The Marri Gudjaga project: a study protocol for a randomised control trial using Aboriginal peer support workers to promote breastfeeding of Aboriginal babies.

BACKGROUND: Breastfeeding protects against a range of conditions in the infant, including sudden infant death syndrome (SIDS), diarrhoea, respiratory infections and middle ear infections [1, 2]. The World Health Organization (WHO) recommends exclusive breastfeeding until six months of age, with continued breastfeeding recommended for at least two years and other complementary nutritious foods [3]. The 2017-18 National Health Survey (NHS) and 2018-19 National Aboriginal and Torres Strait Islander Health Survey (NATSIHS) reported that the proportion of breastfeeding in Aboriginal and Torres Strait Islander infants (0-2 years) were less than half that of non-Indigenous infants (21.2% vs. 45%, respectively)[4]. There is a lack of research on interventions supporting Aboriginal women to breastfeed, identifying an evaluation gap related to peer support interventions to encourage exclusive breastfeeding in Aboriginal women. METHODS: We will evaluate the effect of scheduled breastfeeding peer support for and by Aboriginal women, on breastfeeding initiation and the prevalence of exclusive breastfeeding. This MRFF (Medical Research Future Fund) funded project is designed as a single-blinded cluster randomised controlled trial recruiting six sites across New South Wales, Australia, with three sites being randomised to employ a peer support worker or undertaking standard care. Forty pregnant women will be recruited each year from each of the six sites and will be surveyed during pregnancy, at six weeks, four and six months postnatally with a single text message at 12 months to ascertain breastfeeding rates. In-depth interviews via an Indigenous style of conversation and storytelling called 'Yarning' will be completed at pre- and post-intervention with five randomly recruited community members and five health professionals at each site" [5]. Yarns will be audio recorded, transcribed, coded and thematic analysis undertaken. Health economic analysis will be completed to assess the health system incremental cost and effects of the breastfeeding intervention relative to usual care. DISCUSSION: Evidence will be given on the effectiveness of Aboriginal peer support workers to promote the initiation and continuation of breastfeeding of Aboriginal babies. The findings of this study will provide evidence of effectiveness and cost-effectiveness of including peer support workers in postnatal care to promote breastfeeding practices. TRIAL REGISTRATION: ACTRN12622001208796 The impact of breastfeeding peer support on nutrition of Aboriginal infants.

The uptake of Aboriginal and Torres Strait Islander health assessments fails to improve in some areas.

BACKGROUND: The Medicare-rebated Health Assessment for Aboriginal and Torres Strait Islander People (Medicare Benefits Schedule [MBS] item number 715) has been progressively implemented across Australia since 1999. OBJECTIVE: This paper explores some of the reasons why the uptake of Health Assessment for Aboriginal and Torres Strait Islander People remains low in some metropolitan general practices. METHODS: Semi-structured interviews and self-complete mail surveys with 31 general practice staff and practitioners were combined with an audit of practice systems and patient medical records in seven general practices in Sydney. RESULTS: Barriers to MBS item number 715 uptake included low rates of Indigenous status identification, lack of knowledge of MBS item numbers, lack of organisational teamwork within the practice and avoidance of billing specific MBS item numbers. DISCUSSION: The low uptake of MBS item number 715 in some metropolitan areas is of particular concern given the known gaps in Aboriginal and Torres Strait Islander health. Targeted action is required to address the barriers to uptake and re-evaluate the use of MBS item number 715 as a key performance indicator.

Risk and protective factors for pregnancy outcomes for urban Aboriginal and non-Aboriginal mothers and infants: the Gudaga cohort.

This paper aims to describe delivery and birth outcomes of Aboriginal infants and their mothers in an urban setting on the east coast of Australia. The paper uses a causal pathway approach to consider the role of risk and protective factors for low birthweight. All mothers who delivered at Campbelltown Hospital between October 2005 and May 2007 were eligible. The study included 1,869 non-Aboriginal infants and 178 Aboriginal infants and their mothers. Information on delivery and birthweight was extracted from electronic medical records. Risk factors for poor outcomes were explored using regression and causal pathway analysis. Mothers of Aboriginal infants were younger than mothers of non-Aboriginal infants, and were more likely to be single, less educated, unemployed prior to pregnancy, and live in a disadvantaged neighbourhood. Health and service use was similar. They were significantly more likely to have a vaginal delivery than mothers of non-Aboriginal infants (77% cf 62.5%; χ (1) (2)  = 14.6, P < 0.001) and less likely to receive intervention during delivery. Aboriginal infants (3,281.1 g) weighed 137.5 g (95%CI: 54-221 g; P = 0.001) less then non-Aboriginal infants (3,418.7 g). Gestational age, and single mother with incomplete education, prior unemployment, smoking, and living in a disadvantaged neighbourhood were associated with lower birthweight. Maternal vulnerability had a cumulative impact on birthweight. A causal pathway analysis demonstrated the associations between risk factors.

