Search

Abstract Chronic Obstructive Pulmonary Disease is a progressive lung disease associated with anxiety, depression, and reduced health-related quality of life. Pulmonary rehabilitation (PR) is a cost-effective and transformative treatment, but 31% of referred patients do not take up their PR appointment. The study aimed to develop user requirements for an intervention to increase PR uptake. A systems approach, the Engineering Better Care framework, was used to develop a system map of the PR pathway, translate evidence-based user needs into user requirements, and validate the user requirements in a stakeholder workshop. Eight user requirements addressed patient and health care practitioner needs to understand what PR entails, understand the benefits of PR and have positive conversations about PR to address patient concerns. The solution-independent user requirements can be applied to the development of any intervention sharing similar goals. The study demonstrates potential in taking a systems approach to more challenges within respiratory medicine.

Abstract Background Indigenous adolescents access primary health care services at lower rates, despite their greater health needs and experience of disadvantage. This systematic review identifies the enablers and barriers to primary health care access for Indigenous adolescents to inform service and policy improvements. Methods We systematically searched databases for publications reporting enablers or barriers to primary health care access for Indigenous adolescents from the perspective of adolescents, their parents and health care providers, and included studies focused on Indigenous adolescents aged 10–24 years from Australia, Canada, New Zealand, and United States of America. Results were analyzed against the WHO Global standards for quality health-care services for adolescents. An additional ninth standard was added which focused on cultural safety. Results A total of 41 studies were included. More barriers were identified than enablers, and against the WHO Global standards most enablers and barriers related to supply factors – providers’ competencies, appropriate package of services, and cultural safety. Providers who built trust, respect, and relationships; appropriate package of service; and culturally safe environments and care were enablers to care reported by adolescents, and health care providers and parents. Embarrassment, shame, or fear; a lack of culturally appropriate services; and privacy and confidentiality were common barriers identified by both adolescent and health care providers and parents. Cultural safety was identified as a key issue among Indigenous adolescents. Enablers and barriers related to cultural safety included culturally appropriate services, culturally safe environment and care, traditional and cultural practices, cultural protocols, Indigenous health care providers, cultural training for health care providers, and colonization, intergenerational trauma, and racism. Nine recommendations were identified which aim to address the enablers and barriers associated with primary health care access for Indigenous adolescents. Conclusion This review provides important evidence to inform how services, organizations and governments can create accessible primary health care services that specifically meet the needs of Indigenous adolescents. We identify nine recommendations for improving the accessibility of primary health care services for Indigenous adolescents.

Summary: Background: To address inequitable diagnostic access and improve time-to-treatment for First Nations peoples, molecular point-of-care (POC) testing for chlamydia, gonorrhoea and trichomonas was integrated into 49 primary care clinics across Australia. We conducted an observational evaluation to determine clinical effectiveness and analytical quality of POC testing delivered through this national program. Methods: We evaluated (i) implementation by measuring trends in mean monthly POC testing; ii) clinical effectiveness by comparing proportions of positive patients treated by historical control/intervention period and by test type, and calculated infectious days averted; (iii) analytical quality by calculating result concordance by test type, and proportion of unsuccessful POC tests. Findings: Between 2016 and 2022, 46,153 POC tests were performed; an increasing mean monthly testing trend was observed in the first four years (p

Abstract Globally, there is a growing acknowledgment of Indigenous Peoples’ rights to control data related to their communities. This is seen in the development of Indigenous Data Governance standards. As health data collection increases, it’s crucial to apply these standards in research involving Indigenous communities. Our study, therefore, aims to systematically review research using routinely collected health data of Indigenous Peoples, understanding the Indigenous Data Governance approaches and the associated advantages and challenges. We searched electronic databases for studies from 2013 to 2022, resulting in 85 selected articles. Of these, 65 (77%) involved Indigenous Peoples in the research, and 60 (71%) were authored by Indigenous individuals or organisations. While most studies (93%) provided ethical approval details, only 18 (21%) described Indigenous guiding principles, 35 (41%) reported on data sovereignty, and 28 (33%) addressed consent. This highlights the increasing focus on Indigenous Data Governance in utilising health data. Leveraging existing data sources in line with Indigenous data governance principles is vital for better understanding Indigenous health outcomes.

Introduction The effectiveness of antibiotics for treating gonococcal infections is compromised due to escalating antibiotic resistance; and the development of an effective gonococcal vaccine has been challenging. Emerging evidence suggests that the licensed meningococcal B (MenB) vaccine, 4CMenB is effective against gonococcal infections due to cross-reacting antibodies and 95% genetic homology between the two bacteria, Neisseria meningitidis and Neisseria gonorrhoeae, that cause the diseases. This project aims to undertake epidemiological and genomic surveillance to evaluate the long-term protection of the 4CMenB vaccine against gonococcal infections in the Northern Territory (NT) and South Australia (SA), and to determine the potential benefit of a booster vaccine doses to provide longer-term protection against gonococcal infections.Methods and analyses This observational study will provide long-term evaluation results of the effectiveness of the 4CMenB vaccine against gonococcal infections at 4–7 years post 4CMenB programme implementation. Routine notifiable disease notifications will be the basis for assessing the impact of the vaccine on gonococcal infections. Pathology laboratories will provide data on the number and percentage of N. gonorrhoeae positive tests relative to all tests administered and will coordinate molecular sequencing for isolates. Genome sequencing results will be provided by SA Pathology and Territory Pathology/New South Wales Health Pathology, and linked with notification data by SA Health and NT Health. There are limitations in observational studies including the potential for confounding. Confounders will be analysed separately for each outcome/comparison.Ethics and dissemination The protocol and all study documents have been reviewed and approved by the SA Department for Health and Well-being Human Research Ethics Committee (HREC/2022/HRE00308), and the evaluation will commence in the NT on receipt of approval from the NT Health and Menzies School of Health Research Human Research Ethics Committee. Results will be published in peer-reviewed journals and presented at scientific meetings and public forums.

