Health Promotion and the Preventative Health Taskforce

The release in October of the Preventative Health Taskforce's discussion paper, ‘Australia: the healthiest country by 2020’ offers health promotion practitioners their greatest opportunity to participate in national policy development for many years. The Taskforce, which was established by the Federal Health Minister Nicola Roxon in March, has been asked to develop a National Preventative Health Strategy for the Government by mid‐2009, focusing initially on obesity, smoking and alcohol. The Taskforce has proposed the following targets to be achieved by 2020:

• halt and reverse the rise in overweight and obesity;
• reduce the prevalence of daily smoking to 9% or less;
• reduce the prevalence of harmful drinking for all Australians by 30%; and
• contribute to the ‘Close the Gap’ target for Indigenous people, reducing the 17‐year life expectancy gap between Indigenous and non‐Indigenous Australians.

     

Living longer with a greater health burden – changes in the burden of disease and injury in the Northern Territory Indigenous population between 1994–1998 and 1999–2003

Objective : To measure changes over time in the burden of disease for Northern Territory (NT) Indigenous and non‐Indigenous population. Methods: The numbers, and crude and age‐adjusted rates of disability adjusted life years (DALY) were calculated for periods 1994–1998 and 1999–2003. A measure of information bias was developed to adjust for the tendency of years lost to disability (a component of DALY) to increase over time because of increasing data availability. The jackknife method was used for DALY uncertainty assessment. Results: The all‐cause DALY rate was stable for the non‐Indigenous population, but increased for the Indigenous population. For both populations, the burden of premature death decreased while the burden of disability increased. For the Indigenous population, there were substantial increases in DALY rates for type 2 diabetes, depression, nephritis/nephrosis, suicide and sense organ disorders. Conclusions : The burden of disease for Indigenous people increased over the study periods, with improvement in the burden of fatal outcomes more than offset by substantial increase in the prevalence and severity of non‐fatal conditions. Implications : The paradoxical shift of living longer with a greater health burden has not been previously reported for Indigenous Australians, and highlights the critical importance of prevention for sustaining life expectancy improvement and managing escalation of health costs. This study also demonstrated the usefulness of the DALY to monitor population health.     

Health promotion in Australia: Reviewing the past and looking to the future

Over the last three decades Australia has very successfully adopted and applied the values, methods, and practice of health promotion to improve the average life expectancy and health of the population. Australia has, also, been part of and contributed to the global evolution of the field of health promotion. There is, now, substantial organisational capacity (including a specialist workforce) within the health sector (including the non-government and community sectors), although total financial investment as a proportion of total recurrent health expenditure remains consistently below 2%. However, despite its significant successes, health promotion in Australia has had little impact on improving the health of Indigenous Australians. Closing the 17-year gap in life expectancy is one of the greatest challenges facing health promotion in the future–necessitating a much more substantial investment in working across sectors to redistribute the social determinants of health, including political power.     

Mortality trends in Australian Aboriginal peoples and New Zealand Māori

Background

The health status of Indigenous populations of Australia and New Zealand (NZ) Māori manifests as life expectancies substantially lower than the total population. Accurate assessment of time trends in mortality and life expectancy allows evaluation of progress in reduction of health inequalities compared to the national or non-Indigenous population.

Methods

Age-specific mortality and life expectancy (at birth) (LE) for Indigenous populations (Australia from 1990 and NZ from 1950); and all Australia and non-Māori NZ (from 1890), males (M) and females (F), were obtained from published sources and national statistical agency reports. Period trends were assessed for credible estimates of Indigenous LE, and the LE gap compared to the total population for Australia, and non-Māori for NZ. Period trends in premature adult mortality, as cumulative probability of dying over 15–59 years, were assessed similarly. The relative contribution of differences in age-specific mortality to the LE gap between Indigenous and the all-Australia population, and the non-Māori NZ, was estimated for each country by sex for the most recent period: 2010–2012 for Australia, 2012–2014 for NZ.

Results

LE increased for all populations, although LE gaps between Indigenous and all Australia showed little change over time. LE gaps between NZ Māori and non-Māori increased significantly from the early 1980s to the mid-1990s, and since then have fallen again. Recent LE gaps in Australia (M 12.5; F 12.0 years in 2010–2012) were larger than in NZ (M 7.3; F 6.8 years in 2012–2014). Premature adult mortality (15–59 years) improved for all populations, but mortality ratios show little change since 2000, with Indigenous at 3½-4 times that of all Australians, and Māori 2–3 times that of non-Māori. Using decomposition analysis, the age interval contributing most strongly to differences in LE between Indigenous and all Australia was 35–59 years, but between Māori and non-Māori it was 60–74 years.

