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1.  Enhanced reporting of deaths among Aboriginal and Torres Strait Islander peoples using linked administrative health datasets 
Background
Aboriginal and Torres Strait Islander peoples are under-reported in administrative health datasets in NSW, Australia. Correct reporting of Aboriginal and Torres Strait Islander peoples is essential to measure the effectiveness of policies and programmes aimed at reducing the health disadvantage experienced by Aboriginal and Torres Strait Islander peoples. This study investigates the potential of record linkage to enhance reporting of deaths among Aboriginal and Torres Strait Islander peoples in NSW, Australia.
Methods
Australian Bureau of Statistics death registration data for 2007 were linked with four population health datasets relating to hospitalisations, emergency department attendances and births. Reporting of deaths was enhanced from linked records using two methods, and effects on patterns of demographic characteristics and mortality indicators were examined.
Results
Reporting of deaths increased by 34.5% using an algorithm based on a weight of evidence of a person being Aboriginal or Torres Strait Islander, and by 56.6% using an approach based on 'at least one report' of a person being Aboriginal or Torres Strait Islander. The increase was relatively greater in older persons and those living in less geographically remote areas. Enhancement resulted in a reduction in the urban-remote differential in median age at death and increases in standardised mortality ratios particularly for chronic conditions.
Conclusions
Record linkage creates a statistical construct that helps to correct under-reporting of deaths and potential bias in mortality statistics for Aboriginal and Torres Strait Islander peoples.
doi:10.1186/1471-2288-12-91
PMCID: PMC3413579  PMID: 22747900
2.  Voting with their feet - predictors of discharge against medical advice in Aboriginal and non-Aboriginal ischaemic heart disease inpatients in Western Australia: an analytic study using data linkage 
Background
Discharge Against Medical Advice (DAMA) from hospital is associated with adverse outcomes and is considered an indicator of the responsiveness of hospitals to the needs of Aboriginal and Torres Strait Islander Australians, the indigenous people of Australia. We investigated demographic and clinical factors that predict DAMA in patients experiencing their first-ever inpatient admission for ischaemic heart disease (IHD). The study focuses particularly on the differences in the risk of DAMA in Aboriginal and non-Aboriginal patients while also investigating other factors in their own right.
Methods
A cross-sectional analytical study was undertaken using linked hospital and mortality data with complete coverage of Western Australia. Participants included all first-ever IHD inpatients (aged 25–79 years) admitted between 2005 and 2009, selected after a 15-year clearance period and who were discharged alive. The main outcome measure was DAMA as reflected in the hospital record.
Multiple logistic regression was used to determine disparities in DAMA between Aboriginal and non-Aboriginal patients, adjusting for a range of demographic and clinical factors, including comorbidity based on 5-year hospitalization history. A series of additional models were run on subgroups of the cohort to refine the analysis. Ethics approval was granted by the WA Human Research and the WA Aboriginal Health Ethics Committees.
Results
Aboriginal patients comprised 4.3% of the cohort of 37,304 IHD patients and 23% of the 224 DAMAs. Emergency admission (OR=5.9, 95% CI 2.9-12.2), alcohol admission history (alcohol-related OR=2.9, 95% CI 2.0-4.2) and Aboriginality (OR 2.3, 95% CI 1.5-3.5) were the strongest predictors of DAMA in the multivariate model. Patients living in rural areas while attending non-metropolitan hospitals had a 50% higher risk of DAMA than those living and hospitalised in metropolitan areas. There was consistency in the ORs for Aboriginality in the different multivariate models using restricted sub-cohorts and different Aboriginal identifiers. Sex, IHD diagnosis type and co-morbidity scores imparted different risks in Aboriginal versus non-Aboriginal patients.
Conclusions
Understanding the risks and reasons for DAMA is important for health system policy and proactive management of those at risk of DAMA. Improving care to prevent DAMA should target unplanned admissions, rural hospitals and young men, Aboriginal people and those with alcohol and mental health comorbidities.
doi:10.1186/1472-6963-13-330
PMCID: PMC3765140  PMID: 23962275
Discharge against medical advice; Aboriginal health; Ischaemic Heart Disease; Linked data; Australia
3.  Uptake of influenza vaccination in pregnancy amongst Australian Aboriginal and Torres Strait Islander women: a mixed-methods pilot study 
BMC Research Notes  2015;8:169.
Background
Influenza infection during pregnancy causes significant morbidity and mortality. Immunisation against influenza is recommended during pregnancy in several countries however, there are limited data on vaccine uptake, and the determinants of vaccination, in pregnant Australian Aboriginal and/or Torres Islander women. This study aimed to collect pilot data on vaccine uptake and attitudes towards, and perceptions of, maternal influenza vaccination in this population in order to inform the development of larger studies.
Methods
A mixed-methods study comprised of a cross-sectional survey and yarning circles (focus groups) amongst Aboriginal and Torres Strait Islander women attending two primary health care services. The women were between 28 weeks gestation and less than 16 weeks post-birth. These data were supplemented by data collected in an ongoing national Australian study of maternal influenza vaccination. Aboriginal research officers collected community data and data from the yarning circles which were based on a narrative enquiry framework. Descriptive statistics were used to analyse quantitative data and thematic analyses were applied to qualitative data.
Results
Quantitative data were available for 53 women and seven of these women participated in the yarning circles. The proportion of women who reported receipt of an influenza vaccine during their pregnancy was 9/53. Less than half of the participants (21/53) reported they had been offered the vaccine in pregnancy. Forty-three percent reported they would get a vaccine if they became pregnant again. Qualitative data suggested perceived benefits to themselves and their infants were important factors in the decision to be vaccinated but there was insufficient information available to women to make that choice.
Conclusions
The rates of influenza immunisation may continue to remain low for Aboriginal and/or Torres Strait Islander women during pregnancy. Access to services and recommendations by a health care worker may be factors in the lower rates. Our findings support the need for larger studies directed at monitoring and understanding the determinants of maternal influenza vaccine uptake during pregnancy in Australian Aboriginal and Torres Strait Islander women. This research will best be achieved using methods that account for the social and cultural contexts of Aboriginal and Torres Strait Islander communities in Australia.
doi:10.1186/s13104-015-1147-3
PMCID: PMC4423150  PMID: 25928130
Influenza; Vaccine; Pregnancy; Aboriginal and Torres Strait Islander Australian; Determinants; Uptake
4.  Validation of risk assessment scales and predictors of intentions to quit smoking in Australian Aboriginal and Torres Strait Islander peoples: a cross-sectional survey protocol 
BMJ Open  2014;4(6):e004887.
