Roz Walker

Objective
To identify the barriers and facilitators for timely detection and optimal management of otitis media (OM) in Aboriginal children in a primary care setting from the perspective of Health Care Providers (HCPs).

Setting
A large regional town in the Kimberley region of Western Australia.

Participants
Thirty HCPs to Aboriginal children.

Design
A qualitative, aboriginal co-designed, participatory action research study with semi-structured interviews and focus groups.

Results
Barriers were identified throughout the child's presentation and management and included challenges with paediatric ear examinations, earwax obstructing the view of the tympanic membrane, unfamiliarity with diagnostic tools, multiple guidelines with varying recommendations, and confusion with accessing ENT specialists. Multiple facilitators were identified and included training HCPs in paediatric examination techniques and wax removal, a single best practice guideline, and system changes to facilitate access to ENT specialist support if required. Importantly, an expanded clinical role of Aboriginal Health Practitioners (AHPs) was identified to augment efficient and effective clinical OM assessment and management in children presenting to clinic.

Conclusions
All barriers could potentially be overcome through a programme that enhances theoretical knowledge and practical skills in paediatric ear examination, otoscopy, and safe, timely removal of earwax, improved communication with ENT specialists, and an expanded clinical role for AHPs. Our findings carry important implications for managing OM in primary care services across Australia.

Aboriginal pregnant women and new mothers face an increased risk of mental health issues, often stemming from historical trauma, including violence and discrimination. These challenges could contribute to complex trauma and adverse perinatal outcomes, highlighting the need for culturally sensitive care. However, non-Aboriginal clinicians often face barriers due to limited cultural knowledge, exacerbated by other factors such as time constraints for training and reliance on one-time training. Large Language Models (LLMs)-based chatbots offer the potential to support self-directed learning and enhance clinicians' self-efficacy through interactive question and answer. However, LLMs also pose challenges, including hallucinatory responses, outdated knowledge, fictitious information, unverifiable references, and difficulty handling domain-specific queries. In this study, we aim to mitigate these challenges by developing a specialized chatbot for improving Aboriginal perinatal mental health question-answering. The chatbot integrates Retrieval-Augmented Generation (RAG) with a semantic search engine, enabling it to retrieve verified external knowledge and provide more accurate, contextually relevant responses without frequent retraining. We evaluate its performance against a baseline GPT-3.5-turbo model and compare LLMs integrated with different RAG techniques to assess improvements in accuracy and reliability. Clinical Relevance- This study shows the potential of the specialized RAG LLM-based chatbot to improve domain-specific, clinically relevant, and on-demand question-answering support for clinicians. By providing accurate, verified information through interactive responses, it may help bridge knowledge gaps, support self-directed learning, and complement existing training.

Background
During pregnancy, childbirth and postnatally, women are at their most vulnerable, requiring health and social care systems able to meet their needs. In the context of perinatal care, assessing Aboriginal women’s mental health requires consideration of their whole-of-life to establish their overall social and emotional wellbeing. This requires mechanisms which respect women’s cultural positioning and needs. In the Australian health care system, Aboriginal women’s mental health is routinely viewed through mainstream screening and assessment tools, such as the Edinburgh Postnatal Depression Scale which does not address cultural strengths or the protective nature of being connected to culture. In the face of significant structural inequities, including in perinatal care, Aboriginal women are frequently marginalized which contributes to their disengagement from services. Despite this, women’s resilience remains evident and understanding why may hold the key to better perinatal care planning. As such, the aim of this study was to explore Aboriginal women’s resilience, self-efficacy and empowerment during their perinatal experiences, assessing factors contributing to their cultural strengths when addressing perinatal mental health concerns.

Methods
Situated in a larger pilot implementation project, this qualitative study used an Aboriginal Participatory Action Research method and was undertaken on Whadjuk Country, Boorloo (Perth Western Australia). Aboriginal women (n = 8) were invited to participate in yarns with the study’s lead Aboriginal researcher. Data was inductively and deductively analyzed, with findings interpreted through a decolonizing framework which prioritized strengths and cultural ways of being.

Results
Six themes were identified from analysis of the qualitative data: (1) strengthening identity-reconnecting to Culture; (2) connection to kinship/family sub-theme, strong partner support; (3) connection to country; (4) connection to culture; (5) resilience and self-efficacy; and (6) women’s experiences using the Baby Coming You Ready program’s digital platform. Themes 1–5 clearly demonstrated women’s strengths and resilience which were reported as a direct result of their culture and cultural connections; while theme 6 reported their positive experiences of using a strengths-based and culturally developed perinatal assessment platform.

