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Background: Aboriginal and Torres Strait Islander people do not enjoy equal access to specialist health services that adequately meet their needs. Clinical genetics services are at the vanguard of realising the health benefits of genomic medicine. As the field continues to expand in clinical utility and implementation, it is critical that Aboriginal and Torres Strait Islander people are able to participate and benefit equally to avoid further widening of the existing health gap. This is the first study to explore barriers to accessing clinical genetics services among Aboriginal and Torres Strait Islander people, which has been acknowledged as a key strategic priority in Australian genomic health policy., Methods: A participatory design process engaged a majority-Aboriginal Project Reference Group and Aboriginal End-User Group. 63 semi-structured interviews were conducted with Aboriginal and/or Torres Strait Islander people who had accessed the government-funded clinical genetics service in Western Australia, Queensland or the Northern Territory between 2014 and 2018. The sample included patients, parents and carers. Participants were asked to recount their 'patient journey', from referral through to post-appointment and reflect on their perceptions of genetics and its implications for the health of themselves and their families. Analysis tracked chronological service engagement, followed by an inductive thematic approach., Results: Barriers to access and engagement were present at each stage of the patient journey. These included challenges in obtaining a referral, long waiting periods, limited genetic literacy, absence of Aboriginal support services, communication challenges and lack of adequate psychosocial support and follow-up after attendance. Participants' overall experiences of attending a genetic health service were varied, with positive perceptions tied closely to a diagnosis being achieved. The experience of (and expectation for) recognition of cultural identity and provision of culturally safe care was low among participants. Unaddressed concerns continued to cause significant distress in some people years after their appointment took place., Conclusions: There is significant scope for improving the care provided to Aboriginal and Torres Strait Islander people at clinical genetics services. Immediate attention to minimising logistical barriers, developing relationships with Aboriginal Community Controlled Health Services and providing practical and specific cultural safety training for practitioners is required at the service-level. Our findings strongly support the development of guidelines or policies recognising the collective cultural needs of Aboriginal and Torres Strait Islander people in relation to genomic health care.

Background: Aboriginal and Torres Strait Islander people experience a greater burden of disease and die younger than non-Indigenous Australians, with Aboriginal people living in remote areas of the Northern Territory of Australia having the lowest life expectancy estimates. Despite a high burden of chronic disease among Aboriginal and Torres Strait Islander people, access to specialist health services remains low and models of care that increase engagement, may improve health outcomes., Methods: We describe client and staff perspectives of a model of clinical genetics services provided by the MJD Foundation (MJDF) in geographically and culturally complex contexts within the Northern Territory of Australia. We seek to understand the MJDF model's success in supporting Aboriginal families with the familial, neurodegenerative condition Machado-Joseph disease and how it could be applied in the provision of other specialist services. Thematic analysis was undertaken on semi-structured interviews with primary health care staff (n = 2), Non-Aboriginal MJDF Staff (n = 7) and Aboriginal MJDF Clients / Community workers (n = 13)., Results: Four key themes regarding the MJDF model of service delivery were identified with the service being; 1) client led 2) accepting of various understandings of genetic disease causation 3) focused on relationships, continuity and trust between the service provider and the clients, and 4) committed to incorporating an inclusive whole-of-family practice. The MJDF model takes a community-based, person-and family-centred approach to successfully deliver effective specialist genetic health services in remote community settings. We propose that these approaches have broad application in the future design and delivery of specialist health services particularly in culturally complex settings., Competing Interests: LM and DLG are employees of the MJD Foundation. This does not alter our adherence to PLOS ONE policies on sharing data and material.

