'…you can't work singular when you're working with families': co-creating strategies for fetal alcohol spectrum disorder prevention and support with an Aboriginal and Torres Strait Islander primary healthcare service: a baseline mixed methods study.

The implementation of a national Lung Cancer Screening Program (LCSP), commencing in July 2025, presents a significant opportunity to have an impact on an intractable health problem for Aboriginal and Torres Strait Islander communities.1 Lung cancer is the most common cancer and the leading cause of cancer death for Aboriginal and Torres Strait Islander peoples.2 The Aboriginal and Torres Strait Islander age-standardised incidence rate was 85.2 cases per 100 000 for 2009–2013 and the mortality rate was 56.8 deaths per 100 000, which are double the rates found in non-Indigenous populations.2 Lung cancer mortality rates for Aboriginal and Torres Strait Islander peoples are increasing, in contrast to falling rates in non-Indigenous Australians.2 These diverging trends are expected to increase disparities for many years to come and clearly demonstrate the health system is failing Aboriginal and Torres Strait Islander peoples. The disproportionate lung cancer burden means that an LCSP could deliver greater benefits to Aboriginal and Torres Strait Islander communities and reduce the disparity with non-Indigenous Australians. International trials demonstrate the clinical effectiveness and potential benefits of an LCSP, through low dose computed tomography (LDCT), including identifying disease at an early stage where survival rates are substantially improved.3, 4 The outcomes of existing LCSPs in high income countries such as the United States and the United Kingdom show these results can be achieved in communities with high levels of socio-economic deprivation (eg, Lung Health Check in the UK).5 Aotearoa New Zealand has demonstrated the cost-effectiveness of an LCSP to reduce population level inequities in lung cancer for the Māori population. Māori people will achieve greater per capita health gains compared with non-Māori people due to higher rates of tobacco use and higher incidence and mortality from lung cancer.6 Currently, there are Māori-led implementation trials to provide evidence on strategies that optimise an LCSP for the Māori population, including determining the most effective recruitment strategies (comparing participation via general practitioners versus a central hub).7 Australia is to implement a national LCSP, with the Australian Government funding a risk-tailored LCSP. The program will identify and refer individuals aged 50–70 years with a history of cigarette smoking of at least 30 pack-years, and, if they had formally smoked, had quit within the previous ten years, for an LDCT scan via a medical practitioner.3, 8 An understanding of historical and cultural contexts of Aboriginal and Torres Strait Islander wellbeing in a settler colonial state is essential. Tobacco use and lower rates of participation in existing cancer screening programs reflect the legacy of over two centuries of racism, colonisation, genocide and dispossession of Aboriginal and Torres Strait Islander peoples, creating the social, economic and political context for health care exclusion. A one-size-fits-all approach will not work, as already evidenced in the broader health care system. An equitable LCSP requires ensuring a good fit between the program and the specific contexts within which it will be implemented.9 Although the need for an equitable approach to an LCSP in Australia has been previously identified,3 much remains unknown about suitable implementation strategies to meet the needs of Aboriginal and Torres Strait Islander peoples and communities. The 2023–24 federal budget included funding to ensure mainstream cancer care services are culturally safe and accessible to Aboriginal and Torres Strait Islander peoples.10 However, we argue that an equity lens must be applied to designing and implementing an LCSP with Aboriginal and Torres Strait Islander participation at the core of program design rather than a post hoc alteration to a mainstream program. Principles to guide the codesign of an LCSP with Aboriginal and Torres Strait Islander peoples do exist.11, 12 To ensure equitable access, the design of an LCSP must address known barriers to existing cancer screening programs for Aboriginal and Torres Strait Islander peoples, while gathering LCSP-specific evidence of enablers to implementation. Existing bowel, breast and cervical cancer screening programs have failed to provide equitable outcomes for Aboriginal and Torres Strait Islander peoples, with low reported participation, high screening positivity, low diagnostic assessment rates, and high age-standardised incidence and mortality for these cancers.2, 13-15 Barriers for Aboriginal and Torres Strait Islander peoples participating in existing cancer screening programs are known and include understanding the benefits of screening, fear or shame associated with the screen or cancer diagnosis, and a lack of awareness of cancer screening.16, 17 US research indicates that low awareness of the LCSP and its benefits is a significant barrier to engaging communities.18 Known logistical barriers to screening participation, particularly for Aboriginal and Torres Strait Islander peoples living in rural and remote communities, include transport, accommodation and associated costs.16, 19 Service level barriers include a lack of culturally safe services and communication and language barriers.20 Culturally safe services comprise practitioners who have reflected on and understand how their cultural identity shapes their health care practice and can then apply this knowledge to provide safe, respectful and empowering care to a person of another culture.12 These long-standing structural barriers embedded broadly into the health system result in exclusion or inappropriate care for Aboriginal and Torres Strait Islander peoples and lead to mistrust of mainstream health services.20 The LCSP may result in additional barriers to Aboriginal and Torres Strait Islander peoples' participation. LCSP requirements for targeted recruitment, complex shared decision-making processes, and referral for an LDCT by a GP will place additional resource