The acceptability of a depression screening tool in an urban, Aboriginal community-controlled health service

OBJECTIVE: To assess the acceptability and face validity of a psychological assessment instrument, the Patient Health Questionnaire 9 (PHQ-9), as a depression screening tool for use with Aboriginal and Torres Strait Islander patients. METHODS: Four focus groups were held in an urban, Aboriginal community-controlled health service. Participants' attitudes to screening for depression and the specific components of PHQ-9 were explored. RESULTS: Process-oriented and PHQ-9-specific themes were raised. They included the role of family in the screening process, the need for a trusting relationship between the tool administrator and patient, the risk of confounding by social disadvantage or physical co-morbidities, the absence of a question assessing the presence of anger as a symptom of depression, and the importance of culturally appropriate language within the tool. CONCLUSION: Modification of the screening process and wording of the PHQ-9 in response to these concerns should render it acceptable for use with Aboriginal and Torres Strait Islander patients in this setting. IMPLICATIONS: These results may apply to the use of other psychological screening tools in the Aboriginal and Torres Strait Islander population. This is particularly relevant given the policy emphasis on screening in Indigenous health.     

Challenges,choices, and Canada

The Canadian Coordinating Office for Health Technology Assessment (CCOHTA) was established by the Federal, Provincial, and Territorial Ministers of Health in 1989 for a 3-year trial period. In 1993 CCOHTA was made a permanent organization and in 1999 the Deputy Ministers of Health renewed CCOHTA's mandate and increased its funding. CCOHTA's role is to coordinate health technology assessment (HTA) priorities across jurisdictions, foster and undertake assessment activity, and function as a clearinghouse for technology assessment results while increasing healthcare system stakeholder awareness of HTA findings. The coordinated and collaborated approach adopted by CCOHTA minimizes duplication with other national and provincial organizations and contributes to the ability of the Canadian healthcare system to continue to deliver high-quality health care to its constituents.     

Pap smear screening at an urban Aboriginal health service: report of a practice audit and an evaluation of recruitment strategies

A culturally appropriate women's health service was established at an Aboriginal community-controlled health service in Darwin in 1994. An initial file audit found that 48% of included women had ever been screened with a Pap smear and 37% of women were considered to have been adequately screened. The enhancement of opportunistic screening by file tagging had a modest effect on screening coverage over a 12-month period for women who attended the health service. The proportion of these women who were adequately screened increased from 43% to 48% and of those ever screened increased from 54% to 62%. A randomised trial of recruitment interventions including personal approach, letter and control groups was subsequently performed for women for whom Pap smears were overdue or not recorded. The impact of both interventions on the number of Pap smears performed was low, with 7% of women in the personal approach group, 2% of women in the letter group and no women in the control group having Pap smears during the three-month follow-up period. Low rates of abnormalities were observed for women having Pap smears over a two-year period. The minimal effect of a formal reminder system and letters at this urban Aboriginal health service has resulted in a re-orientation of activities towards strengthening opportunistic screening and the continued promotion of Pap smears in a range of clinic and community settings. It is important to place Pap smear screening in the context of other social, economic and health priorities for Aboriginal women and health workers.     

Aboriginal Physician Use in Canada: Location,Orientation and Identity

The main objectives of this paper are to compare Aboriginal and Canadian health status and physician use and to identify the factors associated with the use of physician services. Data are drawn from the 1991 Aboriginal Peoples Survey (APS) and the 1991 General Social Survey (GSS), which are weighted random samples of the Aboriginal and total Canadian populations, respectively. The results demonstrate that Aboriginals were much less likely to use physician services, even though Aboriginals rank their health similarly to the total Canadian population. Location becomes an important aspect of both physician use and health status, with Aboriginals residing on-reserve generally having lower levels of self-assessed health and less likely to have seen a physician. While Aboriginals with the poorest health status were more likely to have seen a physician, other factors including education were found to be barriers to use of health care. Aboriginal identity and cultural orientation provided mixed results. © 1997 by John Wiley & Sons, Ltd.     

The Gudaga Study: establishing an Aboriginal birth cohort in an urban community

Objective: This paper describes the establishment of the Gudaga Study, an Aboriginal birth cohort in south‐west Sydney, and our approach to follow‐up of participants. The Study describes the health, development, and services use of Aboriginal infants and their mothers. The research team works closely with the local Aboriginal community to implement the research. Methods: All mothers in the maternity ward of an urban hospital were surveyed to identify mothers with an Aboriginal infant. These and some additional mothers identified through other networks were recruited to the study. Results: The number of mothers were surveyed was 2,108. Mothers of Aboriginal infants were younger (25.3 years compared to 28.4 years, p<0.001), less likely to be married (16.1% cf. 58.4%, p<0.001) and to have completed school (63.2% cf. 77.8%, p=0.002) than mothers of non‐Aboriginal infants. Of 155 identified mothers of Aboriginal infants, 136 were recruited and 23 through other networks. At 12 months, 85.5% of infants were followed up. Conclusions: This study, to our knowledge, is the first cohort study of this kind on the eastern seaboard of Australia. The study has strong community support and follow‐up, contrary to views that Aboriginal people are reluctant to participate in research. These data have national and regional significance.     

