Indigenous-led precision public health: a new starting point.

Precision public healthcare has been applied to bring about positive change, narrowing the gap in healthcare inequity for Aboriginal peoples. Three such examples include the Mappa, Lyfe Languages, and Pilbra Faces projects, which were all developed through engagement and codesign with Indigenous Australians and each meet a distinct critical need. The Mappa project offers patients and healthcare providers with the necessary geographical information to navigate and maximally utilize available healthcare services. Lyfe Languages is a community driven translational tool that empowers indigenous languages in healthcare. The Pilbara Faces project aims to create a database of clinical measurements enabling better disease diagnosis and monitoring. These three projects have been integrated into a multi-faceted precision public health program, the Healthy Pilbara Project Initiative, acting synergistically to improve the lives of Aboriginal peoples living in Western Australia.

A Late Devonian coelacanth reconfigures actinistian phylogeny, disparity, and evolutionary dynamics.

The living coelacanth Latimeria (Sarcopterygii: Actinistia) is an iconic, so-called 'living fossil' within one of the most apparently morphologically conservative vertebrate groups. We describe a new, 3-D preserved coelacanth from the Late Devonian Gogo Formation in Western Australia. We assemble a comprehensive analysis of the group to assess the phylogeny, evolutionary rates, and morphological disparity of all coelacanths. We reveal a major shift in morphological disparity between Devonian and post-Devonian coelacanths. The newly described fossil fish fills a critical transitional stage in coelacanth disparity and evolution. Since the mid-Cretaceous, discrete character changes (representing major morphological innovations) have essentially ceased, while meristic and continuous characters have continued to evolve within coelacanths. Considering a range of putative environmental drivers, tectonic activity best explains variation in the rates of coelacanth evolution.

Maternal Breast Growth and Body Mass Index Are Associated with Low Milk Production in Women.

BACKGROUND: Maternal breast volume is determined by the quantity of glandular and adipose tissue, and it undergoes significant changes during pregnancy. These changes are intricately linked to the development of glandular tissue, which most likely reflects lactation capacity. Evidence indicates that women with overweight or obesity exhibit larger breast volume compared to those with a normal body mass index (BMI), emphasizing the close relationship between breast volume and maternal adiposity. Hence, we aim to investigate breast volume growth and maternal BMI as potential risk factors for low milk production. METHODS: Lactating women (n = 609) from the Perth metropolitan area in Western Australia between 2011 and 2023 were included in the analysis. Twenty-four-hour milk production measurements were conducted using the test weighing method, and milk removal frequencies were recorded. Mothers completed questionnaires regarding demographic, obstetric and infant details. Linear and logistic regression models were used to determine maternal and infant factors associated with milk production. RESULTS: Here we show that increasing maternal age and BMI are associated with low milk production. Moreover, larger pre-pregnancy breast volume and breast growth are associated with both higher BMI and milk production. CONCLUSIONS: Women who are older, have an obese BMI and who have minimal pre-pregnancy breast volume and breast growth should be provided with antenatal screening and breastfeeding support as they are more likely to experience low milk production.

COVID-19 Vaccination Program for Migrant and Refugee Women in Western Australia: Community-Led Approach and Decolonizing Practice Reflections.

The COVID-19 pandemic disproportionately impacted culturally and racially marginalized (CARM) migrants in Australia, with communities having varying levels of accurate knowledge about COVID-19 vaccines. At the height of the pandemic, public health programs that prioritized colonial knowledge and practices resulted in negative social, economic, and health outcomes for CARM communities. To support access to COVID-19 vaccinations and equity in delivery, therefore, it is critical that awareness-raising programs are tailored to meet all communities' intersecting needs. In this paper, we share our reflections on a community-led COVID-19 vaccination awareness program designed specifically for CARM migrant women in Perth, Western Australia. The program was led by CARM migrant women who delivered five public information sessions for women in the Pakistani, Iraqi, Chin, and Indonesian communities. This paper offers an overview of the program and critical reflections on the challenges involved in community-led programs that are underpinned by a commitment to decolonization.

