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.     

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.     

Trends in the incidence of treated end-stage kidney disease among Indigenous Australians and access to treatment

OBJECTIVE: To determine temporal trends of incidence of treated end-stage kidney disease in Indigenous Australians and the extent to which these patients had to move from their home community to access renal replacement therapy. METHODS: Data for 1993-2001, regarding place of residence before starting renal replacement therapy, were analysed to give accurate incidence for 1,194 Indigenous treated end-stage kidney disease patients. We calculated indirectly standardised incidence ratios of treated end-stage kidney disease by State and Territory. We surveyed treating renal units about which Indigenous patients relocated to access therapy from 1999 to 2001. RESULTS: The incidence of treated end-stage kidney disease among Indigenous Australians is high and rising; however, the rate of increase is lower than has been previously reported. The Northern Territory (NT) and Queensland have the most new Indigenous treated end-stage kidney disease cases. The highest standardised incidence ratio was in the NT (17.0), followed by Western Australia (WA) (11.9). From 1999 to 2001, half of the 476 Indigenous patients starting therapy had to relocate to access treatment. CONCLUSIONS: The incidence of end-stage kidney disease among Indigenous Australians continues to rise. However, significant gaps in knowledge remain about the burden of early chronic kidney disease and whether many Indigenous patients with end-stage kidney disease still choose not to receive renal replacement therapy. The need to relocate to access treatment has a strong negative impact on individuals, families and entire communities.     

Uncovering the determinants of cardiovascular disease among Indigenous people

Objective . This paper attempts to delineate an appropriate methodology for research into cardiovascular diseases (CVD) in the context of the Australian Indigenous population.

Design . Our argument proceeds in three main stages of critical analysis of the appropriate literature. First we demonstrate the extremely complex aetiology of CVD and also argue that, in any population, exposure to many of the more important risk factors at an individual or group level is generated through social and behavioural factors whose causation, persistence and reproduction are both complex and multilayered. Secondly, and having established that the aetiology and morbidity of CVD in various populations is a product of a complex and interactive hierarchy of biomedical, social and political processes, we argue that only research methodologies capable of encompassing the complete span of this hierarchy can be expected to generate results which are efficacious as a basis for intervention. Thirdly, and most importantly, we argue that in the Indigenous context a central and essential feature in the development of an appropriate methodology must be to centre Indigenous people themselves as the dominant partner in setting the research agenda and the conduct of research.

Results/conclusions . We conclude that an appropriate methodology for the elucidation of the aetiology, and sequelae of CVD in Indigenous people, would go far beyond ‘black box’ epidemiology, would recognise the essentially social nature of chronic disease by deploying appropriate social theory within a transdisciplinary framework and would centre Indigenous people as the dominant partner in the research process.     

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.     

Evaluation of an intervention for patients with alcohol‐related injuries: results of a mixed methods study

Objective: To explore the effect of education and training on the delivery of alcohol screening and brief intervention and referral to high‐risk patients in a hospital setting. Main outcome measures included; delivery of training; practice change in relation to staff performing alcohol screening, brief intervention and referrals. Methods: Observational study design using mixed methods set in a tertiary referral hospital. Pre‐post assessment of medical records and semi‐structured interviews with key informants. Results: Routine screening for substance misuse (9% pre / 71.4% post) and wellbeing concerns (6.6% pre / 15 % post) was more frequent following the introduction of resources and staff participation in educational workshops. There was no evidence of a concomitant increase in delivery of brief intervention or referrals to services. Implementation challenges, including time constraints and staff attitudes, and enablers such as collaboration and visible pathways, were identified. Conclusion: Rates of patient screening increased, however barriers to delivery of brief intervention and referrals remained. Implementation strategies targeting specific barriers and enablers to introducing interventions are both required to improve the application of secondary prevention for patients in acute settings. Implications: Educational training, formalised liaison between services, systematised early intervention protocols, and continuous quality improvement processes will progress service delivery in this area.     

