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

INTRODUCTION

Aboriginal Australians face significant health disparities, with hospitalisation rates 2.3 times greater, and longer hospital length of stay, than non-Indigenous Australians. This additional burden impacts families further through out-of-pocket healthcare expenditure (OOPHE), which includes additional healthcare expenses not covered by universal taxpayer insurance. Aboriginal patients traveling from remote locations are likely to be impacted further by OOPHE. The objective of this study was to examine the impacts and burden of OOPHE for rurally based Aboriginal individuals.

METHODS

Participants were recruited through South Australian community networks to participate in this study. Decolonising methods of yarning and deep listening were used to centralise local narratives and language of OOPHE. Qualitative analysis software was used to thematically code transcripts and organise data.

RESULTS

A total of seven yarning sessions were conducted with 10 participants. Seven themes were identified: travel, barriers to health care, personal and social loss, restricted autonomy, financial strain, support initiatives and protective factors. Sleeping rough, selling assets and not attending appointments were used to mitigate or avoid OOPHE. Government initiatives, such as the patient assistance transport scheme, did little to decrease OOPHE burden on participants. Family connections, Indigenous knowledges and engagement with cultural practices were protective against OOPHE burden.

CONCLUSION

Aboriginal families are significantly burdened by OOPHE when needing to travel for health care. Radical change of government initiative and policies through to health professional awareness is needed to ensure equitable healthcare access that does not create additional financial hardship in communities already experiencing economic disadvantage.

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

Introduction

Zoonoses are a health concern for Aboriginal and Torres Strait Islander peoples in Australia that face elevated risk of disease related to the environment and animals. Internationally, One Health is encouraged to effectively manage zoonoses by taking integrated approaches involving animal, human, and environmental health sectors to improve health outcomes. However, Australia's health systems manage zoonotic diseases in animals and people separately which does not support a One Health approach. For the effective management of zoonoses, a strong evidence base and database regarding the epidemiology of zoonotic pathogens is needed. However, we currently lack this evidence limiting our understanding of the impact of zoonoses on Aboriginal and Torres Strait Islander populations.

Methods

As a first step towards building the evidence base, we undertook a descriptive analysis of Aboriginal and Torres Strait Islander zoonotic notifications in Australia from 1996 to 2021. We presented notifications as annual notification rates per 100,000 population, and percentages of notifications by state, remoteness, sex, and age group.

Results

Salmonellosis and campylobacteriosis were the most notified zoonoses with the highest annual notification rates of 99.75 and 87.46 per 100,000 population, respectively. The north of Australia (Queensland, Northern Territory and Western Australia), remote and outer regional areas, and young children (0-4 years of age) had the highest percentages of notifications.

Discussion

To our knowledge, these findings are the first national presentation of the epidemiology of zoonoses within Aboriginal and Torres Strait Islander populations. A greater understanding of transmission, prevalence and impact of zoonoses on Aboriginal and Torres Strait Islander peoples (including animal and environmental health factors) is required to inform their effective management through a One Health approach.

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

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

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

OBJECTIVES

To identify and describe chronic disease prevention programs offered by Aboriginal Community Controlled Health Services (ACCHSs) in New South Wales (NSW), Australia.

METHODS

ACCHSs were identified through the Aboriginal Health and Medical Research Council of NSW website. Chronic disease programs were identified from the Facebook page and website of each ACCHS. Characteristics, including regions, target population, condition, health behaviour, modality and program frequency were extracted and summarised.

RESULTS

We identified 128 chronic disease programs across 32 ACCHSs. Of these, 87 (68%) programs were broad in their scope, 20 (16%) targeted youth, three (2%) targeted Elders, 16 (12%) were for females only and five (4%) were for males only. Interventions included physical activity (77, 60%), diet and nutrition (74, 58%), smoking (70, 55%), and the Aboriginal and Torres Strait Islander Health Check (44, 34%), with 93 programs (73%) of ongoing duration.

CONCLUSIONS

Chronic disease prevention programs address chronic conditions by promoting physical activity, diet and nutrition, smoking cessation and health screening. Most target the general Aboriginal community, a few target specific groups based on gender and age, and more than one-quarter are time-limited. Implications for public health: Chronic disease programs that are co-produced with specific groups, based on age and gender, may be needed.

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

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

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

In recent decades, several studies have emphasized sense of personal control as a prominent aspect of Aboriginal health. However, one limitation is that instruments available to measure personal control were originally developed in western countries and validation for Aboriginal Australians has not been conducted. The aims of the current study were to evaluate whether the Sense of Personal Control Scale (SPCS) can be used to obtain culturally unbiased measurement of personal control across Aboriginal and non-Aboriginal Australians and to assess the psychometric properties of the SPCS for Aboriginal and non-Aboriginal Australian.

METHODS

The current study utilized two Australian subsamples retrieved from the Teeth Talk Study (n = 317) and the National Survey of Adult Oral Health 2004-2006 (n = 3,857) in which the SPCS was included. Graphical Loglinear Rasch Models (GLLRM) were used to fulfill the aims of the study.

RESULTS

The Perceived Constraints subscale fitted a GLLRM for Aboriginal Australians after the exclusion of three items, while fit to any Rasch model (RM) or GLLRM model could not be found in the non-Aboriginal sample. The Mastery subscale fitted a GLLRM in the non-Aboriginal sample after the exclusion of one item. In the Aboriginal sample, two items of the Mastery subscale fitted the RM, however, two items cannot be considered as a scale.

CONCLUSION

In the present study, we showed that the development of new items is crucial before the revised SPCS might constitute a valid and reliable measure of sense of personal control in both Aboriginal and non-Aboriginal Australian populations, and it is possible to assess whether the SPCS can be measured without bias across these two populations.

The oral health of Indigenous pregnant women: A mixed-methods systematic review

BACKGROUND

Western models of care to improve the oral health of pregnant women have been successfully implemented in the healthcare setting across various developed countries. Even though Indigenous women experience poorer pregnancy and birth outcomes compared to other women, these models have not been developed with Indigenous communities to address the oral health needs of Indigenous pregnant women. This review aimed to understand the oral health knowledge, practices, attitudes and challenges of Indigenous pregnant women globally.

METHODS

A comprehensive search including six electronic databases and grey literature up to September 2018 was undertaken (PROSPERO Registration Number: 111402). Quantitative and qualitative evidence exploring at least one of the four oral health domains relating to Indigenous pregnant women worldwide, including women pregnant with an Indigenous child, were retrieved.

RESULTS

Eleven publications related to nine studies were included. Indigenous pregnant women's attitudes, practices and challenges relating to their oral health were influenced by socioeconomic and psychosocial factors, and their healthcare context. Availability of dental services varied depending on the healthcare model, whether services were public or private, and whether services met their needs. Although there was little evidence related to oral health knowledge, the literature suggests some misconceptions within this population.

CONCLUSIONS

The availability of culturally appropriate dental services that fulfilled the needs of Indigenous pregnant women varied between developed countries. This review highlighted the need for community-tailored dental services and a care coordinator to provide both education and assistance to those navigating services.

