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Background: Indigenous communities worldwide lead calls for all evaluations of research, programmes and policies affecting their communities to reflect the values, priorities and perspectives of the Indigenous peoples and communities involved. Tools, such as the Quality Appraisal Tool (QAT), are available to assess research quality through an Indigenous cultural lens. Good evaluation requires that evaluation efforts be evaluated. We found that critical reflection on the quality of evaluations from an Indigenous perspective is largely absent from the published literature. To ensure that we strive for quality in evaluation as determined by Indigenous people with whom we work, we examined the quality of our own evaluation of an Indigenous health research collaboration by conducting a reflexive dialogue., Methods: The QAT was used to assess our evaluation according to Indigenous health research principles. Our qualitative study used analytical coautoethnography to generate data through a series of reflexive dialogue sessions with Indigenous and non-Indigenous members of the research collaboration, using the QAT criteria as discussion prompts. Our ideas and reflections were compared and contrasted through a collaborative and iterative writing process, multiple review cycles and discussions., Results: We documented our findings against the QAT framework. We found examples that each QAT principle had, to some extent, been adhered to, but constantly needed to assess whether the principles were fully achieved to our satisfaction. Strengths of the evaluation included being adaptable and responsive to emerging issues for the research collaboration, while areas for improvement included more Indigenous leadership of, and involvement in, evaluation., Conclusions: Although reflexive evaluation practice is not always comfortable, it does provide an opportunity to generate insights for improvement. Reflecting as we did-in a partnership between Indigenous and non-Indigenous colleagues-enabled deeper insights and meaning. We anticipate that our process models how other research in Indigenous contexts might better advance ethical, quality Indigenous research through working in collaboration with Indigenous researchers and communities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Problem: Indigenous populations experience higher odds of poor maternal and infant health outcomes than non-Hispanic White mothers yet have lower odds of receiving adequate prenatal care., Background: Many Indigenous communities rely on modern Western medical institutions to provide pregnancy related health care. These systems were not developed with or for Indigenous communities and often fail to meet the needs of Indigenous pregnant patients. Offering culturally congruent models of care may increase prenatal care utilization., Question, Hypothesis or Aim: This paper used qualitative inquiry to identify Indigenous approaches to caring for pregnancy., Methods: Our team conducted 16 semi-structured individual interviews and one group interview with a total of 19 respondents. To arrive at thematic categories, the research team engaged in a modified pile sorting technique. The final set of categories, along with sub-themes, descriptions and example quotes, were sent to interviewees for approval., Findings: Ten Foundational Features of Indigenous Pregnancy Care were identified. These covered themes related to Indigenous cultural practices, relationships, Indigenous sovereignty, local Indigenous community, full spectrum care, wholistic care, birthing person's wisdom, power and autonomy, flexibility, historical trauma, and cultural awareness., Discussion: Modern midwifery care delivered by Indigenous practitioners may partially bridge the cultural gap; however, intentional effort is needed to integrate Indigenous ways into medical doctor practice models and facilities., Conclusion: This paper identifies ten foundational features of Indigenous pregnancy care and demonstrates the importance of recognizing the effects of trauma and providing opportunities for healing, upholding sovereignty, and centering relationships when caring for Indigenous pregnancies., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Cultural safety is increasingly recognised as imperative to delivering accessible and acceptable healthcare for First Nations Peoples within Australia and in similar colonised countries. A literature review undertaken to inform the inaugural Caring for Australians with Renal Insufficiency (CARI) guidelines for clinically and culturally safe kidney care for Aboriginal and Torres Strait Islander peoples revealed a timeline of the emergence of culturally safe kidney care in Australia. Thirty years ago, kidney care literature was purely biomedically focused, with culture, family and community viewed as potential barriers to patient 'compliance' with treatment. The importance of culturally informed care was increasingly recognised in the mid-1990s, with cultural safety within kidney care specifically cited from 2014 onwards. The emergence timeline is discussed in this paper in relation to the five principles of cultural safety developed by Māori nurse Irihapeti Ramsden in Aotearoa/New Zealand. These principles are critical reflection, communication, minimising power differences, decolonisation and ensuring one does not demean or disempower. For the kidney care workforce, culturally safe care requires ongoing critical reflection, deep active listening skills, decolonising approaches and the eradication of institutional racism. Cultural safety is the key to truly working in partnership, increasing Indigenous Governance, respectful collaboration and redesigning kidney care., (© 2024 The Authors. Nursing Inquiry published by John Wiley & Sons Ltd.)

Background: Inequities in health access and outcomes exist between Indigenous and non-Indigenous populations. Embedded pragmatic randomized, controlled trials (ePCTs) can test the real-world effectiveness of health care interventions. Assessing readiness for ePCT, with tools such as the Readiness Assessment for Pragmatic Trials (RAPT) model, is an important component. Although equity must be explicitly incorporated in the design, testing, and widespread implementation of any health care intervention to achieve equity, RAPT does not explicitly consider equity. This study aimed to identify adaptions necessary for the application of the 'Readiness Assessment for Pragmatic Trials' (RAPT) tool in embedded pragmatic randomized, controlled trials (ePCTs) with Indigenous communities., Methods: We surveyed and interviewed participants (researchers with experience in research involving Indigenous communities) over three phases (July-December 2022) in this mixed-methods study to explore the appropriateness and recommended adaptions of current RAPT domains and to identify new domains that would be appropriate to include. We thematically analyzed responses and used an iterative process to modify RAPT., Results: The 21 participants identified that RAPT needed to be modified to strengthen readiness assessment in Indigenous research. In addition, five new domains were proposed to support Indigenous communities' power within the research processes: Indigenous Data Sovereignty; Acceptability - Indigenous Communities; Risk of Research; Research Team Experience; Established Partnership). We propose a modified tool, RAPT-Indigenous (RAPT-I) for use in research with Indigenous communities to increase the robustness and cultural appropriateness of readiness assessment for ePCT. In addition to producing a tool for use, it outlines a methodological approach to adopting research tools for use in and with Indigenous communities by drawing on the experience of researchers who are part of, and/or working with, Indigenous communities to undertake interventional research, as well as those with expertise in health equity, implementation science, and public health., Conclusion: RAPT-I has the potential to provide a useful framework for readiness assessment prior to ePCT in Indigenous communities. RAPT-I also has potential use by bodies charged with critically reviewing proposed pragmatic research including funding and ethics review boards., (© 2024. The Author(s).)

