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To compare the findings of standard clinical assessments and of complementary clinical and laboratory methods for determining whether community-wide treatment for trachoma is warranted in a remote Queensland community.Three cross-sectional screening surveys, 2019-2021, complemented by laboratory pathology testing.Small community in northwest Queensland with geographic and cultural ties to Northern Territory communities where trachoma persists.Children aged 1-14 years; opportunistic screening of people aged 15 years or more.Prevalence of clinical signs of trachoma, Chlamydia trachomatis infection, ocular non-chlamydial infections, and seropositivity for antibodies to the C. trachomatis Pgp3 protein.During the three surveys, 73 examinations of 58 children aged 1-4 years, 309 of 171 aged 5-9 years, and 142 of 105 aged 10-14 years for trachoma were undertaken, as were 171 examinations of 164 people aged 15 years or more; 691 of 695 examinations were of Aboriginal or Torres Strait Islander people (99%), 337 were of girls or young women (48%). Clinical signs consistent with trachomatous inflammation-follicular were identified in 5-9-year-old children 23 times (7%), including in eleven with non-chlamydial infections and one with a C. trachomatis infection. One child (10-14 years) met the criteria for trachomatous scarring. Two of 272 conjunctival swab samples (all ages) were polymerase chain reaction-positive for C. trachomatis (0.7%). Two of 147 people aged 15 years or more examined in 2019 had trichiasis, both aged 40 years or more. Seven of 53 children aged 1-9 years in 2019 and seven of 103 in 2021 were seropositive for anti-Pgp3 antibodies.Despite the prevalence of clinical signs consistent with trachomatous inflammation-follicular among 5-9-year-old children exceeding the 5% threshold for community-wide treatment, laboratory testing indicated that childhood exposure to ocular C. trachomatis is rare in this community. Laboratory testing should be integrated into Australian trachoma guidelines.

Despite the “best of intentions”, Australia has fallen short of federal targets to close the gap in disproportionate health outcomes between Aboriginal and non-Aboriginal Australians. We examined 2150 original research articles published over the 12-year period (from 2008 to 2020), of which 58% used descriptive designs and only 2.6% were randomised controlled trials. There were few national studies. Studies were most commonly conducted in remote settings (28.8%) and focused on specific burdens of disease prevalent in remote areas, such as infectious disease, hearing and vision. Analytic observational designs were used more frequently when addressing burdens of disease, such as cancer and kidney and urinary, respiratory and endocrine diseases. The largest number of publications focused on mental and substance use disorders (n = 322, 20.5%); infectious diseases (n = 222, 14.1%); health services planning, delivery and improvement (n = 193, 33.5%); and health and wellbeing (n = 170, 29.5%). This review is timely given new investments in Aboriginal health, which highlights the importance of Aboriginal researchers, community leadership and research priority. We anticipate future outputs for Aboriginal health research to change significantly from this review, and join calls for a broadening of our intellectual investment in Aboriginal health.

This study aimed to describe Aboriginal and Torres Strait Islander women's views of self-collection introduced in the renewed National Cervical Screening Program.A total of 79 Aboriginal and/or Torres Strait Islander women (50 screened in previous five years, 29 under-screened) from five clinics across three Australian states/territories participated. Topics discussed were perceptions of self-collection, the instruction card and suggestions for implementing self-collection. We employed yarning (a qualitative method), which established relationships and trust between participants and researchers to facilitate culturally safe conversations. Transcripts were analysed thematically.Most women were unaware of self-collection before the yarn but found it to be an acceptable way to participate in cervical screening. Women perceived self-collection would be convenient, provide a sense of control over the screening experience, and maintain privacy and comfort. The instructions were perceived to be simple and easy to follow. Women had concerns about collecting the sample correctly and the accuracy of the sample (compared to clinician-collected samples).Self-collection is acceptable to Aboriginal and Torres Strait Islander women.Given the inequitable burden of cervical cancer experienced by Aboriginal and Torres Strait Islander women, self-collection is likely to significantly improve participation and ultimately improve cervical cancer outcomes.

Recent surveys identified trachomatous inflammation - follicular (TF) at endemic levels in the Torres Strait Islands; however, local health staff do not report trachomatous trichiasis (TT) in adults. We undertook a cross-sectional survey involving eye examination and microbiological testing to better understand this disconnect.We examined 169 of 207 (82%) residents and collected ocular swabs for polymerase chain reaction (PCR) testing for Chlamydia trachomatis. Other viral PCR tests and bacterial culture were also performed.TF prevalence in children aged 5-9 years was 23% (7/30). No ocular C. trachomatis was identified by PCR. For the 72 participants (43%) with follicles, bacterial culture was positive for 11 (15%) individuals. No individual had trachomatous trichiasis.Follicular conjunctivitis consistent with TF was prevalent but ocular C. trachomatis and cicatricial trachoma were absent. Non-chlamydial infections or environmental causes of follicular conjunctivitis may be causing TF in this community.In similar settings, reliance on simplified clinical assessment alone may lead to an overestimation of the public health problem posed by trachoma. Consideration should be given to incorporating C. trachomatis PCR, and in certain settings, a detailed clinical exam could be performed by an experienced ophthalmologist during prevalence surveys.

BackgroundSchools are the primary setting for the delivery of adolescent HPV vaccination in Australia. Although this strategy has achieved generally high vaccination coverage, gaps persist for reasons that are mostly unknown. This study sought to identify school-level correlates of low vaccination course initiation and completion in New South Wales, Tasmania, and Western Australia to inform initiatives to increase uptake.MethodsInitiation was defined as the number of first doses given in a school in 2016 divided by vaccine-eligible student enrolments. Completion was the number of third doses given in a school in 2015-2016 divided by the number of first doses. Low initiation and completion were defined as coverage ≤ 25thpercentile of all reporting schools. We investigated correlations between covariates using Spearman's rank correlation coefficients. Due to multicollinearity, we used univariable logistic regression to investigate associations between school characteristics and low coverage.ResultsMedian initiation was 84.7% (IQR: 75.0%-90.4%) across 1,286 schools and median completion was 93.8% (IQR: 86.0%-97.3%) across 1,295 schools. There were strong correlations between a number of school characteristics, particularly higher Indigenous student enrolments and lower attendance, increasing remoteness, higher postcode socioeconomic disadvantage, and smaller school size. Characteristics most strongly associated with low initiation in univariate analyses were small school size, location in Tasmania, and schools catering for special educational needs. Low completion was most strongly associated with schools in Tasmania and Western Australia, remote location, small size, high proportion of Indigenous student enrolments, and low attendance rates.ConclusionThis study provides indicative evidence that characteristics of schools and school populations are associated with the likelihood of low initiation and completion of the HPV vaccination course. The findings will guide further research and help target initiatives to improve vaccination uptake in schools with profiles associated with lower coverage.

