Perspectives on the essential skills of healthcare decision making in children and adolescents with intellectual disability.

BACKGROUND: Involvement in healthcare decisions is associated with better health outcomes for patients. For children and adolescents with intellectual disability, parents and healthcare professionals need to balance listening to a child's wishes with the responsibility of keeping them safe. However, there is a scarcity of literature evaluating how to effectively involve them in decision making. In this context, we review the concept of health literacy, focusing on the skills of healthcare decision making for children and adolescents with intellectual disability. METHODS: We describe the concept of health literacy and models explaining shared decision making (individuals and healthcare professionals collaborate in decision making process) and supported decision making (when a trusted person supports the individual to collaborate with the healthcare professional in the decision-making process), and a rapid review of the literature evaluating their efficacy. We discuss healthcare decision making for children and adolescents with intellectual disability in the context of relevant recommendations from the recent Disability Royal Commission into Violence, Abuse, Neglect, and Exploitation of People with Disability in Australia. RESULTS: Health literacy skills enable individuals to access, understand, appraise, remember and use health information and services. Shared decision making has been described for children with chronic conditions and supported decision making for adults with intellectual disability. Decision-making contributes to how individuals appraise and use healthcare. The rapid review found very limited evidence of outcomes where children and adolescents with intellectual disability have been supported to contribute to their healthcare decisions. Recommendations from the Disability Royal Commission highlight current needs for greater efforts to support and build the capacity of individuals with disability to be involved in the decisions that affect their life, including healthcare decision making. CONCLUSIONS: Existing rights frameworks and healthcare standards confirm the importance of providing all people with the opportunities to learn and practise health literacy skills including decision making. There is little literature examining interventions for healthcare decision making for children with intellectual disability. Childhood is a critical time for the development of skills and autonomy. Evidence for how children and adolescents with intellectual disability can learn and practice healthcare decision-making skills in preparation for adulthood is needed to reduce inequities in their autonomy.

Social accountability in a medical school: is it sufficient? A regional medical school curriculum and approaches to equip graduates for rural and remote medical services.

BACKGROUND: Social accountability is increasingly integral to medical education, aligning health systems with community needs. Universitas Pattimura's Faculty of Medicine (FMUP) enhances this through a curriculum that prepares graduates for rural and remote (RR) medical practice, exceeding national standards. The impact of this curriculum on graduate readiness in actual work settings remains unassessed. OBJECTIVE: This study was conducted to capture the perspectives of FMUP medical graduates in a rural-centric curriculum, focusing on the teaching and learning opportunities afforded to them during their medical education. These insights are crucial for evaluating the accountability of regional medical schools in delivering quality service, particularly in underserved areas. METHODS: Semistructured interviews were conducted with nine FMUP graduates employed in the RR areas of Maluku Province. A qualitative analysis was employed to examine graduates' views on the curriculum concerning medical school accountability. RESULTS: The FMUP curriculum, informed by social accountability principles, partially prepares graduates to work under Maluku's RR conditions. However, it was reported by participants that their skills and preparedness often fall short in the face of substandard working environments. CONCLUSIONS: The FMUP curriculum supports the government's aim to develop an RR medical workforce. However, the curriculum's social accountability and rural emphasis fall short of addressing community health needs amid inadequate practice conditions. Political investment in standardizing medical facilities and equipment is essential for enhancing graduates' effectiveness and health outcomes in RR communities.

Barriers and enablers of dementia training in healthcare workers in rural and remote Australia: A scoping review to inform future approaches to training.

INTRODUCTION: Dementia is now responsible for the greatest burden of disease of any chronic illness in older Australians. Rural and remote communities bear the impacts of this disproportionately. Additional training and education for healthcare staff to support people living with dementia is needed. OBJECTIVE: The objective of this scoping review was to map and synthesise the evidence related to barriers and enablers of accessing dementia training for Australian healthcare workers located in rural and remote areas. DESIGN: This scoping review systematically searched multiple databases in January 2023 for peer-reviewed literature on the topic. Reviewers used Covidence to screen titles and abstracts of located sources, and to screen full-text articles. FINDINGS: From 187 articles screened, seven peer-reviewed journal articles were included in the final data analysis; all were from Australia or Canada. The most common barrier described was low staffing, precluding release of staff for dementia training. Enablers to participation in dementia training were availability of online training programs, as well as training providers collaborating with end users to ensure the training met their learning needs. DISCUSSION: This review provides evidence of barriers and enablers specific to rural and remote healthcare workers accessing dementia training. It also explores other approaches to training that have been trialled successfully in different settings. CONCLUSION: Addressing the identified barriers and enablers may assist in developing training approaches appropriate for existing staff, and in meeting training needs for the future workforce.

The effect of general practice contact on cancer stage at diagnosis in Aboriginal and non-Aboriginal residents of New South Wales.