Lessons learned: drive-through COVID-19 clinic testing during an adaptive epidemic response and a point-of-care test assessment of a computer-read rapid lateral flow immunoassay with fluorescence-based detection.

Background. The COVID-19 pandemic demonstrated a need for robust SARS-CoV-2 test evaluation infrastructure to underpin biosecurity and protect the population during a pandemic health emergency.Gap statement. The first generation of rapid antigen tests was less accurate than molecular methods due to their inherent sensitivity and specificity shortfalls, compounded by the consequences of self-testing. This created a need for more accurate point-of-care SARS-CoV-2 detection methods.Aim. Here we present the lessons-learned during the COVID-19 emergency response in Western Australia including the detailed set-up, evaluation and operation of rapid antigen test in a state-run drive-through sample collection service during the COVID-19 pandemic after the strict border shutdown ended.Methods. We report a conformity assessment of a novel, second-generation rapid antigen test (Virulizer) comprising a technician-operated rapid lateral flow immunoassay with fluorescence-based detection.Results. The Virulizer rapid antigen test demonstrated up to 100% sensitivity (95% CI: 61.0-100%), 91.94% specificity (95% CI: 82.5-96.5%) and 92.65% accuracy when compared to a commercial PCR assay method. Wide confidence intervals in our series reflect the limits of small sample size. Nevertheless, the Virulizer assay performance was well-suited to point-of-care screening for SARS-CoV-2 in a drive-through clinic setting.Conclusion. The adaptive evaluation process necessary under changing pandemic conditions enabled assessment of a simple sample collection and point-of-care testing process, and showed how this system could be rapidly deployed for SARS-CoV-2 testing, including to regional and remote settings.

Visual field loss and falls requiring hospitalisation: results from the eFOVID study.

BACKGROUND: Visual fields are important for postural stability and ability to manoeuvre around objects. OBJECTIVE: Examine the association between visual field loss and falls requiring hospitalisation in adults aged 50 +. METHODS: Older adults aged 50+ with and without visual field loss were identified using a fields database obtained from a cross-section of ophthalmologists' practices in Western Australia (WA). Data were linked to the Hospital Morbidity Data Collection and WA Hospital Mortality System to identify participants who experienced falls-related hospitalisations between 1990 and 2019. A generalised linear negative binomial regression model examined the association between falls requiring hospitalisation for those with and without field loss, based on the better eye mean deviation (mild: -2 to -6 dB, moderate: -6.01 dB to -12 dB, severe < -12.01 dB) in the most contemporaneous visual field test (3 years prior or if not available, 2 years after the fall), after adjusting for potential confounders. RESULTS: A total of 31 021 unique individuals of whom 6054 (19.5%) experienced 11 818 falls requiring hospitalisation during a median observation time of 14.1 years. Only mean deviation index of <-12.01 dB (severe) was significantly associated with an increased rate of falls requiring hospitalisations by 14% (adjusted IRR 1.14, 95% CI 1.0-1.25) compared with no field loss, after adjusting for potential confounders. Other factors included age, with those aged 80+ having an increased rate (IRR 29.16, 95% CI 21.39-39.84), other comorbid conditions (IRR 1.49, 95% CI 1.38-1.60) and diabetes (IRR 1.25, 95% CI 1.14-1.37). Previous cataract surgery was associated with a decreased rate of falls that required hospitalisations by 13% (IRR 0.87, 95% CI 0.81-0.95) compared with those who did not have cataract surgery. CONCLUSION: The findings highlight the importance of continuous clinical monitoring of visual field loss and injury prevention strategies for older adults with visual field loss.

Developmental trends in young children's device-measured physical activity and sedentary behaviour.

