Benchmarking for healthy food stores: protocol for a randomised controlled trial with remote Aboriginal and Torres Strait Islander communities in Australia to enhance adoption of health-enabling store policy and practice.

BACKGROUND: Aboriginal and Torres Strait Islander communities in remote Australia have initiated bold policies for health-enabling stores. Benchmarking, a data-driven and facilitated 'audit and feedback' with action planning process, provides a potential strategy to strengthen and scale health-enabling best-practice adoption by remote community store directors/owners. We aim to co-design a benchmarking model with five partner organisations and test its effectiveness with Aboriginal and Torres Strait Islander community stores in remote Australia. METHODS: Study design is a pragmatic randomised controlled trial with consenting eligible stores (located in very remote Northern Territory (NT) of Australia, primary grocery store for an Aboriginal community, and serviced by a Nutrition Practitioner with a study partner organisation). The Benchmarking model is informed by research evidence, purpose-built best-practice audit and feedback tools, and co-designed with partner organisation and community representatives. The intervention comprises two full benchmarking cycles (one per year, 2022/23 and 2023/24) of assessment, feedback, action planning and action implementation. Assessment of stores includes i adoption status of 21 evidence-and industry-informed health-enabling policies for remote stores, ii implementation of health-enabling best-practice using a purpose-built Store Scout App, iii price of a standardised healthy diet using the Aboriginal and Torres Strait Islander Healthy Diets ASAP protocol; and, iv healthiness of food purchasing using sales data indicators. Partner organisations feedback reports and co-design action plans with stores. Control stores receive assessments and continue with usual retail practice. All stores provide weekly electronic sales data to assess the primary outcome, change in free sugars (g) to energy (MJ) from all food and drinks purchased, baseline (July-December 2021) vs July-December 2023. DISCUSSION: We hypothesise that the benchmarking intervention can improve the adoption of health-enabling store policy and practice and reduce sales of unhealthy foods and drinks in remote community stores of Australia. This innovative research with remote Aboriginal and Torres Strait Islander communities can inform effective implementation strategies for healthy food retail more broadly. TRIAL REGISTRATION: ACTRN12622000596707, Protocol version 1.

Shifting sands: Indigenous conceptions of health and place in fragile times.

Place and health are deeply interconnected for Indigenous people, and place-based services have been established to better meet people's needs. The meaning of place, however, remains difficult to define, an issue compounded by non-Indigenous settler attempts to erase people's association with place. This paper argues that we must understand place as something more than a geographical locality, and consider the histories, experiences and feelings that connect people to place in the south coast of New South Wales (NSW), Australia. The paper focuses on the role of Aboriginal Community Controlled Organisations (ACCOs) as place-based entities which deliver a range of health and social services to local Aboriginal communities across Australia. This study was undertaken during a period of crisis when places and people's capacity to remain connected to them was perilous due to the 2019/20 bushfires, named in the media as the Black Summer Bushfires. The experience of living through this disastrous period elevated the importance of ACCOs and their unique and deep engagement with the communities they serve.

Pathways between foodways and wellbeing for first nations Australians.

BACKGROUND: Supporting the health and wellbeing of Aboriginal and Torres Strait Islander peoples (hereafter respectfully referred to as First Nations peoples) is a national priority for Australia. Despite immense losses of land, language, and governance caused by the continuing impact of colonisation, First Nations peoples have maintained strong connections with traditional food culture, while also creating new beliefs, preferences, and traditions around food, which together are termed foodways. While foodways are known to support holistic health and wellbeing for First Nations peoples, the pathways via which this occurs have received limited attention. METHODS: Secondary data analysis was conducted on two national qualitative datasets exploring wellbeing, which together included the views of 531 First Nations peoples (aged 12-92). Thematic analysis, guided by an Indigenist research methodology, was conducted to identify the pathways through which foodways impact on and support wellbeing for First Nations peoples. RESULTS AND CONCLUSIONS: Five pathways through which wellbeing is supported via foodways for First Nations peoples were identified as: connecting with others through food; accessing traditional foods; experiencing joy in making and sharing food; sharing information about food and nutrition; and strategies for improving food security. These findings offer constructive, nationally relevant evidence to guide and inform health and nutrition programs and services to harness the strengths and preferences of First Nations peoples to support the health and wellbeing of First Nations peoples more effectively.

Development of a survey tool to assess the environmental determinants of health-enabling food retail practice in Aboriginal and Torres Strait Islander communities of remote Australia.

