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Background: Screening for communication disorders in a cross-cultural context presents numerous challenges, especially when the screening tool has been designed for use in one specific cultural and linguistic context. Translation enables it to be administered to speakers of a variety of languages, but does not account for the effects of worldview nor the linguistic and cultural context that motivated the original version. Clients assessed with tools not appropriate for their culture may be at a disadvantage in completing the assessment. Furthermore, this may influence diagnostic/screening judgements and decision-making related to access to relevant services. Aims: To describe the piloting of a screening tool developed to detect acquired communication disorders in Aboriginal Australians after stroke and traumatic brain injury – the Aboriginal Communication Assessment After Brain Injury (ACAABI). The study aims to i) assess whether a non-speech pathologist (e.g., Aboriginal Health Practitioner) can easily and accurately administer the tool, ii) determine whether the tool can identify acquired communication disorders of any type, and iii) describe a series of practical challenges encountered. Methods and procedures: Aboriginal Research Assistants (ARAs) reflected the role of the Aboriginal Health Practitioner. ARAs administered the tool to 38 Aboriginal brain injury survivors across Western Australia. A Speech Language Pathologist (SLP) observed the assessments to evaluate test administration. Another SLP undertook an independent communication assessment to provide information to an expert panel who produced a consensus diagnosis with which to compare the tool results. Sensitivity and specificity analyses were undertaken in terms of the total score and individual section scores. Field notes captured challenges encountered. Outcomes and results: Aboriginal Research Assistants could administer the tool effectively for the majority of participants, with some variations occurring. The tool appeared to be sensitive to detection of acquired communication disorders but had a high false-positive rate. However, small sample size and lack of comparative groups of non-brain-damaged individuals and those without communication disorders limits interpretation at this time. Challenges included participant recruitment, scheduling of appointments across large geographical distances, and availability of Aboriginal Research Assistants. Conclusions: The ACAABI looks promising in its ability to provide a culturally appropriate and secure way to screen for acquired communication disorders in Aboriginal people after brain injury for the purpose of referring onwards for further investigation. However, numerous challenges were encountered in the piloting and further work is needed to adjust the tool, enabling reliability, sensitivity and specificity analyses to be conclusive. [ABSTRACT FROM AUTHOR]

Objectives: To assess the risks of stroke and cardiovascular mortality for Aboriginal and non-Aboriginal Australians with atrial fibrillation.Design: Retrospective data linkage cohort study.Setting, Participants: All people aged 20-84 years hospitalised with atrial fibrillation in Western Australia during 2000-2012.Main Outcome Measures: Stroke incidence rates and mortality after hospitalisation for atrial fibrillation, and 10-year risks of stroke and of cardiovascular and all-cause mortality.Results: Among 55 482 index admissions with atrial fibrillation, 7.7% of 20-59-year-old patients and 1.3% of 60-84-year-old patients were Aboriginal Australians. A larger proportion of Aboriginal patients aged 20-59 years had CHA2 DS2 -VASc scores of 2 or more (59.8% v 21.8%). In 20-59-year-old Aboriginal patients, the incidence during follow-up (maximum, 10 years; median, 7.1 years) of stroke (incidence rate ratio [IRR], 3.2; 95% CI, 2.5-4.1) and fatal stroke (IRR, 5.7; 95% CI, 3.9-8.9) were markedly higher than for non-Aboriginal patients. Stroke incidence was higher for 60-84-year-old patients, but the difference between Aboriginal and non-Aboriginal patients was smaller (IRR, 1.6; 95% CI, 1.3-2.0). Cardiovascular mortality during follow-up was also higher for 20-59-year-old Aboriginal patients (IRR, 4.4; 95% CI, 4.3-5.9). The hazards of stroke (adjusted HR [aHR], 1.67; 95% CI, 1.22-2.28) and cardiovascular mortality (aHR, 1.47; 95% CI, 1.18-1.83) in younger Aboriginal patients remained significantly higher after multivariable adjustment; age/sex, principal diagnosis of atrial fibrillation, and CHA2 DS2 -VASc score were the most influential factors.Conclusion: Stroke risk and cardiovascular mortality are markedly higher for Aboriginal than non-Aboriginal patients with atrial fibrillation, particularly for patients under 60. Strategies for providing evidence-based therapies and cardiovascular prevention to Aboriginal people with atrial fibrillation must be improved. [ABSTRACT FROM AUTHOR]

Background: The overarching cultural context of the brain injury survivor, particularly that related to minority peoples with a history of colonisation and discrimination, has rarely been referred to in the research literature, despite profoundly influencing a person's recovery journey in significant ways, including access to services. This study highlights issues faced by Australian Aboriginal traumatic brain injury (TBI) survivors in terms of real-life consequences of the high incidence of TBI in this population, current treatment and long-term challenges. Method: A case study approach utilised qualitative interview and file review data related to five male Aboriginal TBI survivors diagnosed with acquired communication disorders. The five TBI survivors were from diverse areas of rural and remote Western Australia, aged between 19 and 48 years at the time of injury, with a range of severity. Case Reports: Common themes included: significant long-term life changes; short-term and long-term dislocation from family and country as medical intervention and rehabilitation were undertaken away from the person's rural/remote home; family adjustments to the TBI including permanent re-location to a metropolitan area to be with their family member in residential care; challenges related to lack of formal rehabilitation services in rural areas; poor communication channels; poor cultural security of services; and lack of consistent follow-up. Discussion and Conclusion: These case reports represent some of the first documented stories of Aboriginal Australian TBI survivors. They supplement available epidemiological data and highlight different contexts for Aboriginal people after TBI, contributing to an overall profile that is relevant for rehabilitation service planning. [ABSTRACT FROM AUTHOR]

Background: Early detection of breast cancer using screening mammography provides an opportunity for treatment which can lead to significantly improved outcomes. Despite considerable efforts having been made, the rate at which Aboriginal and Torres Strait Islander (hereafter respectfully referred to as Aboriginal) women in Western Australia participate in BreastScreen WA's screening mammogram program remains below that for the overall female population of Western Australia. This study aimed to examine perspectives on breast screening amongst Aboriginal women in Western Australia. We explored the factors which impact on participation in breast screening and sought to identify potential initiatives to address lower participation in screening.Methods: Semi-structured interviews, focus group discussions and yarning sessions were conducted with a total of 65 research participants. They were all Aboriginal and comprised consumers and health professionals from locations across the state.Results: Our findings show that research participants generally were willing to have a mammogram. Key reasons given were having a genetic predisposition to breast cancer and a perception of investing in health for the sake of the next generation, as well as personal well-being. Barriers identified included lack of education about or understanding of screening, inadequacies in cultural appropriateness in the screening program, cultural beliefs around cancer in general and breast cancer in particular, and competing health and life priorities. However, many enablers were identified which can serve as potential strategies to assuage fear and increase screening uptake. These included increased education delivered by respected Aboriginal women, culturally appropriate promotion and the provision of care and support from other women in the community.Conclusion: The higher participation rates for Aboriginal women in Western Australia than are found for Aboriginal women nationally demonstrate the success of the strategies put in place by BreastScreen WA. These efforts must be supported and existing policies and practices enhanced to address the limitations in the existing program. Only by implementing and evaluating such initiatives and making breast screening programs more accessible to Aboriginal women can the current disparity between the screening participation rates of Aboriginal and non-Aboriginal women be reduced. [ABSTRACT FROM AUTHOR]

Patients with acute coronary syndrome (ACS) require ongoing treatment and support from their primary care provider to modify cardiovascular risk factors (including diet, exercise and mood), to receive evidence-based pharmacotherapies and be properly monitored and to ensure their take-up and completion of cardiac rehabilitation (CR). This study assesses adherence to National Heart Foundation guidelines for ACS in primary care in a regional centre in Western Australia. Patients discharged from hospital after a coronary event (unstable angina or myocardial infarction) or a coronary procedure (stent or coronary artery bypass graft) were identified through general practice electronic medical records. Patient data was extracted using a data form based on National Heart Foundation guidelines. Summary statistics were calculated and reported. Our study included 22 GPs and 44 patients in a regional centre. In total, 90% (n = 39) of discharge summaries recorded medications. Assessment of pharmacological management showed that 53% (n = 23) of patients received four or more classes of pharmacotherapy and that GPs often augmented medication beyond that prescribed at discharge. Of 15 smokers, 13 (87%) had advice to quit documented. Minimal advice for other risk-factor modification was documented in care plans. Patients with type 2 diabetes (n = 20) were 70% more likely to receive allied health referral (P = 0.02) and 60% more likely to receive advice regarding diet and exercise (P = 0.007). However, overall, only30%(n = 13) of those eligible were referred to a dietician, and only 25% were referred to CR(n = 10) with six completing CR. Although most GPs did not use standardised tools for mood assessment, 18 (41%) patients were diagnosed as depressed, of which 88% (n = 16) were started on antidepressants and 28% (n = 6) were referred to a psychologist. Although pharmacotherapy, mood management and smoking cessation management generally followed recommended guidelines, risk factor management relating to diet and exercise by GPs require improvement. Detailed care plans and referral to CR and allied health staff for patient support is recommended. [ABSTRACT FROM AUTHOR]

