Indigenous health and community services employment in remote Northern Territory: a baseline examination of 2006 and 2001 Census data

Objective: To establish a baseline of levels of Indigenous professional engagement in the health and community services sector in remote Northern Territory. Design: Analysis of data from 2001 and 2006 Census. Setting: Northern Territory – Balance Statistical Division. Participants: Persons employed in health and community services sector in 2006. Main outcome measures: Indigenous status, level of education, current education status, occupation type and residential mobility. Results: Indigenous employment grew by 137% between 2001 and 2006. In 2006, 42% of Indigenous employees were labourers and 9% professionals, in contrast to non‐Indigenous workers of whom 41% were professionals and 5% labourers. Over 50% of workers who moved into the region between 2001 and 2006 were professionals, compared with 20% of those who had remained in the region. Indigenous in‐migrants were twice as likely as Indigenous people who had stayed in the region to be professionals. Indigenous workers were much less likely to have post‐school educational qualifications than non‐Indigenous workers. Indigenous workers were also less likely to be studying for a post‐school qualification. Indigenous in‐migrants were three times as likely to have post‐school qualifications than Indigenous people who had remained in the region and were also more likely to be enrolled in post‐school education. Conclusions: The baseline is low Indigenous engagement as professional labour, and low Indigenous engagement in formal education. Mobile Indigenous people have higher levels of engagement. The situation might be addressed by increased formal education in remote areas and increased mobility of Indigenous health labour.     

Doing it hard in the bush: Aligning what gets measured with what matters

What gets measured gets managed. Funding of health services is substantially determined by operational activity and specific outcome indicators. In day‐to‐day clinical decision‐making, surrogate markers, such as glycosylated haemoglobin and blood pressure, are commonly used to modify risks of ‘hard’ outcomes that include kidney failure, ischaemic cardiac events, stroke and all‐cause mortality. In many settings, surrogates are all we have to go on. As a consequence, current health funding models heavily rely on surrogate‐based key performance indicators [KPIs]. While surrogates are convenient and provide immediate information, there is an obligation to ensure that they are appropriate, reliable and validated in context. In contrast, hard outcomes, the real consequences of illness, are usually realised over an extended timeframe. Additionally, and for a host of reasons, hard endpoints have the greatest social, emotional and economic impact for people at the far end of the health system; those in rural and remote settings – ‘in the bush’ – especially Indigenous Australians. We propose a health service assessment approach that aligns short‐term decision‐making with patient‐centred and longer term hard outcomes, one that takes into account community, cultural and environmental factors, especially remoteness. Communities should have a major say in determining what health indicators are measured and managed.     

The comparison of health status and health services utilisation between Indigenous and non-Indigenous infants in Australia

Objective: To examine the differences in health services utilisation and the associated risk factors between Indigenous and non-Indigenous infants at a national level in Australia.
Methods: We analysed data from a national representative longitudinal study, the Longitudinal Study for Australian Children (LSAC) starting in 2004. We used survey logistic regression and survey multiple linear regression to examine the factors associated with health services utilisation.
Results: Health status of Indigenous infants was poorer than that of non-Indigenous. In comparison to non-Indigenous infants, in the previous 12-month period, the Indigenous infants were significantly less likely to use the following health services: maternal and child health centre or help lines (OR=0.35, 95%CI: 0.24-0.49); maternal and child health nurse visits (OR=0.45, 95%CI: 0.32-0.63); general practitioners (GPs) (OR=0.45, 95%CI: 0.31-0.64); and paediatrician (OR=0.52, 95%CI: 0.35-0.77). In contrast, they were more likely to visit a hospital outpatient clinic (OR=1.82, 95%CI: 1.16-2.85). Mothers' age, education and marital status were associated with certain health services use. Financial status and residential location were the important predictors of the use of health services.
Conclusion: The rates of health services utilisation by Indigenous infants were lower and were associated with mothers' characteristics and socio-economic status.
Implications: The gaps in health services utilisation between Indigenous and non-Indigenous infant requires immediate policy initiatives. Further research is needed to explore the causal pathways between health status, health services utilisation and multiple risk factors at different levels.     