implications on an already scarce and limited workforce servicing Aboriginal and Torres Strait Islander peoples.21 Access barriers faced by Aboriginal and Torres Strait Islander peoples living across rural and remote Australia need to be addressed, for example, through a mobile lung cancer LDCT screening program. Lung cancer risk assessment tools that inform LDCT referral decisions have not yet been validated in Aboriginal and Torres Strait Islander populations. Validation will require engagement with key stakeholders to identify critical risk factors, the ability to routinely collect Aboriginal and Torres Strait Islander status in the health services that provide lung cancer investigation and management, and ensuring that race is not used as a proxy factor for more relevant socio-economic risk factors.22 Promoting awareness of lung cancer screening and its benefits among Aboriginal and Torres Strait Islander peoples and health professionals who work with them is fundamental to access. Successful promotional strategies for Aboriginal and Torres Strait Islander peoples used in existing cancer screening programs include promotional campaigns tailored to local communities, the use of peer educators and community champions, and promoting positive messages and emotions toward screening, could inform LCSP strategies.16, 17 Developing strong, trusting relationships with clinicians and health services, is effective in increasing Aboriginal and Torres Strait Islander participation in breast and cervical screening programs20, 23 and will be important in an LCSP. BreastScreen Australia has had a focus on cultural safety through codesign of resources and a flexible approach to service delivery, including the use of mobile vans. Similarly, bowel screening participation increased in a pilot of an alternative pathway for Aboriginal and Torres Strait Islander peoples developed in consultation with communities, which resulted in the distribution and explanation of tests via known and trusted local health care workers.24 Aboriginal and Torres Strait Islander health care professionals and services are essential to building strong relationships. Aboriginal community controlled health services have enabled and fostered culturally safe programs and access to cancer screening programs through initiatives such as making group bookings for community members and providing group travel to and from screening.17, 25 Smoking cessation is integral to an LCSP, and trials have demonstrated higher quit rates than in the general population.3 As smoking is a leading contributor to disease burden for Aboriginal and Torres Strait Islander peoples, smoking cessation delivered through an LCSP is an important primary prevention mechanism for lung cancer as well as delivering other health benefits. Referring to established and successful culturally safe smoking cessation services will be essential to the long term success of the program, particularly for Aboriginal and Torres Strait Islander peoples for whom, despite impressive declines in smoking prevalence, smoking rates remain high.26 Access to a culturally safe LCSP is essential as is timely referral and access to health services for participants who require follow-up after an LDCT scan. Access to navigators (culturally safe trained health care workers) to navigate specialist and hospital appointments to overcome structural barriers to Aboriginal and Torres Strait Islander participants accessing mainstream services is needed to realise the benefits of early lung cancer detection.27, 28 This navigation role could be extended more broadly across the lung cancer screening and assessment pathway and into the mainstream health system. Strategies to be codesigned with Aboriginal and Torres Strait Islander communities and organisations to support the LCSP completion are summarised in Box 1. LCS = lung cancer screening; LCSP = Lung Cancer Screening Program; LDCT = low dose computed tomography. Aboriginal and Torres Strait Islander leaders, organisations and people with lived experience of lung cancer must drive the design of an equitable LCSP including tailoring program promotion, workforce development, and program delivery to a range of contexts in which the program will be delivered. A commitment to culturally appropriate codesign processes will shape the development of an equitable lung cancer screening pathway. The key elements of an equitable LCSP for Aboriginal and Torres Strait Islander peoples underpinned by the principles of codesign are outlined in Box 2. Community-defined leaders, Elders and Aboriginal and Torres Strait Islanders with lived experience engaging early to identify specific points in the pathway where adaptations are essential, such as: Aboriginal and Torres Strait Islander populations have the most to gain from an equitable approach to implementation and, conversely, the greater burden to bear if population-specific implementation barriers are not identified and addressed as part of an LCSP. An equitable LCSP will ensure that potentially underscreened populations are able to participate through culturally safe and appropriate screening and service delivery models. Applying the principle of proportionate universalism, increasing services and resourcing in line with the gradient of health need,30 will be essential to achieving equity. Lisa Whop is supported by a National Health and Medical Research Council (NHMRC) Investigator Grant (2009380). Gail Garvey is funded by an NHMRC Investigator Grant (1176651). Claire Nightingale is supported by a Mid-Career Research Fellowship (MCRF21039) from the Victorian Government acting through the Victorian Cancer Agency. Nicole Rankin is funded by an NHMRC Ideas Grant (2019/GA65812) and a Medical Research Future Fund Grant (2019/MRF2008603). The funding sources had no role in the content of this article. Open access publishing facilitated by The University of Melbourne, as part of the Wiley – The University of Melbourne agreement via the Council of Australian University Librarians. We received funding from Cancer Australia for conducting consultations with Aboriginal and Torres Strait Islander workforce around lung cancer screening but we were not directly funded for the publication of this article. Not commissioned; externally peer reviewed.

