and non-First Nations (n= 639) respondents across all sociodemographic categories. The results reflect a significantly higher level of anxiety among the First Nations Australians in the sample: they felt afraid more often, felt it was highly likely they would catch the virus and if they did catch the virus perceived that it would be very harmful. Living with children under eighteen years of age and in small rural towns were key factors linked to feeling afraid of COVID-19 and First Nations status. CONCLUSION: Health risk communication in pandemic response should include an equitable focus on rural areas, recognising that First Nations Australians are a significant proportion of the rural population with different risk factors and concerns than those of non-First Nations Australians. This principle of First Nations-led design is critical to all health policy and planning. The Australian Government should include rural areas in planning pandemic responses, recognising that First Nations populations are a significant proportion of the rural population creating syndemic conditions.

Indigenous Cultural Identity of Research Authors Standard: research and reconciliation with Indigenous Peoples in rural health journals.

The Indigenous Cultural Identity of Research Authors Standard (ICIRAS) is based on a gap in research publishing practice where Indigenous peoples' identity is not systematically and rigorously recognised in rural health research publications. There are widespread reforms, in different research areas, to counter the reputation of scientific research as a vehicle of racism and discrimination. Reflecting on these broader movements, the editorial teams of three rural health journals - Rural and Remote Health, the Australian Journal of Rural Health, and the Canadian Journal of Rural Medicine - adopted a policy of 'Nothing about Indigenous Peoples, without Indigenous Peoples'. This meant changing practices so that Indigenous Peoples' identity could be embedded in authorship credentials - such as in the byline. An environmental scan of literature about the inclusion of Indigenous Peoples in research revealed many ways in which editorial boards of journals could improve their process to signal to readers that Indigenous voices are included in rural health research publication governance. Improving the health and wellbeing of Indigenous peoples worldwide requires high-quality research evidence. This quality benchmark needs to explicitly signal the inclusion of Indigenous authors. The ICIRAS is a call to action for research journals and institutions to rigorously improve research governance and leadership to amplify the cultural identity of Indigenous peoples in rural health research.

Concerns and priorities of Aboriginal and Torres Strait Islander peoples regarding food and nutrition: a systematic review of qualitative evidence.

BACKGROUND: Aboriginal and Torres Strait Islander Australians experience persistent health and social inequities. Chronic conditions, many of which are diet-related, are leading contributors to the burden of disease and health inequity in Australia. First Nations Peoples have the right to be involved in all policy decisions affecting them. This review aimed to synthesise Aboriginal and Torres Strait Islander Peoples' concerns and priorities about food and nutrition in order to inform policies to improve health equity. METHODS: MEDLINE, CINAHL, Informit and Google Scholar were systematically searched to identify qualitative studies-published from January 2008-that included data from Aboriginal and/or Torres Strait Islander Peoples about their concerns and priorities related to food and nutrition. Data were extracted from included studies using a pre-determined template and study quality was assessed using the Aboriginal and Torres Strait Islander Quality Appraisal Tool. Qualitative findings were synthesised using inductive thematic analysis and categorised based on an ecological model of health. RESULTS: Twenty-one studies were included. Key factors influencing food and nutrition were identified across all levels of the ecological framework. These included interpersonal and institutional racism, junk food availability and marketing, food accessibility and affordability, housing conditions, food knowledge and cooking skills, and connection to family and culture. CONCLUSIONS: Documenting Aboriginal and Torres Strait Islander Peoples' lived experiences of the colonised food system is one step necessary for informing policy to tackle food and nutrition inequities. Based on existing qualitative research, food and nutrition policymakers should prioritise building a supportive food environment by focusing on self-determination; ensuring access to healthy, affordable food and safe housing; and by eliminating systemic racism.

Aboriginal and Torres Strait Islander community governance of health research: Turning principles into practice.

