The oral health care experiences of NSW Aboriginal Community Controlled Health Services

Objectives: Aboriginal people continue to experience a disproportionately heavy burden of oral disease. A range of oral health services may be available to Aboriginal communities, including those provided by Aboriginal Community Controlled Health Services (ACCHSs). This study explored the oral health care experiences and activities of ACCHSs to inform policy and program decision making. Methods: Mixed methods, including an online survey and semi‐structured interviews with senior ACCHS staff, were used. Areas of inquiry included perceived community need for oral health care, oral health care models, accessibility of other oral health services and barriers to providing oral health care. Twenty‐nine NSW ACCHSs participated in the study. Results: The activities of NSW ACCHSs in oral health care are diverse and reflect the localised approaches they take to delivering primary health care. ACCHSs commonly face barriers in delivering oral health care, as do Aboriginal communities in accessing other oral health services. Conclusion: NSW ACCHSs are important but under‐acknowledged providers of a range of oral health services to Aboriginal communities and are well placed to provide this care as part of their comprehensive primary health care model. Implications: ACCHS roles in improving Aboriginal oral health would be strengthened by greater acknowledgement of their contributions and expertise and the development of transparent, long‐term funding policies that respond to community need.     

Robust data to close the gap: current vascular and maternal/newborn indicators as measures of progress in Aboriginal health in New South Wales

Objective: Focussing on maternal/newborn health and vascular diseases, to review NSW Health's reporting, by Aboriginal status, against national performance indicators relevant to preventable chronic diseases. Methods: We reviewed seven indicator documents and the Australian Institute of Health and Welfare Chronic Disease Indicator Database to identify national indicators. Indicators from six NSW Health reports were then compared with these national indicators to assess reporting by Aboriginal status and region. Results: NSW Health routinely reports against six maternal/newborn indicators and fourteen vascular national indicators. Five of the former report performance by both Aboriginal status and region. Eight of the latter report by Aboriginal status, one of which (diabetes hospitalisations) also reports by region. Indicator quality and breadth was substantially limited by under‐enumeration of Aboriginal status, small or potentially unrepresentative samples, inadequate longitudinal or regional data and few primary health care indicators. Notwithstanding these limitations, we found wide and persistent disparities in outcomes for Aboriginal people for all indicators in all regions. Conclusions: NSW Health reports adequately, by Aboriginal status, for maternal/newborn health monitoring (albeit constrained by under‐enumeration), but provides limited information about vascular health. A minimum, national chronic disease indicator dataset against which all jurisdictions would report performance by Aboriginal status and region is needed. Improved monitoring requires sustained efforts to address under‐enumeration, better survey sampling, and population representative data from the primary care system.     

Aboriginal mothers in prison in Australia: a study of social,emotional and physical wellbeing

Objective : To describe the social, emotional and physical wellbeing of Aboriginal mothers in prison. Methods : Cross‐sectional survey, including a Short Form Health Survey (SF‐12) and Kessler Psychological Distress Scale (5‐item version) administered to Aboriginal women who self‐identified as mothers. Results : Seventy‐seven Aboriginal mothers in New South Wales (NSW) and 84 in Western Australia (WA) participated in the study. Eighty‐three per cent (n=59) of mothers in NSW were in prison for drug‐related offences, 64.8% (n=46) of mothers in WA were in prison for offences committed under the influence of alcohol. Sixty‐eight per cent (n=52) of mothers in NSW and 35% (n=28) of mothers in WA reported mental health problems. Physical (PCS) and Mental (MCS) component scores of SF‐12 varied for mothers in NSW and WA. Mothers in NSW experienced poorer health and functioning than mothers in WA (NSW: PCS 49.5, MCS 40.6; WA: PCS 54.4, MCS 48.3) and high levels of psychological distress (NSW: 13.1; WA 10.1). Conclusions : Aboriginal mothers in prison have significant health needs associated with physical and mental health, and psychological distress. Implications for public health : Adoption of social and emotional wellbeing as an explanatory framework for culturally secure healthcare in prison is essential to improving health outcomes of Aboriginal mothers in prison in Australia.     

