Experiences and impacts of out-of-pocket healthcare expenditure on remote Aboriginal families.

INTRODUCTION: Aboriginal Australians face significant health disparities, with hospitalisation rates 2.3 times greater, and longer hospital length of stay, than non-Indigenous Australians. This additional burden impacts families further through out-of-pocket healthcare expenditure (OOPHE), which includes additional healthcare expenses not covered by universal taxpayer insurance. Aboriginal patients traveling from remote locations are likely to be impacted further by OOPHE. The objective of this study was to examine the impacts and burden of OOPHE for rurally based Aboriginal individuals. METHODS: Participants were recruited through South Australian community networks to participate in this study. Decolonising methods of yarning and deep listening were used to centralise local narratives and language of OOPHE. Qualitative analysis software was used to thematically code transcripts and organise data. RESULTS: A total of seven yarning sessions were conducted with 10 participants. Seven themes were identified: travel, barriers to health care, personal and social loss, restricted autonomy, financial strain, support initiatives and protective factors. Sleeping rough, selling assets and not attending appointments were used to mitigate or avoid OOPHE. Government initiatives, such as the patient assistance transport scheme, did little to decrease OOPHE burden on participants. Family connections, Indigenous knowledges and engagement with cultural practices were protective against OOPHE burden. CONCLUSION: Aboriginal families are significantly burdened by OOPHE when needing to travel for health care. Radical change of government initiative and policies through to health professional awareness is needed to ensure equitable healthcare access that does not create additional financial hardship in communities already experiencing economic disadvantage.

A rapid review to inform the policy and practice for the implementation of chronic disease prevention and management programs for Aboriginal and Torres Strait Islander people in primary care.

BACKGROUND: More than 35% of Aboriginal and Torres Strait Islander adults live with cardiovascular disease, diabetes, or chronic kidney disease. There is a pressing need for chronic disease prevention and management among Aboriginal and Torres Strait Islander people in Australia. Therefore, this review aimed to synthesise a decade of contemporary evidence to understand the barriers and enablers of chronic disease prevention and management for Aboriginal and Torres Strait Islander People with a view to developing policy and practice recommendations. METHODS: We systematically searched for peer-reviewed published articles between January 2014 to March 2023 where the search was performed using subject headings and keywords related to "Aboriginal and Torres Strait Islander peoples," "Chronic Disease," and "Primary Health Care". Quality assessment for all included studies was conducted using the Aboriginal and Torres Strait Islander Quality Appraisal Tool. The data were extracted and summarised using a conventional content analysis approach and applying strength-based approaches. RESULTS: Database searches identified 1653 articles where 26 met inclusion criteria. Studies varied in quality, primarily reporting on 14 criteria of the Aboriginal and Torres Strait Islander Quality Appraisal Tool. We identified six key domains of enablers and barriers of chronic disease prevention and management programs and implied a range of policy and practice options for improvement. These include culturally acceptable and safe services, patient-provider partnerships, chronic disease workforce, primary health care service attributes, clinical care pathways, and accessibility to primary health care services. This review also identified the need to address social and cultural determinants of health, develop the Aboriginal and Torres Strait Islander and non-Indigenous chronic disease workforce, support multidisciplinary teams through strengthening clinical care pathways, and engage Aboriginal and Torres Strait Islander communities in chronic disease prevention and management program design and delivery. CONCLUSION: Enabling place-based partnerships to develop contextual evidence-guided strategies that align with community priorities and aspirations, with the provision of funding mechanisms and models of care through policy and practice reforms will strengthen the chronic disease prevention and management program for Aboriginal and Torres Strait Islander people.

Discharge interventions for First Nations people with a chronic condition or injury: a systematic review.