Background: In the Northern Territory (NT) the prevalence of otitis media (OM) in young Aboriginal children living in remote communities has persisted at around 90% over the last few decades. OM-associated hearing loss can cause developmental delay and adversely impact life course trajectories. This study examined the 5-year trends in OM prevalence and quality of ear health services in remote NT communities., Methods: A retrospective analysis was performed on de-identified clinical data for 50 remote clinics managed by the NT Government. We report a 6-monthly cascade analysis of the proportions of children 0-16 years of age receiving local guideline recommendations for surveillance, OM treatment and follow-up at selected milestones between 2014 and 2018., Results: Between 6,326 and 6,557 individual children were included in the 6-monthly analyses. On average, 57% (95%CI: 56-59%) of eligible children had received one or more ear examination in each 6-monthly period. Of those examined, 36% (95%CI: 33-40%) were diagnosed with some type of OM, of whom 90% had OM requiring either immediate treatment or scheduled follow-up according to local guidelines. Outcomes of treatment and follow-up were recorded in 24% and 23% of cases, respectively. Significant decreasing temporal trends were found in the proportion diagnosed with any OM across each age group. Overall, this proportion decreased by 40% over the five years (from 43 to 26%)., Conclusions: This cascade of care analysis found that ear health surveillance and compliance with otitis media guidelines for treatment and follow-up were both low. Further research is required to identify effective strategies that improve ear health services in remote settings., (© 2023. The Author(s).)

Background: The continued use of a deficit discourse when researching Aboriginal and Torres Strait Islander Peoples of Australia is problematic. Understanding and challenging the researchers position and the power of the words they use is important. It will ensure we do not persist in framing Aboriginal and Torres Strait Islander People as a problem to be solved., Design: Indigenist review of the evidence of Aboriginal young people's health and well-being., Methods: This review was conducted using an Indigenist approach to identify texts which amplified the voices of Aboriginal young people of Australia and presents a narrative summary of their accounts. This review is reported in line with the PRISMA-ScR reporting guidelines., Results: Culture and connection are critical components of Aboriginal young people's health and well-being. Aboriginal young people describe feeling of powerlessness to influence health and well-being of their community, and they understood the risks they and their communities faced. Young people identified the importance of connection to culture, community and Elders as crucial to their social and emotional well-being., Conclusion: By harnessing an Indigenous analysis, we were able to reveal a strong counter narrative of strength and resilience within their historical, social, and political contexts through the storied accounts of Aboriginal young people., Relevance to Clinical Practice: Most of the currently available evidence about Aboriginal health and well-being is immersed in deficit discourse. Literature reviews being the foundation of research and informing nursing practice, we call for a purposeful shift towards the adoption of an Indigenist strength-based approach which emphasises the strength and resilience of Aboriginal young people., (© 2022 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Objectives: To identify the financing and policy challenges for Medicare and universal health care in Australia, as well as opportunities for whole-of-system strengthening., Study Design: Review of publications on Medicare, the Pharmaceutical Benefits Scheme, and the universal health care system in Australia published 1 January 2000 - 14 August 2021 that reported quantitative or qualitative research or data analyses, and of opinion articles, debates, commentaries, editorials, perspectives, and news reports on the Australian health care system published 1 January 2015 - 14 August 2021. Program-, intervention- or provider-specific articles, and publications regarding groups not fully covered by Medicare (eg, asylum seekers, prisoners) were excluded., Data Sources: MEDLINE Complete, the Health Policy Reference Centre, and Global Health databases (all via EBSCO); the Analysis & Policy Observatory, the Australian Indigenous HealthInfoNet, the Australian Public Affairs Information Service, Google, Google Scholar, and the Organisation for Economic Co-operation and Development (OECD) websites., Results: The problems covered by the 76 articles included in our review could be grouped under seven major themes: fragmentation of health care and lack of integrated health financing, access of Aboriginal and Torres Strait Islander people to health services and essential medications, reform proposals for the Pharmaceutical Benefits Scheme, the burden of out-of-pocket costs, inequity, public subsidies for private health insurance, and other challenges for the Australian universal health care system., Conclusions: A number of challenges threaten the sustainability and equity of the universal health care system in Australia. As the piecemeal reforms of the past twenty years have been inadequate for meeting these challenges, more effective, coordinated approaches are needed to improve and secure the universality of public health care in Australia., (© 2023 The Authors. Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.)

Background: Mental health inequities between Indigenous and non-Indigenous populations are well documented. There is growing recognition of the role that culturally safety plays in achieving equitable outcomes. However, a clear understanding of the key characteristics of culturally safe mental health care is currently lacking. This protocol outlines a qualitative systematic review that aims to identify the key characteristics of culturally safe mental health care for Aboriginal and Torres Strait Islander peoples, at the individual, service, and systems level. This knowledge will improve the cultural safety of mental health care provided to Indigenous peoples, with a focus on Aboriginal and Torres Strait Islander peoples in Australia., Methods and Expected Outputs: Through a review of academic, grey, and cultural literature, we will identify the key characteristics of culturally safe mental health care for Aboriginal and Torres Strait Islander peoples in Australia. We will consider the characteristics of culturally safe care at the individual practitioner, service, and systems levels., Prospero Registration Number: CRD42021258724., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Milroy et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Competing Interests: We declare no competing interests. The Lancet Commission on Arctic and Northern Health is grateful for the generous support from Dartmouth College, USA, and the Inuit Circumpolar Council, USA.

