Indigenous health: Journals & articles

Abstract
Chronic or persistent non-cancer pain disproportionately affects Māori - the Indigenous population of Aotearoa New Zealand (NZ) and their whānau (family and significant others). In a previous study with a Māori community service provider - Tū Kotahi Māori Asthma and Research Trust - Tū Kotahi, identified a need for a Kaupapa Māori (by Māori, for Māori) pain management programme (PMP) with embedded principles of Whānau Ora (care focusing on the wellbeing of the individual and their significant others as a collective). Using a qualitative case-study design, the main aims were to describe (1) the implementation of a community-based, whānau-focused PMP; (2) the participant experiences of the programme. This is community-based participatory action research guided by a Māori-centred research approach. Based on our previous co-design study with Tū Kotahi, a 6-week PMP (July - August 2021) was implemented at Kokiri Marae (community meeting place). Eight whānau living with persistent pain participated in the 6 sessions led by our Māori community partner and a pain management physiotherapist including a dedicated session on Rongoā Māori (Māori traditional treatment). Supporting resources were co-developed with our community partner, pain service clinicians, a Māori Health literacy expert, and a Māori illustrator. On completion, whānau reported enhanced confidence towards managing pain with "more tools to manage". The role of meaningful relationships, co-design, use of metaphors, and inclusion of traditional treatments - Rongoā were key aspects for the successful implementation. This initiative provides an exemplar for community and mainstream pain service partnership to address inequities in accessing pain management services for Māori. PERSPECTIVE: This study explains the key cultural processes of implementing a community-based pain management programme for Māori with persistent pain in Aotearoa New Zealand. The principles from our engagement could be applicable globally to engage with Indigenous and culturally and linguistically diverse communities with persistent pain to address longstanding health inequities.

Abstract
Background: Together with addressing social determinants of health, culturally safe healthcare provision is essential for closing the health outcomes gap experienced by Aboriginal and Torres Strait Islander (Indigenous) Australians. Rural placements potentially provide students of the health professions with opportunities to enhance their knowledge and skills regarding cultural safety. We used rural placements data systematically collected from allied health students, including commencement- and end-of-placement questionnaire responses, to investigate the determinants of confidence in working with Indigenous people.

Methods: The study comprised data from all students who provided survey data at both commencement and end of their first placement directly supervised by the administering University Department of Rural Health during the period 2019-2022. Five-point ordered responses to the question 'How confident do you feel about working with Aboriginal people?' were used to assess student and placement-related determinants of confidence (Confident/Very confident versus other) at baseline and increased confidence (≥ 1 point) during the placement using crude and adjusted multivariable robust Poisson regression.

Results: Participating students (N = 489) were from diverse allied health disciplines (including pharmacy n = 94, 19.2%; chiropractic n= 66, 13.5%; physiotherapy n= 65, 13.3%; social work n = 59, 12.1%; and occupational therapy 58, 11.9%). Confidence in dealing with Aboriginal people was lower at commencement among females compared with males (adjusted relative risk [aRR] 0.65; 95% confidence interval [CI] 0.53-0.80), and higher among students of Australian rural origin compared with others (aRR 1.49; CI 1.22-1.83) and those who reported previous experience working with Indigenous people compared with those reporting none (aRR 1.40; CI 1.14-1.72). Placement attributes associated with increased confidence working with Indigenous people between placement commencement and end were interaction with Indigenous people within the placement (aRR 2.32; CI 1.24-4.34), placement model reflecting more structured academic supervision (aRR 1.18; CI 1.02-1.37), and placement length (aRR per additional day 1.002; CI 1.001-1.004). These associations were robust to modelling that accounted for a ceiling effect on increased confidence.

Conclusions: While influenced by students' demographic attributes and prior experiences, confidence of allied health students in working with Indigenous people is enhanced during rural placements, particularly through direct contact with Indigenous people.

Abstract
Background: Community attitudes influence health outcomes especially for racially diverse and minority groups exposed to the detrimental effects of racism and discrimination. Using the results from Australia's national referendum to establish an Aboriginal and Torres Strait Islander Voice to Parliament ('the Voice') as a proxy for attitudes to Indigenous Australians, this study examined health outcomes for Indigenous and non-Indigenous Australians according to levels of opposition to the Voice.

Methods: The regional share of votes against the Voice was linked to 2021 data from the Household, Income and Labour Dynamics in Australia survey, a large, national probability sample (n∽17,000) of Australian adults. Adjusting for regional-level confounders, we used logistic regression analyses to predict health outcomes, healthcare use, and risk-taking behaviours among Indigenous and non-Indigenous Australians for different levels (quartiles) of opposition to the Voice.

Findings: Greater opposition to the Voice was associated with widening Indigenous disparities in health, healthcare use, and health behaviours. Indigenous Australians living in regions with the highest opposition to the Voice (top quartile:
≥
72% community voting 'No') were more likely to report fair/poor health [OR 2.28 (95% CI 1.45-3.58)] and poor mental health [OR 2.24 (95% CI 1.48-3.39)], were less likely to have visited any healthcare provider [OR 0.52 (95% CI 0.36-0.75)], and were more likely to smoke [OR 4.21 (95% CI 2.78-6.38)] or engage in risky drinking [OR 2.66 (95% CI 1.60-4.43)] relative to non-Indigenous Australians.

Interpretation: Indigenous Australians living in communities with greater opposition to the Voice experience poorer health relative to non-Indigenous Australians. Disparities in health may be partially due to poorer healthcare access and increased risk-taking behaviours, which may be associated with racism. These findings align with discrimination-related stress processes and potentially reduced availability of culturally inclusive healthcare. Health and social policy should consider how broader societal level conditions shape Indigenous health disparities in Australia.

Funding: This work is supported by the Australian Research Council (project ID FT200100630), the University of Melbourne Faculty Research Grant, and the National Health and Medical Research Council of Australia Investigator Grant (project ID 1201937).

Abstract
Introduction: Innovative, culturally safe strategies are required to address the disproportionate level of poorer health outcomes for Indigenous people in Australia compared to non-Indigenous populations. An emerging body of evidence supports the efficacy of Indigenous-specific health assessments, or health checks, despite poor uptake since their introduction in Australia. This poor uptake is attributed to a range of system, patient and provider barriers. Services have begun to deliver preventative health assessments as a community event to address barriers faced by Aboriginal and Torres Strait Islander people in accessing quality preventative care. However, there is a lack of literature exploring how community events have increased the uptake of Indigenous-specific health assessments to date. We expect this review will underpin a larger study to better understand how community engagement supports increased uptake of health checks. The objective of this scoping review was to investigate what is currently known about how community events have been used to increase uptake of Indigenous-specific health assessments.