Australian Aboriginal peoples are the oldest living culture in the world, with Euro-Western academic research and science currently dating a continuing connection to Country at over 75 000 years.1 Aboriginal and Torres Strait Islander birthing practices have been critical to the oldest living culture, comprising a living discipline with origins that predate Euro-Western medicine by millennia and continue to foster environments for Aboriginal and Torres Strait Islander peoples to thrive.2 However, the ongoing nature of colonisation, associated policies and systemic racism3 continue to impact Aboriginal and Torres Strait Islander peoples today, including maternal and child health outcomes.4 One factor contributing to this is smoking, which has been systematically embedded through colonisation. Colonisers used tobacco to exploit Aboriginal and Torres Strait Islander peoples’ labour and services, providing tobacco as payment in lieu of wages and in rations until the late 1960s. This entrenched smoking among Aboriginal and Torres Strait Islander peoples.5 The mechanics of colonisation also increase exposure to the basic causes or drivers of tobacco use, including economic and educational exclusion.6 Such racialised inequities result in Aboriginal and Torres Strait Islander smoking during pregnancy being over three times higher than among their non-Indigenous counterparts.5 Identifying culturally safe and acceptable strategies that increase effectiveness for Aboriginal and Torres Strait Islander women to quit smoking are urgently required. However, appropriate evidence to inform smoking cessation care, particularly during pregnancy, drawn from Indigenous peoples is scarce. Evidence included in this MJA supplement aims to privilege Aboriginal and Torres Strait Islander women in the development of Indigenous-led evidence on smoking cessation care.7, 8 Most health care providers have and will continue to encounter Aboriginal and Torres Strait Islander peoples in their daily practice. As such, identifying respectful and effective strategies that resonate with Aboriginal and Torres Strait Islander peoples to quit tobacco use, particularly during pregnancy, through health care systems are required. Researchers and clinicians have conducted qualitative,9-13 quantitative14-16 and pilot trials17-19 and one randomised trial20 to develop an evidence base to address the disproportionate smoking rates experienced by Aboriginal and Torres Strait Islander women during pregnancy. All trials have incorporated health provider smoking cessation training and resources for women and health providers and offered nicotine replacement therapy to pregnant women who we unable to quit unaided.17-20 Two included peer support groups and financial incentives.18, 19 One considered the wider social and economic context of smoking in pregnancy and tailored supports to incorporate broader support services for women.19 However, to date no trial has been able to report effective strategies to empower smoke-free pregnancies and the evidence base is still lacking. Research and evaluation are particularly important to better tailor supports for Aboriginal and Torres Strait Islander peoples, especially given the diverse language, social and nation groups. Research has the potential to quantify the nature and characteristics of smoking in pregnancy and what types of smoking cessation supports resonate with Aboriginal and Torres Strait Islander women.21 Generally, data from diverse nation groups across Australia report smoking characteristics as a binary outcome (yes/no). However, our previous research reports that Aboriginal and Torres Strait Islander women are making multiple quit attempts during pregnancy,22 with national data commonly failing to accurately detail such nuance in the quitting journey that can be critical to guiding best practice. Given the lack of Indigenous-specific evidence and the substantial room for improvement in health outcomes, the Which Way? study, reported in this supplement of the MJA,7, 8 aims to address an urgent need to better understand smoking, for and by Aboriginal and Torres Strait Islander women, using community-led research questions informed through an Indigenous lens.23 In the words of Linda Tuhiwai Smith: When Indigenous peoples become the researchers and not merely the researched, the activity of research is transformed. Questions are framed differently, priorities are ranked differently, problems are defined differently, people participate on different terms.24 The foundations of Which Way? are derived from Aboriginal and Torres Strait Islander-led research which recognised that Aboriginal and Torres Strait Islander women want to quit smoking and are interested in non-pharmacological options to be smoke-free.22 The project aims to build an Indigenous-led evidence base for culturally responsive smoking cessation care and to inform policymakers and health service providers on how improvements can be made to the health and wellbeing of Aboriginal and Torres Strait Islander mothers and babies. Which Way? is a culturally responsive, co-designed and co-owned study with urban and regional Aboriginal communities in New South Wales.25 The study is consistent with the United Nations Declaration on the Rights of Indigenous Peoples,26 the World Health Organization Framework Convention on Tobacco Control,27 and the updated Aboriginal Health and Medical Research Council guidelines for ethical research with communities.28 This national cross-sectional survey was developed through collaborative, community-driven processes with partnering communities to understand community-led research questions, address current knowledge gaps, and refine content and questions for relevance, cultural acceptability and sensitivities. This process was iterative and completed during COVID-19 lockdowns. The survey was developed and then approved by community partners, and included pilot testing with 15 Aboriginal women known to the research team before going live. Online recruitment for research of this sensitive nature was not common research practice in Aboriginal and Torres Strait Islander health research at the time of recruitment, but we recognise that COVID-19 has also driven significant changes in innovative recruitment processes. As such, establishing trust and rapport, and highlighting social accountability in this research was critical. All Aboriginal community partners shared posts recruiting participants in the study. Sharing of posts was also supported by peak bodies, such as the National Aboriginal Community Controlled Health Organisation. The project also utilised paid advertisement and sharing via