Ethical issues: the multi-centre low-risk ethics/governance review process and AMOSS.

BACKGROUND: The Australasian Maternity Outcomes Surveillance System (AMOSS) conducts surveillance and research of rare and serious conditions in pregnancy. This multi-centre population health study is considered low risk with minimal ethical impact. OBJECTIVE: To describe the ethics/governance review pathway undertaken by AMOSS. METHOD: Prospective, descriptive study during 2009-2011 of the governance/ethical review processes required to gain approval for Australian and New Zealand (ANZ) maternity units with more than 50 births per year (n = 303) to participate in AMOSS. RESULTS: Review processes ranged from a single application for 24 NZ sites, a single application for eligible hospitals in two Australian states, full Health Research Ethics Committee (HREC) applications for individual hospitals, through simple letters of support. As of September 2011, 46 full/expedited ethics applications, 131 site governance applications and 136 letters of support requests were made over 33 months, involving an estimated 3261 hours by AMOSS staff/investigators, and an associated resource burden by participating sites, to obtain approval to receive nonidentifiable data from 291 hospitals. CONCLUSION: The AMOSS research system provides an important resource to enhance knowledge of conditions that cause rare and serious maternal morbidity. Yet the highly variable ethical approval processes required to implement this study have been excessively repetitive and burdensome. This process jeopardises timely, efficient research project implementation, without corresponding benefits to research participants. The resource burden to establish research governance for AMOSS confirms the urgent need for the Harmonisation of Multi-centre Ethical Review (HoMER) to further streamline ethics/governance review processes for multi-centre research.

Types and timing of breastfeeding support and its impact on mothers' behaviours.

AIM: To determine the types and timing of breastfeeding support for mothers of newborn babies and the extent to which this affects breastfeeding intentions and behaviours in a region with low rates of breastfeeding initiation and duration. METHODS: A cross-sectional study by interviewer-administrated questionnaire was undertaken of women birthing at a large teaching hospital in South Western Sydney, between August and October 2006 (n= 164), with a 2-week follow-up of breastfeeding or breastfeeding-intending women (n= 107). Types, timing and satisfaction with personal and professional sources of support (e.g. antenatal classes, help at birth, practical lessons on how to breastfeed, providing information, and attitude towards breastfeeding) and the impact of these on breastfeeding intention and behaviours were assessed. RESULTS: Most women had intended to breastfeed (76.2%), and, within the first 24 hours, 77.4% of babies were breastfed to some extent (45.1% exclusively), and at 2 weeks 65.9% were breastfed (9.7% exclusively). Women felt most supported by their partners and least supported by their health-care team. Antenatal classes, breastfeeding help within half an hour of birth and positive health-care team attitudes were related to improved breastfeeding intentions and behaviours. However, these supports were infrequently reported. Personal support was commonly reported although support delivered by professionals was related to better breastfeeding behaviours. CONCLUSION: Despite the effectiveness of professional support interventions, particularly those delivered in the antenatal and immediate post-natal period, access to these sources of support was very low. For breastfeeding outcomes to be improved, effective professional support strategies need to be much more widely available.

The iBobbly Aboriginal and Torres Strait Islander app project: Study protocol for a randomised controlled trial.

