Evaluating a complex health promotion program to reduce hepatitis C among Aboriginal and Torres Strait Islander peoples in New South Wales, Australia: the Deadly Liver Mob.

The Deadly Liver Mob (DLM) is a peer-delivered incentivised health promotion program by and for Aboriginal and Torres Strait Islander Australians, and was introduced in response to the disproportionate number of Aboriginal and Torres Strait Islander Australians who are impacted by blood borne viruses (BBVs) and sexually transmitted infections (STIs). The goal of the program is to increase access to BBV and STI education, screening, treatment, and vaccination in recognition and response to the systemic barriers that Aboriginal and Torres Strait Islander peoples face in accessing health care. This commentary introduces a series of papers that report on various aspects of the evaluation of the Deadly Liver Mob (DLM) program. In this paper, we explain what DLM is and how we constructed an evaluation framework for this complex health promotion intervention.

Increasing access to screening for blood-borne viruses and sexually transmissible infections for Aboriginal and Torres Strait Islander Australians: evaluation of the Deadly Liver Mob program's 'cascade of care' across nine sites in New South Wales, Australia.

BACKGROUND: Aboriginal and Torres Strait Islander Australians are disproportionately impacted by blood-borne viruses (BBVs) and sexually transmissible infections (STIs). Stigma remains one of the key barriers to testing and treatment for BBVs and STIs, particularly among Aboriginal and Torres Strait Islander people. The Deadly Liver Mob (DLM) is a peer-delivered incentivised health promotion program by and for Aboriginal and Torres Strait Islander Australians. The program aims to increase access to BBV and STI education, screening, treatment, and vaccination for Aboriginal and Torres Strait Islander Australians in recognition of the systemic barriers for First Nations people to primary care, including BBV- and STI-related stigma, and institutional racism. This paper presents routinely collected data across nine sites on the 'cascade of care' progression of Aboriginal and Torres Strait Islander clients through the DLM program: hepatitis C education, screening, returning for results, and recruitment of peers. METHODS: Routinely collected data were collated from each of the DLM sites, including date of attendance, basic demographic characteristics, eligibility for the program, recruitment of others, and engagement in the cascade of care. RESULTS: Between 2013 and 2020, a total of 1787 Aboriginal and Torres Strait Islander clients were educated as part of DLM, of which 74% went on to be screened and 42% (or 57% of those screened) returned to receive their results. The total monetary investment of the cascade of care progression was approximately $56,220. Data highlight the positive impacts of the DLM program for engagement in screening, highlighting the need for culturally sensitive, and safe programs led by and for Aboriginal and Torres Strait Islander people. However, the data also indicate the points at which clients 'fall off' the cascade, underscoring the need to address any remaining barriers to care. CONCLUSIONS: The DLM program shows promise in acting as a 'one stop shop' in addressing the needs of Aboriginal and Torres Strait Islander people in relation to BBVs and STIs. Future implementation could focus on addressing any potential barriers to participation in the program, such as co-location of services and transportation.

Health state utilities for beta-thalassemia: a time trade-off study.

BACKGROUND: Beta-thalassemia (BT) is an inherited blood disorder characterized by reduced levels of functional hemoglobin resulting in phenotypes ranging from clinically asymptomatic to severely anemic. Patients with BT may require lifelong regular blood transfusions supported by appropriate iron chelation therapy (ICT). This study aimed to determine how the UK general population values BT health states associated with differing transfusion burden and ICT. METHODS: Composite time trade-off (cTTO) methodology was employed to elicit health state utilities in BT. Relevant BT literature related to symptom and quality-of-life impact, including physical, functional, and emotional well-being, and safety profiles of BT treatments were considered when drafting health state descriptions. Eleven health state descriptions were developed and validated by hematologists and patient advocates for clinical accuracy and completeness. 200 individuals from the UK general population participated in the cTTO interviews. RESULTS: The mean age of participants was 41.50 years (SD 16.01, range 18-81); 88 (46.8%) were female. Utility values ranged from 0.78 (SD 0.34) for non-transfusion dependent BT with oral ICT to 0.37 (SD 0.50) for high transfusion burden with subcutaneous ICT in transfusion-dependent BT. CONCLUSIONS: This study provides health utilities for a range of BT health states from the UK general population perspective. Importantly, lower transfusion burden and lower burden of anemia were associated with higher utilities. To a lesser extent, differential modes of ICT were found to impact utility valuations in patients with BT. The utilities obtained in this study can be employed as inputs in cost-effectiveness analyses of BT therapies.