community pages such as Tiddas for Tiddas, to increase reach and provide the opportunity to participate, particularly for Aboriginal and Torres Strait Islander women who did not use or follow an Aboriginal health service. Indigenous governance and meaningful engagement of Aboriginal and Torres Strait Islander peoples informed the analysis and reporting but was embedded from conception to reporting the study findings, consistent with the United Nations Declaration on the Rights of Indigenous Peoples and the Framework Convention on Tobacco Control. Australia is a party to the Framework Convention on Tobacco Control, which details the need for Aboriginal and Torres Strait Islander peoples to be engaged in the development, implementation and evaluation of tobacco control programs. The analysis and reporting process privileged Aboriginal and Torres Strait Islander voices, knowledges and experiences, particularly communities as the knowledge holders, to address the health and wellbeing of their peoples. In facilitating meaningful analysis and interpretation, an iterative analysis process was undertaken in partnership with community partners and guided by an Indigenous-led analysis team. Preliminary findings were initially exported using REDCap electronic data capture software, and summarised for community partners. Lead researcher (MK) provided presentations to community partners for response and direction, including prioritising analysis in an iterative process. All analysis plans were driven by community partners’ questions, and only community relevant factors were reported. Shifting from problem-based to solution-focused Aboriginal and Torres Strait Islander-led tobacco control enacts Indigenous sovereignty to be ultimately free from nicotine dependence and related death and disease. In the words of Walter and Anderson: From an Indigenous ontology the more important question is not what differences exist, but why? A reversing of the ontological lens would compel different questions in a different research agenda.23 The Which Way? project upholds the prioritisation of the CONSIDER statement29 and acknowledges the need for transparency of research practice (Box). Governance: The community governance committee oversees all aspects of the research, guiding and strengthening the research process and ensuring all conducted research is held accountable. This means the research is Aboriginal-led, Aboriginal-owned, and upholds the prioritisation of Aboriginal communities. Prioritisation: Strong community partnerships are developed and sustained through ongoing respect, consultation and appropriate dissemination of research and continued transparency with all communities. The research priorities are built on community strengths, interests, and worldviews. Development of lasting relationships with partnered community services and engagement of staff and community at all services ensures research aims address specific community priorities. Methodology: The research acknowledges the importance of building on gulbanha (knowledge), to ensure the research is relevant and meaningful to improving the health and wellbeing of Aboriginal and Torres Strait Islander peoples. Indigenous knowledges are the processes and the outcome of the research. Participation: The seeking of individual and community consent is imperative to mitigate the burden placed upon both the individual and the communities involved in the research. This upholds Indigenous data sovereignty, and ensures the safety and security of participants remains unidentified throughout the research. Capacity: Guidance and mentorship is woven through the research process at every level. Capacity building is enabled through the mentorship of two Aboriginal and Torres Strait Islander medical students working as research assistants throughout the research. Through respectful relationships with partnering communities, 360° learning and knowledge sharing is offered, to build capacity within the academy in Indigenous and wellbeing, as well as in the health sector with diverse community health needs, research design and implementation, knowledge translation, and health promotion. This is reflected through, but not limited to, authorship opportunities and governance committee membership. Analysis and interpretation: Aboriginal and Torres Strait Islander communities direct the analysis and interpretation that is then undertaken by an Indigenous-led team. Dissemination: Accountability of the research is upheld through monthly updates and consultation with partnering services, governance committees and communities. Ongoing translation plans are co-developed with the research team, governing bodies and community partners to appropriately acknowledge the wisdom, leadership and expertise of partnering communities in developing an Indigenous-led evidence base for smoking cessation care. Outcomes of this research have been presented through a range of webinars with peak bodies (Cancer Institute NSW, the Aboriginal Health and Medical Research Council, the Victorian Aboriginal Community Controlled Health Organisation). We have also developed infographics for community to share, and have developed and conducted workshops for Tackling Indigenous Smoking teams nationally. The Which Way? study reported in this MJA supplement highlights the need to embed culturally safe care, including cessation supports, into everyday practice. The study also provides an example of how research in Aboriginal and Torres Strait Islander contexts can be undertaken in a “good way”, with Aboriginal and Torres Strait Islander communities. Michelle Kennedy is funded by an NHMRC Early Career Fellowship, grant number 1158670. This study was funded by the National Heart Foundation Aboriginal and Torres Strait Islander Award, grant number 102458. The funding bodies were not involved in the conduct of this research. We acknowledge the partnering services and staff for their time and commitment to this long term project, including the Dhanggan Gudjagang team, Yerin Eleanor Duncan Aboriginal Health Centre, Tamworth Aboriginal Medical Service, Nunyara Aboriginal Health Clinics, and Waminda South Coast Women’s Health and Welfare Aboriginal Corporation. We also acknowledge all the Aboriginal and Torres Strait Islander women who contributed to this research project — thank you for sharing your experiences with us, it is our honour to privilege your voices. Open access publishing facilitated by The University of Newcastle, as part of the Wiley - The University of Newcastle agreement via the Council of Australian University Librarians. No relevant disclosures. Commissioned; externally peer reviewed.

