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Objective: This qualitative study explores the experiences and perceptions of new and expectant First Nations fathers in an urban setting in Australia. Background: Little is known about the experiences of First Nations men as fathers, including their transition to fatherhood and their strengths and challenges as fathers. Method: Eight First Nations men who were expectant or new fathers participated in individual yarning interviews. Data were analyzed using descriptive phenomenological analysis. Results: Men perceived a father to be a protector, provider and someone who reflects on how to be a better father. To be a better father, men were trying to heal and learn from their past and build their identity as a father, while managing the stress of fatherhood. Conclusion: The study identified four strategies to support new First Nations fathers: (a) create gathering places for men to connect with and learn from other dads, (b) maternity and early childhood services should be inclusive of men and their role as fathers, (c) clinical intervention and supportive pathways into fatherhood, and (d) promote and celebrate the strengths and roles of First Nations fathers. Implications: Maternity and early childhood services can better support First Nations men in their transition to fatherhood by being more responsive to their needs and inclusive of their important role in child development and strengthening the family unit.

First Nations people who use methamphetamine are overrepresented in regional and remote Australia and more likely to turn to family for support. This can place strain on families. The support needs of family members of individuals using methamphetamine are poorly understood.We conducted 19 focus groups and seven interviews with mostly First Nations community, family members and service providers. In total, 147 participants across six sites participated as part of a larger study investigating First Nations perspectives of how to address methamphetamine use and associated harms. We applied a social and emotional wellbeing framework to examine support needs and role of family in mitigating methamphetamine harms.Findings highlighted the importance of families in providing support to people using methamphetamine and in reducing associated harms, often without external support. The support provided encompassed practical, social, emotional, financial, access to services and maintaining cultural connection. Providing support took a toll on family and negatively impacted their own social and emotional wellbeing.First Nations families play an important and under-recognised role in reducing methamphetamine-related harms and greater efforts are required to support them. Professional resources are needed to deal with impacts of methamphetamine on families; these should be pragmatic, accessible, targeted and culturally appropriate. Support for families and communities should be developed using the social and emotional wellbeing framework that recognises wellbeing and healing as intrinsically connected to holistic health, kinship, community, culture and ancestry, and socioeconomic and historical influences on peoples' lives.

First Nations doulas offer an innovative approach for strengthening capacity and increasing the Australian First Nations maternity workforce to improve access to services that produce optimal outcomes. Currently, there is no published evidence on the training needs and health sector industry support for developing a First Nations doula workforce.In the context of the 'Top End,' Northern Territory, Australia, the aim of this article is to document Industry feedback on the training needs and support for developing a First Nations doula workforce.Ten purposively recruited Industry representatives participated in a facilitated workshop using the Kaospiolit Vision Backcasting education design tool.Participants identified and reached consensus on almost all the underpinning skills, knowledge, mindset, and attitudes required to work as a First Nations doula. Overall participants indicated strong Industry appetite and support for formally developing the doula role.There was participant consensus that accredited doula training would be a 'game-changer', addressing inadequacies and inequities in NT's reproductive and maternal health services for remote-living First Nations women.More research is required to explore First Nations doula practice in addressing perinatal inequities and workforce issues. Investigation is required to identify funding and appropriate workforce models.

Sophie Hickey,1,* Yvette Roe,1,* Caroline Harvey,2 Sue Kruske,1,2 Anton Clifford-Motopi,2 Ike Fisher,2 Brenna Bernardino,3,4 Sue Kildea1 1Molly Wardaguga Research Centre, Charles Darwin University, Brisbane, Queensland, Australia; 2Institute for Urban Indigenous Health, Brisbane, Queensland, Australia; 3School of Population Health, University of Queensland, Brisbane, Queensland, Australia; 4Poche Centre for Indigenous Health, University of Queensland, Brisbane, Queensland, Australia*These authors contributed equally to this workCorrespondence: Yvette RoeMolly Wardaguga Research Centre, Charles Darwin University, 410 Ann St, Level 11 East Tower, Brisbane, 4000, Queensland, AustraliaTel +61 7 3169 4266Email Yvette.roe@cdu.edu.auContext: Little is known about sexual and reproductive health (SRH) access and health promotion for First Nations peoples in Australia. This study aimed to better understand community preferences, knowledge and access to contraception and SRH services, and use this understanding to make recommendations which support approaches led by local Aboriginal community-controlled health organisations (ACCHOs).Methods: Qualitative First Nations-led yarning circles were conducted with 55 community members and health service providers using and/or working at ACCHOs in urban South East Queensland. Cultural protocols ensured women’s and men’s interviews were separately collected and analysed. Thematic analysis was conducted by multiple coders, privileging interpretations by First Nations researchers.Results: Family, kin and friends were described as key knowledge holders and ACCHOs as knowledge spaces for sharing information about maintaining positive SRH and wellbeing for First Nations people. Interviewees wanted accurate and timely information in an accessible, culturally appropriate way. Making informed choices about family planning was described as an important process of agency and self-determination for First Nations people, and contextualized within broader aspirations for growing strong families and healthy relationships.Conclusion: Understanding SRH through the concept of “knowledge spaces” and “knowledge holders” highlights the collective importance of community relationality to support individual agency and informed SRH decision-making. ACCHOs appear to be acceptable knowledge spaces for SRH information; and evidence-based recommendations may increase their reach. Health services should consider upskilling community SRH knowledge holders to share consistent, accurate and accessible SRH information.Keywords: Indigenous, community-based health promotion, sexual and reproductive health, contraception, strength-based