Patient self-report versus medical records for smoking status and alcohol consumption at Aboriginal Community Controlled Health Services.

OBJECTIVE: This study assessed the level of agreement, and predictors of agreement, between patient self-report and medical records for smoking status and alcohol consumption among patients attending one of four Aboriginal Community Controlled Health Service (ACCHSs). METHODS: A convenience sample of 110 ACCHS patients self-reported whether they were current smokers or currently consumed alcohol. ACCHS staff completed a medical record audit for corresponding items for each patient. The level of agreement was evaluated using the kappa statistic. Factors associated with levels of agreement were explored using logistic regression. RESULTS: The level of agreement between self-report and medical records was strong for smoking status (kappa=0.85; 95%CI: 0.75-0.96) and moderate for alcohol consumption (kappa=0.74; 95%CI: 0.60-0.88). None of the variables explored were significantly associated with levels of agreement for smoking status or alcohol consumption. CONCLUSIONS: Medical records showed good agreement with patient self-report for smoking and alcohol status and are a reliable means of identifying potentially at-risk ACCHS patients. Implications for public health: ACCHS medical records are accurate for identifying smoking and alcohol risk factors for their patients. However, strategies to increase documentation and reduce missing data in the medical records are needed.

Can a continuous quality improvement program create culturally safe emergency departments for Aboriginal people in Australia? A multiple baseline study.

BACKGROUND: Providing culturally safe health care can contribute to improved health among Aboriginal people. However, little is known about how to make hospitals culturally safe for Aboriginal people. This study assessed the impact of an emergency department (ED)-based continuous quality improvement program on: the accuracy of recording of Aboriginal status in ED information systems; incomplete ED visits among Aboriginal patients; and the cultural appropriateness of ED systems and environments. METHODS: Between 2012 and 2014, the Aboriginal Identification in Hospitals Quality Improvement Program (AIHQIP) was implemented in eight EDs in NSW, Australia. A multiple baseline design and analysis of linked administrative data were used to assess program impact on the proportion of Aboriginal patients correctly identified as Aboriginal in ED information systems and incomplete ED visits in Aboriginal patients. Key informant interviews and document review were used to explore organisational changes. RESULTS: In all EDs combined, the AIHQIP was not associated with a reduction in incomplete ED visits in Aboriginal people, nor did it influence the proportion of ED visits made by Aboriginal people that had an accurate recording of Aboriginal status. However, in two EDs it was associated with an increase in the trend of accurate recording of Aboriginality from baseline to the intervention period (odds ratio (OR) 1.31, p < 0.001 in ED 4 and OR 1.15, p = 0.020 in ED 5). In other words, the accuracy of recording of Aboriginality increased from 61.4 to 70% in ED 4 and from 72.6 to 73.9% in ED 5. If the program were not implemented, only a marginal increase would have occurred in ED 4 (from 61.4 to 64%) and, in ED 5, the accuracy of reporting would have decreased (from 72.6 to 71.1%). Organisational changes were achieved across EDs, including modifications to waiting areas and improved processes for identifying Aboriginal patients and managing incomplete visits. CONCLUSIONS: The AIHQIP did not have an overall effect on the accuracy of recording of Aboriginal status or on levels of incomplete ED visits in Aboriginal patients. However, important organisational changes were achieved. Further research investigating the effectiveness of interventions to improve Aboriginal cultural safety is warranted.

The impact of telephone follow up on adverse events for Aboriginal people with chronic disease in new South Wales, Australia: a retrospective cohort study.

