Community-based participatory action research on rheumatic heart disease in an Australian Aboriginal homeland: Evaluation of the 'On track watch' project

Rheumatic Heart Disease Burden in Africa and the Need to Build Robust Infrastructure

Rheumatic heart disease (RHD) is an important public health problem in Africa. Mapping the epidemiology of RHD involves elucidating its geographic distribution, temporal trends, and demographic characteristics. The prevalence of RHD in Africa varies widely, with estimates ranging from 2.9 to 30.4 per 1,000 population. Factors contributing to this burden include limited access to health care, poverty, lack of research interest, and genetic fragility. Studies have highlighted differences in group A Streptococcus (GAS) incidence among different African countries, emphasizing the importance of effective monitoring and intervention strategies. RHD epidemiological mapping in Africa indicates regional differences and socioeconomic determinants. The high prevalence among females in most studies and among children underscores the urgency for targeted interventions. Diagnosing RHD in Africa faces challenges of inaccessibility of health facilities and trained personnel. Efforts to develop cost-effective and accessible diagnostic tools, such as mobile/portable echocardiography machines, molecular biomarkers such as Tenascin-C and microRNA expression profile shows promise for accurate diagnosis of RHD, but their validation and utilization is limited due to resource constraints. Furthermore, lack of an effective licensed vaccine for GAS causes significant retardation in RHD control in Africa. Addressing the burden of RHD in Africa and other low- and middle-income countries requires robust RHD biomarkers and effective vaccines. This review provides a comprehensive overview of the landscape of RHD in Africa, covering the bacteriology of GAS, the burden of GAS infections, exploring diagnostic avenues, challenges, and opportunities in RHD biomarkers, diagnosis, effective prevention strategies, and RHD management in Africa.

Patient preferences for prophylactic regimens requiring regular injections in children and adolescents: a systematic review and thematic analysis

BACKGROUND

At present, limited literature exists exploring patient preferences for prophylactic treatment of acute rheumatic fever (ARF) and rheumatic heart disease (RHD). Given low treatment completion rates to this treatment in Australia, where the burden of disease predominantly affects Aboriginal and Torres Strait Islander people, an improved understanding of factors driving patient preference is required to improve outcomes. Due to limited available literature, this review sought to explore treatment preferences for conditions for which the findings might be generalisable to the ARF/RHD context.

OBJECTIVE

Explore treatment preferences of patients, parents/caregivers and healthcare providers towards regular injection regimens in paediatric and adolescent populations for any chronic condition. Findings will be applied to the development of benzathine penicillin G (BPG) prophylactic regimens that are informed by treatment preferences of patients and their caregivers. This in turn should contribute to optimisation of successful BPG delivery.

METHODS

A systematic review of databases (Medline, Embase and Global Health) was conducted using a search strategy developed with expert librarian input. Studies were selected using a two-stage process: (1) title and abstract screen and (2) full text review. Data were extracted using a reviewer-developed template and appraised using the JBI Critical Appraisal tool. Data were synthesised according to a thematic analytical framework.

RESULTS

1725 papers were identified by the database search, conducted between 12 February 2022 and 8 April 2022, and 25 were included in the review. Line-by-line coding to search for concepts generated 20 descriptive themes. From these, five overarching analytical themes were derived inductively: (1) ease of use, (2) tolerability of injection, (3) impact on daily life, (4) patient/caregiver agency and (5) home/healthcare interface.

CONCLUSIONS

The findings of this review may be used to inform the development of preference-led regular injection regimens for paediatric and adolescent patient cohorts-specifically for BPG administration in ARF/RHD secondary prophylaxis.

TRIAL REGISTRATION NUMBER

Patient, parent and health personnel preferences towards regular injection regimes in paediatric and adolescent populations-a protocol for a systematic review. PROSPERO 2021 CRD42021284375. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021284375.

The complexity of leadership in coproduction practices: a guiding framework based on a systematic literature review

BACKGROUND

As coproduction in public services increases, understanding the role of leadership in this context is essential to the tasks of establishing relational partnerships and addressing power differentials among groups. The aims of this review are to explore models of coproduction leadership and the processes involved in leading coproduction as well as, based on that exploration, to develop a guiding framework for coproduction practices.

METHODS

A systematic review that synthesizes the evidence reported by 73 papers related to coproduction of health and welfare.

RESULTS

Despite the fact that models of coleadership and collective leadership exhibit a better fit with the relational character of coproduction, the majority of the articles included in this review employed a leader-centric underlying theory. The practice of coproduction leadership is a complex activity pertaining to interactions among people, encompassing nine essential practices: initiating, power-sharing, training, supporting, establishing trust, communicating, networking, orchestration, and implementation.

CONCLUSIONS

This paper proposes a novel framework for coproduction leadership practices based on a systematic review of the literature and a set of reflective questions. This framework aims to help coproduction leaders and participants understand the complexity, diversity, and flexibility of coproduction leadership and to challenge and enhance their capacity to collaborate effectively.

Impact of community-based employment on Aboriginal and Torres Strait Islander wellbeing, aspirations, and resilience

BACKGROUND

This study evaluated a research project that provided employment in an Aboriginal and Torres Strait Islander community-based setting and supported participants to identify and achieve their goals and aspirations. The evaluation examined changes in personal, relationship, community and cultural strengths and resources and explored empowerment and resilience, in terms of promoting wellbeing.

METHODS

Ten Aboriginal people employed as life coaches and peer researchers participated in semi-structured interviews and also completed the Aboriginal Resilience and Recovery Questionnaire at the beginning of their employment and 6-months after employment. Interviews with the 10 participants explored changes in their wellbeing, relationships, resilience, opportunity to lead, aspirations, goal setting skills, connection to culture and community, and empowerment.

RESULTS

Participants personal strengths, and cultural and community strengths, sub-scale scores showed improvements across the 6-month period, however these changes were not statistically significant. Using reflexive thematic analysis, we generated five themes including Aspirations; Personal capabilities; Constraints to wellbeing; Community engagement and cultural connection; and Employment facilitators. Overall, participants identified that despite the challenges of their work and the additional challenges posed by the COVID-19 lockdowns, they were able to develop their skills to set and achieve goals. They reported feeling empowered and proud of their work, and engaged more frequently with their communities and culture.

CONCLUSIONS

The study outcomes evidence the role of employment in an Aboriginal and Torres Strait Islander community-based project in strengthening wellbeing, enhancing resilience, and supporting participants to advance their personal goals and aspirations. These findings reinforce the importance of supporting the aspirations and employment of Aboriginal and Torres Strait Islander Peoples through employment.

