Blending Western and Australian Aboriginal Approaches: A Study Protocol for Codesign of Bicultural Teleoncology Models of Care in Remote Australian Communities

Abstract

Cancer treatments have failed to reach people who live in rural and remote Australia. Geographic constraints on service delivery are exacerbated for Aboriginal and Torres Strait Islander peoples who continue to be marginalised by a colonial legacy that drives disparities in access to healthcare. This is particularly evident in the remote communities of Bourke and Brewarrina which are home to significant Aboriginal populations. They are located 100 km apart and 400 km from the nearest cancer centre. We aim to codesign bicultural models of care to deliver a bespoke cancer service, enabling administration of low and medium risk chemotherapies via teleoncology in two remote Australian communities. Aboriginal philosophy and pedagogy will be used with Community-Led participatory research methods. Maximum variation and snowball sampling will ensure diversity of participants in the codesign. Up to 100 participants will contribute, with multiple data collection events held in each monthly data collection cycle. Data will be collected in individual or small group yarning style sessions and recorded on a visual template. Framework analysis will be used to map each round of data collection to consolidate visual models of cancer care for each town. This incremental data collection involves participants in cycles of analysis and interpretation. Both communities have study-specific Research Governance Groups with representation from Aboriginal and non-Aboriginal community members to guide investigators. This study approaches codesign by following Aboriginal cultural protocols. Ethical (axiology) and relational (ontological) processes precede intellectual (epistemology) and operational (methodology) processes. A direct outcome of this research will be provision of teleoncology aligned with the models in each community supported by the nearest regional cancer centre (Western Cancer Centre Dubbo). Another novel aspect is use of the Australian Bicultural Model of care which was first described in an alcohol treatment context and is tested here for transferability to other settings.

Keywords

Indigenous First Nations oncology two worlds community-led research

Background and Study Justification

Cancer is never a ‘good’ diagnosis. Cancer is a leading cause of death in 57 countries across the world including Australia (Bray et al., 2021) where it now accounts for 18% of the burden of illness (Australian Institute of Health and Welfare, 2021). There are additional stressors for people in rural and remote areas when diagnosed with cancer. Access to treatment requires extensive travel to regional or metropolitan centres, creating financial and emotional stresses in populations already experiencing social inequity (Australian Institute of Health and Welfare, 2021; National Rural Health Alliance, 2012; Pye et al., 2022). The combination of these factors is reported to result in rates of cancer incidence and mortality which are not equitably distributed across the Australian population. Aboriginal and Torres Strait Islander peoples (Indigenous Australians) and those in remote areas, have higher incidence and higher mortality from cancer. Poorer cancer outcomes also increase with remoteness (Australian Institute of Health and Welfare, 2021).

Aboriginal and Torres Strait Islander peoples have lived in Australia for at least 60,000 years. In north-western New South Wales, where this study is set, people prefer to be described as Aboriginal and this term is used hereafter. Brewarrina is located on the traditional homelands of the Ngemba people and has a long history as central place for cultural ceremony and trading for Muruwari, Gamilaroi, Wailwan, Barkinji, Yuwallaraay Wiradjuri and Wongaibon people (Steadman, 2023). These gatherings have taken place at stone fish traps which have drawn people together for at least 40,000 years and are thought to be the oldest manmade structures in the world (Steadman, 2023). Brewarrina and Bourke are 100 kms apart located on the Baaka River (also known as the Barwon River in Brewarrina and the Darling River in Bourke). The river is an important source of spiritual connection to the Country (traditional homelands of the local Aboriginal peoples). The town of Bourke has Barkinji Country to the west and Ngemba Country to the east and is now home to Aboriginal people from 21 diverse Nations (Canty, 2023). Colonisation resulted in forced relocation of people from many other Aboriginal Nations from thousands of kilometres away (now the states of Victoria, South Australia and Queensland) to Ngemba Country (Steadman, 2023). In Aboriginal culture, traditional custodians or owners have the responsibility of caring for land, people, animals and stories. Dispossession has disrupted cultural practices and caused significant spiritual harm. Despite this, Aboriginal people have maintained their presence in these communities (31.5% of the population in Bourke (Australian Bureau of Statistics, 2016a) and 64.6% of the population in Brewarrina (Australian Bureau of Statistics, 2016b) are Aboriginal or Torres Strait Islander) and have helped shape the unique cultures and qualities of each town. People still come together for cultural ceremony and to look after one another in each of these towns. These unique qualities are widely seen as a strength and provide a foundation on which to codesign improved models of healthcare.