Methods: A scoping review guided by the Joanna Briggs Institute methodology for scoping reviews was conducted. A search was completed in eight electronic databases using keywords relating to Aboriginal and Torres Strait Islander health, community engagement and preventative health assessments. Published and unpublished sources of evidence were included in the review. As this study aims to explore the entire published literature on the topic, and given there was an expectation that the subject itself is specific, no date ranges were included in the search criteria. Extracted data were reviewed by numerical analysis and conventional content analysis to conduct a narrative synthesis, allowing a summary of the main findings, and addressing the research question.

Results: Eighteen sources met the eligibility criteria and were included in the scoping review. Programs varied widely in the characteristics of program design and delivery across geographical location, setting of delivery, program format and target population. Programs employed a range of methods to engage with community, including incentivising participation, identifying and addressing specific community healthcare needs, and utilising cultural or sporting ambassadors to promote the program. The conventional content analysis identified three key themes regarding how community events have been used to increase uptake of health checks: adapting the program to the community; providing a culturally safe participant experience; and prioritising community engagement.

Discussion: The findings indicate that an individualised approach to community events is important to their success. Aboriginal Controlled Community Health Services may be best placed to have responsibility for program design and implementation to ensure community control of programs. Aboriginal health workers play a critical role in ensuring the programs deliver culturally safe healthcare, and a clear role for Aboriginal health workers in program delivery is important in their success. An authentic commitment to community engagement is important for program uptake, including the use of passionate cultural ambassadors and individualised cultural programs.

Conclusion: Community events are a promising and well-regarded strategy to increase uptake of Indigenous-specific health assessments. Future research that explores how specific community supports increase engagement with Health Check Day programs and evaluates the delivery of 715 health check programs will strengthen the capacity of Aboriginal Community Controlled Health Services to delivery this intervention effectively.

Abstract
Introduction: The effects of racism, oppression, and colonization in Australia are reflected in the inequitable experience of chronic kidney disease (CKD) among Aboriginal and Torres Strait Islander peoples. Despite having the highest incidence of CKD, Aboriginal and Torres Strait Islander people have the lowest rate of kidney transplant, with poor oral health commonly being an obstacle to receiving a transplant. This research reflects the exploratory phase of a larger project aimed at maximizing oral health outcomes for Aboriginal and Torres Strait Islander people living with CKD in Australia through the provision of culturally secure dental care.

Methods: The present research uses reflexive thematic analysis to analyze qualitative data from yarns, interviews, and focus groups with dental, renal, and Aboriginal and Torres Strait Islander stakeholders to generate a conceptual understanding of equity at the nexus of oral health and kidney health. NVivo software was used for organizing data and an inductive line-by-line coding approach.

Results: Twenty-eight stakeholders participated; 12 of the stakeholders identified as Aboriginal and/or Torres Strait Islander, and most were female. Factors at the nexus of oral health and CKD included the continuous effects of colonization, the centrality of cultural security for improved care, as well as several challenges and opportunities at a system level. Challenges included the luxury of oral health access, limited health care team involvement in oral health pathways, high-intensity engagement with medical systems, and no communication between dental and renal teams. Opportunities identified included the role of integrated care, cross-discipline knowledge sharing, Aboriginal and Torres Strait Islander leadership, clear referral pathways, prevention, and assistance with navigating the oral health system.

Conclusion: We argue that collective responsibility for the oral health of Aboriginal and Torres Strait Islander people living with CKD is required for improved health and eligibility for kidney transplant. Cross-discipline collaboration is required to overcome the rigidness of the current colonial and biomedical model that silos oral health and CKD.

Knowledge transfer statement: The siloed approach to management of oral health for Aboriginal and Torres Strait Islander peoples with chronic kidney disease results in low knowledge sharing and communication across chronic disease management teams and can prevent kidney transplantation. Collective responsibility for oral health within this context is required to ensure that just and equitable access to kidney transplant can be achieved.

Keywords: chronic disease; dentistry; holistic health; indigenous peoples; kidney disease; oral health.

Abstract
Introduction: Aboriginal and Torres Strait Islander peoples are the First Peoples of Australia. Up to 45% of dementia in these populations is due to potentially modifiable risk factors. The Dementia Prevention and Risk Management Program for Aboriginal Australians (DAMPAA) is an Aboriginal Health Practitioner led programme that aims to reduce cognitive decline and functional impairment in older Aboriginal people.

Methods: Design: DAMPAA is a multisite, randomised controlled trial aiming to deliver and evaluate a culturally appropriate risk factor management programme.

Population: Community-dwelling Aboriginal people aged 45-90 years.

Intervention: Participants will be randomly assigned to either usual care (control) or to a group programme comprising exercise and health education yarning sessions and pharmacist-delivered medication reviews delivered over a 12-month period.

Primary outcome: Cognitive function (Kimberley Indigenous Cognitive Assessment (KICA)-Cog score), daily function (KICA-Activities of Daily Living (ADL) score) and quality of life (Good Spirit, Good Life and EQ-5D-5L scores).

Secondary outcomes: Process evaluation interviews, cardiovascular risk factors, falls and death. Process evaluation will be conducted with qualitative methods. Quantitative outcomes will be analysed with generalised linear mixed models.

Ethics and dissemination: The study was approved by the Western Australian Aboriginal Health Ethics Committee and the University of Western Australia Human Research Ethics Committee. Study results will be published in peer-reviewed journals and presented at scientific meetings. We will also develop and disseminate a comprehensive DAMPAA toolkit for health services. The study's findings will guide future prevention strategies and outline a comprehensive process evaluation that may be useful in other Aboriginal health research to contextualise findings.

Abstract
Background: The recent crises of bushfires, floods, and the COVID-19 pandemic on the southeast coast of Australia were unprecedented in their extent and intensity. Few studies have investigated responses to cumulative disasters in First Nations communities, despite acknowledgement that these crises disproportionately impact First Nations people. This study was conducted by Aboriginal and non-Aboriginal researchers in partnership with Waminda, South Coast Women's Health and Wellbeing Aboriginal Corporation, an Aboriginal Community Controlled Health Organisation (ACCHO). It investigated the collective experiences of people affected by cumulative disasters to identify the practices that support healing, and recovery for Aboriginal communities. The study addresses a knowledge gap of how Waminda, designs, manages and delivers responses to address complex health and social issues in the context of cumulative disasters.

Methods: Underpinned by practice theory this study employed Indigenous-informed, narrative inquiry. Culturally-appropriate, multiple interpretive methods were used to collect data including: observations; yarns with Aboriginal community members, yarns with Waminda practitioners, management and board members; interviews-to-the-double, visual images and documentation. The data were collated and analysed using the phases of reflexive thematic analysis.

