The Benefits of Cooperative Inquiry in Health Services Research: Lessons from an Australian Aboriginal and Torres Strait Islander Health Study.

Health services research is underpinned by partnerships between researchers and health services. Partnership-based research is increasingly needed to deal with the uncertainty of global pandemics, climate change induced severe weather events, and other disruptions. To date there is very little data on what has happened to health services research during the COVID-19 pandemic. This paper describes the establishment of an Australian multistate Decolonising Practice research project and charts its adaptation in the face of disruptions. The project used cooperative inquiry method, where partner health services contribute as coresearchers. When the COVID-19 pandemic hit, data collection needed to be immediately paused, and when restrictions started to lift, all research plans had to be renegotiated with services. Adapting the research surfaced health service, university, and staffing considerations. Our experience suggests that cooperative inquiry was invaluable in successfully navigating this uncertainty and negotiating the continuance of the research. Flexible, participatory methods such as cooperative inquiry will continue to be vital for successful health services research predicated on partnerships between researchers and health services into the future. They are also crucial for understanding local context and health services priorities and ways of working, and for decolonising Indigenous health research.

Exploring self-determined solutions to service and system challenges to promote social and emotional wellbeing in Aboriginal and Torres Strait Islander people: a qualitative study.

Introduction: Many Aboriginal and Torres Strait Islander people living on Kaurna Country in northern Adelaide experience adverse health and social circumstances. The Taingiwilta Pirku Kawantila study sought to understand challenges facing Aboriginal and Torres Strait Islander communities and identify solutions for the health and social service system to promote social and emotional wellbeing. Methods: This qualitative study applied Indigenous methodologies undertaken with Aboriginal and Torres Strait Islander governance and leadership. A respected local Aboriginal person engaged with Aboriginal and Torres Strait Islander community members and service providers through semi-structured interviews and yarning circles that explored community needs and challenges, service gaps, access barriers, success stories, proposed strategies to address service and system challenges, and principles and values for service design. A content analysis identified the breadth of challenges in addition to describing key targets to empower and connect communities and optimize health and social services to strengthen individual and collective social and emotional wellbeing. Results: Eighty-three participants contributed to interviews and yarning circles including 17 Aboriginal community members, 38 Aboriginal and Torres Strait Islander service providers, and 28 non-Indigenous service providers. They expressed the need for codesigned, strengths-based, accessible and flexible services delivered by Aboriginal and Torres Strait Islander workers with lived experience employed in organisations with Aboriginal and Torres Strait Islander leadership and governance. Community hubs and cultural events in addition to one-stop-shop service centres and pre-crisis mental health, drug and alcohol and homelessness services were among many strategies identified. Conclusion: Holistic approaches to the promotion of social and emotional wellbeing are critical. Aboriginal and Torres Strait Islander people are calling for places in the community to connect and practice culture. They seek culturally safe systems that enable equitable access to and navigation of health and social services. Aboriginal and Torres Strait Islander workforce leading engagement with clients is seen to safeguard against judgement and discrimination, rebuild community trust in the service system and promote streamlined access to crucial services.

Majority support for access to abortion care including later abortion in South Australia.

OBJECTIVE: To measure public opinion about access to abortion in South Australia. METHODS: An online survey conducted in 2019. SPSS statistical package version 22 was used for data analysis, with data weighted by age, gender, and region. RESULTS: The majority (65%) of the 1,012 respondents supported the ready availability of abortion care and an additional 25% supported availability in certain circumstances. Most (70%) were unaware that abortion remains in criminal law and 80% supported decriminalisation. Support for safe access zones (88%) and the application of existing protections (69%) and obligations (94%) for conscientious objectors was high. A majority (63%) considered that later abortion should be available 'when the woman and her healthcare team decide it is necessary'. CONCLUSIONS: These results confirm the trend of increasing support for access to abortion and add two new insights. There was majority support for using existing general protections for the rights and obligations of those with a conscientious objection to abortion. Second, there was strong support for decisions about later abortion to be decided through normal clinical consultation. These results indicate general community approval of abortion being normalised as healthcare, with the safeguards and accountabilities that status entails. Implications for public health: These results invite repeal of special laws about abortion care, to enable better access.

Role of Aboriginal Health Workers and Liaison Officers in quality care in the Australian acute care setting: a systematic review.

