Introduction

The primary aim of the National Guide is to present clear and up-to-date guidance for general practitioners (GPs) and primary healthcare teams on preventive healthcare for Aboriginal and Torres Strait Islander people.

The National Guide does this by:

• gathering existing guidelines and recommendations and presenting them as they apply to Aboriginal and Torres Strait Islander people
• developing recommendations that support the implementation and/or effectiveness of preventive health activities.

The main criteria for the inclusion of topics in the National Guide are health issues 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. Important health issues include complex sociopolitical issues like racism and the climate crisis (both included for the first time in this edition), as well as organ- or disease-specific conditions like otitis media, cardiovascular disease and dementia.

The National Guide makes specific recommendations regarding the elements of preventive healthcare across the life cycle. The recommendations aim to promote health and wellbeing, prevent disease, and detect early and unrecognised disease while acknowledging the importance of variation based on regional and local context. 

In general, the focus is on primary prevention and early detection, with some topics including secondary prevention and occasionally tertiary prevention (see Table 1 ).

In addition to providing guidance for primary healthcare teams, recognised secondary uses of the National Guide include:

• supporting planning and quality improvement activities in health services and practices
• in education and training across health disciplines
• as a key reference in preventive healthcare for Aboriginal and Torres Strait Islander people in the development of:
  • other clinical guidelines
  • other resources for clinicians
  • clinical software
  • government and other organisational policy and programs
  • local health programs and projects.

For the first time, recommendations for annual health checks, which offer a structured approach to preventive healthcare and are a key implementation strategy of the National Guide, were updated alongside the development of the fourth edition.

Development of the National Guide is built on Aboriginal and Torres Strait Islander leadership and contribution, strong collaboration as a way of working, and recognition of different knowledge systems.
Many of the principles that underpin the guide are about recognising and understanding the context and experience of Aboriginal and Torres Strait Islander people’s lives, including:

• that health encompasses physical, social, emotional spiritual and cultural wellbeing and is both individual and collective⁷ (see Figure 1)
• that cultural and community connection is protective⁸
• the importance of identifying and building on individual and collective strengths
• the ongoing impact of colonisation and racism
• the primary importance of community leadership and involvement in identifying priorities and making decisions about service responses and programs (collective self-determination)
• the primary importance of partnership and shared decision making in how healthcare is available and experienced (individual self-determination)
• the determinants and drivers of health and disease (social, political, cultural) and how they impact on health and wellbeing
• that the way healthcare is available and experienced matters.

Figure 1. Social and emotional wellbeing from an Aboriginal and Torres Strait Islander perspective.
Reproduced with permission from Gee et al.⁷

Applying a cultural lens that considered these contextual factors, as well as cultural appropriateness and acceptability, informed the general approach to topics, and specifically to the development of key messages and recommendations. This included:

• positively stating what promotes, supports, protects and strengthens health and wellbeing
• the importance of culturally safe healthcare and culturally appropriate advice, including when considering referral
• the importance of trauma-informed healing-focused healthcare.

Finally, the aim of the National Guide is to have an impact on improving health and preventing disease by supporting primary care teams in effective preventive interventions with Aboriginal and Torres Strait Islander people, and this has informed the content, style and recommendations. Thinking about implementation and translation into practice was a key principle from the outset.

Preventive healthcare is key part of comprehensive primary healthcare.^9,10 GPs and all members of primary healthcare teams have the opportunity to promote health and wellbeing, and to prevent disease through assessment, advice and action with individuals and communities in everyday healthcare interactions, in the implementation of population health programs such as immunisation and cancer screening, in structured activities such as annual health checks and in individually focused and broader advocacy.

Particularly given the disparities in health and life expectancy between Aboriginal and Torres Strait Islander and non-Indigenous Australian people, a systematic approach to preventive healthcare has the potential for huge impact. Preventing and detecting disease early can translate into people living longer, healthier lives and reduced hospital admissions and health costs.

