Suicides in Aboriginal and non-Aboriginal people following hospital admission for suicidal ideation and self-harm: A retrospective cohort data linkage study from the Northern Territory.

PURPOSE: This study aimed to explore risk factors for suicide in Aboriginal and non-Aboriginal people following hospital admission for suicidal ideation and self-harm in the Northern Territory, Australia to help clarify opportunities for improved care and intervention for these population groups. METHODS: Individuals with at least one hospital admission involving suicidal ideation and/or self-harm between 1 July 2001 and 31 December 2013 were retrospectively recruited and followed up using linked mortality records to 31 December 2014. Survival analyses stratified by Indigenous status identified socio-demographic and clinical characteristics from index hospital admissions associated with suicide. RESULTS: Just over half of the 4391 cohort members identified as Aboriginal (n = 2304; 52.4%). By 2014, 281 deaths were observed comprising 68 suicides, representing a 2.6% and 2.0% probability of suicide for Aboriginal and non-Aboriginal people, respectively. After adjusting for other characteristics, a higher risk of suicide was associated with male sex (Aboriginal adjusted hazard ratio: 4.14; 95% confidence interval: [1.76, 9.75]; non-Aboriginal adjusted hazard ratio: 5.96; 95% confidence interval: [1.98, 17.88]) and repeat hospital admissions involving self-harm (Aboriginal adjusted hazard ratio: 1.37; 95% confidence interval: [1.21, 1.55]; non-Aboriginal adjusted hazard ratio: 1.29; 95% confidence interval: [1.10, 1.51]). Severe mental disorders were associated with a four times higher risk of suicide (adjusted hazard ratio: 4.23; 95% confidence interval: [1.93, 9.27]) in Aboriginal people only. CONCLUSION: The findings highlight non-clinical risk factors for suicide that suggest the need for comprehensive psychosocial assessment tailored to Aboriginal and non-Aboriginal people hospitalised with suicidal ideation or self-harm. Implementing appropriate management and aftercare within a broader public health framework is needed to support recovery and reduce long-term suicide risk in the community, especially for Aboriginal people and males.

Mental health and well-being of Aboriginal and Torres Strait Islander peoples in Australia during COVID-19.

In May 2020, an independent working party was convened to determine the mental health and well-being needs of Aboriginal and Torres Strait Islander peoples in Australia, in response to COVID-19. Thirty Aboriginal and Torres Strait Islander leaders and allies worked together in a two-month virtual collaboration process. Here, we provide the working party's five key recommendations and highlight the evidence supporting these proposals. Aboriginal and Torres Strait Islander self-determination and governance must be prioritised to manage the COVID-19 recovery in Aboriginal and Torres Strait Islander communities. To mitigate long-term social and economic impacts of COVID-19 to Australian society, the historical underinvestment in Aboriginal and Torres Strait Islander peoples must be reconciled. Equitable, needs-based funding is required to support strengths-based, place-based initiatives that address the determinants of health. This includes workforce and infrastructure development and effective evaluation. There is a clear, informed pathway to health and healing for Aboriginal and Torres Strait Islander peoples being enacted by Aboriginal and Torres Strait Islander leadership and community organisations; it remains to be seen how these recommendations will be implemented.

Developing best practice guidelines for the psychosocial assessment of Aboriginal and Torres Strait Islander people presenting to hospital with self-harm and suicidal thoughts.