Background: Given the persistence of Indigenous health inequities across national contexts, many countries have adopted strategies to improve the health of Indigenous peoples. Governmental recognition of the unique health needs of Indigenous populations is necessary for the development of targeted programs and policies to achieve universal health coverage. At the same time, the participation of Indigenous peoples in decision-making and program and policy design helps to ensure that barriers to health services are appropriately addressed and promotes the rights of Indigenous peoples to self-determination. Due to similar patterns of Indigenous health and health determinants across borders, there have been calls for greater global collaboration in this field. However, most international studies on Indigenous health policy link Anglo-settler democracies (Canada, Australia, Aotearoa/New Zealand and the United States), despite these countries representing a small fraction of the world's Indigenous people., Aim: This paper examines national-level policy in Australia, Brazil, Chile and New Zealand in relation to governmental recognition of differential Indigenous health needs and engagement with Indigenous peoples in health. The paper aims to examine how Indigenous health needs and engagement are addressed in national policy frameworks within each of the countries in order to contribute to the understanding of how to develop pro-equity policies within national health care systems., Methods: For each country, a review was undertaken of national policies and legislation to support engagement with, and participation of, Indigenous peoples in the identification of their health needs, development of programs and policies to address these needs and which demonstrate governmental recognition of differential Indigenous health needs. Government websites were searched as well as the following databases: Google, OpenGrey, CAB Direct, PubMed, Web of Science and WorldCat., Findings: Each of the four countries have adopted international agreements regarding the engagement of Indigenous peoples in health. However, there is significant variation in the extent to which the principles laid out in these agreements are reflected in national policy, legislation and practice. Brazil and New Zealand both have established national policies to facilitate engagement. In contrast, national policy to enable engagement is relatively lacking in Australia and Chile. Australia, Brazil and New Zealand each have significant initiatives and policy structures in place to address Indigenous health. However, in Brazil this is not necessarily reflected in practice and although New Zealand has national policies these have been recently reported as insufficient and, in fact, may be contributing to health inequity for Māori. In comparison to the other three countries, Chile has relatively few national initiatives or policies in place to support Indigenous engagement or recognise the distinct health needs of Indigenous communities., Conclusions: The adoption of international policy frameworks forms an important step in ensuring that Indigenous peoples are able to participate in the formation and implementation of health policy and programs. However, without the relevant principles being reflected in national legislature, international agreements hold little weight. At the same time, while a national legislative framework facilitates the engagement of Indigenous peoples, such policy may not necessarily translate into practice. Developing multi-level approaches that improve cohesion between international policy, national policy and practice in Indigenous engagement in health is therefore vital. Given that each of the four countries demonstrate strengths and weaknesses across this causal chain, cross-country policy examination provides guidance on strengthening these links.

Objectives: Indigenous Australians have a disproportionately high burden of chronic illness, and relatively poor access to healthcare. This paper examines how a national multicomponent programme aimed at improving prevention and management of chronic disease among Australian Indigenous people addressed various dimensions of access., Design: Data from a place-based, mixed-methods formative evaluation were analysed against a framework that defines supply and demand-side dimensions to access. The evaluation included 24 geographically bounded 'sentinel sites' that included a range of primary care service organisations. It drew on administrative data on service utilisation, focus group and interview data on community members' and service providers' perceptions of chronic illness care between 2010 and 2013., Setting: Urban, regional and remote areas of Australia that have relatively large Indigenous populations., Participants: 670 community members participated in focus groups; 374 practitioners and representatives of regional primary care support organisations participated in in-depth interviews., Results: The programme largely addressed supply-side dimensions of access with less focus or impact on demand-side dimensions. Application of the access framework highlighted the complex inter-relationships between dimensions of access. Key ongoing challenges are achieving population coverage through a national programme, reaching high-need groups and ensuring provision of ongoing care., Conclusions: Strategies to improve access to chronic illness care for this population need to be tailored to local circumstances and address the range of dimensions of access on both the demand and supply sides. These findings highlight the importance of flexibility in national programme guidelines to support locally determined strategies., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: To address the gap in access to healthcare between Aboriginal people and other Australians, we developed Ways of Thinking, Ways of Doing (WoTWoD) to embed cultural respect into routine clinical practice. WoTWoD includes a workshop, toolkit and cultural mentors in a partnership of general practice and Aboriginal organisations. The aim of this study was to examine the im-pact of WoTWoD on cultural respect, health checks and risk factor management for Aboriginal patients in general practice., Methods: A multi-methods and multi-perspective pre- and-post-intervention pragmatic study with 10 general practices was undertaken, using information from medical records, practice staff, cultural mentors and patients., Results: Cultural respect, service and clinical measures improved after implementing WoTWoD. Qualitative information confirmed and explained improvements. Knowledge of Aboriginal history needed further improvement., Discussion: The WoTWoD may improve culturally appropriate care in general practice. Further research requires adequately powered randomised controlled trials.

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.

