Indigenous health

Objectives To estimate the direct medical costs of the Hep B Partnership Program (Hep B PAST) model of care compared with chronic hepatitis B (CHB) usual care from the health system perspective (Northern Territory (NT) Department of Health and the Commonwealth).Study TypeRetrospective cohort study (2014–2023) that linked primary care with inpatient, emergency, outpatient and outreach datasets. Costs were applied using National Weighted Activity Units, the Pharmaceutical Benefits Scheme and NT Government costings. A pre- and post-implementation design from a health system perspective was applied, with costs in 2023 Australian dollars.SettingRemote communities in the NT, Australia.ParticipantsThe cohort included all First Nations people living with CHB who were attending a clinic in a remote community that had consented to the Hep B PAST program, and who received care between 1 July 2014 and 31 May 2023.Main Outcome MeasuresAnnual mean and median healthcare costs per contact and per individual across service types, with comparisons of annual mean costs per individual between pre- and post-Hep B PAST using partially overlapping t-tests.ResultsAmong 1063 First Nations individuals with CHB, annual median costs per individual were similar for usual care ($639 [interquartile range, $366–1156]) and Hep B PAST ($770 [interquartile range, $400–1272]); mean costs were also similar for usual care versus Hep B PAST ($1701 vs. $1970; p = 0.12). By service type, annual median costs were similar for inpatient services ($7777 vs. $7795), primary care ($327 vs. $302) and outpatient visits ($1985 vs. $1858), and higher for Hep B PAST for emergency services ($1339 vs. $1672) and outreach care ($373 vs. $746).ConclusionsIn remote First Nations communities, Hep B PAST was delivered with a modest increase in direct medical costs compared with usual care. These findings can be used to inform future cost-effective evaluations. Future cost savings from decreased hepatocellular carcinoma and liver failure were not included.

Hoa Nguyen, Anh Le Tuan Nguyen, Paula Binks, Melita McKinnon, Emily Vintour-Cesar, Karen Wills, Nicola Stephens, Benjamin Cowie, Joshua S. Davis, Yuejen Zhao, Peter Nihill, Julie A. Campbell, Andrew J. Palmer, Jane Davies, Barbara de Graaff

Objectives To examine the epidemiology of stroke and transient ischaemic attack (TIA), and quality of care provided to Aboriginal and Torres Strait Islander (‘Indigenous’) patients presenting to emergency medical services (EMSs) with stroke or TIA.DesignRetrospective population-based data linkage study.Setting, ParticipantsVictoria, Australia. Patients aged ≥ 18 years with hospital-confirmed stroke or TIA who presented to EMSs between 1 January 2015 and 30 June 2019 and were successfully linked with hospital or mortality datasets.Main Outcome MeasuresThirty- and 90-day mortality, crude and age-standardised incidence rates, EMS quality of care.ResultsAmong 32,163 patients, 287 (0.9%) were Indigenous. Indigenous patients were younger than non-Indigenous patients (median age, 62 vs. 77 years, p < 0.001). Age-standardised incidence of EMS attendance was higher within the Indigenous population (343 vs. 144 per 100,000 person-years; incidence rate ratio, 2.383 [95% confidence interval (CI), 2.084–2.711]). Rates of call-taker identification of stroke or TIA and hospital diagnoses were comparable; however, Indigenous patients were less likely to receive a stroke assessment from paramedics (166/285 [58.2%] vs. 21,271/31,605 [67.3%]; p = 0.001) and more frequently taken to stroke-capable hospitals (257/275 [93.5%] vs. 27,371/30,647 [89.3%]; p = 0.027), but less frequently taken to endovascular thrombectomy-capable hospitals (67/275 [24.4%] vs. 10,015/30,647 [32.7%]; p = 0.003). Adjusted mortality was similar between groups (30 days: hazard ratio, 0.814 [95% CI, 0.518–1.279]; 90 days: hazard ratio, 0.805 [95% CI, 0.534–1.214]). However, age-standardised incidence of 90-day mortality was higher within the Indigenous population (39 vs. 24 per 100,000 person-years; incidence rate ratio, 1.621 [95% CI, 1.031–2.398]). Indigenous patients also more often recontacted EMSs for any reason within 90 days (subdistribution hazard ratio, 1.548 [95% CI, 1.194–2.007]).ConclusionsThe age-standardised incidence of EMS attendance for stroke in the Indigenous population was more than double that for the non-Indigenous population. Although there was no difference in stroke identification at the time of the emergency call, Indigenous patients were less likely to be evaluated by paramedics for stroke.