Conclusion

In Australia and NZ, Indigenous LE and adult mortality are improving in absolute terms, but not relative to the entire or non-Indigenous populations, causing gaps in life expectancy to persist.

     

Limited progress in closing the mortality gap for Aboriginal and Torres Strait Islander Australians of the Northern Territory

Objectives : To assess whether progress is being made towards reducing Aboriginal and Torres Strait Islander inequality in life expectancy and under‐five mortality in the Northern Territory. Methods : Life tables for five‐year periods from 1966–71 to 2011–16 were calculated using standard abridged life table methods with Aboriginal and Torres Strait Islander deaths and population estimates as inputs. The latter were calculated using reverse cohort survival. Results : In 2011–16, life expectancy at birth for the Aboriginal and Torres Strait Islander population was 68.2 years for females and 64.9 years for males. Limited progress in under‐five mortality rates has been made in recent years. Conclusions : Although Aboriginal and Torres Strait Islander life expectancy has increased in the long run, the gap with all‐Australian life expectancy has not narrowed. The gap in under‐five mortality rates is much lower than it was in the 1960s and 1970s, but progress has been limited over the past decade. Implications for public health : The ‘Closing the Gap’ target of halving the gap in under‐five mortality by 2018 will not be met in the Northern Territory, and there is no evidence yet of progress on the target to eliminate the gap in life expectancy by 2031.     

Indigenous Australians are under-represented in longitudinal ageing studies

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

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.     

Mortality following the Haitian earthquake of 2010: a stratified cluster survey

Background

The estimated gap in life expectancy (LE) between Indigenous and non-Indigenous Australians was 12 years for men and 10 years for women, whereas the Northern Territory Indigenous LE gap was at least 50% greater than the national figures. This study aims to explain the Indigenous LE gap by common modifiable risk factors.

Methods

This study covered the period from 1986 to 2005. Unit record death data from the Northern Territory were used to assess the differences in LE at birth between the Indigenous and non-Indigenous populations by socioeconomic disadvantage, smoking, alcohol abuse, obesity, pollution, and intimate partner violence. The population attributable fractions were applied to estimate the numbers of deaths associated with the selected risks. The standard life table and cause decomposition technique was used to examine the individual and joint effects on health inequality.

Results

The findings from this study indicate that among the selected risk factors, socioeconomic disadvantage was the leading health risk and accounted for one-third to one-half of the Indigenous LE gap. A combination of all six selected risks explained over 60% of the Indigenous LE gap.

Conclusions

Improving socioeconomic status, smoking cessation, and overweight reduction are critical to closing the Indigenous LE gap. This paper presents a useful way to explain the impact of risk factors of health inequalities, and suggests that reducing poverty should be placed squarely at the centre of the strategies to close the Indigenous LE gap.     

Excess Indigenous mortality: are Indigenous Australians more severely disadvantaged than other Indigenous populations?

BACKGROUND: International targets for reducing health inequalities, such as the Millennium Development Goals, are stated in terms of national targets. However, dramatic health differentials exist within countries, even developed ones. Studies indicate that the Indigenous population of Australia suffers a life expectancy disadvantage greater than differentials found in Indigenous populations of other developed countries. We re-examine recent national mortality levels and trends of Indigenous Australians. METHODS: Analyses of Indigenous mortality are plagued by 'numerator-denominator bias', whereby reporting of Indigenous status differs in deaths (numerators) and population (denominators). We apply demographic evaluation methods developed to address such problems to data from the 1991, 1996 and 2001 censuses of Australia and to the death registration data for the period. RESULTS: The propensity of Australia's population to report Indigenous status increased between each census, particularly between 1991 and 1996, while recording of deaths as Indigenous increased sharply. Adjusted for bias, the Indigenous population had a life expectancy approximately 13 years below that of the non-Indigenous population, a 2-year greater disadvantage than recently estimated for the Maori in New Zealand. Indigenous mortality fell during the 1990s, but slightly more slowly than that of non-Indigenous Australians, leaving differentials slightly increased. CONCLUSIONS: Around the world Indigenous populations are estimated to suffer a mortality disadvantage compared with non-Indigenous populations. However, establishing the magnitude of and trend in the disadvantage is difficult because of bias. Using appropriate methods to adjust for bias, the Indigenous population of Australia is estimated to suffer a life expectancy shortfall of about 13 years, greater than similar gaps in other developed countries.     