BACKGROUND: Environmental factors can impact the ability of food retail businesses to implement best practice health-enabling food retail. METHODS: We co-designed a short-item survey on factors influencing food retail health-enabling practice in a remote Australian setting. Publicly available submissions to an Australian Parliamentary Inquiry into food pricing and food security in remote Indigenous communities were coded using an existing remote community food systems assessment tool and thematically analysed. Themes informed survey questions that were then prioritised, refined and pre-tested with expert stakeholder input. RESULTS: One-hundred and eleven submissions were coded, and 100 themes identified. Supply chain related data produced the most themes (n = 25). The resulting 26-item survey comprised questions to assess the perceived impact of environmental factors on a store's health-enabling practice (n = 20) and frequency of occurrence (n = 6). CONCLUSIONS: The application of this evidence-informed, co-designed survey will provide a first-time cross-sectional analysis and the potential for ongoing longitudinal data and advocacy on how environmental factors affect the operations of remote stores.

Mapping pandemic responses in urban Indigenous Australia: Reflections on systems thinking and pandemic preparedness.

OBJECTIVES: We investigate some of the strengths and challenges associated with Covid-19 responses in urban Indigenous communities in Brisbane, Australia. Our research reflects on the interconnected dynamics that impact health outcomes and mitigate or exacerbate the risk of Covid-19 spreading within urban Indigenous communities. METHODS: Three systems thinking workshops were held in 2021 with Indigenous and non-Indigenous stakeholders (N15/workshop) from State and Federal services, along with Aboriginal Community Controlled Health Organisations. All worked in the urban Indigenous health sector. Stakeholders produced a Causal Loop Diagram (CLD) incorporating the critical feedbacks determining the dynamics influencing health outcomes. The aim of the research was to help stakeholders' build awareness of how the structure of the system influences health outcomes. RESULTS: Stakeholders identified 6 key dynamics which have a negative or positive impact on mitigating risks of Covid-19 infection. By mapping these dynamics within a CLD, 7 intervention points were identified. CONCLUSIONS: Systems thinking provides a useful tool in identifying the complexities associated with navigating health challenges, but further research is needed to develop frameworks that work in conjunction with Indigenous Australian methodologies. IMPLICATIONS FOR PUBLIC HEALTH: Indigenous voices and communities must lie central to health responses/policies for Indigenous peoples. When systems thinking is done by or in collaboration with stakeholders it provides a visual language that can help design public health policy. What can be ascertained is that their effectiveness is predicated on systems thinking's integration with Indigenous methodologies that acknowledges Indigenous self-determination and challenges Eurocentric representations of health and Indigeneity.

"It's research, our input can grow": identifying health research priorities with Aboriginal and Torres Strait Islander communities-study protocol.

BACKGROUND: In Australia, Aboriginal and Torres Strait Islander (Indigenous) families have strong, cohesive, and nurturing cultural practices that contribute to effective family functioning and child rearing. These practices can lead to positive effects on children and communities, and include kinship relations, traditional knowledge systems, collective community focus, respect for Elders contributions, and spirituality. However, poor health and wellbeing outcomes exist across the lifespan for Indigenous Australians. Health programs, services and research that support Indigenous women, babies and their families are a critical investment to improve birthing and health outcomes and impact the life trajectories of Indigenous Australians. AIM: The Indigenous Health Research Priorities study aims to identify the research priorities for families during the perinatal and early childhood period through a co-designed and collaborative process. This has been led by communities to determine the priorities identified with and for local Indigenous families in Queensland. This paper aims to report on engagement and involvement with Indigenous communities to identity health research priorities for families and presents preliminary findings of the research process including participants' demographic information and feedback on the yarning sessions, as part of the study protocol. METHODS: The study protocol showcases the Participatory Action Research approach, yarning sessions with clients and staff of three community-controlled health services to date, and Delphi workshop methods to prioritise the health issues identified during the yarns with corresponding communities. The study will undertake qualitative data collection and analysis to identify and report on community and health service research priorities for Indigenous families in Queensland. A short survey was conducted to collect participants' demographic information. A feedback form with five open-ended questions was also administered to collect data on participants' views and satisfaction with the research process. PRELIMINARY RESULTS: This protocol paper reports on the participant demographic information and feedback on the research process and reactions to participating in the yarning sessions. There have been 12 yarning sessions in Far North Queensland to date. The qualitative analysis of these will be reported on in future, with South East Queensland and further sites to follow. Feedback from 61 community members and health professionals has highlighted they valued sharing stories, being heard, and feeling hopeful. Preliminary findings will be reported. DISCUSSION: Identification of health research priorities will allow each organisation and region of Queensland to develop research initiatives and the translational outcomes that are a focus for their community members.

