Area Health Service Research Articles

Geographic Variation in Breast Reconstruction Modality Use Among Women Undergoing Mastectomy.

Despite changes in legislation and an increase in public awareness, many women may not have access to the various types of breast reconstruction. The purpose of this study was to evaluate variation in reconstructive modality at the health service area (HSA) level and its relationship to the plastic surgeon workforce in the same area. Using the Arkansas, California, Florida, Nebraska, and New York state inpatient databases, we conducted a cross-sectional study of adult women undergoing mastectomy for cancer from 2009 to 2012. The primary outcomes were receipt of reconstruction and the reconstructive modality (autologous tissue versus implant) used. All data were aggregated to the HSA level and augmented with plastic surgeon workforce data. Correlation coefficients were calculated for the relationship between the outcomes and workforce. The final sample included 67,984 women treated across 103 HSAs. The average patient was 58.5 years, had private insurance (53.5%), and underwent unilateral mastectomy for invasive cancer. At the HSA level, the median immediate breast reconstruction rate was 25.0% and varied widely (interquartile range, 43.2%). In areas where reconstruction was performed, the median autologous (10.2%) and free tissue (0.4%) reconstruction rates were low, with more than 30% of HSAs never using autologous tissue. There was a direct correlation between an HSA's plastic surgeon density and autologous reconstruction rate (r = 0.81, P < 0.001). Despite efforts to remove financial barriers and improve patients' awareness, accessibility to various modalities of reconstruction is inadequate for many women. Efforts are needed to improve the availability of more comprehensive breast reconstruction care.

A Randomised Placebo-Controlled Trial to Determine If Fluoxetine Is Effective for Improving Autistic Behaviours

Background: Selective Serotonin Receptor Inhibitors (SSRIs) are often used to reduce the severity of core behaviours of Autism Spectrum Disorders (ASD) but their efficacy remains uncertain. This study was a multi-centre randomized, placebo-controlled trial examining the efficacy and tolerability of fluoxetine, a commonly prescribed SSRI, for reducing the frequency and severity of restricted, repetitive and stereotypic behaviours in ASD. Methods: Participants were aged 7·5-18 years with ASD, who were randomised to receive fluoxetine or placebo. Study medication was commenced at 4 or 8mg/day for the first week (4mg if <40Kg; 8mg if ≥40Kg), then titrated up to a maximum dose of 20mg/day for participants <40kg and 30mg/day for participants ≥40kg, over 4 weeks. Participants remained on the medication for a total of 16 weeks. The primary outcome was the total score on the Children's Yale-Brown Obsessive Compulsion Scale - Modified for Pervasive Developmental Disorders at 16 weeks. A range of secondary outcomes were also examined, measuring anxiety, repetitive and challenging behaviours at 16 weeks. Findings: 146 participants (124 male, 85%) were enrolled in the trial (75 fluoxetine, 71 placebo). The mean age of study participants was 11·2 (standard deviation 2·9) years, and 30% (n = 44) had an intellectual disability. There was little evidence that fluoxetine reduced obsessivecompulsive behaviours at 16 weeks compared with placebo (mean difference -1·62 (CI -3·57; 0·33), p = 0·10), with little evidence of group differences in any of the secondary outcomes (all p>0.07). Adverse events were similar in the two groups. Interpretation: This randomised placebo-controlled trial did not demonstrate that fluoxetine reduced the restricted and repetitive behaviours associated with ASD compared with placebo. Fluoxetine is therefore not recommended in the routine treatment of ASD symptoms. Trail Registration Number: Australian and New Zealand Clinical Trials Registry (ACTRN12608000173392). Funding Statement: The study was funded by the National Health and Medical Research Council of Australia (NHMRC project grant number 607332) and the Royal Children’s Hospital Foundation, Melbourne, Australia. Infrastructure support was provided by the Victorian Government’s Operational Infrastructure Support Program. Declaration of Interests: Dinah Reddihough, Catherine Marraffa, Anissa Mouti, Molly O’Sullivan, Katherine Lee, Francesca Orsini, Joanna Granich, Andrew Whitehouse, John Wray, David Dossetor, Natalie Silove and Michael Kohn all have no conflicts of interest to declare. Philip Hazell’s employer has received payment from Shire for speaker fees. Paramala Santosh’s employer has received payment from Medice for speaker fees and from Newron Pharma for conducting clinical trials. Ethics Approval Statement: The study was approved by Human Research Ethics Committees (HRECs) at each site: The Royal Children’s Hospital Human Research Ethics Committee (EC00238) for the site in Victoria, the Sydney West Area Health Service Human Research Ethics Committee, Westmead Campus (EC00152) for the site in New South Wales and the Princess Margaret Hospital for Children Ethics Committee (EC00268) for the site in Western Australia.

