Intersectoral Partnerships Between Local Governments and Health Organisations in High-Income Contexts: A Scoping Review.

BACKGROUND: Local governments are the closest level of government to the communities they serve. Traditionally providing roads, rates and garbage services, they are also responsible for policy and regulation, particularly land use planning and community facilities and services that have direct and indirect impacts on (equitable) health and well-being. Partnerships between health agencies and local government are therefore an attractive proposition to progress actions that positively impact community health and well-being. Yet, the factors underpinning these partnerships across different contexts are underdeveloped, as mechanisms to improve population health and well-being. METHODS: A scoping review was conducted to gain insight into the concepts, theories, sources, and knowledge gaps that shape partnerships between health and local governments. The search strategy followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines and was informed by a critical realist approach that identifies necessary, contingent and contextual factors in the literature. MEDLINE, Scopus, Web of Science, and ProQuest Central databases were searched for studies published between January 2005 and July 2021. RESULTS: The search yielded 3472 studies, after deleting duplicates and initial title and abstract screening, 188 papers underwent full text review. Twenty-nine papers were included in the review. Key themes shaping partnerships included funding and resources; partnership qualities; governance and policy; and evaluation and measures of success. The functional, organisational and individual aspects of these themes are explored and presented in a framework. CONCLUSION: Given that local government are the closest level of government to community, this paper provides a sophisticated roadmap that can underpin partnerships between local government and health agencies aiming to influence population health outcomes. By identifying key themes across contexts, we provide a framework that may assist in designing and evaluating evidence-informed health and local government partnerships.

Australian and Canadian financial wellbeing policy landscape during COVID-19: An equity-informed policy scan.

Background: This targeted and comprehensive policy scan examined how different levels of governments in Australia and Canada responded to the financial crisis brought on by the COVID-19 pandemic. We mapped the types of early policy responses addressing financial strain and promoting financial wellbeing. We also examined their equity considerations. Methods: Through a systematic search, snowballing, and manual search, we identified Canadian and Australian policies at all government levels related to financial strain or financial wellbeing enacted or amended in 2019-2020. Using a deductive-inductive approach, policies were categorized by jurisdiction level, focal areas, and target population groups. Results: In total, 213 and 97 policies in Canada and Australia, respectively, were included. Comparisons between Canadian and Australian policies indicated a more diversified and equity-targeted policy landscape in Canada. In both countries, most policies focused on individual and family finances, followed by housing and employment areas. Conclusions: The policy scan identified gaps and missed opportunities in the early policies related to financial strain and financial wellbeing. While fast, temporary actions addressed individuals' immediate needs, we recommend governments develop a longer-term action plan to tackle the root causes of financial strain and poor financial wellbeing for better health and non-health crisis preparedness. Statement on Ethics and Informed Consent: This research reported in this paper did not require ethical clearance or patient informed consent as the data sources were published policy documents. This study did not involve data collection with humans (or animals), nor any secondary datasets involving data provided by humans (or from animal studies).

Therapeutic aspects of Connection to Country and cultural landscapes among Aboriginal peoples from the Stolen Generations living in urban NSW, Australia.

Objectives and importance of the study: Most older Aboriginal peoples live in urban locations. Many of these people were displaced by the policies and practices that produced the Stolen Generations. As a result, access to 'Country' and cultural landscapes that are minimally impacted by urbanisation can be limited for older Aboriginal peoples, restricting the health and wellbeing benefits these environments promote. STUDY TYPE: Qualitative study. METHODS: Our study worked collaboratively with Aboriginal traditional cultural knowledge holders to observe and analyse how participation in a 'cultural camp' on a Yuwaalaraay sacred site in New South Wales (NSW), Australia, impacted wellbeing and connection to place among older Aboriginal people who were survivors or descendants of the Stolen Generations. RESULTS: Eight participants (three women; five men) attended the cultural camp and took part in the yarning circle. Thematic analysis of a yarning circle uncovered memories of traumatic experiences of institutionalisation, including abuse and loss of Country, community, and culture. Experiences of the cultural camp generated a sense of reconnection, cultural pride, wellbeing and place attachment. The sensory experience of Country emphasised a sense of belonging and healing. CONCLUSIONS: Our findings reflect the importance of sensory-led experiences on Country for older urban Aboriginal peoples and reinforce previous evidence on the 'therapeutic' aspects of culture and natural landscapes minimally impacted by colonisation. Policies and resources supporting grassroots initiatives such as Aboriginal cultural camps are needed to ensure accessibility for older Aboriginal peoples living in urban places.

