Remote Indigenous Populations Research Articles

Cross-sectional study of the prevalence of chronic liver disease risk factors and liver fibrosis in a remotely living Indigenous Australian population

ObjectivesRemotely living Indigenous Australians have a disproportionate mortality from cirrhosis and hepatocellular cancer (HCC). However, there are no local population studies examining the prevalence of chronic liver disease (CLD) in...

The burden of rheumatologic disease in Aboriginal and Torres Strait Islander Australians.

The objective of this article is to summarise the current knowledge regarding the prevalence of six rheumatological conditions in indigenous Australians - rheumatoid arthritis (RA), osteoarthritis (OA), osteoporosis (OSP), systemic lupus erythematosus (SLE), gout and musculoskeletal (MSK) pain. Online medical literature databases were searched for 'indigenous', 'Aboriginal' and 'Torres Strait Islander', as well as the names of the six conditions. Other included search terms were 'crystal', 'urate', 'arthritis' and 'arthropathy'. No limitations were placed on publication data or language. Forty-five articles examining the prevalence of the six conditions were identified. Based on the published literature, SLE appears to have a higher prevalence, while RA appears to have a lower prevalence in indigenous Australians compared to the non-indigenous community. MSK pain is prevalent, has a significant impact on indigenous people and is perceived as an important area of need. There is a paucity of data regarding these conditions in indigenous Australians. This may be impacted by the uncertainty of case ascertainment by self-report, differences in disease phenotypes and prevalence between the metropolitan compared to the rural or remote indigenous population, and difficulty with access to healthcare. Further studies in conjunction with local indigenous communities are needed to accurately determine the burden of rheumatological disease in the indigenous population. This will assist with resource and workforce planning to deliver culturally appropriate interventions. Strategies for future clinical work and research include the development and dissemination of culturally safe rheumatology resources, rheumatology training of Aboriginal Health Workers and wider integration of rheumatology clinics into community-controlled Aboriginal Health Services.

Abstract 993: Comprehensive immunophenotypic strategies to enable equity in remote settings for improved cancer prognosis

Abstract Improved cancer prognosis begins with insights obtained from high quality data during clinical trials. Execution of longitudinal clinical trials in flow cytometry is complex, primarily due to logistical challenges in high quality sample collection. For instance, highly remote indigenous population centers are both disadvantaged in access to healthcare and often underrepresented in clinical trials. This paradox is highlighted in the case of Australian First Nations communities, for which lung cancer prevalence peaks in males at twice the magnitude of the general population. Our group has developed a novel blood “immune signature” that robustly predicts failure to make a clinical response to checkpoint therapies targeting the PD-1/PD-L1 pathway. Encouraged by these groundbreaking findings, which were achieved through applying a comprehensive 38-plex immunophenotyping CyTOF panel to biobanked cancer samples, recent advances in CyTOF technology now give us the opportunity to expand our clinical implementation to remote settings, with a further expanded panel to 50+ markers. CyTOF is the only technology that allows easily implemented remote asynchronous sample collection and the largest immunophenotyping panel that yields reproducible results. Asynchronous collection is uniquely enabled using a stable lyophilized large-scale staining panel and achieving comprehensive marker coverage in one panel minimizes blood sample required. Furthermore, the new technology enables a highly simplified workflow including blood collection and processing in remote locations to enable the simplest clinical trial infrastructure complexity and cost, easily implemented in current hospital lab environments. As such, this study is designed to ultimately demonstrate both clinical impact of the large panel and utility of CyTOF technology for highly simplified and robust workflow for multi-site clinical trials. This project has 3 phases; i) implementation and evaluation of the collection, analysis technique and data management of this new approach across multiple sites, ii) collection of samples for analysis both pre- and post- initiation of therapy to establish efficacy and optimize as necessary, and iii) blinded clinical trial. We will report on the first phase of this project which is implementing new workflow across clinical collection site, data integration and analysis. This workflow would enable highly simplified collection to access indigenous and under-served populations spread across remote sites in Australia. Citation Format: Natalie J. Smith, Michael Cohen, Julie Alipaz, Christina Loh, David King, Barbara Fazekas de St Groth, Helen M. McGuire. Comprehensive immunophenotypic strategies to enable equity in remote settings for improved cancer prognosis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 993.

