Brief intervention resource kits for Indigenous Australians: generally evidence‐based,but missing important components

Objective : Little is known about the content and quality of brief intervention kits specifically targeting SNAP risk factors (smoking, poor nutrition, alcohol misuse or physical inactivity) among Indigenous Australians. This paper reviews the type and quality of these kits. Methods : Brief intervention kits were primarily identified by contacting 74 health‐related organisations in Australia between 1 February 2007 and 4 March 2007. Results : Ten brief intervention kits met inclusion criteria: four targeted smoking; three targeted alcohol; one targeted alcohol, smoking and other drugs; one targeted alcohol, other drugs and mental health; and one targeted all SNAP risk factors. Brief intervention kits were reviewed using criteria developed from clinical guidelines for SNAP risk factors and guidelines for evaluating health promotion resources. Three kits met all review criteria. Five kits were consistent with evidence‐based guidelines, but lacked a training package, patient education materials and/or behavioural change strategies. All kits used images and language identifiable with Indigenous Australia, however, their cultural appropriateness for Indigenous Australians remains unclear. Conclusions and implications : The specific content of the missing components should be guided by the best‐available evidence, such as established mechanisms for health care provider feedback to patients as a behaviour change strategy, as well as the needs and preferences of health care providers and patients.     

Prevalence and correlates of alcohol dependence in adult prisoners vary according to Indigenous status

Objective : To estimate the prevalence and identify independent correlates of alcohol dependence among Indigenous and non‐Indigenous adult prisoners in Queensland. Methods : A confidential, cross‐sectional survey of 1,155 adult prisoners (n=274 Indigenous, n=881 non‐Indigenous) in seven adult prisons in Queensland. The usual alcohol consumption in the year before prison was assessed using the Alcohol Use Disorders Identification Test (AUDIT); scores ≥20 are considered consistent with alcohol dependence. Results : Indigenous prisoners were significantly more likely than non‐Indigenous prisoners to report patterns of alcohol consumption consistent with dependence. Separate multivariable analyses revealed different independent correlates of alcohol dependence according to Indigenous status. Among Indigenous prisoners, significant independent correlates of alcohol dependence included income below the poverty line and daily cannabis use before incarceration. Daily heroin use and history of injecting drug use were protective. Among non‐Indigenous prisoners, significant independent correlates included history of mental illness or self harm, and daily tobacco or cannabis use before incarceration. Older age and daily heroin use before incarceration were protective. Conclusions and Implications : The prevalence of risky alcohol use and dependence is high in Australian prisoner populations, particularly among Indigenous prisoners. Risk factors for alcohol dependence differ according to Indigenous status, indicating that separate, culturally appropriate interventions to reduce alcohol‐related harm for Indigenous prisoners may be required.     

Epidemiology of alcohol‐related burden of disease among Indigenous Australians

Objective: To compare the burden of alcohol‐related harm and underlying factors of this harm, by age and sex, for Indigenous and general population Australians. Methods: Population attributable fractions are used to estimate the disability adjusted life years (DALYs) for alcohol‐related disease and injury. The DALYs were converted to rates per 1,000 by age and sex for the Indigenous and general populations. Results: Homicide and violence rates were much higher for Indigenous males: greatest population difference was for 30–44 years, Indigenous rate 8.9 times higher. Rates of suicide were also greater: the largest population difference was for 15–29 years, Indigenous rate 3.9 times higher. Similarly, for Indigenous females, homicide and violence rates were much higher: greatest population difference was for 30–44 years, Indigenous rate 18.1 times higher. Rates of suicide were also greater: the largest population difference was for 15–29 years, Indigenous rate 5.0 times higher. Conclusions: Alcohol consumption and associated harms are of great concern for Indigenous Australians across all ages. Violent alcohol‐related harms have been highlighted as a major concern. Implications: To reduce the disproportionate burden of alcohol‐related harm experienced by Indigenous Australians, targeted interventions should include the impact on families and communities and not just the individual.     

