Remote Australia Online

Background: The Edinburgh Postnatal Depression Scale (EPDS) is widely recommended for perinatal anxiety and depression screening. However, many Aboriginal women find EPDS language complex and confusing, and providers find using it with Aboriginal women challenging. The two part Kimberley Mum’s Mood Scale (KMMS) was developed to improve screening: Part 1 is a Kimberley version of EPDS; Part 2 is a psychosocial tool that enables contextualisation of Part 1 scores. We aimed to determine if KMMS is a valid and acceptable method of identifying Kimberley Aboriginal perinatal women at risk of anxiety or depressive disorders compared to a semi-structured clinical interview. Methods Across 15 sites in the Kimberley, Western Australia, 97 Aboriginal women aged 16 years and older who intended to continue with their pregnancy or had a baby within the previous 12 months were administered the KMMS by trained healthcare providers who provided an overall assessment of no, low, moderate or high risk; 91 participants were then independently assessed by a blinded clinical expert using Diagnostic and Statistical Manual of Mental Disorders, 4th Edition criteria. A qualitative approach was used to determine KMMS’ acceptability. Results Part 1 had high internal consistency (Cronbach’s alpha, 0.89), and overall KMMS risk equivalence for screening for anxiety or depressive disorders was moderate (sensitivity, 83%; specificity, 87%; positive predictive value, 68%). Participants found the process easy and useful, and healthcare providers found KMMS more useful than EPDS. Part 2 allowed healthcare providers to ask questions that gave participants an opportunity to express themselves, resulting in a deeper understanding between them. Conclusion KMMS is an effective tool for identifying Kimberley Aboriginal perinatal women at risk of anxiety and depressive disorders. Adoption of KMMS with culturally safe training and support is likely to improve screening processes, and with further validation may have broader applicability across remote Australia.

Objective: To examine the barriers and facilitators among health professionals to providing referrals to Quitline for Aboriginal and Torres Strait Islander clients who smoke. Methods: A brief online survey, based on the Theoretical Domains Framework, was completed by 34 health professionals who work with Aboriginal and Torres Strait Islander people in South Australia and the Northern Territory. Results: Respondents who frequently made referrals had higher domain scores than less frequent referrers for ‘Skills and knowledge’ (M=4.44 SD=0.39 vs. M=4.09 SD=0.47, p<0.05) and ‘beliefs about capabilities’ (M=4.33 SD=0.44 vs. M=3.88 SD=0.42, p<0.01). Barriers to providing referrals to Quitline were lack of client access to a phone, cost of a phone call, preference for face-to-face interventions, and low client motivation to quit. Conclusions: Health professionals working with Aboriginal and Torres Strait Islander clients should be supported to build their skills and confidence to provide referrals to Quitline and other brief cessation interventions. Building capacity for face-to-face support locally would be beneficial where phone support is not preferable. Implications for public health: Engaging with health professionals who work with Aboriginal and Torres Strait Islander people to increase referrals to Quitline is strategic as it builds on their existing capacity to provide cessation support.

The agriculture sector in northern Australia is vulnerable to the impacts of climate change and climate variability. Climate change risks for future agricultural development include higher atmospheric temperature, increased rainfall variability and an increase in the frequency and severity of extreme weather events such as floods, droughts, heatwaves and fires. An uncertain future climate can affect agricultural production, efficient resource use and sustainable livelihoods. A balance needs to be achieved between resource use and livelihood security for sustainable agricultural development amid stressors such as climate change. This paper examines sustainable agricultural development in northern Australia using the environmental livelihood framework, a new approach that explores the relationships between water, energy and food resources and the livelihoods they sustain. The study shows that developments in the renewable energy sector, water infrastructure sector and advances in research and development for climate resilient infrastructure and climate resilient species are likely to improve agricultural production in northern Australia. Measures to attract and retain agricultural workforce is also key to maintaining a sustainable agricultural workforce in northern Australia. Adequate monitoring and evaluation of agricultural investments is important as future climatic impacts remain uncertain.