IMPACT World+: a globally regionalized life cycle impact assessment method

IMPACT World+: a globally regionalized life cycle impact assessment method

Understanding the Impact and Misconceptions of Rural Plastic Surgery.

In the United States, 54 million people live in a designated health service area with either no plastic surgeon or less than 1 plastic surgeon per 100,000 population. Previous studies demonstrate that patients in rural communities often have limitations with access to basic primary care services and subspecialty care services. Such limitations can have significant adverse impacts on health care and quality of life. Plastic and reconstructive surgeons offer unique advantages especially within rural settings given their broad scope of surgical skillsets. The purposes of this study are to illustrate the shortage of plastic and reconstructive surgeons within rural America catchment regions, identify and outline certain care offerings provided by these surgical specialists, and highlight the potential impact having such specialists directly involved in provision of care to patients within rural community settings. Our group will present data demonstrating misperceptions and an unawareness by hospital administrators on routine care services provided through plastic surgery practices. We will also report on selective surgical offerings of 2 rural-based plastic surgeons and outline certain financial and reimbursement findings from their practices, while also illustrating the impact of their practice on their patients and the health care systems they provide coverage.

Health services utilization among slum dwellers: An experience from Iran.

INTRODUCTION:Health services utilization is a complex behavioral phenomenon affected by multiple factors including availability, distance, cost and quality of health services as well as personal attitudes, cultural beliefs, and socioeconomic characteristics. This study aimed to assess the status of health-care utilization among dwellers of slums in one of the Iran's big cities.METHODS:This was a cross-sectional study in which 559 slums people were selected using a random clustered sampling method. Data on health services utilization were collected using health equity assessment and response tool questionnaire. Data analysis was performed using descriptive statistics and logistic regression analysis through SPSS ver. 22.RESULTS:In this study, 42.5% (238) people who required outpatient services. 21% (118) of them were able to use them. Furthermore, among the families, who needed outpatient services during the past month, 15% (38) were able to use the services for at least once. Regarding inpatient services, 62% (349) of people needed hospitalization, of which 31% (175) were able to be hospitalized. Age (P = 0.2), gender (P = 0 <001), marital status (P = 0 <001), income status (P = 0.1), and education (P = 0.21) determined utilization of outpatient services; however, inpatient services utilization was affected by age (P = 0.03), gender (P = 0.02), marital status (P = 0 <001), and income status (P = 0.32). The final model of multiple regression showed that, there was a relationship between age (odds ratio [OR] =1.7, confidence interval [CI] 95% = 0.47–0.88), marital status (OR = 2.78, CI 95% = 0.64–1.2), and the use of inpatient services.CONCLUSION:The utilization of health services in slum areas is not desirable. As it was showed that the utilization of health services in slums people is a multifactorial event; thus, proper planning and policy for this increasingly demand are essential.

The Contributions of Community Radios in Fostering Social Services in Tanzania: An Evaluation of &amp;lt;i&amp;gt;“Maendeleo vijijini”&amp;lt;/i&amp;gt; Program by Radio SAUT FM in Misungwi District

Being one among the peripheral countries in the world, the provision and access of social services in the rural areas in Tanzania is still one of the major stumbling blocks facing the country. Access to clean water and health services in the rural Tanzania areas are one of the major challenges facing residents in those areas. Likewise, about 85% of the roads in the rural Tanzania areas are either rough roads or mad roads. In Misungwi, access to clean drinking water and the provision of health services are still problematic. The roads are also very poor to allow a free movement of people and goods. The focus of this study was to evaluate the contributions made by community radio stations in fostering the improvements of social services in Tanzania. Specifically, the study evaluated the maendeleo vijijini program aired by radio SAUT FM and its contributions in the improvement of roads, safe drinking water, and health services in Misungwi rural area. This was a qualitative research whereby the data collection method used was interviews. A purposive sampling technique was used to select respondents for this study whereby a total of 33 respondents were interviewed. They included; three (3) head of units from Misungwi district, 20 members of the development committee, and 10 local leaders. The finding show that community radios through maendeleo vijijini program had played significant contribution towards the promotion and improvements of social services in the rural areas of Misungwi district. Nearly over 60% of the interviewees confirmed that the program had played grate contributions in promoting and education residences and government officials about the importance of good roads, safe drinking water, and improved health services. In conclusion, these findings have confirmed that community radios have not played any noticeable contributions in Tanzania. The findings also suggest that running a community radio in Tanzania need to be well prepared in terms of financial and human capital. Because of untrained staff to run the program and financial shortages, community radios will continue suffering because of poor coverage, frequent power cut-offs, poor program preparations, just a few to mention.

