Aboriginal families living with MJD in remote Australia: questions of access and equity.

Managing genetic disease using medically assisted reproductive technology is increasingly promoted as a feasible option, given revolutionary advances in genomics. Far less attention has been directed to the issue of whether there is equitable access to this option. Context and circumstance determine equitable access; however, reporting has drawn overwhelmingly from affluent Anglo-western populations in developed countries. The experiences of poorer, less educated subpopulations within affluent countries and populations in less developed countries are underreported. The ability of consumers to understand the opportunities and risks of medically assisted reproductive technology is likewise not well described in the literature despite significant technological complexity and evidence that genetic disease may be overrepresented within some disadvantaged population groups.Equity is achieved by identifying barriers and allocating appropriate resources to enable understanding and access. In the case of utilising medically assisted technology, social and power relationships, regulations, and the presumptions of authority figures and policymakers reduce equitable access. Physical or cultural marginalisation from mainstream health services may result in reduced access to genetic and prenatal testing, in-vitro fertilisation and genetic screening of embryos necessary for medically assisted reproduction. Cost and regulatory frameworks can likewise limit opportunities to engage with services. Moreover, the quality of the information provided to prospective users of the technology and how it is received governs understanding of prevention and inhibits adequately informed choice.Best practice care and adequately informed choice can only be achieved by conscientiously attending to these accessibility issues. Deep engagement with at-risk people and critical reflection on mainstream accepted standpoints is required. This paper outlines issues associated with engaging with medically assisted reproduction encountered by Aboriginal families living with Machado-Joseph Disease in some of the most remote areas of Australia. It is the right of these families to access such technologies regardless of where they live. Current barriers to access raise important questions for service providers with implications for practice as new technologies increasingly become part of standard medical care.

Feasibility and impact of a physical activity and lifestyle program for Aboriginal families with Machado-Joseph disease in the Top End of Australia.

INTRODUCTION: Physical activity and lifestyle programs are scarce for people with hereditary ataxias and neurodegenerative diseases. Aboriginal families in the Top End of Australia who have lived with Machado-Joseph disease (MJD) for generations co-designed a physical activity and lifestyle program called the Staying Strong Toolbox. The aim of the present study was to explore feasibility and impact of the program on walking and moving around. METHODS: A mixed-methods, multiple case study design was used to pilot the Staying Strong Toolbox. Eight individuals with MJD participated in the program for 4 weeks. Participants tailored their own program using the Toolbox workbook. Families, support workers and researchers facilitated each individual's program. Feasibility was determined through program participation, adherence, coinciding or serious adverse events, participant acceptability and cost. Impact was determined through measures of mobility, ataxia, steps, quality of life, wellbeing and goal attainment, assessed before and after the program. RESULTS: All participants completed the program, averaging five activity sessions per week, 66 minutes per session, of walking (63.5%), strengthening/balance-based activities (16%), cycling (11.4%) and activities of daily living, cultural and lifestyle activities (10.5%). Seven participants were assessed on all measures on three occasions (baseline, pre-program and post-program), while one participant could not complete post-program measures due to ceremonial responsibilities. All had significant improvements in mobility, steps taken and ataxia severity (p<0.05) after the program. Quality of life and wellbeing were maintained. CONCLUSION: The program helped participants remain 'strong on the inside and outside'. Participants recommended implementation in 4-week blocks and for the program to be shared internationally. The Staying Strong Toolbox program was feasible for families with MJD. The program had a positive impact on walking and moving around, with participants feeling stronger on the outside (physically) and inside (emotionally, spiritually, psychosocially). The program could be adapted for use by other families with MJD.

Indigenous traumatic brain injury research: responding to recruitment challenges in the hospital environment.

