Management of chronic hepatitis B virus infection in remote-dwelling Aboriginals and Torres Strait Islanders: an update for primary healthcare providers

Chronic HBV infection is common in remote Aboriginal and Torres Strait Islander communities, where resources are scarce and patients may have several concurrent illnesses. The management of chronic HBV infection has changed over recent years, with greater application of serological and radiological investigations and new, more acceptable treatments for chronic liver disease, cirrhosis and hepatocellular carcinoma. Optimal follow-up procedures for patients with chronic HBV infection are still being debated, but may not be applicable to Aboriginal and Torres Strait Islander communities where factors such as endemicity, remoteness, frequent comorbidities, shorter life expectancy and cultural differences in health priorities must be taken into consideration. We have defined an algorithm to assist primary care providers caring for patients with chronic HBV infection in Aboriginal and Torres Strait Islander communities. Patients are divided into one of three categories for follow-up and referral based on clinical features, and results of liver enzyme and serological tests.     

General practice training in Aboriginal and Torres Strait Islander health

This article reviews the history of general practice vocational training in Aboriginal and Torres Strait Islander health, identifies current initiatives and recommends future approaches based on recent evidence. General practice vocational training in Aboriginal and Torres Strait Islander health requires ongoing support and investment from governments and training and general practice organisations if the gains made to date are to be consolidated and health outcomes are to improve. In particular, investment in sustained and respectful partnerships with Aboriginal and Torres Strait Islander peoples and organisations will continue to provide the groundwork for effective training of general practitioners in this critical health area, and will also play an important role in capacity-building in Aboriginal and Torres Strait Islander communities.     

Overseas-trained doctors in Aboriginal and Torres Strait Islander health services: many unanswered questions

Aboriginal and Torres Strait Islander health services are heavily dependent on overseas-trained doctors (OTDs). These OTDs are increasingly from countries with variable English language and educational equivalency compared with locally trained doctors. Aboriginal and Torres Strait Islander health services create particular demands for all doctors, such as negotiating "cultural domains" and acknowledging the contribution of Aboriginal health workers. Little is known about the roles and experience of OTDs in health service provision in Indigenous communities. Barriers to effective research into the experience of OTDs include privacy legislation and a lack of standardised data. Researching the narratives of OTDs in Indigenous health services offers an opportunity to explore the diversity and complexity of the cultural interfaces in health service provision.     

Reform in Australian medical schools: a collaborative approach to realising Indigenous health potential

The Australian medical education system is at a critical juncture in relation to what and how it delivers for Aboriginal and Torres Strait Islander health. Since 2004, three key organisations concerned with medical education have worked to provide a toolkit for implementation of sustainable reform within medical schools. The aim is a medical workforce trained in Indigenous health, and more Aboriginal and Torres Strait Islander doctors, leading to better health for Australia's Indigenous peoples.     

The International Covenant on Economic, Social and Cultural Rights and the right to health: is Australia meeting its obligations to Aboriginal peoples?

There is evidence that Australia is not meeting its obligations to Aboriginal and Torres Strait Islander peoples for their right to the "highest attainable standard" of health, required under the International Covenant on Economic, Social and Cultural Rights (ICESCR). Poor access to primary health care for Aboriginal peoples and substantial shortfalls in government spending to address this are in violation of the ICESCR. Aboriginal and Torres Strait Islander peoples' share of the universal health coverage expenditure offered to all Australians is less per person than for other Australians. The failure to monitor the provision of mainstream health services to Aboriginal peoples and inequitable distribution of health facilities and services compound these violations. Equality in health between Indigenous and non-Indigenous Australians is achievable, but not until the shortfall in health services expenditure for Indigenous Australians is addressed.     

Remote Indigenous Australians with cataracts: they are blind and still can't see

Aboriginal and Torres Strait Islander people are three times more likely than non-Indigenous Australians to report vision loss due to cataracts, but are four times less likely to have cataract surgery. To increase access for Aboriginal and Torres Strait Islander people to cataract surgery, we need to identify the barriers to current services and trial strategies to overcome these barriers. Barriers to cataract surgery exist at the health service, community and individual level. Health service factors include infrastructure, cost, and provision of interpreters, escorts and transport. Community factors include social support, perceptions about the success of surgery, and beliefs about the causes of cataracts. Individual factors include ignorance that cataracts can be cured, fear of surgery or poor outcome, and comorbidity. Strategies proven to increase uptake of cataract surgery in other countries could be trialled in remote Australia.     

How can Australia do better for Indigenous health?

Respect, tolerance and trust in Aboriginal and Torres Strait Islander people are needed from government to improve the health and wellbeing of Indigenous Australians.     

The National Health and Medical Research Council Road Map: a strategic framework for improving Aboriginal and Torres Strait Islander health through research

What impact has the NHMRC Road Map had on Aboriginal and Torres Strait Islander health? A review process now underway aims to find out.     

