Development of the National Guide (methodology)

Governance of the NACCHO–RACGP partnership that developed the National Guide was provided by an Aboriginal and Torres Strait Islander-led Project Reference Group and Executive Group who guided implementation of the project. These groups included representatives of NACCHO and RACGP and nominated experts. Governance included oversight of cultural, clinical and project domains.

Formal review of the third edition of the National Guide was conducted to gather as much understanding as possible about the process of developing the guide, as well as usage and how the structure, content and modes of dissemination could be improved. This included:

• feedback from third edition authors on their experiences as authors (conducted soon after publication in 2018)
• an online survey in 2022 (distributed to RACGP members and all NACCHO affiliates and member services) primarily involving GPs and Aboriginal and Torres Strait Islander health workers and health practitioners seeking feedback and suggestions for improvements to the structure and content for the fourth edition
• input from the Project Reference Group, including review of existing topics and suggestions for new topics
• review of the third edition and consideration of possible new topics by the Executive Group based on all feedback and suggestions received since publication of the third edition.

The topics included in the fourth edition were finalised by the Project Reference Group, including some minor changes to existing topics (see What’s new in the fourth edition) and the addition of the following new topics:

• Health impacts of racism
• Healthy eating
• Sleep
• Vaping
• Preconception care
• Health impacts of climate change

Each topic, including the development of recommendations, was led by an author or by co-authors and ongoing liaison with the clinical lead. A commitment in the fourth edition was to increase Aboriginal and Torres Strait Islander authorship. The fourth edition has 16 Aboriginal and/or Torres Strait Islander authors in 21 of the 45 topics. Many topics are co-authored, often with combinations of clinicians and researchers. Among the clinicians, there is a range of disciplines including GPs, nurses, Aboriginal health practitioner, exercise physiologist, psychologist and some non-GP medical specialists.

The Executive Group identified several topics of particular cultural and/or other complexities that may affect the applicability, usefulness, cultural appropriateness and/or acceptability of the recommendations. An advisory group, all of whom were Aboriginal or Torres Strait Islander, was appointed for the racism topic to inform the scope of the evidence review and the recommendations developed.

Authors, particularly those with less experience in evidence review and writing, were given an option of having a more experienced clinician-researcher as an advisor.

In line with the commitment to increasing Aboriginal and Torres Strait Islander authorship, all Aboriginal and Torres Strait Islander GP members of the RACGP Aboriginal and Torres Strait Islander Health faculty were invited to complete an expression of interest (EOI) to author and indicate their topic(s) of interest. Previous authors and other suitable colleagues who were nominated by NACCHO, the Lowitja Institute (Executive Manager, Research and Knowledge Translation) or known to project team members were also invited to complete EOIs and/or discuss with the project team. Authors were selected and topics allocated by the clinical lead and project team based on relevant interest and experience.

Information webinars were promoted as part of the recruitment process and orientation webinars were run for appointed authors.

Topics were developed as per the structure shown in Box 1 .

The National Guide focuses on topics that are important for Aboriginal and Torres Strait Islander peoples where there is evidence for preventive activities that can be offered or supported in primary healthcare settings. In general, the focus is on primary prevention and early detection. Some topics include secondary prevention and occasionally tertiary prevention.

Interventions were included if they were considered effective, feasible to implement, acceptable to patients and communities, and likely to make a substantial contribution to health and wellbeing and/or reduce overall disease burden. A pragmatic approach was taken for each topic area to determine which secondary prevention activities should be included (recognising that components of active management of many chronic conditions constitute secondary prevention and may extend beyond the scope of the National Guide).

In this fourth edition, recommendations for preventive activities are presented in the five categories used in previous editions:¹

• Immunisation – the administration of vaccines to prevent infection and/or reduce the severity of infectious disease
• Screening – the systematic detection and management of risk factors or disease before symptoms develop
• Behavioural – activities that target the actions a person may take for the purpose of promoting or maintaining health (eg physical activity) or brief interventions by clinicians (eg to support smoking cessation or safe sex)
• Medications – to prevent a condition and/or prevent complications of existing disease (ie secondary prevention)
• Environmental - activities that could include:
  • managing environmental hazards (eg ensuring adequate ventilation when cooking with solid fuels)
  • community-based programs (eg improved food supply, school-based programs, study groups)
  • actions related to social determinants of health (eg advocacy for priority housing, advocacy to government stakeholders for local/regional liquor licencing regulations)

