Despite recent reductions in deaths from cardiovascular disease (CVD), Aboriginal and Torres Strait Islander peoples continue to experience a high burden of chronic diseases such as diabetes, CVD and chronic kidney disease (CKD) from a young age. CVD remains a leading cause of Aboriginal and Torres Strait Islander mortality and the largest contributor to difference in life expectancy between First Nation’s and non-Indigenous people in Australia.

Our program of work aims to improve prevention of chronic disease for Aboriginal and Torres Strait Islander Peoples at the population, health service and individual levels.

Our approach is guided by evidence, shared knowledge and systems strengthening.

Read more about the implementation of health check in prevention and early detection of chronic diseases here. Read about the outcomes of the new CVD risk calculator here.

Our ECDC team works with organisations and governments across Australia using a community-focused and strengths-based approach that emphasises Aboriginal and Torres Strait Islander people’s leadership and expertise. Our efforts to achieve long term sustainable improvement are underpinned by a collaborative approach. We are funded by the Australian Government Department of Health, Indigenous Health Division.

Aboriginal and Torres Strait Islander people’s knowledge, expertise and leadership are central to our way of working alongside a continuous cycle of sharing, discussion, feedback and refinement.

Our team involves Aboriginal and Torres Strait Islander leadership and voices at all stages of our research, from design through to output development and dissemination:

• Our investigator team and collaborators include Aboriginal and Torres Strait Islander researchers
• We meet regularly with Thiitu Tharrmay, our Aboriginal and Torres Strait Islander Health Program Reference Group
• We are guided by principles of Indigenous Data Sovereignty and Indigenous Data Governance put forth by the Maiam nayri Wingara Indigenous Data Sovereignty Collective.

Our team has several intersecting pieces of work that aim to support best practice chronic disease prevention and management.

This project aims to improve chronic disease prevention and care for all Aboriginal and Torres Strait Islander peoples using a health systems approach.

Our team worked with the AIHW to use routinely collected primary health care data to find lighthouse services. These were services in the top 20% of national key performance indicators related to chronic disease.

Four services across 2 jurisdictions participated in our study. We spoke to 75 clients, carers and providers over 12 hours of interviews.

We wanted to learn from the strengths of individual services and help translate these lessons and processes to wider contexts.

We have done this by reviewing the evidence from peer-reviewed research  combining what we heard from talking with services and their communities with the evidence from research. We are working with services to develop policy recommendations to government to inform how best to support good care for Aboriginal and Torres Strait Islander chronic disease.

Summary: Methodology for Exploring what makes good chronic disease care for Aboriginal and Torres Strait Islander people.

Site specific approval details are available on request, please email ecdc@anu.edu.au

A rapid review of opportunities and challenges in the implementation of social prescription interventions for addressing the unmet needs of individuals living with chronic long-term conditions.

People with chronic conditions often struggle to access and navigate complex health and social services. Social prescription (SP) interventions, a patient-centered approach, help individuals identify their holistic needs and increase access to non-clinical resources, thus leading to improved health and well-being. This review will explore existing SP interventions for people with chronic conditions and identify the opportunities and challenges of implementing them in primary healthcare (PHC) settings. This rapid review will follow the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines and involve searching for relevant articles in three databases (PubMed/MEDLINE, EMBASE, and Web of Science) using a combination of subject headings and keywords pertinent to “social prescription,” “chronic disease,” and “primary health care” intertwined through the Boolean operators “OR” and “AND.” Research findings will address an important evidence gap on how long-term chronic conditions can be supported by SP in ways that are different from other conditions. Findings may also guide researchers and practitioners to design and implement SP interventions to benefit people with long-term chronic conditions.

If you need details with regard to research questions or methodology, please contact Dr Uday N Yadav (uday.yadav@anu.edu.au)

Project brief

Chronic diseases are a recognized global health concern, and are a leading cause of morbidity and mortality among Aboriginal and Torres Strait Islander people in Australia.  Emerging evidence shows the improvement in health outcomes of Aboriginal and Torres Strait Islanders health in recent years; however, underutilization and regional variation in access to/utilization of chronic disease initiatives focusing on cardiovascular disease, diabetes, and chronic kidney disease delivered by primary health care is a recognised concern. To understand this knowledge gap, this review aims to:

• To identify the opportunities and challenges to the implementation of chronic disease initiatives for the Aboriginal and Torres Strait Islander People in primary health care settings.
• To provide recommendations to guide the implementation of chronic disease initiatives for Aboriginal and Torres Strait Islander People in primary health care settings.

This rapid review method will be conducted based on the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) guideline. We will run a search of two databases (Medline and Web of Science) to identify relevant studies from January 2014 to March 2023. This timeframe follows on from a systematic review conducted by Gibson et. al. that operated the search until December 2013. This rapid review mirrors the Gibson methodology with two main changes: 1) narrowing focus from Indigenous communities globally to Aboriginal and Torres Strait Islander contexts in Australia, 2) narrowing focus from all chronic diseases to focus on the three major contributors to chronic disease burden (cardiovascular disease, diabetes, and chronic kidney disease). Findings from this study will be disseminated through academic publications, policy briefs, conference presentations, and knowledge exchange seminars with policymakers This project is a part of the Department of Health Project, Australian Government and estimated time for project completion is December 2023.

If you need details with regard to research questions or methodology, please don’t hesitate to contact Dr. Uday N Yadav (uday.yadav@anu.edu.au) or Dr. Rosemary Wyber (rosemary.wyber@anu.edu.au).