BACKGROUND Human papillomavirus (HPV) infection, a common sexually transmitted disease, is associated with cancers of the cervix, vulva, vagina, penis, anus, and head and neck. Oropharyngeal squamous cell carcinoma (OPSCC; throat cancer) is a type of cancer involving the head and neck area that is rapidly increasing across the globe. There are higher rates of OPSCC among Indigenous populations relative to non–Indigenous Australian populations, although the HPV-attributable fraction remains unknown. For the first time at a global level, we plan to extend an Indigenous Australian adult cohort to monitor, screen, and ultimately prevent HPV-associated OPSCC and to undertake extensive cost-effectiveness modelling around HPV vaccination. OBJECTIVE This study aims to (1) extend follow-up to a minimum of 7 years post recruitment to describe the prevalence, incidence, clearance, and persistence of oral HPV infection; and (2) conduct clinical examinations of the head and neck, oral cavity, and oropharynx and collect saliva samples for early-stage OPSCC testing. METHODS We will continue to implement a longitudinal design for the next study phase, where we will ascertain the prevalence, incidence, clearance, and persistence of oral HPV infection at 48, 60, and 72 months; undertake clinical examinations/saliva assessments to detect early-stage OPSCC; and refer for treatment. The primary outcome measures are changes in oral HPV infection status, biomarker measures of early HPV-related cancer, and clinical evidence of early-stage OPSCC. RESULTS Participant 48-month follow-up will commence in January 2023. The first results are expected to be submitted for publication 1 year after 48-month follow-up begins. CONCLUSIONS Our findings have potential to change the way in which OPSCC among Australian Indigenous adults is managed, with desired impacts including cost-savings on expensive cancer treatments; improved nutritional, social, and emotional outcomes; and improved quality of life for both Indigenous adults and the Indigenous community more broadly. Continuing a large, representative Indigenous adult cohort to track oral HPV infection and monitor early OPSCC is essential to yield critical information to include in the management armamentarium of health and well-being recommendations for Australia’s First Nations. INTERNATIONAL REGISTERED REPORT PRR1-10.2196/44593

We undertook a screening program between 2016 and 2019 to determine if trachoma was endemic in the Torres Strait Islands of Queensland, Australia. Eleven screening surveys assessing trachoma prevalence were undertaken in seven communities using the World Health Organization (WHO) simplified grading tool. Additionally, an ophthalmologist performed a detailed clinical assessment including examination for Herbert’s pits and corneal pannus and, where clinically indicated, collection of conjunctival specimens to investigate the presence of Chlamydia trachomatis nucleic acid. Prevalence of trachomatous inflammation—follicular (TF) in children aged 5–9 years for the aggregated first survey across all communities was 6% (17/284). No child had trachomatous inflammation—intense, trachomatous scarring, corneal pannus, or Herbert’s pits. Of the 66 times any child was tested for C. trachomatis by polymerase chain reaction (PCR), the result was negative. No cicatricial trachoma was identified amongst the adults (n = 186) who were opportunistically offered examination. Whilst TF was present, the lack of intense inflammatory thickening in any child examined, the lack of end-stage trachomatous disease, and the lack of ocular C. trachomatis detection by PCR indicate trachoma is not endemic in the Torres Strait Islands, and no ongoing public health intervention is required. These findings add to a growing body of evidence suggesting that use of the WHO simplified grading tool alone in the peri-elimination setting may overestimate the community burden of trachoma.

IntroductionAboriginal and Torres Strait Islander peoples are the First Peoples of Australia. Since settler colonisation, Aboriginal and Torres Strait Islander peoples have experienced disparities in health outcomes, including cancer, when compared with non-Indigenous Australians, including higher cancer incidence and mortality rates, and lower participation in cancer screening programmes. Data to monitor and improve outcomes are limited.Aims, method and analysisThe Kulay Kalingka Study will be a national cohort study aiming to understand Aboriginal and Torres Strait Islander people’s beliefs about cancer and experiences with cancer care and treatment, and to improve experiences and outcomes. It will be nested within the Mayi Kuwayu Study, a national community-controlled cohort study of Aboriginal and Torres Strait Islander people (n>11 000), with supplementary in-community recruitment.Mayi Kuwayu Study participants aged ≥18 years who consented to being recontacted, and a diversity of local community members will be invited to participate through completing a questionnaire relevant to their cancer status, aiming to recruit 2800 participants without prior doctor-diagnosed cancer and 700 with a cancer diagnosis.This community-driven data will enable monitoring and reporting of national trends over time and will guide national cancer control research, policy and clinical care, to improve outcomes for Aboriginal and Torres Strait Islander peoples.Ethics and disseminationThe Kulay Kalingka Study has ethics approval from Australian Institute of Aboriginal and Torres Strait Islander Studies (#EO324-20220414 and REC-0121) and the Australian National University (#2022/465). The Kulay Kalingka Study is being developed with Aboriginal and Torres Strait Islander communities, following the Maiam nayri Wingara Indigenous Data Sovereignty Collective principles. Meaningful, accessible and culturally adapted study findings will be disseminated to Aboriginal and Torres Strait Islander communities through activities including community workshops, reports and feedback sheets, and in other ways as determined by the community. We will also return data to participating communities.

Objective: To investigate perspectives of primary health care providers (HCPs) on providing cervical screening for Aboriginal and Torres Strait Islander women, who experience a higher burden of cervical cancer than other Australian women. Methods: Semi‐structured interviews with 13 HCPs from four Australian Indigenous primary health care centres (PHCCs). Transcripts were thematically analysed. Results: HCPs discussed the need to approach cervical screening with sensitivity to women's emotional and cultural needs and sustaining relationships built on trust and respect. HCPs reported challenges in promoting screening to Aboriginal and Torres Strait Islander women due to cumbersome systems, competing clinical priorities, workforce capacity limitations and specific challenges associated with implementing the renewed National Cervical Screening Program. Conclusions: In practice, HCPs experience several challenges to delivering cervical screening. Understanding HCPs’ perspectives on their approach to cervical screening delivery, and the systems in which this occurs, can help to ensure that they receive adequate support and resources to deliver cervical screening to Aboriginal and Torres Strait Islander women. Implications for public health: It is important that HCPs adopt a multi‐faceted, person‐centred approach to cervical screening that is responsive to women's needs and that works synchronously with supportive PHCC services and systems and the National Cancer Screening Register.