People living in the very remote towns of Bourke and Brewarrina (population 2634 and 1143 people respectively (Australian Bureau of Statistics, 2016a; 2016b)) in north western New South Wales (NSW) currently travel an 800 km round trip to receive cancer treatments. Access to chemotherapy treatments has recently been estimated and compared to treatment incidence in the nearest regional centre. Chemotherapy treatment incidence has been found to be 25.5 per 10,000 residents for people in Bourke and Brewarrina compared to 36.9 per 10,000 residents in Dubbo (p = .0263, OR 0.689, 95% CI 0.495–0.956) (Jones et al., 2022). Using these figures, if cancer incidence were similar between these populations, in the five years 2017–2021, an additional 17 people including five Aboriginal people would have accessed chemotherapy treatments. These estimates are likely to be conservative as official population data is thought to substantially underestimate counts of Aboriginal people as a result of ongoing mistrust of government and stated reasons for collecting personal data.

Access to healthcare is described as achieving best fit between services and populations (Levesque et al., 2013). In Australia, specialist cancer treatment services are funded by the state government, referred to as ‘mainstream’ services as they are provided to all residents, with few, if any, customisations for Aboriginal peoples. Like First Nations peoples worldwide, Australian Aboriginal peoples can face challenges accessing mainstream healthcare due to cultural differences, racism (Amery, 2017; Kelaher et al., 2014; Larson et al., 2007) and a colonial legacy of institutional harm such as the forced removal of children in hospital settings (Canty, 2023). Research with cultural integrity has been undertaken with Aboriginal peoples to improve access to cancer care in Aboriginal Community Controlled Health Services (general practice), however these settings are specifically designed to accommodate local Aboriginal community needs (Ivers et al., 2019, 2023; Trees et al., 2022). Research with Aboriginal peoples to improve access to mainstream specialist cancer treatments is yet to be undertaken.

Teleoncology has been used in other remote areas in Australia to minimise access barriers to cancer treatments and reduce the overall burden on patients (Chan et al., 2015; Sabesan, 2015; Taylor et al., 2018; Whop et al., 2012). Current teleoncology services in western NSW are delivered by Remote Video Assisted Chemotherapy (RVAC) from a regional cancer centre (Dubbo) to small outlying hospitals where it has also found to be a safe and effective way to deliver low and medium risk chemotherapy (Honeyball, 2018; Jhaveri et al., 2016). When the RVAC service was established in the small town of Coonabarabran in 2017, it resulted in the tripling of referrals for people living within 100 kms of the town (Howpage et al., 2018). Various models of teleoncology have demonstrated broad applicability and high levels of patient satisfaction in cancer patients from a range of demographic backgrounds (Hamilton et al., 2019; Pye et al., 2022). Enhanced focus should be placed on designing culturally appropriate models of care due to the proportion of Aboriginal people living in remote areas (Hamilton et al., 2019; Pye et al., 2022). The challenge remains that models of care need to be provided by mainstream health services, and to all people with cancer.

Research has a colonial history, where western research ideology and methodology have been used to justify colonising practices and oppress Aboriginal peoples (Riley, 2021; Sherwood, 2013; Smith, 2021). Therefore, our research needs to rise to two challenges. Firstly, the research methodology needs to consider Aboriginal approaches (but not alienate non-Aboriginal people) and secondly, produce models of care that can be provided by mainstream services to treat all people with cancer. In Canada this approach is known as ‘two-eyed seeing’- with one eye each on First Nations and western approaches (Bartlett et al., 2012; Marsh et al., 2015; Quinn, 2022). This blended approach has its challenges (Lavallée, 2009) but has successfully been applied to health services and programs (Marsh et al., 2015). The blending or bringing together of Australian Aboriginal and western approaches has also occurred in healthcare in Australia (Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women’s Council, 2017). However, this bi-cultural approach is not yet well established in research as academia has been slower to embrace Aboriginal ways of knowing, being and doing. In bringing Aboriginal and western approaches together to create a model of cancer care, our research represents an exciting progression of research methodology and praxis.