PURPOSE: Older age, risks from pre-existing health conditions and socio-economic disadvantage are negatively related to the prospects of an early-stage cancer diagnosis. With older Aboriginal Australians having an elevated prevalence of these underlying factors, this study examines the potential for the mitigating effects of more frequent contact with general practitioners (GPs) in ensuring local-stage at diagnosis. METHODS: We compared the odds of local vs. more advanced stage at diagnosis of solid tumours according to GP contact, using linked registry and administrative data. Results were compared between Aboriginal (n = 4,084) and non-Aboriginal (n = 249,037) people aged 50 + years in New South Wales with a first diagnosis of cancer in 2003-2016. RESULTS: Younger age, male sex, having less area-based socio-economic disadvantage, and fewer comorbid conditions in the 12 months before diagnosis (0-2 vs. 3 +), were associated with local-stage in fully-adjusted structural models. The odds of local-stage with more frequent GP contact (14 + contacts per annum) also differed by Aboriginal status, with a higher adjusted odds ratio (aOR) of local-stage for frequent GP contact among Aboriginal people (aOR = 1.29; 95% CI 1.11-1.49) but not among non-Aboriginal people (aOR = 0.97; 95% CI 0.95-0.99). CONCLUSION: Older Aboriginal Australians diagnosed with cancer experience more comorbid conditions and more socioeconomic disadvantage than other Australians, which are negatively related to diagnosis at a local-cancer stage. More frequent GP contact may act to partly offset this among the Aboriginal population of NSW.

Supporting nursing and allied health student placements in rural and remote Australia: a narrative review of publications by university departments of rural health.

University departments of rural health are Commonwealth-funded to improve recruitment and retention of the rural allied health and nursing (including midwifery) workforce, primarily through student placements. We examined publications by university departments of rural health that were focused on allied health and nursing students undertaking placements in rural Australia, to understand the characteristics, main findings and implications of the research conducted. Interprofessional learning was a key feature of placements and placement education, although other activities such as community engagement added to placement experiences. Factors such as quality supervision and being involved in the community contributed to a positive placement experience and increased rural practice intention. Tracking studies showed a relationship between rural placements, rural practice intention and rural practice. Rural placements occurred across a variety of settings and in locations consistent with the policy framework. Embedding university departments of rural health in rural communities enabled staff to build relationships and increase placement capacity.

Expert consensus on the attributes and competencies required for rural and remote junior physicians to work effectively in isolated indonesian communities.

Indonesian physicians working in rural and remote areas must be equipped not only with generic competencies but also with the attributes and skills necessary to provide health care services without compromising quality. This study sought to reach a consensus on the attributes and competencies that are viewed as essential and important for working effectively as an early career doctor in rural and remote practice in Indonesia. A two-round Delphi study was conducted by reference to 27 consenting physicians working in rural and remote Indonesia. Forty-three items covering 9 attributes and 34 competencies were sent to these physicians to be rated on a Likert scale ranging from 1 to 5 in terms of their importance for effective rural and remote practice. Nine attributes and 29 competencies progressed to Round 2. All nine attributes and 29 competencies were identified as essential or important for junior physicians' ability to be effective in their practice. The essential attributes included professional quality related to prioritising the rural community. The essential competencies included medical skills, professional behaviour, interprofessional skills, health promotion and connection to the rural community. The consensus thus reached on these essential and important attributes and competencies can inform curriculum development for the undergraduate and postgraduate training of junior rural and remote physicians.

Co-design of dementia prevention program for Aboriginal Australians (DAMPAA).

INTRODUCTION: Dementia is highly prevalent in older Aboriginal Australians, with several modifiable risk factors. Currently, there is limited evidence on how to prevent cognitive decline in Aboriginal Australians. METHODS: Based on our Theory of Change (ToC) framework, we co-developed the Dementia risk management and prevention program for Aboriginal Australians (DAMPAA) aged over 45 years in partnership with Aboriginal community-controlled organizations (ACCOs) and Elders. Qualitative data were collected through ACCO staff workshops, Elders yarning, and governance groups to inform the protocol. Additionally, we conducted a small pilot study. RESULTS: Expected DAMPAA ToC outcomes are: (1) improved daily function, (2) better cardiovascular risk management, (3) falls reduction, (4) improved quality of life, and (5) reduced cognitive decline. Attendance enablers are social interaction, environment, exercise type/level, and logistics. DISCUSSION: Findings suggest that ToC is an effective collaborative approach for co-designing Aboriginal health programs.

A qualitative study of how COVID-19 impacts on Australians' hopes and dreams.

BACKGROUND: Although beginning in 2019, it was early in 2020 that the global community began to comprehend the significant impact that a pandemic of a new coronavirus might have on their own lives. This study was undertaken 6-9 months after significant public health restrictions were introduced within Australia and examined the impact of the COVID-19 on individuals' hopes and dreams for their future. METHODS: Community members who responded to a survey about COVID-19 were invited to participate in follow up interviews if they reported living with a chronic condition. Participants across Australia who consented were interviewed between August and December in 2020 over telephone or videoconferencing. A specific question was included regarding the impact of COVID-19 on their hopes and dreams for the future. Rapid identification of themes with an audio recordings technique was used to generate themes from the data. RESULTS: The 90 participants were predominantly female (77%) and ranged in age from 20 to 81 years with a mean age of 50 years and lived in several Australian states. Following immersive analysis of interviews, the identified common themes impacting people's hopes and dreams revealed: concerns for their own and others' job stability and future work; the impact on travel both for holidays, business and reconnecting with family; reassessing of personal and social values; and the intergenerational impact of such a profound pandemic, with concern for younger people particularly prominent in those concerns. Participants reflected on their loss of future dreams, with possibilities they had planned and worked towards not possible in the short term. CONCLUSIONS: The responses provide a window into how people view their future goals and aspirations during a time of global and local instability and highlights the potential future impacts of the COVID-19 pandemic.