Objective Despite Australia’s National Cervical Screening Program, Indigenous women have a disproportionately high burden of cervical cancer. We describe temporal and area-level patterns in prevalence of histologically conformed high-grade cervical abnormalities (hHGA) among cytologically screened women by Indigenous status. Methods This was a population-based study of 2,132,925 women, aged 20–69, who underwent cervical screening between 2008 and 2017, in Queensland, Australia. Of these, 47,136 were identified as Indigenous from linked hospital records. Overall patterns in hHGA prevalence by Indigenous status were quantified using prevalence rate ratios (PrRR) from negative binomial models. Bayesian spatial models were used to obtain smoothed prevalence estimates of hHGA across 528 small areas compared to the state average. Results are presented as maps and graphs showing the associated uncertainty of the estimates. Results Overall, screened Indigenous women had significantly higher hHGA prevalence than non-Indigenous women. However, the magnitude of the difference reduced over time ( p Conclusions While the temporal reduction in Indigenous: non-Indigenous differential in hHGA prevalence is encouraging, further research into the key drivers of the continuing higher risk among Indigenous women is warranted.

Ethical publishing practices are vital to tobacco control research practice, particularly research involving Indigenous (Indigenous peoples: For the purposes of this Special Communication, we use the term Indigenous people(s) to include self-identified individuals and communities who frequently have historical continuity with precolonial/presettler societies; are strongly linked to the land on which they or their societies reside; and often maintain their own distinct language(s), belief and social-political systems, economies and sciences. The authors humbly acknowledge, respect and value that Indigenous peoples are diverse and constitute many nations, cultures and language groups. Many Indigenous peoples also exist as governments in treaty relations with settler-colonial societies, and all Indigenous peoples have inherent rights under international law. The language and terminology used should reflect the local context(s) and could include, but are not limited to, terms such as Aboriginal, Bagumani, Cherokee, First Peoples, First Nations, Inuit, Iwaidja, Kungarakan, Lakota, Māori, Mѐtis, American Indian, Navajo, Wagadagam, Wiradjuri, Yurok, etc) people. These practices can minimise, correct and address biases that tend to privilege Euro-Western perspectives. Ethical publishing practices can minimise and address harms, such as appropriation and misuse of knowledges; strengthen mechanisms of accountability to Indigenous peoples and communities; ensure that tobacco control research is beneficial and meaningful to Indigenous peoples and communities; and support Indigenous agency, sovereignty and self-determination. To ensure ethical practice in tobacco control, the research methodology and methods must incorporate tangible mechanisms to include and engage those Indigenous peoples that the research concerns, affects and impacts.Tobacco Controlis currently missing an ethical research and evaluation publishing protocol to help uphold ethical practice. The supporters of this Special Communication call onTobacco Controlto adopt publication practice that explicitly upholds ethical research and evaluation practices, particularly in Indigenous contexts. We encourage researchers, editors, peer reviewers, funding bodies and those publishing inTobacco Controlto reflect on their conduct and decision-making when working, developing and undertaking research and evaluation of relevance to Indigenous peoples.Tobacco Controland other publishers, funding bodies, institutions and research teams have a fundamental role in ensuring that the right peoples are doing the right work in the right way. We call forTobacco Controlto recognise, value and support ethical principles, processes and practices that underpin high-quality, culturally safe and priority-driven research, evaluation and science that will move us to a future that is commercial tobacco and nicotine free.

Background: Australian adolescents are routinely offered HPV and dTpa (diphtheria, tetanus, pertussis) vaccines simultaneously in the secondary school vaccination program. We identified schools where HPV initiation was lower than dTpa coverage and associated school-level factors across three states. Methods: HPV vaccination initiation rates and dTpa vaccination coverage in 2016 were calculated using vaccine databases and school enrolment data. A multivariate analysis assessed sociodemographic and school-level factors associated with HPV initiation being &gt, 5% absolute lower than dTpa coverage. Results: Of 1280 schools included, the median school-level HPV initiation rate was 85% (interquartile range (IQR):75–90%) and the median dTpa coverage was 86% (IQR:75–92%). Nearly a quarter (24%) of all schools had HPV vaccination initiation &gt, 5% lower than dTpa coverage and 11 % had &gt, 10% difference. School-level factors independently associated with &gt, 5% difference were remote schools (aOR:3.5, 95% CI = 1.7–7.2) and schools in major cities (aOR:1.8, 95% CI = 1.0–3.0), small schools (aOR:3.3, 95% CI = 2.3–5.7), higher socioeconomic advantage (aOR:1.7, 95% CI = 1.1–2.6), and lower proportions of Language-background-other-than-English (aOR:1.9, 95% CI = 1.2–3.0). Conclusion: The results identified a quarter of schools had lower HPV than dTpa initiation coverage, which may indicate HPV vaccine hesitancy, and the difference was more likely in socioeconomically advantaged schools. As hesitancy is context specific, it is important to understand the potential drivers of hesitancy and future research needs to understand the reasons driving differential uptake.

This paper outlines the development of Indigenist Health Humanities as a new and innovative field of research building an intellectual collective capable of bridging the knowledge gap that hinders current efforts to close the gap in Indigenous health inequality. Bringing together health and the humanities through the particularity of Indigenous scholarship, a deeper understanding of the human experience of health will be developed alongside a greater understanding of the enablers to building a transdisciplinary collective of Indigenist researchers. The potential benefits include a more sustainable, relational, and ethical approach to advancing new knowledge, and health outcomes, for Indigenous people in its fullest sense.