Objective The aim of this study was to identify the contribution of Aboriginal Health Workers and Liaison Officers (AHWLOs) to quality of care in the acute health care setting in Australia. Methods A systematic review of peer-reviewed literature focused on the role of AHWLOs and quality processed and quality outcomes. Authors undertook study selection based on inclusion criteria and performed quality assessment using critical appraisal tools from the Joanna Briggs Institute. Results The search revealed limited literature that met the inclusion criteria, namely four quantitative studies and one mixed-methods study. The settings of the included studies were mental health and cardiac care units within various hospitals. The studies indicated that AHWLOs may have a positive effect on communication between healthcare professionals and patients, rates of discharge against medical advice and continuity of care. Methodological constraints among the included studies made it difficult to establish specific contributions of AHWLOs to quality care markers across acute care units. Conclusions The role of AHWLOs in providing quality care in the acute care setting has received minimal research. The limited existing research highlights the importance of the AHWLO role. For example, AHWLOs may influence patient communication, discharge against medical advice and continuity of care within mental health and cardiac care units. Further, because of methodological constraints among the limited studies, research into the role of AHWLOs in these and other acute care settings is needed to assess effects on a range of specific clinical quality markers. What is known about the topic? Aboriginal and Torres Strait Islander people experience unacceptable health inequities. AHWLOs are a unique workforce introduced to increase access to culturally safe care and, ultimately, help to address these inequities. What does this paper add? This review explores the current evidence for the contribution of AHWLOs to quality care in the acute care setting. The findings suggest that these professionals may improve communication between patients and medical staff, improve continuity of care and reduce patient discharge against medical advice. However, these findings highlight that the use of quality care markers across acute care settings is needed to generate tangible evidence to help establish the legitimacy of these health professionals. What are the implications for practitioners? AHWLOs have a place in the acute care team. Although further research is required to expand the preliminary evidence base of their effect on quality acute care, this workforce should be supported at the individual, organisational and policy levels to enhance the health and well-being of one the most vulnerable communities in Australia.

What Indigenous Australian clients value about primary health care: a systematic review of qualitative evidence.

OBJECTIVE: To synthesise client perceptions of the unique characteristics and value of care provided in Aboriginal Community Controlled Health Organisations (ACCHOs) compared to mainstream/general practitioner services, and implications for improving access to quality, appropriate primary health care for Indigenous Australians. METHOD: Standardised systematic review methods with modification informed by ethical and methodological considerations in research involving Indigenous Australians. RESULTS: Perceived unique valued characteristics of ACCHOs were: 1) accessibility, facilitated by ACCHOs welcoming social spaces and additional services; 2) culturally safe care; and 3) appropriate care, responsive to holistic needs. CONCLUSION: Provider-client relationships characterised by shared understanding of clients' needs, Indigenous staff, and relationships between clients who share the same culture, are central to ACCHO clients' perceptions of ACCHOs' unique value. The client perceptions provide insights about how ACCHOs address socio-economic factors that contribute to high levels of chronic disease in Indigenous communities, why mainstream PHC provider care cannot substitute for ACCHO care, and how to improve accessibility and quality of care in mainstream providers. Implications for public health: To increase utilisation of PHC services in Indigenous Australian communities, and help close the gaps between the health status of Indigenous and non-Indigenous Australians, Indigenous community leaders and Australian governments should prioritise implementing effective initiatives to support quality health care provision by ACCHOs.

Coproducing Aboriginal patient journey mapping tools for improved quality and coordination of care.

This paper describes the rationale and process for developing a set of Aboriginal patient journey mapping tools with Aboriginal patients, health professionals, support workers, educators and researchers in the Managing Two Worlds Together project between 2008 and 2015. Aboriginal patients and their families from rural and remote areas, and healthcare providers in urban, rural and remote settings, shared their perceptions of the barriers and enablers to quality care in interviews and focus groups, and individual patient journey case studies were documented. Data were thematically analysed. In the absence of suitable existing tools, a new analytical framework and mapping approach was developed. The utility of the tools in other settings was then tested with health professionals, and the tools were further modified for use in quality improvement in health and education settings in South Australia and the Northern Territory. A central set of patient journey mapping tools with flexible adaptations, a workbook, and five sets of case studies describing how staff adapted and used the tools at different sites are available for wider use.

Implementing Indigenous community control in health care: lessons from Canada.