Introduction
Tobacco smoking is a very significant behavioural risk factor for the health of Australian Aboriginal and Torres Strait Islanders, and is embedded as a social norm. With a focus on women of childbearing age, and men of similar age, this project aims to determine how Aboriginal and Torres Strait Islander smokers assess smoking risks and how these assessments contribute to their intentions to quit. The findings from this pragmatic study should contribute to developing culturally targeted interventions.
Methods and analysis
A cross-sectional study using quantitative and qualitative data. A total of 120 Aboriginal and Torres Strait Islander community members aged 18–45 years will be recruited at community events and through an Aboriginal Community Controlled Health Service (ACCHS). Participants will be interviewed using a tablet computer or paper survey. The survey instrument uses modified risk behaviour scales, that is, the Risk Behaviour Diagnosis (RBD) scale and the Smoking Risk Assessment Target (SRAT) (adapted from the Risk Acceptance Ladder) to determine whether attitudes of Aboriginal and Torres Strait Islander smokers to health risk messages are predictors of intentions to quit smoking.
The questionnaire will be assessed for face and content validity with a panel of Indigenous community members. The internal consistency of the RBD subscales and their patterns of correlation will be explored. Multivariate analyses will examine predictors of intentions to quit. This will include demographics such as age, gender, nicotine dependence, household smoking rules and perceived threat from smoking and efficacy for quitting. The two risk-assessment scales will be examined to see whether participant responses are correlated.
Ethics and dissemination
The Aboriginal Health & Medical Research Council Ethics Committee and university ethics committees approved the study. The results will be published in a peer-reviewed journal and a community report will be disseminated by the ACCHS, and at community forums.
Note about terminology
We use the term Aboriginal and Torres Strait Islander peoples, except where previous research has reported findings from only one group for example, Aboriginal people. Indigenous is used here to refer to Indigenous peoples in the international context, and issues, policies or systems, for example, Indigenous health, Indigenous tobacco control.
doi:10.1136/bmjopen-2014-004887
PMCID: PMC4054635  PMID: 24902729
PREVENTIVE MEDICINE; PUBLIC HEALTH
5.  Culturally appropriate methodology in obtaining a representative sample of South Australian Aboriginal adults for a cross-sectional population health study: challenges and resolutions 
BMC Research Notes  2015;8:200.
Background
The considerably lower average life expectancy of Aboriginal and Torres Strait Islander Australians, compared with non-Aboriginal and non-Torres Strait Islander Australians, has been widely reported. Prevalence data for chronic disease and health risk factors are needed to provide evidence based estimates for Australian Aboriginal and Torres Strait Islanders population health planning. Representative surveys for these populations are difficult due to complex methodology. The focus of this paper is to describe in detail the methodological challenges and resolutions of a representative South Australian Aboriginal population-based health survey.
Methods
Using a stratified multi-stage sampling methodology based on the Australian Bureau of Statistics 2006 Census with culturally appropriate and epidemiological rigorous methods, 11,428 randomly selected dwellings were approached from a total of 209 census collection districts. All persons eligible for the survey identified as Aboriginal and/or Torres Strait Islander and were selected from dwellings identified as having one or more Aboriginal person(s) living there at the time of the survey.
Results
Overall, the 399 interviews from an eligible sample of 691 SA Aboriginal adults yielded a response rate of 57.7%. These face-to-face interviews were conducted by ten interviewers retained from a total of 27 trained Aboriginal interviewers. Challenges were found in three main areas: identification and recruitment of participants; interviewer recruitment and retainment; and using appropriate engagement with communities. These challenges were resolved, or at least mainly overcome, by following local protocols with communities and their representatives, and reaching agreement on the process of research for Aboriginal people.
Conclusions
Obtaining a representative sample of Aboriginal participants in a culturally appropriate way was methodologically challenging and required high levels of commitment and resources. Adhering to these principles has resulted in a rich and unique data set that provides an overview of the self-reported health status for Aboriginal people living in South Australia. This process provides some important principles to be followed when engaging with Aboriginal people and their communities for the purpose of health research.
doi:10.1186/s13104-015-1080-5
PMCID: PMC4445986  PMID: 25986553
Aboriginal health; Methodology; Recruitment; Population survey; Cultural appropriateness
6.  Invasive pneumococcal disease in New South Wales, Australia: reporting Aboriginal and Torres Strait Islander status improves epidemiology 
The aim of this work was to determine the feasibility of improving Aboriginal and Torres Strait Islander status recording for notifiable diseases using all Invasive Pneumococcal Disease (IPD) notifications in a regional area of New South Wales, Australia.
In Australia people with IPD are nearly always admitted to hospital and their Aboriginal and Torres Strait Islander status is recorded. Aboriginal and Torres Strait Islander status was determined for IPD notifications by referring to the routine hospital admission data in a regional area of New South Wales, Australia.
There were 234 notifications in the regional area of Hunter New England during the period 2007–2009. Initially, 168 (72%) notifications had Aboriginal and Torres Strait Islander status recorded. After referring to the routine hospital admission data, the recorded status increased to 232 (99%). Updating the surveillance data required less than five minutes per notification.
Referring to routine hospital admission data proved a useful and time-efficient surveillance strategy to increase the proportion of notifications with Aboriginal and Torres Strait Islander status. These data can then be used to better understand the current epidemiology of IPD. Aboriginal and Torres Strait Islander children aged 0–4 years have a two- to threefold higher rate of invasive pneumococcal disease than non-Aboriginal children, thus high levels of timely pneumococcal immunization coverage remain important for young Aboriginal and Torres Strait Islander children.
doi:10.5365/WPSAR.2011.2.1.007
PMCID: PMC3729061  PMID: 23908887
7.  Social determinants and lifestyle risk factors only partially explain the higher prevalence of food insecurity among Aboriginal and Torres Strait Islanders in the Australian state of Victoria: a cross-sectional study 
BMC Public Health  2014;14:598.
Background
The prevalence of food insecurity is substantially higher among Australians of Aboriginal or Torres Strait Islander descent. The purpose of this study is to explain the relationship between food insecurity and Aboriginal and Torres Islander status in the state of Victoria.
