Dr Josephine Gwynn

Introduction Process evaluations examining programme implementation are often conducted in conjunction with effectiveness studies. Their inclusion in studies with Aboriginal participants can give an understanding of programme delivery in Aboriginal community contexts. The Ironbark: Standing Strong and Tall programme was codesigned with Aboriginal communities and includes exercise and facilitated ¿ yarning' discussion about fall risk and prevention strategies. The programme pilot showed favourable outcomes and acceptability for Aboriginal people aged 45 years and over. The Ironbark: Standing Strong and Tall programme is now being compared with a ¿ Healthy Community' programme in a cluster randomised controlled trial within Aboriginal health and community services. An embedded process evaluation aims to explore relationships between participation and programme outcomes and the quality of programme implementation. Methods and analysis The process evaluation will use a mixed methods design, guided by Indigenous research methodology. It will evaluate quantitative data (number of completed sessions, site coaching checklist tool, participant and facilitator questionnaire data and a participant habit formation scale), as well as qualitative data (open-ended responses from project and site staff and semistructured interviews using yarning with study participants and site managers). A programme logic model was developed to explain the intended inputs, activities, outputs and outcomes, which guided this process evaluation design. Conclusion This process evaluation of a fall prevention programme for older Aboriginal people using a mixed methods design and data triangulation will allow for a comprehensive understanding of study findings. Multiple study sites allow for generalisability of findings and exploration of variation across sites. Trial registration number ACTRN12619000349145.

Background: Circulatory diseases continue to be the greatest cause of mortality for Australian Aboriginal and Torres Strait Islander people, and a major cause of persistently lower life expectancy compared with non-Aboriginal Australians. The limited information that exists on atrial fibrillation (AF) prevalence in Aboriginal and Torres Strait Islander communities is mostly based on hospital admission data. This shows AF as principal or additional admission diagnosis was 1.4 times higher compared to non-Aboriginal Australians, a higher incidence of AF across the adult life span after age 20 years and a significantly higher prevalence among younger patients. Our study estimates the first national community prevalence and age distribution of AF (including paroxysmal) in Australian Aboriginal people. A handheld single-lead electrocardiograph (ECG) device (iECG), known to be acceptable in this population, was used to record participant ECGs. Methods: This co-designed, descriptive cross-sectional study was conducted in partnership with 16 Aboriginal Community Controlled Health organisations at their facilities and/or with their services delivered elsewhere. The study was also conducted at one state community event. Three (3) Australian jurisdictions were involved: New South Wales, Western Australia and the Northern Territory. Study sites were located in remote, regional and urban areas. Opportunistic recruitment occurred between June 2016 and December 2017. People <45 years of age were excluded. Results: Thirty (30) of 619 Aboriginal people received a ¿Possible AF¿ and 81 an ¿Unclassified¿ result from a hand-held smartphone ECG device. A final diagnosis of AF was made in 29 participants (4.7%; 95%CI 3.0¿6.4%), 25 with known AF (five paroxysmal), and four with previously unknown AF. Three (3) of the four with unknown AF were aged between 55¿64 years, consistent with a younger age of AF onset in Aboriginal people. Estimated AF prevalence increased with age and was higher in those aged >55 years than the general population (7.2% compared with 5.4%). Slightly more men than women were diagnosed with AF. Conclusions: This study is a significant contribution to the evidence which supports screening for AF in Aboriginal and Torres Strait Islander people commencing at a younger age than as recommended in the Australian guidelines (>65 years). We recommend the age of 55 years. Consideration should be given to the inclusion of AF screening in the Australian Government Department of Health annual ¿Aboriginal and Torres Strait Islander Health Assessment¿. Clinical Trial Registration: ACTRN12616000459426.

Background: To review the international literature on community-based interventions aiming to improve the oral health of Indigenous adolescents and identify which demonstrate a positive impact. Methods: Data sources were MEDLINE, EMBASE, CINAHL, SCOPUS, the COCHRANE library and the Australian Indigenous HealthInfoNet. Articles were included where they: were published in English from 1990 onwards; described oral health outcomes for Indigenous adolescents aged 10 to 19 years; implemented a community based oral health intervention. The Quality Assessment Tool for Quantitative Studies from the Effective Public Health Practice Project was applied. Results: Nine studies met inclusion criteria; two rated strong in quality; only one study was conducted with an urban community; five reported moderate community engagement. Five intervention strategies were identified, and schools were the most common setting reported. Statistically significant improvements were described in eight studies with the most frequently reported outcome being change in decayed missing or filled teeth. Conclusions: Few good quality peer reviewed international studies of community-based oral health interventions which address the needs of Indigenous adolescents exist. Studies must include strong Indigenous community leadership and governance at all stages of the research, adopt participatory action-based research approaches, and are required in urban communities.