Trust in Nurse Scale Developed on the Basis of the Standardized Trust in Physician Scale by Anderson and Dedrick.

Introduction:Nursing care is one of the most important areas of health services, taking place in direct contact with the patient, constituting a subsystem deciding about the general level of services.Aim:The aim of the study was to construct the Trust in Nurse Scale on the basis of the standardized Trust in Physician Scale by Anderson and Dedrick.Methods:The study included a group of 1,200 people selected at random, 600 each from surgical and medical treatment wards. Patients did not report any problems with understanding the statements on the scale.Results:The internal accuracy scores were excellent, all Cronbach’s a values were well above 0.70. The Spearman’s rank correlation coefficient values were highly statistically significant (p <0.001), and correlation strength was very high (for most items rs > 0.90).Conclusion:We suggest that The Trust in Nurse Scale, developed on the basis of the standardized Trust in Physician Scale by Anderson and Dedrick, can be used in studies on patient satisfaction with nursing care.

Randomised controlled trial of the impact of haemodiafiltration on uraemic neuropathy: FINESSE study protocol

IntroductionThe majority of patients undergoing haemodialysis (HD) show evidence of uraemic neuropathy, a condition with no known disease-modifying treatments. The pathogenesis of uraemic neuropathy is poorly understood, but may be...

Evaluating Hospital Inpatient Discharges at the Regional Level

Historically, the evaluation of hospital utilization in the United States has been addressed by providers and health planning agencies. This study evaluated resident inpatient hospital discharges for adult medicine and adult surgery in the Central New York Health Service Area, an eleven county region of upstate New York. It focused on small local hospitals and larger referral center hospitals in the region. The study demonstrated that numbers of adult medicine resident discharges from small local hospitals declined by 17.3 percent in most counties of the region between 2012 and 2017. This reduction resulted, in part, from the implementation of medical observation programs that shifted many patients with low severity of illness to outpatient status. The study also demonstrated that numbers of adult surgery resident inpatient discharges from small local hospitals declined by 15.8 percent. This resulted from the inmigration of many surgical patients from these providers to larger hospitals in the region. The study suggested that there may not be sufficient inpatient adult surgery and medicine volumes to support the current number of hospitals in the region.

Resident Hospital Discharges by Severity of Illness at the Regional Level

In the twentieth century, government sponsored health planning focused on the use of services by population in the United States. This case study evaluated the impact of severity of illness for resident hospital discharges for 2017, the latest time period for which this information was available. It focused on the Central New York Health Service Area, one of the original health planning populations. The study demonstrated that patients at Extreme severity of illness constituted similar percentages of adult medicine and adult surgery populations in the Central New York Region. The sizes of Moderate severity of illness populations were also similar. The study identified considerable differences in the sizes of Minor and Major severity of illness populations for adult medicine and adult surgery in the Central New York Region. These differences resulted from large numbers of healthy patients in the adult surgery population. They were admitted for orthopedic procedures and procedures to address obesity.

The Business Model and Innovation Analyses: The Sustainable Transition Obstacles and Drivers for the Hospital Supply Chains

This research aims to discuss the business model themes supported by the innovation regarding the sustainable transition difficulties to promote the hospital supply chains. A model for future applications and empirical analyzes in the health service area is proposed. In the current hospital scenario, the systems are characterized by the individualistic attention of the closed business models, hampering the promotion of the business models, the innovation, and the sustainable transitions as the sustainable supply chain (SSC) enablers. The survey evaluates the private hospital chain in Brazil. The model was evaluated by seven specialists indicated by the main private Brazilian hospitals that are accredited by Joint Commission International and Public Ministry. The discussion presented seeks to advance the observation and the understanding of the relationships among the business models, the innovation, the sustainable transitions, and the sustainable supply chains in the health socioeconomic context through the lens of the service provider, without exhausting these themes separately. The main results are the issues related to the difficulties of sustainable transition to promote the SSC in the hospital context, showing the elements into which the hospitals are inserted and helping to close the gap in the literature on the subject. Sustainable transitions, along with the SSC, present themselves as rich and challenging themes, but are beneficial for conducting dialogues between approaches.