BACKGROUND: Chronic diseases are more prevalent and occur at a much younger age in Aboriginal people in Australia compared with non-Aboriginal people. Aboriginal people also have higher rates of unplanned hospital readmissions and emergency department presentations. There is a paucity of research on the effectiveness of follow up programs after discharge from hospital in Aboriginal populations. This study aimed to assess the impact of a telephone follow up program, 48 Hour Follow Up, on rates of unplanned hospital readmissions, unplanned emergency department presentations and mortality within 28 days of discharge among Aboriginal people with chronic disease. METHODS: A retrospective cohort of eligible Aboriginal people with chronic diseases was obtained through linkage of routinely-collected health datasets for the period May 2009 to December 2014. The primary outcome was unplanned hospital readmissions within 28 days of separation from any acute New South Wales public hospital. Secondary outcomes were mortality, unplanned emergency department presentations, and at least one adverse event (unplanned hospital readmission, unplanned emergency department presentation or mortality) within 28 days of separation. Logistic regression models were used to assess outcomes among Aboriginal patients who received 48 Hour Follow Up compared with eligible Aboriginal patients who did not receive 48 Hour Follow Up. RESULTS: The final study cohort included 18,659 patients with 49,721 separations, of which 8469 separations (17.0, 95% confidence interval (CI): 16.7-17.4) were recorded as having received 48 Hour Follow Up. After adjusting for potential confounders, there were no significant differences in rates of unplanned readmission or mortality within 28 days between people who received or did not receive 48 Hour Follow Up. Conversely, the odds of an unplanned emergency department presentation (Odds ratio (OR) = 0.92; 95% CI: 0.85, 0.99; P = 0.0312) and at least one adverse event (OR = 0.91; 95% CI: 0.85,0.98; P = 0.0136) within 28 days were significantly lower for separations where the patient received 48 Hour Follow Up compared with those that did not receive follow up. CONCLUSIONS: Receipt of 48 Hour Follow Up was associated with both a reduction in emergency department presentations and at least one  adverse event within 28 days of discharge, suggesting there may be merit in providing post-discharge telephone follow up to Aboriginal people with chronic disease.

The impact of a community-led program promoting weight loss and healthy living in Aboriginal communities: the New South Wales Knockout Health Challenge.

BACKGROUND: Aboriginal people in Australia experience significant health burden from chronic disease. There has been limited research to identify effective healthy lifestyle programs to address risk factors for chronic disease among Aboriginal people. METHODS: The Knockout Health Challenge is a community-led healthy lifestyle program for Aboriginal communities across New South Wales, Australia. An evaluation of the 2013 Knockout Health Challenge was undertaken. Participants' self-reported physical activity and diet were measured at four time points - at the start and end of the Challenge (via paper form), and 5 and 9 months after the Challenge (via telephone survey). Participants' weight was measured objectively at the start and end of the Challenge, and self-reported (via telephone survey) 5 and 9 months after the Challenge. Changes in body composition, physical activity and diet between time points were analysed using linear mixed models. As part of the telephone survey participants were also asked to identify other impacts of the Challenge; these were analysed descriptively (quantitative items) and thematically (qualitative items). RESULTS: A total of 586 people registered in 22 teams to participate in the Challenge. The mean weight at the start was 98.54kg (SD 22.4), and 94% of participants were overweight or obese. Among participants who provided data at all four time points (n=122), the mean weight loss from the start to the end of the Challenge was 2.3kg (95%CI -3.0 to -1.9, p<0.001), and from the start to 9 months after the Challenge was 2.3kg (95%CI -3.3 to -1.3, p<0.001). Body mass index decreased by an average of 0.9kg/m2 (95%CI -1.0 to -0.7, p<0.001) from the start to the end of the Challenge, and 0.8kg/m2 (95%CI -1.2 to -0.4, p<0.001) 9 months after. At the end of the Challenge, participants reported they were more physically active and had increased fruit and vegetable consumption compared with the start of the Challenge, and identified a range of other positive impacts. CONCLUSIONS: The Challenge was effective in reducing weight and promoting healthy lifestyles among Aboriginal people across New South Wales, and has potential to contribute to closing the health gap between Aboriginal and non-Aboriginal people.

A qualitative study trialling the acceptability of new hepatitis C prevention messages for people who inject drugs: symbiotic messages, pleasure and conditional interpretations.