Background: Increasing global diabetes incidence has profound implications for health systems and for people living with diabetes. Guidelines have established clinical targets but there may be variation in clinical outcomes including HbA1c, based on location and practice size. Investigating this variation may help identify factors amenable to systemic improvement interventions. The aims of this study were to identify centre-specific and patient-specific factors associated with variation in HbA1c levels and to determine how these associations contribute to variation in performance across diabetes centres., Methods: This cross-sectional study analysed data for 5,872 people with type 1 (n = 1,729) or type 2 (n = 4,143) diabetes mellitus collected through the Australian National Diabetes Audit (ANDA). A linear mixed-effects model examined centre-level and patient-level factors associated with variation in HbA1c levels., Results: Mean age was: 43±17 years (type 1), 64±13 (type 2); median disease duration: 18 years (10,29) (type 1), 12 years (6,20) (type 2); female: 52% (type 1), 45% (type 2). For people with type 1 diabetes, volume of patients was associated with increases in HbA1c (p = 0.019). For people with type 2 diabetes, type of centre was associated with reduction in HbA1c (p <0.001), but location and patient volume were not. Associated patient-level factors associated with increases in HbA1c included past hyperglycaemic emergencies (type 1 and type 2, p<0.001) and Aboriginal and Torres Strait Islander status (type 2, p<0.001). Being a non-smoker was associated with reductions in HbA1c (type 1 and type 2, p<0.001)., Conclusions: Centre-level and patient-level factors were associated with variation in HbA1c, but patient-level factors had greater impact. Interventions targeting patient-level factors conducted at a centre level including sick-day management, smoking cessation programs and culturally appropriate diabetes education for and Aboriginal and Torres Strait Islander peoples may be more important for improving glycaemic control than targeting factors related to the Centre itself., Competing Interests: Sally Green is employed by Monash University and receives funding from the National Health and Medical Research Council (NHMRC), the Medical Research Future Fund (MRFF) and the Victorian Department of Health and Human Services. She has no declaration of interest specific to the research reported in this paper. Sophia Zoungas reports financial activities outside the submitted work including: Eli Lilly Australia Ltd – Participation in Steering Committee (CVOT) 2019 & 2021 on behalf of Monash University – payment to institution; Boehringer-Ingelheim – Participation in Advisory Board, expert committees or educational meeting 2019 on behalf of Monash University – payment to institution; MSD Australia - Participation in Advisory Board, expert committees or educational meeting 2019 & 2020 on behalf of Monash University – payment to institution; AstraZeneca – Participation in Advisory Board, expert committees or educational meeting 2017, 2018, 2019, 2020 & 2021 on behalf of Monash University – payment to institution; Novo Nordisk - Participation in Advisory Board, expert committees or educational meeting 2016, 2018, 2019 & 2020 on behalf of Monash University – payment to institution; Sanofi – Participation in Advisory Board, expert committees or educational meeting 2018 on behalf of Monash University – payment to institution. This does not alter her adherence to PLOS ONE policies on sharing data and materials. The other authors declare no relevant declarations of interest with regards to this manuscript.

Our scoping review sought to consider how Etuaptmumk or Two-Eyed Seeing is described in Indigenous health research and to compare descriptions of Two-Eyed Seeing between original authors (Elders Albert and Murdena Marshall, and Dr. Cheryl Bartlett) and new authors. Using the JBI scoping review methodology and qualitative thematic coding, we identified seven categories describing the meaning of Two-Eyed Seeing from 80 articles: guide for life, responsibility for the greater good and future generations, co-learning journey, multiple or diverse perspectives, spirit, decolonization and self-determination, and humans being part of ecosystems. We discuss inconsistencies between the original and new authors, important observations across the thematic categories, and our reflections from the review process. We intend to contribute to a wider dialogue about how Two-Eyed Seeing is understood in Indigenous health research and to encourage thoughtful and rich descriptions of the guiding principle., Competing Interests: The authors have declared no competing interests exist.

Background: Indigenous Australians diagnosed with cancer have substantially higher cancer mortality rates compared with non-Indigenous Australians, yet there is a paucity of information about their end-of-life service utilisation and supportive care needs., Purpose: To describe the service utilisation and supportive care needs of Aboriginal and Torres Strait Islander people with cancer at end-of-life., Method: Hospital admission data were linked to self-reported data from a study of Indigenous cancer patients from Queensland, Australia during the last year of their life. Needs were assessed by the Supportive Care Needs Assessment Tool for Indigenous Cancer Patients which measures 26 need items across 4 domains (physical/psychological; hospital care; information/communication; practical/cultural). A descriptive analysis of health service utilisation and unmet needs was conducted., Results: In total, 58 Indigenous cancer patients were included in this analysis. All patients had at least one hospital admission within the last year of their life. Most hospital admissions occurred through emergency (38%) and outpatient (31%) departments and were for acute care (85%). Palliative care represented 14% of admissions and 78% died in hospital. Approximately half (48%) did not report any unmet needs. The most frequently reported moderate-to-high unmet need items were worry about the treatment results (17%), money worries (16%) and anxiety (16%)., Conclusions: Utilisation of palliative care services that manage a full range of physical and psychosocial needs was low. Addressing worries about treatment results, finances and generalised anxiety are priorities in this population.

The Health and Disability System Review (the 'Simpson Review') was an opportunity for health sector transformation, particularly in light of the recent damning WAI 2575 Waitangi Tribunal report released during the review process. There appears to have been a concerted effort to engage with the sector, an impressive Māori Expert Advisory Group and an extensive body of available scholarship documenting where improvements could be made. In this viewpoint, the authors, tangata whenua (Indigenous people of the land) and tangata Tiriti (people of te Tiriti) and health scholars and leaders undertook a high-level review of the Simpson Review report and analysed it against key elements of te Tiriti o Waitangi. The Simpson Review was an opportunity to share power, commit to Māori health and embed structural mechanisms, such as the proposed Māori health authority, to uphold te Tiriti o Waitangi. It was also an opportunity to recommit to health equity and eliminate institutional racism. We conclude that the Simpson Review did not take up these opportunities, but instead perpetuated further breaches of te Tiriti., Competing Interests: Dr Came reports being co-chair of STIR: Stop Institutional Racism.

Background: Lung Cancer is the leading cause of cancer deaths in Aotearoa New Zealand. Māori communities in particular have higher incidence and mortality rates from Lung Cancer. Diagnosis of lung cancer at an early stage can allow for curative treatment. This project aimed to document the barriers to early diagnosis and treatment of lung cancer in secondary care for Māori communities., Methods: This project used a kaupapa Māori approach. Nine community hui (focus groups) and nine primary healthcare provider hui were carried out in five rural localities in the Midland region. Community hui included cancer patients, whānau (families), and other community members. Healthcare provider hui comprised staff members at the local primary healthcare centre, including General Practitioners and nurses. Hui data were thematically analysed., Results: Barriers and enablers to early diagnosis of lung cancer were categorised into two broad themes: Specialist services and treatment, and whānau journey. The barriers and enablers that participants experienced in specialist services and treatment related to access to care, engagement with specialists, communication with specialist services and cultural values and respect, whereas barriers and enablers relating to the whānau journey focused on agency and the impact on whānau., Conclusions: The study highlighted the need to improve communication within and across healthcare services, the importance of understanding the cultural needs of patients and whānau and a health system strategy that meets these needs. Findings also demonstrated the resilience of Māori and the active efforts of whānau as carers to foster health literacy in future generations.

