A reduction in reported alcohol use in pregnancy in Australian Aboriginal communities: a prevention campaign showing promise

Objective : Aboriginal leaders in remote Western Australian communities with high rates of prenatal alcohol exposure invited researchers to evaluate the community‐led Marulu foetal alcohol spectrum disorder (FASD) Prevention Strategy initiated in 2010. Methods : The proportion of women reporting alcohol use during pregnancy to midwives was compared between 2008, 2010 and 2015. Initial midwife appointments were calculated by weeks of gestation. The proportions of women reporting alcohol use by age at birth were compared. Results : Alcohol use reduced significantly from 2010 (61.0%) to 2015 (31.9%) with first‐trimester use reducing significantly from 2008 (45.1%) to 2015 (21.6%). Across all years, 40.8% reported alcohol use during pregnancy and 14.8% reported use in both first and third trimesters. Most women attended the midwife in the first trimester. There was a significant relationship between increased maternal age and third‐trimester alcohol use. Conclusions : The reduction in reported prenatal alcohol exposure in an Aboriginal community setting during a period of prevention activities provides initial evidence for a community‐led strategy that might be applicable to similar communities. Implications for public health : The reductions in alcohol use reduce the risk of children being born with FASD in an area with high prevalence, with possible resultant reductions in associated health, economic and societal costs.     

Supporting healthy drink choices in remote Aboriginal and Torres Strait Islander communities: a community‐led supportive environment approach

Objective : To create supportive environments to reduce sugary drink consumption and increase water consumption by partnering with remote Aboriginal and Torres Strait Islander communities in Cape York. Methods : This paper applied qualitative and quantitative methods to evaluate a co‐designed multi‐strategy health promotion initiative, implemented over 12 months from 2017 to 2018. Outcome measures included changes in community readiness, awareness of the social marketing campaign and changes in drink availability. Changes in store drink sales were measured in one community and compared to sales in a control store. Results : Community readiness to address sugary drink consumption increased in two of the three communities. Awareness of social marketing campaign messaging was high (56–94%). Availability of drinking water increased in all communities. Water sales as a proportion of total drink volume sales increased by 3.1% (p<0.001) while sugary drink volume sales decreased by 3.4% (p<0.001). Conclusions : A multi‐component strategy with strong engagement from local government, community leaders and the wider community was associated with positive changes in community readiness, drink availability and sales. Implications for public health : Partnering with community leaders in the co‐design of strategies to create environments that support healthy drink consumption can stimulate local action and may positively affect drink consumption.     

Perspectives on childhood resilience among the Aboriginal community: an interview study

Objective : To describe Aboriginal community members' perspectives on the outcomes and origins of resilience among Aboriginal children. Methods : Face‐to‐face interviews were conducted with 36 Aboriginal adults (15 health service professionals, 8 youth workers and 13 community members) at two urban and one regional Aboriginal Community Controlled Health Service in New South Wales. Interviews were transcribed and analysed thematically. Results : We identified six themes: withstanding risk (displaying normative development, possessing inner fortitude); adapting to adversity (necessary endurance, masking inner vulnerabilities); positive social influences (secure family environments, role modelling healthy behaviours and relationships); instilling cultural identity (investing in Aboriginal knowledge, building a strong cultural self‐concept); community safeguards (offering strategic sustainable services, holistic support, shared responsibility, providing enriching opportunities); and personal empowerment (awareness of positive pathways, developing self‐respect, fostering positive decision making). Conclusions : Community members believed that resilient Aboriginal children possessed knowledge and self‐belief that encouraged positive decision making despite challenging circumstances. A strong sense of cultural identity and safe, stable and supportive family environments were thought to promote resilient behaviours. Implications for public health : Many Aboriginal children continue to face significant adversity. More sustainable, Aboriginal‐led programs are needed to augment positive family dynamics, identify at‐risk children and provide safeguards during periods of familial adversity.     

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.     