Learn more about experience based co-design methods

• What is experience-based co-design? The King’s Fund
• Co-design with Aboriginal communities Agency for Clinical Innovation

Co-designed shared-decision making resources to support patient-centred care for Aboriginal and Torres Strait Islander peoples

Building on previous work of decision aids and CVD risk calculators, resources have been developed through co-design to support shared decision making around health for Aboriginal and Torres Strait Islander peoples.

This objective is led by Dr Carissa Bonner and her team at USYD.

Working group

Carissa Bonner: CVD risk communication, decision aids, Heart Foundation roles

Judith Parnham (Ankamuthi/Erub): Health Worker, NAATSIHWP role, MPhil candidate

Natasha Freeman: GP, AMS roles in NT/NSW, qualitative research

Carys Batcup: behaviour change, qualitative research, administrative support

Shannon McKinn: community health literacy, qualitative research

Advisory group

Michelle Dickson (Darkinjung/Ngarigo): Indigenous Public Health, yarning research methodology

Lyndal Trevena: GP, shared decision making, ACI roles

Marguerite Tracey: GP, health literacy, RACGP & AMS roles

Kirsten McCaffery: health literacy, shared decision making

The project team has created a toolkit to enhance knowledge and skills in CVD risk assessment and management. The Healthy Heart: Communities toolkit has been designed as a resource for all clinical staff in primary care, and aims to support conversations about CVD risk. During development, the team consulted the Australian National University’s Aboriginal Reference Group (Thiitu Tharrmay) and partnered with Saltwater People, an Indigenous-owned graphic design company based in QLD to create original artwork, design and layout. Original artwork was created by Tyrown Waigana.

The toolkit is designed for use across a variety of primary healthcare settings, and as a complementary resource to CVD Risk Communication Workshops that can be conducted within these settings.

This toolkit will help you:

• Facilitate discussions with your patient to motivate behavioural change
• Use culturally appropriate techniques to communicate risk to your patient
• Work in partnership with your patient.

The full toolkit including all resources can be downloaded in full colour from here and in black and white from here.

Information on the individual resources in the toolkit and how to use them are available below. If you have any questions or feedback on these resources, please email ecdc@anu.edu.au

This two page resource provides an overview of Absolute CVD risk and Aboriginal and Torres Strait Islander peoples, including statistics highlighting the differences from CVD risk in the general population. This can be used for your own reference, and these facts can be included in your discussions with your patients about their own CVD risk.

Visual guide for explaining CVD risk to patients

This one page resource is a visual explanation for your patient about their CVD risk and what it means for them, and can complement the use of motivational interviewing techniques.

After conducting the health assessment with your patient, which will include the use of a CVD risk calculator, this resource is a template that you can write on to help you talk through what CVD risk is, what your patients’ specific risk factors are, and how they contribute to their risk of heart attack or stroke in the next 5 years.

How to use this template:

1. Circle patients’ specific risk factors
2. Based on the CVD risk calculator’s output, insert whether your patient is at HIGH, MODERATE or LOW risk in the heart graphic
3. Convert this risk score to a proportion and enter the appropriate number in the corresponding statement, e.g. if your patient’s risk score is 10%, the statement should read “This means that if there were 100 people like you, we would expect 10 of them to have a heart attack or stroke within the next 5 years”
4. Indicate on the risk spectrum where they currently fall
5. Discuss what changes can be made to reduce their risk
6. Indicate on the risk spectrum where they would fall if they made these specific changes
7. Refer your patient to appropriate services

Communicate CVD risk effectively: Motivational interviewing and the 5 stages of change

This resource gives an introduction to motivational interviewing techniques and how they can be applied in your discussions about risk with patients. It includes background on the 5 stages of change.  This can be used as a guide during your patient consultations.

Other helpful resources

This includes a handy guide to Medicare Benefits Schedule (MBS) item numbers relevant to CVD risk assessment, and useful links to ensure you provide the best health assessment for your patient.

Materials to guide workshops on risk communication

These are a suite of resources that can be used as supporting materials for CVD Risk Communication Workshops that can be conducted in your own practice. They include:

• Overview of the CVD risk communication workshop
• Case studies
• Role play debrief: how to identify motivational interview techniques
• Quiz: testing your knowledge about CVD risk and risk communication for Aboriginal and Torres Strait Islander peoples

Toolkit evaluation to inform update

We are currently conducting an evaluation of the toolkit to inform an update of the resource. Health provider perspectives will be used to refine the toolkit and improve it for use, as well as aligning with the latest national guidelines, including the National CVD Guidelines and NACCHO/RACGP Preventive Guide.

Resources and Key Outputs

• CVD Risk communication Toolkit for Health Professionals
• National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people
• Australian guideline and calculator for assessing and managing cardiovascular disease risk
• Gibson, O., Lisy, K., Davy, C. et al. Enablers and barriers to the implementation of primary health care interventions for Indigenous people with chronic diseases: a systematic review. Implementation Sci 10, 71 (2015). https://doi.org/10.1186/s13012-015-0261-x
• Yadav UN, Smith M, Agostino J, et al. Understanding the implementation of health checks in the prevention and early detection of chronic diseases among Aboriginal and Torres Strait Islander people in Australia: a realist review protocol. BMJ Open 2023;13:e071234. doi:10.1136/ bmjopen-2022-071234 
• ‘Drivers’ of wellbeing: transport key for Aboriginal and Torres Strait Islander communities accessing primary care

For more information about this project, please contact Dr Rosemary Wyber (Lead Investigator) rosemary.wyber@anu.edu.au  or ecdc@anu.edu.au