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Introduction: Rheumatic heart disease (RHD) is underdiagnosed globally resulting in missed treatment opportunities and adverse clinical outcomes. We describe the protocol for a study which aims to co-design, implement and conduct an evaluation of a task-sharing approach to echocardiographic active case finding for early detection and management of RHD in high-risk settings in Australia and Timor-Leste., Methods and Analysis: Echocardiograms will be obtained by trained local staff using hand-held echocardiographic devices employing the 'Single Parasternal Long Axis view with a Sweep of the Heart' (SPLASH) technique and interpreted by experts remote from the site of acquisition. Approximately 1500 children and pregnant women will be screened across high-risk communities in Australia and Timor-Leste over an 18-month period. The study will use a type II effectiveness-implementation hybrid design. A tailored package of implementation strategies will be co-designed with communities and health services and mapped onto a Theory of Change framework. The clinical effectiveness will be assessed as the change in the proportion of the target population that are prescribed secondary prophylaxis for RHD by the end of the study compared with baseline. The implementation will be assessed as the adoption, penetration, sustainability, fidelity and cost of the programme with a mixed-methods theory-based and economic evaluation. Data will include numbers of normal, abnormal and uninterpretable SPLASH echocardiograms obtained, numbers of participants progressing through the cascade of care, interviews with staff and programme costs., Ethics and Dissemination: Ethical approval has been obtained from the Human Research Ethics Committee of the NT Department of Health and Menzies School of Health Research, Darwin (HREC-2022-4479), the Western Australian Aboriginal Health Ethics Committee (HREC-1237) and the Instituto Nasional Saude Publika Timor-Leste Ethics and Technical Committee (03-UEPD/INSP-TL/V/2023). Informed consent is required to be enrolled. Study findings will be disseminated in the communities involved and submitted for publication., Trial Registration Number: NCT06002243., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Despite disproportionate rates of mental ill-health compared with non-Indigenous populations, few programs have been tailored to the unique health, social, and cultural needs and preferences of young Aboriginal and Torres Strait Islander males. This paper describes the process of culturally adapting the US-based Young Black Men, Masculinities, and Mental Health (YBMen) Project to suit the needs, preferences, culture, and circumstances of Aboriginal and Torres Strait Islander males aged 16-25 years in the Northern Territory, Australia. YBMen is an evidence-based social media-based education and support program designed to promote mental health, expand understandings of gender and cultural identities, and enhance social support in college-aged Black men., Methods: Our adaptation followed an Extended Stages of Cultural Adaptation model. First, we established a rationale for adaptation that included assessing the appropriateness of YBMen's core components for the target population. We then investigated important and appropriate models to underpin the adapted program and conducted a non-linear, iterative process of gathering information from key sources, including young Aboriginal and Torres Strait Islander males, to inform program curriculum and delivery., Results: To maintain program fidelity, we retained the core curriculum components of mental health, healthy masculinities, and social connection and kept the small cohort, private social media group delivery but developed two models: 'online only' (the original online delivery format) and 'hybrid in-person/online' (combining online delivery with weekly in-person group sessions). Adaptations made included using an overarching Aboriginal and Torres Strait Islander social and emotional wellbeing framework and socio-cultural strengths-based approach; inclusion of modules on health and wellbeing, positive Indigenous masculinities, and respectful relationships; use of Indigenous designs and colours; and prominent placement of images of Aboriginal and Torres Strait Islander male sportspeople, musicians, activists, and local role models., Conclusions: This process resulted in a culturally responsive mental health, masculinities, and social support health promotion program for young Aboriginal and Torres Strait Islander males. Next steps will involve pilot testing to investigate the adapted program's acceptability and feasibility and inform further refinement., (© 2024. The Author(s).)

Aboriginal and Torres Strait Islander women are key members of the community who have specific roles within their families that may result in lower levels of physical activity (PA) undertaken. Clearly identifying barriers for women to engage with PA, and exploring culturally based activities (i.e. Traditional Indigenous Games), may help to improve long-term health benefits. Subsequently, the aim of this study was to identify the barriers and facilitators for Aboriginal and Torres Strait Islander women engaging in PA, and their interest in participating in Traditional Indigenous Games. Seventeen Aboriginal and Torres Strait Islander women (34.3 ± 10.2 years) participated in focus groups. Through thematic analysis, participants experienced a range of common barriers such as lack of time due to family commitments, limited finances, ageing and poor physical and/or mental health. Common facilitators were also identified such as fun, access and improving mental and/or physical health. Importantly, unique themes were identified for Aboriginal and Torres Strait Islander women including barriers (e.g. racism, shame) and facilitators (e.g. culture, interactions with other Aboriginal and Torres Strait Islander women) that influenced PA participation. Notably, Traditional Indigenous Games were considered as an appealing PA mode to engage with their culture, experience nostalgia and be around other Aboriginal and Torres Strait Islander women. These key findings will guide future PA programs including Traditional Indigenous Games to improve health outcomes of Aboriginal and Torres Strait Islander women, vital members of the community., (© The Author(s) 2024. Published by Oxford University Press.)

Background: Australia does not have a national strategy for Aboriginal and Torres Strait Islander adolescent health and as a result, policy and programming actions are fragmented and may not be responsive to needs. Efforts to date have also rarely engaged Aboriginal and Torres Strait Islander people in co-designing solutions. The Roadmap Project aims to work in partnership with young people to define priority areas of health and well-being need and establish the corresponding developmentally appropriate, evidence-based actions., Methods and Analysis: All aspects of this project are governed by a group of Aboriginal and Torres Strait Islander young people. Needs, determinants and corresponding responses will be explored with Aboriginal and Torres Strait Islander adolescents (aged 10-24 years) across Australia through an online qualitative survey, interviews and focus group discussions. Parents, service providers and policy makers (stakeholders) will share their perspectives on needs and support required through interviews. Data generated will be co-analysed with the governance group and integrated with population health data, policy frameworks and evidence of effective programmes (established through reviews) to define responsive and effective actions for Aboriginal and Torres Strait Islander adolescent health and well-being., Ethics and Dissemination: Ethical approval for this study has been obtained from the Aboriginal Health Council of South Australia (Ref: 04-21-956), the Aboriginal Health and Medical Research Council of New South Wales (Ref: 1918/22), the Western Australian Aboriginal Health Ethics Committee (Ref: HREC1147), the Northern Territory Health and Menzies School of Health Research (Ref: 2022-4371), ACT Health Human Research Ethics Committee (Ref: 2022.ETH.00133), the St. Vincent's Hospital, Victoria (Ref: HREC 129/22), University of Tasmania (Ref: 28020), Far North Queensland Human Research Ethics Committee (Ref: HREC/2023/QCH/89911) and Griffith University (Ref: 2023/135). Prospective adolescent participants will provide their own consent for the online survey (aged 13-24 years) and, interviews or focus group discussions (aged 15-24 years); with parental consent and adolescent assent required for younger adolescents (aged 10-14 years) participating in interviews.Study findings (priority needs and evidence-based responses) will be presented at a series of co-design workshops with adolescents and stakeholders from relevant sectors. We will also communicate findings through reports, multimedia clips and peer-reviewed publications as directed by the governance group., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The period before, during, and after pregnancy presents an opportunity to reduce diabetes-related risks, which in Australia disproportionately impact Aboriginal and Torres Strait Islander women. Collaboration with Aboriginal and Torres Strait Islander women/communities is essential to ensure acceptability and sustainability of lifestyle modifications. Using a novel co-design approach, we aimed to identify shared priorities and potential lifestyle strategies. We also reflected on learnings from this approach., Methods: We conducted 11 workshops and 8 interviews at two sites in Australia's Northern Territory (Central Australia and Top End), using experience-based co-design (EBCD) and incorporating principles of First Nations participatory research. Workshops/interviews explored participant' experiences and understanding of diabetes in pregnancy, contextual issues, and potential lifestyle strategies. Participants included three groups: 1) Aboriginal and Torres Strait Islander women of reproductive age (defined as aged 16-45 years); 2) Aboriginal and Torres Strait Islander community members; and 3) health/community services professionals. The study methodology sought to amplify the voices of Aboriginal women., Findings: Participants included 23 women between ages 16-45 years (9 with known lived experience of diabetes in pregnancy), 5 community members and 23 health professionals. Key findings related to identified priority issues, strategies to address priorities, and reflections on use of EBCD methodology. Priorities were largely consistent across study regions: access to healthy foods and physical activity; connection to traditional practices and culture; communication regarding diabetes and related risks; and the difficulty for women of prioritising their health among competing priorities. Strategies included implementation of a holistic women's program in Central Australia, while Top End participants expressed the desire to improve nutrition, peer support and community awareness of diabetes. EBCD provided a useful structure to explore participants' experiences and collectively determine priorities, while allowing for modifications to ensure co-design methods were contextually appropriate. Challenges included the resource-intensive nature of stakeholder engagement, and collaborating effectively with services and communities when researchers were "outsiders"., Conclusions: A hybrid methodology using EBCD and First Nations participatory research principles enabled collaboration between Aboriginal women, communities and health services to identify shared priorities and solutions to reduce diabetes-related health risks. Genuine co-design processes support self-determination and enhance acceptability and sustainability of health strategies., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Dias, MacKay, Canuto, Boyle, D’Antoine, Hampton, Martin, Phillips, Bartlett, Mcintyre, Graham, Corpus, Connors, McCarthy, Kirkham and Maple-Brown.)