Measurement and outcomes of co-production in health and social care: a systematic review of empirical studies

BACKGROUND

Co-production is promoted as an effective way of improving the quality of health and social care but the diversity of measures used in individual studies makes their outcomes difficult to interpret.

OBJECTIVE

The objective is to explore how empirical studies in health and social care have described the outcomes of co-production projects and how those outcomes were measured.

DESIGN AND METHODS

A scoping review forms the basis for this systematic review. Search terms for the concepts (co-produc* OR coproduc* OR co-design* OR codesign*) and contexts (health OR 'public service* OR "public sector") were used in: CINAHL with Full Text (EBSCOHost), Cochrane Central Register of Controlled trials (Wiley), MEDLINE (EBSCOHost), PsycINFO (ProQuest), PubMed (legacy) and Scopus (Elsevier). There was no date limit. Papers describing the process, original data and outcomes of co-production were included. Protocols, reviews and theoretical, conceptual and psychometric papers were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was followed. The Mixed Methods Appraisal Tool underpinned the quality of included papers.

RESULTS

43 empirical studies were included. They were conducted in 12 countries, with the UK representing >50% of all papers. No paper was excluded due to the Mixed Methods Quality Appraisal screening and 60% of included papers were mixed methods studies. The extensive use of self-developed study-specific measures hampered comparisons and cumulative knowledge-building. Overall, the studies reported positive outcomes. Co-production was reported to be positively experienced and provided important learning.

CONCLUSIONS

The lack of common approaches to measuring co-production is more problematic than the plurality of measurements itself. Co-production should be measured from three perspectives: outputs of co-production processes, the experiences of participating in co-production processes and outcomes of co-production. Both self-developed study-specific measures and established measures should be used. The maturity of this research field would benefit from the development and use of reporting guidelines.

"The most culturally safe training I've ever had": the co-design of a culturally safe Managing hepatitis B training course with and for the Aboriginal health workforce of the Northern Territory of Australia

BACKGROUND

The Aboriginal health workforce provide responsive, culturally safe health care. We aimed to co-design a culturally safe course with and for the Aboriginal health workforce. We describe the factors which led to the successful co-design, delivery, and evaluation of the "Managing hepatitis B" course for the Aboriginal health workforce.

METHODS

A Participatory Action Research approach was used, involving ongoing consultation to iteratively co-design and then develop course content, materials, and evaluation tools. An Aboriginal and Torres Strait Islander research and teaching team received education in chronic hepatitis B and teaching methodologies. Pilot courses were held, in remote communities of the Northern Territory, using two-way learning and teach-back methods to further develop the course and assess acceptability and learnings. Data collection involved focus group discussions, in-class observations, reflective analysis, and use of co-designed and assessed evaluation tools.

RESULTS

Twenty-six participants attended the pilot courses. Aboriginal and Torres Strait Islander facilitators delivered a high proportion of the course. Evaluations demonstrated high course acceptability, cultural safety, and learnings. Key elements contributing to success and acceptability were acknowledging, respecting, and integrating cultural differences into education, delivering messaging and key concepts through an Aboriginal and Torres Strait Islander lens, using culturally appropriate approaches to learning including storytelling and visual teaching methodologies. Evaluation of culturally safe frameworks and findings from the co-design process led to the creation of a conceptual framework, underpinned by meeting people's basic needs, and offering a safe and comfortable environment to enable productive learning with attention to the following: sustenance, financial security, cultural obligations, and gender and kinship relationships.

CONCLUSIONS

Co-designed education for the Aboriginal health workforce must embed principles of cultural safety and meaningful community consultation to enable an increase in knowledge and empowerment. The findings of this research can be used to guide the design of future health education for First Nations health professionals and to other non-dominant cultures. The course model has been successfully transferred to other health issues in the Northern Territory.

The evidence that rheumatic heart disease control programs in Australia are making an impact

OBJECTIVE

Rheumatic heart disease (RHD) comprises heart-valve damage caused by acute rheumatic fever (ARF). The Australian Government Rheumatic Fever Strategy funds RHD Control Programs to support detection and management of ARF and RHD. We assessed epidemiological changes during the years of RHD Control Program operation.

METHODS

Linked RHD register, hospital and death data from four Australian jurisdictions were used to measure ARF/RHD outcomes between 2010 and 2017, including: 2-year progression to severe RHD/death; ARF recurrence; secondary prophylaxis delivery and earlier disease detection.

RESULTS

Delivery of secondary prophylaxis improved from 53% median proportion of days covered (95%CI: 46-61%, 2010) to 70% (95%CI: 71-68%, 2017). Secondary prophylaxis adherence protected against progression to severe RHD/death (hazard ratio 0.2, 95% CI 0.1-0.8). Other measures of program effectiveness (ARF recurrences, progression to severe RHD/death) remained stable. ARF case numbers and concurrent ARF/RHD diagnoses increased.

CONCLUSIONS

RHD Control Programs have contributed to major success in the management of ARF/RHD through increased delivery of secondary prevention yet ARF case numbers, not impacted by secondary prophylaxis and sensitive to increased awareness/surveillance, increased.

IMPLICATIONS FOR PUBLIC HEALTH

RHD Control Programs have a major role in delivering cost-effective RHD prevention. Sustained investment is needed but with greatly strengthened primordial and primary prevention.

Culturally Informed Australian Aboriginal and Torres Strait Islander Evaluations: A Scoping Review

Rigorous and effective evaluations inform policy and service delivery and create evidence of program impacts and outcomes for the communities they are designed to support. Genuine engagement of communities is a key feature of effective evaluation, building trust and enhancing relevancy for communities and providing meaningful outcomes and culturally relevant findings. This applies to Indigenous peoples' leadership and perspectives when undertaking evaluations on programs that involve Indigenous communities. This systematic scoping review sought to explore the characteristics of culturally informed evaluations and the extent of their application in Australia, including the use of specific evaluation tools and types of community engagement. Academic and grey literature were searched between 2003 and 2023, with 57 studies meeting the inclusion criteria. Over time, there was an increase in the number of culturally informed evaluations undertaken, predominantly in the health and wellbeing sector. Around a quarter used a tool specifically developed for Indigenous evaluations. Half of the publications included Indigenous authorship; however, most studies lacked detail on how evaluations engaged with communities. This review highlights the need for further development of evaluation tools and standardised reporting to allow for shared learnings and improvement in culturally safe evaluation practices for Aboriginal and Torres Strait Islander communities.