Diabetes care in remote northern Australian Indigenous communities

OBJECTIVE: To assess primary care processes and clinical characteristics of adults with diabetes in remote northern Australian Indigenous communities. DESIGN: Clinical audit from diabetes registers in 21 remote primary healthcare centres in the Torres Strait Health Service District (n = 921), three in Cape York, Queensland (n = 252), and three in the Northern Territory (n = 194), between September 2002 and February 2003. PARTICIPANTS AND SETTING: Aboriginal and Torres Strait Islander adults with diabetes who were receiving their routine diabetes care in these 27 centres. MAIN OUTCOME MEASURES: Provision of regular checks for weight, blood pressure, glycaemia (HbA(1c)), proteinuria, lipid levels, renal function, eyes and feet, influenza and pneumococcal vaccination. Weight, blood pressure and glycaemic control. RESULTS: Most routine diabetes checks were delivered according to recommended schedules, except for eye and foot checks in the NT. There were uniformly high rates of appropriate treatment for hypertension and albuminuria, but low rates of insulin treatment and self-monitoring despite a high mean HbA(1c) level (8.9%). Vaccination rates were low in the NT. Torres Strait Islanders with diabetes were significantly heavier than Aboriginals, but had lower mean diastolic blood pressure (77.3 mmHg compared with 79.5 mmHg) and lower prevalence of albuminuria and smoking. CONCLUSION: A high proportion of Aboriginals and Torres Strait Islanders requiring treatment for high blood pressure and proteinuria are receiving it. However, there is dissonance between the relatively high rates of routine checks and apparent lack of therapeutic action on glycaemia. More intensive management of glycaemia, including improved nutrition, exercise and (probably) insulin, is required to reduce microvascular complications.     

Acute rheumatic fever and rheumatic heart disease in a rural central Australian aboriginal community

A retrospective study of clinical case records was conducted at the health centre of a rural central Australian Aboriginal community to determine the frequency of acute rheumatic fever and of rheumatic heart disease between 1978 and 1987. The case records of 976 residents over 5 years of age were examined for evidence of the clinical indicators of acute rheumatic fever or rheumatic heart disease; together they contributed 8015 person-years of study. During the 10-year study period, 18 patients developed acute rheumatic fever and 12 patients had rheumatic heart disease. The annual incidence of acute rheumatic fever (first and recurrent attacks) for children aged 5-14 years was 815 per 100,000 person-years. For the residents aged 5 years and over, the point prevalence for rheumatic heart disease at the end of 1987 was between 7.9 and 12.3 per 1000 persons, according to health clinic records and the official population census, respectively. These rates are similar to those reported for Third World countries. Preventive measures must include efforts by health professionals to help to alleviate the adverse living conditions in Aboriginal communities.     

Indigenous participation in the Australian Health Survey: a response

The Australian Health Survey will deliver key health measures for all Australian children and adults, and collect information across Australia. The Australian Bureau of Statistics has consulted widely on the development of the Survey, and has shaped the survey according to strong and consistent advice in relation to Aboriginal and Torres Strait Islander peoples. It is hoped that this approach will maximise survey response rates and place us in good trust to embark on the next survey round.     

Our doctors making a difference

Aboriginal and Torres Strait Islander doctors walking in both worlds for the benefit of all Australians.     

The upsurge of interest in Indigenous health in the 1950s and 1960s

During the 1950s and 1960s, there was a dramatic explosion in the number of letters to the editor about Indigenous health published in the MJA, reflecting increased reader interest. The letters from Barry Christophers were part of the Federal Council for Aboriginal Advancement's largely successful campaign for equal civil rights for Aboriginal and Torres Strait Islander people. His letters not only drew attention to discriminatory legislation and policies, but also emphasised the structural (especially economic) determinants of Indigenous ill-health, and the negative impact on Indigenous people of racist medical representations.     

Unidentified trematode eggs in faeces of Australian aboriginal children

In routine surveys for intestinal parasites among Aboriginal/Torres Strait Islander populations, eggs of unidentified trematode species have been found in the faeces of three children. In two of these, the eggs appeared to belong to a schistosome, or perhaps monogenean, species, and in the third, they were most likely from a monostome of dugongs. Although these probably represent cases of spurious parasitism, one or more may have been a true infection.     