Exploring mental health practice among Traditional health practitioners: a qualitative study in rural Kenya

BackgroundInvolvement of traditional health practitioners (THPs) in the form of collaboration with the formal health care system is suggested to improve the pathways to mental health care in Kenya, yet understanding of the current traditional practice and THPs’ perspectives is lacking. The aim of this study was to explore the views of THPs with respect to their mental health practice.MethodsThis study qualitatively explored the views of THPs, using four focus group discussions (FDGs) each consisting of 8–10 traditional and faith healers, resulting in a total of 36 participants. Thematic content analysis using a grounded theory approach was performed using QSR NVivo 10. Emerging topics were identified and examined by re-reading the transcripts several times and constantly re-sorting the material.ResultsFour themes that reflect THPs’ mental health practice perspectives emerged as follows: 1) Categorization of mental illness; 2) Diagnostics in traditional mental health practice; 3) Treatments and challenges in current traditional mental health practice; and 4) Solutions to improve traditional mental health practice.ConclusionsThese themes provide insight into the perspectives of Kenyan traditional and faith healers on their mental health practice, in an attempt to offer a meaningful contribution to the debate on collaboration between informal and formal health care providers in improving mental health services in Kenya. Furthermore, the presented challenges and solutions can inform policy makers in their task to improve and scale up mental health services in resource-poor areas in Kenya. Addressing these issues would be a first step towards understanding the solid foundation of traditional medicine that is necessary before collaboration can be successfully attempted. Further research is also recommended to assess patients’ needs and explore potential forms of collaboration, in order to achieve sustainable improvement in the mental health care pathways for patients.

Psychotropic medication and psychotherapeutic treatment of adults with intellectual disabilities (PROMPT-ID): a cross-sectional, epidemiological study in Saxony, Germany

IntroductionThe psychotropic medication and psychotherapeutic treatment of adults with intellectual disabilities study is a cross-sectional, epidemiological study carried out in Saxony, Germany. The main aim of the study is, among...

Results of a two year dental health education program to reduce dental caries in young Aboriginal children in New South Wales, Australia.

To assess the effectiveness of a dental health education program, 'Smiles not Tears' in preventing Early Childhood Caries in young Aboriginal children. Community trial. Aboriginal Community Controlled Health Services in rural, remote and metropolitan areas in New South Wales, Australia. Aboriginal families who had a child six months of age. Aboriginal Health Workers from eight Aboriginal Community Controlled Health Services in rural, remote and metropolitan areas in New South Wales recruited Aboriginal families with young children to participate in the Smiles not Tears dental education program. A convenience sample of Aboriginal children from the same communities was recruited to form a historical control group. The caries prevalence at 30 months of age compared to children of a similar age in the control group. More children in the test group were caries free (n =104; 97.2%) when compared to the historical control group (n = 54; 65.9%). Only three children in the test group had caries which is less than the control group (n = 29). These results suggest that the Smiles not Tears dental education program has a positive impact on reducing the caries prevalence in young Aboriginal children.

FACTORS RESPONSIBLE FOR WOMEN’S PREFERENCE FOR TRADITIONAL MATERNAL HEALTH CARE SERVICES IN AKOK NORTH AREA OF ONDO STATE, NIGERIA