Objectives: Our aim in this study was to assess the impact of the Mobile Diabetes Telemedicine Clinic, which serves First Nations communities in British Columbia, on clients' with diabetes condition and management., Methods: A travelling team visits approximately 120 sites annually. Assessment of persons with diabetes includes interview, physical exam, point-of-care laboratory (glycated hemoglobin, blood glucose, lipid profile, kidney profile) and retinal fundus photographs. Nurses provide education and lifestyle, medication and wellness recommendations. The endocrinologist reviews records and provides further recommendations to primary care providers. To assess the impact at second and later visits, compared with the immediately preceding visit, we measured mean changes in body weight, glycated hemoglobin, urinary albumin:creatinine ratio and estimated glomerular filtration rate, as well as changes in proportions of clients meeting targets for blood pressure, low-density lipoprotein cholesterol, medications, smoking and physical activity., Results: From 2012 to 2018, a total of 3,045 visits were completed by 1,056 clients with diabetes who attended on at least 2 occasions. Mean time since the preceding visit was 1.6 years. Mean change (after vs before) in glycated hemoglobin was 0.06 (95% confidence limit, -0.03 to 0.14), body weight 0.0 kg (-0.2 to 0.2), albumin:creatinine ratio 1.31 mg/mmol (0.27 to 2.35) and estimated glomerular filtration rate -4.8 mL/min (-6.2 to -3.4). The proportion of clients meeting both blood pressure targets (systolic <130 mmHg and diastolic <80 mmHg) increased from 25% at first visit to 33% at the second and 32% at the third or later visits (p<0.001, chi-square test). The proportion of those with low-density lipoprotein cholesterol of <2.0 mmol/L increased from 56% to 62% at the second visit and 69% at the third or later visits (p<0.001). The proportion of those taking renin-angiotensin-aldosterone system inhibitors or other antihypertensive agents and statins increased (p<0.001), and proportions decreased for smoking (p<0.001) and exercising ≥60 min/week (p=0.002)., Conclusions: Weight and diabetic control were stabilized. Most management practices showed improvement., (Copyright © 2020 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Background: In Australia, health services are seeking innovative ways to utilize data stored in health information systems to report on, and improve, health care quality and health system performance for Aboriginal Australians. However, there is little research about the use of health information systems in the context of Aboriginal health promotion. In 2008, the Northern Territory's publicly funded healthcare system introduced the quality improvement program planning system (QIPPS) as the centralized online system for recording information about health promotion programs. The purpose of this study was to explore the potential for utilizing data stored in QIPPS to report on quality of Aboriginal health promotion, using chronic disease prevention programs as exemplars. We identify the potential benefits and limitations of health information systems for enhancing Aboriginal health promotion., Methods: A retrospective audit was undertaken on a sample of health promotion projects delivered between 2013 and 2016. A validated, paper-based audit tool was used to extract information stored in the QIPPS online system and report on Aboriginal health promotion quality. Simple frequency counts were calculated for dichotomous and categorical items. Text was extracted and thematically analyzed to describe community participation processes and strategies used in Aboriginal health promotion., Results: 39 Aboriginal health promotion projects were included in the analysis. 34/39 projects recorded information pertaining to the health promotion planning phases, such as statements of project goals, 'needs assessment' findings, and processes for consulting Aboriginal people in the community. Evaluation findings were reported in approximately one third of projects and mostly limited to a recording of numbers of participants. For almost half of the projects analyzed, community participation strategies were not recorded., Conclusion: This is the first Australian study to shed light on the feasibility of utilizing data stored in a purposefully designed health promotion information system. Data availability and quality were limiting factors for reporting on Aboriginal health promotion quality. Based on our learnings of QIPPS, strategies to improve the quality and accuracy of data entry together with the use of quality improvement approaches are needed to reap the potential benefits of future health promotion information systems.

Context.—: Since 2008, the Northern Territory Point-of-Care Testing Program has improved patient access to pathology testing for acute and chronic disease management for remote health services., Objective.—: To evaluate the analytical quality, service delivery, and clinical utility of an expanding remote point-of-care testing network., Design.—: Four years (2016-2019) of data on analytical quality, test numbers, and training statistics and 6 months of clinical point-of-care testing data from Abbott i-STATs at remote health services throughout the Northern Territory were analyzed to assess analytical performance, program growth, and clinical utility., Results.—: From 2016 to 2019, point-of-care test numbers increased, with chemistry and blood gas testing more than doubling to 8500 and 6000 tests, respectively, troponin I testing almost doubling (to 6000), and international normalized ratio testing plateauing at 8000 tests. Participation in quality control and proficiency testing was high, with quality comparable to laboratory-based analytical goals. A shift toward flexible training and communication modes was noted. An audit of point-of-care test results demonstrated elevated creatinine, associated with chronic kidney disease management, as the most common clinically actionable patient result., Conclusions.—: The Northern Territory Point-of-Care Testing Program provides high quality point-of-care testing within remote primary health services for acute and chronic patient management and care. Clinical need, sound analytical performance, flexibility in training provision, and effective support services have facilitated the sustainability of this expanding point-of-care testing model in the remote Northern Territory during the past 11 years., (© 2020 College of American Pathologists.)

This article explores the relationships and tensions between ethnicity and health, describing the perspectives of various social actors on a Mapuche clinic in the context of a national health program. A qualitative methodology was used to carry out this case study of the Mapuche clinic "La Ruka," located in an urban area of the Metropolitan Region of Chile. The study analyzes the narratives of traditional health practitioners (including a machi, lawentuchefe, lonko, and intercultural facilitator), consumers, conventional healthcare professionals, and local health authorities and community leaders who share a physical, political, and symbolic space around the Mapuche health experience. The systemization of experiences method was applied to the data, acquired through nonparticipant observation, individual interviews, and focus groups. The results suggest that this healthcare experience is highly valued by its protagonists. However, there is a tension surrounding cultural diversity programs that recognize non-Western approaches to healing, such as indigenous practices. This study examines the health-related, cultural, and political tensions involved in projecting indigenous traditions into a homogenizing space such as healthcare in a multicultural neoliberalism system.