In Australia, fetal alcohol spectrum disorder (FASD) is a largely hidden disability that is currently under-recognized, under-resourced, and under- or misdiagnosed. Unsurprisingly, efforts to prevent FASD in urban Aboriginal and Torres Strait Islander communities are lacking. Further, mainstream approaches are not compatible with diverse and distinct Aboriginal and Torres Strait Islander ways of approaching family, pregnancy, and parenting life. To support the creation of culturally appropriate urban Aboriginal and Torres Strait Islander FASD prevention strategies, we sought to understand local perspectives, experiences, and priorities for supporting healthy and alcohol-free pregnancies. Using a narrative methodology, we undertook research yarns with eight female and two male community participants. Data were analyzed using a narrative, thematic analysis and guided by an Indigenist research practice of reflexive listening. Participant yarns provided important insights into local urban Aboriginal and Torres Strait Islander cultural, social, and structural determinants that support family and child health, alcohol-free pregnancies, and the prevention of FASD. The results provide critical guidance for Indigenizing and decolonizing FASD prevention strategies to support culturally safe, relevant, and strengths-based services. This approach has critical implications for all health and social professionals and can contribute to Aboriginal and Torres Strait Islander peoples’ justice, recovery, and healing from colonization.

Deadly declines and diversity – understanding the variations in regional Aboriginal and Torres Strait Islander smoking prevalence

Ngaaminya (find, be able to see): summary of key findings from the Which Way? project

Burden of the Beast

Fetal Alcohol Spectrum Disorder (FASD) is a preventable, lifelong disability that disproportionately affects Aboriginal and Torres Strait Islander people. This review provides a comprehensive synthesis of the available information on FASD among Aboriginal and Torres Strait Islander people, with reference to the limitations on population-based data and evaluated programs. The review outlines; the harms of alcohol use in the context of colonisation, cultural perspectives on assessment and diagnosis, effective prevention programs and a summary of state and national policies. Health impacts, educational outcomes and the effects of FASD on vulnerable populations such as children in protection and young people in the justice system, are also discussed. Specific perspectives on why women drink during pregnancy and the role of Aboriginal women in preventing FASD are explored. Recommendations include that there be greater focus on the benefits of involving men in the prevention and management of FASD and that future FASD prevention strategies for Aboriginal and Torres Strait Islander people should be community identified, led, and driven. FASD assessment, treatment and public health programs must also consider the history of trauma incurred by Aboriginal and Torres Strait Islander communities as a result of colonisation.