Traditional food availability and consumption in remote Aboriginal communities in the Northern Territory,Australia

Objective: To explore availability, variety and frequency consumption of traditional foods and their role in alleviating food insecurity in remote Aboriginal Australia. Methods: Availability was assessed through repeated semi‐structured interviews and consumption via a survey. Quantitative data were described and qualitative data classified. Results: Aboriginal and non‐Indigenous key informants (n=30 in 2013; n=19 in 2014) from 20 Northern Territory (NT) communities participated in interviews. Aboriginal primary household shoppers (n=73 in 2014) in five of these communities participated in a survey. Traditional foods were reported to be available year‐round in all 20 communities. Most participants (89%) reported consuming a variety of traditional foods at least fortnightly and 71% at least weekly. Seventy‐six per cent reported being food insecure, with 40% obtaining traditional food during these times. Conclusions: Traditional food is consumed frequently by Aboriginal people living in remote NT. Implications for public health: Quantifying dietary contribution of traditional food would complement estimated population dietary intake. It would contribute evidence of nutrition transition and differences in intakes across age groups and inform dietary, environmental and social interventions and policy. Designing and conducting assessment of traditional food intake in conjunction with Aboriginal leaders warrants consideration.     

Community, social capital and Indigenous health in the Northern Territory

Objective. The objective of this paper is to explore the discourse of ‘community’ and its offshoots, ‘social capital’ and ‘community capacity building’, in the contexts of health service delivery to, and the health status of, Indigenous people in the Northern Territory of Australia, and to link this discourse to the wider context of social control and the management of diversity in a multicultural society.

Design. The discourse is subjected to critical theoretical and historical analysis and comparisons are drawn between this and similar discourses in the immigration and settlement area.

Results/conclusions. The constitution of Indigenous society as a series of ‘communities’ and the orientation of primary health care policy towards ‘capacity building’ has the effect, if not the intention, of depoliticising Indigenous health, whilst reproducing, legitimising and mystifying relations of white dominance and permitting the maintenance of a health service delivery system for Indigenous people which, in relation to need, is grotesquely underfunded and incapable of making serious inroads into the appalling health problems of the Indigenous population.     

Preventable infant deaths,lone births and lack of registration in Mexican indigenous communities: health care services and the afterlife of colonialism

ABSTRACT

Mexico’s indigenous communities continue to experience higher levels of mortality and poorer access to health care services than non-indigenous regions, a pattern that is repeated across the globe. We conducted a two-year ethnographic study of pregnancies and childbirth in an indigenous Wixárika community to explore the structural causes of this excess mortality. In the process we also identified major differences between official infant mortality rates, and the numbers of infants born to women in our sample who did not survive.

We interviewed 67 women during pregnancy and followed-up after the birth of their child. At baseline, socio-demographic data was collected as well as information regarding birthing intentions. In depth-interviews and semi-structured interviews were conducted with 62 of these women after the birth of their child, using a checklist of questions. Women were asked about choices regarding, and experiences of childbirth.

Of the 62 women we interviewed at follow-up 33 gave birth at home without skilled attendance and five gave birth completely alone in their homes. Five neonates died during labour or the perinatal period. Concerns about human resources, the structure of service delivery and unwanted interventions during childbirth all appear to contribute to the low institutional childbirth rate. Our data also suggests a low rate of death registration, with the custom of burying infants where they die. This excess mortality, occurring in the context of unnecessary lone and unassisted childbirth are structurally generated forms of violence.     