For decades Indigenous peoples have argued for health research reform claiming methods used and results obtained often reflect the exploitative history of colonisation. In 2006 the Kimberley Aboriginal Health Planning Forum (KAHPF) Research Subcommittee (hereafter, the Subcommittee) was formed to improve research processes in the remote Kimberley region of north Western Australia. This paper explores the major perceptions, attitudes and concerns of stakeholders in the Subcommittee.

The Blacktip gas project, owned by the multinational corporation Ente Nazionale Idrocarburi (ENI) and located near the marginalised, Indigenous-majority town of Wadeye in the Northern Territory of Australia, is the ethnographic setting to explore the connections of energy industry projects in the age of the Anthropocene. At the core of these issues are considerations of how carbon energy industries operate, how these industries are transforming natural and social ecologies, and how the benefits and costs of the sector are circulated. Much of influential research work and government policy tend to frame these considerations within analytical methodologies of “economic development”: despite pockets of public opposition, the presence of energy projects such as Blacktip are largely taken for granted by authorities, and debates are limited to questions around business-state cooperation and wealth generation. As a methodological alternative, I apply Deleuze and Guattari’s concept of the assemblage to analyse the Blacktip project as a complex network that expresses broader social power relations. I suggest the disrupting image of the cyborg – as the colonising, techno-capitalist blend of human and computer, with carbon-based energy as its lifeblood – as a modern-day assemblage that offers a new method for understanding modern energy cycles, in particular how they are structured by contemporary carbon energy industry corporations. I conclude by arguing that if dominant, taken-for-granted discourses around the benefits of projects such as Blacktip are critically challenged by the (albeit limited) analytical device of the cyborg, social and ecological alternatives can be more openly imagined.

Objective: To describe how a novel program of diabetic retinopathy screening was conceived, refined and sustained in a remote region over 10 years, and to evaluate its activities and outcomes. Design: Program description; analysis of regional screening database; audit of electronic client registers of Aboriginal community controlled health services (ACCHSs). Setting and participants: 1318 Aboriginal and 271 non-Aboriginal individuals who underwent retinal screening in the 5 years to September 2004 in the Kimberley region of north-west Australia; 11 758 regular local Aboriginal clients of Kimberley ACCHSs as at January 2005. Main outcome measures: Characteristics of clients and camera operators, prevalence of retinopathy, photograph quality, screening intervals and coverage. Results: Among Aboriginal clients, 21% had diabetic retinopathy: 19% with non-proliferative retinopathy, 1.2% with proliferative retinopathy, and 2.8% with maculopathy. Corresponding figures for non-Aboriginal clients were 11%, 11%, 0 and 0.4%, respectively. Photograph quality was generally high, and better for non-Aboriginal clients, younger Aboriginal clients and from 2002 (when mydriatic use became universal). Quality was not related to operator qualifications, certification or experience. Of 718 regular Aboriginal clients with diabetes on local ACCHS databases, 48% had a record of retinal screening within the previous 18 months, and 65% within the previous 30 months. Conclusions: Screening for diabetic retinopathy performed locally by Aboriginal health workers and nurses with fundus cameras can be successfully sustained with regional support. Formal certification appears unnecessary. Data sharing across services, client recall and point-of-care prompts generated by electronic information systems, together with policies making primary care providers responsible for care coordination, support appropriate timely screening.

This paper presents the findings of a study that interviewed Aboriginal nurses to explore their experiences of the whiteness of nursing. Despite concerted efforts to improve the health of Aboriginal Australians, it still remains equivalent to third world countries. One strategy identified to address this is to increase the participation rates of Aboriginal registered nurses within the Australian healthcare workforce. Presently Aboriginal nurses account for only a small percentage of the nursing workforce. While there has been research into the recruitment and retention strategies dedicated to improving the numbers of Aboriginal registered nurses, this paper focus on the experiences of Aboriginal registered nurses within Australia's mainstream healthcare system, where they are exposed and subjected on a daily basis to the 'whiteness of nursing.'