Aboriginal Australians are at higher risk of developing certain types of cancer and, once diagnosed, they have poorer outcomes than their non-Aboriginal counterparts. Lower access to cancer screening programmes, deficiencies in treatment and cultural barriers contribute to poor outcomes. Additional logistical factors affecting those living in rural areas compound these barriers. Cancer support groups have positive effects on people affected by cancer; however, there is limited evidence on peer-support programmes for Aboriginal cancer patients in Australia. This paper explores the roles played by an Aboriginal women's cancer support network operating in a regional town in Western Australia. Data were collected through semi-structured interviews with 24 participants including Aboriginal and mainstream healthcare service providers, and network members and clients. Interviews were audiotaped and transcribed verbatim. Transcripts were subjected to inductive thematic analysis. Connecting and linking people and services was perceived as the main role of the network. This role had four distinct domains: (i) facilitating access to cancer services; (ii) fostering social interaction; (iii) providing a culturally safe space; and (iv) building relationships with other agencies. Other network roles included providing emotional and practical support, delivering health education and facilitating engagement in cancer screening initiatives. Despite the network's achievements, unresolved tensions around role definition negatively impacted on the working relationship between the network and mainstream service providers, and posed a threat to the network's sustainability. Different perspectives need to be acknowledged and addressed in order to build strong, effective partnerships between service providers and Aboriginal communities. Valuing and honouring the Aboriginal approaches and expertise, and adopting an intercultural approach are suggested as necessary to the way forward. [ABSTRACT FROM AUTHOR]

Undergraduates who undertake rural placements often choose a rural career. Reluctance from universities to send students to rural settings limits placement numbers. The Western Australian Centre for Rural Health (WACRH) invited allied health and nursing academics and clinical placement coordinators from Western Australian (WA) universities to an Academic Bush Camp. Based on situated learning theory, this camp modelled student programs through experiential learning and structured workshops. It aimed to build relationships and showcase innovative rural learning opportunities. Objective To build relationships and showcase innovative rural learning opportunities. Design An evaluation of a residential camp based on situated learning theory. Setting The camp stated and finished in Geraldton, WA and was centered in Mt Magnet, WA a remote town 600 kilometres northeast of Perth. Participants WACRH invited allied health and nursing academics and clinical placement coordinators from Western Australian (WA) universities. Intervention This camp modelled student programs through experiential learning and structured workshops. Online pre- and post-camp questionnaires included open-ended questions and questions on a 5-point Likert scale. Responses were analysed in SPSS 22 using descriptive statistics and Wilcoxon signed-rank test. Follow-up phone interviews six months later assessed longer-term reflections and changes in student placement practice. Main outcome measures The main outcome measure was whether the camp met participants' expectations, and their knowledge about and interest in WACRH's programs. Results Twelve academics from five WA universities and seven health disciplines attended. Nine had previously lived or worked rurally. The camp met participants' expectations and all would recommend the opportunity to a colleague. Many valued the interaction with community and clinical placement partners and would have preferred more of this. The camp increased awareness of WACRH's programs and benefits of longer rural placements and a service-learning environment. Six months later, participants' familiarity with WACRH's placement model, supports and staff had led to an enhanced willingness to place students. Conclusion Rural academics can influence rural placement intentions by demonstrating the infrastructure, learning and academic support available. A camp experience increases metropolitan academics' awareness of rural placement programs and willingness to encourage student participation. Participants with rural backgrounds appeared more receptive to rural learning possibilities. [ABSTRACT FROM AUTHOR]

Objective To describe midwifery students' insights on promoting health to Aboriginal women in remote Australia following a supervised clinical placement. Design Semistructured, in-depth interviews were conducted with all midwifery students who undertook the placement between 2010 and 2013. Setting Aboriginal communities on the Ngaanyatjarra Lands, Western Australia. Participants Undergraduate and postgraduate midwifery students from a Western Australian university. Interventions Remote cultural immersion clinical placement. Main outcome measures Student learning related to culturally respectful health care delivery and promotion of health. Results Students observed that, despite vast distances, high rates of participation in a breast screening program were achieved due to the informal provision of culturally relevant information and support. Opportunistic encounters in communities also enabled sexual health messages to be delivered more widely and in less formal settings. The role played by Aboriginal Health Workers and female family members was vital. The importance of culturally respectful approaches to sensitive women's business, including discretion, the use of local language and pictorial representations of information, was recognised as was the socio-cultural context and its impact on the health and well-being of the community. Conclusions Although short in duration, the Ngaanyatjarra Lands clinical placement provided midwifery students with a rare opportunity to observe the importance of local contexts and cultural protocols in Aboriginal communities, and to adapt health promotion strategies to meet local needs and ways of doing things. These strategies embraced the strengths, assets and capacities of communities, yet students also witnessed challenges associated with access, delivery and acceptance of health care in remote settings. [ABSTRACT FROM AUTHOR]

Introduction Aboriginal Australians have a substantially higher frequency of ischaemic heart disease (IHD) events than their non-Aboriginal counterparts, together with a higher prevalence of comorbidities. The pattern of health service provision for IHD suggests inequitable delivery of important diagnostic procedures. Published data on disparities in IHD management among Aboriginal Australians are conflicting, and the role of comorbidities has not been adequately delineated. We compared the profiles of Aboriginal and non-Aboriginal patients in the metropolitan area undergoing emergency IHD admissions at Western Australian metropolitan hospitals, and investigated the determinants of receiving coronary angiography. Methods Person-linked administrative hospital and mortality records were used to identify 28-day survivors of IHD emergency admission events (n =20,816) commencing at metropolitan hospitals in 2005-09. The outcome measure was receipt of angiography. The Aboriginal to non-Aboriginal risk ratio (RR) was estimated from a multivariable Poisson log-linear regression model with allowance for multiple IHD events in individuals. The subgroup of myocardial infarction (MI) events was modelled separately. Results Compared with their non-Aboriginal counterparts, Aboriginal IHD patients were younger and more likely to have comorbidities. In the age- and sex-adjusted model, Aboriginal patients were less likely than others to receive angiography (RR IHD 0.77, 95%CI 0.72-0.83; RR MI 0.81, 95%CI 0.75-0.87) but in the full multivariable model this disparity was accounted for by comorbidities as well as IHD category and MI subtype, and private health insurance (RR IHD 0.95, 95%CI 0.89-1.01; RR MI 0.94, 95% CI 0.88-1.01). When stratified by age groups, this disparity was not significant in the 25-54 year age group (RR MI 0.95, 95% CI 0.88-1.02) but was significant in the 55-84 year age group (RR MI 0.88, 95% CI 0.77-0.99). Conclusions The disproportionate under-management of older Aboriginal IHD patients is of particular concern. Regardless of age, the disparity between Aboriginal and non-Aboriginal Australians in receiving angiography for acute IHD in a metropolitan setting is mediated substantially by comorbidities. This constellation of health problems is a 'double-whammy' for Aboriginal people, predisposing them to IHD and also adversely impacting on their receipt of angiography. Further research should investigate how older age and comorbidities influence clinical decision making in this context. [ABSTRACT FROM AUTHOR]

Background Aboriginal people have a disproportionately higher incidence rate of ischaemic heart disease (IHD) than non-Aboriginal people. The findings on Aboriginal disparity in receiving coronary artery procedures are inconclusive. We describe the profile and transfers of IHD patients admitted to rural hospitals as emergency admissions and investigate determinants of transfers and coronary angiography. Methods Person-linked hospital and mortality records were used to identify 28-day survivors of IHD events commencing at rural hospitals in Western Australia. Outcome measures were receipt of coronary angiography, transfer to a metropolitan hospital, and coronary angiography if transferred to a metropolitan hospital. Results Compared to non-Aboriginal patients, Aboriginal patients with IHD were more likely to be younger, have more co-morbidities, reside remotely, but less likely to have private insurance. After adjusting for demographic characteristics, Aboriginal people with MI were less likely to be transferred to a metropolitan hospital, and if transferred were less likely to receive coronary angiography. These disparities were not significant after adjusting for comorbidities and private insurance. In the full multivariate model age, comorbidities and private insurance were adversely associated with transfer to a metropolitan hospital and coronary angiography. Conclusion Disparity in receiving coronary angiography following emergency admission for IHD to rural hospitals is mediated through the lower likelihood of being transferred to metropolitan hospitals where this procedure is performed. The likelihood of a transfer is increased if the patient has private insurance, however, rural Aboriginal people have a lower rate of private insurance than their non-Aboriginal counterparts. Health practitioners and policy makers can continue to claim that they treat Aboriginal and non-Aboriginal people alike based upon clinical indications, as private insurance is acting as a filter to reduce rural residents accessing interventional cardiology. If health practitioners and policy makers are truly committed to reducing health disparities, they must reflect upon the broader systems in which disparity is perpetuated and work towards a systems improvement. [ABSTRACT FROM AUTHOR]