Summary of Consultation/Pilot Work in Developing the Proposal

Aboriginal cultural protocols determined the way this study has been designed (more about this in explanation and justification of method). Investigators were introduced to key people in both Bourke (n = 10) and Brewarrina (n = 6) so that cultural protocols could be prioritised. We described our interests with community representatives and invited discussion about the RVAC service. Support for RVAC was unequivocal and there was strong support for the Australian Bicultural Model (Purcell-Khodr et al., 2022) and local research governance structures. Community discussions also involved proposed methodology and methods. Community members’ suggestions from these consultations were integrated into the protocol. These changes included monthly data collection sessions extending over at least six months and the ability for participants to contribute to iterations of the models of care. Visual data collection methods (see Supplemental material) consisting of written summaries made during data collection sessions were preferred over audio recordings. This consultation occurred in May 2021.

Study Aims

This study aims to codesign models of care with community members and healthcare professionals to deliver cancer treatments to people in Bourke and Brewarrina.

Specifically, the research aims are to:

1. Follow cultural protocols to engage in conversations about important bicultural aspects of cancer treatments for each community.

2. Using an Australian Bicultural Model as a framework (Purcell-Khodr et al., 2022), identify and document existing community and service strengths.

3. Describe tailored bicultural models of care for Bourke and Brewarrina.

4. Identify work and training required to commence delivery of cancer treatments.

The primary outcome of this study is the development of bicultural models of care to deliver low and moderate risk cancer treatments to people who live within 100 kms of Bourke and Brewarrina. The Western New South Wales Local Health District (WNSWLHD) Western Cancer Centre Dubbo will then train staff and deliver cancer treatments in line with these models as an ongoing part of their service. The anticipated long-term benefit of this study is the doubling of access to cancer treatments for people in Bourke and Brewarrina, therefore improving cancer outcomes for people who live in these remote and unique locations.

Explanation and Justification of Method

Theoretical Positioning and Methodological Approach

Our research will be underpinned by Aboriginal ways of knowing (epistemology), being (ontology) and doing (methodology and methods). We will be informed by Aboriginal philosophies, processes (McPhail-Bell et al., 2018; NSW Department of Education, 2019; NSW Department of Education and Communities. Regional Aboriginal Education Team Western Area, 2012; Yunkaporta, 2009, 2019) and Community-Led research approaches (Webster et al., 2021). These approaches bring ethical (axiology) and relational (ontology) processes forward so that they precede and inform epistemology, methodology and methods (Webster et al., 2021). Community introductions, relationship building and consultation in the protocol development stage, are ways we have put ethical and relational processes first. These discussions included how research strengthens relationships between people and clarified responsibilities for those involved to both share knowledge and learn from others. Discussion is ongoing to ensure community members (Aboriginal and non-Aboriginal) benefit from the research process and resulting models of care. At a minimum our research process involves (but not limited to): research skill development, employment and inclusion of participants as research investigators, facilitating community data analysis and interpretation (National Health and Medical Research Council, 2018) and overall control of data.

Relational responsibility (prioritising people and relationships) is also at the heart of 8 Aboriginal Ways of Learning (8 Ways). 8 Ways is an Aboriginal pedagogy which emphasises teaching based on Aboriginal cultural perspectives and mechanisms for learning including story sharing, learning maps, non-verbal communication, symbols and images, land links, non-linear thinking, deconstruction/reconstruction of concepts, and community links (see Figure 1). A key tenet of 8 Ways is that Aboriginal perspectives are found in the process rather than the content, so applying these philosophies is more about ‘how’ we develop the model (NSW Department of Education, 2019). 8 Ways has recently been introduced to mainstream health services, which demonstrates potential to increase Aboriginal people’s access to health services by contributing to a better fit between service and client (Webster et al., 2022).

Figure 1.

Symbolic representation of 8 Aboriginal Ways of Learning (modified and reproduced with permission (Yunkaporta, 2009).

Our model of care will be derived from the Australian Bicultural Model of care. This model was originally developed to describe alcohol care delivered by Australian First Nations health workers in Aboriginal Community Controlled Health Services (Purcell-Khodr et al., 2022).

The Australian Bicultural Model of alcohol care proposes three levels to providing care: Level 1 refers to the requirement for therapeutic alliance between patient and clinician founded on relational responsibility. Level 2 describes treatments and healing available to the patient, which include both western (medicines and counselling approaches) and cultural (e.g., support groups for men and women, yarning circles, or smoking ceremonies) aspects. Level 3 describes the policies and structures needed by the organisation to deliver the treatment and healing described at Level 2. Whilst each level of care is important, they are connected and often dependent (Purcell-Khodr et al., 2022).