The Chronic Care for Aboriginal People program in NSW

Aboriginal people living in NSW continue to experience greater health risks, poorer health and shorter life expectancies than non-Aboriginal Australians. The NSW Health-funded program, Chronic Care for Aboriginal People, was established from existing initiatives to rethink the way chronic care services were delivered to Aboriginal people in NSW. Refocusing and building on existing projects led to NSW Health providing an evidence base of what was working in Aboriginal communities. A model of care for Aboriginal people with chronic disease has been developed. Recommendations from two evaluations have allowed further improvement for the delivery of chronic care services for Aboriginal people. The Local Health District Service Agreements include relevant indicators and strategic priorities relating to the chronic care program.     

A case study of enhanced clinical care enabled by Aboriginal health research: the Hearing,EAr health and Language Services (HEALS) project

Objective : To describe and evaluate Hearing EAr health and Language Services (HEALS), a New South Wales (NSW) health initiative implemented in 2013 and 2014 as a model for enhanced clinical services arising from Aboriginal health research. Methods : A case‐study involving a mixed‐methods evaluation of the origins and outcomes of HEALS, a collaboration among five NSW Aboriginal Community Controlled Health Services (ACCHS), the Sydney Children's Hospitals Network, NSW Health, the Aboriginal Health and Medical Research Council, and local service providers. Service delivery data was collected fortnightly; semi‐structured interviews were conducted with healthcare providers and caregivers of children who participated in HEALS. Results : To circumvent health service barriers, HEALS used relationships established through the Study of Environment on Aboriginal Resilience and Child Health (SEARCH) to form a specialist healthcare network. HEALS employed dedicated staff and provided a Memorandum of Understanding (detailing mutual goals and responsibilities) for each ACCHS. Despite very tight timeframes, HEALS provided services for 653 Aboriginal children, including 5,822 speech‐language pathology sessions and 219 Ear, Nose and Throat procedures. Four themes reflecting the perceived impact of HEALS were identified: valued clinical outcomes, raising community awareness, developing relationships/networks and augmented service delivery. Conclusions : HEALS delivered rapid and effective specialist healthcare services through an existing research collaboration with five ACCHS, cooperation from local health service providers, and effective community engagement. Implications for Public Health : HEALS serves as a framework for targeted, enhanced healthcare that benefits Aboriginal communities by encapsulating the ‘no research without service’ philosophy.     

Chlamydia sentinel surveillance in Aboriginal Community Controlled Health Services finds higher testing and positivity rates among younger people

Objective: To measure chlamydia testing and positivity rates among 16–39 year olds attending Aboriginal Community Controlled Health Services (ACCHSs). Methods: Retrospective non‐identifiable computerised records containing consultation and chlamydia testing data were collected for patients (16–39 years) attending eight ACCHSs during 2008–09 in urban, regional and remote settings for the Australian Collaboration for Chlamydia Enhanced Sentinel Surveillance (ACCESS) system. Annual chlamydia testing and positivity rates were estimated. Results: Over two years, 13,809 patients aged 16–39 years (57.8% female, 82.3% Aboriginal or Torres Strait Islander) attended. The annual overall chlamydia testing rate was 13.0% (2008) and 16.0% (2009). Testing rates were higher among females (p<0.001) and among patients aged 16–29 than 30–39 years (males: p=0.01; females: p<0.001). Chlamydia positivity was 8.5% overall; similar in females (8.7%) and males (7.8%) (p=0.46); highest among 16–19 years (females: 17.4%; males: 13.0%), declining to 1.5% among females 35–39 years (p<0.001) and 4.8% among males 30–34 years (p<0.001). Conclusions: Chlamydia testing at these ACCHSs approached recommended levels among some patient groups, however, it should increase. High positivity among younger people highlights they should be targeted. Implications: Young people should be targeted for sexual health interventions. ACCHSs are well placed to provide enhanced sexual health services if appropriately resourced.     