BACKGROUND: Hospitals are common recruitment sites for injury and disability studies. However, the clinical and rehabilitation environment can create unique challenges for researchers to recruit participant populations. While there is growing injury and disability focused research involving Indigenous people to understand the types of services and supports required by this population to enhance their recovery experiences, there is limited knowledge of researchers' experiences implementing recruitment processes in the tertiary hospital environment. This paper reflects on the specific challenges of recruiting Indigenous patients following a traumatic brain injury from two tertiary hospitals in Northern Australia. METHODS: Between July 2016 and April 2018, research staff recruited eligible patients from one hospital in Queensland and one hospital in the Northern Territory. Qualitative records summarising research staff contact with patients, family members and clinical hospital staff were documented. These qualitative records, in addition to field trip notes and researcher reflections were reviewed to summarise the main challenges in gaining access to patients who fit the eligibility criteria. RESULTS: During the recruitment process, there were five main challenges encountered: (1) Patients discharging against medical advice from hospital; (2) Discharge prior to formal emergence from Post Traumatic Amnesia as per the Westmead Post Trauma Amnesia Scale; (3) Patients under adult guardianship orders; (4) Narrow participant eligibility criteria and (5) Coordinating around patient commitments and treatment. Details of how the recruitment processes were modified throughout the recruitment phase of the study to ensure greater access to patients that met the criteria are described. CONCLUSION: Based on our recruitment experiences, several recommendations are proposed for future TBI studies with Indigenous Australians. In addition to treatment, Indigenous TBI patients have wide range of needs that must be addressed while in hospital. Patient engagement and data collection processes should be flexible to respond to patient needs and the hospital environment. Employment of a centralized recruiter at each hospital site may help to minimise the challenges researchers need to navigate in the hospital environment. To improve recruitment processes in hospitals, it is essential for researchers examining other health or injury outcomes to describe their recruitment experiences.

"Need Everyone Helping to Keep Off Because Everyone Helping to Keep On" - Reducing Harms from Cannabis use in Remote Indigenous Australian Communities Involves More Than Just Users.

BACKGROUND: Heavy cannabis use in remote Indigenous Australian communities potentially contributes to existing health disparities. Community members' perceptions of cannabis harms will support harm-minimization in these settings. OBJECTIVE: To describe perceived cannabis harms reported by a cohort of Indigenous Australians living in small, isolated communities as an indication of their existing resources for change. METHOD: Inductive thematic analysis of 407 semi-structured interviews with participants in a cohort study in three remote communities in Cape York in far north Queensland (Australia) revealed major areas of concern about cannabis. Three attitudinal categories were defined according to reported cannabis impacts and urgency for change: 1- "LOW CONCERN" said cannabis was a low priority community issue; 2- "SOME CONCERN" tolerated cannabis use but identified personal or community-level concerns; and 3- "HIGH CONCERN" expressed strong aversion to cannabis and identified serious personal or community-level harms. The characteristics and the patterns of concerns were summarized across the groups. RESULTS: "Category 1- LOW CONCERN" (n = 107), mostly current users, emphasized personal "financial impacts" and "stress." "Category 2 - SOME CONCERN" (n = 141) perceived community level impacts warranting systematic action, particularly on "employment"; and "Category 3 - HIGH CONCERN" (n = 159), most of the never users, emphasized concerns for families and youth. Irrespective of use history, the cohort reported financial and abstinence-related stress, overlapping alcohol issues and generally endorsed alleviating impacts on children and youth. CONCLUSION: Nearly ubiquitous experience with cannabis harms and impacts in this cohort suggests resources for harm reduction including family and cultural obligation, stress relief, financial management, and engagement are available across all community members, not just users.

A village-matched evaluation of providing a local supplemental food during pregnancy in rural Bangladesh: a preliminary study.

BACKGROUND: Prenatal balanced protein energy supplementation consumed by undernourished women improves mid-upper arm circumference in early infancy. This study aimed to identify whether locally produced maternal food-based supplementation improved anthropometric measures at birth and early infancy. METHODS: A village-matched evaluation, applying principles of a cluster randomised controlled trial, of a locally produced supplemental food to 87 undernourished pregnant women. 12 villages (intervention: n = 8; control: n = 4) in Pirganj sub-district, Rangpur District, northern Bangladesh. Daily supplements were provided. RESULTS: Anthropometric data at birth were available for 77 mother-infant dyads and longer-term infant growth data for 75 infants. Mid-upper arm circumference (MUAC) was significantly larger in infants of mothers in the intervention group compared with the control group at 6 months (p < 0.05). The mean birth weight in babies of supplemented mothers (mean: 2·91 kg; SD: 0·19) was higher than in babies of mothers in the control group (mean: 2·72 kg; SD: 0·13), and these changes persisted until 6 months. Also, the proportion of low birth weight babies in the intervention group was much lower (event rate = 0.04) than in the control group (event rate = 0.16). However, none of these differences were statistically significant (p > 0·05; most likely due to small sample size). The intervention reduced the risk of wasting at 6 months by 63.38% (RRR = 0.6338), and of low birth weight by 88·58% (RRR = 0.8858), with NNT of 2.22 and 6.32, respectively. Only three pregnant women require this intervention in order to prevent wasting at 6 months in one child, and seven need the intervention to prevent low birth weight of one child. CONCLUSIONS: Locally produced food-based balanced protein energy supplementation in undernourished pregnant women in northern Bangladesh resulted in larger MUAC in infants at 6 months. Further research, with larger sample sizes, is required to confirm the role of locally produced supplementation for undernourished pregnant women on weight and linear growth in newborns and infants. TRIAL REGISTRATION: This research was registered with the ISRCTN registry (ISRCTN97447076). This project had human research ethical approval from the James Cook University (Australia) Ethics committee (H4498) and the Bangladesh Medical Research Council (BMRC/NREC/2010-2013/58).