IntroductionCerebral palsy (CP) is the most common childhood physical disability with rates approximately 50% higher in First Nations Australian children. This study aims to evaluate a culturally-adapted parent-delivered early intervention programme for First Nations Australian infants at high risk of CP (Learning through Everyday Activities with Parents for infants with CP; LEAP-CP).Methods and analysisThis study is a randomised assessor masked controlled trial. Infants with birth/postnatal risk factors will be eligible for screening. Infants at high risk of CP (‘absent fidgety’ on General Movements Assessment, and/or ‘suboptimal score’ on the Hammersmith Infant Neurological Examination) aged 12–52 weeks corrected age will be recruited. Infants and their caregivers will be randomised to receive LEAP-CP (intervention) or health advice (comparator). LEAP-CP is a culturally-adapted programme of 30 home visits delivered by a peer trainer (First Nations Community Health Worker); and includes goal-directed active motor/cognitive strategies, CP learning games and caregiver educational modules. The control arm receives a monthly health advice visit, based on the Key Family Practices, WHO. All infants continue to receive standard (mainstream) Care as Usual. Dual child primary outcomes are Peabody Developmental Motor Scales-2 (PDMS-2) and Bayley Scales of Infant Development-III. The primary caregiver outcome is the Depression, Anxiety and Stress Scale. Secondary outcomes include function, goal attainment, vision, nutritional status and emotional availability. Sample size: total of 86 children (43/group) will enable an effect size of 0.65 on the PDMS-2 to be detected (80% power, α=0.05; 10% attrition).Ethics and disseminationEthics approval through Queensland ethics committees and Aboriginal Controlled Community Health Organisation Research Governance Groups, with families providing written informed consent. Findings will be disseminated with guidance from the Participatory Action Research, in collaboration with First Nations communities; peer-reviewed journal publications and national/international conference presentations.Trial registration numberACTRN12619000969167p.

In this call to action, a coalition of Indigenous and non-Indigenous researchers from Australia, Aotearoa New Zealand, United States and Canada argue for the urgent need for adequately funded Indigenous-led solutions to perinatal health inequities for Indigenous families in well-resourced settler-colonial countries. Authors describe examples of successful community-driven programs making a difference and call on all peoples to support and resource Indigenous-led perinatal health services by providing practical actions for individuals and different groups.

INTRODUCTION AND AIMS: There is a need for detailed information on methamphetamine use in Aboriginal and Torres Strait Islander communities. We describe a national survey on methamphetamine use among Aboriginal and Torres Strait Islander people and non-Indigenous people. DESIGN AND METHODS: Participants aged 16 years or older who reported using methamphetamine in the past year were recruited for a cross-sectional survey through 10 Aboriginal Community Controlled Organisations. Surveys were completed anonymously on electronic tablets. Measures included the Australian Treatment Outcomes Profile, the Severity of Dependence Scale, subscales from Opiate Treatment Index and the Kessler 10. A Chronic Stress Scale was used to assess culturally situated chronic stress factors. RESULTS: Of the 734 participants, 416 (59%) were Aboriginal or Torres Strait Islander and 331 (45%) were female. In the previous year, most participants reported smoking (48.7%) or injecting (34%) methamphetamine and 17.4% reported daily use. Aboriginal and Torres Strait Islander people did not differ significantly from non-Indigenous participants on methamphetamine use patterns (age at first use, frequency of use, main mode of use, injecting risk, poly drug use). Aboriginal and Torres Strait Islander participants felt less able to access health care (32% vs. 48%, P < 0.001), including mental health services (19% vs. 29%, P < 0.002), were less likely to report a mental health diagnosis (50% vs. 60%, P < 0.002) and were more likely to turn to family for support (52% vs. 34%, P < 0.001). DISCUSSION AND CONCLUSIONS: We recruited and surveyed a large sample of Aboriginal and Torres Strait Islander people from which we can derive detailed comparative data on methamphetamine use and related health service needs for Aboriginal and Torres Strait Islander and non-Indigenous Australians.

Reducing the rate of over-representation of Aboriginal and Torres Strait Islander children in out-of- home care (OOHC) is a key Closing the Gap target committed to by all Australian governments. Current strategies are failing. The ���gap��� is widening, with the rate of Aboriginal and Torres Strait Islander children in OOHC at 30 June 2020 being 11 times that of non- Indigenous children. Approximately, one in five Aboriginal and Torres Strait Islander children entering OOHC each year are younger than one year. These figures represent compound-ing intergenerational trauma and institutional harm to Aboriginal and Torres Strait Islander families and communities. This article outlines systemic failures to address the needs of Aboriginal and Torres Strait Islander parents during pregnancy and following birth, causing cumulative harm and trauma to families, communities and cultures. Major reform to child and family notification and service systems, and significant investment to address this crisis, is urgently needed. The Family Matters Building Blocks and five elements of the Aboriginal and Torres Strait Islander Child Placement Principle (Prevention, Participation, Partnership, Placement and Connection) provide a trans-formative foundation to address historical, institutional, well- being and socioeconomic drivers of current catastrophic trajectories. The time for action is now.