Authors were provided with a guide of factors to identify or consider in defining scope of the topic:

• Type of preventive activities in identified domains – immunisation, screening, behavioural, medication, environmental
• Activities actionable in primary healthcare settings (see below)
• Areas of uncertainty and variability in practice
• Applicability and generalisability to Aboriginal and Torres Strait Islander populations  and to primary healthcare  settings (see below)
• Important outcomes and priorities and other considerations, such as acceptability, feasibility, equity and resource use, whether or how cultural factors may inform a different approach
• Extent of secondary prevention to be included

Applicability to Aboriginal and Torres Strait Islander people

Applicability to Aboriginal and Torres Strait Islander people is considered with regard to:

• differences in prevalence of disease, health conditions and/or protective and risk factors that may influence the population benefits, acceptability, cost-effectiveness of the intervention and predictive value of screening tests
• sociocultural and/or environmental factors that may inform a different approach
• evidence on variation in the effectiveness and appropriateness of an intervention/approach across settings, including different geographical settings

If the evidence from other populations (indirect evidence) was considered not fit for purpose, this was identified. Specific evidence against generalising national and international recommendations to Aboriginal and Torres Strait Islander populations was necessary to determine when recommendations did not apply.

While recognising research and discussion about Aboriginal and Torres Strait Islander genomics is a growing field, recommendations based on a genetic predisposition to disease were considered ungeneralisable due to the wide heterogeneity of Aboriginal and Torres Strait Islander populations.² The consideration of individual predisposing risk factors, including family history was deemed relevant.

Applicability to primary healthcare

Recommendations are for preventive activities that can be provided in primary healthcare settings. Preventive interventions considered out of scope are those implemented outside the primary healthcare context. Examples include screening for tuberculosis, interventions to increase workforce participation and housing and education initiatives. However, where appropriate, recommendations to support an advocacy role in relation to broader determinants of health are included.

The clinical lead met with all authors/author groups to discuss and agree on the scope of each topic.

The evidence base for the National Guide is informed primarily by current national and international evidence-based guidelines (see Box 2). Where existing guidelines were considered insufficient for a particular topic area, systematic reviews and meta-analyses of primary research were reviewed. In the absence of these studies, or where the scope was considered insufficient, authors were instructed to review empirical research and other evidence (grey literature; see Box 3), and, particularly in the absence of direct or relevant indirect evidence, expert opinion. Whenever available, evidence and other literature regarding cultural factors, including acceptability, feasibility and implementation of recommendations, was included.

Authors were instructed to focus on publications from July 2017 (cut-off date for third edition of the National Guide) initially to August 2022. This date was extended as timelines for the completion of topics extended, particularly to include updated guidelines, such as:

• Recommendations for culturally safe and clinical kidney care for First Nations Australians³
• Clinical practice guidelines for the prevention, early detection and management of colorectal cancer^5,6
• lung cancer screening recommendations⁷
• recommendations for routine ear health and hearing checks for Aboriginal and Torres Strait Islander children⁸
• Australian guide for assessing and managing cardiovascular disease risk⁹
• National healthy skin guideline.¹⁰

Authors were instructed to examine the evidence, summarise existing recommendations and other evidence, critically appraise the source recommendations, assign the strength of recommendation and record relevant references. Further, a key purpose of the guide is the step appraising the suitability of existing recommendations for Aboriginal and Torres Strait Islander people. Based on previous experience, this is especially important for determining the optimal frequency of an intervention or the age from which to commence an intervention. For example, based on disease prevalence data, many preventive interventions are recommended to start at an earlier age in Aboriginal and Torres Strait Islander people than in the broader population.

The following questions were provided to authors to help with the assessment of a guideline or other recommendation:

• What are the most relevant primary and secondary preventive interventions to report on this topic?
• Are the benefits/harms clinically significant?
• What is the target population of the recommendation? Is the intervention applicable/generalisable to the Aboriginal and Torres Strait Islander population or are there significant differences (eg earlier age of commencing screening, such as calculating cardiovascular disease risk)?
• Are there parts of the topic that are specific or particularly relevant to Aboriginal and Torres Strait Islander populations?
• Are there choices and uncertainties that arise in this area in practice?
• Is the intervention relevant to primary healthcare?
• Do the interventions need to be adapted?
• Is there other evidence that should be included in developing recommendations?
• What else needs to be considered in developing and implementing recommendations?