Injuries and alcohol management plans in remote Indigenous communities: a two-community comparison.

To curb high rates of alcohol-related violence and injury in Indigenous communities, alcohol management plans (AMPs) were implemented in 2002-2003 and tightened in 2008. This project compares injury presentations and alcohol involvement from two Indigenous Cape York communities, one that entered full prohibition and one that did not. Aclinical file audit was performed for the period 2006-2011, capturing changes in alcohol availability. Medical files were searched for injury presentation documenting type of injury, cause of injury (including alcohol), date of injury and outcomes of all presenting injuries for the time period 1 January 2006 to 31 December 2011, capturing the major changes of the 2008 AMP restrictions. Findings indicated injury presentation rates were higher in both communities before prohibition than afterwards andreduction was more pronounced in community 2 (prohibition). Ongoing research is imperative, as this area is characterised by a near-absence of evidence.

A longitudinal observation study assessing changes in indicators of serious injury and violence with alcohol controls in four remote indigenous Australian communities in far north Queensland (2000-2015).

BACKGROUND: Legal restrictions on alcohol availability have been used to address violence and injury in the world's remote Indigenous communities. In Australia, alcohol management plans (AMPs) were implemented by the Queensland Government in 2002. This study reports changes in indicators of alcohol-related violence and injury in selected communities. METHODS: Design and setting: A longitudinal observational study was conducted in four Aboriginal and Torres Strait Islander (Indigenous) communities in Cape York, far north Queensland. All communities are similarly-isolated from population centres where alcohol is available. DATA: For 2000 to 2015 inclusive: 1019 Royal Flying Doctor Service aeromedical trauma retrievals; 5641 Queensland Police Service records of unique assault occurrences, including 2936 involving alcohol; and records for 2741 unique assault victims were examined. DATA ANALYSIS: Rates (per 1000 population) of trauma retrievals, assault occurrences and assault victims (per 1000 population) were compared across three policy phases. Phase 1: 2000 to 2008. Initial restrictions on possession and consumption of alcohol in 'restricted areas' were implemented during 2002-2003. Phase 2: 2009 to 2012. All alcohol was prohibited in three study communities and its legal availability limited in the fourth from 2009. Phase 3: 2013 to 2015. Government reviews of AMP policies in light of legal challenges and community responses characterise this phase. RESULTS: Compared with Phase 1, in Phase 2 retrieval rates declined by - 29.4%, assault occurrences by - 34.1% with less than one-third involving alcohol, and assault victims by - 21.1%, reaching historically low levels in 2010-2012. These reductions did not continue consistently. Compared with Phase 1, in Phase 3 retrieval rates, assault occurrence rates and assault victim rates declined by somewhat lesser amounts, - 13.9%, - 15.0% and - 13.4%, respectively. In Phase 3, the proportion of assault occurrences involving alcohol in communities 2, 3 and 4 rose towards pre-2008 levels. CONCLUSIONS: Early successes of these controversial alcohol restrictions are jeopardised. Indicators of violence and injury appear to be rising once more in some AMP communities. Importantly, rates have not generally exceeded the highest levels seen in Phase 1. Fresh policy action is required with rigorous monitoring to prevent erosion of initial important successes.

Cultural challenges when developing anti-tobacco messages for Indigenous Australians.