AIM: Prevention of hepatitis C (HCV) remains a public health challenge. A new body of work is emerging seeking to explore and exploit "symbiotic goals" of people who inject drugs (PWID). That is, strategies used by PWID to achieve other goals may be doubly useful in facilitating the same behaviours (use of sterile injecting equipment) required to prevent HCV. This project developed and trialled new HCV prevention messages based on the notion of symbiotic messages. METHOD: New HCV prevention messages were developed in a series of 12 posters after consultation with staff from needle and syringe programs (NSPs) and a drug user organisation. Two posters were displayed each week for a 6-week period within one NSP. NSP staff and clients were invited to focus groups to discuss their responses to the posters. RESULTS: A total of four focus groups were conducted; one group of seven staff members and three groups of clients with a total of 21 participants. Responses to each of the posters were mixed. Staff and clients interpreted messages in literal ways rather than as dependent on context, with staff concerned that not all HCV prevention information was included in any one message; while clients felt that some messages were misleading in relation to the expectations of pleasure. Clients appreciated the efforts to use bright imagery and messages that included acknowledgement of pleasure. Clients were not aware of some harm reduction information contained in the messages (such as "shoot to the heart"), and this generated potential for misunderstanding of the intended message. Clients felt that any message provided by the NSP could be trusted and did not require visible endorsement by health departments. CONCLUSIONS: While the logic of symbiotic messages is appealing, it is challenging to produce eye-catching, brief messages that provide sufficient information to cover the breadth of HCV prevention. Incorporation of symbiotic messages in conversations or activities between staff and clients may provide opportunities for these messages to be related to the clients' needs and priorities and for staff to provide HCV prevention information in accord with their professional ethos.

Influenza vaccination during pregnancy: a qualitative study of the knowledge, attitudes, beliefs, and practices of general practitioners in Central and South-Western Sydney.

BACKGROUND: Pregnant women have an increased risk of influenza complications. Influenza vaccination during pregnancy is safe and effective, however coverage in Australia is less than 40%. Pregnant women who receive a recommendation for influenza vaccination from a health care provider are more likely to receive it, however the perspectives of Australian general practitioners has not previously been reported. The aim of the study was to investigate the knowledge, attitudes, beliefs, and practices of general practitioners practicing in South-Western Sydney, Australia towards influenza vaccination during pregnancy. METHODS: A qualitative descriptive study was conducted, with semi-structured interviews completed with seventeen general practitioners in October 2012. A thematic analysis was undertaken by four researchers, and transcripts were analysed using N-Vivo software according to agreed codes. RESULTS: One-third of the general practitioners interviewed did not consider influenza during pregnancy to be a serious risk for the mother or the baby. The majority of the general practitioners were aware of the government recommendations for influenza vaccination during pregnancy, but few general practitioners were confident of their knowledge about the vaccine and most felt they needed more information. More than half the general practitioners had significant concerns about the safety of influenza vaccination during pregnancy. Their practices in the provision of the vaccine were related to their perception of risk of influenza during pregnancy and their confidence about the safety of the vaccine. While two-thirds reported that they are recommending influenza vaccination to their pregnant patients, many were adopting principles of patient-informed choice in their approach and encouraged women to decide for themselves whether they would receive the vaccine. CONCLUSIONS: General practitioners have varied knowledge, attitudes, and beliefs about influenza vaccination during pregnancy, which influence their practices. Addressing these could have a significant impact on improving vaccine uptake during pregnancy.

Disparities in cataract surgery between Aboriginal and non-Aboriginal people in New South Wales, Australia.

BACKGROUND: To investigate variation in rates of cataract surgery in New South Wales, Australia by area of residence for Aboriginal and non-Aboriginal adults. DESIGN: Observational data linkage study of hospital admissions. PARTICIPANTS: Two hundred eighty-nine thousand six hundred forty-six New South Wales residents aged 30 years and over admitted to New South Wales hospitals for 444,551 cataract surgery procedures between 2001 and 2008. METHODS: Analysis of linked routinely collected hospital data using direct standardization and multilevel negative binomial regression models accounting for clustering of individuals within Statistical Local Areas. MAIN OUTCOME MEASURES: Age-standardized cataract surgery rates and adjusted rate ratios. RESULTS: Aboriginal people had lower rates of cataract procedures than non-Aboriginal people of the same age and sex, living in the same Statistical Local Area (adjusted rate ratio 0.71, 95% confidence interval 0.68-0.75). There was significant variation in cataract surgery rates across Statistical Local Areas for both Aboriginal and non-Aboriginal people, with the disparity greater in major cities and less disadvantaged areas. Rates of surgery were lower for Aboriginal than non-Aboriginal people in most Statistical Local Areas, but in a few, the rates were similar or higher for Aboriginal people. CONCLUSIONS: Aboriginal people in New South Wales received less cataract surgery than non-Aboriginal people, despite evidence of higher cataract rates. This disparity was greatest in urban and wealthier areas. Higher rates of surgery for Aboriginal people observed in some specific locations are likely to reflect the availability of public ophthalmology services, targeted services for Aboriginal people and higher demand for surgery in these populations.

Influenza vaccination during pregnancy: coverage rates and influencing factors in two urban districts in Sydney.