Acute rheumatic fever: adherence to secondary prophylaxis and follow up of Indigenous patients in the Katherine region of the Northern Territory

OBJECTIVE: This paper evaluates adherence with secondary preventative treatment and follow up of acute rheumatic fever (ARF) within the Katherine region of the Northern Territory after the introduction of an ARF register. We aimed to assess the rate of adherence with penicillin prophylaxis and follow-up guidelines in patients with previous ARF and the effect of factors such as age, sex, disease severity and clinic attendance. DESIGN: Retrospective study. SETTING: Five Indigenous Community Health Centres located in the Katherine region of the Northern Territory, Australia. PARTICIPANTS: Fifty-nine people resident in five communities who were prescribed monthly prophylactic penicillin for ARF during the 24 months between September 2002 and September 2004. All subjects were Indigenous. MAIN OUTCOME MEASURE: Main outcome measures were the number of penicillin injections received over the 24-month period and frequency of echocardiogram and specialist follow up in comparison to Rheumatic Fever Registry Guidelines. RESULTS: Mean adherence with prophylaxis was 56% of prescribed doses. A non-significant trend towards improved adherence was seen in children, patients with less severe disease and those who attended the clinic more frequently. Rheumatic Fever Registry Guidelines for echocardiogram and specialist review were met by 63% and 59% of subjects, respectively. CONCLUSION: Within this population adherence with penicillin prophylaxis is inadequate to protect against recurrence of ARF and consequent worsening of rheumatic heart disease. In addition, the Rheumatic Fever Registry Guidelines for specialist follow up and echocardiogram are not being adhered to for many patients.     

Trends in hepatitis B prevalence and associated risk factors among Indigenous and non‐Indigenous prison entrants in Australia, 2004 to 2013

Objective : This study describes and compares prevalence trends of markers for hepatitis B (HBV) from 2004 to 2013 and HBV risk factors between Indigenous and non‐Indigenous prison entrants. Methods : A cross‐sectional survey carried out over two weeks in 2004, 2007, 2010 and 2013 in reception prisons in New South Wales, Queensland, Western Australia and Tasmania. Results : The study included 2,223 prison entrants; 544 were Indigenous. Indigenous prison entrants had significantly higher hepatitis B core antibody (anti‐HBc) prevalence than non‐Indigenous prisoners in 2004 (29% vs. 18%, P=0.026), 2007 (40% vs. 15%, P<0.001) and 2010 (21% vs. 16% 2010, P=0.002), and similar anti‐HBc prevalence to non‐Indigenous entrants in 2013 (14% vs. 14%, P=0.888), with a significant decline from 2007 for Indigenous entrants (P=0.717)^?. Being more than 30 years old and coming from an area classified as ‘non‐highly accessible’ were associated with anti‐HBc positivity in both populations. For Indigenous prison entrants, first time in prison and survey year was associated with anti‐HBc positivity. For non‐Indigenous participants, a history of injecting drug use and body piercings was associated with anti‐HBc positivity. Conclusion : There are unique risk factors associated with HBV prevalence for both Indigenous and non‐Indigenous prison entrants. Implications for public health : In developing public health programs and policies for HBV, consideration of similarities and differences of associated HBV risk factors between Indigenous and non‐Indigenous offenders is required.     

PneuMum: Impact from a randomised controlled trial of maternal 23-valent pneumococcal polysaccharide vaccination on middle ear disease amongst Indigenous infants,Northern Territory,Australia

