The Be Our Ally Beat Smoking (BOABS) study, a randomised controlled trial of an intensive smoking cessation intervention in a remote aboriginal Australian health care setting

Background: Australian Aboriginal and Torres Strait Islander peoples (Indigenous Australians) smoke at much higher rates than non-Indigenous people and smoking is an important contributor to increased disease, hospital admissions and deaths in Indigenous Australian populations. Smoking cessation programs in Australia have not had the same impact on Indigenous smokers as on non-Indigenous smokers. This paper describes the outcome of a study that aimed to test the efficacy of a locally-tailored, intensive, multidimensional smoking cessation program. Methods: A randomised controlled trial of Aboriginal researcher delivered tailored smoking cessation counselling during face-to-face visits, aiming for weekly for the first four weeks, monthly to six months and two monthly to12 months. The control (“usual care”) group received routine care relating to smoking cessation at their local primary health care service. Data collection occurred at enrolment, six and 12 months. The primary outcome was self-reported smoking cessation with urinary cotinine confirmation at final follow-up (median 13 (interquartile range 12–15) months after enrolment).Results: Participants in the intervention (n = 55) and usual care (n = 108) groups were similar in baseline characteristics, except the intervention group was slightly older. At final follow-up the smoking cessation rate for participants assigned to the intervention group (n = 6; 11%), while not statistically significant, was double that of usual care (n = 5; 5%; p = 0.131). A meta-analysis of these findings and a similarly underpowered but comparable study of pregnant Indigenous Australian women showed that Indigenous Australian participants assigned to the intervention groups were 2.4 times (95% CI, 1.01-5.5) as likely to quit as participants assigned to usual care. Conclusions: Culturally appropriate, multi-dimensional Indigenous quit smoking programs can be successfully implemented in remote primary health care. Intensive one-on-one interventions with substantial involvement from Aboriginal and Torres Strait Islander workers are likely to be effective in these settings. Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN12608000604303)

Clinical trials in a remote Aboriginal setting: lessons from the BOABS smoking cessation study

Background: There is limited evidence regarding the best approaches to helping Indigenous Australians to stop smoking. The composite analysis of the only two smoking cessation randomised controlled trials (RCTs)investigating this suggests that one-on-one extra support delivered by and provided to Indigenous Australians in a primary health care setting appears to be more effective than usual care in encouraging smoking cessation. This paper describes the lessons learnt from one of these studies, the Be Our Ally Beat Smoking (BOABS) Study, and how to develop and implement an integrated smoking cessation program. Methods: Qualitative study using data collected from multiple documentary sources related to the BOABS Study. As the project neared completion the research team participated in four workshops to review and conduct thematic analyses of these documents. Results: Challenges we encountered during the relatively complex BOABS Study included recruiting sufficient number of participants; managing the project in two distant locations and ensuring high quality work across both sites; providing appropriate training and support to Aboriginal researchers; significant staff absences, staff shortages and high workforce turnover; determining where and how the project fitted in the clinics and consequent siloing of the Aboriginal researchers relating to the requirements of RCTs; resistance to change, and maintaining organisational commitment and priority for the project.The results of this study also demonstrated the importance of local Aboriginal ownership, commitment, participation and control. This included knowledge of local communities, the flexibility to adapt interventions to local settings and circumstances, and taking sufficient time to allow this to occur. Conclusions: The keys to the success of the BOABS Study were local development, ownership and participation, worker professional development and support, and operating within a framework of cultural safety. There were difficulties associated with the BOABS Study being an RCT, and many of these are shared with stand-alone programs. Interventions targeted at particular health problems are best integrated with usual primary health care. Research to investigate complex interventions in Indigenous health should not be limited to randomised clinical trials and funding needs to reflect the additional, but necessary, cost of providing for local control of planning and implementation

‘Making the invisible visible’ through alcohol screening and brief intervention in community pharmacies: an Australian feasibility study

Background: Screening and brief interventions (SBI) for alcohol related problems have been shown to be effective in health settings such as general practice or emergency departments. Recent data from the United Kingdom and New Zealand suggest that SBI can be delivered through community pharmacies, but this approach has not been tested in Australia. This study assesses the feasibility of delivering alcohol SBI via community pharmacists. Method: We recruited five pharmacies and developed an SBI training package to be delivered by pharmacy staff, who screened consumers and delivered the brief intervention where appropriate. Consumers also completed a questionnaire on the process. At three months consumers were telephoned to enable ‘retention’ to be quantified. After completing recruitment, a semi-structured interview was conducted with pharmacists on the process of delivering the intervention, potential improvements and sustainability. Results: Fifty consumer participants were screened, ten from each pharmacy. There were 28 (57 %) men and 21 (43 %) women with one not responding. Most (67 %) were aged 25-55 years. Their AUDIT scores had a range of 0 to 39 (mean 10.9, SD 9.8) with 11 categorised as ‘hazardous (8-15)’, four as ‘harmful (16-19)’ and eight as ‘probably dependent (20+)’ consumers of alcohol. Reactions to the process of SBI were generally favourable: for example 75 % agreed that it was either appropriate or very appropriate being asked about their alcohol consumption. With respect to follow-up interviews, 23 (46 %) agreed that they could be contacted, including five from the highest AUDIT category. Subsequently 11 (48 %) were contactable at three months. Three of the five non-low risk drinkers had reduced their level of risk over the three months. Ten pharmacists participated in semi-structured telephone interviews. Overall these pharmacists were positive about the intervention and five main themes emerged from the interviews: 1) flexibility applied in recruitment of participants, 2) easiness in use of AUDIT score to facilitate discussions, 3) perceived positive intervention impact, 4) enhanced role of community pharmacists and 5) facilitators and challenges experienced. Conclusions: Pharmacy-based SBI appears to be acceptable to consumers and feasible for pharmacy staff to deliver. Challenges remain in translating this potential into actual services