To undertake a study with Aboriginal ways of valuing, being, knowing and doing at the forefront, Aboriginal leadership in the research process is paramount. Six of the eight authors are Aboriginal people. They hold and share knowledge in 8 Ways (AH, YH, CS), Bicultural models of care (GP-K), Aboriginal Community-Controlled primary care (KW) and research (GP-K, BT, AH, YH, CS, KW).

Methods

Sampling and Recruitment

The study population are men and women 16 years or older who live or work within 100 kms of Bourke and Brewarrina. A combination of maximum variation and snowball sampling will be used to ensure diversity of participants. Achieving a diverse sample is important as the models of cancer care need to work for Aboriginal and non-Aboriginal residents and suit the skill mix of local health services. A matrix will be prepared with guidance from the Research Governance Group to ensure relevant diversity is achieved for each community (see example in Table 1). Snowball sampling encourages participants to nominate other people (Morgan, 2008). The sample size is difficult to estimate but is likely to be between 35 and 50 people at each site. Both maximum variation sampling and snowball sampling are considered purposive sampling techniques (Palinkas et al., 2015; Patton, 2002).

Table 1.

Example of Maximum Variation Sampling Matrix.

	Community members	Health services or community	Total
Aboriginal	M F	M F	M F
Non-aboriginal	M F	M F	M F
Total	M F	M F	M F

Participants will be recruited through community advertisement and by word-of-mouth. Researchers will attend whenever invited to meet with potential participants and explain the research and what participation involves. This is expected, and may happen more than once to build trust with researchers and is an important component of relational responsibility (Webster et al., 2017). In addition, health workers will be recruited by email invitation sent to an appropriate manager to be circulated to staff (this might include, but not be limited to: Aboriginal health workers, nurses, pharmacists, general practitioners, other allied health, and cancer specialists). Up to three email reminders will be offered.

A verbal explanation of the study, including what participation involves and what consent means, will be given in addition to the participation information statement and before signed consent is obtained or audio recorded if by zoom. Participants will be made aware of the need for researchers to keep the signed consent form or audio recording of consent (which will identify who took part in the study) on the participant information sheet (PIS). Each data collection event might include one or more participants. The researcher will explain that while the information given will remain de-identified in future descriptions of the model, group members present will know who is involved in the research. Participants will be asked not to share the details other people have contributed to the model. This reminder about confidentiality in group settings is outlined in the PIS.

Participants will be able to contribute data on one or on multiple occasions. Consenting to the study will cover all data collection events. Food and a gratuity (T-shirt) for participation will be offered for in-person data collection. For zoom data collection the shirt will be posted or dropped at an agreed location for collection. The T-shirt depicts an Aboriginal carved tree design by Wiradjuri artist Cara Shields and is valued at $35 (AUD) each.

At the conclusion of each data collection event the researcher will ask “who else do we need to be talking to?” to prompt snowball sampling. We will not record the names or contact details of the people recommended but will ask that a PIS be passed on to the nominated party to make direct contact with the research team.

Exclusions

Participants who attend interviews and are distressed, unwell, or who have insufficient English to participate in an interview will be excluded.

Withdrawals

Participants can withdraw from the study for any reason by emailing or phoning the principal coordinating investigator. Participants will be made aware of how to withdraw in the PIS. Any information already collected prior to the date of withdrawal will be kept and may be included in the study results. The reason for this is that anonymised data is impossible to re-identify for withdrawal. Participants will be made aware of this in the PIS. Any withdrawals will be added to a withdrawal log.

Data Collection

Each data collection event involves in-person yarning discussion, with one or more people (Bessarab & Ng’andu, 2010). The Australian Bicultural Model of care (Figure 2) will be used as a visual data collection tool (with text written on hard copy for in-person data collection). First rounds of data collection will commence with a blank model. Once sufficient data is collected to anonymise participants, each data collection event will then be incrementally added to the overall models of care being developed. There will be multiple data collection events each month. More data will be added to the models with continued discussion and refinement. This iterative approach to data collection is inclusive and collaborative. Data collection will continue monthly until November 2022.

Figure 2.

Australian Bicultural Model of care described by Aboriginal Community Controlled Health Service staff (Purcell-Khodr et al., 2022).

Participants will also have the option to conduct research interviews via virtual platform (Zoom) for those who do not wish to meet in-person. Zoom interviews will not be recorded. The Australian Bicultural Model of care will be displayed using the ‘share screen’ option so the participant can see the data which is being recorded manually.

A data collection event memo will be written to provide context for each data collection event, check key discussion points are recorded, prepare the researcher’s questions for future data collection events and guide co-investigator discussions.

