Making Big Business Everybody's Business: Aboriginal leaders' perspectives on commercial activities influencing aboriginal health in Victoria, Australia.

BACKGROUND: The commercial determinants of health is a rapidly expanding field of research; however Indigenous perspectives remain notably underrepresented. For Indigenous peoples the intersection of globalisation, colonialism and capitalism may amplify commercially-driven health inequities. This study aimed to explore the perspectives of Aboriginal leaders regarding the influence of commercial activities on Aboriginal health and wellbeing in Victoria, Australia. METHODS: Semi-structured interviews with 23 Aboriginal leaders from across five sectors (n = 15 urban, n = 8 rural/regional) were analysed through reflexive thematic analysis. RESULTS: Three overarching themes were identified encompassing (i) harmful commercial practices and processes, (ii) improving corporate engagement and (iii) opportunities for self-determination through business. Participants expressed concern over aggressive marketing by the gambling industry, commercial exploitation of Aboriginal culture, the privatisation of public services, and lack of oversignt of corporate social responsibility strategies. Simultaneously, Aboriginal-led businesses were viewed as opportunities for cultural connection, and financial empowerment and self-determination. CONCLUSION: Numerous commercial entities and activities are perceived to influence Aboriginal health and wellbeing. This study highlights the need for stronger policy and regulation to mitigate harmful industry practices while incentivising the potential positive impacts of the commercial activities on Aboriginal health and wellbeing.

'A recipe for cultural disaster!'- a case study of Woolworths Group's proposal to build an alcohol megastore in Darwin, Northern Territory.

BACKGROUND: The health and wellbeing impacts of commercial activity on Indigenous populations is an emerging field of research. The alcohol industry is a key driver of health and social harms within Australia. In 2016 Woolworths, the largest food and beverage retailer in Australia, proposed to build a Dan Murphy's alcohol megastore in Darwin, near three 'dry' Aboriginal communities. This study examines the tactics used by Woolworths to advance the Dan Murphy's proposal and understand how civil society action can overcome powerful commercial interests to protect Aboriginal and Torres Strait Islander health and wellbeing. METHODS: Data from 11 interviews with Aboriginal and non-Aboriginal informants were combined with data extracted from media articles and government, non-government and industry documents. Thematic analysis was informed by an adapted corporate health impact assessment framework. RESULTS: Woolworths employed several strategies including lobbying, political pressure, litigation, and divisive public rhetoric, while ignoring the evidence suggesting the store would increase alcohol-related harm. The advocacy campaign against the proposal highlighted the importance of Aboriginal and non-Aboriginal groups working together to counter commercial interests and the need to champion Aboriginal leadership. Advocacy strategies included elevating the voices of community Elders in the media and corporate activism via Woolworths' investors. CONCLUSIONS: The strategies used by the coalition of Aboriginal and non-Aboriginal groups may be useful in future advocacy campaigns to safeguard Aboriginal and Torres Strait Islander health and wellbeing from commercial interests.

Factors influencing infant feeding for Aboriginal and Torres Strait Islander women and their families: a systematic review of qualitative evidence.

BACKGROUND: Breastfeeding provides all the necessary energy and nutrients for an infant and provides many benefits for mothers and babies. The effects of colonisation have contributed to reduced prevalence and duration of breastfeeding among Australian Aboriginal women and widespread use of infant formula as a substitute for breastmilk. This review aimed to synthesise qualitative evidence about the factors that influence breastfeeding and infant feeding practices of Aboriginal and Torres Strait Islander women and their families. METHODS: MEDLINE, CINAHL, Informit and Google Scholar were systematically searched for qualitative studies that included the perspective of Aboriginal and Torres Strait Islander women and their families about the factors influencing infant feeding decisions. Included studies were appraised using an Indigenous quality assessment tool and were synthesised via inductive thematic analysis informed by an ecological framework. RESULTS: The search identified 968 studies with 7 meeting the inclusion criteria. Key factors influencing breastfeeding and infant feeding practices of Aboriginal women included cultural practices, normalisation of bottle feeding, shame associated with breastfeeding in public, access to culturally safe nutrition education, support services and health professionals, family/partner support, knowledge of the benefits of breastfeeding, experiences with previous babies and concern that the baby was not getting enough milk. CONCLUSION: The perspectives of Aboriginal and Torres Strait Islander women must be considered when providing breastfeeding and infant feeding advice. This can be achieved through Aboriginal and Torres Strait Islander people designing, implementing, and leading the delivery of education and information regarding breastfeeding and health infant feeding practices that have been influenced by the priorities of Aboriginal and Torres Strait Islander communities.

Media coverage of commercial industry activities impacting Aboriginal and Torres Strait Islander health, 2018-2022.