BackgroundWe assessed maternal 23-valent pneumococcal polysaccharide (23vPPV) vaccine efficacy (VE) against middle ear disease and pneumococcal carriage amongst Australian Indigenous infants.MethodsIn an open label, allocation concealed, outcome-assessor blinded, community stratified, randomised controlled trial, healthy pregnant Indigenous women aged 17–39 years in the Northern Territory of Australia received the 23vPPV (1:1:1) at: 30–36 weeks gestation, birth, or were unvaccinated (ClinicalTrials.gov NCT00714064). Co-primary outcomes were the point prevalences of infant middle ear disease and 23vPPV-type carriage at age 7 months.ResultsThe consent rate was 50% (313/632). Among 227 eligible participants randomised, retention rates were 86% (66/77) controls; 89% (67/75) pregnancy vaccinees; 88% (66/75) birth vaccinees. At infant age 7 months, ear disease prevalence was: 71% (47/66) controls, 63% (42/67) pregnancy vaccinees, 76% (50/66) birth vaccinees; and 23vPPV-type carriage was: 26% (17/66) controls, 18% (12/67) pregnancy vaccinees, 18% (12/66) birth vaccinees. For pregnancy vaccinees, VE was 12% (95% CI −12% to 31%) against infant ear disease and 30% (95% CI −34% to 64%) against 23vPPV-type carriage. In a post-hoc analysis, VE against infant ear disease concurrent with carriage of 23vPPV or related types was 51% (95% CI −2% to 76%). There were no serious adverse effects following receipt of the 23vPPV in pregnancy or at birth.ConclusionsIn a high risk population, our study was unable to demonstrate efficacy of 23vPPV in pregnancy against the co-primary outcomes of either all-cause infant ear disease or 23vPPV-type nasopharyngeal carriage at age 7 months. Efficacy against ear disease concurrent with carriage of vaccine-related serotypes (a more specific outcome) suggests 23vPPV in pregnancy may complement childhood pneumococcal vaccination programs.     

Pragmatic indicators for remote Aboriginal maternal and infant health care: why it matters and where to start

Objective: There are challenges in delivering maternal and infant health (MIH) care to remote Northern Territory (NT) communities. These include fragmented care with birthing in regional hospitals resulting in cultural and geographical dislocation for Aboriginal women. Many NT initiatives are aimed at improving care. Indicators for evaluating these for remote Aboriginal mothers and infants need to be clearer. We reviewed existing indicators to inform a set of pragmatic indicators for reporting improvement in remote MIH care. Methods: Scientific databases and grey literature (organisational websites and Google Scholar) were searched using the terms ‘Aboriginal/maternal/infant/remote health/monitoring performance’. Key stakeholders identified omitted indicators sets. Relevant sets were reviewed and organised by indicator type, stage of patient journey, topic and theme. Results: Forty‐two indicators sets were found. Seven focused on Aboriginal health, 23 on reproductive/maternal health, eight on child/infant health and four on other aspects, e.g. remote health. We identified more than 1,000 individual indicators. Of these, 656 were relevant for our purpose and were subsequently organised into 300 topics and 16 themes for antenatal, birth and postpartum, and infant care by indicator type. Conclusion: There are many measures for monitoring health care delivery to mothers and infants. Few are framed around remote MIH services, despite poorer health outcomes of remote mothers and infants and the specific challenges with providing care in this setting. Establishing relevant indicators is vital to support relevant data collection and the development of appropriate policy for remote Aboriginal maternal and infant care.     

Discourses within the roles of Remote Area Nurses in Northern Territory (Australia) government-run health clinics

The Northern Territory (NT) government operates remote clinics which are primarily staffed by Aboriginal Health Practitioners and Remote Area Nurses (RANs). RAN practice has been described as particularly complex due to high health needs, workforce shortages and high levels of turnover in remote Aboriginal communities. While individual incentives are offered, there has been little examination of the role and why the work takes such a toll on RANs. This study aims to identify dominant discourses underpinning RAN practice and how these discourses reflect tensions and reinforce power relations that impact on the RAN role. Discourses were identified from a Foucauldian-inspired discourse analysis of 29 interviews with RANs in six remote NT communities. Five dominant discourses were identified, namely, that permanent RANs are preferred to agency RANs, RANs portray themselves as experienced and certain, RANs use autonomous clinical judgement, Aboriginal staff are important and RAN’s belief in making a difference. However, the experience of RANs suggested that there are many types of employment that learning from was also important, RANs often struggled to work with Aboriginal staff and they were unsure if they were making a difference. Furthermore, these discourses created tensions between RANs who were permanent–agency, older–younger, experienced–newer and certain–reflexive. Deconstructing these rigid discourses could allow the RAN role to be reconstructed in ways that lead to better retention, job satisfaction and health outcomes.     

