Data analysis of zoonoses notifications in Aboriginal and Torres Strait Islander populations in Australia 1996-2021: implications for One Health.

Introduction: Zoonoses are a health concern for Aboriginal and Torres Strait Islander peoples in Australia that face elevated risk of disease related to the environment and animals. Internationally, One Health is encouraged to effectively manage zoonoses by taking integrated approaches involving animal, human, and environmental health sectors to improve health outcomes. However, Australia's health systems manage zoonotic diseases in animals and people separately which does not support a One Health approach. For the effective management of zoonoses, a strong evidence base and database regarding the epidemiology of zoonotic pathogens is needed. However, we currently lack this evidence limiting our understanding of the impact of zoonoses on Aboriginal and Torres Strait Islander populations. Methods: As a first step towards building the evidence base, we undertook a descriptive analysis of Aboriginal and Torres Strait Islander zoonotic notifications in Australia from 1996 to 2021. We presented notifications as annual notification rates per 100,000 population, and percentages of notifications by state, remoteness, sex, and age group. Results: Salmonellosis and campylobacteriosis were the most notified zoonoses with the highest annual notification rates of 99.75 and 87.46 per 100,000 population, respectively. The north of Australia (Queensland, Northern Territory and Western Australia), remote and outer regional areas, and young children (0-4 years of age) had the highest percentages of notifications. Discussion: To our knowledge, these findings are the first national presentation of the epidemiology of zoonoses within Aboriginal and Torres Strait Islander populations. A greater understanding of transmission, prevalence and impact of zoonoses on Aboriginal and Torres Strait Islander peoples (including animal and environmental health factors) is required to inform their effective management through a One Health approach.

Social and Emotional Wellbeing of Aboriginal Community Controlled Health Services Staff during the COVID-19 Pandemic.

This study explores the impact of the COVID-19 pandemic on the work and social and emotional well-being (SEWB) of staff at Aboriginal Community Controlled Health Services (ACCHS) in Australia. Between September and November 2021, staff from three ACCHSs in New South Wales completed an online survey to report changes to their roles, concerns about becoming infected with the COVID-19 virus, and job satisfaction in the last month. The survey measured emotional exhaustion and psychological distress by using the Maslach Burnout Inventory-Human Services Survey and Kessler-5 scale, respectively. The survey determined staff's access to SEWB support. Descriptive statistics were calculated for each variable. Among 92 staff from three ACCHSs, 36% reported a COVID-19-related change in their role and 64% were concerned about becoming infected. In spite of the pandemic, most staff (69%) were satisfied with their job. While most staff were not burnt out or psychologically distressed, 25% had high emotional exhaustion and 30% had high to very high psychological distress. Relatedly, 37% had accessed SEWB support at least once in their lifetime and 24% had accessed support in the last month. As the pandemic continues, it is important to identify factors influencing burnout or psychological distress among ACCHS staff and implement evidence-based solutions.

Pregnant and early parenting Indigenous women who use substances in Canada: A scoping review of health and social issues, supports, and strategies.

This study reviews and synthesizes the literature on Indigenous women who are pregnant/early parenting and using substances in Canada to understand the scope and state of knowledge to inform research with the Aboriginal Health and Wellness Centre of Winnipeg in Manitoba and the development of a pilot Indigenous doula program. A scoping review was performed searching ten relevant databases, including one for gray literature. We analyzed 56 articles/documents. Themes include: (1) cyclical repercussions of state removal of Indigenous children from their families; (2) compounding barriers and inequities; (3) prevalence and different types of substance use; and (4) intervention strategies. Recommendations for future research are identified and discussed.

Effect of a Birthing on Country service redesign on maternal and neonatal health outcomes for First Nations Australians: a prospective, non-randomised, interventional trial.