Results: The paper articulates a suite of culturally safe and place-based practices that enhance social, emotional and spiritual well-being following cumulative disasters. These practice bundles include: adopting a Country-centred conception of local communities; being community-led; viewing care as a collective, relational, sociomaterial accomplishment and having fluid boundaries. These practice bundles 'hang together' through organising practices including the Waminda Model of Care, staff wellbeing framework and emergency management plan which orient action and manage risks. The paper demonstrates the need for disaster responses to be community-led and culturally situated. ACCHOs are shown to play a crucial role, and their local responses to immediate community needs are grounded in contextual knowledge and use existing resources rather than relying on mainstream system-wide interventions.

Conclusions: The paper suggests crafting responses that focus on assisting communities (re)gain their sense of belonging, hope for the future, control over their lives and their capacities to care for and to be cared for by Country, are key to both enhancing healing, health and well-being and harnessing the strengths of communities.

Keywords: Aboriginal community-controlled health organisations; Community action; Covid-19; Cultural safety; Disaster relief planning; Disasters; Indigenous health service; Personal narratives; Practice theory; Social and emotional well-being.

Abstract
This narrative review discusses the important characteristics of electronic health (eHealth) interventions and critiques the cultural quality of eHealth research with Aboriginal and Torres Strait Islander peoples. Thirty-nine publications reporting on a variety of eHealth modalities to address health challenges with Aboriginal and Torres Strait Islander people were identified. Content analysis signified authentic co-design, governance and strong partnerships as foundational qualities of eHealth interventions that are culturally safe and sustainable. The pragmatics of eHealth setting, content and engagement must be underscored by trust, responsiveness and cultural values. The application of the Aboriginal and Torres Strait Islander Quality Appraisal Tool (QAT) revealed higher scores for studies with two or more Aboriginal and Torres Strait Islander authors. This narrative review is fundamental to the development of a best practice framework for eHealth interventions with Aboriginal and Torres Strait Islander people that are culturally safe, sustainable and effective. With a foundation of Aboriginal and Torres Strait Islander governance with strong partnerships for authentic co-design, eHealth interventions are more likely to meet the priorities and values of the Aboriginal and Torres Strait Islander communities for which they are intended.

Abstract
We first encountered one another around a decade ago when sharing an office at a rural health campus of The University of Sydney, where both of us were working on health research projects. From that first meeting we were intuitively drawn to each other, and soon discovered shared interests, and some surprisingly common perspectives and opinions on health services, seen with an Indigenous Australian lens.

Abstract
Indigenous nurse scholars across nations colonised by Europeans articulate the need for accomplices (as opposed to mere performative allies) to work alongside them and support their ongoing struggle for health equity and respect and to prioritise and promote culturally safe healthcare. Although cultural safety is now being mandated in nursing codes of practice as a strategy to address racism in healthcare, it is important that white nurse educators have a comprehensive understanding about cultural safety and the pedagogical skills needed to teach it to undergraduate nurses. We open this article with stories of our journeys as two white nurses in becoming accomplices and working alongside Indigenous Peoples, as patients and colleagues. Our lived experience of the inertia of healthcare and education organisations to address systemic and institutional resistance to the practice of cultural safety underpins the intention of this article. We understand that delivering this challenging and complex topic effectively and respectfully is best achieved when Indigenous and white educators work together at the cultural interface. Doing so requires commitment from white nurses and power holders within universities and healthcare institutions. A decolonising approach to nurse education at individual and institutional levels is fundamental to support and grow the work that needs to be done to reduce health inequity and increase cultural safety. White nurse accomplices can play an important role in teaching future nurses the importance of critical reflection and aiming to reduce power imbalances and racism within healthcare environments. Reducing power imbalances in healthcare environments and decolonising nursing practice is the strength of a cultural safety framework.

Abstract
Australia and New Zealand are two countries in the Southern Pacific region. They share many pediatric anesthesia similarities in terms of medical organizational systems, education, training, and research, however there are important differences between the two nations in relation to geography, the First Nations populations and the history of colonization. While the standards for pediatric anesthesia and the specialty training requirements are set by the Australian and New Zealand College of Anesthetists and the Society for Pediatric Anesthesia in New Zealand and Australia, colonization has created distinct challenges that each nation now faces in order to improve the anesthetic care of its pediatric population. Australia generally has a high standard of living and good access to health care; disparities exist for First Nations People and for those living in rural or remote areas. Two influences have shaped training within New Zealand over the past 40 years; establishment of a national children's hospital in 1990 and, more importantly, acknowledgement that the First Nations people of New Zealand (Māori) have suffered because of failure to recognize their rights consequent to establishing a partnership treaty between Māori and the British Crown in 1840. Health inequities among Māori in New Zealand and First Nations People in Australia have implications for the health system, culturally appropriate approaches to treatment, and the importance of having an appreciation of First Nations people's history and culture, language, family structure, and cultural safety. Trainees in both countries need to be adequately supported in these areas in order for the sub-specialty of pediatric anesthesia to develop further and improve the anesthetic and surgical outcomes of our children.

Keywords: Aboriginal health; access issues; health policy; remote health delivery; rural health.

Abstract
Background: The commercial determinants of health is a rapidly expanding field of research; however Indigenous perspectives remain notably underrepresented. For Indigenous peoples the intersection of globalisation, colonialism and capitalism may amplify commercially-driven health inequities. This study aimed to explore the perspectives of Aboriginal leaders regarding the influence of commercial activities on Aboriginal health and wellbeing in Victoria, Australia.

Methods: Semi-structured interviews with 23 Aboriginal leaders from across five sectors (n = 15 urban, n = 8 rural/regional) were analysed through reflexive thematic analysis.

Results: Three overarching themes were identified encompassing (i) harmful commercial practices and processes, (ii) improving corporate engagement and (iii) opportunities for self-determination through business. Participants expressed concern over aggressive marketing by the gambling industry, commercial exploitation of Aboriginal culture, the privatisation of public services, and lack of oversignt of corporate social responsibility strategies. Simultaneously, Aboriginal-led businesses were viewed as opportunities for cultural connection, and financial empowerment and self-determination.

Conclusion: Numerous commercial entities and activities are perceived to influence Aboriginal health and wellbeing. This study highlights the need for stronger policy and regulation to mitigate harmful industry practices while incentivising the potential positive impacts of the commercial activities on Aboriginal health and wellbeing.