Background Midwifery continuity of care models are the only health system intervention associated with both a reduction in preterm birth (PTB) and an improvement in perinatal survival; however, questions remain about the mechanisms by which such positive outcomes are achieved. We aimed to uncover theories of change by which we can postulate how and why continuity of midwifery care models might affect PTB. Methods We followed Pawson's guidance for conducting a realist review and performed a comprehensive search to identify existing literature exploring the impact of continuity models on PTB in all pregnant women. A realist methodology was used to uncover the context (C), mechanisms (M), and outcomes (O) and to develop a group of CMO configurations to illuminate middle-range theories. Results Eleven papers were included from a wide variety of settings in the United Kingdom, Australia, and the United States. The majority of study participants had low socioeconomic status or social risk factors and received diverse models of midwifery continuity of care. Three themes-woman-midwife partnership, maternity pathways and processes, and system resources-encompassed ten CMO configurations. Building relationships, trust, confidence, and advocacy resulted in women feeling safer, less stressed, and more secure and respected, and encouraged them to access and engage in antenatal care with more opportunities for early prevention and diagnosis of complications, which facilitated effective management when compliance to guidelines was ensured. Organizational infrastructure, innovative partnerships, and robust community systems are crucial to overcome barriers, address women's complex needs, ensure quality of care, and reduce PTB risk. Conclusions Pregnant women living in different contexts in the United Kingdom, Australia, and the United States at low and mixed risk of complications and with low socioeconomic status or social risk factors experienced continuity models in similar ways, and similar underlying mechanisms may have influenced PTB outcomes. Further research is required to understand how continuity models may influence behavioral change, physiological stress levels, ethnic disparities in PTB and care coordination, and navigation of health services.

IntroductionFor 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 analysisOur 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 disseminationThis 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.

Background The Australian Nurse Family Partnership Program (ANFPP) is an evidence-based, home visiting program that offers health education, guidance, social and emotional support to first-time mothers having Aboriginal and/or Torres Strait Islander (First Nations) babies. The community-controlled sector identified the need for specialised support for first time mothers due to the inequalities in birthing and early childhood outcomes between First Nations’ and other babies in Australia. The program is based on the United States’ Nurse Family Partnership program which has improved long-term health outcomes and life trajectories for mothers and children. International implementation of the Nurse Family Partnership program has identified interagency service integration as key to program recruitment, retention, and efficacy. How the ANFPP integrates with other services in an Australian urban setting and how to improve this is not yet known. Our research explores the barriers and enablers to interagency service integration for the Australian Nurse Family Partnership Program ANFPP in an urban setting. Methods A qualitative study using individual and group interviews. Purposive and snowball sampling was used to recruit clients, staff (internal and external to the program), Elders and family members. Interviews were conducted using a culturally appropriate ‘yarning’ method with clients, families and Elders and semi-structured interview guide for staff. Interviews were audio-recorded and transcribed prior to reflexive thematic analysis. Results Seventy-six participants were interviewed: 26 clients, 47 staff and 3 Elders/family members. Three themes were identified as barriers and three as enablers. Barriers: 1) confusion around program scope, 2) duplication of care, and 3) tensions over ‘ownership’ of clients. Enablers (existing and potential): 1) knowledge and promotion of the program; 2) cultural safety; and 3) case coordination, co-location and partnership forums. Conclusion Effective service integration is essential to maximise access and acceptability of the ANFPP; we provide practical recommendations to improve service integration in this context.

Background Birthing on Country is an international movement to return maternity services to First Nations communities and community control for improved health and wellbeing. Question How can we implement Birthing on Country services for Aboriginal and/or Torres Strait Islander families across Australia? Methods We have developed a framework from theoretical, policy and research literature on Birthing on Country; Aboriginal and Torres Strait Islander voices from across Australia; reviews exploring programs that have improved outcomes for Indigenous mothers and infants; and the retrospective synthesis of learnings from two empirical studies that have redesigned maternal infant health services and improved outcomes for Aboriginal and Torres Strait Islander families. Results The RISE Framework has four pillars to drive important reform: (1) R edesign the health service; (2) I nvest in the workforce; (3) S trengthen families; and, (4) E mbed Aboriginal and/or Torres Strait Islander community governance and control. We present the evidence base for each pillar and practical examples of moving from the standard ‘western’ model of maternity care towards Birthing on Country services. Conclusions Application of the RISE framework to plan, develop and monitor Birthing on Country services is likely to result in short and long-term health gains for Aboriginal and Torres Strait Islander families.