Aboriginal mothering,FASD prevention and the contestations of neoliberal citizenship

Over the past 25 years, Aboriginal leaders, community advocates, children's and women's health specialists and Canadian government agencies have drawn increasing attention to the perceived need to undertake targeted initiatives to prevent fetal alcohol spectrum disorder (FASD) in indigenous communities. In pursuit of this goal, a range of prevention campaigns have been undertaken – generally with funding from the State – urging pregnant women to abstain from alcohol. Because both risk and protective factors for FASD are intimately connected to the social conditions in which women become pregnant, give birth to and mother their children, FASD prevention campaigns targeting Aboriginal communities suggest possibilities that are both provocative and problematic for advancing movements for social justice, decolonisation and improved maternal and child health. In this essay, I consider how the gendered and racialised legacies of colonisation emerge alongside concerns for improved health and well-being of indigenous children to inform contemporary, state-funded efforts to prevent FASD. In so doing, I examine the ways that neoliberal economic and political trajectories of Canadian state formation intersect with some aspects of decolonisation movements to raise important questions about when, how and under what conditions colonial states support FASD prevention efforts among indigenous peoples.     

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.     

Transforming the urban food desert from the grassroots up: a model for community change

Confronted by continuing health disparities in vulnerable communities, Community Health Councils (CHC), a nonprofit community-based organization in South Los Angeles, worked with the African Americans Building a Legacy of Health Coalition and research partners to develop a community change model to address the root causes of health disparities within the community's African American population. This article discusses how the CHC Model's development and application led to public policy interventions in a "food desert." The CHC Model provided a systematic approach to engaging impacted communities in support of societal level reforms, with the goal to influence health outcomes.     

Addressing the barriers to driver licensing for Aboriginal people in New South Wales and South Australia

Objective: Low rates of driver licensing have been linked to increased risk of transport‐related injury, and reduced access to health services, employment and educational opportunities in the Aboriginal population. This paper reports on how barriers to obtaining a driver licence are being addressed in four Aboriginal communities in New South Wales and South Australia. Methods: Qualitative data were collected over a four‐month period in 2013. Interviews with Aboriginal and non‐Aboriginal stakeholders (n=31) and 11 focus groups with Aboriginal participants (n=46) were analysed thematically using a framework approach. Results: Factors facilitating licensing included: family support, professional lessons, alternative testing and programs that assist with literacy, fines management, financial assistance and access to a supervising driver. Stakeholders recommended raising awareness of existing services and funding community‐based service provision to promote access to licensing. Discussion: Facilitating licence participation requires systemic change and long‐term investment to ensure interagency collaboration, service use and sustainability of relevant programs, including job search agencies. Implications for public health: The disadvantage faced by Aboriginal people in driver licensing is a fundamental barrier to participation and a social determinant of health. Understanding the factors that promote licensing is crucial to improving access for under‐serviced populations; recommendations provide pragmatic solutions to address licensing disadvantage.     

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.     

Evaluation of the Aboriginal and Torres Strait Islander Mental Health First Aid Program

Objective : This study reports findings from an uncontrolled evaluation of a course designed to educate participants in how to recognise and respond to mental health problems until professional help is received. Methods : Utilising a mixed methods design, participants in 21 different courses, delivered across two Australian states, were invited to complete pre‐, post‐, and follow‐up surveys and provide qualitative feedback on their training experiences. Results : Participants reported feeling more confident in their capacity to respond appropriately to a person presenting with a mental health need and believed they would be more likely to provide assistance. Satisfaction was attributed to the skills and sensitivities of instructors who had lived experience of mental health concerns in Aboriginal and Torres Strait Islander communities. Conclusion : This course holds promise in improving mental health literacy in relation to Aboriginal and Torres Strait Islander mental health. Implications for public health : Few courses are available that address issues relating to the social and emotional wellbeing of Aboriginal and Torres Strait Islander People. This study illustrates how community engagement with primary health and specialist mental health services might be strengthened.     

Working with an Aboriginal community liaison worker

FPA Health (Family Planning NSW) has conducted two integrated clinical and health promotion projects with Aboriginal communities in western NSW, Australia. The first was in Coonamble, a small rural community which had been selected as a pilot site for the Royal Australian College of General Practitioners Women's Aboriginal and Torres Strait Islander Project and was managed by FPA Health with support from the Dubbo/Plains Division of General Practice and Macquarie Area Health Service. The second was in Dubbo, a regional city where FPA Health had an existing centre and which had funding support from the Rio Tinto Aboriginal Foundation. The aim of this article was to share the learning and knowledge gained in managing these projects and to describe the experience of working with Aboriginal Community Liaison Workers who belong to and are supported by, the local Aboriginal community. The article aimed to illustrate the role and value of utilising these workers within a mainstream health service. The beneficial outcomes include improving service provision to Aboriginal women, adding to community knowledge about reproductive and sexual health issues and increasing the cultural knowledge and competency of a mainstream health service organisation.     