This study aimed to examine the extent and nature of Australian news media coverage of commercial industry activities that explicitly speak to Aboriginal and Torres Strait Islander contexts. We undertook content and framing analysis of Australian newspaper and online media articles published between January 2018 and March 2022 that included terms related to 'Indigenous', 'commercial' and 'health'. Analysis focused on the nature of coverage, framing of responsibility, patterns over time and stakeholder representation. Forty-six media articles were included in the analysis. Half of these articles related to the actions of three companies (Woolworths, WAM Clothing and Rio Tinto). Most articles described negative health and well-being impacts of commercial activity, while four described positive impacts. The most common voice represented in media articles was from industry (n = 25). Aboriginal or Torres Strait Islander voices were represented in 21 articles. This analysis highlights how commercial activities in Australia are reported to negatively influence Aboriginal and Torres Strait Islander health and well-being, and that industry voices are more commonly represented in the media related to these issues.

ICIRAS: Research and reconciliation with indigenous peoples in rural health journals.

AIM: We aim to promote discussion about an Indigenous Cultural Identity of Research Authors Standard (ICIRAS) for academic journal publications. CONTEXT: This is based on a gap in research publishing practice where Indigenous peoples' identity is not systematically and rigorously flagged in rural health research publications. There are widespread reforms, in different research areas, to counter the reputation of scientific research as a vehicle of racism and discrimination against the world's Indigenous peoples. Reflecting on these broader movements, the editorial teams of three rural health journals-the Australian Journal of Rural Health, the Canadian Journal of Rural Medicine, and Rural and Remote Health-recognised that Indigenous peoples' identity could be embedded in authorship details. APPROACH: An environmental scan (through a cultural safety lens where Indigenous cultural authority is respected, valued, and empowered) of literature was undertaken to detect the signs of inclusion of Indigenous peoples in research. This revealed many ways in which editorial boards of Journals could systematically improve their process so that there is 'nothing about Indigenous people, without Indigenous people' in rural health research publications. CONCLUSION: Improving the health and wellbeing of Indigenous peoples worldwide requires high quality research evidence. The philosophy of cultural safety supports the purposeful positioning of Indigenous peoples within the kaleidoscope of cultural knowledges as identified contributors and authors of research evidence. The ICIRAS is a call-to-action for research journals and institutions to rigorously improve publication governance that signals "Editing with IndigenUs and for IndigenUs".

Indigenous Cultural Identity of Research Authors Standard: research and reconciliation with Indigenous Peoples in rural health journals.

The Indigenous Cultural Identity of Research Authors Standard (ICIRAS) is based on a gap in research publishing practice where Indigenous peoples' identity is not systematically and rigorously recognised in rural health research publications. There are widespread reforms, in different research areas, to counter the reputation of scientific research as a vehicle of racism and discrimination. Reflecting on these broader movements, the editorial teams of three rural health journals - Rural and Remote Health, the Australian Journal of Rural Health, and the Canadian Journal of Rural Medicine - adopted a policy of 'Nothing about Indigenous Peoples, without Indigenous Peoples'. This meant changing practices so that Indigenous Peoples' identity could be embedded in authorship credentials - such as in the byline. An environmental scan of literature about the inclusion of Indigenous Peoples in research revealed many ways in which editorial boards of journals could improve their process to signal to readers that Indigenous voices are included in rural health research publication governance. Improving the health and wellbeing of Indigenous peoples worldwide requires high-quality research evidence. This quality benchmark needs to explicitly signal the inclusion of Indigenous authors. The ICIRAS is a call to action for research journals and institutions to rigorously improve research governance and leadership to amplify the cultural identity of Indigenous peoples in rural health research.

Concerns and priorities of Aboriginal and Torres Strait Islander peoples regarding food and nutrition: a systematic review of qualitative evidence.

BACKGROUND: Aboriginal and Torres Strait Islander Australians experience persistent health and social inequities. Chronic conditions, many of which are diet-related, are leading contributors to the burden of disease and health inequity in Australia. First Nations Peoples have the right to be involved in all policy decisions affecting them. This review aimed to synthesise Aboriginal and Torres Strait Islander Peoples' concerns and priorities about food and nutrition in order to inform policies to improve health equity. METHODS: MEDLINE, CINAHL, Informit and Google Scholar were systematically searched to identify qualitative studies-published from January 2008-that included data from Aboriginal and/or Torres Strait Islander Peoples about their concerns and priorities related to food and nutrition. Data were extracted from included studies using a pre-determined template and study quality was assessed using the Aboriginal and Torres Strait Islander Quality Appraisal Tool. Qualitative findings were synthesised using inductive thematic analysis and categorised based on an ecological model of health. RESULTS: Twenty-one studies were included. Key factors influencing food and nutrition were identified across all levels of the ecological framework. These included interpersonal and institutional racism, junk food availability and marketing, food accessibility and affordability, housing conditions, food knowledge and cooking skills, and connection to family and culture. CONCLUSIONS: Documenting Aboriginal and Torres Strait Islander Peoples' lived experiences of the colonised food system is one step necessary for informing policy to tackle food and nutrition inequities. Based on existing qualitative research, food and nutrition policymakers should prioritise building a supportive food environment by focusing on self-determination; ensuring access to healthy, affordable food and safe housing; and by eliminating systemic racism.

