The views of parents and carers on managing acute otitis media in urban Aboriginal and Torres Strait Islander children: a qualitative study.

OBJECTIVES: To explore the views of parents and carers regarding the management of acute otitis media in urban Aboriginal and Torres Strait Islander children who are at low risk of complications living in urban communities. STUDY DESIGN: Qualitative study; semi-structured interviews and short telephone survey. SETTING, PARTICIPANTS: Interviews: purposive sample of parents and carers of urban Aboriginal and Torres Strait Islander children (18 months - 16 years old) screened in Aboriginal medical services in Queensland, New South Wales, and Canberra for the WATCH study, a randomised controlled trial that compared immediate antibiotic therapy with watchful waiting for Aboriginal and Torres Strait Islander children with acute otitis media. SURVEY: parents and carers recruited for the WATCH trial who had completed week two WATCH surveys. RESULTS: We interviewed twenty-two parents and carers, including ten who had declined participation in or whose children were ineligible for the WATCH trial. Some interviewees preferred antibiotics for managing acute otitis media, others preferred watchful waiting, expressing concerns about side effects and reduced efficacy with overuse of antibiotics. Factors that influenced this preference included the severity, duration, and recurrence of infection, and knowledge about management gained during the trial and from personal and often multigenerational experience of ear disease. Participants highlighted the importance of shared decision making by parents and carers and their doctors. Parents and carers of 165 of 262 WATCH participants completed telephone surveys (63%); 81 were undecided about whether antibiotics should always be used for treating acute otitis media. Open-ended responses indicated that antibiotic use should be determined by clinical need, support for general practitioners' decisions, and the view that some general practitioners prescribed antibiotics too often. CONCLUSIONS: Parents and carers are key partners in managing acute otitis media in urban Aboriginal and Torres Strait Islander children. Our findings support shared decision making informed by the experience of parents and carers, which could also lead to reduced antibiotic use for managing acute otitis media.

Immediate versus delayed versus no antibiotics for respiratory infections.