Problem It is not well known how to prepare new multidisciplinary teams aiming to provide culturally safe maternity care for Aboriginal and Torres Strait Islander families in an urban setting. Background National policies recommend increasing the Aboriginal and Torres Strait Islander workforce and cultural competencies of the non-Indigenous workforce as key drivers of culturally safe care. Question What are the key learnings from staff experiences establishing multidisciplinary teams aiming to provide culturally safe maternity care that aims to privilege Indigenous ways of knowing, being and doing? Methods As part of a larger participatory action research project, semi-structured qualitative interviews were conducted December 2014–April 2015 with 21 Aboriginal and Torres Strait Islander and non-Indigenous healthcare staff. Thematic analysis was used to identify learnings for practice. Findings Four key learnings were identified for forming new teams aiming to provide culturally safe care: (a) having a shared understanding of what characterises cultural safety in the local program context; (b) understanding and valuing different roles and knowledges people bring to the team; (c) acknowledging the influence of race and culture on staff behaviour; and (d) acting on individual and organisational responsibilities for continuous improvement towards cultural safety. Discussion We present recommendations from our participatory action research approach to respond to these learnings in practice. Conclusion A deliberate workforce investment at the early stages of team development is crucial when aiming to provide culturally safe maternity care that can respond to the unique needs of Aboriginal and Torres Strait Islander women and families.

Background: Prevention of avoidable preterm birth in Aboriginal and Torres Strait Islander (Indigenous) families is a major public health priority in Australia. Evidence about effective, scalable strategies to improve maternal and infant outcomes is urgently needed. In 2013, a multiagency partnership between two Aboriginal Community Controlled Health Organisations and a tertiary maternity hospital co-designed a new service aimed at reducing preterm birth: ‘Birthing in Our Community’. Methods: A prospective interventional cohort study compared outcomes for women with an Indigenous baby receiving care through a new service (n = 461) to women receiving standard care (n = 563), January 2013–December 2017. The primary outcome was preterm birth (

The 2020 International Year of the Nurse and Midwife has harshly revealed the need to increase the nursing and midwifery workforce and for the disciplines to invest in anti-racism initiatives. The World Health Organization (WHO) (2020) has called for a marked increase in the numbers of nurses and midwives, academics and students. However, to ensure the cultural safety of patients and staff, WHO (2020) stated this increase in workforce must include clinicians and educators from underrepresented populations, in particular Indigenous populations. Stemming from our experiences as First Nations nurses, midwives, practitioners, researchers, educators, and allies, this editorial outlines our agenda to reform Indigenous health and cultural safety curricula in Australian higher education institutions.

Background & problem Birthing On Country (BOC) is an international movement for returning childbirth to First Nations peoples and their communities. The RISE Framework was developed to guide evidence-based BOC implementation but has not yet been tested in a remote Australian community setting. Aim To test the transferability and acceptability of the RISE Framework in a remote multilingual setting in a Yolŋu (First Nations) community in Northern Australia. Methods Working in partnership with one remote Yolŋu community, we used a decolonising participatory action research (D-PAR) approach to begin co-designing services and test the acceptability of the RISE Framework. A three-phased transferability process was developed: Warming the ground; Co-Interpreting; and Acceptability Testing. Findings The RISE Framework was customized to the local Yolŋu context and called ‘Caring for Mum on Country’. It was articulated in two languages: Djambarrpuyŋu and English. We successfully used it to guide discussions at a community gathering privileging the voices of senior women to inform the design of local maternity services. Discussion Using the D-PAR approach, the RISE Framework was readily adapatable to this complex, remote and multilingual setting. It resonated with the Yolŋu community and proved useful for identifying current limitations of existing maternity services and importantly facilitating the design of Yolŋu centred strength-based maternity services. Conclusion The RISE Framework, combined with our transformative methodology, offers a promising approach to guiding complex interventions for returning services to First Nations communities in diverse contexts. Testing in other settings will further contribute to growing an evidence-base for BOC service planning and implementation.

Background and Aims There is a need for more evidence to guide efforts to address harmful methamphetamine use amongst young Aboriginal and Torres Strait Islander Australians. ‘Communities that Care’ (CTC) is an evidence-based process developed to prevent alcohol and other drug-related harm but its suitability for use in Aboriginal contexts has not been established. This study sought to explore whether risk and protective factors for methamphetamine use, as described by Aboriginal stakeholders, align with the CTC risk and protective factor framework. Method Focus groups and individual interviews were conducted in Aboriginal communities nationally. Data were analysed thematically using the CTC framework as a deductive coding framework. Additional themes were captured and summarised. Results Participants were 147 (80% Aboriginal; 44% female) key stakeholders aged between 16 and 69 (median=40), recruited via organisational and community networks in each site. Relevant factors were identified in all four CTC domains: community, family, school, peer/individual. However, these four domains did not capture issues of central importance to Aboriginal people. These were summarised as an additional domain, ‘Culture and Identity.’ Conclusions Given that the Communities that Care risk and protective framework did not sufficiently capture issues of central importance to Aboriginal people, there is a need for different, community-informed models that reflect the unique determinants of use in this context.