Gaawaadhi Gadudha: understanding how cultural camps impact health, well-being and resilience among Aboriginal adults in New South Wales, Australia-a collaborative study protocol.

INTRODUCTION: The health and well-being of Aboriginal Australians is inextricably linked to culture and Country. Our study challenges deficit approaches to health inequities by seeking to examine how cultural connection, practice and resilience among Aboriginal peoples through participation in 'cultural camps' held on sites of cultural significance promotes health and well-being. METHODS AND ANALYSIS: The study will be undertaken in close collaboration and under the governance of traditional cultural knowledge holders from Yuwaalaraay, Gamilaraay and Yuin nation groups in New South Wales, Australia. Three cultural camps will be facilitated, where participants (n=105) will engage in activities that foster a connection to culture and cultural landscapes. A survey assessing connection to culture, access to cultural resources, resilience, self-rated health and quality of life will be administered to participants pre-camp and post-camp participation, and to a comparative group of Aboriginal adults who do not attend the camp (n=105). Twenty participants at each camp (n=60) will be invited to participate in a yarning circle to explore cultural health, well-being and resilience. Quantitative analysis will use independent samples' t-tests or χ2 analyses to compare camp and non-camp groups, and linear regression models to determine the impact of camp attendance. Qualitative analysis will apply inductive coding to data, which will be used to identify connections between coded concepts across the whole data set, and explore phenomenological aspects. Results will be used to collaboratively develop a 'Model of Cultural Health' that will be refined through a Delphi process with experts, stakeholders and policymakers. ETHICS AND DISSEMINATION: The study has ethics approval from the Aboriginal Health and Medical Research Council (#1851/21). Findings will be disseminated through a combination of peer-reviewed articles, media communication, policy briefs, presentations and summary documents to stakeholders.

Health behaviours associated with healthy body composition among Aboriginal adolescents in Australia in the 'Next Generation: Youth Well-being study'.

This study described the distribution of healthy body composition among Aboriginal adolescents in Australia aged 10-24 years and examined associations with health behaviours and self-rated health. Data were cross-sectional from the 'Next Generation: Youth Well-being study' baseline (N = 1294). We used robust Poisson regression to quantify associations of self-reported health behaviours (physical activity, screen time, sleep, consumption of vegetables, fruit, soft drinks and fast food, and tobacco smoking and alcohol) and self-rated health to healthy body mass index (BMI) and waist/height ratio (WHtR). Overall, 48% of participants had healthy BMI and 64% healthy WHtR, with healthy body composition more common among younger adolescents. Higher physical activity was associated with healthy body composition (5-7 days last week vs none; adjusted prevalence ratio (aPR) healthy BMI 1.31 [95% CI 1.05-1.64], and healthy WHtR 1.30 [1.10-1.54]), as was recommended sleep duration (vs not; aPR healthy BMI 1.56 [1.19-2.05], and healthy WHtR 1.37 [1.13-1.67]). There was a trend for higher proportion of healthy body composition with more frequent fast food consumption. Healthy body composition was also associated with higher self-rated health ('very good/excellent' vs 'poor/fair'; aPR healthy BMI 1.87 [1.45-2.42], and healthy WHtR 1.71 [1.40-2.10]). Culturally appropriate community health interventions with a focus on physical activity and sleep may hold promise for improving body composition among Aboriginal adolescents.

The Generative Mechanisms of Financial Strain and Financial Well-Being: A Critical Realist Analysis of Ideology and Difference.