Submission to the Inquiry into Agricultural Innovation

One of climate change’s most certain impacts is increasingly frequent and extreme heat. Heat management and climate adaptation policies generally utilize temperature and humidity thresholds to identify what constitutes ‘extreme’ conditions. In the workplace, such thresholds can be used to trigger reductions in work intensity and/or duration. However, in regions that routinely exceed proposed thresholds, this approach can be deeply problematic and raises critical questions about how frequently exposed populations already manage and mitigate the effects of extreme heat. Drawing on social practice theories, this paper repositions everyday engagements with extreme heat in terms of practices of work. It finds that bodies absorb and produce heat through practices, challenging the view that extreme heat is an ‘external’ risk that bodies are ‘exposed’ to. This theoretical starting point also challenges the utility of threshold-based adaptation strategies, by demonstrating how heat is actively co-produced by living, performing bodies-in-weather. This argument is exemplified through a case study of outdoor, manual workers in Australia’s Monsoon Tropics, where work practices were adapted to reduce thermal load. More specifically, we find that workers ‘weather’ work and ‘work’ the weather to enable work to be done in extreme conditions. Our analysis of everyday heat adaptation draws attention to the generative capacities of bodies and unsettles two established separations: (1) between climatic exposure and sensitivity, calling for a more embodied, experiential and performed perspective; and (2) between climatic impacts and (mal)adaptation, calling for an understanding of climate adaptation as located in everyday practices, in the management of bodies-in-weather.

Improving the food security of people living in remote Indigenous communities is an identified priority of Australian Governments. As Indigenous Australians suffer a disproportionate burden from diet-related diseases, improved food security will result in health gains. This chapter describes a practical approach to developing and selecting interventions to improve food security in remote Indigenous communities. Food security interventions aim to achieve a secure, sustainable and healthy food supply to remote Indigenous communities with increased purchase and consumption of a healthy diet by community members as the outcome. Therefore, the menu of interventions must address both supply and demand issues. Policy makers need to take three simple, yet difficult steps when choosing which interventions are suitable to improve public health. Firstly, define the problem; secondly, consider ‘what could or should be done?’; and thirdly, appraise a full range of intervention options to choose the most effective in the real world.

Remote settlements face many challenges in striving to achieve a sustainable local economy. The aim of this paper is to identify key barriers that many remote communities face in adopting tourism as a strategy for achieving long-term economic sustainability. A case study approach was adopted based on Cooktown, a remote settlement in north eastern Australia. Data was collected from secondary sources and interviews with key stakeholders in the town's tourism industry.

Background Although racism is increasingly acknowledged as a determinant of health, few studies have examined the relationship between racism, housing and child health outcomes.Methods Cross-sectional data from the Housing Improvement and Child Health study collected in ten remote indigenous communities in the Northern Territory, Australia were analysed using hierarchical logistic regression. Carer and householder self-reported racism was measured using a single item and child illness was measured using a carer report of common childhood illnesses. A range of confounders, moderators and mediators were considered, including socio-demographic and household composition, psychosocial measures for carers and householders, community environment, and health-related behaviour and hygienic state of environment.Results Carer self-reported racism was significantly associated with child illness in this sample after adjusting for confounders (OR 1.65; 95% CI 1.09 to 2.48). Carer negative affect balance was identified as a significant mediator of this relationship. Householder self-reported racism was marginally significantly associated with child illness in this sample after adjusting for confounders (OR 1.43; 95% CI 0.94 to 2.18, p=0.09). Householder self-reported drug use was identified as a significant mediator of this relationship.Conclusions Consistent with evidence from adult populations and children from other ethnic minorities, this study found that vicarious racism is associated with poor health outcomes among an indigenous child population.