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

BACKGROUND

Foot health of Aboriginal and Torres Strait Islander Australians' has not been established. Additionally, studies have shown that there is a lack of engagement of this population with general preventive foot care services. The aim of this study was to establish foot health in Aboriginal and Torres Strait Islander people attending two recently developed, culturally safe podiatry services in rural and regional New South Wales (NSW), Australia. Secondarily the relationship between self-perceived foot health and some medical and demographic characteristics was investigated.

METHODS

This descriptive cross-sectional study included participants attending the culturally safe foot health care services managed by the University of Newcastle on the Central Coast or in Wellington, both located in NSW, Australia. At the consultation, participants completed the Foot Health Status Questionnaire (FHSQ) with the assistance of an Aboriginal health care worker, underwent basic vascular and neurological screening, and podiatric treatment.

RESULTS

A total of 111 Aboriginal and Torres Strait Islander Australians (48 from the Central Coast, and 63 from Wellington) were included. FHSQ scores for pain (75.7 ± 26.8), function (80.2 ± 25.2), footwear (53.9 ± 33.4), and general foot health (62.0 ± 30.9) were generally good, but below the optimal score of 100. The presence of diabetes (n = 39 of 111 participants or 35.1%) was associated with lower levels of self-perceived foot function (r = - 0.20, n = 107, p = 0.04).

CONCLUSION

We found that community-based foot health care services that are culturally safe are utilised by Aboriginal and Torres Strait Islander Peoples not currently at high risk of foot complications. This supports the use of culturally safe foot care services to improve engagement with preventative foot care. Future research should continue to be driven by Aboriginal and Torres Strait Islander Peoples and investigate ways to implement additional screening measures and undertake prospective evaluation of the impact of such services on health related outcomes in these communities.

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

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

Remote health workforce turnover and retention: what are the policy and practice priorities?

BACKGROUND

Residents of remote communities in Australia and other geographically large countries have comparatively poorer access to high-quality primary health care. To inform ongoing policy development and practice in relation to remote area health service delivery, particularly in remote Indigenous communities, this review synthesizes the key findings of (1) a comprehensive study of workforce turnover and retention in remote Northern Territory (NT) of Australia and (2) a narrative review of relevant international literature on remote and rural health workforce retention strategies. This synthesis provides a valuable summary of the current state of international knowledge about improving remote health workforce retention.

MAIN TEXT

Annual turnover rates of NT remote area nurses (148%) and Aboriginal health practitioners (80%) are very high and 12-month stability rates low (48% and 76%, respectively). In remote NT, use of agency nurses has increased substantially. Primary care costs are high and proportional to staff turnover and remoteness. Effectiveness of care decreases with higher turnover and use of short-term staff, such that higher staff turnover is always less cost-effective. If staff turnover in remote clinics were halved, the potential savings would be approximately A$32 million per annum. Staff turnover and retention were affected by management style and effectiveness, and employment of Indigenous staff. Review of the international literature reveals three broad themes: Targeted enrolment into training and appropriate education designed to produce a competent, accessible, acceptable and 'fit-for-purpose' workforce; addressing broader health system issues that ensure a safe and supportive work environment; and providing ongoing individual and family support. Key educational initiatives include prioritising remote origin and Indigenous students for university entry; maximising training in remote areas; contextualising curricula; providing financial, pedagogical and pastoral support; and ensuring clear, supported career pathways and continuing professional development. Health system initiatives include ensuring adequate funding; providing adequate infrastructure including fit-for-purpose clinics, housing, transport and information technology; offering flexible employment arrangements whilst ensuring a good 'fit' between individual staff and the community (especially with regard to cultural skills); optimising co-ordination and management of services that empower staff and create positive practice environments; and prioritising community participation and employment of locals. Individual and family supports include offering tailored financial incentives, psychological support and 'time out'.

CONCLUSION

Optimal remote health workforce stability and preventing excessive 'avoidable' turnover mandates alignment of government and health authority policies with both health service requirements and individual health professional and community needs. Supportive underpinning policies include: Strong intersectoral collaboration between the health and education sectors to ensure a fit-for-purpose workforce;A funding policy which mandates the development and implementation of an equitable, needs-based formula for funding remote health services;Policies that facilitate transition to community control, prioritise Indigenous training and employment, and mandate a culturally safe work context; andAn employment policy which provides flexibility of employment conditions in order to be able to offer individually customised retention packages There is considerable extant evidence from around the world about effective retention strategies that contribute to slowing excessive remote health workforce turnover, resulting in significant cost savings and improved continuity of care. The immediate problem comprises an 'implementation gap' in translating empirical research evidence into actions designed to resolve existing problems. If we wish to ameliorate the very high turnover of staff in remote areas, in order to provide an equitable service to populations with arguably the highest health needs, we need political and executive commitment to get the policy settings right and ensure the coordinated implementation of multiple strategies, including better linking existing strategies and 'filling the gaps' where necessary.

Service Level Factors Associated with Cervical Screening in Aboriginal and Torres Strait Islander Primary Health Care Centres in Australia

Aboriginal and Torres Strait Islander women have significantly higher cervical cancer incidence and mortality than other Australian women. In this study, we assessed the documented delivery of cervical screening for women attending Indigenous Primary Health Care (PHC) centres across Australia and identified service-level factors associated with between-centre variation in screening coverage. We analysed 3801 clinical audit records for PHC clients aged 20–64 years from 135 Indigenous PHC centres participating in the Audit for Best Practice in Chronic Disease (ABCD) continuous quality improvement (CQI) program across five Australian states/territories during 2005 to 2014. Multilevel logistic regression models were used to identify service-level factors associated with screening, while accounting for differences in client-level factors. There was substantial variation in the proportion of clients who had a documented cervical screen in the previous two years across the participating PHC centres (median 50%, interquartile range (IQR): 29–67%), persisting over years and audit cycle. Centre-level factors explained 40% of the variation; client-level factors did not reduce the between-centre variation. Screening coverage was associated with longer time enrolled in the CQI program and very remote location. Indigenous PHC centres play an important role in providing cervical screening to Aboriginal and Torres Strait Islander women. Thus, their leadership is essential to ensure that Australia’s public health commitment to the elimination of cervical cancer includes Aboriginal and Torres Strait Islander women. A sustained commitment to CQI may improve PHC centres delivery of cervical screening; however, factors that may impact on service delivery, such as organisational, geographical and environmental factors, warrant further investigation.