BACKGROUND: Aboriginal and Torres Strait Islander peoples have a unique place in Australia as the original inhabitants of the land. Similar to other First Nations people globally, they experience a disproportionate burden of injury and chronic health conditions. Discharge planning ensures ongoing care to avoid complications and achieve better health outcomes. Analysing discharge interventions that have been implemented and evaluated globally for First Nations people with an injury or chronic conditions can inform the implementation of strategies to ensure optimal ongoing care for Aboriginal and Torres Strait Islander people. METHODS: A systematic review was conducted to analyse discharge interventions conducted globally among First Nations people who sustained an injury or suffered from a chronic condition. We included documents published in English between January 2010 and July 2022. We followed the reporting guidelines and criteria set in Preferred Reporting Items for Systematic Review (PRISMA). Two independent reviewers screened the articles and extracted data from eligible papers. A quality appraisal of the studies was conducted using the Mixed Methods Appraisal Tool and the CONSIDER statement. RESULTS: Four quantitative and one qualitative study out of 4504 records met inclusion criteria. Three studies used interventions involving trained health professionals coordinating follow-up appointments, linkage with community care services and patient training. One study used 48-hour post discharge telephone follow-up and the other text messages with prompts to attend check-ups. The studies that included health professional coordination of follow-up, linkage with community care and patient education resulted in decreased readmissions, emergency presentations, hospital length of stay and unattended appointments. CONCLUSION: Further research on the field is needed to inform the design and delivery of effective programs to ensure quality health aftercare for First Nations people. We observed that discharge interventions in line with the principal domains of First Nations models of care including First Nations health workforce, accessible health services, holistic care, and self-determination were associated with better health outcomes. REGISTRATION: This study was prospectively registered in PROSPERO (ID CRD42021254718).

Codesigning informative resources for families of Aboriginal and Torres Strait Islander children who sustained a burn injury: a protocol for a participatory action research study.

INTRODUCTION: Parents of children hospitalised in a burn unit experience psychological trauma and later post-traumatic stress. Aboriginal and Torres Strait Islander families whose child has been admitted to a burn unit encounter additional burdens through a culturally unsafe healthcare system. Psychosocial interventions can help reduce anxiety, distress and trauma among children and parents. There remains a lack of interventions or resources that reflect Aboriginal and Torres Strait Islander people's perspective of health. The objective of this study is to codevelop a culturally appropriate informative resource to assist Aboriginal and Torres Strait Islander parents whose child has been hospitalised in a burn unit. METHODS: In this participatory research study, the development of a culturally safe resource will build on Aboriginal and Torres Strait Islander families' experiences and voices, complemented by the knowledge and expertise of an Aboriginal Health Worker (AHW) and burn care experts. Data will be collected through recorded yarning sessions with families whose child has been admitted to a burn unit, the AHW and burn care experts. Audiotapes will be transcribed and data will be analysed thematically. Analysis of yarning sessions and resource development will follow a cyclical approach. ETHICS AND DISSEMINATION: This study has been approved by the Aboriginal Health and Medical Research Council (AH&MRC) (1690/20) and the Sydney Children's Hospitals Network ethics committee (2020/ETH02103). Findings will be reported to all participants and will be disseminated with the broader community, the funding body and health workers at the hospital. Dissemination with the academic community will be through peer-reviewed publications and presentations in relevant conferences.

Discharge Interventions for First Nations People with Injury or Chronic Conditions: A Protocol for a Systematic Review.

Severe injury and chronic conditions require long-term management by multidisciplinary teams. Appropriate discharge planning ensures ongoing care to mitigate the long-term impact of injuries and chronic conditions. However, First Nations peoples in Australia face ongoing barriers to aftercare. This systematic review will locate and analyse global evidence of discharge interventions that have been implemented to improve aftercare and enhance health outcomes among First Nations people with an injury or chronic condition. A systematic search will be conducted using five databases, Google, and Google scholar. Global studies published in English will be included. We will analyse aftercare interventions implemented and the health outcomes associated. Two independent reviewers will screen and select studies and then extract and analyse the data. Quality appraisal of the included studies will be conducted using the Mixed Methods Appraisal Tool and the CONSIDER statement. The proposed study will analyse global evidence on discharge interventions that have been implemented for First Nations people with an injury or chronic conditions and their associated health outcomes. Our findings will guide healthcare quality improvement to ensure Aboriginal and Torres Strait Islander peoples have ongoing access to culturally safe aftercare services.