IntroductionAboriginal and Torres Strait Islander women experience a higher burden of cervical cancer than non-Indigenous women in Australia. Cervical cancer is preventable partly through human papillomavirus (HPV) vaccination; in Australia, this is delivered through the national school-based immunisation programme. While HPV vaccination uptake is high among Australian adolescents, there remain gaps in uptake and completion among Aboriginal and Torres Strait Islander adolescents. This study aims to gain a comprehensive understanding of the barriers and facilitators to HPV vaccination uptake and completion among Aboriginal and Torres Strait Islander adolescents in Queensland, Australia.Methods and analysisThe study will be guided by an Indigenist research approach and an ecological model for health promotion. Yarning, a qualitative Indigenous research method, will be conducted in up to 10 schools. Participants will include Year 7 (12/13 years old) Aboriginal and Torres Strait Islander adolescents; parents/caregivers; and local key informants and immunisation programme partners involved in the delivery of school-based HPV immunisation programme. Participants will be recruited through school representatives and investigator networks using purposive and snowball sampling and samples of convenience. Field notes, HPV vaccination clinic observations and sequential diagramming of the HPV vaccination process will be conducted. Thematic analysis of data will be led by Aboriginal and Torres Strait Islander researchers. Synthesised sequential diagrams of the process of HPV vaccination and qualitative themes summarising key findings will be produced.Ethics and disseminationThe Aboriginal Health and Medical Research Council of New South Wales Ethics Committee (1646/20), the Australian National University Human Research Ethics Committee (HREC, 2020/478), the HREC of the Northern Territory Department of Health and Menzies School of Health Research (19-3484) and the Townsville Hospital and Health Service HREC (HREC/QTHS/73789) have approved the study. Dissemination will occur via conferences and peer-reviewed publications. Further dissemination will be determined in partnership with the Aboriginal and Torres Strait Islander Steering Committee, including Youth Representatives and Consultation Network.

Wellbeing is culturally bound and is shaped by many aspects of life, including experiences, beliefs and values. As such, in order to accurately measure wellbeing for a specific cultural group, it is necessary to understand the experiences, beliefs and values that influence the conception and experience of wellbeing of that group. This paper presents a conceptual model of wellbeing for Aboriginal and Torres Strait Islander people, which was developed from a large national qualitative study that explored the views of 359 Aboriginal and Torres Strait Islander adults. An Aboriginal- and Torres Strait Islander-led research team used an Indigenist research approach to iteratively develop this conceptual model, called the Fabric of Aboriginal and Torres Strait Islander Wellbeing model, which takes inspiration from Aboriginal and Torres Strait Islander weaving traditions whereby individual strands are twined to create fabrics that are both beautiful and strong. This reflects our findings that the parts of life that are most important to wellbeing for many Aboriginal and Torres Strait Islander people are interwoven with their families, communities and culture.

BackgroundAboriginal and Torres Strait Islander Community-Controlled Health Organisations (ACCHOs) provides culturally appropriate primary care for Aboriginal and Torres Strait Islander people in Australia. The population of North Queensland has a higher proportion of Aboriginal and Torres Strait Islander people, a greater population coverage of ACCHOs, and higher cervical screening participation than the Rest of Queensland. The association between regional differences in the use of ACCHOs for cervical screening and variations in screening participation among Aboriginal and Torres Strait Islander women is currently unknown.MethodsThis is a population-based study of 1,107,233 women, aged 20–69 years who underwent cervical screening between 2013 and 2017. Of these women, 132,972 (12%) were from North Queensland, of which 9% were identified as Aboriginal and Torres Strait Islander women (2% Rest of Queensland) through linkage to hospital records. Regional differentials in screening by Aboriginal and Torres Strait Islander status were quantified using participation rate ratios (PRRs) with 95% confidence intervals (CIs) from negative binomial regression models. Logistic regression was used to identify factors associated with Aboriginal and Torres Strait Islander women being screened at ACCHOs.ResultsAboriginal and Torres Strait Islander women from North Queensland (versus) Rest of Queensland had higher odds of screening at ACCHOs after adjusting for age and area-level variables. After adjustment for non-ACCHO variables, the regional differential in screening among Aboriginal and Torres Strait Islander women was significantly higher (PRR 1.28, 95% CI 1.20–1.37) than that among other Australian women [PRR = 1.11 (1.02–1.18)], but was attenuated on further adjustment for ACCHO variables, [PRR = 1.15, (1.03–1.28)] to become similar to the corresponding point estimate for other Australian women [PRR = 1.09, (1.01–1.20)]. However, the significant interaction between Aboriginal and Torres Strait Islander status and region (p < 0.001) remained, possibly reflecting the large cohort size. Screening participation increased with better access to health services for all women.ConclusionsImproving access to primary health care for Aboriginal and Torres Strait Islander women, especially through ACCHOs, may reduce existing disparities in cervical screening participation. Further gains will require greater levels of local community engagement and understanding of the experiences of screened Aboriginal and Torres Strait Islander women to inform effective interventions.

Aboriginal and Torres Strait Islander people experience a greater range of health and social disadvantages compared to other Australians. Wellbeing is a culturally-bound construct, and to date, a national evidence base around the components of wellbeing for Aboriginal and Torres Strait Islander people is lacking. Understanding and measurement of wellbeing for this population is critical in achieving health equity. This paper aims to identify and describe the foundations of wellbeing for Aboriginal and Torres Strait Islander adults. This national qualitative study was underpinned by an Indigenist research approach which privileges the voices of Aboriginal and Torres Strait Islander people. Aboriginal and Torres Strait Islander adults were purposively recruited from around Australia between September 2017 and September 2018 to participate in Yarning Circles, led by Aboriginal and Torres Strait Islander researchers. Yarning Circles were audio recorded, transcribed and analyzed. A Collaborative Yarning Methodology was used, which incorporated reflexive thematic analysis to identify and describe the foundations of wellbeing reported by participants. A total of 359 Aboriginal and Torres Strait Islander adults participated. Our analysis revealed five foundations of wellbeing: belonging and connection, holistic health, purpose and control, dignity and respect, and basic needs. These foundations were deeply interwoven by three interconnected aspects of Aboriginal and Torres Strait Islander life: family, community and culture. The findings of this study will substantially aid our efforts to develop a new wellbeing measure for Aboriginal and Torres Strait Islander adults. The iterative Indigenist methods used in this study provide a robust research methodology for conducting large-scale, nationally-relevant qualitative research with Aboriginal and Torres Strait Islander people. Policies and practices that are informed by our results have the potential to address outcomes that are meaningful for Aboriginal and Torres Strait Islander people.