Research Governance Groups

Research Governance Groups will be formed for Bourke and Brewarrina. The groups will act as a sounding board for researchers: discussing research progress, helping to problem solve; and, making suggestions to enhance codesign. The groups will also discuss and approve communication, reports and presentations prior to their submission or publication. All research investigators will be invited to join each meeting to facilitate discussion. Governance groups will consist of 7–10 people who live within 100 kms of the town and will be led by a male and female co-chair and represent the diversity of people in each community. Aboriginal people respected for their cultural knowledge will be included in the groups. Males and females will be represented equally.

Data Handling and Analysis

Data will be analysed using framework analysis (Green & Thorogood, 2009). Initial data written on the visual model and documented in data collection event memos, will be coded and a codebook prepared. Code labels and descriptions will be discussed between three researchers (two Aboriginal and one non-Aboriginal) familiar with qualitative research and any differences resolved by consensus. Coded data will be mapped to the three levels of the Australian Bicultural Model of care. Analysis will stay close to the data and be descriptive. As data collection and analysis will happen concurrently, additional questions can be added as the research progresses. Researchers, governance group members and participants will see the model developing incrementally, allowing participants to expand on their initial answers as more is understood about the consolidated model. This process will also serve as a form of member checking. The building of the models of care will therefore be an iterative process with ongoing communication of developments and changes. Developing the model in this visual and collaborative way helps to build relationships and trust. Participants are actively involved in the interpretation, analysis, and design of the model of care.

Record Storage

Hard copy records, such as consent forms and visual data collection sheets will be digitised by scanning or photographing and will be archived electronically on the University-licensed data storage system which is password protected. Only the named investigators will have access to electronic or hardcopy data. All primary research materials will be retained for five years after publication, in accordance with the University data retention policy.

Anonymised data from this study might be used to teach students.

Ethics

In NSW, research which intends to include Aboriginal people or where overrepresentation of Aboriginal people is likely must be reviewed by the NSW Aboriginal Health & Medical Research Council (AH&MRC). When submitting to this committee, researchers present an argument that their research has attended to five key principles. These principles are (1) the research will result in net benefits for Aboriginal people and communities, (2) that Aboriginal community control of the research will occur, (3) the research will be undertaken with cultural sensitivity, (4) appropriate reimbursement of costs will be made and (5) Aboriginal people will develop research skills and knowledge.

People who might wish to take part in the study are likely to come from a range of socioeconomic and cultural backgrounds. Literacy will not be assumed, and verbal explanation will accompany the consent process.

Interviews and focus groups will be conducted in a community setting, allowing the participant(s) to decide on a comfortable environment, where they feel safe and are able to share freely. Meeting in a community setting (such as a public meeting area or café) does present issues with non-research participants overhearing information shared. Participant(s) will be made aware of this issue prior to agreeing to meet in a public place.

Pseudonyms will be given and interview data carefully anonymised. Very limited demographic data will be collected, and participants will not be able to be re-identified later.

Publication or presentation of research findings will be done with permission from all members of the research team and approval from the Research Governance Groups. Additionally, the NSW AH&MRC require prior approval of presentations or publications. Manuscripts of the research findings will be submitted to relevant journals and include authorship of team members consistent with International Committee of Medical Journal Editors guidelines for authorship (International Committee of Medical Journal Editors, 2022). Order of authorship will relate directly to the contribution to the manuscript and decided by consensus.

Abstracts relating to findings from this study will be submitted to relevant conferences. Members of the research team will present findings, with members being able to present as a team or solo as appropriate. Intellectual property is to be shared between contributors.

Summaries of the model of care will be made available to research participants and the wider communities in Bourke and Brewarrina. This could take the form of a newspaper article, Internet news, or media release. Approval by all members of the research team and associated research partners is required prior to publication of such items.

Support will be extended to any person perceived to be distressed during the interview. This might include calling a family member, facilitating contact with a local medical service or recommending a telephone support service.

Rigor

We consider rigor in terms of maintaining internal theoretical and methodological consistency within our study to produce knowledge (Carter & Little, 2007). This requires explicit inclusion of 8 Ways positioning of axiology (the heart) and ontology (relational responsibility) to guide epistemology (the head) and therefore knowledge production (see Figure 3). Methodology is described as ‘what guides my hands and feet’ and methods as ‘what my hands and feet do’ (NSW Department of Education and Communities. Regional Aboriginal Education Team Western Area, 2012). These links are articulated in Figure 4.

