Aim Address health inequities for Pasifika (Pacific people living in Aotearoa New Zealand)

Content Following attendance at a Patient and Clinician Engagement workshop in North America, a general practitioner and her Samoan patient returned to New Zealand to form Pacific People’s Health Advisory Group and Pacific practice-based research network which together with university Pacific researchers forms the Pacific Research Collective.

Research questions to reduce health inequalities experienced by Pasifika were generated. Successful grants applications provided funding. Two concurrent projects are in process, addressing improving uptake of urate-lowering therapy for with gout and preventing/reducing rheumatic fever in Pasifika, both high-prevalent conditions with significant morbidity. Literature reviews have determined previous interventions and their degree of effectiveness. Using co-design, guided by principles of Samoan research framework fa’afaletui, which emphasises collective approach and importance of reciprocity and relationships, novel culturally appropriate interventions are being designed, implemented and evaluated.

In a series of Research Collective workshops using talanga (interactive conversations) existing approaches were summarised, novel interventions brainstormed then collated, synthesised, expert advisory group consulted for feasibility and possible impact then fed back to group for refinement.

For gout, the intervention is to improve access by establishing pharmacist-led one-stop-shops with point-of-care urate testing, prescribing and dispensing allopurinol plus texted reminders for three-monthly follow-ups. New Zealand Crown entity Pharmac has brokered stakeholder meetings with various Ministries, Health New Zealand, Māori Health Authority and non-government organisations to establish funding sponsors and partners for intervention implementation. The rheumatic fever intervention follows the same model.

Community and practice involvement and ownership throughout the projects from their onset ensures champions for behavioural change and knowledge transfer and intervention uptake is facilitated.

Goals Interventions are developed, implemented and evaluated in an egalitarian approach to decrease Pasfika health disparities by removing systematic barriers, and may also prove relevant and valuable for Indigenous Māori.

At the conclusion of my presentation attendees will take away
o How community, clinical practices and university researchers can work collaboratively to general research questions, then design and conduct studies to answer them
o The relationship between the Samoan research framework fa’afaletui, which emphasises collective approach and importance of reciprocity and relationships, and use of mixed methodology and co-design
o The importance of grass-roots co-design in knowledge translation

Tū Ora is a Primary Care Network covering a population of 360,000 people in the Wellington region. We deliver care through a network of medical centres and community-based providers.

In New Zealand, as is frequently the case around the world, public health programmes deliver inequitable outcomes for indigenous people.

In 2021, our government’s target was a 90% covid vaccination uptake for the general population.

Applying a pro-equity approach, we deliberately targeted our indigenous Māori population, focussing on addressing the constraints that might limit peoples’ access to the vaccine, with the aim of ensuring the same uptake as non-Māori.

We partnered with iwi (Māori community)-based organisations to co-design an approach to deliver our vaccination programme, including:
predictive modelling, dashboards, and heat maps, to support a directed pro-equity approach.

We applied a communication technique, designed by Māori companies to resonate with key target groups. It was intended to address the specific needs of the people.

Vaccination clinics on Maraes, in Māori immersion schools and places of work were delivered. Outreach events were organised, targeting Black Power bikers, homeless hostels and churches. Family centred festival events, to facilitate large groups being vaccinated together were another success, and we employed a diverse, representative workforce to head up these initiatives.

We were the first region to hit 90% vaccine coverage for our Māori population. Some regions have yet to achieve this uptake. To date, Tū Ora has maintained its nation-leading performance on vaccination rates.

Due to the success of this approach, we have made the decision to continue using it with other public health programmes, e.g., childhood immunisation, cervical, bowel and breast screening.

We will present information on our implementation approach, and on outcomes. This will include the recent success we have attained with our cervical screening rates for Māori women overdue a cervical screen.

1. How to implement a successful pro-equity approach
2. The importance of co-design with your target population
3. Taking what works and applying it to other population health programmes.