Annual health checks for Aboriginal and Torres Strait Islander people, which were introduced as a dedicated Medicare Benefits Schedule (MBS) item through the early 2000s, are a structured way of organising age-appropriate preventive health activities and are a key Australian Government strategy for reducing health inequities. The National Aboriginal and Torres Strait Islander Health Plan 2021–2031 includes a specific objective to ‘increase the quality and uptake of health checks’.⁴

Access to healthcare is one of the important determinants of health. To be meaningful, appropriate and effective, preventive healthcare for Aboriginal and Torres Strait Islander people needs to be provided in a way that is acceptable, affirms cultural understandings of health and wellbeing and recognises the cultural and linguistic diversity of Aboriginal and Torres Strait Islander peoples.

This edition of the National Guide includes, for the first time, a chapter on the health impacts of racism. The imperative for healthcare to be free of racism and stigma and the need for culturally safe healthcare is clear. The Australian Health Practitioner Regulation Agency identifies the ‘inextricably linked elements of clinical and cultural safety’.¹¹ The effectiveness of the recommendations in the National Guide depends on people having access to and experiencing culturally safe services.

Key features of effective primary health services for Aboriginal and Torres Strait Islander people include:

• welcoming, respectful and culturally safe experience for patients
• healthcare based on trust and continuity
• recognising and building on individual and collective strengths
• building partnership and shared decision making
• an understanding of trauma and the way trauma impacts health and wellbeing
• collaboration between patients, providers and services, with Aboriginal and Torres Strait Islander staff whenever possible
• flexible service design.

Healthcare providers are responsible for making sure that the identification of Aboriginal and Torres Strait Islander people is undertaken appropriately and is accurately recorded in their health records within clinical software systems.

Identifying Aboriginal and Torres Strait Islander patients is an essential first step in ensuring access to and offering specific and appropriate healthcare, including initiatives such as Medicare item annual health checks, the Pharmaceutical Benefits Scheme co-payment measure and the Practice Incentives Program Indigenous Health Incentive.

Accurate identification of Aboriginal and Torres Strait Islander patients is also required to make sure the health data about Aboriginal and Torres Strait Islander people are accurate. This is an essential part of health service- and practice-level monitoring and quality improvement, as well as tracking the performance of the health system, including high-level commitments such as those included in the National Agreement on Closing the Gap.¹²

The Australian Institute of Health and Welfare recommends asking everyone who attends a health service:

Are you of Aboriginal or Torres Strait Islander origin? ¹³

The National Guide and the RACGP Guidelines for preventive activities in general practice (Red Book)¹⁴ both provide evidence-based clinical guidance for primary care clinicians. The chosen health topics and the way they are presented in the National Guide reflect important health issues for Aboriginal and Torres Strait Islander peoples, particularly where there are differences between Aboriginal and Torres Strait Islander and non-Indigenous populations. Significant differences are informed by prevalence, age of onset, impact of health conditions and cultural factors. Many recommendations in the National Guide also relate to the context of health and healthcare and provide guidance on how to offer healthcare and what to do. The Red Book is a synthesis of evidence-based guidelines on primary prevention from Australian and international sources and provides recommendations for the general population and for everyday use in general practice. Primary care clinicians are encouraged to refer to the Red Book for common health issues not included in the National Guide.

Effective preventive healthcare, including components of annual health checks, should reflect local needs and priorities, as well as general advice. Healthcare providers are encouraged to consult local guidelines where appropriate and available. This is especially relevant for conditions that are endemic in certain regions, such as acute rheumatic fever/rheumatic heart disease and trachoma, or where there are differences in access to services and/or jurisdictional variation in programs.

Preventive healthcare can be provided in any clinical encounter in primary care, both planned and opportunistically (ie without being planned for). It can be offered in individual components or in the structured format of an annual health check.

Medicare rebates are available for annual health checks, which provide an opportunity for dedicated time to consider and discuss what supports health and wellbeing and to identify health risks.

Health checks should:

• recognise that there are diverse experiences, socioeconomic circumstances and exposure to risk factors and protective factors among Aboriginal and Torres Strait Islander peoples
• be completed in partnership between healthcare providers and patients
• support individuals and families to take charge of their health and wellbeing
• identify strengths and health needs, guided by patient goals and priorities
• include age-appropriate evidence-based preventive health activities
• include a plan for responding to and the follow-up of identified health needs.

Updated recommendations on what to include in annual health checks and a range of other resources are available on the NACCHO–RACGP resource hub.