Chronic kidney disease (CKD) is important in the fields of public health and health geography because of its heavy burden on the health system and high cost of treatment in its advanced stages. The causes of CKD are associated with diabetes and hypertension, but in some parts of the world, the disease occurs in the absence of these factors. Researchers identify this condition as CKD of “unknown” causes (CKDu). CKDu is a multi-factored health problem and one suspected causal factor is contaminated drinking water. The disease occurs globally but is found in particularly high concentrations among people of certain ethnic and disadvantaged social groups living in very different locations around the world. CKD has become endemic in Western Australia where hospital admissions for Aboriginal people requiring renal dialysis or treatment for diabetes are much higher than for the general population. The possible proportions of CKDu cases among the CKD patients are unknown. This study examines the drinking water quality among communities such as these. Water chemistry analysis in these areas indicates that the nitrate and uranium content greatly exceed officially recommended levels. Most of these communities rely on raw groundwater to supply their domestic needs, and it is very likely that the people are unwittingly ingesting high levels of nitrates and uranium, probably including uranyl nitrates. Very few such remote communities have access to treated drinking water, and cost-effective water treatment systems are required to provide potable water at the local scale.

Background: Health system strengthening is needed to improve delivery of secondary prophylaxis against rheumatic heart disease. Methods and Results: We undertook a stepped-wedge, randomized trial in northern Australia. Five pairs of Indigenous community clinics entered the study at 3-month steps. Study phases comprised a 12 month baseline phase, 3 month transition phase, 12 month intensive phase and a 3- to 12-month maintenance phase. Clinics received a multicomponent intervention supporting activities to improve penicillin delivery, aligned with the chronic care model, with continuous quality-improvement feedback on adherence. The primary outcome was the proportion receiving ≥80% of scheduled penicillin injections. Secondary outcomes included “days at risk” of acute rheumatic fever recurrence related to late penicillin and acute rheumatic fever recurrence rates. Overall, 304 patients requiring prophylaxis were eligible. The proportion receiving ≥80% of scheduled injections during baseline was 141 of 304 (46%)—higher than anticipated. No effect attributable to the study was evident: in the intensive phase, 126 of 304 (41%) received ≥80% of scheduled injections (odds ratio compared with baseline: 0.78; 95% confidence interval, 0.54–1.11). There was modest improvement in the maintenance phase among high-adhering patients (43% received ≥90% of injections versus 30% [baseline] and 28% [intensive], P<0.001). Also, the proportion of days at risk in the whole cohort decreased in the maintenance phase (0.28 versus 0.32 [baseline] and 0.34 [intensive], P=0.001). Acute rheumatic fever recurrence rates did not differ between study sites during the intensive phase and the whole jurisdiction (3.0 versus 3.5 recurrences per 100 patient-years, P=0.65). Conclusions: This strategy did not improve adherence to rheumatic heart disease secondary prophylaxis within the study time frame. Longer term primary care strengthening strategies are needed.

Background: Rheumatic heart disease (RHD), caused by acute rheumatic fever (ARF), is a major health problem in Australian Aboriginal communities. Progress in controlling RHD requires improvements in the delivery of secondary prophylaxis, which comprises regular, long-term injections of penicillin for people with ARF/RHD. Methods/Design: This trial aims to improve uptake of secondary prophylaxis among Aboriginal people with ARF/RHD to reduce progression or worsening of RHD. This is a stepped-wedge, randomised trial in consenting communities in Australia’s Northern Territory. Pairs of randomly-chosen clinics from among those consenting enter the study at 3-monthly steps. The intervention to which clinics are randomised comprises a multi-faceted systems-based package, in which clinics are supported to develop and implement strategies to improve penicillin delivery, aligned with elements of the Chronic Care Model. Continuous quality improvement processes will be used, including 3-monthly feedback to clinic staff of adherence rates of their ARF/RHD clients. The primary outcome is the proportion of people with ARF/RHD receiving ≥80 % of scheduled penicillin injections over a minimum 12-month period. The sample size of 300 ARF/RHD clients across five community clusters will power the study to detect a 20 % increase in the proportion of individuals achieving this target, from a worrying low baseline of 20 %, to 40 %. Secondary outcomes pertaining to other measures of adherence will be assessed. Within the randomised trial design, a mixed-methods evaluation will be embedded to evaluate the efficiency, effectiveness, impact and relevance, sustainability, process and fidelity, and performance of the intervention. The evaluation will establish any causal link between outcomes and the intervention. The planned study duration is from 2013 to 2016. Discussion: Continuous quality improvement has a strong track record in Australia’s Northern Territory, and its use has resulted in modest benefits in a pilot, non-randomised ARF/RHD study. If successful, this new intervention using the Chronic Care Model as a scaffold and evaluated using a well-developed theory-based framework, will provide a practical and transferable approach to ARF/RHD control.