Australia in 2030: what is our path to health for all?

CHAPTER 1: HOW AUSTRALIA IMPROVED HEALTH EQUITY THROUGH ACTION ON THE SOCIAL DETERMINANTS OF HEALTH: Do not think that the social determinants of health equity are old hat. In reality, Australia is very far away from addressing the societal level drivers of health inequity. There is little progressive policy that touches on the conditions of daily life that matter for health, and action to redress inequities in power, money and resources is almost non-existent. In this chapter we ask you to pause this reality and come on a fantastic journey where we envisage how COVID-19 was a great disruptor and accelerator of positive progressive action. We offer glimmers of what life could be like if there was committed and real policy action on the social determinants of health equity. It is vital that the health sector assists in convening the multisectoral stakeholders necessary to turn this fantasy into reality. CHAPTER 2: ABORIGINAL AND TORRES STRAIT ISLANDER CONNECTION TO CULTURE: BUILDING STRONGER INDIVIDUAL AND COLLECTIVE WELLBEING: Aboriginal and Torres Strait Islander peoples have long maintained that culture (ie, practising, maintaining and reclaiming it) is vital to good health and wellbeing. However, this knowledge and understanding has been dismissed or described as anecdotal or intangible by Western research methods and science. As a result, Aboriginal and Torres Strait Islander culture is a poorly acknowledged determinant of health and wellbeing, despite its significant role in shaping individuals, communities and societies. By extension, the cultural determinants of health have been poorly defined until recently. However, an increasing amount of scientific evidence supports what Aboriginal and Torres Strait Islander people have always said - that strong culture plays a significant and positive role in improved health and wellbeing. Owing to known gaps in knowledge, we aim to define the cultural determinants of health and describe their relationship with the social determinants of health, to provide a full understanding of Aboriginal and Torres Strait Islander wellbeing. We provide examples of evidence on cultural determinants of health and links to improved Aboriginal and Torres Strait Islander health and wellbeing. We also discuss future research directions that will enable a deeper understanding of the cultural determinants of health for Aboriginal and Torres Strait Islander people. CHAPTER 3: PHYSICAL DETERMINANTS OF HEALTH: HEALTHY, LIVEABLE AND SUSTAINABLE COMMUNITIES: Good city planning is essential for protecting and improving human and planetary health. Until recently, however, collaboration between city planners and the public health sector has languished. We review the evidence on the health benefits of good city planning and propose an agenda for public health advocacy relating to health-promoting city planning for all by 2030. Over the next 10 years, there is an urgent need for public health leaders to collaborate with city planners - to advocate for evidence-informed policy, and to evaluate the health effects of city planning efforts. Importantly, we need integrated planning across and between all levels of government and sectors, to create healthy, liveable and sustainable cities for all. CHAPTER 4: HEALTH PROMOTION IN THE ANTHROPOCENE: THE ECOLOGICAL DETERMINANTS OF HEALTH: Human health is inextricably linked to the health of the natural environment. In this chapter, we focus on ecological determinants of health, including the urgent and critical threats to the natural environment, and opportunities for health promotion arising from the human health co-benefits of actions to protect the health of the planet. We characterise ecological determinants in the Anthropocene and provide a sobering snapshot of planetary health science, particularly the momentous climate change health impacts in Australia. We highlight Australia's position as a major fossil fuel producer and exporter, and a country lacking cohesive and timely emissions reduction policy. We offer a roadmap for action, with four priority directions, and point to a scaffold of guiding approaches - planetary health, Indigenous people's knowledge systems, ecological economics, health co-benefits and climate-resilient development. Our situation requires a paradigm shift, and this demands a recalibration of health promotion education, research and practice in Australia over the coming decade. CHAPTER 5: DISRUPTING THE COMMERCIAL DETERMINANTS OF HEALTH: Our vision for 2030 is an Australian economy that promotes optimal human and planetary health for current and future generations. To achieve this, current patterns of corporate practice and consumption of harmful commodities and services need to change. In this chapter, we suggest ways forward for Australia, focusing on pragmatic actions that can be taken now to redress the power imbalances between corporations and Australian governments and citizens. We begin by exploring how the terms of health policy making must change to protect it from conflicted commercial interests. We also examine how marketing unhealthy products and services can be more effectively regulated, and how healthier business practices can be incentivised. Finally, we make recommendations on how various public health stakeholders can hold corporations to account, to ensure that people come before profits in a healthy and prosperous future Australia. CHAPTER 6: DIGITAL DETERMINANTS OF HEALTH: THE DIGITAL TRANSFORMATION: We live in an age of rapid and exponential technological change. Extraordinary digital advancements and the fusion of technologies, such as artificial intelligence, robotics, the Internet of Things and quantum computing constitute what is often referred to as the digital revolution or the Fourth Industrial Revolution (Industry 4.0). Reflections on the future of public health and health promotion require thorough consideration of the role of digital technologies and the systems they influence. Just how the digital revolution will unfold is unknown, but it is clear that advancements and integrations of technologies will fundamentally influence our health and wellbeing in the future. The public health response must be proactive, involving many stakeholders, and thoughtfully considered to ensure equitable and ethical applications and use. CHAPTER 7: GOVERNANCE FOR HEALTH AND EQUITY: A VISION FOR OUR FUTURE: Coronavirus disease 2019 has caused many people and communities to take stock on Australia's direction in relation to health, community, jobs, environmental sustainability, income and wealth. A desire for change is in the air. This chapter imagines how changes in the way we govern our lives and what we value as a society could solve many of the issues Australia is facing - most pressingly, the climate crisis and growing economic and health inequities. We present an imagined future for 2030 where governance structures are designed to ensure transparent and fair behaviour from those in power and to increase the involvement of citizens in these decisions, including a constitutional voice for Indigenous peoples. We imagine that these changes were made by measuring social progress in new ways, ensuring taxation for public good, enshrining human rights (including to health) in legislation, and protecting and encouraging an independent media. Measures to overcome the climate crisis were adopted and democratic processes introduced in the provision of housing, education and community development.