This article traces Jonathan Swift’s legacy in the work of three modern Irish poets: Jessica Traynor, Rita Ann Higgins and Derek Mahon. I use two motifs to explore this inheritance: institutions and shadows. Using the work of Genevieve Lloyd, I argue that meaningful engagement with Enlightenment’s legacy must recognise its moral ambiguity and emotional complexity through the metaphor of shadow. Institutions, whether in the case of St Patrick’s Hospital, Dublin (Ireland’s first psychiatric hospital, founded by Swift), the residential institutions of the twentieth century or the modern apparatus of Direct Provision, embody a continuing legacy of suffering, control and containment. Imagination and empathy are the difficult but necessary means through which these legacies must be acknowledged and confronted.

Summary: Background: Smoking impacts DNA methylation, but data are lacking on smoking-related differential methylation by sex or dietary intake, recent smoking cessation (

Abstract Background The patient-centred medical home (PCMH) is a model of team-based primary care that is patient-centred, coordinated, accessible, and focused on quality and safety. In response to substantial population growth and increasing demand on existing primary care services, the Institute for Urban Indigenous Health (IUIH) developed the IUIH System of Care-2 (ISoC2), based on an international Indigenous-led PCMH. ISoC2 was piloted at an urban Aboriginal and Torres Strait Islander Community-Controlled Health Service in South-East Queensland between 2019–2020, with further adaptations made to ensure its cultural and clinical relevance to local Aboriginal and Torres Strait Islander people. Little is known on the implementation and impact of PCMH in the Australian Indigenous primary care setting. Changes in implementation process measures and outcomes relating to engagement and quality-of-care are described here. Methods De-identified routinely collected data extracted from electronic health records for clients regularly attending the service were examined to assess pre-post implementation changes relevant to the study. Process measures included enrolment in PCMH team-based care, and outcome measures included engagement with the health service, continuity-of-care and clinical outcomes. Results The number of regular clients within the health service increased from 1,186 pre implementation to 1,606 post implementation; representing a small decrease as a proportion of the services’ catchment population (38.5 to 37.6%). In clients assigned to a care team (60% by end 2020), care was more evenly distributed between providers, with an increased proportion of services provided by the Aboriginal and Torres Strait Islander Health Worker (16–17% versus 10–11%). Post-implementation, 41% of clients had continuity-of-care with their assigned care team, while total, preventive and chronic disease services were comparable pre- and post-implementation. Screening for absolute cardiovascular disease risk improved, although there were no changes in clinical outcomes. Conclusions The increase in the number of regular clients assigned to a team and their even distribution of care among care team members provides empirical evidence that the service is transforming to a PCMH. Despite a complex transformation process compounded by the COVID-19 pandemic, levels of service delivery and quality remained relatively stable, with some improvements in risk factor screening.

Abstract Background First Nations Peoples of Australia are disproportionally affected by hepatitis C (HCV) infection. Through a prospective study we evaluated the outcome of direct-acting antiviral (DAA) therapy among First Nations Peoples with HCV infection. Methods Adults who initiated DAA therapy at one of 26 hospitals across Australia, 2016–2019 were included in the study. Clinical data were obtained from medical records and the Pharmaceutical and Medicare Benefits Schemes. Outcomes included sustained virologic response (SVR) and loss to follow-up (LTFU). A multivariable analysis assessed factors associated with LTFU. Results Compared to non-Indigenous Australians (n = 3206), First Nations Peoples (n = 89) were younger (p

Abstract The interplay between genes harboring single nucleotide polymorphisms (SNPs) is vital to better understand underlying contributions to the etiology of breast cancer. Much attention has been paid to epistasis between nuclear genes or mutations in the mitochondrial genome. However, there is limited understanding about the epistatic effects of genetic variants in the nuclear and mitochondrial genomes jointly on breast cancer. We tested the interaction of germline SNPs in the mitochondrial (mtSNPs) and nuclear (nuSNPs) genomes of female breast cancer patients in The Cancer Genome Atlas (TCGA) for association with morphological features extracted from hematoxylin and eosin (H&E)-stained pathology images. We identified 115 significant (q-value

Abstract Objective: To quantify the prevalence of known health‐related risk factors for severe COVID‐19 illness among Aboriginal and Torres Strait Islander adults, and their relationship with social determinants. Methods: Weighted cross‐sectional analysis of the 2018‐19 National Aboriginal and Torres Strait Islander Health Survey; Odds Ratios for cumulative risk count category (0, 1, or ≥2 health‐related risk factors) by social factors calculated using ordered logistic regression. Results: Of the adult population, 42.9%(95%CI:40.6,45.2) had none of the examined health‐related risk factors; 38.9%(36.6,41.1) had 1, and 18.2%(16.7,19.7) had ≥2. Adults experiencing relative advantage across social indicators had significantly lower cumulative risk counts, with 30‐70% lower odds of being in a higher risk category. Conclusions: Aboriginal and Torres Strait Islander peoples must continue to be recognised as a priority population in all stages of pandemic preparedness and response as they have disproportionate exposure to social factors associated with risk of severe COVID‐19 illness. Indigeneity itself is not a ‘risk’ factor and must be viewed in the wider context of inequities that impact health Implications for public health: Multi‐sectoral responses are required to improve health during and after the COVID‐19 pandemic that: enable self‐determination; improve incomes, safety, food security and culturally‐safe healthcare; and address discrimination and trauma.