BACKGROUND: Rapid, strategic action is required to mitigate the negative and unequal impact of the coronavirus disease 2019 (COVID-19) pandemic on the financial well-being (FWB) of global populations. Personal financial strain (FS) worsened most significantly among systematically excluded groups. Targeted government- and community-led initiatives are needed to address these inequities. The purpose of this applied research was to identify what works for whom, under what conditions, and why in relation to community and government initiatives that promote personal and household FWB and/or address FS in high income economies. METHODS: We employed a critical realist analysis to literature that reported on FWB/FS initiatives in high income countries. This included initiatives introduced in response to the pandemic as well as those that began prior to the pandemic. We included sources based on a rapid review. We coded academic, published literature (n=39) and practice-based (n=36) reports abductively to uncover generative mechanisms - ie, underlying, foundational factors related to community or government initiatives that either constrained and/or enabled FWB and FS. RESULTS: We identified two generative mechanisms: (1) neoliberal ideology; and (2) social equity ideology. A third mechanism, social location (eg, characteristics of identity, location of residence), cut across the two ideologies and demonstrated for whom the initiatives worked (or did not) in what circumstances. Neoliberal ideology (ie, individual responsibility) dominated initiative designs, which limited the positive impact on FS. This was particularly true for people who occupied systematically excluded social locations (eg, low-income young mothers). Social equity-based initiatives were less common within the literature, yet mostly had a positive impact on FWB and produced equitable outcomes. CONCLUSION: Equity-centric initiatives are required to improve FWB and reduce FS among systemically excluded and marginalized groups. These findings are of relevance now as nations strive for financial recovery in the face of the ongoing global pandemic.

A rapid review of initiatives to address financial strain and wellbeing in high-income contexts.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has exacerbated financial strain among populations worldwide. This is concerning, given the link between financial strain and health. There is little evidence to guide action in this area, particularly from a public health perspective. To address this gap, we examined initiatives to address financial wellbeing and financial strain in high-income contexts. METHODS: We used rapid review methodology and applied an equity-focused lens in our analysis. We searched six databases (MEDLINE, PsycINFO, Web of Science, ProQuest, Informit, and Google Advanced) for peer-reviewed, academic and practice-based literature evaluating initiatives to address financial strain and wellbeing in high-income contexts published between 2015-2020. We conducted a relevancy and quality appraisal of included academic sources. We used EPPI-reviewer software to extract equity-related, descriptive data, and author-reported outcomes. RESULTS: We conducted primary screening on a total of 4779 titles/abstracts (academic n = 4385, practice-based n = 394); of these, we reviewed 182 full text articles (academic n = 87, practice-based n = 95) to assess their relevancy and fit with our research question. A total of 107 sources were excluded based on our selection criteria and relevance to the research question (Figure 1), leaving 75 sources that were extracted for this review (academic n = 39, practice-based n = 36). These sources focused on initiatives predominantly based in Australia, the US, and Canada, with a smaller number from the UK and Europe. Most sources primarily targeted financial literacy and personal/family finances, followed by employment, housing, and education. CONCLUSIONS: We found that holistic initiatives (i.e., complex, wrap-around) that ensured people's basic needs were met (for example, before building financial skills) were aligned with positive and equitable financial wellbeing and financial strain outcomes, as reported in the reviewed studies. We noted significant gaps in the literature related to equity, such as the impact of initiatives on socially excluded populations (e.g., Indigenous peoples, racialised peoples, and rural dwellers). More research using a public health lens is required to guide equitable and sustainable action in this area.

Integrating eye care in low-income and middle-income settings: a scoping review.