Delivering culturally appropriate residential rehabilitation for urban Indigenous Australians: a review of the challenges and opportunities

Objective: To review the challenges facing Indigenous and mainstream services in delivering residential rehabilitation services to Indigenous Australians, and explore opportunities to enhance outcomes. Methods: A literature review was conducted using keyword searches of databases, on‐line journals, articles, national papers, conference proceedings and reports from different organisations, with snowball follow‐up of relevant citations. Each article was assessed for quality using recognised criteria. Results: Despite debate about the effectiveness of mainstream residential alcohol rehabilitation treatment, most Indigenous Australians with harmful alcohol consumption who seek help have a strong preference for residential treatment. While there is a significant gap in the cultural appropriateness of mainstream services for Indigenous clients, Indigenous‐controlled residential organisations also face issues in service delivery. Limitations and inherent difficulties in rigorous evaluation processes further plague both areas of service provision. Conclusion: With inadequate evidence surrounding what constitutes ‘best practice’ for Indigenous clients in residential settings, more research is needed to investigate, evaluate and contribute to the further development of culturally appropriate models of best practice. In urban settings, a key area for innovation involves improving the capacity and quality of service delivery through effective inter‐agency partnerships between Indigenous and mainstream service providers.     

Indigenous Australians are under-represented in longitudinal ageing studies

Objective: Evidence‐based policy depends on the availability of high‐quality research that is relevant to the population. This study aimed to identify the available data on the health of older Indigenous Australians in population‐based longitudinal studies of ageing. Approach: Evaluation of the Dynamic Analyses to Optimise Ageing Project (DYNOPTA) dataset that has pooled nine Australian longitudinal ageing studies, six of which were analysed here. Main outcome measures: Proportions of the DYNOPTA sample identified as Indigenous. Results: Indigenous participants made up 0.7% of males and 0.5% of females in the weighted sample, compared with 0.8% of both sexes in the Australian population. Indigenous under‐representation is greater at ages 45–54 than at older ages, despite overall greater participation in this age range. Conclusions and implications: Within the existing Australian longitudinal ageing studies, Indigenous Australians are under‐represented. This means there is a significant gap in the evidence base relating to the health of older Indigenous Australians. Research approaches specifically designed to address the health and wellbeing of older Indigenous Australians are urgently required.     

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.     

Betting on the evidence: Reported gambling problems among the Indigenous population of the Northern Territory

Objectives: To address a shortfall in evidence with which to justify gambling‐specific interventions for the Indigenous population, we analysed two surveys (2002 National Aboriginal and Torres Strait Islander Social Survey and General Social Survey) that contain information on reported gambling problems for the NT. Methods: Estimates of reported gambling problems are presented for each state and territory by remoteness for the Indigenous and total population for 2002. Factor analysis was used to identify the relationship between gambling problems and other negative life events for the NT Indigenous and total population. Results: High levels of reported gambling problems were apparent for the Indigenous population particularly in the remote parts of the NT and Queensland. Gambling problems were associated with other stressors relating to social transgressions. Among the NT Indigenous population, gambling problems were correlated with levels of crowding, community involvement, personal and community violence and self‐assessed health status. Conclusions: The high levels of reported gambling problems suggest that gambling is causing significant problems for Indigenous people. The multivariable adjusted associations indicate that gambling‐related problems are intimately connected to a range of community contexts. Implications: Policies of intervention need to address broader social and environmental contexts that are intrinsically associated with gambling (and associated problems), in addition to public education in harm associated with gambling and provision of counselling services to assist problem gamblers.     