Introduction Education provides a key pathway to economic opportunities, health and wellbeing. Yet limited or no locally available secondary schooling in remote Queensland Aboriginal and Torres Strait Islander communities requires more than 500 Indigenous students to transition to boarding schools. We report baseline quantitative data from the pilot phase (2016) of a 5-year study to explore a multicomponent mentoring approach to increase resilience and wellbeing for these students. Materials and Methods An interrupted time series design is being applied to evaluate levels of change in students’ resilience and wellbeing. Surveys were collaboratively developed, with questions adapted from the Child and Youth Resilience Measure (CYRM-28), Kessler Psychological Distress Scale (K5), and questions which identified upstream risk factors for self-harm (De Leo, Sveticic et al. 2011). They were completed by 94 students from five randomly selected schools (2 primary and 3 secondary) and one remote community. Results Pre-transition, most primary school students reported high levels of resilience, but only a third reported moderate - high levels of psychological wellbeing. Secondary students attending a boarding school reported lower scores on resilience and psychosocial wellbeing measures. Students who transitioned back to community after being from boarding school reported a lower sense of connection to peers and family, and they reported even lower resilience and psychosocial wellbeing scores. Learning Outcomes Students have many strengths and can be adaptable, but their levels of resilience and psychosocial wellbeing are affected by the schooling transitions they are required to navigate. The findings are informing the development of intervention strategies to enhance student resilience and wellbeing.

Tobacco-related conditions contribute significantly to the health gap between Indigenous and non-Indigenous Australians. Smoking rates in Australia's Indigenous population has failed to decline even though smoking rates in Australia have declined in general. In some Indigenous communities, smoking rates remain very high. This paper outlines a project to investigate appropriate strategies to assist Indigenous smokers to quit and the important role nurses can play.

Background: The melanoma incidence and mortality rates in rural and remote communities are exponentially higher than in urban areas. Digital health could be used to close the urban/rural gap for melanoma and improve access to posttreatment and support care services. Objective: The aim of this review was to understand how digital health is currently used for melanoma posttreatment care and determine the benefits for Australian rural and remote areas. Methods: A systematic search of PubMed, Medline, PsycINFO, and Scopus was conducted in March 2018. Findings were clustered per type of intervention and related direct outcomes. Results: Five studies met the inclusion criteria, but none investigated the benefits of digital health for melanoma posttreatment care in rural and remote areas of Australia. Some empirical studies demonstrated consumers’ acceptance of digital intervention for posttreatment care. The findings did not take into consideration individual, psychological, and socioeconomic factors, even though studies show their significant impacts on melanoma quality of aftercare. Conclusions: Digital interventions may be used as an adjunct service by clinicians during melanoma posttreatment care, especially in regions that are less-resourced by practitioners and health infrastructure, such as rural and remote Australia. Technology could be used to reduce the disparity in melanoma incidence, mortality rates, and accessibility to posttreatment care management between urban and rural/remote populations.

ustainable Land Sector Development in Northern Australia sets out a vision for developing North Australia based on a culturally appropriate and ecologically sustainable land sector economy. This vision supports both Indigenous cultural responsibilities and aspirations, as well as enhancing enterprise opportunities for society as a whole. In the past, well-meaning if often misguided policy agendas have failed - and continue to fail - North Australians. This book helps breach that gap by acknowledging and harnessing Indigenous cultural strengths and knowledge systems for looking after the country and its people, as part of a smart, novel and diversified ecosystem services economy.