OBJECTIVE: To develop guidelines for the culturally responsive psychosocial assessment of Aboriginal and Torres Strait Islander people presenting to hospital with self-harm and suicidal thoughts. METHOD: The Delphi method was used to establish expert consensus. A systematic search and review of relevant research literature, existing guidelines and grey literature was undertaken to develop a 286-item questionnaire. The questionnaire contained best practice statements to guide clinicians undertaking psychosocial assessment of Aboriginal and Torres Strait Islander people presenting to hospital with self-harm and suicidal thoughts. An expert panel comprising 28 individuals with clinical, community-based and lived experience in Aboriginal and Torres Strait Islander mental health and/or suicide prevention were recruited and independently rated the items over three rounds. Statements endorsed as essential or important by 90% or more of the expert panel were then synthesised into recommendations for the best practice guideline document. RESULTS: A total of 226 statements across all relevant areas of clinical practice were endorsed. No statements covering the use of structured assessment tools were endorsed. The endorsed statements informed the development of a set of underlying principles of culturally competent practice and recommendations for processes of effective and appropriate engagement; risks, needs and strengths to be assessed; formulation of psychosocial assessment; and recommendations specific to children and young people. CONCLUSION: The guidelines are based on recommendations endorsed across a range of expertise to address an important gap in the evidence-base for clinically effective and culturally responsive assessment of self-harm and suicidal thoughts by Aboriginal and Torres Strait Islander people in hospital settings. Further work is needed to develop an implementation strategy and evaluate the recommendations in practice.

Healing the Past by Nurturing the Future: trauma-aware, healing-informed care to improve support for Aboriginal and Torres Strait Islander families - implementation and evaluation study protocol.

INTRODUCTION: Complex trauma can have serious impacts on the health and well-being of Aboriginal and Torres Strait Islander families. The perinatal period represents a 'critical window' for recovery and transforming cycles of trauma into cycles of healing. The Healing the Past by Nurturing the Future (HPNF) project aims to implement and evaluate a programme of strategies to improve support for Aboriginal and Torres Strait islander families experiencing complex trauma. METHOD: The HPNF programme was codesigned over 4 years to improve awareness, support, recognition and assessment of trauma. Components include (1) a trauma-aware, healing-informed training and resource package for service providers; (2) trauma-awareness resources for parents; (3) organisational readiness assessment; (4) a database for parents and service providers to identify accessible and appropriate additional support and (5) piloting safe recognition and assessment processes. The programme will be implemented in a large rural health service in Victoria, Australia, over 12 months. Evaluation using a mixed-methods approach will assess feasibility, acceptability, cost, effectiveness and sustainability. This will include service user and provider interviews; service usage and cost auditing; and an administrative linked data study of parent and infant outcomes. ANALYSIS: Qualitative data will be analysed using reflexive thematic analysis. Quantitative and service usage outcomes will be described as counts and proportions. Evaluation of health outcomes will use interrupted time series analyses. Triangulation of data will be conducted and mapped to the Consolidated Framework for Implementation Research and Reach, Effectiveness, Adoption, Implementation and Maintenance frameworks to understand factors influencing feasibility, acceptability, effectiveness, cost and sustainability. ETHICS AND DISSEMINATION: Approval granted from St Vincent's Melbourne Ethics Committee (approval no. 239/22). Data will be disseminated according to the strategy outlined in the codesign study protocol, in-line with the National Health and Medical Research Council Aboriginal and Torres Strait Islander Research Excellence criteria.

Partnering with Aboriginal and Torres Strait Islander Peoples: An Evaluation Study Protocol to Strengthen a Comprehensive Multi-Scale Evaluation Framework for Participatory Systems Modelling through Indigenous Paradigms and Methodologies.

The social and emotional wellbeing of young Aboriginal and Torres Strait Islander peoples should be supported through an Indigenous-led and community empowering approach. Applying systems thinking via participatory approaches is aligned with Aboriginal and Torres Strait Islander research paradigms and can be an effective method to deliver a decision support tool for mental health systems planning for Indigenous communities. Evaluations are necessary to understand the effectiveness and value of such methods, uncover protective and healing factors of social and emotional wellbeing, as well as to promote Aboriginal and Torres Strait Islander self-determination over allocation of funding and resources. This paper presents modifications to a published evaluation protocol for participatory systems modelling to align with critical Aboriginal and Torres Strait Islander guidelines and recommendations to support the social and emotional wellbeing of young people. This paper also presents a culturally relevant participatory systems modelling evaluation framework. Recognizing the reciprocity, strengths, and expertise Aboriginal and Torres Strait Islander methodologies can offer to broader research and evaluation practices, the amended framework presented in this paper facilitates empowering evaluation practices that should be adopted when working with Aboriginal and Torres Strait Islander peoples as well as when working with other diverse, non-Indigenous communities.

