Objective: Effective interventions to improve population and individual health require environmental change as well as strategies that target individual behaviours and clinical factors. This is the basis of implementing an ecological approach to health programs and health promotion. For Aboriginal People and Torres Strait Islanders, colonisation has made the physical and social environment particularly detrimental for health. Methods and Results: We conducted a literature review to identify Aboriginal health interventions that targeted environmental determinants of health, identifying 21 different health programs. Program activities that targeted environmental determinants of health included: Caring for Country; changes to food supply and/or policy; infrastructure for physical activity; housing construction and maintenance; anti-smoking policies; increased workforce capacity; continuous quality improvement of clinical systems; petrol substitution; and income management. Targets were categorised according to Miller’s Living Systems Theory. Researchers using an Indigenous community based perspective more often identified interpersonal and community-level targets than were identified using a Western academic perspective. Conclusions: Although there are relatively few papers describing interventions that target environmental determinants of health, many of these addressed such determinants at multiple levels, consistent to some degree with an ecological approach. Interpretation of program targets sometimes differed between academic and community-based perspectives, and was limited by the type of data reported in the journal articles, highlighting the need for local Indigenous knowledge for accurate program evaluation. Implications: While an ecological approach to Indigenous health is increasingly evident in the health research literature, the design and evaluation of such programs requires a wide breadth of expertise, including local Indigenous knowledge.

Aims To improve diabetes management in Indigenous Australians using an integrated nurse‐led model of diabetes education and eye screening in indigenous primary care and specialist diabetes clinics. Design A pre–post study. Methods This study will be implemented in indigenous primary care and specialist diabetes clinics in Victoria, Australia. Participants recruited to the study will be existing adult patient with diagnosed diabetes attending study sites. A nurse‐credentialled diabetes educator and certified retinal imager will deliver three study components: (a) retinal photography as a diabetic retinopathy screening and patient engagement tool; (b) lifestyle and behaviour surveys, administered at baseline and at the final visit, in 12 months. Findings from the surveys and participants’ retinal images will be used to guide; and (c) personalized diabetes education. The primary outcomes are participant adherence to diabetic eye screening recommendations and health service diabetic retinopathy screening coverage. Secondary outcomes are baseline DR prevalence and changes in clinical and lifestyle risk factor levels, diabetes knowledge and satisfaction with diabetes care. Discussion Compared with non‐indigenous Australians, Indigenous Australians have a high prevalence of diabetic retinopathy and blindness, low adherence to eye screening recommendations and suboptimal health literacy. Nurse‐credentialled diabetes educators can be trained to incorporate retinal imaging and eye screening into their clinical practice to give image‐based diabetes education to facilitate diabetic retinopathy management. Impact Credentialled nurse diabetes educators who integrate eye screening and diabetes education can facilitate timelier diabetic retinopathy screening, referral pathways and treatment of sight‐threatening retinopathy. We believe that this model of integrated diabetes education and eye screening will also improve adherence to eye screening recommendations, population screening coverage, health literacy, risk factor levels and diabetes self‐care. Clinical Trial Registration: ANZCTRN1261800120435.

