Indigenous health: Journals & articles

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.

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.

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.

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.