Abstract
Background This report provides the theory, method and practice of culturally secure translation and knowledge exchange in the Healing Right Way Clinical Trial (2017-2022), outlining activities to date. Healing Right Way was a stepped wedge cluster randomised controlled trial conducted in Western Australia, aimed at enhancing rehabilitation services and quality of life for Aboriginal Australians following acquired brain injury. The trial translation plan was aspirational and action-oriented, with its implementation iterative and ongoing. Translational activities aimed to inform service and research planning for Aboriginal people with brain injury. Situated in the intercultural space, the work guards against undertaking activities that are monocultural, colonial and appropriating in favour of work that is authentically viewed through the dual lens of whiteness and Aboriginal and Torres Strait Islander ways of knowing, being and doing, and is strengths-based. Methods Three translational and knowledge exchange components were identified, relating to the role of Aboriginal Brain Injury Coordinators, cultural training of hospital staff and the research process itself. Knowledge plans were developed for key audiences, with potential translation products to be monitored for ongoing impact. Results Results demonstrate that translational and knowledge exchange were iteratively embedded throughout the trial life cycle. Data sources included community engagement, partnership meetings and interviews. Activities involved presentations to diverse audiences including bureaucrats, community and participants. Conclusions This report provides a snapshot of the first translation knowledge exchange plan and activities constructed in relation to brain injury rehabilitation services for Aboriginal people. Challenges encountered, as well as successes to date, are discussed.

Abstract
Background: For Indigenous Peoples the disparities in health status are largely associated with the direct social determinants of invasion and colonisation, marginalisation, intergenerational traumas, and lack of conscious government policy to address these ongoing effects. There is currently limited evidence in the literature on what Cultural Safety practices mean in acute care settings.

Objective: We aimed to understand the extent and type of evidence in relation to current knowledge and evidence regarding Cultural Safety practices for Indigenous Peoples in acute care settings.

Design: This is a scoping review.

Methods: We searched six databases in consultation with a librarian experienced in health research.

Results: A total of 16 papers were included in the scoping review. Four main barriers to Cultural Safety in practice were identified; Among the included studies, only one quality improvement study reported an intervention, which improved culturally safe care.

Conclusion: The four barriers identified each have a variable impact on Indigenous Peoples' health outcomes and are dependent upon the circumstances and experiences of both Indigenous Peoples and healthcare professionals.

Abstract
This protocol describes the methodology and methods for a collaborative project with eight Aboriginal and Torres Strait Islander primary health care (PHC) organisations, across three Australian states and one territory, to increase clinical service performance and access to preventive health and health promotion services for preventing, identifying, treating, and managing dementia risk in Aboriginal and Torres Strait Islander communities. Aboriginal participatory action research (APAR) methodology will be the framework for this project, incorporating continuous quality improvement (CQI), informed by research yarning with stakeholder groups, comprising community members and PHC staff and service providers and data collected from the auditing of client health records and the mapping of existing clinical processes and health services at each partnering PHC organisation. The qualitative and quantitative data will be summarised and discussed with stakeholder groups. Priorities will be identified and broken down into tangible PHC organisation deliverable strategies and programs, which will be co-developed with stakeholder groups and implemented cyclically over 24 months using the Plan, Do, Study, Act model of change. Key project outcome measures include increased clinical service performance and availability of preventive health and health promotion services for safeguarding against dementia. Project implementation will be evaluated for quality and transparency from an Indigenous perspective using an appropriate appraisal tool. The project processes, impact, and sustainability will be evaluated using the RE-AIM framework. A dementia safeguarding framework and accompanying tool kit will be developed from this work to support Aboriginal and Torres Strait Islander PHC organisations to identify, implement, and evaluate dementia safeguarding practice and service improvements on a broader scale.

Abstract
Introduction: Zoonoses are a health concern for Aboriginal and Torres Strait Islander peoples in Australia that face elevated risk of disease related to the environment and animals. Internationally, One Health is encouraged to effectively manage zoonoses by taking integrated approaches involving animal, human, and environmental health sectors to improve health outcomes. However, Australia's health systems manage zoonotic diseases in animals and people separately which does not support a One Health approach. For the effective management of zoonoses, a strong evidence base and database regarding the epidemiology of zoonotic pathogens is needed. However, we currently lack this evidence limiting our understanding of the impact of zoonoses on Aboriginal and Torres Strait Islander populations.

Methods: As a first step towards building the evidence base, we undertook a descriptive analysis of Aboriginal and Torres Strait Islander zoonotic notifications in Australia from 1996 to 2021. We presented notifications as annual notification rates per 100,000 population, and percentages of notifications by state, remoteness, sex, and age group.

Results: Salmonellosis and campylobacteriosis were the most notified zoonoses with the highest annual notification rates of 99.75 and 87.46 per 100,000 population, respectively. The north of Australia (Queensland, Northern Territory and Western Australia), remote and outer regional areas, and young children (0-4 years of age) had the highest percentages of notifications.

Discussion: To our knowledge, these findings are the first national presentation of the epidemiology of zoonoses within Aboriginal and Torres Strait Islander populations. A greater understanding of transmission, prevalence and impact of zoonoses on Aboriginal and Torres Strait Islander peoples (including animal and environmental health factors) is required to inform their effective management through a One Health approach.

Abstract
Given that Indigenous populations globally are impacted by similar colonial global legacies, their health and other disaprities are usually worse than non-indigenous people. Indigenous peoples of Australia have been seriously impacted by colonial legacies and as a result, their health has negatively been affected. If Indigenous health and wellbeing are to be promoted within the existing Australian health services, a clear understanding of what preventive health means for Indigenous peoples is needed. The aim of this scoping review was to explore the available literature on the uptake/engagement in health assessments or health checks by Indigenous Australian peoples and to determine the enablers and barriers and of health assessment/check uptake/engagement. Specifically, we aimed to: investigate the available evidence reporting the uptake/engagement of health checks/assessments for Australian Indigenous; assess the quality of the available evidence on indigenous health checks/assessments; and identify the enablers or barriers affecting Indigenous persons' engagement and access to health assessment/health checks. A systematic search of online databases (such as Cinhl, Scopus, ProQuest health and medicine, PubMed, informit, google scholar and google) identified 10 eligible publications on Indigenous preventive health assessments. Reflexive thematic analysis identified three major themes on preventive health assessments: (1) uptake/engagement; (2) benefits and limitations; and (3) enablers and barriers. Findings revealed that Indigenous peoples' uptake and/or engagement in health assessments/check is a holistic concept varied by cultural factors, gender identity, geographical locations (living in regional and remote areas), and Indigenous clinical leadership/staff's motivational capacity. Overall, the results indicate that there has been improving rates of uptake of health assessments by some sections of Indigenous communities. However, there is clearly room for improvement, both for aboriginal men and women and those living in regional and remote areas. In addition, barriers to uptake of health asessments were identified as length of time required for the assessment, intrusive or sensitive questions and shame, and lack of access to health services for some. Indigenous clinical leadership is needed to improve services and encourage Indigenous people to participate in routine health assessments.

Abstract
Introduction: Many Aboriginal and Torres Strait Islander people living on Kaurna Country in northern Adelaide experience adverse health and social circumstances. The Taingiwilta Pirku Kawantila study sought to understand challenges facing Aboriginal and Torres Strait Islander communities and identify solutions for the health and social service system to promote social and emotional wellbeing.