Abstract Objective: To describe the methods of recruitment and demographic results of an online sexual health survey using social networking sites (SNS) to recruit people aged 16–29 years in the state of South Australia (SA) during 2019. Methods: A crosssectional online survey titled ‘Let's Talk About It’ using SNS (Facebook and Instagram) was administered between July and August 2019, targeting Aboriginal and Torres Strait Islander and non‐Indigenous young people. The survey comprised questions on demographics information, sexual health knowledge, behaviours and healthcare access. Results: During the data collection period, the study team closely monitored the demographics of participants and adjusted SNS messaging through paid advertising to increase the recruitment of under‐represented population groups, especially Aboriginal people, males and regional and remote residents of SA. A total of 2,724 people accessed the survey predominately via Facebook during a six‐week period between July and August 2019; 2,380 people were eligible and included in the analysis. Conclusions and implications for public health: Even though SNS have been used previously in recruitment for sexual health issues, small adjustments to the study during recruitment were specifically made to include under‐represented populations in the final study. Using SNS is an effective method for recruiting survey participants; during recruitment phases, additional strategies may be required to be inclusive of diverse and under‐represented populations.

Introduction For over 40 years, Aboriginal and Torres Strait Islander Community-Controlled Health Services (ACCHS) in Australia have led strategic responses to address the specific needs of Aboriginal and Torres Strait Islander populations. Globally, there has been rapid growth in urban Indigenous populations requiring an adaptive primary healthcare response. Patient-centred medical homes (PCMH) are an evidenced-based model of primary healthcare suited to this challenge, underpinned by principles aligned with the ACCHS sector—relational care responsive to patient identified healthcare priorities. Evidence is lacking on the implementation and effectiveness of the PCMH model of care governed by, and delivered for, Aboriginal and Torres Strait Islander populations in large urban settings.Method and analysis Our multiphased mixed-methods prospective cohort study will compare standard care provided by a network of ACCHS to an adapted PCMH model of care. Phase 1 using qualitative interviews with staff and patients and quantitative analysis of routine primary care health record data will examine the implementation, feasibility and acceptability of the PCMH. Phase 2 using linked survey, primary care and hospitalisation data will examine the impact of our adapted PCMH on access to care, relational and quality of care, health and wellbeing outcomes and economic costs. Phase 3 will synthesise evidence on mechanisms for change and discuss their implications for sustainability and transferability of PCMHs to the broader primary healthcare systemEthics and dissemination This study has received approval from the University of Queensland Human Research Ethics Committee (2021/HE00529). This research represents an Aboriginal led and governed partnership in response to identified community priorities. The findings will contribute new knowledge on how key mechanisms underpinning the success and implementation of the model can be introduced into policy and practice. Study findings will be disseminated to service providers, researchers, policymakers and, most importantly, the communities themselves.

Global Environmental Assessments (GEAs) are in a unique position to influence environmental decision-making in the context of sustainability challenges. To do this effectively, however, new methods are needed to respond to the needs of decision-makers for a more integrated, contextualized and goal-seeking evaluation of different policies, geared for action from global to local. While scenarios are an important tool for GEAs to link short-term decisions and medium and long-term consequences, these current information needs cannot be met only through deductive approaches focused on the global level. In this paper, we argue that a more diverse set of futures tools operating at multiple scales are needed to improve GEA scenario development and analysis to meet the information needs of policymakers and other stakeholders better. Based on the literature, we highlight four challenges that GEAs need to be able to address in order to contribute to global environmental decision-making about the future: 1. anticipate unpredictable future conditions; 2. be relevant at multiple scales, 3. include diverse actors, perspectives and contexts; and 4. leverage the imagination to inspire action. We present a toolbox of future-oriented approaches and methods that can be used to effectively address the four challenges currently faced by GEAs.