PROBLEM: Gaps exist in researchers' understanding of the 'practice' of community governance in relation to research with Aboriginal and Torres Strait Islander peoples. DESIGN: We examine Aboriginal community governance of two rural NSW research projects by applying principles-based criteria from two independent sources. SETTING: One research project possessed a strong Aboriginal community governance structure and evaluated a 2-year healthy lifestyle program for children; the other was a 5-year cohort study examining factors influencing the mental health and well-being of participants. KEY MEASURES FOR IMPROVEMENT: The National Health and Medical Research Council of Australia's 'Values and ethics: guidelines for ethical conduct in Aboriginal and Torres Strait Islander research' and 'Ten principles relevant to health research among Indigenous Australian populations' described by experts in the field. STRATEGIES FOR CHANGE: Adopt community-based participatory research constructs. Develop clear governance structures and procedures at the beginning of the study and allow sufficient time for their establishment. Capacity-building must be a key component of the research. Ensure sufficient resources to enable community engagement, conduct of research governance procedures, capacity-building and results dissemination. EFFECTS OF CHANGE: The implementation of governance structures and procedures ensures research addresses the priorities of the participating Aboriginal and Torres Strait Islander communities, minimises risks and improves outcomes for the communities. LESSONS LEARNT: Principles-based Aboriginal and Torres Strait Islander community governance of research is very achievable. Next steps include developing a comprehensive evidence base for appropriate governance structures and procedures, and consolidating a suite of practical guides for structuring clear governance in health research.

Considering Aboriginal palliative care models: the challenges for mainstream services.

This review discusses palliative care and end-of-life models of care for Aboriginal people in the Australian state New South Wales, and considers Aboriginal palliative care needs by reflecting on recent literature and lessons derived from Aboriginal consultation. Aboriginal people in Australia account for a very small proportion of the population, have poorer health outcomes and their culture demonstrates a clear resistance to accessing mainstream health services which are viewed as powerful, isolating and not relevant to their culture, way of life, family and belief systems. Aboriginal people regard their land as spiritual and their culture dictates that an Aboriginal person needs to know their origins, emphasising the value placed on kin and also demonstrating a strong desire to remain within their own country. Currently Aboriginal people tend to not access palliative care services in mainstream facilities; and there is very little data on Aboriginal admissions to palliative care centres. Over the last two decades only two models of palliative care focusing on and developed in Aboriginal communities have been implemented. The seminal contribution to Aboriginal Palliative Care was in the form of a resource kit developed to support palliative care providers to examine their practice for cultural appropriateness for Aboriginal and Torres Strait Islanders. The 'living model' coming from this project is adaptive and flexible, enabling implementation in different Aboriginal country as a participative process with community input. The Australian government's National Indigenous Palliative Care Needs Study similarly indicated that Australian empirical research on Aboriginal palliative care service provision is in its infancy, and comprehensive data on the rates of Aboriginal access to palliative care services did not exist. What literature does exist is drawn together in an argument for the development and need for culturally specific Aboriginal palliative care models, which are culturally appropriate, locally accessible and delivered in collaboration and partnership with Aboriginal controlled health services. This is essential because Aboriginal people are a minority cultural group who are disconnected from mainstream health service delivery, and have a sense of cultural isolation when accessing mainstream services. It is preferable that palliative care is delivered in a collaboration between Aboriginal Controlled Health Service and mainstream palliative care services to ensure a dignified end of life for the Aboriginal person. These collaborations and partnerships are fundamental to ensure that a critical mass of Aboriginal clinicians are trained and experienced in end of life care and palliation. Developing palliative care programs within Aboriginal communities and training Aboriginal Health Workers, promoted and developed in partnership with the Aboriginal community, are important strategies to enhance palliative care service provision. Further partnerships should be championed in this collaborative process, acknowledging a need for palliative care models that fit with Aboriginal peoples' community values, beliefs, cultural/ spiritual rituals, heritage and place.

Recasting Jung Through an Indigenist Approach to Deepen Shared Knowledges of Well-being and Healing on Australian Soils: Protocol for a Qualitative Landscape Research Study.