Recently, many programs have been funded to tackle Indigenous Australian smoking. This study assessed what challenges and unexpected responses could occur when developing anti-tobacco messages for Indigenous communities. A cross-sectional telephone survey of organizations involved in making anti-tobacco messages for the target population was conducted in 2012-2013. Open-ended questions explored cultural challenges to message development and unexpected outcomes. Responses were noted and these qualitative data were independently coded by two researchers using an inductive analysis. Non-parametric tests explored associations between organization orientation, whether target group feedback about messages was sought (pre-tests) and the presence of the above factors. The 47 organizations represented included: 22 Aboriginal Medical Services (AMS), 13 government organizations (GO), eight non-government organizations (NGO) and four universities. The response rate was 83%. Cultural challenges were reported equally by organizations oriented towards Aboriginal communities and those oriented towards the general population. Organizations conducting target group pre-tests of the messages were more likely to report cultural challenges (p = 0.002). Four main themes were revealed: the diversity of Aboriginal and Torres Strait Islander cultures; the selection of role models; conflicts and delays; and unexpected outcomes. Nearly 60% of organizations reported better-than-expected outcomes e.g. community appreciation and pride. A further 40% reported negative responses, e.g. messages being misunderstood or confronting. Cultural challenges and unexpected outcomes are reported by Australian organizations when developing anti-tobacco messages for Indigenous Australians warranting attention to improve the salience of anti-tobacco messages for Indigenous peoples.NB. In this paper, Indigenous Australians is a term used to refer to Aboriginal and Torres Strait Islander peoples, the first inhabitants of Australia. No offence is intended. The authors acknowledge and respect that Aboriginal and Torres Strait Islander people are diverse populations with different language and cultural groups.

The role of seasonality on the diet and household food security of pregnant women living in rural Bangladesh: a cross-sectional study.

OBJECTIVE: To investigate the association of seasonality with dietary diversity, household food security and nutritional status of pregnant women in a rural district of northern Bangladesh. DESIGN: A cross-sectional study was conducted from February 2013 to February 2015. Data were collected on demographics, household food security (using the Household Food Insecurity Access Scale), dietary diversity (using the women's dietary diversity questionnaire) and mid-upper arm circumference. Descriptive statistics were used to explore demographics, dietary diversity, household food security and nutritional status, and inferential statistics were applied to explore the role of seasonality on diversity, household food security and nutritional status. SETTING: Twelve villages of Pirganj sub-district, Rangpur District, northern Bangladesh. SUBJECTS: Pregnant women (n 288). RESULTS: Seasonality was found to be associated with dietary diversity (P=0·026) and household food security (P=0·039). Dietary diversity was significantly lower in summer (P=0·029) and spring (P=0·038). Food security deteriorated significantly in spring (P=0·006) and late autumn (P=0·009). CONCLUSION: Seasons play a role in women's household food security status and dietary diversity, with food security deteriorating during the lean seasons and dietary diversity deteriorating during the second 'lesser' lean season and the season immediately after. Interventions that aim to improve the diet of pregnant women from low-income, subsistence-farming communities need to recognise the role of seasonality on diet and food security and to incorporate initiatives to prevent seasonal declines.

Alcohol management plans in Aboriginal and Torres Strait Islander (Indigenous) Australian communities in Queensland: community residents have experienced favourable impacts but also suffered unfavourable ones.

BACKGROUND: In Australia, 'Alcohol Management Plans' (AMPs) provide the policy infrastructure for State and Commonwealth Governments to address problematic alcohol use among Aboriginal and Torres Strait Islanders. We report community residents' experiences of AMPs in 10 of Queensland's 15 remote Indigenous communities. METHODS: This cross-sectional study used a two-stage sampling strategy: N = 1211; 588 (48%) males, 623 (52%) females aged ≥18 years in 10 communities. Seven propositions about 'favourable' impacts and seven about 'unfavourable' impacts were developed from semi-structured interviews. For each proposition, one-sample tests of proportions examined participant agreement and multivariable binary logistic regressions assessed influences of gender, age (18-24, 25-44, 45-64, ≥65 years), residence (≥6 years), current drinking and Indigenous status. Confirmatory factor analyses estimated scale reliability (ρ), item loadings and covariances. RESULTS: Slim majorities agreed that: AMPs reduced violence (53%, p = 0.024); community a better place to live (54%, 0.012); and children were safer (56%, p < 0.001). More agreed that: school attendance improved (66%, p < 0.001); and awareness of alcohol's harms increased (71%, p < 0.001). Participants were equivocal about improved personal safety (53%, p = 0.097) and reduced violence against women (49%, p = 0.362). The seven 'favourable' items reliably summarized participants' experiences of reduced violence and improved community amenity (ρ = 0.90). Stronger agreement was found for six 'unfavourable' items: alcohol availability not reduced (58%, p < 0.001); drinking not reduced (56%, p < 0.001)); cannabis use increased (69%, p < 0.001); more binge drinking (73%, p < 0.001); discrimination experienced (77%, p < 0.001); increased fines, convictions and criminal records for breaching restrictions (90%, p < 0.001). Participants were equivocal (51% agreed, p = 0.365) that police could enforce restrictions effectively. 'Unfavourable' items were not reliably reflected in one group (ρ = 0.48) but in: i) alcohol availability and consumption not reduced and ii) criminalization and discrimination. In logistic regressions, longer-term (≥ 6 years) residents more likely agreed that violence against women had reduced and that personal safety had improved but also that criminalization and binge drinking had increased. Younger people disagreed that their community was a better place to live and strongly agreed about discrimination. Current drinkers' views differed little from the sample overall. CONCLUSIONS: The present Government review provides an opportunity to reinforce 'favourable' outcomes while targeting: illicit alcohol, treatment and diversion services and reconciliation of criminalization and discrimination issues.