Maternal smoking during pregnancy among Aboriginal women in New South Wales is linked to social gradient

Objective: Social gradients in Aboriginal health are seldom explored. This study describes social gradients and trends in smoking during pregnancy among Aboriginal mothers in NSW. Methods: This was a secondary analysis of the NSW Midwives Data Collection (MDC) 1994–2007, covering all births in NSW. Analyses examined associations between socio‐demographic characteristics and smoking during pregnancy. Results: Data from 1,214,206 pregnant women showed that 17.4% smoked during pregnancy. The rate of smoking during pregnancy among all NSW women declined from 22.3% in 1994 to 12.8% in 2007; the rate among Aboriginal women remained high, declining from 61.4% in 1994 to 50.2% in 2007. Smoking was substantially higher among Aboriginal mothers compared to non‐Aboriginal mothers. Socio‐economic analyses showed that the smoking rate among low SES Aboriginal mothers was approximately two and a half times that of high SES Aboriginal women, a similar gradient to non‐Aboriginal women. Conclusions: Indicators of socio‐economic position are a consistent, independent correlate of smoking during pregnancy for Aboriginal and non‐Aboriginal women. Implications: There is a need for a social inequalities approach to smoking during pregnancy, specifically targeting more disadvantaged Aboriginal mothers and all teenage mothers for smoking prevention. Strategies to access more disadvantaged mothers should not be missed through broadly focused Aboriginal tobacco control strategies.     

Feasibility and acceptability of opportunistic screening to detect atrial fibrillation in Aboriginal adults

Objective : Examine the feasibility and acceptability of an electrocardiogram (ECG) attached to a mobile phone (iECG) screening device for atrial fibrillation (AF) in Aboriginal Controlled Community Health Services (ACCHS) and other community settings. Methods : Semi‐structured interviews were conducted with ACCHS staff in urban, rural and remote communities in three Australian states/territories. Quantitative and qualitative questions identified the enabling factors and barriers for staff and Aboriginal patients' receptiveness to the device. Mean quantitative scores and their standard deviation were calculated in Microsoft Excel and qualitative questions were thematically analysed. Results : Eighteen interviews were conducted with 23 staff across 11 ACCHS. Quantitative data found staff were confident in providing iECG screening and managing the referral pathway, and thought the process was beneficial for patients. Qualitative data highlighted the usefulness of the device to undertake opportunistic screening and acceptability in routine practice, and provided opportunities to engage patients in education around AF. Conclusion : The iECG device was well accepted within ACCHSs and was feasible to use to screen for AF among Aboriginal patients. Implications for public health : The device can be used in clinical and community settings to screen Aboriginal people for atrial fibrillation to help reduce rates of stroke and other cardiovascular diseases.     

Effects of Nutritional Interventions on Cardiovascular Disease Health Outcomes in Aboriginal and Torres Strait Islander Australians: A Scoping Review

Nutrition interventions can support Aboriginal and Torres Strait Islander peoples to reduce their risk of cardiovascular disease (CVD). This review examines nutritional interventions aiming to improve CVD outcomes and appraises peer-reviewed interventions using an Aboriginal and Torres Strait Islander Quality Appraisal Tool. Five electronic databases and grey literature were searched, applying no time limit. Two reviewers completed the screening, data extraction and quality assessment independently. The study quality was assessed using the South Australian Health and Medical Research Institute and the Centre of Research Excellence in Aboriginal Chronic Disease Knowledge Translation and Exchange Aboriginal and Torres Strait Islander Quality Appraisal Tool (QAT). Twenty-one nutrition programs were included in this review. Twelve reported on anthropometric measurements, ten on biochemical and/or hematological measurements and sixteen on other outcome domains. Most programs reported improvements in measurable CVD risk factors, including reduced body mass index (BMI), waist circumference (WC), weight, blood pressure and improved lipid profiles. Most programs performed well at community engagement and capacity strengthening, but many lacked the inclusion of Indigenous research paradigms, governance and strengths-based approaches. This review highlights the need for contemporary nutrition programs aimed at improving cardiovascular health outcomes to include additional key cultural components.     

