Trends in purchasing patterns of sugar‐sweetened water‐based beverages in a remote Aboriginal community store following the implementation of a community‐developed store nutrition policy

Aim: Aboriginal people living in remote communities experience high levels of chronic illness partly as a result of diet‐related body mass index above 25 kg/m². Remote stores are typically the only source of food and store nutrition policies are effective in enabling better health for community residents by changing product lines. The aim of the present study was to examine trends in purchasing patterns of sugar‐sweetened water‐based beverages in a remote Aboriginal community store following the implementation of a community‐developed store nutrition policy. Methods: Documents outlining the objectives and strategies of the store policy were examined. Store sales data were quantified to determine changes in purchasing patterns, volume of beverages sold, sugar and energy purchased before and after the withdrawal of the three highest selling sugar‐sweetened water‐based beverages. Results: The community‐developed policy was effective in implementing changes to product lines sold in the remote Aboriginal store. The withdrawal of the three top selling sugar‐sweetened water‐based beverages did not affect the total volume of all beverages sold but a shift in purchasing trends towards beverages with lower or zero sugar content resulted in a reduction in sugar and kilojoules consumed through water‐based beverages. Conclusion: The approach of a community‐driven store nutrition policy described here was successful and could be applied to other products in store that provide excess kilojoules with minimal nutritional benefit. The policy and aspects of implementation could also be applied in other remote Aboriginal communities.     

Food and nutrition policy issues in remote aboriginal communities: lessons from Arnhem Land.

There is a high incidence of nutrition-related diseases amongst Aborigines living in remote areas. An outline of the corporate food and nutrition policy of the Arnhemland Progress Association is given to demonstrate the potential for positive strategies in remote area stores. The Association is a retailer owned by Aboriginal groups and operates 11 remote community stores. Factors such as price, Aboriginal buying habits, seasonality, consumer demand and most importantly remote area stock management affect the supply of and demand for food items. Further, government policy on sales tax and private sector capital city pricing policies influence retailing in remote areas. The experience of the Arnhemland Progress Association illustrates the extent to which factors affecting supply of and demand for food lie outside the health sector and points to the need for an intersectoral policy on food and nutrition.     

Food and nutrition policy issues in remote Aboriginal communities: lessons from Arnhem Land

Abstract: There is a high incidence of nutrition-related diseases amongst Aborigines living in remote areas. An outline of the corporate food and nutrition policy of the Arnhemland Progress Association is given to demonstrate the potential for positive strategies in remote area stores. The Association is a retailer owned by Aboriginal groups and operates 11 remote community stores. Factors such as price, Aboriginal buying habits, seasonality, consumer demand and most importantly remote area stock management affect the supply of and demand for food items. Further, government policy on sales tax and private sector capital city pricing policies influence retailing in remote areas. The experience of the Arnhemland Progress Association illustrates the extent to which factors affecting supply of and demand for food lie outside the health sector and points to the need for an intersectoral policy on food and nutrition.     

Coverage of Aboriginal and Torres Strait Islander nutrition in major Australian newspapers, 1996–2015

Objective: To examine the extent and nature of coverage of Aboriginal and Torres Strait Islander nutrition issues in major Australian newspapers over two decades. Methods : Content and framing analysis of Australian newspaper articles published between 1996 and 2015 that included the terms ‘Aboriginal or Indigenous’ and ‘nutrition or diet’ in the headline and/or lead paragraph. Analysis focused on the nature of coverage, trends over time, stakeholder representation and how coverage related to policy. Results : A total of 79 articles were included. Coverage of nutrition fluctuated over time, with peaks in 1998 and 2008. The majority of articles focused on remote Aboriginal communities. Both individual and structural representations of nutrition were used and dietary quality and food insecurity were the most commonly reported nutrition issues. Few articles employed positive representations of Aboriginal peoples. Six policy functions of articles were identified: highlighting problems; reporting government announcements; promoting programs; advocating solutions; critiquing government; and defending policy. Conclusion : The coverage of Aboriginal and Torres Strait Islander nutrition in newspapers does not reflect the diversity and strengths of Australia’s First Peoples. Implications for public health : This study highlights the role of the media in policy advocacy; however, advocates should ensure that they do not perpetuate negative representations of Aboriginal and Torres Strait Islander peoples.     

The effect of retail store managers on Aboriginal diet in remote communities

Abstract: Key nutrient densities of the diet of two remote northern coastal Aboriginal communities were measured using the store-turnover method during the periods that three store managers were responsible for each store respectively. Individual store managers were a greater determinant of nutrient density than the community itself. Furthermore, nutrient densities tended to be highest in both communities when their stores were administered by one particular store manager. The results support the notion that store managers wield considerable power over the food supply of remote Aboriginal communities, and raise questions concerning the ability of Aboriginal community members to influence their own food supplies in retail stores. However, the study also confirms that store managers can be important allies in efforts to improve Aboriginal dietary intake.     