Aims: TransFORmation of IndiGEnous PrimAry HEAlthcare Delivery (FORGE AHEAD) partnered with local clinical and community teams in 11 First Nations (FN) communities across Canada to develop quality improvement (QI) initiatives aimed at improving T2DM., Methods: Pre-post mixed-methods case study design was used. The 18-month intervention included community and clinical readiness, development of a community diabetes registry and clinical system, and QI activities. Participants consisted of community members, 18 yrs and older, with diabetes. Changes in clinical outcomes and clinical practice guideline (CPG) recommendations were assessed pre and post intervention using multilevel regression (patients nested within communities) adjusted forindividual andcommunity baseline characteristics., Results: No significant change in HbA1c orsBP, but a small reduction indBP(-0.75 mmHg, p < 0.05) and LDL (-0.09 mmol/L, p < 0.05) was observed in 2008 adults with T2DM (mean age: 60·5 (SD:14·6) years; female: 57·2%). Individuals not at CPG targets at baseline had significant reductions in: %HbA1c (N = 616): -0.40 (95%CI:-0·55,-0·24),sBP (N = 561): -7·67 mmHg (95%CI:-9·23, -5·72),dBP (N = 291): -7·46 mmHg (95%CI:-8·69, -6·26), LDL (N = 450): -0·37mmo/l (95%CI:-0·44, -0·29).Annual HbA1c (OR: 1·95; 95%CI:1·66, 2·29), BP (OR: 1·78; 95%CI:1·52, 2·09), LDL (OR: 1·27; 95%CI:1·10, 1·47) and CKD screening (OR: 6·37; 95%CI:5·16, 7·92)increased but retinopathy screening decreased (OR: 0·68; 95%CI:0·57, 0·82). No significant change in foot exams (OR: 0·97; 95%CI:0·76, 1·23) or BMI recordings (OR: 0·96; 95%CI:0·82, 1·12) was seen. Overall, individualsweremorelikely to receive ≥75% of CPG recommended services compared to baseline (OR: 1·51; 95%CI:1·27, 1·80)., Conclusions: FORGE AHEAD is the first Canadian study to demonstrate that a FN community-led QI intervention can lead to diabetes improvements., Competing Interests: Declaration of Competing Interest MNH, HZ, and SH were funded from the grant supporting this study. All remaining authors declare that they have no competing interests., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Context: Medical education has a role in preparing future health care practitioners to have the skills to meaningfully address health disparities while providing effective clinical care considerate of diversity in our societies. This calls for medical education researchers to approach their craft in ways that prioritise and value inputs from a broader range of perspectives and worldviews in an effort to redress the negative impacts of social, political and structural forces on health outcomes., Methods: Given the entrenched health inequities experienced by Indigenous populations across the globe, this paper details an approach to medical education research put forward by Canadian Mi'kmaw Elders Murdena and Albert Marshall and named 'two-eyed seeing'. This approach provides the opportunity for medical education researchers to address the ongoing impacts of colonisation, racism and marginalisation on health outcomes by prioritising Indigenous worldviews in medical curricula. The need for researchers and medical academies to critically consider Indigenous governance and processes of respectful knowledge sharing within the wider institutional and societal contexts is addressed., Conclusions: The benefits of two-eyed seeing in the context of better preparing the future workforce to effectively meet the needs of those most vulnerable, and to action change against health inequities, situate it as a promising research approach in medical education., (© 2020 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: In India, Accredited Social Health Activists (ASHAs) deliver services for diagnosis and treatment of malaria, although unlicensed medical practitioners (UMPs) (informal health providers) are most preferred in communities. A cross sectional survey was conducted to: (i) assess knowledge and treatment-seeking practices in the community, and (ii) explore the diagnosis and treatment practices related to malaria of UMPs working in rural and tribal-dominated high malaria endemic areas of central India, and whether they adhere to the national guidelines., Methods: A multi-stage sampling method and survey technique was adopted. Heads of the households and UMPs were interviewed using a structured interview schedule to assess knowledge and malaria treatment practices., Results: Knowledge regarding malaria symptoms was generally accurate, but misconceptions emerged related to malaria transmission and mosquito breeding places. Modern preventive measures were poorly accessed by the households. UMPs were the most preferred health providers (49%) and the first choice in households for seeking treatment. UMPs typically lacked knowledge of the names of malaria parasite species and species-specific diagnosis and treatment. Further, irrational use of anti-malarial drugs was common., Conclusions: UMPs were the most preferred type of health care providers in rural communities where health infrastructure is poor. The study suggests enhancing training of UMPs on national guidelines for malaria diagnosis and treatment to strengthen their ability to contribute to achievement of India's malaria elimination goals.

Purpose: The role of general practitioners in cancer care has expanded in recent years. However, little is known about utilization of primary health care (PHC) services by patients with cancer, particularly among socio-economically disadvantaged groups. We describe utilization of PHC services by patients with cancer, and the nature of the care provided. The study focuses on a disadvantaged group in Australia, namely Indigenous Australians., Methods: A retrospective audit of clinical records in ten PHC services in Queensland, Australia. Demographic and clinical data of Indigenous Australians diagnosed with cancer during 2010-2016 were abstracted from patient's medical records at the PHC services. The rates of cancer-related visits were calculated using person years at risk as a denominator., Results: A total of 138 patients' records were audited. During 12 months following the cancer diagnosis, patients visited the PHC service on average 5.95 times per year. Frequency of visits were relatively high in remote areas and among socioeconomic disadvantaged patients (IRR = 1.87, 95%CI 1.61-2.17; IRR = 1.79, 95%CI 1.45-2.21, respectively). Over 80% of visits were for seeking attention for symptoms, wound care, and emotional or social support. Patients who did not undergo surgery, had greater comorbidity, received chemotherapy and/or radiotherapy, and male gender had significantly greater rate of visits than their counterparts., Conclusion: The frequency of utilization of PHC services, especially by patients with comorbidities, and the range of reasons for attendance highlights the important role of PHC services in providing cancer care. The reliance on PHC services, particularly by patients in remote and disadvantaged communities, has important implications for appropriate resourcing and support for services in these locations.

Background: Cancer care involves many different healthcare providers. Delayed or inaccurate communication between specialists and general practitioners (GP) may negatively affect care., Aim: To describe the pattern and variation of communication between primary healthcare (PHC) services and hospitals and specialists in relation to the patient's cancer care., Methods: A retrospective audit of clinical records of Indigenous Australians diagnosed with cancer during 2010-2016 identified through 10 PHC services in Queensland is described. Poisson regression was used to model the dichotomous outcome availability of hospital discharge summary versus not., Results: A total of 138 patient records was audited; 115 of those patients visited the PHC service for cancer-related care after cancer diagnosis; 40.0% visited the service before a discharge summary was available, and 36.5% of the patients had no discharge summary in their medical notes. While most discharge summaries noted important information about the patient's cancer, 42.4% lacked details regarding the discharge medications regimen., Conclusions: Deficits in communication and information transfer between specialists and GP may adversely affect patient care. Indigenous Australians are a relatively disadvantaged group that experience poor health outcomes and relatively poor access to care. The low proportion of discharge summaries noting discharge medication regimen is of concern among Indigenous Australians with cancer who have high comorbidity burden and low health literacy. Our findings provide an insight into some of the factors associated with quality of cancer care, and may provide guidance for focus areas for further research and improvement efforts., (© 2019 Royal Australasian College of Physicians.)