BackgroundThere are no available school-based alcohol and drug prevention programs with evidence of effectiveness among Aboriginal and Torres Strait Islander youth. To address this, we codeveloped the Strong & Deadly Futures well-being and alcohol and drug prevention program in partnership with an Indigenous creative design agency and 4 Australian schools. ObjectiveThis paper presents the protocol to evaluate the effectiveness of Strong & Deadly Futures in reducing alcohol and other drug use and improving well-being among Aboriginal and Torres Strait Islander youth. MethodsThe target sample will be 960 year 7 and 8 students from 24 secondary schools in Australia, of which approximately 40% (384/960) will identify as Aboriginal or Torres Strait Islander. The study design is a 2-group, parallel cluster randomized controlled trial with allocation concealment. Recruited schools will be block randomized (ratio 1:1), stratified by geographical remoteness, by an independent statistician. Schools will be randomized to receive Strong & Deadly Futures, a web-based alcohol and drug prevention and social and emotional well-being program that delivers curriculum-aligned content over 6 lessons via an illustrated story, or health education as usual (control). Control schools will be supported to implement Strong & Deadly Futures following trial completion. Surveys will be administered at baseline, 6 weeks, 12 months, and 24 months (primary end point) post baseline. Primary outcomes are alcohol use (adapted from the National Drug Strategy Household Survey), tobacco use (Standard High School Youth Risk Behavior Survey), and psychological distress (Kessler-5 Psychological Distress Scale). Secondary outcomes are alcohol and drug knowledge and intentions, alcohol-related harms, binge drinking, cannabis use, well-being, empowerment, appreciation of cultural diversity, and truancy. ResultsThe trial was funded by the National Health and Medical Research Council in January 2019, approved by the Human Research Ethics Committee of the University of Sydney (2020/039, April 2020), the Aboriginal Health and Medical Research Council of New South Wales (1620/19, February 2020), the Western Australian Aboriginal Health Ethics Committee (998, October 2021), and the ethics committees of each participating school, including the New South Wales Department of Education (2020170, June 2020), Catholic Education Western Australia (RP2020/39, November 2020), and the Queensland Department of Education (550/27/2390, August 2021). Projected dates of data collection are 2022-2024, and we expect to publish the results in 2025. A total of 24 schools have been recruited as of submission of the manuscript. ConclusionsThis will be the first cluster randomized controlled trial of a culturally inclusive, school-based alcohol and drug prevention program for Aboriginal and Torres Strait Islander youth; therefore, it has significant potential to address alcohol and other drug harms among Aboriginal and Torres Strait Islander youth. Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN12620001038987; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380038&isReview=true International Registered Report Identifier (IRRID)PRR1-10.2196/34530

IntroductionDuring the course of the COVID-19 pandemic, there have been suggestions that various techniques could be employed to improve the fit and, therefore, the effectiveness of face masks. It is well recognized that improving fit tends to improve mask effectiveness, but whether these fit modifiers are reliable remains unexplored. In this study, we assess a range of common "fit hacks" to determine their ability to improve mask performance.MethodsBetween July and September 2020, qualitative fit testing was performed in an indoor living space. We used quantitative fit testing to assess the fit of both surgical masks and KN95 masks, with and without 'fit hacks', on four participants. Seven fit hacks were evaluated to assess impact on fit. Additionally, one participant applied each fit hack multiple times to assess how reliable hacks were when reapplied. A convenience of four participants took part in the study, three females and one male with a head circumference range of 54 to 60 centimetres.Results and discussionThe use of pantyhose, tape, and rubber bands were effective for most participants. A pantyhose overlayer was observed to be the most effective hack. High degrees of variation were noted between participants. However, little variation was noted within participants, with hacks generally showing similar benefit each time they were applied on a single participant. An inspection of the fit hacks once applied showed that individual facial features may have a significant impact on fit, especially the nose bridge.ConclusionsFit hacks can be used to effectively improve the fit of surgical and KN95 masks, enhancing the protection provided to the wearer. However, many of the most effective hacks are very uncomfortable and unlikely to be tolerated for extended periods of time. The development of effective fit-improvement solutions remains a critical issue in need of further development.

Introduction Since 2011, remote Australian Aboriginal and Torres Strait Islander communities have experienced an outbreak of infectious syphilis, with young people aged 15–29 years over-represented in notifications. The Young Deadly Syphilis Free multi-media campaign was implemented in 12 remote regions in four Australian jurisdictions over nine months from 2017–2018. Campaign components included television and radio advertisements, social media posts, and health promotion resources available via a dedicated website. The aim of this research was to evaluate the impacts (proximal, mediator, distal) of the Young Deadly Syphilis Free campaign for young Aboriginal people and health and community workers residing in remote campaign regions. Methods A cross-sectional (post-only) evaluation design was used. Data were collected through online surveys; metrics for social media (Facebook, Instagram) were also collected to determine campaign engagement via social media. A 22-item young people survey assessed campaign awareness, exposure, message recognition and diagnostics (proximal variables); along with intended behaviour and knowledge and attitudes (mediator variables). A 24-item health and community worker survey assessed campaign awareness, exposure, message recognition and diagnostics (proximal variables); and changes in professional practice (distal variable). Descriptive statistics summarised demographic characteristics and univariate analysis examined associations between key variables. Results Just over half (n = 25, 58%) of young people and three quarters (n = 36; 75%) of health and community workers were aware of the campaign. Recognition of key campaign messages was high for both participant groups (>64%), and television, Facebook, and website were the most common campaign exposure routes. Positive impacts on intended behaviour (young people) and professional practice (health and community workers) were also reported. Facebook was effective in engaging some young people in campaign content and was preferred by young people for accessing information. Conclusion The findings point to the value of utilising a multi-media campaign in raising awareness about syphilis among young Aboriginal people and health and community workers in remote Australian regions. A longer-term campaign that accommodates the diverse needs of Aboriginal young people from geographically remote communities would optimise campaign impacts and support behavioural change.