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

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

Fighting disease with fruit

Otitis media and chronic suppurative otitis media are common conditions in Aboriginal communities, and are associated with poor nutrition, overcrowding and passive smoking. This article reports on an extension of our nutrition program, which was first reported in Australian Family Physician under the title 'Are there health benefits from improving basic nutrition in a remote Aboriginal community?'     

Apparent dietary intake in remote Aboriginal communities

Abstract: Apparent per capita food and nutrient intake in six remote Australian Aboriginal communities using the ‘store-turnover’ method is described. The method is based on the analysis of community-store food invoices. The face validity of the method supports the notion that, under the unique circumstances of remote Aboriginal communities, the turnover of foodstuffs from the community store is a useful measure of apparent dietary intake for the community as a whole. In all Aboriginal communities studied, the apparent intake of energy, sugars and fat was excessive, while the apparent intake of dietary fibre and several nutrients, including folic acid, was low. White sugar, flour, bread and meat provided in excess of 50 per cent of the apparent total energy intake. Of the apparent high fat intake, fatty meats contributed nearly 40 per cent in northern coastal communities and over 60 per cent in central desert communities. Sixty per cent of the apparent high intake of sugars was derived from sugar per se in both regions. Compared with national Australian apparent consumption data, intakes of sugar, white flour and sweetened carbonated beverages were much higher in Aboriginal communities, and intakes of wholemeal bread, fruit and vegetables were much lower. Results of the store-turnover method have important implications for community-based nutrition intervention programs.     

Public hospital activity,expenditure and staffing levels for indigenous and nonindigenous settlements in remote Queensland

Abstract: Aborigines and Torres Strait Islanders who live in discrete communities have poor health. Their life expectancy is relatively low and the underlying rates of morbidity, mortality and hospitalisation are much higher than the Australian average. For Aborigines and Torres Strait Islanders in the remote communities, the mortality rate is some three times higher than that of the total population. By comparing remote Aboriginal and Torres Strait Islander communities with similarly remote nonindigenous settlements, the paper shows that there was greater hospital activity per person in remote Aboriginal and Torres Strait Islander communities. Paradoxically, whereas there was greater hospital activity in discrete indigenous communities, there was lower expenditure per person on hospital services. The paper finds also that there were fewer medical and nursing staff per person in remote Aboriginal and Torres Strait communities.     

Coverage of Aboriginal and Torres Strait Islander nutrition in the Koori Mail

Objective : To examine the extent and nature of coverage of nutrition in the Koori Mail. Methods : Content and framing analysis were used to examine articles in the Koori Mail published between 2013 and 2017 that included the terms ‘nutrition?’, ‘diet?’, ‘food’, ‘eating’, ‘weight’, ‘tucker’ or ‘sugary drinks’. The analysis focused on the portrayal of Aboriginal and Torres Strait Islander people/communities, inclusion of First Peoples’ voices and the framing of nutrition issues. Results : A total of 102 articles were included. Most articles (88%, n=90) portrayed Aboriginal and Torres Strait Islander communities in a neutral or positive way and more than half (53%, n=54) included an Aboriginal or Torres Strait Islander voice. While nutrition was often framed as an individual or community responsibility, articles predominantly promoted programs or initiatives undertaken in local communities. Conclusion : Despite the limited prominence of Aboriginal and Torres Strait Islander nutrition in the mainstream media, the coverage of nutrition issues in the Koori Mail demonstrates the salience of this topic for local communities. This study highlights how journalism can better reflect the diversity and strengths of First Peoples. Implications for public health : Including more Aboriginal and Torres Strait Islander voices and using a strengths‐based approach in press releases may improve media advocacy.     

Monitoring local trends in Indigenous tobacco consumption

Objective : To compare two methods of monitoring tobacco consumption in remote Indigenous communities.
Methods : We examined the monthly difference between wholesale invoice and point-of-sale data for tobacco products from three stores from remote Aboriginal communities in the Northern Territory. We assessed three measures of wholesale data.
Results : The average monthly difference between the sale data and the average of wholesale invoices for the previous, same and following month was -33 cigarettes per day (95% CI -157, 92). This average of three months' wholesale invoices provided a more precise estimate than either wholesale invoices from the same or previous month.
Conclusion : Tobacco wholesale data provided a close estimate of sales data in these stores.
Implications : This wholesale data could be used to monitor local trends in remote Indigenous tobacco consumption, facilitating the evaluation of the impact of tobacco control activities and informing future work to reduce Indigenous smoking and its harms.     