Haemophilus influenzae type b carriage in Indigenous children and children attending childcare centers in the Northern Territory, Australia, spanning pre- and post-vaccine eras

This paper investigates Haemophilus influenzae type b (Hib) carriage in Indigenous children and children attending childcare centres in the Northern Territory of Australia, 1992-2005. More than 10 years after the introduction of the Hib conjugate vaccine, Hib carriage persists in Indigenous children (3.4%, 2003-2005) and children attending childcare centres (0.2%, 2004). This is the first Australian study to examine Hib carriage spanning the pre- and post-vaccination eras. Increasing carriage rates contribute to Hib disease resurgence especially in those with higher disease burdens, such as remote Indigenous Australians, ongoing carriage surveillance provides a sentinel warning system for invasive disease.

Background

Following the introduction of H. influenzae type b (Hib) conjugate vaccine to Australia in 1993 as a three dose (2, 4, 12 month) schedule, the incidence of Hib disease decreased dramatically in children, especially in those aged under 5 years. We investigate Hib carriage in Indigenous children and children attending childcare centres from the Northern Territory (NT) of Australia between 1992 and 2005. We report Hib carriage rates in this well vaccinated population, with previously documented high rates of invasive disease.

Methods

Hib carriage was reviewed in nasopharyngeal or nasal swabs collected between 1992 and 2005; from over 2000 children (61% Indigenous) aged 0-6 years enrolled in 7 otitis media or carriage surveillance studies in the NT.

Results

More than 10 years after the introduction of the Hib conjugate vaccine, Hib carriage persists at low levels, but at a higher rate in Indigenous children (3.4%, 2003-2005) than children attending childcare centres (0.2%, 2004), in the NT of Australia.

Conclusions

This is the first Australian study to examine Hib carriage spanning the pre- and post-vaccination eras. Ongoing carriage surveillance provides a sentinel warning system for invasive disease. This notifies public health professionals of potential invasive disease, creating early warning systems for intervention if Australian Indigenous children or children attending childcare centres are to follow current international trends associated with high rates of carriage preceding invasive disease—despite high vaccination rates. Internationally there is growing concern that increasing carriage rates are the driving force behind Hib disease resurgence especially in those with higher disease burdens, such as remote Indigenous Australians. Changes to the vaccination schedule from PRP-OMPC (PedvaxHIB^®), to PRP-T (2, 4, 6, 12 months) from January 2010—may affect carriage and in time, invasive disease rates. This work is important for national and International comparisons as well as feeding back information to vaccine policy makers of the Hib carriage environment throughout this period.     

Disadvantage and discontent: a review of issues relevant to the mental health of rural and remote Indigenous Australians

OBJECTIVE: To provide an overview of the mental health of Aboriginal and Torres Strait Islander residents of rural and remote Australia and to identify associated factors. FINDINGS: Indigenous Australians have higher rates of serious mental disorders and of mental health problems associated with social disadvantage. This disadvantage is greater for Indigenous Australians living outside metropolitan centres. Contrary to romanticised constructions of remote Aboriginal Australia, those living in such settings are not immune to such hardship - which is often unrelenting. The psychological and behavioural problems that emerge as a result are compounded by narrowly focused and inadequate mental health services, with children being particularly vulnerable. CONCLUSION: Indigenous residents of rural and remote Australia experience high levels of mental disorder. Although addressing the predisposing social disadvantage will demand significant whole-of-government investment, ensuring equitable access to effective mental health services is an immediate priority.     