BACKGROUND: Knowledge of developmental trends in meeting age-specific 24-hour movement behaviour guidelines is lacking. This study describes developmental trends in device-measured physical activity and sedentary time over a three-year period among Western Australian children aged two to seven years, including differences between boys and girls. The proportion of children meeting age-specific physical activity guidelines before and after they transition to full-time school was also examined. METHODS: Data from waves 1 and 2 of the Play Spaces and Environments for Children's Physical Activity (PLAYCE) cohort study were used (analysis n = 1217). Physical activity and sedentary time were measured by accelerometry at ages two to five (preschool, wave 1) and ages five to seven (commenced full-time school, wave 2). Accelerometer data were processed using a validated machine-learning physical activity classification model. Daily time spent in sedentary behaviour, energetic play (moderate-to-vigorous physical activity (MVPA)), total physical activity, and meeting physical activity guidelines were analysed using linear and generalised linear mixed-effects models with age by sex interaction terms. RESULTS: All movement behaviours changed significantly with increasing age, and trends were similar in boys and girls. Total daily physical activity increased from age two to five then declined to age seven. Mean daily total physical activity exceeded 180 min/day from ages two to five. Daily energetic play increased significantly from age two to seven, however, was below 60 min/day at all ages except for seven-year-old boys. Daily sedentary time decreased to age five then increased to age seven but remained lower than at age two. All two-year-olds met their age-specific physical activity guideline, decreasing to 5% of girls and 6% of boys at age four. At age seven, 46% of boys and 35% of girls met their age-specific physical activity guideline. CONCLUSIONS: Young children's energetic play and total physical activity increased with age, but few children aged three to seven met the energetic play (MVPA) guideline. Interventions should focus on increasing children's energetic play in early childhood. Clearer guidance and strategies are needed to support young children as they change developmentally and as they transition from one age-specific movement guideline to the next.

Respiratory Viral Testing Rate Patterns in Young Children Attending Tertiary Care Across Western Australia: A Population-Based Birth Cohort Study.

BACKGROUND: An understanding of viral testing rates is crucial to accurately estimate the pathogen-specific hospitalisation burden. We aimed to estimate the patterns of testing for respiratory syncytial virus (RSV), influenza virus, parainfluenza virus (PIV) and human metapneumovirus (hMPV) by geographical location, age and time in children <5 years old in Western Australia. METHODS: We conducted a population-based cohort study of children born between 1 January 2010 and 31 December 2021, utilising linked administrative data incorporating birth and death records, hospitalisations and respiratory viral surveillance testing records from state-wide public pathology data. We examined within-hospital testing rates using survival analysis techniques and identified independent predictors of testing using binary logistic regression. RESULTS: Our dataset included 46,553 laboratory tests for RSV, influenza, PIV, or hMPV from 355,021 children (52.5% male). Testing rates declined in the metropolitan region over the study period (RSV testing in infants: from 242.11/1000 child-years in 2012 to 155.47/1000 child-years in 2018) and increased thereafter. Conversely, rates increased in non-metropolitan areas (e.g., RSV in Goldfields: from 364.92 in 2012 to 504.37/1000 child-years in 2021). The strongest predictors of testing were age <12 months (adjusted odds ratio [aOR] = 2.25, 95% CI 2.20-2.31), preterm birth (<32 weeks: aOR = 2.90, 95% CI 2.76-3.05) and remote residence (aOR = 0.77, 95% CI 0.73-0.81). CONCLUSION: These current testing rates highlight the potential underestimation of respiratory virus hospitalisations by routine surveillance and the need for estimation of the true burden of respiratory virus admissions.

Psychomotor Vigilance Testing on Neonatal Transport: A Western Australian Experience.