Problem There is increasing demand for capacity building among the Aboriginal and Torres Strait Islander (Indigenous) maternal and infant health workforce to improve health outcomes for mothers and babies; yet few studies describe the steps taken to mentor novice Indigenous researchers to contribute to creating a quality evidence-base in this space. Background The Indigenous Birthing in an Urban Setting study is a partnership project aimed at improving maternity services for Indigenous families in South East Queensland. Aim To describe our experience setting up a Participatory Action Research team to mentor two young Indigenous women as research assistants on the Indigenous Birthing in an Urban Setting study. Methods Case study reflecting on the first six months. Findings Participatory Action Research was a very effective method to actively mentor and engage all team members in reflective, collaborative research practice, resulting in positive changes for the maternity care service. The research assistants describe learning to conduct interviews and infant assessments, as well as gaining confidence to build rapport with families in the study. Reflecting on the stories shared by the women participating in the study has opened up a whole new world and interest in studying midwifery and child health after learning the difficulties and strengths of families during pregnancy and beyond. Discussion We encourage others to use Participatory Action Research to enable capacity building in the Aboriginal and Torres Strait Islander midwifery workforce and in health research more broadly.

BackgroundA national accreditation policy for the Australian primary healthcare (PHC) system was initiated in 2008. While certification standards are mandatory, little is known about their effects on the efficiency and sustainability of organisations, particularly in the Aboriginal Community Controlled Health Service (ACCHS) sector.AimThe literature review aims to answer the following: to what extent does the implementation of the International Organisation for Standardization 9001:2008 quality management system (QMS) facilitate efficiency and sustainability in the ACCHS sector?MethodsThematic analysis of peer-reviewed and grey literature was undertaken from Australia and New Zealand PHC sector with a focus on First Nations people. The databases searched included Medline, Scopus and three Informit sites (AHB-ATSIS, AEI-ATSIS and AGIS-ATSIS). The initial search strategy included quality improvement, continuous quality improvement, efficiency and sustainability.ResultsSixteen included studies were assessed for quality using the McMaster criteria. The studies were ranked against the criteria of credibility, transferability, dependability and confirmability. Three central themes emerged: accreditation (n=4), quality improvement (n=9) and systems strengthening (n=3). The accreditation theme included effects on health service expenditure and clinical outcomes, consistency and validity of accreditation standards and linkages to clinical governance frameworks. The quality improvement theme included audit effectiveness and value for specific population health. The theme of systems strengthening included prerequisite systems and embedded clinical governance measures for innovative models of care.ConclusionThe ACCHS sector warrants reliable evidence to understand the value of QMSs and enhancement tools, particularly given ACCHS (client-centric) services and their specialist status. Limited evidence exists for the value of standards on health system sustainability and efficiency in Australia. Despite a mandatory second certification standard, no studies reported on sustainability and efficiency of a QMS in PHC.

Australian policy encourages multiagency partnerships between hospitals and Aboriginal Community Controlled Health Organisations to improve the health of Aboriginal and Torres Strait Islander people. Service planners remain unsure about how to implement such partnerships in maternity care, and there is a lack of appropriate tools designed to gauge the state of such partnerships for the Australian Indigenous context. In 2013, two Aboriginal health services and a major tertiary hospital partnered to deliver best practice maternity care to Indigenous families in Brisbane, Australia. A participatory action research approach underpinned this study. Semi-structured qualitative interviews and focus groups were conducted with 21 of the partnership staff. All interviewees emphasized the partnership's commitment to improving long-term health and wellbeing for Indigenous families. Strategic planners were more likely to report a positive partnership than staff involved in service delivery who had diverse views. This highlights the challenges of change management when conducting such a significant service redesign in this cross-cultural context. We detail changes made within the partnership in response to the findings and provide suggestions for future development of an evaluation tool to review the state of Aboriginal-Mainstream Partnerships.

Maternity models that provide midwifery continuity of care have been established to increase access to appropriate services for Indigenous Australian women. Understanding the development and implementation of continuity models for Indigenous women in Australia provides useful insights for the development and implementation of similar models in other contexts such as those for vulnerable and socially disadvantaged women living in the United Kingdom. To ensure better health outcomes for mothers and babies, it is crucial to promote culturally competent and safe public health models in which midwives work collaboratively with the multidisciplinary team.

In this article, we provide an emic perspective of being uniquely positioned as part of Australia’s only multidisciplinary Indigenous research network, the National Indigenous Research and Knowledges Network (NIRAKN). We used collaborative autoethnography and reflection in our practices and experiences. Our purpose was to better understand and improve the functionality of our research network and practice, and to offer some direction for the growth and sustainability of NIRAKN and similar networks. Our narratives strongly demonstrate that mainstream models of support for Indigenous researchers have major limitations for professional development and cultural safety, and do not meet our needs and realities. The significant message is that we need appropriately resourced exclusive spaces and must lead, develop and define the theoretical and cultural specifications and applications of Indigenous researcher support models in higher education institutions. The model should be cross-disciplinary, have national and international reach and be characterised by connectedness, cultural safety and self-determination, and be located in a resource-rich environment.

© 2018 The Author(s). Background: With persisting maternal and infant health disparities, new models of maternity care are needed to meet the needs of Aboriginal and Torres Strait Islander people in Australia. To date, there is limited evidence of successful and sustainable programs. Birthing on Country is a term used to describe an emerging evidence-based and community-led model of maternity care for Indigenous families; its impact requires evaluation. Methods: Mixed-methods prospective birth cohort study comparing different models of care for women having Aboriginal and Torres Strait Islander babies at two major maternity hospitals in urban South East Queensland (2015-2019). Includes women's surveys (approximately 20 weeks gestation, 36 weeks gestation, two and six months postnatal) and infant assessments (six months postnatal), clinical outcomes and cost comparison, and qualitative interviews with women and staff. Discussion: This study aims to evaluate the feasibility, acceptability, sustainability, clinical and cost-effectiveness of a Birthing on Country model of care for Aboriginal and Torres Strait Islander families in an urban setting. If successful, findings will inform implementation of the model with similar communities. Trial registration: Australian New Zealand Clinical Trial Registry # ACTRN12618001365257. Registered 14 August 2018 (retrospectively registered).