Despite progression in the ethical and methodological conduct of Aboriginal and Torres Strait Islander health research, disparities still pervade, indicating limitations in knowledge translation. One identified gap is a lack of documented experiences detailing how ethical guidelines may be practically applied. This paper aims to (i) describe the research processes involved in co-designing a physical activity and psychosocial health program for Aboriginal and Torres Strait Islander girls and (ii) highlight learnings of the collaborative research journey. The Criteria for Strengthening Reporting of Health Research involving Indigenous Peoples (CONSIDER) statement was used to document participatory research activities undertaken with an Aboriginal community partner. Building upon the CONSIDER statement, Aboriginal (N = 3), Torres Strait Islander (N = 1) and non-Indigenous (N = 4) research team members engaged in critical reflection to identify lessons learnt. Researchers identified a tension between participatory research principles and the expectations of funding agencies and research institutions. Consequently, timelines must be flexible to foster meaningful community engagement and participatory processes. Additionally, researchers and community stakeholders are encouraged to embrace tensions that may associated with participatory research or the pressures Aboriginal and Torres Strait Islander researchers face from their community and organization. Furthermore, differences in professional (i.e. occupational) and cultural knowledge systems need to be acknowledged and accounted for within the early stages of a project to ensure informed decision-making. Identified lessons will assist relevant stakeholders in the development of future Aboriginal and Torres Strait Islander health programming, ensuring the most appropriate health solutions are devised with community., (© The Author(s) 2023. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Issue Addressed: Physical activity participation can improve the physical health and social and emotional wellbeing of Aboriginal and Torres Strait Islander peoples. The evaluation of physical activity programmes can elicit a clearer understanding of where these impacts occur and to what extent. We describe applying a collaborative approach to the selection of a set of measures that can be used to examine health and wellbeing impacts of Indigenous community running groups., Methods: Physical activity, health and wellbeing measurement tools previously used with Aboriginal and Torres Strait Islander peoples were collated. Participants in the collaborative process were nine female running group members aged 30+ years from a regional New South Wales (NSW) town. The Indigenous research method, Yarning, explored views of participating in the group on health and wellbeing and how these could be measured using those collated measurement tools., Results: Runners described participating for holistic physical, mental and social reasons and stated the importance of the group participating together and providing social support to each other. There was broad support for the identified physical activity, lifestyle, physical health, and social and emotional wellbeing measures, with social networks and sports injuries identified as additionally relevant., Conclusions: Co-selecting measures to evaluate a physical activity programme for Aboriginal and Torres Strait Islander participants can better inform the development of relevant future healthy lifestyle programme evaluation, revealing factors that may be missed as relevant by researchers. SO WHAT?: This process presents an example of determining evaluation measures with Aboriginal and Torres Strait Islander participants that could be applied more broadly to evaluation design., (© 2022 The Authors. Health Promotion Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of Australian Health Promotion Association.)

Aims: To focus on the needs, challenges and opportunities to improve access to cardiac rehabilitation (CR) (Heart: Road to health [HRH]) for Aboriginal and Torres Strait Islander peoples in rural and remote (R&R) areas of North Queensland., Context: It is known that there is insufficient access to HRH for Aboriginal and Torres Strait Islander peoples in R&R areas of NQ, who have the highest rates of heart disease and socioeconomic disadvantage mainly due to poor social determinants of health. However, at least in part due to the impact of colonialism and predominantly western medicalised approach to health care, few gains have been made., Approach: This commentary draws on recent research and literature and reflects on cultural issues that impact on improving access to an HRH for Aboriginal and Torres Strait Islander peoples in R&R areas. The underutilisation of the skills of Aboriginal and Torres Strait Islander Health Workers (ATSIHW) and a lack of a defined process to ensure access to culturally responsive HRH are discussed. Finally, a way forward is proposed that includes the development of policies, pathways and guidelines to ensure that appropriate support is available in the client's home community., Conclusion: It is proposed that culturally responsive, accessible and effective HRH is achievable through the reorientation of current health systems that include a continuous client-centred pathway from hospital to home. In this model, ATSIHW will take a lead or partnership role in which their clinical, cultural brokerage and health promotion skills are fully utilised., (© 2022 The Authors. Australian Journal of Rural Health published by John Wiley & Sons Australia, Ltd on behalf of National Rural Health Alliance Ltd.)

Background and Aims: A concerning rise in incidence of young-onset cancers globally led to the examination of trends in incidence and survival of gastrointestinal (GI) adenocarcinomas in the Northern Territory (NT), Australia, over a 28-year period, with a special emphasis on Indigenous peoples. Methods: This cross-sectional analysis of a prospective longitudinal database, NT Cancer Registry (1990−2017), includes all reported cases of GI (oesophagus, gastric, small intestinal, pancreas, colon, and rectum) adenocarcinomas. Poisson regression was used to estimate incidence ratio ratios, and survival was modelled using Cox proportional hazard models separately for people aged 18−50 years and >50 years. Results: A total of 1608 cases of GI adenocarcinoma were recorded during the time of the study. While the overall incidence in people 18−50 years remained unchanged over this time (p = 0.51), the rate in individuals aged >50 years decreased (IRR = 0.65 (95% CI 0.56−0.75; p < 0.0001)). Incidence rates were significantly less in females >50 years (IRR = 0.67 95% CI 0.59−0.75; p < 0.0001), and their survival was significantly better (HR = 0.84 (95%CI 0.72−0.98; p < 0.03)) compared to males. Overall survival across all GI subsites improved in both age cohorts, especially between 2010 and 2017 (HR = 0.45 (95%CI 0.29−0.72; p < 0.0007) and HR = 0.64 (95%CI 0.52−0.78; p < 0.0001), respectively) compared to 1990−1999, driven by an improvement in survival in colonic adenocarcinoma alone, as the survival remained unchanged in other GI subsites. The incidence was significantly lower in Indigenous patients compared to non-Indigenous patients, in both age cohorts (18−50 years IRR = 0.68 95% CI 0.51−0.91; p < 0.009 and >50 years IRR = 0.48 95% CI 0.40−0.57; p < 0.0001). However, Indigenous patients had worse survival rates (18−50 years HR = 2.06 95% CI 1.36−3.11; p < 0.0007 and >50 years HR = 1.66 95% CI 1.32−2.08; p < 0.0001). Conclusions: There is a trend towards an increased incidence of young-onset GI adenocarcinomas in the NT. Young Indigenous patients have lower incidence but worse survival across all GI subsites, highlighting significant health inequities in life expectancy. Targeted, culturally safe Indigenous community-focussed programs are needed for early detection and patient-centred management of GI adenocarcinomas.