OBJECTIVE: This study aimed to assess whether undertaking retrieval was associated with fatigue independent of sleep and circadian disruption. It also aimed to assess the feasibility of routinely measuring the psychomotor vigilance test (PVT) on neonatal transport. Fatigue is associated with impaired clinician performance and safety. The association between shift work, sleep deprivation, and circadian disruption is well established. No studies have specifically assessed the independent effect of the retrieval environment on fatigue. METHODS: Medical and nursing staff of the neonatal retrieval team were prospectively recruited over a 12-month period. Simple reaction times (RTs) were recorded at the start and end of a day shift using a validated 3-minute PVT. RESULTS: The end-of-shift RT increased (not significant) by 6.38 milliseconds (95% confidence interval [CI], -2.17 to 14.92 milliseconds; P = .149) when retrieval was undertaken. A 1-millisecond increase in RT increased the odds of being in a subjective sleepy category by 0.57% (95% CI, 0.0036-0.0078; P < .001). Consuming caffeine during the shift increased the mean RT by 16.26 milliseconds (95% CI, 4.43-28.1 milliseconds; P < .01). CONCLUSION: The RT of participants exposed to the retrieval environment was not significantly increased. Further studies are needed to consolidate these results as well as to further assess longer-range air medical retrievals.

Predicting anxiety treatment outcome in community mental health services using linked health administrative data.

Anxiety disorders is ranked as the most common class of mental illness disorders globally, affecting hundreds of millions of people and significantly impacting daily life. Developing reliable predictive models for anxiety treatment outcomes holds immense potential to help guide the development of personalised care, optimise resource allocation and improve patient outcomes. This research investigates whether community mental health treatment for anxiety disorder is associated with reliable changes in Kessler psychological distress scale (K10) scores and whether pre-treatment K10 scores and past health service interactions can accurately predict reliable change (improvement). The K10 assessment was administered to 46,938 public patients in a community setting within the Western Australia dataset in 2005-2022; of whom 3794 in 4067 episodes of care were reassessed at least twice for anxiety disorders, obsessive-compulsive disorder, or reaction to severe stress and adjustment disorders (ICD-10 codes F40-F43). Reliable change on the K10 was calculated and used with the post-treatment score as the outcome variables. Machine learning models were developed using features from a large health service administrative linked dataset that includes the pre-treatment K10 assessment as well as community mental health episodes of care, emergency department presentations, and inpatient admissions for prediction. The classification model achieved an area under the receiver operating characteristic curve of 0.76 as well as an F1 score, precision and recall of 0.69, and the regression model achieved an R2 of 0.37 with mean absolute error of 5.58 on the test dataset. While the prediction models achieved moderate performance, they also underscore the necessity for regular patient monitoring and the collection of more clinically relevant and contextual patient data to further improve prediction of treatment outcomes.

Taste aversion training can educate free-ranging crocodiles against toxic invaders.

Apex predators play critical ecological roles, making their conservation a high priority. In tropical Australia, some populations of freshwater crocodiles (Crocodylus johnstoni) have plummeted by greater than 70% due to lethal ingestion of toxic invasive cane toads (Rhinella marina). Laboratory-based research has identified conditioned taste aversion (CTA) as a way to discourage consumption of toads. To translate those ideas into landscape-scale management, we deployed 2395 baits (toad carcasses with toxin removed and containing a nausea-inducing chemical) across four gorge systems in north-western Australia and monitored bait uptake with remote cameras. Crocodile abundance was quantified with surveys. Free-ranging crocodiles rapidly learned to avoid toad baits but continued to consume control (chicken) baits. Toad invasion at our sites was followed by high rates of crocodile mortality (especially for small individuals) at a control site but not at nearby treatment sites. In areas with high connectivity to other waterbodies, repeated baiting over successive years had continuing positive impacts on crocodile survival. In summary, we succeeded in buffering the often-catastrophic impact of invasive cane toads on apex predators.

Sexual harassment and sexual assault in the Western Australian mining industry: a qualitative examination of the perceptions of key stakeholders.