BACKGROUND: Suicide amongst Australian Aboriginal and Torres Strait Islander communities occurs at twice the rate of the general population and, with significant barriers to treatment, help-seeking prior to a suicide attempt is low. This trial aims to test the effectiveness of an app (iBobbly) designed with Aboriginal and Torres Strait Islander people for reducing suicidal ideation. METHODS/DESIGN: This is a two-arm randomised controlled trial that will compare iBobbly to a wait-list control condition. The trial aims to recruit Aboriginal and Torres Strait Islander participants aged 16 years and over to test iBobbly, which is a self-help app delivering content based on acceptance and commitment therapy. The primary outcome for the study is suicidal ideation, and secondary outcomes include depression, hopelessness, distress tolerance, perceived burdensomeness and thwarted belonging, and help-seeking intentions. Data will be collected for both groups at baseline, post-intervention (after 6 weeks of app use), and at 6 months post-baseline (with a final 12-month follow-up for the iBobbly group). Primary analysis will compare changes in suicidal ideation for the intervention condition relative to the wait-list control condition using mixed models. An examination of the cost-effectiveness of the intervention compared to the control condition will be conducted. DISCUSSION: If effective, iBobbly could overcome many barriers to help-seeking amongst a group of people who are at increased risk of suicide. It may provide a low-cost, accessible intervention that can reach more people. This trial will add to a sparse literature on indigenous suicide prevention and will increase our knowledge about the effectiveness of e-health interventions for suicide prevention. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12614000686606 . Registered on 30 June 2014.

Overseas-trained doctors in Indigenous rural health services: negotiating professional relationships across cultural domains.

OBJECTIVE: To examine how OTDs and staff in rural and remote Indigenous health contexts communicate and negotiate identity and relationships, and consider how this may influence OTDs' transition, integration and retention. METHOD: Ten case studies were conducted in rural and remote settings across Australia, each of an OTD providing primary care in a substantially Indigenous practice population, his/her partner, co-workers and Indigenous board members associated with the health service. Cases were purposefully sampled to ensure diversity in gender, location and country of origin. RESULTS: Identity as 'fluid' emerged as a key theme in effective communication and building good relationships between OTDs and Indigenous staff. OTDs enter a social space where their own cultural and professional beliefs and practices intersect with the expectations of culturally safe practice shaped by the Australian Indigenous context. These are negotiated through differences in language, role expectation, practice, status and identification with locus with uncertain outcomes. Limited professional and cultural support often impeded this process. CONCLUSION: The reconstruction of OTDs' identities and mediating beyond predictable barriers to cultural engagement contributes significantly not only to OTDs' integration and, to a lesser extent, their retention, but also to maximising effective communication across cultural domains. IMPLICATIONS: Retention of OTDs working in Indigenous health contexts rests on a combination of OTDs' capacity to adapt culturally and professionally to this complex environment, and of effective strategies to support them.

The Graniators support group program.

Aboriginal grandmothers (grannies) in many communities throughout Australia are considered the backbone of the social structure. This is the case for the Murri Granies in a town in regional eastern Australia. Many of these women are also their grandchildren's primary caregivers and disciplinarians, and sometimes this role is detrimental to their own care and wellbeing. As a response to this stress, the local Aboriginal Medical Service (AMS), which includes a comprehensive primary health care facility, began promoting the program 'Relax to the Max' to the Grannies as part of the holistic care they offer. Since these humble beginnings some three years ago, the group has grown to become the Graniators support group. In addition to their initial work of supporting each other, the group extended their field of action to the entire community to address social issues, particularly those around youth and children. To complement and strengthen their initiative, the Graniators partnered with other organizations in the community including the police, the municipal council, the state government's department of housing, the local primary school and a special youth service group. The program's evaluation has proved to be extremely positive in providing others in the community a clear and positive formula for driving change at a grass roots level.

Cancer mortality in Aboriginal people in New South Wales, Australia, 1994-2002.

OBJECTIVE: To describe, for the first time, mortality from cancer for Aboriginal residents of New South Wales (NSW). METHODS: These are the results of a descriptive study of cancer deaths from the NSW Central Cancer Registry for 1994 to 2002. Standardised mortality ratios were calculated with Poisson confidence intervals to compare the relative rates in the Indigenous and non-Indigenous populations. RESULTS: The overall standardised mortality rates were 66% higher for males and 59% higher for females for Aboriginal people compared with non-Indigenous people. Mortality from lung cancer was 50% and 100% higher than for NSW non-Indigenous males and females respectively. The high mortality rate from cervical cancer in Aboriginal females is contrary to the trends in the general population since the introduction of free population-based screening. CONCLUSIONS: For the first time, data are available for cancer mortality for Aboriginal people in NSW. Mortality for all cancers combined was higher than that of the non-Indigenous population. This suggests that a combination of later diagnoses and perhaps poorer treatment outcomes as well as being diagnosed with poorer prognosis cancers is occurring in Aboriginal people of NSW. IMPLICATIONS: It was possible to increase the rate of identification in a population register using routinely collected data, but the completeness and accuracy of Indigenous status should, and can, be improved in all notifying data collections. Public health planners in NSW can now begin to address the issues of prevention, treatment and palliation of cancer in Aboriginal people with local, rather than imputed, evidence.