The political economy of restricting marketing to address the double burden of malnutrition: two case studies from Fiji.

OBJECTIVE: To draw lessons from Fiji regarding the challenges and opportunities for policy initiatives to restrict (i) food marketing to children and (ii) marketing of breast milk substitutes, to inform policy for the double burden of malnutrition. DESIGN: Qualitative political economy analysis of two policy case studies. SETTING: Fiji. PARTICIPANTS: Eleven key informants from relevant sectors, representing public health, economic and consumer interests. RESULTS: This study used two policy initiatives as case studies to examine factors influencing decision-making: Marketing Controls (Foods for Infants and Young Children) Regulations 2010, amended in 2016 to remove guidelines and restrictions on marketing in the form of labelling, and the draft Advertising and Promotion of Unhealthy Foods and Non-Alcoholic Beverages to Children Regulation developed in 2014 but awaiting review by the Solicitor General's Office. Factors identified included: a policy paradigm in which regulation of business activity contradicts economic policy goals; limited perception by key policy actors of links between nutrition and marketing of breast milk substitutes, foods and beverages; and a power imbalance between industry and public health stakeholders in policymaking. Regulation of marketing for health purposes sits within the health sector's interest but not its legislative remit, while within the economic sector's remit but not interest. Opportunities to strengthen restrictions on marketing to improve nutrition and health include reframing the policy issue, strategic advocacy and community engagement. CONCLUSIONS: Restricting marketing should be recognised by public health actors as a public health and an industry policy issue, to support strategic engagement with economic policy actors.

Beyond the black stump: rapid reviews of health research issues affecting regional, rural and remote Australia.