This article describes the use and effectiveness of the participatory action research (PAR) framework to better understand community members' perceptions and risks of pandemic influenza. In 2009, the H1N1 influenza pandemic affected Indigenous populations more than non-Indigenous populations in Oceania and the Americas. Higher prevalence of comorbidities (diabetes, obesity, asthma and chronic obstructive pulmonary disease) as well as pregnancy in Indigenous communities may have contributed to the higher risks of severe disease. Social disparity, institutionalised racism within health services and differences in access to culturally safe health services have also been reported as contributors to disadvantage and delayed appropriate treatment. Given these factors and the subsequent impact they had on Australian Aboriginal and Torres Strait Islander communities, the authors set out to ensure that the Australian national, state and territory pandemic plans adequately reflected the risk status of Aboriginal and Torres Strait Islander peoples and promoted meaningful engagement with communities to mitigate this risk. A national study explored the views of Aboriginal and Torres Strait Islander people and their experiences with H1N1 and used a qualitative PAR framework that was effective in gaining deep understandings from participants. Aboriginal and Torres Strait Islander community-controlled organisations and health services were involved in the implementation, interpretation and monitoring of this project. As a result, important features of the implementation of this PAR framework with Aboriginal and Torres Strait Islander communities and organisations emerged. These features included the importance of working in a multidisciplinary team with Aboriginal and Torres Strait Islander researchers; the complexities and importance of obtaining multi-site human research ethics approval processes; the importance and value of building the research capacity of both experienced and novice researchers in PAR; the need to use localised sampling protocols; and the process of undertaking a collective research process and enacting action research and feedback. The most effective responses of this project were embedded in pre-existing relationships with individuals within organisations that had been established over a long period of time between Aboriginal medical services and investigators; however, research relationships established specifically for the purposes of the project were less successful because of changes in personnel and organisational support. The participatory approach used in this study has the potential to be applied to vulnerable populations in other countries.

Tobacco use is the most significant modifiable risk factor for adverse health outcomes, and early research indicates there are also significant harms associated with vaping. National targets aim to reduce smoking and vaping during pregnancy for Aboriginal and Torres Strait Islander people. While most Aboriginal and Torres Strait Islander people want to quit, cessation is frequently attempted without support, increasing the chance of relapse. Group-based smoking cessation programmes increase quit success by 50%-130% in the general population; however, they have never been evaluated in Aboriginal and/or Torres Strait Islander communities. The Gulibaa study is an Indigenous-led and community-embedded project that will co-design, implement and evaluate a group-based model of care to support Aboriginal and Torres Strait Islander women to be smoke- and vape-free. Staff of Health Services in New South Wales, Australia, will receive training to deliver a face-to-face group-based smoking and vaping cessation intervention. Aboriginal and/or Torres Strait Islander people who identify as a woman or non-binary, are pregnant or of reproductive age (16 to 49 years), currently smoke or vape at least once per day and are willing to attend the programme are eligible to participate. Up to 500 participants will be recruited. A mixed method evaluation approach will be implemented guided by the RE-AIM framework. Outcomes will include intervention reach, intervention effectiveness (determined primarily by self-reported 7-day point prevalence abstinence at 6 months follow-up), acceptability and feasibility of the intervention, programme fidelity and maintenance and cost effectiveness. Embedding culturally safe support to quit during pregnancy can result in improved outcomes for both mother and child and immediately improve intergenerational health and well-being. Ethics approval has been provided by the Aboriginal Health and Medical Research Council and the University of Newcastle. Study findings will be disseminated to Aboriginal and Torres Strait Islander communities in ways that are meaningful to them, as well as through Aboriginal health services, key national bodies, relevant state and federal government departments. ACTRN12625001050448.