Where there's smoke, there's fire: high prevalence of smoking among some sub-populations and recommendations for intervention.

In Australia, the prevalence of smoking is higher among certain sub-populations compared to the general population. These sub-populations include Aboriginal and Torres Strait Islander people, people from culturally and linguistically diverse backgrounds, as well as people with mental and substance use disorders and prisoners. The aims of this paper are to: describe the high prevalence of smoking among these particular sub-populations and harms associated with smoking; explore possible reasons for such high prevalence of smoking; review the evidence regarding the efficacy of existing smoking cessation interventions; and make recommendations for smoking interventions and further research among these groups. In addition to low socio-economic status, limited education and other factors, there are social, systems and psychobiological features associated with the high prevalence of smoking in these sub-groups. General population-based approaches to reducing smoking prevalence have been pursued for decades with great success and should be continued with further developments that aim specifically to affect Aboriginal and Torres Strait Islander people and some cultural groups. However, increasing attention, more specific targeting and flexible goals and interventions are also required for these and other distinct sub-populations with high smoking prevalence. Recommendations include: more funding and increased resources to examine the most appropriate education and treatment strategies to promote smoking cessation among people from Aboriginal and Torres Strait Islander and some culturally and linguistically diverse backgrounds; larger and better-designed studies evaluating smoking cessation/reduction interventions among distinct sub-groups; and system-wide interventions requiring strong leadership among clients and staff within mental health, drug and alcohol and prison settings.

Smoking, nutrition, alcohol and physical activity interventions targeting Indigenous Australians: rigorous evaluations and new directions needed.

OBJECTIVE: To describe and critique methodological aspects of interventions targeting reductions in smoking, poor nutrition, alcohol misuse and physical inactivity (SNAP risk factors) among Indigenous Australians. METHODS: An electronic search of eight databases and a manual search of reference lists of literature reviews and reference libraries for Indigenous-specific intervention studies published in peer-reviewed journals (January 1990 to August 2007) were undertaken. Alcohol, smoking, nutrition or physical activity needed to be the primary focus of the study and the intervention needed to specifically target Indigenous Australians. RESULTS: Twenty studies were selected for inclusion in the review. Methodologically, few studies employed randomisation or a control group, most omitted important details (e.g. costs), some did not report process measures (e.g. attrition rates), and some did not use validated measures. Two-thirds of interventions were implemented at the community level and employed multiple strategies. CONCLUSION: There is a need for more rigorous evaluations of interventions targeting reductions in SNAP risk factors among Indigenous Australians, and to establish the reliability and validity of measures to quantify their effect. IMPLICATIONS: It may be beneficial for future Indigenous-specific intervention research to focus on the evaluation of secondary prevention to complement the current concentration of effort targeting primary prevention. Community-wide interventions, combining strategies of greater intensity for high risk individuals with those of less intensity targeting lower risk individuals, might also offer considerable promise.

Initiation and duration of breastfeeding in an aboriginal community in south western Sydney.

The Gudaga Study is a prospective, longitudinal birth cohort study of Australian urban Aboriginal children. Mothers of Aboriginal infants were recruited using a survey of all mothers admitted to the maternity ward of an outer urban hospital in Sydney. These data established initiation rates among Gudaga infants and those of non-Aboriginal infants born locally (64.7% and 75.2%, respectively) and factors associated with breastfeeding. Older (relative risk, 1.24; confidence interval, 1.01-1.44), more educated (relative risk, 1.30; confidence interval, 1.11-1.48) mothers who intended to breastfeed (relative risk, 2.22; confidence interval, 2.12-2.3) were more likely to breastfeed. Smokers (relative risk, 0.72) and mothers of Aboriginal infants (relative risk, 0.78) were less likely to initiate breastfeeding. Breastfeeding rates for Gudaga infants dropped rapidly, with 26.3% breastfeeding at 2 months. Local health services providers can benefit from such information as they target relevant prenatal, perinatal, and postnatal services for Aboriginal mothers and their infants.