CHAPTER 1: RETAIL INITIATIVES TO IMPROVE THE HEALTHINESS OF FOOD ENVIRONMENTS IN RURAL, REGIONAL AND REMOTE COMMUNITIES: Objective: To synthesise the evidence for effectiveness of initiatives aimed at improving food retail environments and consumer dietary behaviour in rural, regional and remote populations in Australia and comparable countries, and to discuss the implications for future food environment initiatives for rural, regional and remote areas of Australia. STUDY DESIGN: Rapid review of articles published between January 2000 and May 2020. DATA SOURCES: We searched MEDLINE (EBSCOhost), Health and Society Database (Informit) and Rural and Remote Health Database (Informit), and included studies undertaken in rural food environment settings in Australia and other countries. DATA SYNTHESIS: Twenty-one articles met the inclusion criteria, including five conducted in Australia. Four of the Australian studies were conducted in very remote populations and in grocery stores, and one was conducted in regional Australia. All of the overseas studies were conducted in rural North America. All of them revealed a positive influence on food environment or consumer behaviour, and all were conducted in disadvantaged, rural communities. Positive outcomes were consistently revealed by studies of initiatives that focused on promotion and awareness of healthy foods and included co-design to generate community ownership and branding. CONCLUSION: Initiatives aimed at improving rural food retail environments were effective and, when implemented in different rural settings, may encourage improvements in population diets. The paucity of studies over the past 20 years in Australia shows a need for more research into effective food retail environment initiatives, modelled on examples from overseas, with studies needed across all levels of remoteness in Australia. Several retail initiatives that were undertaken in rural North America could be replicated in rural Australia and could underpin future research. CHAPTER 2: WHICH INTERVENTIONS BEST SUPPORT THE HEALTH AND WELLBEING NEEDS OF RURAL POPULATIONS EXPERIENCING NATURAL DISASTERS?: Objective: To explore and evaluate health and social care interventions delivered to rural and remote communities experiencing natural disasters in Australia and other high income countries. STUDY DESIGN: We used systematic rapid review methods. First we identified a test set of citations and generated a frequency table of Medical Subject Headings (MeSH) to index articles. Then we used combinations of MeSH terms and keywords to search the MEDLINE (Ovid) database, and screened the titles and abstracts of the retrieved references. DATA SOURCES: We identified 1438 articles via database searches, and a further 62 articles via hand searching of key journals and reference lists. We also found four relevant grey literature resources. After removing duplicates and undertaking two stages of screening, we included 28 studies in a synthesis of qualitative evidence. DATA SYNTHESIS: Four of us read and assessed the full text articles. We then conducted a thematic analysis using the three phases of the natural disaster response cycle. CONCLUSION: There is a lack of robust evaluation of programs and interventions supporting the health and wellbeing of people in rural communities affected by natural disasters. To address the cumulative and long term impacts, evidence suggests that continuous support of people's health and wellbeing is needed. By using a lens of rural adversity, the complexity of the lived experience of natural disasters by rural residents can be better understood and can inform development of new models of community-based and integrated care services. CHAPTER 3: THE IMPACT OF BUSHFIRE ON THE WELLBEING OF CHILDREN LIVING IN RURAL AND REMOTE AUSTRALIA: Objective: To investigate the impact of bushfire events on the wellbeing of children living in rural and remote Australia. STUDY DESIGN: Literature review completed using rapid realist review methods, and taking into consideration the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement for systematic reviews. DATA SOURCES: We sourced data from six databases: EBSCOhost (Education), EBSCOhost (Health), EBSCOhost (Psychology), Informit, MEDLINE and PsycINFO. We developed search terms to identify articles that could address the research question based on the inclusion criteria of peer reviewed full text journal articles published in English between 1983 and 2020. We initially identified 60 studies and, following closer review, extracted data from eight studies that met the inclusion criteria. DATA SYNTHESIS: Children exposed to bushfires may be at increased risk of poorer wellbeing outcomes. Findings suggest that the impact of bushfire exposure may not be apparent in the short term but may become more pronounced later in life. Children particularly at risk are those from more vulnerable backgrounds who may have compounding factors that limit their ability to overcome bushfire trauma. CONCLUSION: We identified the short, medium and long term impacts of bushfire exposure on the wellbeing of children in Australia. We did not identify any evidence-based interventions for supporting outcomes for this population. Given the likely increase in bushfire events in Australia, research into effective interventions should be a priority. CHAPTER 4: THE ROLE OF NATIONAL POLICIES TO ADDRESS RURAL ALLIED HEALTH, NURSING AND DENTISTRY WORKFORCE MALDISTRIBUTION: Objective: Maldistribution of the health workforce between rural, remote and metropolitan communities contributes to longstanding health inequalities. Many developed countries have implemented policies to encourage health care professionals to work in rural and remote communities. This scoping review is an international synthesis of those policies, examining their effectiveness at recruiting and retaining nursing, dental and allied health professionals in rural communities. STUDY DESIGN: Using scoping review methods, we included primary research - published between 1 September 2009 and 30 June 2020 - that reported an evaluation of existing policy initiatives to address workforce maldistribution in high income countries with a land mass greater than 100 000 km2 . DATA SOURCES: We searched MEDLINE, Ovid Embase, Ovid Emcare, Informit, Scopus, and Web of Science. We screened 5169 articles for inclusion by title and abstract, of which we included 297 for full text screening. We then extracted data on 51 studies that had been conducted in Australia, the United States, Canada, United Kingdom and Norway. DATA SYNTHESIS: We grouped the studies based on World Health Organization recommendations on recruitment and retention of health care workers: education strategies (n = 27), regulatory change (n = 11), financial incentives (n = 6), personal and professional support (n = 4), and approaches with multiple components (n = 3). CONCLUSION: Considerable work has occurred to address workforce maldistribution at a local level, underpinned by good practice guidelines, but rarely at scale or with explicit links to coherent overarching policy. To achieve policy aspirations, multiple synergistic evidence-based initiatives are needed, and implementation must be accompanied by well designed longitudinal evaluations that assess the effectiveness of policy objectives. CHAPTER 5: AVAILABILITY AND CHARACTERISTICS OF PUBLICLY AVAILABLE HEALTH WORKFORCE DATA SOURCES IN AUSTRALIA: Objective: Many data sources are used in Australia to inform health workforce planning, but their characteristics in terms of relevance, accessibility and accuracy are uncertain. We aimed to identify and appraise publicly available data sources used to describe the Australian health workforce. STUDY DESIGN: We conducted a scoping review in which we searched bibliographic databases, websites and grey literature. Two reviewers independently undertook title and abstract screening and full text screening using Covidence software. We then assessed the relevance, accessibility and accuracy of data sources using a customised appraisal tool. DATA SOURCES: We searched for potential workforce data sources in nine databases (MEDLINE, Embase, Ovid Emcare, Scopus, Web of Science, Informit, the JBI Evidence-based Practice Database, PsycINFO and the Cochrane Library) and the grey literature, and examined several pre-defined websites. DATA SYNTHESIS: During the screening process we identified 6955 abstracts and examined 48 websites, from which we identified 12 publicly available data sources - eight primary and four secondary data sources. The primary data sources were generally of modest quality, with low scores in terms of reference period, accessibility and missing data. No single primary data source scored well across all domains of the appraisal tool. CONCLUSION: We identified several limitations of data sources used to describe the Australian health workforce. Establishment of a high quality, longitudinal, linked database that can inform all aspects of health workforce development is urgently needed, particularly for rural health workforce and services planning. CHAPTER 6: RAPID REALIST REVIEW OF OPIOID TAPERING IN THE CONTEXT OF LONG TERM OPIOID USE FOR NON-CANCER PAIN IN RURAL AREAS: Objective: To describe interventions, barriers and enablers associated with opioid tapering for patients with chronic non-cancer pain in rural primary care settings. STUDY DESIGN: Rapid realist review registered on the international register of systematic reviews (PROSPERO) and conducted in accordance with RAMESES standards. DATA SOURCES: English language, peer-reviewed articles reporting qualitative, quantitative and mixed method studies, published between January 2016 and July 2020, and accessed via MEDLINE, Embase, CINAHL Complete, PsycINFO, Informit or the Cochrane Library during June and July 2020. Grey literature relating to prescribing,deprescribing or tapering of opioids in chronic non-cancer pain, published between January 2016 and July 2020, was identified by searching national and international government, health service and peek organisation websites using Google Scholar. DATA SYNTHESIS: Our analysis of reported approaches to tapering conducted across rural and non-rural contexts showed that tapering opioids is complex and challenging, and identified several barriers and enablers. Successful outcomes in rural areas appear likely through therapeutic relationships, coordination and support, by using modalities and models of care that are appropriate in rural settings and by paying attention to harm minimisation. CONCLUSION: Rural primary care providers do not have access to resources available in metropolitan centres for dealing with patients who have chronic non-cancer pain and are taking opioid medications. They often operate alone or in small group practices, without peer support and access to multidisciplinary and specialist teams. Opioid tapering approaches described in the literature include regulation, multimodal and multidisciplinary approaches, primary care provider support, guidelines, and patient-centred strategies. There is little research to inform tapering in rural contexts. Our review provides a synthesis of the current evidence in the form of a conceptual model. This preliminary model could inform the development of a model of care for use in implementation research, which could test a variety of mechanisms for supporting decision making, reducing primary care providers' concerns about potential harms arising from opioid tapering, and improving patient outcomes.

