A mixed methods study of Aboriginal health workers' and exercise physiologists' experiences of co-designing chronic lung disease 'yarning' education resources.

BACKGROUND: Despite the high incidence of chronic obstructive pulmonary disease (COPD) in Aboriginal communities in Australia, Aboriginal Health Workers (AHWs) have limited knowledge about effective management. AIM: To evaluate an online education program, co-designed with AHWs and exercise physiologists (EPs) or physiotherapists (PTs), to increase knowledge about COPD and its management. METHODS: AHWs and EPs from four Aboriginal Community Controlled Health Services (ACCHS) were recruited. An Aboriginal researcher and a physiotherapist experienced in COPD management and pulmonary rehabilitation (PR) delivered seven online education sessions. These sessions used co-design principles and an Aboriginal pedagogy framework '8 Ways of learning', which incorporates Aboriginal protocols and perspectives to realign teaching techniques and strengthen learning outcomes. Topics covered were: How the lungs work; What is COPD; Medications and how to use inhalers and COPD Action Plans; Why exercise is important; Managing breathlessness; Healthy eating; Managing anxiety and depression. After each session, AHWs with support from EPs, co-designed education 'yarning' resources using Aboriginal ways of learning to ensure topics were culturally safe for the local Aboriginal community and practiced delivering this at the following session. At the end of the program participants completed an anonymous online survey (5-point Likert scale) to assess satisfaction, and a semi-structured interview about their experience of the online education. RESULTS: Of the 12 participants, 11 completed the survey (7 AHWs, 4 EPs). Most (90%) participants strongly agreed or agreed that the online sessions increased knowledge and skills they needed to support Aboriginal patients with COPD. All (100%) participants felt: their cultural perspectives and opinions were valued and that they were encouraged to include cultural knowledge. Most (91%) reported that delivering their own co-designed yarning scripts during the online sessions improved their understanding of the topics. Eleven participants completed semi-structured interviews about participating in online education to co-design Aboriginal 'yarning' resources. Themes identified were: revealing the Aboriginal lung health landscape; participating in online learning; structuring the online education sessions; co-designing with the facilitators. CONCLUSIONS: Online education using co-design and 8 Ways of learning was rated highly by AHWs and EPs for improving COPD knowledge and valuing cultural perspectives. The use of co-design principles supported the cultural adaptation of COPD resources for Aboriginal people with COPD. TRIAL REGISTRATION: PROSPERO (registration number: CRD42019111405).

"Everyone needs a Deb": what Australian indigenous women say about breast cancer screening and treatment services.

BACKGROUND: Breast cancer continues to be the second most diagnosed cancer overall and the most diagnosed cancer for women in Australia. While mortality rates overall have declined in recent years, Indigenous women continue to be diagnosed at more marginal rates (0.9 times) and are more likely to die (1.2 times). The literature provides a myriad of reasons for this; however, the voices of Indigenous women are largely absent. This study sets out to understand what is happening from the perspectives of Australian Indigenous women with a view to charting culturally safer pathways that improve participation in screening and treatment by Indigenous women. METHODS: This co-design study was conducted using semi-structured, in-depth interviews and focus group discussions. Recruitment of study participants was via snowball sampling. Participants were subsequently consented into the study through the Aboriginal Health Service and the research team. Interviews were audio recorded and transcribed verbatim, and data coded in NVivo12 using inductive thematic analysis. RESULTS: A total of 21 Indigenous women and 14 health service providers were interviewed predominantly from the same regional/rural area in NSW, with a small proportion from other states in Australia. Six major themes were identified: Access, Awareness, Community and Family, Lack of control, Negative feelings and associations and Role of services. CONCLUSION: To improve access and participation of Indigenous women and ultimately improve mortality rates, breast cancer services must explicitly address cultural and community needs.

Implementing evidence into practice to improve chronic lung disease management in Indigenous Australians: the breathe easy, walk easy, lungs for life (BE WELL) project (protocol).