Health Challenges of the Pacific Region: Insights From History, Geography, Social Determinants, Genetics, and the Microbiome

The Pacific region, also referred to as Oceania, is a geographically widespread region populated by people of diverse cultures and ethnicities. Indigenous people in the region (Melanesians, Polynesians, Micronesians, Papuans, and Indigenous Australians) are over-represented on national, regional, and global scales for the burden of infectious and non-communicable diseases. Although social and environmental factors such as poverty, education, and access to health-care are assumed to be major drivers of this disease burden, there is also developing evidence that genetic and microbiotic factors should also be considered. To date, studies investigating genetic and/or microbiotic links with vulnerabilities to infectious and non-communicable diseases have mostly focused on populations in Europe, Asia, and USA, with uncertain associations for other populations such as indigenous communities in Oceania. Recent developments in personalized medicine have shown that identifying ethnicity-linked genetic vulnerabilities can be important for medical management. Although our understanding of the impacts of the gut microbiome on health is still in the early stages, it is likely that equivalent vulnerabilities will also be identified through the interaction between gut microbiome composition and function with pathogens and the host immune system. As rapid economic, dietary, and cultural changes occur throughout Oceania it becomes increasingly important that further research is conducted within indigenous populations to address the double burden of high rates of infectious diseases and rapidly rising non-communicable diseases so that comprehensive development goals can be planned. In this article, we review the current knowledge on the impact of nutrition, genetics, and the gut microbiome on infectious diseases in indigenous people of the Pacific region.

Aboriginal and Torres Strait Islander patients requiring critical care: characteristics, resource use, and outcomes

OBJECTIVE

To provide a contemporary description of the demographics, characteristics and outcomes of critically ill Indigenous patients in Australia.

DESIGN, SETTING AND PARTICIPANTS

Retrospective database review using the Australian and New Zealand Intensive Care Society Adult Patient Database for intensive care unit (ICU) admissions in 2017-18. Characteristics of critically ill Indigenous patients were compared with non-Indigenous patients.

MAIN OUTCOME MEASURES

Primary outcome was hospital mortality. Secondary outcomes examined demographics and resource use.

RESULTS

Per capita, Indigenous Australians were overrepresented in the intensive care. They were younger (51 v 66 years), more likely to be admitted from outer regional, rural and remote settings (59% v 15%), more likely to require emergency admission (81% v 59%), and had higher rates of mechanical ventilation (35% v 32%; P < 0.01 for all). Indigenous patients were over-represented in the diagnostic categories of sepsis (15% v 9%), trauma (7% v 5%), and respiratory illness (17% v 15%), and had higher rates of ICU re-admission (7% v 5%; P < 0.01 for all). There was no difference in either unadjusted (7.9% for each; P = 0.96) or adjusted (odds ratio, 1.1; 95% CI, 1.0-1.2) in-hospital mortality.

CONCLUSION

Indigenous patients, especially young Indigenous patients, were disproportionately represented in Australian ICUs, particularly for sepsis. The high level of acute illness and high proportion of emergency admissions could be interpreted as representing delayed presentation, which, with a higher re-admission rate, suggest access barriers to health care may exist. Nevertheless, there was no mortality gap between Indigenous and non-Indigenous Australians during a hospital admission for critical illness.

Geographical analysis of evaluated chronic disease programs for Aboriginal and Torres Strait Islander people in the Australian primary health care setting: a systematic scoping review

BACKGROUND

Targeted chronic disease programs are vital to improving health outcomes for Indigenous people globally. In Australia it is not known where evaluated chronic disease programs for Aboriginal and Torres Strait Islander people have been implemented. This scoping review geographically examines where evaluated chronic disease programs for Aboriginal people have been implemented in the Australian primary health care setting. Secondary objectives include scoping programs for evidence of partnerships with Aboriginal organisations, and use of ethical protocols. By doing so, geographical gaps in the literature and variations in ethical approaches to conducting program evaluations are highlighted.

METHODS

The objectives, inclusion criteria and methods for this scoping review were specified in advance and documented in a published protocol. This scoping review was undertaken in accordance with the Joanna Briggs Institute (JBI) scoping review methodology. The search included 11 academic databases, clinical trial registries, and the grey literature.

RESULTS

The search resulted in 6894 citations, with 241 retrieved from the grey literature and targeted organisation websites. Title, abstract, and full-text screening was conducted by two independent reviewers, with 314 citations undergoing full review. Of these, 74 citations evaluating 50 programs met the inclusion criteria. Of the programs included in the geographical analysis (n = 40), 32.1% were implemented in Major Cities and 29.6% in Very Remote areas of Australia. A smaller proportion of programs were delivered in Inner Regional (12.3%), Outer Regional (18.5%) and Remote areas (7.4%) of Australia. Overall, 90% (n = 45) of the included programs collaborated with an Aboriginal organisation in the implementation and/or evaluation of the program. Variation in the use of ethical guidelines and protocols in the evaluation process was evident.

CONCLUSIONS

A greater focus on the evaluation of chronic disease programs for Aboriginal people residing in Inner and Outer Regional areas, and Remote areas of Australia is required. Across all geographical areas further efforts should be made to conduct evaluations in partnership with Aboriginal communities residing in the geographical region of program implementation. The need for more scientifically and ethically rigorous approaches to Aboriginal health program evaluations is evident.

Predictors of medical student interest in Indigenous health learning and clinical practice: a Canadian case study

BACKGROUND

Including content on Indigenous health in medical school curricula has become a widely-acknowledged prerequisite to reducing the health disparities experienced by Indigenous peoples in Canada. However, little is known about what levels of awareness and interest medical students have about Indigenous peoples when they enter medical school. Additionally, it is unclear whether current Indigenous health curricula ultimately improve students' beliefs and behaviours.

METHODS

A total of 129 students completed a 43-item questionnaire that was sent to three cohorts of first-year medical students (in 2013, 2014, 2015) at one undergraduate medical school in Canada. This survey included items to evaluate students' sociopolitical attitudes towards Indigenous people, knowledge of colonization and its links to Indigenous health inequities, knowledge of Indigenous health inequities, and self-rated educational preparedness to work with Indigenous patients. The survey also assessed students' perceived importance of learning about Indigenous peoples in medical school, and their interest in working in an Indigenous community, which were examined as outcomes. Using principal component analysis, survey items were grouped into five independent factors and outcomes were modelled using staged multivariate regression analyses.

RESULTS

Generally, students reported strong interest in Indigenous health but did not believe themselves adequately educated or prepared to work in an Indigenous community. When controlling for age and gender, the strongest predictors of perceived importance of learning about Indigenous health were positive sociopolitical attitudes about Indigenous peoples and knowledge about colonization and its links to Indigenous health inequities. Significant predictors for interest in working in an Indigenous community were positive sociopolitical attitudes about Indigenous peoples. Knowledge about Indigenous health inequities was negatively associated with interest in working in an Indigenous community.

CONCLUSIONS

Students' positive sociopolitical attitudes about Indigenous peoples is the strongest predictor of both perceived importance of learning about Indigenous health and interest in working in Indigenous communities. In addition to teaching students about the links between colonization, health inequities and other knowledge-based concepts, medical educators must consider the importance of attitude change in designing Indigenous health curricula and include opportunities for experiential learning to shape students' future behaviours and ultimately improve physician relationships with Indigenous patients.

The Indigenous Birthing in an Urban Setting study: the IBUS study : A prospective birth cohort study comparing different models of care for women having Aboriginal and Torres Strait Islander babies at two major maternity hospitals in urban South East Queensland, Australia

BACKGROUND

With persisting maternal and infant health disparities, new models of maternity care are needed to meet the needs of Aboriginal and Torres Strait Islander people in Australia. To date, there is limited evidence of successful and sustainable programs. Birthing on Country is a term used to describe an emerging evidence-based and community-led model of maternity care for Indigenous families; its impact requires evaluation.