Trachoma surveillance in Australia, 2009. A report by the National Trachoma Surveillance and Reporting Unit

Trachoma is highly prevalent in remote Indigenous communities in Australia. The National Trachoma Surveillance and Reporting Unit was established in 2006 as a result of a Federal Government initiative to provide comprehensive surveillance data from regional and remote Indigenous communities considered by the jurisdictional population health staff to be 'At Risk' for endemic trachoma, defined as a trachoma prevalence of 5% or more. This report details the findings from the 2009 trachoma screening program together with trends in trachoma prevalence and screening coverage since 2006. Aboriginal children aged 1-9 years resident in At Risk communities were examined for trachoma using the World Health Organization (WHO) simplified trachoma grading criteria. In the Northern Territory, screening was conducted by staff from the Healthy School Age Kids program and the Aboriginal Community Controlled Health Services. In South Australia, screening was conducted by the Eye Health and Chronic Disease Specialist Support Program and a team of visiting ophthalmologists and optometrists. In Western Australia, screening was conducted by staff from State Government population health units and Aboriginal Community Controlled Health Services. In the Northern Territory, 53 of 86 At Risk communities were screened and data were reported for 2283 children. In South Australia, 12 of 72 At Risk communities were screened and data were reported for 149 children. In Western Australia, 68 of 74 At Risk communities were screened and data were reported for 1684 children. The prevalence of active trachoma ranged from 1%-44% in the Northern Territory, 0%-57% in South Australia and 13%-15% in Western Australia. Trend analysis across all three jurisdictions combined found that neither the prevalence of trachoma nor community screening coverage changed significantly between 2006 and 2009. When trend analysis was "done by jurisdiction, there was a significant decrease in trachoma prevalence and a significant increase in community screening coverage only for Western Australia over the same 4 year period. The implementation of the and Environmental improvement (SAFE) strategy has been variable. Surgery referral processes for trichiasis were reported as available in all screened communities in the Northern Territory and South Australia but only in 35% of screened communities in Western Australia. Antibiotics were distributed according to Communicable Diseases Network Australia guidelines in 89% of communities where treatment was indicated. Facial cleanliness programs and resources were reported as poorly implemented in South Australia and Western Australia while minimal data were reported for environmental conditions in all jurisdictions. No significant change was found in bacterial resistance to azithromycin from 2007 to 2009. Significant gaps remain in community screening coverage and in the full implementation of the SAFE strategy. However, the parallel increase in community screening coverage and decrease in trachoma prevalence in Western Australia suggests that the SAFE strategy might have had an effect in reducing trachoma prevalence in that jurisdiction.     

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.     

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.     

“No‐one’s driving this bus” – qualitative analysis of PrEP health promotion for Aboriginal and Torres Strait Islander gay and bisexual men

Objective : HIV prevention tools such as pre‐exposure prophylaxis require equitable access and uptake to protect all at‐risk populations. This project assessed the perceived barriers to accessible HIV prevention for Aboriginal and Torres Strait Islander gay and bisexual men (GBM) and evaluated the presence of health promotion for pre‐exposure prophylaxis (PrEP) for this population from the perspective of service providers. Methods : Eighteen semi‐structured interviews with healthcare providers, researchers and AIDS Council employees were qualitatively analysed for themes and concepts related to PrEP‐specific health promotion. Results : Respondents noted AIDS Councils and affiliated sexual health clinics had been instrumental in promoting PrEP to at‐risk GBM. However, many Aboriginal gay and bisexual men who are not well connected with these communities and services may not have been exposed to this health promotion and therefore have not accessed PrEP effectively. Conclusions : Aboriginal community and gay community controlled health organisations need to collaborate to ensure they deliver effective and tailored health promotion to Aboriginal communities. Implications for public health : The rising HIV notification rates in Aboriginal Australians is an example of the health gap experienced by First Nation people. Effective HIV prevention is required to ensure this gap does not widen further, and that Australia meets its goal of preventing all new HIV infections. However, these efforts will be hampered by ineffective health promotion of HIV prevention tools, such as PrEP, for Aboriginal Australians.     