Background Although the challenges of working with culturally and linguistically diverse groups can lead to the exclusion of some communities from research studies, cost effective strategies to encourage access and promote cross-cultural linkages between researchers and ethnic minority participants are essential to ensure their views are heard and their health needs identified. Using bilingual research assistants is one means to achieve this. In a study exploring alcohol and other drug service use by migrant women in Western Australia, bilingual workers were used to assist with participant recruitment and administration of a survey to 268 women who spoke more than 40 different languages. Discussion Professional interpreters, bilingual students, bilingual overseas-trained health professionals and community sector bilingual workers were used throughout the research project. For the initial qualitative phase, professional interpreters were used to conduct interviews and focus group sessions, however scheduling conflicts, inflexibility, their inability to help with recruitment and the expense prompted exploration of alternative options for interview interpreting in the quantitative component of the study. Bilingual mature-age students on work placement and overseas-trained health professionals provided good entry into their different community networks and successfully recruited and interviewed participants, often in languages with limited interpreter access. Although both groups required training and supervision, overseas-trained health professionals often had existing research skills, as well as understanding of key issues such as confidentiality and referral processes. Strategies to minimise social desirability bias and the need to set boundaries were discussed during regular debriefing sessions. Having a number of workers recruiting participants also helped minimise the potential for selection bias. The practical and educational experience gained by the bilingual workers was regarded as capacity building and a potentially valuable community resource for future health research projects. Summary The use of bilingual workers was key to the feasibility and success of the project. The most successful outcomes occurred with students and overseas-trained health professionals who had good community networks for recruitment and the required linguistic skills. By describing the advantages and disadvantages encountered when working with bilingual workers, we offer practical insights to assist other researchers working with linguistically diverse groups. [ABSTRACT FROM AUTHOR]

Background: A culturally relevant educational flipchart targeting Aboriginal people was distributed across Western Australia to support education on bowel cancer screening and encourage participation in the National Bowel Cancer Screening Program. Methods: Respondents sampled from the flipchart distribution list were surveyed on the appropriateness, usefulness, and the extent to and manner in which they used the flipchart for educating Aboriginal clients. Results: Despite praising the resource, few respondents used the flipchart as intended for various reasons, including the view that Aboriginal health education was the responsibility of Aboriginal health workers. Conclusions: Greater recognition by all health service providers is needed of their potential role in Aboriginal health education. Promoting a national health program of under-appreciated importance for a marginalised population is challenging. Effective utilisation of an educational tool is predicated on factors beyond its production quality and wide dissemination. Intended users require awareness of the underlying problem, and adequate time for and specific training in implementation of the tool. [ABSTRACT FROM AUTHOR]

Objectives: The emotional responses of students undertaking a new, compulsory unit on Indigenous cultures and health were investigated as part of a broader study looking at culturally secure practice in midwifery education and service provision for Aboriginal women. Methods: Classroom observations were conducted on a first year midwifery cohort from July to October 2012 and students completed 'before and after' questionnaires. Results: A spectrum of emotional responses was identified and found to be consistent with studies of medical student exposure to Aboriginal content. While stereotypes were challenged and perceptions altered as a result of the content, issues surrounding racism remained unresolved, with some students expressing dismay at the attitudes of their peers. Conclusion: This study confirmed the need for content on Aboriginal health and cultures to extend beyond one unit in a course. Learning and knowledge must be carefully integrated and developed to maximise understanding and ensure that unresolved issues are addressed. [ABSTRACT FROM AUTHOR]

Background: Discharge Against Medical Advice (DAMA) from hospital is associated with adverse outcomes and is considered an indicator of the responsiveness of hospitals to the needs of Aboriginal and Torres Strait Islander Australians, the indigenous people of Australia. We investigated demographic and clinical factors that predict DAMA in patients experiencing their first-ever inpatient admission for ischaemic heart disease (IHD). The study focuses particularly on the differences in the risk of DAMA in Aboriginal and non-Aboriginal patients while also investigating other factors in their own right. Methods: A cross-sectional analytical study was undertaken using linked hospital and mortality data with complete coverage of Western Australia. Participants included all first-ever IHD inpatients (aged 25-79 years) admitted between 2005 and 2009, selected after a 15-year clearance period and who were discharged alive. The main outcome measure was DAMA as reflected in the hospital record. Multiple logistic regression was used to determine disparities in DAMA between Aboriginal and non-Aboriginal patients, adjusting for a range of demographic and clinical factors, including comorbidity based on 5-year hospitalization history. A series of additional models were run on subgroups of the cohort to refine the analysis. Ethics approval was granted by the WA Human Research and the WA Aboriginal Health Ethics Committees. Results: Aboriginal patients comprised 4.3% of the cohort of 37,304 IHD patients and 23% of the 224 DAMAs. Emergency admission (OR=5.9, 95% CI 2.9-12.2), alcohol admission history (alcohol-related OR=2.9, 95% CI 2.0-4.2) and Aboriginality (OR 2.3, 95% CI 1.5-3.5) were the strongest predictors of DAMA in the multivariate model. Patients living in rural areas while attending non-metropolitan hospitals had a 50% higher risk of DAMA than those living and hospitalised in metropolitan areas. There was consistency in the ORs for Aboriginality in the different multivariate models using restricted sub-cohorts and different Aboriginal identifiers. Sex, IHD diagnosis type and co-morbidity scores imparted different risks in Aboriginal versus non-Aboriginal patients. Conclusions: Understanding the risks and reasons for DAMA is important for health system policy and proactive management of those at risk of DAMA. Improving care to prevent DAMA should target unplanned admissions, rural hospitals and young men, Aboriginal people and those with alcohol and mental health comorbidities. [ABSTRACT FROM AUTHOR]

Background: Aboriginal Australians have a lower rate of utilisation of palliative care services than the general population. This study aimed to explore care providers' experiences and concerns in providing palliative care for Aboriginal people, and to identify opportunities for overcoming gaps in understanding between them and their Aboriginal patients and families. Methods: In-depth, qualitative interviews with urban, rural and remote palliative care providers were undertaken in inpatient and community settings in Western Australia. Interviews were audio-recorded, transcribed verbatim and coded independently by two researchers with QSR NVivo 10 software used to help manage data. Data analysis was informed by multiple theoretical standpoints, including the social ecological model, critical cultural theories and the 'cultural security' framework. Thematic analysis was carried out that identified patterns within data. Results: Fifteen palliative care providers were interviewed. Overall they reported lack of understanding of Aboriginal culture and being uncertain of the needs and priorities of Aboriginal people during end-of-life care. According to several participants, very few Aboriginal people had an understanding of palliative care. Managing issues such as anger, denial, the need for non-medical support due to socioeconomic disadvantage, and dealing with crises and conflicts over funeral arrangements were reported as some of the tensions between Aboriginal patients and families and the service providers. Conclusion: Early referral to palliative care is important in demonstrating and maintaining a caring therapeutic relationship. Paramount to meeting the needs for Aboriginal patients was access to appropriate information and logistical, psychological and emotional support. These were often seen as essential but additional to standard palliative care services. The broader context of Aboriginal history and historical distrust of mainstream services was seen to impinge on Aboriginal people's willingness and ability to accept care and support from these services. This context needs to be understood and acknowledged at the system level. More cultural safety training was requested by care providers but it was not seen as replacing the need for an Aboriginal worker in the palliative care team. [ABSTRACT FROM AUTHOR]

Objective To determine the impact of remoteness on Aboriginal and non- Aboriginal myocardial infarction incidence rates in men and women of different ages. Design Descriptive study. Setting Western Australia. Participants Incident cases of myocardial infarction in Western Australia from 2000-2004 identified from person-linked files of hospital and mortality records. Analysis was undertaken for Aboriginal and non- Aboriginal populations, separately and combined, by broad age group, sex and remoteness. Main outcome measure Incidence of myocardial infarction. Results In the combined analysis, age-standardised incidence was significantly higher for men in very remote areas (rate ratio 1.31: 95% confidence interval ( CI), 1.19-1.45) and in women in both regional (rate ratio 1.12: 95% CI, 1.01-1.20) and very remote (rate ratio 2.05: 95% CI, 1.75-2.41) areas. Aboriginal rates were substantially higher than non- Aboriginal rates in all substrata. Compared with metropolitan people, regional Aboriginal men and very remote non- Aboriginal men aged 25-54 years had significantly higher incidence rates. For the remaining rural strata, there was either no geographical disadvantage or inconclusive findings. Conclusions Non-metropolitan disadvantage in myocardial infarction rates is confirmed in regional areas and women in very remote areas. This disadvantage is partly explained by the high rates in Aboriginal people. Non-metropolitan dwellers are not uniformly disadvantaged, reflecting the interplay of the many factors contributing to the complex relationship between myocardial infarction incidence and sex, age, Aboriginality and residence. Aboriginal Western Australians in all regions and young non- Aboriginal men living in very remote areas need to be targeted to reduce disparities in myocardial infarction. [ABSTRACT FROM AUTHOR]