BACKGROUND: Concerns exist regarding antibiotic prescribing for respiratory tract infections (RTIs) owing to adverse reactions, cost and antibacterial resistance. One proposed strategy to reduce antibiotic prescribing is to provide prescriptions, but to advise delay in antibiotic use with the expectation that symptoms will resolve first. This is an update of a Cochrane Review originally published in 2007, and updated in 2010, 2013 and 2017. OBJECTIVES: To evaluate the effects on duration and/or severity of clinical outcomes (pain, malaise, fever, cough and rhinorrhoea), antibiotic use, antibiotic resistance and patient satisfaction of advising a delayed prescription of antibiotics in respiratory tract infections. SEARCH METHODS: From May 2017 until 20 August 2022, this was a living systematic review with monthly searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL and Web of Science. We also searched the WHO International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov on 20 August 2022. Due to the abundance of evidence supporting the review's key findings, it ceased being a living systematic review on 21 August 2022. SELECTION CRITERIA: Randomised controlled trials involving participants of all ages with an RTI, where delayed antibiotics were compared to immediate or no antibiotics. We defined a delayed antibiotic as advice to delay the filling of an antibiotic prescription by at least 48 hours. We considered all RTIs regardless of whether antibiotics were recommended or not. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures. MAIN RESULTS: For this 2022 update, we added one new trial enrolling 448 children (436 analysed) with uncomplicated acute RTIs. Overall, this review includes 12 studies with a total of 3968 participants, of which data from 3750 are available for analysis. These 12 studies involved acute RTIs including acute otitis media (three studies), streptococcal pharyngitis (three studies), cough (two studies), sore throat (one study), common cold (one study) and a variety of RTIs (two studies). Six studies involved only children, two only adults and four included both adults and children. Six studies were conducted in primary care, four in paediatric clinics and two in emergency departments. Studies were well reported and appeared to provide moderate-certainty evidence. Randomisation was not adequately described in two trials. Four trials blinded the outcome assessor, and three included blinding of participants and doctors. We conducted meta-analyses for pain, malaise, fever, adverse effects, antibiotic use and patient satisfaction. Cough (four studies): we found no differences amongst delayed, immediate and no prescribed antibiotics for clinical outcomes in any of the four studies. Sore throat (six studies): for the outcome of fever with sore throat, four of the six studies favoured immediate antibiotics, and two found no difference. For the outcome of pain related to sore throat, two studies favoured immediate antibiotics, and four found no difference. Two studies compared delayed antibiotics with no antibiotic for sore throat, and found no difference in clinical outcomes. Acute otitis media (four studies): two studies compared immediate with delayed antibiotics - one found no difference for fever, and the other favoured immediate antibiotics for pain and malaise severity on Day 3. Two studies compared delayed with no antibiotics: one found no difference for pain and fever severity on Day 3, and the other found no difference for the number of children with fever on Day 3. Common cold (two studies): neither study found differences for clinical outcomes between delayed and immediate antibiotic groups. One study found delayed antibiotics were probably favoured over no antibiotics for pain, fever and cough duration (moderate-certainty evidence). ADVERSE EFFECTS: there were either no differences for adverse effects or results may have favoured delayed over immediate antibiotics with no significant differences in complication rates (low-certainty evidence). Antibiotic use: delayed antibiotics probably resulted in a reduction in antibiotic use compared to immediate antibiotics (odds ratio (OR) 0.03, 95% confidence interval (CI) 0.01 to 0.07; 8 studies, 2257 participants; moderate-certainty evidence). However, a delayed antibiotic was probably more likely to result in reported antibiotic use than no antibiotics (OR 2.52, 95% CI 1.69 to 3.75; 5 studies, 1529 participants; moderate-certainty evidence). Patient satisfaction: patient satisfaction probably favoured delayed over no antibiotics (OR 1.45, 1.08 to 1.96; 5 studies, 1523 participants; moderate-certainty evidence). There was probably no difference in patient satisfaction between delayed and immediate antibiotics (OR 0.77, 95% CI 0.45 to 1.29; 7 studies, 1927 participants; moderate-certainty evidence). No studies evaluated antibiotic resistance. Reconsultation rates and use of alternative medicines were similar for delayed, immediate and no antibiotic strategies. In one of the four studies reporting use of alternative medicines, less paracetamol was used in the immediate group compared to the delayed group. AUTHORS' CONCLUSIONS: For many clinical outcomes, there were no differences between prescribing strategies. Symptoms for acute otitis media and sore throat were modestly improved by immediate antibiotics compared with delayed antibiotics. There were no differences in complication rates. Delaying prescribing did not result in significantly different levels of patient satisfaction compared with immediate provision of antibiotics (86% versus 91%; moderate-certainty evidence). However, delay was favoured over no antibiotics (87% versus 82%). Delayed antibiotics achieved lower rates of antibiotic use compared to immediate antibiotics (30% versus 93%). The strategy of no antibiotics further reduced antibiotic use compared to delaying prescription for antibiotics (13% versus 27%). Delayed antibiotics for people with acute respiratory infection reduced antibiotic use compared to immediate antibiotics, but was not shown to be different to no antibiotics in terms of symptom control and disease complications. Where clinicians feel it is safe not to prescribe antibiotics immediately for people with RTIs, no antibiotics with advice to return if symptoms do not resolve is likely to result in the least antibiotic use while maintaining similar patient satisfaction and clinical outcomes to delayed antibiotics. Where clinicians are not confident in not prescribing antibiotics, delayed antibiotics may be an acceptable compromise in place of immediate prescribing to significantly reduce unnecessary antibiotic use for RTIs, while maintaining patient safety and satisfaction levels. Further research into antibiotic prescribing strategies for RTIs may best be focused on identifying patient groups at high risk of disease complications, enhancing doctors' communication with patients to maintain satisfaction, ways of increasing doctors' confidence to not prescribe antibiotics for RTIs, and policy measures to reduce unnecessary antibiotic prescribing for RTIs.