Background and objective: Poor lung function is a predictor of future all-cause mortality. In Australia, respiratory diseases are particularly prevalent among the Indigenous population, especially in remote communities. However, there are little published pulmonary function tests (PFT) data of remote-based adult Indigenous patients. We aimed to evaluate the severity of airflow obstruction and other PFT abnormalities of adults referred to specialist respiratory clinics in remote Indigenous communities. Methods: Retrospective analysis of PFTs [pre- and post-bronchodilator spirometry, total lung capacity (TLC) and diffusing capacity to carbon monoxide (DLCO)] of Indigenous patients collected during specialist respiratory clinics in remote Northern Territory (NT) Indigenous communities (Australia) between 2013-2015. The National Health and Nutrition Examination Survey (NHANES) III without ethnic correction was used as the reference. Results: Of the 357 patients, 150 had acceptable spirometry and 71 had acceptable DLCO and TLC studies. Despite the relatively young age (mean=49 years, SD=12.9) their lung function was generally low; mean % predicted values were FEV1=55%(SD=20.5%), FVC=61%(SD=15.6%), DLCO=64.0%(SD=19.7%), TLC=70.1%(SD=18.2%). Mean FEV1/FVC ratio was preserved (0.71, SD=0.16). Post-bronchodilator airflow obstruction (FEV1/FVC<0.7) was found in 37% of patients, where a large proportion (67%) demonstrated at least severe airflow obstruction with a mean FEV1 of 41% predicted. Conclusion: In this first study of PFT findings of Indigenous adults from a remote-based clinical service, we found a high rate of at least moderate airflow limitation and low FVC along with preserved FEV1/FVC ratio. Increased awareness and screening for reduced lung function needs to be considered in this population. This article is protected by copyright. All rights reserved.

Many Indigenous Australians hold cultural, ecological and language knowledge, but common representations of Indigenous Australians focus on social disadvantage and poor comparisons with other Australians in education, employment and health. Indigenous Land Management works with Indigenous people’s cultural, ecological and language expertise, employing Indigenous people in activities contributing to biodiversity conservation. The Interplay research surveyed 841 Indigenous people in remote communities. Those employed in land management reported greater participation in cultural activities, language knowledge, and belief that their land was looked after. These related assets provide an opportunity for policy approaches based on Indigenous people’s strengths and contribution to Australia.

Restrictions on the supply of alcohol are amongst the most effective and cost effective interventions to address harmful use. However, despite international human rights bodies recognising that self determination must be pre-eminent in efforts to improve Indigenous health, little is known about the role of Indigenous communities in designing and implementing alcohol controls as well as the degree to which government resourcing and/or regulation is utilised. This commentary explores Australian examples of the governance models used to ensure Indigenous participation and leadership when developing regulatory interventions for alcohol control within communities. We identify four models of Indigenous governance: alcohol control interventions that were community conceived and implemented, government-facilitated community-led, community coalitions backed by government intervention and government initiated community partnerships. Each model is underpinned by specific governance arrangements which incorporate rules and processes that determine authority, accountability and Indigenous participation in decision-making. The aim of this paper is to benchmark these models of governance along a spectrum of community engagement beginning with forms of non-participation and ending with full citizen control. In addition, we put forward recommendations for governments at all levels to facilitate culturally acceptable and robust models of Indigenous governance that have the potential to improve health and social outcomes.