Are we closing the Aboriginal child injury gap? A cohort study

Objective: To assess if rates of hospitalised injury in Australian Aboriginal children, and differences in these rates between Aboriginal and non‐Aboriginal children, have changed over time. Methods: We used linked hospital data for New South Wales (NSW), Australia, to construct cohorts of children born in NSW hospitals between 2003–2007 and 2008–2012. We calculated rates of hospitalised injuries per 10,000 person years for Aboriginal and non‐Aboriginal children for both cohorts, and compared these using rate differences and rate ratios. Results: Rates of unintentional injury hospitalisation were similar in Aboriginal children in both cohorts and Aboriginal children had 1.7 times higher rates of unintentional injury hospitalisation compared with non‐Aboriginal children. Rate ratios between Aboriginal and non‐Aboriginal children for leading injury mechanisms, burns, poisonings and transport were similar in both cohorts, with 2.5, 3.0 and 2.4 times higher rates in Aboriginal children in the 2008–2012 cohort, respectively. Conclusions and Implications for public health: Our findings suggest that current injury prevention measures have not been successful in reducing either rates of unintentional injury in Aboriginal children, or injury inequalities between Aboriginal and non‐Aboriginal children. We recommend the implementation of targeted Aboriginal led injury prevention measures.     

Collecting and using aboriginal health information in New South Wales

OBJECTIVE: To describe the development of guidelines for the management of Aboriginal health information in NSW. The purpose of the guidelines is to promote the ethical management of Aboriginal health information, with appropriate consideration for cultural factors. METHODS: The guidelines were developed collaboratively by the NSW Aboriginal Health Partnership, which comprises NSW Health (the central administrative office, named NSW Department of Health, and the Area Health Services) and the NSW Aboriginal Health and Medical Research Council (AHMRC), the peak body representing member Aboriginal Community Controlled Health Services in NSW. A lengthy and comprehensive consultation process enabled a wide range of interested groups to have input into the guidelines. RESULTS: The project culminated in the production of the NSW Aboriginal Health Information Guidelines, covering the collection, ownership, storage, security, release, usage, interpretation and reporting of information, as well as issues of privacy and confidentiality. The Guidelines formed the basis of a formal Memorandum of Understanding, signed by the NSW Minister for Health, NSW Department of Health and the AHMRC, on 24 August 1998. CONCLUSIONS AND IMPLICATIONS: The Guidelines make an important contribution to meeting a need for protocols on the collection, ownership and use of Aboriginal health information. Their production reflects successful collaboration between government and Aboriginal Community Controlled Health Services in NSW. Future reviews of the Guidelines will ensure their effectiveness and consistency with Aboriginal community principles.     

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.     

Closing the Aboriginal child injury gap: targets for injury prevention

Objective : To describe the leading mechanisms of hospitalised unintentional injury in Australian Aboriginal children and identify the injury mechanisms with the largest inequalities between Aboriginal and non‐Aboriginal children. Methods : We used linked hospital and mortality data to construct a whole of population birth cohort including 1,124,717 children (1,088,645 non‐Aboriginal and 35,749 Aboriginal) born in the state of New South Wales (NSW), Australia, between 1 July 2000 and 31 December 2012. Injury hospitalisation rates were calculated per person years at risk for injury mechanisms coded according to the ICD10‐AM classification. Results : The leading injury mechanisms in both groups of children were falls from playground equipment. For 66 of the 69 injury mechanisms studied, Aboriginal children had a higher rate of hospitalisation compared with non‐Aboriginal children. The largest relative inequalities were observed for injuries due to exposure to fire and flame, and the largest absolute inequalities for injuries due to falls from playground equipment. Conclusion : Aboriginal children in NSW experience a significant higher burden of unintentional injury compared with their non‐Aboriginal counterparts. Implications for Public Health : We suggest the implementation of targeted injury prevention measures aimed at injury mechanism and age groups identified in this study.     