This study compared the population of women that prefer traditional maternal health care services in Akoko North area of Ondo State and identified factors responsible preference for traditional maternal health care services. This was with a view to providing information on reasons responsible for women’ preference for traditional maternal health care services. The study used descriptive survey research design. The population for the study comprised women of child bearing age who had a life birth in the last five years in Akoko North–East (ANE) and North-West (ANW) LGAs of Ondo State. The sample comprised a total of 200 women. Each of the two LGAs was first stratified according to wards. In Akoko North-East and North-West, there are 13 and 11 wards respectively. From each of the LGAs, five wards were selected totaling 10 wards using simple random sampling technique. From each ward, 20 respondents were selected using snowballing sampling technique. A self-developed questionnaire was used to collect information on the population of women preferring TMHCS and reasons underlying their preferences. Data collected were analysed using percentage and chi-square analysis. The results indicated that 59% of the 200 women used in Akoko North–East preferred traditional maternal health care services while 69.0% of the women in Akoko North–West preferred it. Results also showed that spiritual reasons (59%), cultural belief (57.8%), cheaper services (57%) and provision of more compassionate care (53.9%) were reasons for women preference for traditional maternal health services in the study areas. The study concluded that spiritual reasons, cultural belief, compassionate care, low economic status, low education status are factors responsible for women’ preference for traditional maternal health services in Akoko North–East and North–West Areas of Ondo State. Article visualizations:

Impact of internal migration on fertility in Cotonou, Benin Republic

Context/Background: In developing countries, fertility is usually higher in rural than urban areas. This is partly due to lower access to and utilization of reproductive health services in rural areas. However, migration to cities may alter the fertility behaviour of migrants from rural areas. Data Source and Methods: The study used 2012 Benin Republic Demographic and Health Survey data and focused on married women aged 15-49 years and residing in Cotonou (n=722). Tobit regression was employed for the multivariate-level analysis. Findings: The results showed that migrants adapt gradually to the fertility patterns of non-migrants. This gradual adaptation is compounded by a relative selectivity of migrants whose fertility preferences are similar to those of non-migrants. Finally, recent migrants for employment or school reason had the lowest number of births over the past five years, which supports the disruption hypothesis. Conclusion: The migration-fertility relationship depends on the length of residence, migrant’ socioeconomic characteristics and reason for migration.

Inequalities in childhood vaccination timing and completion in London

The UK primary vaccination course includes vaccination against diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type b (DTaP/IPV/Hib) and is scheduled at ages four, 8 and 12 weeks, followed by a ‘preschool booster’ at age three years four months. Vaccine coverage is generally measured at age one, two and five years. In addition to high coverage, vaccination should be timely to maximise population protection.Vaccination histories for 315,381 children born March 2001 to April 2010 were extracted from Child Health Information Systems in nine London health service areas and grouped into first and fifth birthday cohorts. We assessed timeliness of receipt of DTaP/IPV/Hib and drop-out rates by ethnicity, deprivation and area.Most children received their first, second and third doses on time at two, three, and four months. Among children completing by one year and after adjusting for deprivation and health area, compared with White-British children, Somali and Bangladeshi children were less likely to have received three doses of DTaP/IPV/Hib by six months of age (−11% and −5% respectively). Differences in timeliness by deprivation and health area existed, but were smaller. Compared with White-British children, children of Polish, Somali and Caribbean ethnicities were less likely to return for preschool booster, with a drop-out rate at least 7% higher in these groups. Within the fifth birthday cohort, only 2.3% of children who were completely unvaccinated (575/25,095) at age one year were fully vaccinated by age five. Higher proportions of partially vaccinated (one or two doses) children at age one year went on to be fully vaccinated by age five ((836/3213) 26.0% and (3565/6076) 58.7% respectively).These inequalities suggest that tailored approaches may be required to target specific groups with regards to improving vaccine uptake.

The Comparison of Effectiveness between Static Clinic and Mobile Health Clinic in Remote Areas in Sabah

Background: The population of Malaysia is estimated in 2018 to be around 32.04 million and 23.5% of the population resides in rural areas. The Ministry of Health has provided healthcare services to the rural areas with the access of modern healthcare facilities based on the two-tier healthcare system. In remote areas, mobile health clinic is the extension of healthcare service by the nearest static health clinic. However, most of the remote areas only covered by a community clinic or Klinik Desa which is limited for mother and child healthcare. There is demand from the people in remote areas for static health clinic or Klinik Kesihatan. Objectives: This study is to evaluate and compare the effectiveness between two health services in remote areas applied in Sabah. This study also determines which type of health services that able to worth the service to people in remote areas. Methods: This is a descriptive study. Data was taken from HMIS report (Per PL 206) under Sabah State Health Department. The data analysed by using Microsoft Excel. Results: This study was conducted based from the data obtained in 2015 till 2017 for the number of patients attended to static health clinics and mobile health clinics on selected remote areas. For example, Jambongan Health Clinic only have an average of 10 – 15 patients per day while the Mobile Health Clinic team under Beluran Health District which covers the adjacent remote areas of Jambongan Island have more than 20 patients per day on a single visit. Another example is from Terian Health Clinic in Penampang, which only have an averageof 5 – 10 patients per day. However, on the mobile health team on a single visit to the village next to Terian which is Kg. Buayan, the average patients attended for the service is mo re than 20 patients. Conclusion: From the study, it was noted that people in remote areas prefer the mobile health service to visit their villages. This can be due to financial issue and limitation of transportation service to the nearest static clinic. The density of population and the development of the rural areas play important roles for the healthcare service to be effective in remote areas.&#x0D; Keywords: mobile health clinic, static clinic, effectiveness of healthcare, primary healthcare