Holding the complex whole: Generalist philosophy, priorities and practice that facilitate whole-person care.

BACKGROUND: Generalist work is often complex, especially in the face of undifferentiated, uncertain, uncomfortable or unremitting presentations. This complexity can be exacerbated by difficult social circumstances and health system constraints, as well as by dissonance between patient and clinician conceptions of ideal care. OBJECTIVE: This article offers philosophical and practical encouragement to help general practitioners (GPs) 'be with' patients, care for their own needs and value their complex work. DISCUSSION: Caring for the whole person is challenging. When done well, this complex care may look simple. Alongside biomedical knowledge, generalists require sophisticated relational sensitivity and capacity to notice and attend to context, culture, meaning and subjective inner experience, including the person's strengths and deepest fears. Generalist philosophy, priorities and clinical skills are named in this paper as part of the ongoing effort to help GPs value, hone and protect the often-misunderstood complexity of their work.

A crisis is also an opportunity: GP teachers' views on continuing clinical placements in general practice during the evolving COVID-19 pandemic.

BACKGROUND AND OBJECTIVES: Early in the COVID-19 pandemic, some universities suspended student placements in general practice. The aim of this study was to explore the views of general practitioners (GPs) teaching in clinical practice ('GP teachers'). METHOD: Semi-structured interviews were held with 15 GP teachers in southeast Queensland from June to August 2020. RESULTS: Challenges included lack of masks and space, and concerns about infection control, medico-legal liability and student learning. Telehealth created more time for reflection and accessing information, increased student access to sensitive consultations, and provided opportunities to think-through rather than rote-do physical examinations. Students could be an extra pair of hands, also accessing and implementing the latest public health advice. GP teachers wanted clear communication and guidance from universities and for students to be trained in infection control and telehealth skills. DISCUSSION: Findings suggest that many GP teachers can be supported to continue clinical placements during an evolving crisis. The pandemic presented many challenges for general practice but also new opportunities for students to learn and contribute in practice.

"I'm outta here!": a qualitative investigation into why Aboriginal and non-Aboriginal people self-discharge from hospital.

BACKGROUND: Occasions of self-discharge from health services before being seen by a health profession or against medical advice are often used by health systems as an indicator of quality care. People self-discharge because of factors such as dissatisfaction with care, poor communication, long waiting times, and feeling better in addition to external factors such as family and employment responsibilities. These factors, plus a lack of cultural safety, and interpersonal and institutional racism contribute to the disproportionately higher rates of Indigenous people self-discharging from hospital. This qualitative study aimed to increase understanding about the causative and contextual factors that culminate in people self-discharging and identify opportunities to improve the hospital experience for all. METHODS: Semi-structured interviews with five Aboriginal and/or Torres Strait Islander (hereafter, respectfully, Indigenous) people and six non-Indigenous people who had self-discharged from a major tertiary hospital in Brisbane, Australia, were audio-recorded, transcribed and thematically analysed. RESULTS: Study participants all respected hospitals' vital role of caring for the sick, but the cumulative impact of unmet needs created a tipping point whereby they concluded that remaining in hospital would compromise their health and wellbeing. Five key categories of unmet needs were identified - the need for information; confidence in the quality of care; respectful treatment; basic comforts; and peace of mind. Although Indigenous and non-Indigenous participants had similar unmet needs, for the former, the deleterious impact of unmet needs was compounded by racist and discriminatory behaviours they experienced while in hospital. CONCLUSIONS: Respectful, empathetic, person-centred care is likely to result in patients' needs being met, improve the hospital experience and reduce the risk of people self-discharging. For Indigenous people, the ongoing legacy of white colonisation is embodied in everyday lived experiences of interpersonal and institutional racism. Racist and discriminatory behaviours experienced whilst hospitalised are thus rendered both more visible and more traumatic, and exacerbate the deleterious effect of unmet needs. Decreasing self-discharge events requires a shift of thinking away from perceiving this as the behaviour of a deviant individual, but rather as a quality improvement opportunity to ensure that all patients are cared for in a respectful and person-centred manner.