Queensland Alcohol-related violence and Night Time Economy Monitoring project (QUANTEM): a study protocol.

BACKGROUND: Alcohol-related harm is a substantial burden on the community in Australia and internationally, particularly harm related to risky drinking practices of young people in the night-time economy. This protocol paper describes a study that will report on the changes in a wide range of health and justice outcome measures associated with major policy changes in the state of Queensland, Australia. A key element includes trading hours restrictions for licensed premises to 2 am for the state and 3 am in Safe Night Precincts (SNPs). Other measures introduced include drinks restrictions after midnight, increased patron banning measures for repeat offenders, mandatory ID scanning of patrons in late-night venues, and education campaigns. METHODS: The primary aim of the study is to evaluate change in the levels of harm due to these policy changes using administrative data (e.g., police, hospital, ambulance, and court data). Other study elements will investigate the impact of the Policy by measuring foot traffic volume in SNPs, using ID scanner data to quantify the volume of people entering venues and measure the effectiveness of banning notices, using patron interviews to quantify the levels of pre-drinking, intoxication and illicit drug use within night-time economy districts, and to explore the impacts of the Policy on business and live music, and costs to the community. DISCUSSION: The information gathered through this project aims to evaluate the effectiveness of the Policy and to draw on these findings to inform future prevention and enforcement approaches by policy makers, police, and venue staff.

Is population flow an unintended consequence of alcohol management plans?

AIMS AND OBJECTIVES: The aim of this study was to gauge whether, and to what extent, population flow occurred as a result of the implementation of alcohol management plans in Indigenous communities. BACKGROUND: Alcohol management plans involving carriage limits and dry places were introduced into 15 Queensland Indigenous communities between 2002-2004. Controls on alcohol availability were further tightened between 2008-2010, seeing the closure of eight mainly remote community taverns/canteens. DESIGN: A retrospective observational study was undertaken using data from the Queensland Injury Surveillance Unit. METHODS: Population flow was measured by changing patterns of alcohol-related injuries in a mining region near dry Indigenous communities following the introduction of alcohol management plans and a control mining region distant from Indigenous communities with alcohol management plans. Data were analysed using descriptive and inferential statistics. Logistic regression was used for the comparison of the characteristics between the emergency department presentations. The rates of alcohol-related injury presentations per 1000/population were calculated and age-standardised to the Australian population. RESULTS: Between the five-year periods 2003-2007 and 2008-2012, alcohol-related injury presentations to the Mount Isa emergency department trebled from an age-adjusted average annual rate of 9·5/1000 in the region's population to 27·1/1000 population. In the control region, alcohol-related emergency department injury presentations did not increase to the same degree with age-adjusted average annual rates of 1·42/1000 and 2·21/1000, respectively. CONCLUSIONS: The 10-year pattern of emergency department presentations for alcohol-related injuries increased significantly in the Mount Isa region compared with the control region. Further research should investigate the impacts of population flow related to Indigenous community alcohol management plans. RELEVANCE TO CLINICAL PRACTICE: Although initiatives such as alcohol management plans have been implemented to reduce alcohol use and related consequences in Indigenous communities, there needs to be a greater consideration of the impact of these policies in nearby towns in the future.

Getting over the shock: taking action on Indigenous maternal smoking.