Community Engagement and Psychometric Methods in Aboriginal and Torres Strait Islander Patient-Reported Outcome Measures and Surveys-A Scoping Review and Critical Analysis.

(1) Background: In healthcare settings, patient-reported outcome measures (PROMs) and surveys are accepted, patient-centered measures that provide qualitative information on dimensions of health and wellbeing. The level of psychometric assessment and engagement with end users for their design can vary significantly. This scoping review describes the psychometric and community engagement processes for PROMs and surveys developed for Aboriginal and Torres Strait Islander communities. (2) Methods: The PRISMA ScR guidelines for scoping reviews were followed, aimed at those PROMs and surveys that underwent psychometric assessment. The Aboriginal and Torres Strait Islander Quality Appraisal Tool and a narrative synthesis approach were used. (3) Results: Of 1080 articles, 14 were eligible for review. Most articles focused on a validity assessment of PROMs and surveys, with reliability being less common. Face validity with Aboriginal and Torres Strait Islander communities was reported in most studies, with construct validity through exploratory factor analyses. Methodological design risks were identified in the majority of studies, notably the absence of explicit Indigenous knowledges. Variability existed in the development of PROMs and surveys for Aboriginal and Torres Strait Islander communities. (4) Conclusions: Improvement in inclusion of Indigenous knowledges and research approaches is needed to ensure relevance and appropriate PROM structures. We provide suggestions for research teams to assist in future design.

Outcomes following severe septic shock in a cohort of Aboriginal and Torres Strait Islander people: a nested cohort study from the ADRENAL trial.

Objective: To describe the pattern of acute illness and 6-month mortality and health-related quality-of-life outcomes for a cohort of Aboriginal and Torres Strait Islander patients presenting with septic shock. Design: Nested cohort study of Aboriginal and Torres Strait Islander participants recruited to a large randomised controlled trial of corticosteroid treatment in patients with septic shock. Setting: Royal Darwin Hospital, Northern Territory. Participants: All Aboriginal and Torres Strait Islander patients recruited to the Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock (ADRENAL) trial at Royal Darwin Hospital were compared with a non-Indigenous cohort drawn from the same site, and a cohort matched for age, sex and severity of disease. Main outcome measures: Mortality at 90 days and 6 months, time to shock resolution, mechanical ventilation requirement, renal replacement therapy requirement, and five-domain, five-level EuroQol questionnaire (EQ-5D-5L) score at 6 months. Results: Aboriginal and Torres Strait Islander patients had significantly reduced risk of death at 90 days when compared with non-Indigenous patients recruited to ADRENAL at Royal Darwin Hospital (12/60 v 23/62; adjusted odds ratio, 0.40 [95% CI, 0.17 to 0.94]) which was robust to additional adjustment for baseline covariates (odds ratio, 0.35 [95% CI, 0.14 to 0.90]). When compared with the matched population drawn from the broader ADRENAL cohort, there was no significant difference in 90-day mortality (12/60 v 16/61; adjusted odds ratio, 1.43 [95% CI, 0.60 to 3.39]; P = 0.42). Only nine Aboriginal and Torres Strait Islander patients provided 6-month health-related quality-of-life data. Conclusions: Aboriginal and Torres Strait Islander patients had reduced risk of death at 90 days when compared with non- Indigenous patients recruited to the ADRENAL trial at Royal Darwin Hospital, which was robust to adjustment for covariates, but similar outcomes when compared with a cohort matched for age, sex and severity of disease.

Integrating Trauma and Violence Informed Care in Primary Health Care Settings for First Nations Women Experiencing Violence: A Systematic Review.