Towards guidelines for survey research in remote Aboriginal communities

Abstract: Based on our experience in developing and evaluating community–based health promotion programs in Aboriginal and Torres Strait Islander communities, we offer guidelines to assist nonindigenous health and public policy professionals whose information gathering in these communities includes the use of unstructured interviewing or survey questionnaires. The guidelines primarily apply to research among mainland remote Aboriginal communities, but are placed in a cultural context such that those dealing with Torres Strait Islanders and rural or urban community Aborigines also may benefit from the guidelines. The major aims of these guidelines are to facilitate communication between interviewers and indigenous interviewees and to ensure that interviewing is done with maximum sensitivity to cultural differences and with minimum discomfort to the respondents.     

Food and beverage price discounts to improve health in remote Aboriginal communities: mixed method evaluation of a natural experiment

Objective: Retrospectively evaluate food price discounts in remote Aboriginal community stores. Methods: Four price discount strategies of 10% were designed in 2010, aiming to influence grocery, fruit, vegetables and diet soft‐drink sales. This natural experiment across a group of stores was evaluated using an explanatory, sequential mixed method design through analysis of store point‐of‐sale, document, observation and interview data. The outcome was measured by change in: 1) percentage of grocery sales to total food and beverage; 2) fruit and vegetable sales; and 3) diet soft‐drink sales. Qualitative data enabled the interpretation of outcomes through understanding perceived success and benefits, and enablers and barriers to implementation. Results: Eighteen community stores and 54 informants participated. While targeted price discounts were considered important to improving health, no discernible effect was evident, due to inadequate design and communication of discount promotion, and probably inadequate magnitude of discount. Conclusions: Strategy impact on food and beverage sales was limited by promotion and magnitude of discount. Implication for Public Health: This study demonstrates key factors and commitment required to design, communicate, implement and monitor strategies to improve health in this challenging remote retail context. Evaluation of natural experiments can contribute evidence to policy‐making.     

Private business: the uptake of confidential HIV testing in remote Aboriginal communities on the Ananau Pitiantiatiara Lands

Background and methods: Despite a concentration of risk factors for HIV transmission, many remote Aboriginal communities in central Australia have a low uptake of HIV testing. We studied, the uptake of HIV testing in six clinics in remote Aboriginal communities following the introduction of voluntary confidential testing to assess the impact of the intervention and to determine if the program was reaching people most at risk of HIV infection and transmission.
Setting: The study was conducted by Nganampa Health Council, an Aboriginal-controlled health service on the A n angu Pitjantjatjara Lands in the far north-west of South Australia.
Results: Since the introduction of confidential coded testing in August 1994 the number of HIV tests provided through the remote clinics has increased from 83 tests/year to 592 tests/year. In the 12-month audit period (August 1, 1995, to July 31, 1996) 62.7% of women aged 20–24 years, 44.6% of people aged 12–40 years and 24% of the total population had an HIV test. Fifty per cent of tests were accounted for by the 15–25 year age groups and 60% of tests related to an STD consult.
Discussion: This study shows that a high uptake of HIV testing in high-risk groups can be achieved in remote Aboriginal communities where a high level of confidentiality is maintained.     

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

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

Positive community responses to an arts–health program designed to tackle diabetes and kidney disease in remote Aboriginal communities in Australia: a qualitative study

Objective : The Western Desert Kidney Health Project (WDKHP) is an innovative clinical screening, arts–health and community development program, staffed by Aboriginal health workers. The WDKHP is aimed at prevention and early detection, improving the chance of better management of kidney disease among people in 10 predominantly Aboriginal communities in rural Western Australia. This paper aimed to understand community responses to the WDKHP in three of these communities. Methods : Interviews were undertaken with 26 Aboriginal people living in three remote communities. Community responses were analysed with attention to the social organisation of participants in each community and a focus on the perspectives of key groups, identified here as ‘Community Leaders’, ‘Homelanders’, ‘Refuge Seekers’ and ‘Dislocated’. Results : Participants from all groups reported that the WDKHP was highly acceptable, and an effective means of drawing attention to the need for prevention, early detection and management of diabetes and kidney disease. The integration of Aboriginal health workers to explain the project contributed to the high rates of participation in clinical screening. Conclusions : Outreach clinical services can be an appropriate method of engaging people in remote communities in addressing diabetes and kidney disease. Implications : The remote community setting can act as an ‘enabler’ of healthy lifestyle for Aboriginal people, particularly when augmented by well‐designed outreach programs.     