Introduction: The prevalence, pervasiveness, and minimization of sexual harassment and sexual assault (SHSA) within the Western Australian mining industry has been revealed in recent Australian reports and inquiries. However, there remains a gap in scholarship focusing on SHSA within the mining sector, specifically that engages with mining employees to understand this issue. Methods: This study aimed to fill this gap by exploring the experiences and perspectives of Western Australian mining employees in relation to SHSA. Through qualitative research methods, stakeholders (n = 30) from various industry roles (e.g., front-line operations, administrative staff) participated in semi-structured interviews. A deductive thematic analysis was conducted to analyze the data. Results: The study revealed diverse perspectives of SHSA among participants, highlighting how this issue is understood, addressed, and discussed within the workplace. While some participants recognized positive shifts in workplace culture, it became apparent that additional efforts are needed to tackle the underlying and persistent factors that contribute to sexism, misogyny, and, ultimately, SHSA. Participants shared their perspectives regarding strategies and initiatives that could effectively combat SHSA within the industry. Discussion: This study constitutes a significant contribution to the limited body of research on SHSA in the Western Australian mining sector, offering valuable insights and recommendations for future prevention initiatives.

What happens at two? Immunisation stakeholders' perspectives on factors influencing sub-optimal childhood vaccine uptake for toddlers in regional and remote Western Australia.

BACKGROUND: In Western Australia (WA), children aged 24 months living regionally or remotely (non-urban) have suboptimal vaccine uptake. As there has not yet been a systematic approach to understanding the facilitators and barriers to childhood vaccination in regional and remote WA, this study aimed to understand the views of key immunisation stakeholders regarding barriers and solutions. METHODS: Drawing on the World Health Organization's "Tailoring Immunization Programmes" approach, we undertook a qualitative study with three forms of data collection: (1) semi-structured interviews with immunisation experts within Australia's immunisation system, (2) a semi-structured focus group with immunisation coordinators and health workers working in regional or remote WA, and (3) member checking with senior staff from WA Health. Data from the interviews and focus group was deductively analysed using the Capability-Opportunity-Motivation-Behaviour (COM-B) model on NVivo 20. RESULTS: There was no clear consensus on the typical under-vaccinated child in country WA. A range of barriers were identified: lack of awareness of the vaccine schedule, difficult access to vaccination services, a shortage in a workforce able to have meaningful conversations with vaccine hesitant parents, ineffective reminder systems, and the rapid spread of misinformation. Participants described previous efforts used to improve vaccine uptake, and felt the following would improve uptake: better access to vaccine clinics, building capacity of Aboriginal Health Workers, and vaccine reminders. CONCLUSION: This is the first time the facilitators and barriers to routine childhood vaccine uptake in country WA has been explored. Addressing some of these barriers may see an increase in uptake.

Cost-effectiveness analysis and return on investment of SunSmart Western Australia to prevent skin cancer.

Each year, malignant melanoma accounts for 57 000 deaths globally. If current rates continue, there will be an estimated 510 000 new cases annually and 96 000 deaths by 2040. Melanoma and keratinocyte cancers (KCs) incur a large societal burden. Using a mathematical population model, we performed an economic evaluation of the SunSmart program in the state of Western Australia (WA), a primary prevention program to reduce the incidence of skin cancer, versus no program. A societal perspective was taken combining costs to the health system, patients and lost productivity. The model combined data from pragmatic trial evidence of sun protection, epidemiological studies and national cost reports. The main outcomes modelled were societal and government costs, skin cancer counts, melanoma deaths, life years and quality-adjusted life years. Over the next 20 years, the model predicted that implementing the WA SunSmart program would prevent 13 728 KCs, 636 melanomas and 46 melanoma deaths per 100 000 population. Furthermore, 251 life years would be saved, 358 quality-adjusted life years gained and AU$2.95 million in cost savings to society per 100 000 population would be achieved. Key drivers of the model were the rate reduction of benign lesions from sunscreen use, the costs of purchasing sunscreen and the effectiveness of reducing KCs in sunscreen users. The likelihood of WA SunSmart being cost-effective was 90.1%. For the WA Government, the estimated return on investment was $8.70 gained for every $1 invested. Primary prevention of skin cancer is a cost-effective strategy for preventing skin cancers.

Clinician's perspectives on the feasibility of patient controlled analgesia in emergency departments: A qualitative descriptive study.

