Aboriginal and Torres Strait Islander health screening

general-practice6 free questions

Australian guidance: NACCHO / RACGP National Guide to Preventive Healthcare for Aboriginal and Torres Strait Islander People

1. Definition and epidemiology

Preventive healthcare for Aboriginal and Torres Strait Islander people encompasses structured screening, early detection, and risk reduction activities delivered across the life course in primary care settings. Aboriginal and Torres Strait Islander people experience disproportionate rates of chronic disease compared with non-Indigenous Australians, with type 2 diabetes at almost three times the rate, cardiovascular disease (CVD) mortality higher at all ages, chronic kidney disease (CKD) overrepresented, and cancer mortality 1.7-fold higher despite some cancers occurring at lower incidence. Life expectancy remains substantially lower, driven by the compounding effects of colonisation, racism, poverty, housing insecurity, and limited access to culturally safe care.

2. Pathophysiology

The health disparities experienced by Aboriginal and Torres Strait Islander people reflect the interaction of biomedical risk factors with powerful social and structural determinants. The ongoing impacts of colonisation produce high allostatic load through chronic stress, socioeconomic marginalisation, trauma, and disrupted social and cultural connection. These drive early-onset cardiometabolic dysregulation including insulin resistance, endothelial dysfunction, hypertension, and glomerular injury at younger ages than seen in the general Australian population. Low birth weight, a common sequela of intergenerational disadvantage, programs susceptibility to obesity, hypertension, and diabetic nephropathy via developmental plasticity mechanisms. Recurrent childhood infections, including skin infections and otitis media, initiate inflammatory cascades that contribute to valvular heart disease via acute rheumatic fever (ARF) and accelerated glomerulosclerosis via post-streptococcal glomerulonephritis. Protective factors including cultural identity, connection to Country, community cohesion, and physical activity attenuate but do not eliminate these biological pathways. The result is a pattern of multimorbidity presenting one to two decades earlier than in non-Indigenous Australians, which requires screening to commence at substantially younger ages.

3. Clinical presentation and diagnostic criteria

Preventive health assessments are delivered opportunistically at any clinical encounter and in the structured format of the annual health check (Medicare Benefits Schedule item 715 for people of any age identifying as Aboriginal or Torres Strait Islander). The health check identifies risk factors and undiagnosed disease before symptoms develop. Key domains assessed include growth and development in children, blood pressure, blood glucose, lipids, renal function, hearing, vision, oral health, mental health and social emotional wellbeing, smoking and substance use, immunisation status, and cancer screening eligibility. Clinical findings prompting further investigation include elevated blood pressure (systolic above 130 mmHg in adults), glycated haemoglobin (HbA1c) at or above 5.7% in high-risk children or above 6.5% in adults, urine albumin to creatinine ratio (uACR) above 2.5 mg/mmol in males or above 3.5 mg/mmol in females, or a low estimated glomerular filtration rate (eGFR). Cultural safety at the point of care, trauma-informed practice, and shared decision making with the patient are prerequisites for assessment quality.

4. Investigations and AU-specific cutoffs

The National Guide recommends earlier commencement and higher frequency of several investigations compared with general population guidance.

Type 2 diabetes screening: - Children and adolescents aged 10 years and over with one or more risk factors (overweight or obesity, family history of diabetes, gestational diabetes, signs of insulin resistance, dyslipidaemia, or psychotropic medication): HbA1c or fasting blood glucose (FBG) opportunistically. Repeat annually if HbA1c below 5.7%; repeat in six months if HbA1c 5.7 to 6.4%. Oral glucose tolerance test (OGTT) if equivocal. - All adults aged 18 years and over: FBG or HbA1c opportunistically. Given higher T2D prevalence in this population, blood testing is preferred over the AUSDRISK tool as the primary screening method. - Diagnostic thresholds: FBG at or above 7.0 mmol/L, two-hour plasma glucose at or above 11.1 mmol/L on OGTT, HbA1c at or above 6.5% (48 mmol/mol), or random plasma glucose at or above 11.1 mmol/L with symptoms.

Cardiovascular disease screening: - Ages 12 to 17 years: assess CVD risk factors opportunistically (smoking, family history of hypercholesterolaemia, BMI, waist circumference; testing only if clinically indicated). - Ages 18 to 29 years: assess individual risk factors including blood pressure, BSL or HbA1c, eGFR, lipids, uACR. The Aboriginal and Torres Strait Islander-specific consensus statement supports CVD risk assessment in this younger age group, which is not routine in the general population. - Ages 30 to 79 years: apply the 2023 Australian CVD risk algorithm. Categories are high risk (at or above 10% over five years), intermediate risk (5 to less than 10%), and low risk (below 5%). Aboriginal and Torres Strait Islander ethnicity is a reclassification factor that may shift patients to a higher risk category. - AF screening: pulse palpation followed by ECG in people aged over 50 years, opportunistically and annually.

Chronic kidney disease screening: - Adults aged 18 years and over: annual kidney health check comprising blood pressure, eGFR, and uACR. - Referral criteria: eGFR below 45 mL/min/1.73 m2, uACR above 30 mg/mmol persistently, rapidly declining eGFR (above 10 mL/min/1.73 m2 per year), or difficult-to-treat hypertension. Lower thresholds for referral apply in Aboriginal and Torres Strait Islander people.