It is imperative that access to primary health care services is equitable as health care practitioners are often the first responders to women who experience violence. This is of particular importance for First Nations women who disproportionately experience interpersonal and structural violence when compared to non-First Nations women, as well as the ongoing impact of colonization, racism, and intergenerational trauma. To understand how primary health care services can provide equitable and effective care for First Nations women, we explored how trauma and violence informed care is integrated in primary health care settings through the lens of an equity-oriented framework. A systematic search of electronic databases included Medline (via Ovid), Scopus, Informit, and PubMed and grey literature. Six studies were included in the review and we undertook a narrative synthesis using the equity-oriented framework to draw together the intersection of trauma and violence informed care with culturally safe and contextually tailored care. This review demonstrates how equity-oriented primary health care settings respond to the complex and multiple forms of violence and intergenerational trauma experienced by First Nations women and thus mitigate shame and stigma to encourage disclosure and help seeking. Key attributes include responding to women's individual contexts by centering family, engaging elders, encouraging community ownership, which is driven by a culturally competent workforce that builds trust, reduces retraumatization, and respects confidentiality. This review highlights the importance of strengthening and supporting the workforce, as well as embedding cultural safety within intersectoral partnerships and ensuring adequate resourcing and sustainability of initiatives.

Indigenous Community-Led Programs to Address Food and Water Security: Protocol for a Systematic Review.

The connection between indigenous peoples and Country (a multidimensional concept including land and water) enabled communities to thrive and survive over millennia. This has been eroded by colonisation, dispossession and increasing food and water insecurity due to climate change and supply constraints. Globally, indigenous peoples experience a disproportionate burden of chronic disease and poor nutrition is a major risk factor. Indigenous leaders have been advocating for community-led solutions. The primary aim of this systematic review is to determine what community-led programs have been undertaken to address food and/or water security globally. A comprehensive search of peer-reviewed literature will be performed in EMBASE, CINAHL, PsycINFO, PubMed, Scopus, LILACs, Informit and Business Source Premier. The grey literature search will include grey literature databases, customised Google search engines, targeted websites, and consultation with experts. The search strategy will consist of four concepts, combined as follows: (1) indigenous peoples AND (2) community program AND (3) food security OR (4) water security. Covidence will be used for study screening and data extraction by two authors. A deductive thematic analysis using indigenous-informed methodologies will be used to synthesise data. This review seeks to provide insight on models and mechanisms to encourage action and metrics for quantifying success of indigenous community-led programs to improve food and water security.

Impact of racism and discrimination on physical and mental health among Aboriginal and Torres Strait islander peoples living in Australia: a systematic scoping review.

BACKGROUND: Racism is increasingly recognised as a significant health determinant that contributes to health inequalities. In Australia efforts have been made to bridge the recognised health gap between Aboriginal and Torres Strait Islander people and other Australians. This systematic scoping review aimed to assess, synthesise, and analyse the evidence in Australia about the impacts of racism on the mental and physical health of Aboriginal and Torrens Strait Islander peoples. METHODS: A systematic search was conducted to locate Australian studies in English published between 2000 and 2020. Five electronic databases were used: PubMed, CINAHL, Embase, Web of Science and the Australia's National Institute for Aboriginal and Torres Strait Islander Health Research. The search strategy included a combination of key words related with racism, mental health, physical health and Indigenous people. Data were extracted based on review questions and findings were synthesized in a narrative summary. RESULTS: Of total 338 searched studies from five databases, 12 studies met the inclusion criteria for narrative synthesis where eight were cross-sectional studies and four prospective cohorts. General mental health and general health perception were the most frequently studied outcomes followed by child behaviour, smoking and substance consumption and specific health conditions. The prevalence of racism varied between 6.9 and 97%. The most common health outcomes associated with racism were general poor mental health and poor general health perception. More specific health outcomes such as anxiety, depression, child behaviour, asthma, increased BMI and smoking were also associated with racism but were analysed by a limited number of studies. Three studies analysed psychological distress, negative mental health, sleeping difficulties and negative perceived mental health according to severity of exposition to racism. CONCLUSION: Racism is associated with negative overall mental and negative general health outcomes among Aboriginal and Torres Strait Islander peoples. Strategies to prevent all forms and sources of racism are necessary to move forward to bridging the health gap between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians. Further research is needed to understand in more detail the impact of racism from an Aboriginal and Torres Strait Islander definition of health and wellbeing.

Understanding implementation factors and participant experiences of a cluster randomised controlled trial to prevent falls among older Aboriginal people: a process evaluation protocol.