BACKGROUND: Despite pain being the most common reason for patients to visit the emergency department (ED), conventional pain management methods are often inadequate. Patient controlled analgesia (PCA), which allows patients to self-administer intravenous analgesia, is widely used across many hospital wards, however, is not routinely used in ED. We aimed to identify clinicians' perceptions of PCA use in the ED setting. METHODS: A qualitative descriptive approach was employed using semi-structured individual interviews conducted with ED clinicians from two hospitals in Western Australia. Interviews were recorded and transcribed. Data was analysed using qualitative content analysis. RESULTS: Data saturation was achieved after 20 participant interviews. Five themes emerged from the interview data: sustainability and choosing the right patient; time; safety concerns and side effects; anticipating the patient's perspective (staff perception); facilitating PCA use in ED. CONCLUSION: Most participants perceived that patients would experience several benefits from PCA use in ED. Several perceived barriers and facilitators were also identified. To facilitate the use of PCA in ED, there is a need for staff education on PCA use, patient selection guidelines and effective change management strategies. Further research about the time it takes to administer analgesia via PCA compared with conventional methods is needed.

Patterns of health workforce turnover and retention in Aboriginal Community Controlled Health Services in remote communities of the Northern Territory and Western Australia, 2017-2019.

BACKGROUND: Aboriginal Community Controlled Health Services (ACCHSs) in Australia aim to optimise access to comprehensive and culturally safe primary health care (PHC) for Aboriginal populations. Central to quality service provision is the retention of staff. However, there is lack of published research reporting patterns of staff turnover and retention specific to ACCHSs. This study quantified staff turnover and retention in regional and remote ACCHSs in the Northern Territory (NT) and Western Australia (WA), and examined correlations between turnover and retention metrics, and ACCHSs' geographical and demographic characteristics. METHODS: The study used 2017-2019 payroll data for health workers in 22 regional and remote PHC clinics managed by 11 ACCHSs. Primary outcome measures included annual turnover and 12-month stability rates, calculated at both clinic and organisation levels. RESULTS: There was a median of five client-facing (Aboriginal health practitioners, allied health professionals, doctors, nurses/midwives, and 'other health workers' combined) and two non-client-facing (administrative and physical) staff per remote clinic, at any timepoint. Mean annual turnover rates for staff were very high, with 151% turnover rates at the clinic level and 81% turnover rates at the organisation level. Mean annual turnover rates for client-facing staff were 164% and 75%, compared to 120% and 98% for non-client-facing staff, at clinic and organisational levels, respectively. Mean 12-month stability rates were low, with clinic-level stability rates of only 49% and organisation-level stability rates of 58%. Mean annual clinic-level turnover rates were 162% for non-Aboriginal staff and 81% for Aboriginal staff. Both workforce metrics were moderately to highly correlated with the relative remoteness of clinics, size of regular clients serviced, and average annual headcount of employees in each clinic (p values < 0.01). CONCLUSIONS: Participating ACCHSs in remote NT and WA have very high turnover and low retention of healthcare staff. Overall, clinic-level turnover rates increase as distance from regional centres increases and are lower for Aboriginal staff, suggesting that greater employment of Aboriginal staff could help stabilise staffing. Improved retention could reduce burden on ACCHSs' resources and may also support quality of service delivery due to improved cultural safety and continuity of care.

Maternal exposure to bioclimatic stress and hypertensive disorders of pregnancy in Western Australia: identifying potential critical windows of susceptibility.