Background: Australian Aboriginal and Torres Strait Islander peoples experience health and socioeconomic disparities, including lower life-expectancy, have a younger mean age of colorectal cancer (CRC) diagnosis, and lower CRC survival than non-Indigenous Australians. The National Bowel Cancer Screening Program (NBCSP) provides biennial CRC screening for Australians aged 50-74 years to reduce the burden of CRC. The 2019 participation rate was 42% nationwide and 23% in Aboriginal and Torres Strait Islander peoples. For Aboriginal and Torres Strait Islander peoples, this study aims to estimate the health outcomes and cost-effectiveness of the current NBCSP and extensions to include people < 50 years., Methods: An existing microsimulation model, Policy1-Bowel, was adapted to the Aboriginal and Torres Strait Islander population and was used to evaluate three strategies assuming biennial iFOBT screening from 50-74, 45-74, or 40-74 years under two participation scenarios: 23% and 42% per screening round (psr.)., Results: At 23-42% participation psr., the current NBCSP was predicted to reduce lifetime CRC incidence and mortality by 14-24% and 23-39%, respectively, be cost-effective (incremental cost-effectiveness ratio <$13,000/life-year saved), and be associated with a benefits-and-burden balance of 51-53 number-needed-to-colonoscope (NNC) per CRC death prevented of . Lowering the screening start age to 40(45) would further reduce CRC incidence and CRC mortality by 7-11(4-5) percentage points, be cost-effective, and be associated with an incremental NNC- of > 95 (> 60)., Conclusion: For Aboriginal and Torres Strait Islander peoples, the current NBCSP is cost-effective but participation is limited. Lowering the screening start age will further reduce CRC incidence and mortality., Policy Summary: These findings highlight a need to increase NBCSP participation whilst exploring the feasibility and acceptability of lowering the NBCSP start age for Aboriginal and Torres Strait Islander peoples. These findings could inform new co-designed, community-led strategies to improve CRC outcomes for Aboriginal and Torres Strait Islander peoples., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: To assess implementation of in-patient cardiac rehabilitation (Phase-1-cardiac rehabilitation), impact on people in rural and remote areas of Australia and potential methods for addressing identified weaknesses., Design: Exploratory case study methodology using qualitative and quantitative methods. Qualitative data collection via semi-structured interviews, using thematic analysis, augmented by quantitative data collection via a medical record audit., Setting: Four regional hospitals (2 Queensland Health and 2 private) providing tertiary health care., Participants: (a) Hospital in-patients with heart disease ≥18 years. (b) Staff responsible for their care., Outcome Measures: Implementation of Phase-1-cardiac rehabilitation in tertiary hosptials in North Queensland and the impact on in-patients discharge planning and post discharge care. Recommentations and implications for practice are proposed to address deficits., Results: Phase-1-cardiac rehabilitation implementation rates, in-patient understanding and multidisciplinary team involvement were low. The highest rates of Phase-1-cardiac rehabilitation were for in-patients with a length of stay three days or more  in cardiac units with cardiac educators. Rates were lower in cardiac units with no cardiac educators, and lowest for in-patients in all areas of all hospitals with length of stay of two days or less days. Low Phase-1-cardiac rehabilitation implementation rates resulted in poor in-patient understanding about their disease, treatment and post-discharge care. Further, medical discharge summaries rarely mentioned cardiac rehabilitation/secondary prevention or risk factor management resulting in a lack of information for health care providers on cardiac rehabilitation and holistic health care., Conclusion: Implementation of Phase-1-cardiac rehabilitation in regional hospitals in this study fell short of recommended best practice, resulting in patients' poor preparation for discharge, and insufficient information on holistic care for health care providers in rural and remote areas. These factors potentially impact on holistic care for people returning home following treatment for heart disease., (© 2021 National Rural Health Alliance Ltd.)

Background: This systematic review was undertaken to assist the implementation of the WOmen's action for Mums and Bubs (WOMB) project which explores Aboriginal and Torres Strait Islander community women's group (WG) action to improve maternal and child health (MCH) outcomes. There is now considerable international evidence that WGs improve MCH outcomes, and we were interested in understanding how and why this occurs. The following questions guided the review: (1) What are the characteristics, contextual influences and group processes associated with the MCH outcomes of WGs? (2) What are the theoretical and conceptual approaches to WGs? (3) What are the implications likely to inform Aboriginal and Torres Strait Islander WGs?, Methods: We systematically searched electronic databases (MEDLINE (Ovid); CINAHL (Ebsco); Informit health suite, Scopus, Emcare (Ovid) and the Cochrane Library and Informit), online search registers and grey literature using the terms mother, child, group, participatory and community and their variations during all time periods to January 2021. The inclusion criteria were: (1) Population: studies involving community WGs in any country. (2) Intervention: a program/intervention involving any aspect of community WGs planning, acting, learning and reviewing MCH improvements. (3) Outcome: studies with WGs reported a component of: (i) MCH outcomes; or (ii) improvements in the quality of MCH care or (iii) improvements in socioemotional well-being of mothers and/or children. (4) Context: the primary focus of initiatives must be in community-based or primary health care settings. (5) Process: includes some description of the process of WGs or any factors influencing the process. (6) Language: English. (7) Study design: all types of quantitative and qualitative study designs involving primary research and data collection.Data were extracted under 14 headings and a narrative synthesis identified group characteristics and analysed the conceptual approach to community participation, the use of theory and group processes. An Australian typology of community participation, concepts from Aboriginal and Torres Strait Islander group work and an adapted framework of Cohen and Uphoff were used to synthesise results. Risk of bias was assessed using Joanna Briggs Institute Critical Appraisal Tools., Results: Thirty-five (35) documents were included with studies conducted in 19 countries. Fifteen WGs used participatory learning and action cycles and the remainder used cultural learning, community development or group health education. Group activities, structure and who facilitated groups was usually identified. Intergroup relationships and decision-making were less often described as were important concepts from an Aboriginal or Torres Strait Islander perspective (the primacy of culture, relationships and respect). All but two documents used an explicit theoretical approach. Using the typology of community participation, WGs were identified as predominantly developmental (22), instrumental (10), empowerment (2) and one was unclear., Discussion: A framework to categorise links between contextual factors operating at micro, meso and macro levels, group processes and MCH improvements is required. Currently, despite a wealth of information about WGs, it was difficult to determine the methods through which they achieved their outcomes. This review adds to existing systematic reviews about the functioning of WGs in MCH improvement in that it covers WGs in both high-income and low-income settings, identifies the theory underpinning the WGs and classifies the conceptual approach to participation. It also introduces an Australian Indigenous perspective into analysis of WGs used to improve MCH., Prospero Registration Number: CRD42019126533., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Physical activity has cultural significance and population health benefits. However, Aboriginal and Torres Strait Islander adults may experience challenges in participating in physical activity. This mixed methods systematic review aimed to synthetize existing evidence on facilitators and barriers for physical activity participation experienced by Aboriginal and Torres Strait Islander adults in Australia. The Joanna Briggs Institute methodology was used. A systematic search was undertaken of 11 databases and 14 grey literature websites during 2020. The included studies reported physical activity facilitators and barriers experienced by Aboriginal or Torres Strait Islander participants aged 18+ years, living in the community. Twenty-seven studies met the inclusion criteria. Sixty-two facilitators were identified: 23 individual, 18 interpersonal, 8 community/environmental and 13 policy/program facilitators. Additionally, 63 barriers were identified: 21 individual, 17 interpersonal, 15 community/environmental and 10 policy/program barriers. Prominent facilitators included support from family, friends, and program staff, and opportunities to connect with community or culture. Prominent barriers included a lack of transport, financial constraints, lack of time, and competing work, family or cultural commitments. Aboriginal and Torres Strait Islander adults experience multiple facilitators and barriers to physical activity participation. Strategies to increase participation should seek to enhance facilitators and address barriers, collaboratively with communities, with consideration to the local context.