BACKGROUND: Strong evidence exists for the benefits of pulmonary rehabilitation (PR) for people with chronic obstructive pulmonary disease (COPD), however the availability of culturally safe PR for Aboriginal and Torres Strait Islander (Indigenous) Peoples is limited. The study aims to determine whether PR can be implemented within Aboriginal Community Controlled Health Services (ACCHS) to improve outcomes for Indigenous people with COPD. METHODS: Multi-centre cohort study using participatory action research guided by the Knowledge-to-Action Framework. ACCHS supportive of enhancing services for chronic lung disease will be recruited. Aboriginal Health Workers (AHW) and the exercise physiologist (EP) or physiotherapist (PT) within these ACCHS will attend a workshop aimed at increasing knowledge and skills related to management of COPD and the provision of PR. Indigenous people with COPD will be invited to attend an 8-week, twice weekly, supervised PR program. OUTCOMES: AHW, EP/PT knowledge, skills and confidence in the assessment and management of COPD will be measured before and immediately after the BE WELL workshop and at 3, 6 and 12 months using a survey. PR participant measures will be exercise capacity (6-minute walk test (6MWT), health-related quality of life and health status at commencement and completion of an 8-week PR program. Secondary outcomes will include: number, length and cost of hospitalisations for a COPD exacerbation in 12-months prior and 12-months post PR; local contextual factors influencing implementation of PR; specific respiratory services provided by ACCHS to manage COPD prior to project commencement and at project completion. Repeated measures ANOVA will be used to evaluate changes in knowledge and confidence over time of AHWs and EP/PTs. Paired t-tests will be used to evaluate change in patient outcomes from pre- to post-PR. Number of hospital admissions in the 12 months before and after the PR will be compared using unpaired t-tests. DISCUSSION: Pulmonary rehabilitation is an essential component of best-practice management of COPD and is recommended in COPD guidelines. Indigenous peoples have limited access to culturally safe PR programs. This study will evaluate whether PR can be implemented within ACCHS and improve outcomes for Indigenous people with COPD. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001337369, Registered 2nd September 2017 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373585&isClinicalTrial=False.

A graduate oral health therapist program to support dental service delivery and oral health promotion in Aboriginal communities in New South Wales, Australia.

INTRODUCTION: The early closure of the Voluntary Dental Graduate Year Program and the Oral Health Therapy Graduate Year Program by the Australian Government adversely impacted New South Wales (NSW) Aboriginal Community Controlled Health Services (ACCHSs). This led to the co-design of a small-scale oral health therapy graduate year program for ACCHSs known as the Dalang Project, which enabled oral health therapists to engage with local Aboriginal communities and implement culturally competent, practical and evidence-based oral health promotion activities. This article provides an overview of the Dalang Project and its evaluation. METHODS: All graduates of the Dalang Project were invited via email and social media to complete an online survey. The survey included questions about their year in the Dalang Project, why they applied, what they liked and disliked about the project, where they planned to work post-placement, and examples of the most significant changes they observed in the communities where they were placed. Host sites were also surveyed and data were collated on clinical services performed as well as oral health promotion activity. RESULTS: Prior to commencing the Dalang Project only 4 of the 15 respondents came from rural or regional areas. Nine of the 15 respondents were considering working in a regional, rural or remote area prior to applying for the Dalang Project. Twelve respondents were working at the time of the survey and half were working in regional, rural or remote locations in NSW and one in the Northern Territory. All reported that they would be more likely to work in an ACCHS as a result of being a part of the Dalang Project. The majority of respondents said they would recommend the program to future graduates. A total of 63 schools, 21 preschools and 15 community health services received regular dental health education through the Dalang Project. A total of 3250 toothbrushes and fluoride toothpastes were distributed to children and families through the Dalang Project. A key part of the program was the installation of refrigerated and filtered water fountains in schools where there was no free filtered or refrigerated water supply. The inclusion of this component in the program was part of the co-design process and links the program to the wider population health strategies in NSW to help prevent childhood obesity. CONCLUSION: The Dalang Project is an example of a successful co-designed project that has positively impacted oral health service delivery for Aboriginal children and has provided a valuable experience for new graduate oral health therapists working in ACCHSs. Overall, the Dalang Project was found to be a positive professional experience for the oral health therapists with many remaining in rural, remote and regional locations after completing the program.