Statistical methods to enhance reporting of Aboriginal Australians in routine hospital records using data linkage affect estimates of health disparities

Objective: To investigate under‐recording of Aboriginal people in hospital data from New South Wales (NSW), Australia, define algorithms for enhanced reporting, and examine the impact of these algorithms on estimated disparities in cardiovascular and injury outcomes. Methods: NSW Admitted Patient Data were linked with NSW mortality data (2001–2007). Associations with recording of Aboriginal status were investigated using multilevel logistic regression. The number of admissions reported as Aboriginal according to six algorithms was compared with the original (unenhanced) Aboriginal status variable. Age‐standardised admission, and 30‐ and 365‐day mortality ratios were estimated for cardiovascular disease and injury. Results: Sixty per cent of the variation in recording of Aboriginal status was due to the hospital of admission, with poorer recording in private and major city hospitals. All enhancement algorithms increased the number of admissions reported as Aboriginal, from between 4.1% and 37.8%. Admission and mortality ratios varied markedly between algorithms, with less strict algorithms resulting in higher admission rate ratios, but generally lower mortality rate ratios, particularly for cardiovascular disease. Conclusions: The choice of enhancement algorithm has an impact on the number of people reported as Aboriginal and on estimated outcome ratios. The influence of the hospital on recording of Aboriginal status highlights the importance of continued efforts to improve data collection. Implications: Estimates of Aboriginal health disparity can change depending on how Aboriginal status is reported. Sensitivity analyses using a number of algorithms are recommended.     

Building a strategic approach to improve Aboriginal health research and evaluation in NSW

A 5-year strategic plan for Aboriginal health research and evaluation has been developed to support the NSW Ministry of Health in its efforts to create the evidence for what works in addressing the health disparity between Aboriginal and non-Aboriginal people. The plan has the following objectives: that all Aboriginal health policies and programs are evidence informed; that programs and strategies are rigorously evaluated and contribute to building the evidence for improving Aboriginal health outcomes; that new research evidence is generated for improving Aboriginal health outcomes; and that robust monitoring and accountability mechanisms in Aboriginal health are in place, with improved data quality. This paper describes the development of the NSW Ministry of Health's Aboriginal Health Research and Evaluation Strategic Plan 2011-15, including a review of the evidence and policy documents, facilitated planning sessions, and consultation with staff within the Population and Public Health Division of the Ministry.     

Successful chronic disease care for Aboriginal Australians requires cultural competence

Objective: To review the literature to determine the attributes of culturally appropriate healthcare to inform the design of chronic disease management (CDM) models for Aboriginal patients in urban general practice. Methods: A comprehensive conceptual framework, drawing on the Access to Care, Pathway to Care, Chronic Care, Level of Connectedness, and Cultural Security, Cultural Competency and Cultural Respect models, was developed to define the search strategy, inclusion criteria and appraisal methods for the literature review. Selected papers were reviewed in detail if they examined a chronic disease intervention for an Aboriginal population and reported on its evaluation, impacts or outcomes. Results: In the 173 papers examined, only 11 programs met the inclusion criteria. All were programs conducted in rural and remote Aboriginal community‐controlled health services. Successful chronic disease care and interventions require adequate Aboriginal community engagement, utilising local knowledge, strong leadership, shared responsibilities, sustainable resources and integrated data and systems. These success factors fitted within the conceptual framework developed. Conclusions: Research and development of culturally appropriate CDM models concurrently in both urban and rural settings will enable more rigorous evaluation, leading to stronger evidence for best practice. A partnership of mainstream and Aboriginal‐controlled health services is essential to successfully ‘close the gap’. Implications: Findings will inform and guide the development, implementation and evaluation of culturally appropriate CDM in mainstream general practice and primary care.     