Police, permits and politics: Navigating life on Australia's state borders during the COVID-19 pandemic.

OBJECTIVE: To explore the ways in which the Coronavirus disease-19 (COVID-19) pandemic has affected Australians who live and travel in cross-border regions in the course of their daily lives. DESIGN: Semi-structured interviews were undertaken with participants by telephone. The analysis utilised qualitative exploratory methods and provided rich data through immersive and reflexive analysis. SETTING: Interviews of people across Australia. PARTICIPANTS: Of 90 people interviewed in relation to their experiences of the COVID-19 pandemic, 13 described challenges related to border crossing that impacted their usual work and personal life. MAIN OUTCOME MEASURE: Description of challenges faced by Australians living close to state borders due to internal border closures in the early period of COVID-19 (2020). RESULTS: Policy changes surrounding border closures negatively impacted people's wellbeing in Australia with three key interconnected themes identified for Australians living in cross-border regions. First, border closures presented participants of these communities with physical barriers which reduced access to healthcare and employment. Second, participants reported how restrictions on travel to neighboring states and territories impacted their mental wellbeing. Finally, many Australians in cross-border regions faced financial struggles exacerbated by border closures. CONCLUSION: Normally, interstate borders are largely invisible with formalities relevant to few circumstances. Since the emergence of the COVID-19 pandemic, Australians who used to regularly cross these borders in the course of their daily activities were no longer able or willing to do so due to the uncertain circumstances surrounding border policy. This study elaborates on the impact of these closures on people's physical, financial, and emotional state.

Preventing depression among older people living in rural areas: A randomised controlled trial of behavioural activation in collaborative care.

OBJECTIVES: This study aimed to test if a behavioural activation (BA) programme was more effective than usual care at reducing the risk of conversion to major depression over 52 weeks among adults aged 65 years or older living in rural Western Australia. Secondary aims were to test if participants assigned to the BA intervention experienced greater decline in the severity of depressive and anxiety symptoms than older adults treated with usual care over 26 and 52 weeks, as well as greater improvement in physical and mental health-related quality of life. METHODS: Randomised controlled clinical trial that started recruitment in February 2016 in rural Western Australia. We used the electoral roll to invite adults aged 65 years or over living in suitable regions of Western Australia to take part in the study. We recruited those who consented and screened positive to at least one of the two Whooley questions: feeling down/depressed/hopeless or little interest or pleasure over the past month. Participants were randomly assigned to usual care or usual care plus a phone-delivered BA program (1:1). The intervention consisted of a self-managed BA program supported by three 45-min phone sessions delivered by a BA therapist over a period of 8 weeks. We used the DSM-5 criteria to establish the presence of a major depressive episode, and Patient Health Questionnaire, Generalised Anxiety Disorder Scale and SF-36 to assess symptoms of depression, anxiety and quality of life. RESULTS: Of the 309 older adults randomised, 307 started the trial: 153 usual care and 154 BA (computer-generated random permuted even blocks ranging in size from 8 to 20). Six participants developed a major depressive episode during follow-up, four of them in the usual care group (odds ratio of depression associated with the intervention = 0.49, 95% CI = 0.04, 3.49-blind assessment). Seventy-three (23.8%) participants were lost over 52 weeks-there were no differences between usual care and intervention group. Intention-to-treat analyses using mixed regression models found modest non-significant effects of the BA intervention, while complete-case analyses showed that participants treated with BA compared with usual care experienced significant improvements in depression and anxiety symptoms over 52 weeks, as well as improved mental health quality of life. CONCLUSIONS: Few participants developed a major depressive episode during follow-up. The BA intervention was associated with improved symptoms of depression and anxiety, although the clinical significance of these benefits remains unclear.

Factors associated with the rural and remote practice of medical workforce in Maluku Islands of Indonesia: a cross-sectional study.