A sexual health quality improvement program (SHIMMER) triples chlamydia and gonorrhoea testing rates among young people attending Aboriginal primary health care services in Australia.

BACKGROUND: In Australia, chlamydia is the most commonly notifiable infection and over the past ten years chlamydia and gonorrhoea notification rates have increased. Aboriginal compared with non-Aboriginal Australians have the highest notifications rates of chlamydia and gonorrhoea. Regular testing of young people for chlamydia and gonorrhoea is a key prevention strategy to identify asymptomatic infections early, provide treatment and safe sex education. This study evaluated if a sexual health quality improvement program (QIP) known as SHIMMER could increase chlamydia and gonorrhoea testing among young people attending four Aboriginal primary health care services in regional areas of New South Wales, Australia. METHODS: We calculated the proportion of 15-29 year olds tested and tested positivity for chlamydia and gonorrhoea in a 12-month before period (March 2010-February 2011) compared with a 12-month QIP period (March 2012-February 2013). Logistic regression was used to assess the difference in the proportion tested for chlamydia and gonorrhoea between study periods by gender, age group, Aboriginal status and Aboriginal primary health service. Odds ratios (OR) and their 95 % confidence intervals (CIs) were calculated with significance at p < 0.05. RESULTS: In the before period, 9 % of the 1881 individuals were tested for chlamydia, compared to 22 % of the 2259 individuals in the QIP period (OR): 1.43, 95 % CI: 1.22-1.67). From the before period to the QIP period, increases were observed in females (13 % to 25 %, OR: 1.32, 95 % CI: 1.10-1.59) and males (3 % to 17 %, OR: 1.85, 95 % CI: 1.36-2.52). The highest testing rate in the QIP period was in 15-19 year old females (16 % to 29 %, OR: 1.02, 95 % CI: 0.75-1.37), yet the greatest increase was in 20-24 year olds males (3 % to 19 %, OR: 1.65, 95 % CI: 1.01-2.69). Similar increases were seen in gonorrhoea testing. Overall, there were 70 (11 %) chlamydia diagnoses, increasing from 24 in the before to 46 in the QIP period. Overall, 4 (0.7 %) gonorrhoea tests were positive. CONCLUSIONS: The QIP used in SHIMMER almost tripled chlamydia and gonorrhoea testing in young people and found more than twice as many chlamydia infections. The QIP could be used by other primary health care centres to increase testing among young people.

Incidence and predictors of annual chlamydia testing among 15-29 year olds attending Aboriginal primary health care services in New South Wales, Australia.