METHODS

Mixed-methods prospective birth cohort study comparing different models of care for women having Aboriginal and Torres Strait Islander babies at two major maternity hospitals in urban South East Queensland (2015-2019). Includes women's surveys (approximately 20 weeks gestation, 36 weeks gestation, two and six months postnatal) and infant assessments (six months postnatal), clinical outcomes and cost comparison, and qualitative interviews with women and staff.

DISCUSSION

This study aims to evaluate the feasibility, acceptability, sustainability, clinical and cost-effectiveness of a Birthing on Country model of care for Aboriginal and Torres Strait Islander families in an urban setting. If successful, findings will inform implementation of the model with similar communities.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry # ACTRN12618001365257 . Registered 14 August 2018 (retrospectively registered).

Integrated Care with Indigenous Populations: A Systematic Review of the Literature

INTRODUCTION

The integration of behavioral health into medical care is related to positive results including improved patient health outcomes, provider satisfaction, and cost-offset. Indigenous people suffer from the highest health disparities in the nation and disproportionately experience barriers to health care; yet it is unknown if integrated care is effective for this population.

METHODS

A systematic literature review was completed on the state of integrated care at Indigenous-serving health care sites in 2014 and was updated in 2016. Three databases were selected (Eric, Medline, and PsycInfo) and keywords pertaining to an Indigenous population and integrated care services (e.g., Native American, American Indian, or First Nations with integrated care, primary care, or family medicine) were used. After inclusion and exclusion criteria were applied, nine articles were selected out of the 2,889 articles found. Five additional articles were added in the 2016-update search. The selected articles were then evaluated using standards of integrated care.

RESULTS

The selected articles demonstrated wide-ranging and positive results including improved physical and mental health symptoms, reduced substance use, improvements in education and employment status, as well as a decreased involvement with the criminal justice system. It appears that interventions that additionally integrated culturally relevant health beliefs and practices experienced the largest gains in health outcomes.

DISCUSSION

Integrated care appears to be an intervention that can ameliorate these disparities by reducing stigma for those seeking care and providing coordinated care to prevent or reduce health care disparities in this population. While integrated care appears to be an effective system of care for Indigenous people, it must be noted that integration of local Indigenous health beliefs and practices is equally necessary.

Factors that impact access to ongoing health care for First Nation children with a chronic condition

BACKGROUND

Access to multidisciplinary health care services for First Nation children with a chronic condition is critical for the child's health and well-being, but disparities and inequality in health care systems have been almost impossible to eradicate for First Nation people globally. The objective of this review is to identify the factors that impact access and ongoing care for First Nation children globally with a chronic condition.

METHODS

An extensive systematic search was conducted of nine electronic databases to identify primary studies that explored factors affecting access to ongoing services for First Nation children with a chronic disease or injury. Due to the heterogeneity of included studies the Mixed Method Appraisal Tool (MMAT) was used to assess study quality.

RESULTS

A total of six studies from Australia, New Zealand and Canada were identified and included in this review. Four studies applied qualitative approaches using in-depth semi structured interviews, focus groups and community fora. Two of the six studies used quantitative approaches. Facilitators included the utilisation of First Nation liaison workers or First Nation Health workers. Key barriers that emerged included lack of culturally appropriate health care, distance, language and cultural barriers, racism, the lack of incorporation of First Nation workers in services, financial difficulties and transport issues.

CONCLUSION

There are few studies that have identified positive factors that facilitate access to health care for First Nation children. There is an urgent need to develop programs and processes to facilitate access to appropriate health care that are inclusive of the cultural needs of First Nation children.

An Exploration of Underrepresentation of Aboriginal Cancer Patients Attending a Regional Radiotherapy Service in Western Australia

Travel logistics impede Aboriginal patients' uptake of cancer treatments and is one reason for the poorer outcomes of Aboriginal people with cancer. This research examined benefits of a newly established rurally based radiotherapy unit in southwest Western Australia (WA), and included exploring the experience of Aboriginal patients and possible reasons for Aboriginal people's underrepresentation in treatment. Semi-structured in-depth interviews with 21 service providers involved in the treatment and care of people with cancer, and 3 Aboriginal patients with cancer who undertook radiotherapy at the Service were undertaken. Data were subject to thematic analysis involving immersion in the data for familiarization, inductive coding, investigator discussion and refining of emerging themes and triangulation of patient and provider interviews. Aboriginal cancer patients were positive about the treatment and support they had received, highlighting the often complex challenges faced by rural Aboriginal cancer patients in accessing and maintaining treatment. Service providers offered suggestions for small numbers presenting to the Service, including late presentation, potential perceptions of cultural insensitivity on the part of service providers, out-of-pocket costs and under-ascertainment of Aboriginal status. The Service has put in place practices and initiatives to support patient health and wellbeing, including making the facility more welcoming towards Aboriginal people and ensuring culturally appropriate care.

Web-based therapeutic interventions for assessing, managing and treating health conditions in Indigenous people: a scoping review protocol

REVIEW OBJECTIVES/QUESTIONS

The objective of the scoping review is to map the international scientific literature on web-based therapeutic interventions (WBTI) used by Indigenous people for assessing, managing and treating health conditions. The focus of this review is WBTIs for a broad range of health conditions, including but not limited to, communicable and non-communicable diseases, mental health conditions (including the broader concept of social and emotional wellbeing), use of harmful substances and gambling.The questions for the scoping review are.

Intervention mapping to address social and economic factors impacting indigenous people's health in Suriname's interior region

BACKGROUND

Previous studies found that while internationally financed economic development projects reduced poverty when measured in terms of per capita GDP, they also caused indigenous people to become disassociated, impoverished and alienated minorities whose health status has declined to unacceptable lows when measured in terms of mercury poisoning and the burgeoning rate of suicide. In this study, we developed a needs assessment and a policy-oriented causal diagram to determine whether the impaired health of the people in this region was at least partially due to the role the country has played within the global economy. Specifically, could the health and well-being of indigenous people in Suriname be understood in terms of the foreign investment programs and economic development policies traceable to the Inter-American Development Bank's Suriname Land Management Project.

METHODS

Interviews took place from 2004 through 2015 involving stakeholders with an interest in public health and economic development. A policy-oriented causal diagram was created to model a complex community health system and weave together a wide range of ideas and views captured during the interview process.

RESULTS

Converting land and resources held by indigenous people into private ownership has created an active market for land, increased investment and productivity, and reduced poverty when measured in terms of per capita GDP. However, it has also caused indigenous people to become disassociated, impoverished and alienated minorities whose health status has declined to unacceptable lows. While the effects of economic development programs on the health of vulnerable indigenous communities are clear, the governance response is not. The governance response appeared to be determined less by the urgency of the public health issue or by the compelling logic of an appropriate response, and more by competing economic interests and the exercise of power.