OBJECTIVES: Integrated people-centred eye care has been recommended as a strategic framework for reducing global vision impairment and blindness. The extent to which eye care has integrated with other services has not been widely reported. We aimed to investigate approaches to integrating eye care service delivery with other systems in low resource settings, and identify factors associated with integration. DESIGN: Rapid scoping review based on Cochrane Rapid Review and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES: MEDLINE, Embase, Web of Science, Scopus and Cochrane Library databases were searched in September 2021. ELIGIBILITY CRITERIA: Papers with interventions involving eye care or preventative eye care integrated into other health systems, peer-reviewed in English, conducted in low-income or middle-income countries, and published between January 2011 and September 2021 were included. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers screened, quality appraised and coded included papers. A deductive-inductive iterative analysis approach was used with a focus on integrating service delivery. RESULTS: The search identified 3889 potential papers, of which 24 were included. Twenty papers incorporated more than one intervention type (promotion, prevention and/or treatment), but none included rehabilitation. Most articles involved human resources development yet rarely appeared to be people-centred. The level of integration was associated with building relationships and enhancing service coordination. Integrating human resources was challenged by the need for ongoing support and worker retention. In primary care settings, workers were often already at full capacity, had competing priorities, varying capabilities and limited motivation. Additional barriers included inadequate referral and information systems, poor supply chain management and procurement practices and finite financing. CONCLUSION: Integrating eye care into low resource health systems is a challenging task, compounded by resource limitations, competing priorities and ongoing support needs. This review highlighted a need for people-centred approaches to future interventions, and further investigation into integrating vision rehabilitation services.

Racially minoritized people's experiences of racism during COVID-19 in Australia: A qualitative study.

OBJECTIVE: Drawing from a broader study exploring how New South Wales community members from racially minoritized backgrounds experienced living through a pandemic, this paper reports specifically on experiences of racism during the COVID-19 pandemic in 2020. METHODS: Using an in-depth, qualitative interpretive approach, 11 semi-structured interviews and one focus group hosting three participants (n=14) were held via an online videoconferencing platform from September to December 2020. Inductive thematic analysis was undertaken using QRS NVivo as a data management tool. RESULTS: Racism was heightened during the pandemic and experienced in various ways by racially minoritized peoples in New South Wales. All participants in this research cited experiences of racism that impacted their wellbeing during COVID-19. These experiences are represented by the following four themes: experiencing racism is common; how racisms are experienced; increased fear of racism during COVID-19; and ways of coping with racisms. CONCLUSIONS: Racism was heightened during the pandemic and generated fear and anxiety that prevented racially minoritized peoples from participating in everyday life. IMPLICATIONS FOR PUBLIC HEALTH: Messaging from broader public platforms must be harnessed to stop the spread of moral panic so that during times of pandemic, public health strategies need only confirmation, not creation.

An action-oriented public health framework to reduce financial strain and promote financial wellbeing in high-income countries.

BACKGROUND: Perceived financial security impacts physical, mental, and social health and overall wellbeing at community and population levels. Public health action on this dynamic is even more critical now that the COVID-19 pandemic has exacerbated financial strain and reduced financial wellbeing. Yet, public health literature on this topic is limited. Initiatives targeting financial strain and financial wellbeing and their deterministic effects on equity in health and living conditions are missing. Our research-practice collaborative project addresses this gap in knowledge and intervention through an action-oriented public health framework for initiatives targeting financial strain and wellbeing. METHODS: The Framework was developed using a multi-step methodology that involved review of theoretical and empirical evidence alongside input from a panel of experts from Australia and Canada. In an integrated knowledge translation approach, academics (n = 14) and a diverse group of experts from government and non-profit sectors (n = 22) were engaged throughout the project via workshops, one-on-one dialogues, and questionnaires. RESULTS: The validated Framework provides organizations and governments with guidance for the design, implementation, and assessment of diverse financial wellbeing- and financial strain-related initiatives. It presents 17 priority actionable areas (i.e., entry points for action) likely to have long-lasting, positive effects on people's financial circumstances, contributing to improved financial wellbeing and health. The 17 entry points relate to five domains: Government (All Levels), Organizational & Political Culture, Socioeconomic & Political Context, Social & Cultural Circumstances, and Life Circumstances. CONCLUSIONS: The Framework reveals the intersectionality of root causes and consequences of financial strain and poor financial wellbeing, while also reinforcing the need for tailored actions to promote socioeconomic and health equity for all people. The dynamic, systemic interplay of the entry points illustrated in the Framework suggest opportunities for multi-sectoral, collaborative action across government and organizations towards systems change and the prevention of unintended negative impacts of initiatives.