Conclusion
The results of this study confirm the positive benefits and value of co-designing tools for use in clinical settings which incorporate the cultural determinants of health and holistic perspectives of social and emotional wellbeing when screening Aboriginal women’s perinatal mental health.

Purpose
Aboriginal and Torres Strait Islander leaders are establishing new research methodologies that are grounded in cultural ways of knowing, being and doing. This paper weaves together Indigenous standpoint theory, yarning and consensus modelling to 1) develop a novel Indigenous consensus methodology and 2) outline the application of this methodology in co-designing an Aboriginal and Torres Strait Islander systems approach to suicide prevention.

Methods
Members from an expert advisory group were invited to participate in this study, which involved a co-design phase grounded in an Aboriginal participatory action research approach. The expert advisory group informed the consensus process, which involved the completion of a survey followed by a consensus yarn. The group of 15 yarned until there was consensus regarding items that were important in an Aboriginal and Torres Strait Islander systems approach to suicide prevention.

Main findings and principal conclusions
Group consensus was reached on 134 statements. This study demonstrates how the Indigenist consensus methodology, grounded in the principles of bricolage (i.e. deliberate mixing of qualitative methods), offers a transformative lens to designing more culturally responsive ways of strengthening Aboriginal and Torres Strait Islander social and emotional wellbeing and preventing suicide.

Background:
Perinatal depression and anxiety significantly impact maternal and infant health, potentially leading to severe outcomes like preterm birth and suicide. Aboriginal women, despite their resilience, face elevated risks due to the long-term effects of colonization and cultural disruption. The Baby Coming You Ready (BCYR) model of care, centered on a digitized, holistic, strengths-based assessment, was co-designed to address these challenges. The successful BCYR pilot demonstrated its ability to replace traditional risk-based screens. However, some health professionals still overrely on psychological risk scores, often overlooking the contextual circumstances of Aboriginal mothers, their cultural strengths, and mitigating protective factors. This highlights the need for new tools to improve clinical decision-making.

Objective:
We explored different explainable artificial intelligence (XAI)–powered machine learning techniques for developing culturally informed, strengths-based predictive modeling of perinatal psychological distress among Aboriginal mothers. The model identifies and evaluates influential protective and risk factors while offering transparent explanations for AI-driven decisions.

Methods:
We used deidentified data from 293 Aboriginal mothers who participated in the BCYR program between September 2021 and June 2023 at 6 health care services in Perth and regional Western Australia. The original dataset includes variables spanning cultural strengths, protective factors, life events, worries, relationships, childhood experiences, family and domestic violence, and substance use. After applying feature selection and expert input, 20 variables were chosen as predictors. The Kessler-5 scale was used as an indicator of perinatal psychological distress. Several machine learning models, including random forest (RF), CatBoost (CB), light gradient-boosting machine (LightGBM), extreme gradient boosting (XGBoost), k-nearest neighbor (KNN), support vector machine (SVM), and explainable boosting machine (EBM), were developed and compared for predictive performance. To make the black-box model interpretable, post hoc explanation techniques including Shapley additive explanations and local interpretable model-agnostic explanations were applied.

Results:
The EBM outperformed other models (accuracy=0.849, 95% CI 0.8170-0.8814; F1-score=0.771, 95% CI 0.7169-0.8245; area under the curve=0.821, 95% CI 0.7829-0.8593) followed by RF (accuracy=0.829, 95% CI 0.7960-0.8617; F1-score=0.736, 95% CI 0.6859-0.7851; area under the curve=0.795, 95% CI 0.7581-0.8318). Explanations from EBM, Shapley additive explanations, and local interpretable model-agnostic explanations identified consistent patterns of key influential factors, including questions related to “Feeling Lonely,” “Blaming Herself,” “Makes Family Proud,” “Life Not Worth Living,” and “Managing Day-to-Day.” At the individual level, where responses are highly personal, these XAI techniques provided case-specific insights through visual representations, distinguishing between protective and risk factors and illustrating their impact on predictions.

Conclusions:
This study shows the potential of XAI-driven models to predict psychological distress in Aboriginal mothers and provide clear, human-interpretable explanations of how important factors interact and influence outcomes. These models may help health professionals make more informed, non-biased decisions in Aboriginal perinatal mental health screenings.