Smoking rates are slow to decline among pregnant Indigenous women. One in two pregnant Indigenous Australian women is a tobacco smoker compared with one in eight in the non-Indigenous population. The National Close the Gap strategy ambitiously aims to reduce Indigenous smoking prevalence to half by 2018, but this goal is unlikely to be achieved. Evidence is growing to better inform targeted strategies for Indigenous pregnant women based on national and international studies. It is proposed to be an appropriate time to refine translational approaches for anti-tobacco messages and cessation support in this population, rather than waiting for further empirical research before making these essential changes. Systemic barriers to Indigenous pregnant women receiving equitable primary health care have been identified, are remediable, and urgently require addressing. These barriers include: (1) lack of subsidised access to suitable oral forms of nicotine replacement therapy; (2) lack of clinician training in the complex area of management of maternal Indigenous smoking; and (3) lack of targeted health promotion programs addressing the psychosocial challenges that Indigenous women face. In the interim, translational strategies to target tobacco control and cessation in pregnant Indigenous women need to be based on current evidence.

A Review of Trends in Indigenous Australian Tobacco Research (From 2004 to 2013), its Associated Outputs and Evidence of Research Translation.

INTRODUCTION: Smoking prevalence among Indigenous Australians nationally (45%) is more than double that of other Australians but ranges up to 82% in remote communities, causing significant health disparities. This paper examines trends in peer-reviewed research outputs related to Indigenous Australian tobacco control over the past decade and describes their research translation potential and alignment with national and jurisdictional policy priorities. METHODS: Systematic searches of electronic databases were conducted: Medline, CINAHL, Cochrane Systematic Reviews, PsychInfo, and Australian HealthInfoNET for English-language peer-reviewed publications (2004-2013) primarily focusing on Indigenous Australian tobacco use. Publications were categorized by types, topics, and geographic location. Following established procedures, "reviews" and "commentaries" were distinguished from "original research," the latter further classified as "measurement," "descriptive," or "intervention" studies. Research translation categories used were: "synthesis," "dissemination," "exchange," and "application." RESULTS: The majority of 78 publications meeting selection criteria focused on cessation treatment (28%), monitoring and prevalence (24%) and passive smoking (13%). "Original research" was mostly "descriptive/epidemiologic" (81%) with few "intervention" studies (9%). Many studies were in remote communities. Components of research translation were identified in 50% of the publications with little evidence of dissemination strategies. CONCLUSION: Remote community populations are an area of great need. However, generally it is disappointing that since 2004, few intervention studies are available to guide efforts to reduce tobacco-related health disparities. Stronger and more immediate alignment of policy with research that contributes to the evidence-base is required together with more systematic use of research dissemination translation strategies to better match evidence with priorities which may develop rapidly over time.

The effect of balanced protein energy supplementation in undernourished pregnant women and child physical growth in low- and middle-income countries: a systematic review and meta-analysis.

The beneficial effect of balanced protein energy supplementation during pregnancy on subsequent child growth is unclear and may depend upon the mother entering pregnancy adequately nourished or undernourished. Systematic reviews to-date have included studies from high-, middle- and low-income countries. However, the effect of balanced protein energy supplementation should not be generalised. This review assesses the effect of balanced protein energy supplementation in undernourished pregnant women from low- and middle-income countries on child growth. A systematic review of articles published in English (1970-2015) was conducted via MEDLINE, Scopus, the Cochrane Register and hand searching. Only peer-reviewed experimental studies analysing the effects of balanced protein energy supplementation in undernourished pregnant women from low- and middle-income countries with measures of physical growth as the primary outcome were included. Two reviewers independently assessed full-text articles against inclusion criteria. Validity of eligible studies was ascertained using the Quality Assessment Tool for Quantitative Studies (EPHPP QAT). In total, seven studies met the inclusion criteria. All studies reported on birthweight, five on birth length, three on birth head circumference, and one on longer-term growth. Standardised mean differences were calculated using a random-effects meta-analysis. Balanced protein energy supplementation significantly improved birthweight (seven randomised controlled trials, n = 2367; d = 0.20, 95% confidence interval, 0.03-0.38, P = 0.02). No significant benefit was observed on birth length or birth head circumference. Impact of intervention could not be determined for longer-term physical growth due to limited evidence. Additional research is required in low- and middle-income countries to identify impacts on longer-term infant growth.

Using a participatory action research framework to listen to Aboriginal and Torres Strait Islander people in Australia about pandemic influenza.