A qualitative exploration of the experiences of Aboriginal and Torres Strait Islander people using a real-time video-based telehealth service for diabetes-related foot disease.

Diabetes-related foot disease (DFD) is one of the most prevalent causes of global hospitalisation and morbidity, and it accounts for up to 75% of lower-extremity amputations globally. The 5-year mortality rate following any amputation ranges from 53% to 100%. Early identification of wounds and multidisciplinary management can reduce amputation rates by 39-56%. Rural and remote communities and Indigenous populations are disproportionately affected by DFD. This is reflected in amputation rates, which are much higher for Indigenous than for non-Indigenous Australians and for those in very remote areas than for those in major cities or inner regional areas. The large geographical spread of the population in Australia is a substantial barrier for those providing or accessing health services, particularly multidisciplinary and specialist services, which undoubtedly contributes to poorer DFD outcomes in rural and remote communities. A real-time, video-based telehealth service for DFD management was established at the Royal Adelaide Hospital Vascular Services clinic to improve access to specialist services for rural and remote Aboriginal and Torres Strait Islander communities. An exploratory qualitative study that utilised one-on-one, semi-structured interviews was conducted with 11 participants who identified as Aboriginal and who had participated in the telehealth foot service. Interviews were transcribed, de-identified and analysed using thematic analysis, using an inductive approach. Four interrelated themes emerged. 'Practical benefits of staying home' describes the reduced burden of travel and advantages of having local healthcare providers and support people at consultations. 'Access to specialists and facilities' highlights how some participants felt that there was a lack of appropriate facilities in their area and appreciated the improved access telehealth provided. 'Feeling reassured that a specialist has seen their feet' reflects the positive impact on wellbeing that participants experienced when their feet were seen by specialist health staff. 'Facilitates communication' describes how participants felt included in consultations and how seeing a person on screen assisted conversation. The advantages of real-time, video-based telehealth go beyond reduced travel burden and improved access to specialist care. This model of care may facilitate relationship-building, patient wellbeing, and feelings of trust and safety for Aboriginal and Torres Strait Islander DFD patients.

Teledermatology in remote Indigenous populations: Lessons learned and paths to explore, an experience from Canada (Québec) and Australia.

Recent introduction of a provincially funded and administered teledermatology platform in Quebec presents a major opportunity to improve healthcare delivery to rural Indigenous communities where healthcare is suboptimal. In this study, we assessed approaches, challenges, solutions, and outcomes in implementing teledermatology in rural Indigenous communities of Australia and Canada. A narrative review was performed using journal articles and grey literatures to assess challenges encountered in Canadian and Australian teledermatology programs in rural Indigenous communities. We then conducted a focused search to identify solutions and outcomes to these challenges. We identified four main areas of focus for implementing teledermatology: financial, cultural, legal, and provider competency. Main financial concerns included identifying the cost-to-benefit ratio of teledermatology and financial benefits of the store-and-forward system compared to videoconferencing. Delivery of teledermatology through culturally considerate services is crucial to mend the mistrust felt by Indigenous people toward mainstream health services. From a legal standpoint, patient confidentiality and physician liability must be considered. A uniform teledermatology platform and physician competency in both telemedicine and dermatology are needed to ensure standard of care. Teledermatology initiatives represent great opportunities to improve healthcare services to rural Indigenous populations.

Remoteness, models of primary care and inequity: Medicare under-expenditure in the Northern Territory.