Health programs and services designed to support Aboriginal and Torres Strait Islander (herein Indigenous) women, babies and their families are a critical investment to improve birthing and health outcomes, and potentially impact the life course of Indigenous Australians. The Indigenous Health Research Priorities study aims to identify research priorities for families during pregnancy, birthing, and early childhood through a collaborative consultation process. We engaged with community members, both clients and health care staff of three community-controlled health services in Far North Queensland. Yarning sessions were held to identify health research priorities with and for local Indigenous families. Feedback forms were collected to gauge engagement and satisfaction with the research process. Twelve yarning sessions with 61 participants highlighted they valued sharing stories, being heard, having a voice, and feeling hopeful. Identifying health research priorities will allow each organisation and region of Queensland to develop health programs and services and research initiatives that are important for their community members.Once the yarning group data is analysed, we will return to discuss, prioritise, and reach consensus on those health issues identified during the yarns with communities, using a Delphi study. The Delphi will run as an interactive workshop using playing cards and group discussions, where participants will rank the importance of the health issues for their community. Prioritising the top 10 health issues will help to ensure research is designed better for and with communities, so that future research directions meet the needs identified and self-determined by Indigenous communities.

Communities Setting the Direction for Their Right to Nutritious, Affordable Food: Co-Design of the Remote Food Security Project in Australian Indigenous Communities.

Despite long histories of traditional food security, Indigenous peoples globally are disproportionately exposed to food insecurity. Addressing this imbalance must be a partnership led by Indigenous peoples in accordance with the UN Declaration of the Rights of Indigenous Peoples. We report the co-design process and resulting design of a food security research project in remote Australia and examine how the co-design process considered Indigenous peoples' ways of knowing, being, and doing using the CREATE Tool. Informed by the Research for Impact Tool, together Aboriginal Community Controlled Health Organisation staff, Indigenous and non-Indigenous public health researchers designed the project from 2018-2019, over a series of workshops and through the establishment of research advisory groups. The resulting Remote Food Security Project includes two phases. Phase 1 determines the impact of a healthy food price discount strategy on the diet quality of women and children, and the experience of food (in)security in remote communities in Australia. In Phase 2, community members propose solutions to improve food security and develop a translation plan. Examination with the CREATE Tool showed that employing a co-design process guided by a best practice tool has resulted in a research design that responds to calls for food security in remote Indigenous communities in Australia. The design takes a strengths-based approach consistent with a human rights, social justice, and broader empowerment agenda. Trial registration: The trial included in Phase 1 of this project has been registered with Australian New Zealand Clinical Trials Registry: ACTRN12621000640808.

Conceptualisation, experiences and suggestions for improvement of food security amongst Aboriginal and Torres Strait Islander parents and carers in remote Australian communities.

This study aimed to determine perceptions of the lived experience of food insecurity and suggestions to improve food security in four remote Aboriginal communities in the Northern Territory, and Queensland. Participants were Aboriginal and/or Torres Strait Islander pregnant and breastfeeding women, and parents/carers of children aged six months to five years. Semi-structured interviews (n=17) were conducted between June-July 2021 and the data thematically analysed using a four stage process. No specific term was used by participants to describe being either food secure or insecure. Descriptions of food security were centred in food sharing, food sufficiency, and family activities. Elements describing food insecurity were physical pain and emotional stress, adults going without food, seeking family help and managing without food until payday. Factors contributing to food insecurity were reported to be: (i) Low income and unemployment, (ii) Cost of living remotely, (iii) Resource sharing, and (iv) Impact of spending on harmful commodities and activities. Three themes were conceptualised: (1) Cultural practices buffer food insecurity, (2) Coping with food insecurity, (3) People accept a degree of food insecurity as normal. Findings suggest Aboriginal and Torres Strait Islander cultural practices such as sharing food buffer episodic food insecurity and constitute 'cultural food security'. Despite use of cultural practices (e.g., procuring traditional food) and generic coping strategies, regular episodes of food insecurity often aligned with the off week of social assistance payments. Household energy (electricity) security was coupled to food security. Suggestions for improving food security included better transport and food access, extending electricity rebates, increases in the regularity of social assistance payments, and computer access and training in budgeting. Policies to advance food security should embody deeper Aboriginal and Torres Strait Islander descriptions and experiences. Community-derived policy suggestions which aim to increase access to adequate, regular, stable household income are likely to succeed.

