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ItemA model of culturally informed integration of Diabetes Education and diabetic Eye disease Screening (iDEES) in Indigenous primary care settingsAtkinson-Briggs, Sharon Ruth ( 2021)Diabetes mellitus, particularly Type 2 diabetes (T2D), is a fast-growing pandemic and leading public health problem. If not managed well, T2D can lead to serious complications, such as diabetic retinopathy (DR). DR is a retinal complication of diabetes and one of the leading causes of vision impairment and blindness in working-aged adults globally. Although there have been many attempts to treat and eradicate DR, the burden tends to fall on the most vulnerable people in low-income countries, rural settings, and indigenous populations. Indigenous Australians are more likely to have T2D and are at higher risk of being visually impaired or going blind due to DR then non-Indigenous Australians. Studies have demonstrated that early detection and management practices, such as DR screening, are effective strategies to detect and manage DR to reduce the risk of sight-threatening visual complications and blindness (NHMRC, 2008). Despite the benefits of DR screening, screening rates among Indigenous Australians are substantially lower than in non-Indigenous Australians. Thus, understanding the association between diabetes and its complications, above all DR, and the importance of regular eye screening is very important for both individuals with diabetes and healthcare clinicians involved in providing diabetes support and diabetes self-management education. Technological advances and the Medicare rebates that support the use of non-ophthalmic clinicians (general practitioners, diabetes educators, health workers and endocrinologists) to supplement coverage by ophthalmologists and optometrists can extend retinopathy screening capacity and should also facilitate improved DR screening rates among Indigenous Australians. Diabetes educators are part of a multidisciplinary healthcare team and are integral to improving diabetes support and self-management education to assist people with diabetes. Integrating ocular screening and diabetes education in primary healthcare settings has potential to synergistically improve retinopathy screening coverage, patient self-management, risk factor control, diabetes care satisfaction, health economics and sustainability of under-resourced services. Hypotheses The studies in this thesis are based on the hypotheses that Indigenous Australian with diabetes are at high risk of diabetic retinopathy due to multiple factors, including suboptimal risk factor profiles; and that a novel model of nurse-led care provision can improve diabetic retinopathy screening rates, reduce risk factors for diabetic retinopathy, and in the longer-term reduce the rates of diabetic retinopathy and related complications. The overall goal is to develop, implement and assess a novel nurse-led model of culturally informed integrated diabetic eye screening and diabetes education in Aboriginal Community Controlled Health Organisations (ACCHOs). Specific Aims 1. To develop, implement and assess a novel nurse-led model of culturally informed integrated diabetic eye screening and diabetes education for Indigenous Australian adults with diabetes in ACCHO primary care centres and related clinics in regional Victoria; including to determine (a) diabetic retinopathy screening coverage rates; (b) the prevalence of impaired vision and of diabetic retinopathy; (c) lifestyle-related risk factors for diabetes complications; (d) traditional risk factors levels including HbA1c, blood pressure and kidney function (ACCHO national key performance indicators), lipids and smoking; and (e) patient satisfaction with diabetes care. 2. To conduct a thematic review of self-management practices in Indigenous Australians related to smoking, nutrition, alcohol, physical activity and emotional wellbeing, as there is a paucity of data in this area. Methods The candidate developed a novel integrated Diabetes Education and diabetic Eye disease Screening (iDEES) model of care that was implemented and tested at three Indigenous-led primary care practices in regional Victoria, Australia. The trial was registered (ANZCTRN1261800120435) and ethics committee approved, and each participant provided written informed consent. The trial was of a pre-post design, with a single clinic visit at baseline and follow-up. Each visit included eye testing, surveys regarding lifestyle and diabetes education. Traditional risk factors, including BMI, blood pressure, smoking, HbA1c, kidney function, and lipid levels, were collected from the electronic medical record system, if available. The candidate was responsible for collecting all qualitative data, based on the surveys which, due to potential low literacy issues, she verbally administered to each study participant. This is culturally acceptable and often preferred in a culture with a strong oral tradition. The surveys were usually administered during a one-hour diabetes education and eye imaging appointment. Results were analysed using descriptive statistics, with significance taken at p < 0.05. A thematic literature review was undertaken. Results Overall 334 eligible patients, 171 (51%) participated. A high rate of 78% of the target population was screened at the main study site, in spite of COVID-19 restrictions with 76% being re-screened as per national recommendations. Smaller clinical services strived, but struggled, to embed this additional technology-based service for a range of reasons, predominantly due to understaffing, high staff turnover and management changes, with screening coverage of 18% and 27%. This study of screening coverage for diabetes eye care is one of very few available in the literature, in spite of it being a key metric for diabetes eye care. High rates of diabetic retinopathy (29%) were identified at all sites, on par with other studies of Indigenous Australians. The study also identified high rates of suboptimal self-management behaviour at all study sites, and at the main study site also identified suboptimal systemic risk factor control in adults with diabetes, with a median of four of nine traditional risk factor targets being achieved for women and three of nine for men. The vast majority participants reported being very satisfied with their current diabetes treatment. Follow-up regarding lifestyle and risk factors could not be repeated due to COVID-19 limitations. The literature review identified a knowledge gap in the areas of lifestyle and traditional risk factors among Indigenous Australians with diabetes. Hence, the data generated by the thesis contributed valuable new knowledge to the field. Conclusions An integrated nurse-led model of care was implemented in regional Australian ACCHOs and achieved diabetic retinopathy screening coverage rates of over 75% in the fully engaged sites, with much lower coverage at the less engaged sites. High rates of retinopathy and of adverse lifestyle and traditional risk factors were identified. This culturally acceptable nurse-led model of care merits longer-term follow-up and assessment in other sites, including whether it can improve long-term health outcomes for Indigenous Australians with diabetes.