BACKGROUND: There is an urgency to redress unacceptable maternal and infant health outcomes for First Nations families in Australia. A multi-agency partnership between two Aboriginal Community-controlled health services and a tertiary hospital in urban Australia designed, implemented, and evaluated the new Birthing in Our Community (BiOC) service. In this study, we aimed to assess and report the clinical effectiveness of the BiOC service on key maternal and infant health outcomes compared with that of standard care. METHODS: Pregnant women attending the Mater Mothers Public Hospital (Brisbane, QLD, Australia) who were having a First Nations baby were invited to receive the BiOC service. In this prospective, non-randomised, interventional trial of the service, we specifically enrolled women who intended to birth at the study hospital, and had a referral from a family doctor or Aboriginal Medical Service. Participants were offered either standard care services or the BiOC service. Prespecified primary outcomes to test the effectiveness of the BiOC service versus standard care were the proportion of women attending five or more antenatal visits, smoking after 20 weeks of gestation, who had a preterm birth (<37 weeks), and who were exclusively breastfeeding at discharge from hospital. We used inverse probability of treatment weighting to balance confounders and calculate treatment effect. This trial is registered with the Australian New Zealand Clinical Trial Registry, ACTRN12618001365257. FINDINGS: Between Jan 1, 2013, and June 30, 2019, 1867 First Nations babies were born at the Mater Mothers Public Hospital. After exclusions, 1422 women received either standard care (656 participants) or the BiOC service (766 participants) and were included in the analyses. Women receiving the BiOC service were more likely to attend five or more antenatal visits (adjusted odds ratio 1·54, 95% CI 1·13-2·09; p=0·0064), less likely to have an infant born preterm (0·62, 0·42-0·93; p=0·019), and more likely to exclusively breastfeed on discharge from hospital (1·34, 1·06-1·70; p=0·014). No difference was found between the two groups for smoking after 20 weeks of gestation, with both showing a reduction compared with smoking levels reported at their hospital booking visit. INTERPRETATION: This study has shown the clinical effectiveness of the BiOC service, which was co-designed by stakeholders and underpinned by Birthing on Country principles. The widespread scale-up of this new service should be prioritised. Dedicated funding, knowledge translation, and implementation science are needed to ensure all First Nations families can access Birthing on Country services that are adapted for their specific contexts. FUNDING: Australian National Health and Medical Research Council.

Chronic disease prevention programs offered by Aboriginal Community Controlled Health Services in New South Wales, Australia.

OBJECTIVES: To identify and describe chronic disease prevention programs offered by Aboriginal Community Controlled Health Services (ACCHSs) in New South Wales (NSW), Australia. METHODS: ACCHSs were identified through the Aboriginal Health and Medical Research Council of NSW website. Chronic disease programs were identified from the Facebook page and website of each ACCHS. Characteristics, including regions, target population, condition, health behaviour, modality and program frequency were extracted and summarised. RESULTS: We identified 128 chronic disease programs across 32 ACCHSs. Of these, 87 (68%) programs were broad in their scope, 20 (16%) targeted youth, three (2%) targeted Elders, 16 (12%) were for females only and five (4%) were for males only. Interventions included physical activity (77, 60%), diet and nutrition (74, 58%), smoking (70, 55%), and the Aboriginal and Torres Strait Islander Health Check (44, 34%), with 93 programs (73%) of ongoing duration. CONCLUSIONS: Chronic disease prevention programs address chronic conditions by promoting physical activity, diet and nutrition, smoking cessation and health screening. Most target the general Aboriginal community, a few target specific groups based on gender and age, and more than one-quarter are time-limited. Implications for public health: Chronic disease programs that are co-produced with specific groups, based on age and gender, may be needed.

US Rural Surgeons Leading During COVID-19: Where Are They Now?

Rural surgeons from disparate areas of the United States report on the effects of the COVID-19 pandemic in their communities as the virus has spread across the country. The pandemic has brought significant changes to the professional, economic, and social lives of the individual surgeons and their communities.

Older Aboriginal Australians' Health Concerns and Preferences for Healthy Ageing Programs.