Identifying and dismantling racism in Australian perinatal settings: Reframing the narrative from a risk lens to intentionally prioritise connectedness and strengths in providing care to First Nations families.

INTRODUCTION: The perinatal period is a time when provision of responsive care offers a life course opportunity for positive change to improve health outcomes for mothers, infants and families. Australian perinatal systems carry the legacy of settler-colonialism, manifesting in racist events and interactions that First Nations parents encounter daily. OBJECTIVE: The dominance of a western risk lens, and conscious and unconscious bias in the child protection workforce, sustains disproportionately high numbers of First Nations infants being removed from their parents' care. Cascading medical interventions compound existing stressors and magnify health inequities for First Nations women. DESIGN: Critical discourse was informed by Indigenous ways of knowing, being and doing via targeted dialogue with a group of First Nations and non-Indigenous experts in Australian perinatal care who are co-authors on this paper. Dynamic discussion evolved from a series of yarning circles, supplemented by written exchanges and individual yarns as themes were consolidated. RESULTS: First Nations maternity services prioritise self-determination, partnership, strengths and communication and have demonstrated positive outcomes with, and high satisfaction from First Nations women. Mainstream perinatal settings could be significantly enhanced by embracing similar principles and models of care. CONCLUSIONS AND RELEVANCE: The Australian Anti-racism in Perinatal Practice (AAPP) Alliance calls for urgent transformations to Australian perinatal models of care whereby non-Indigenous health policy makers, managers and clinicians take a proactive role in identifying and redressing ethnocentrism, judgemental and culturally blind practices, reframing the risk narrative, embedding strength-based approaches and intentionally prioritising engagement and connectedness within service delivery.

Affordability of Heathy, Equitable and More Sustainable Diets in Low-Income Households in Brisbane before and during the COVID-19 Pandemic.

The COVID-19 pandemic has increased food insecurity worldwide, yet there has been limited assessment of shifts in the cost and affordability of healthy, equitable and sustainable diets. This study explores the impact of the COVID-19 pandemic and income supplements provided by the Australian government on diet cost and affordability for low-income households in an Australian urban area. The Healthy Diets ASAP method protocol was applied to assess the cost and cost differential of current and recommended diets before (in 2019) and during the COVID-19 pandemic (late 2020) for households with a minimum-wage and welfare-only disposable household income, by area of socioeconomic disadvantage, in Greater Brisbane, Queensland, Australia. Data were collected between August and October, 2020, from 78 food outlets and compared with data collected in the same locations between May and October, 2019, in an earlier study. The price of most healthy food groups increased significantly during the pandemic-with the exception of vegetables and legumes, which decreased. Conversely, the price of discretionary foods and drinks did not increase during the pandemic. The cost of the current and recommended diets significantly increased throughout this period, but the latter continued to be less expensive than the former. Due to income supplements provided between May and September 2020, the affordability of the recommended diet improved greatly, by 27% and 42%, for households with minimum-wage and welfare-only disposable household income, respectively. This improvement in the affordability of the recommended diet highlights the need to permanently increase welfare support for low-income families to ensure food security.

Deadly Choices empowering Indigenous Australians through social networking sites.

The potential for health promotion through social networking sites (SNSs) is widely recognized. However, while health promotion prides itself in focusing on the social determinants of health, its partiality for persuading individuals to comply with health behaviours dominates the way health promotion utilizes SNSs. This paper contributes to an understanding of collaborative ways SNSs can work for health promotion agendas of self-determination and empowerment in an Indigenous Australia context. An ethnographic study was undertaken with Deadly Choices, an Indigenous-led health promotion initiative. The study involved participant observation of interactions on Deadly Choices SNSs between Deadly Choices and its online community members. Deadly Choices provides an example of SNSs providing a powerful tool to create a safe, inclusive and positive space for Indigenous people and communities to profile their healthy choices, according to Indigenous notions of health and identity. The study found five principles that underpin Deadly Choices' use of SNSs for health promotion. These are: create a dialogue; build community online and offline; incentivise healthy online engagement; celebrate Indigenous identity and culture; and prioritize partnerships. Deadly Choices SNSs empowers Indigenous people and communities to be health promoters themselves, which represents a power shift from health promotion practitioner to Indigenous people and communities and more broadly, an enactment of Indigenous self-determination on SNSs. Mainstream health promotion can learn from Indigenous health promotion practice regarding the use of SNSs for health promotion agendas.