"The Problem Is that We Hear a Bit of Everything ": A Qualitative Systematic Review of Factors Associated with Alcohol Use, Reduction, and Abstinence in Pregnancy.

Understanding the factors that contribute to women's alcohol use in pregnancy is critical to supporting women's health and wellness and preventing Fetal Alcohol Spectrum Disorder. A systematic review of qualitative studies involving pregnant and recently postpartum women was undertaken to understand the barriers and facilitators that influence alcohol use in pregnancy (PROSPERO: CRD42018098831). Twenty-seven (n = 27) articles were identified through EMBASE, CINAHL, PsycINFO, PubMed and Web of Science. The included articles were thematically analyzed using NVivo12. The analysis was informed by Canada's Action Framework for Building an Inclusive Health System to articulate the ways in which stigma and related barriers are enacted at the individual, interpersonal, institutional and population levels. Five themes impacting women's alcohol use, abstention and reduction were identified: (1) social relationships and norms; (2) stigma; (3) trauma and other stressors; (4) alcohol information and messaging; and (5) access to trusted equitable care and essential resources. The impact of structural and systemic factors on prenatal alcohol use was largely absent in the included studies, instead focusing on individual choice. This silence risks perpetuating stigma and highlights the criticality of addressing intersecting structural and systemic factors in supporting maternal and fetal health.

Factors Associated with Thoughts of Self-Harm or Suicide among Aboriginal and Torres Strait Islander People Presenting to Urban Primary Care: An Analysis of De-Identified Clinical Data.

Suicide amongst Aboriginal and Torres Strait Islander people is a major cause of premature mortality and a significant contributor to the health and life expectancy gap. This study aimed to estimate the prevalence of thoughts of self-harm or suicide in Aboriginal and Torres Strait Islander people attending an urban primary health care service and identify factors associated with these thoughts. Multilevel mixed-effects modified Poisson regression models were employed to analyse three years of data gathered during the annual Aboriginal and Torres Strait Islander health assessments. At their first health assessment, 11.5% (191/1664) of people reported thoughts of suicide or self-harm in the prior two weeks. Having children, participating in sport or community activities or being employed full-time decreased the risk of such thoughts. Conversely, factors relating to social exclusion including homelessness, drug use, unemployment and job insecurity increased the risk of thoughts of self-harm or suicide. Individual clinicians, health services, and policy-makers all have a role in suicide prevention. Clinicians need appropriate training to be able to respond to people expressing these thoughts. Aboriginal and Torres Strait Islander community organisations need sovereignty and self-determination over resources to provide programs that promote cultural connectivity and address social exclusion, thereby saving lives.

Oral Health Among Older Adults With Complex Needs Living in the Community and in Aged Residential Care Facilities within New Zealand.

OBJECTIVES: To describe the oral health status and dental service use of older adults with complex needs living within the community and aged residential care (ARC) facility settings, and to determine associations between dental service utilization and sociodemographic variables. DESIGN: Secondary analysis of 2 continuously recruited national cohorts. SETTING AND PARTICIPANTS: Adults aged ≥65 years having standardized assessments between July 1, 2012, and May 31, 2018, within New Zealand and who provided consent. METHODS: All community-living older people with complex needs undergo a standardized assessment, using the Home Care International Residential Assessment Instrument (interRAI-HC), whereas all ARC facility residents undergo Long Term Care Facilities assessments (interRAI-LTCF). Anonymized data from consenting participants were extracted. Cross-sectional analyses of oral health status and dental service use variables employed logistic regression models, whereas longitudinal analysis of factors influencing dental service utilization employed binary generalized estimating equation models. RESULTS: Overall, 144,380 interRAI-HC assessments from 97,229 participants, and 195,549 interRAI-LTCF assessments from 62,798 participants were eligible. At first assessment, their average age was 81.9 years (range: 65-109 years) and 84.4 years (range: 65-110 years), respectively. Approximately 65% of the participants wore dentures; 9% had broken, fragmented, loose, or otherwise nonintact natural teeth; and 10% reported difficulties chewing. Overall, only 25.3% of community-dwelling older adults and 17.5% of ARC residents had a dental examination within the previous year. Stark inequalities were observed with, for example, Maori participants having adjusted odds 3.14 [95% confidence interval (CI): 2.88, 3.42] and 2.08 (95% CI: 1.81, 2.39) of not having a dental examination in community and ARC facility settings compared with their New Zealand European counterparts. CONCLUSIONS AND IMPLICATIONS: Heavy and unequal oral health burdens were observed among older adults with complex needs, together with low dental service uptake. New Zealand needs an oral health policy for older adults.