Context
Comprehensive Primary Health Care (CPHC) is an interconnected, holistic, and strengths-based health and wellbeing approach fundamental to Aboriginal Community Controlled Health Organisations (ACCHOs) in Australia. However, policy and funding trends increasingly threaten the capacity of ACCHOs to deliver CPHC by imposing burdensome administrative and accountability requirements. A central constraint is the marginalisation of culturally informed data measures and tools that could enable improved development, implementation, evaluation and reporting of CHPC services and programs. To mitigate this, ACCHOs must be enabled to take charge of collecting and using meaningful data to increase self-determination and drive impactful policy and service delivery. Central to this approach is the capacity, skills, and infrastructure to collect and use culturally informed data and tools that align with community needs and organisational imperatives.

Materials and methods
This project will undertake an Aboriginal participatory action research (APAR) mixed methods developmental evaluation approach to Aboriginal Data Sovereignty (ADS) initiatives. The project will be conducted both centrally and across the regional sites of the South West Aboriginal Medical Service (SWAMS), an ACCHO in regional Western Australia. Activities to initiate the APAR process include the development and training of a Community Research Panel to lead/facilitate APAR projects. A series of regional workshops will be held to build data literacy (including regional population health data) and identify innovative culturally-informed health and wellbeing data measures and tools for selected health priorities. Project team Aboriginal academic researchers and Aboriginal researchers at SWAMS will ensure the inclusion of Aboriginal research methods (Aboriginal ways of knowing, being and doing). Data collection will include both quantitative and qualitative data which will be analysed to identify the enabling processes and community and organisational outcomes as they align to the principles of ADS.

Discussion and next steps
The protocol herein describes the first phase of a two-phase project, where the second phase will implement the new and/or adapted data measures and tools established in phase one of the project. This project will build capacity towards evidence-based decision making by ACCHOs and support self-determination by enabling local, real-time evaluation of the integrated models of care that ACCHOs deliver.

Access to high-quality, culturally responsive nutrition advice during pregnancy is necessary for optimal health outcomes for mothers and babies. Evidence indicates that age, education and access to trained healthcare practitioners have a positive correlation with healthy food intake and positive outcomes. There are limited studies that discuss the importance of providing culturally responsive nutrition advice to pregnant Indigenous women. Therefore, this paper investigates the sources from which Indigenous women access nutrition information, assesses its adequacy in meeting needs, and identifies the effective ways to deliver this information. This study took place in Queensland (QLD), New South Wales (NSW), and Western Australia (WA), which were chosen to represent diverse cultural communities. A total of 103 participants were recruited, including Indigenous women and healthcare practitioners. Focus groups were audio-recorded, transcribed and analysed. Participants indicated that pregnant women are highly interested in improving their nutrition knowledge during pregnancy and actively seek information from their healthcare practitioners and dietitians. Findings suggested dissatisfaction with the information received, as it failed to address their needs. Results of this paper call for an urgent increased presence of community dietitians in antenatal clinics dedicated to Indigenous pregnant women as an additional way to provide families with the information they need for healthy pregnancies.

Background:
Effective mental health primary prevention and early detection strategies targeting perinatal mental healthcare settings are vital. Poor maternal mental health places the developing foetus at risk of lasting cognitive, developmental, behavioural, physical, and mental health problems. Indigenous women endure unacceptably poor mental health compared to all other Australians and disproportionately poorer maternal and infant health outcomes. Mounting evidence demonstrates that screening practices with Indigenous women are neither effective nor acceptable. Improved understanding of their perinatal experiences is necessary for optimizing successful screening and early intervention. Achieving this depends on adopting culturally safe research methodologies.

Methodology:
Decolonizing translational research methodologies are described. Perspectives of Australian Indigenous peoples were centred on leadership in decision-making throughout the study. This included designing the research structure, actively participating throughout implementation, and devising solutions. Methods included community participatory action research, codesign, and yarning with data analysis applied through the cultural lenses of Indigenous investigators to inform culturally meaningful outcomes.

Discussion:
The Indigenous community leadership and control, maintained throughout this research, have been critical. Allowing time for extensive community collaboration, fostering mutual trust, establishing strong engagement with all stakeholders and genuine power sharing has been integral to successfully translating research outcomes into practice. The codesign process ensured that innovative strengths-based solutions addressed the identified screening barriers. This process resulted in culturally sound web-based perinatal mental health and well-being assessment with embedded potential for widespread cultural adaptability.