Methods
Data were obtained from the 2008 Victorian Population Health Survey; a cross-sectional landline computer-assisted telephone interview survey of 34,168 randomly selected Victorians aged 18 years and older; including 339 Aboriginal and Torres Strait Islanders. We categorised a respondent as food insecure, if in the previous 12 months, they reported having run out of food and not being able to afford to buy more. We used multivariable logistic regression to adjust for age, sex, socioeconomic status (household income), lifestyle risk factors (smoking, alcohol consumption and obesity), social support (ability to get help from family, friends or neighbours), household composition (lone parent status, household with a child, and household size), and geographic location (rurality).
Results
Aboriginal and Torres Strait Islanders (20.3%) were more likely than their non-Aboriginal and Torres Strait Islander counterparts (5.4%) to have experienced food insecurity; odds ratio (OR) = 4.5 (95% CI; 2.7-7.4). Controlling for age, SES, smoking, obesity and inability to get help from family or friends reduced the odds ratio by 38%; ORadjusted = 2.8 (1.6-5.0).
Conclusions
Social determinants and lifestyle risk factors only partially explained the higher prevalence of food insecurity among Aboriginal and Torres Strait Islanders in Victoria. Further research is needed to explain the disparity in food insecurity between the two populations in order to inform and guide corrective action.
doi:10.1186/1471-2458-14-598
PMCID: PMC4076758  PMID: 24924598
8.  “Makes you proud to be black eh?”: Reflections on meaningful Indigenous research participation 
Introduction
This article outlines the meaningful participation of eight Aboriginal and Torres Strait Islander community members employed as community researchers investigating the impact of pandemic influenza in rural and remote Indigenous communities in Australia. Aboriginal and Torres Strait Islander participation is now a requirement of health research involving Aboriginal and Torres Strait Islander communities. There is a growing literature on the different approaches to such involvement. Fundamental to this literature is an acknowledgement that Indigenous communities are no longer prepared to be research objects for external, mostly non-Indigenous researchers, and demand a role in decisions about what is researched and how it will be researched. In this paper, we describe the protracted process for site identification and recruitment and training of community researchers. We focus on the backgrounds of the Indigenous researchers and their motivations for involvement, and the strengths and challenges posed by Indigenous people researching in their own communities. Throughout the paper our concern is to document how genuine participation and the building of research capacity can occur.
Discussion
A key feature of the research was the employment, training and strengthening the capacity of local Aboriginal and Torres Strait Islander community members in the role of community researchers. A series of training workshops were conducted in northern Australia and focussed on qualitative research methods, including data collection, data analysis and writing. The Indigenous researchers collected the community-based data, and worked in partnership with experienced academic researchers in the analysis and compilation of community reports. Parts of those community reports, as well as additional information supplied by the community researchers, forms the basis of this article. As the demand increases for involvement of Indigenous community members as researchers, focus needs to be paid to what constitutes meaningful participation. If active participation in all aspects of the research process is intended, this necessitates close attention to the knowledge and skills required for this to occur at every stage. Building research capacity means not simply equipping local people to undertake research on a particular project, but to have the knowledge and skills to undertake research in other areas.
Conclusions
There are considerable benefits for Indigenous people researching in their own communities. Most important for the community researchers on this project was the sense that they were doing important health work, not just conducting research. Given the persistent gaps between Indigenous and non-Indigenous health, this is perhaps one of the most important contributions of this type of research. Whilst research outcomes are undoubtedly important, in many cases the process used is of greater importance.
doi:10.1186/1475-9276-11-40
PMCID: PMC3439313  PMID: 22873769
Indigenous; Participatory action research; Aboriginal; Torres Strait Islander; Participation
9.  ‘Choice, culture and confidence’: key findings from the 2012 having a baby in Queensland Aboriginal and Torres Strait Islander survey 
Background
To describe the maternity care experiences of Aboriginal and/or Torres Strait Islander women in Queensland, Australia and to identify areas for policy and practice improvements.
Methods
A culturally-tailored survey requesting both quantitative and qualitative information was completed by respondents either independently (online or in hard copy) or with the assistance of a trained peer-interviewer. Data were analysed using descriptive statistics and thematic analysis.
Eligible women were over 16 years of age, identified as Aboriginal and/or Torres Strait Islander, resided in Queensland, and had a live, singleton birth between the first of July 2011 and the first of July 2012.
Results
187 women of 207 respondents were included in analyses. Women reported high rates of stressful life events in pregnancy, low levels of choice in place of birth and model of care and limited options to carry out cultural practices. High levels of confidence in parenting were also reported. Women were less likely to report being treated with kindness, understanding and respect by maternity care staff than women answering a similar mainstream survey.
Conclusions
Aboriginal and Torres Strait Islander women have additional needs to mainstream Australian women. This study identified a number of recommendations to improve services including the need to enhance the cultural competence of maternity services; increase access to continuity of midwifery care models, facilitate more choices in care, work with the strengths of Aboriginal and Torres Strait Islander women, families and communities, and engage women in the design and delivery of care.
doi:10.1186/1472-6963-14-196
PMCID: PMC4012088  PMID: 24884930
Birthing on country; Indigenous; Aboriginal; Torres Strait Islander; Maternity care
10.  The protocol for the Be Our Ally Beat Smoking (BOABS) study, a randomised controlled trial of an intensive smoking cessation intervention in a remote Aboriginal Australian health care setting 
BMC Public Health  2012;12:232.
Background
Australian Aboriginal peoples and Torres Strait Islanders (Indigenous Australians) smoke at much higher rates than non-Indigenous people and smoking is an important contributor to increased disease, hospital admissions and deaths in Indigenous Australian populations. Smoking cessation programs in Australia have not had the same impact on Indigenous smokers as on non-Indigenous smokers. This paper describes the protocol for a study that aims to test the efficacy of a locally-tailored, intensive, multidimensional smoking cessation program.
Methods/Design
This study is a parallel, randomised, controlled trial. Participants are Aboriginal and Torres Strait Islander smokers aged 16 years and over, who are randomly allocated to a 'control' or 'intervention' group in a 2:1 ratio. Those assigned to the 'intervention' group receive smoking cessation counselling at face-to-face visits, weekly for the first four weeks, monthly to six months and two monthly to 12 months. They are also encouraged to attend a monthly smoking cessation support group. The 'control' group receive 'usual care' (i.e. they do not receive the smoking cessation program). Aboriginal researchers deliver the intervention, the goal of which is to help Aboriginal peoples and Torres Strait Islanders quit smoking. Data collection occurs at baseline (when they enrol) and at six and 12 months after enrolling. The primary outcome is self-reported smoking cessation with urinary cotinine confirmation at 12 months.