Objectives: to assess the attributes of Primary Health Care from the perspective of health professionals, comparing services in the Special Indigenous Health District and the Municipal Health Offices., Methods: a cross-sectional study in the Upper Rio Negro region, State of Amazonas, with 116 professionals. The data were collected through the Primary Care Assessment Tool. Scores were categorized (≥ 6.6) - strong orientation and (<6.6) - low orientation. The chi-square and maximum likelihood test for crossover analysis. The comparison between professionals the Kruskal-Wallis Test., Results: a higher overall score was observed in the Indigenous Health District (7.2). The same trend was observed individually in the essential and derived attributes., Conclusions: this work may support strategies that positively impact the management model and work processes from the perspective of strengthening the primary care offered to the population from Rio Negro.

Childhood obesity poses an urgent and serious public health challenge in Australia. Aboriginal children are more profoundly affected than non-Aboriginal children, with the gap in weight status between the two groups widening, indicating an increased risk of metabolic disorders earlier in life. Obesity is the second biggest contributor (16%) to the gap in health status between Aboriginal and non-Aboriginal people. The bulk of this gap is attributable to people living in non-remote settings who make up 81% of the total Aboriginal population in Australia. The complex interplay of socio-environmental factors that contribute to obesity are well known and include prolonged financial stress associated with food insecurity, urbanisation, substandard and overcrowded housing, and lack of adequate access to health services. In addition, Aboriginal people, specifically, contend with the loss of traditional lands, and poor dietary behaviours due to the transition from traditional to Western diets as a result of colonisation. There are very few national policies and guidelines for obesity prevention and treatment for Australian children. This is especially the case for Aboriginal children. Most Australian states and territories have a suite of programs targeting obesity in childhood through healthy eating and active living strategies but with the exception of a few programs, the reach and effectiveness among Aboriginal children is either not known or has not been adequately assessed. Where programs have assessed Aboriginal participation, completion rates have generally been lower compared with the general population. The problem cannot be addressed without proper Aboriginal governance and leadership, and collaborative program development for Aboriginal-specific obesity interventions. Meaningful engagement and empowering Aboriginal communities to have control over programs that affect their health and wellbeing are more likely to result in positive health outcomes. Importantly, appropriate funding and support is essential to simultaneously facilitate the building of an Aboriginal health workforce to develop, coordinate, deliver and evaluate programs., Competing Interests: None declared.

The impacts of colonization have had significant impacts on the mental health and community wellness Indigenous peoples in the Northwest Territories (NWT). It is important that all communities in the NWT have access to key services in a culturally relevant way in achieving mental and community wellness. A scoping review was conducted to identify mental health services available in the NWT. To guide the understanding of the landscape of mental health services in the NWT, the information on health services gathered was organized using the First Nations Mental Wellness Continuum (FNMWC) Model's Continuum of Essential Services. Documents accessed included grey literature, consisting of government documents, practice guidelines, education materials, community wellness reports, internet searches and expert consult interviews to collect data on mental health and wellness services in the NWT. 68 mental health services were included in this review, from 23 different sources. Results were summarized and described the Continuum of Essential Services from the FNMWC Model. This guided approach was found to be useful for mapping mental health services for communities in the NWT. The findings highlight and catagorize existing mental health services and gaps in relation to a First Nation's perspective using the FNMWC Model. Specific areas examined included the Continuum of Essential Services, Key Partners, Culture as a Foundation, and Indigenous Social Determinants of Health. Findings can guide communities and health authorities in planning, implementing and coordinating a full range of optimized mental health services in the NWT.

Introduction: Despite the recognition of Traditional Medicine systems as a critical component of health care by the WHO and the African Union, its integration into the health care mainstream remains very subdued in South Africa. This is partly due to the lack of empirical data pertinent to traditional healer training that could inform the accreditation process., Objective: To determine core competencies acquired by Traditional Health Practitioners (THP) of KwaZulu-Natal Province, South Africa during their apprenticeship., Materials and Methods: Purposeful, convenient and snowballing sampling and the sequential data collection methods of questionnaires, journaling and focus groups was used to collect data from the THP tutors and their trainees in rural, peri-urban and urban areas of eThekwini and uThungulu Districts of Kwa Zulu Natal (KZN)., Results: Eleven core competencies were identified: consultation, diagnoses, holistic patient care and treatment, integrative and holistic healing, application of healing procedures and cultural rituals, spiritual development, ethical competencies, problem solving, herbalism, ancestral knowledge and end of life care., Conclusion: The apprenticeship of THPs in KZN is based on eleven core competencies. These competencies are fundamental pillars for critical health care provided by THPs and are crucial for setting standards for the accreditation of traditional training in South Africa if the THP Act 22 of 2007 is to achieve its purpose of providing for the management of and control over the registration, training and conduct of the practitioners. Hence, the appointed interim THP Council should include the identified competencies when articulating bases for accreditation of the training and assessments., (© 2019 Nompumelelo et al.)

Background: The capacity of the Indigenous primary healthcare (PHC) sector to continue playing a crucial role in meeting the health needs of Aboriginal and Torres Strait Islander Australians is in large part reliant on the skills, motivation and experience of its workforce. While exhibiting many workforce strengths, the sector faces significant challenges in building and maintaining a strong and stable workforce. Drawing on data from one Aboriginal Community Controlled Health Service (ACCHS), this study reports what is working well and what could be improved to strengthen the Indigenous PHC sector workforce., Methods: Using grounded theory methods, interviews with 17 ACCHS staff from a range of organisational positions were transcribed, coded and analysed. This paper focuses on the strategies identified that contribute towards strengthening the Indigenous PHC workforce., Results: Four overarching strategies for Indigenous PHC workforce strengthening were identified. These were Strengthening Workforce Stability, Having Strong Leadership, Growing Capacity, and Working Well Together. A range of enabling factors at the macro, community, organisational and individual levels were also identified., Conclusion: Indigenous PHC services are already implementing many important workforce-development strategies that are having a positive impact on the sector. There are also several persistent challenges which need to be addressed through action at organisational and structural levels. Approaches to workforce strengthening in Indigenous PHC should be tailored to local needs to ensure they address the unique workforce challenges experienced in different contexts.