Methods: This qualitative study applied Indigenous methodologies undertaken with Aboriginal and Torres Strait Islander governance and leadership. A respected local Aboriginal person engaged with Aboriginal and Torres Strait Islander community members and service providers through semi-structured interviews and yarning circles that explored community needs and challenges, service gaps, access barriers, success stories, proposed strategies to address service and system challenges, and principles and values for service design. A content analysis identified the breadth of challenges in addition to describing key targets to empower and connect communities and optimize health and social services to strengthen individual and collective social and emotional wellbeing.

Results: Eighty-three participants contributed to interviews and yarning circles including 17 Aboriginal community members, 38 Aboriginal and Torres Strait Islander service providers, and 28 non-Indigenous service providers. They expressed the need for codesigned, strengths-based, accessible and flexible services delivered by Aboriginal and Torres Strait Islander workers with lived experience employed in organisations with Aboriginal and Torres Strait Islander leadership and governance. Community hubs and cultural events in addition to one-stop-shop service centres and pre-crisis mental health, drug and alcohol and homelessness services were among many strategies identified.

Conclusion: Holistic approaches to the promotion of social and emotional wellbeing are critical. Aboriginal and Torres Strait Islander people are calling for places in the community to connect and practice culture. They seek culturally safe systems that enable equitable access to and navigation of health and social services. Aboriginal and Torres Strait Islander workforce leading engagement with clients is seen to safeguard against judgement and discrimination, rebuild community trust in the service system and promote streamlined access to crucial services.

Abstract
Background: Indigenous Australians experience significant socioeconomic disadvantage and healthcare disparity compared to non-Indigenous Australians. A retrospective cohort study to describe the association between rates of self-discharge in Indigenous orthopaedic patients and the introduction of routine Aboriginal Liaison Officers (ALO) within the Orthopaedic multi-disciplinary team (MDT) was performed.

Methods: ALO were introduced within our routine Orthopaedic MDT on the 22nd of February 2021. Two patient cohorts were analysed, Group 1; patients admitted in the 9-months prior to inclusion of ALO, and Group 2; patients admitted within 9-months thereafter. The primary outcome of interest was the rate of self-discharge among Indigenous patients. Secondary outcomes of interest were the stage of treatment when patients self-discharged, recurrent self-discharge, risk factors for self-discharge and association between self-discharge and length of hospital stay.

Results: Introduction of ALO within routine Orthopaedic MDT was associated with a significant 37% reduced risk of self-discharge among Indigenous patients (p = 0·009), and significantly fewer self-discharges before their definitive surgical and medical treatment (p = 0·0024), or before completion of postoperative intravenous antibiotic treatment (p = 0·030). There was no significant change in the risk of recurrent self-discharge (p = 0·557). Risk factors for self-discharge were younger age; pensioners or unemployed; residents of Alice Springs Town-Camps or of communities within 51 to 100 km of Alice Springs; and those diagnosed with lacerations of the upper limb, but without tendon injury, wound and soft tissue infections or osteomyelitis. In Group 2, the odds of self-discharge decreased with increased length of hospital stay (p = 0·040).

Conclusions: Routine inclusion of ALO within the Orthopaedic MDT reduced the risk of self-discharge in Indigenous patients. Those who self-discharged did so only after critical aspects of their care were met.

Keywords: Indigenous health; Orthopaedics; Self-discharge; Surgery

Australia will soon vote on constitutional recognition of its Indigenous people, and to give them a direct voice to Parliament. Health will be high on the agenda. Chris McCall reports.

Abstract
Background: There is evidence of Indigenous and ethnic minority inequities in the incidence and outcomes of early psychosis. Racism has been implicated as having an important role.

Aim: To use Indigenous experiences to develop a more detailed understanding of how racism operates to impact early psychosis outcomes.

Methods: Critical Race Theory informed the methodology used. Twenty-three Indigenous participants participated in four family focus group interviews and thirteen individual interviews, comprising of 9 Māori youth with early psychosis, 10 family members and 4 Māori mental health professionals. An analysis of the data was undertaken using deductive structural coding to identify descriptions of racism, followed by inductive descriptive and pattern coding.

Results: Participant experiences revealed how racism operates as a socio-cultural phenomenon that interacts with institutional policy and culture across systems pertaining to social responsiveness, risk discourse, and mental health service structures. This is described across three major themes: 1) selective responses based on racial stereotypes, 2) race related risk assessment bias and 3) institutional racism in the mental health workforce. The impacts of racism were reported as inaction in the face of social need, increased use of coercive practices and an under resourced Indigenous mental health workforce.

Conclusion: The study illustrated the inter-related nature of interpersonal, institutional and structural racism with examples of interpersonal racism in the form of negative stereotypes interacting with organizational, socio-cultural and political priorities. These findings indicate that organizational cultures may differentially impact Indigenous and minority people and that social responsiveness, risk discourse and the distribution of workforce expenditure are important targets for anti-racism efforts.

Increased support for Indigenous scholars and Indigenous-led and controlled research is needed to address a critical gap in the Closing the Gap agenda, according to scholars from the ARC Centre of Excellence for Indigenous Futures at The University of Queensland.

“Indigenous scholars are largely underrepresented in the Coalition of Peaks and in agenda setting and measurement guidance for Closing the Gap. This surely has to change,” write Professor Bronwyn Fredericks, Professor Aileen Moreton-Robinson, Professor James Ward and Professor Brendan Hokowhitu.

Their article also highlights some of the issues likely to be on the agenda of the Indigenous Studies and Courageous Conversations Symposium, co-hosted by the University of Queensland and The Australian Academy of the Humanities on 28-29 September.

Abstract
Despite decades of evidence showing that institutional and interpersonal racism serve as significant barriers to accessible healthcare for Aboriginal and Torres Strait Islander Peoples, attempts to address this systemic problem still fall short. The social determinants of health are particularly poignant given the socio-political-economic history of invasion, colonisation, and subsequent entrenchment of racialised practices in the Australian healthcare landscape. Embedded within Euro-centric, bio-medical discourses, Western dominated healthcare processes can erase significant cultural and historical contexts and unwittingly reproduce unsafe practices. Put simply, if Black lives matter in healthcare, why do Aboriginal and Torres Strait Islander Peoples die younger and experience 'epidemic' levels of chronic diseases as compared to white Australians? To answer this, we utilise critical race perspectives to theorise this gap and to de-center whiteness as the normalised position of 'doing' healthcare. We draw on our diverse knowledges through a decolonised approach to promote a theoretical discussion that we contend can inform alternative ways of knowing, being, and doing in healthcare practice in Australia.