Objective To analyse Medicare expenditure by State/Territory, remoteness, and Indigenous demography to assess funding equality in meeting the health needs of remote Indigenous populations in the Northern Territory. Methods Analytic descriptions of Medicare online reports on services and benefits by key demographic variables linked with Australian Bureau of Statistics data on remoteness and Indigenous population proportion. The Northern Territory Indigenous and non-Indigenous populations were compared with the Australian average between the 2010/2011 and 2019/2020 fiscal years in terms of standardised rates of Medicare services and benefits. These were further analysed using ordinary least squares, simultaneous equations and multilevel models. Results In per capita terms, the Northern Territory receives around 30% less Medicare funds than the national average, even when additional Commonwealth funding for Aboriginal medical services is included. This funding shortfall amounts to approximately AU$80 million annually across both the Medicare Benefits Schedule and Pharmaceutical Benefits Scheme. The multilevel models indicate that providing healthcare for an Aboriginal and Torres Strait Islander person in a remote area involves a Medicare shortfall of AU$531-AU$1041 less Medicare Benefits Schedule benefits per annum compared with a non-Indigenous person in an urban area. Indigenous population proportion, together with remoteness, explained 51% of the funding variation. An age-sex based capitation funding model would correct about 87% of the Northern Territory primary care funding inequality. Conclusions The current Medicare funding scheme systematically disadvantages the Northern Territory. A needs-based funding model is required that does not penalise the Northern Territory population based on the remote primary health care service model.

From spirits to conspiracy? Nomadic perceptions of climate change, pandemics and disease

This article illustrates how the Yamal‐Nenets, a group of reindeer pastoralists in West Siberia, perceive a series of recent natural disasters to be connected to one another through a conspiracy – i.e. caused by the agency of malevolent human forces which are beyond the pastoralists’ control. Recent fieldwork during the peak of the global Covid‐19 epidemic served as a trigger for this observation. Their self‐confidence in the robustness of their lifestyle and their embeddedness within their natural environment is so strong that Yamal‐Nenets nomads believe only evil forces – not nature – can stop them from being mobile. Alongside Covid‐19, they interpret the severe consequences of natural disasters, such as iced pastures, related reindeer starvation and the outbreak of anthrax as man‐made attempts to reduce the number of people and animals in the tundra. The blame they place on humans for these disasters takes place in the context of hitherto unseen gas industry developments in the area. Such interpretations may become a general pattern for changing perceptions of the world by remote indigenous populations when deprived of their once customary shamanic dialogue with the spirits.

Clinical Utility of Stress Echocardiography in Remote Indigenous and Non-Indigenous Populations: A 10-Year Study in Central Australia

Remote Central Australia has a large Indigenous population and a significant burden of cardiovascular disease. Stress echocardiography has been previously validated as a useful investigation for long-term prognostication. However, there are no prior studies assessing its utility in remote or Indigenous populations. Consecutive individuals undergoing stress echocardiography in Central Australia between 2007 and 2017 were included. Stress echocardiography was performed and reported via standard protocols. Individuals were followed up for all-cause mortality. One-thousand and eight patients (1,008) (54% Indigenous Australian) were included. After a mean follow-up of 3.5±2.4 years, 54 (5%) patients were deceased. Overall, 797 (79%) patients had no abnormalities during rest or stress echocardiography, with no difference according to ethnicity (p>0.05). In patients with a normal test, annual mortality averaged 1.3% over 5 years of follow-up, with annual mortality significantly higher in Indigenous compared to non-Indigenous individuals (1.8% vs 0.6% respectively). In those with an abnormal test, annual mortality was 4.4% vs 1.3% in Indigenous and non-Indigenous individuals respectively. Increasing age, Indigenous ethnicity and cardiometabolic comorbidities were associated with mortality in univariate analyses (p<0.05 for all). In multivariate models, only chronic kidney disease remained predictive of mortality, with other associations (including Indigenous ethnicity) becoming attenuated. This is the first study to report on the use of stress echocardiography in a remote or Indigenous population. A normal stress echocardiogram in remote Indigenous individuals was able to identify a lower risk group of patients in this setting. Although Indigenous individuals with a normal test still had a higher annual rate of mortality compared to non-Indigenous individuals, this association appeared to be mediated by cardiometabolic comorbidities.