Abstract Background Sexually transmissible infection (STI) and blood-borne virus (BBV) diagnoses data are a core component of the Australian National Notifiable Diseases Surveillance System (NNDSS). However, the NNDSS data alone is not enough to understand STI and BBV burden among priority population groups, like Aboriginal and Torres Strait Islander people, because it lacks testing, treatment and management data. Here, we describe the processes involved in establishing a STI and BBV sentinel surveillance network representative of Aboriginal Community-Controlled Health Services (ACCHS)—known as the ATLAS network—to augment the NNDSS and to help us understand the burden of disease due to STI and BBV among Aboriginal and Torres Strait Islander peoples. Methods Researchers invited participation from ACCHS in urban, regional and remote areas clustered in five clinical hubs across four Australian jurisdictions. Participation agreements were developed for each clinical hub and individual ACCHS. Deidentified electronic medical record (EMR) data relating to STI and BBV testing, treatment and management are collected passively from each ACCHS via the GRHANITEtm data extraction tool. These data are analysed centrally to inform 12 performance measures which are included in regular surveillance reports generated for each ACCHS and clinical hub. Results The ATLAS network currently includes 29 ACCHS. Regular reports are provided to ACCHS to assess clinical practice and drive continuous quality improvement initiatives internally. Data is also aggregated at the hub, jurisdictional and national level and will be used to inform clinical guidelines and to guide future research questions. The ATLAS infrastructure can be expanded to include other health services and potentially linked to other data sources using GRHANITE. Conclusions The ATLAS network is an established national surveillance network specific to Aboriginal and Torres Strait Islander peoples. The data collected through the ATLAS network augments the NNDSS and will contribute to improved STI and BBV clinical care, guidelines and policy program-planning.

Abstract Background Barriers to receiving optimal healthcare exist for Indigenous populations globally for a range of reasons. To overcome such barriers and enable greater access to basic and specialist care, developments in information and communication technologies are being applied. The focus of this scoping review is on web-based therapeutic interventions (WBTI) that aim to provide guidance, support and treatment for health problems. Objectives This review identifies and describes international scientific evidence on WBTI used by Indigenous peoples in Australia, New Zealand, Canada and USA for managing and treating a broad range of health conditions. Eligibility criteria Studies assessing WBTI designed for Indigenous peoples in Australia, Canada, USA and New Zealand, that were published in English, in peer-reviewed literature, from 2006 to 2018 (inclusive), were considered for inclusion in the review. Studies were considered if more than 50% of participants were Indigenous, or if results were reported separately for Indigenous participants. Sources of evidence Following a four-step search strategy in consultation with a research librarian, 12 databases were searched with a view to finding both published and unpublished studies. Charting methods Data was extracted, synthesised and reported under four main conceptual categories: (1) types of WBTI used, (2) community uptake of WBTI, (3) factors that impact on uptake and (4) conclusions and recommendations for practice. Results A total of 31 studies met the inclusion criteria. The WBTI used were interactive websites, screening and assessment tools, management and monitoring tools, gamified avatar-based psychological therapy and decision support tools. Other sources reported the use of mobile apps, multimedia messaging or a mixture of intervention tools. Most sources reported moderate uptake and improved health outcomes for Indigenous people. Suggestions to improve uptake included as follows: tailoring content and presentation formats to be culturally relevant and appropriate, customisable and easy to use. Conclusions Culturally appropriate, evidence-based WBTI have the potential to improve health, overcome treatment barriers and reduce inequalities for Indigenous communities. Access to WBTI, alongside appropriate training, allows health care workers to better support their Indigenous clients. Developing WBTI in partnership with Indigenous communities ensures that these interventions are accepted and promoted by the communities.

Abstract Background Australian surveillance data document higher rates of sexually transmissible infections (STIs) among young Aboriginal people (15–29 years) in remote settings than non-Aboriginal young people. Epidemiological data indicate a substantial number of young Aboriginal people do not test for STIs. Rigorous qualitative research can enhance understanding of these findings. This paper documents socio-ecological factors influencing young Aboriginal people’s engagement with clinic-based STI testing in two remote settings in the Northern Territory, Australia. Methods In-depth interviews with 35 young Aboriginal men and women aged 16–21 years; thematic analysis examining their perceptions and personal experiences of access to clinic-based STI testing. Results Findings reveal individual, social and health service level influences on willingness to undertake clinic-based STI testing. Individual level barriers included limited knowledge about asymptomatic STIs, attitudinal barriers against testing for symptomatic STIs, and lack of skills to communicate about STIs with health service staff. Social influences both promoted and inhibited STI testing. In setting 1, local social networks enabled intergenerational learning about sexual health and facilitated accompanied visits to health clinics for young women. In setting 2, however, social connectedness inhibited access to STI testing services. Being seen at clinics was perceived to lead to stigmatisation among peers and fear of reputational damage due to STI-related rumours. Modalities of health service provision both enhanced and inhibited STI testing. In setting 1, outreach strategies by male health workers provided young Aboriginal men with opportunities to learn about sexual health, initiate trusting relationships with clinic staff, and gain access to clinics. In setting 2, barriers were created by the location and visibility of the clinic, appointment procedures, waiting rooms and waiting times. Where inhibitive factors at the individual, social and health service levels exist, young Aboriginal people reported more limited access to STI testing. Conclusions This is the first socio-ecological analysis of factors influencing young Aboriginal people’s willingness to undertake testing for STIs within clinics in Australia. Strategies to improve uptake of STI testing must tackle the overlapping social and health service factors that discourage young people from seeking sexual health support. Much can be learned from young people’s lived sexual health experiences and family- and community-based health promotion practices.