Relation of child,caregiver, and environmental characteristics to childhood injury in an urban Aboriginal cohort in New South Wales,Australia

Objective : Despite being disproportionately affected by injury, little is known about factors associated with injury in Aboriginal children. We investigated factors associated with injury among urban Aboriginal children attending four Aboriginal Community Controlled Health Services in New South Wales, Australia. Methods : We examined characteristics of caregiver‐reported child injury, and calculated prevalence ratios of ‘ever‐injury’ by child, family, and environmental factors. Results : Among children in the cohort, 29% (n=373/1,303) had ever broken a bone, been knocked out, required stitches or been hospitalised for a burn or poisoning; 40–78% of first injuries occurred at home and 60–91% were treated in hospital. Reported ever‐injury was significantly lower (prevalence ratio ≤0.80) among children who were female, younger, whose caregiver had low psychological distress and had not been imprisoned, whose family experienced few major life events, and who hadn't experienced alcohol misuse in the household or theft in the community, compared to other cohort members. Conclusions : In this urban Aboriginal child cohort, injury was common and associated with measures of family and community vulnerability. Implications for public health : Prevention efforts targeting upstream injury determinants and Aboriginal children living in vulnerable families may reduce child injury. Existing broad‐based intervention programs for vulnerable families may present opportunities to deliver targeted injury prevention.     

Patient preferences and adherence to colorectal cancer screening in an urban population

We measured patient preferences for colorectal cancer (CRC) screening strategies and actual receipt of alternative CRC screening tests among an urban minority sample participating in an intervention study. The fecal occult blood test was the most preferred test, reportedly owing to its convenience and the noninvasive nature. For individuals who obtained a test that was other than their stated preference (41.1%), reasons for this discordance may be due to physician preferences that override patient preferences.     

Influences on infant–feeding beliefs and practices in an urban Aboriginal community

Abstract: The Victorian Aboriginal Health Service initiated a project to increase breastfeeding rates in the Melbourne Aboriginal community. The results of focus–group discussions on infant–feeding experiences and beliefs provided a wealth of information for the design of appropriate interventions. Most women wanted and expected to breast–feed. Some chose artificial feeding because of embarrassment, a belief that it is as good as breast–feeding, or perceptions that breast–feeding is painful and inconvenient. The most common reasons that women stopped breast–feeding were sore nipples, worries about their supply of milk and tiredness. Lack of knowledge, hospital practices, lack of support and appropriate advice, and lack of confidence and self–esteem contributed to these problems. Disruption of the passing on of knowledge of healthy infant–feeding practices between generations is another cultural loss suffered by Aboriginal communities. Efforts to restore traditional rates of breast–feeding need to be under Aboriginal control and to take account of these influences. ( Aust N Z J Public Health 1997; 21: 504–10)     

Novel HIV-1 recombinant forms in antenatal cohort, Montreal, Quebec, Canada

Near full-length genomes of 4 unclassified HIV-1 variants infecting patients enrolled in an antenatal cohort in Canada were obtained by sequencing. All 4 variants showed original recombination profiles, including A1/A2/J, A1/D, and A1/G/J/CRF11_cpx structures. Identification of these variants highlights the growing prevalence of unique recombinant forms of HIV-1 in North America.     

An evaluation of opioid replacement pharmacotherapy in an urban Aboriginal Health Service

OBJECTIVE: This study aimed to evaluate the opioid replacement pharmacotherapy at Winnunga Nimmityjah Aboriginal Health Service (Winnunga) in the Australian Capital Territory. METHODS: Existing and new adult patients at Winnunga who were receiving opioid replacement pharmacotherapy were recruited. Twenty-one of 30 eligible patients participated in this cohort study. The Brief Treatment Outcome Measure was administered to patients twice with an interval of at least three months. Primary outcome measures were retention rate in the program and self-reported heroin use. RESULTS: Eighty-one per cent (17/21) of patients remained in treatment at three months. Median self-reported heroin use for existing patients was 0 days/month at initial interview and follow-up (95% CI 0-1). There was no significant difference between self-reported heroin use at initial and follow-up interview (paired Wilcoxon test, R=10, alpha=0.05). Mean self-reported heroin use was 1.5 days/month at initial interview and 2.4 days/month at follow-up. CONCLUSION: The retention rate of 81% and low levels of heroin use suggest that opioid replacement pharmacotherapy at Winnunga is comparable to the outcomes of mainstream treatment programs. IMPLICATIONS: Opioid replacement pharmacotherapy is beneficial to opioid-dependent Aboriginal people in urban settings. Access to this treatment in culturally appropriate settings needs to be expanded.     

