Objective: To examine whether hospital patients with cancer who were identified as Indigenous were as likely to receive surgery for the cancer as non‐Indigenous patients. Design, setting and patients: Epidemiological survey of all Western Australian (WA) patients who had a cancer registration in the state‐based WA Record Linkage Project that mentioned cancer of the breast (1982–2000) or cancer of the lung or prostate (1982–2001). Main outcome measures: The likelihoods of receiving breast‐conserving surgery or mastectomy for breast cancer, lung surgery for lung cancer, or radical or non‐radical prostatectomy for prostate cancer were compared between the Indigenous and non‐Indigenous populations using adjusted logistic regression analyses. Results: Indigenous people were less likely to receive surgery for their lung cancer (odds ratio [OR], 0.64; 95% CI, 0.41–0.98). Indigenous men were as likely as non‐Indigenous men to receive non‐radical prostatectomy (OR, 0.69; 95% CI, 0.40–1.17); only one Indigenous man out of 64 received radical prostatectomy. Indigenous women were as likely as non‐Indigenous women to undergo breast‐conserving surgery (OR, 0.86; 95% CI, 0.60–1.21). Conclusions: These results indicate a different pattern of surgical care for Indigenous patients in relation to lung and prostate, but not breast, cancer. Reasons for these disparities, such as treatment choice and barriers to care, require further investigation.

Design Qualitative study SettingMetropolitan and rural tertiary and community-based public CR services and Aboriginal health services in WA. ParticipantsThirty-eight health professionals working in the CR setting. MethodSemi-structured interviews were undertaken with 28 health professionals at public CR services and 10 health professionals from Aboriginal Medical Services in WA. The participants represented 17 services (10 rural, 7 metropolitan) listed in the WA Directory of CR services. ResultsEmergent themes included (1) a lack of awareness of Aboriginal CR patients' needs; (2) needs related to cultural awareness training for health professionals; and (3) Aboriginal health staff facilitate access for Aboriginal patients. ConclusionsUnderstanding the institutional barriers to Aboriginal participation in CR is necessary to recommend viable solutions. Promoting cultural awareness training, recruiting Aboriginal health workers and monitoring participation rates are important in improving health outcomes.

BackgroundCardiovascular disease is the major cause of premature death of Indigenous Australians, and despite evidence that cardiac rehabilitation (CR) and secondary prevention can reduce recurrent disease and deaths, CR uptake is suboptimal. The National Health and Medical Research Council (NHMRC) guidelines Strengthening Cardiac Rehabilitation and Secondary Prevention for Aboriginal and Torres Strait Islander peoples, published in 2005, provide checklists for services to assist them to reduce the service gap for Indigenous people. This study describes health professionals' awareness, implementation, and perspectives of barriers to implementation of these guidelines based on semi-structured interviews conducted between November 2007 and June 2008 with health professionals involved in CR within mainstream health services in Western Australia (WA). Twenty-four health professionals from 17 services (10 rural, 7 metropolitan) listed in the WA Directory of CR services were interviewed.ResultsThe majority of respondents reported that they were unfamiliar with the NHMRC guidelines and as a consequence implementation of the recommendations was minimal and inconsistently applied. Respondents reported that they provided few in-patient CR-related services to Indigenous patients, services upon discharge were erratic, and they had few Indigenous-specific resources for patients. Issues relating to workforce, cultural competence, and service linkages emerged as having most impact on design and delivery of CR services for Indigenous people in WA.ConclusionsThis study has demonstrated limited awareness and poor implementation in WA of the recommendations of the NHMRC Strengthening Cardiac Rehabilitation and Secondary Prevention for Aboriginal and Torres Strait Islander Peoples: A Guide for Health Professionals. The disproportionate burden of CVD morbidity and mortality among Indigenous Australians mandates urgent attention to this problem and alternative approaches to CR delivery. Dedicated resources and alternative approaches to CR delivery for Indigenous Australians are needed.

The prevailing disparities in Aboriginal health in Australia are a sobering reminder of failed health reforms, compounded by inadequate attention to the social determinants shaping health and well-being. Discourse around health reform often focuses on the role of government, health professionals and health institutions. However, not-for-profit health organisations are also playing an increasing role in health policy, research and program delivery across the prevention to treatment spectrum. This paper describes the journey of the National Heart Foundation of Australia in West Australia (Heart Foundation WA hereafter) with Aboriginal employees and the Aboriginal community in taking a more proactive role in reducing Aboriginal health disparities, focusing in particular on lessons learnt that are applicable to other non-government organisations. Although the Heart Foundation WA has employed and worked with Aboriginal people and has long identified the Aboriginal community as a priority population, recent years have seen greater embedding of this within its organisational culture, governance, policies and programs. In turn, this has shaped the organisation's response to external health reforms and issues. Responses have included the development of an action plan to eliminate disparities of cardiovascular care in the hospital system, and collaboration and engagement with health professional groups involved in delivery of care to Aboriginal people. Examples of governance measures are also described in this paper. Although strategies and the lessons learnt have been in the context of cardiovascular health disparities, they are applicable to other organisations across the health sector. Moreover, the most powerful lesson learnt is universal in its relevance; individual programs, policies and reforms are more likely to succeed when they are underpinned by whole of organisation ownership and internalisation of the need to redress disparities in health.

Abstract:Introduction: In 2005, NHMRC published an outline of processes to guide services on improving cardiac rehabilitation (CR) for Indigenous Australians. This recognised the increased incidence and mortality from cardiovascular causes in Indigenous Australians with onset occurring at a younger age then in other Australians Methods: Site visits and interviews with CR staff in 15 mainstream CR/secondary prevention services (hospitals plus community health) across WA and 9 Aboriginal Community Controlled Health Services. Qualitative and quantitative data regarding CR provision to Indigenous people with CVD, involvement of Aboriginal Health workers, adaptation to local settings, cultural competency and interagency collaboration was collected by a CR nurse (+/-an Aboriginal nurse) using semistructured interviews. Results: Within tertiary hospitals the processes for identifying Indigenous patients were suboptimal, there were few Indigenous staff and processes for linking Indigenous patients into CR services at discharge were suboptimal. Many CR services are private and others operate for very limited hours and see very few Aboriginal clients. Of public CR services, many were unaware of the NHMRC guidelines and no mainstream service had fully implemented its recommendations. Workforce turnover and capacity issues severely constrain efforts to improve CR service delivery. Conclusions: Substantial deficits were identified in linking Aboriginal people post cardiac event into CR services that offer a comprehensive approach to reduce subsequent cardiac events and hospitalisation. Alternative approaches are needed. We recommend further development of CR partnerships between Aboriginal and mainstream services. Programs with a focus on cardiovascular risk reduction should be an important component of the government focus on improving self-management and strengthening community based care for chronic disease