Making a difference: the early impact of an Aboriginal health undergraduate medical curriculum

OBJECTIVE: To describe the implementation of an integrated Aboriginal health curriculum into the medical course at the University of Western Australia (UWA) and the early effect on students' perceptions of their knowledge and ability in the area of Aboriginal health. DESIGN, SETTING AND PARTICIPANTS: Final-year medical students at UWA in 2003 (first cohort) and 2004 (second cohort) were surveyed by questionnaire (with answers on a five-point Likert scale) to assess their attitudes to various aspects of Aboriginal health. A subset of students provided open-ended comments on key priorities in Aboriginal health, cultural security and suggestions for Aboriginal health policy. INTERVENTIONS: Integrated learning experiences were implemented within each year of the medical course, based on specific learning outcomes in Aboriginal health. MAIN OUTCOME MEASURES: Changes in students' self-perceptions of their preparedness for and future commitment to working for change in Aboriginal health. RESULTS: Response rates were 76% and 85% in the 2003 and 2004 cohorts, respectively. Compared with first-cohort students, second-cohort students were more likely to agree with items relating to their preparedness and ability to work with and care for Aboriginal and Torres Strait Islander people (P < 0.05); second-cohort students also reported greater preparedness to advocate and improve the health of Aboriginal people (P < 0.05); 65% of respondents in the second cohort (versus 34% in the first) agreed they had a social responsibility to work for change in Aboriginal health (P < 0.05). CONCLUSION: With a relatively small amount of targeted and structured teaching and learning in Aboriginal health, significant shifts in students' self-perceived levels of knowledge, skills and attitudes are possible.     

Indigenous health: effective and sustainable health services through continuous quality improvement

The Australian government's Healthy for Life program is supporting capacity development in Indigenous primary care using continuous quality improvement (CQI) techniques. An important influence on the Healthy for Life program has been the ABCD research project. The key features contributing to the success of the project are described. The ABCD research project: uses a CQI approach, with an ongoing cycle of gathering data on how well organisational systems are functioning, and developing and then implementing improvements; is guided by widely accepted principles of community-based research, which emphasise participation; and adheres to the principles and values of Indigenous health research and service delivery. The potential for improving health outcomes in Aboriginal and Torres Strait Islander communities using a CQI approach should be strengthened by clear clinical and managerial leadership, supporting service organisations at the community level, and applying participatory-action principles.     

Challenging perceptions of non-compliance with rheumatic fever prophylaxis in a remote Aboriginal community

AIM: To identify factors that affect rheumatic fever prophylaxis for remote-living Aboriginal patients, and to determine the proportion who received adequate prophylaxis. DESIGN AND SETTING: Interview (with analysis based on principles of grounded theory) of patients with a history of rheumatic fever or rheumatic heart disease and their relatives, and health service providers in a remote Aboriginal community; audit of benzathine penicillin coverage of patients with rheumatic heart disease. PARTICIPANTS: 15 patients with rheumatic heart disease or a history of rheumatic fever, 18 relatives and 18 health care workers. RESULTS: Patients felt that the role of the clinic was not only to care for them physically, but that staff should also show nurturing holistic care to generate trust and treatment compliance. Differing expectations between patients and health care providers relating to the responsibility for care of patients absent from the community was a significant factor in patients missing injections. Neither a biomedical understanding of the disease nor a sense of taking responsibility for one's own health were clearly related to treatment uptake. Patients did not generally refuse injections, and 59% received adequate prophylaxis (> 75% of prescribed injections). CONCLUSION: In this Aboriginal community, concepts of being cared for and nurtured, and belonging to a health service were important determinants of compliance.     

Long-term trends in Indigenous deaths from chronic diseases in the Northern Territory: a foot on the brake, a foot on the accelerator

OBJECTIVE: To examine trends in Northern Territory Indigenous mortality from chronic diseases other than cancer. DESIGN: A comparison of trends in rates of mortality from six chronic diseases (ischaemic heart disease [IHD], chronic obstructive pulmonary disease [COPD], cerebrovascular disease [CVD], diabetes mellitus [DM], renal failure [RF] and rheumatic heart disease [RHD]) in the NT Indigenous population with those of the total Australian population. PARTICIPANTS: NT Indigenous and total Australian populations, 1977-2001. MAIN OUTCOME MEASURES: Estimated average annual change in chronic disease mortality rates and in mortality rate ratios. RESULTS: Death rates from IHD and DM among NT Indigenous peoples increased between 1977 and 2001, but this increase slowed after 1990. Death rates from COPD rose before 1990, but fell thereafter. There were non-significant declines in death rates from CVD and RHD. Mortality rates from RF rose in those aged > or = 50 years. The ratios of mortality rates for NT Indigenous to total Australian populations from these chronic diseases increased throughout the period. CONCLUSIONS: Mortality rates from IHD and DM in the NT Indigenous population have been increasing since 1977, but there is evidence of a slower rise (or even a fall) in death rates in the 1990s. These early small changes give reason to hope that some improvements (possibly in medical care) have been putting the brakes on chronic disease mortality among Aboriginal and Torres Strait Islander peoples.     

Reducing the burden of cancer for Aboriginal and Torres Strait Islander Australians: time for a coordinated, collaborative, priority-driven, Indigenous-led research program

Australia's efforts to prevent, diagnose and treat cancer are not as successful for Aboriginal and Torres Strait Islander people as they are for other Australians. There is a need for a nationally coordinated, collaborative, priority-driven research effort to better understand what works, and we need to implement that knowledge. All aspects of the process must involve genuine Indigenous leadership and participation.