Quantitative evaluation of an outreach case management model of care for urban Aboriginal and Torres Strait Islander adults living with complex chronic disease: a longitudinal study.

BACKGROUND: Chronic diseases are the leading contributor to the excess morbidity and mortality burden experienced by Aboriginal and Torres Strait Islander (hereafter, respectfully, Indigenous) people, compared to their non-Indigenous counterparts. The Home-based Outreach case Management of chronic disease Exploratory (HOME) Study provided person-centred, multidisciplinary care for Indigenous people with chronic disease. This model of care, aligned to Indigenous peoples' conceptions of health and wellbeing, was integrated within an urban Indigenous primary health care service. We aimed to determine the impact of this model of care on participants' health and wellbeing at 12 months. METHODS: HOME Study participants were Indigenous, regular patients of the primary health care service, with a diagnosis of at least one chronic disease, and complex health and social care needs. Data were collected directly from participants and from their medical records at baseline, and 3, 6 and 12 months thereafter. Variables included self-rated health status, depression, utilisation of health services, and key clinical outcomes. Participants' baseline characteristics were described using frequencies and percentages. Generalized estimating equation (GEE) models were employed to evaluate participant attrition and changes in outcome measures over time. RESULTS: 60 participants were enrolled into the study and 37 (62%) completed the 12-month assessment. After receiving outreach case management for 12 months, 73% of participants had good, very good or excellent self-rated health status compared with 33% at baseline (p < 0.001) and 19% of participants had depression compared with 44% at baseline (p = 0.03). Significant increases in appointments with allied health professionals (p < 0.001) and medical specialists other than general practitioners (p = 0.001) were observed at 12-months compared with baseline rates. Mean systolic blood pressure decreased over time (p = 0.02), but there were no significant changes in mean HbA1c, body mass index, or diastolic blood pressure. CONCLUSIONS: The HOME Study model of care was predicated on a holistic conception of health and aimed to address participants' health and social care needs. The positive changes in self-rated health and rates of depression evinced that this aim was met, and that participants received the necessary care to support and improve their health and wellbeing.

Urinary and fecal incontinence are independently associated with falls risk among older women and men with complex needs: A national population study.

AIMS: To determine the relationships between urinary incontinence (UI), fecal incontinence (FI), and falls risk among community-dwelling older women and men with complex needs, after controlling for confounders. METHODS: All community care recipients in New Zealand undergo standardized needs assessments, using the Home Care International Residential Assessment Instrument (interRAI-HC), which elicits information over multiple domains, including UI and FI frequency and falls. Consenting women and men aged greater than or equal to 65 years with at least one interRAI-HC assessment undertaken between 1 July 2012 and 1 June 2018 were investigated using multilevel mixed effects ordinal regression models, stratified by sex. RESULTS: Overall, 57 781 (61.8%) women and 35 681 (38.2%) men were eligible, contributing 138 302 interRAI-HC assessments. At first assessment, the average age was 82.0 years (range: 65-109 years); high falls risk was common, found among 8.8% of women and 12.4% of men; and 43.7% of women and 33.7% of men reported some incontinence. For women, the adjusted odds of increasing falls risk was 1.24 (95% CI: 1.18, 1.30) for those with occasional UI, 1.36 (95% CI: 1.29, 1.43) for those with frequent UI, and 1.19 (95% CI: 1.13, 1.26) for those with any FI compared with their continent counterparts. Among men, the adjusted odds were 1.49 (95% CI: 1.41, 1.58) for any UI and 1.18 (95% CI: 1.10, 1.27) for any FI. CONCLUSION: UI and FI are common, have separate associations with falls risk among women and men, and would benefit from routine screening in primary health care for older adults.