CONCLUSION

The health and well-being of the indigenous Wayana in Suriname's interior region is at least partially due to the role the country has played within the global economy. Specifically, the health and well-being of indigenous people in Suriname can be understood to be a result of foreign development bank-funded projects that drive the government of Suriname to trade land and natural resources on the global market to manage their country's balance of payments.

How can GPs drive software changes to improve healthcare for Aboriginal and Torres Strait Islanders peoples?

BACKGROUND

Changes to the software used in general practice could improve the collection of the Aboriginal and Torres Strait Islander status of all patients, and boost access to healthcare measures specifically for Aboriginal and Torres Strait Islander peoples provided directly or indirectly by general practitioners (GPs).

OBJECTIVE

Despite longstanding calls for improvements to general practice software to better support Aboriginal and Torres Strait Islander health, little change has been made. The aim of this article is to promote software improvements by identifying desirable software attributes and encouraging GPs to promote their adoption.

DISCUSSION

Establishing strong links between collecting Aboriginal and Torres Strait Islander status, clinical decision supports, and uptake of GP-mediated health measures specifically for Aboriginal and Torres Strait Islander peoples - and embedding these links in GP software - is a long overdue reform. In the absence of government initiatives in this area, GPs are best placed to advocate for software changes, using the model described here as a starting point for action.

Why are men less tested for sexually transmitted infections in remote Australian Indigenous communities? A mixed-methods study

Gender disparities in testing rates for sexually transmitted infections (STIs) have been identified as one potential factor sustaining high rates of STIs and repeat infections in the Northern Territory of Australia, especially in remote Indigenous communities. The study aimed to investigate the reasons for these disparities utilising a mixed-method study design. We conducted an audit on client information at a remote community health clinic, focus-group discussions with young men in the same community and interviews with experienced remote area clinicians. The clinic audit found a significantly higher proportion of female residents of the community than males visited the clinic (72.8 versus 55.3%, p < 0.005). Women were also more likely to be tested for STIs than men when visiting the clinic (49.7 versus 40.3%, p = 0.015). Major barriers to men's seeking STI testing included a sense of shame from being seen visiting the clinic by women, men's lack of understanding of STIs and the need for testing, and inadequate access to male clinicians. Increasing men's access to healthcare and STI testing requires offering testing at a gender-sensitive and separate locations, and community-based sexual health promotion to increase knowledge of STIs.

The uptake of Aboriginal and Torres Strait Islander health assessments fails to improve in some areas

BACKGROUND

The Medicare-rebated Health Assessment for Aboriginal and Torres Strait Islander People (Medicare Benefits Schedule [MBS] item number 715) has been progressively implemented across Australia since 1999.

OBJECTIVE

This paper explores some of the reasons why the uptake of Health Assessment for Aboriginal and Torres Strait Islander People remains low in some metropolitan general practices.

METHODS

Semi-structured interviews and self-complete mail surveys with 31 general practice staff and practitioners were combined with an audit of practice systems and patient medical records in seven general practices in Sydney.

RESULTS

Barriers to MBS item number 715 uptake included low rates of Indigenous status identification, lack of knowledge of MBS item numbers, lack of organisational teamwork within the practice and avoidance of billing specific MBS item numbers.

DISCUSSION

The low uptake of MBS item number 715 in some metropolitan areas is of particular concern given the known gaps in Aboriginal and Torres Strait Islander health. Targeted action is required to address the barriers to uptake and re-evaluate the use of MBS item number 715 as a key performance indicator.

Increasing Pap smear rates at an urban Aboriginal Community Controlled Health Service through translational research and continuous quality improvement

This article describes translational research (TR) and continuous quality improvement (CQI) processes used to identify and address barriers and facilitators to Pap smear screening within an urban Aboriginal Community Controlled Health Service (ACCHS). Rapid Plan-Do-Study-Act (PDSA) cycles were conducted, informed by client surveys, a data collection tool, focus groups and internal research. There was a statistically significant increase in Pap smear numbers during PDSA cycles, continuing at 10 months follow up. The use of TR with CQI appears to be an effective and acceptable way to affect Pap smear screening. Community and service collaboration should be at the core of research in Aboriginal and Torres Strait Islander health settings. This model is transferrable to other settings and other health issues.

How good are routinely collected primary healthcare data for evaluating the effectiveness of health service provision in a remote Aboriginal community?

INTRODUCTION

Evaluation and monitoring of primary health care requires the establishment and maintenance of an appropriate data system. This study reviews the application and effectiveness of the Communicare data management system in the delivery of health services to the Fitzroy Valley in the Kimberley region of Western Australia.

METHODS

Key demographic fields (sex, date of birth and Aboriginal status) were examined for completeness (whether the date fields were all completed and correct when compared with the paper file) while the 'conditions' field was examined for accuracy. Three chronic diseases (diabetes, hypertension and chronic kidney disease) in adults and age-specific incidence for four acute diseases (otitis media, gastroenteritis, lower respiratory tract infection and skin infection) in children were included.

RESULTS

Completeness of chosen demographic fields was 100% for date of birth and sex and 98% for Aboriginal status. Chronic conditions matched the paper files 100%, while the recording of acute conditions was incomplete. Among older adults (≥55 years) the prevalences of diabetes, chronic kidney disease and hypertension were 43%, 42% and 39% respectively. Age-specific incidence of acute conditions was highest in the 0-4 years age group where 25% had had at least one episode of otitis media and 20% at least one episode of skin infection.

CONCLUSIONS

The recording of demographic and chronic disease data was complete, but lower for acute conditions. Routinely collected data have a number of limitations, but nonetheless are a feasible way to establish population health indices, particularly for chronic diseases for this remote health service with minimal expenditure and effort. These rates provide useful baselines for monitoring and evaluating the impact of service delivery on health outcomes. This audit provides an indication of the accuracy of routinely collected data in the electronic system compared to the paper medical records, which have traditionally been considered the gold standard. Data collected on chronic disease information were accurate and clinically useful for health service planning, monitoring and evaluation. Acute disease data were not accurate enough to be clinically useful.

Mā mahi, ka ora: by work, we prosper--traditional healers and workforce development

AIM

Rongoā Māori practitioners make a valuable contribution towards Māori health outcomes, albeit with limited resourcing or formal training. This paper reports on a survey of healers/healing practices-specifically healers' aspirations for professional development and training-and considers the implications for healing practice and future training undertakings.

METHODS

Healers in seven districts around the country were surveyed about rongoā practice and service delivery during 2013. Consenting healers completed surveys either in person, via phone, or returned them via post, according to their preference and convenience. Resulting data were analysed and reported according to frequency of responses.

RESULTS

Thirty-eight healers/rongoā clinics completed the survey--a 79% response rate. Respondents were primarily Māori (88%), female (69%), aged 50 years or older (60%), and worked as volunteers. Informal training modes focused on te reo, mātauranga and tikanga were the most common means of skill/ knowledge acquisition, and preferred modes for further training.