Strengthening Aboriginal and Torres Strait Islander health policy: lessons from a case study of food and nutrition.

OBJECTIVE: To examine key factors influencing the prioritisation of food and nutrition in Aboriginal and Torres Strait Islander health policy during 1996-2015. DESIGN: A qualitative policy analysis case study was undertaken, combining document analysis with thematic analysis of key informant interviews. SETTING: Australia. PARTICIPANTS: Key actors involved in Aboriginal and Torres Strait Islander health policy between 1996 and 2015 (n 38). RESULTS: Prioritisation of food and nutrition in policy reduced over time. Several factors which may have impeded the prioritisation of nutrition were identified. These included lack of cohesion among the community of nutritionists, Aboriginal and Torres Strait Islander leaders and civil society actors advocating for nutrition; the absence of an institutional home for nutrition policy; and lack of consensus and a compelling policy narrative about how priority nutrition issues should be addressed. Political factors including ideology, dismantling of public health nutrition governance structures and missing the opportunities presented by 'policy windows' were also viewed as barriers to nutrition policy change. Finally, the complexity and multifaceted nature of nutrition as a policy problem and perceived lack of evidence-based solutions may also have constrained its prioritisation in Aboriginal and Torres Strait Islander health policy. CONCLUSIONS: Future advocacy should focus on embedding nutrition within holistic approaches to health and building a collective voice through advocacy coalitions with Aboriginal and Torres Strait Islander leadership. Strategic communication and seizing political opportunities may be as important as evidence for raising the priority of Aboriginal and Torres Strait Islander health issues.

A guide to policy analysis as a research method.

Policy analysis provides a way for understanding how and why governments enact certain policies, and their effects. Public health policy research is limited and lacks theoretical underpinnings. This article aims to describe and critique different approaches to policy analysis thus providing direction for undertaking policy analysis in the field of health promotion. Through the use of an illustrative example in nutrition it aims to illustrate the different approaches. Three broad orientations to policy analysis are outlined: (i) Traditional approaches aim to identify the 'best' solution, through undertaking objective analyses of possible solutions. (ii) Mainstream approaches focus on the interaction of policy actors in policymaking. (iii) Interpretive approaches examine the framing and representation of problems and how policies reflect the social construction of 'problems'. Policy analysis may assist understanding of how and why policies to improve nutrition are enacted (or rejected) and may inform practitioners in their advocacy. As such, policy analysis provides researchers with a powerful tool to understand the use of research evidence in policymaking and generate a heightened understanding of the values, interests and political contexts underpinning policy decisions. Such methods may enable more effective advocacy for policies that can lead to improvements in health.