This study reports on integrating community perspectives to adapt a family-focused, culturally appropriate behavioural intervention program to prevent diabetes among Aboriginal children (6-11 years) in Central Australia. A participatory action research approach was used to engage a range of service providers, cultural advisors, and family groups. Appropriateness, acceptability, content, and delivery of a prevention program within the Central Australian context were discussed through a series of workshops with twenty-five service providers and seven family groups separately. The data obtained were deductively coded for thematic analysis. Main findings included: (i) the strong need for a diabetes prevention program that is community owned, (ii) a flexible and culturally appropriate program delivered by upskilling community members as program facilitators, and (iii) consideration of social and environmental factors when implementing the program. It is recommended that a trial of the adapted prevention program for effectiveness and implementation is led by an Aboriginal community-controlled health service.

Objective: To synthesize the existing research about physical activity and sport facilitators and barriers experienced by Aboriginal and Torres Strait Islander adults in Australia., Introduction: Physical activity and sport have cultural importance for First Nations peoples. Achieving health and broader benefits from physical activity and sport is impacted by experiences of both facilitators and barriers to participation. Identifying how to facilitate participation and overcome barriers to physical activity and sport is important to develop strategies to increase physical activity levels and sport participation among Aboriginal and Torres Strait Islander adults. Several studies have examined physical activity and sport facilitators and barriers experienced by Aboriginal and Torres Strait Islander adults, and collective synthesis of these studies can provide a more comprehensive understanding of their findings., Inclusion Criteria: This mixed methods systematic review will consider studies that include Aboriginal and Torres Strait Islander peoples aged 18 years and over from any setting or region of Australia. Studies will be considered if they report on facilitators and barriers to physical activity and/or sport participation., Methods: Eleven databases will be searched, as well as gray literature sources, and a selection of websites containing resources relevant to physical activity participation for Aboriginal and Torres Strait Islander adults. Studies published in English will be included. No date limits will be set. After screening the titles and abstracts of identified citations, potentially relevant studies will be retrieved in full. Study selection, critical appraisal, data extraction, and data synthesis will be undertaken according to the convergent integrated approach to mixed methods reviews., Systematic Review Registration Number: PROSPERO CRD42020162134., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 JBI.)

CHAPTER 1: HOW AUSTRALIA IMPROVED HEALTH EQUITY THROUGH ACTION ON THE SOCIAL DETERMINANTS OF HEALTH: Do not think that the social determinants of health equity are old hat. In reality, Australia is very far away from addressing the societal level drivers of health inequity. There is little progressive policy that touches on the conditions of daily life that matter for health, and action to redress inequities in power, money and resources is almost non-existent. In this chapter we ask you to pause this reality and come on a fantastic journey where we envisage how COVID-19 was a great disruptor and accelerator of positive progressive action. We offer glimmers of what life could be like if there was committed and real policy action on the social determinants of health equity. It is vital that the health sector assists in convening the multisectoral stakeholders necessary to turn this fantasy into reality. CHAPTER 2: ABORIGINAL AND TORRES STRAIT ISLANDER CONNECTION TO CULTURE: BUILDING STRONGER INDIVIDUAL AND COLLECTIVE WELLBEING: Aboriginal and Torres Strait Islander peoples have long maintained that culture (ie, practising, maintaining and reclaiming it) is vital to good health and wellbeing. However, this knowledge and understanding has been dismissed or described as anecdotal or intangible by Western research methods and science. As a result, Aboriginal and Torres Strait Islander culture is a poorly acknowledged determinant of health and wellbeing, despite its significant role in shaping individuals, communities and societies. By extension, the cultural determinants of health have been poorly defined until recently. However, an increasing amount of scientific evidence supports what Aboriginal and Torres Strait Islander people have always said - that strong culture plays a significant and positive role in improved health and wellbeing. Owing to known gaps in knowledge, we aim to define the cultural determinants of health and describe their relationship with the social determinants of health, to provide a full understanding of Aboriginal and Torres Strait Islander wellbeing. We provide examples of evidence on cultural determinants of health and links to improved Aboriginal and Torres Strait Islander health and wellbeing. We also discuss future research directions that will enable a deeper understanding of the cultural determinants of health for Aboriginal and Torres Strait Islander people. CHAPTER 3: PHYSICAL DETERMINANTS OF HEALTH: HEALTHY, LIVEABLE AND SUSTAINABLE COMMUNITIES: Good city planning is essential for protecting and improving human and planetary health. Until recently, however, collaboration between city planners and the public health sector has languished. We review the evidence on the health benefits of good city planning and propose an agenda for public health advocacy relating to health-promoting city planning for all by 2030. Over the next 10 years, there is an urgent need for public health leaders to collaborate with city planners - to advocate for evidence-informed policy, and to evaluate the health effects of city planning efforts. Importantly, we need integrated planning across and between all levels of government and sectors, to create healthy, liveable and sustainable cities for all. CHAPTER 4: HEALTH PROMOTION IN THE ANTHROPOCENE: THE ECOLOGICAL DETERMINANTS OF HEALTH: Human health is inextricably linked to the health of the natural environment. In this chapter, we focus on ecological determinants of health, including the urgent and critical threats to the natural environment, and opportunities for health promotion arising from the human health co-benefits of actions to protect the health of the planet. We characterise ecological determinants in the Anthropocene and provide a sobering snapshot of planetary health science, particularly the momentous climate change health impacts in Australia. We highlight Australia's position as a major fossil fuel producer and exporter, and a country lacking cohesive and timely emissions reduction policy. We offer a roadmap for action, with four priority directions, and point to a scaffold of guiding approaches - planetary health, Indigenous people's knowledge systems, ecological economics, health co-benefits and climate-resilient development. Our situation requires a paradigm shift, and this demands a recalibration of health promotion education, research and practice in Australia over the coming decade. CHAPTER 5: DISRUPTING THE COMMERCIAL DETERMINANTS OF HEALTH: Our vision for 2030 is an Australian economy that promotes optimal human and planetary health for current and future generations. To achieve this, current patterns of corporate practice and consumption of harmful commodities and services need to change. In this chapter, we suggest ways forward for Australia, focusing on pragmatic actions that can be taken now to redress the power imbalances between corporations and Australian governments and citizens. We begin by exploring how the terms of health policy making must change to protect it from conflicted commercial interests. We also examine how marketing unhealthy products and services can be more effectively regulated, and how healthier business practices can be incentivised. Finally, we make recommendations on how various public health stakeholders can hold corporations to account, to ensure that people come before profits in a healthy and prosperous future Australia. CHAPTER 6: DIGITAL DETERMINANTS OF HEALTH: THE DIGITAL TRANSFORMATION: We live in an age of rapid and exponential technological change. Extraordinary digital advancements and the fusion of technologies, such as artificial intelligence, robotics, the Internet of Things and quantum computing constitute what is often referred to as the digital revolution or the Fourth Industrial Revolution (Industry 4.0). Reflections on the future of public health and health promotion require thorough consideration of the role of digital technologies and the systems they influence. Just how the digital revolution will unfold is unknown, but it is clear that advancements and integrations of technologies will fundamentally influence our health and wellbeing in the future. The public health response must be proactive, involving many stakeholders, and thoughtfully considered to ensure equitable and ethical applications and use. CHAPTER 7: GOVERNANCE FOR HEALTH AND EQUITY: A VISION FOR OUR FUTURE: Coronavirus disease 2019 has caused many people and communities to take stock on Australia's direction in relation to health, community, jobs, environmental sustainability, income and wealth. A desire for change is in the air. This chapter imagines how changes in the way we govern our lives and what we value as a society could solve many of the issues Australia is facing - most pressingly, the climate crisis and growing economic and health inequities. We present an imagined future for 2030 where governance structures are designed to ensure transparent and fair behaviour from those in power and to increase the involvement of citizens in these decisions, including a constitutional voice for Indigenous peoples. We imagine that these changes were made by measuring social progress in new ways, ensuring taxation for public good, enshrining human rights (including to health) in legislation, and protecting and encouraging an independent media. Measures to overcome the climate crisis were adopted and democratic processes introduced in the provision of housing, education and community development., (© 2021 AMPCo Pty Ltd.)