CONCLUSIONS

The survey highlights the pressing need for expansion of the rongoā Māori workforce and training/service funding, to sustain rongoā practice. The findings add to what little is known about the training pathways and aspirations of practising healers, identified targets of the Māori Health Workforce Development Plan 2006.

Understanding Overrepresentation of Indigenous Children in Child Welfare Data: An Application of the Drake Risk and Bias Models

Child welfare data collected for administrative purposes are often used as a source of information for understanding the population impact of child abuse and neglect (CA/N). This study used administrative data linked at the individual level for a cohort of Aotearoa New Zealand (NZ) children to follow and extend a model developed by Drake et al. In this investigation, we aimed to build an understanding of the high representation of indigenous NZ children in administratively sourced measures of CA/N. Variation in rate ratios (RRs) within infant mortality and birth outcomes considered as possible proxies for actual CA/N RRs leaves open a range of interpretations. Our findings indicate that a more nuanced interpretation of the overrepresentation of indigenous children in administratively recorded maltreatment statistics is required. Rather than considering risk and bias as competing explanations, we suggest an acknowledgment of the impact of colonization and the existence of systemic bias generating increased risk as key drivers. As linked administrative data are increasingly used for research and evaluation, and considered for use in supporting decision making, there is a need for a deeper understanding of the drivers of administratively recorded CA/N in order to effectively address the needs of indigenous populations.

Retrospective audit of postnatal attendance for Aboriginal and Torres Strait Islander women attending a community-controlled health service in north Queensland

BACKGROUND

Low uptake of postnatal care among Aboriginal and Torres Strait Islander women is a concern. The aim of this study was to ex-amine any associations with postnatal attendance by Aboriginal and Torres Strait Islander women.

METHODS

A retrospective cohort study was conducted of 198 women who attended Townsville Aboriginal and Islander Health Service (TAIHS) for antenatal care between 1 January 2009 and 1 January 2011. Postnatal attendance and its relationship to demographic, behavioural, antenatal and intrapartum factors was assessed.

RESULTS

Of the women included in the study, 48.0% (95/198) returned to TAIHS for postnatal care. A statistically significant positive association between antenatal and postnatal attendance was found using multivariate analysis (P DISCUSSION: Strategies are needed to improve postnatal attendance for Aboriginal and Torres Strait Islander women, and strengthening attendance during the antenatal period may be an indirect way of facilitating this. Better postnatal follow-up will enhance the capacity for health services to deliver preventive care to this population.

Care and treatment of hepatitis C among Aboriginal people in New South Wales, Australia: implications for the implementation of new treatments

INTRODUCTION

Despite Aboriginal Australians being over-represented in populations of people living with hepatitis C (HCV), there is a dearth of research to guide policy and programme development in the area of care and treatment, particularly relating to new HCV treatments.

METHOD

In-depth interviews were conducted with 39 people identifying as Aboriginal Australians and living with HCV in New South Wales.

RESULTS

Participants' experiences were characterised by a lack of detailed or appropriate information provided at diagnosis, high levels of stigma associated with HCV and low overall knowledge of HCV as reported for themselves and their communities. Despite poor diagnosis experiences, participants had undertaken changes to their lifestyle, especially in relation to alcohol use, in order to promote liver health. Concerns about treatment side effects and efficacy impacted participants' decisions to undertake treatment. Eleven participants had undertaken HCV treatment in a variety of care models with a peer worker and in prison.

CONCLUSIONS

The similarities between concerns and experiences of Aboriginal people and other populations living with HCV do not suggest that services and strategies to engage these populations should also be the same. These results suggest that further engagement of the primary care sector in HCV care is important as well as increasing Aboriginal community knowledge of HCV. A variety of service models should be available to meet individuals' preferences, including those offered within Aboriginal community controlled health services emphasising holistic notions of health, and supported by information and communication programmes using principles of health literacy relevant to Aboriginal people.

The association of depression with diabetes management among urban American Indians/Alaska Natives in the United States, 2011

OBJECTIVE

To determine the relationship between depression and diabetes management among urban American Indians/Alaska Natives (AI/ANs).

DESIGN

Retrospective, cross-sectional analysis of medical records.

SETTING

33 Urban Indian Health Organizations that participated in the Indian Health Service Diabetes Care and Outcomes Audit.

PATIENTS

3,741 AI/AN patient records.

MAIN OUTCOME MEASURES

Diabetes management outcomes, including HbA1c, smoking, BMI, systolic blood pressure, creatinine, total cholesterol, and receipt of preventive services.

RESULTS

Individuals with depression and diabetes were 1.5 times more likely to smoke than individuals with diabetes but without depression (OR=1.51; 95% Cl: 1.23, 1.86), controlling for age, sex, and facility. After adjustment, the geometric mean BMI in diabetes patients with depression was 3% higher than in patients without depression (β=.034; 95% CI: .011, .057).

CONCLUSIONS

Urban AI/ANs with diabetes and depression are more likely to smoke and have higher BMI than those with diabetes but without depression. These findings inform programmatic efforts to address the care of patients with both depression and diabetes.

The nurse’s role in improving indigenous health

The health status of indigenous peoples is a global concern with mortality and hospitalisation data indicating that the health of indigenous groups falls below that of other ethnic groups within their countries. The preliminary findings of grounded theory research project undertaken with a group of 23 New Zealand Maori women about their health priorities and 'mainstream' health service needs provide the foundation for an exploration of issues impacting on the health status of indigenous people. The role that nursing and nurses have in improving access and use of health services by indigenous people will be discussed. Strategies are suggested that nurses can utilise within their practice when working with local indigenous groups.

Initiation of maternity care for young Maori women under 20 years of age

AIM

To explore the lived realities of pregnant Maori women <20 years through pregnancy and motherhood, to identify barriers to, and facilitators of, access to maternity care.

METHOD

Using a Kaupapa Maori research paradigm, 44 pregnant or recently pregnant Maori woman <20 years of age were recruited in two case study sites. Participants completed a series of interviews during different stages of pregnancy and motherhood. Interview transcripts were read, re-read and cross-compared by the two interviewing researchers to identify emergent themes, and organised using the software programme Nvivo. Thematic data was grouped, and re-grouped into topic areas for further analysis.

RESULTS

Participants engaged early with health care services both to confirm their pregnancy and to initiate maternity care. Barriers to access occurred at the first contact with a lack of information, and support along the maternity care pathway to mainly community based midwifery care. Many participants felt inadequately supported to be able to identify, confirm, and enrol with a midwife or hospital care. Participants who received proactive support at the first interaction with health services had an appropriate maternity care pathway toward obtaining early and seamless maternity care.

CONCLUSION

Interviews with participants identified that contrary to published literature young Maori women are engaging early with health services (GP services, school and community based youth health services) for maternity care, but system barriers from this first health contact lead to avoidable delays to them accessing a seamless maternity care pathway. There is a lack of sufficient and appropriate information and support for this young population group who have limited resources and experience to navigate through health services. These inequities in access to maternity care could be reduced through an integrated model of care that sees maternity care beginning at the first interaction with health care services. The service, primarily general practitioners, would then take responsibility for first trimester screening and navigation to a lead maternity carer.