Background: Recognition of the importance of the early years in determining health and educational attainment and promotion of the World Health Organization Health for All (HFA) principles has led to an international trend towards community-based initiatives to improve developmental outcomes among socio-economically disadvantaged children. In this study we examine whether, Best Start, an Australian area-based initiative to improve child health was effective in improving access to Maternal and Child Health (MCH) services., Methods: The study compares access to information, parental confidence and annual 3.5 year Ages and Stages visiting rates before (2001/02) and after (2004/05) the introduction of Best Start. Access to information and parental confidence were measured in surveys of parents with 3 year old children. There were 1666 surveys in the first wave and 1838 surveys in the second wave. The analysis of visiting rates for the 3.5 year Ages and Stages visit included all eligible Victorian children. Best Start sites included 1,739 eligible children in 2001/02 and 1437 eligible children in 2004/05. The comparable figures in the rest of the state were and 45, 497 and 45, 953 respectively., Results: There was a significant increase in attendance at the 3.5 year Ages and Stages visit in 2004/05 compared to 2001/02 in all areas. However the increase in attendance was significantly greater at Best Start sites than the rest of the state. Access to information and parental confidence improved over the course of the intervention in Best Start sites with MCH projects compared to other Best Start sites., Conclusion: These results suggest that community-based initiatives in disadvantaged areas may improve parents' access to child health information, improve their confidence and increase MCH service use. These outcomes suggest such programmes could potentially contribute to strategies to reduce child health inequalities.

Policy addressing the provision of primary care after hours (AH) is currently in flux because of concerns about equity of access and cost. In this study we examine the effects of socioeconomic disadvantage on access to AH care and episodes of not seeking AH care when needed among users and non-users of AH care. The effects of health on these relationships were also explored. The total sample consisted of 5538 users of AH care and 891 non-users of AH care who were randomly selected for telephone interviews. Factors determining AH care included accessibility that is structural barriers to use of care such as distance and transport, as well as affordability and availability. Logistic regression was used to determine the impact of financial disadvantage on episodes of not seeking AH care. Barriers to use of AH care and household health were subsequently added to the models to assess their impact. The results suggested that there were inequities in access to AH care but these were a function of barriers to AH care use rather than financial disadvantage per se. Accessibility and availability were significant barriers to use of AH clinics among both user and non-user samples. Affordability was only a significant barrier among users of AH care. The study suggests that policy aimed at reducing these barriers may effectively address inequities in AH care but that to be optimally effective policy change would also need to be accompanied by changes in consumer awareness.

Background: The After Hours Primary Medical Trials were initiated by the Australian government to redress difficulties in after hours (AH) GP care in areas of high need. The study's objective is to study the impact of two standalone call centres and one GP cooperative offering comprehensive services, in improving consumer access to services for residents of a defined geographic area., Methods: A pre-post design was used to evaluate their impact after adjusting for secular trend at a national level. Access was considered in terms of availability, accessibility, affordability, acceptability and responsiveness of care. Unmet need and ease of obtaining AH telephone professional medical advice were also considered. Pre-trial and post-trial telephone surveys of two separate random samples of approximately 350 households using AH services in each trial area as well as in a national sample outside the trial areas., Results: Consumer acceptability and affordability increased in residents in the area served by the GP cooperative. Access, however measured, did not improve in either of the standalone call centre areas. Reduction in unmet need approached but did not achieve statistical significance in most but not all trial areas., Conclusions: Improvements in access in the GP cooperative conformed to expectations based on current and pre-existing AH care arrangements put in place. Absence of improvements in access in the standalone call centres did not conform to expectations but may be partly explained by the reductions in consumer acceptability, following introduction of telephone triage systems reported elsewhere.

Despite unequivocally worse health, expenditure on Indigenous people through the Pharmaceutical Benefits Scheme (PBS) is considerably less than for other Australians. We report on the effectiveness of a program to supply PBS medicines to remote Aboriginal and Torres Strait Islander Health Services (ATSIHSs) under section 100 (s. 100) of the National Health Act 1953., The Program: Under the special PBS arrangements (SPBSAs), approved ATSIHSs are able to order PBS medicine in bulk through local pharmacies and supply them as needed to patients on-site. The usual co-payment associated with PBS medicine is not charged and the pharmacist remuneration structure is different., Methods: The project involved consultation with the evaluation reference group and other stakeholders at all stages. There were six main data collection components: public submissions; interviews with government and other key stakeholders; pharmacist survey; medicine utilisation and expenditure data; national ATSIHS minimum dataset; and case studies of ATSIHSs., Results: These SPBSA potentially benefit 36% of the Aboriginal and Torres Strait Islander population. They have resulted in improved access to much-needed medicines, representing an increase of dollar 36.5 million in expenditure on Aboriginal and Torres Strait Islander people through the PBS between 2000/01 and 2002/03. They have further ensured that dollar 8.3 million of State and Territory expenditure formerly directed at medicine can be spent on prevention and primary care., Conclusion: Overall, the SPBSAs have been very successful and demonstrates an effective model for the development of Indigenous health policy.