Background: Education for health literacy of Australian Aboriginal people living remotely is challenging as their languages and worldviews are quite different from English language and Western worldviews. Becoming health literate depends on receiving comprehensible information in a culturally acceptable manner. Methods: The study objective was to facilitate oral health literacy through community education about scabies and strongyloidiasis, including their transmission and control, preceding an ivermectin mass drug administration (MDA) for these diseases. A discovery education approach where health concepts are connected to cultural knowledge in the local language was used. Aboriginal and non-Aboriginal educators worked collaboratively to produce an in-depth flip-chart of the relevant stories in the local language and to share them with clan elders and 27% of the population. Results: The community health education was well received. Feedback indicated that the stories were being discussed in the community and that the mode of transmission of strongyloidiasis was understood. Two-thirds of the population participated in the MDA. This study documents the principles and practice of a method of making important Western health knowledge comprehensible to Aboriginal people. This method would be applicable wherever language and culture of the people differ from language and culture of health professionals.

Key findings: - The study findings first and foremost demonstrate the extent to which sociocultural and economic circumstances influence all children’s early health, development and learning, and why it is essential that current efforts to improve school attendance and achievement also focus on addressing the known early determinants of these outcomes. - Findings highlight the extent to which children’s development and school learning are underpinned by their health status—particularly in early life and throughout childhood. - Addressing community-level factors, such as housing overcrowding, is likely to result in substantial improvements in school attendance, especially in very remote communities. - Improving levels of attendance at preschool offers one of the best immediately available strategies for improving the NT’s concerning rates of Aboriginal school attendance and achievement. - It is also evident that the initial benefits of preschool can easily ‘fade out’ unless they are reinforced by regular attendance and effective engagement with school learning in the early years of primary school. - The study findings are consistent with other research in identifying critical transition points in children’s school careers which are opportunities for leveraging better outcomes: a) From preschool to Year 1—especially for Aboriginal students through targeted additional learning and language support; and b) From Year 6 to Year 7—through middle school programs maintaining student engagement and retention in high school. - The overall findings strongly support the direction and potential benefits of the NT Government’s recent investment of $35.6 million over four years to implement a whole-of-government plan in collaboration with community organisations to improve early childhood services and the lives of Territorian children (Northern Territory Government 2018). They particularly validate the emphasis on developing a more integrated, place-based approach to the planning and delivery of universal and targeted services to young children and their families. - Finally, the study findings provide a baseline against which the NT Early Childhood Plan’s immediate and longer-term performance outcomes could be monitored using similar data linkage methods. Implications for future research: The study findings suggest the potential value of future research in the following areas: 1. Investigating reasons for the recent decreasing trend in Aboriginal and non-Aboriginal teenage pregnancy e.g. whether this is associated with increased uptake of contraception in this age group and/or other health and social factors. 2. Investigating the implications of the declining Aboriginal total fertility rate which by 2013 was approaching the population replacement rate of 2.1 live births to women in their reproductive years. 3. Conducting qualitative studies to inform the development and evaluation of preventive public health strategies to reduce the continuing high proportion of Aboriginal women in remote and very remote areas who report smoking during pregnancy. 4. Investigating whether there are homogenous subgroups of students who share similar patterns of attendance over the course of their school career using newly available analytical methods, e.g. trajectory analysis (Nagin et al. 2010) and latent class analysis (Thompson et al. 2017; Hancock et al. 2018). This would assist in the early identification and targeted support for students at increased risk of adverse school outcomes. 5. Undertaking mixed-methods research to investigate family, community and school factors which explain why some communities have better early childhood development (AEDC) outcomes than would be predicted on the basis of their socioeconomic status. 6. Qualitative research into the child, school and curriculum factors which optimise children’s engagement with school learning in the early years of primary school. This should also include a focus on the specific learning and school adjustment needs of boys.

In response to the statement made by ACARA in 2010 that 'Indigenous perspectives [...] will be written into the national curriculum to ensure that all young Australians have the opportunity to learn about, acknowledge and respect the history and culture of Aboriginal people and Torres Strait Islanders', Kevin Lowe and Tyson Yunkaporta published 'The inclusion of Aboriginal and Torres Strait Islander content in the Australian National Curriculum: A cultural, cognitive and socio-political evaluation'.