Issue Addressed: Noncommunicable chronic disease underlies much of the life expectancy gap experienced by Aboriginal and Torres Strait Islander people. Modifying contributing risk factors; tobacco smoking, nutrition, alcohol consumption, physical activity, social and emotional wellbeing (SNAPS) could help close this disease gap. This scoping review identified and describes SNAPS health promotion programs implemented for Aboriginal and Torres Strait Islander people in Australia., Methods: Databases PubMed, CINAHL, Informit (Health Collection and Indigenous Peoples Collection), Scopus, Trove and relevant websites and clearing houses were searched for eligible studies until June 2015. To meet the inclusion criteria the program had to focus on modifying one of the SNAPS risk factors and the majority of participants had to identify as being of Aboriginal and/or Torres Strait Islander heritage., Results: The review identified 71 health promotion programs, described in 83 publications. Programs were implemented across a range of health and community settings and included all Australian states and territories, from major cities to remote communities. The SNAPS factor addressed most commonly was nutrition. Some programs included the whole community, or had multiple key audiences, whilst others focused solely on one subgroup of the population such as chronic disease patients, pregnant women or youth. Fourteen of the programs reported no outcome assessments., Conclusions: Health promotion programs for Aboriginal and Torres Strait Islander people have not been adequately evaluated. The majority of programs focused on the development of individual skills and changing personal behaviours without addressing the other health promotion action areas, such as creating supportive environments or reorienting health care services. SO WHAT?: This scoping review provides a summary of the health promotion programs that have been delivered in Australia for Aboriginal and Torres Strait Islander people to prevent or manage chronic disease. These programs, although many are limited in quality, should be used to inform future programs. To improve evidence-based health promotion practice, health promotion initiatives need to be evaluated and the findings published publicly., (© 2019 The Authors. Health Promotion Journal of Australia published by John Wiley & Sons Ltd on behalf of Australian Health Promotion Association.)

Objective: This systematic review aims to synthesize evidence to determine the effect of physical activity on the prevention and management of type 2 diabetes among Aboriginal and Torres Strait Islander Australians., Introduction: Physical activity interventions have been shown to have a positive influence in the prevention and management of type 2 diabetes. A body of evidence for the impact among Aboriginal and Torres Strait Islander people is emerging, but a definitive understanding is yet to be realized., Inclusion Criteria: The review will include studies with Aboriginal and Torres Strait Islander populations of any age group and from any setting or region in Australia. Studies will be included if they report on physical activity interventions, programs, or activities to prevent or manage type 2 diabetes. Studies may compare physical activity interventions to usual care, alternate treatments, or no intervention, or may be pre-post studies. This review will consider studies that measure change in physical activity or exercise levels and/or change in HbA1c level., Methods: Nine databases will be searched, and studies published in English will be included. No date limits will be set. Methodological quality will be determined using critical appraisal checklists appropriate to the study design and the CREATE Critical Appraisal Tool to appraise research from Aboriginal and Torres Strait Islander perspectives. Data extracted will include population group, study design, methods, intervention components, and physical activity-related outcomes. Quantitative data will be pooled where possible to enable a meta-analysis to be conducted. Heterogeneous studies will be synthesized narratively., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 JBI.)

Objective: Colorectal cancer (CRC) screening using a Faecal Occult Blood Test (FOBT) is a well-established population intervention to reduce mortality and morbidity of CRC. As Indigenous people are not fully benefiting from the screening programs, a greater understanding of barriers and enablers affecting participation is needed., Methods: Searches were carried out in PubMed, Embase, Sociological Abstracts, Scopus, CINAHL, and selected websites. Both qualitative and quantitative studies related to Indigenous populations of Canada, New Zealand, Australia and the United States of America were assessed for quality and data related to FOBT were extracted and synthetised., Results: A total of 375 publications were identified and screened against the inclusion/exclusion criteria. Thirty-four studies were included in the review. The barriers for participation in CRC screening included the lack of culturally competent health service access, particularly access to Indigenous health service providers. Medical discrimination, long-standing distrust in Western medicine and/or health staff and screening tests were all identified as barriers for Indigenous people. There were a small number of promising interventions to improve participation, which could be considered on a broader scale to increase overall participation by Indigenous people in CRC screening., Conclusions: The review identified barriers and possible enablers for Indigenous participation in the CRC screening program, some which appear to be unique to Indigenous people. Further intervention studies conducted in partnership with Indigenous communities are needed to improve participation., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The lack of attention to Indigenous epistemologies and, more broadly, Indigenous values in primary research, is mirrored in the standardised critical appraisal tools used to guide evidence-based practice and systematic reviews and meta-syntheses. These critical appraisal tools offer no guidance on how validity or contextual relevance should be assessed for Indigenous populations and cultural contexts. Failure to tailor the research questions, design, analysis, dissemination and knowledge translation to capture understandings that are specific to Indigenous peoples results in research of limited acceptability and benefit and potentially harms Indigenous peoples. A specific Aboriginal and Torres Strait Islander Quality Appraisal Tool is needed to address this gap., Method: The Aboriginal and Torres Strait Islander Quality Appraisal Tool (QAT) was developed using a modified Nominal Group and Delphi Techniques and the tool's validity, reliability, and feasibility were assessed over three stages of independent piloting. National and international research guidelines were used as points of reference. Piloting of the Aboriginal and Torres Strait Islander QAT with Aboriginal and Torres Strait Islander and non-Indigenous experts led to refinement of the tool., Results: The Aboriginal and Torres Strait Islander QAT consists of 14 questions that assess the quality of health research from an Aboriginal and Torres Strait Islander perspective. The questions encompass setting appropriate research questions; community engagement and consultation; research leadership and governance; community protocols; intellectual and cultural property rights; the collection and management of research material; Indigenous research paradigms; a strength-based approach to research; the translation of findings into policy and practice; benefits to participants and communities involved; and capacity strengthening and two-way learning. Outcomes from the assessment of the tool's validity, reliability, and feasibility were overall positive., Conclusion: This is the first tool to appraise research quality from the perspective of Indigenous peoples. Through the uptake of the Aboriginal and Torres Strait Islander QAT we hope to improve the quality and transparency of research with Aboriginal and Torres Strait Islander peoples, with the potential for greater improvements in Aboriginal and Torres Strait Islander health and wellbeing.