Globally, Indigenous populations experience a disproportionately higher burden of disease related to substance use. Effective prevention of harm related to substance use is a key strategy for improving the health and wellbeing of Aboriginal and Torres Strait Islander peoples in Australia. To inform preventative approaches, this review synthesised the evidence of risk and protective factors of substance use and related harms among Aboriginal and Torres Strait Islander peoples. Eight peer-reviewed and two grey literature databases were systematically searched for quantitative or qualitative studies assessing factors associated with substance use and related harms among Aboriginal and Torres Strait Islander peoples, published between 1 January 1990 and 30 April 2018. Study quality was assessed using validated instruments. Risk or odds ratios were extracted or calculated and factors were summarised in an ecological model into individual, relationship, community, societal or culturally-distinct levels. Thirty-eight relevant studies were identified and reviewed. Individual-level risk factors for substance use were identified including low socio-economic status, high psychological distress, poly drug use and being male. Relationship-level factors were peer pressure and partner/family substance use; protective factors were supportive environments and positive role models. Community-level risk factors included availability of substances. Culturally-distinct factors included cultural connection as a protective factor, but cultural obligations around sharing was a risk factor. Societal risk factors included intergenerational trauma caused by government policies. These findings highlight the importance of tailored preventative approaches for Aboriginal and Torres Strait Islander communities that address identified risk factors and promote protective factors across all ecological levels.

Objectives To systematically review the evidence base for a systems approach to healthcare design, delivery or improvement.Design Systematic review with meta-analyses.Methods Included were studies in any patients, in any healthcare setting where a systems approach was compared with usual care which reported quantitative results for any outcomes for both groups. We searched Medline, Embase, HMIC, Health Business Elite, Web of Science, Scopus, PsycINFO and CINAHL from inception to 28 May 2019 for relevant studies. These were screened, and data extracted independently and in duplicate. Study outcomes were stratified by study design and whether they reported patient and/or service outcomes. Meta-analysis was conducted with Revman software V.5.3 using ORs—heterogeneity was assessed using I2 statistics.Results Of 11 405 records 35 studies were included, of which 28 (80%) were before-and-after design only, five were both before-and-after and concurrent design, and two were randomised controlled trials (RCTs). There was heterogeneity of interventions and wide variation in reported outcome types. Almost all results showed health improvement where systems approaches were used. Study quality varied widely. Exploratory meta-analysis of these suggested favourable effects on both patient outcomes (n=14, OR=0.52 (95% CI 0.38 to 0.71) I2=91%), and service outcomes (n=18, OR=0.40 (95% CI 0.31 to 0.52) I2=97%).Conclusions This study suggests that a systems approaches to healthcare design and delivery results in a statistically significant improvement to both patient and service outcomes. However, better quality studies, particularly RCTs are needed.PROSPERO registration numberCRD42017065920.

IntroductionThe COVID-19 pandemic has made well-fitting face masks a critical piece of protective equipment for healthcare workers and civilians. While the importance of wearing face masks has been acknowledged, there remains a lack of understanding about the role of good fit in rendering protective equipment useful. In addition, supply chain constraints have caused some organizations to abandon traditional quantitative or/and qualitative fit testing, and instead, have implemented subjective fit checking. Our study seeks to quantitatively evaluate the level of fit offered by various types of masks, and most importantly, assess the accuracy of implementing fit checks by comparing fit check results to quantitative fit testing results.MethodsSeven participants first evaluated N95 and KN95 respirators by performing a fit check. Participants then underwent quantitative fit testing wearing five N95 respirators, a KN95 respirator, a surgical mask, and fabric masks.ResultsN95 respirators offered higher degrees of protection than the other categories of masks tested; however, it should be noted that most N95 respirators failed to fit the participants adequately. Fit check responses had poor correlation with quantitative fit factor scores. KN95, surgical, and fabric masks achieved low fit factor scores, with little protective difference recorded between respiratory protection options. In addition, small facial differences were observed to have a significant impact on quantitative fit.ConclusionFit is critical to the level of protection offered by respirators. For an N95 respirator to provide the promised protection, it must fit the participant. Performing a fit check via NHS self-assessment guidelines was an unreliable way of determining fit.

Introduction In Australia, the notification rate for hepatitis C is 5 times greater among Aboriginal and Torres Strait Islander peoples than non‑Indigenous populations (164 vs. 35 per 100,000). Infection with Hepatitis C virus is associated with increased morbidity, mortality and health-related costs. Recently, the use of simple, tolerable and short-duration HCV therapies with extremely high efficacy (cure rates >90%) became available through the Pharmaceutical Benefits Scheme (PBS) on 1 March 2016. Objectives and Approach Overall, this project aims to identify inequities in hepatitis C healthcare for Aboriginal and Torres Strait Islander peoples across SA and NT. By using 19 routinely collected health administration datasets, we will evaluate hepatitis C diagnoses, treatment uptake, and treatment outcomes, with focus on identifying patterns in healthcare access among Aboriginal and Torres Strait Islander people. The study links state-based and federal datasets, including Medicare, Pharmaceutical Benefits Scheme, and National Mortality Database, to hepatitis C notifications reported in SA since 1992 or in NT since 1999 using probabilistic data linkage methodology in a secured online environment. Results The study population includes all hepatitis C notifications recorded in SA and NT, totalling more than 25,000 cases. Preliminary findings will be reported including incidence of hospitalisation, mortality, and morbidity by Aboriginal and Torres Strait Islander status. Conclusion / Implications This project is of national importance to address hepatitis C related morbidity and mortality in Australia, particularly among Aboriginal and Torres Strait Islander peoples. Now that highly effective direct acting anti-viral treatments are available, it is crucial to ensure key affected populations, including Aboriginal and Torres Strait Islander people, have access to these novel biomedical approaches. Findings will underpin future policy to reduce the burden of hepatitis C across SA and NT populations.