Dentofacial biometry as a discriminant factor in the identification of remote Amazon indigenous populations

This study aimed to examine the role of dentofacial morphology in discriminating semi-isolated indigenous groups. These populations present a similar pattern of dietary habits. Studies in human genetics have reported a large intertribal genetic distance and low intratribal variation. This study was conducted following the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Face dimensions were measured through facial photogrammetry, and dental arches and tooth size were evaluated using plaster models. A total of 98 subjects in the permanent dentition and belonging to 4 indigenous groups were analyzed: Arara-Iriri (n=20), Arara-Laranjal (n=33), Assurini (n=25), and Xicrin-Kayapó (n=20). The random and systematic errors were verified using the Dahlberg formula and the intraclass correlation coefficient (ICC), respectively. In order to evaluate the discrimination of the variables to identify the indigenous groups, a discriminant analysis was performed (P<0.05). A small causal error (Dahlberg, 0.13-1.81) and excellent replicability (ICC, 0.75-0.99) for face dimensions as well as for models (Dahlberg, 0.10-0.68; ICC, 0.94-0.99) were observed. The discriminant analysis allowed the identification of 4 populations by facial and dental arch dimensions and tooth size. Dentofacial biometry revealed an accuracy of 98% for females and 100% for males, which confirms a high intragroup homogeneity and considerable intergroup heterogeneity for dentofacial features. Biometric measurements of the human face added with tooth size and dental arch dimensions are very useful to identify remote indigenous populations with high accuracy. Supported by previous studies in human genetics, these findings reinforce the role of genetic variation in the determination of dentofacial features.

P5 Clinical utility of stress echocardiography in remote indigenous and non-indigenous populations: a 10-year study in central Australia

Abstract Background Central Australia is a vast, geographical region spanning some 830,000 square kilometres. It is the most populous Indigenous region in Australia (44%) and a great distance from tertiary centres (1,500km). Non-invasive testing is important in this setting due to the high prevalence of cardiovascular disease and long-distance travel required for coronary angiography, the latter with significant logistical, financial, and cultural barriers. Although stress echocardiography has been extensively validated as a long-term prognostic tool in selected populations, we are not aware of prior studies in remote Indigenous and non-Indigenous individuals. Purpose To determine whether stress echocardiography can adequately risk stratify and quantify the long-term prognosis of Indigenous and non-Indigenous individuals in remote Central Australia. Methods Consecutive individuals undergoing stress echocardiography in Central Australia between 2007 and 2017 were included. Exercise or dobutamine stress echocardiography was performed and reported via standard protocols. Individuals were followed up for the primary outcome of all-cause mortality. Results One thousand and eight patients (54% Indigenous, 63% dobutamine stress) were included. Indigenous patients were younger, more likely to be female, and had a greater prevalence of cardiometabolic comorbidities (p &amp;lt; 0.05 for all). Overall, 797 (79%) patients had no abnormality during rest or stress echocardiography, with no difference according to ethnicity (p &amp;gt; 0.05). After a mean follow up of 3.5 ± 2.4 years, 54 (5%) of patients were deceased; 127 (14%) patients underwent revascularization and were censored from follow-up. In patients with a normal test, annual mortality averaged 1.3% over 5 years of follow up, with annual mortality being significantly higher in Indigenous compared to non-Indigenous individuals (2.0% vs 0.6% respectively). Individuals with either ischemia or scar had a significantly worse long-term outcome compared to those with a normal test (Figure). In multivariate analyses, increasing age (HR 1.04 [95% CI 1.01-1.08]), chronic kidney disease (HR 4.83 [1.79-13.02]), and lack of ACEI/ARB use (HR 0.19 [95% CI 0.09-0.42]) were associated with all-cause mortality. Although Indigenous ethnicity was a univariate predictor of mortality, this association was attenuated and non-significant in multivariate analyses. Conclusion Indigenous patients in remote Central Australia with a normal stress echocardiogram had a significantly higher annual rate of mortality compared to their non-Indigenous counterparts. However, this association may be in large part due to comorbid conditions. A normal test in Indigenous individuals was still able to adequately risk-stratify and identify a lower risk group of patients in whom ongoing local medical management and focusing on cardiometabolic risk factor reduction is likely to be appropriate. Abstract P5 Figure. Kaplan Meier survival curve

Characteristics and Impact of Disseminated Gonococcal Infection in the "Top End" of Australia.