Objectives: To review intervention programs that measure gait to investigate what features of the intervention may contribute to improving gait in older adults with cognitive impairment or dementia. Design: Systematic review using Medline, Cinahl, Scopus, PsychInfo, Amed, Embase, Web of Science, and PubMed for original research published in English between January 1, 2000, and July 23, 2018, to identify interventional controlled trials. Narrative synthesis was undertaken. Results: Of 6,379 citations, 36 articles met inclusion criteria. Interventions were categorized as medication or medical devices (8 studies), exercise (19 studies), and exercise plus cognitive training (9 studies). Antidementia medication may improve gait variability in people with Alzheimer's disease. Exercise programs focusing on strength and balance training, especially when combined with functional mobility training, improve gait in people with mild cognitive impairment or dementia. Exercise plus cognitive training programs combining strength and balance training, functional mobility training, and training on attention and executive function also improve gait. Conlusion: Physical and cognitive factors affect gait performance, and both should be addressed in intervention programs. Physical exercises including functional mobility training, especially walking, have better results than physical programs with only static, resistance, and flexibility training. Cognitive intervention should be concomitant with physical exercises rather than separate, with a focus on attention and executive function. Combining physical training with cognitive training in a functional context may assist older adults with cognitive impairment generalize from training to everyday activity. J Am Geriatr Soc 67:381¿391, 2019.

Objective: Examine the feasibility and acceptability of an electrocardiogram (ECG) attached to a mobile phone (iECG) screening device for atrial fibrillation (AF) in Aboriginal Controlled Community Health Services (ACCHS) and other community settings. Methods: Semi-structured interviews were conducted with ACCHS staff in urban, rural and remote communities in three Australian states/territories. Quantitative and qualitative questions identified the enabling factors and barriers for staff and Aboriginal patients' receptiveness to the device. Mean quantitative scores and their standard deviation were calculated in Microsoft Excel and qualitative questions were thematically analysed. Results: Eighteen interviews were conducted with 23 staff across 11 ACCHS. Quantitative data found staff were confident in providing iECG screening and managing the referral pathway, and thought the process was beneficial for patients. Qualitative data highlighted the usefulness of the device to undertake opportunistic screening and acceptability in routine practice, and provided opportunities to engage patients in education around AF. Conclusion: The iECG device was well accepted within ACCHSs and was feasible to use to screen for AF among Aboriginal patients. Implications for public health: The device can be used in clinical and community settings to screen Aboriginal people for atrial fibrillation to help reduce rates of stroke and other cardiovascular diseases.

Background: Older people with cognitive impairment are at increased risk of falls; however, fall prevention strategies have limited success in this population. The aim of this paper is to review the literature to inform a theoretical framework for fall prevention in older adults with dementia. Summary: A narrative review was conducted on fall risk factors in people with cognitive impairment, the relationship between cognition and gait, and their joint impact on the risk of falls. This was used to develop a theoretical framework for fall prevention for people with dementia. Executive function and motor function are closely related as they share neuroanatomy. This close relationship has been confirmed by observational studies including neuroimaging and intervention studies. Executive function is the cognitive domain most commonly associated with gait dysfunction. Attention, sensory integration, and motor planning are the sub-domains of executive function associated with risk of falls through gait dysfunction, whereas cognitive flexibility, judgement, and inhibitory control affect risk of falls through risk-taking behaviour. Key Messages: Gait, cognition, and falls are closely related. The comorbidity and interaction between gait abnormality and cognitive impairment may underpin the high prevalence of falls in older adults with dementia. Gait assessment and cognitive assessment, particularly executive function, should be integrated in fall risk screening. Assessment results should be interpreted and utilised using a multidisciplinary approach; specific strategies such as customised gait training and behavioural modulation should be considered as part of falls prevention for people with dementia.