Evaluative criteria in practice: Findings from an analysis of evaluations published in Evaluation and Program Planning

BACKGROUND

Evaluative criteria represent values about characteristics that define a successful evaluand. Criteria direct evaluators' lines of inquiry, including how aims are framed, which questions are asked, and what conclusions are reached. Yet, criteria often remain unstated, and little is known about criteria employed in practice.

METHODS

We analyzed 141 evaluations published in Evaluation and Program Planning over four years (2016-2019). Applying a model of criteria domains, we utilized collaborative, interpretive coding to surface and examine the criteria embedded in evaluation aims, questions, and conclusions. We also identified methods used to gather evaluation data.

FINDINGS

Analysis illuminated eight criteria domains evident in the sample and revealed how multiple domains were combined within individual evaluations. We found overlap among data collection methods used to investigate different domains.

CONCLUSIONS

Findings reveal the variety of criteria employed in practice and how evaluators combine criteria to examine multifaceted evaluands. Findings also highlight the need for evaluators to understand how to adapt methods to investigate different criteria domains. This article contributes to the empirical knowledge base about evaluative criteria and identifies revisions to the criteria model.

A Comprehensive Review of Optimal Approaches to Co-Design in Health with First Nations Australians

BACKGROUND

Australia's social, structural, and political context, together with the continuing impact of colonisation, perpetuates health care and outcome disparities for First Nations Australians. A new approach led by First Nations Australians is required to address these disparities. Co-design is emerging as a valued method for First Nations Australian communities to drive change in health policy and practice to better meet their needs and priorities. However, it is critical that co-design processes and outcomes are culturally safe and effective. Aims: This project aimed to identify the current evidence around optimal approaches to co-design in health with First Nations Australians.

METHODS

First Nations Australian co-led team conducted a comprehensive review to identify peer-reviewed and grey literature reporting the application of co-design in health-related areas by and with First Nations Australians. A First Nations Co-Design Working Group (FNCDWG) was established to guide this work and team.A Collaborative Yarning Methodology (CYM) was used to conduct a thematic analysis of the included literature.

RESULTS

After full-text screening, 99 studies were included. Thematic analysis elicited the following six key themes, which included 28 practical sub-themes, relevant to co-design in health with First Nations Australians: First Nations Australians leadership; Culturally grounded approach; Respect; Benefit to First Nations communities; Inclusive partnerships; and Evidence-based decision making.

CONCLUSION

The findings of this review provide a valuable snapshot of the existing evidence to be used as a starting point to guide appropriate and effective applications of co-design in health with First Nations Australians.

Starting the SToP trial: Lessons from a collaborative recruitment approach

OBJECTIVE

Recruitment in research can be challenging in Australian Aboriginal contexts. We aimed to evaluate the SToP (See, Treat, Prevent skin infections) trial recruitment approach for Aboriginal families to identify barriers and facilitators and understand the utility of the visual resource used.

METHODS

This qualitative participatory action research used purposive sampling to conduct six semi-structured interviews with staff and five yarning sessions with Aboriginal community members from the nine communities involved in the SToP trial that were audio recorded and transcribed verbatim before thematic analysis.

FINDINGS

Community members valued the employment of local Aboriginal facilitators who used the flipchart to clearly explain the importance of healthy skin and the rationale for the SToP trial while conducting recruitment. A prolonged process, under-developed administrative systems and stigma of the research topic emerged as barriers.

CONCLUSION

Partnering with a local Aboriginal organisation, employing Aboriginal researchers, and utilising flip charts for recruitment was seen by some as successful. Strengthening governance with more planning and support for recordkeeping emerged as future success factors.

IMPLICATIONS FOR PUBLIC HEALTH

Our findings validate the importance of partnership for this critical phase of a research project. Recruitment strategies should be co-designed with Aboriginal research partners. Further, recruitment rates for the SToP trial provide a firm foundation for building partnerships between organisations and ensuring Aboriginal perspectives determine recruitment methods.

Appraising community driven health research with Aboriginal and Torres Strait Islander communities: a scoping review using the Aboriginal and Torres Strait Islander Quality Appraisal Tool

Most 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.

"The world is so white": improving cultural safety in healthcare systems for Australian Indigenous people with rheumatic heart disease

OBJECTIVE

To examine the views of senior health system knowledge holders, including Aboriginal experts, regarding the spaces where elimination strategies for rheumatic heart disease take place: Aboriginal and Torres Strait Islander ways of knowing, being and doing; and biomedical healthcare models. We aimed to support the implementation of the RHD Endgame Strategy by providing some of the 'how'.

METHODS

In-depth interviews were undertaken with 23 participants. The design of the interview questions and analysis of the data used strengths-based approaches as directed by Aboriginal researchers.

RESULTS

Given the dominance of the biomedical worldview, and the complex trajectory of RHD, there is significant tension in the intersection of worldviews. Tensions that limit productive dialogue are juxtaposed with suggestions on how to reduce tension through reflexivity, power shifting and endorsing Aboriginal leadership and governance. Evidence supported cultural safety for RHD care, prevention and elimination as the key action.

CONCLUSIONS

Recommendations include addressing power imbalances between dominant and minority populations throughout the health system; reform that both supports and is supported by Non-Indigenous and Aboriginal and Torres Strait Islander leadership.

IMPLICATIONS FOR PUBLIC HEALTH

Increased understanding of and support for Indigenous leadership and cultural safety will enable implementation of the new RHD strategy.

Evaluation of a Community-Led Program for Primordial and Primary Prevention of Rheumatic Fever in Remote Northern Australia

Environmental factors including household crowding and inadequate washing facilities underpin recurrent streptococcal infections in childhood that cause acute rheumatic fever (ARF) and subsequent rheumatic heart disease (RHD). No community-based 'primordial'-level interventions to reduce streptococcal infection and ARF rates have been reported from Australia previously. We conducted a study at three Australian Aboriginal communities aiming to reduce infections including skin sores and sore throats, usually caused by Group A Streptococci, and ARF. Data were collected for primary care diagnoses consistent with likely or potential streptococcal infection, relating to ARF or RHD or related to environmental living conditions. Rates of these diagnoses during a one-year Baseline Phase were compared with a three-year Activity Phase. Participants were children or adults receiving penicillin prophylaxis for ARF. Aboriginal community members were trained and employed to share knowledge about ARF prevention, support reporting and repairs of faulty health-hardware including showers and provide healthcare navigation for families focusing on skin sores, sore throat and ARF. We hypothesized that infection-related diagnoses would increase through greater recognition, then decrease. We enrolled 29 participants and their families. Overall infection-related diagnosis rates increased from Baseline (mean rate per-person-year 1.69 [95% CI 1.10-2.28]) to Year One (2.12 [95% CI 1.17-3.07]) then decreased (Year Three: 0.72 [95% CI 0.29-1.15]) but this was not statistically significant (p = 0.064). Annual numbers of first-known ARF decreased, but numbers were small: there were six cases of first-known ARF during Baseline, then five, 1, 0 over the next three years respectively. There was a relationship between household occupancy and numbers (p = 0.018), but not rates (p = 0.447) of infections. This first Australian ARF primordial prevention study provides a feasible model with encouraging findings.