Access to school-based eye health programs in Central Region, Malawi: a qualitative case study.

Vision impairment among children is associated with lower levels of educational attainment. School-based eye health programs have the potential to provide high-quality and cost-effective services that assist in the prevention of blindness and uncorrected vision impairment, particularly in low-resources settings. The aim of this study was to identify key factors that inhibit or facilitate the provision of school-based eye health programs, including referral to eye care services, for Malawian children in the Central Region. In-depth interviews (n = 10) and focus groups (n = 5) with children, parents, school staff, eye care practitioners, government and NGO workers (total participants n = 44) in rural and urban contexts within central region, Malawi, were conducted. Taking a rights-based approach, we used the AAAQ (availability, accessibility, acceptability, quality) framework to identify barriers and enablers to school eye health programs. Complex factors shape access to school-based eye health programs. While intersectoral collaboration between ministries was present, infrastructure and resourcing restricted the delivery of school eye health programs. School staff were supportive of being trained as vision screeners. Parents voiced geographic access to follow up eye care, and spectacle cost as a barrier; and children revealed experiences of stigma related to spectacle as barriers to uptake. School-based eye care may be facilitated through teachers, community informants and health workers through; the provision of school vision screening; increased awareness of the impact of vision impairment on education and future employment; and through educational approaches that seek to decrease stigma and misconceptions associated with wearing spectacles.

A Policy-Ready Public Health Guidebook of Strategies and Indicators to Promote Financial Well-Being and Address Financial Strain in Response to COVID-19.

INTRODUCTION: The COVID-19 pandemic has adversely affected the financial well-being of populations globally, escalating concerns about links with health care and overall well-being. Governments and organizations need to act quickly to protect population health relative to exacerbated financial strain. However, limited practice- and policy-relevant resources are available to guide action, particularly from a public health perspective, that is, targeting equity, social determinants of health, and health-in-all policies. Our study aimed to create a public health guidebook of strategies and indicators for multisectoral action on financial well-being and financial strain by decision makers in high-income contexts. METHODS: We used a multimethod approach to create the guidebook. We conducted a targeted review of existing theoretical and conceptual work on financial well-being and strain. By using rapid review methodology informed by principles of realist review, we collected data from academic and practice-based sources evaluating financial well-being or financial strain initiatives. We performed a critical review of these sources. We engaged our research-practice team and government and nongovernment partners and participants in Canada and Australia for guidance to strengthen the tool for policy and practice. RESULTS: The guidebook presents 62 targets, 140 evidence-informed strategies, and a sample of process and outcome indicators. CONCLUSION: The guidebook supports action on the root causes of poor financial well-being and financial strain. It addresses a gap in the academic literature around relevant public health strategies to promote financial well-being and reduce financial strain. Community organizations, nonprofit organizations, and governments in high-income countries can use the guidebook to direct initiative design, implementation, and assessment.

Social and Behavioural Correlates of High Physical Activity Levels among Aboriginal Adolescent Participants of the Next Generation: Youth Wellbeing Study.

Physical activity typically decreases during teenage years and has been identified as a health priority by Aboriginal adolescents. We examined associations between physical activity levels and sociodemographic, movement and health variables in the Aboriginal led 'Next Generation: Youth Well-being (NextGen) Study' of Aboriginal people aged 10-24 years from Central Australia, Western Australia and New South Wales. Baseline survey data collected by Aboriginal researchers and Aboriginal youth peer recruiters from 2018 to 2020 examined demographics and health-related behaviours. Logistic regression was used to estimate odds ratios (OR) for engaging in high levels of physical activity in the past week (3-7 days; 0-2 days (ref), or 'don't remember') associated with demographic and behavioural factors. Of 1170 adolescents, 524 (41.9%) had high levels of physical activity; 455 (36.4%) had low levels; 191 (15.3%) did not remember. Factors independently associated with higher odds of physical activity 3-7 days/week were low weekday recreational screen time [55.3% vs. 44.0%, OR 1.79 (1.16-2.76)], having non-smoking friends [50.4% vs. 25.0%, OR 2.27 (1.03-5.00)] and having fewer friends that drink alcohol [48.1% vs. 35.2%, OR 2.08 (1.05-4.14)]. Lower odds of high physical activity were independently associated with being female [40.2% vs. 50.9%, OR 0.57 (0.40-0.80)] and some findings differed by sex. The NextGen study provides evidence to inform the co-design and implementation of strategies to increase Aboriginal adolescent physical activity such as focusing on peer influences and co-occurring behaviours such as screen time.