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.     

Gender differences in the dialysis treatment of Indigenous and non‐Indigenous Australians

Objective: Access to dialysis treatment and the types of treatments employed in Australia differs by Indigenous status. We examined whether dialysis treatment utilisation in Indigenous and non‐Indigenous Australians also differs by gender. Methods: Using registry data we evaluated 21,832 incident patients (aged ≥18 years) commencing dialysis, 2001–2013. Incidence rates were calculated and multivariate regression modelling used to examine differences in dialysis treatment (modality, location and vascular access creation) by race and gender. Results: Dialysis incidence was consistently higher in Indigenous women compared to all other groups. Compared to Indigenous women, both non‐Indigenous women and men were more likely to receive peritoneal dialysis as their initial treatment (non‐Indigenous women RR=1.91, 95%CI 1.55–2.35; non‐Indigenous men RR=1.73, 1.40–2.14) and were more likely to commence initial treatment at home (non‐Indigenous women RR=2.07, 1.66–2.59; non‐Indigenous men RR=1.95, 1.56–2.45). All groups were significantly more likely than Indigenous women to receive their final treatment at home. Conclusions: Contemporary dialysis treatment in Australia continues to benefit the dominant non‐Indigenous population over the Indigenous population, with non‐Indigenous men being particularly advantaged. Implications for Public Health: Treatment guidelines that incorporate a recognition of gender‐based preferences and dialysis treatment options specific to Indigenous Australians may assist in addressing this disparity.     

Factors relating to high psychological distress in Indigenous Australians and their contribution to Indigenous–non‐Indigenous disparities

Objective: To explore factors associated with high psychological distress among Aboriginal and non‐Aboriginal Australians and their contribution to the elevated distress prevalence among Aboriginal people. Methods: Questionnaire data from 1,631 Aboriginal and 233,405 non‐Aboriginal 45 and Up Study (NSW, Australia) participants aged ≥45 years were used to calculate adjusted prevalence ratios for high psychological distress (Kessler‐10 score ≥22) for socio‐demographic, health and disability‐related factors, and to quantify contributions to differences in distress prevalence. Results: While high‐distress prevalence was increased around three‐fold in Aboriginal versus non‐Aboriginal participants, distress‐related risk factors were similar. Morbidity and physical disability had the strongest associations; high distress affected 43.8% of Aboriginal and 20.9% of non‐Aboriginal participants with severe physical limitations and 9.5% and 3.9% of those without limitations, respectively. Differences in distress prevalence between Aboriginal and non‐Aboriginal participants were essentially attributable to differences in SES, morbidity, disability/functional limitations and social support (fully‐adjusted PR 1.19 [95% 1.08, 1.30]); physical morbidity and disability explained the bulk. Conclusions: The markedly elevated prevalence of high distress among older Aboriginal Australians appears largely attributable to greater physical morbidity and disability. Implications for public health: Addressing upstream determinants of physical morbidity and improved integration of social and emotional wellbeing care into primary care and chronic disease management are essential.     

Case study of a decolonising Aboriginal community controlled comprehensive primary health care response to alcohol‐related harm

Objective: This paper provides a case study of the responses to alcohol of an Aboriginal Community Controlled Health Service (The Service), and investigates the implementation of comprehensive primary health care and how it challenges the logic of colonial approaches. Methods: Data were drawn from a larger comprehensive primary health care study. Data on actions on alcohol were collected from: a) six‐monthly service reports of activities; b) 29 interviews with staff and board members; c) six interviews with advocacy partners; and d) community assessment workshops with 13 service users. Results: The Service engaged in rehabilitative, curative, preventive and promotive work targeting alcohol, including advocacy and collaborative action on social determinants of health. It challenged other government approaches by increasing Aboriginal people’s control, providing culturally safe services, addressing racism, and advocating to government and industry. Conclusions: This case study provides an example of implementation of the full continuum of comprehensive primary health care activities. It shows how community control can challenge colonialism and ongoing power imbalances to promote evidence‐based policy and practice that support self‐determination as a positive determinant for health. Implications for public health: Aboriginal Community Controlled Health Services are a good model for comprehensive primary health care approaches to alcohol control.     