Abstract
Background: Embedded attitudes within the medical workforce mean supervisors have a key role in the practice and promotion of decolonised and antiracist approaches to their engagement with Aboriginal and Torres Strait Islander health medical education.

Objective: The aim of this paper is to provide an understanding of the practical application of decolonised and antiracist approaches for the general practitioner (GP) supervisor.

Discussion: Decolonised and antiracist approaches can elevate supervisor engagement with their GP trainees and assist understanding of the health of Aboriginal and Torres Strait Islander peoples.

Acute pain; Advanced pain procedure; Cancer; Chronic pain; Disparities; Diversity; Elderly; Ethnicity; Gender; Geography; Obstetric; Pediatric; Race; Rural; Socioeconomic; Veteran.

Introduction: Questioning is a key method in general information-seeking behaviour and teaching used by the dominant culture in Australia. Within an Australian health context the fundamental diagnostic tool used by medical staff is the biomedical interview or history taking, which is based on a battery of direct questions. Similarly, many health professionals rely on patient questions to prompt the sharing of information, or to make them aware of gaps in communication. This is problematic for many First Nations peoples, including Yolηu (First Nations people of North-East Arnhem Land), who are culturally less inclined to use direct questioning as it is deemed impolite within their cultural context.

Methods: Semi-structured conversational interviews using culturally congruent communication processes were conducted with participants in their preferred language. Interviews were translated, transcribed and analysed inductively using NVivo v12.

Results: A total of 30 participants were interviewed (10 health staff and 20 Yolηu with recent experience in engaging with health services). All participating health staff believed that questioning was essential for determining how to best treat patients but many felt that questions created problems for some Yolηu patients. They also felt that Yolηu patients ask fewer questions related to their health issues than patients of other cultures. Yolηu participants conveyed overwhelmingly negative experiences with the health system and at the tertiary hospital in particular. Yolηu participants described feelings of frustration, fear and trauma when talking of their experiences, and these feelings were often direct outcomes of poor communication with staff. Regarding the use of questions in health care specifically, Yolηu participants identified four key and interrelated conditions within which questioning was deemed an acceptable communication mechanism. Dhämanapan (connection) was identified as an essential condition for effective communication between health staff and patients. This connection was established and maintained through a shared understanding of matha (language), dukmaram (Yolηu understandings of healing) and djuηuny (Yolηu norms of polite communication). Strategies for overcoming barriers to effective communication related to the concept of dhuwurr (skill) in health communication, which could increase the acceptability of health staff asking questions of Yolηu and the confidence of Yolηu patients in asking questions of health staff.

Conclusion: The findings from this study indicate a fundamental disconnect between the current health system and the needs of the Yolηu patients it seeks to serve. In order for this to change, Yolηu patients and health staff need to develop dhuwurr in health communication, which incorporates the four key conditions for effective communication identified in this study. To achieve this, ongoing and mandatory intercultural communication training for health staff is needed, just as mandatory training is required for hygiene and resuscitation training. Intercultural communication training must be comprehensive - reflecting the complexity involved in developing this dhuwurr - and sustained, for example with ongoing support from cultural communication mentors.

Improving cancer outcomes for Indigenous people by providing culturally safe, patient-centred care is a critical challenge for health services worldwide. This article explores how three Australian cancer services perform when compared to two national best practice guidelines: the National Aboriginal and Torres Strait Islander Cancer Framework (Cancer Framework) and the National Safety and Quality Health Service (NSQHS) User Guide for Aboriginal and Torres Strait Islander Health (User Guide). The services were identified through a nationwide project undertaken to identify cancer services providing treatment to Indigenous cancer patients. A small number of services which were identified as particularly focused on providing culturally safe cancer care participated in case studies. Interviews were conducted with 35 hospital staff (Indigenous and non-Indigenous) and 8 Indigenous people affected by cancer from the three services. The interviews were analysed and scored using a traffic light system according to the seven priorities of the Cancer Framework and the six actions of the NSQHS User Guide. While two services performed well against the User Guide, all three struggled with the upstream elements of the Cancer Framework, suggesting that the treatment-focused Optimal Care Pathway for Aboriginal and Torres Strait Islander People with Cancer (Cancer Pathway) may be a more appropriate framework for tertiary services. This article highlights the importance of a whole-of-organisation approach when addressing and embedding the six actions of the User Guide. Health services which have successfully implemented the User Guide are in a stronger position to implement the Cancer Framework and Cancer Pathway.

Introduction: Persistent non-cancer pain affects one in five adults and is more common in Māori-the Indigenous population of New Zealand (NZ), adults over 65 years, and people living in areas of high deprivation. Despite the evidence supporting multidisciplinary pain management programmes (PMPs), access to PMPs is poor due to long waiting lists. Although online-delivered PMPs enhance access, none have been codesigned with patients or compared with group-based, in-person PMPs. This non-inferiority trial aims to evaluate the clinical and cost-effectiveness of a cocreated, culturally appropriate, online-delivered PMP (iSelf-help) compared with in-person PMP in reducing pain-related disability.

Methods and analysis: Mixed-methods, using a modified participatory action research (PAR) framework, involving three phases. Phase I involved cocreation and cultural appropriateness of iSelf-help by PAR team members. Phase II: The proposed iSelf-help trial is a pragmatic, multicentred, assessor-blinded, two-arm, parallel group, non-inferiority randomised controlled trial. Adults (n=180, age ≥18 years) with persistent non-cancer pain eligible for a PMP will be recruited and block randomised (with equal probabilities) to intervention (iSelf-help) and control groups (in-person PMP). The iSelf-help participants will participate in two 60-minute video-conferencing sessions weekly for 12 weeks with access to cocreated resources via smartphone application and a password-protected website. The control participants will receive group-based, in-person delivered PMP. Primary outcome is pain-related disability assessed via modified Roland Morris Disability Questionnaire at 6 months post intervention. Secondary outcomes include anxiety, depression, stress, pain severity, quality of life, acceptance, self-efficacy, catastrophising and fear avoidance. Data will be collected at baseline, after the 12-week intervention, and at 3 and 6 months post intervention. We will conduct economic analyses and mixed-method process evaluations (Phase IIA).

Ethics and dissemination: The Health and Disability Ethics Committee approved the study protocol (HDEC18/CEN/162). Phase III involves dissemination of findings guided by the PAR team as outcomes become apparent.

Trial registration number: ACTRN 12619000771156.