The "Top End" of Australia is presently experiencing a gonorrhea epidemic. Gonococcal infection is usually limited to mucosal tissues but can lead to disseminated gonococcal infection (DGI), joint destruction, and severe sepsis. This study aimed to explore the epidemiology, presentation, management, and health-care impact of DGI in the Top End of the Northern Territory. Health records of patients diagnosed with proven, probable, or possible DGI between January 2010 and September 2018 were analyzed retrospectively. One hundred six cases of DGI were identified. Ninety-four patients (88.7%) were Indigenous Australian. The incidence of proven and probable DGI in the Indigenous population was 27.1 per 100,000 person-years, compared with 7.1 in the Top End population overall. Of 7,540 laboratory-proven gonococcal notifications, 1.3% (n = 97) were complicated by DGI. The highest incidence was in the 15-19-year age-group. Thirteen cases (12.3%) occurred in patients younger than 15 years. High rates of comorbid alcohol misuse, diabetes, systemic lupus erythematosus, rheumatic fever, and complement deficiency were observed. The "classic triad" of tenosynovitis, dermatitis, and polyarthralgia was rare. Ninety-four patients (88.7%) presented with purulent arthritis. Disseminated gonococcal infection was estimated to cause at least 10.0% of nonpenetrating septic arthritis in the Top End and 1,234 days of hospitalization during the study period. DGI is an important cause of morbidity in the Top End, particularly in the young, remote Indigenous Australian population. Clinical presentation varies from classical teaching. Urgent action in the health and community sector is required, particularly for at-risk populations, to prevent further debilitating and costly complications of gonococcal infection.

P2498Exercise capacity and all-cause mortality in remote Indigenous and non-Indigenous populations

Abstract Background Exercise capacity is a powerful predictor of all-cause mortality. However, its association with Indigenous populations in Central Australia, who face disproportionate health burdens, is unclear. Given the isolation from tertiary centers, exercise testing could provide useful local risk-stratification. Purpose To characterize the association of exercise capacity with all-cause mortality in Indigenous and non-Indigenous individuals in remote Central Australia. Methods Demographic, medication, and all-cause mortality data were prospectively collected from patients undergoing exercise stress tests from 2007–2017. Results A total of 3,414 patients (34% Indigenous) were included. At 4.8±2.9 years of follow-up, 86 (2.5%) deaths had occurred. Each 1-MET increase in exercise capacity conferred a 14% lower risk for mortality among Indigenous individuals (HR 0.86, 95% CI 0.79–0.94) and 20% lower risk for mortality among non-Indigenous individuals (HR 0.80, 95% CI 0.73–0.89) after adjusting for age, comorbidities, and medications. Mortality risk reduction for each 1-MET increase in exercise capacity was similar (p=0.32) for Indigenous and non-Indigenous individuals. Conclusions Exercise capacity is a significant predictor of all-cause mortality in Indigenous and non-Indigenous individuals. These findings have important clinical implications towards exercise capacity for risk-stratification and preventative importance of physical activity.

Health-related behaviours in a remote Indigenous population with Type 2 diabetes: a Central Australian primary care survey in the Telehealth Eye and Associated Medical Services Network [TEAMSnet] project.