BACKGROUND: Many factors contribute to engagement in rural and remote (RR) medical practice, but little is known about the factors associated with rural and remote medical practice in such remote locations as the Maluku Province of Indonesia. This study describes factors associated with actual RR practice, preferred RR practice, and intention to remain practice in Maluku Province. METHODS: An online survey of work-related experience and intentions for future rural work was administered to 410 doctors working in the Maluku province of Indonesia. Participant characteristics were described using descriptive statistics, associations between the independent variables with the location of the workforce, intention to remain practice in Maluku, preference for future RR practice in Maluku were analysed using Chi-square tests and logistic regression. RESULTS: A total of 324 responses (79% response rate) were recorded, comprising 70% females and 30% Pattimura University graduates of doctors employed in Maluku. Doctors working in RR areas were more likely to be a GP (OR 3.49, CI 1.03-11.8), have a monthly salary of more than IDR 6 million (OR 11.5, CI 4.24-31.1), and have no additional practice (OR 2.78, CI 1.34-5.78). Doctors intended to stay practice in Maluku were more likely to be born in Maluku (OR 7.77, CI 3.42-17.7) and have graduated from Pattimura University (OR 3.06, CI 1.09-8.54), and less likely to be a temporary employee (OR 0.24, CI 0.10-0.57). Doctors who prefer future RR practice in Maluku were more likely to experience rural living (OR 2.05 CI 1.05-3.99), have a positive indication of the impact of community exposure during medical schools on their current practice (OR 2.08, CI 1.06-4.09), currently practising in RR Maluku (OR 8.23, CI 3.27-20.8); and less likely to have bigger take-home pay (OR 0.30, CI 0.13-0.70). CONCLUSION: This study indicates that special attention should be given to recruiting doctors with a rural background and ongoing support through attractive opportunities to build a sustainable RR workforce. Since a regional medical school helps supply doctors to the RR areas in its region, a sustained collaboration between medical schools and local government implementing relevant strategies are needed to widen participation and improve the recruitment and retention of RR doctors.

Can the CHA2 DS2 -VA schema be used to decide on anticoagulant therapy in Aboriginal and other Australians with non-valvular atrial fibrillation?

The Australasian guidelines recommend use of the CHA2 DS2 -VA schema to stratify ischaemic stroke risk in patients with non-valvular atrial fibrillation (N-VAF) and determine risk thresholds for recommending oral anticoagulant (OAC) therapy. However, the CHA2 DS2 -VA score has not been validated in a representative Australian population cohort with N-VAF, including in Aboriginal people who are known to have a higher age-adjusted stroke risk than other Australians. In a retrospective data-linkage study of 49 114 patients aged 24-84 years with N-VAF, 40.0% women and 2.5% Aboriginal, we found that patients with a CHA2 DS2 -VA score >2 had high annual stroke rates (>2%) that would justify OAC therapy. This occurred regardless of Aboriginal status. Non-Aboriginal patients with a CHA2 DS2 -VA score of 0 had a mean annual stroke rate of 0.4%, and hence were not likely to benefit from antithrombotic therapy. However, Aboriginal patients with a zero CHA2 DS2 -VA score had a significantly higher annual stroke rate of 0.9%, and could potentially obtain net clinical benefit from anticoagulation, primarily with the safer non-vitamin K antagonist OAC. We conclude that clinicians can confidently use the CHA2 DS2 -VA score to make decisions regarding anticoagulation in accordance with stroke risk in patients with N-VAF, except in Aboriginal people in whom the risk score was unable to identify those at truly low risk of stroke.

"The support has been brilliant": experiences of Aboriginal and Torres Strait Islander patients attending two high performing cancer services.

BACKGROUND: Improving health outcomes for Indigenous people by providing person-centred, culturally safe care is a crucial challenge for the health sector, both in Australia and internationally. Many cancer providers and support services are committed to providing high quality care, yet struggle with providing accessible, culturally safe cancer care to Indigenous Australians. Two Australian cancer services, one urban and one regional, were identified as particularly focused on providing culturally safe cancer care for Indigenous cancer patients and their families. The article explores the experiences of Indigenous cancer patients and their families within the cancer services and ascertains how their experiences of care matches with the cancer services' strategies to improve care. METHODS: Services were identified as part of a national study designed to identify and assess innovative services for Indigenous cancer patients and their families. Case studies were conducted with a small number of identified services. In-depth interviews were conducted with Indigenous people affected by cancer and hospital staff. The interviews from two services, which stood out as particularly high performing, were analysed through the lens of the patient experience. RESULTS: Eight Indigenous people affected by cancer and 23 hospital staff (Indigenous and non-Indigenous) were interviewed. Three experiences were shared by the majority of Indigenous cancer patients and family members interviewed in this study: a positive experience while receiving treatment at the cancer service; a challenging time between receiving diagnosis and reaching the cancer centre; and the importance of family support, while acknowledging the burden on family and carers. CONCLUSIONS: This article is significant because it demonstrates that with a culturally appropriate and person-centred approach, involving patients, family members, Indigenous and non-Indigenous staff, it is possible for Indigenous people to have positive experiences of cancer care in mainstream, tertiary health services. If we are to improve health outcomes for Indigenous people it is vital more cancer services and hospitals follow the lead of these two services and make a sustained and ongoing commitment to strengthening the cultural safety of their service.

A qualitative exploration of priorities for quality improvement amongst Aboriginal and Torres Strait Islander primary health care services.