Objectives: To describe rates of hospitalisation and Coaching on Achieving Cardiovascular Health referral, for Queensland's adults with heart and related disease, and comparisons between Aboriginal and Torres Strait Islander and non-Indigenous peoples in northern Queensland., Design: Descriptive retrospective epidemiological study of Queensland Health Patient Admission Data Collection for adults with heart and related disease, and Coaching on Achieving Cardiovascular Health referral data. Relative risk and age standardisation were calculated for Aboriginal and Torres Strait Islander and non-Indigenous peoples., Participants: Queensland's adults ≥20 years, hospitalised with heart and related disease (1 January 2012-31 December 2016)., Setting: Queensland, Australia., Main Outcome Measures: Queensland Health Hospital and Health Services' hospitalisation and Coaching on Achieving Cardiovascular Health referral rates for heart and related disease., Results: Queensland's Aboriginal and Torres Strait Islander peoples have a higher hospitalisation rate for heart and related disease, with higher rates for northern Queensland. Queensland's overall Coaching on Achieving Cardiovascular Health referral rates were low, but higher for Aboriginal and Torres Strait Islander peoples. Deficiencies in documentation of Aboriginal and Torres Strait Islander people's status affected results in some areas., Conclusion: Queensland's Aboriginal and Torres Strait Islander peoples were more likely to be admitted to hospital for heart and related disease and referred to Coaching on Achieving Cardiovascular Health than non-Indigenous peoples. However, hospitalisation and Coaching on Achieving Cardiovascular Health referral rates are unlikely to reflect the needs of Aboriginal and Torres Strait Islander peoples especially in rural and very remote areas given their higher mortality and morbidity rates and fewer services., (© 2020 National Rural Health Alliance Ltd.)

Aboriginal and Torres Strait Islander men rarely rate a mention within discussions of parenting unless framed in the negative, or as the cause of dysfunctional family life. Consequently, the roles and responsibilities of Aboriginal and Torres Strait Islander men within parenting have largely been neglected or ignored. This scoping review aimed to identify and describe Aboriginal and Torres Strait Islander parenting programs that focused on male parents. A comprehensive search was conducted of databases, PubMed and Informit ATSIhealth, to identify peer-review publications, while relevant websites were also searched for grey literature. The review identified eight programs that met the inclusion criteria. The review highlights the lack of rigorously researched and published literature on parenting programs that focus on Aboriginal and Torres Strait Islander male parents. The programs all reported positive outcomes and demonstrate that given the opportunity, Aboriginal and Torres Strait Islander male parents are ready and determined to fulfil their roles and responsibilities as parents to the best of their ability for the benefit of their families and communities. The provision of inclusive parenting programs and services will equip Aboriginal and Torres Strait Islander male parents to better support their families during these important times.

Objectives: To identify and describe existing evidence of the impact of sport and physical activity programs on social outcomes among Aboriginal and Torres Strait Islander people., Design: Systematic scoping review., Methods: Nine scientific databases (MEDLINE, Scopus, SPORTSDiscus, PsycINFO, Informit, Database of Abstracts of Reviews of Effects (DARE), The Cochrane Library, The Campbell Library, ProQuest Dissertations and Theses) and grey literature were systematically searched for programs or activities that target Aboriginal and Torres Strait Islander people and use physical activity and sport participation to improve one or more of six social and community outcomes of: (i) education; (ii) employment; (iii) culture; (iv) social and emotional wellbeing; (v) life skills; (vi) crime reduction., Results: Of the 1160 studies identified, 20 met the inclusion criteria and were published between 2003 and 2018. Most studies reported positive findings across multiple, broad outcomes of education (N = 11), employment (N = 1), culture (N = 9), social and emotional wellbeing (N = 12), life skills (N = 5) and crime reduction (N = 5). Some evidence was found for increased school attendance and improved self-esteem resulting from physical activity and sport participation as well as enhanced aspects of culture, such as cultural connections, connectedness, values and identity., Conclusions: There is some evidence of benefit across the six social outcomes from physical activity and sport programs. This promotes their continuation and development, although critical appraisal of their methods is needed to better quantify benefits, as well as the generation of new evidence across indicators where gaps currently exist, particularly for employment and crime reduction outcomes., (Crown Copyright © 2019. Published by Elsevier Ltd. All rights reserved.)

Background: Aboriginal and Torres Strait Islander Australians have poorer cancer outcomes than other Australians. Comparatively little is known of the type and amount of cancer treatment provided to Aboriginal and Torres Strait Islander people and the consequences for cancer survival. This study quantifies the influence of surgical, systemic and radiotherapy treatment on risk of cancer death among matched cohorts of cancer cases and, the comparative exposure of cohorts to these treatments., Methods: Cancers registered among Aboriginal South Australians in 1990-2010 (N = 777) were matched with randomly selected non-Indigenous cases by sex, birth and diagnostic year, and primary site, then linked to administrative cancer treatment for the period from 2 months before to 13 months after diagnosis. Competing risk regression summarised associations of Indigenous status, geographic remoteness, comorbidities, cancer stage and treatment exposure with risk of cancer death., Results: Fewer Aboriginal cases had localised disease at diagnosis (37.2% versus 50.2%) and they were less likely to: experience hospitalisation with cancer diagnosis, unadjusted odds ratio (UOR) = 0.76; 95%CI = 0.59-0.98; have surgery UOR = 0.65; 95%CI = 0.53-0.80; systemic therapies UOR = 0.64; 95%CI = 0.52-0.78; or radiotherapy, UOR = 0.76; 95%CI = 0.63-0.94. Localised disease carried lower risk of cancer death compared to advanced cases receiving surgery or systemic therapies, SHR = 0.34; 95%CI = 0.25-0.47 and SHR = 0.35; 95%CI = 0.25-0.48. Advanced disease and no treatment carried higher risk of cancer death, SHR = 1.82; 95%CI = 1.26-2.63., Conclusion: The effects of treatment did not differ between Aboriginal and non-Indigenous cohorts. However, comparatively less exposure to surgical and systemic treatments among Aboriginal cancer cases further complicated the disadvantages associated with geographic remoteness, advanced stage of disease and co-morbid conditions at diagnosis and add to disparities in cancer death. System level responses to improving access, utilisation and quality of effective treatments are needed to improve survival after cancer diagnosis.

Introduction: Community-based Participatory Women's Groups (PWGs) have proven to be an effective intervention to improve maternal and child health (MCH) outcomes in low/middle-income countries (LMICs). Less is known about how PWGs exert their effects in LMICs and virtually nothing is known about the contextual issues, processes and power relationships that affect PWG outcomes in high resource settings. The aim of this systematic review is to synthesise and critically analyse the current evidence on how and why PWGs improve the quality of MCH care. We aim to demonstrate how PWGs function and why PWG interventions contribute to social and health outcomes., Methods and Analysis: The protocol will follow Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. The databases Medline (Ovid): Cumulative Index to Nursing and Allied Health Literature (Ebsco); Informit health suite Scopus, Australian HealthInfoNet, the Cochrane Library and other sources will be searched under broad categories: intervention, context and outcomes to 30 June 2019., Ethics and Dissemination: As only secondary data will be analysed; ethical approval is not required. The review will be disseminated to relevant organisations and presented in peer-reviewed papers and at conferences. This will be the first attempt to summarise the current available evidence on the characteristics, contextual influences and mechanisms that are associated with the outcomes and effectiveness of PWGs., Prospero Registration Number: CRD42019126533., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The objective of this scoping review is to identify and describe existing research on the impact of sport and physical activity programs on social outcomes among Aboriginal and Torres Strait Islander people in Australia., Introduction: Physical activity can be particularly beneficial for groups such as Indigenous populations, who have increased rates of chronic disease. Systematic reviews have demonstrated the positive impact of physical activity on a range of health indicators, and there is also support for the positive impact of physical activity on wider social outcomes. However, there is a lack of evidence for the benefits of physical activity for broader social outcomes among Aboriginal and Torres Strait Islander people., Inclusion Criteria: This scoping review will consider studies that include Aboriginal and Torres Strait Islander people of any age from any setting or region of Australia. Studies will be considered if they report on programs or activities that use physical activity and sport participation as a component or tool to improve one or more of six social and community outcomes: education, employment, culture, social wellbeing, life skills and crime prevention., Methods: Nine databases will be searched, as well as a selection of websites containing resources related to physical activity, sport and social outcomes for Aboriginal and Torres Strait Islander people. Studies published in English will be included. No date limits will be set. After screening the titles and abstracts of identified citations, potentially relevant studies will be retrieved in full. Data extraction will be presented in a table with accompanying narrative.