Paths to improving care of Australian Aboriginal and Torres Strait Islander women following gestational diabetes.

Aim To understand enablers and barriers influencing postpartum screening for type 2 diabetes following gestational diabetes in Australian Indigenous women and how screening might be improved. BACKGROUND: Australian Indigenous women with gestational diabetes mellitus (GDM) are less likely than other Australian women to receive postpartum diabetes screening. This is despite a fourfold higher risk of developing type 2 diabetes within eight years postpartum. METHODS: We conducted interviews with seven Indigenous women with previous GDM, focus groups with 20 Indigenous health workers and workshops with 24 other health professionals. Data collection included brainstorming, visualisation, sorting and prioritising activities. Data were analysed thematically using the Theoretical Domains Framework. Barriers are presented under the headings of 'capability', 'motivation' and 'opportunity'. Enabling strategies are presented under 'intervention' and 'policy' headings. Findings Participants generated 28 enabling environmental, educational and incentive interventions, and service provision, communication, guideline, persuasive and fiscal policies to address barriers to screening and improve postpartum support for women. The highest priorities included providing holistic social support, culturally appropriate resources, improving Indigenous workforce involvement and establishing structured follow-up systems. Understanding Indigenous women's perspectives, developing strategies with health workers and action planning with other health professionals can generate context-relevant feasible strategies to improve postpartum care after GDM. Importantly, we need evidence which can demonstrate whether the strategies are effective.

'We don't tell people what to do': ethical practice and Indigenous health promotion.

Health promotion aspires to work in empowering, participatory ways, with the goal of supporting people to increase control over their health. However, buried in this goal is an ethical tension: while increasing people's autonomy, health promotion also imposes a particular, health promotion-sanctioned version of what is good. This tension positions practitioners precariously, where the ethos of empowerment risks increasing health promotion's paternalistic control over people, rather than people's control over their own health. Herein we argue that this ethical tension is amplified in Indigenous Australia, where colonial processes of control over Indigenous lands, lives and cultures are indistinguishable from contemporary health promotion 'interventions'. Moreover, the potential stigmatisation produced in any paternalistic acts 'done for their own good' cannot be assumed to have evaporated within the self-proclaimed 'empowering' narratives of health promotion. This issue's guest editor's call for health promotion to engage 'with politics and with philosophical ideas about the state and the citizen' is particularly relevant in an Indigenous Australian context. Indigenous Australians continue to experience health promotion as a moral project of control through intervention, which contradicts health promotion's central goal of empowerment. Therefore, Indigenous health promotion is an invaluable site for discussion and analysis of health promotion's broader ethical tensions. Given the persistent and alarming Indigenous health inequalities, this paper calls for systematic ethical reflection in order to redress health promotion's general failure to reduce health inequalities experienced by Indigenous Australians.

Development and feasibility testing of an education program to improve knowledge and self-care among Aboriginal and Torres Strait Islander patients with heart failure.