INTRODUCTION: This article describes the use and effectiveness of the participatory action research (PAR) framework to better understand community members' perceptions and risks of pandemic influenza. In 2009, the H1N1 influenza pandemic affected Indigenous populations more than non-Indigenous populations in Oceania and the Americas. Higher prevalence of comorbidities (diabetes, obesity, asthma and chronic obstructive pulmonary disease) as well as pregnancy in Indigenous communities may have contributed to the higher risks of severe disease. Social disparity, institutionalised racism within health services and differences in access to culturally safe health services have also been reported as contributors to disadvantage and delayed appropriate treatment. METHODS: Given these factors and the subsequent impact they had on Australian Aboriginal and Torres Strait Islander communities, the authors set out to ensure that the Australian national, state and territory pandemic plans adequately reflected the risk status of Aboriginal and Torres Strait Islander peoples and promoted meaningful engagement with communities to mitigate this risk. A national study explored the views of Aboriginal and Torres Strait Islander people and their experiences with H1N1 and used a qualitative PAR framework that was effective in gaining deep understandings from participants. Aboriginal and Torres Strait Islander community-controlled organisations and health services were involved in the implementation, interpretation and monitoring of this project. RESULTS: As a result, important features of the implementation of this PAR framework with Aboriginal and Torres Strait Islander communities and organisations emerged. These features included the importance of working in a multidisciplinary team with Aboriginal and Torres Strait Islander researchers; the complexities and importance of obtaining multi-site human research ethics approval processes; the importance and value of building the research capacity of both experienced and novice researchers in PAR; the need to use localised sampling protocols; and the process of undertaking a collective research process and enacting action research and feedback. CONCLUSIONS: The most effective responses of this project were embedded in pre-existing relationships with individuals within organisations that had been established over a long period of time between Aboriginal medical services and investigators; however, research relationships established specifically for the purposes of the project were less successful because of changes in personnel and organisational support. The participatory approach used in this study has the potential to be applied to vulnerable populations in other countries.

Study protocol--resilience in individuals and families coping with the impacts of alcohol related injuries in remote indigenous communities: a mixed method study.

BACKGROUND: Alcohol Management Plans (AMPs) were first implemented by the Queensland Government a decade ago (2002-03). In 2008, further stringent controls were implemented and alcohol was effectively prohibited in some of the affected remote Indigenous communities. With the Queensland Government currently reviewing AMPs, prohibitions may be lifted making alcohol readily available once more in these communities. As yet no work explores the impact of alcohol related injuries in relation to individual, family and community resilience in Indigenous Australians. A resilience model recognises individuals and families for their strengths rather than their deficits. By revealing how some individuals and families survive and thrive, new ways of working with families who need support may be identified and adopted. The research will explore in detail the long-term impact of this kind of injury on individuals, families and communities. METHODS/DESIGN: This project will use a sequential explanatory mixed method design. Four discrete Indigenous communities in Cape York, far north Queensland are included in this program of research, chosen because there is previous data available regarding injury and alcohol related injuries. Four sequential studies will be conducted in order to address the research questions and provide a rich description of the impact of alcohol related injuries and resilience in these populations. The time period January 2006 to December 2011 was chosen because it captures the three years before and three years after 2008 when tight alcohol restrictions were implemented in the four communities. DISCUSSION: Long term effects of the AMPs are as yet unknown and only fragmented attempts to look at the impact of injury related to alcohol have been conducted. A well-structured research program that explores the long-term impact of alcohol related injuries in these communities will help inform policy development to capture the current situation and so that appropriate benchmarking can occur.The project has been approved by the James Cook University Human Research Ethics Committee H5618 & H5241.

Developing anti-tobacco messages for Australian Aboriginal and Torres Strait Islander peoples: evidence from a national cross-sectional survey.