Aim The aim of this study was to evaluate the usefulness of seven brochures for Aboriginal and Torres Strait Islander women with urinary incontinence (UI). Method Twenty-three Aboriginal and Torres Strait Islander women, aged between 40 and 76 years, experiencing UI and attending an urban Aboriginal and Torres Strait Islander primary healthcare service, participated in semi-structured digitally recorded interviews. They appraised seven brochures, developed by the Continence Foundation of Australia, for use by Aboriginal and Torres Strait Islander communities. Participants were provided with one brochure at a time to read and comment on its usefulness; presentation including appropriateness of the artwork, colours, structure and design; any improvements; and whether the brochures should be provided to all women with UI. A thematic analysis of the interview contents was conducted by two researchers. Results The interviews identified four main themes including usefulness of the information presented in the brochures; readability and comprehensibility of the information; suggestions for refining the brochures; and usefulness of brochures to Aboriginal and Torres Strait Islander women. All women found the information in all the brochures useful, easy to read and understand, and recommended that they should be provided to Aboriginal and Torres Strait Islander women with risk factors for developing, or those with UI. A few suggestions to refine the brochures were identified. Conclusions This study has provided evidence that the brochures are a valuable resource for raising awareness about UI among Aboriginal and Torres Strait Islander women attending urban Aboriginal and Torres Strait Islander primary healthcare settings.

SummaryMost research involving Aboriginal and Torres Strait Islander peoples has been conducted by non-Indigenous people and has not been a positive experience for many Aboriginal and Torres Strait Islander communities. This scoping review maps approaches to health research involving Aboriginal and Torres Strait Islander peoples and communities in Australia from the last two decades. A literature search found 198 papers, of which 34 studies met the inclusion criteria. The Aboriginal and Torres Strait Islander Quality Appraisal Tool was then used to map the quality of the reported community driven research. The Quality Appraisal Tool privileges, Aboriginal and Torres Strait Islander people’s epistemologies and ethical research governance. The findings reported on strengths and identified areas for improvement in reporting community driven research.

In May 2020, an independent working party was convened to determine the mental health and well‐being needs of Aboriginal and Torres Strait Islander peoples in Australia, in response to COVID‐19. Thirty Aboriginal and Torres Strait Islander leaders and allies worked together in a two‐month virtual collaboration process. Here, we provide the working party's five key recommendations and highlight the evidence supporting these proposals. Aboriginal and Torres Strait Islander self‐determination and governance must be prioritised to manage the COVID‐19 recovery in Aboriginal and Torres Strait Islander communities. To mitigate long‐term social and economic impacts of COVID‐19 to Australian society, the historical underinvestment in Aboriginal and Torres Strait Islander peoples must be reconciled. Equitable, needs‐based funding is required to support strengths‐based, place‐based initiatives that address the determinants of health. This includes workforce and infrastructure development and effective evaluation. There is a clear, informed pathway to health and healing for Aboriginal and Torres Strait Islander peoples being enacted by Aboriginal and Torres Strait Islander leadership and community organisations; it remains to be seen how these recommendations will be implemented.

BackgroundMore than 35% of Aboriginal and Torres Strait Islander adults live with cardiovascular disease, diabetes, or chronic kidney disease. There is a pressing need for chronic disease prevention and management among Aboriginal and Torres Strait Islander people in Australia. Therefore, this review aimed to synthesise a decade of contemporary evidence to understand the barriers and enablers of chronic disease prevention and management for Aboriginal and Torres Strait Islander People with a view to developing policy and practice recommendations.MethodsWe systematically searched for peer-reviewed published articles between January 2014 to March 2023 where the search was performed using subject headings and keywords related to “Aboriginal and Torres Strait Islander peoples,” “Chronic Disease,” and “Primary Health Care”. Quality assessment for all included studies was conducted using the Aboriginal and Torres Strait Islander Quality Appraisal Tool. The data were extracted and summarised using a conventional content analysis approach and applying strength-based approaches.ResultsDatabase searches identified 1653 articles where 26 met inclusion criteria. Studies varied in quality, primarily reporting on 14 criteria of the Aboriginal and Torres Strait Islander Quality Appraisal Tool. We identified six key domains of enablers and barriers of chronic disease prevention and management programs and implied a range of policy and practice options for improvement. These include culturally acceptable and safe services, patient-provider partnerships, chronic disease workforce, primary health care service attributes, clinical care pathways, and accessibility to primary health care services. This review also identified the need to address social and cultural determinants of health, develop the Aboriginal and Torres Strait Islander and non-Indigenous chronic disease workforce, support multidisciplinary teams through strengthening clinical care pathways, and engage Aboriginal and Torres Strait Islander communities in chronic disease prevention and management program design and delivery.ConclusionEnabling place-based partnerships to develop contextual evidence-guided strategies that align with community priorities and aspirations, with the provision of funding mechanisms and models of care through policy and practice reforms will strengthen the chronic disease prevention and management program for Aboriginal and Torres Strait Islander people.