Closing the gap between rhetoric and practice in strengths-based approaches to Indigenous public health: a qualitative study.

OBJECTIVE: To understand strengths-based practice as articulated by urban Indigenous community workers and to consider its application for public health approaches to Australian Indigenous health advancement. METHODS: Semi-structured interviews with community workers from an urban Indigenous community. Interviews were video and audio recorded and transcribed verbatim. Data were analysed using thematic analysis, using an Indigenist research framework. RESULTS: For our participants (11 Indigenous and one non-Indigenous), a strengths-based approach was fundamental to their practice. This approach reconfigured the usual relationship of client and service provider to fellow community member. They understood the strength of Indigeneity that empowers individuals and communities. They were not blinkered to the challenges in the community but resisted defining themselves, their community or their community practice by these deficits. CONCLUSIONS: Our participants had a sophisticated experiential understanding that a strengths-based practice is not simply a 'culturally acceptable' way for non-Indigenous peoples to work for Indigenous peoples, but rather it is the only way of working with Indigenous people. Implications for public health: Strengths-based practice requires a reconfiguring of relationships of power, of attending to structure over stereotypes, and privileging Indigenous ways of knowing, being and doing. This reconfiguration is an ethical prerequisite for an approach that is genuinely strengths-based.

Hearing ability is not a risk factor for admission to aged residential care of older persons in New Zealand.

Aged residential care (ARC) admission needs are increasing beyond the available capacity in many countries, including New Zealand. Therefore, identifying modifiable factors which may prevent or delay ARC admissions is of international importance. Hearing impairment is common among older adults and thought to be an important predictor, although the current evidence-base is equivocal. Using the largest national database to date, competing-risk regression analysis was undertaken on 34,277 older adults having standardised home care assessments between 1 July 2012 and 31 May 2014, aged ≥65 years, and still living in the community 30 days after that assessment. Minimal hearing difficulty was reported by 10,125 (29.5%) participants, moderate difficulty by 5,046 (14.7%), severe difficulty/no hearing by 1,334 (3.9%), while 17,769 (51.8%) participants reported adequate hearing. By 30 June 2014, the study end-point, 6,389 (18.6%) participants had an ARC admission while 6,082 (17.7%) had died. In unadjusted competing-risk regression analyses, treating death as a competing event, hearing ability was significantly associated with ARC admission (p < 0.001). However, in adjusted analyses, this relationship was completely confounded by other variables (p = 0.67). This finding implies that screening for hearing loss among community-living older adults is unlikely to impact on ARC admission rates.

A mixed methods exploratory study tackling smoking during pregnancy in an urban Aboriginal and Torres Strait Islander primary health care service.