Implementing Interventions to Improve Health Communication Equity for First Nations People: Guidance from a Rapid Realist Review

Effective communication is critical for engagement between clients and health professionals, transfer of health information and health decision-making. Internationally, there is recognition that if health communication interventions were successfully implemented, then health communication equity would improve. This rapid realist review was undertaken with the aim of providing guidance on the circumstances in which communication interventions were likely to work in regional health service settings accessed by First Nations people from remote and very remote geographic areas of Australia. The realist review involved a process of searching literature on key terms and the identification of relevant studies and policies by a content expert group, including non-Indigenous and First Nations health researchers. Evidence was extracted to inform and synthesize into guiding principles, using a realist perspective. This review identified studies that provided evidence from 37 Australian and international settings where the dominant language and culture of the health sector differs from that of the majority of service users. A number of guiding principles were synthesized: 1) to build trust and respect by inclusion of an individual patient's cultural perspective; 2) to enhance concordant understanding of health information through two-way health literacies and learning; 3) to recognize the entanglement of health communication equity with regional socio-cultural and health determinants. This review generated realist informed guiding principles to suggest how and under what conditions health communication interventions can enable healthcare decision-making at an individual and service level.

Co-design for indigenous and other children and young people from priority social groups: A systematic review

Background

Co-design has increasingly been posited as a useful approach for Indigenous peoples and other social groups that experience inequities. However, the relatively rapid rise in co-design rhetoric has not necessarily been accompanied by increased understanding of whether co-design works for these social groups, and how equity is addressed.

Methods

We conducted a systematic review to identify the current state of co-design as theory and praxis within the context of health and/or disability related interventions or services, with a specific focus on equity considerations for Indigenous and other children and young people from priority social groups. Six electronic databases were searched systematically to identify peer-reviewed papers and grey literature (dissertation and theses) published between January 1, 2000 to December 31, 2020, and a hand-search of reference lists for selected full texts was undertaken.

Results

Fifteen studies met the inclusion criteria. Although all studies used the term ‘co-design’, only three provided a definition of what they meant by use of the term. Nine studies described one or more theory-based frameworks and a total of 26 methods, techniques and tools were reported, with only one study describing a formal evaluation. The key mechanism by which equity was addressed appeared to be the inclusion of participants from a social group experiencing inequities within an area of interest.

Conclusion

A dearth of information limits the extent to which the literature can be definitive as to whether co-design works for Indigenous and other children and young people from priority social groups, or whether co-design reduces health inequities. It is critical for quality reporting to occur regarding co-design definitions, theory, and praxis. There is an urgent requirement for evaluation research that focuses on co-design impacts and assesses the contribution of co-design to achieving equity. We also recommend culturally safe ethical processes be implemented whenever undertaking co-design.

•

Limited studies report co-design contribution to positive outcomes.

•

Evaluatin Evaluation of co-design impacts and contribution to equity is urgently required.

•

Culturally safe ethical processes must be implemented in co-design.

Living with Rheumatic Heart Disease at the Intersection of Biomedical and Aboriginal Worldviews

Rheumatic heart disease (RHD) significantly impacts the lives of First Nations Australians. Failure to eliminate RHD is in part attributed to healthcare strategies that fail to understand the lived experience of RHD. To rectify this, a PhD study was undertaken in the Northern Territory (NT) of Australia, combining Aboriginal ways of knowing, being and doing with interviews (24 participants from clinical and community settings) and participant observation to privilege Aboriginal voices, including the interpretations and experiences of Aboriginal co-researchers (described in the adjunct article). During analysis, Aboriginal co-researchers identified three interwoven themes: maintaining good feelings; creating clear understanding (from good information); and choosing a good djalkiri (path). These affirm a worldview that prioritises relationships, positive emotions and the wellbeing of family/community. The findings demonstrate the inter-connectedness of knowledge, choice and behaviour that become increasingly complex in stressful and traumatic health, socioeconomic, political, historical and cultural contexts. Not previously heard in the RHD domain, the findings reveal fundamental differences between Aboriginal and biomedical worldviews contributing to the failure of current approaches to communicating health messages. Mitigating this, Aboriginal co-researchers provided targeted recommendations for culturally responsive health encounters, including: communicating to create positive emotions; building trust; and providing family and community data and health messages (rather than individualistic).

"Weaving a Mat That We Can All Sit On": Qualitative Research Approaches for Productive Dialogue in the Intercultural Space

Research remains a site of struggle for First Nations peoples globally. Biomedical research often reinforces existing power structures, perpetuating ongoing colonisation by dominating research priorities, resource allocation, policies, and services. Addressing systemic health inequities requires decolonising methodologies to facilitate new understandings and approaches. These methodologies promote a creative tension and productive intercultural dialogue between First Nations and Western epistemologies. Concurrently, the potential of critical theory, social science, and community participatory action research approaches to effectively prioritise First Nations peoples' lived experience within the biomedical worldview is increasingly recognised. This article describes learnings regarding research methods that enable a better understanding of the lived experience of rheumatic heart disease-an intractable, potent marker of health inequity for First Nations Australians, requiring long-term engagement in the troubled intersection between Indigenist and biomedical worldviews. Working with Yolŋu (Aboriginal) co-researchers from remote Northern Territory (Australia), the concept of ganma (turbulent co-mingling of salt and fresh water) was foundational for understanding and applying relationality (gurrutu), deep listening (nhina, nhäma ga ŋäma), and the use of metaphors-approaches that strengthen productive dialogue, described by Yolŋu co-researchers as weaving a 'mat we can all sit on'. The research results are reported in a subsequent article.

Long-term outcomes following rheumatic heart disease diagnosis in Australia

Aims 

Rheumatic heart disease (RHD) is a major contributor to cardiac morbidity and mortality globally. This study aims to estimate the probability and predictors of progressing to non-fatal cardiovascular complications and death in young Australians after their first RHD diagnosis.