Discussion
Stopping smoking has been described as the single most important individual change Aboriginal and Torres Strait Islander smokers could make to improve their health. Smoking cessation programs are a major priority in Aboriginal and Torres Strait Islander health and evidence for effective approaches is essential for policy development and resourcing. A range of strategies have been used to encourage Aboriginal peoples and Torres Strait Islanders to quit smoking however there have been few good quality studies that show what approaches work best. More evidence of strategies that could work more widely in Indigenous primary health care settings is needed if effective policy is to be developed and implemented. Our project will make an important contribution in this area.
Trial Registration
Australian New Zealand Clinical Trials Registry (ACTRN12608000604303)
doi:10.1186/1471-2458-12-232
PMCID: PMC3349500  PMID: 22439653
Indigenous; Aboriginal; Torres Strait Islander; Randomised controlled trial; Smoking cessation; Study protocol; Be Our Ally Beat Smoking (BOABS) Study
11.  Recent developments in national Aboriginal and Torres Strait Islander health strategy 
In this paper I will describe some of the sentinel events in Aboriginal and Torres Strait Islander health policy and strategy during 2003 and the early part of 2004. This will involve discussion on the:
• National Strategic Framework in Aboriginal and Torres Strait Islander Health
• National Strategic Framework for Aboriginal and Torres Strait Islander Peoples Mental Health and Social and Emotional Well Being 2004–2009
• National Aboriginal and Torres Strait Islander Health Performance Framework
• The roll-out of the Primary Health Care Access Program
• The National Aboriginal and Torres Strait Islander Social Survey and the National Indigenous Health Survey
These developments are consistent with a policy agenda that has evolved, in general terms, since the release of the National Aboriginal Health Strategy in 1989. However, I will also consider significant developments in the broader context for Aboriginal and Torres Strait Islander affairs, particularly the decision made in early 2004 by the Howard government to abolish the Aboriginal and Torres Strait Islander Commission (ATSIC). While the key events and developments that are reported in this paper elaborate on an agenda that has been developing for more than a decade, the decision to abolish ATSIC is likely to have a revolutionary impact on the future development of Aboriginal health strategy.
doi:10.1186/1743-8462-1-3
PMCID: PMC544962  PMID: 15679932
12.  Pre-pregnancy predictors of hypertension in pregnancy among Aboriginal and Torres Strait Islander women in north Queensland, Australia; a prospective cohort study 
BMC Public Health  2013;13:138.
Background
Compared to other Australian women, Indigenous women are frequently at greater risk for hypertensive disorders of pregnancy. We examined pre-pregnancy factors that may predict hypertension in pregnancy in a cohort of Aboriginal and Torres Strait Islander women in north Queensland.
Methods
Data on a cohort of 1009 Indigenous women of childbearing age (15–44 years) who participated in a 1998–2000 health screening program in north Queensland were combined with 1998–2008 Queensland hospitalisations data using probabilistic data linkage. Data on the women in the cohort who were hospitalised for birth (n = 220) were further combined with Queensland perinatal data which identified those diagnosed with hypertension in pregnancy.
Results
Of 220 women who gave birth, 22 had hypertension in the pregnancy after their health check. The mean age of women with and without hypertension was similar (23.7 years and 23.9 years respectively) however Aboriginal women were more affected compared to Torres Strait Islanders. Pre-pregnancy adiposity and elevated blood pressure at the health screening program were predictors of a pregnancy affected by hypertension. After adjusting for age and ethnicity, each 1 cm increase in waist circumference showed a 4% increased risk for hypertension in pregnancy (PR 1.04; 95% CI; 1.02-1.06); each 1 point increase in BMI showed a 9% adjusted increase in risk (1.09; 1.04-1.14). For each 1 mmHg increase in baseline systolic blood pressure there was an age and ethnicity adjusted 6% increase in risk and each 1 mmHg increase in diastolic blood pressure showed a 7% increase in risk (1.06; 1.03-1.09 and 1.07; 1.03-1.11 respectively). Among those free of diabetes at baseline, the presence of the metabolic syndrome (International Diabetes Federation criteria) predicted over a three-fold increase in age-ethnicity-adjusted risk (3.5; 1.50-8.17).
Conclusions
Pre-pregnancy adiposity and features of the metabolic syndrome among these young Aboriginal and Torres Strait Islander women track strongly to increased risk of hypertension in pregnancy with associated risks to the health of babies.
doi:10.1186/1471-2458-13-138
PMCID: PMC3599805  PMID: 23410045
Indigenous; Pre-pregnancy; Hypertension; Preeclampsia
13.  How an urban Aboriginal and Torres Strait Islander primary health care service improved access to mental health care 
Introduction
Aboriginal and Torres Strait Islander people experience higher levels of psychological distress and mental ill health than their non-Indigenous counterparts, but underuse mental health services. Interventions are required to address the structural and functional access barriers that cause this underuse. In 2012, the Southern Queensland Centre of Excellence in Aboriginal and Torres Strait Islander Primary Health Care employed a psychologist and a social worker to integrate mental health care into its primary health care services. This research study examines the impact of this innovation.
Methods
A mixed-method research design was used whereby a series of qualitative open-ended interviews were conducted with 7 psychology clients, 5 social work clients, the practice dietician, and the social worker and psychologist. General practitioners, practice nurses, Aboriginal Health Workers and receptionists participated in 4 focus groups. Key themes were identified, discussed, refined and agreed upon by the research team. Occasions of service by the psychologist and social worker were reviewed and quantitative data presented.
Results
Clients and staff were overwhelmingly positive about the inclusion of a psychologist and a social worker as core members of a primary health care team. In one-year, the psychologist and social worker recorded 537 and 447 occasions of service respectively, and referrals to a psychologist, psychiatrist, mental health worker or counsellor increased from 17 % of mental health clients in 2010 to 51 % in 2012. Increased access by Aboriginal and Torres Strait Islander people to mental health care was related to three main themes: (1) Responsiveness to community needs; (2) Trusted relationships; and (3) Shared cultural background and understanding. The holistic nature and cultural safety of the primary health care service, its close proximity to where most people lived and the existing trusted relationships were identified as key factors in decreasing barriers to access.