Cancer survival in Indigenous and non-Indigenous Australian children: what is the difference?

PURPOSE

This study assessed variation in childhood cancer survival by Indigenous status in Australia, and explored the effect of place of residence and socio-economic disadvantage on survival.

METHODS

All children diagnosed with cancer during 1997-2007 were identified through the Australian Pediatric Cancer Registry. Cox regression analysis was used to assess the adjusted differences in survival.

RESULTS

Overall, 5-years survival was 75.0 % for Indigenous children (n = 196) and 82.3 % for non-Indigenous children (n = 6,376, p = 0.008). Compared to other children, Indigenous cases had 1.36 times the risk of dying within 5 years of diagnosis after adjustments for rurality of residence, socio-economic disadvantage, cancer diagnostic group, and year of diagnosis (95 % CI 1.01-1.82). No significant survival differential was found for leukemias or tumors of the central nervous system; Indigenous children were 1.83 times more likely (95 % CI 1.22-2.74) than other children to die within 5 years from 'other tumors' (e.g., lymphomas, neuroblastoma). Among children who lived in 'remote/very remote/outer regional' areas, and among children with a subgroup of 'other tumors' that were staged, being Indigenous significantly increased the likelihood of death (HR = 1.69, 95 % CI 1.10-2.59 and HR = 2.99, 95 % CI 1.35-6.62, respectively); no significant differences by Indigenous status were seen among children with stage data missing.

CONCLUSIONS

Differences in place of residence, socio-economic disadvantage, and cancer diagnostic group only partially explain the survival disadvantage of Indigenous children. Other reasons underlying the disparities in childhood cancer outcomes by Indigenous status are yet to be determined, but may involve factors such as differences in treatment.

Health inequity in the Northern Territory, Australia

INTRODUCTION

Understanding health inequity is necessary for addressing the disparities in health outcomes in many populations, including the health gap between Indigenous and non-Indigenous Australians. This report investigates the links between Indigenous health outcomes and socioeconomic disadvantage in the Northern Territory of Australia (NT).

METHODS

Data sources include deaths, public hospital admissions between 2005 and 2007, and Socio-Economic Indexes for Areas from the 2006 Census. Age-sex standardisation, standardised rate ratio, concentration index and Poisson regression model are used for statistical analysis.

RESULTS

There was a strong inverse association between socioeconomic status (SES) and both mortality and morbidity rates. Mortality and morbidity rates in the low SES group were approximately twice those in the medium SES group, which were, in turn, 50% higher than those in the high SES group. The gradient was present for most disease categories for both deaths and hospital admissions. Residents in remote and very remote areas experienced higher mortality and hospital morbidity than non-remote areas. Approximately 25-30% of the NT Indigenous health disparity may be explained by socioeconomic disadvantage.

CONCLUSIONS

Socioeconomic disadvantage is a shared common denominator for the main causes of deaths and principal diagnoses of hospitalisations for the NT population. Closing the gap in health outcomes between Indigenous and non-Indigenous populations will require improving the socioeconomic conditions of Indigenous Australians.

Impact of latent infection treatment in indigenous populations

The aims of the present study were to identify risk factors associated with latent tuberculosis (TB), examine the development of active disease among contacts, and assess the effectiveness of treating latent infection in indigenous Brazilians from January 2006 to December 2011. This was a retrospective study consisting of 1,371 tuberculosis contacts, 392 of whom underwent treatment for latent infection. Morbidity-from-TB data were obtained from the Information System for Disease Notification (SINAN) database, and the contacts’ data were collected from the clinical records using forms employed by Special Department of Indigenous Health (SESAI) multidisciplinary teams, according to SESAI’s instructions. The variables that were associated with latent infection among the contacts were age (odds ratio [OR]: 1.03; 95% confidence interval [CI]: 1.02–1.04) and close contact with a smear-positive index case (OR: 2.26, 95% CI: 1.59–3.22). The variables associated with the development of active TB among the contacts were a tuberculin skin test (TST) ≥10 mm (relative risk [RR]: 1.12, 95% CI: 1.07–1.17), age (RR: 1.01, 95% CI: 1.00–1.03), and treatment of latent infection (RR: 0.03, 95% CI: 0.01–0.27). The estimated number of latent infection treatments needed to prevent one case of active TB among the contacts was 51 treatments (95% CI: 33–182). In contacts with TST ≥10 mm, 10 (95% CI: 6–19) latent infection treatments were necessary to prevent one case of active TB. Age and close contact with a smear-positive index case were associated with latent TB. Screening with TST is a high priority among individuals contacting smear-positive index cases. Age and TST are associated with the development of active TB among contacts, and treatment of latent infection is an effective measure to control TB in indigenous communities.

[Persisting health and health access inequalities in Mexican indigenous population, 2006-2012]

OBJECTIVE

To analyze socioeconomic, health conditions and access to health services of Mexican indigenous population between 2006 and 2012.

MATERIALS AND METHODS

A comparative analysis was done between indigenous and non indigenous population, using the information from th National Health and Nutrition Survey (2006 and 2012).

RESULTS

60% of the indigenous population was allocated at the poorest socioeconomic level in 2012 despite the implementation of social programs. The Seguro Popular increased its coverage from 14 to 61.9% in indigenous population. The increase observed in coverage in no indigenous population was from 10 to 35.7%. Nevertheless, no increase was observed in the utilization of healthcare services between indigenous and non indigenous population. The access to hospital services for childbirth delivery increased from 63.8 to 76.4% in indigenous population. However there is an important difference with non indigenous population (93.9%).

CONCLUSIONS

The increase in the coverage of the Seguro Popular in Mexico has had heterogeneous results in the utilization of health care services. Other social programs such a Oportunidades have not had an impact to alleviate poverty in indigenous groups.

Validation and enhancement of Australian Aboriginal and Torres Strait Islander psychiatric hospitalisation statistics through an Indigenous Mental Health Worker Register

INTRODUCTION

Inaccuracy in identification of Indigenous status on health records hampers collection of the good quality data required to guide policies, programs and services. This study examined the use of an Indigenous Mental Health Worker Register to assess the level of correct identification of Indigenous status and sources of error among psychiatric admissions within a regional public hospital information system.

METHOD

The study was conducted in 2004/2005 and 2005/2006 at the Cairns Base Hospital Mental Health Unit, Queensland, Australia, serving a population of 230,000 of which 13.2% identify as Aboriginal and/or Torres Strait Islander. Psychiatric admissions data, including Indigenous status, accessed from the hospital-based corporate information system (HBCIS) were compared with data collected through an Indigenous Mental Health Worker Register that is maintained through extensive networking. Investigation of mismatches enabled estimation of the frequency and sources of incorrect identification of Indigenous status and the impact of this on hospital statistics.