Abstract
Māori are the indigenous people of New Zealand, and suffer disparate health outcomes compared to non-Māori. Waikato District Health Board provides level III intensive care unit services to New Zealand's Midland region. In 2016, our institution formalised a corporate strategy to eliminate health inequities for Māori. Our study aimed to describe Māori health outcomes in our intensive care unit and identify inequities. We performed a retrospective audit of prospectively entered data in the Australian and New Zealand Intensive Care Society database for all general intensive care unit admissions over 15 years of age to Waikato Hospital from 2014 to 2018 (n = 3009). Primary outcomes were in-intensive care unit and in-hospital mortality. The secondary outcome was one-year mortality. In our study, Māori were over-represented relative to the general population. Compared to non-Māori, Māori patients were younger (51 versus 61 years, P < 0.001), and were more likely to reside outside of the Waikato region (37.2% versus 28.0%, P < 0.001) and in areas of higher deprivation (P < 0.001). Māori had higher admission rates for trauma and sepsis (P < 0.001 overall) and required more renal replacement therapy (P < 0.001). There was no difference in crude and adjusted mortality in-intensive care unit (16.8% versus 16.5%, P = 0.853; adjusted odds ratio 0.98 (95% confidence interval 0.68 to 1.40)) or in-hospital (23.7% versus 25.7%, P = 0.269; adjusted odds ratio 0.84 (95% confidence interval 0.60 to 1.18)). One-year mortality was similar (26.1% versus 27.1%, P=0.6823). Our study found significant ethnic inequity in the intensive care unit for Māori, who require more renal replacement therapy and are over-represented in admissions, especially for trauma and sepsis. These findings suggest upstream factors increasing Māori risk for critical illness. There was no difference in mortality outcomes.

Summary
Background
There is an urgency to redress unacceptable maternal and infant health outcomes for First Nations families in Australia. A multi-agency partnership between two Aboriginal Community-controlled health services and a tertiary hospital in urban Australia designed, implemented, and evaluated the new Birthing in Our Community (BiOC) service. In this study, we aimed to assess and report the clinical effectiveness of the BiOC service on key maternal and infant health outcomes compared with that of standard care.
Methods
Pregnant women attending the Mater Mothers Public Hospital (Brisbane, QLD, Australia) who were having a First Nations baby were invited to receive the BiOC service. In this prospective, non-randomised, interventional trial of the service, we specifically enrolled women who intended to birth at the study hospital, and had a referral from a family doctor or Aboriginal Medical Service. Participants were offered either standard care services or the BiOC service. Prespecified primary outcomes to test the effectiveness of the BiOC service versus standard care were the proportion of women attending five or more antenatal visits, smoking after 20 weeks of gestation, who had a preterm birth (<37 weeks), and who were exclusively breastfeeding at discharge from hospital. We used inverse probability of treatment weighting to balance confounders and calculate treatment effect. This trial is registered with the Australian New Zealand Clinical Trial Registry, ACTRN12618001365257.
Findings
Between Jan 1, 2013, and June 30, 2019, 1867 First Nations babies were born at the Mater Mothers Public Hospital. After exclusions, 1422 women received either standard care (656 participants) or the BiOC service (766 participants) and were included in the analyses. Women receiving the BiOC service were more likely to attend five or more antenatal visits (adjusted odds ratio 1·54, 95% CI 1·13–2·09; p=0·0064), less likely to have an infant born preterm (0·62, 0·42–0·93; p=0·019), and more likely to exclusively breastfeed on discharge from hospital (1·34, 1·06–1·70; p=0·014). No difference was found between the two groups for smoking after 20 weeks of gestation, with both showing a reduction compared with smoking levels reported at their hospital booking visit.
Interpretation
This study has shown the clinical effectiveness of the BiOC service, which was co-designed by stakeholders and underpinned by Birthing on Country principles. The widespread scale-up of this new service should be prioritised. Dedicated funding, knowledge translation, and implementation science are needed to ensure all First Nations families can access Birthing on Country services that are adapted for their specific contexts.
Funding
Australian National Health and Medical Research Council.

General practice must be the cornerstone for restructuring Indigenous health policy, and this must include reforming Medicare.

Hepatocellular carcinoma (HCC) is an urgent public health issue in Australia. Indigenous Australians are disproportionately affected by liver disease and HCC and suffer substantially greater HCC related mortality than non-Indigenous Australians. With the release of the Australian national consensus statement on hepatocellular carcinoma in December 2020 and international focus on equity and the rights of Indigenous peoples, it is timely to reflect upon the key actions that must be taken to reduce HCC incidence and mortality for Indigenous Australians.

Before COVID-19, Aboriginal people faced health disadvantages and inequitable access to health care. Any decrease in health care access for Aboriginal people through missed, delayed or avoided health care may lead to further adverse health outcomes and inequities

Since June, the monthly rate of incomplete treatment for Indigenous patients at St Vincent’s Hospital has reduced from 19.5% to 1.6%. One of the programs that have helped achieve this is the new Indigenous Flexi-Clinic that ensures Aboriginal and Torres Strait Islander patients presenting to the emergency room are quickly triaged and treated and provided culturally safe care.

Babies of Māori, Pacific and Indian mothers are still more likely than babies of New Zealand European mothers to die in pregnancy or within the first 28 days, the Perinatal and Maternal Mortality Review Committee (PMMRC) 14th report shows.

Key points:
'Captain Sanitiser' is the creation of two filmmakers in Wadeye.

They're using the character to spread messages about COVID safety.

Now, a local corporation is helping them tackle other issues head-on.

Abstract
Alcohol misuse is a disproportionately large contributor to morbidity and mortality in the Northern Territory. A number of alcohol harm minimisation policies have been implemented in recent years. The effect of these on intensive care unit (ICU) admissions has not been fully explored. A retrospective before-after cross-sectional study was conducted at the Alice Springs Hospital ICU between 1 October 2017 and 30 September 2019. The primary outcome was the proportion of admissions in which alcohol misuse was a contributing factor in the 12 months before (pre-reforms phase) versus the 12 months following (post-reforms phase) implementation of alcohol legislation reforms. Secondary outcomes were measures of critical care resource use (length of stay, need for and duration of mechanical ventilation). After exclusions, 1323 ICU admissions were analysed. There was a reduction in the proportion of admissions associated with alcohol misuse between the pre-reforms and post-reforms phases (18.8% versus 11.7%, P < 0.01). This was true for both acute (10.6% versus 3.6%, P < 0.01) and chronic misuse (13.3% versus 9.6%, P = 0.03). Rates of mechanical ventilation were unchanged during the post-reforms phase (18.3% versus 14.7%). Admissions with a primary diagnosis of trauma were lower (10.5% versus 4.7%, P < 0.01). This study demonstrated a reduction in ICU admissions associated with alcohol misuse following the implementation of new alcohol harm minimisation policies. This apparent reduction in alcohol-related harm is suggestive of the effectiveness of the Northern Territory's integrated alcohol harm reduction framework.

Researchers call for more spending and shift in health messaging after discovering figures were underestimated by more than 50%

Abstract
Objectives: In this manuscript, we describe broad trends in postoperative mortality in New Zealand (a country with universal healthcare) for acute and elective/waiting list procedures conducted between 2005 and 2017.