IntroductionCardiovascular disease (CVD) represents a significant burden of disease for Aboriginal and Torres Strait Islander people, a population that continues to experience a lower life expectancy than other Australians. The aim of the Better Cardiac Care Data Linkage project is to describe patient care pathways and to identify disparities in care and health outcomes between Aboriginal and Torres Strait Islander people and other Queensland residents diagnosed with CVD in the state of Queensland.MethodsThis is a population-based retrospective cohort study using linked regional, state and national health and administrative data collections to describe disparities in CVD healthcare in primary and secondary prevention settings and during hospitalisation. The CVD cohort will be identified from the Queensland Hospital Admitted Patient Data Collection for admissions that occurred between 1 July 2010 and 31 June 2016 and will include relevant International Classification of Disease codes for ischaemic heart disease, congestive heart failure, stroke, acute rheumatic fever and rheumatic heart disease. Person-level data will be linked by Data Linkage Queensland and the Australian Institute of Health and Welfare (AIHW) in accordance with ethical and public health approvals to describe the patient journey prior to, during and post the hospital admission.AnalysisThis project will focus largely on descriptive epidemiological measures and multivariate analysis of clinical care standards and outcomes for Aboriginal and Torres Strait Islander people compared with other Queenslanders, including identification of risk factors for suboptimal care and change over time. Variation in care pathways and patient outcomes will be compared by Indigenous status, sex, age group, remoteness of residence, year of index hospitalisation and socioeconomic status. Cox models for time-to-event data and mixed models or generalised estimating equations for longitudinal data will be used to measure change over time where temporal effects exist.Ethics and disseminationEthical approval has been granted by Human Research Ethics Committees of the Prince Charles Hospital (HREC/15/QPCH/289) and the AIHW (EO2016-1-233). The Northern Territory Department of Health and Menzies School of Health Research have also provided reciprocal ethical approval of the project (HREC 2019–3490). The deidentified results will be summarised in a report and shared with investigators, advisory groups, Queensland Health and key stakeholders. Findings will be disseminated through workshops, conferences and will be published in peer-reviewed journals.

Chelsea Bond is a recipient of an Australian Research Council Discovery Early Career Award (180100090). Lisa Whop is a recipient of a National Health and Medical Research Council Early Career Fellowship (1142035), and a member of the Aboriginal and Torres Strait Islander Health Strategy Group of the Australian Health Practitioner Regulation Agency.

Achieving the World Health Organisation (WHO) cervical cancer elimination target of fewer than four new cases per 100,000 woman-years requires scaling up HPV vaccination of girls, cervical screening, and pre-cancer and cancer treatment. We reviewed data from four high-income colonised countries (Australia, Canada, Aotearoa New Zealand (NZ), and the United States (US)) to identify how each is currently performing compared to the cervical cancer incidence elimination and triple-intervention targets, nationally and in Indigenous women. We also summarise barriers and enablers to meeting targets for Indigenous women. To achieve elimination, cervical cancer incidence must be reduced by 74% in Indigenous women in Australia, and 63% in Maori women in NZ; data were not published in sufficient detail to compare incidence in Indigenous women in Canada or the US to the WHO target. Only Australia meets the vaccination coverage target, but uptake appears comparatively equitable within Australia, NZ and the US, whereas there appears to be a substantial gap in Canada. Screening coverage is lower for Indigenous women in all four countries though the differential varies by country. Currently, only Australia universally offers HPV-based screening. Data on pre-cancer and cancer treatment were limited in all countries. Large inequities in cervical cancer currently exist for Indigenous peoples in Australia, Canada, New Zealand and the US, and elimination is not on track for all women in these countries. Current data gaps hinder improvements. These countries must urgently address their systemic failure to care and provide health care for Indigenous women.

Indigenous women continue to experience a disproportionately higher burden of cervical cancer than non‐Indigenous women in Australia. The National Indigenous Cervical Screening Project used probabilistic record linkage to combine population‐based administrative databases and identify Indigenous women on Pap Smear Registers. This study aimed to quantify the spatial variation by local government areas (LGAs) for Indigenous and non‐Indigenous women in Queensland in cervical screening participation rates and related outcomes. Empirical Bayes local geostatistical smoothing was performed to reduce the likelihood of spurious variation between small areas. The cohort included 1,091,260 women (2 per cent Indigenous) aged 20 to 69 with 2,393,708 Pap smears between 2006 and 2011. Indigenous women had smoothed LGA‐specific 5‐year participation rates (interquartile range (IQR) 38.9–53.3 per 100 eligible women) consistently lower than non‐Indigenous women (IQR 80.7–85.3). The non‐overlapping confidence intervals of these rates suggest that the Indigenous differential was significant. Compared with Indigenous women, non‐Indigenous women had consistently lower and more stable prevalence rates of histologically confirmed high grade abnormalities (IQR 8.0–10.1 versus 15.0–21.3 per 1,000 screened women). Although the LGA‐specific rates also suggest that a higher proportion of non‐Indigenous women were followed‐up within two months of an abnormal screening result, the wide confidence intervals for these estimates limit our ability to draw definitive conclusions about spatial patterns for this outcome. These findings highlight the importance of continued monitoring and ongoing efforts to identify drivers of these patterns and develop effective strategies to improve participation and potentially reduce the cervical cancer burden among Indigenous women.

Indigenous and Tribal peoples account for approximately 6 [...]

There are significant health and social disparities between the world's Indigenous and non-Indigenous people on factors likely to influence quality of life (QOL) and wellbeing. However, these disparities in wellbeing are not captured in conventional QOL instruments, as they often do not include dimensions that are likely to be relevant to Indigenous people. The objective of this comprehensive literature review was to identify these wellbeing domains for Aboriginal and Torres Strait Islander people in Australia (hereafter, respectfully referred to collectively as Indigenous Australians). We searched PsycINFO, MEDLINE, Econlit, CINAHL, and Embase (from inception to June 2017, and updated in March 2019), and grey literature sources using keywords relating to adult Indigenous Australians' QOL and wellbeing. From 278 full-text articles assessed for eligibility, 95 were included in a thematic analysis. This synthesis revealed nine broad interconnected wellbeing dimensions: autonomy, empowerment and recognition; family and community; culture, spirituality and identity; Country; basic needs; work, roles and responsibilities; education; physical health; and mental health. The findings suggest domains of wellbeing relevant to and valued by Indigenous Australians that may not be included in existing QOL and wellbeing instruments, domains that may be shared with Indigenous populations globally. This indicates the need for a tailored wellbeing instrument that includes factors relevant to Indigenous Australians. Developing such an instrument will ensure meaningful, culturally-relevant measurement of Indigenous Australians' wellbeing.