Background: Australia's Aboriginal and Torres Strait Islander women have poorer survival and twice the disease burden from breast cancer compared to other Australian women. These disparities are influenced, but not fully explained, by more diagnoses at later stages. Incorporating breast screening, hospital and out of hospital treatment and cancer registry records into a person-linked data system can improve our understanding of breast cancer outcomes. We focussed one such system on a population-based cohort of Aboriginal women in South Australia diagnosed with breast cancer and a matched cohort of non-Aboriginal women with breast cancer. We quantify Aboriginal and non-Aboriginal women's contact with publicly funded screening mammograms; quantify exposure to a selection of cancer treatment modalities; then assess the relationship between screening, treatment and the subsequent risk of breast cancer death., Methods: Breast cancers registered among Aboriginal women in South Australia in 1990-2010 (N = 77) were matched with a random selection of non-Aboriginal women by birth and diagnostic year, then linked to screening records, and treatment 2 months before and 13 months after diagnosis. Competing risk regression summarised associations of Aboriginality, breast screening, cancer stage and treatment with risk of breast cancer death., Results: Aboriginal women were less likely to have breast screening (OR = 0.37, 95%CIs 0.19-0.73); systemic therapies (OR = 0.49, 95%CIs 0.24-0.97); and, surgical intervention (OR = 0.35, 95%CIs 0.15-0.83). Where surgery occurred, mastectomy was more common among Aboriginal women (OR = 2.58, 1.22-5.46). Each of these factors influenced the risk of cancer death, reported as sub-hazard ratios (SHR). Regional spread disease (SHR = 34.23 95%CIs 6.76-13.40) and distant spread (SHR = 49.67 95%CIs 6.79-363.51) carried more risk than localised disease (Reference SHR = 1). Breast screening reduced the risk (SHR = 0.07 95%CIs 0.01-0.83). So too did receipt of systemic therapy (SHR = 0.06 95%CIs 0.01-0.41) and surgical treatments (SHR = 0.17 95%CIs 0.04-0.74). In the presence of adjustment for these factors, Aboriginality did not further explain the risk of breast cancer death., Conclusion: Under-exposure to screening and treatment of Aboriginal women with breast cancers in South Australia contributed to excess cancer deaths. Improved access, utilisation and quality of effective treatments is needed to improve survival after breast cancer diagnosis.

Poor diet including inadequate fruit and vegetable consumption is a major contributor to the global burden of disease. Aboriginal and Torres Strait Islander Australians experience a disproportionate level of preventable chronic disease and successful strategies to support Aboriginal and Torres Strait Islander people living in remote areas to consume more fruit and vegetables can help address health disadvantage. Healthy Choice Rewards was a mixed methods study to investigate the feasibility of a monetary incentive: store vouchers, to promote fruit and vegetable purchasing in a remote Australian Aboriginal community. Multiple challenges were identified in implementation, including limited nutrition workforce. Challenges related to the community store included frequent store closures and amended trading times, staffing issues and poor infrastructure to support fruit and vegetable promotion. No statistically significant increases in fruit or vegetable purchases were observed in the short time frame of this study. Despite this, community members reported high acceptability of the program, especially for women with children. Optimal implementation including, sufficient time and funding resources, with consideration of the most vulnerable could go some way to addressing inequities in food affordability for remote community residents.

Issue Addressed: Physical inactivity is a key health risk among Aboriginal and Torres Strait Islander (Indigenous) Australians. We examined perceptions of the Indigenous Marathon Program (IMP) in a remote Torres Strait island community., Methods: Semi-structured interviews with community and program stakeholders (n = 18; 14 Indigenous) examined barriers and enablers to running and the influence of the IMP on the community. A questionnaire asked 104 running event participants (n = 42 Indigenous) about their physical activity behaviours, running motivation and perceptions of program impact. Qualitative data were analysed using thematic content analysis, and quantitative data were analysed using descriptive statistics., Results: Interviews revealed six main themes: community readiness, changing social norms to adopt healthy lifestyles, importance of social support, program appeal to hard-to-reach population groups, program sustainability and initiation of broader healthy lifestyle ripple effects beyond running. Barriers to running in the community were personal (cultural attitudes; shyness) and environmental (infrastructure; weather; dogs). Enablers reflected potential strategies to overcome described barriers. Indigenous questionnaire respondents were more likely to report being inspired to run by IMP runners than non-Indigenous respondents., Conclusions: Positive "ripple" effects of the IMP on running and broader health were described to have occurred through local role modelling of healthy lifestyles by IMP runners that reduced levels of "shame" and embarrassment, a common barrier to physical activity among Indigenous Australians. A high initial level of community readiness for behaviour change was also reported. SO WHAT?: Strategies to overcome this "shame" factor and community readiness measurement should be incorporated into the design of future Indigenous physical activity programs., (© 2018 Australian Health Promotion Association.)

Background: A healthy start predicts better health in later life. Many remote-living Aboriginal and Torres Strait Islander Australian families lack access to consistent, culturally-safe health services. This paper presents a study of implementation of the Baby One Program (BOP). The BOP was designed as a family-centred, Indigenous Healthworker-led, home-visiting model of care focused on promoting family health to give children the best start to life. It was developed by Aboriginal community-controlled Apunipima Cape York Health Council and delivered in Queensland Cape York remote communities. We aimed to determine how the BOP was implemented, enablers, strategies used and formative implementation outcomes., Methods: The qualitative approach utilised theoretical and purposive sampling to explore people's experiences of a program implementation process. Data were generated from semi-structured interviews with four family members enrolled in the BOP and 24 Apunipima staff members. In addition, twenty community members, including two program users, participated in a men's community focus group. The findings are presented according to themes arising from the data., Results: The BOP was rolled out in nine remote Cape York communities between July 2014 and December 2015 and there was high uptake. Indigenous Healthworkers were supported by midwives and maternal and child health nurses to deliver health education to 161 eligible families. The key to effective implementation of family-centred care appeared to be the relationships formed between health practitioners, especially Indigenous Healthworkers, and families. The data revealed the following themes: challenging environments for new families and valuing cultural ways, resourcing program delivery, working towards a team approach, negotiating the cultural interface, engaging families, exchanging knowledge through 'yarning', strengthening the workforce, and seeing health changes in families. Healthworker education and training, and knowledge exchange between Healthworkers, midwives and nurses was critical to program effectiveness. The program continues to grow despite substantial logistic, financial and practical challenges., Conclusions: This study describes an evolving process and explores how health providers connect with families and how the program responds to family and cultural issues. Program development is ongoing; strengthened by more community-level involvement, embedded strategies for ongoing self-evaluation and continuous quality improvements that are responsive to family needs.

Review Objectives: The scoping review project will identify and describe the existing research on health promotion programs and activities focusing on modifying risk factors (specifically to reduce smoking and alcohol consumption, increase physical activity and improve nutrition and social and emotional wellbeing) and/or improving the management of chronic diseases (specifically obesity, type 2 diabetes, chronic kidney disease and cardiovascular disease) for Aboriginal and Torres Strait Islander peoples across a diverse range of health and community settings.

Objective: To describe the main characteristics of systematic reviews addressing questions of chronic disease and related risk factors for Indigenous Australians., Methods: We searched databases for systematic reviews meeting inclusion criteria. Two reviewers assessed quality and extracted characteristics using pre-defined tools., Results: We identified 14 systematic reviews. Seven synthesised evidence about health intervention effectiveness; four addressed chronic disease or risk factor prevalence; and six conducted critical appraisal as per current best practice. Only three reported steps to align the review with standards for ethical research with Indigenous Australians and/or capture Indigenous-specific knowledge. Most called for more high-quality research., Conclusion: Systematic review is an under-utilised method for gathering evidence to inform chronic disease prevention and management for Indigenous Australians. Relevance of future systematic reviews could be improved by: 1) aligning questions with community priorities as well as decision maker needs; 2) involvement of, and leadership by, Indigenous researchers with relevant cultural and contextual knowledge; iii) use of critical appraisal tools that include traditional risk of bias assessment criteria and criteria that reflect Indigenous standards of appropriate research., Implications: Systematic review method guidance, tools and reporting standards are required to ensure alignment with ethical obligations and promote rigor and relevance., (© 2015 Public Health Association of Australia.)