Aboriginal and Torres Strait Islander ways of knowing, being and doing have fostered physical, social, and emotional wellbeing for millenia, forming a foundation of strength and resilience. However, colonisation, systemic violence and discrimination—including the forced removal of Aboriginal and Torres Strait Islander children, which continues today—have disrupted this foundation, leading to compounding cycles of intergenerational and complex trauma. The enduring impact of intergenerational and complex trauma is exemplified in increasing proportions of Aboriginal and Torres Strait Islander children being removed from their families and involved in the child protection and youth justice system—which represents a national crisis. Despite this crisis, the national response remains insufficient. To address these urgent issues, over 200 predominantly Aboriginal and Torres Strait Islander stakeholders, participated in Gathering the Seeds Symposium, the inaugural meeting for the Replanting the Birthing Trees project held in Perth in April 2023. This meeting marked the beginning of a public dialogue aimed at Closing the Gap by advancing community-led strategies to break cycles of trauma and foster cycles of nurturing, recovery, and wellbeing for Aboriginal and Torres Strait Islander parents and children across the first 2000 days. We outline critical shortcomings in the current child protection and youth justice systems, and the urgent need for child wellbeing reform. Importantly we highlight recommendations made in submissions in 2023 to two key Australian inquiries—the National Early Years Strategy and the Human Rights Commission inquiry into out of home care and youth justice systems. We argue that structural reforms and culturally safe and skillful care for parents experiencing trauma and violence is a serious gap, and a national priority. The first 2000 days represents a critical window of opportunity to transform cycles of trauma into cycles of healing. It is time to ‘replant the birthing trees’ and ensure that all Aboriginal and Torres Strait Islander babies and families can have the best possible start to life through comprehensive models of care grounded in recognition of the right to self-determination and culture.

Introduction
Reflexivity is crucial for researchers and health professionals working within Aboriginal health. Reflexivity provides a tool for non-Aboriginal researchers to contribute to the broader intention of reframing historical academic positivist paradigms into Indigenous research methodologies (IRM) to privilege Aboriginal voices in knowledge construction and decision-making. This practice requires researchers to transition from safe and familiar research environments into unfamiliar and uncomfortable spaces. This uncomfortable space is often referred to as the ‘third space’—the ‘in-between’ space that can be turbulent and difficult to navigate. However, it is also a productive space where new collaborations are created, and ideas can emerge. This manuscript provides reflections from a cross-cultural team working on a transdisciplinary healthy skin program—the See, Treat, Prevent (SToP) Trial in Aboriginal communities in the Kimberley region of Western Australia (WA). Cultural mentors guided our team to work in an Oombarl Oombarl (steady steady) way to navigate the cultural interface between familiar biomedical elements and unknown health promotion activities. Our third space was the intangible space in-between the S, T and P of the SToP Trial.

Methods
Narratives were collected through semi-structured interviews and yarning sessions. All participants provided written consent for audio recording; in one instance, consent was provided to record graphically. A thematic analysis aligning with the question guide was conducted.

Findings
Reflections include team members' experiences of learning the Oombarl Oombarl way, individually and collectively. Initially, most team members revealed it was challenging to work in an Oombarl Oombarl way, having to move out of the safe, familiar research environment into the unknown community-led health promotion space. This in-between space became our third space—the uncomfortable space where we relinquished ‘control’ of research agendas and learnt to work to the rhythm of Aboriginal communities in WA's Kimberley region.

Conclusion
Reflexivity is necessary when working in a cross-cultural context. In Aboriginal homeland communities situated in remote settings, researchers benefit from being ‘on the ground’ to enable trust and genuine relationships to be developed. Visits on Country provide a rich experiential learning experience and a space for story sharing and yarning. Cultural guidance and two-way learning partnerships with cultural mentors assist non-Aboriginal researchers in understanding and adhering to cultural protocols and community processes. Allowing sufficient time to build relationships and flexible timelines are important considerations when developing research grants and protocols.

So What?
Our findings demonstrate the importance of building genuine relationships and yarning on Country with Aboriginal communities to build health promotion knowledge together. Making meaning of health literacy can only evolve through two-way learning partnerships where Aboriginal people guide the process. Our research reveals a novel approach to developing meaningful health promotion initiatives and resources on Country that centralise local Aboriginal language, artwork and community context.