Background: Little is known about the use of bush medicine and traditional healing among Aboriginal Australians for their treatment of cancer and the meanings attached to it. A qualitative study that explored Aboriginal Australians' perspectives and experiences of cancer and cancer services in Western Australia provided an opportunity to analyse the contemporary meanings attached and use of bush medicine by Aboriginal people with cancer in Western Australia Methods: Data collection occurred in Perth, both rural and remote areas and included individual in-depth interviews, observations and field notes. Of the thirty-seven interviews with Aboriginal cancer patients, family members of people who died from cancer and some Aboriginal health care providers, 11 participants whose responses included substantial mention on the issue of bush medicine and traditional healing were selected for the analysis for this paper. Results: The study findings have shown that as part of their healing some Aboriginal Australians use traditional medicine for treating their cancer. Such healing processes and medicines were preferred by some because it helped reconnect them with their heritage, land, culture and the spirits of their ancestors, bringing peace of mind during their illness. Spiritual beliefs and holistic health approaches and practices play an important role in the treatment choices for some patients. Conclusions: Service providers need to acknowledge and understand the existence of Aboriginal knowledge (epistemology) and accept that traditional healing can be an important addition to an Aboriginal person's healing complementing Western medical treatment regimes. Allowing and supporting traditional approaches to treatment reflects a commitment by modern medical services to adopting an Aboriginal-friendly approach that is not only culturally appropriate but assists with the cultural security of the service. [ABSTRACT FROM AUTHOR]

Smoking among Aboriginal people is extremely widespread (50 v. 17% of the general population). Aboriginal Health Workers (AHW) are at the vanguard of tackling this problem but many themselves smoke and little is known of their knowledge, attitudes and practices regarding smoking cessation. Structured telephone interviews were conducted with 36 AHW, including 31% current smokers, 31% ex-smokers and 38% non-smokers, to assess their current smoking cessation practices and knowledge of health risks, nicotine dependence, cessation strategies and pharmacotherapies. AHW considered diabetes, alcohol use and heart disease more problematic than smoking among Aboriginal people. Fear of appearing hypocritical stopped many who smoke from discussing smoking cessation with clients but also stopped some non-smoking AHW whose colleagues or family smoked. Cultural concerns about telling others 'what to do' was also a major impediment. Knowledge of the health effects of smoking was good, but knowledge of appropriate advice around cessation pharmacotherapies was suboptimal. AHW trained in smoking cessation were more knowledgeable and active in smoking cessation, but most AHW had received no training, despite being keen to do so. Specific smoking cessation training is sought and appears needed by AHW, particularly in the areas of brief interventions, motivational interviewing, dependence assessment and pharmacotherapies. [ABSTRACT FROM AUTHOR]

The article discusses a qualitative study which was conducted to determine the extent of effective communication between Aboriginal people and health service providers, under the context of cancer care, in Western Australian hospital settings. The scope includes patients' views about the quality of communication within the hospitals, factors impairing communication and suggestions for improvement. The results found out that attention on factors such as language, shared understanding, knowledge and use of medical terminology are required.

Background: Indigenous Australians have significantly poorer status on a large range of health, educational and socioeconomic measures and successive Australian governments at state and federal level have committed to redressing these disparities. Despite this, improvements in Aboriginal health status have been modest, and Australia has much greater disparities in the health of its Indigenous people compared to countries that share a history characterised by colonisation and the dispossession of indigenous populations such as New Zealand, Canada and the United States of America. Efforts at policy and planning must ultimately be translated into practical strategies. This article outlines an approach that was effective in Western Australia in increasing the engagement and concern of Aboriginal people about high rates of sexually transmissible infections and sexual health issues. Many aspects of the approach are relevant for other health issues. Results: The complexity of Indigenous sexual health necessitates inter-agency and cross-governmental collaboration, in addition to Aboriginal leadership, accurate data, and community support. A recent approach covering all these areas is described. This has resulted in Aboriginal sexual health being more actively discussed within Aboriginal health settings than it once was and additional resources for Indigenous sexual health being available, with better communication and partnership across different health service providers and sectors. The valuable lessons in capacity building, collaboration and community engagement are readily transferable to other health issues, and may be useful for other health professionals working in the challenging area of Aboriginal health. Conclusion: Health service planners and providers grapple with achieving Aboriginal ownership and leadership regarding their particular health issue, despite sincere concern and commitment to addressing Aboriginal health issues. This highlights the need to secure genuine Aboriginal engagement. Building capacity that enables Indigenous people and communities to fulfill their own goals is a long-term strategy and requires sustained commitment, but we argue is a prerequisite for better Indigenous health outcomes. [ABSTRACT FROM AUTHOR]

This paper examines the supportive care in place to meet the needs of patients receiving radiotherapy at a regional oncology service in Bunbury, Western Australia. Semi‐structured in‐depth interviews with 21 service providers and 17 adults diagnosed with cancer who underwent radiotherapy at the Service were recorded, transcribed and analysed thematically. Key themes relevant were co‐operation and collaboration of interdisciplinary team members; support from organisations to assist with accommodation, transport, emotional support and provision of practical assistance, as well as barriers to accessing support. Most participants were positive about the support available, recognising the needs of rural radiotherapy patients for assistance with travel, accommodation and psychosocial support to help deal with the stressors they face. Collaboration between the various service providers maximised the support available to patients but the drop off in psychosocial support once the intensity of treatment was completed was identified as a weakness in the support available. The support system, established around a regional radiotherapy service, was enhanced by the collaborative professional relationships developed among service providers. The service extends beyond clinical service delivery by recognising financial, logistical and psychosocial support needs, factors to be considered to ensure rural radiotherapy patients are provided with holistic care. [ABSTRACT FROM AUTHOR]

The article discusses research on barriers to cardiac rehabilitation (CR) use among Aboriginal cardiac patients in Perth, Western Australia. A semistructured interview guide was used to interview study participants about their views, experiences and suggestions for improvement for CR. The need for improvement in media and public health campaigns relating to CR is emphasized.

Abstract: Objectives: To compare the incidence of first heart failure (HF) hospitalisation, antecedent risk factors and 1-year mortality between Aboriginal and non-Aboriginal populations in Western Australia (2000–2009). Methods: A population-based cohort aged 20–84years comprising Aboriginal (n=1013; mean 54±14years) and non-Aboriginal patients (n=16,366; mean 71±11years) with first HF hospitalisation was evaluated. Age and sex-specific incidence rates and HF antecedents were compared between subpopulations. Regression models were used to examine 30-day and 1-year (in 30-day survivors) mortality. Results: Aboriginal patients were younger, more likely to reside in rural/remote areas (76% vs 23%) and to be women (50.6% vs 41.7%, all p<0.001). Aboriginal (versus non-Aboriginal) HF incidence rates were 11-fold higher in men and 23-fold in women aged 20–39years, declining to about 2-fold in patients aged 70–84years. Ischaemic and rheumatic heart diseases were more common antecedents of HF in younger (<55years) Aboriginal versus non-Aboriginal patients (p<0.001). Hypertension, diabetes, chronic kidney disease, renal failure, chronic obstructive pulmonary disease, and a high Charlson comorbidity index (>=3) were also more prevalent in younger and older Aboriginal patients (p<0.001). Although 30-day mortality was similar in both subpopulations, Aboriginal patients aged <55years had a 1.9 risk-adjusted hazard ratio (HR) for 1-year mortality (p=0.015). Conclusions: Aboriginal people had substantially higher age and sex-specific HF incidence rate and prevalence of HF antecedents than their non-Aboriginal counterparts. HR for 1-year mortality was also significantly worse at younger ages, highlighting the urgent need for enhanced primary and secondary prevention of HF in this population. [Copyright &y& Elsevier]