BACKGROUND: Achieving quality improvement in primary care is a challenge worldwide, with substantial gaps between best practice and actual practice. Within the context of Australia, Aboriginal and Torres Strait Primary Health Care (PHC) services have great variation across settings, structures and context. Research has highlighted how these contextual differences can critically influence the success of Quality Improvement (QI) interventions and outcomes. Less understood is the interaction between local context and other factors, which may impact the implementation of QI interventions. This paper aims to explore the strengths and challenges in QI for Aboriginal and Torres Strait Islander PHC services and their priorities for improvement. METHODS: A multiple case study design was adopted, working with eight Aboriginal and Torres Strait Islander PHC services in Northern Territory, Queensland and Western Australia. Data were collected via a health service survey, semi-structured interviews with health service staff and service users and researcher observations, to explore QI and perceptions of care quality at the service level. Data reported here were analysed using an iterative thematic technique, within-case and across-case. RESULTS: A total of 135 interviews were conducted with health service staff, service users and community members. Participants emphasised the centrality of resilient community, committed workforce and valued Aboriginal and Torres Strait Islander team members in delivering care. A shared purpose around improving the health of community was a significant driver. Key challenges included staff turnover and shortages, a complex and overwhelming acute and chronic care workload, building relationships and trust between health services and the community. Service-suggested priority areas for improvement were categorised into five themes: i) cultural safety (community driving health and planning for culturally safe services); ii) community engagement (through clinical activities in the community); iii) shared ownership and a team approach around QI; iv) strengthening systems and consistent ways of doing things in the health service; and v) strengthening local workforce (and resources for a culturally safe workforce). CONCLUSIONS: These findings advance understandings of relational, community and cultural factors which are identified priorities for the delivery of quality care in Aboriginal and Torres Strait Islander PHC services across varied contexts.

Atrial Fibrillation in Indigenous Australians: A Multisite Screening Study Using a Single-Lead ECG Device in Aboriginal Primary Health Settings.

BACKGROUND: Circulatory diseases continue to be the greatest cause of mortality for Australian Aboriginal and Torres Strait Islander people, and a major cause of persistently lower life expectancy compared with non-Aboriginal Australians. The limited information that exists on atrial fibrillation (AF) prevalence in Aboriginal and Torres Strait Islander communities is mostly based on hospital admission data. This shows AF as principal or additional admission diagnosis was 1.4 times higher compared to non-Aboriginal Australians, a higher incidence of AF across the adult life span after age 20 years and a significantly higher prevalence among younger patients. Our study estimates the first national community prevalence and age distribution of AF (including paroxysmal) in Australian Aboriginal people. A handheld single-lead electrocardiograph (ECG) device (iECG), known to be acceptable in this population, was used to record participant ECGs. METHODS: This co-designed, descriptive cross-sectional study was conducted in partnership with 16 Aboriginal Community Controlled Health organisations at their facilities and/or with their services delivered elsewhere. The study was also conducted at one state community event. Three (3) Australian jurisdictions were involved: New South Wales, Western Australia and the Northern Territory. Study sites were located in remote, regional and urban areas. Opportunistic recruitment occurred between June 2016 and December 2017. People <45 years of age were excluded. RESULTS: Thirty (30) of 619 Aboriginal people received a 'Possible AF' and 81 an 'Unclassified' result from a hand-held smartphone ECG device. A final diagnosis of AF was made in 29 participants (4.7%; 95%CI 3.0-6.4%), 25 with known AF (five paroxysmal), and four with previously unknown AF. Three (3) of the four with unknown AF were aged between 55-64 years, consistent with a younger age of AF onset in Aboriginal people. Estimated AF prevalence increased with age and was higher in those aged >55 years than the general population (7.2% compared with 5.4%). Slightly more men than women were diagnosed with AF. CONCLUSIONS: This study is a significant contribution to the evidence which supports screening for AF in Aboriginal and Torres Strait Islander people commencing at a younger age than as recommended in the Australian guidelines (>65 years). We recommend the age of 55 years. Consideration should be given to the inclusion of AF screening in the Australian Government Department of Health annual 'Aboriginal and Torres Strait Islander Health Assessment'. CLINICAL TRIAL REGISTRATION: ACTRN12616000459426.

Men Against Violence: Engaging men and boys in prevention of family violence.

ISSUES ADDRESSED: Discussion of family violence is important but many men and boys struggle to engage with the topic. Primary prevention approaches focus on communicating with and educating the population, including men and boys, in the areas of healthy relationships, gender and violence. There can be both barriers to and also gains from these interventions. This paper describes a project implemented in Geraldton, Western Australia, and discusses what has been effective and ineffective during the project. METHODS: The 'Men Against Violence' project targeted men and boys through local sporting clubs in the City of Greater Geraldton, in the Midwest region of Western Australia, through the use of face to face education, community radio and television interviews and other appropriate engagement strategies. 'Men Against Violence' events were held to connect with local male community members and address the role men can have in family violence prevention. RESULTS: We describe the three key engagement activities, working with the local Australian Rules football league, state-league basketball team and a local high school Aboriginal football academy. These strategies provided avenues for contact with and the education of men and boys aged 12 years and older. CONCLUSION: Through successful partnerships with a number of local organisations, the 'Men Against Violence' project saw a high level of engagement with local men. The project also gained strong community support, with pockets of resistance encountered and managed. SO WHAT: The 'Men Against Violence' project experienced highlights and barriers throughout the pilot project that can guide and inform future family violence prevention programs.