Methods and results 

This retrospective cohort study used linked RHD register, hospital, and death data from five Australian states and territories (covering 70% of the whole population and 86% of the Indigenous population). Progression from uncomplicated RHD to all-cause death and non-fatal cardiovascular complications (surgical intervention, heart failure, atrial fibrillation, infective endocarditis, and stroke) was estimated for people aged <35 years with first-ever RHD diagnosis between 2010 and 2018, identified from register and hospital data. The study cohort comprised 1718 initially uncomplicated RHD cases (84.6% Indigenous; 10.9% migrant; 63.2% women; 40.3% aged 5–14 years; 76.4% non-metropolitan). The composite outcome of death/cardiovascular complication was experienced by 23.3% (95% confidence interval: 19.5–26.9) within 8 years. Older age and metropolitan residence were independent positive predictors of the composite outcome; history of acute rheumatic fever was a negative predictor. Population group (Indigenous/migrant/other Australian) and sex were not predictive of outcome after multivariable adjustment.

Conclusion 

This study provides the most definitive and contemporary estimates of progression to major cardiovascular complication or death in young Australians with RHD. Despite access to the publically funded universal Australian healthcare system, one-fifth of initially uncomplicated RHD cases will experience one of the major complications of RHD within 8 years supporting the need for programmes to eradicate RHD.

Formative evaluation of a community-based approach to reduce the incidence of Strep A infections and acute rheumatic fever

OBJECTIVES

To explore the acceptability of a novel, outreached-based approach to improve primary and primordial prevention of Strep A skin sores, sore throats and acute rheumatic fever in remote Aboriginal communities.

METHODS

A comprehensive prevention program delivered by trained Aboriginal Community Workers was evaluated using approximately fortnightly household surveys about health and housing and clinical records.

RESULTS

Twenty-seven primary participants from three remote Aboriginal communities in the Northern Territory consented, providing 37.8 years of retrospective baseline data and 18.5 years of prospective data during the study period. Household members were considered to be secondary participants. Five Aboriginal Community Workers were trained and employed, delivering a range of supports to households affected by acute rheumatic fever including environmental health support and education. Clinical record audit and household self-report of Strep A infections were compared. No association between clinical- and self-report was identified.

CONCLUSIONS

Ongoing participation suggests this outreach-based prevention program was acceptable and associated with improved reporting of household maintenance issues and awareness of prevention opportunities for Strep A infections. Implications for public health: Biomedical, clinic-based approaches to the management of Strep A infections in remote communities can be usefully augmented by outreach-based supports delivered by Aboriginal Community Workers responding to community needs.

Conducting decolonizing research and practice with Australian First Nations to close the health gap

The purpose of this paper is to highlight a perspective for decolonizing research with Australian First Nations and provide a framework for successful and sustained knowledge translation by drawing on the recent work conducted by a research group, in five remote communities in North-Western Australia. The perspective is discussed in light of national and international calls for meaningful and dedicated engagement with First Nations people in research, policy and practice, to help close the health gap between First Nations and other Australians.

Rheumatic Heart Disease in the United States: Forgotten But Not Gone: Results of a 10 Year Multicenter Review

Background

Recent evaluation of rheumatic heart disease (RHD) mortality demonstrates disproportionate disease burden within the United States. However, there are few contemporary data on US children living with acute rheumatic fever (ARF) and RHD.

Methods and Results

Twenty‐two US pediatric institutions participated in a 10‐year review (2008–2018) of electronic medical records and echocardiographic databases of children 4 to 17 years diagnosed with ARF/RHD to determine demographics, diagnosis, and management. Geocoding was used to determine a census tract‐based socioeconomic deprivation index. Descriptive statistics of patient characteristics and regression analysis of RHD classification, disease severity, and initial antibiotic prescription according to community deprivation were obtained. Data for 947 cases showed median age at diagnosis of 9 years; 51% and 56% identified as male and non‐White, respectively. Most (89%) had health insurance and were first diagnosed in the United States (82%). Only 13% reported travel to an endemic region before diagnosis. Although 96% of patients were prescribed secondary prophylaxis, only 58% were prescribed intramuscular benzathine penicillin G. Higher deprivation was associated with increasing disease severity (odds ratio, 1.25; 95% CI, 1.08–1.46).

Conclusions

The majority of recent US cases of ARF and RHD are endemic rather than the result of foreign exposure. Children who live in more deprived communities are at risk for more severe disease. This study demonstrates a need to improve guideline‐based treatment for ARF/RHD with respect to secondary prophylaxis and to increase research efforts to better understand ARF and RHD in the United States.

Ngarraanga Giinganay ('thinking peacefully'): Co-design and pilot study of a culturally-grounded mindfulness-based stress reduction program with older First Nations Australians

First Nations 'survivors' are ageing in increasing numbers. Life-course stress and depression are of concern for older First Nations Australians, yet there are limited psychosocial interventions. This study aimed to co-design a culturally-grounded mindfulness-based program ('Ngarraanga Giinganay') and evaluate acceptability/feasibility with an Aboriginal community on Gumbaynggirr Country. An expert Working Group guided program development, with Aboriginal and non-Aboriginal clinicians/consultants. A workshop, collaborative yarning group with older Aboriginal people (n = 9), and further consultation contributed to the design/refinement of the 8-session group-based program, ensuring content aligned with therapeutic principles of mindfulness and cultural understandings of the Gumbaynggirr community. A single-group pilot study was conducted (n = 7, 62-81 years), co-facilitated by an Aboriginal clinician and Elder. Outcomes were qualitative (understandings of mindfulness, program acceptability, benefits to health/wellbeing). Pilot results demonstrated feasibility, acceptability and preliminary effectiveness. The program enhanced understandings of mindfulness and participants highlighted benefits such as helping anxiety, relaxation, focusing on the moment and connection to Country/land. Trends were seen for reducing depression, anxiety and stress symptoms, and blood pressure. This study provides insight into partnering with underrepresented populations through ageing research, highlighting the effectiveness of this co-design approach. Ngarraanga Giinganay has considerable potential for supporting health and wellbeing of First Nations peoples.