Candice Menezes, Ziad Nehme, Luke J. Burchill, Tegwyn McManamny, Angela Dos Santos, Michelle Crilly, Luke P. Dawson, Benjamin Clissold, David Anderson, Emily Nehme

Australia aims to eliminate hepatitis C as a public health threat by 2030 among all populations. It is timely to review national elimination efforts for First Nations Australians and discuss what is required to reach elimination targets. In 2020, First Nations Australians accounted for 18% of people living with chronic hepatitis C, despite representing 4% of the population. Over the past 5 years, about 15% of hepatitis C cases notified nationally occurred among First Nations peoples, with slower uptake of curative direct-acting antiviral treatment than non-Indigenous people. Achieving elimination will require implementation of strategies with an equity framework applied to address gaps in data and care cascades for hepatitis C.

James Ward, Emily Pegler, Kellie Stacy, Stephen Harfield

Objective To identify factors contributing to the known increased age-standardised incidence and mortality rates for lung cancer for Aboriginal and Torres Strait Islander people in Victoria, Australia.Study TypeRetrospective, population-based, case–control study using Victorian Cancer Registry (VCR) data and linked health administrative datasets.Setting and ParticipantsSelf-identified Aboriginal and Torres Strait Islander people (respectfully referred to hereon as Aboriginal) and non-Aboriginal people (aged > 18 years) diagnosed with lung cancer from 1 January 2008 to 31 December 2022.Main Outcome MeasuresClinical, pathological, demographic, socio-economic factors and biomarkers (programmed cell death-ligand 1 [PD-L1], anaplastic lymphoma kinase [ALK] and c-ros oncogene [ROS1]) were assessed. Endpoints were all-cause and lung cancer-specific mortality. Survival analyses were conducted using Cox regression.ResultsAboriginal people (N = 512) were younger (p < 0.001), more likely to live outside a major city (p < 0.001) and in areas of greatest disadvantage (p < 0.001) than non-Aboriginal people (N = 43,468). More Aboriginal females had small cell lung cancer compared with non-Aboriginal females (17% vs. 10%), more Aboriginal males had adenocarcinomas (41% vs. 36%) and squamous cell carcinomas (26% vs. 20%), compared with non-Aboriginal males. There were no differences in the proportions of PD-L1-positive disease nor ALK or ROS1 gene rearrangements. A higher risk of all-cause mortality (hazard ratio, 1.12; 95% CI, 1.01–1.24; p = 0.03) for Aboriginal people after stratification for age, sex and lung cancer subtype was identified.ConclusionThis study identified that Aboriginal people were younger, more likely to be living outside of major cities and in areas of greatest inequity than non-Aboriginal people, which is an ongoing manifestation of colonisation. Aboriginal people diagnosed with lung cancer had an increased all-cause mortality compared with non-Aboriginal people.

Alice R. T. Bergin, Luc te Marvelde, Roger L. Milne, Benjamin J. Solomon, Kris Ivanova, Peter Savas, Stephen J. Luen, Jay Hamann, Andrea Casey, Nicole Watt, Sue M. Evans, Gail Garvey, Sherene Loi

Elimination of rheumatic heart disease (RHD) as a public health problem requires a multifaceted approach, including better primordial and primary prevention and early case detection and treatment of rheumatic fever, the autoimmune precursor to RHD. Here, we reflect on progress made in the decade since the 2015 revision of the Jones Criteria for rheumatic fever diagnosis. Advances in understanding rheumatic fever pathophysiology, the identification of potential biomarkers and improved clinical insights are bringing us closer to a diagnostic test for rheumatic fever and to targeted treatments that could prevent progression to RHD.

Anna P. Ralph, Rachel Webb, Tom Parks, Nicole J. Moreland, Asha C. Bowen, Benjamin Jones, Emma Ndagire, Andrea Z. Beaton