Post-mammographic screening behaviour: A survey investigating what women do after being told they have dense breasts.

ISSUE ADDRESSED: Despite widespread calls for women undergoing mammographic screening to be informed of their breast density, concerns remain as to how this is interpreted and acted upon given the absence of evidence-based supplemental screening recommendations for women with dense breasts. This study investigates the action women take in response to being notified they have dense breasts and what subsequent advice women receive from health professionals. METHODS: Via a survey of nearly 7000 women, we assessed the post-screening actions of women attending a population-based mammographic screening program (BreastScreen) in Western Australia from 21 November 2017 to 19 April 2018. Women who reported that they were notified they had dense breasts were compared to controls (where applicable). Descriptive and logistic regression analyses were used to summarise responses from 6,183 women. RESULTS: Half of women notified that they have dense breasts consulted or intended to consult their General Practitioner (GP), particularly those notified for the first time (55%). Of those notified women who consulted their GP, 50% were referred to have supplemental screening. Overall, 20% of women notified as having dense breasts reported that they had an ultrasound due to their breast density. CONCLUSION: Self-reported health service usage after mammographic screening is higher in women who have been notified they have dense breasts. So what? There is growing pressure for screening programs in Australia and internationally to routinely measure and report breast density to participants. Results from this study can inform screening programs of the likely impact of breast density notification on health service usage. While more information is needed to fill knowledge gaps in recommended action for women with dense breasts, the greatest risks to women arise from not being screened. Hence, health promotion practitioners and health providers should continue to encourage women to participate in BreastScreen programs.

Cultural respect in midwifery service provision for Aboriginal women: longitudinal follow-up reveals the enduring legacy of targeted program initiatives.

BACKGROUND: Culturally competent maternity care provision to Aboriginal and Torres Strait Islander women was identified as a priority area by Australia's National Maternity Services Plan in 2011. While midwifery programs responded by including core Indigenous content and community placements in curricula, little is known about whether knowledge learned, and insights gained in response to these initiatives have endured and been applied in clinical practice. This follow-up study explores the impact of a compulsory Indigenous unit and a remote clinical placement on two cohorts of non-Indigenous midwives who were participants in an earlier 2012-14 study. METHODS: Fourteen non-Indigenous participants who were either students or recent graduates in 2012-14 were located and re-interviewed in 2019-20. In-depth interviews based on a semi-structured interview guide were conducted by telephone or face-to face; recordings were transcribed and thematically analysed using standard qualitative procedures. RESULTS: Exposure to Indigenous content and settings during training had an enduring impact on participants' midwifery practice; most felt better prepared to provide culturally safe care, build respectful relationships and advocate for improved services for Aboriginal women. Despite this positive legacy, they also expressed apprehension about causing offence and recognised their own knowledge deficits with regard to Aboriginal cultural practices. Organisational constraints, including restrictions on the number of family members accompanying a birthing mother were identified as barriers to optimal care; some positive organisational initiatives were also described. CONCLUSIONS: This follow-up study provides encouraging evidence that well-designed and delivered Indigenous content and community placement opportunities in midwifery programs can have a lasting impact on service provision to Aboriginal women, contribute to a more informed, empathetic and culturally competent maternity workforce and help catalyse health service changes towards more culturally safe care.

Differences in stroke risk and cardiovascular mortality for Aboriginal and other Australian patients with atrial fibrillation.

OBJECTIVES: To assess the risks of stroke and cardiovascular mortality for Aboriginal and non-Aboriginal Australians with atrial fibrillation. DESIGN: Retrospective data linkage cohort study. SETTING, PARTICIPANTS: All people aged 20-84 years hospitalised with atrial fibrillation in Western Australia during 2000-2012. MAIN OUTCOME MEASURES: Stroke incidence rates and mortality after hospitalisation for atrial fibrillation, and 10-year risks of stroke and of cardiovascular and all-cause mortality. RESULTS: Among 55 482 index admissions with atrial fibrillation, 7.7% of 20-59-year-old patients and 1.3% of 60-84-year-old patients were Aboriginal Australians. A larger proportion of Aboriginal patients aged 20-59 years had CHA2 DS2 -VASc scores of 2 or more (59.8% v 21.8%). In 20-59-year-old Aboriginal patients, the incidence during follow-up (maximum, 10 years; median, 7.1 years) of stroke (incidence rate ratio [IRR], 3.2; 95% CI, 2.5-4.1) and fatal stroke (IRR, 5.7; 95% CI, 3.9-8.9) were markedly higher than for non-Aboriginal patients. Stroke incidence was higher for 60-84-year-old patients, but the difference between Aboriginal and non-Aboriginal patients was smaller (IRR, 1.6; 95% CI, 1.3-2.0). Cardiovascular mortality during follow-up was also higher for 20-59-year-old Aboriginal patients (IRR, 4.4; 95% CI, 4.3-5.9). The hazards of stroke (adjusted HR [aHR], 1.67; 95% CI, 1.22-2.28) and cardiovascular mortality (aHR, 1.47; 95% CI, 1.18-1.83) in younger Aboriginal patients remained significantly higher after multivariable adjustment; age/sex, principal diagnosis of atrial fibrillation, and CHA2 DS2 -VASc score were the most influential factors. CONCLUSION: Stroke risk and cardiovascular mortality are markedly higher for Aboriginal than non-Aboriginal patients with atrial fibrillation, particularly for patients under 60. Strategies for providing evidence-based therapies and cardiovascular prevention to Aboriginal people with atrial fibrillation must be improved.