The Institute for Urban Indigenous Health (IUIH) aimed to improve access to cataract surgery in urban South East Queensland (SEQ) for Indigenous Australians, without compromising clinical visual outcomes. The Penchansky and Levesque concept of access as the ‘fit’ between the patient’s needs and the ability of the system to meet those needs was used to inform the redesign of the mainstream cataract surgical pathway. The IUIH staff and community stakeholders mapped the traditional external cataract surgical pathway and then innovatively redesigned it to reduce the number of patients being removed by the system at key transition points. The integration of eye health within the primary health care (PHC) clinic has improved the continuity and coordination of care along the surgical pathway, and ensured the sustainability of collaborative partnerships with key external organisations. Audit data demonstrated a significant increase in utilisation of cataract surgical services after the process redesign. Previous studies have found that PHC models involving integration, coordination and continuity of care enhance patient health outcomes; however, the IUIH surgical model extends this to tertiary care. There is scope to apply this model to other surgical pathways and communities who experience access inequity.

Background: The Institute for Urban Indigenous Health believes that continuous quality improvement (CQI) contributes to the delivery of high-quality care, thereby improving health outcomes for Aboriginal and Torres Strait Islander people. The opening of a new health service in 2015 provided an opportunity to implement best practice CQI strategies and apply them to a regional influenza vaccination campaign. Objective: The aim of this project was to implement an evidence-based CQI process within one Aboriginal Community Controlled Health Service in South East Queensland and use staff engagement as a measure of success. Method: A CQI tool was selected from the Joanna Briggs Institute Practical Application of Clinical Evidence System (PACES) to be implemented in the study site. The study site was a newly established Aboriginal and Torres Strait Islander Community Controlled Health Service located in the northern suburbs of Brisbane. This project used the evidence-based information collected in PACES to develop a set of questions related to known variables resulting in proven CQI uptake. A pre implementation clinical audit, education and self-directed learning, using the Plan Do Study Act framework, included a total of seven staff and was conducted in April 2015. A post implementation audit was conducted in July 2015. Results: There were a total of 11 pre- and post-survey respondents which included representation from most of the clinical team and medical administration. The results of the pre implementation audit identified a number of possible areas to improve engagement with the CQI process including staff training and support, understanding CQI and its impacts on individual work areas, understanding clinical data extraction, clinical indicator benchmarking, strong internal leadership and having an external data extractor. There were improvements to all audit criteria in the post-survey, for example, knowledge regarding the importance of CQI activity, attendance at education and training sessions on CQI, active involvement with CQI activity and a multidisciplinary team approach to problem solving within the CQI process. Conclusion: The study found that the implementation of regular, formally organized CQI strategies does have an immediate impact on clinical practice, in this case, by increasing staff awareness regarding the uptake of influenza vaccination against regional targets. The Plan Do Study Act cycle is an efficient tool to record and monitor the change and to guide discussions. For the CQI process to be effective, continued education and training on data interpretation is pivotal to improve staff confidence to engage in regular data discussions, and this should be incorporated into all future CQI sessions.

Background Methamphetamine use is of deep concern to Aboriginal and Torres Strait Islander communities, but access to culturally appropriate treatment resources and services is limited. Web-based programs have potential as flexible and cost-effective additions to the range of treatment options available to Aboriginal people. The We Can Do This online intervention is designed to incorporate evidence-based therapies in a culturally relevant format using narratives from Aboriginal people to contextualize the therapeutic content. Objective The goal of the research will be to test the effectiveness of the online intervention in a wait-list controlled randomized trial across multiple sites in urban, regional, and remote locations. Methods Participants will be Aboriginal and Torres Strait Islander people aged 16 years and over who have used methamphetamine at least weekly for the previous 3 months. They will be recruited online and via health services. During the intervention phase, participants will have access to the online intervention for 6 weeks with optional telephone or face-to-face support provided by participating health services. The primary outcome measure will be the number of days the participant used methamphetamine over the past 4 weeks compared to wait-list controls, assessed at baseline, 1, 2, and 3 months. Secondary outcomes will include help-seeking, readiness to change, severity of dependence, and psychological distress. Any important changes to the protocol will be agreed upon by the trial management committee and communicated to all relevant parties, including trial site representatives and the trial registry. Results Recruitment will commence in July 2019, and results are expected in early 2021. This research is funded by National Health and Medical Research Council project grant #1100696. The primary sponsor for the trial is the South Australian Health and Medical Research Institute. A trial management committee with representation from the participating health services, chief investigators, other Aboriginal experts, and consumers will oversee procedures, trial conduct, analysis, and reporting of the results. Conclusions The trial of this online intervention builds on existing research supporting the effectiveness of Web-based therapies for a range of psychological and other health-related issues including substance use. If successful, the We Can Do this online intervention will increase the range of options available to Aboriginal people seeking to reduce or stop methamphetamine use. It may provide a pathway into treatment for people who may otherwise be disengaged with health services for a range of reasons and will be a culturally appropriate, evidence-based resource for health practitioners to offer their clients. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12619000134123p; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=376088&isReview=true International Registered Report Identifier (IRRID) PRR1-10.2196/14084