Conclusions
Improving social and emotional well-being is critical to addressing the health inequalities experienced by Aboriginal and Torres Strait Islander peoples. This study demonstrates the benefits for clients and health professionals of integrating culturally safe mental health services into primary health care.
doi:10.1186/s12939-015-0183-x
PMCID: PMC4469323  PMID: 26048616
Access; Cultural safety; Indigenous; Aboriginal and Torres Strait Islander; Mental health services; Primary health care; Integrated care; Qualitative research; Psychology; Social work
14.  Measuring emotional and social wellbeing in Aboriginal and Torres Strait Islander populations: an analysis of a Negative Life Events Scale 
Aboriginal and Torres Strait Islander Australians experience widespread socioeconomic disadvantage and health inequality. In an attempt to make Indigenous health research more culturally-appropriate, Aboriginal and Torres Strait Islander Australians have called for more attention to the concept of emotional and social wellbeing (ESWB). Although it has been widely recognised that ESWB is of crucial importance to the health of Aboriginal and Torres Strait Islander peoples, there is little consensus on how to measure in Indigenous populations, hampering efforts to better understand and improve the psychosocial determinants of health. This paper explores the policy and political context to this situation, and suggests ways to move forward. The second part of the paper explores how scales can be evaluated in a health research setting, including assessments of endorsement, discrimination, internal and external reliability.
We then evaluate the use of a measure of stressful life events, the Negative Life Events Scale (NLES), in two samples of Aboriginal people living in remote communities in the Northern Territory of Australia. We argue that the Negative Life Events Scale is a promising assessment of psychosocial wellbeing in Aboriginal and Torres Strait Islander populations. Evaluation of the scale and its performance in other samples of Aboriginal and Torres Strait Islander populations is imperative if we hope to develop better, rather than more, scales for measuring ESWB among Indigenous Australians. Only then will it be possible to establish standardized methods of measuring ESWB and develop a body of comparable literature that can guide both a better understanding of ESWB, and evaluation of interventions designed to improve the psychosocial health of Indigenous populations and decrease health inequalities.
doi:10.1186/1475-9276-6-18
PMCID: PMC2203968  PMID: 18001479
15.  Comparison of the uptake of health assessment items for Aboriginal and Torres Strait Islander people and other Australians: Implications for policy 
Background
Health Assessment (HA) items were introduced in 1999 for Aboriginal and Torres Strait Islander people aged at least 55 years and all Australians aged over 75 years. In 2004 a new item was introduced for HAs among adult Aboriginal and Torres Strait Islander people aged 15–54 years. The new item has been applauded as a major policy innovation however this enthusiasm has been tempered with concern about potential barriers to its uptake. In this study we aim to determine whether there are disparities in uptake of HA items for Aboriginal and Torres Strait Islander people compared to other Australians.
Method
The analysis was based on Health Insurance Commission data. Indigenous status was ascertained based on the item number used. Logistic regression was used to compare uptake of HA items for older people among Aboriginal and Torres Strait Islander people compared to other Australians. Adjustments were made for dual eligibility. Uptake of the HA items for older people was compared to the uptake of the new item for Aboriginal and Torres Strait Islander people aged 15–44 years.
Results
Our analyses suggest a significant and persistent disparity in the uptake of items for older patients among Aboriginal and Torres Strait Islander people compared to other Australians. A similar disparity appears to exist in the uptake of the new adult Aboriginal and Torres Strait Islander HA item.
Conclusion
Further engagement of primary care providers and the community around the uptake of the new HA items may be required to ensure that the anticipated health benefits eventuate.
doi:10.1186/1743-8462-2-21
PMCID: PMC1239906  PMID: 16150154
16.  Implementing computerised Aboriginal and Torres Strait Islander health checks in primary care for clinical care and research: a process evaluation 
Background
Paper-based Aboriginal and Torres Strait Islander health checks have promoted a preventive approach to primary care and provided data to support research at the Inala Indigenous Health Service, south-west Brisbane, Australia. Concerns about the limitations of paper-based health checks prompted us to change to a computerised system to realise potential benefits for clinical services and research capability. We describe the rationale, implementation and anticipated benefits of computerised Aboriginal and Torres Strait Islander health checks in one primary health care setting.
Methods
In May 2010, the Inala Indigenous Health Service commenced a project to computerise Aboriginal and Torres Strait Islander child, adult, diabetic, and antenatal health checks. The computerised health checks were launched in September 2010 and then evaluated for staff satisfaction, research consent rate and uptake. Ethical approval for health check data to be used for research purposes was granted in December 2010.
Results
Three months after the September 2010 launch date, all but two health checks (378 out of 380, 99.5%) had been completed using the computerised system. Staff gave the system a median mark of 8 out of 10 (range 5-9), where 10 represented the highest level of overall satisfaction. By September 2011, 1099 child and adult health checks, 138 annual diabetic checks and 52 of the newly introduced antenatal checks had been completed. These numbers of computerised health checks are greater than for the previous year (2010) of paper-based health checks with a risk difference of 0.07 (95% confidence interval 0.05, 0.10). Additionally, two research projects based on computerised health check data were underway.
Conclusions
The Inala Indigenous Health Service has demonstrated that moving from paper-based Aboriginal and Torres Strait Islander health checks to a system using computerised health checks is feasible and can facilitate research. We expect computerised health checks will improve clinical care and continue to enable research projects using validated data, reflecting the local Aboriginal and Torres Strait Islander community’s priorities.
doi:10.1186/1472-6947-13-108
PMCID: PMC3849740  PMID: 24053425
Computerised medical record systems; Aboriginal and Torres Strait Islander health; Primary health care
17.  Mortality in an Aboriginal Medical Service (Redfern) cohort 
Background
Published estimates of Aboriginal mortality and life expectancy (LE) for the eastern Australian states are derived from demographic modelling techniques to estimate the population and extent of under-recording of Aboriginality in death registration. No reliable empirical information on Aboriginal mortality and LE exists for New South Wales (NSW), the most populous Australian state in which 29% of Aboriginal people reside.
This paper estimates mortality and LE in a large, mainly metropolitan cohort of Aboriginal clients from the Aboriginal Medical Service (AMS) Redfern, Sydney, NSW.