Introduction: The inequity of randomising participants to control groups in randomised controlled trials (RCTs) is often considered inappropriate, especially for research trials that include vulnerable populations such as Indigenous peoples. The Aboriginal and Torres Strait Islander Women's Fitness Program conducted a trial that randomly assigned participants to 'active' and 'waitlisted' groups. This paper reports on participant views of the randomisation protocol., Methods: A pragmatic RCT was conducted in an urban setting to assess the effectiveness of the 12-week Aboriginal and Torres Strait Islander Women's Fitness Program on metabolic health outcomes and waist circumference. Qualitative interviews were conducted at follow-up, one of the objectives was to explore participant perspectives on the research protocol, including participant randomisation to 'Active' and 'Waitlisted' groups., Results: A total of 49 interviews were conducted (26 Active and 23 Waitlisted participants). Two key factors influenced participant views on the protocol: 1) group assignment; and 2) how well they understood the research design, including the justification for randomisation. 'Active' participants were concerned about the inequity of the randomisation process but overall supported the study protocol. Although most Waitlisted participants were disappointed about having to wait 12-months for the program, some participants derived motivation from being waitlisted, whilst others lost motivation. Well-informed participants were more likely to express both support for the randomisation process and an understanding of the research benefits than participants not attending an information session prior to registration., Conclusions: Participants were more accepting of the research protocol if it was clearly explained to them, if they understood the randomisation process and felt the randomisation was justified in terms of the potential for the results to benefit other Aboriginal and Torres Strait Islander women. Our study suggests that the time and resources required to adequately explain the research protocol in research trials should not be undervalued., Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN12610000224022).

Background: Aboriginal and Torres Strait Islander women experience higher rates of obesity, chronic disease, and are less active than non-Indigenous Australian women. Lifestyle programs designed to increase physical activity and encourage healthy eating are needed to ameliorate this disparity. The aim of this study was to identify participants' perceived barriers and enablers to attend group exercise classes as part of a 12-week fitness program., Methods: To understand the factors that influence attendance, a mixed method process evaluation was undertaken in which a quantitative measure of attendance in the group exercise classes was used to identify cases for further qualitative investigation. Aboriginal and/or Torres Strait Islander women aged 18 to 64 years were recruited to a research trial of a fitness program. The 12-week program included two 60-minute group exercise classes per week, and four nutrition education workshops. Semi-structured interviews were conducted at program completion. Participants were stratified by attendance, and interviews from the highest and lowest 25 percentiles analysed. Rigour was strengthened through use of multiple data analysts, member checking and prolonged engagement in the field., Results: Analyses of the post-program interviews revealed that participants enrolled in the program primarily for the perceived health benefits and all (with one exception) found the program met their needs and expectations. The atmosphere of classes was positive and comfortable and they reported developing good relationships with their fellow participants and program staff. Low attendees described more barriers to attendance, such as illness and competing work and family obligations, and were more likely to report logistical issues, such as inconvenient venue or class times., Conclusions: Attendance to the 'Aboriginal and Torres Strait Islander Women's Fitness Program' was primarily influenced by the participant's personal health, logistics and competing obligations. Low attendees reported more barriers during the 12-week period and identified fewer enabling factors than high attendees., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12610000224022.

Background: Aboriginal and Torres Strait Islander women experience higher rates of heart disease and type 2 diabetes than non-Indigenous Australian women. Increasing physical activity, improving diets and losing weight have been shown to reduce cardio metabolic risk. The primary aim was to evaluate the effectiveness of a 12-week structured exercise and nutrition program in a cohort of urban Indigenous Australian women on waist circumference, weight and biomedical markers of metabolic functioning from baseline (T1) to program completion (T2). The secondary aim assessed whether these outcomes were maintained at 3-month follow-up., Methods: One hundred Aboriginal and/or Torres Strait Islander women aged 18-64 years living in the Adelaide metropolitan area were recruited. The program included two 60-minute group cardiovascular and resistance training classes per week, and four nutrition education workshops. Participants were randomly assigned to an 'active' group or 'waitlisted' control group. Body weight, height, waist and hip circumference, blood pressure, fasting glucose, fasting insulin, glycated haemoglobin (HbA1C), lipid profile and C-reactive protein (CRP) were assessed at baseline (T1), immediately after the program (T2) and three months post program (T3)., Results: The active group showed modest reductions in weight and body mass index (BMI). Compared to the waitlisted group, the active group had a statistically significantly change in weight and BMI from baseline assessments; at T2, (-)1.65 kg and (-)0.66 kg/m(2) and at T3, (-)2.50 kg and (-)1.03 kg/m(2), respectively. Systolic and diastolic blood pressure also had a statistically significant difference from baseline in the active group compared to the waitlisted group at T2, (-)1.24 mmHg and (-)2.46 mmHg and at T3, (-)4.09 mmHg and (-)2.17 mmHg, respectively. The findings were independent of the baseline measure of the outcome variable, age, households with children and employment status. Changes in waist circumference and other clinical measures were not significant at T2 or T3. The primary outcome measure, waist circumference, proved problematic to assess reliably. Missing data and participants lost to follow-up were significant., Conclusions: This 12-week exercise program demonstrated modest reductions in weight, BMI and blood pressure at T2, which improved further at 3-month follow-up (T3). Positive intervention effects were observed despite low attendance at exercise classes. Structured exercise programs implemented in community settings require attention to understanding the barriers to participation for this high risk group., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12610000224022.

Background: Aboriginal and Torres Strait Islander women have a higher prevalence and incidence of obesity and type 2 diabetes than non-Indigenous Australian women. Physical inactivity is a key modifiable risk factor for obesity and evidence shows that even modest reductions in waist circumference (WC) have significant health benefits. Trialing physical activity programs in difficult-to-reach high risk groups, especially urban Indigenous Australians poses distinct implementation challenges., Methods/design: The trial objective is to evaluate the effectiveness of a structured 12-week physical activity group program with nutritional advice. The design is a pragmatic randomised controlled trial. This study protocol describes the implementation and evaluation of the program. Participants are randomised into either an intervention or waitlisted group. The waitlisted group have a 12 month waiting period before commencing the 12-week program. Participant data is collected at baseline, 12, 24 and 52 weeks. Participants are Aboriginal and Torres Strait Islander women, aged 18-64 years with a waist circumference greater than 80 centimetres residing in Adelaide. The primary outcome measure is WC change immediately post program from baseline. Secondary outcomes include short term and long term changes in WC, weight, blood pressure, fasting blood glucose, insulin, insulin resistance (calculated HOMA), haemoglobin A1C (HbA1C), triglycerides and C-reactive protein (CRP). Behavioural and psychosocial surveys are administered to assess physical activity, dietary intake and the participant's motivation, self-efficacy and perceived social support for physical activity. Qualitative interviews focusing on participants' motivation, enablers and barriers to healthy eating and physical activity will be undertaken. Implementation fidelity and participation are also assessed., Discussion: The Aboriginal and Torres Strait Islander Women's Fitness Program (WFP) is designed to provide a rigorous physiological and client-based evaluation of a structured 12-week program aimed to increase metabolic fitness and reduce WC in this high risk population. Evaluation results aim to provide the support necessary to design programs that are accessible, affordable and effective at reducing WC, while also improving the metabolic profile of overweight Aboriginal and Torres Strait Islander women., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12610000224022.