Trusting relationships are difficult to measure in standardised performance metrics. However, they are essential to the provision of high-quality primary health care. Drawing on Aboriginal health and wellbeing principles, this presentation demonstrates the value of relationship-based care, particularly when working in cross-cultural settings.

The Yolŋu term ‘gurruṯu’, translated as ‘kinship relationships’ provides a framework for understanding and valuing these connections. As an Aboriginal community-controlled organisation, Laynhapuy delivers culturally appropriate primary health care to residents in Homelands across a 6500 square kilometre geographic area in North-East Arnhem Land, Australia. Gurruṯu or relationship-based care, including two-way learning and reflective practice allow the Laynhapuy team to engage with community and respond to their healthcare needs.

This region has some of the highest rates of rheumatic heart disease (RHD) in the world. Using the RHD program as a case study, this presentation demonstrates the value of trusting longitudinal relationships to improve health and wellbeing outcomes for individuals and communities. Using an outreach model, the team engages in prevention and education activities, ensuring early detection and treatment of skin sores and sore throats, as well as prompt recognition and management of acute rheumatic fever (ARF). For patients diagnosed with ARF, secondary prophylaxis with monthly intra-muscular penicillin injections, can prevent the development of rheumatic heart disease. The model works because communities trust and can access their primary health care team.

A key element of the program is the team-based approach, including recognition and involvement of Aboriginal Health Workers, families, and community members. Recent innovations to improve access to echocardiography for screening and monitoring in community are having an impact too. However, their benefits are realised because they are embedded within existing relationships and responding to community need. This presentation reminds us of the essential value of relationships as we reconnect and revive primary health care.

1. Recognise the critical importance of relationships when providing primary health care
2. Acknowledge the burden of rheumatic heart disease still present in Aboriginal communities in Australia
3. Appreciate the value of Aboriginal health and wellbeing principles, including wholistic, strengths-based approaches when designing and delivering primary health care programs

Background: In remote communities of northern Australia, First Nations children with hearing impairment (HI) are disproportionately at risk of poor school readiness and performance compared to their peers without HI. Our objective was to determine a mixed pneumococcal conjugate vaccine (PCV) schedule to maximise immunogenicity and thereby reduce bacterial otitis media (OM), disabling HI, and developmental delays from birth to age 3 years.
Methods: We conducted two parallel, open-label, randomised controlled trials. Eligible infants were first allocated 1:1:1 to standard or mixed primary PCV schedules at age 28-38 days, then at age 12 months to a booster dose (1:1) of 13-valent PCV, PCV13 (Prevenar13®, +P) or 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugated vaccine, PHiD-CV10 (Synflorix®, +S).
Findings: From March 2013 to September 2018, 261 children were allocated to booster +P (n=131) or +S (n=130). Adverse events, primary and select secondary outcomes to age 18 months have been reported. Here we report six-monthly by booster dose, standardised ear, hearing, and developmental assessments from age 12 to 36 months. We found high levels and non-significant group differences in prevalence of OM at each age (for example 88% and 91%, respectively at age 18 months, Difference -3% [95% Confidence Interval -11, 5]). Analyses stratified by primary schedules were non-significant. Compared to +S, the +P group had significantly lower prevalence of moderate HI at age 18 months (23% and 42%, respectively), and a lower prevalence of expressive language delays (Differences 17% to 20%) at ages 24 and 30 months.
Interpretation: Our study adds evidence of the high prevalence of chronic OM and early life trajectory of disability and disadvantage associated with OM and HI. Communities, primary health care services, and specialists must be resourced and directed to evidence-based OM prevention and treatment for this population. Expanded valency PCVs should be evaluated.