You wouldn't eat 16 teaspoons of sugar-so why drink it? Aboriginal and Torres Strait Islander responses to the LiveLighter sugary drink campaign.

ISSUE ADDRESSED: The reach and impact of the LiveLighter and Aboriginal sugar-sweetened beverage (SSB) advertisements among Aboriginal and Torres Strait Islander adults. METHODS: The Aboriginal SSB advertisement launched online in January 2015 and aired on NITV in October/November 2015 as part of the Government-funded LiveLighter campaign. The advertisement was developed in Victoria and featured members of the Victorian Aboriginal community. Another LiveLighter advertisement targeting the general population was broadcast over the same period. Online surveys were completed by 150 Aboriginal and/or Torres Strait Islander adults in November/December 2015. RESULTS: Around half of respondents reported seeing either the Aboriginal (47%) or the LiveLighter (56%) SSB advertisement, and the proportion was significantly greater in Victoria (Aboriginal: 60%, LiveLighter: 66%) than other states/territories (Aboriginal: 29%, LiveLighter: 43%). Compared to the LiveLighter advertisement, the Aboriginal campaign was seen to be more believable, to be more relevant and to have an important message for the Aboriginal community (P < 0.001). Participants from Victoria were significantly more likely to identify the sugar content of regular soft drink, compared with those from other states/territories (68% vs 40%, P < 0.001). Sixty per cent of participants who had seen the Aboriginal SSB advertisement reported they drank less SSBs compared with 48% of those not exposed, though the difference was not statistically significant (P > 0.05). CONCLUSIONS: Results suggest the Aboriginal advertisement resonated with Aboriginal and Torres Strait Islander people and impacted knowledge about the sugar content of SSBs, particularly in Victoria where the campaign originated. SO WHAT?: This study highlights the importance of Aboriginal and Torres Strait Islander-led health promotion campaigns and tailoring health messages to the local Aboriginal and/or Torres Strait Islander community.

Transformative effects of Aboriginal health placements for medical, nursing, and allied health students: A systematic review.

The aim of the present systematic review was to investigate whether placements in Aboriginal health affect the self-perceived skill in working in Aboriginal health settings and career aspirations of health students, and in particular, aspects of the placement that had the greatest impact. The Embase, Cinahl, ProQuest, Scopus, Informit, Ovid MEDLINE, PsychINFO, and PubMed databases were searched in April/May 2016. Placements of at least 1 week duration in an Aboriginal health setting involving Australian students of medical, nursing, dentistry, or allied health disciplines, with outcomes relating to changes in students' knowledge, attitudes, and/or career aspirations, were included. The search retrieved 1351 papers. Fourteen studies were eligible for inclusion in this review. Narrative synthesis found that work placements in Aboriginal health increased understanding and awareness of Aboriginal culture, promoted deeper understanding of Aboriginal health determinant complexity, increased awareness of everyday racism toward Aboriginal Australians, and enhanced desire to work in Aboriginal health. There is a need for improved teaching and learning scholarship to understand whether placements improve students' skill working with Aboriginal people in health care or increase the likelihood of future employment in these settings.

Is Aboriginal nutrition a priority for local government? A policy analysis.

OBJECTIVE: The present study aimed to explore how Australian local governments prioritise the health and well-being of Aboriginal populations and the extent to which nutrition is addressed by local government health policy. DESIGN: In the state of Victoria, Australia, all seventy-nine local governments' public health policy documents were retrieved. Inclusion of Aboriginal health and nutrition in policy documents was analysed using quantitative content analysis. Representation of Aboriginal nutrition 'problems' and 'solutions' was examined using qualitative framing analysis. The socio-ecological framework was used to classify the types of Aboriginal nutrition issues and strategies within policy documents. SETTING: Victoria, Australia. SUBJECTS: Local governments' public health policy documents (n 79). RESULTS: A small proportion (14 %, n 11) of local governments addressed Aboriginal health and well-being in terms of nutrition. Where strategies aimed at nutrition existed, they mostly focused on individual factors rather than the broader macroenvironment. CONCLUSIONS: A limited number of Victorian local governments address nutrition as a health issue for their Aboriginal populations in policy documents. Nutrition needs to be addressed as a community and social responsibility rather than merely an individual 'behaviour'. Partnerships are required to ensure Aboriginal people lead government policy development.

Sectoral system capacity development in health promotion: evaluation of an Aboriginal nutrition program.