Figure 3.

The simplified relationship between axiology, ontology, epistemology, methodology and methods modified from Carter & Little (2007).

Figure 4.

Explanation of internal theoretical and methodological consistency within the study.

These philosophical and theoretical underpinnings will guide interaction between researchers, clinicians and communities and aid decision making and problem solving.

Full Copies of Interview Schedules/Focus Group Schedules/Fieldwork Plans

The data collection tool, yarning prompts and data collection event memo template are included as supplemental files.

Discussion

This study represents a novel and important application of Australian Aboriginal ways of knowing, being and doing in qualitative research to drive improvements in healthcare. Qualitative research has a tradition of being explicit about philosophical stance and theoretical perspective (including Indigenist perspectives) to inform study design and methods (Crotty, 1998; Liamputtong, 2012). Qualitative research also has a track record of driving change through the emancipatory traditions of action and participatory action research (Pant, 2014). However, qualitative research usually starts with discussion of the epistemological (what is the research question?) and methodological perspective (how can we answer the question?), which we contend is a western approach to research that pushes to the margin values important to Aboriginal peoples. Our study is approaching research with an Aboriginal perspective of the correct way to proceed. We are reordering the research process and attending to ontological (strengthen human relationships) and axiological (ethical) aspects first. While Aboriginal ways of knowing (8 Ways), being (relational responsibility) and doing (Australian Bicultural Model of care) have each been used in research before, they have not been combined. We envisage this approach will produce bespoke models of cancer care for two remote communities.

Another original aspect is the application of this approach in a mainstream healthcare setting where it is anticipated that non-Aboriginal people will also benefit. A direct outcome of this research will be the provision of chemotherapy via teleoncology in each community supported by the Western Cancer Centre Dubbo in line with the models.

A further novel aspect is the use of an Australian Bicultural Model of care which was first described in an alcohol treatment context and is tested here for transferability to other settings.

Our research advances qualitative methods by blending western and Australian Aboriginal approaches to codesign bicultural teleoncology models of care in remote Australian communities.

Strengths

The investigator team consists of Aboriginal knowledge holders, healthcare professionals and researchers. This team represents an ideal combination of investigators to contribute to the advancement of qualitative methods and implement a model of healthcare which improves access to specialist cancer treatments for non-Aboriginal and Aboriginal peoples in remote Australian communities.

Supplemental Material

Supplemental Material - Blending Western and Australian Aboriginal Approaches: A Study Protocol for Codesign of Bicultural Teleoncology Models of Care in Remote Australian Communities

Supplemental Material for Blending Western and Australian Aboriginal Approaches: A Study Protocol for Codesign of Bicultural Teleoncology Models of Care in Remote Australian Communities by Emma Webster, Gemma Purcell-Khodr, Billie Townsend, Allan Hall, Yvonne Hill, Cecil See, Katrina Ward, and Florian Honeyball in International Journal of Qualitative Methods

Supplemental Material

Supplemental Material - Blending Western and Australian Aboriginal Approaches: A Study Protocol for Codesign of Bicultural Teleoncology Models of Care in Remote Australian Communities

Supplemental Material

Supplemental Material - Blending Western and Australian Aboriginal Approaches: A Study Protocol for Codesign of Bicultural Teleoncology Models of Care in Remote Australian Communities

Footnotes

Acknowledgments

Research Governance Group members in Bourke and Brewarrina are acknowledged for their leadership, guidance and governance of this project. Vivian Slack-Smith (co-chair Brewarrina), Doug Gordon (co-chair Brewarrina), Kim (Sandra) Hardy, Bernadette Herstlet, Lini Lucas, Judy Caswell, Uncle Bradley Steadman (Ngemba), Steve Crotty, Aunty Loreen Coffey, John Reidy, Aunty Pat Canty (Barkinji) (co-chair Bourke), Joseph Clarke (Gomeroi/Gamilaraay) (co-chair Bourke), Possum (Cheryl) Swinton (Malangyapa), Leonie Brown, Aunty Louise Brown, Uncle Alister Ferguson, Tracey Coyne, Stuart Gordon.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is funded by the Australian Government, Department of Health under the Indigenous Australians Health Programme Emerging Priorities Round 2 (Reference GO4300).

Ethical Statement

ORCID iDs

Emma Webster

Gemma Purcell-Khodr

Supplemental Material

Supplemental material for this article is available online.

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