Cancer screening: - Cervical: National Cervical Screening Program (Cervical Screening Test every five years from age 25, or within 12 months of first sexual activity under 25). - Bowel: National Bowel Cancer Screening Program (faecal immunochemical test every two years from age 45). - Breast: BreastScreen Australia (mammography every two years from age 40 is supported given higher mortality rates despite lower incidence). - Liver: hepatocellular carcinoma surveillance (ultrasound and alpha-fetoprotein every six months) in those with cirrhosis or chronic hepatitis B.

5. Management

Management is organised around the five preventive activity domains in the National Guide: immunisation, screening, behavioural, medication, and environmental.

Behavioural interventions underpin all management. For all people regardless of identified condition, the primary care team should provide advice on smoking cessation, physical activity (at least 30 minutes of moderate-intensity activity on most days), healthy eating (vegetables, fruit, legumes, high-fibre cereals, fish, lean meats), harmful alcohol reduction, and weight management. Cultural community and family connections are formally included as a protective factor and should be recognised and supported.

Immunisation should be up to date as per the National Immunisation Program Schedule, noting that Aboriginal and Torres Strait Islander people are eligible for additional vaccines including pneumococcal vaccine (from 50 years rather than 65), hepatitis A vaccine in endemic regions, and broader influenza vaccine eligibility.

Medication for primary prevention of CVD is not routinely recommended for people with low CVD risk (below 5% over five years). For intermediate risk (5 to 10%), consider blood pressure lowering and lipid-modifying therapy depending on clinical context. For high risk (at or above 10%), prescribe blood pressure lowering and lipid-modifying therapy unless contraindicated.

For CKD with albuminuria, initiate an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) regardless of blood pressure, aiming for home systolic blood pressure of 115 to 125 mmHg if tolerated. Add a sodium-glucose cotransporter 2 (SGLT2) inhibitor as clinically indicated.

Health checks should be completed in genuine partnership with the patient, recognising individual and community strengths, and should include a plan for responding to identified health needs including recall and follow-up systems.

6. Pharmacology and AU PBS notes

Cardiovascular risk reduction: - Statins: rosuvastatin (Crestor, PBS streamlined authority not required for primary prevention at standard doses), atorvastatin (Lipitor). Target LDL cholesterol below 1.8 mmol/L in high-risk patients. - ACE inhibitors: ramipril, perindopril (PBS listed). - ARBs: candesartan, irbesartan (PBS listed). - Antihypertensives: amlodipine, hydrochlorothiazide, indapamide (PBS listed). Avoid NSAIDs in combination with ACE inhibitor and diuretic (triple whammy nephrotoxicity risk).

Diabetes prevention and management: - Metformin (PBS listed, first-line for T2D). - SGLT2 inhibitors: dapagliflozin (Forxiga), empagliflozin (Jardiance). PBS listed with streamlined authority for T2D. Also indicated for CKD with albuminuria. - Glucagon-like peptide 1 (GLP-1) receptor agonists: semaglutide (Ozempic), dulaglutide (Trulicity). PBS listed for T2D not meeting glycaemic targets. - Medications to withhold when acutely unwell or fasting (SAD MANS): Sulfonylureas, ACE inhibitors, Diuretics, Metformin, ARBs, NSAIDs, SGLT2 inhibitors.

Note: the CARPA Standard Treatment Manual (used in remote and very remote services) provides jurisdiction-specific prescribing guidance that may differ from national defaults. Services using CARPA should continue to follow that guidance for CVD risk calculation and management.

7. Complications and monitoring

Ongoing surveillance schedule:

Annual health check (MBS item 715): blood pressure, weight, BMI, waist circumference, HbA1c or FBG, eGFR, uACR, lipid profile, urine dipstick, hearing and vision assessment, immunisation review, cancer screening eligibility, mental health and social emotional wellbeing screen, smoking and substance use.
CVD risk recalculation: annually from age 12 (opportunistic risk factor assessment) and formally from age 18 to 30 (consensus statement), and from age 30 using the 2023 Australian CVD risk calculator.
CKD progression: eGFR and uACR at least annually in all adults; more frequently in those with established CKD or rapidly declining eGFR. Refer early (lower thresholds apply in Aboriginal and Torres Strait Islander patients).
Diabetes complications: annual foot examination, dilated fundoscopy or retinal photography, uACR, eGFR, and blood pressure review in all patients with T2D.
Cancer: maintain recall systems for cervical screening, bowel screening, breast screening, and hepatocellular carcinoma surveillance where indicated.
Rheumatic heart disease: annual echocardiography and benzathine penicillin prophylaxis in patients with a history of ARF, as per local and jurisdictional guidelines.
Mental health and social emotional wellbeing: screen at every health check; use trauma-informed approaches and refer to Aboriginal community controlled health service mental health workers or Aboriginal health workers where available.

The most important lever for reducing complications is ensuring sustained, trusting, long-term relationships between patients and their primary care team, with culturally safe services that include Aboriginal and Torres Strait Islander health workers and practitioners wherever possible.

Practise this in Lucan

Written for Australian practice and grounded in the guidance named above. Study material only — not medical advice. Always check against current guidelines.