BACKGROUND: Pregnancy can be a time of joy and a time of significant stress. For many Aboriginal and Torres Strait Islander (hereafter, respectfully, Indigenous) women, cigarette smoking, even during pregnancy, is a socially sanctioned behavioural response to stress. Indigenous women smoke during pregnancy at higher rates than their non-Indigenous counterparts. METHODS: A mixed methods, exploratory study, undertaken in an urban, Indigenous primary health care service, tested the impact and acceptability of a smoking cessation intervention for women pregnant with an Indigenous baby, their significant other (SO), and their primary health care service. The intervention included case management, incentivised smoking cessation support and culturally-based art activities. RESULTS: Thirty-one pregnant women and 16 SOs participated. Nearly half attempted to quit at least once during the study, 36% (4/11) of pregnant women had quit at the 3 month assessment and two remained smoke free 1 month postpartum. Most participants self-reported a reduction in tobacco smoking. Exhaled CO confirmed this for SOs (mean reduction - 2.2 ppm/assessment wave, 95% CI: -4.0, - 0.4 ppm/assessment wave, p = 0.015) but not for pregnant women. Many participants experienced social and economic vulnerabilities, including housing and financial insecurity and physical safety concerns. CONCLUSIONS: Tobacco smoking is normalised and socially sanctioned in Indigenous communities and smoking is frequently a response to the multitude of stressors and challenges that Indigenous people experience on a daily basis. Smoking cessation interventions for pregnant Indigenous women must be cognisant of the realities of their private lives where the smoking occurs, in addition to the impact of the broader societal context. Narrow definitions of success focussing only on smoking cessation ignore the psychological benefit of empowering women and facilitating positive changes in smoking behaviours. Our smoking cessation intervention supported pregnant women and their SOs to manage these stressors and challenges, thereby enabling them to develop a solid foundation from which they could address their smoking. A broad definition of success in this space is required: one that celebrates positive smoking behaviour changes in addition to cessation.

Knowing our patients: a cross-sectional study of adult patients attending an urban Aboriginal and Torres Strait Islander primary healthcare service.

Many Aboriginal and Torres Strait Islander people live in urban areas, but epidemiological data about their health status and health needs are lacking. This knowledge is critical to informing and evaluating initiatives to improve service delivery and health outcomes. One potential data source is de-identified routinely collected clinical data. This cross-sectional study, conducted in an urban Aboriginal and Torres Strait Islander primary healthcare service, involved randomly selecting a sample of 400 patients aged ≥15 years, and manually extracting electronic health record data. In the sample, 49% of patients were aged <35 years, 56% were female and 38% were employed. Overall, 56% of females and 47% of males aged 35-54 years had depression, 26% had experienced a bereavement within the last 12 months, and while 44% were alcohol abstainers, 35% were drinking at high-risk levels. The present study cannot demonstrate causal relationships between the observed high rates of chronic disease in older people and frequent experiences of bereavement and high levels of mental ill health in young- and middle-aged adults. However, a life course approach provides a framework to understand the interconnectedness of these results, and suggests that strategies to blunt the intergenerational burden of chronic disease need to address the social and emotional wellbeing of youth.

Understanding practitioner professionalism in Aboriginal and Torres Strait Islander health: lessons from student and registrar placements at an urban Aboriginal and Torres Strait Islander primary healthcare service.

Aboriginal and Torres Strait Islander peoples continue to be pathologised in medical curriculum, leaving graduates feeling unequipped to effectively work cross-culturally. These factors create barriers to culturally safe health care for Aboriginal and Torres Strait Islander peoples. In this pilot pre-post study, the learning experiences of seven medical students and four medical registrars undertaking clinical placements at an urban Aboriginal and Torres Strait Islander primary healthcare service in 2014 were followed. Through analysis and comparison of pre- and post-placement responses to a paper-based case study of a fictitious Aboriginal patient, four learning principles for medical professionalism were identified: student exposure to nuanced, complex and positive representations of Aboriginal peoples; positive practitioner role modelling; interpersonal skills that build trust and minimise patient-practitioner relational power imbalances; and knowledge, understanding and skills for providing patient-centred, holistic care. Though not exhaustive, these principles can increase the capacity of practitioners to foster culturally safe and optimal health care for Aboriginal peoples. Furthermore, competence and effectiveness in Aboriginal health care is an essential component of medical professionalism.

'I'm not sure it paints an honest picture of where my health's at' - identifying community health and research priorities based on health assessments within an Aboriginal and Torres Strait Islander community: a qualitative study.