While there is strong evidence of the need for healthy ageing programs for older Aboriginal Australians, few are available. It is important to understand older Aboriginal Australians' perspectives on healthy ageing in order to co-design culturally-appropriate programs, including views on technology use in this context. Semi-structured interviews were conducted with 34 Aboriginal Australians aged 50 years and older from regional and urban communities to explore participants' health concerns, preferences for healthy ageing programs, and receptiveness to technology. Qualitative data were analyzed using a grounded theory approach. This study found that older Aboriginal Australians are concerned about chronic health conditions, social and emotional well-being, and difficulties accessing health services. A range of barriers and enablers to participation in current health programs were identified. From the perspective of older Aboriginal people, a successful healthy ageing program model includes physical and cognitive activities, social interaction, and health education. The program model also provides culturally safe care and transport for access as well as family, community, cultural identity, and empowerment regarding ageing well as central tenets. Technology could also be a viable approach for program delivery. These findings can be applied in the implementation and evaluation of culturally-appropriate, healthy ageing programs with older Aboriginal people.

Healthcare and Health Problems from the Perspective of Indigenous Population of the Peruvian Amazon: A Qualitative Study.

Indigenous communities usually experience higher levels of mortality and poorer access to healthcare services compared to non-indigenous communities. This study aims to understand the most prevalent health problems and their treatment in the Asháninka indigenous communities of the Peruvian Amazon. We conducted an ethnographic study in order to explore the perceived health problems, the use of traditional medicine and the resources offered by the official Peruvian healthcare system. Field notes and semi-structured interviews were used. A total of 16 indigenous and four non-indigenous people were interviewed, and interpretative analysis was used to identify themes. The Asháninka community is an overlooked population, which, due to distance restrictions, misconceptions and ethnical disparities, is far away from an appropriate healthcare system and is subjected to acute medical conditions such as infections and gastrointestinal problems. This group tends to seek traditional medicine, mostly herbal medications and traditional healers. The use of a health professional is seen as a last resort. Although the official Peruvian health system incorporates community participation strategies to improve the healthcare of indigenous people, the shortage of material, human resources and cultural sensitivity makes this difficult. Healthcare strategies should be devised and implemented in order to minimize health inequality in this population.

Sustained Quality and Service Delivery in an Expanding Point-of-Care Testing Network in Remote Australian Primary Health Care.

CONTEXT.­: Since 2008, the Northern Territory Point-of-Care Testing Program has improved patient access to pathology testing for acute and chronic disease management for remote health services. OBJECTIVE.­: To evaluate the analytical quality, service delivery, and clinical utility of an expanding remote point-of-care testing network. DESIGN.­: Four years (2016-2019) of data on analytical quality, test numbers, and training statistics and 6 months of clinical point-of-care testing data from Abbott i-STATs at remote health services throughout the Northern Territory were analyzed to assess analytical performance, program growth, and clinical utility. RESULTS.­: From 2016 to 2019, point-of-care test numbers increased, with chemistry and blood gas testing more than doubling to 8500 and 6000 tests, respectively, troponin I testing almost doubling (to 6000), and international normalized ratio testing plateauing at 8000 tests. Participation in quality control and proficiency testing was high, with quality comparable to laboratory-based analytical goals. A shift toward flexible training and communication modes was noted. An audit of point-of-care test results demonstrated elevated creatinine, associated with chronic kidney disease management, as the most common clinically actionable patient result. CONCLUSIONS.­: The Northern Territory Point-of-Care Testing Program provides high quality point-of-care testing within remote primary health services for acute and chronic patient management and care. Clinical need, sound analytical performance, flexibility in training provision, and effective support services have facilitated the sustainability of this expanding point-of-care testing model in the remote Northern Territory during the past 11 years.

Sense of personal control: Can it be assessed culturally unbiased across Aboriginal and non-Aboriginal Australians?