Abstract: Objectives: To investigate the impact of prevalence correction of population denominators on myocardial infarction (MI) incidence rates, rate ratios, and rate differences in Aboriginal vs. non-Aboriginal Western Australians aged 25–74 years during the study period 2000–2004. Study Design and Setting: Person-based linked hospital and mortality data sets were used to estimate the number of prevalent and first-ever MI cases each year from 2000 to 2004 using a 15-year look-back period. Age-specific and -standardized MI incidence rates were calculated using both prevalence-corrected and -uncorrected population denominators, by sex and Aboriginality. Results: The impact of prevalence correction on rates increased with age, was higher for men than women, and substantially greater for Aboriginal than non-Aboriginal people. Despite the systematic underestimation of incidence, prevalence correction had little impact on the Aboriginal to non-Aboriginal age-standardized rate ratios (6% and 4% underestimate in men and women, respectively), although the impact on rate differences was more marked (12% and 6%, respectively). The percentage underestimate of differentials was greater at older ages. Conclusion: Prevalence correction of denominators, while more accurate, is difficult to apply and may add modestly to the quantification of relative disparities in MI incidence between populations. Absolute incidence disparities using uncorrected denominators may have an error >10%. [Copyright &y& Elsevier]

Objective: To illuminate the enablers and challenges of implementing a communication strategy designed to support Community, Respect, Equality (CRE) and a family and domestic violence (FDV) primary prevention plan in a regional Western Australian town., Method: This research draws on documentation and interviews with members of Leading Lights, an advocacy group arising from a collaboration of local organisations to communicate the goals and priorities of the CRE action plan. Interviews explored how primary prevention messages were promoted to foster supportive community attitudes toward addressing the drivers of FDV., Results: The initiative fostered a learning community that coordinated public messaging about the drivers of FDV for organisations pledged to the CRE values. The diffusion of messaging was affected over time by inconsistent staffing, discontinuities in resourcing and individual organisational commitment, and concerns about gender equality messaging., Conclusion: The communications strategy increased awareness of the drivers of FDV among the members of the Leading Lights. In turn, this group produced media content that made visible each organisation's commitment to addressing the attitudes and behaviours that enable FDV., Implications for Public Health: Community collaborations need time, resourcing, and coordination to sustainably prompt changes in social norms that underpin violence., Competing Interests: Conflicts of interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Sandra Thompson reports financial support was provided by The University of Western Australia., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

In the Midwest region of Western Australia, rates of intimate partner and family violence (IPV/FV) are high. We undertook research into social workers' knowledge, attitudes, and skills as part of addressing this significant public health issue. Social workers come into contact with people experiencing IPV/FV in multiple settings, so their understandings and responses are critical to the prevention and interventions related to violence against women. The goal of the research was to determine the issues that the social workers in this region needed to be addressed that could assist in tackling the problem of IPV/FV. A questionnaire included open-ended questions to capture information on respondents' profiles, knowledge, attitudes, practices, and education around IPV/FV, with 29 of 37 social workers working in the region responding. We also elicited respondents' recommendations related to training and service delivery. Despite working in many settings, most social workers had contact with people experiencing IPV/FV and had reasonable confidence and knowledge that showed an understanding of the complexity of FV, including why women stay in violent relationships. This paper identified social workers' need for more education, including during their university training, resources, and service coordination to support best practice delivery of services to people affected by IPV/FV. Training to develop skills for conversations about IPV/FV with clients, around safety planning, and greater access to safe alternative accommodation for those leaving FV were identified priorities.

The nursing workforce is the backbone of healthcare provision in rural and remote Australia. Introducing student nurses to rural clinical placements is one strategy used to address the shortfall of healthcare workers outside of major cities, with the goal of improving the training, recruitment and retention of nurses in rural areas. The aim of this qualitative, longitudinal study was to better understand personal and professional decision-making around rural nursing practice intentions and subsequent rural employment and retention. The study methodology consisted of repeated semi-structured interviews with student nurses who had completed at least one rural placement and following them on their journey to becoming graduate nurses over a 6-year period. Thematic longitudinal analysis was undertaken, with three main themes developing, each with further subthemes: (1) participants' satisfaction with rural placements; (2) their challenges with gaining employment; and (3) considerations regarding 'going rural' for work. The participants engaged in both prospective and retrospective reflection around several professional, personal, and wider systemic barriers and enablers to rural practice, which are discussed in detail in this paper. The insights from this longitudinal study have the potential to assist the development of a sustainable rural nursing workforce through informing rural workforce programs, strategies and policies.

Objectives: This research aimed to gain insights into the reporting of family violence (FV) and to explore any changes in FV reporting associated with a FV primary prevention initiative in Geraldton, Western Australia., Methods: An in-depth analysis of articles published by the Geraldton Guardian in 2019 examined the nature of FV reporting. Analysis was based on deductive coding from existing literature and inductive identification of new themes. A comparative analysis examined articles from the Geraldton Guardian and Albany Advertiser over the same three-month period in 2015, 2017 and 2019 to analyse trends in FV reporting., Results: Of 135 articles analysed, there was alignment with five previously reported themes and two new themes were identified: FV as a public health issue; and community responses to reduce FV. Episodic framing was overwhelmingly associated with court reporting. There was more reporting of efforts at primary prevention of FV over time in both newspapers., Conclusions: Local media can contribute to the promotion of community and public health issues related to FV. Efforts are needed to improve court reporting to situate FV in a broader context., Implications for Public Health: Concerted efforts to educate the public and journalists can support FV being recognised as a public health issue., (© 2022 The Authors.)

Purpose: Aboriginal Australians are under-represented in brain injury rehabilitation services despite a high incidence of both stroke and traumatic brain injury in this population. This study aimed to explore the experiences of Aboriginal Australian adults with acquired communication disorders (ACDs) after brain injury for the first time to inform the development of accessible and culturally secure service delivery models., Methods and Materials: Semi-structured interviews were undertaken with 32 Aboriginal people who had experienced a brain injury resulting in ACDs (aged 35-79 years) and 18 family members/carers across Western Australia. Thematic analysis identified common themes across participants., Results: Overall themes related to communication (both related to the communication disorder and general healthcare interactions), health and social contexts, recovery, and support, being away from family and country, knowledge and beliefs about brain injury, and follow-up., Conclusions: An increase in healthcare staff's appreciation of the health and social contexts of Aboriginal people after brain injury is needed in order to improve communication with Aboriginal patients and the ability to offer accessible rehabilitation services. Ongoing support is required, with cultural identity noted as key to ensuring cultural security and ultimately recovery. Involvement of family and other Aboriginal people in recovery processes, as well as access to relevant Aboriginal languages and proximity to ancestral lands is central.Implications for rehabilitationAcknowledgment of cultural identity and strengths through involvement of extended family and Aboriginal Hospital Liaison Officers, access to language and proximity to country all central to rehabilitation planning for Aboriginal people after brain injury.Cultural security training for rehabilitation staff is recommended focusing on clear two-way communication skills to make medical information accessible for Aboriginal patients and to listen to patients' concerns in a way that respects cultural context.Information regarding practical support and implications for ongoing management of life after brain injury (for the person and their family) is essential, and should supplement the medical-related information provided.Follow-up post discharge from hospital best facilitated through establishing contact with local Aboriginal community through Aboriginal community controlled health services, community elders, and Aboriginal health workers across organisations.

Primary healthcare organisations have an important role in addressing health literacy as this is a barrier to accessing and utilising health care. Until recently, no organisational development tool operationalising health literacy in an Australian context existed. This research evaluated the efficacy of the Organisational Health Literacy Responsiveness (Org-HLR) tool and associated assessment process in a primary healthcare organisation in the Pilbara region of Western Australia. This study utilised a sequential explanatory mixed methods research design incorporating the collection and analysis of data in two phases: (1) Pre- and post-survey data and; (2) seven semi-structured interviews. Survey results showed that participants' confidence in core health literacy concepts improved from baseline following the intervention. Analysis of the interview data revealed participants' initial understanding of health literacy was limited, and this impeded organisational responsiveness to health literacy needs. Participants reported the workshop and tool content were relevant to their organisation; they valued involving members from all parts of the organisation and having an external facilitator to ensure the impartiality of the process. External barriers to improving their internal organisational health literacy responsiveness were identified, with participants acknowledging the management style and culture of open communication within the organisation as enablers of change. Participants identified actionable changes to improve their organisational health literacy responsiveness using the process of organisational assessment and change.

Health research is important for innovation and assessment of health status and health interventions, and maintaining a strong, engaged cohort of rural health researchers is essential for the ongoing improvement of the health of rural populations. Ethical guidelines and processes ensure research is undertaken in a way that protects and, where possible, empowers participants. We set out to systematically examine and document the challenges posed by ethics and governance processes for rural health researchers in Western Australia (WA) and the impact on the research undertaken. In this qualitative study, fifteen WA-based rural health researchers were interviewed. The identified challenges included inefficient systems, gatekeeping, apparent resistance to research and the lack of research experience of those involved in approval processes. For researchers seeking to conduct studies to improve rural and Aboriginal health, extended delays in approvals can hold up and impede research, ultimately changing the nature of the research undertaken and constraining the willingness of practitioners and researchers to undertake health research. Unwieldy ethics processes were seen to have a particularly onerous impact on rural research pertaining to service delivery, multiple sites, and research involving Aboriginal people, impeding innovation and inquiry in areas where it is much needed.