Objective Over past decades, Australian and Canadian Indigenous primary healthcare policies have focused on supporting community controlled Indigenous health organisations. After more than 20 years of sustained effort, over 89% of eligible communities in Canada are currently engaged in the planning, management and provision of community controlled health services. In Australia, policy commitment to community control has also been in place for more than 25 years, but implementation has been complicated by unrealistic timelines, underdeveloped change management processes, inflexible funding agreements and distrust. This paper discusses the lessons from the Canadian experience to inform the continuing efforts to achieve the implementation of community control in Australia. Methods We reviewed Canadian policy and evaluation grey literature documents, and assessed lessons and recommendations for relevance to the Australian context. Results Our analysis yielded three broad lessons. First, implementing community control takes time. It took Canada 20 years to achieve 89% implementation. To succeed, Australia will need to make a firm long term commitment to this objective. Second, implementing community control is complex. Communities require adequate resources to support change management. And third, accountability frameworks must be tailored to the Indigenous primary health care context to be meaningful. Conclusions We conclude that although the Canadian experience is based on a different context, the processes and tools created to implement community control in Canada can help inform the Australian context. What is known about the topic? Although Australia has promoted Indigenous control over primary healthcare (PHC) services, implementation remains incomplete. Enduring barriers to the transfer of PHC services to community control have not been addressed in the largely sporadic attention to this challenge to date, despite significant recent efforts in some jurisdictions. What does this paper add? The Canadian experience indicates that transferring PHC from government to community ownership requires sustained commitment, adequate resourcing of the change process and the development of a meaningful accountability framework tailored to the sector. What are the implications for practitioners? Policy makers in Australia will need to attend to reform in contractual arrangements (towards pooled or bundled funding), adopt a long-term vision for transfer and find ways to harmonise the roles of federal and state governments. The arrangements achieved in some communities in the Australian Coordinated Care Trials (and still in place) provide a model.

Legally invisible: stewardship for Aboriginal and Torres Strait Islander health.

OBJECTIVES: The need to improve access to good health care for Aboriginal and Torres Strait Islander people has been the subject of policy debate for decades, but progress is hampered by complex policy and administrative arrangements and lack of clarity about the responsibilities of governments. This study aimed to identify the current legal basis of those responsibilities and define options available to Australian governments to enact enduring responsibility for Aboriginal health care. METHODS: This study used a framework for public health law research and conducted a mapping study to examine the current legal underpinnings for stewardship and governance for Aboriginal health and health care. More than 200 pieces of health legislation were analysed in the context of the common and statutory law and health policy goals. RESULTS: Very little specific recognition of the needs of Aboriginal people was found, and nothing that creates responsibility for stewardship and governance. The continuing absence of a legislative framework to address and protect Aboriginal health can be traced back to the founding doctrine of terra nullius (unoccupied land). CONCLUSIONS: We considered the results applying both a human rights perspective and the perspective of therapeutic jurisprudence. We suggest that national law for health stewardship would provide a strong foundation for progress, and should itself be based on recognition of Australia's First Peoples in the Australian Constitution, as is currently proposed.

Hospitals caring for rural Aboriginal patients: holding response and denial.

OBJECTIVE: To investigate how policy requiring cultural respect and attention to health equity is implemented in the care of rural and remote Aboriginal people in city hospitals. METHODS: Interviews with 26 staff in public hospitals in Adelaide, South Australia, were analysed (using a framework based on cultural competence) to identify their perceptions of the enabling strategies and systemic barriers against the implementation of official policy in the care of rural Aboriginal patients. RESULTS: The major underlying barriers were lack of knowledge and skills among staff generally, and the persistent use of 'business as usual' approaches in their hospitals, despite the clear need for proactive responses to the complex care journeys these patients undertake. Staff reported a sense that while they are required to provide responsive care, care systems often fail to authorise or guide necessary action to enable equitable care. CONCLUSIONS: Staff caring for rural Aboriginal patients are required to respond to complex particular needs in the absence of effective authorisation. We suggest that systemic misinterpretation of the principle of equal treatment is an important barrier against the development of culturally competent organisations. WHAT IS KNOWN ABOUT THIS TOPIC?: The care received by Aboriginal patients is less effective than it is for the population generally, and access to care is poorer. Those in rural and remote settings experience both severe access barriers and predictable complexity in their patient care journeys. This situation persists despite high-level policies that require tailored responses to the particular needs of Aboriginal people. WHAT DOES THIS PAPER ADD?: Staff who care for these patients develop skills and modify care delivery to respond to their particular needs, but they do so in the absence of systematic policies, procedures and programs that would 'build in' or authorise the required responsiveness. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: Systematic attention, at hospital and clinical unit level, to operationalising high policy goals is needed. The framework of cultural competence offers relevant guidance for efforts (at system, organisation and care delivery levels) to improve care, but requires organisations to address misinterpretation of the principle of equal treatment.

Travelling to the city for hospital care: access factors in country Aboriginal patient journeys.

OBJECTIVE: This study described the challenges for rural and remote Aboriginal people requiring transport to city hospitals for tertiary care. DESIGN: Semi-structured qualitative interviews. SETTING: South Australian rural and remote health services and tertiary hospitals. PARTICIPANTS: Twenty-eight urban health professionals from six hospitals and 32 health professionals from four rural and remote regions were interviewed. Twelve patients, three carers, four people responding as patient and carers, and one patient and carer couple were also interviewed, with eight elder women meeting as a focus group. MAIN OUTCOME MEASURES: The study identified specific structural barriers in urban health services or policy that prevented rural and remote Indigenous patients from receiving optimum care. RESULTS: Problems accessing transport were identified as the most significant factor affecting access to care by the majority of patients and staff. They reported that travel to an urban hospital was costly, and coordination of travel with care was poor. A further problem was travelling while unwell. CONCLUSIONS: Travelling to a city hospital is a significant barrier for rural and remote Indigenous patients. Arranging and supporting travel is a time-consuming work that is not recognised by the health care system.