Methods
Identifying information from patient records accrued by the AMS Redfern since 1980 of definitely Aboriginal clients, without distinction between Aboriginal and Torres Strait Islander (n=24,035), was extracted and linked to the National Death Index (NDI) at the Australian Institute of Health and Welfare (AIHW). Age-specific mortality rates and LEs for each sex were estimated using the AMS patient population as the denominator, discounted for deaths. Directly age-standardised mortality and LEs were estimated for 1995–1999, 2000–2004 and 2005–2009, along with 95% confidence intervals. Comparisons were made with other estimates of Aboriginal mortality and LE and with the total Australian population.
Results
Mortality declined in the AMS Redfern cohort over 1995–2009, and the decline occurred mostly in the ≤44 year age range. Male LE at birth was estimated to be 64.4 years (95%CI:62.6-66.1) in 1995–1999, 65.6 years (95%CI:64.1-67.1) in 2000–2004, and 67.6 years (95%CI:65.9-69.2) for 2005–2009. In females, these LE estimates were 69.6 (95%CI:68.0-71.2), 71.1 (95%CI:69.9-72.4), and 71.4 (95%CI:70.0-72.8) years. LE in the AMS cohort was 11 years lower for males and 12 years lower for females than corresponding all-Australia LEs for the same periods. These were similar to estimates for Australian Aboriginal people overall for the same period by the Aboriginal Burden of Disease for 2009, using the General Growth Balance (GGB) model approach, and by the Australian Bureau of Statistics (ABS) for 2005–2007. LE in the AMS cohort was somewhat lower than these estimates for NSW Aboriginal people, and higher than ABS 2005–2007 estimates for Aboriginal people from Northern Territory, South Australia, and Western Australia.
Conclusions
The AMS Redfern cohort has provided the first empirically based estimates of mortality and LE trends in a large sample of Aboriginal people from NSW.
doi:10.1186/1478-7954-11-2
PMCID: PMC3602118  PMID: 23391275
18.  Inclusion of mobile phone numbers into an ongoing population health survey in New South Wales, Australia: design, methods, call outcomes, costs and sample representativeness 
Background
In Australia telephone surveys have been the method of choice for ongoing jurisdictional population health surveys. Although it was estimated in 2011 that nearly 20% of the Australian population were mobile-only phone users, the inclusion of mobile phone numbers into these existing landline population health surveys has not occurred. This paper describes the methods used for the inclusion of mobile phone numbers into an existing ongoing landline random digit dialling (RDD) health survey in an Australian state, the New South Wales Population Health Survey (NSWPHS). This paper also compares the call outcomes, costs and the representativeness of the resultant sample to that of the previous landline sample.
Methods
After examining several mobile phone pilot studies conducted in Australia and possible sample designs (screening dual-frame and overlapping dual-frame), mobile phone numbers were included into the NSWPHS using an overlapping dual-frame design. Data collection was consistent, where possible, with the previous years’ landline RDD phone surveys and between frames. Survey operational data for the frames were compared and combined. Demographic information from the interview data for mobile-only phone users, both, and total were compared to the landline frame using χ2 tests. Demographic information for each frame, landline and the mobile-only (equivalent to a screening dual frame design), and the frames combined (with appropriate overlap adjustment) were compared to the NSW demographic profile from the 2011 census using χ2 tests.
Results
In the first quarter of 2012, 3395 interviews were completed with 2171 respondents (63.9%) from the landline frame (17.6% landline only) and 1224 (36.1%) from the mobile frame (25.8% mobile only). Overall combined response, contact and cooperation rates were 33.1%, 65.1% and 72.2% respectively. As expected from previous research, the demographic profile of the mobile-only phone respondents differed most (more that were young, males, Aboriginal and Torres Strait Islanders, overseas born and single) compared to the landline frame responders. The profile of respondents from the two frames combined, with overlap adjustment, was most similar to the latest New South Wales (NSW) population profile.
Conclusions
The inclusion of the mobile phone numbers, through an overlapping dual-frame design, did not impact negatively on response rates or data collection, and although costing more the design was still cost-effective because of the additional interviews that were conducted with young people, Aboriginal and Torres Strait Islanders and people who were born overseas resulting in a more representative overall sample.
doi:10.1186/1471-2288-12-177
PMCID: PMC3536693  PMID: 23173849
Sample survey; Mobile phone; Sampling frame
19.  Policy context and narrative leading to the commissioning of the Australian Indigenous Burden of Disease study 
Background
Burden of disease (BoD) studies have been conducted in numerous international settings since the early 1990’s. Two national BoD studies have been undertaken in Australia, in 1998 and 2003, although neither study estimated the BoD specifically for Indigenous Australians. In 2005 the Australian Government Department of Health and Ageing Office for Aboriginal and Torres Strait Islander Health formally commissioned the University of Queensland to undertake, in parallel with the second national BoD study, the “Burden of Disease and Injury in Aboriginal and Torres Strait Islander Peoples” study, drawing on available data up to 2003. This paper aims to explore the policy context and narrative in the lead up to commissioning the Indigenous BoD (IBoD) study, focusing on relevant contextual factors and insights regarding the perspectives of key stakeholders and their anticipated value of the study. It is part of a broader project that examines the uptake of evidence to policy, using the IBoD study as a case study.
Methods
A systematic review of the literature was undertaken in late 2013 and early 2014, and the findings triangulated with 38 key informant interviews with Indigenous and non-Indigenous academics, researchers, statisticians, policy advisors, and policymakers, conducted between 2011 and 2013.
Findings
Contextual features which led to commissioning the IBoD study included widespread recognition of longstanding Indigenous disadvantage, lower life expectancy than non-Indigenous Australians, and the lack of an adequate evidence base upon which to determine priorities for interventions. Several anticipated benefits and expectations of key stakeholders were identified. Most informants held at least one of the following expectations of the study: that it would inform the evidence base, contribute to priority setting, and/or inform policy. There were differing or entirely contrasting views to this however, with some sharing concerns about the study being undertaken at all.
Conclusions
The IBoD study, in concept, offered the potential to generate much desired ‘answers’, in the form of a quantified ranking of health risks and disease burden, and it was hoped by many that the results of the study would feed into determining priorities and informing Indigenous health policy.
doi:10.1186/s12961-015-0004-0
PMCID: PMC4409780  PMID: 25890380
Australia; Burden of Disease; Health policy; Indigenous disadvantage; Research translation
20.  Aboriginal and Torres Strait Islander maternal and child health and wellbeing: a systematic search of programs and services in Australian primary health care settings 
Background
Persistent disparities in pregnancy and birth outcomes between Aboriginal and Torres Strait Islander and other Australians evidence a need to prioritise responsive practice in Maternal Child Health (MCH). This study reviewed the existing knowledge output on Aboriginal and Torres Strait Islander MCH programs and services with the objective to advance understanding of the current evidence base and inform MCH service development, including the identification of new research priorities.