For over 40 years, First Nations communities in Australia have called for community-controlled birthing and maternal–infant health programs that restore First Nations-led, community-controlled birthing systems grounded in cultural authority and sovereignty. ‘Birthing on Country’ services have demonstrated improved First Nations maternal–infant health outcomes, more babies kept out of the child protection system, and reduced health system costs. Restoration and expansion of Birthing on Country services across regions has been inconsistent, and has lacked support for national implementation. In 2022, a large national gathering (‘Best Start to Life’) was co-hosted in Mparntwe (Alice Springs). The focus was Birthing on Country service implementation to address inequities in birthing service provision for First Nations communities. A deliverable of this gathering was the National Roadmap for Birthing on Country Services 2026–2036 (the Roadmap). The co-creation of the Roadmap maintained enhanced engagement from a range of stakeholders, to produce inclusive and democratic solutions to perpetual perinatal inequities in health. A two-phased process facilitated national co-creation where national priorities in the reclamation of First Nations Birth Rights were upheld. The Roadmap builds on an evidence-informed and First Nations knowledge-grounded framework, the RISE Implementation Framework. The formation of the Roadmap contrasts against traditional policy creation, transitioning from an evidence-based proposal to a First Nations-endorsed national framework, ready for implementation and government adoption. This novel, national strategic approach to upscale Birthing on Country services has received formal endorsement nationally. The Roadmap provides detailed strategies to address structural reform, and its foundational co-creation process demonstrates that to change practice, researchers must do more than publish evidence in journals for policy change and knowledge translation. The 10-year key deliverables in the Roadmap are a call to action to recognise Birthing on Country as an inherent sovereign right grounded in First Nations Law and governance.

Res McCalman, Anneka J. Bowman, Roianne West, Kristie Watego, Jyai Allen, Claire Clack, Sue Kildea, Sue Kruske, Melanie Briggs, Cleone Wellington, Rebecca Coddington, Yu Gao, Isabella Garti, Sascha Kowalenko, Sarah Ireland, Catherine Austin, John D. Boffa, Marah Prior, Kelsie Kahl, Bettina Chaseling, Sarah Khaw, Emily Armstrong, Donna Hartz, Yvette Roe

Indigenous children are seen as an intrinsic, systematic foundation of hope in Aboriginal conceptualisations of hope, yet are grossly overrepresented in Australian suicide statistics. Despite being a target of the Australian Government's almost 20-year-long Closing the Gap campaign, the numbers are only getting worse. ‘It's not depression, it's despair’ are words that echo a sentiment so ghastly for parents of Indigenous children who only hope to bestow them with the gift of exactly that: hope. It is only sensible to counteract this with holistic, culturally empowered, strengths-based well-being programs to both develop Cultural strength while concurrently instilling a sense of Cultural pride and identity.

Rudi Louis Taylor-Bragge

In response to the revised Australian Medical Council Standards for Assessment and Accreditation of Primary Medical Programs, many medical education providers are adapting to meet increased expectations regarding First Nations Health and Cultural Safety. Rather than a competency-based approach, which is prevalent throughout medical education, the revised expectations require a fundamental shift in institutional ideological, ontological and epistemological function. To meaningfully engage in this transformation, medical education providers must consider principles and qualities that enable development in these focus areas. To realise progress, an ongoing, personal and collective critical self-reflexive process that centres First Nations self-determination, and that is underpinned by humility, courage, accountability, responsiveness and perseverance, is beneficial for providers and their staff. Conversely, those institutions and individuals who omit such practise, risk inertia in their development.

Sophie Pitt, Ashlee Williams-Barnes, Ryan Dashwood, Keira Edwards, Paul Saunders

Objectives To identify drivers of routine vaccination for Aboriginal and Torres Strait Islander children, from a health service provider perspective, to increase and maintain uptake.DesignThis qualitative study was designed, analysed and guided by Indigenous data sovereignty and governance principles. Data were analysed using inductive content analysis. Subcategories were refined using Miro (Miro Inc), an online collaboration platform. Aboriginal and Torres Strait Islander worldviews were privileged, with Aboriginal researchers leading data analysis in New South Wales (NSW) and contributing to analysis in the Northern Territory (NT).SettingThe study was conducted in NSW and the NT, Australia, with health service providers from urban, rural and remote settings.ParticipantsIndividual and group interviews were undertaken in person or online between 2 May and 28 August 2024, with 18 health service provider participants in the Hunter New England Local Health District in NSW and 17 health service provider participants in the NT.ResultsWe identified six key themes addressing drivers of vaccination for Aboriginal and Torres Strait Islander children for families (knowledge, attitudes and information sources; decision-making), health staff (workforce roles, responsibilities and relationships) and health services (improving access; health service operations; data for decision-making). Providers recommended strategies to improve uptake.ConclusionsHealth service providers in urban, rural and remote locations in Australia can provide valuable insights to inform tailored strategies to improve declining vaccine coverage for Aboriginal and Torres Strait Islander children, aligned with the priorities of the National Immunisation Strategy 2025–2030.