In July 2022, Human Papillomavirus (HPV) self-collection became available as a choice to all participants in Australia's National Cervical Screening Program (NCSP). This policy change aims to facilitate equitable access to cervical screening; however, further evidence is needed to support its implementation and reach under-screened women and people with a cervix. This implementation study seeksto embed HPV self-collection into Aboriginal and Torres Strait Islander Community Controlled Health Organisations (ACCHOs) and/or primary care organisations whose context is similar to that of an ACCHO. This will be achieved by co-designing, implementing, and evaluating models of care tailored to local needs. The aim is to increase cervical screening participation, particularly among under- and never-screened, Aboriginal and Torres Strait Islander women and people with a cervix. Ultimately the aim is to achieve equity in cervical cancer elimination. Screen Your Way will use a before-and-after study design to evaluate the effectiveness, acceptability and sustainability of implemented strategies on cervical screening participation among Aboriginal and Torres Strait Islander women and people with a cervix. The study will be guided by an Indigenist implementation research approach and will employ mixed methods. Ethical approval has been obtained from the Australian Institute of Aboriginal and Torres Strait Islander Studies Research Ethics Committee (REC-0092), Aboriginal Health and Medical Research Council of New South Wales Ethics Committee (2078/23), Australian National University Human Research Ethics Committee (H/2023/1103), Northern Territory Department of Health and Menzies School of Health Research (HREC2023-4557), and Metro South Human Research Ethics Committee (HREC/2025/QMS/115155). Additional approvals will be obtained in accordance with the locally nominated governance protocols of each participating service. This may include approvals from ACCHO Boards, Community Juries, or other designated decision-making bodies. The research team will work closely with each service to ensure all required processes are respected and adhered to prior to commencing any research activities. Findings will be disseminated via workshops, reports, evidence briefs and resource creation to assist with the evidence-based scale up of self-collection in the ACCHO setting. Further dissemination will occur via conferences and peer-reviewed publications in partnership with the Screen Your Way Aboriginal and Torres Strait Islander Caucus.

BackgroundAboriginal and Torres Strait Islander peoples are disproportionately impacted by type 2 diabetes. Continuous glucose monitoring (CGM) technology (such as Abbott Freestyle Libre 2, previously referred to as Flash Glucose Monitoring) offers real-time glucose monitoring that is convenient and easy to use compared to self-monitoring of blood glucose (SMBG). However, this technology’s use is neither widespread nor subsidised for Aboriginal and Torres Strait Islander peoples with type 2 diabetes. Building on existing collaborations with a national network of Aboriginal and Torres Strait Islander communities, this randomised controlled trial aims to assess the effect of CGM compared to SMBG on (i) haemoglobin A1c (HbA1c), (ii) achieving blood glucose targets, (iii) reducing hypoglycaemic episodes and (iv) cost-effective healthcare in an Aboriginal and Torres Strait Islander people health setting.MethodsThis is a non-masked, parallel-group, two-arm, individually randomised, controlled trial (ACTRN12621000753853). Aboriginal and Torres Strait Islander adults with type 2 diabetes on injectable therapy and HbA1c ≥ 7.5% (n = 350) will be randomised (1:1) to CGM or SMBG for 6 months. The primary outcome is change in HbA1c level from baseline to 6 months. Secondary outcomes include (i) CGM-derived metrics, (ii) frequency of hypoglycaemic episodes, (iii) health-related quality of life and (iv) incremental cost per quality-adjusted life year gained associated with the CGM compared to SMBG. Clinical trial sites include Aboriginal Community Controlled Organisations, Aboriginal Medical Services, primary care centres and tertiary hospitals across urban, rural, regional and remote Australia.DiscussionThe trial will assess the effect of CGM compared to SMBG on HbA1c for Aboriginal and Torres Strait Islander people with type 2 diabetes in Australia. This trial could have long-term benefits in improving diabetes management and providing evidence for funding of CGM in this population.Trial registrationAustralian and New Zealand Clinical Trials Registry ACTRN12621000753853. Registered on 15th June 2021.