Authors were instructed to present recommendations as per the reporting template, which includes the type of preventive activity, the target population, what to do, the timing or interval, the strength of recommendation, the type of key source(s) and a brief rationale (Table 1).

Table 1. Reporting template for recommendation.

The strength of recommendation was assigned by authors as ‘Strong’, ‘Conditional’ or ‘Good practice point’ (see Box 4). The strength was informed by the robustness and reliability of the source, the certainty of evidence as it applied to the target population and any other evidence about acceptability or fit, particularly with respect to cultural factors. For many interventions there is limited direct evidence from which to draw conclusions. Expert opinion is therefore also considered particularly important in interpreting the evidence and making judgements about recommendations, including the strength of recommendation, for Aboriginal and Torres Strait Islander populations.

Review of the strength of recommendation was part of the clinical editorial and expert review processes.

Key sources

The type of key source(s) is described, as well as the reference being provided, with the aim of providing greater transparency about what is informing the recommendations, particularly for a broader audience with widely varying academic experience (see Box 5).

One of the strengths of the National Guide is providing guidance for activities within the health service to support implementation of recommendations. Authors were instructed to include guidance on implementation, which is generally provided as either good practice points (eg recommendations about cultural safety and trauma-informed practice) or implementation tips (eg establishing recall and reminder systems, identifying indicators for clinical audit and continuous quality improvement activities, staff training and increasing participation in screening and other preventive health activities).

Authors submitted drafts to the clinical lead, who reviewed and provided suggestions for revisions. All topics were reviewed by the NACCHO senior medical advisor as advanced drafts. Topics were also reviewed by topic-specialist NACCHO teams where NACCHO had established program areas and expertise. These include child health topics, ear health, sexually transmissible infections and blood-borne viruses, acute rheumatic fever/rheumatic heart disease and all the mental health and cancer topics. An editorial team, comprising the clinical lead, NACCHO senior medical advisor, project lead and coordinator and RACGP Aboriginal and Torres Strait Islander health faculty medical advisor, reviewed all topics as a group.

All topics were sent to one or more independent expert reviewers, who were given a template to complete in which they were asked to comment on:

• consistency of recommendations with your knowledge of the evidence
• applicability of recommendations to Aboriginal and Torres Strait Islander peoples, including rationale for significant differences to existing general guidelines
• any key gaps in relation to primary prevention, screening/early detection and, where relevant, secondary prevention
• other recommendations to support knowledge translation and implementation (implementation tips)
• comments on key messages
• any other feedback you may have on this topic.

Reviewers were also invited to make specific suggestions and comments within the draft topics. All feedback was considered by the clinical lead, who liaised with authors. Relevant peak bodies were approached to review key messages and recommendations. Those that were able to provided feedback, which was considered by the clinical lead, who liaised as needed with authors. Most peak body organisations that provided feedback were asked to consider final drafts for their support and/or endorsement.

All authors, external reviewers, external peak body organisations and other contributors are listed in the Acknowledgments.

The RACGP Red Book and National Guide were updated simultaneously. Final drafts of both were compared to make sure of alignment or sound rationale for recommendations where there are differences. The final draft of the National Guide was reviewed by the RACGP Expert Committee – Quality Care (REC–QC).

The fourth edition of the NACCHO–RACGP National guide to preventive healthcare for Aboriginal and Torres Strait Islander people was funded through a grant from the Australian Government Department of Health and Aged Care, administered by the RACGP through a collaboration agreement with NACCHO. This work was also supported by a Memorandum of Understanding between NACCHO and the RACGP. The funding bodies were not involved in either the conception and design or in development of the content of the National Guide. The RACGP contracted the clinical lead, project lead and project coordinator. NACCHO appointed the clinical advisor to the project. All authors were signatories to a statement of works with the RACGP.

All authors made signed declarations of financial or other conflicts of interest. No financial or other relevant conflicts were identified. Authors received a modest payment. External reviewers and peak body organisations were not paid by the project. Their contribution is a vital part of the robustness of the National Guide and their generosity is greatly appreciated.

NACCHO owns the intellectual property rights to the National Guide and has granted the RACGP a license to use and publish the National Guide as a resource for all health professionals providing primary healthcare to Aboriginal and Torres Strait Islander people.