Systems thinking for Aboriginal Health: Understanding the value and acceptability of group model building approaches

Systems thinking is increasingly applied to understand and address systemic drivers of complex health problems. In Australia, group model building, a participatory method from systems science, has been applied in various locations to engage communities in systems-based health promotion projects. To date there is limited evidence regarding GMB use with Australian Aboriginal communities. This study aimed to determine the value and acceptability of group model building (GMB) as a methodological approach in research with Aboriginal communities and identify any adaptations required to optimise its utility. Semi-structured interviews were undertaken with 18 Aboriginal health and university staff who had prior experience with a GMB research project. Interview transcripts were inductively analysed using thematic analysis and key themes were organised using an Indigenous research framework. Participants reported that GMB methods generally aligned well with Aboriginal ways of knowing, being, and doing. Participants valued the holistic, visual and collaborative nature of the method and its emphasis on sharing stories and collective decision-making. Group model building was viewed as a useful tool for identifying Aboriginal-led actions to address priority issues and advancing self-determination. Our findings suggest that by bringing together Aboriginal and non-Aboriginal knowledge, GMB is a promising tool, which Aboriginal communities could utilise to explore and address complex problems in a manner that is consistent with their worldviews. In adapting group model building methods, non-Aboriginal researchers should aspire to move beyond co-design processes and enable Aboriginal health research to be entirely led by Aboriginal people.

•

Group model building is a promising method for research with Aboriginal communities that is generally consistent with Aboriginal worldviews.

•

Group Model Building may be a useful tool for identifying actions to address priority issues and advancing Aboriginal self-determination.

•

Capacity building is required so that Group Model Building workshops, and ideally entire research projects, can be led by Aboriginal people.

Can a formalised model of co-production contribute to empowering indigenous communities in decisions about land use?

Purpose

Co-production has been used in public services in the UK areas such as mental health to improve the participation of service users in decisions made about the services traditionally provided for them and done to them. It has also been used in areas such as mental health and to address concerns about the quality of services provided to members of minority communities. Western Australia is currently passing legislation to address the issue of aboriginal cultural heritage management in the context of recent adverse incidents such as the incident where Rio Tinto was responsible for the destruction of the site. This paper aims to show how a formalised model of co-production can assist in the implementation of this legislation.

Design/methodology/approach

This paper considers how effective co-production has been within the domain of mental health services in the UK and then considers whether they are lessons that may be learnt in other contexts. It considers whether concepts from co-production have a role to play in ensuring that the legislation and its implementation are not seen as actions done to or on behalf of the aboriginal communities and if a more structured approach to coproduction can produce a model, which facilitates genuinely collaborative aboriginal heritage management.

Findings

The approach has facilitated the development of a model to monitor and improve collaboration within aboriginal cultural heritage management, which complements existing participatory approaches and enables businesses to demonstrate their legislatory compliance.

Social implications

The study offers an approach, which may be used globally to empower indigenous communities in decision-making in other contexts, such as deforestation in South America and oil and gas exploitation on Inuit and First Nations land in Canada.

Originality/value

The use of co-production concepts and capability modelling is novel in this space.

Using community-led development to build health communication about rheumatic heart disease in Aboriginal children: a developmental evaluation

OBJECTIVE

A high prevalence of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) among Aboriginal children in northern Australia is coupled with low understanding among families. This has negative impacts on children's health, limits opportunities for prevention and suggests that better health communication is needed.

METHODS

During an RHD echocardiography screening project, Aboriginal teachers in a remote community school created lessons to teach children about RHD in their home languages, drawing on principles of community-led development. Access to community-level RHD data, previously unknown to teachers and families, was a catalyst for this innovative work. Careful, iterative discussions among speakers of four Aboriginal languages ensured a culturally coherent narrative and accompanying teaching resources.

RESULTS

The evaluation demonstrated the importance of collective work, local Indigenous Knowledge and metaphors. As a result of the lessons, some children showed new responses and attitudes to skin infections and their RHD treatment. Language teachers used natural social networks to disseminate new information. A community interagency collaboration working to prevent RHD commenced. Conclusions and implications for public health: Action to address high rates of RHD must include effective health communication strategies that value Indigenous Knowledge, language and culture, collaborative leadership and respect for Indigenous data sovereignty.

Decolonizing Indigenous health: Generating a productive dialogue to eliminate Rheumatic Heart Disease in Australia

In common with colonized Indigenous people worldwide, many Australian Aboriginal people experience inequitable health outcomes. While the commitment and advocacy of researchers and health practitioners has resulted in many notable improvements in policy and practice, systemic and structural impediments continue to restrain widespread gains in addressing Indigenous health injustices. We take Rheumatic Heart Disease (RHD), a potent marker of extreme health inequity, as a case study, and critically examine RHD practitioners' perspectives regarding the factors that need to be addressed to improve RHD prevention and care. This study is an important explanatory component of a broader study to inform new clinical practices, and health system strategies and policies to reduce RHD. A decolonising, critical medical anthropology (CMA) analysis of findings from 22 RHD practitioner in-depth interviews conducted in May 2016 revealed both practitioners' perceptions of health system shortcomings and a sense of hopelessness and powerlessness to transform existing health system inequities, the negative impacts of which were subsequently confirmed in a separate study of RHD patients' lived realities. We reveal how biomedical dominance, normalized deficit discourses and systemic racism influence the current policy and practice landscape, narrowing the intercultural space for productive dialogue and reinforcing the conditions that cause disease. To counter biomedical approaches that contribute to existing health inequities in health care, we recommend localized, strength-based, community-led research projects focused on actions that use critical decolonizing social science approaches to achieve system change. We demonstrate the importance of integrating biological and social sciences approaches in research, education/training, and practice to: 1) be guided by Indigenous strengths, knowledges and worldview, and 2) adopt a critical reflexive stance to examine systems, structures and practices. Such an approach facilitates productive cross-cultural dialogue and social transformation; providing direction and hope to practitioners, enhancing their knowledge, skills and capacity and improving Aboriginal health outcomes.

What do you mean by engagement? - evaluating the use of community engagement in the design and implementation of chronic disease-based interventions for Indigenous populations - scoping review

BACKGROUND

Indigenous populations have remained strong and resilient in maintaining their unique culture and values, despite centuries of colonial oppression. Unfortunately, a consequential result of facing years of adversity has led Indigenous populations to experience a disproportionate level of poorer health outcomes compared to non-Indigenous populations. Specifically, the rate of Indigenous chronic disease prevalence has significantly increased in the last decade. Many of the unique issues Indigenous populations experience are deeply rooted in their colonial history and the intergenerational traumas that has subsequently impacted their physical, mental, emotional and spiritual well-being. With this, to better improve Indigenous health outcomes, understanding the local context of their challenges is key. Studies have begun to use modes of community engagement to initiate Indigenous partnerships and design chronic disease-based interventions. However, with the lack of a methodological guideline regarding the appropriate level of community engagement to be used, there is concern that many interventions will continue to fall short in meeting community needs.

OBJECTIVE

The objective of this study was to investigate the how various community engagement strategies have been used to design and/or implement interventions for Indigenous populations with chronic disease.