Aim To assess the prevalence of modifiable health‐risk behaviours among Indigenous Australian adults with diabetes attending a regional Victorian Indigenous primary‐care clinic. Design A cross‐sectional observational single‐site study. Methods As part of a multi‐study project we administered the Smoking, Nutrition, Alcohol consumption, Physical activity and Emotional wellbeing (SNAPE) survey tool during the study baseline visit to methodically capture health‐related behavioural data in the nurse‐led integrated Diabetes Education and Eye Screening (iDEES) project in a regional Indigenous primary healthcare setting between January 2018 and March 2020. This descriptive SNAPE study helps address the lack of health behaviour data for Indigenous people with diabetes. Results Of 172 eligible adults, 135 (79%) were recruited to the iDEES study, 50 (37%) male. All participated in at least one survey. Median (range) age was 56 (46–67) years; 130 (96%) had Type 2 diabetes of median [IQR] duration 6 (2–12) years. All 135 provided smoking data; 88 (65%) completed all surveys. Forty‐nine (36%) and 29 (22%) were current or former smokers, respectively; 5 (6%) met vegetable intake guidelines, 22 (25%) met fruit intake guidelines; 38 [43%] drank alcohol in the past year. On average, participants walked for ≥10 min at a time 4 days/week and sat for an average of 8 h on weekdays; 35 (40%) had minimal‐mild, and 30 (34%) had moderate‐severe depressive symptoms. Conclusion Suboptimal modifiable health‐risk behaviours and depressive symptoms are common in Indigenous Australian adults with diabetes. Impact Orderly assessment and reporting of health‐risk behaviours using a single multi‐component survey instrument (SNAPE tool) during a nurse‐led diabetes education clinical visit is feasible and efficient. Such data may facilitate personalised interventions and improve diabetes management at both individual and health service levels.

BackgroundAboriginal Community Controlled Organisations (ACCOs) provide community-focussed and culturally safe services for First Peoples in Australia, including crisis intervention and health promotion activities, in a holistic manner. The ecological model of health promotion goes some way towards describing the complexity of such health programs. The aims of this project were to: 1) identify the aims and purpose of existing health promotion programs conducted by an alliance of ACCOs in northern Victoria, Australia; and 2) evaluate the extent to which these programs are consistent with an ecological model of health promotion, addressing both individual and environmental determinants of health.MethodsThe project arose from a long history of collaborative research. Three ACCOs and a university formed the Health Promotion Alliance to evaluate their health promotion programs. Local community members were trained in, and contributed to developing culturally sensitive methods for, data collection. Information on the aims and design of 88 health promotion activities making up 12 different programs across the ACCOs was systematically and prospectively collected.ResultsThere was a wide range of activities addressing environmental and social determinants of health, as well as physical activity, nutrition and weight loss. The design of the great majority of activities had a minimal Western influence and were designed within a local Aboriginal cultural framework. The most common focus of the activities was social connectedness (76 %). Physical activity was represented in two thirds of the activities, and nutrition, weight loss and culture were each a focus of about half of the activities. A modified coding procedure designed to assess the ecological nature of these programs showed that they recruited from multiple settings; targeted a range of individual, social and environmental determinants; and used numerous and innovative strategies to achieve change.ConclusionFirst Peoples’ health promotion in the Goulburn-Murray Rivers region encompasses a broad range of social, cultural, lifestyle and community development activities, including reclaiming and strengthening cultural identity and social connectedness as a response to colonisation.

As diabetes occurs in all ethnicities and regions it is essential that retinopathy screening be widely available. Screening rates are lower in Indigenous than in non‐Indigenous Australians. Technological advances and Medicare rebates should facilitate improved outcomes. Use of non‐ophthalmic clinicians, (general practitioners, diabetes educators, health‐workers and endocrinologists) to supplement coverage by ophthalmologists and optometrists would extend retinopathy screening capacity. Diabetes educators are an integral part of diabetes management. Integrating ocular screening and diabetes education in primary care settings has potential to improve synergistically retinopathy screening coverage, patient self‐management, risk factor control, care satisfaction, health economics and sustainability of under‐resourced services.