Self-rated health status in an urban indigenous primary care setting: implications for clinicians and public health policy

Background: Self‐rated health status provides insights into the health beliefs of a population. This will be important for framing public health messages in the context of the need to ‘close the gap’ for Australian Indigenous people. Our primary objectives were to describe the self‐rated health status of Indigenous people attending the Inala Indigenous Health service, identify associations with positive and negative self‐rated health status and identify targets for public health awareness raising activity. Methods: Using a convenience sample, we approached all Indigenous patients attending the Inala Indigenous Health Service for an Indigenous adult health check between June 2007 and July 2008. From Indigenous adult health check data we analysed self‐rated health status and chronic disease risk factors. Results: Out of a possible 509, 413 patients were recruited (response rate 81%). The number of participants who rated their health as fair or poor was 47%. The association of greatest magnitude and statistical significance with Indigenous patients’ self rated health status (negative versus positive) was waist circumference followed by smoking, depression and age. Chronic disease risk factors not associated with self‐rated health status included systolic blood pressure, harmful alcohol use, marijuana use, presence of diabetes and lack of exercise. Conclusions: High rates of negative self‐rated health status were found. Public health awareness‐raising for Indigenous audiences should consider targeting chronic disease risk factors such as systolic blood pressure, harmful alcohol use, marijuana use, presence of diabetes and lack of exercise.     

Managing alcohol‐related problems among Indigenous Australians: what the literature tells us

Objective: To contextualise and provide an overview of two review papers – prepared as part of a larger research program – dealing with different aspects of the treatment of Indigenous Australians with alcohol‐related problems. Method: The papers were reviewed thematically and compared to identify key issues raised in them. Findings: Together, the papers highlight the paucity of the evidence base for the provision of treatment for Indigenous Australians with alcohol‐related problems. Among the key issues identified are: the need to engage with clients in culturally safe ways; practitioner, organisational and client barriers to engagement; the contexts in which Indigenous drinking and treatment take place; the need to develop rigorous methods of evaluation more appropriate to Indigenous cultural and service provision settings; and the importance of effective partnerships in the provision of services. Conclusion: For those working in the field, the reviews direct attention to the need to review and interrogate our current practice. They also provide clear directions for future research.     

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.     

Social and emotional outcomes of Australian children from Indigenous and culturally and linguistically diverse backgrounds

Objectives: 1) profile the living environments and 2) examine the social and emotional outcomes of Australian children from Indigenous and cultural and linguistically diverse (CALD) backgrounds at school entry. Method: Secondary analysis of cross‐sectional data collected in Wave 1 of the Longitudinal Study of Australian Children (n=4,735). Child mental‐health outcomes were measured using parent report of the Strengths and Difficulties Questionnaire (SDQ). Results: Significant differences in family and neighbourhood characteristics, including parental income, maternal education, maternal parenting quality and neighbourhood safety, were found in children of Indigenous and CALD backgrounds compared to the reference group of Australian‐born, English‐speaking children. After controlling for family and neighbourhood characteristics, significant differences in parent‐reported SDQ total difficulties were found for Indigenous children. Significant differences in emotional difficulties and peer problems subscales were found for children with overseas‐born mothers regardless of English proficiency. Conclusions: Children from Indigenous and CALD backgrounds experience poorer mental health outcomes at school entry than their Australian‐born English‐speaking peers. They are also more likely to be exposed to risk factors for poor child mental‐health outcomes within their family and neighbourhood environments.     

Culture and healthy lifestyles: a qualitative exploration of the role of food and physical activity in three urban Australian Indigenous communities

Objective: 1) To explore the links between Indigenous Australian children's perspectives on culture, and healthy lifestyle behaviours. 2) To provide insight into how to approach the development of a health intervention targeting lifestyle behaviours in Australian Indigenous children. Methods: Seven semi‐structured focus groups sessions were conducted with Australian Indigenous children aged 5–12 years living on the South Coast of New South Wales. Audio‐recordings were transcribed and thematic analyses were conducted and related to principles of grounded theory. Results: Participants had connections to aspects of Australian Indigenous culture that were embedded in their everyday lives. Healthy lifestyle behaviours (such as healthy eating and physical activity) were found to be interconnected with Australian Indigenous culture and positive emotional wellbeing was identified as an important outcome of connecting Australian Indigenous children to cultural practices. Conclusion: Understanding the importance of culture and its role in healthy lifestyles is critical in the development of health interventions for Indigenous populations. Implication: Health interventions embedded with Australian Indigenous culture may have potential to improve physical and emotional health within Australian Indigenous communities. However, it is unlikely that a ‘one size fits all’ approach to health interventions can be taken.     