Knowledge, attitudes and other factors associated with assessment of tobacco smoking among pregnant Aboriginal women by health care providers: a cross-sectional survey

<p>Abstract</p> <p>Background</p> <p>As with many Indigenous peoples, smoking rates among Aboriginal Australians are considerably higher than those of the non-Indigenous population. Approximately 50% of Indigenous women smoke during pregnancy, a time when women are more motivated to quit. Antenatal care providers are potentially important change agents for reducing the harms associated with smoking, yet little is known about their knowledge, attitudes or skills, or the factors associated with providing smoking cessation advice.</p> <p>Methods</p> <p>This paper aimed to explore the knowledge and attitudes of health care providers caring for pregnant Australian Aboriginal women with regard to smoking risks and cessation; and to identify factors associated with self-reported assessment of smoking. A cross-sectional survey was undertaken with 127 staff providing antenatal care to Aboriginal women from two jurisdictions: the Northern Territory and New South Wales, Australia. Measures included respondents' estimate of the prevalence of smoking among pregnant women; optimal and actual assessment of smoking status; knowledge of risks associated with antenatal smoking; knowledge of smoking cessation; attitudes to providing cessation advice to pregnant women; and perceived barriers and motivators for cessation for pregnant women.</p> <p>Results</p> <p>The median provider estimate of the smoking prevalence was 69% (95%CI: 60,70). The majority of respondents considered assessment of smoking status to be integral to antenatal care and a professional responsibility. Most (79%) indicated that they assess smoking status in 100% of clients. Knowledge of risks was generally good, but knowledge of cessation was poor. Factors independently associated with assessing smoking status among all women were: employer service type (<it>p </it>= 0.025); cessation knowledge score (<it>p </it>= 0.011); and disagreeing with the statement that giving advice is not worth it given the low level of success (<it>p </it>= 0.011).</p> <p>Conclusions</p> <p>Addressing knowledge of smoking risks and cessation counselling is a priority and should improve both confidence and ability, and increase the frequency and effectiveness of counselling. The health system must provide supports to providers through appropriate policy and resourcing, to enable them to address this issue.</p

Delivery of maternal health care in Indigenous primary care services: baseline data for an ongoing quality improvement initiative

Extent: 10p.BACKGROUND: Australia's Aboriginal and Torres Strait Islander (Indigenous) populations have disproportionately high rates of adverse perinatal outcomes relative to other Australians. Poorer access to good quality maternal health care is a key driver of this disparity. The aim of this study was to describe patterns of delivery of maternity care and service gaps in primary care services in Australian Indigenous communities. METHODS: We undertook a cross-sectional baseline audit for a quality improvement intervention. Medical records of 535 women from 34 Indigenous community health centres in five regions (Top End of Northern Territory 13, Central Australia 2, Far West New South Wales 6, Western Australia 9, and North Queensland 4) were audited. The main outcome measures included: adherence to recommended protocols and procedures in the antenatal and postnatal periods including: clinical, laboratory and ultrasound investigations; screening for gestational diabetes and Group B Streptococcus; brief intervention/advice on health-related behaviours and risks; and follow up of identified health problems. RESULTS: The proportion of women presenting for their first antenatal visit in the first trimester ranged from 34% to 49% between regions; consequently, documentation of care early in pregnancy was poor. Overall, documentation of routine antenatal investigations and brief interventions/advice regarding health behaviours varied, and generally indicated that these services were underutilised. For example, 46% of known smokers received smoking cessation advice/counselling; 52% of all women received antenatal education and 51% had investigation for gestational diabetes. Overall, there was relatively good documentation of follow up of identified problems related to hypertension or diabetes, with over 70% of identified women being referred to a GP/Obstetrician. CONCLUSION: Participating services had both strengths and weaknesses in the delivery of maternal health care. Increasing access to evidence-based screening and health information (most notably around smoking cessation) were consistently identified as opportunities for improvement across services.Alice R. Rumbold, Ross S. Bailie, Damin Si, Michelle C. Dowden, Catherine M. Kennedy, Rhonda J. Cox, Lynette O’Donoghue, Helen E. Liddle, Ru K. Kwedza, Sandra C. Thompson, Hugh P. Burke, Alex D. H. Brown, Tarun Weeramanthri and Christine M. Connor