In recent decades, several studies have emphasized sense of personal control as a prominent aspect of Aboriginal health. However, one limitation is that instruments available to measure personal control were originally developed in western countries and validation for Aboriginal Australians has not been conducted. The aims of the current study were to evaluate whether the Sense of Personal Control Scale (SPCS) can be used to obtain culturally unbiased measurement of personal control across Aboriginal and non-Aboriginal Australians and to assess the psychometric properties of the SPCS for Aboriginal and non-Aboriginal Australian. METHODS: The current study utilized two Australian subsamples retrieved from the Teeth Talk Study (n = 317) and the National Survey of Adult Oral Health 2004-2006 (n = 3,857) in which the SPCS was included. Graphical Loglinear Rasch Models (GLLRM) were used to fulfill the aims of the study. RESULTS: The Perceived Constraints subscale fitted a GLLRM for Aboriginal Australians after the exclusion of three items, while fit to any Rasch model (RM) or GLLRM model could not be found in the non-Aboriginal sample. The Mastery subscale fitted a GLLRM in the non-Aboriginal sample after the exclusion of one item. In the Aboriginal sample, two items of the Mastery subscale fitted the RM, however, two items cannot be considered as a scale. CONCLUSION: In the present study, we showed that the development of new items is crucial before the revised SPCS might constitute a valid and reliable measure of sense of personal control in both Aboriginal and non-Aboriginal Australian populations, and it is possible to assess whether the SPCS can be measured without bias across these two populations.

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.

Monitoring, treatment and control of blood glucose and lipids in Ontario First Nations people with diabetes.

BACKGROUND: Indigenous people worldwide are disproportionately affected by diabetes and its complications. We aimed to assess the monitoring, treatment and control of blood glucose and lipids in First Nations people in Ontario. METHODS: We conducted a longitudinal population-based study using administrative data for all people in Ontario with diabetes, stratified by First Nations status. We assessed age- and sex-specific rates of completion of recommended monitoring for low-density lipoprotein (LDL) and glycated hemoglobin (A1c) from 2001/02 to 2014/15. We used data from 2014/15 to conduct a cross-sectional analysis of rates of achievement of A1c and LDL targets and use of glucose-lowering medications. RESULTS: The study included 22 240 First Nations people and 1 319 503 other people in Ontario with diabetes. Rates of monitoring according to guidelines were 20%-50% for A1c and 30%-70% for lipids and were lowest for younger First Nations men. The mean age- and sex-adjusted A1c level was higher among First Nations people than other people (7.59 [95% confidence interval (CI) 7.57 to 7.61] v. 7.03 [95% CI 7.02 to 7.03]). An A1c level of 8.5% or higher was observed in 24.7% (95% CI 23.6 to 25.0) of First Nations people, compared to 12.8% (95% CI 12.1 to 13.5) of other people in Ontario. An LDL level of 2.0 mmol/L or less was observed in 60.3% (95% CI 59.7 to 61.6) of First Nations people, compared to 52.0% (95% CI 51.1 to 52.9) of other people in Ontario. Among those aged 65 or older, a higher proportion of First Nations people than other Ontarians were using insulin (28.1% v. 15.1%), and fewer were taking no medications (28.3% v. 40.1%). INTERPRETATION: As of 2014/15, monitoring and achievement of glycemic control in both First Nations people and other people in Ontario with diabetes remained suboptimal. Interventions to support First Nations patients to reach their treatment goals and reduce the risk of complications need further development and study.

Primary Health Care attributes in the context of indigenous health.

OBJECTIVES: to assess the attributes of Primary Health Care from the perspective of health professionals, comparing services in the Special Indigenous Health District and the Municipal Health Offices. METHODS: a cross-sectional study in the Upper Rio Negro region, State of Amazonas, with 116 professionals. The data were collected through the Primary Care Assessment Tool. Scores were categorized (≥ 6.6) - strong orientation and (<6.6) - low orientation. The chi-square and maximum likelihood test for crossover analysis. The comparison between professionals the Kruskal-Wallis Test. RESULTS: a higher overall score was observed in the Indigenous Health District (7.2). The same trend was observed individually in the essential and derived attributes. CONCLUSIONS: this work may support strategies that positively impact the management model and work processes from the perspective of strengthening the primary care offered to the population from Rio Negro.

Invisible or high-risk: Computer-assisted discourse analysis of references to Aboriginal and Torres Strait Islander people(s) and issues in a newspaper corpus about diabetes.