Smoking, nutrition, alcohol and physical activity interventions targeting Indigenous Australians: rigorous evaluations and new directions needed

Objective: To describe and critique methodological aspects of interventions targeting reductions in smoking, poor nutrition, alcohol misuse and physical inactivity (SNAP risk factors) among Indigenous Australians. Methods: An electronic search of eight databases and a manual search of reference lists of literature reviews and reference libraries for Indigenous‐specific intervention studies published in peer‐reviewed journals (January 1990 to August 2007) were undertaken. Alcohol, smoking, nutrition or physical activity needed to be the primary focus of the study and the intervention needed to specifically target Indigenous Australians. Results: Twenty studies were selected for inclusion in the review. Methodologically, few studies employed randomisation or a control group, most omitted important details (e.g. costs), some did not report process measures (e.g. attrition rates), and some did not use validated measures. Two‐thirds of interventions were implemented at the community level and employed multiple strategies. Conclusion: There is a need for more rigorous evaluations of interventions targeting reductions in SNAP risk factors among Indigenous Australians, and to establish the reliability and validity of measures to quantify their effect. Implications: It may be beneficial for future Indigenous‐specific intervention research to focus on the evaluation of secondary prevention to complement the current concentration of effort targeting primary prevention. Community‐wide interventions, combining strategies of greater intensity for high risk individuals with those of less intensity targeting lower risk individuals, might also offer considerable promise.     

Respecting cultural values: conducting a gambling survey in an Australian Indigenous community

Objective: This paper details how we, as ‘cultural outsiders’, conducted a large gambling survey in an Indigenous Australian community that adhered to Indigenous ethical protocols and values while differing from some standard survey practices. Approach: The paper summarises the ethical guidelines for conducting Indigenous public health research. It describes research processes used in the study in eight generic steps identified in Keeping Research on Track: A Guide for Aboriginal and Torres Strait Islander Peoples About Health Research Ethics. ¹ It explains how adherence to these guidelines contributed to successful project completion. Conclusion: The research processes used to conduct this project gave explicit recognition and commitment to respecting Indigenous cultural values and principles. It engaged the Indigenous community in ways that promoted its ownership of the research issue, ensured the validity and reliability of the research data and unearthed potential solutions to problems identified. Implications: By sharing our experiences in attempting to conduct research that respected these values and principles, we have contributed to culturally appropriate and ethical research with participating Indigenous peoples and communities.     

What Indigenous Australian clients value about primary health care: a systematic review of qualitative evidence

Objective: To synthesise client perceptions of the unique characteristics and value of care provided in Aboriginal Community Controlled Health Organisations (ACCHOs) compared to mainstream/general practitioner services, and implications for improving access to quality, appropriate primary health care for Indigenous Australians. Method: Standardised systematic review methods with modification informed by ethical and methodological considerations in research involving Indigenous Australians. Results: Perceived unique valued characteristics of ACCHOs were: 1) accessibility, facilitated by ACCHOs welcoming social spaces and additional services; 2) culturally safe care; and 3) appropriate care, responsive to holistic needs. Conclusion: Provider‐client relationships characterised by shared understanding of clients' needs, Indigenous staff, and relationships between clients who share the same culture, are central to ACCHO clients' perceptions of ACCHOs' unique value. The client perceptions provide insights about how ACCHOs address socio‐economic factors that contribute to high levels of chronic disease in Indigenous communities, why mainstream PHC provider care cannot substitute for ACCHO care, and how to improve accessibility and quality of care in mainstream providers. Implications for public health: To increase utilisation of PHC services in Indigenous Australian communities, and help close the gaps between the health status of Indigenous and non‐Indigenous Australians, Indigenous community leaders and Australian governments should prioritise implementing effective initiatives to support quality health care provision by ACCHOs.     

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.     