INTRODUCTION: Process evaluations examining programme implementation are often conducted in conjunction with effectiveness studies. Their inclusion in studies with Aboriginal participants can give an understanding of programme delivery in Aboriginal community contexts. The Ironbark: Standing Strong and Tall programme was codesigned with Aboriginal communities and includes exercise and facilitated 'yarning' discussion about fall risk and prevention strategies. The programme pilot showed favourable outcomes and acceptability for Aboriginal people aged 45 years and over. The Ironbark: Standing Strong and Tall programme is now being compared with a 'Healthy Community' programme in a cluster randomised controlled trial within Aboriginal health and community services. An embedded process evaluation aims to explore relationships between participation and programme outcomes and the quality of programme implementation. METHODS AND ANALYSIS: The process evaluation will use a mixed methods design, guided by Indigenous research methodology. It will evaluate quantitative data (number of completed sessions, site coaching checklist tool, participant and facilitator questionnaire data and a participant habit formation scale), as well as qualitative data (open-ended responses from project and site staff and semistructured interviews using yarning with study participants and site managers). A programme logic model was developed to explain the intended inputs, activities, outputs and outcomes, which guided this process evaluation design. CONCLUSION: This process evaluation of a fall prevention programme for older Aboriginal people using a mixed methods design and data triangulation will allow for a comprehensive understanding of study findings. Multiple study sites allow for generalisability of findings and exploration of variation across sites. TRIAL REGISTRATION NUMBER: ACTRN12619000349145.

Responses to the primary health care needs of Aboriginal and Torres Strait Islander women experiencing violence: A scoping review of policy and practice guidelines.

ISSUE ADDRESSED: It is demonstrated that primary health care (PHC) providers are sought out by women who experience violence. Given the disproportionate burden of violence experienced by Aboriginal and Torres Strait Islander women, it is essential there is equitable access to appropriate PHC services. This review aimed to analyse whether Australian PHC policy accounts for the complex needs of Aboriginal and Torres Strait Islander women experiencing violence and the importance of PHC providers responding to violence in culturally safe ways. METHODS: Using the Arskey and O'Malley framework, an iterative scoping review determined the policies for analysis. The selected policies were analysed against concepts identified as key components in responding to the needs of Aboriginal and Torres Strait Islander women experiencing violence. The key components are Family Violence, Violence against Aboriginal and Torres Strait Islander Women, Social Determinants of Aboriginal and Torres Strait Islander Health and Wellbeing, Cultural Safety, Holistic Health, Trauma, Patient-Centred Care and Trauma-and-Violence-Informed Care. RESULTS: Following a search of Australian government websites, seven policies were selected for analysis. Principally, no policy embedded or described best practice across all key components. CONCLUSION: The review demonstrates the need for a specific National framework supporting Aboriginal and Torres Strait Islander women who seek support from PHC services, as well as further policy analysis and review. SO WHAT?: Aboriginal and Torres Strait Islander women disproportionately experience more severe violence, with complex impact, than other Australian women. PHC policy and practice frameworks must account for this, together with the intersection of contemporary manifestations of colonialism and historical and intergenerational trauma.

Trauma and Violence Informed Care Through Decolonising Interagency Partnerships: A Complexity Case Study of Waminda's Model of Systemic Decolonisation.

Through the lens of complexity, we present a nested case study describing a decolonisation approach developed and implemented by Waminda South Coast Women's Health and Welfare Aboriginal Corporation. Using Indigenous research methods, this case study has unfolded across three phases: (1) Yarning interviews with the workforce from four partner health services (n = 24); (2) Yarning circle bringing together key informants from yarning interviews to verify and refine emerging themes (n = 14); (3) Semi-structured interviews with a facilitator of Waminda's Decolonisation Workshop (n = 1) and participants (n = 10). Synthesis of data has been undertaken in stages through collaborative framework and thematic analysis. Three overarching themes and eight sub-themes emerged that centred on enhancing the capabilities of the workforce and strengthening interagency partnerships through a more meaningful connection and shared decolonisation agenda that centres Aboriginal and Torres Strait Islander families and communities. Health and social services are complex systems that function within the context of colonisation. Waminda's innovative, model of interagency collaboration enhanced workforce capability through shared language and collective learning around colonisation, racism and Whiteness. This process generated individual, organisational and systemic decolonisation to disable power structures through trauma and violence informed approach to practice.