METHODS

A scoping review guided by the methods outlined by Arksey and O'Malley was conducted. A comprehensive search was completed by two reviewers in five electronic databases using keywords related to community engagement, Indigenous health and chronic disease. Studies were reviewed using a descriptive-analytical narrative method and data was categorized into thematic groups reflective of the main findings.

RESULTS

We identified 23 articles that met the criteria for this scoping review. The majority of the studies included the use a participatory research model and the procurement of study approval. However, despite the claimed use of participatory research methods, only 6 studies had involved community members to identify the area of priority and only five had utilized Indigenous interview styles to promote meaningful feedback. Adapting for the local cultural context and the inclusion of community outreach were identified as the key themes from this review.

CONCLUSION

Many studies have begun to adopt community engagement strategies to better meet the needs of Indigenous Peoples. With the lack of a clear guideline to approach Indigenous-based participatory research, we recommend that researchers focus on 1) building partnerships, 2) obtaining study approval and 3) adapting interventions to the local context.

Community engagement approaches for Indigenous health research: recommendations based on an integrative review

OBJECTIVE

Community engagement practices in Indigenous health research are promoted as a means of decolonising research, but there is no comprehensive synthesis of approaches in the literature. Our aim was to assemble and qualitatively synthesise a comprehensive list of actionable recommendations to enhance community engagement practices with Indigenous peoples in Canada, the USA, Australia and New Zealand.

DESIGN

Integrative review of the literature in medical (Medline, Cumulative Index to Nursing and Allied Health Literature and Embase) and Google and WHO databases (search cut-off date 21 July 2020).

ARTICLE SELECTION

Studies that contained details regarding Indigenous community engagement frameworks, principles or practices in the field of health were included, with exclusion of non-English publications. Two reviewers independently screened the articles in duplicate and reviewed full-text articles.

ANALYSIS

Recommendations for community engagement approaches were extracted and thematically synthesised through content analysis.

RESULTS

A total of 63 studies were included in the review, with 1345 individual recommendations extracted. These were synthesised into a list of 37 recommendations for community engagement approaches in Indigenous health research, categorised by stage of research. In addition, activities applicable to all phases of research were identified: partnership and trust building and active reflection.

CONCLUSIONS

We provide a comprehensive list of recommendations for Indigenous community engagement approaches in health research. A limitation of this review is that it may not address all aspects applicable to specific Indigenous community settings and contexts. We encourage anyone who does research with Indigenous communities to reflect on their practices, encouraging changes in research processes that are strengths based.

Risk Perception & Risk-Reduction Behavior Model for Blue-Collar Workers: Adapted From the Health Promotion Model

This study examined the health promotion model (HPM) as a framework for assessing perceptions and health-related behaviors related to cardiovascular disease (CVD) risk among blue-collar workers. This was done with the aim of providing time-sensitive educational and training materials for workers while on the job or functioning in their communities. The revised HPM was evaluated in the above context using specific criteria developed by Chinn and Kramer (2008) and scoping literature review. Specifically, we assessed the model based on five criteria such as its clarity, simplicity, generality, accessibility, and importance. The revised HPM showed strengths in both accessibility and generality. That is, it applied to all populations and chronic illnesses through clearly defined and specified major concepts. However, there were several weaknesses in areas of clarity and consistency; the model included three new concepts (i.e., activity-related affect, commitment to a plan of action, and immediate competing demands and preference) that actually decreased these elements. In this context, situational influences require adequately reflected external variables. Nevertheless, the revised HPM showed predictive power among this study's target population. The HPM was modified to address deficiencies in regard to the concept of risk perception. Work-related situational influences were also restructured based on individual and environmental characteristics. The modified framework can be used to clarify health-related behaviors among blue-collar workers.

Ending rheumatic heart disease in Australia: the evidence for a new approach

■The RHD Endgame Strategy: the blueprint to eliminate rheumatic heart disease in Australia by 2031 (the Endgame Strategy) is the blueprint to eliminate rheumatic heart disease (RHD) in Australia by 2031. Aboriginal and Torres Strait Islander people live with one of the highest per capita burdens of RHD in the world. ■The Endgame Strategy synthesises information compiled across the 5-year lifespan of the End Rheumatic Heart Disease Centre of Research Excellence (END RHD CRE). Data and results from priority research projects across several disciplines of research complemented literature reviews, systematic reviews and narrative reviews. Further, the experiences of those working in acute rheumatic fever (ARF) and RHD control and those living with RHD to provide the technical evidence for eliminating RHD in Australia were included. ■The lived experience of RHD is a critical factor in health outcomes. All future strategies to address ARF and RHD must prioritise Aboriginal and Torres Strait Islander people's knowledge, perspectives and experiences and develop co-designed approaches to RHD elimination. The environmental, economic, social and political context of RHD in Australia is inexorably linked to ending the disease. ■Statistical modelling undertaken in 2019 looked at the economic and health impacts of implementing an indicative strategy to eliminate RHD by 2031. Beginning in 2019, the strategy would include: reducing household crowding, improving hygiene infrastructure, strengthening primary health care and improving secondary prophylaxis. It was estimated that the strategy would prevent 663 deaths and save the health care system $188 million. ■The Endgame Strategy provides the evidence for a new approach to RHD elimination. It proposes an implementation framework of five priority action areas. These focus on strategies to prevent new cases of ARF and RHD early in the causal pathway from Streptococcus pyogenes exposure to ARF, and strategies that address the critical systems and structural changes needed to support a comprehensive RHD elimination strategy.

Contemporary Incidence and Prevalence of Rheumatic Fever and Rheumatic Heart Disease in Australia Using Linked Data: The Case for Policy Change

Background In 2018, the World Health Organization prioritized control of acute rheumatic fever (ARF) and rheumatic heart disease (RHD), including disease surveillance. We developed strategies for estimating contemporary ARF/RHD incidence and prevalence in Australia (2015-2017) by age group, sex, and region for Indigenous and non-Indigenous Australians based on innovative, direct methods. Methods and Results This population-based study used linked administrative data from 5 Australian jurisdictions. A cohort of ARF (age <45 years) and RHD cases (<55 years) were sourced from jurisdictional ARF/RHD registers, surgical registries, and inpatient data. We developed robust methods for epidemiologic case ascertainment for ARF/RHD. We calculated age-specific and age-standardized incidence and prevalence. Age-standardized rate and prevalence ratios compared disease burden between demographic subgroups. Of 1425 ARF episodes, 72.1% were first-ever, 88.8% in Indigenous people and 78.6% were aged <25 years. The age-standardized ARF first-ever rates were 71.9 and 0.60/100 000 for Indigenous and non-Indigenous populations, respectively (age-standardized rate ratio=124.1; 95% CI, 105.2-146.3). The 2017 Global Burden of Disease RHD prevalent counts for Australia (<55 years) underestimate the burden (1518 versus 6156 Australia-wide extrapolated from our study). The Indigenous age-standardized RHD prevalence (666.3/100 000) was 61.4 times higher (95% CI, 59.3-63.5) than non-Indigenous (10.9/100 000). Female RHD prevalence was double that in males. Regions in northern Australia had the highest rates. Conclusions This study provides the most accurate estimates to date of Australian ARF and RHD rates. The high Indigenous burden necessitates urgent government action. Findings suggest RHD may be underestimated in many high-resource settings. The linked data methods outlined here have potential for global applicability.