This article employs computer-assisted methods to analyse references to Aboriginal and Torres Strait Islander people(s) and issues in a newspaper corpus about diabetes. The objectives are to identify both the frequency and quality of social representation. The dataset consisted of 694 items from 12 Australian newspapers in a five-year period (2013-2017). The quantitative analysis focused on frequency (raw/normalised) and range (number/percentage of texts). The qualitative analysis focused on the identification of semantic prosody (co-occurrence with negative/positive words and phrases) and on selective social actor analysis. The qualitative analysis also compared choices made by the press to language practices recommended in relevant reporting guidelines. Key results include that references to Aboriginal and Torres Strait Islander people(s) or matters appear to be extremely rare. In addition, newspapers' language choices only partially align with guidelines. References that do occur can be classified into four categories: a) references to [groups of] people and other references to identity; b) names of services, institutions, professions, roles etc; c) non-human nouns related to health; d) non-human nouns related to culture. Qualitative analysis of the word COMMUNITY suggests that newspapers for the most part do recognise the existence of different communities at a national level. However, analysis of all references to [groups of] people shows that the vast majority occur in contexts to do with negativity, therefore having a negative semantic prosody. More specifically, there is a strong association with mentions of a higher risk, likelihood, or incidence of having or developing diabetes (or complications/effects). In sum, Aboriginal and Torres Strait Islander people(s) and issues lack in visibility in Australian diabetes coverage, and are associated with deficit framing, which can be disempowering. To change the discourse would require both an increased visibility as well as changing the deficit lens.

Modern Contraceptive Utilization and Its Associated Factors among Indigenous and Nonindigenous Married Women of Reproductive Age Group in Jigjiga Town, Eastern Ethiopia, 2018.

BACKGROUND: The use of birth control and its promotion has potential benefits of reducing poverty, maternal, and child mortality. However, there is limited evidence regarding modern contraceptive utilization among indigenous and nonindigenous married women of the reproductive age group in Ethiopia. Therefore, this study aimed to assess the magnitude of modern contraceptive utilization and its associated factors among indigenous and nonindigenous married women in Eastern Ethiopia. Methodology. A community based comparative cross-sectional study design was conducted among married women of the reproductive age group from February 01 to March 01/2018 in Jigjiga town, Eastern Ethiopia. A total of 1004 married women were selected using a simple random sampling method. The collected data were entered into EpiData software version 3.1 and exported to SPSS version 22.0 for analysis. Bivariable and multivariable logistic regression analyses were used to identify the associated factors. Statistical significance was declared using 95% confidence interval and p value of less than 0.05. RESULT: A total of 987 study participants were included in the study with a response rate of 98.3%. The overall prevalence of modern contraceptive utilization among married reproductive age group women was found to be 19.9% (95% CI (17.4%-22.3%) with 26.5% and 11.4% for nonindigenous and indigenous women, respectively. Primary level of education (AOR 0.84; 95% CI (0.15-0.85) p 0.0001) and Somali in ethnicity (AOR 0.75; 95% CI (0.15-0.94) p 0.03) were associated factors among indigenous group, while age group 30-34 years (AOR 1.56; 95% CI (1.31-9.52) p 0.02) and being a housewife in occupation (AOR 0.49; 95% CI (0.42-0.96) p 0.04) were the associated factors among the nonindigenous group. CONCLUSION: Overall utilization of modern contraceptives was approximately one-fifth, with markedly lower use among indigenous participants. One-third of nonindigenous and less than one-seventh of indigenous were utilizing modern contraceptive methods. There is a need to further explore and understand the factors across indigenous and nonindigenous women for the use of modern contraceptives; hence, a longitudinal study is desirable.

"Everything is provided free, but they are still hesitant to access healthcare services": why does the indigenous community in Attapadi, Kerala continue to experience poor access to healthcare?