Therapeutic Management of Primary Immunodeficiency in Older Patients

Primary immunodeficiency disease (PID) has traditionally been viewed as a group of illnesses seen in the paediatric age group. New advances in diagnosis and treatment have led to an increase in the number of elderly PID patients. However, there is lack of research evidence on which to base clinical management in this group of patients. Management decisions often have to be based therefore on extrapolations from other patient cohorts or from younger patients. Data from the European Society for Immunodeficiencies demonstrates that the vast majority of elderly patients suffer from predominantly antibody deficiency syndromes. We review the management of PID disease in the elderly, with a focus on antibody deficiency disease

Maternal fetal programming of birthweight among Australian Aboriginal infants: a population-based data linkage study

BACKGROUND: Low birthweight, which is common among Australian Aboriginal infants, has been found to persist across generations because of shared genetic and environmental factors and possibly fetal programming. Fetal programming refers to the response of a fetus to hostile uterine conditions with lifelong effects and possibly, in turn, providing a poorer uterine environment for future offspring. Fetal programming might have a greater effect in populations that have undergone rapid lifestyle transitions-for example, Indigenous populations. Disentangling causal effects is difficult, but family-based approaches could provide insights. We explored whether poor maternal fetal growth caused low birthweight in Aboriginal infants. METHODS: In this data linkage study, we used linked administrative health records of 12 865 singleton Aboriginal infants born in Western Australia between 1980 and 2010 and their relatives (including siblings born in 2011). Electronic birth records included all births since 1980 with at least 20 weeks completed gestation or a birthweight of 400 g. We compared parental-offspring birthweight associations using three approaches-a regression analysis of the complete sample, adjusting for confounding variables; a comparison of the maternal-offspring and paternal-offspring associations; and a within-cousin group comparison. We used binary and continuous measures of birthweight. We categorised infants and their parents as small for gestational age (SGA) if their birthweight was below the first decile of birthweights for all singleton livebirths of the same sex and gestational age in Australia between 1998 and 2007. FINDINGS: The relative risk (RR) of SGA birth was higher for infants with SGA mothers than for those with non-SGA mothers (RR 1·65, 95% CI 1·49 to 1·83), after adjusting for grandmaternal parity. After additional adjustment for maternal height, the risk remained higher for those with non-SGA mothers (RR 1·51, 1·36 to 1·68). The maternal birthweight Z score coefficient was 0·17 (95% CI 0·14 to 0·20), compared with 0·13 (0·10 to 0·16) for paternal birthweight, a difference of 0·03 (-0·01 to 0·08). In the cousin analysis, the maternal-offspring association was fully attenuated (0·00, 95% CI -0·05 to 0·06). Conditions in the current pregnancy were strongly associated with offspring birthweight Z score. Smoking was associated with a mean decrease of 0·39 (95% CI -0·45 to -0·34) in offspring birthweight Z score, drug misuse with a decrease of 0·31 (-0·43 to -0·20), and diabetes with an increase of 0·58 (0·39 to 0·77). INTERPRETATION: We found little support for maternal fetal programming causing low offspring birthweight. The similar maternal and paternal influence on birthweight and our cousin analysis suggested transmission of genetic and environmental factors could explain much of the maternal-offspring birthweight association. Compared with other risk factors in the current pregnancy, fetal programming appears to have little or no role in the high numbers of infants with low birthweight among Aboriginal populations. FUNDING: National Health and Medical Research Council of Australia and Bellberry Ltd

Identifying young Aboriginal and Torres Strait Islander children in linked administrative data: A comparison of methods.

Background: In the ongoing debate on optimum methods for identification of Indigenous people within linked administrative data, few studies have examined the impacts of method on population counts and outcomes in family-based linkage studies of Aboriginal children. Objective: To quantify differences between three algorithms in ascertaining Aboriginal and Torres Strait Islander children in linked administrative data. Methods: Linked administrative health data for children born in Western Australia (WA) from 2000-2013, were used to examine the cohorts identified by three methods: A) the Indigenous Status Flag (ISF, derived by the WA Data Linkage Branch using a multistage-median approach) for the children alone; B) the ISF of the children, their parents and grandparents; and C) Indigenous status of the child, mother or father on either of the child's perinatal records (Midwives or birth registration), to determine differing characteristics of each cohort. Results: Method B established a larger cohort (33,489) than Method C (33,306) and Method A (27,279), with all methods identifying a core group of 26,790 children (80-98%). Compared with children identified by Method A, additional children identified by Methods B or C, were from less-disadvantaged and more urban areas, and had better perinatal outcomes (e.g. lower proportions of small-for-gestational age, 10% vs 16%). Differences in demographics and health outcomes between Methods C and B were minimal. Conclusions: Demographic and perinatal health characteristics differ by Aboriginal identification method. Using perinatal records or the ISF of parents and grandparents (in addition to the ISF of the child) appear to be more inclusive methods for identifying young Indigenous children in administrative datasets. Keywords: Aboriginal health, identification, data linkage, Indigenous, child, methodology