Methods
A systematic search of the electronic databases Informit, Proquest, PubMed, Scopus, Wiley, and Cinahl, and 9 relevant websites was undertaken for the period 1993–2012. The reference lists of MCH program reviews were hand-searched for additional relevant studies which met the eligibility criteria. The study designs of included publications were classified and the characteristics extracted and categorized. Evaluation quality was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies and the Critical Appraisal Skills Program (CASP) tool for qualitative studies.
Results
Twenty-three search results were identified for inclusion, with the majority published in 2003–2012. Fifty two percent of publications reported on programs and services operating out of Aboriginal Community Controlled Health Organisations, with antenatal and postnatal care the main intervention type/s, and health promotion/education and advice/support the most common intervention component. Outcomes such as increased antenatal attendance and higher infant birth weights were reported in some intervention studies, however methodological quality varied considerably with quantitative studies typically rated weak.
Conclusion
The prevalence of community controlled and/or community-based programs is significant given the health and wellbeing implications of self-determination. While the literature highlights the promise of many intervention models and program components used there are some significant gaps in the documentation and implementation of important MCH interventions. Similarly, while positive health outcomes were reported there are issues with key measures used and study quality. This review highlights the need to improve the quality of evaluations of MCH programs for Aboriginal and Torres Strait Islander women and to address the key evidence gaps in responding to their health and wellbeing needs.
doi:10.1186/1471-2393-14-251
PMCID: PMC4261787  PMID: 25073873
Antenatal; Postnatal; Indigenous Australians; Pregnancy; Women’s health
21.  Postpartum care for Aboriginal and non-Aboriginal women with Gestational Diabetes Mellitus across urban, rural and remote locations: a protocol for a cohort linkage study 
SpringerPlus  2013;2:576.
Background
Gestational diabetes mellitus (GDM) is increasing, along with obesity and type 2 diabetes (T2DM), with Aboriginal and Torres Strait Islander (Aboriginala) women in Australia particularly affected. GDM causes serious complications in pregnancy, birth, and the longer term, for women and their infants. Women with GDM have an eightfold risk of developing T2DM after pregnancy, compared to women without GDM. Indigenous women have an even higher risk, at a younger age, and progress more quickly from GDM to T2DM, compared to non-Indigenous women. If left undetected and untreated, T2DM increases risks in subsequent pregnancies, and can lead to heart disease, stroke, kidney failure, limb amputations and blindness for the woman in the longer term. A GDM diagnosis offers a ‘window of opportunity’ to provide acceptable and effective prevention, treatment, and postpartum care. Low rates of postpartum T2DM screening are reported among non-Aboriginal women in Australia and Indigenous women in other countries, however, data for Aboriginal women in Australia are scarce. A healthy diet, exercise and breastfeeding can delay the onset of T2DM, and together with T2DM screening are recommended elements of postpartum care for women with GDM. This paper describes methods for a study evaluating postpartum care among Aboriginal and non-Aboriginal women with GDM.
Methods/Design
This retrospective cohort includes all women who gave birth at Cairns Hospital in far north Queensland, Australia, from 2004 to 2010, coded as having GDM in the Cairns Hospital Clinical Coding system. Data is being linked with the Midwives Perinatal Data Collection, and the three local laboratories. Hospital medical records are being reviewed to validate accuracy of GDM case ascertainment, and gather information on breastfeeding and provision of dietary advice. Survival analysis is being used to estimate time to screening, and rates of progression from GDM to T2DM. Logistic regression is being used to compare postpartum care between Aboriginal and non-Aboriginal women, and assess factors that may be associated with provision of postpartum care.
Discussion
There are challenges to collecting postpartum data for women with GDM, however, this research is urgently needed to ensure adequate postpartum care is provided for women with GDM.
Electronic supplementary material
The online version of this article (doi:10.1186/2193-1801-2-576) contains supplementary material, which is available to authorized users.
doi:10.1186/2193-1801-2-576
PMCID: PMC4320232  PMID: 25674406
Gestational diabetes mellitus; Type 2 diabetes mellitus; Diabetes; Pregnancy; Aboriginal; Indigenous
22.  Serum vitamin D levels, diabetes and cardio-metabolic risk factors in Aboriginal and Torres Strait Islander Australians 
Background
Low levels of serum 25–hydroxy vitamin D (25(OH)D), have been associated with development of type 2 diabetes and cardiovascular disease (CVD); however there are limited data on serum 25(OH)D in Indigenous Australians, a population at high risk for both diabetes and CVD. We aimed to assess levels of serum 25(OH)D in Aboriginal and Torres Strait Islander Australians and to explore relationships between 25(OH)D and cardio-metabolic risk factors and diabetes.
Methods
592 Aboriginal and/or Torres Strait Islander Australian participants of The eGFR (estimated glomerular filtration rate) Study, a cross-sectional analysis of a cohort study performed in 2007–2011, from urban and remote centres within communities, primary care and tertiary hospitals across Northern Territory, Far North Queensland and Western Australia. Assessment of serum 25(OH)D, cardio-metabolic risk factors (central obesity, diabetes, hypertension, history of cardiovascular disease, current smoker, low HDL-cholesterol), and diabetes (by history or HbA1c ≥6.5%) was performed. Associations were explored between 25(OH)D and outcome measures of diabetes and number of cardio-metabolic risk factors.
Results
The median (IQR) serum 25(OH)D was 60 (45–77) nmol/L, 31% had 25(OH)D <50 nmol/L. For participants with 25(OH)D < 50 vs ≥50 nmol/L, cardio-metabolic risk profile differed for: diabetes (54%, 36% p < 0.001), past history of cardiovascular disease (16%, 9%, p = 0.014), waist-hip ratio (0.98, 0.92, p < 0.001), urine albumin-creatinine ratio (2.7, 1.5 mg/mmol, p < 0.001). The OR (95% CI) for diabetes was 2.02 (1.03 – 3.95) for people in the lowest vs highest tertiles of 25(OH)D (<53 vs >72 nmol/L, respectively) after adjusting for known cardio-metabolic risk factors.