Associations with low rates of postpartum glucose screening after gestational diabetes among Indigenous and non‐Indigenous Australian women

Objectives: To explore factors associated with postpartum glucose screening among women with Gestational Diabetes Mellitus (GDM). Methods: A retrospective study using linked records from women with GDM who gave birth at Cairns Hospital in Far North Queensland, Australia, from 1 January 2004 to 31 December 2010. Results: The rates of postpartum Oral Glucose Tolerance Test (OGTT) screening, while having increased significantly among both Indigenous* and non‐Indigenous women from 2004 to 2010 (HR 1.15 per year, 95%CI 1.08–1.22, p<0.0001), remain low, particularly among Indigenous women (10% versus 27%, respectively at six months postpartum). Indigenous women in Cairns had a longer time to postpartum OGTT than Indigenous women in remote areas (HR 0.58, 0.38–0.71, p=0.01). Non‐Indigenous women had a longer time to postpartum OGTT if they: were born in Australia (HR 0.76, 0.59–1.00, 0.05); were aged <25 years (HR 0.45, 0.23–0.89, p=0.02); had parity >5 (HR 0.33, 0.12–0.90, p=0.03); smoked (HR 0.48, 0.31–0.76, p=0.001); and did not breastfeed (HR 0.09, 0.01–0.64, p=0.02). Conclusions: Postpartum diabetes screening rates following GDM in Far North Queensland are low, particularly among Indigenous women, with lower rates seen in the regional centre; and among non‐Indigenous women with indicators of low socioeconomic status. Implications: Strategies are urgently needed to improve postpartum diabetes screening after GDM that reach women most at risk.     

Learning from the past,looking to the future: Exploring our place with Indigenous Australians

This paper aims to explore ways in which we as occupational therapists in Australia can participate in enabling a different and better future for all Australians. In doing so, it is necessary to explore our history and our cultures, both individually and collectively as a profession, and to understand the ways in which these shape who we are and what we do. As occupational therapists, we have valuable knowledge and skills that have the potential to contribute in a positive way to the health and educational outcomes of Indigenous Australians. As a profession operating in Australia, we also have a responsibility to reach this potential. This paper aims to present some of these contributions and to provide examples of practical and culturally safe ways in which we can take action.     

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.     

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.     

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.     

Closing the Gaps: competing estimates of Indigenous Australian life expectancy in the scientific literature

Objective: Closing the gap in life expectancy between Indigenous and other Australians within a generation is central to national Indigenous reform policy (Closing the Gap). Over time, various methods of estimating Indigenous life expectancy and with that, the life expectancy gap, have been adopted with differing, albeit non‐comparable results. We present data on the extent of the gap and elucidate the pattern of use and interpretations of the different estimates of the gap, between 2007 and 2012. Methods: An extensive search was conducted for all peer‐reviewed health publications citing estimates of and/or discussing the life expectancy of Indigenous Australians, for the period 2007–2012. Results: Five predominant patterns of citation of the gap estimates were identified: 20 years, 17 years, 15–20 years, 13 years, and 11.5 years for males and 9.7 years for females. Some authors misinterpret the most recent estimates as reflecting improvement from the 17‐year figure, rather than the result of different methods of estimation. Support for the direct methods used to calculate Indigenous life expectancy is indicated. Conclusions and Implications: A specific estimate of the life expectancy gap has not been established among stakeholders in Indigenous health. Agreement on the magnitude of the gap is arguably needed in order to evaluate strategies aimed at improving health outcomes for Indigenous Australians. Moreover, measuring progress towards ‘closing the gap’ depends on the availability of comparable estimates, using the same techniques of measurement to assess changes over time.