Integrated people-centered eye care: A scoping review on engaging communities in eye care in low- and middle-income settings.

BACKGROUND: Community engagement has been endorsed as a key strategy to achieving integrated people-centered eye care that enables people and communities to receive a full spectrum of eye care across their life-course. Understanding the ways communities are engaged in eye care, to what degree participation is achieved, and the factors associated with intervention implementation is currently limited. OBJECTIVE: The scoping review aimed to assess how community engagement is approached and implemented in eye care interventions in low- and middle-income countries, and to identify the barriers and facilitators associated with intervention implementation. METHODS: Searches were conducted across five databases for peer-reviewed research on eye care interventions engaging communities published in the last ten years (January 2011 to September 2021). Studies were screened, reviewed and appraised according to Cochrane Rapid Reviews methodology. A hybrid deductive-inductive iterative analysis approach was used. RESULTS: Of 4315 potential studies screened, 73 were included in the review. Studies were conducted across 28 countries and 55 targeted populations across more than one life-course stage. A variety of community actors were engaged in implementation, in four main domains of eye care: health promotion and education; drug and supplement distribution and immunization campaigns; surveillance, screening and detection activities; and referral and pathway navigation. With the approaches and level of participation, the majority of studies were community-based and at best, involved communities, respectively. Involving community actors alone does not guarantee community trust and therefore can impact eye care uptake. Community actors can be integrated into eye care programs, although with varying success. Using volunteers highlighted sustainability issues with maintaining motivation and involvement when resources are limited. CONCLUSION: This scoping review provides researchers and policy makers contextual evidence on the breadth of eye care interventions and the factors to be considered when engaging and empowering communities in integrated people-centered eye care programs.

Developing culturally safe education practices in optometry schools across Australia and Aotearoa New Zealand.

Access to culturally safe health services is a basic human right, however through the lasting effects of colonisation, oppression, and systemic racism, the individual and community health of Indigenous peoples in Australia and Aotearoa New Zealand have been severely impacted. The Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy of the Australian Health Practitioners Regulation Agency, and the Standards of Cultural Competence and Cultural Safety of the Optometrists and Dispensing Opticians Board of New Zealand, recognise the importance of access to safe health care for Aboriginal, Torres Strait Islander and Maori patients, which encompasses both clinical competency and cultural safety. Universities have an ongoing responsibility to ensure their learning and teaching activities result in graduates being able to provide culturally safe practice. This article highlights the emergence of culturally safe practices in the Australian and Aotearoa New Zealand optometry curricula over the last five years incorporating Indigenous ways of knowing, being and doing into the curricula, understanding the local Indigenous histories and contexts, the adoption of online cultural education modules, and clinical placement partnerships with local Indigenous communities. Whilst there is still much work to do to achieve the goal of graduating culturally safe optometrists, this paper focuses on features that enable or impede progress in the development of culturally safe practices within the optometry programmes to improve eye health equity for Indigenous recognise the diversity of Indigenous cultures across Australia and NZ.

Appraising community driven health research with Aboriginal and Torres Strait Islander communities: a scoping review using the Aboriginal and Torres Strait Islander Quality Appraisal Tool.

Most research involving Aboriginal and Torres Strait Islander peoples has been conducted by non-Indigenous people and has not been a positive experience for many Aboriginal and Torres Strait Islander communities. This scoping review maps approaches to health research involving Aboriginal and Torres Strait Islander peoples and communities in Australia from the last two decades. A literature search found 198 papers, of which 34 studies met the inclusion criteria. The Aboriginal and Torres Strait Islander Quality Appraisal Tool was then used to map the quality of the reported community driven research. The Quality Appraisal Tool privileges, Aboriginal and Torres Strait Islander people's epistemologies and ethical research governance. The findings reported on strengths and identified areas for improvement in reporting community driven research.