• Otitis media and hearing impairment cause developmental delays which further disadvantage First Nations children throughout early childhood
• Culturally safe comprehensive primary and specialist services could change quality of life trajectory for many children
• GPs need resources and training to follow the national guidelines for diagnosis and management of otitis media in Aboriginal and Torres Strait Islander children

Background

Acute respiratory failure (ARF) is the most frequent reason for non-elective hospital admissions in children aged less than 5 years, with a high global health burden. ARF is the common endpoint for many underlying specific diagnoses such as bronchiolitis, asthma and pneumonia. Rural and remote Queenslander’s account for approximately 38% of Queensland’s total population with approximately 47% of First Nations people living in rural and remote regions. Aboriginal and Torres Strait Islander children have a higher incidence rate of ARF including bronchiolitis than non-Indigenous people.
Whilst mortality due to ARF has improved in high-income countries (1-2%), mortality remains between 13-20% in less well-resourced settings. In Far North Queensland 50%, mostly indigenous children with ARF, require transfer to a metropolitan hospital, whereas in South-East Queensland only 9-12% of these children require inter-hospital transfer. The Torres Strait and Cape York Hospitals admitted 216 infants with bronchiolitis with bronchiolitis between July 2016-June 2018 with 108 (50%) of infants were airlifted to tertiary hospitals due to higher care needs at an average cost of $24,500/patient.
Proposed Practice Change
To address this inequality, we evaluated a measured model of care using a comprehensive Clinical Guideline including nasal high-flow oxygen therapy for children with ARF in remote hospitals in Queensland. The practice change included a comprehensive training package to empower the bedside nurses and doctors to apply the model of care which had been normally provided in metropolitan/tertiary hospitals. The change was implemented in Nov 2021 – Oct 2022 and practice was compared to a period between Jan 2018 - Oct 2021. The admission rate dropped from 34 to 12 hospital admissions per months as a result of the COVID-19 pandemic related isolation measures in the region.
Over the one-year implementation period there were no adverse events recorded and the proportion of transfers was reduced.

1. Nasal high flow therapy's implementation for children in remote communities contributes to improving equity of access to care.
2. Implementing nasal high flow therapy in resource poor remote communities is safe and can increase resilience and build clinical capacity.
3. Implementing nasal high flow therapy in remote sites can reduce unnecessary aeromedical retrievals to tertiary sites.

Aboriginal and Torres Strait Islander children experience a high burden of otitis media and hearing impairment which can affect development and quality of life for years. Early detection and evidence-based management can improve the trajectory of these children through the early years and beyond. During the first study of antibiotic management of acute OM management in urban Aboriginal and Torres Strait Islander children, a GP diagnosis of AOM was made according to stringent criteria (middle ear effusion, tympanic membrane bulge and/or pain). Two scales were employed to monitor symptoms over time: the AOM-Severity of Symptoms scale (AOM-SOS) and the AOM-Faces Scale (AOM-FS). Data were derived from 224 children aged 18 months to 16 years (median 3.6 years) at day 0, 7, and 14 post recruitment. We tabulated the symptoms and compared the scale symptom scores for trends, correlation, and responsiveness. Symptoms associated with AOM at day 0 were runny nose (40%), cough (38%) and irritability (36%). More than one third had no or minimal symptoms at day 0 according to AOM-SOS (1-2/10) and AOM-FS scores (1-2/7). The scales were moderately correlated at all study points. However, trends and mean scores were the same whether AOM was judged as persistent or resolved at day 7. Therefore, it is likely the scales measured resolution of symptoms related to concurrent upper respiratory tract infections rather than symptoms due to AOM. Monitoring symptoms is not an effective way of determining whether AOM is present or resolved. Middle ear effusion and bulging of the tympanic membrane should be monitored using tympanometry and otoscopy, rather than reliance on symptoms and scales when monitoring AOM treatment among Aboriginal and Torres Strait Islander children.

1. Asymptomatic or minimally symptomatic AOM can be common in Aboriginal and Torres Strait Islander children living in urban areas
2. Relying on symptoms alone will miss AOM in many Aboriginal and Torres Strait Islander children, leading to hearing impairment, significant educational impact and ear complications.
3. Research tools which rely on parental report of AOM symptoms have limited usefulness. AOM should be clinically diagnosed according to stringent criteria (middle ear effusion, tympanic membrane bulge and/or pain).