Patterns of child protection service involvement by Aboriginal children associated with a higher risk of self-harm in adolescence: A retrospective population cohort study using linked administrative data.

BACKGROUND: A history of child maltreatment is known to elevate the risk of self-harm in adolescence. However, this link has not been investigated for Aboriginal children who experience a greater burden of both. OBJECTIVE: Identify patterns of involvement with child protection services by Aboriginal children associated with a higher risk of self-harm in adolescence. PARTICIPANTS AND SETTING: A cohort study was established using linked administrative records of Aboriginal children born in the Northern Territory (NT) of Australia. METHODS: Survival analysis techniques were used to determine the risk of self-harm in adolescence associated with different levels and timing of child protection involvement throughout childhood. RESULT: The relative risk of self-harm was greatest for children with substantiated maltreatment in both early and middle childhood had nine times higher risk for self-harm (aHR: 9.11, 95% CI: 3.39-24.46,p < 0.001) and six times higher for children who experienced notifications in early childhood and substantiated maltreatment in middle childhood (aHR: 6.72, 95% CI:2.16-20.90, p < 0.001). Other patterns of child protection involvement observed in middle childhood alone also conferred a higher relative risk of self-harm in adolescence. CONCLUSION: This study confirms a higher risk of self-harm in adolescence is associated with child maltreatment, especially in middle childhood. Addressing the intergenerational trauma in Aboriginal families is crucial to preventing child maltreatment and informing reforms to child protection responses that can better identify and address the culturally-specific unmet needs of Aboriginal families. This would go some way to fostering the healthy growth and development of Aboriginal children and reduce self-harm risk.

Effectiveness and appropriateness of culturally adapted approaches to treating alcohol use disorders in Indigenous people: a mixed methods systematic review protocol.

OBJECTIVE: The objective of this review is to investigate the effectiveness and appropriateness of culturally adapted approaches for treating alcohol use disorders in Indigenous peoples in Canada, New Zealand, Australia, and the USA. INTRODUCTION: Poor and disadvantaged people, particularly those who are Indigenous, suffer more health effects due to alcohol misuse and are therefore subject to more law enforcement actions. Analyses have identified strategies for improving health services for Indigenous people; chief among these is culturally safe care specifically tailored to the context. Alcohol addiction is a chronic relapsing condition that usually requires ongoing treatment, so it is vital that treatment therapies are appropriate, meaningful, and effective. Many evidence-based therapies for substance abuse have not been specifically designed for or tested in Indigenous and First Nations communities. This absence of cultural considerations may be a contributor to the failure of these programs to engage with clients and successfully influence their behavior. INCLUSION CRITERIA: This review will consider qualitative and quantitative studies of any methodology, published in any language after 1998. Studies including adult and/or adolescent participants in inpatient or outpatient alcohol treatment programs described as being adapted to meet cultural needs will be considered. METHODS: This review will use the convergent segregated approach to mixed methods reviews. A range of databases will be searched, including MEDLINE, CINAHL, Embase, and PsycINFO. Two reviewers will critically appraise and extract data from studies meeting the inclusion criteria. Qualitative research findings will, where possible, be pooled using JBI SUMARI with the meta-aggregation approach, and quantitative studies will, where possible, be pooled in statistical meta-analysis using JBI SUMARI. The JBI convergent segregated approach to mixed methods reviews will be followed.

Community Perspectives of Complex Trauma Assessment for Aboriginal Parents: 'Its Important, but How These Discussions Are Held Is Critical'.