Improving the mental health of rural New South Wales communities facing drought and other adversities

Objective: NSW has just experienced its worst drought in a century. As years passed with insufficient rain, drought‐related mental health problems became evident on farms. Our objective is to describe how, in response, the Rural Adversity Mental Health Program was introduced in 2007 to raise awareness of drought‐related mental health needs and help address these needs in rural and remote NSW. The program has since expanded to include other forms of rural adversity, including recent floods. Setting: Rural NSW. Design, participants, interventions: Designed around community development principles, health, local service networks and partner agencies collaborated to promote mental health, education and early intervention. Strategies included raising mental health literacy, organising community social events and disseminating drought‐related information. Priority areas were Aboriginal communities, older farmers, young people, women, primary health care and substance use. Results: Over 3000 people received mental health literacy training in the four years of operation from 2007 to 2010. Stakeholders collaborated to conduct hundreds of mental health‐related events attended by thousands of people. A free rural mental health support telephone line provided crisis help and referral to rural mental health‐related services. Conclusion: Drought affected mental health in rural NSW. A community development model was accepted and considered effective in helping communities build capacity and resilience in the face of chronic drought‐related hardship. Given the scale, complexity and significance of drought impacts and rural adjustment, and the threats posed by climate change, a long‐term approach to funding such programs would be appropriate.     

The development and implementation of a strategic framework to improve Aboriginal child development and wellbeing in far west NSW: a collaborative approach

In 2005, the Maari Ma Chronic Disease Strategy of the Maari Ma Health Aboriginal Corporation in far west NSW identified the importance of addressing the fetal, infant and child origins of chronic disease in adults. In 2008a process for developing a strategic framework to improve the development and wellbeing of children was initiated. The process incorporated all organisations involved with children. A multisectoral working group was established to facilitate the development of the strategic framework which was published in 2009 and a Project Officer was employed by Maari Ma to implement it. This included working with agencies that have the potential to affect the social determinants of health. It is anticipated that, in the medium to long term, this approach will contribute to reducing the rate of chronic disease in adulthood, and reduce the gap between Aboriginal and non-Aboriginal health outcomes.     

If the land's sick, we're sick:* the impact of prolonged drought on the social and emotional well-being of Aboriginal communities in rural New South Wales

Objective: To report Aboriginal communities' views of how prolonged drought in rural NSW has affected their social and emotional well‐being, and of possible adaptive strategies. Design: Content analysis of issues, priorities and adaptive strategies raised in semistructured community forums. Setting: Rural centres across NSW. Participants: Aboriginal people, service providers and other stakeholders. Voluntary participation by invitation with consent to record discussions. Results: Three themes (containing six issues) emerged: (i) impacts on culture (harm to traditional family structure, culture and place; bringing shame to culture); (ii) sociodemographic and economic impacts (skewing of the population profile; loss of livelihood and participation; aggravation of existing socioeconomic disadvantage); and (iii) loss. In addition to continuing well‐being programs that were already successful, proposed adaptive strategies were: capturing the spirit of Aboriginal knowledge and traditions; knowing your land; and Aboriginal arts. Conclusion: Prolonged drought presented substantial and unique adversity for rural NSW Aboriginal communities, compounding existing, underlying disadvantage. Drought‐induced degradation of and, sometimes, the necessity to leave traditional land drove people apart and disrupted Caring for Country activities. Some people reported despair at not being able to discharge cultural obligations. At the same time, the drought prompted increased love of and concern for land and a renewed enthusiasm for expressing connectedness to land through all forms of art. Modern Aboriginal and wider community well‐being programs helped frame a response to drought alongside traditional Aboriginal dreaming and cultural approaches to emotional health and well‐being.