Population-level HIV incidence estimates using a combination of synthetic cohort and recency biomarker approaches in KwaZulu-Natal, South Africa.

IntroductionThere is a notable absence of consensus on how to generate estimates of population-level incidence. Incidence is a considerably more sensitive indicator of epidemiological trends than prevalence, but is harder to estimate. We used a novel hybrid method to estimate HIV incidence by age and sex in a rural district of KwaZulu-Natal, South Africa.MethodsOur novel method uses an ‘optimal weighting’ of estimates based on an implementation of a particular ‘synthetic cohort’ approach (interpreting the age/time structure of prevalence, in conjunction with estimates of excess mortality) and biomarkers of ‘recent infection’ (combining Lag-Avidity, Bio-Rad Avidity and viral load results to define recent infection, and adapting the method for age-specific incidence estimation). Data were obtained from a population-based cross-sectional HIV survey conducted in Mbongolwane and Eshowe health service areas in 2013.ResultsUsing the combined method, we find that age-specific HIV incidence in females rose rapidly during adolescence, from 1.33 cases/100 person-years (95% CI: 0.98,1.67) at age 15 to a peak of 5.01/100PY (4.14,5.87) at age 23. In males, incidence was lower, 0.34/100PY (0.00-0.74) at age 15, and rose later, peaking at 3.86/100PY (2.52-5.20) at age 30. Susceptible population-weighted average incidence in females aged 15-29 was estimated at 3.84/100PY (3.36-4.40), in males aged 15-29 at 1.28/100PY (0.68-1.50) and in all individuals aged 15-29 at 2.55/100PY (2.09-2.76). Using the conventional recency biomarker approach, we estimated HIV incidence among females aged 15-29 at 2.99/100PY (1.79-4.36), among males aged 15-29 at 0.87/100PY (0.22-1.60) and among all individuals aged 15-59 at 1.66/100PY (1.13-2.27).DiscussionHIV incidence was very high in women aged 15-30, peaking in the early 20s. Men had lower incidence, which peaked at age 30. The estimates obtained from the hybrid method are more informative than those produced by conventional analysis of biomarker data, and represents a more optimal use of available data than either the age-continuous biomarker or synthetic cohort methods alone. The method is mainly useful at younger ages, where excess mortality is low and uncertainty in the synthetic cohort estimates is reasonably small.ConclusionApplication of this method to large-scale population-based HIV prevalence surveys is likely to result in improved incidence surveillance over methods currently in wide use. Reasonably accurate and precise age-specific estimates of incidence are important to target better prevention, diagnosis and care strategies.

Mental Health Nursing Practice and Indigenous Australians: A Multi-Sited Ethnography

Criticism of public mental services provided to Indigenous Australians have persisted over the last two decades, despite several national reports and policies that have attempted to promote positive service change. Mental health nurses represent the largest professional group practising within these services. This paper reports on a multi-sited ethnography of mental health nursing practice as it relates to this group of mental health service users. It explores the beliefs and ideas that nurses identified about specialist mental health nursing practice and Indigenous Australians. The study found a disunited approach to practice during the fieldwork. Practice was expressed as a series of individual constructions built upon the nurses’ beliefs about Indigenous Australians and their experiences in practice with these peoples. The criticism of mental health services from Indigenous communities was understandable to the mental health nurses, but how they could address this through their individual practices was not always clear to them. The actions by public mental health services to improve cultural safety through generic training related to the broad area of Indigenous health and health service needs, does not appear to evolve into informed specialist mental health nursing practice for Indigenous Australian service users.