Bianca F. Middleton, Kristy Crooks, Kylie Taylor, Elizabeth Harwood, Katrina K. Clark, Caitlin Kent, Kelly McCrory, Marita Hefler, Jessica Kaufman, David N. Durrheim, Margie H. Danchin

Breast milk provides both short-term and long-term health benefits and is critical for infants admitted to neonatal intensive care units (NICUs). Presently, there is a large focus on increasing breastfeeding rates among Aboriginal and Torres Strait Islander women; however, culturally safe breastfeeding support is under-recognised and inadequately addressed in the NICU setting. This perspective highlights cultural and structural barriers and calls for urgent action to include the following four proposed strategies: strengthening the Aboriginal lactation workforce, embedding culturally inclusive education, partnering with community-controlled services, and developing a culturally specific NICU breastfeeding policy to improve outcomes.

Jessica Bennett, Jamie Bryant, Kade Booth, Michelle Kennedy

Objectives Our goal was to explore and compare risk factors, patterns of management and survival outcomes in Indigenous compared with non-Indigenous Australian patients using the Victorian Lung Cancer Registry (VLCR).Study TypeA retrospective observational cohort study of the VLCR.SettingData collected from the VLCR between 18 January 2011 and 24 January 2024.ParticipantsPrimary lung cancer patients in the VLCR.Main Outcome MeasuresPatient, disease and management characteristics of Indigenous and non-Indigenous Australian patients. Impacts of patient and clinical variables on treatment and survival, measured by multivariable Cox regression and propensity-matched survival analysis.ResultsWe included 186 Indigenous and 17,439 non-Indigenous Australian patients. Indigenous Australian lung cancer patients were younger in age {median, 62 years (interquartile range [IQR], 55–69 years) vs. median, 71 years (IQR, 63–77 years); p < 0.001}, had lower socio-economic status (lowest quintile, 57 patients [31%] vs. 3274 patients [19%]; p < 0.001), were more likely to be current smokers (118 patients [65%] vs. 5963 patients [35%]; p < 0.001) and had higher levels of respiratory comorbidity (64 patients [34%] vs. 4088 patients [23%]; p < 0.001). There were no statistically significant differences in receipt of guideline-concordant treatment (82 patients [51%] vs. 8036 patients [56%]; p = 0.12) and survival outcomes (median survival, 1.4 vs. 1.5 years; hazard ratio, 1.06 [95% confidence interval, 0.88–1.27]).ConclusionWe found lung cancer patients of Indigenous status were more likely to have demographic disadvantage and clinical risk factors that may contribute to discrepancies in management compared with patients of non-Indigenous status. Identifying barriers to healthcare and treatment in the Indigenous Australian population is an important research priority to improve disparities between the two populations.

Melanie Wong, Mike Lloyd, Jessie Zeng, Sanuki Tissera, Kalinda E. Griffiths, Justine Clark, Jonathan Gillies, Lisa Briggs, Jacqueline Lesage, Tom Wood, Craig Underhill, Sagun Parakh, Louis B. Irving, Wasek Faisal, Rob Blum, Gary E. Richardson, Phillip Parente, Michelle Caldecott, Inger Olesen, Javier Torres, Evangeline Samuel, Christopher Lyne, Katharine See, David Langton, Thomas John, Gavin Wright, Matthew Conron, James Bartlett, Golsa Adabi, Maggie Moore, Susan Harden, Zoe K. McQuilten, John R. Zalcberg, Rob Stirling

The scale and complexity of diabetes in rural and remote Indigenous communities is an urgent health issue. Progress in improving diabetes care, closing entrenched gaps and, ultimately, improving the health of Indigenous people and communities nationwide can be achieved with concerted, multidisciplinary, culturally informed evidence-based efforts

Natalie Nanayakkara · Sharon Atkinson‐Briggs · Alicia J Jenkins · Neale D Cohen

We stand at the beginning of the next bioscience revolution in asthma

Anthony Flynn · Wendy Edmondson · Alan James · Caroline Lodge · Vanessa M McDonald · Christine R Jenkins · John Blakey · Gary P Anderson

Cures for asthma will require a sustained, decade-long program of discovery science partnered with best clinical expertise

Gary P Anderson · Anthony Flynn · Phil G Bardin · John D Blakey · Shyamali C Dharmage · Paul Foster · Peter G Gibson · Adam Jaffe · Alan James · Christine R Jenkins · Sundram Sivamalai · Peter D Sly · Guy B Marks · Vanessa M McDonald · Judy Wetttenhall

Journalism and independent media are important for supporting public health through contributing to a healthy information environment, fostering dialogue and respect for rights, making governments more transparent and accountable, and societies more informed, inclusive and sustainable

Bronwyn Fredericks · Neha Lalchandani · Melissa A Sweet · Alex Cramb · Carmel Williams