BACKGROUND: Inequity in access to healthcare services is a constant concern. While advances in healthcare have progressed in the last several decades, thereby significantly improving the prevention and treatment of disease, these benefits have not been shared equally. Excluded communities such as Indigenous communities typically face a lack of access to healthcare services that others do not. This study seeks to understand why the indigenous communities in Attapadi continue to experience poor access to healthcare in spite of both financial protection and adequate coverage of health services. METHODS: Ethnographic fieldwork was carried out among the various stakeholders living in Attapadi. A total of 47 in-depth interviews and 6 focus group discussions were conducted amongst the indigenous community, the healthcare providers and key informants. The data was coded utilising a reflexive and inductive approach leading to the development of the key categories and themes. RESULTS: The health system provided a comprehensive financial protection package in addition to a host of healthcare facilities for the indigenous communities to avail services. In spite of this, they resisted attempts by the health system to improve their access. The failure to provide culturally respectful care, the discrimination of the community at healthcare facilities, the centralisation of the delivery of services as well as the lack of power on the part of the indigenous community to negotiate with the health system for services that were less disruptive for their lives were identified as the barriers to improving healthcare access. The existing power differentials between the community and the health system stakeholders also ensured that meaningful involvement of the community in the local health system did not occur. CONCLUSION: Improving access to health care for indigenous communities would require UHC interventions to be culturally safe, locally relevant and promote active involvement of the community at all stages of the intervention. Continuing structural power imbalances that affect access to resources and prevent meaningful involvement of indigenous communities also need to be addressed.

Foot health of Aboriginal and Torres Strait Islander Peoples in regional and rural NSW, Australia.

BACKGROUND: Foot health of Aboriginal and Torres Strait Islander Australians' has not been established. Additionally, studies have shown that there is a lack of engagement of this population with general preventive foot care services. The aim of this study was to establish foot health in Aboriginal and Torres Strait Islander people attending two recently developed, culturally safe podiatry services in rural and regional New South Wales (NSW), Australia. Secondarily the relationship between self-perceived foot health and some medical and demographic characteristics was investigated. METHODS: This descriptive cross-sectional study included participants attending the culturally safe foot health care services managed by the University of Newcastle on the Central Coast or in Wellington, both located in NSW, Australia. At the consultation, participants completed the Foot Health Status Questionnaire (FHSQ) with the assistance of an Aboriginal health care worker, underwent basic vascular and neurological screening, and podiatric treatment. RESULTS: A total of 111 Aboriginal and Torres Strait Islander Australians (48 from the Central Coast, and 63 from Wellington) were included. FHSQ scores for pain (75.7 ± 26.8), function (80.2 ± 25.2), footwear (53.9 ± 33.4), and general foot health (62.0 ± 30.9) were generally good, but below the optimal score of 100. The presence of diabetes (n = 39 of 111 participants or 35.1%) was associated with lower levels of self-perceived foot function (r = - 0.20, n = 107, p = 0.04). CONCLUSION: We found that community-based foot health care services that are culturally safe are utilised by Aboriginal and Torres Strait Islander Peoples not currently at high risk of foot complications. This supports the use of culturally safe foot care services to improve engagement with preventative foot care. Future research should continue to be driven by Aboriginal and Torres Strait Islander Peoples and investigate ways to implement additional screening measures and undertake prospective evaluation of the impact of such services on health related outcomes in these communities.

Young Aboriginal people's engagement with STI testing in the Northern Territory, Australia.