Objective The aim of this study was to assess the change in recording of client population smoking attributes (smoking status recorded and smoking status) in Tackling Indigenous Smoking (TIS)-funded services compared with non-funded services for Aboriginal and Torres Strait Islander people, 2014–16. Methods The study included a cohort of 152 Aboriginal-community controlled services with aggregate client smoking data from 2014 to 2016. Negative binomial regression was used to assess change in smoking status recorded and smoking status between TIS and non-TIS funded organisations. The models controlled for size of client population, jurisdiction and remoteness. Results From 2014 to 2016, the overall reporting rate (change in recording of smoking status) of client smoking status was 1.58-fold higher (95% confidence interval (CI) 1.30–1.91; P

Background In Australia, significant disparity persists in stillbirth rates between Aboriginal and Torres Strait Islander (Indigenous Australian) and non-Indigenous women. Diabetes, hypertension, antepartum haemorrhage and small-for-gestational age (SGA) have been identified as important contributors to higher rates among Indigenous women. The objective of this study was to examine gestational age specific risk of stillbirth associated with these conditions among Indigenous and non-Indigenous women. Methods Retrospective population-based study of all singleton births of at least 20 weeks gestation or at least 400 grams birthweight in Queensland between July 2005 and December 2011 using data from the Queensland Perinatal Data Collection, which is a routinely-maintained database that collects data on all births in Queensland. Multivariate logistic regression was used to calculate adjusted odds ratios (aOR) and 95 % confidence intervals, adjusting for maternal demographic and pregnancy factors. Results Of 360987 births analysed, 20273 (5.6 %) were to Indigenous women and 340714 (94.4 %) were to non-Indigenous women. Stillbirth rates were 7.9 (95 % CI 6.8–9.2) and 4.1 (95 % CI 3.9–4.3) per 1000 births, respectively. For both Indigenous and non-Indigenous women across most gestational age groups, antepartum haemorrhage, SGA, pre-existing diabetes and pre-existing hypertension were associated with increased risk of stillbirth. There were mixed results for pre-eclampsia and eclampsia and a consistently raised risk of stillbirth was not seen for gestational diabetes. Conclusion This study highlights gestational age specific stillbirth risk for Indigenous and non-Indigenous women; and disparity in risk at term gestations. Improving access to and utilisation of appropriate and responsive healthcare may help to address disparities in stillbirth risk for Indigenous women. Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-0943-7) contains supplementary material, which is available to authorized users.

Developing high-quality and culturally responsive maternal and infant health services is a critical part of ‘closing the gap’ in health disparities between Aboriginal and Torres Strait Islander people and other Australians. The National Maternity Services Plan led work that describes and recommends Birthing on Country best-practice maternity care adaptable from urban to very remote settings, yet few examples exist in Australia. This paper demonstrates Birthing on Country principles can be applied in the urban setting, presenting our experience establishing and developing a Birthing on Country partnership service model in Brisbane, Australia. An initial World Café workshop effectively engaged stakeholders, consumers and community members in service planning, resulting in a multiagency partnership program between a large inner city hospital and two local Aboriginal Community-Controlled Health Services (ACCHS). The Birthing in Our Community program includes: 24/7 midwifery care in pregnancy to six weeks postnatal by a named midwife, supported by Indigenous health workers and a team coordinator; partnership with the ACCHS; oversight from a steering committee, including Indigenous governance; clinical and cultural supervision; monthly cultural education days; and support for Indigenous student midwives through cadetships and placement within the partnership. Three years in, the partnership program is proving successful with clients, as well as showing early signs of improved maternal and infant health outcomes. What is known about the topic? Birthing on Country has been described as a metaphor for the best start in life for Aboriginal and Torres Strait Islander babies, and services that incorporate Birthing on Country principles can improve outcomes for mothers and babies. Currently, few such models exist in Australia. What does this paper add? This paper demonstrates that Birthing on Country principles can be successfully applied to the urban context. We present a real case example of the experience of setting up one such best-practice, community-engaged and informed partnership model of maternity and child healthcare in south-east Queensland. We share our experience using a World Café to facilitate community engagement, service delivery and workforce planning. What are the implications for practitioners? Health professionals providing maternity care for Aboriginal and Torres Strait Islander families are encouraged to incorporate Birthing on Country principles into their model of care to address the specific needs and demands of the local Indigenous community and improve maternal and infant health outcomes.