Adolescent and young adult substance use in Australian Indigenous communities: a systematic review of demand control program outcomes

Objective: Identifying preventative approaches to substance use in Indigenous communities is the foundation for developing evidence‐based responses. This study reports the findings of a systematic review of the published literature evaluating the impact of substance use programs on Australian Indigenous youth. Methods: Evidence about the impact of substance use programs for Indigenous young people was identified from a systematic review of the literature conducted according to the Preferred Reporting Items for Systematic reviews and Meta‐Analyses guidelines. Results: Only four original studies that met the inclusion criteria were identified, although a further 19 papers that described characteristics of programs that may be associated with improved outcomes were reviewed. Conclusions: Evidence relevant to the outcomes of demand control programs that target Australian Indigenous youth substance use is both weak and inconsistent. There is a need to support the type of evaluation activity required to better understand program effectiveness and build the Indigenous knowledge base. Implications for public health: These findings are discussed in relation to the development of evidence‐based practice and the type of knowledge that is likely to be of most use to those seeking to address problems associated with youth substance use.     

Socio‐economic gradients in self‐reported diabetes for Indigenous and non‐Indigenous Australians aged 18–64

Objective : To examine and compare socio‐economic gradients in diabetes among Indigenous and non‐Indigenous Australians. Methods : I analysed weighted data on self‐reported diabetes and a range of socio‐economic status (SES) measures for 5,417 Indigenous and 15,432 non‐Indigenous adults aged 18–64 years from two nationally representative surveys conducted in parallel by the Australian Bureau of Statistics in 2004–05. Results : After adjusting for age, diabetes prevalence was significantly higher among those of lower SES in both Indigenous and non‐Indigenous populations. The age‐ and sex‐adjusted odds ratios (OR) for diabetes for the lowest versus the highest SES group were similar for the two populations on many variables. For example, the OR for the lowest quintile of equivalised household income (compared with quintiles 3–5 combined) was 2.3 (95% CI 1.6–3.4) for the Indigenous population and 2.0 (95% CI 1.5–2.8) for the non‐Indigenous population. However, Indigenous people of high SES had greater diabetes prevalence than low SES non‐Indigenous people on every SES measure examined. Conclusion : Socio‐economic status explains some but not all of the difference in diabetes prevalence between Indigenous and non‐Indigenous Australians. Other factors that may operate across the socio‐economic spectrum, such as racism, stress, loss and grief, may also be relevant and warrant further examination. Implications : Indigenous Australians do not constitute a homogeneous group with respect to socio‐economic status or diabetes prevalence, and this diversity must be recognised in developing measures to redress Indigenous health disadvantage.     

Indigenous health program evaluation design and methods in Australia: a systematic review of the evidence

Objective: Indigenous Australians experience a disproportionately higher burden of disease compared to non‐Indigenous Australians. High‐quality evaluation of Indigenous health programs is required to inform health and health services improvement. We aimed to quantify methodological and other characteristics of Australian Indigenous health program evaluations published in the peer‐reviewed literature. Methods: Systematic review of peer‐reviewed literature (November 2009–2014) on Indigenous health program evaluation. Results: We identified 118 papers describing evaluations of 109 interventions; 72.0% were university/research institution‐led. 82.2% of evaluations included a quantitative component; 49.2% utilised quantitative data only and 33.1% used both quantitative and qualitative data. The most common design was a before/after comparison (30.5%, n=36/118). 7.6% of studies (n=9/118) used an experimental design: six individual‐level and three cluster‐randomised controlled trials. 56.8% (67/118) reported on service delivery/process outcomes (versus health or health risk factor outcomes) only. Conclusions: Given the number of Indigenous health programs that are implemented, few evaluations overall are published in the peer‐reviewed literature and, of these, few use optimal methodologies such as mixed methods and experimental design. Implications for public health: Multiple strategies are required to increase high‐quality, accessible evaluation in Indigenous health, including supporting stronger research‐policy‐practice partnerships and capacity building for evaluation by health services and government.