Chronic disease prevention programs offered by Aboriginal Community Controlled Health Services in New South Wales,Australia

Objectives : To identify and describe chronic disease prevention programs offered by Aboriginal Community Controlled Health Services (ACCHSs) in New South Wales (NSW), Australia. Methods : ACCHSs were identified through the Aboriginal Health and Medical Research Council of NSW website. Chronic disease programs were identified from the Facebook page and website of each ACCHS. Characteristics, including regions, target population, condition, health behaviour, modality and program frequency were extracted and summarised. Results : We identified 128 chronic disease programs across 32 ACCHSs. Of these, 87 (68%) programs were broad in their scope, 20 (16%) targeted youth, three (2%) targeted Elders, 16 (12%) were for females only and five (4%) were for males only. Interventions included physical activity (77, 60%), diet and nutrition (74, 58%), smoking (70, 55%), and the Aboriginal and Torres Strait Islander Health Check (44, 34%), with 93 programs (73%) of ongoing duration. Conclusions : Chronic disease prevention programs address chronic conditions by promoting physical activity, diet and nutrition, smoking cessation and health screening. Most target the general Aboriginal community, a few target specific groups based on gender and age, and more than one‐quarter are time‐limited. Implications for public health : Chronic disease programs that are co‐produced with specific groups, based on age and gender, may be needed.     

The WAMI Rural Hospital Project. Part 6: Overview and conclusions.

The Rural Hospital Project (RHP) appeared to make a meaningful difference in the six Northwest rural communities that participated in this integrated community development and strategic planning effort. Although the methodological approach used in the evaluation precludes us from attributing observed changes in outcomes solely to the project interventions themselves, several elements of the process appear to be useful in stabilizing or expanding local health care systems. These include: (1) the involvement of outside organizations in fostering community change, (2) a high degree of community commitment and investment in all stages of the process, (3) comprehensive identification of problems in the health care system by outside consultants, (4) the use of periodic meetings of communities confronting similar issues, (5) identification and development of local leadership, (6) enhancing teamwork among local health care providers, and (7) the development of conflict-resolution mechanisms within health care organizations. Future attempts to use this strategy to strengthen rural health care systems can be enhanced by broadening the range of participation in health services planning, enlisting involvement of medical staff throughout the strategic planning cycle, addressing the issue of physician recruitment, and clarifying responsibility for implementation of community plans. Rural communities will predictably need to identify and resolve a set of core issues. To the extent that external organizations such as medical schools can strengthen the ability of rural health professionals and community leaders to identify and address these issues, the quality and viability of rural health care systems will be enhanced.     

Participant profile and impacts of an Aboriginal healthy lifestyle and weight loss challenge over four years 2012–2015

Objective: To explore participation, consistency of demographic and health profiles, and short‐term impacts across six Aboriginal Knockout Health Challenge (KHC) team‐based weight loss competitions, 2012 to 2015. Methods: Data comprised one competition each from 2012 and 2013 and two per year in 2014 and 2015. We compared baseline and change (pre‐ to post‐competition) in weight, fruit and vegetable consumption, physical activity and waist circumference (baseline only) across competitions using mixed models. Results: Numbers of teams and participants increased from 2012 to 2015 from 13 and 324 to 33 and 830, respectively. A total of 3,625 participants registered, representing 2,645 unique people (25.4% repeat participation). Participants were mainly female and >90% were classified obese at baseline. Baseline weight and weight lost (between 1.9% and 2.5%) were significantly lower in subsequent competitions compared with the first. Improvements in fruit and vegetable consumption and physical activity were comparable across competitions. Conclusion: The KHC has increasing and sustained appeal among Aboriginal communities, attracting those at risk from lifestyle‐associated chronic disease and effectively reducing weight and promoting healthy lifestyles in the short term. Implications for public health: Community‐led programs generated by, and responsive to, Aboriginal Australians’ needs can demonstrate consistent community reach and sustained program‐level lifestyle improvements.