Background There is a disparity in the burden of gynaecological cancer for Indigenous women compared with non-Indigenous women in Australia. Understanding how Indigenous women currently experience gynaecological cancer care services and factors that impact on their engagement with care is critical. This study explored Indigenous Australian women’s experience of gynaecological cancer care at a major metropolitan hospital in Queensland. Methods Indigenous women receiving care at a major metropolitan Queensland hospital for investigation or diagnosis of gynaecological cancer were invited to participate in a larger longitudinal study exploring women’s experiences of gynaecological cancer care. This component was an in-depth, qualitative interview exploring the women’s experiences of hospital care at approximately three-month post initial referral. A peer-approach was used to interview women. Hospital-based care providers involved in the care of Indigenous gynaecological cancer patients were invited to be interviewed. Interviews were transcribed and thematically analysed using an interpretative phenomenological approach enabling a multi-layered, contextualised understanding of the patients' experience and their interaction with tertiary cancer services. Results Eight Indigenous patients and 18 care providers were interviewed. Analysis of all interviews revealed four broad issues affecting Indigenous patients’ early experiences of care: (1) navigating the system, impacted by timely diagnosis, access to support services and follow up; (2) communication and decision-making, patients’ decision-making, efficacy of doctor-patient communication, and patients’ knowledge about cancer; (3) coping with treatment demands, was impacted by emotional stress, access to services and support by hospital staff; and (4) feeling welcome and safe in the hospital, impacted by patients’ relationship with care providers and their access to culturally-safe services. The combination of factors impacting these women’s’ experience of gynaecological care commonly left these women at breaking point, often with limited access to information, resources or support. Conclusions Our findings revealed that experiences of cancer care for Indigenous women are overlain by challenges associated with late referral, misdiagnosis, miscommunication, lack of information, logistics in accessing treatment and services and system cultural insensitivities. Our findings offer insights that can inform cancer care provision to more effectively support Indigenous women accessing gynaecological cancer services. Electronic supplementary material The online version of this article (10.1186/s12913-019-4455-9) contains supplementary material, which is available to authorized users.

Objective Cervical cancer mortality has halved in Australia since the national cervical screening program began in 1991, but elevated mortality rates persist for Aboriginal and Torres Strait Islander women (referred to as Aboriginal women in this report). We investigated differences by Aboriginal status in abnormality rates predicted by cervical cytology and confirmed by histological diagnoses among screened women. Methods Using record linkage between cervical screening registry and public hospital records in South Australia, we obtained Aboriginal status of women aged 20–69 for 1993–2016 (this was not recorded by the registry). Differences in cytological abnormalities were investigated by Aboriginal status, using relative risk ratios from mixed effect multinomial logistic regression modelling. Odds ratios were calculated for histological high grade results for Aboriginal compared with non-Aboriginal women. Results Of 1,676,141 linkable cytology tests, 5.8% were abnormal. Abnormal results were more common for women who were younger, never married, and living in a major city or socioeconomically disadvantaged area. After adjusting for these factors and numbers of screening episodes, the relative risk of a low grade cytological abnormality compared with a normal test was 14% (95% confidence interval 5–24%) higher, and the relative risk of a high grade cytological abnormality was 61% (95% confidence interval 44–79%) higher, for Aboriginal women. The adjusted odds ratio of a histological high grade was 76% (95% confidence interval 46–113%) higher. Conclusions Ensuring that screen-detected abnormalities are followed up in a timely way by culturally acceptable services is important for reducing differences in cervical cancer rates between Aboriginal and non-Aboriginal women.

BACKGROUND: Cervical cancer incidence and mortality have declined in Australia since the implementation of a national cervical screening program in 1991, however, disparities in both measures between Indigenous and non-Indigenous women remain. We describe spatial and temporal changes in Pap test participation rates by Indigenous status for Queensland (Australia). Analyses were done in the context of renewed screening program in December 2017. METHODS: Population-based study 2,132,925 Queensland female residents, aged 20-69 years who underwent cervical screening from 2008 to December 2017; 47,136 were identified as Indigenous through linkage to hospital records. Bayesian spatial models were used to generate smoothed estimates of participation across 528 small areas during 2008-2012 and 2013-2017 compared to the overall state average (2008-2017). Results are presented as thematic maps and graphs showing the associated uncertainty of the estimates. RESULTS: Overall screening participation decreased over time for both Indigenous and non-Indigenous women. Strong spatial patterns were evident in five-year participation for both groups. Indigenous women had significantly lower participation than the Queensland average for ≥ 88 % of areas during both reporting periods whereas corresponding estimates were lower than average for

ObjectiveTo describe parents'/carers' views of the characteristics of a clinical service model shown to improve asthma outcomes.

Aboriginal and Torres Strait Islander (collectively, Indigenous Australian) women experience a higher burden of cervical cancer than other women. The National Cervical Screening Program (NCSP) is failing to meet the needs of Indigenous Australian women, resulting in many women not regularly participating in cervical screening. However, one third of Indigenous Australian women do participate in cervical screening. The reasons that some women in this population commence and continue to screen remain unheard but could provide insights to support women who currently do not participate. We aimed to describe Indigenous Australian women's experiences and views of participation in cervical screening by yarning (a culturally-appropriate interview technique) with 50 Indigenous Australian women aged 25-70 years who had completed cervical screening in the past five years, recruited via Primary Health Care Centres (PHCCs) from three jurisdictions. Aboriginal or Torres Strait Islander women researchers conducted the interviews. Thematic analysis identified six themes: screening as a means of staying strong and in control; overcoming fears, shame, and negative experiences of screening; needing to talk openly about screening; the value of trusting relationships with screening providers; logistical barriers; and overcoming privacy concerns for women employed at PHCCs. Despite describing screening as shameful, invasive, and uncomfortable, women perceived it as a way of staying healthy and exerting control over their health. This ultimately supported their participation and a sense of empowerment. Women valued open discussion about screening and strong relationships with health providers. We identified logistical barriers and specific barriers faced by women employed at PHCCs. This study is strengthened by a research approach that centred Indigenous Australian women's voices. Understanding the experiences of Indigenous Australian women who participate in screening will help screening providers support women to start and continue to screen regularly. Recommendations for practice are provided.

Objective To estimate human papillomavirus (HPV) vaccination coverage and course completion rates for Indigenous adolescents in four Australian states and territories. Participants, setting Adolescents who were 12 years old in 2015 and received the quadrivalent HPV vaccine (three doses: 0, 2, 6 months) as part of the National HPV Vaccination Program in 2015 or 2016 in New South Wales, Queensland, the Northern Territory, or the Australian Capital Territory. Main outcome measures Estimated HPV vaccination coverage by dose and by Indigenous status and sex, based on National HPV Vaccination Program Register data; vaccination course completion rates (proportion of dose 1 recipients who received dose 3) for 12-year-olds vaccinated during 2013-2016, by sex, jurisdiction, and Indigenous status. Results Dose 1 coverage exceeded 80% for all Indigenous status/jurisdiction/sex groups (range, 83.3-97.7%). Coverage was similar for Indigenous and non-Indigenous girls in Queensland (87.3% v 87.0%), lower for Indigenous girls in the ACT (88.7% v 97.7%) and the NT (91.1% v 97.0%), and higher in NSW (95.9% v 89.9%); it was similar for Indigenous and non-Indigenous boys in all jurisdictions except the NT (88.6% v 96.3%). Dose 3 coverage (range, 61.2-87.7%) was markedly lower for Indigenous than non-Indigenous 12-year-olds in all jurisdictions, except for girls in NSW (82.6% v 83.6%). Conclusion HPV vaccine coverage is high, but course completion is generally lower for Indigenous adolescents. Strategies for improving completion rates for Indigenous Australians are needed to end the higher burden of cervical cancer among Indigenous than non-Indigenous women.