School screening in remote Aboriginal communities — results of an evaluation

As part of ongoing quality assurance, the effectiveness of the school screening program in meeting the health needs of Aboriginal children in a rural district in the Northern Territory Top End was evaluated. The major health problems of Aboriginal children were analysed for their suitability for screening programs. A prospective cross-sectional study used routinely collected field data from the school screening program in 1993. To ascertain follow-up, children who had failed screening tests had their clinic notes reviewed. A total of 774 children from 11 remote communities were screened.
The results confirmed high level of disease, with rates for anaemia, malnutrition and trachoma reaching 39%, 22% and 26% respectively. Nearly one-third failed the hearing screening, urinalysis was abnormal in 19%, 3% failed visual acuity and 6% were considered to have abnormal heart auscultation.
Many of the major health problems did not meet the recommended criteria for screening programs and others would be better dealt with by ongoing surveillance rather than a single screening. Some abnormalities found on screening were inadequately investigated and/or treated. This evaluation has demonstrated a limited role for school screening in identifying and meeting the health needs of Aboriginal children living in remote areas. In collaboration with the NT Department of Education, a school-age child health policy, including a new school-age child health surveillance program, is being developed. This promotes greater participation by communities, families and schools with the aim of improving the health and learning outcomes for all school-age children in the NT.     

A socioecological framework to understand weight-related issues in Aboriginal children in Canada

Obesity prevention efforts in Aboriginal (First Nations, Métis, or Inuit) communities in Canada should focus predominantly on children given their demographic significance and the accelerated time course of occurrence of type 2 diabetes mellitus in the Aboriginal population. A socioecological model to address childhood obesity in Aboriginal populations would focus on the numerous environments at different times in childhood that influence weight status, including prenatal, sociocultural, family, and community environments. Importantly, for Aboriginal children, obesity interventions need to also be situated within the context of a history of colonization and inequities in the social determinants of health. This review therefore advocates for the inclusion of a historical perspective and a life-course approach to obesity prevention in Aboriginal children in addition to developing interventions around the socioecological framework. We emphasize that childhood obesity prevention efforts should focus on promoting maternal health behaviours before and during pregnancy, and on breastfeeding and good infant and child nutrition in the postpartum and early childhood development periods. Ameliorating food insecurity by focusing on improving the sociodemographic risk factors for it, such as increasing income and educational attainment, are essential. More research is required to understand and measure obesogenic Aboriginal environments, to examine how altering specific environments modifies the foods that children eat and the activities that they do, and to examine how restoring and rebuilding cultural continuity in Aboriginal communities modifies the many determinants of obesity. This research needs to be done with the full participation of Aboriginal communities as partners in the research.     

Access to primary care from the perspective of Aboriginal patients at an urban emergency department

In this article, we discuss findings from an ethnographic study in which we explored experiences of access to primary care services from the perspective of Aboriginal people seeking care at an emergency department (ED) located in a large Canadian city. Data were collected over 20 months of immersion in the ED, and included participant observation and in-depth interviews with 44 patients triaged as stable and nonurgent, most of whom were living in poverty and residing in the inner city. Three themes in the findings are discussed: (a) anticipating providers' assumptions; (b) seeking help for chronic pain; and (c) use of the ED as a reflection of social suffering. Implications of these findings are discussed in relation to the role of the ED as well as the broader primary care sector in responding to the needs of patients affected by poverty, racialization, and other forms of disadvantage.     

Risk of lung cancer from residential heating and cooking fuels in Montreal, Canada

Among the major sources of indoor air pollution are combustion by-products from heating and cooking. Concern is increasing that use of polluting heating and cooking sources can increase cancer risk. In Canada, most cooking and heating currently relies on electricity or natural gas, but, in the past, and still in some areas, coal and wood stoves were used for heating and gas and wood for cooking. In the course of a case-control study of lung cancer carried out in Montreal in 1996-2001, the authors collected information on subjects' lifetime exposure to such sources of domestic pollution by means of a personal interview with the subject or a next-of-kin proxy. Questionnaires were completed for 739 male cases, 925 male controls, 466 female cases, and 616 female controls. Odds ratios were computed in relation to a few indices of exposure to traditional heating and cooking sources, adjusting for a number of covariates, including smoking. Among men, there was no indication of excess risks. Among women, the odds ratio for those exposed to both traditional heating and cooking sources was 2.5 (95% confidence interval: 1.5, 3.6; n = 253). The findings for women suggest the need for research dedicated to exploring this association, with particular emphasis on improved exposure assessment.