Background Diabetic retinopathy (DR) prevalence is higher in Indigenous Australians than in other Australians and is a major cause of vision loss. Consequently, timely screening and treatment is paramount, and annual eye screening is recommended for Indigenous Australians. Aims To assess the prevalence of DR, reduced vision and DR treatment coverage among Indigenous Australian adults with diabetes attending Top End indigenous primary care health services. Methods A cross‐sectional DR screening study conducted from November 2013 to December 2015 in two very remote Northern Territory Aboriginal primary healthcare services. Results In 287 subjects, the prevalence of non‐proliferative DR, proliferative DR and clinically significant diabetic macular oedema was 37.3%, 5.4% and 9.0% respectively. Treatment coverage for PDR was 60% (of 10 patients) and for CSMO was 17% (of 23 patients). Vision data were available from 122 participants at one site. The proportion with normal vision, reduced vision, impaired vision and blindness was 31.1%, 52.5%, 15.6% and 0.8% respectively. Overall, ungradable monocular image sets (46%) were associated with poorer quality images and missing protocol images (both P < 0.001). Ungradable images for DR were associated with presence of small pupils/media opacities (P < 0.001). Ungradable images for diabetic macular oedema were associated with poorer image quality (P < 0.001), cataracts (P < 0.001) and small pupils (P = 0.04). Conclusions A high prevalence of DR, CSMO and impaired vision was noted in Indigenous Australians with diabetes. Screening in primary care is feasible, but more effective screening methods are needed.

Background: Aboriginal and Torres Strait Islander people have higher rates of diabetes and its complications than non-Aboriginal people. Rumbalara Aboriginal Co-operative is the major primary healthcare provider for Aboriginal people in the Greater Shepparton region.Aims: To evaluate the baseline metabolic parameters and presence of diabetes complications in people with type 2 diabetes attending Rumbalara Aboriginal Co-operative in 2017 and compare it with other Aboriginal and Torres Strait Islander studies and Australian specialist diabetes services.Methods: Clinical and biochemical characteristics, including diabetes type, age, weight, body mass index (BMI), blood pressure, micro-and macrovascular complications, glycosylated haemoglobin (HbA1c), haemoglobin, renal function, lipid profile, urine albumin:creatinine ratio, diabetes medications, renin angiotensin system inhibition therapies, HMG-CoA reductase inhibitors and antiplatelet agents, were determined.Results: One hundred and twenty-six individuals had diabetes, 121 had type 2 diabetes. One hundred and thirteen identified as Aboriginal and/or Torres Strait Islander. Median age was 57.5 (48-68) years, median HbA1c was 7.8% (6.8-9.6) and median BMI was 33.4 kg/m 2 (29-42.3). Compared with other Australian Aboriginal and Torres Strait Islander populations, this population was older and had more obesity, but with better glycaemia management. Compared with specialist diabetes services, this population was of similar age, with greater BMI but comparable HbA1c.Conclusions: Aboriginal people living with type 2 diabetes attending this regional Aboriginal health service have comparable glycaemic management to specialist diabetes services in Australia, managed largely by primary care physicians with limited access to specialist care for the past 5 years.

Aboriginal and Torres Strait Islander Australians are at high risk of Type 2 diabetes and its complications. Optimal lifestyle choices can improve health outcomes. A thematic review of original research publications related to smoking, nutrition, alcohol intake, physical activity and emotional wellness in Aboriginal and Torres Strait Islander Australians with diabetes was performed. Overall, 7118 English-language publications were identified by search engines (PubMed, CINAHL, Scopus, Medline-Web of Science, and Google Scholar) with search terms Indigenous Australians OR Aboriginal and Torres Strait Islanders AND diabetes AND lifestyle OR smoking OR nutrition OR alcohol OR physical activity OR emotional wellbeing and their common synonyms. After review of abstracts and publication reference lists, 36 articles met inclusion criteria and were reviewed. In general, the self-reported health-related behaviours of Aboriginal and Torres Strait Islander Australian adults with diabetes, which is predominantly Type 2 diabetes, was suboptimal. An important clinical challenge in diabetes care is to sustainably reduce smoking, improve nutrition (including alcohol use), increase physical activity, reduce sedentary time, and improve emotional wellbeing, which should lead to reduced rates of diabetes complications. Regular assessments and multi-stakeholder input, including individuals, communities, clinical, health policy, societal and government inputs and partnerships, are desirable to facilitate closing the gap in health between Aboriginal and Torres Strait Islander and non-Indigenous Australians.