Background Little is known about the impact of comorbidity on cervical cancer survival in Australian women, including whether Indigenous women’s higher prevalence of comorbidity contributes to their lower survival compared to non-Indigenous women. Methods Data for cervical cancers diagnosed in 2003–2012 were extracted from six Australian state-based cancer registries and linked to hospital inpatient records to identify comorbidity diagnoses. Five-year cause-specific and all-cause survival probabilities were estimated using the Kaplan-Meier method. Flexible parametric models were used to estimate excess cause-specific mortality by Charlson comorbidity index score (0,1,2+), for Indigenous women compared to non-Indigenous women. Results Of 4,467 women, Indigenous women (4.4%) compared to non-Indigenous women had more comorbidity at diagnosis (score 1: 24.2% vs. 10.0%) and lower five-year cause-specific survival (60.2% vs. 76.6%). Comorbidity was associated with increased cervical cancer mortality for non-Indigenous women, but there was no evidence of such a relationship for Indigenous women. There was an 18% reduction in the Indigenous: non-Indigenous hazard ratio (excess mortality) when comorbidity was included in the model, yet this reduction was not statistically significant. The excess mortality for Indigenous women was only evidentamong those without comorbidity (Indigenous: non-Indigenous HR 2.5, 95%CI 1.9–3.4), indicating that factors other than those measured in this study are contributing to the differential. In a subgroup of New South Wales women, comorbidity was associated with advanced-stage cancer, which in turn was associated with elevated cervical cancer mortality. Conclusions Survival was lowest for women with comorbidity. However, there wasn’t a clear comorbidity-survival gradient for Indigenous women. Further investigation of potential drivers of the cervical cancer survival differentials is warranted. Impact The results highlight the need for cancer care guidelines and multidisciplinary care that can meet the needs of complex patients. Also, primary and acute care services may need to pay more attention to Indigenous Australian women who may not obviously need it (i.e. those without comorbidity) Refereed/Peer-reviewed

Objective To examine the association between residential remoteness and stage of cancer at diagnosis, treatment uptake, and survival within the Australian Indigenous population. Design Systematic review and matched retrospective cohort study. Setting Australia. Participants Systematic review: published papers that included a comparison of cancer stage at diagnosis, treatment uptake, mortality and/or survival for Indigenous people across remoteness categories were identified (n = 181). Fifteen papers (13 studies) were included in the review. Original analyses: new analyses were conducted using data from the Queensland Indigenous Cancer Study (QICS) comparing cancer stage at diagnosis, treatment uptake, and survival for Indigenous cancer patients living in rural/remote areas (n = 627, 66%) and urban areas (n = 329, 34%). Main Outcome Measures Systematic review: Papers were included if there were related to stage of disease at diagnosis, treatment, mortality and survival of cancer. Restrictions were not placed on the outcome measures reported (e.g. standardised mortality ratios versus crude mortality rates). Original analyses: Odds ratios (OR, 95%CI) were used to compare stage of disease and treatment uptake between the two remoteness groups. Treatment uptake (treated/not treated) was analysed using logistic regression analysis. Survival was analysed using Cox proportional hazards regression. The final multivariate models included stage of cancer at diagnosis and area-level socioeconomic status (SEIFA). Results Existing evidence of variation in cancer outcomes for Indigenous people in remote compared with metropolitan areas is limited. While no previous studies have reported on differences in cancer stage and treatment uptake by remoteness within the Indigenous population, the available evidence suggests Indigenous cancer patients are less likely to survive their cancer the further they live from urban centres. New analysis of QICS data indicates that Indigenous cancer patients in rural/remote Queensland were less likely to be diagnosed with localised disease and less likely to receive treatment for their cancer compared to their urban counterparts. Conclusion More research is needed to fully understand geographic differentials in cancer outcomes within the Indigenous population. Knowing how geographical location interacts with Indigenous status can help to identify ways of improving cancer outcomes for Indigenous Australians.

Objectives: To investigate time to follow-up (clinical investigation) for Indigenous and non-Indigenous women in Queensland after a high grade abnormality (HGA) being detected by Pap smear. Design, setting, participants: Population-based retrospective cohort analysis of linked data from the Queensland Pap Smear Register (PSR), the Queensland Hospital Admitted Patient Data Collection, and the Queensland Cancer Registry. 34 980 women aged 20e68 years (including 1592 Indigenous women) with their first HGA Pap smear result recorded on the PSR (index smear) during 2000e2009 were included and followed to the end of 2010. Main outcome measures: Time from the index smear to clinical investigation (histology test or cancer diagnosis date), censored at 12 months. Results: The proportion of women who had a clinical investigation within 2 months of a HGA finding was lower for Indigenous (34.1%; 95% CI, 31.8e36.4%) than for non-Indigenous women (46.5%; 95% CI, 46.0e47.0%; unadjusted incidence rate ratio [IRR], 0.65; 95% CI, 0.60e0.71). This difference remained after adjusting for place of residence, area-level disadvantage, and age group (adjusted IRR, 0.74; 95% CI, 0.68e0.81). However, Indigenous women who had not been followed up within 2 months were subsequently more likely to have a clinical investigation than non-Indigenous women (adjusted IRR for 2e4 month interval, 1.21; 95% CI, 1.08e1.36); by 6 months, a similar proportion of Indigenous (62.2%; 95% CI, 59.8e64.6%) and non-Indigenous women (62.8%; 95% CI, 62.2e63.3%) had been followed up. Conclusions: Prompt follow-up after a HGA Pap smear finding needs to improve for Indigenous women. Nevertheless, slow follow-up is a smaller contributor to their higher cervical cancer incidence and mortality than their lower participation in cervical screening. Acknowledgements: The National Indigenous Cervical Screening Project is funded by a National Health and Medical Research Council (NHMRC) Project Grant (104559). This project is part of the NHMRC Centre of Research Excellence in Discovering Indigenous Strategies to Improve Cancer Outcomes via Engagement, Research Translation and Training (DISCOVER-TT CRE; 1041111) and the Cancer Council NSW Strategic Research Partnership to Improve Cancer Control for Indigenous Australians (STREP Ca-CIndA; SRP13-01). We also acknowledge the ongoing support of the Lowitja Institute, Australia’s national institute for Aboriginal and Torres Strait Islander health research. Lisa Whop was supported by a Sidney Myer Health scholarship, a Menzies Enhanced Living scholarship, and a Lowitja Institute scholarship. Abbey Diaz was supported by an NHMRC postgraduate scholarship (1055587) and a DISCOVER-TT CRE-funded Menzies Enhanced Living scholarship. The NHMRC supported Joan Cunningham with a research fellowship (1058244), Patricia Valery with a career development fellowship (1083090), and Karen Canfell with a career development award (1082989). We acknowledge the staff and registrars from the Queensland Health Pap Smear Register, the Queensland Cancer Registry, and the Queensland Health Admitted Patient Data Collection for their assistance in providing the data, and the Queensland Research Linkage Group for linking the data. We gratefully acknowledge Tegan Harris for a range of contributions, including designing and building the database. The views expressed in this p