Community efforts at the primary prevention of family violence (FV) involve changing values, structures and norms that support gender inequality. This study examines the attitudes of a group of highly engaged community leaders and service providers involved in FV primary prevention in Geraldton, a small city in regional Western Australia. The outcomes of focus group discussions were mapped against a readiness for change model. Despite considerable involvement in discussions of FV prevention over time, the readiness level of these engaged community members for taking leadership roles in the prevention strategy were between pre-planning and preparation stages, although some individuals' understanding of the drivers of FV and readiness for implementing change was higher. Key areas for further education are the role of gender inequality as the primary driver of FV, particularly rigid gender roles and men's control of decision making, and the role of alcohol and drugs as reinforcers but not primary drivers of FV.

Study Background: Increasing cultural safety in health settings is essential to address stark health disparities between Indigenous and non-Indigenous Australians. Respect for cultural knowledge, better communication, and recognition of racism as a determinant of health are required for improved service delivery. How this knowledge is acquired in health professional training and translated to clinical settings is poorly understood., Purpose: Impacts of an innovative Indigenous health unit and remote clinical placements on knowledge acquisition and attitude change were explored among midwifery students to inform cultural competency initiatives in health professional training., Methods: A multiphased, mixed methods research design used surveys, observations, and interviews. Qualitative analysis was strengthened through triangulation with quantitative data., Results: A unit conceived with substantial Indigenous Australian input and which privileged these voices enhanced knowledge and shifted attitudes in a positive direction; however, immediate gains diminished over time. Remote placements had a profound effect on student learning. Exposure to Indigenous Australians in classrooms and communities, and the self-reflection generated, helped dispel stereotypes and challenge assumptions based on limited cultural knowledge and contact., Conclusion: Optimization of receptivity to Indigenous Australian content and opportunities for remote placements contributed to students' developing cultural capabilities with implications for all health professional training. Whether this heightened awareness is enough to address institutional racism identified in health service delivery remains unanswered. The focus must include those established health practitioners and administrators who influence organizational culture if real systemic change is to occur. Given appropriate on-going support, graduates can play a vital role in expediting this process.

Aim: The aim of this study was to examine stakeholders' views of how the establishment of the South West Radiation Oncology Service in Bunbury, Western Australia, has affected treatment decision-making, and the extent to which patients are involved in the decision-making process., Methods: Semi-structured in-depth interviews were undertaken with 21 service providers involved in the treatment and care of people with cancer, and 17 adults diagnosed with cancer who opted to undergo radiotherapy (RT) treatment at the Service. Data were subject to thematic analysis using the qualitative data analysis software NVivo 10., Results: Patients were overwhelmingly positive about their experiences at the Service, praising the quality of the care provided and noting the convenience associated with receiving treatment locally. Most patients reported feeling involved in decision-making, but tended to rely on and generally adopt advice from medical professionals regarding type and location of treatment. Although service providers in the region had become more aware of the regional RT service and referrals had increased, some patients continued to travel to the metropolitan area for treatment. Reasons identified for this included the need for more specialized RT treatment and the more extensive range of allied health services offered., Conclusion: Increased convenience and a lower financial burden are key reasons why rural cancer patients prefer treatment at a regional RT service rather than travelling to metropolitan centers. These factors highlight the need for ongoing improvement in access to local RT services so that disparities in cancer outcomes between rural and metropolitan patients are reduced., (© 2018 John Wiley & Sons Australia, Ltd.)

Background: Hospitalisation for atherothrombotic disease (ATD) is expected to rise in coming decades. However, increasingly, associated comorbidities impose challenges in managing patients and deciding appropriate secondary prevention. We investigated the prevalence and pattern of multimorbidity (presence of two or more chronic conditions) in Aboriginal and non-Aboriginal Western Australian residents with ATDs., Methods and Findings: We used population-based de-identified linked administrative health data from 1 January 2000 to 30 June 2014 to identify a cohort of patients aged 25-59 years admitted to Western Australian hospitals with a discharge diagnosis of ATD. The prevalence of common chronic diseases in these patients was estimated and the patterns of comorbidities and multimorbidities empirically explored using two different approaches: identification of the most commonly occurring pairs and triplets of comorbid diseases, and through latent class analysis (LCA). Half of the cohort had multimorbidity, although this was much higher in Aboriginal people (Aboriginal: 79.2% vs. non-Aboriginal: 39.3%). Only a quarter were without any documented comorbidities. Hypertension, diabetes, alcohol abuse disorders and acid peptic diseases were the leading comorbidities in the major comorbid combinations across both Aboriginal and non-Aboriginal cohorts. The LCA identified four and six distinct clinically meaningful classes of multimorbidity for Aboriginal and non-Aboriginal patients, respectively. Out of the six groups in non-Aboriginal patients, four were similar to the groups identified in Aboriginal patients. The largest proportion of patients (33% in Aboriginal and 66% in non-Aboriginal) was assigned to the "minimally diseased" (or relatively healthy) group, with most patients having less than two conditions. Other groups showed variability in degree and pattern of multimorbidity., Conclusion: Multimorbidity is common in ATD patients and the comorbidities tend to interact and cluster together. Physicians need to consider these in their clinical practice. Different treatment and secondary prevention strategies are likely to be useful for management in these cluster groups., Competing Interests: The authors have declared that no competing interests exist.

Objective: To assess the school breakfast program (SBP) in two schools with high Aboriginal student populations in rural Western Australia, their contribution to holistic support, nutritional health education and possibilities for improvement., Methods: The operations and functioning of one regional and one remote SBP were assessed by stakeholder inquiry related to process and challenges, observations and documentary review. An intervention to increase health education, social interaction and learning about nutrition and food origins implemented in one school was assessed., Results: Strengths, system and structural factors that impeded realisation of optimal outcomes of the SBPs were identified. The SBPs focussed on serving food rather than building nutritional understanding or on social interactions and support. Systems for delivery and management of the programs largely relied on staff with limited time. When offered a more interactive and social environment, children enjoyed learning about food., Conclusions: Opportunities for SBPs to offer holistic support and educational enhancement for disadvantaged children are limited by the realities of pressures on staff to support them and a view constraining their primary role as food delivery. The lack of volunteer support in disadvantaged schools limits the potential benefits of SBPs in providing psychosocial support. Health education resources which exist for use in SBPs are not necessarily used., Competing Interests: The authors declare no conflict of interest. Miranda Chester is an employee of FoodBank WA but was not involved directly in the design or execution of the intervention.

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., Competing Interests: Siddhartha Baxi is Medical Director of the South West Radiation Oncology Service. While involved in the planning of this research, he was not involved in any interviews with patients or service providers (other than himself as a participant) or in the analysis of data.

Background: Rural and remote communities in Australia fare worse than their urban counterparts across major health indicators, with geographic isolation, restricted accessibility to health services, socioeconomic disadvantage, lifestyle and behavioural factors all implicated in poorer health outcomes. Health disparities, which are especially stark in Australian Aboriginal and Torres Strait Islander populations, underscore the urgent need to build a culturally responsive and respectful rural health workforce. Allied health student placements in settings with high Aboriginal populations provide opportunities for the development of cultural capabilities and observation of the causes and impact of health disparities. A service learning pedagogy underpinned by strong campus-community partnerships can contribute to effective situated learning. Positive placement experiences can also encourage future rural practice alleviating workforce shortages. This article reports on the first stage of a proposed longitudinal investigation into the impact of remote placements on clinical practice and employment choices., Methods: In-depth interviews were undertaken with health science students and recent graduates from Australian universities who spent up to 4 weeks at the remote community of Mt. Magnet (Badimaya country) in Western Australia. Interviews, which occurred between two and 12 months following the placement were recorded, transcribed and thematically analysed for patterns of meaning., Results: Factors which contributed to positive professional, personal and socially responsive learning experiences were identified. These included pre-placement cultural training to build understanding of the local Aboriginal community, peer support, community engagement, cultural exchanges and interprofessional collaboration. Highlights were associated with relationship-building in the community and opportunities to apply insights into Aboriginal cultural ways to clinical and community practice. The role of the Aboriginal mentor was integral to students' understanding of the social and cultural dynamics in the practice setting. Challenges related to the logistics of supervision in remote locations and workloads., Conclusions: The interprofessional placement offered students a unique opportunity to experience how isolation, socioeconomic disadvantage and cultural factors conspire to produce health inequities in remote Australian settings and to observe how communities respond to their circumstances. Despite difficulties encountered, learnings derived from the application of clinical, social and interprofessional skills, and rural employment opportunities that arose following graduation, were all highly valued.