The anthropogenic climate change may impact pregnancy outcomes. Rather than ambient temperature, we aimed to use a composite bioclimatic metric (Universal Thermal Climate Index, UTCI) to identify critical susceptible windows for the associations between bioclimatic exposure and hypertensive disorders of pregnancy (HDPs) risk. Daily UTCI exposure from 12 weeks of preconception through pregnancy was linked to 415,091 singleton pregnancies between 1st January 2000 and 31st December 2015 in Western Australia. Adjusted weekly-specific and cumulative odds ratios (ORs) and 95% confidence intervals (CIs) of gestational hypertension and preeclampsia were estimated with distributed lag non-linear and standard non-linear logistic regressions. Exposures from early pregnancy to week 30 were associated with greater odds of HDPs with critical susceptible windows, particularly elevated at the 1st (10.2 °C) and 99th (26.0 °C) exposure centiles as compared to the median (14.2 °C). The most elevated ORs were 1.07 (95% CI 1.06, 1.08) in weeks 8-18 for gestational hypertension and 1.10 (95% CI 1.08, 1.11) in weeks 11-16 for preeclampsia for the 99th exposure centile. Cumulative exposures associated with HDPs with relatively higher but less precise ORs. The effects of high exposure to HDPs indicated sociodemographic inequalities. The identified critical periods and subpopulations could benefit from climate-related interventions.

Incidence and Predictors of Stroke in Australian Adults With Congenital Heart Disease (2000-2017).

BACKGROUND: Adults with congenital heart disease (CHD) are at increased risk of stroke but high-quality population level data on stroke incidence in these patients are scant. METHODS AND RESULTS: A retrospective whole-population Western Australian cohort of adult patients with CHD aged 18 to 64 years was created and followed from January 2000 to December 2017 using linked hospital data. Stroke incidence rates within the adult cohort with CHD were calculated and compared with the general population via direct standardization. A nested case-control design assessed predictors of ischemic and hemorrhagic stroke within the cohort. Among 7916 adults with CHD, 249 (3.1%) incident strokes occurred at a median age of 47 years; 186 (2.3%) ischemic, 33 (0.4%) hemorrhagic and 30 (0.4%) unspecified strokes. Ischemic and hemorrhagic stroke incidence was, respectively, 9 and 3 times higher in adults with CHD than the general population. Absolute risk was low with annual rates of 0.26% (ischemic) and 0.05% (hemorrhagic). Highest rates were observed in adults with shunt and left-sided lesions. Predictors of ischemic stroke in adults with CHD included recent cardiac surgery, left-sided valve repair/replacements, shunt lesions, and traditional risk factors (hypertension, infective endocarditis, peripheral vascular disease, and tobacco use). Mental health disorders and increasing Charlson's comorbidity scores were strongly associated with higher risk of ischemic and hemorrhagic stroke. The CHA2DS2VASc score was associated with ischemic stroke incidence. CONCLUSIONS: This study provides the first population-based stroke incidence estimates for adults with CHD in Australia, showing elevated stroke risk across different CHD lesions. It highlights the potential clinical importance of managing comorbidities, especially mental health.

Food Banks as a "Treasure Trove": Users' Experiences of a Western Australian Food Relief Organization.

Food banks are providing crucial relief as food insecurity increases worldwide. While these services are essential for vulnerable populations, there is variability in foods available and users may experience poor nutritional quality, and an overabundance of discretionary foods, contributing to public health risks including overnutrition and obesity. Understanding how customers perceive food availability, variety, and quality is important to inform relief services and health interventions. This study reports the findings of a convergent parallel mixed-methods investigation of user experiences and perceptions of food availability, variety, and quality at a major food bank in Western Australia. Food bank customers (N = 207) at a food bank branch and mobile van locations completed a survey, with an option to complete a subsequent semi-structured interview (n = 15). Approximately 80% of the survey sample had low (48%) or very low (30%) food security, half of the sample had been using the food bank for longer than 6 months, and 77% reported the food bank as their first choice for food. Three-quarters (77%) reported financial barriers to a balanced diet in the past twelve months and described how limited availability and variety complicated shopping. Interviewees explained complex perceptions of these issues, including favouring healthy food while considering discretionary food as a "luxury" that enhanced their quality of life. Our findings suggest that food bank users experience barriers to maintaining a balanced diet, encounter variable supplies of healthy and nutritious foods, and have concerns about the impacts of frequent discretionary food consumption. These findings have implications for public health promotion.