BACKGROUND: For the past two decades, chlamydia has been the most commonly notified infectious disease among young people (15-29 year olds) in Australia, the United States of America and the United Kingdom and rates have increased annually in these three countries. In Australia, rates of chlamydia are three times higher in Aboriginal compared with non-Aboriginal people. Australian sexually transmissible infection guidelines recommend annual chlamydia testing for 15-29 year old females and males. This analysis will examine the incidence and predictors of annual chlamydia testing in 15-29 year olds attending four Aboriginal Community Controlled Health Services (ACCHS) in Australia. METHODS: From 2009-2011, attendance and chlamydia testing data were extracted from the patient system to calculate the number and proportion of 15-29 year olds that were tested for chlamydia and that tested positive for chlamydia by gender (male, female), age-group (15-19, 20-24, 25-29 years), Aboriginal status (Aboriginal, non-Aboriginal people) and by the four ACCHSs sites (1, 2, 3 and 4). A cohort was created to calculate the incidence rate per 100 person-years (PY) and predictors of an annual chlamydia test (a test within 12-months of a previous test/visit) by the above factors using Cox regression. Unadjusted and adjusted hazard ratios (AHR) and their 95 % confidence intervals (CIs) and p-values were calculated with significance at p < 0.05. RESULTS: From 2009-2011, there were 2896 individuals who attended the four ACCHSs. Overall , 17 % (22 % of females and 10 % of males) were tested for chlamydia and 9 % tested positive (8 % of females and 14 % of males). The median time to an annual chlamydia test was 10.7 months. The cohort included 2318 individuals. Overall the incidence rate of an annual chlamydia test was 9.1 per 100 PY (11.6 in females and 5.8 in males). Predictors of an annual chlamydia test were being female (AHR: 1.7, 95 % CI: 1.2-2.2, p < 0.01), being 15-19 years old (AHR: 1.6, 95 % CI: 1.1-2.3, p < 0.01) and attending ACCHS site 2 (AHR: 3.8, 95 % CI: 1.8-8.0, p < 0.01). CONCLUSIONS: This analysis highlights that opportunistic STI testing strategies are needed to increase annual chlamydia testing in young people; especially males.

Aboriginal and Torres Strait Islander peoples.

BackgroundIn Australia, medications can be prescribed by medical practitioners, dentists, nurses, and dispensed by pharmacists. Until recently, pharmacists have been limited to prescribing Schedule 2 and 3 medications, and optometrists, podiatrists, and nurse practitioners can prescribe medications under their scope of practice in some areas of Australia. Recently, the New South Wales (NSW) Government initiated a trial where approved pharmacists in NSW and Australian Capital Territory have an expanded scope of practice to prescribe further medications for urinary tract infections, dermatology conditions (mild to moderate atopic dermatitis, herpes zoster (shingles), impetigo, and mild plaque psoriasis), and resupply of contraceptives. This protocol is for a sub-study of the larger research trial and will explore the perspectives of Aboriginal and Torres Strait Islander peoples and communities including clinicians, healthcare services, and community members about the expanded scope of pharmacists' practice.Methods and analysisYarning circles (group) and individual yarns (semi-structured interviews) will be conducted with leaders, clinicians working with Aboriginal and Torres Strait Islander peoples (general practitioners, nurses, Aboriginal health workers, community pharmacists), Aboriginal Elders, and community members to understand perspectives of the risks, benefits, opportunities, and issues associated with pharmacists prescribing for these specific conditions. Ethics approval was obtained through the Aboriginal Health and Medical Research Council of NSW.ConclusionThe findings of this sub-study will clarify Aboriginal and Torres Strait Islander peoples' unique perspectives, including perception of risks and opportunities.

Improving breast cancer outcomes for Aboriginal women: a mixed-methods study protocol.

INTRODUCTION: Breast cancer is the most commonly diagnosed cancer affecting Australian women, and the second highest cause of cancer death in Australian women. While the incidence of breast cancer is lower in Aboriginal women than non-Aboriginal women, the mortality rate for Aboriginal women is higher, with Aboriginal women 1.2 times more likely to die from the disease. In New South Wales, Aboriginal women are 69% more likely to die from their breast cancer than non-Aboriginal women.Co-design is a research method recognised to enhance collaboration between those doing the research and those impacted by the research; which when used with Aboriginal communities, ensures research and services are relevant, culturally competent and empowers communities as co-researchers. We report the development of a new protocol using co-design methods to improve breast cancer outcomes for Aboriginal women. METHODS AND ANALYSIS: Through a Community Mapping Project in 2018, we co-designed an iterative quantitative and qualitative study consisting of five phases. In Phase 1, we will establish a governance framework. In Phase 2, we will provide information to community members regarding the modified parts of the screening, diagnosis, treatment and follow-up processes and invite them to partake. In Phase 3, the research team will collect data on the outcomes of the modified processes and the outcomes for the women who have and have not participated. The data shall be analysed quantitatively and thematically in Phase 4 with Aboriginal community representatives and reported back to community. Lastly, in Phase 5, we evaluate the co-design process and adapt our protocol for use in partnership with other communities. ETHICS AND DISSEMINATION: This study has ethics approval of the Aboriginal Health and Medical Research Council ref:1525/19. The findings will be published in the literature, presented at conferences and short summaries will be issued via social media.