The treatment experiences of Australian women with gynaecological cancers and how they can be improved: a qualitative study.

Gynaecological cancers are the fourth most common form of cancer and the fifth most common cause of cancer mortality for women in Australia. Definitive treatment is available in tertiary hospitals in major capital cities. This study aimed to understand how care is received by women in order to improve both their experience and outcomes. We interviewed 25 women treated for ovarian, cervical and uterine cancers in public or private hospitals in four states, including urban, rural and Indigenous women. Referral pathways were efficient and effective; the women were diagnosed and referred for definitive management through well-established systems. They appreciated the quality of treatment and the care they received during the inpatient and acute phases of their care. Three main problems were identified - serious post-operative morbidity that caused additional pain and suffering, lack of coordination between the surgical team and general practitioners, and poor pain management. The lack of continuity between the acute and primary care settings and inadequate management of pain are acknowledged problems in health care. The extent of post-operative morbidity was not anticipated. Establishing links between the surgical team and primary care in the immediate post-operative period is crucial for the improvement of care for women with gynaecological cancer in Australia.

Indigenous women's expectations of clinical care during treatment for a gynaecological cancer: rural and remote differences in expectations.

OBJECTIVES: To report on differences in Indigenous women's expectations of clinical care during treatment for a gynaecological cancer in rural and remote regions. DESIGN: Qualitative interviews were conducted in New South Wales, Victoria, South Australia and the Northern Territory in 2008 with 37 clinicians working in gynaecological cancer and 24 women with a gynaecological cancer. Three of the participants were Indigenous women living in large rural towns (others were non-Indigenous), whereas six of the 37 clinicians interviewed worked closely with Indigenous women in remote settings. Indigenous women were contacted through an Indigenous researcher. Interviews were analysed for emerging themes, then compared with each other and with the research literature for similarities and differences. RESULTS: There is considerable variation between clinician observations of the expectations of Indigenous women in remote regions, and the views of Aboriginal women in rural settings. CONCLUSION: Indigenous women in rural settings have specific views about quality medical care. These include expectations of timely and culturally appropriate care, and strong ties to family and kin, but do not accord with other research findings that suggest Aboriginal women must receive care from same sex clinicians or that care is often delayed. The paper alerts practitioners to the fact that culturally appropriate care will vary from group to group, particularly between remote, rural and urban populations.

Analysing contractual environments: lessons from Indigenous health in Canada, Australia and New Zealand.

Contracting in health care is a mechanism used by the governments of Canada, Australia and New Zealand to improve the participation of marginalized populations in primary health care and improve responsiveness to local needs. As a result, complex contractual environments have emerged. The literature on contracting in health has tended to focus on the pros and cons of classical versus relational contracts from the funder's perspective. This article proposes an analytical framework to explore the strengths and weaknesses of contractual environments that depend on a number of classical contracts, a single relational contract or a mix of the two. Examples from indigenous contracting environments are used to inform the elaboration of the framework. Results show that contractual environments that rely on a multiplicity of specific contracts are administratively onerous, while constraining opportunities for local responsiveness. Contractual environments dominated by a single relational contract produce a more flexible and administratively streamlined system.

Unwanted pregnancy, mental health and abortion: untangling the evidence.

Abortion policy is still contentious in many parts of the world, and periodically it emerges to dominate health policy debates. This paper examines one such debate in Australia centering on research findings by a New Zealand research group, Fergusson, Horwood & Ridder, published in early 2006. The debate highlighted the difficulty for researchers when their work is released in a heightened political context. We argue that the authors made a logical error in constructing their analysis and interpreting their data, and are therefore not justified in making policy claims for their work. The paper received significant public attention, and may have influenced the public policy position of a major professional body. Deeply held views on all sides of the abortion debate are unlikely to be reconciled, but if policy is to be informed by research, findings must be based on sound science.

Improving hospital performance: culture change is not the answer.

An inappropriate culture is often presented as the reason why hospitals throughout the world have been unable to achieve best practice. Many have concluded that the organizational culture of hospitals limits the ability of these organizations to improve performance, particularly in relation to improving quality and safety. Establishment of a "better" culture is often presented as the resolution to quality, safety, financial and productivity issues in hospitals. Our research indicates that certain management conditions are required before culture change can be contemplated. This paper suggests that we have underestimated the importance of people management in improving practice within hospitals, with the three most important aspects being the development of teamwork, performance management and sophisticated training. We present evidence of the potential contribution good people management can make to high performance, and argue that better people management is a cause, not an outcome, of cultural change.