BACKGROUND: The colonization of Australia is responsible for complex layers of trauma for the First Nations peoples of the continent. First Nations Australians' well-being is irrevocably tied to the well-being of the land. The application of a landscape-based approach to collaborative research shows promise in enabling genuine relationships that yield rich and informative data. However, there is a lack of practical evidence in the field of landscape research-research tied to First Nations Australians' worldviews of landscape. OBJECTIVE: This study aims to deepen shared knowledges of well-being and healing on Australian soils. We aim to examine ritual co-design as a novel method for deepening these shared knowledges. METHODS: This research comprises a qualitative and participatory action research design operationalized through an Indigenist approach. It is a 2-phase project that is co-designed with First Nations Australians. Phase 1 of this project is a relational study that endeavors to deepen the theory underpinning the project, alongside the development of meaningful and reciprocal community connections. Phase 2 is a series of 3 participatory action research cycles to co-design a new communal ritual. This process seeks to privilege First Nations Australians' voices and ways of knowing, which are themselves communal, ritual, and symbolic. The framework developed by psychiatrist Carl Jung informs the psychological nature of the enquiry. An Indigenist approach to landscape research recasts the Jungian frame to enable a culturally safe, context-specific, and landscape-based method of qualitative research. RESULTS: The research is in the preliminary stages of participant recruitment. It is expected that data collection will commence in late 2022. CONCLUSIONS: It is expected that this qualitative and co-designed project will strengthen the cross-cultural co-designer relationships and that the data gathered from these relationships, and the accompanying practical outcomes, will provide new insight into the interaction between human and landscape well-being. The field of landscape research is in an embryonic phase. This new field is embedded in the understanding that First Nations Australians' well-being is irrevocably tied to the well-being of the land, and this study seeks to build on this evidence base. A strength of this research is the relational methodology, in which First Nations Peoples' needs and desires will inform future research directions. It is limited by its context specific nature; however, it is expected that findings will be usable in guiding future research directions in the multidisciplinary field of landscape research. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/36328.

Indigenous participation in an informal national indigenous health policy network.

UNLABELLED: OBJECTIVE; To determine and describe the features of Indigenous participation in an informal national Indigenous health policy network. DESIGN: A questionnaire was administered during 2003-04. Through a snowball nomination process a total of 227 influential persons were identified. Of these, 173 received surveys of which 44 were returned, a return rate of 25%. OUTCOME MEASURES: These data were analysed to detect the existence of network groups; measure the degree of group interconnectivity; and measure the characteristics of bonds between influential persons. Demographic information was used to characterise the network and its groups. RESULTS: Indigenous people were integral to the network due to their high representation, their distribution throughout the 16 groups, and the interconnections between the groups. The network was demographically diverse and multiple relational variables were needed to characterise it. Indigenous and non-Indigenous people had strong ties in this network. CONCLUSION: Social network methods made visible an informal network where Indigenous and non-Indigenous people relate in a complex socio-political environment to influence national Indigenous health policy. What is known about the topic? The participation of Indigenous people is acknowledged as important in health, but there is criticism of the lack of real opportunities for Indigenous people to participate in national Indigenous health policy processes.

Promoting cultural rigour through critical appraisal tools in First Nations peoples' research.

OBJECTIVE: To highlight the emerging ethos of cultural rigour in the use of critical appraisal tools in research involving First Nations peoples. METHODS: Critical reflection on recent systematic review experience. RESULTS: The concept of cultural rigour is notably undefined in peer-reviewed journal articles but is evident in the development of critical appraisal tools developed by First Nations peoples. CONCLUSIONS: Conventional critical appraisal tools for assessing study quality are built on a limited view of health that excludes the cultural knowledge of First Nations peoples. Cultural rigour is an emerging field of activity that epitomises First Nations peoples' diverse cultural knowledge through community participation in all aspects of research. Implications for public health: Critical appraisal tools developed by First Nations peoples are available to researchers and direct attention to the social, cultural, political and human rights basis of health research.