Aboriginal and Torres Strait Islander health assessments are conducted annually in Australian primary care to detect risk factors, chronic diseases and implement preventive health measures. At the Inala Indigenous Health Service, health assessment data have also been used for research purposes. This research has been investigator-driven, which risks misinterpreting or ignoring community priorities compared with community-led research. The objective of this research was to learn about the Aboriginal and Torres Strait Islander community's health priorities that could be translated into research themes, and investigate these using health assessment data. A thematic analysis of data was conducted from 21 semi-structured interviews with purposively selected key informants from an urban Aboriginal and Torres Strait Islander community. Key informants articulated an authoritative understanding of how interrelated, inter-generational, social, cultural and environmental determinants operated in a 'cycle' to influence the community's health. Key informant views supported the inclusion of these determinants in health assessments, reinforced the importance of comprehensive primary healthcare and strengthened referral pathways to community resources. Some key informants were ambivalent about Aboriginal and Torres Strait Islander health assessments because of their biomedical emphasis. This research also revealed limitations of health assessment-based research and the biomedical emphasis of the health system more broadly.

Investigating the feasibility, acceptability and appropriateness of outreach case management in an urban Aboriginal and Torres Strait Islander primary health care service: a mixed methods exploratory study.

BACKGROUND: The disparities in health and life expectancy of Aboriginal and Torres Strait Islander peoples compared to non-Indigenous Australians are well documented. Chronic diseases are a leading contributor to these disparities. We aimed to determine the feasibility, acceptability and appropriateness of a case management approach to chronic disease care integrated within an urban Aboriginal and Torres Strait Islander primary health care service. METHODS: The Home-based, Outreach case Management of chronic disease Exploratory (HOME) Study provided holistic, patient centred multidisciplinary care for Aboriginal and Torres Strait Islander people with chronic disease. A developmental evaluation approach supported the implementation and ongoing adaptations in the delivery of the model of care, and ensured its alignment with Aboriginal and Torres Strait Islander peoples' understandings of, and approaches to, health and wellbeing. In-depth, semi-structured interviews were conducted with nine patient participants (one interview also included a participant's spouse) and 15 health service staff and key themes were identified through an iterative reflective process. Quantitative data were collected directly from patient participants and from their medical records at baseline, 3 and 6 months. Patient participants' baseline characteristics were described using frequencies and percentages. Attrition and patterns of missing values over time were evaluated using binomial generalized estimating equation (GEE) models and mean differences in key clinical outcomes were determined using normal GEE models. RESULTS: Forty-one patients were recruited and nine withdrew over the 6 month period. There was no evidence of differential attrition. All participants (patients and health service staff) were very positive about the model of care. Patient participants became more involved in their health care, depression rates significantly decreased (p = 0.03), and significant improvements in systolic blood pressure (p < 0.001) and diabetes control (p = 0.05) were achieved. CONCLUSIONS: The exploratory nature of our study preclude any definitive statements about the effectiveness of our model of care. However, staff and patients' high levels of satisfaction and improvements in the health and wellbeing of patients are promising and suggest its feasibility, acceptability and appropriateness. Further research is required to determine its efficacy, effectiveness and cost-effectiveness in improving the quality of life and quality of care for Aboriginal and Torres Strait Islander peoples living with chronic disease.

Predictors of specialist referral for developmental and behavioural problems in a Queensland urban Aboriginal and Torres Strait Islander community: a cross-sectional study.

BACKGROUND: The prevalence of developmental and/or behavioural problems is greater among Aboriginal and Torres Strait Islander children, compared with their non-Indigenous counterparts. We aimed to identify predictors of specialist paediatric referral for these problems that could enable primary health professionals to identify at-risk children and implement early interventions. METHODS: A cross-sectional study of urban Aboriginal and Torres Strait Islander children aged 0-14 years having annual child health checks from September 2010 to February 2012 was undertaken. Predictors of paediatric referral were identified using univariable and multivariable analyses. RESULTS: Of the 183 eligible children, 30% were referred to a paediatrician. Parental/carer mental illness was self-reported in 36% of cases and these children were more likely to be referred (OR = 3.07; 95% CI: 1.44, 6.57). DISCUSSION: The strong association between paediatric referral for behavioural and/or developmental problems and self-reported parental/carer mental illness highlights the intergenerational nature of health and social disadvantage.