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

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

Brief intervention resource kits for Indigenous Australians: generally evidence-based, but missing important components.

OBJECTIVE: Little is known about the content and quality of brief intervention kits specifically targeting SNAP risk factors (smoking, poor nutrition, alcohol misuse or physical inactivity) among Indigenous Australians. This paper reviews the type and quality of these kits. METHODS: Brief intervention kits were primarily identified by contacting 74 health-related organisations in Australia between 1 February 2007 and 4 March 2007. RESULTS: Ten brief intervention kits met inclusion criteria: four targeted smoking; three targeted alcohol; one targeted alcohol, smoking and other drugs; one targeted alcohol, other drugs and mental health; and one targeted all SNAP risk factors. Brief intervention kits were reviewed using criteria developed from clinical guidelines for SNAP risk factors and guidelines for evaluating health promotion resources. Three kits met all review criteria. Five kits were consistent with evidence-based guidelines, but lacked a training package, patient education materials and/or behavioural change strategies. All kits used images and language identifiable with Indigenous Australia, however, their cultural appropriateness for Indigenous Australians remains unclear. CONCLUSIONS AND IMPLICATIONS: The specific content of the missing components should be guided by the best-available evidence, such as established mechanisms for health care provider feedback to patients as a behaviour change strategy, as well as the needs and preferences of health care providers and patients.

The Gudaga Study: establishing an Aboriginal birth cohort in an urban community.

OBJECTIVE: This paper describes the establishment of the Gudaga Study, an Aboriginal birth cohort in south-west Sydney, and our approach to follow-up of participants. The Study describes the health, development, and services use of Aboriginal infants and their mothers. The research team works closely with the local Aboriginal community to implement the research. METHODS: All mothers in the maternity ward of an urban hospital were surveyed to identify mothers with an Aboriginal infant. These and some additional mothers identified through other networks were recruited to the study. RESULTS: The number of mothers were surveyed was 2,108. Mothers of Aboriginal infants were younger (25.3 years compared to 28.4 years, p<0.001), less likely to be married (16.1% cf. 58.4%, p<0.001) and to have completed school (63.2% cf. 77.8%, p=0.002) than mothers of non-Aboriginal infants. Of 155 identified mothers of Aboriginal infants, 136 were recruited and 23 through other networks. At 12 months, 85.5% of infants were followed up. CONCLUSIONS: This study, to our knowledge, is the first cohort study of this kind on the eastern seaboard of Australia. The study has strong community support and follow-up, contrary to views that Aboriginal people are reluctant to participate in research. These data have national and regional significance.

Identification of Aboriginal infants at an urban hospital.

AIM: This study explored the accuracy of identification of Aboriginal infants at an urban hospital. METHODS: Data on the Aboriginal status of all infants who were delivered at the hospital to mothers who resided in the surrounding Local Government Area during 2002 were extracted from the Obstetrics Data Package (ODP). These data were supplemented with local health worker knowledge about the Aboriginal status of infants and compared with NSW Birth Register data held by the Australian Bureau of Statistics. RESULTS: There were 1739 deliveries at the hospital to mothers from the Local Government Area. Our study showed that 71.4% (n = 90) of Aboriginal and 77.5% (n = 1649) of non-Aboriginal infants identified through ODP were included in the Birth Register. The proportion of Aboriginal infants identified through the ODP was 5.2% and the Birth Register was 5.6%. The 90 Aboriginal infants included 38 with an Aboriginal mother, 34 with an Aboriginal father, and 18 with two Aboriginal parents. CONCLUSIONS: This was the first use of these data to examine the accuracy of identification of Aboriginal infants born at this facility. The study highlighted the importance of systematically seeking information on the Aboriginal status of both parents by antenatal services; of providing opportunities for timely feedback on the data quality to maternity service providers; and ensuring that the data are used to inform development of culturally appropriate services. As a result of this study, services have implemented strategies to routinely identify infants with an Aboriginal father as well as those with an Aboriginal mother.