There is a wealth of data concerning the health behaviours of Indigenous Australians, but the health behaviours of Indigenous Australians with diabetes are not systematically documented. At the clinical level, understanding a person's health behaviours can help identify and address barriers to diabetes care and promote good clinical outcomes. We used a novel survey tool to systematically collect health behaviour data on Smoking, Nutrition, Alcohol consumption, Physical activity and Emotional well-being (SNAPE) from Indigenous Australians with Type 2 diabetes in a remote primary care setting in Alice Springs. At least one of the five surveys in the SNAPE tool was completed by 210 participants: 30% male, mean age 52.6 years (range 22.9 - 87.4). Fifty per cent of men and 23% of women were current smokers (P<0.001). None of the participants reported an adequate intake of vegetables. Only 9.6% reported an adequate fruit intake. Some 49% of men and 32% of women consumed alcohol in the past year (P=0.022), and 46% of drinkers were considered high-risk or likely-dependent drinkers. On average, participants walked 10min or more at a time 6.0 days a week and spent 4.8h sitting on a weekday. Mean adapted Patient Health Questionnaire 9 score was 4.61, with 34% of participants having mild depressive symptoms and 11% having moderate-severe depressive symptoms. Our SNAPE survey tool results present a high-risk, disadvantaged Indigenous population with Type 2 diabetes. More resources will be needed to sustainably implement interventions with the goal of improving health behaviours and subsequent long-term health.

Salivary characteristics and dental caries experience in remote Indigenous children in Australia: a cross-sectional study

BackgroundWhile associations between salivary characteristics and dental caries have been well studied, we are not aware of this being assessed in a remote Indigenous child population, where lifestyles may be different from urban children. Our aim was to assess associations between caries experience and putative biomarkers in saliva, accounting for oral hygiene and dietary habits.MethodsChildren attending schools in an Indigenous community in remote north Queensland, Australia were invited to an oral examination by qualified and calibrated examiners. Salivary flow rate, pH, buffering capacity and loads of mutans streptococci (MS), lactobacilli (LB) and yeasts were determined. Also, data on tooth brushing frequency and soft drinks consumption were obtained via a questionnaire. Caries experience was recorded by the International Caries Detection and Assessment System (ICDAS-II), and quantified as decayed, missing and filled surfaces. Relationships between the salivary variables and the cumulative caries experience (dmfs+DMFS) in the deciduous and permanent dentitions were examined by multivariate analyses to control the effect of confounders.ResultsThe mean cumulative decayed (DS + ds), missing (MS + ms) and filled (FS + fs) surfaces were 3.64 (SD: 4.97), 1.08 (4.38) and 0.79 (1.84) respectively. Higher salivary MS and LB counts, low tooth brushing frequency and daily soft drink consumption were significantly related to greater caries experience. Caries experience was about twice in those with ≥10^5 CFU/ml saliva counts of MS (mean = 6.33, SD: 8.40 vs 3.11, 5.77) and LB (7.03, 7.49 vs 4.41, 8.00). In the fully-adjusted multivariate model, caries experience in those with higher counts of MS and LB were 51 and 52% more than those with lower counts.ConclusionsAs with studies in other populations, childhood salivary counts of MS and LB were significantly associated with greater caries experience in this remote Indigenous community. To address the serious burden of oral disease, we are researching ways to promote a healthy oral environment by encouraging good dietary habits, and emphasising the importance of daily tooth brushing with a fluoridated toothpaste. Our ongoing longitudinal studies will indicate the success of measures employed to reduce the counts of bacteria closely associated with cariogenesis and their impact on caries increment.Trial registrationAustralian New Zealand Clinical Trials Registry (ANZCTR), No: ACTRN12615000693527; date of registration: 3rd July 2015.

Exercise Capacity and All-Cause Mortality in Remote Indigenous and Non-Indigenous Populations

Exercise Capacity and All-Cause Mortality in Remote Indigenous and Non-Indigenous Populations

Prevalence of Atrial Fibrillation in Remote Indigenous and non-Indigenous Populations: A Ten-Year Study in Central Australia

Prevalence of Atrial Fibrillation in Remote Indigenous and non-Indigenous Populations: A Ten-Year Study in Central Australia

Utility of Stress Echocardiography in Remote Indigenous and Non-Indigenous Populations

Utility of Stress Echocardiography in Remote Indigenous and Non-Indigenous Populations

Clinical Utility of Stress Echocardiography in Remote Indigenous and Non-Indigenous Populations: A 10-Year Study in Central Australia

Clinical Utility of Stress Echocardiography in Remote Indigenous and Non-Indigenous Populations: A 10-Year Study in Central Australia

The cost-effectiveness of a 20% price discount on fruit, vegetables, diet drinks and water, trialled in remote Australia to improve Indigenous health.