Background/objectives: Delayed presentation of symptomatic cancer is associated with poorer survival. Aboriginal patients with cancer have higher rates of distant metastases at diagnosis compared with non-Aboriginal Australians. This paper examined factors contributing to delayed diagnosis of cancer among Aboriginal Australians from patient and service providers' perspectives., Methods: In-depth, open-ended interviews were conducted in two stages (2006-2007 and 2011). Inductive thematic analysis was assisted by use of NVivo looking around delays in presentation, diagnosis and referral for cancer., Participants: Aboriginal patients with cancer/family members (n=30) and health service providers (n=62) were recruited from metropolitan Perth and six rural/remote regions of Western Australia., Results: Three broad themes of factors were identified: (1) Contextual factors such as intergenerational impact of colonisation and racism and socioeconomic deprivation have negatively impacted on Aboriginal Australians' trust of the healthcare professionals; (2) health service-related factors included low accessibility to health services, long waiting periods, inadequate numbers of Aboriginal professionals and high staff turnover; (3) patient appraisal of symptoms and decision-making, fear of cancer and denial of symptoms were key reasons patients procrastinated in seeking help. Elements of shame, embarrassment, shyness of seeing the doctor, psychological 'fear of the whole health system', attachment to the land and 'fear of leaving home' for cancer treatment in metropolitan cities were other deterrents for Aboriginal people. Manifestation of masculinity and the belief that 'health is women's domain' emerged as a reason why Aboriginal men were reluctant to receive health checks., Conclusions: Solutions to improved Aboriginal cancer outcomes include focusing on the primary care sector encouraging general practitioners to be proactive to suspicion of symptoms with appropriate investigations to facilitate earlier diagnosis and the need to improve Aboriginal health literacy regarding cancer. Access to health services remains a critical problem affecting timely diagnosis., (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: In Australia, the two major pathways of refugee entry are the United Nations High Commissioner for Refugees resettlement programme and irregular maritime arrivals (IMAs) seeking asylum. The Australian Government's policies towards IMAs since July 2013 are controversial, uncompromising and consistently harsh, with asylum seekers held in detention centres for prolonged periods. Refugees and asylum seekers have distinct and unique stressors that make resettlement difficult., Methods: This exploratory study examines resettlement experiences for refugee youth in Western Australia using the psychosocial conceptual framework and qualitative methods. Focus group discussions and key informant interviews were undertaken with verbatim transcripts analysed using thematic analysis to identify themes., Results: Themes documented that language and its impact, and experience with education, health, and social activities, support structures provided to youth and supporting future aspirations as critical to successful resettlement. This exploratory study contributes to developing a broader understanding of the resettlement experiences of refugee youth, drawing on their current and past experiences, cultural differences and mechanisms for coping., Conclusion: Fluency in English language, especially spoken, was a facilitator of successful resettlement. Our results align with previous studies documenting that support programs are vital for successful resettlement. Although faced with immense difficulties refugee youth are resilient, want to succeed and have aspirations for the future. Strategies and recommendations suggested by refugee youth themselves could be used for developing interventions to assist successful resettlement.

Objective: The epidemiology of atrial fibrillation (AF) among Aboriginal Australians is poorly described. We compared risk factors, incidence rates and mortality outcomes for first-ever hospitalised AF among Aboriginal and non-Aboriginal Western Australians 20-84 years., Methods: This retrospective cohort study used whole-of-state person-based linked hospital and deaths data. Incident hospital AF admissions (previous AF admission-free for 15 years) were identified and subsequent mortality determined. Disease-specific comorbidity histories were ascertained by 10-year look-back. Age-standardised incidence rates were estimated and the adjusted risk of 30-day and 1-year mortality calculated using regression methods., Results: Aboriginal patients accounted for 923 (2.5%) of 37 097 incident AF admissions during 2000-2009. Aboriginal patients were younger (mean age 54.8 vs 69.3 years), had lower proportions of primary field AF diagnoses and higher comorbidities than non-Aboriginal patients. The Aboriginal and non-Aboriginal age-standardised incidence rates per 100,000 for men 20-54 years were 197 and 55 (ratio=3.6), for women 20-54 years were 122 and 19 (ratio=6.4), for men 55-84 years were 1151 and 888 (ratio=1.3), and for women 55-84 years were 1050 and 571 (ratio=1.8). While 30-day mortality was similar, crude 1-year mortality risks in Aboriginal and non-Aboriginal patients were 20.6% and 16.3% (adjusted HR=1.24) and 14.4% and 9.9% in 30-day survivors (adjusted HR=1.58)., Conclusions: The incidence (particularly at young ages) and long-term mortality following hospitalised AF is significantly higher in Aboriginal people. Better control of the antecedent risk factors for AF, improved detection and management of AF itself and prevention of its complications are needed., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Culturally secure health care settings enhance accessibility by Aboriginal Australians and improve their satisfaction with service delivery. A culturally secure health service recognises and responds to the legitimate cultural rights of the recipients of care. Focus is upon the health care system as well as the practice and behaviours of the individuals within it. In an attempt to produce culturally secure practitioners, the inclusion of Aboriginal content in health professional programs at Australian universities is now widespread. Studies of medical students have identified the positive impact of this content on knowledge and attitudes towards Aboriginal people but relatively little is known about the responses of students in other health professional education programs. This study explored undergraduate midwifery students' knowledge and attitudes towards Aboriginal people, and the impact of Aboriginal content in their program., Methods: The study surveyed 44 students who were in their first, second and third years of a direct entry, undergraduate midwifery program at a Western Australian (WA) university. The first year students were surveyed before and after completion of a compulsory Aboriginal health unit. Second and third year students who had already completed the unit were surveyed at the end of their academic year., Results: Pre- and post-unit responses revealed a positive shift in first year students' knowledge and attitudes towards Aboriginal people and evidence that teaching in the unit was largely responsible for this shift. A comparison of post-unit responses with those from students in subsequent years of their program revealed a significant decline in knowledge about Aboriginal issues, attitudes towards Aboriginal people and the influence of the unit on their views. Despite this, all students indicated a strong interest in more clinical exposure to Aboriginal settings., Conclusions: The inclusion of a unit on Aboriginal health in an undergraduate midwifery program has been shown to enhance knowledge and shift attitudes towards Aboriginal people in a positive direction. These gains may not be sustained, however, without vertical integration of content and reinforcement throughout the program. Additional midwifery-specific Aboriginal content related to pregnancy and birthing, and recognition of strong student interest in clinical placements in Aboriginal settings provide opportunities for future curriculum development.

Objectives: We examined differentials in short-term (30-day mortality) and 1-year mortality (in 30-day survivors) following index (first-ever) hospitalisation for heart failure (HF), between rural and metropolitan patients resident in Western Australia., Design: A population-based cohort study., Setting: Hospitalised patients in Western Australia, Australia., Participants: Index patients aged 20-84 years with a first-ever hospitalisation for HF between 2000 and 2009 (with no prior admissions for HF in previous 10 years), identified using the Western Australia linked health data., Main Outcome Measures: 30-day and 1-year all-cause mortality (in 30-day survivors) following index admission for HF., Results: Of 17 379 index patients with HF identified, 25.9% (4499) were from rural areas. Rural patients were significantly younger at first HF hospitalisation than metropolitan patients. Aboriginal patients comprised 1.9% of metropolitan and 17.2% of rural patients. Despite some statistical differences, the prevalence of antecedents including ischaemic heart disease, hypertension, diabetes and chronic kidney disease was high (>20%) in both subpopulations. After adjusting for age only, patients from rural areas had a higher risk of 30-day death (OR 1.16 (95% CI 1.01 to 1.33)) and 1-year death in 30-day survivors (HR 1.11 (95% CI 1.01 to 1.23)). These relative risk estimates increased and remained significant after further progressive adjustments for Aboriginality, socioeconomic status, insurance status, emergency presentation, individual comorbidities and revascularisation with OR 1.25 (1.06 to 1.48) for 30-day mortality and HR 1.13 (1.02 to 1.27) for 1-year mortality. The addition of the weighted Charlson index to the 30-day model improved the 'c' statistic (under the receiver operating characteristic curve) from 0.656 (using a variation of administrative claims model) to 0.714., Conclusions: Remoteness and variable access to healthcare can cause important disparities in health outcomes. Rural patients with HF in Western Australia have poorer risk-adjusted outcomes compared with metropolitan patients. This finding has important implications for chronic disease management and provision of health services in rural Australia.