INTRODUCTION: There is a 70% higher age-adjusted incidence of heart failure (HF) among Aboriginal and Torres Strait Islander people, three times more hospitalisations and twice as many deaths as among non-Aboriginal people. There is a need to develop holistic yet individualised approaches in accord with the values of Aboriginal community health care to support patient education and self-care. The aim of this study was to re-design an existing HF educational resource (Fluid Watchers-Pacific Rim) to be culturally safe for Aboriginal and Torres Strait Islander peoples, working in collaboration with the local community, and to conduct feasibility testing. METHODS: This study was conducted in two phases and utilised a mixed-methods approach (qualitative and quantitative). Phase 1 used action research methods to develop a culturally safe electronic resource to be provided to Aboriginal HF patients via a tablet computer. An HF expert panel adapted the existing resource to ensure it was evidence-based and contained appropriate language and images that reflects Aboriginal culture. A stakeholder group (which included Aboriginal workers and HF patients, as well as researchers and clinicians) then reviewed the resources, and changes were made accordingly. In Phase 2, the new resource was tested on a sample of Aboriginal HF patients to assess feasibility and acceptability. Patient knowledge, satisfaction and self-care behaviours were measured using a before and after design with validated questionnaires. As this was a pilot test to determine feasibility, no statistical comparisons were made. RESULTS: Phase 1: Throughout the process of resource development, two main themes emerged from the stakeholder consultation. These were the importance of identity, meaning that it was important to ensure that the resource accurately reflected the local community, with the appropriate clothing, skin tone and voice. The resource was adapted to reflect this, and members of the local community voiced the recordings for the resource. The other theme was comprehension; images were important and all text was converted to the first person and used plain language. Phase 2: Five Aboriginal participants, mean age 61.6±10.0 years, with NYHA Class III and IV heart failure were enrolled. Participants reported a high level of satisfaction with the resource (83.0%). HF knowledge (percentage of correct responses) increased from 48.0±6.7% to 58.0±9.7%, a 20.8% increase, and results of the self-care index indicated that the biggest change was in patient confidence for self-care, with a 95% increase in confidence score (46.7±16.0 to 91.1±11.5). Changes in management and maintenance scores varied between patients. CONCLUSIONS: By working in collaboration with HF experts, Aboriginal researchers and patients, a culturally safe HF resource has been developed for Aboriginal and Torres Strait Islander patients. Engaging Aboriginal researchers, capacity-building, and being responsive to local systems and structures enabled this pilot study to be successfully completed with the Aboriginal community and positive participant feedback demonstrated that the methodology used in this study was appropriate and acceptable; participants were able to engage with willingness and confidence.

Associations with low rates of postpartum glucose screening after gestational diabetes among Indigenous and non-Indigenous Australian women.

OBJECTIVES: To explore factors associated with postpartum glucose screening among women with Gestational Diabetes Mellitus (GDM). METHODS: A retrospective study using linked records from women with GDM who gave birth at Cairns Hospital in Far North Queensland, Australia, from 1 January 2004 to 31 December 2010. RESULTS: The rates of postpartum Oral Glucose Tolerance Test (OGTT) screening, while having increased significantly among both Indigenous* and non-Indigenous women from 2004 to 2010 (HR 1.15 per year, 95%CI 1.08-1.22, p<0.0001), remain low, particularly among Indigenous women (10% versus 27%, respectively at six months postpartum). Indigenous women in Cairns had a longer time to postpartum OGTT than Indigenous women in remote areas (HR 0.58, 0.38-0.71, p=0.01). Non-Indigenous women had a longer time to postpartum OGTT if they: were born in Australia (HR 0.76, 0.59-1.00, 0.05); were aged <25 years (HR 0.45, 0.23-0.89, p=0.02); had parity >5 (HR 0.33, 0.12-0.90, p=0.03); smoked (HR 0.48, 0.31-0.76, p=0.001); and did not breastfeed (HR 0.09, 0.01-0.64, p=0.02). CONCLUSIONS: Postpartum diabetes screening rates following GDM in Far North Queensland are low, particularly among Indigenous women, with lower rates seen in the regional centre; and among non-Indigenous women with indicators of low socioeconomic status. IMPLICATIONS: Strategies are urgently needed to improve postpartum diabetes screening after GDM that reach women most at risk.

Retinal photography screening programs to prevent vision loss from diabetic retinopathy in rural and urban Australia: a review.

PURPOSE: This review assessed the effectiveness of diabetic retinopathy (DR) screening programs, using retinal photography in Australian urban and rural settings, and considered implications for public health strategy and policy. METHODS: An electronic search of MEDLINE, PubMed, and Embase for studies published between 1 January 1996 and the 30 June 2013 was undertaken. Key search terms were "diabetic retinopathy," "screening," "retinal photography" and "Australia." RESULTS: Twelve peer-reviewed publications were identified. The 14 DR screening programs identified from the 12 publications were successfully undertaken in urban, rural and remote communities across Australia. Locations included a pathology collection center, and Indigenous primary health care and Aboriginal community controlled organizations. Each intervention using retinal photography was highly effective at increasing the number of people who underwent screening for DR. The review identified that prior to commencement of the screening programs a median of 48% (range 16-85%) of those screened had not undergone a retinal examination within the recommended time frame (every year for Indigenous people and every 2 years for non-Indigenous people in Australia). A median of 16% (range 0-45%) of study participants had evidence of DR. CONCLUSIONS: This review has shown there have been many pilot and demonstration projects in rural and urban Australia that confirm the effectiveness of retinal photography-based screening for DR.