Design, participants and setting: We use high-quality national-level hospitalisation data to compare the risk of postoperative mortality between demographic subgroups after adjusting for key patient-level confounders and mediators. We also present temporal trends and consider how rates in postoperative death following acute and elective/waiting list procedures have changed over this time period.

Results and conclusion: A total of 1 836 683 unique patients accounted for 3 117 374 admissions in which a procedure was performed under general anaesthetic over the study period. We observed an overall 30-day mortality rate of 0.5 per 100 procedures and a 90-day mortality rate of 0.9 per 100. For acute procedures, we observed a 30-day mortality rate of 1.6 per 100, compared with 0.2 per 100 for elective/waiting list procedures. In terms of procedure specialty, respiratory and cardiovascular procedures had the highest rate of 30-day mortality (age-standardised rate, acute procedures: 3-6 per 100; elective/waiting list: 0.7-1 per 100). As in other contexts, we observed that the likelihood of postoperative death was not proportionally distributed within our population: older patients, Māori patients, those living in areas with higher deprivation and those with comorbidity were at increased risk of postoperative death, even after adjusting for all available factors that might explain differences between these groups. Increasing procedure risk (measured using the Johns Hopkins Surgical Risk Classification System) was also associated with an increased risk of postoperative death. Encouragingly, it appears that risk of postoperative mortality has declined over the past decade, possibly reflecting improvements in perioperative quality of care; however, this decline did not occur equally across procedure specialties.

Abstract
The New Zealand Ministry of Health reported that respiratory disease affects 700,000 people, annually costs New Zealand NZ$7.05 billion, and is the third-highest cause of death. The hospitalisation rate for asthma of Māori communities is 2.0 higher than that of other ethnic groups, and hospitalisation rates for deprived homes are 2.3 times higher than those of the least deprived homes. Based on physical data and evidence, which were drawn from a mixed methodology that includes field studies of the indoor microclimate, dust-mite allergens, mould growth, and occupants' Respiratory Health Survey of a number of sample houses of Māori communities in Minginui, Te Whaiti, Murupara, and Rotorua of New Zealand, the study identifies unhealthy indoor thermal conditions, thresholds or ranges of indoor micro-climate related to different levels of dust-mite allergen and mould growth, the most common type of indoor mould, and correlations between dust-mite and mould and correlations. The study not only identified that the poor health of occupants is closely related to their inadequate living conditions, but also identifies the threshold of indoor micro-climates to maintain indoor allergens at the acceptable level, which can be used as a guideline to maintain or improve indoor health conditions for future housing development or retrofitted old housing.

Abstract
Objective: The burden of chronic disease is not evenly shared within our society. In this manuscript, we use comprehensive national-level data to compare morbidity burden between ethnic groups in New Zealand.

Methods: We investigated the prevalence of morbidity among all New Zealanders aged 18+ (n = 3,296,837), stratified by ethnic group (Māori, Pacific, Asian, Middle Eastern/Latin American/African, European/Other), using national-level hospitalisation and pharmaceutical data and two measures of morbidity (the M3 and P3 indices).

Results and conclusions: We observed substantial disparities for Māori and Pacific peoples compared to other ethnic groups for the vast majority of commonly-diagnosed morbidities. These disparities appeared strongest for the most-common conditions - meaning that Māori and Pacific peoples disproportionately shoulder an increased burden of these key conditions. We also observed that prevalence of these conditions emerged at earlier ages, meaning that Māori and Pacific peoples also experience a disproportionate impact of individual conditions on the quality and quantity of life. Finally, we observed strong disparities in the prevalence of conditions that may exacerbate the impact of COVID-19, such as chronic pulmonary, liver or renal disease. The substantial inequities we have presented here have been created and perpetuated by the social determinants of health, including institutionalised racism: thus solutions will require addressing these systemic issues as well as addressing inequities in individual-level care.

The Australian Journal of Rural Health (AJRH) is a multidisciplinary journal, which aims to facilitate the formation of interdisciplinary networks to build and advance rural practice for all health professionals. It includes articles on anaesthesia, pain medicine, medical education and indigenous health practice in a rural/remote context.

First Nations* Health and Wellbeing - The Lowitja Journal is the official journal of the Lowitja Institute, Australia's first community-controlled research institute. It is a community-controlled, international, community member, inter- and multi-disciplinary peer-reviewed open access journal that is dedicated to expanding access to First Nations research. We focus on primary research papers, systematic reviews, and informed short reports and community contributions on all aspects of the science, culture, philosophy and practice regarding health and wellbeing for First Nations communities.

A peer-reviewed, open-access online journal that shares multi-disciplinary knowledge and research about Aboriginal and Torres Strait Islander health.

Māori Health Review is a regular update that features the latest research in the Māori Health area. It costs nothing to subscribe to Maori Health Review. It is available for health professionals and anyone with an interest in Maori Health.

Abstract
Background: Royal Darwin Hospital (RDH) is the only major hospital for the 'Top End' of Northern Territory and Western Australia. As retrieval distances exceed 2600 km, resident generalist surgeons undertake all emergency neurosurgery.

Methods: Retrospective clinical study from RDH records and review of prospectively collected datasets from RDH Intensive Care Unit and National Critical Care Trauma Response Centre for all emergency neurosurgery patients between 2008 and 2013.

Results: Data were obtained from 161 patients with 167 admissions (73% male, 39% indigenous) who underwent 195 procedures (33 per year), including burr hole, craniotomy, cerebral and posterior fossa craniectomy, elevation fracture and ventricular drain. Trauma accounted for 68%, with alcohol as a known factor in 57%. Subdural haematoma (SDH) accounted for 53%. Severity of head injury at presentation correlated with outcome (R(2) = 0.12, P < 0.001). Factors associated with death included injury at remote location (P = 0.022), time injury to operation >24 h (P = 0.023) and specific diagnoses of acute SDH (P = 0.006), acute-on-chronic SDH (P = 0.053) and infection (P = 0.052). Indigenous patients were younger (40 versus 55 years, P < 0.001) and more likely to have alcohol as a factor in trauma cases (71% versus 49%, P = 0.027). Time from injury to hospital was high for accidents at a remote location (12.9 versus 1.3 h, P < 0.001); however, Glasgow Outcome Scales (P = 0.13) were no different to accident at metropolitan Darwin.

Conclusion: General surgeons at RDH perform a wide range of emergency neurosurgical procedures primarily for trauma. Factors contributing to poor outcomes included remote location of trauma and delay in reaching the hospital. Outcomes at 3 months appear acceptable.

Māori Health Review is a regular update that features the latest research in the Māori Health area. It costs nothing to subscribe to Maori Health Review. It is available for health professionals and anyone with an interest in Maori Health.