BACKGROUND: Smoking rates in Australian Aboriginal and Torres Strait Islander peoples remain high, with limited impact of government measures for many subgroups. The aim of this cross-sectional study was to investigate differences in organisational practice for developing anti-tobacco messages for these target populations. METHODS: Telephone interviews were conducted with 47 organisation representatives using a structured questionnaire based on health communication and health promotion frameworks. Responses were coded into phases of message development, message types (educational, threat, positive or advocacy), target groups, message recommendations, and evaluations undertaken. Cultural sensitivity for message development was divided into surface structure (use of images, language, demographics) and deep structure (use of socio-cultural values). A categorical principal component analysis explored the key dimensions of the findings and their component relationships. RESULTS: Among organisations interviewed, a community-orientated, bottom-up approach for developing anti-tobacco messages was reported by 47% (n=24); 55% based message development on a theoretical framework; 87% used a positive benefit appeal; 38% used threat messages. More Aboriginal Medical Services (AMSs) targeted youth (p<0.005) and advised smokers to quit (p<0.05) than other types of organisations. AMSs were significantly more likely to report using deep structure in tailoring messages compared with non-government (p<0.05) and government organisations (p<0.05). Organisations that were oriented to the general population were more likely to evaluate their programs (p<0.05). A two-dimensional non-linear principal component analysis extracted components interpreted as "cultural understanding" (bottom-up, community-based approaches, deep structures) and "rigour" (theoretical frameworks, and planned/completed evaluations), and accounted for 53% of the variability in the data. CONCLUSION: Message features, associated with successful campaigns in other populations, are starting to be used for Aboriginal and Torres Strait Islander peoples. A model is proposed to facilitate the development of targeted anti-tobacco messages for Aboriginal and Torres Strait Islander peoples. Organisations could consider incorporating both components of cultural understanding-rigour to enable the growth of evidence-based practice.

Study Protocol--Alcohol Management Plans (AMPs) in remote indigenous communities in Queensland: their impacts on injury, violence, health and social indicators and their cost-effectiveness.

BACKGROUND: In 2002/03 the Queensland Government responded to high rates of alcohol-related harm in discrete Indigenous communities by implementing alcohol management plans (AMPs), designed to include supply and harm reduction and treatment measures. Tighter alcohol supply and carriage restrictions followed in 2008 following indications of reductions in violence and injury. Despite the plans being in place for over a decade, no comprehensive independent review has assessed to what level the designed aims were achieved and what effect the plans have had on Indigenous community residents and service providers. This study will describe the long-term impacts on important health, economic and social outcomes of Queensland's AMPs. METHODS/DESIGN: The project has two main studies, 1) outcome evaluation using de-identified epidemiological data on injury, violence and other health and social indicators for across Queensland, including de-identified databases compiled from relevant routinely-available administrative data sets, and 2) a process evaluation to map the nature, timing and content of intervention components targeting alcohol. Process evaluation will also be used to assess the fidelity with which the designed intervention components have been implemented, their uptake and community responses to them and their perceived impacts on alcohol supply and consumption, injury, violence and community health. Interviews and focus groups with Indigenous residents and service providers will be used. The study will be conducted in all 24 of Queensland's Indigenous communities affected by alcohol management plans. DISCUSSION: This evaluation will report on the impacts of the original aims for AMPs, what impact they have had on Indigenous residents and service providers. A central outcome will be the establishment of relevant databases describing the parameters of the changes seen. This will permit comprehensive and rigorous surveillance systems to be put in place and provided to communities empowering them with the best credible evidence to judge future policy and program requirements for themselves. The project will inform impending alcohol policy and program adjustments in Queensland and other Australian jurisdictions.The project has been approved by the James Cook University Human Research Ethics Committee (approval number H4967 & H5241).

Influence of Rurality on Oral Cancer Trends among Organisation for Economic Co-Operation and Development (OECD) Member Countries-A Scoping Review.

Oral cancer is the general term used to describe cancers of the oral cavity and oropharyngeal region. These cancers are one of the leading causes of death in elderly residents within the Organisation for Economic Co-operation and Development (OECD) member countries in the 21st century. This scoping review was carried out to assess the influence of rurality on oral cancer trends and patterns among OECD member countries. Four online databases (Medline, PubMed, Scopus, and CINAHL) were searched for studies that reported on oral cancer trends in rural and remote areas in OECD member countries. A total of 1143 articles were obtained initially; among them, 995 papers were screened to include 18 articles for this scoping review. Studies have reported increasing incidence and prevalence in the United States, Australia, Canada, and European countries wherein risk factors such as tobacco, alcohol, and human papilloma virus (HPV) infections were associated with oral and oropharyngeal cancers. Awareness among people living in rural areas about HPV-related cancers was very low, while rates of tobacco and alcohol abuse were noted to be rising more rapidly than among their urban counterparts. Furthermore, the ageing population was most affected compared to the younger age groups of people with oral and oropharyngeal cancer that are prevalent in these regions. Overall, despite living in developed countries, rurality was noted to be a significant factor in the lower life expectancy of oral cancer patients, mainly due to the limited accessibility to tertiary cancer care centres and advanced medical care.