BACKGROUND AND PURPOSE: Becoming a parent can be an exciting and also challenging transition, particularly for parents who have experienced significant hurt in their own childhoods, and may be experiencing 'complex trauma.' Aboriginal and Torres Strait Islander (Aboriginal) people also experience historical trauma. While the parenting transition is an important time to offer support for parents, it is essential to ensure that the benefits of identifying parents experiencing complex trauma outweigh any risks (e.g., stigmatization). This paper describes views of predominantly Aboriginal stakeholders regarding (1) the relative importance of domains proposed for complex trauma assessment, and (2) how to conduct these sensitive discussions with Aboriginal parents. SETTING AND METHODS: A co-design workshop was held in Alice Springs (Central Australia) as part of an Aboriginal-led community-based participatory action research project. Workshop participants were 57 predominantly Aboriginal stakeholders with expertise in community, clinical, policy and academic settings. Twelve domains of complex trauma-related distress had been identified in existing assessment tools and through community consultation. Using story-telling and strategies to create safety for discussing complex and sensitive issues, and delphi-style methods, stakeholders rated the level of importance of the 12 domains; and discussed why, by whom, where and how experiences of complex trauma should be explored. MAIN FINDINGS: The majority of stakeholders supported the importance of assessing each of the proposed complex trauma domains with Aboriginal parents. However, strong concerns were expressed regarding where, by whom and how this should occur. There was greater emphasis and consistency regarding 'qualities' (e.g., caring), rather than specific 'attributes' (e.g., clinician). Six critical overarching themes emerged: ensuring emotional and cultural safety; establishing relationships and trust; having capacity to respond appropriately and access support; incorporating less direct cultural communication methods (e.g., yarning, dadirri); using strengths-based approaches and offering choices to empower parents; and showing respect, caring and compassion. CONCLUSION: Assessments to identify Aboriginal parents experiencing complex trauma should only be considered when the prerequisites of safety, trusting relationships, respect, compassion, adequate care, and capacity to respond are assured. Offering choices and cultural and strengths-based approaches are also critical. Without this assurance, there are serious concerns that harms may outweigh any benefits for Aboriginal parents.

Healing the Past by Nurturing the Future-co-designing perinatal strategies for Aboriginal and Torres Strait Islander parents experiencing complex trauma: framework and protocol for a community-based participatory action research study.

INTRODUCTION: Child maltreatment and other traumatic events can have serious long-term physical, social and emotional effects, including a cluster of distress symptoms recognised as 'complex trauma'. Aboriginal and Torres Strait Islander (Aboriginal) people are also affected by legacies of historical trauma and loss. Trauma responses may be triggered during the transition to parenting in the perinatal period. Conversely, becoming a parent offers a unique life-course opportunity for healing and prevention of intergenerational transmission of trauma. This paper outlines a conceptual framework and protocol for an Aboriginal-led, community-based participatory action research (action research) project which aims to co-design safe, acceptable and feasible perinatal awareness, recognition, assessment and support strategies for Aboriginal parents experiencing complex trauma. METHODS AND ANALYSIS: This formative research project is being conducted in three Australian jurisdictions (Northern Territory, South Australia and Victoria) with key stakeholders from all national jurisdictions. Four action research cycles incorporate mixed methods research activities including evidence reviews, parent and service provider discussion groups, development and psychometric evaluation of a recognition and assessment process and drafting proposals for pilot, implementation and evaluation. Reflection and planning stages of four action research cycles will be undertaken in four key stakeholder workshops aligned with the first four Intervention Mapping steps to prepare programme plans. ETHICS AND DISSEMINATION: Ethics and dissemination protocols are consistent with the National Health and Medical Research Council Indigenous Research Excellence criteria of engagement, benefit, transferability and capacity-building. A conceptual framework has been developed to promote the application of core values of safety, trustworthiness, empowerment, collaboration, culture, holism, compassion and reciprocity. These include related principles and accompanying reflective questions to guide research decisions.