Indigenous community members' views on silver diamine fluoride to manage early childhood caries

OBJECTIVES

Early childhood caries (ECC) continues to be the leading reason for pediatric dental surgery in Canada and is particularly prevalent among Indigenous children. Silver diamine fluoride (SDF) offers an alternative method to manage non-restoratively caries. It is important to determine Indigenous communities' views on and receptivity toward SDF.

AIM

To understand Indigenous community members' views on pediatric dental surgery to treat ECC under general anesthesia (GA) and receptivity to SDF as an alternative to restorative surgery.

METHODS

Focus groups and sharing circles congruent with an Indigenous ways of gathering information were conducted. Three interviewers engaged eight groups of First Nation and Metis communities in three rural Indigenous communities and ne metropolitan urban setting in Manitoba, Canada. Overall, 59 individuals participated. Open coding was guided by grounded theory and further analysis using Nvivo 12 software™.

RESULTS

Participants mean age was 35.6 years, 88 percent (52 individuals) had a least one child, and 32 percent (19 individuals) were employed. Eight themes emerged, including respondents' fear of dental surgery under GA, fear of pain after dental surgery, parents' need for more information before accepting SDF treatment, and concern about the black staining of treated lesions.

CONCLUSIONS

Indigenous parents' acceptance of SDF as a treatment option is contingent on having more information and assurance that treatment under GA can be avoided. Understanding Indigenous parents' views may ensure better acceptance of SDF as a minimally invasive treatment option to manage ECC. A cautious and informative approach to SDF implementation in Indigenous communities is recommended.

Voices behind the Statistics: A Systematic Literature Review of the Lived Experience of Rheumatic Heart Disease

In Australia, Aboriginal children almost entirely bear the burden of acute rheumatic fever (ARF) which often leads to rheumatic heart disease (RHD), a significant marker of inequity in Indigenous and non-Indigenous health experiences. Efforts to eradicate RHD have been unsuccessful partly due to lack of attention to voices, opinions and understandings of the people behind the statistics. This systematic review presents a critical, interpretive analysis of publications that include lived experiences of RHD. The review approach was strengths-based, informed by privileging Indigenous knowledges, perspectives and experiences, and drawing on Postcolonialism and Critical Race Theory. Fifteen publications were analysed. Nine themes were organised into three domains which interact synergistically: sociological, disease specific and health service factors. A secondary sociolinguistic analysis of quotes within the publications articulated the combined impact of these factors as 'collective trauma'. Paucity of qualitative literature and a strong biomedical focus in the dominant narratives regarding RHD limited the findings from the reviewed publications. Noteworthy omissions included: experiences of children/adolescents; evidence of Indigenous priorities and perspectives for healthcare; discussions of power; recognition of the centrality of Indigenous knowledges and strengths; and lack of critical reflection on impacts of a dominant biomedical approach to healthcare. Privileging a biomedical approach alone is to continue colonising Indigenous healthcare.

'It Shouldn't Be This Hard': Exploring the Challenges of Rural Health Research

Health research is important for innovation and assessment of health status and health interventions, and maintaining a strong, engaged cohort of rural health researchers is essential for the ongoing improvement of the health of rural populations. Ethical guidelines and processes ensure research is undertaken in a way that protects and, where possible, empowers participants. We set out to systematically examine and document the challenges posed by ethics and governance processes for rural health researchers in Western Australia (WA) and the impact on the research undertaken. In this qualitative study, fifteen WA-based rural health researchers were interviewed. The identified challenges included inefficient systems, gatekeeping, apparent resistance to research and the lack of research experience of those involved in approval processes. For researchers seeking to conduct studies to improve rural and Aboriginal health, extended delays in approvals can hold up and impede research, ultimately changing the nature of the research undertaken and constraining the willingness of practitioners and researchers to undertake health research. Unwieldy ethics processes were seen to have a particularly onerous impact on rural research pertaining to service delivery, multiple sites, and research involving Aboriginal people, impeding innovation and inquiry in areas where it is much needed.

The End Rheumatic Heart Disease in Australia Study of Epidemiology (ERASE) Project: data sources, case ascertainment and cohort profile

PURPOSE

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) persist as public health issues in developing countries and among disadvantaged communities in high-income countries, with rates in Aboriginal and Torres Strait Islander peoples in Australia among the highest recorded globally. A robust evidence base is critical to support policy recommendations for eliminating RHD, but available data are fragmented and incomplete. The End RHD in Australia: Study of Epidemiology (ERASE) Project aims to provide a comprehensive database of ARF and RHD cases in Australia as a basis for improved monitoring and to assess prevention and treatment strategies. The objective of this paper is to describe the process for case ascertainment and profile of the study cohort.

PATIENTS AND METHODS

The ERASE database has been built using linked administrative data from RHD registers, inpatient hospitalizations, and death registry data from 2001 to 2017 (mid-year). Additional linked datasets are available. The longitudinal nature of the data is harnessed to estimate onset and assess the progression of the disease. To accommodate systematic limitations in diagnostic coding for RHD, hospital-only identified RHD has been determined using a purposefully developed prediction model.

RESULTS

Of 132,053 patients for whom data were received, 42,064 are considered true cases of ARF or RHD in the study period. The patient population under 60 years in the compiled dataset is more than double the number of patients identified in ARF/RHD registers (12,907 versus 5049). Non-registered patients were more likely to be older, non-Indigenous, and at a later disease stage.

CONCLUSION

The ERASE Project has created an unprecedented linked administrative database on ARF and RHD in Australia. These data provide a critical baseline for efforts to end ARF/RHD in Australia. The methodological work conducted to compile this database resulted in significant improvements in the robustness of epidemiological estimates and entails valuable lessons for ARF/RHD research globally.