This paper estimates the cost-effectiveness of a 20% price discount on healthy food and beverages with and without consumer nutrition education, as trialled in remote Northern Australia. Changes in actual store sales, from the pre-discount baseline period, were analysed for population impact on consumption of fruit and vegetables, water and artificially sweetened soft drinks, in addition with total dietary weight (grams), energy (Mega Joules), and sodium (milligrams). Disability Adjusted Life Years (DALYs), arising from changes in dietary risk factor prevalence in the population, were estimated as the primary health outcome in a multi health-state Markov model. The costs of the strategies were sourced from paid invoices and time estimates of staff providing store-based discount promotion and consumer education. The incremental cost-effectiveness ratio adopted a partial societal perspective, (including health and retail sector costs), as cost per DALY averted and was presented in 2011 Australian dollars. The price discount, helped address a gap in food price equity for residents of remote communities. However, the discount strategy, with or without consumer education led to a net loss of population health –36 95%CI (-47,-25) or -21(-28, -15) DALYs respectively, at increased cost to the retail and health sectors, of AUD860000 95%CI (710000, 1million) or AUD500000 (410000, 590000). The strategies trialled were thereby categorised as dominated by current practice while acknowledging considerable uncertainty surrounding the health outcome estimates. The 20% discount on limited targeted products appeared to need to be considered in conjunction with other marketing strategies to support healthy food choices, if remote Australian Indigenous population health is to be improved.

LO04: Health effects of training laypeople to deliver emergency care in underserviced populations: preliminary results of a systematic review

Introduction: The World Health Organization recommends emergency care training for laypeople in low-resource settings, but the effects of these programs on patient outcomes and community health have not been systematically reviewed. Our objective was to identify the individual and community health effects of educating laypeople to deliver emergency care in low-resource settings. Methods: We conducted a systematic review to address this question: in low-resource populations (P), does emergency care education for laypeople (I) confer any measurable effect on patient morbidity and mortality, or community capacity and resilience for emergency health conditions (O), in comparison with no training or other education(C)? We searched 12 electronic databases and grey literature for quantitative studies. We conducted duplicate and independent title and abstract screening, methodological and outcomes extraction, and study quality assessment using the Effective Public Health Practice Tool. We developed a narrative summary of findings. (PROSPERO: CRD42014009685) Results: We reviewed 16,017 abstracts and 372 full-text papers. 38 met inclusion criteria. Most topically relevant papers were excluded because they assessed educational outcomes. Cardiopulmonary resuscitation training (6 papers) improved cardiac arrest survival and enhanced capacity to respond to cardiac arrest in rural Norway, Denmark and commercial aircraft operations. A public education campaign in remote Denmark improved absolute cardiac arrest survival by 5.4% (95%CI 2-12). Lay trauma training (12 papers) reduced absolute injury mortality and improved community capacity in Iraq, Cambodia, Iran and Indigenous New Zealand communities. A trauma care program in Iraq and Cambodia reduced absolute mortality by 25% (95%CI 17.2-33). Education for mothers on paediatric fevers in Ethiopia was associated with 40% relative reductions in under-5 mortality (95%CI 29.2-50.6). Similar training improved access to care for paediatric malnutrition, malaria, pneumonia, and gastrointestinal disease in Nigeria, Kenya, Senegal, Burkina Faso, Mali, and India (13 papers). Overdose education and naloxone distribution was associated with reductions in opioid overdose deaths (3 papers), including in Massachusetts where high-uptake communities for overdose education had significantly lower overdose fatality rates than no-uptake communities (rate ratio 0.54, 95%CI 0.39-0.76). Community education improved measures of access to emergency care for remote Indigenous populations in Canada, Alaska and Nepal (3 papers) and adolescent mental health capacity in Australia (1 paper). Studies were of low or medium quality. Conclusion: In addition to established interventions for injury and cardiac arrest, emergency care training can improve community capacity in underserviced populations, and save lives in opioid overdose, paediatric infectious disease and malnutrition.