A Pathway to Precision Medicine for Aboriginal Australians: A Study Protocol.

(1) Background: Genomic precision medicine (PM) utilises people's genomic data to inform the delivery of preventive and therapeutic health care. PM has not been well-established for use with people of Aboriginal and Torres Strait Islander ancestry due to the paucity of genomic data from these communities. We report the development of a new protocol using co-design methods to enhance the potential use of PM for Aboriginal Australians. (2) Methods: This iterative qualitative study consists of five main phases. Phase-I will ensure appropriate governance of the project and establishment of a Project Advisory Committee. Following an initial consultation with the Aboriginal community, Phase-II will invite community members to participate in co-design workshops. In Phase-III, the Chief Investigators will participate in co-design workshops and document generated ideas. The notes shall be analysed thematically in Phase-IV with Aboriginal community representatives, and the summary will be disseminated to the communities. In Phase-V, we will evaluate the co-design process and adapt our protocol for the use in partnership with other communities. (3) Discussion: This study protocol represents a crucial first step to ensure that PM research is relevant and acceptable to Aboriginal Australians. Without fair access to PM, the gap in health outcome between Aboriginal and non-Aboriginal Australians will continue to widen.

Customised approaches to vocational education can dramatically improve completion rates of Australian Aboriginal students.

Objective Completion rates in vocational education are typically poor for Aboriginal students (<30%). A scholarship program was designed for Australian Aboriginal students using five enablers of success previously identified for Aboriginal preregistration tertiary nursing students. The purpose of this study was to evaluate whether the five enablers contributed to the success of Aboriginal students in vocational education and whether there were any other enablers. Methods Semistructured interviews were conducted with two groups of Aboriginal students in Certificate III and IV Dental Assisting and Certificate IV in Allied Health Assistance, and their teaching and support staff. The data were initially coded inductively. Initial codes were then categorised according to the five enablers identified to contribute to the success of Bachelor of Nursing students. New categories were created for data not assigned to the enablers. Results Twenty students (64.5% of the cohort) and six staff (75%) consented to participate. The five enablers were perceived to have contributed to the success of the scholarship recipients and two additional enablers were identified. A completion rate of 96.8% was achieved by the scholarship recipients (30 completions of 31 enrolments). Conclusions In contrast with the state average, a completion rate of 96.8% was achieved using seven enablers in this study. To improve completion rates for Aboriginal students, vocational education programs need to be customised to cultural, family and community context. The seven enablers in this study should be subject to a larger study to inform policy, funding, design and delivery of vocational training for Aboriginal students. What is known about the topic? It is well established in the literature that Aboriginal students have poorer educational outcomes than other students. What does this paper add? This paper validates five previously identified enablers to improve outcomes for Aboriginal students and an additional two for vocational education. These enablers may also be applicable to other types of education. What are the implications for practitioners? Practitioners can use the enablers in this study to design and implement vocational education programs and improve educational outcomes for Aboriginal students.

Developing a Sustainable Model of Oral Health Care for Disadvantaged Aboriginal People Living in Rural and Remote Communities in NSW, Using Collective Impact Methodology.

A sustainable model of oral health care for disadvantaged Aboriginal people living in rural and remote communities in New South Wales was developed using collective impact methodology. Collective impact is a structured process which draws together organizations to develop a shared agenda and design solutions which are jointly resourced, measured and reported upon.

Developing a Sustainable Model of Oral Health Care for Disadvantaged Aboriginal People Living in Rural and Remote Communities in NSW, Using Collective Impact Methodology.