BACKGROUND: Pregnant women have an increased risk of complications from influenza. Influenza vaccination during pregnancy is considered effective and safe; however estimates of vaccine coverage are low. This study aimed to determine influenza vaccination coverage and factors associated with vaccine uptake in pregnant women in two Sydney-based health districts. METHODS: A random sample of women who delivered a baby in a public hospital in Sydney and South-Western Sydney Local Health Districts between June and September 2012 were surveyed using a computer assisted telephone interviewing service. RESULTS: Of the 462 participants (participation rate 92%), 116 (25%) reported receiving the influenza vaccine during their pregnancy. In univariate analysis, vaccination coverage varied significantly depending on antenatal care type, hospital of birth, and parity (p<0.05), but not for age category, highest level of education, country of birth, language spoken at home, or Aboriginal status. Women who received antenatal care through a general practitioner (GP) had 2.3 (95% CI 1.4-3.6) times the odds (unadjusted) of receiving the influenza vaccination than those who received their antenatal care through a public hospital. The main reason cited for vaccination was GP recommendation (37%), while non-recommendation (33%) and lack of knowledge (26%) were cited as main reasons for not receiving the vaccination. 30% of women recalled receiving a provider recommendation for the vaccination and these women had 33.0 times the odds (unadjusted) of receiving the vaccination than women who had not received a recommendation. In a multivariate model a provider recommendation was the only variable that was significantly associated with vaccination (OR 41.9; 95% CI 20.7-84.9). CONCLUSION: Rates of influenza vaccination during pregnancy are low. There is a significant relationship between healthcare provider recommendation for the vaccination and vaccine uptake. Increasing provider recommendation rates has the potential to increase coverage rates of influenza vaccination in pregnant women.

Eye health services for Aboriginal people in the western region of NSW, 2010.

AIM: To assess the availability, accessibility and uptake of eye health services for Aboriginal people in western NSW in 2010. METHODS: The use of document review, observational visits, key stakeholder consultation and service data reviews, including number of cataract operations performed, to determine regional service availability and use. RESULTS: Aboriginal people in western NSW have a lower uptake of tertiary eye health services, with cataract surgery rates of 1750 per million for Aboriginal people and 9702 per million for non-Aboriginal people. Public ophthalmology clinics increase access to tertiary services for Aboriginal people. CONCLUSION: Eye health services are not equally available and accessible for Aboriginal people in western NSW. Increasing the availability of culturally competent public ophthalmology clinics may increase access to tertiary ophthalmology services for Aboriginal people. The report of the review was published online, and outlines a list of recommendations.

Building a strategic approach to improve Aboriginal health research and evaluation in NSW.

A 5-year strategic plan for Aboriginal health research and evaluation has been developed to support the NSW Ministry of Health in its efforts to create the evidence for what works in addressing the health disparity between Aboriginal and non-Aboriginal people. The plan has the following objectives: that all Aboriginal health policies and programs are evidence informed; that programs and strategies are rigorously evaluated and contribute to building the evidence for improving Aboriginal health outcomes; that new research evidence is generated for improving Aboriginal health outcomes; and that robust monitoring and accountability mechanisms in Aboriginal health are in place, with improved data quality. This paper describes the development of the NSW Ministry of Health's Aboriginal Health Research and Evaluation Strategic Plan 2011-15, including a review of the evidence and policy documents, facilitated planning sessions, and consultation with staff within the Population and Public Health Division of the Ministry.

Eye care in Fiji: a population-based study of use and barriers.

PURPOSE: To determine the use of medical services for eye problems in Fiji, and barriers to seeking that care. METHODS: An interview-based questionnaire was administered as part of a population-based cross-sectional survey of adults selected by multistage random sampling from those aged ≥40 years living on Fiji's main island. RESULTS: Participation rate was 73.0% (n = 1381). A current vision or eye problem was reported by 931 participants, and a further 235 recalled a previous difficulty. Urban dwellers (P = 0.002) and those aged ≥50 years (P = 0.017) were more likely to report a problem. Gender was not predictive (P = 0.215). "Blurred/poor vision" was the most common complaint (78.5%). Over half (53.3%) had not sought care for the problem most important to them. For current problems, being younger (P < 0.001) and from a household without paid income (P = 0.007) were predictive of being less likely to seek treatment. Gender was not (P = 0.416). The most frequently cited principal reason for not seeking care was "able to manage/accept the problem" (66.5%; of whom 84.7% claimed vision problems). Direct and indirect costs were mentioned as deterrents. "Thought nothing could be done" (P = 0.032) and "lack of awareness of service availability" (P = 0.026) were more common among rural dwellers. Of participants who sought care, 75.6% used government services. Most participants requiring spectacles or medication incurred costs for these. Satisfaction with overall care was independent of provider (P = 0.062) and user gender (P = 0.851). CONCLUSION: With expanding service delivery, increased eye health promotion, and attention to the financing of treatments, improved service use ought to be possible in Fiji.