BACKGROUND: Australian surveillance data document higher rates of sexually transmissible infections (STIs) among young Aboriginal people (15-29 years) in remote settings than non-Aboriginal young people. Epidemiological data indicate a substantial number of young Aboriginal people do not test for STIs. Rigorous qualitative research can enhance understanding of these findings. This paper documents socio-ecological factors influencing young Aboriginal people's engagement with clinic-based STI testing in two remote settings in the Northern Territory, Australia. METHODS: In-depth interviews with 35 young Aboriginal men and women aged 16-21 years; thematic analysis examining their perceptions and personal experiences of access to clinic-based STI testing. RESULTS: Findings reveal individual, social and health service level influences on willingness to undertake clinic-based STI testing. Individual level barriers included limited knowledge about asymptomatic STIs, attitudinal barriers against testing for symptomatic STIs, and lack of skills to communicate about STIs with health service staff. Social influences both promoted and inhibited STI testing. In setting 1, local social networks enabled intergenerational learning about sexual health and facilitated accompanied visits to health clinics for young women. In setting 2, however, social connectedness inhibited access to STI testing services. Being seen at clinics was perceived to lead to stigmatisation among peers and fear of reputational damage due to STI-related rumours. Modalities of health service provision both enhanced and inhibited STI testing. In setting 1, outreach strategies by male health workers provided young Aboriginal men with opportunities to learn about sexual health, initiate trusting relationships with clinic staff, and gain access to clinics. In setting 2, barriers were created by the location and visibility of the clinic, appointment procedures, waiting rooms and waiting times. Where inhibitive factors at the individual, social and health service levels exist, young Aboriginal people reported more limited access to STI testing. CONCLUSIONS: This is the first socio-ecological analysis of factors influencing young Aboriginal people's willingness to undertake testing for STIs within clinics in Australia. Strategies to improve uptake of STI testing must tackle the overlapping social and health service factors that discourage young people from seeking sexual health support. Much can be learned from young people's lived sexual health experiences and family- and community-based health promotion practices.

Priorities for improved management of acute rheumatic fever and rheumatic heart disease: analysis of cross-sectional continuous quality improvement data in Aboriginal primary healthcare centres in Australia.

Objective This study investigated the delivery of guideline-recommended services for the management of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in Australian primary healthcare centres participating in the Audit and Best Practice for Chronic Disease (ABCD) National Research Partnership project. Methods ARF and RHD clinical audit data were collected from 63 Aboriginal centres in four Australian jurisdictions using the ABCD ARF/RHD audit tool. Records of up to 30 patients treated for ARF and/or RHD were analysed per centre from the most recent audit conducted between 2009 and 2014. The main outcome measure was a quality of ARF and RHD care composite indicator consisting of nine best-practice service items. Results Of 1081 patients, most were Indigenous (96%), female (61%), from the Northern Territory and Queensland (97%) and <25 years of age (49%). The composite indicator was highest in the 0-14 year age group (77% vs 65-67% in other age groups). Timely injections and provision of client education are important specific areas for improvement. Multiple regression showed age >15 years to be a significant negative factor for several care indicators, particularly for the delivery of long-acting antibiotic injections and specialist services in the 15-24 year age group. Conclusions The results suggest that timely injection and patient education are priorities for managing ARF and RHD, particularly focusing on child-to-adult transition care. What is known about the topic? The burden of rheumatic fever and RHD in some Aboriginal communities is among the highest documented globally. Guideline-adherent RHD prevention and management in primary health care (PHC) settings are critically important to reduce this burden. Continuous quality improvement (CQI) is a proven strategy to improve guideline adherence, using audit cycles and proactive engagement of PHC end users with their own data. Previously, such CQI strategies using a systems approach were shown to improve delivery of ARF and RHD care in six Aboriginal health services (three government and three community controlled). What does this paper add? This paper focuses on the variation across age groups in the quality of ARF and/or RHD care according to nine quality of care indicators across 63 PHC centres serving the Aboriginal population in the Northern Territory, Queensland, South Australia and Western Australia. These new findings provide insight into difference in quality of care by life stage, indicating particular areas for improvement of the management of ARF and RHD at the PHC level, and can act as a baseline for monitoring of care quality for ARF and RHD into the future. What are the implications for practitioners? Management plans and innovative strategies or systems for improving adherence need to be developed as a matter of urgency. PHC professionals need to closely monitor adherence to secondary prophylaxis at both the clinic and individual level. RHD priority status needs to be assigned and recorded as a tool to guide management. Systems strengthening needs to particularly target child-to-adult transition care. Practitioners are urged to keep a quick link to the RHDAustralia website to access resources and guidelines pertaining to ARF and RHD (https://www.rhdaustralia.org.au/arf-rhd-guideline, accessed 3 October 2019). CQI strategies can assist PHC centres to improve the care they provide to patients.