Background: Aboriginal Australians experience poorer outcomes from cancer compared to the non-Aboriginal population. Some progress has been made in understanding Aboriginal Australians' perspectives about cancer and their experiences with cancer services. However, little is known of cancer service providers' (CSPs) thoughts and perceptions regarding Aboriginal patients and their experiences providing optimal cancer care to Aboriginal people. Communication between Aboriginal patients and non-Aboriginal health service providers has been identified as an impediment to good Aboriginal health outcomes. This paper reports on CSPs' views about the factors impairing communication and offers practical strategies for promoting effective communication with Aboriginal patients in Western Australia (WA)., Methods: A qualitative study involving in-depth interviews with 62 Aboriginal and non-Aboriginal CSPs from across WA was conducted between March 2006-September 2007 and April-October 2011. CSPs were asked to share their experiences with Aboriginal patients and families experiencing cancer. Thematic analysis was carried out. Our analysis was primarily underpinned by the socio-ecological model, but concepts of Whiteness and privilege, and cultural security also guided our analysis., Results: CSPs' lack of knowledge about the needs of Aboriginal people with cancer and Aboriginal patients' limited understanding of the Western medical system were identified as the two major impediments to communication. For effective patient-provider communication, attention is needed to language, communication style, knowledge and use of medical terminology and cross-cultural differences in the concept of time. Aboriginal marginalization within mainstream society and Aboriginal people's distrust of the health system were also key issues impacting on communication. Potential solutions to effective Aboriginal patient-provider communication included recruiting more Aboriginal staff, providing appropriate cultural training for CSPs, cancer education for Aboriginal stakeholders, continuity of care, avoiding use of medical jargon, accommodating patients' psychosocial and logistical needs, and in-service coordination., Conclusion: Individual CSPs identified challenges in cross-cultural communication and their willingness to accommodate culture-specific needs within the wider health care system including better communication with Aboriginal patients. However, participants' comments indicated a lack of concerted effort at the system level to address Aboriginal disadvantage in cancer outcomes.

Issues Addressed: Preferences for topics and means of access to health information among newly arrived, culturally and linguistically diverse women in Perth, Western Australia, were explored., Methods: A mixed-methods approach was adopted. Qualitative material obtained from focus groups and interviews with 22 service providers and 26 migrant women was used to develop a questionnaire, which was then administered to 268 newly arrived migrant and refugee women from 50 countries. Participants' information and support priorities were ascertained from a ranking exercise conducted in a non-threatening context. Responses of migrant and refugee women were compared quantitatively., Results: Women's top priorities for information and support included employment advice, as well as information regarding mental health issues, women's health, exercise and nutrition, family violence and alcohol and other drug issues. Their preferred methods for receiving information were interactive talks or presentations, with written material support. Audiovisual and Web-based material were also considered useful. There were differences between refugee women's and other migrants' preferences for means of receiving information and topics of most concern., Discussion: The use of a non-threatening ranking process encouraged women to prioritise sensitive topics, such as family violence, and revealed a need for such topics to be incorporated within general health information presentations. Internet-based technologies are becoming increasingly important methods for disseminating information to migrant women. SO WHAT? Differences between migrant and refugee women's priority health issues and their preferred methods for receiving information highlight the desirability of tailoring information to particular groups. Although advice on employment pathways and mental health concerns were top priorities, the study revealed a need for more discussion on other sensitive topics, such as family violence and alcohol-related issues, and that ideally these should be incorporated into general information sessions to destigmatise attendance The increasing relevance of computer technology and social media for information dissemination was also of note.

Background: Partnerships between different health services are integral to addressing the complex health needs of vulnerable populations. In Australia, partnerships between Aboriginal community controlled and mainstream services can extend health care options and improve the cultural safety of services. However, although government funding supports such collaborations, many factors can cause these arrangements to be tenuous, impacting the quality of health care received. Research was undertaken to explore the challenges and enhancers of a government initiated service partnership between an Aboriginal Community Controlled alcohol and drug service and three mainstream alcohol rehabilitation and support services., Methods: Sixteen staff including senior managers (n=5), clinical team leaders (n=5) and counsellors (n=6) from the four services were purposively recruited and interviewed. Interviews were semi-structured and explored staff experience of the partnership including the client intake and referral process, shared client care, inter-service communication and ways of working., Results & Discussion: Communication issues, partner unfamiliarity, 'mainstreaming' of Aboriginal funding, divergent views regarding staff competencies, client referral issues, staff turnover and different ways of working emerged as issues, emphasizing the challenges of working with a population with complex issues in a persistent climate of limited resourcing. Factors enhancing the partnership included adding a richness and diversity to treatment possibilities and opportunities to explore different, more culturally appropriate ways of working., Conclusion: While the literature strongly advises partnerships be suitably mature before commencing service delivery, the reality of funding cycles may require partnerships become operational before relationships are adequately consolidated. Allowing sufficient time and funding for both the operation and relational aspects of a partnership is critical, with support for partners to regularly meet and workshop arrangements. Documentation that makes clear and embeds working arrangements between partners is important to ameliorate many of the issues that can arise. Given the historical undercurrents, flexible approaches are required to focus on strengths that contribute to progress, even if incremental, rather than on weaknesses which can undermine efforts. This research offers important lessons to assist other services collaborating in post-colonial settings to offer treatment pathways for vulnerable populations.

Background: Missing or incorrect Indigenous status in health records hinders monitoring of Indigenous health indicators. Linkage of administrative data has been used to improve the ascertainment of Indigenous status. Data linkage was pioneered in Western Australia (WA) and is now being used in other Australian states. This systematic review appraises peer-reviewed Australian studies that used data linkage to elucidate the impact of under-ascertainment of Indigenous status on health indicators., Methods: A PubMed search identified eligible studies that used Australian linked data to interrogate Indigenous identification using more than one identifier and interrogated the impact of the different identifiers on estimation of Indigenous health indicators., Results: Eight papers were included, five from WA and three from New South Wales (NSW). The WA papers included a self-identified Indigenous community cohort and showed improved identification in hospital separation data after 2000. In CVD hospitalised patients (2000-05), under-identification was greater in urban residents, older people and socially more advantaged Indigenous people, with varying algorithms giving different estimates of under-count. Age-standardised myocardial infarction incidence rates (2000-2004) increased by about 10%-15% with improved identification. Under-ascertainment of Indigenous identification overestimated secular improvements in life expectancy and mortality whereas correcting infectious disease notifications resulted in lower Indigenous/ non-Indigenous rate ratios. NSW has a history of poor Indigenous identification in administrative data systems, but the NSW papers confirmed the usefulness of data linkage for improving Indigenous identification and the potential for very different estimates of Indigenous disease indicators depending upon the algorithm used for identification., Conclusions: Under-identification of Indigenous status must be addressed in health analyses concerning Indigenous health differentials - they cannot be ignored or wished away. This problem can be substantially diminished through data linkage. Under-identification of Indigenous status impacts differently in different disease contexts, generally resulting in under-estimation of absolute and relative Indigenous health indicators, but may perversely overestimate Indigenous rates and differentials in the setting of stigma-associated conditions such as sexually-transmitted and blood-borne virus infections. Under-numeration in Census surveys also needs consideration to address the added problem of denominator undercounts.

Background: We investigated the relationship between Aboriginality and 2-year cardiovascular disease outcomes in non-fatal first-ever myocardial infarction during 2000-04, with progressive adjustment of covariates, including comorbidities., Design: Historical cohort study., Methods: Person-linked hospital and mortality records were used to identify 28-day survivors of first-ever myocardial infarction in Western Australia during 2000-04 with 15-year lookback. The outcome measures were: (1) cardiovascular disease death; (2) recurrent admission for myocardial infarction; and (3) the composite of (1) and (2)., Results: Compared with non-Aboriginal patients, Aboriginals were younger and more likely to live remotely. The proportions having 5-year histories of diabetes and chronic kidney disease were double and triple those of non-Aboriginals. When adjusting for demographic variables alone, the Aboriginal to non-Aboriginal hazard ratios for cardiovascular death or recurrent myocardial infarction were 3.6 (95% CI 2.5-5.3) in men and 4.5 (95% CI 2.8-7.3) in women. After adjustment for comorbidities, including diabetes, chronic kidney disease and heart failure, the hazard ratios decreased 36% and 47% to 2.3 (1.6-3.0) and 2.4 (1.5-4.0) in males and females, respectively., Conclusions: The high prevalence of comorbidities in Aboriginal people, including diabetes, kidney disease, heart failure, and other risk factors contribute substantially to the disparity in post-myocardial infarction outcomes in Aboriginal people, reinforcing the importance of both primary prevention and comprehensive management of chronic conditions in this population. Aboriginality remains a significant independent risk factor for disease recurrence or mortality, even after adjusting for comorbidity, suggesting the need for society-level interventions addressing social disadvantage.