Impact of racism and discrimination on the physical and mental health among Aboriginal and Torres Strait Islander peoples living in Australia: a protocol for a scoping review.

BACKGROUND: Racism is increasingly recognised internationally as a key factor contributing to health disparities. A comprehensive body of strong research from international authors has reported negative associations between racism and health outcomes. In Australia, although the literature is more limited, available findings follow global trends. Australia has an identified health gap between Aboriginal and Torres Strait Islander peoples and non-indigenous Australians, and despite efforts to bridge this gap, health inequities continue to exist. This scoping review aims to assess, analyse and synthesise the relationship between racism and discrimination on the physical and mental health of Aboriginal and Torres Strait Islander peoples living in Australia. METHOD: This is the study protocol for a scoping review. A systematic search will be conducted using five electronic databases: PubMed, CINAHL, Embase, Web of Science and the Australia's National Institute for Aboriginal and Torres Strait Islander Health Research. The database search will include studies published between 2000 and 2020. Reference lists of the included articles will be searched. Outcome measures will include physical and mental health components including chronic conditions, depression and anxiety, psychological distress, social and emotional difficulties, suicide and health-related outcomes such as wellbeing and life satisfaction. Duplications will be removed, and titles and abstracts will be reviewed to select studies. Full-text screening of preselected studies will be performed by four reviewers independently, to select studies according to inclusion criteria. Included studies will be appraised for quality using appropriate tools tailored for each study design. Data will be extracted, and study findings and characteristics synthesised in a narrative summary. DISCUSSION: Our scoping review will synthesise the evidence on the impacts of racism and discrimination in relation to the physical and mental health of Aboriginal and Torres Strait Islander peoples living in Australia. These findings could guide future health interventions by addressing the exposure of racism and racial discrimination in order to reduce health disparity. It is anticipated the findings to be of interest to policymakers, researchers, Aboriginal and Torres Strait Islander communities and community health organisations and other stakeholders interested in optimising public health interventions for and in partnership with Aboriginal and Strait Torres Islander communities of Australia. SCOPING REVIEW REGISTRATION: The protocol for this review has been registered on the international prospective register of systematic reviews (PROSPERO). The registration ID is CRD42020186193 .

The role of Aboriginal family workers in delivering a child safety-focused home visiting program for Aboriginal families in an urban region of New South Wales.

ISSUE ADDRESSED: Aboriginal Australian children experience higher rates of injury than other Australian children. However, few culturally acceptable programs have been developed or evaluated. The Illawarra Aboriginal Medical Service (IAMS) developed the Safe Homes Safe Kids program as an injury prevention program targeting disadvantaged Aboriginal families with children aged 0-5 in an urban region of New South Wales. Delivered by Aboriginal Family Workers (AFWs), the program aims to reduce childhood injury by raising awareness of safety in the home. A program evaluation was conducted to determine the effectiveness of the home visiting model as an injury prevention program. This study reports on the qualitative interviews which explored the ways in which clients, IAMS staff and external service providers experienced the program and assessed its delivery by the AFWs. METHODS: A qualitative program evaluation was conducted between January 2014 and June 2015. We report here on the semi-structured interviews undertaken with 34 individuals. RESULTS: The results show increased client engagement in the program; improved child safety knowledge and skills; increased access to services; improved attitudes to home and community safety; and changes in the home safety environment. CONCLUSIONS: Safe Homes Safe Kids provides a culturally appropriate child safety program delivered by AFWs to vulnerable families. Clients, IAMS staff and external service were satisfied with the family workers' delivery of the program and the holistic model of service provision. SO WHAT&QUEST: This promising program could be replicated in other Aboriginal health services to address unintentional injury to vulnerable Aboriginal children.