First Nations Peoples' Participation in the Development of Population-Wide Food and Nutrition Policy in Australia: A Political Economy and Cultural Safety Analysis.

BACKGROUND: Healthy and sustainable food systems underpin the well-being of Indigenous peoples. Increasingly governments are taking action to improve diets via population-wide policies. The United Nations Declaration on the Rights of Indigenous People states that Indigenous peoples have the right to participate in all decisions that affect them. We analysed Australian national food and nutrition policy processes to determine: (i) the participation of Aboriginal organisations, (ii) the issues raised in Aboriginal organisations' policy submissions, and (iii) the extent to which Aboriginal organisations' recommendations were addressed in final policy documents. METHODS: Political economy and cultural safety lenses informed the study design. We analysed publicly-available documents for Australian population-wide food and nutrition policy consultations occurring 2008-2018. Data sources were policy documents, committee reports, terms of reference and consultation submissions. The submissions made by Aboriginal organisations were thematically analysed and key policy recommendations extracted. We examined the extent to which key recommendations made by Aboriginal organisations were included in the subsequent policy documents. RESULTS: Five food and nutrition policy processes received submissions from Aboriginal organisations. Key themes centred on self-determination, culturally-appropriate approaches to health, and the need to address food insecurity and social determinants of health. These messages were underrepresented in final policy documents, and Aboriginal people were not included in any committees overseeing policy development processes. CONCLUSION: This analysis suggests that very few Aboriginal organisations have participated in Australian population-wide food and nutrition policy processes and that these policy development processes are culturally unsafe. In order to operationalise First Nations peoples' right to self-determination, alternative mechanisms are required to redress the power imbalances preventing the full participation of Aboriginal and Torres Strait Islander peoples in population-wide food and nutrition policy decisions. This means reflecting on deeply embedded institutional structures and the normative assumptions upon which they rest.

Effects of food policy actions on Indigenous Peoples' nutrition-related outcomes: a systematic review.

INTRODUCTION: Indigenous Peoples worldwide endure unacceptable health disparities with undernutrition and food insecurity often coexisting with obesity and chronic diseases. Policy-level actions are required to eliminate malnutrition in all its forms. However, there has been no systematic synthesis of the evidence of effectiveness of food and nutrition policies for Indigenous Peoples around the world. This review fills that gap. METHODS: Eight databases were searched for peer-reviewed literature, published between 2000 and 2019. Relevant websites were searched for grey literature. Articles were included if they were original studies, published in English and included data from Indigenous Peoples from Western colonised countries, evaluated a food or nutrition policy (or intervention), and provided quantitative impact/outcome data. Study screening, data extraction and quality assessment were undertaken independently by two authors, at least one of whom was Indigenous. A narrative synthesis was undertaken with studies grouped according to the NOURISHING food policy framework. RESULTS: We identified 78 studies from Canada, Australia, Aotearoa/New Zealand and the USA. Most studies evaluated targeted interventions, focused on rural or remote Indigenous communities. The most effective interventions combined educational strategies with policies targeting food price, composition and/or availability, particularly in retail and school environments. Interventions to reduce exposure to unhealthy food advertising was the only area of the NOURISHING framework not represented in the literature. Few studies examined the impact of universal food policies on Indigenous Peoples' diets, health or well-being. CONCLUSION: Both targeted and universal policy action can be effective for Indigenous Peoples. Actions that modify the structures and systems governing food supply through improved availability, access and affordability of healthy foods should be prioritised. More high-quality evidence on the impact of universal food and nutrition policy actions for Indigenous Peoples is required, particularly in urban areas and in the area of food marketing.

Voice of the Clinician: the case of an Australian health system.