Introduction Aboriginal Community-Controlled Health Services (ACCHSs) routinely collect sexually transmissible infection (STI) and blood-borne virus (BBV) clinical data from individuals through electronic medical records (EMRs). At a population level these data are an underutilised resource and can be used to help drive clinical and public health interventions. Accordingly, we have established a national STI and BBV sentinel surveillance network for ACCHSs —the ATLAS network. Objectives and Approach In establishing the ATLAS network, we standardised and automated extraction of deidentified clinical data from multiple EMRs using The University of Melbourne’s GRHANITE™ software. Regular reports are provided to each ACCHS, addressing 12 clinical indicators considered best practice in STI and BBV control and management. Data are used to drive Continuous Quality Improvement strategies, can be aggregated at regional and national levels, and have the ability to link to other surveillance networks also using GRHANITE™. Results The ATLAS network currently includes more than 30 ACCHSs, including urban, regional and remote areas. To date, data have been analysed for >50,000 individuals aged ≥15 years attending medical consultations at ACCHS between January 2016 and December 2018. For clients in the key age-range for STI testing of 15–29 years, the mean annual rate of chlamydia/gonorrhoea testing was 25% (range: 1–59%). The mean annual rate of chlamydia positivity for clients 15–29 years was 3% (range: 0–19%) and the mean annual rate of gonorrhoea positivity was 2% (range: 0–18%). Conclusion / Implications An integrated network of STI and BBV testing and management data has been successfully established amongst ACCHSs nationally. The ATLAS network can be readily expanded and has the potential to link to other datasets using the GRHANITE™ tool. ATLAS provides a unique data infrastructure with capacity to support novel research programs as well as underpin quality improvement activities within participating sites.

Invasive meningococcal disease (IMD) causes significant morbidity and mortality worldwide with serogroup B being the predominant serogroup in Australia and other countries for the past few decades. The licensed 4CMenB vaccine is effective in preventing meningococcal B disease. Emerging evidence suggests that although 4CMenB impact on carriage is limited, it may be effective against gonorrhoea due to genetic similarities between Neisseria meningitidis and Neisseria gonorrhoeae. This study protocol describes an observational study that will assess the effect of the 4CMenB vaccine against meningococcal carriage, IMD and gonorrhoea among adolescents in the Northern Territory (NT). All 14–19-year-olds residing in the NT with no contraindication for 4CMenB vaccine will be eligible to participate in this cohort study. Following consent, two doses of 4CMenB vaccine will be administered two months apart. An oropharyngeal swab will be collected at baseline and 12 months to detect pharyngeal carriage of Neisseria meningitidis by PCR. The main methodological approaches to assess the effect of 4CMenB involve a nested case control analysis and screening method to assess vaccine effectiveness and an Interrupted Time Series regression analysis to assess vaccine impact. Research ethics approvals have been obtained from Menzies and Central Australian Human Research Ethics Committees and the Western Australian Aboriginal Health Ethics Committee. Results will be provided in culturally appropriate formats for NT remote and regional communities and published in international peer reviewed journals. ClinicalTrials.gov Identifier: NCT04398849.

A newly matriculated medical student must transition from college student to physician in four short years. The call has been made to help students in this transition. There is little data on how this can occur and how the system of medical education can guide students. We set out to describe and understand medical students' process of professional identity formation (PIF) longitudinally from first-year to fourth-year students. Using a qualitative thematic analysis of 58 survey responses from the anatomy dissection laboratory (1st and 2nd year students), 78 clerkship reflective practice essays (3rd year students), and 26 survey responses to a realistic field exercise (4th year students) we developed a grounded theory: We found four developmental/transformational stages (Building, Becoming, Bridging, and Being) in PIF of a physician with the end result that the physician is confident, resilient, and embraces his/her identity. Additionally, there were three longitudinal supports identified that faculty provide: promoting self-reflection, promoting mastery of difficult tasks, and being available. Successful transition is tied to transformational experiences that with the faculty support propel the student toward PIF. These findings serve as a framework for medical educators to develop a curriculum that supports positive PIF in medical students.

As the dominant form of urban agriculture (UA) in Australia, existing home food gardens potentially represent a significant resource in the context of future urban food security and sustainability. However, a severe lack of in-field data has hindered our understanding of the form and function of home food gardens which in turn may hinder innovation and improvement. We investigated the productivity, resource efficiency and potential financial savings of home food gardens in South Australia. A group of 34 citizen science participants measured and recorded inputs and outputs from their gardens. Inputs included time spent on various gardening activities, financial costs, and water use. Outputs included crop yields, from which retail value and nutritional content were then derived. The paper outlines a field-demonstrated, comprehensive methodology for continued and consistent data collection for all forms of UA. We found smaller gardens to be more intensive than larger gardens, requiring higher inputs, but also returning higher outputs per unit area. Both productivity and resource efficiency varied among the gardens, and labour requirements were significantly lower than previously estimated. Water use efficiency of the gardens were calculated and found to have comparable water use efficiency to commercial horticulture. Of the gardens involved, we calculated that 65% should break even in five or less years and save money. After applying a minimum wage almost one in five gardens were financially viable. The results represent the most comprehensive measurements on home food gardens to date, and allow practical, evidence-based recommendations for diversification, time saving and smart irrigation practices to improve garden productivity and enhance the viability of UA.