Background
The NACCHO-RACGP National guide to preventive healthcare for Aboriginal and Torres Strait Islander people (National Guide) is a flagship resource supporting best practice health promoting and disease preventing activities for Aboriginal and Torres Strait Islander people in primary healthcare settings. Originally conceived by NACCHO in the early 2000s, the now-fourth edition of the National Guide is being developed through a NACCHO-RACGP Partnership Project and will be published in October 2023.
The purpose of the National Guide is to provide guidance for primary healthcare teams on health issues that are preventable, actionable in primary healthcare settings and important (priorities) for Aboriginal and Torres Strait Islander communities. A key aim of the National Guide is to provide practical guidance that is useful for clinical decision making, including in areas where there is uncertainty or variation in clinical practice, or where an issue is contentious.

Methodology
The development of the National Guide comprises three key stages:
- user review of the third edition
- evidence review and formulation of recommendations by authors and
- expert review, editorial review and stakeholder consultation.
Implementation has been a key focus from the start and has part of scoping conversations with authors to include
- Positively stating what promotes, supports, protects and strengthens health and wellbeing
- Using concise plain language with key messages at the start of the topic
- Addressing the whole of the primary healthcare team as the audience
- Emphasising translation into practice

Results
This presentation will focus on updates and recommendations from the chapter on prevention of harms from drinking alcohol.

Conclusion
Recommendations, aimed at the whole of the primary healthcare team, positively state what promotes, supports, protects and strengthens health and wellbeing, using concise plain language with key messages.
Recommendations emphasise translation into practice.

1. There are no physical health benefits from alcohol; even low-level consumption.
2. Explore alcohol consumption and screen for harmful alcohol use, provide information about Australian guidelines and offer support to cease alcohol as part of pre-pregnancy counselling, and antenatal and postnatal care.
3. • When screening identifies a person who is drinking alcohol with a high risk of harms the next step is a brief intervention and further support offered as appropriate.

Background: In remote communities of northern Australia, the high prevalence of early and persisting otitis media (OM) and associated hearing impairment (HI) contribute to further educational and social disadvantage of First Nations children. Inadequate resourcing and high staff turnover impede primary health services efforts to meet the needs of these children, and <10% of fly-in fly-out specialist services reach children <3 years of age. The objective of the Hearing for Learning Initiative (HfLI) is to co-design, deliver, and evaluate the broad impacts of community-based training and employment of Ear Health Facilitators.
Methods: The HfLI is a 5-year stepped-wedge (community) cluster randomised trial. The primary outcome is the difference in the proportion of children 0 to 16 years who receive 6-monthly ear and hearing checks. The intervention is 6-weeks training on-country for community members, delivered by qualified research nurse trainers. Secondary outcomes are retrospective and prospective measures of adherence to OM guideline recommendations, and prospective interviews of stakeholders’ perspectives on the workforce model.
Phases of the HfLI are i) Lead-in - co-design consultation and trainee recruitment (6-months), ii) Training (~3 months), iii) Integration into workforce (~2 months), iv) Employment and 6-monthly refreshers (3 days) to end of the project.
Findings: In January 2020, following 18 months consultation, twenty communities agreed to participate and were allocated to 6-monthly start dates. Adjustments to Lead-in and Integration phases have been implemented in response to co-design recommendations. To end 2022, training had been successful for 35 trainees in 10 communities who reported pre- to post- levels of confidence, knowledge, and skills increasing from 4% to 94% (skills), and performance evaluations across 7 elements increasing from 45% (hear screen) to 90% (otoscopy and tympanometry).
Interpretation: The HfLI workforce model has strong potential to support effective, culturally safe and sustainable ear and hearing services across the NT.

• Effective coherent Primary Health Care and specialist services could change quality of life trajectory for many First Nations children
• The workforce model builds on the cultural knowledge of local residents to create skilled, knowledgeable, and confident Ear Health Facilitators and a culturally safe, comprehensive, sustainable ear and hearing service.
• Ongoing co-design is needed to finalise the model and prepare for research translation into policy and practice.