Issue addressed The study examined effective ways to build the capacity of health organisations and professionals in the public health sector to reduce Aboriginal chronic disease risk factors. It investigated the capacity-building strategies of the Victorian Aboriginal Community Controlled Health Organisation (VACCHO) nutrition team in the facilitation of the statewide implementation of the Victorian Aboriginal Nutrition and Physical Activity Strategy 2009-2014 (VANPAS). Methods Using a qualitative design, the study analysed the VACCHO program from 2009-2014 across five domains of capacity development: workforce, resources, organisations, partnerships and leadership. Data were sourced from archival program documents and 62 semi-structured participant interviews. Results Diverse Aboriginal and non-Aboriginal professional, organisation representatives and community participants engaged in the implementation of the VANPAS. The VACCHO team used the VANPAS to solidify participant buy-in, strengthen workforce effectiveness, increase health promotion and resource appropriateness, improve organisational policy and build an evidence-base through collaborative dialogue using action-reflection principles. Conclusion A credible, high-profile Aboriginal community led and evidence-based statewide program and a commitment to dialogue through action-reflection provided a meaningful basis for both Aboriginal community and mainstream organisational engagement. Upon this foundation, the VACCHO team built a coherent sectoral system with increased capacity to enhance the nutrition of Aboriginal Victorians. So what? In an historical context of mistrust and unmet expectations, program implementation methods that build confidence amongst collaborating Aboriginal and non-Aboriginal health agencies is fundamental to building capacity to enhance Aboriginal nutrition and health.

Establishing health-promoting workplaces in Aboriginal community organisations: healthy eating policies.

Aboriginal community controlled health organisations (ACCHOs) and cooperatives function at the centre of community life for local Aboriginal people across Victoria. Local Aboriginal people govern them, work within them as managers and service providers, access health and community services from them and form the constituents who determine their directions. Victorian ACCHOs reflect the unique characteristics of the local Aboriginal community. Thus, potentially, Victorian ACCHOs are key strategic sites for health promotion activities that seek to establish and nurture healthy community, family and peer norms. The Victorian Aboriginal Community Controlled Health Organisation (VACCHO) partnered five metropolitan, regional and rural ACCHOs in a pilot project towards the establishment of healthy food policies and practices in their organisations. Project activities combined both 'top-down' policy-oriented and 'bottom-up' practice-oriented strategies. This paper, drawing upon both baseline and follow-up quantitative and qualitative data, describes initiatives leading to increases in healthy catering choices and related challenges for Aboriginal workplace health promotion practice.

Feltman: evaluating the acceptability of a diabetes education tool for Aboriginal health workers.

There is an urgent need to address the lack of Aboriginal-specific diabetes prevention and management resources. Following consultation with Victorian Aboriginal health workers, the Victorian Aboriginal Community Controlled Health Organisation and Diabetes Australia - Victoria developed 'Feltman', a life-sized felt body showing the main organs involved in the digestion and metabolism of food, and the main parts of the body affected by diabetes. Feltman was distributed to all Victorian Aboriginal Community Controlled Health Organisations and an additional 32 Victorian organisations. In total, 276 people from 57 organisations were trained to use Feltman. An online evaluation survey was developed and sent to all people who were trained to use Feltman in Victoria. Sixty-six people completed the survey. All respondents agreed Feltman was an appropriate tool for the Aboriginal community, 89% of health workers felt more confident in their ability to discuss diabetes with their community but would like further training to maintain skills and confidence and 70% of workers had used Feltman with the community. Qualitative feedback noted its strength as a highly visual resource that was popular with the Aboriginal community. Workers reported that Feltman was a highly acceptable diabetes education resource, which they believed had increased knowledge and improved the management of diabetes among clients.

Sharing the tracks to good tucker: identifying the benefits and challenges of implementing community food programs for Aboriginal communities in Victoria.

Food insecurity is a significant issue in the Victorian Aboriginal population, contributing to the health disparity and reduced life expectancy. Community food programs are a strategy used to minimise individual level food insecurity, with little evidence regarding their effectiveness for Aboriginal populations. The aim of this study was to explore the role of community food programs operating for Aboriginal people in Victoria and their perceived influence on food access and nutrition. Semistructured interviews were conducted with staff (n=23) from a purposive sample of 18 community food programs across Victoria. Interviews explored the programs' operation, key benefits to the community, challenges and recommendations for setting up a successful community food program. Results were analysed using a qualitative thematic approach and revealed three main themes regarding key factors for the success of community food programs: (1) community food programs for Aboriginal people should support access to safe, affordable, nutritious food in a socially and culturally acceptable environment; (2) a community development approach is essential for program sustainability; and (3) there is a need to build the capacity of community food programs as part of a strategy to ensure sustainability. Community food programs may be an effective initiative for reducing food insecurity in the Victorian Aboriginal population.

A Different View of Health Information Technology Workarounds in Critical Care.

When health information technology (HIT) was introduced into the hospital setting there was an obvious disruption to nursing workflow. In many cases it took a nurse extra steps or extra time to complete processes such as clinical documentation and medication administration. In response to HIT problems, nurses developed workarounds. Research on nursing workarounds has been hindered by a lack of variable definitions, measures and research models. This paper offers the results of an exploratory mixed methods study that proposes definitions for workarounds and describes the variable relationships with turbulence and patient safety in critical care.