The dynamic nature of group A streptococcal epidemiology in tropical communities with high rates of rheumatic heart disease

Prospective surveillance was conducted in three remote Aboriginal communities with high rates of rheumatic heart disease in order to investigate the epidemiology of group A beta-haemolytic streptococci (GAS). At each household visit, participants were asked about sore throat. Swabs were taken from all throats and any skin sores. GAS isolates were emm sequence and pattern-typed using standard laboratory methods. There were 531 household visits; 43 different emm types and subtypes (emmST) were recovered. Four epidemiological patterns were observed. Multiple emmST were present in the population at any one time and household acquisition rates were high. Household acquisition was most commonly via 5- to 9-year-olds. Following acquisition, there was a 1 in 5 chance of secondary detection in the household. Throat detection of emmST was brief, usually <2 months. The epidemiology of GAS in these remote Aboriginal communities is a highly dynamic process characterized by emmST diversity and turnover.     

The Marulu Strategy 2008–2012: overcoming Fetal Alcohol Spectrum Disorder (FASD) in the Fitzroy Valley

Objective: Aboriginal leaders concerned about high rates of Fetal Alcohol Spectrum Disorder (FASD) in the Fitzroy Valley, remote north‐western Australia, introduced restrictions on access to take‐away full‐strength alcohol. Following this, Aboriginal leaders engaged strategic partners in a broader strategy to address FASD in the region. The aim of this study was to develop and implement a community‐led, researcher‐supported, FASD strategy. Methods: A review of literature focusing on community‐led FASD strategies identified key components that informed the Marulu FASD strategy. These included strategy ownership, leadership, and governance by participating communities, and a research framework. Results: Community meetings and workshops led to the development of The Marulu FASD Strategy (2008). Feasibility and community consent to conduct a FASD prevalence study (the Lililwan Project) was confirmed, and implementation was progressed (2010–2013). Concurrent FASD prevention activities were conducted. In 2012, the Marulu FASD Unit was established within a local Aboriginal organisation to sustain and coordinate ongoing strategy activities. Conclusions: Community control of public health initiatives can be achieved when Aboriginal communities prioritise issues of significant concern, and engage strategic partners to overcome them. Implications for public health: The Marulu Strategy forms a template for action to address FASD and other public health issues in Aboriginal communities in Australia and internationally.     

Specialist clinics in remote Australian Aboriginal communities: where rock art meets rocket science

People in remote Aboriginal communities in the Northern Territory have greater morbidity and mortality than other Australians, but face considerable barriers when accessing hospital-based specialist services. The Specialist Outreach Service, which began in 1997, was a novel policy initiative to improve access by providing a regular multidisciplinary visiting specialist services to remote communities. It led to two interesting juxtapositions: that of 'state of the art' specialist services alongside under-resourced primary care in remote and relatively traditional Aboriginal communities; and that of attempts to develop an evidence base for the effectiveness of outreach, while meeting the short-term evaluative requirements of policy-makers. In this essay, first we describe the development of the service in the Northern Territory and its initial process evaluation. Through a Cochrane systematic review we then summarise the published research on the effectiveness of specialist outreach in improving access to tertiary and hospital-based care. Finally we describe the findings of an observational population-based study of the use of specialist services and the impact of outreach to three remote communities over 11 years. Specialist outreach improves access to specialist care and may lessen the demand for both outpatient and inpatient hospital care. Specialist outreach is, however, dependent on well-functioning primary care. According to the way in which outreach is conducted and the service is organised, it can either support primary care or it can hinder primary care and, as a result, reduce its own effectiveness.     

A cross-sectional survey of environmental health in remote Aboriginal communities in Western Australia

Introduction: The Australian Aboriginal population experiences significantly poorer health than the non-Aboriginal population. The contribution of environmental risk factors in remote communities to this health disparity is poorly understood.

Objective: To describe and quantify major environmental risk factors and associated health outcomes in remote Aboriginal communities in Western Australia.

Methods: The association between environmental health indicators, community infrastructure and reported health outcomes was analysed using linear and logistic regression of survey data.

Results: Housing/overcrowding was significantly associated with increased reports of hearing/eyesight (OR 3.01 95?% CI 1.58–5.73), skin (OR 2.71 95?% CI 1.31–5.60), gastrointestinal (OR 3.51 95 % CI 1.49–8.26) and flu/colds (OR 2.47 95 % CI 1.27–4.78) as health concerns. Dust was significantly associated with hearing/eyesight (OR 3.16 95 % CI 1.82–5.48), asthma/respiratory (OR 2.48 95 % CI 1.43–4.29) and flu/colds (OR 3.31 95 % CI 1.88–5.86) as health concerns.

Conclusion: Poor environmental health is prevalent in remote Aboriginal communities and requires further delineation to inform environmental health policy.