Health inequities inhibit global development and achievement of the Sustainable Development Goals. One gendered health area, Menstrual Health & Hygiene (MHH), has received increasing attention in Low- and Middle-Income Countries as a barrier to health, wellbeing, and gender equity. Recent anecdotal evidence in Australia highlights that MHH also present challenges to High Income Countries, particularly among underrepresented populations, such as Indigenous Australian peoples, people from low socio-economic backgrounds, or communities that are remotely located. In this article, we chart the emergence of attention to MHH in the Australian context and highlight key considerations for the conduct of research with Aboriginal and Torres Strait Islander Peoples within the culturally- and gender-sensitive area of MHH. Further we draw on insights offered by a partnership between female Aboriginal and Torres Strait Islander leaders, NGO stakeholders, and non-Indigenous researchers. Through a convening (yarning circle) held in March 2018, the group identified multiple socioecological considerations for MHH research and practice, including: affordability and access to menstrual products, barriers to knowledge and culturally sensitive education, infrastructure and supply chain challenges, and the necessity of Indigenous-led research and community-driven data collection methods in addressing the sensitive topic. We draw together these insights to develop recommendations for future research, advocacy, and action in Australia.

Drawing from Australian Aboriginal and Torres Strait Islander perspectives, we conceptualize the association between community participation and continuous quality improvement (CQI) processes in Indigenous primary health care (PHC) services. Indigenous experiences of community participation were drawn from our study identifying contextual factors affecting CQI processes in high-improving PHC services. Using case study design, we collected quantitative and qualitative data at the micro-, meso-, and macro-health system level in 2014 and 2015 in six services in northern Australia. Analyzing qualitative data, we found community participation was an important contextual factor in five of the six services. Embedded in cultural foundations, cultural rules, and expectations, community participation involved interacting elements of trusting relationships in metaphorically safe spaces, and reciprocated learning about each other's perspectives. Foregrounding Indigenous perspectives on community participation might assist more effective participatory processes in Indigenous PHC including in CQI processes.

Introduction: Indigenous patients with life-limiting conditions have complex needs, experience reduced access to and uptake of treatment, and have lower utilisation of palliative care services than the general population. Lack of understanding of the role of palliative care and poor availability of culturally safe specialist palliative care services impact on Indigenous people's end-of-life decision-making., Methods: To understand Aboriginal people's perspectives and experiences at the end of life, an exploratory study using facilitated group discussions in community settings in a region of Western Australia was undertaken. Local Aboriginal people were engaged to talk frankly about their wishes and concerns around end of life. The community consultations included two meetings at the local Aboriginal corporation, an evening meeting for invited community members, a meeting at the local Aboriginal community controlled health service and two further meetings of community members at local gathering places. These were supplemented by the analysis of previous in-depth video-recorded interviews that were undertaken with Aboriginal people with cancer reporting on their concerns and wishes., Results: The community consultations raised considerable discussion about wills, where to die, burial versus cremation, and the cost of funerals. Possibilities emerging from participants' reflections on the issue were public celebrations to honour someone's life, the potential use of sorting cards to help discussions about end-of-life personal wishes, and interest in making and decorating coffins. Aboriginal people with cancer raised similar issues, and focused on avoiding family disharmony by ensuring their family were aware of their end-of-life wishes., Conclusion: Within a safe space, Aboriginal people were happy to talk about end-of-life wishes, although certain aspects of death remain contentious. Sorting cards, ceremonies, education and care roles involving Aboriginal people offer potential means for effectively engaging Aboriginal people in preparing for death and dealing with grief.

Objective: To compare the perception of the quality of ambulatory care in users of health services in 2012 and 2018, by indigenous and non-indigenous condition., Materials and Methods: With information from two population surveys (Encuesta Nacional de Salud y Nutrición [Ensanut] 2012 and Ensanut 100k) the quality of care was analyzed based on indicators of structure, process, health outcome and care satisfaction., Results: Between 2012 and 2018, the use of private health services increased; favorable opinion about the conditions of the site, and perception of short waiting times decreased among non-indigenous people. In public health services, the supply of medicines remained high, the laboratory and Rx tests in the same care unit and pharma- cology treatment explanation decreased, particularly among non-indigenous patients. Perception of health improvement and satisfaction of care was adequate., Conclusions: An ambulatory care model aimed to response needs and expectations of the most vulnerable population, mainly the indigenous population, is a priority., Competing Interests: Declaration of conflict of interests. The authors declare that they have no conflict of interests.

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

Background: The Getting it Right study determined the validity, sensitivity, specificity and acceptability of the culturally adapted 9-item Patient Health Questionnaire (aPHQ-9) as a screening tool for depression in Aboriginal and Torres Strait Islander (hereafter referred to as Indigenous) people. In this process evaluation we aimed to explore staff perceptions about whether Getting it Right was conducted per protocol, and if the aPHQ-9 was considered an acceptable and feasible screening tool for depression in primary healthcare. This process evaluation will provide information for clinicians and policy makers about the experiences of staff and patients with Getting it Right and what they thought about using the aPHQ-9., Methods: Process evaluation using grounded theory approaches. Semi-structured interviews with primary healthcare staff from services participating in Getting it Right were triangulated with feedback (free-text and elicited) from participants collected during the validation study and field notes. Data were thematically analysed according to the Getting it Right study protocol to identify the acceptability and feasibility of the aPHQ-9., Results: Primary healthcare staff (n = 36) and community members (n = 4) from nine of the ten participating Getting it Right services and Indigenous participants (n = 500) from the ten services that took part. Most staff reported that the research was conducted according to the study protocol. Staff from two services reported sometimes recruiting opportunistically (rather than recruiting consecutive patients attending the service as outlined in the main study protocol), when they spoke to patients who they knew from previous interactions, because they perceived their previous relationship may increase the likelihood of patients participating. All Getting it Right participants responded to at least six of the seven feedback questions and 20% provided free-text feedback. Most staff said they would use the aPHQ-9 and most participants said that the questions were easy to understand (87%), the response categories made sense (89%) and that they felt comfortable answering the questions (91%)., Conclusion: Getting it Right was predominantly conducted according to the study protocol. The aPHQ-9, the first culturally adapted, nationally validated, freely available depression screening tool for use by Indigenous people, appears to be acceptable and feasible to use., Trial Registration: Australian New Zealand Clinical Trial Registry ANZCTR12614000705684 , 03/07/2014.