Beyond the black stump: rapid reviews of health research issues affecting regional, rural and remote Australia.

CHAPTER 1: RETAIL INITIATIVES TO IMPROVE THE HEALTHINESS OF FOOD ENVIRONMENTS IN RURAL, REGIONAL AND REMOTE COMMUNITIES: Objective: To synthesise the evidence for effectiveness of initiatives aimed at improving food retail environments and consumer dietary behaviour in rural, regional and remote populations in Australia and comparable countries, and to discuss the implications for future food environment initiatives for rural, regional and remote areas of Australia. STUDY DESIGN: Rapid review of articles published between January 2000 and May 2020. DATA SOURCES: We searched MEDLINE (EBSCOhost), Health and Society Database (Informit) and Rural and Remote Health Database (Informit), and included studies undertaken in rural food environment settings in Australia and other countries. DATA SYNTHESIS: Twenty-one articles met the inclusion criteria, including five conducted in Australia. Four of the Australian studies were conducted in very remote populations and in grocery stores, and one was conducted in regional Australia. All of the overseas studies were conducted in rural North America. All of them revealed a positive influence on food environment or consumer behaviour, and all were conducted in disadvantaged, rural communities. Positive outcomes were consistently revealed by studies of initiatives that focused on promotion and awareness of healthy foods and included co-design to generate community ownership and branding. CONCLUSION: Initiatives aimed at improving rural food retail environments were effective and, when implemented in different rural settings, may encourage improvements in population diets. The paucity of studies over the past 20 years in Australia shows a need for more research into effective food retail environment initiatives, modelled on examples from overseas, with studies needed across all levels of remoteness in Australia. Several retail initiatives that were undertaken in rural North America could be replicated in rural Australia and could underpin future research. CHAPTER 2: WHICH INTERVENTIONS BEST SUPPORT THE HEALTH AND WELLBEING NEEDS OF RURAL POPULATIONS EXPERIENCING NATURAL DISASTERS?: Objective: To explore and evaluate health and social care interventions delivered to rural and remote communities experiencing natural disasters in Australia and other high income countries. STUDY DESIGN: We used systematic rapid review methods. First we identified a test set of citations and generated a frequency table of Medical Subject Headings (MeSH) to index articles. Then we used combinations of MeSH terms and keywords to search the MEDLINE (Ovid) database, and screened the titles and abstracts of the retrieved references. DATA SOURCES: We identified 1438 articles via database searches, and a further 62 articles via hand searching of key journals and reference lists. We also found four relevant grey literature resources. After removing duplicates and undertaking two stages of screening, we included 28 studies in a synthesis of qualitative evidence. DATA SYNTHESIS: Four of us read and assessed the full text articles. We then conducted a thematic analysis using the three phases of the natural disaster response cycle. CONCLUSION: There is a lack of robust evaluation of programs and interventions supporting the health and wellbeing of people in rural communities affected by natural disasters. To address the cumulative and long term impacts, evidence suggests that continuous support of people's health and wellbeing is needed. By using a lens of rural adversity, the complexity of the lived experience of natural disasters by rural residents can be better understood and can inform development of new models of community-based and integrated care services. CHAPTER 3: THE IMPACT OF BUSHFIRE ON THE WELLBEING OF CHILDREN LIVING IN RURAL AND REMOTE AUSTRALIA: Objective: To investigate the impact of bushfire events on the wellbeing of children living in rural and remote Australia. STUDY DESIGN: Literature review completed using rapid realist review methods, and taking into consideration the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement for systematic reviews. DATA SOURCES: We sourced data from six databases: EBSCOhost (Education), EBSCOhost (Health), EBSCOhost (Psychology), Informit, MEDLINE and PsycINFO. We developed search terms to identify articles that could address the research question based on the inclusion criteria of peer reviewed full text journal articles published in English between 1983 and 2020. We initially identified 60 studies and, following closer review, extracted data from eight studies that met the inclusion criteria. DATA SYNTHESIS: Children exposed to bushfires may be at increased risk of poorer wellbeing outcomes. Findings suggest that the impact of bushfire exposure may not be apparent in the short term but may become more pronounced later in life. Children particularly at risk are those from more vulnerable backgrounds who may have compounding factors that limit their ability to overcome bushfire trauma. CONCLUSION: We identified the short, medium and long term impacts of bushfire exposure on the wellbeing of children in Australia. We did not identify any evidence-based interventions for supporting outcomes for this population. Given the likely increase in bushfire events in Australia, research into effective interventions should be a priority. CHAPTER 4: THE ROLE OF NATIONAL POLICIES TO ADDRESS RURAL ALLIED HEALTH, NURSING AND DENTISTRY WORKFORCE MALDISTRIBUTION: Objective: Maldistribution of the health workforce between rural, remote and metropolitan communities contributes to longstanding health inequalities. Many developed countries have implemented policies to encourage health care professionals to work in