Objective To review the literature on nutrition interventions and identify which work to improve diet-related and health outcomes in Australian Aboriginal and Torres Strait Islander people. Study design Systematic review of peer-reviewed literature. Data sources MEDLINE, PubMed, Embase, Science Direct, CINAHL, Informit, PsychInfo and Cochrane Library, Australian Indigenous Health InfoNet. Study selection Peer-reviewed article describing an original study; published in English prior to December 2017; inclusion of one or more of the following outcome measures: nutritional status, food/dietary/nutrient intake, diet-related biomedical markers, anthropometric or health measures; and conducted with Australian Aboriginal and Torres Strait Islander people. Data extraction and synthesis Two independent reviewers extracted data and applied the Quality Assessment Tool for Quantitative Studies from the Effective Public Health Practice Project. A purpose designed tool assessed community engagement in research, and a framework was applied to interventions to report a score based on numbers of settings and strategies. Heterogeneity of studies precluded a meta-analysis. The effect size of health outcome results were estimated and presented as forest plots. Results Thirty-five articles (26 studies) met inclusion criteria; two rated moderate in quality; 12 described cohort designs; 18 described interventions in remote/very remote communities; none focused solely on urban communities; and 11 reported moderate or strong community engagement. Six intervention types were identified. Statistically significant improvements were reported in 14 studies of which eight reported improvements in biochemical/haematological markers and either anthropometric and/or diet-related outcomes. Conclusions Store-based intervention with community health promotion in very remote communities, fiscal strategies and nutrition education and promotion programmes show promise. Future dietary intervention studies must be rigorously evaluated, provide intervention implementation details explore scale up of programmes, include urban communities and consider a multisetting and strategy approach. Strong Aboriginal and Torres Strait Islander community engagement is essential for effective nutrition intervention research and evaluation. PROSPERO registration number CRD42015029551.

Values and ethics: guidelines for ethical conduct in Aboriginal and Torres Strait Islander health research (Values and ethics) describes key values that should underpin Aboriginal and Torres Strait Islander (Indigenous)-focused health research. It is unclear how research teams address this document in primary health care research. We systematically review the primary health care literature focusing on Indigenous social and emotional wellbeing (SEWB) to identify how Values and ethics and community preferences for standards of behaviour (local protocols) are addressed during research. Study type: Systematic review in accordance with PRISMA Guidelines and MOOSE Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies. Methods: We searched four databases and one Indigenous-specific website for qualitative, quantitative and mixed-method studies published since Values and ethics was implemented (2003). Included studies were conducted in primary health care services, focused on Indigenous SEWB and were conducted by research teams. Using standard data extraction forms, we identified actions taken (reported by authors or identified by us) relating to Values and ethics and local protocols. Results: A total of 25 studies were included. Authors of two studies explicitly mentioned the Values and ethics document, but neither reported how their actions related to the document's values. In more than half the studies, we identified at least three actions relating to the values. Some actions related to multiple values, including use of culturally sensitive research processes and involving Indigenous representatives in the research team. Local protocols were rarely reported. Conclusion: Addressing Values and ethics appears to improve research projects. The academic community should focus on culturally sensitive research processes, relationship building and developing the Indigenous research workforce, to facilitate acceptable research that affects health outcomes. For Values and ethics to achieve its full impact and to improve learning between research teams, authors should be encouraged to report how the principles are addressed during research, including barriers and enablers that are encountered.

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

Consuming a healthy diet forms an important component of diabetes management; however, adhering to a healthy diet is challenging. Dietary behaviour is often guided by socio-cultural, environmental and emotional factors, and not necessarily by physical and nutritional needs. This study explored Nepalese patients' perceptions of the impact of diet, diet management requirement for diabetes and how Nepalese food culture in particular influenced diet management. Interviews were conducted with Nepalese participants with type 2 diabetes in Sydney and Kathmandu; and data was thematically analysed. Diet was recognized as a cause of, and a key treatment modality, in diabetes. Besides doctors, participants in Nepal received a large amount of dietary information from the community. Dietary changes formed a major component of lifestyle modifications adopted after diagnosis, and mostly consisted of removal of foods with added sugar and foods with high total sugar content from the diet, and a reduction in overall quantity of foods consumed. Perceived dietary restriction requirements created social and emotional discomfort to patients. Most participants perceived the Nepalese food culture as a barrier to effective diet management. Meals high in carbohydrates, limited food choices, and food preparation methods were identified as barriers, particularly in Nepal. In Australia, participants reported greater availability and easier access to appropriate food, and healthier cooking options. The socio-cultural aspects of food behaviour, mainly, food practices during social events were identified as significant barriers. Although diet was acknowledged as an important component of diabetes care, and most adopted changes in their diet post-diagnosis, effective and sustained changes were difficult to achieve. Future public health campaigns and education strategies should focus on improving diet knowledge, awareness of food options for diabetes, and effective dietary management.