Diabetes and its ocular complications: awareness among adults aged 40 years and older in Timor-Leste.

PURPOSE: The aim was to assess awareness of diabetes mellitus and its ocular complications among Timorese aged 40 years and older. METHODS: An interview-based questionnaire was administered to a subset of five urban and five rural clusters of 45 people aged 40 years and older as part of a population-based cross-sectional survey. RESULTS: The participation rate was 96.2 per cent and data were analysed for 413 respondents. Correct nomination of at least one symptom, risk factor, prevention or treatment of diabetes was made by 6.1 per cent of participants. When explicitly asked, 6.8 per cent thought that diabetes caused problems with the body and 3.6 per cent thought diabetes caused eye problems. CONCLUSION: There is little awareness of diabetes and its ocular complications in Timor-Leste. Given the predicted urbanisation and economic development in the coming decades, as other health challenges are addressed and resources become available, consideration of diabetes might be prudent. Improving knowledge among the population will be an important component of any strategy developed.

Prevalence and causes of blindness and low vision among adults in Fiji.

BACKGROUND: To estimate the prevalence and causes of blindness and low vision among adults aged ≥40 years in Fiji. DESIGN: Population-based cross-sectional study. PARTICIPANTS: Adults aged ≥40 years in Viti Levu, Fiji. METHOD: A population-based cross-sectional survey used multistage cluster random sampling to identify 34 clusters of 40 people. A cause of vision loss was determined for each eye with presenting vision worse than 6/18. MAIN OUTCOME MEASURES: Blindness (better eye presenting vision worse than 6/60), low vision (better eye presenting vision worse than 6/18, but 6/60 or better). RESULTS: Of 1892 people enumerated, 1381 participated (73.0%). Adjusting sample data for ethnicity, gender, age and domicile, the prevalence of blindness was 2.6% (95% confidence interval 1.7, 3.4) and low vision was 7.2% (95% confidence interval 5.9, 8.6) among adults aged ≥40 years. On multivariate analysis, being ≥70 years was a risk factor for blindness, but ethnicity, gender and urban/rural domicile were not. Being Indo-Fijian, female and older were risk factors for vision impairment (better eye presenting vision worse than 6/18). Cataract was the most common cause of bilateral blindness (71.1%). Among participants with low vision, uncorrected refractive error caused 63.3% and cataract was responsible for 25.0%. CONCLUSION: Strategies that provide accessible cataract and refractive error services producing good quality outcomes will likely have the greatest impact on reducing vision impairment.

The Early Childhood Oral Health Program: promoting prevention and timely intervention of early childhood caries in NSW through shared care.

ISSUE ADDRESSED: Early childhood caries (ECC) continues to have high prevalence worldwide, despite being largely preventable. The Early Childhood Oral Health (ECOH) Program was established in New South Wales (NSW) using a model of shared responsibility for oral health, which involves a partnership between child health professionals, oral health professionals and parents of young children, to facilitate the primary prevention, early identification and early intervention of ECC. METHODS: An evaluation of the ECOH program was conducted, using mixed methods. Data were obtained through document review, surveys and interviews with program implementers, and analysis of the Information System for Oral Health (ISOH) database for public oral health services activity in NSW. RESULTS: Key achievements of the ECOH program include the establishment of governance mechanisms, policy, structures and responsibilities for implementation, support mechanisms for child health professionals, referral processes, communications resources, and the delivery of training. Parents receive oral health information, education and support through written resources and contact with child health professionals. Child and family health nurses interviewed reported routinely incorporating oral health promotion and early identification for ECC into their practices. The referral rate to public oral health services for children under five years of age by community health professionals has increased steadily since the program began, with the rate in 2009 five times higher than in 2007. CONCLUSIONS: Models of shared responsibility for oral health between parents, child health professionals and oral health professionals can facilitate primary prevention and early intervention for ECC.