Conclusion
The percentage of 25(OH)D levels <50 nmol/L was high among Aboriginal and Torres Strait Islander Australians from Northern and Central Australia. Low 25(OH)D level was associated with adverse cardio-metabolic risk profile and was independently associated with diabetes. These findings require exploration in longitudinal studies.
doi:10.1186/1758-5996-6-78
PMCID: PMC4155864  PMID: 25197323
25-hydroxy vitamin D; Type 2 diabetes; Aboriginal; Cardiovascular risk
23.  A service-level action research intervention to improve identification and treatment of cannabis and related mental health issues in young Indigenous Australians: a study protocol 
BMJ Open  2014;4(7):e005689.
Introduction
Regular cannabis use is associated with negative mental health impacts including psychosis, depression and anxiety. Rates of cannabis use have increased in Aboriginal and Torres Strait Islander communities in northern Australia within the last two decades, presenting a significant increased risk to young people's mental health in these regions. Improved screening, early detection and treatment for cannabis-related mental health issues are urgently required. This paper describes a service-level action research intervention and evaluation protocol for use in the few services where it is possible to engage young Aboriginal and Torres Strait Islander Australians.
Methods/Design
The protocol is being developed in two services where youth mental health is core business: a primary healthcare centre and a youth service in the Cairns and hinterland region, far north Queensland. The protocol calls first for baseline data to be collected using staff and client surveys; network mapping; and analysis of screening, treatment and referral rates. The protocol's intervention phase is driven by service needs identified from baseline data. Intervention strategies focus on implementing/enhancing cannabis screening instruments and processes in line with current best practice; enhancing networks with external drug and mental health services; developing culturally acceptable training and resources; developing activities aiming to reduce cannabis use in young Aboriginal and Torres Strait Islander clients using the services. The protocol requires implementation of the multilevel intervention within each service for 1 year, with follow-up data then collected and compared to baseline. Process evaluation identifies the more effective intervention strategies and documents the challenges to be overcome for full implementation.
Ethics and dissemination
Ethics approval was provided by The James Cook University, Human Research Ethics Committee. Ethics Approval Number H5322. Peer-reviewed publications will also be used to disseminate the finding. Results will also be discussed with stakeholder organisations.
doi:10.1136/bmjopen-2014-005689
PMCID: PMC4120335  PMID: 25082422
Mental Health
24.  General Practitioner Supervisor assessment and teaching of Registrars consulting with Aboriginal patients – is cultural competence adequately considered? 
BMC Medical Education  2014;14:167.
Background
General Practitioner (GP) Supervisors have a key yet poorly defined role in promoting the cultural competence of GP Registrars who provide healthcare to Aboriginal and Torres Strait Islander people during their training placements. Given the markedly poorer health of Indigenous Australians, it is important that GP training and supervision of Registrars includes assessment and teaching which address the well documented barriers to accessing health care.
Methods
A simulated consultation between a GP Registrar and an Aboriginal patient, which illustrated inadequacies in communication and cultural awareness, was viewed by GP Supervisors and Medical Educators during two workshops in 2012. Participants documented teaching points arising from the consultation which they would prioritise in supervision provided to the Registrar. Content analysis was performed to determine the type and detail of the planned feedback. Field notes from workshop discussions and participant evaluations were used to gain insight into participant confidence in cross cultural supervision.
Results
Sixty four of 75 GPs who attended the workshops participated in the research. Although all documented plans for detailed teaching on the Registrar’s generic communication and consultation skills, only 72% referred to culture or to the patient’s Aboriginality. Few GPs (8%) documented a plan to advise on national health initiatives supporting access for Aboriginal and Torres Strait Islander people. A lack of Supervisor confidence in providing guidance on cross cultural consulting with Aboriginal patients was identified.
Conclusions
The role of GP Supervisors in promoting the cultural competence of GP Registrars consulting with Aboriginal and Torres Strait Islander patients could be strengthened. A sole focus on generic communication and consultation skills may lead to inadequate consideration of the health disparities faced by Indigenous peoples and of the need to ensure Registrars utilise health supports designed to decrease the disadvantage faced by vulnerable populations.
doi:10.1186/1472-6920-14-167
PMCID: PMC4136400  PMID: 25115609
25.  Aboriginal medical services cure more than illness: a qualitative study of how Indigenous services address the health impacts of discrimination in Brisbane communities 
Background
Aboriginal and Torres Strait Islanders persistently experience a significantly lower standard of health in comparison to non-Indigenous Australians. The factors contributing to this disparity are complex and entrenched in a history of social inequality, disempowerment, poverty, dispossession and discrimination. Aboriginal medical services (AMS) provide a culturally appropriate alternative to mainstream medical services as a means to address this health disparity and also advocate for Indigenous rights and empowerment. This study provides a vignette of lay perspectives of Aboriginal and Torres Strait Islanders accessing community and government controlled AMS in Brisbane, Queensland with the intention of identifying self-perceived health determinants to inform the post-2015 international development goals.
Methods
Focus group discussions and semi-structured interviews were held with clients of a government-controlled AMS and an Aboriginal community controlled health service (ACCHS) in order to identify their self-identified essential health needs. Conversations were audio recorded, transcribed verbatim and de-identified for analysis. Common themes were identified to highlight important issues around community health needs, how they can be addressed and what lessons can be extended to inform the post-2015 development goals.
Findings and discussion
Participants acknowledge the complexity of health determinants faced by their peoples. Thematic analysis highlighted the pervasive influence of racism through many perceived health determinants; resulting in reduced healthcare seeking behaviour, unhealthy lifestyles and mental health issues. Participants emphasised the marked health improvements seen due to the establishment of Aboriginal medical services in their communities and the importance of the AMS’ role in addressing the negative effects of discrimination on Indigenous health.
Conclusion
It is concluded from this study that AMS are crucial in addressing the negative impacts of continued discrimination on Indigenous health by providing comprehensive, culturally appropriate, community empowering health services. Such services improve Indigenous healthcare seeking rates, provide invaluable health education services and address mental health concerns in communities and must be supported in order to address health inequalities in Australia. Community driven and culturally informed health services should be encouraged globally to address health disparities.
doi:10.1186/1475-9276-13-56
PMCID: PMC4283121  PMID: 25301439
Discrimination; Indigenous; Aboriginal; Community controlled health services; Healthcare-seeking behaviour; Fear; Mental health; Australia

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