Introduction: American Indian/Alaska Native (AI/AN) populations are disproportionately affected by chronic hepatitis C virus (HCV) infection. Federal facilities of the Indian Health Service, in conjunction with Tribally operated and Urban Indian (I/T/U) health care facilities, serve an estimated 2.2 million AI/AN patients. The facilities are mainly rural and have few specialists. To fill the gap in specialists in I/T/U clinics, the Extension for Community Healthcare Outcomes (ECHO) telehealth model was used to support clinicians to treat HCV in primary care., Methods: Participants in 3 regional HCV ECHO networks serving AI/AN patients were surveyed by e-mail and text message to determine patterns of ECHO usage, usefulness, and barriers to treating patients with HCV at their primary care clinics., Results: From a total of 44 respondents from 72 eligible health care facilities, a majority (61%) stated that they started treating patients with HCV subsequent to participating in the telehealth program. Participants with more telehealth experience sought increasing complexity in patient case presentations. In California, 7 of 8 clinicians who had attended more than 10 ECHO sessions expressed diminishing need for ECHO sessions to manage cases (<25% of patients). All elements of the ECHO sessions (presenting patient cases, listening to patient case presentations, teaching sessions, and sharing of programmatic insights) were considered "extremely useful" by the majority of respondents. The factors most cited as moderate or extensive barriers to providing HCV care were access to HCV direct acting antivirals (60%) and linking patients to care (50%)., Discussion: Extension for Community Healthcare Outcomes may play a key role not only in increasing clinical capacity for HCV treatment but also in the inception of HCV services in this sample of I/T/U facilities. Participants with more telehealth experience demonstrated signs of increasing clinical capacity, where they were more likely to seek complex patient case presentations in ECHO sessions. A number of barriers continue to keep AI/ANs from being cured and stop clinicians from ending the epidemic, including access to HCV medications, time to provide HCV clinical services, and linking patients to HCV services.

Competing Interests: Competing interests: None declared.

Introduction: The Cherokee Nation Comprehensive Cancer Control Program collaborated with the Cherokee Nation Hepatitis C Virus (HCV) Elimination Program within Cherokee Nation's Health Services to plan and implement activities to increase knowledge and awareness of liver cancer prevention among health care providers and the Cherokee Nation community. From August 2017 to April 2018, the 2 programs implemented liver cancer prevention interventions that focused on education of health care providers and community members. We used descriptive statistics to analyze data collected from a brief, retrospective pre-post survey for each intervention. We assessed overall awareness and knowledge of liver cancer and ability and intention to address it on a scale of 1 to 5. Project Extension for Community Healthcare Outcomes didactic sessions resulted in a 1.1-point improvement, provider education workshops resulted in a 1.4-point improvement, and presentations at community coalition meetings resulted in a 1.7-point improvement. Our study shows that HCV interventions can be used by public health and medical professionals interested in controlling HCV and related diseases such as liver cancer.

Objective: An expert reference group met on four occasions to consider ways forward in terms of Indigenous mental health. This paper summarises the discussion and recommendations., Conclusion: While the negative effects of colonisation and trans-generational trauma continue, we propose renewed emphasis on improving access, cultural orientation and trauma-informed care, and a focus on the needs of young Indigenous Australians.

Background: Ischaemic strokes lead to significant morbidity and mortality within the Australian Indigenous population, with known variances in the management of strokes between indigenous and non-indigenous populations., Aims: To compare investigations and management of indigenous and non-indigenous patients presenting to a New South Wales rural referral hospital with an ischaemic stroke to the national stroke standards across inpatient and outpatient settings., Methods: Historical cohort study of 43 indigenous and 167 non-indigenous patients admitted to Tamworth Rural Referral Hospital with an ischaemic cerebrovascular accident., Results: Indigenous patients were significantly less likely to have investigations completed, including carotid imaging (93.8% vs 100%, P = 0.012) and echocardiography (73.3% vs 97.7%, P = 0.004). Discharge follow up was significantly lower for the indigenous population (74.4% vs 87.4%, P = 0.034). Indigenous stroke patients were 15.8 years younger than non-indigenous subjects (56.8 vs 72.6 years old; P < 0.001). Indigenous patients were more likely to have stroke risk factors, including smoking (51.2% vs 15.0%; P < 0.001), diabetes mellitus (37.2% vs 16.8%, P = 0.003) and past history of cerebrovascular accident or transient ischaemic attack (50.2% vs 31.1%, P = 0.032)., Conclusions: The investigation and post-discharge care of indigenous ischaemic stroke patients is inferior to non-indigenous patients. Indigenous patients within rural NSW have a higher prevalence of preventable disease, including those that confer a higher stroke risk. Further research is needed to investigate the cause of these discrepancies and to improving indigenous stroke care between hospitals and primary care providers., (© 2019 Royal Australasian College of Physicians.)

Background: Australia's Aboriginal and Torres Strait Islander women have poorer survival and twice the disease burden from breast cancer compared to other Australian women. These disparities are influenced, but not fully explained, by more diagnoses at later stages. Incorporating breast screening, hospital and out of hospital treatment and cancer registry records into a person-linked data system can improve our understanding of breast cancer outcomes. We focussed one such system on a population-based cohort of Aboriginal women in South Australia diagnosed with breast cancer and a matched cohort of non-Aboriginal women with breast cancer. We quantify Aboriginal and non-Aboriginal women's contact with publicly funded screening mammograms; quantify exposure to a selection of cancer treatment modalities; then assess the relationship between screening, treatment and the subsequent risk of breast cancer death., Methods: Breast cancers registered among Aboriginal women in South Australia in 1990-2010 (N = 77) were matched with a random selection of non-Aboriginal women by birth and diagnostic year, then linked to screening records, and treatment 2 months before and 13 months after diagnosis. Competing risk regression summarised associations of Aboriginality, breast screening, cancer stage and treatment with risk of breast cancer death., Results: Aboriginal women were less likely to have breast screening (OR = 0.37, 95%CIs 0.19-0.73); systemic therapies (OR = 0.49, 95%CIs 0.24-0.97); and, surgical intervention (OR = 0.35, 95%CIs 0.15-0.83). Where surgery occurred, mastectomy was more common among Aboriginal women (OR = 2.58, 1.22-5.46). Each of these factors influenced the risk of cancer death, reported as sub-hazard ratios (SHR). Regional spread disease (SHR = 34.23 95%CIs 6.76-13.40) and distant spread (SHR = 49.67 95%CIs 6.79-363.51) carried more risk than localised disease (Reference SHR = 1). Breast screening reduced the risk (SHR = 0.07 95%CIs 0.01-0.83). So too did receipt of systemic therapy (SHR = 0.06 95%CIs 0.01-0.41) and surgical treatments (SHR = 0.17 95%CIs 0.04-0.74). In the presence of adjustment for these factors, Aboriginality did not further explain the risk of breast cancer death., Conclusion: Under-exposure to screening and treatment of Aboriginal women with breast cancers in South Australia contributed to excess cancer deaths. Improved access, utilisation and quality of effective treatments is needed to improve survival after breast cancer diagnosis.