Objectives The aim of the study was to assess the utility of national Aboriginal survey data in a regional geospatial analysis of daily smoking prevalence for Aboriginal and Torres Strait Islander Australians and discuss the appropriateness of this analysis for policy and program impact assessment. Methods Data from the last two Australian Bureau of Statistics (ABS) national surveys of Aboriginal and Torres Strait Islander people, the National Aboriginal and Torres Strait Islander Social Survey 2014–15 (n = 7022 adults) and the National Aboriginal and Torres Strait Islander Health Survey 2012–13 (n = 10 896 adults), were used to map the prevalence of smoking by Indigenous regions. Results Daily smoking prevalence in 2014–15 at Indigenous regions ranges from 27.1% (95%CI 18.9–35.3) in the Toowoomba region in Queensland to 68.0% (95%CI 58.1–77.9) in the Katherine region in the Northern Territory. The confidence intervals are wide and there is no significant difference in daily smoking prevalence between the two time periods for any region. Conclusion There are significant limitations with analysing national survey data at finer geographical scales. Given the national program for Indigenous tobacco control is a regional model, evaluation requires finer geographical analysis of smoking prevalence to inform public health progress, policy and program effects. Options to improve the data currently collected include increasing national survey sample sizes, implementing a smoking status question in census surveys, investing in current cohort studies focused on this population or implementing localised surveys. What is known about the topic? The last geospatial analysis of Aboriginal and Torres Strait Islander smoking prevalence was undertaken in 1997. Current national survey data have not been analysed geospatially. What does this paper add? This paper provides new insights into the use of national survey data for understanding regional patterns and prevalence levels of smoking in Aboriginal and Torres Strait Islander populations. What are the implications for practitioners? The findings of the study suggest caution when interpreting prevalence maps and highlight the need for greater sample sizes in national survey data. The analysis is also an opportunity to assess the use of national survey data in evaluating the policy impact of programs targeted at a regional level.

Aim: Using Australian guidelines for management of acute coronary syndromes, we assessed the probability of an Indigenous patient receiving interventional and therapeutic care after presenting in two metropolitan hospitals. Methods: A retrospective case note review of patients admitted through two Adelaide public tertiary hospital emergency departments from December 2007 to December 2009. The study cohort was 488 patients with high-risk clinical features without ST-segment elevation. Results: Indigenous patients were significantly younger, present later in the disease process and have a higher burden of cardiovascular risk factors when compared with non-Indigenous patients. Indigenous patients were 54% more likely to receive angiography (Risk ratios (RR)=1.54; 95% CI 1.31; 1.81) than non-Indigenous patients, however, this difference disappeared after adjustment for age, sex and propensity score. Indigenous patients were 20% more likely to receive the recommended medications (RR=1.19, 95% CI 1.01; 1.40) compared with non-Indigenous patients. Patients over 65years were 53% less likely to receive an angiogram (RR=0.47, 95% CI 0.38; 0.56) and were 35% less likely to receive the recommended medications (RR=0.65, 95% CI 0.54; 0.78) than a patient at the ages of 18-49. Women were almost 20% less likely to receive an angiogram (RR=0.81, 95% CI 0.66; 0.99) and 20% less likely to receive the recommended medications (RR=0.80, 95% CI 0.71; 0.91) when compared with men. The likelihood of receiving medications on discharge was significantly influenced by age, gender, ethnicity, comorbid burden and revascularisation. Conclusions: The younger age and significantly higher-risk profile of Indigenous adults presenting to SA hospitals with acute coronary syndromes appears to lead to different management decisions, which may well be led by patient factors. Many of these risk conditions can be better managed in the primary care setting. Refereed/Peer-reviewed

Using Australian guidelines for management of acute coronary syndromes, we investigated the proportion of high-risk patients enrolled in the Acute Coronary Syndromes Prospective Audit registry who received a coronary angiogram. A prospective nationwide multicentre registry involving 39 Australian hospitals was used. The study cohort were patients with high-risk clinical features without ST segment elevation (n = 1948) admitted from emergency departments between 1 November 2005 and 31 July 2007. Eighty nine per cent of patients with ST segment elevation myocardial infarction and only 53% of eligible patients with high-risk acute coronary syndromes with no ST elevation received a diagnostic angiogram. Increasing age was associated with lower rates of angiography; a high-risk patient at the age of ≥70 years was 19% less likely to receive an angiogram than one at the age of

BACKGROUND: Indigenous patients with acute coronary syndromes represent a high-risk group. There are however few contemporary datasets addressing differences in the presentation and management of Indigenous and non-Indigenous patients with chest pain. METHODS: The Heart Protection Project, is a multicentre retrospective audit of consecutive medical records from patients presenting with chest pain. Patients were identified as Indigenous or non-Indigenous, and time to presentation and cardiac investigations as well as rates of cardiac investigations and procedures were compared between the two groups. RESULTS: Of the 2380 patients included, 199 (8.4%) identified as Indigenous, and 2174 (91.6%) as non-Indigenous. Indigenous patients were younger, had higher rates hyperlipidaemia, diabetes, smoking, known coronary artery disease and a lower rate of prior PCI; and were significantly less likely to have private health insurance, be admitted to an interventional facility or to have a cardiologist as primary physician. Following adjustment for difference in baseline characteristics, Indigenous patients had comparable rates of cardiac investigations and delay times to presentation and investigations. CONCLUSIONS: Although the Indigenous population was identified as a high-risk group, in this analysis of selected Australian hospitals there were no significant differences in treatment or management of Indigenous patients in comparison to non-Indigenous.