rural and remote communities. This scoping review is an international synthesis of those policies, examining their effectiveness at recruiting and retaining nursing, dental and allied health professionals in rural communities. STUDY DESIGN: Using scoping review methods, we included primary research - published between 1 September 2009 and 30 June 2020 - that reported an evaluation of existing policy initiatives to address workforce maldistribution in high income countries with a land mass greater than 100 000 km2 . DATA SOURCES: We searched MEDLINE, Ovid Embase, Ovid Emcare, Informit, Scopus, and Web of Science. We screened 5169 articles for inclusion by title and abstract, of which we included 297 for full text screening. We then extracted data on 51 studies that had been conducted in Australia, the United States, Canada, United Kingdom and Norway. DATA SYNTHESIS: We grouped the studies based on World Health Organization recommendations on recruitment and retention of health care workers: education strategies (n = 27), regulatory change (n = 11), financial incentives (n = 6), personal and professional support (n = 4), and approaches with multiple components (n = 3). CONCLUSION: Considerable work has occurred to address workforce maldistribution at a local level, underpinned by good practice guidelines, but rarely at scale or with explicit links to coherent overarching policy. To achieve policy aspirations, multiple synergistic evidence-based initiatives are needed, and implementation must be accompanied by well designed longitudinal evaluations that assess the effectiveness of policy objectives. CHAPTER 5: AVAILABILITY AND CHARACTERISTICS OF PUBLICLY AVAILABLE HEALTH WORKFORCE DATA SOURCES IN AUSTRALIA: Objective: Many data sources are used in Australia to inform health workforce planning, but their characteristics in terms of relevance, accessibility and accuracy are uncertain. We aimed to identify and appraise publicly available data sources used to describe the Australian health workforce. STUDY DESIGN: We conducted a scoping review in which we searched bibliographic databases, websites and grey literature. Two reviewers independently undertook title and abstract screening and full text screening using Covidence software. We then assessed the relevance, accessibility and accuracy of data sources using a customised appraisal tool. DATA SOURCES: We searched for potential workforce data sources in nine databases (MEDLINE, Embase, Ovid Emcare, Scopus, Web of Science, Informit, the JBI Evidence-based Practice Database, PsycINFO and the Cochrane Library) and the grey literature, and examined several pre-defined websites. DATA SYNTHESIS: During the screening process we identified 6955 abstracts and examined 48 websites, from which we identified 12 publicly available data sources - eight primary and four secondary data sources. The primary data sources were generally of modest quality, with low scores in terms of reference period, accessibility and missing data. No single primary data source scored well across all domains of the appraisal tool. CONCLUSION: We identified several limitations of data sources used to describe the Australian health workforce. Establishment of a high quality, longitudinal, linked database that can inform all aspects of health workforce development is urgently needed, particularly for rural health workforce and services planning. CHAPTER 6: RAPID REALIST REVIEW OF OPIOID TAPERING IN THE CONTEXT OF LONG TERM OPIOID USE FOR NON-CANCER PAIN IN RURAL AREAS: Objective: To describe interventions, barriers and enablers associated with opioid tapering for patients with chronic non-cancer pain in rural primary care settings. STUDY DESIGN: Rapid realist review registered on the international register of systematic reviews (PROSPERO) and conducted in accordance with RAMESES standards. DATA SOURCES: English language, peer-reviewed articles reporting qualitative, quantitative and mixed method studies, published between January 2016 and July 2020, and accessed via MEDLINE, Embase, CINAHL Complete, PsycINFO, Informit or the Cochrane Library during June and July 2020. Grey literature relating to prescribing,deprescribing or tapering of opioids in chronic non-cancer pain, published between January 2016 and July 2020, was identified by searching national and international government, health service and peek organisation websites using Google Scholar. DATA SYNTHESIS: Our analysis of reported approaches to tapering conducted across rural and non-rural contexts showed that tapering opioids is complex and challenging, and identified several barriers and enablers. Successful outcomes in rural areas appear likely through therapeutic relationships, coordination and support, by using modalities and models of care that are appropriate in rural settings and by paying attention to harm minimisation. CONCLUSION: Rural primary care providers do not have access to resources available in metropolitan centres for dealing with patients who have chronic non-cancer pain and are taking opioid medications. They often operate alone or in small group practices, without peer support and access to multidisciplinary and specialist teams. Opioid tapering approaches described in the literature include regulation, multimodal and multidisciplinary approaches, primary care provider support, guidelines, and patient-centred strategies. There is little research to inform tapering in rural contexts. Our review provides a synthesis of the current evidence in the form of a conceptual model. This preliminary model could inform the development of a model of care for use in implementation research, which could test a variety of mechanisms for supporting decision making, reducing primary care providers' concerns about potential harms arising from opioid tapering, and improving patient outcomes.