Summary: Background: Remote Australian Aboriginal communities have among the highest diagnosed rates of sexually transmissible infections (STIs) in the world. We did a trial to assess whether continuous improvement strategies related to sexual health could reduce infection rates. Methods: In this stepped-wedge, cluster-randomised trial (STIs in remote communities: improved and enhanced primary health care [STRIVE]), we recruited primary health-care centres serving Aboriginal communities in remote areas of Australia. Communities were eligible to participate if they were classified as very remote, had a population predominantly of Aboriginal people, and only had one primary health-care centre serving the population. The health-care centres were grouped into clusters on the basis of geographical proximity to each other, population size, and Aboriginal cultural ties including language connections. Clusters were randomly assigned into three blocks (year 1, year 2, and year 3 clusters) using a computer-generated randomisation algorithm, with minimisation to balance geographical region, population size, and baseline STI testing level. Each year for 3 years, one block of clusters was transitioned into the intervention phase, while those not transitioned continued usual care (control clusters). The intervention phase comprised cycles of reviewing clinical data and modifying systems to support improved STI clinical practice. All investigators and participants were unmasked to the intervention. Primary endpoints were community prevalence and testing coverage in residents aged 16–34 years for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. We used Poisson regression analyses on the final dataset and compared STI prevalences and testing coverage between control and intervention clusters. All analyses were by intention to treat and models were adjusted for time as an independent covariate in overall analyses. This study was registered with the Australia and New Zealand Clinical Trials Registry, ACTRN12610000358044. Findings: Between April, 2010, and April, 2011, we recruited 68 primary care centres and grouped them into 24 clusters, which were randomly assigned into year 1 clusters (estimated population aged 16–34 years, n=11 286), year 2 clusters (n=10 288), or year 3 clusters (n=13 304). One primary health-care centre withdrew from the study due to restricted capacity to participate. We detected no difference in the relative prevalence of STIs between intervention and control clusters (adjusted relative risk [RR] 0·97, 95% CI 0·84–1·12; p=0·66). However, testing coverage was substantially higher in intervention clusters (22%) than in control clusters (16%; RR 1·38; 95% CI 1·15–1·65; p=0·0006). Interpretation: Our intervention increased STI testing coverage but did not have an effect on prevalence. Additional interventions that will provide increased access to both testing and treatment are required to reduce persistently high prevalences of STIs in remote communities. Funding: Australian National Health and Medical Research Council.

Abstract Background Young people living in remote Australian Aboriginal communities experience high rates of sexually transmissible infections (STIs). STRIVE (STIs in Remote communities, ImproVed and Enhanced primary care) was a cluster randomised control trial of a sexual health continuous quality improvement (CQI) program. As part of the trial, qualitative research was conducted to explore staff perceptions of the CQI components, their normalisation and integration into routine practice, and the factors which influenced these processes. Methods In-depth semi-structured interviews were conducted with 41 clinical staff at 22 remote community clinics during 2011–2013. Normalisation process theory was used to frame the analysis of interview data and to provide insights into enablers and barriers to the integration and normalisation of the CQI program and its six specific components. Results Of the CQI components, participants reported that the clinical data reports had the highest degree of integration and normalisation. Action plan setting, the Systems Assessment Tool, and the STRIVE coordinator role, were perceived as adding value to the program, but were less readily integrated or normalised. The remaining two components (dedicated funding for health promotion and service incentive payments) were seen as least relevant. Our analysis also highlighted factors which enabled greater integration of the CQI components. These included familiarity with CQI tools, increased accountability of health centre staff and the translation of the CQI program into guideline-driven care. The analysis also identified barriers, including high staff turnover, limited time involved in the program and competing clinical demands and programs. Conclusions Across all of the CQI components, the clinical data reports had the highest degree of integration and normalisation. The action plans, systems assessment tool and the STRIVE coordinator role all complemented the data reports and allowed these components to be translated directly into clinical activity. To ensure their uptake, CQI programs must acknowledge local clinical guidelines, be compatible with translation into clinical activity and have managerial support. Sexual health CQI needs to align with other CQI activities, engage staff and promote accountability through the provision of clinic specific data and regular face-to-face meetings. Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12610000358044. Registered 6/05/2010. Prospectively Registered.

Abstract Background Deadly Liver Mob (DLM) is a peer-driven, incentivised health promotion program aimed at increasing understanding of hepatitis C, promoting harm reduction in relation to injecting drug use, and linking participants to screening for hepatitis C, other blood borne viruses and sexually transmissible infections among Aboriginal people in Western Sydney, NSW. This paper presents the evaluation of a pilot study examining the acceptability of the program as a first step of a scalability assessment. Methods Deadly Liver Mob operated in co-located needle and syringe programs and sexual health clinics in two sites: (Site 1: two and a half years for 2 days/week; Site 2: 1 year for 1 day per week). Comparisons were made of the proportion of Aboriginal clients (Site 1) and occasions of service provided to Aboriginal clients (Site 2) in the 12 months prior and post-introduction of DLM. Interviews were conducted with 13 staff involved in delivery of DLM and with 19 clients. Results A total of 655 and 55 Aboriginal clients, respectively, attended Site 1 and Site 2 for health education. The proportion of Aboriginal clients attending both sites was significantly higher during the DLM compared with prior to its implementation. Of those attending for health education, 79 and 73%, respectively, attended screening following education. DLM clients strongly endorsed the program. Some staff were concerned about workforce capacity to effectively engage Aboriginal clients with multiple and complex needs, managing the differing aims of the participating services involved, and about offering of incentives for attendance at health services. Conclusion While acceptability was high among staff and clients and preliminary results show high engagement with Aboriginal communities, this evaluation of a pilot program raises some issues to consider in scale up of DLM to other sites. The initiation of additional DLM sites should address issues of alignment with governing strategies and workforce capacity.