Overseas‐trained doctors in Indigenous rural health services: negotiating professional relationships across cultural domains

Objective: To examine how OTDs and staff in rural and remote Indigenous health contexts communicate and negotiate identity and relationships, and consider how this may influence OTDs’ transition, integration and retention. Method: Ten case studies were conducted in rural and remote settings across Australia, each of an OTD providing primary care in a substantially Indigenous practice population, his/her partner, co‐workers and Indigenous board members associated with the health service. Cases were purposefully sampled to ensure diversity in gender, location and country of origin. Results: Identity as ‘fluid’ emerged as a key theme in effective communication and building good relationships between OTDs and Indigenous staff. OTDs enter a social space where their own cultural and professional beliefs and practices intersect with the expectations of culturally safe practice shaped by the Australian Indigenous context. These are negotiated through differences in language, role expectation, practice, status and identification with locus with uncertain outcomes. Limited professional and cultural support often impeded this process. Conclusion: The reconstruction of OTDs’ identities and mediating beyond predictable barriers to cultural engagement contributes significantly not only to OTDs’ integration and, to a lesser extent, their retention, but also to maximising effective communication across cultural domains. Implications: Retention of OTDs working in Indigenous health contexts rests on a combination of OTDs’ capacity to adapt culturally and professionally to this complex environment, and of effective strategies to support them.     

A bibliometric analysis of research on Indigenous health in Australia, 1972-2008

Objective: To determine the growth patterns and citation volume of research publications referring to Indigenous health in Australia from 1972 to 2008 compared to seven selected health fields. Methods: Web of Science was used to identify all publications (n=820) referring to the health of Indigenous Australians authored by Australian researchers, 1972 to 2008. Citations for each publication were also captured. Growth was compared with selected health fields as well as with overall Australian research publications. Results: Research publications referring to Indigenous health, while remaining relatively small in number, grew at an average annual rate of 14.1%, compared with 8.2% across all fields of Australian research. The growth rate shown was equal second highest in our seven categories of health and medical research. However, Indigenous publications were cited significantly less than the Australian average. Conclusions: While there has been positive growth in publications referring to Indigenous health, the attention paid to this research through citations remains disappointingly low. Implications: Given that research concentration and impact can be an index of how seriously a nation considers a health problem, the low visibility of Australian research examining Indigenous health does not demonstrate a level of concern commensurate with the gravity of Indigenous health problems. Further investigation for the reasons for lower citations may identify potential intervention strategies.     

Housing and health in Indigenous communities: key issues for housing and health improvement in remote Aboriginal and Torres Strait Islander communities

Indigenous people living in remote communities face some particular difficulties with regard to housing and its impact on their health. This paper reviews the contemporary international understanding of the relationship between housing and health, the history of settlement and housing conditions in remote Aboriginal and Torres Strait Islander communities, and some of the recent initiatives to improve housing in these communities.     

Lessons for Aboriginal tobacco control in remote communities: an evaluation of the Northern Territory 'Tobacco Project'

Objective: To evaluate a Northern Territory (NT) government-led pilot 'Tobacco Project' in six remote communities.
Methods: Monthly surveys of staff, semi-structured interviews with staff and community members, observation of the delivery of tobacco control interventions, review of Project documents, and monitoring of tobacco consumption using sales (or wholesale orders) of tobacco.
Results: There was a substantive amount of tobacco control activity delivered in three of the Project communities. In two of these locations, the majority of work was primarily driven and undertaken by resident staff. Overall, most of the Project's efforts related to community education and awareness-raising. There was variable impact of the Project on tobacco consumption across the six communities. More tobacco control activity was consistently associated with a greater reduction in tobacco consumption. An important predictor of local activity was the presence of strong community drivers. A significant obstacle to the Project was the lack of new resources.
Conclusions: Despite the minimal impact of this Project on tobacco consumption overall, there was a consistent association between on-the-ground tobacco control activity and reductions in tobacco consumption.
Implications: New initiatives will not only need to provide new funding, but identify and then support local staff, who are central to improving local tobacco control activity and so reducing smoking and smoking-related illnesses and deaths.