Purpose The Voice of the Clinician project commenced during an era when practitioner burnout, dissatisfaction, and turnover became an increasingly global health workforce concern. One key problem is clinical staff not being empowered to voice their concerns to decision-makers, as was found in this case study of an Australian public health organization. The following research question informed the present study: What is a better committee system for clinician engagement in decision-making processes? The paper aims to discuss this issue. Design/methodology/approach The Mid North Coast Local Health District in New South Wales aspired to improve engagement between frontline clinicians and decision-makers. Social network analysis methods and mathematical modeling were used in the discovery of how committees are connected to each other and subsequently to other committee members. Findings This effort uncovered a hidden organizational architecture of 323 committees of 926 members which overall cost 84,729 person hours and AUD$2.923 million per annum. Furthermore, frontline clinicians were located far from centers of influence, just 37 percent of committees had terms of reference, and clinicians reported that meeting agendas were not being met. Practical implications In response to the findings, a technological platform was created so that the board of directors could visually see all the committees and the connections between them, thus creating ways to further improve communication, transparency of process, and - ultimately - clinician engagement. Originality/value The breakthrough idea is that all organizational meetings can be seen as a system of engagement and should be analyzed to determine and describe the points and pathways where clinician voice is blocked.

What do we know about the diets of Aboriginal and Torres Strait Islander peoples in Australia? A systematic literature review.

OBJECTIVE: To provide an overview of published research on the dietary intake of Aboriginal and Torres Strait Islander peoples. METHODS: Peer-reviewed literature from 1990 to October 2016 was searched to identify studies that measured the dietary intake of Australian Aboriginal and Torres Strait Islander populations. Study quality was assessed using a purposely devised quality appraisal tool. Meta-analysis was not possible due to the heterogeneity in dietary intake assessment methods. A narrative synthesis of study findings, where key themes were compared and contrasted was completed. RESULTS: Twenty-five articles from twenty studies with outcome measures related to dietary intake were included. Dietary intake was assessed by electronic store sales, store turnover method, 24-hour dietary recall, food frequency questionnaire and short questions. Consistent findings were low reported intakes of fruit and vegetables and high intakes of total sugar and energy-dense, nutrient-poor food and beverages. CONCLUSIONS: While differences between studies and study quality limit the generalisability of the findings, most studies suggest that the diets of Aboriginal and Torres Strait Islander peoples are inadequate. Implications for public health: A more concerted approach to understanding dietary patterns of Aboriginal and Torres Strait Islander peoples is required to inform policy and practice to improve diet and nutrition.

Does more equitable governance lead to more equitable health care? A case study based on the implementation of health reform in Aboriginal health Australia.

There is growing evidence that providing increased voice to vulnerable or disenfranchised populations is important to improving health equity. In this paper we will examine the engagement of Aboriginal community members and community controlled organisations in local governance reforms associated with the Aboriginal Health National Partnership Agreements (AHNPA) in Australia and its impact on the uptake of health assessments. The sample included qualitative and quantitative responses from 188 people involved in regional governance in Aboriginal health. The study included data on the uptake of Aboriginal health assessments from July 2008 to December 2012. The study population was 83190 in 2008/9, 856986 in 2009/10, 88256 in 2010/11 and 90903 in 2011/12. Logistic regression was used to examine the relationships between organisations within forums and the regional uptake of Aboriginal health assessments. The independent variables included before and after the AHNPA, state, remoteness, level of representation from Aboriginal organisations and links between Aboriginal and mainstream organisations. The introduction of the AHNPA was associated with a shift in power from central government to regional forums. This shift has enabled Aboriginal people a much greater voice in governance. The results of the analyses show that improvements in the uptake of health assessments were associated with stronger links between Aboriginal organisations and between mainstream organisations working with Aboriginal organisations. Higher levels of community representation were also associated with improved uptake of health assessments in the AHNPA. The findings suggest that the incorporation of Aboriginal community and community controlled organisations in regional planning plays an important role in improving health equity. This study makes an important contribution to understanding the processes through which the incorporation of disadvantaged groups into governance might contribute to health equity.