RESULTS

Cross-validation of HBCIS data with the Indigenous Register over 2 years revealed 355 Indigenous admissions. Of the total 355 admissions, 301 (84.8%) were correctly identified and included in the hospital system, while 22 (6.2%) were designated non-Indigenous, 13 (3.7%) were 'unspecified' and 19 (5.4%) were missed through incorrect residence or admission designation. Among 1293 non-Indigenous admissions, 1.1% were incorrectly identified as Indigenous, while 25.5% of the 51 with unspecified status were found to be Indigenous. Furthermore, 45 Indigenous separations that had been missed over the previous 5 year period (1999/2000 to 2003/2004) were identified through careful examination of all those with unspecified status (n=174) and those with multiple separations of mixed designation of Indigenous status (n=15); all of the latter 15 were confirmed Indigenous by other mental health database and/or the Indigenous Mental Health Worker. Thus overall this study revealed a total of 89 Indigenous separations and 1261 occupied bed days in the 7 year period that had not be identified in the hospital information system.

CONCLUSION

A novel method was used to ascertain the reliability of Indigenous status identification among mental health admissions within a hospital information system in a region with relatively high Indigenous population representation. This revealed that 85% of admissions were correctly identified over two consecutive years. Perhaps more importantly, the study confirmed a low frequency of false identification of non-Indigenous people as Aboriginal and/or Torres Strait Islander. The work has also demonstrated the value of involving Indigenous Mental Health Workers in routine processes to enhance, validate and improve Indigenous statistics and increase access to culturally informed care.

Access to eye health services among indigenous Australians: an area level analysis

BACKGROUND

This project is a community-level study of equity of access to eye health services for Indigenous Australians.

METHODS

The project used data on eye health services from multiple sources including Medicare Australia, inpatient and outpatient data and the National Indigenous Eye Health Survey.The analysis focused on the extent to which access to eye health services varied at an area level according to the proportion of the population that was Indigenous (very low = 0-1.0%, low = 1.1-3.0%, low medium = 3.1-6.0%, high medium = 6.1-10.0%, high = 10.1-20.0%, very high = 20 + %). The analysis of health service utilisation also took into account age, remoteness and the Socioeconomic Indices for Areas (SEIFA).

RESULTS

The rate of eye exams provided in areas with very high Indigenous populations was two-thirds of the rate of eye exams for areas with very low indigenous populations. The cataract surgery rates in areas with high medium to very high Indigenous populations were less than half that reference areas. In over a third of communities with very high Indigenous populations the cataract surgery rate fell below the World Health Organization (WHO) guidelines compared to a cataract surgery rate of 3% in areas with very low Indigenous populations.

CONCLUSIONS

There remain serious disparities in access to eye health service in areas with high Indigenous populations. Addressing disparities requires a co-ordinated approach to improving Indigenous people's access to eye health services. More extensive take-up of existing Medicare provisions is an important step in this process. Along with improving access to health services, community education concerning the importance of eye health and the effectiveness of treatment might reduce reluctance to seek help.

Prevalence, risk factors and awareness of albuminuria on a Canadian First Nation: a community-based screening study

BACKGROUND

Both diabetic and non-diabetic end stage renal disease (ESRD) are more common among Canadian First Nations people than among the general Canadian population. The purpose of this research was to determine the prevalence of and risk factors for albuminuria in a Canadian First Nation population at high risk for ESRD and dialysis.

METHODS

Data from a community-based screening study of 483 residents of a Plains Ojibway First Nation in Manitoba was used. Participants provided random urine samples. Proteinuria was defined as any dipstick positive for protein (≥1 g/L) or those with ACR in the macroalbuminuric range (≥30 mg/mmol) on at least one sample. Microalbuminuria was defined as ACR ≥2 mg/mmol for males and ≥2.8 mg/mmol for females. Other measures included fasting glucose, haemoglobin A1c, triglycerides, cholesterol, blood pressure, height, weight and waist and hip circumferences.

RESULTS

Twenty percent of study participants had albuminuria, (5% proteinuria and 15% microalbuminuria). Of participants with diabetes, 42% (56/132) had albuminuria compared to 26% (7/27) among those with impaired fasting glucose and 10% (30/303) among those with normal glucose tolerance. Only 5.3% of those with albuminuria were aware of any degree of renal disease. In a multivariate logistic regression, independent associations with albuminuria were male gender [p = 0.002], increasing fasting glucose [p <0.0001], years diagnosed with diabetes [p = 0.03], increasing systolic blood pressure [p = 0.009], and increasing body mass index (BMI) [p = 0.04].

CONCLUSIONS

The independent association between BMI and albuminuria has not been previously reported among indigenous populations. There is a high prevalence of albuminuria in this Canadian First Nation population; the high proportion of patients with diabetes and undiagnosed kidney disease demonstrates the need for screening, education and intervention to halt the progression and development of albuminuria and ultimately ESRD and CVD.

New Zealand evidence for the impact of primary healthcare investment in Capital and Coast District Health Board

AIMS

This paper provides New Zealand evidence on the effectiveness of primary care investment, measured through the Capital and Coast District Health Board's (DHB) Primary Health Care Framework. The Framework was developed in 2002/2003 to guide funding decisions at a DHB level, and to provide a transparent basis for evaluation of the implementation of the Primary Health Care Strategy in this district.

METHODS

The Framework used a mixed method approach; analysis was based on quantitative and qualitative data.

RESULTS AND CONCLUSIONS

This article demonstrates the link between investment in primary health care, increased access to primary care for high-need populations, workforce redistribution, and improved health outcomes. Over the study period, ambulatory sensitive hospitalisations and emergency department use reduced for enrolled populations and the District's immunisation coverage improved markedly. Funding and contracting which enhanced both 'mainstream' and 'niche' providers combined with community-based health initiatives resulted in a measurable impact on a range of health indicators and inequalities. Maori primary care providers improved access for Maori but also for their enrolled populations of Pacific and Other ethnicity. Growth and redistribution of primary care workforce was observed, improving the availability of general practitioners, nurses, and community workers in poorer communities.

The value of te reo in primary care

INTRODUCTION

The influence of indigeneity is widely recognised as a health determinant; however the impact of the utilisation of the indigenous language on health care has not been closely examined.

AIM

To explore the Maori language (te reo) as a determinant of health from a Maori patient's perspective.

METHODS

Maori patients were recruited through Maori health networks and the snowballing technique. Thirty participants participated in one of three focus group interviews. A semistructured interview explored the utilisation of health services, comfortability with service delivery and perceptions of general practice surgeries' cultural competency. Thematic analysis was utilised to interpret the data.

RESULTS

Te reo was recognised as an important cultural competency, noted by participants as contributing to the development of appropriate doctor-patient relationships and their feelings of being valued within a practice. Patient-led use of te reo was identified as most appropriate, an indicator of quality of care.

DISCUSSION

The training of primary care staff in te reo should be encouraged. Developed as a competency, this will see primary care settings better able to respond to Maori patients and in turn support Maori health gains.

2010 Chalmers Oration--what's needed to close the gap?

The 2010 Chalmers Oration was delivered by Dr Tom Calma on 15 August 2010 at Flinders University in Adelaide, South Australia. Dr Calma's presentation concerned the groundbreaking roles that he and the Close the Gap Campaign have played in making a difference to the health of Indigenous Australians, especially those who live in rural and remote Australia.