Through scooping design this study sought to comprehensively map published community driven health research with Aboriginal and Torres Strait Islander communities in the past two decades. Using the Aboriginal and Torres Strait Islander Quality Appraisal Tool the we were able to identify key strengths and areas for improvement that will guide researchers reporting on research focussed on Aboriginal and Torres Strait Islander peoples and communities.

Building patient trust in health systems: A qualitative study of facework in the context of the Aboriginal and Torres Strait Islander Health Worker role in Queensland, Australia.

Healthcare services in Australia are the primary responsibility of state and territory governments, which recruit and deploy health providers in hospital and primary-care services. Among the various health professional roles, that of Aboriginal and Torres Strait Islander Health Worker (A&TSIHW) is one of only two positions that must be occupied by an Aboriginal and/or Torres Strait Islander person, carrying unique responsibility for enacting cultural brokerage and promoting cultural safety at the facility-level. Implicit to these responsibilities is the assumption that A&TSIHW will use cultural capital to build clients' trust in themselves and ultimately the broader health system. Drawing on 82 in-depth interviews including 52 with A&TSIHWs, we applied Kroegar's Facework theory to explore the structures, processes and relationships that contribute to, or inhibit, A&TISHWs' capacity and willingness to build trust (beyond themselves) in government health services in Queensland, Australia. Analysis demonstrates that despite A&TSIHWs viewing and enacting interpersonal trust-building as central to their role, structural features of the health system inhibit the development of service-users' system-level trust. Findings re-establish that health systems are not 'cultureless,' but rather, shaped by a dominant culture that privileges certain actors, types of knowledge, and modes of communication and action, which in turn influence efforts to build trust. The study demonstrates a novel theory-driven approach to exploring the interactions between behavioural and structural factors that influence the production of systems-level trust. In the context of the Queensland public health service findings highlight a disconnect between the expectations of, and support provided to A&TISHWs to engage Aboriginal and Torres Strait Islander service-users.

Rhetoric, Reality and Racism: The Governance of Aboriginal and Torres Strait Islander Health Workers in a State Government Health Service in Australia.

BACKGROUND: In northern Australia, Aboriginal and Torres Strait Islander Health Workers (A&TSIHWs) are unique members of nominally integrated teams of primary care professionals. Spurred by research documenting ongoing structural violence experienced by Indigenous health providers and more recent challenges to recruitment and retention of A&TSIHWs, this study aimed to explore whether the governance of the A&TSIHW role supports full and meaningful participation. METHODS: The qualitative study was co-designed by a team of Aboriginal, Torres Strait Islander and non-Indigenous collaborators. Data collection comprised document review and interviews with A&TSIHWs (n=51), clinicians (n=19) community members (n=8) and administrators (n=5) in a north Queensland health district. We analysed governance at multiple levels (regulatory, organisational, and socio-cultural) and used critical race theory to deepen exploration of the role of race and racism in shaping it. RESULTS: Governance of the A&TSIHW role occurs within a health system where racism is built into, and amplified by, formal and informal rules at all levels. Racially discriminatory structures such as the previous but long-standing relegation of A&TSIHW into the same career stream as cleaners were mirrored in discriminatory rules and managerial practices such as an absence of career-specific corporate support and limited opportunities to participate in, or represent to, key leadership groups. These interacted with and helped perpetuate workplace norms permissive of disrespect and abuse by non-Indigenous professionals. Ongoing resistance to the structural violence required of, and demonstrated by A&TSIHWs speaks to the gap between rhetoric and reality of governance for A&TSIHWs. CONCLUSION: Strengthening governance to support A&TSIHWs requires critical attention be given to the role of race and racism in regulatory structures, organisational practice, and inter-professional relationships. Addressing all domains will be essential to achieve systemic change that recognises, supports and embeds the unique knowledge, skills and functions of the A&TSIHW role.