Since its inception in 1991, Australia's organised approach to cervical screening, the National Cervical Screening Program (NCSP), has seen a 50% reduction in both incidence and mortality from cervical cancer in Australia. However, Indigenous Australian women continue to experience a disproportionately higher burden of cervical cancer. No national data on screening participation of Indigenous women currently exist, in large part because pathology forms, the primary source of data for Pap Test Registers (PTR), do not record Indigenous status. While including Indigenous status on pathology forms is the obvious solution for producing essential information about cervical screening of Indigenous women, this will require an appropriate consultative process and it will be many years before reliable data are available. One interim option being explored is the feasibility of linking the PTR to another data source which includes Indigenous status, such as hospital data. However, despite its promise, there remain major impediments to obtaining useful linked data in Australia, and it continues to be unclear whether such an approach is viable for routine reporting. If we are to understand and improve cervical screening participation and outcomes for Indigenous women in the foreseeable future, Australia needs to act now to include Indigenous status in pathology forms and (subsequently) PTRs.

Aboriginal and Torres Strait Islander women have significantly higher cervical cancer incidence and mortality than other Australian women. In this study, we assessed the documented delivery of cervical screening for women attending Indigenous Primary Health Care (PHC) centres across Australia and identified service-level factors associated with between-centre variation in screening coverage. We analysed 3801 clinical audit records for PHC clients aged 20&ndash, 64 years from 135 Indigenous PHC centres participating in the Audit for Best Practice in Chronic Disease (ABCD) continuous quality improvement (CQI) program across five Australian states/territories during 2005 to 2014. Multilevel logistic regression models were used to identify service-level factors associated with screening, while accounting for differences in client-level factors. There was substantial variation in the proportion of clients who had a documented cervical screen in the previous two years across the participating PHC centres (median 50%, interquartile range (IQR): 29&ndash, 67%), persisting over years and audit cycle. Centre-level factors explained 40% of the variation, client-level factors did not reduce the between-centre variation. Screening coverage was associated with longer time enrolled in the CQI program and very remote location. Indigenous PHC centres play an important role in providing cervical screening to Aboriginal and Torres Strait Islander women. Thus, their leadership is essential to ensure that Australia&rsquo, s public health commitment to the elimination of cervical cancer includes Aboriginal and Torres Strait Islander women. A sustained commitment to CQI may improve PHC centres delivery of cervical screening, however, factors that may impact on service delivery, such as organisational, geographical and environmental factors, warrant further investigation.

Indigenous Australian women have much higher incidence of cervical cancer compared to non-Indigenous women. Despite an organised cervical screening program introduced 25 years ago, a paucity of Indigenous-identified data in Pap Smear Registers remains. Prevalence of cervical abnormalities detected among the screened Indigenous population has not previously been reported. We conducted a retrospective cohort study of population-based linked health records for 1,334,795 female Queensland residents aged 20–69 years who had one or more Pap smears during 2000–2011; from linked hospital records 23,483 were identified as Indigenous. Prevalence was calculated separately for Indigenous and non-Indigenous women, for cytology-detected low-grade (cLGA) and high-grade abnormalities (cHGA), and histologically confirmed high-grade abnormalities (hHGA). Odds ratios (OR) were estimated from logistic regression analysis. In 2010–2011 the prevalence of hHGA among Indigenous women (16.6 per 1000 women screened, 95% confidence interval [CI] 14.6–18.9) was twice that of non-Indigenous women (7.5 per 1000 women screened, CI 7.3–7.7). Adjusted for age, area-level disadvantage and place of residence, Indigenous women had higher prevalence of cLGA (OR 1.4, CI 1.3–1.4), cHGA (OR 2.2, CI 2.1–2.3) and hHGA (OR 2.0, CI 1.9–2.1). Our findings show that Indigenous women recorded on the Pap Smear Register have much higher prevalence for cLGA, cHGA and hHGA compared to non-Indigenous women. The renewed cervical screening program, to be implemented in 2017, offers opportunities to reduce the burden of abnormalities and invasive cancer among Indigenous women and address long-standing data deficiencies. Funding: LJ Whop is supported by a Sidney Myer Health Scholarship, Menzies Enhanced Living Top-up and a student scholarship funded by the Lowitja Institute. J Cunningham was supported by a National Health & Medical Research Council (NHMRC) Research Fellowship [#1058244]. PC Valery was supported by a NHMRC Career Development Fellowship [#1083090]. A Diaz is supported by a National Health and Medical Research Council (NHMRC) Training Scholarship for Indigenous Australian Health Research (No. 1055587). The National Indigenous Cervical Screening Project is funded by a NHMRC Project Grant [#104559]. This study was undertaken under the auspices of the Centre of Research Excellence in Discovering Indigenous Strategies to improve Cancer Outcomes Via Engagement, Research Translation and Training (DISCOVER-TT CRE, funded by the NHMRC [#1041111]), and the Strategic Research Partnership to improve Cancer control for Indigenous Australians (STREP Ca-CIndA, funded through Cancer Council NSW [SRP 13-01] with supplementary funding from Cancer Council WA). We also acknowledge the ongoing support of the Lowitja Institute, Australia's National Institute for Aboriginal and Torres Strait Islander Health Research. The views expressed in this publication are those of the authors and do not necessarily reflect the views of the funding agencies. Funding bodies have no role in the study design, data collection, access, analysis or interpretation or decision to publish.