A sustainable model of oral health care for disadvantaged Aboriginal people living in rural and remote communities in New South Wales was developed using collective impact methodology. Collective impact is a structured process which draws together organizations to develop a shared agenda and design solutions which are jointly resourced, measured and reported upon.

Opportunistic screening to detect atrial fibrillation in Aboriginal adults in Australia.

INTRODUCTION: There is a 10-year gap in life expectancy between Aboriginal and non-Aboriginal Australians. The leading cause of death for Aboriginal Australians is cardiovascular disease, including myocardial infarction and stroke. Although atrial fibrillation (AF) is a known precursor to stroke there are no published studies about the prevalence of AF for Aboriginal people and limited evidence about AF in indigenous populations globally. METHODS AND ANALYSIS: This mixed methods study will recruit and train Aboriginal health workers to use an iECG device attached to a smartphone to consecutively screen 1500 Aboriginal people aged 45 years and older. The study will quantify the proportion of people who presented for follow-up assessment and/or treatment following a non-normal screening and then estimate the prevalence and age distribution of AF of the Australian Aboriginal population. The study includes semistructured interviews with the Aboriginal health workers about the effectiveness of the iECG device in their practice as well as their perceptions of the acceptability of the device for their patients. Thematic analysis will be undertaken on the qualitative data collected in the study. If the device and approach are acceptable to the Aboriginal people and widely adopted, it may help prevent the effects of untreated AF including ischaemic stroke and early deaths or impairment in Aboriginal people. ETHICS AND DISSEMINATION: This mixed methods study received ethics approval from the Aboriginal Health and Medical Research Council (1135/15) and the Australian Health Council of Western Australia (HREC706). Ethics approval is being sought in the Northern Territory. The findings of this study will be shared with Aboriginal communities, in peer reviewed publications and at conferences. There are Aboriginal investigators in each state/territory where the study is being conducted who have been actively involved in the study. They will also be involved in data analysis, dissemination and research translation. TRIAL REGISTRATION NUMBER: ACTRN12616000459426.

Attendance patterns and chlamydia and gonorrhoea testing among young people in Aboriginal primary health centres in New South Wales, Australia.

UNLABELLED: Background To inform a sexual health quality improvement program we examined chlamydia and gonorrhoea testing rates among 15-29 year olds attending Aboriginal Community Controlled Health Services (ACCHS) in New South Wales, Australia, and factors associated with chlamydia and gonorrhoea testing. METHODS: From 2009 to 2011, consultation and testing data were extracted from four ACCHS. Over the study period, we calculated the median number of consultations per person and interquartile range (IQR), the proportion attending (overall and annually), the proportion tested for chlamydia and gonorrhoea, and those who tested positive. We examined factors associated with chlamydia and gonorrhoea testing using logistic regression. RESULTS: Overall, 2896 15-29-year-olds attended the ACCHSs, 1223 were male and 1673 were female. The median number of consultations was five (IQR 2-12), four (IQR 1-8) for males and seven (IQR 3-14) for females (P<0.001). Nineteen percent of males and 32% of females attended in each year of the study (P<0.001). Overall, 17% were tested for chlamydia (10% of males and 22% of females, P<0.001), and 7% were tested annually (3% of males and 11% of females, P<0.001). Findings were similar for gonorrhoea testing. In the study period, 10% tested positive for chlamydia (14% of males and 9% of females, P<0.001) and 0.6% for gonorrhoea. Factors independently associated with chlamydia testing were being female (adjusted odds ratio (AOR) 2.64, 95% confidence interval (CI) 2.07-3.36), being 20-24 years old (AOR: 1.58, 95% CI: 1.20-2.08), and having >3 consultations (AOR: 16.97, 95% CI: 10.32-27.92). CONCLUSIONS: More frequent attendance was strongly associated with being tested for chlamydia and gonorrhoea. To increase testing, ACCHS could develop testing strategies and encourage young people to attend more frequently.