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.     

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.     

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.     

Estimating cancer incidence in Indigenous Australians

Objective: To assess data quality of cancer registrations for Indigenous Australians and produce reliable national Indigenous cancer incidence statistics. Methods: Completeness of Indigenous identification was assessed for the eight Australian cancer registries using an innovative indirect assessment method based on registry‐specific registration rates for smoking‐related cancers. National age‐standardised incidence rates and rate ratios (Indigenous:non‐Indigenous) were calculated for all cancers combined and 26 individual cancer sites. Multivariate regression analysis was used to investigate trends in Indigenous cancer incidence by time or remoteness of residence, and whether the incidence rate ratio (Indigenous:non‐Indigenous) was different in younger than older age‐groups. Results: Four registries covering 84% of the Indigenous population had sufficiently complete Indigenous identification to be included in analysis. Compared to other Australians, Indigenous Australians had much higher incidence of lung and other smoking‐related cancers, cervix, uterus and liver cancer, but much lower incidence of breast, prostate, testis, colorectal and brain cancer, melanoma of skin, lymphoma and leukaemia. Incidence was higher in remote areas for some cancers (including several smoking‐related cancers) but lower for others. The incidence rate ratios (IRRs) for smoking‐related cancers were higher in younger than older people. Conclusions: Indigenous Australians have a different pattern of incidence of specific cancers than other Australians and large geographical variations for several cancers. Implications: All cancer registries need to further improve Indigenous identification, but national Indigenous cancer incidence statistics can, and should, be regularly reported. Tobacco control is a critical cancer‐control issue for Indigenous Australians.     

Avoidable mortality trends in Aboriginal and non‐Aboriginal populations in the Northern Territory, 1985‐2004

Objectives: To analyse rates of avoidable mortality in Aboriginal and non‐Aboriginal residents of the Northern Territory (NT) from 1985 to 2004, in order to assess the contribution of health care to life expectancy improvements. Methods: Australian Bureau of Statistics (ABS) death registration data for NT residents were used to identify ‘avoidable’ deaths, with further separation into three categories of conditions amenable to either medical care or health policy, and a category for ischaemic heart disease (IHD). A Poisson regression model was used to calculate the average annual change in avoidable mortality by sex and Aboriginality in the NT compared with Australia as a whole. Results: In the 20 years between 1985 and 2004, avoidable mortality rates fell 18.9% in NT Aboriginal people, 61.1% in NT non‐Aboriginal people and 59.5% in Australians overall. NT Aboriginal people continued to experience higher avoidable mortality than other Australians and the disparity increased over time. Most of the decline in avoidable mortality for Aboriginal Territorians occurred for conditions amenable to medical care. Conclusion: Medical care has made a significant contribution to improvements in Aboriginal life expectancy in the NT, however, reductions in avoidable mortality from IHD and conditions amenable to health policy have been variable. Implications: The results highlight the need for ongoing investment in comprehensive programs incorporating appropriate health policy interventions and management of chronic diseases.     

The real divide: the use of algorithm‐derived Indigenous status to measure disparities in sudden unexpected deaths in infancy in Queensland

Objective : To investigate the under‐identification of Indigenous ^? ? Due to repeated use throughout this paper the term Indigenous people will be respectfully used when referring to individuals who identify as Aboriginal and/or Torres Strait Islander.
infants in death records and examine the impact of a multi‐stage algorithm on disparities in sudden unexpected deaths in infancy (SUDI). Methods : Data on SUDI in Queensland between 2010 and 2014 were linked to birth and death registrations, health data, and child protection and coronial records. An algorithm was applied to cases of SUDI and population data to derive Indigenous status. Numbers, proportions and rates of SUDI were compared. Results : Using multiple sources of Indigenous status resulted in a 64.9% increase in the number of infants identified as Indigenous. The Indigenous SUDI rate increased by 54.3%, from 1.38 to 2.13 per 1,000 live births after applying the algorithm to SUDI and live births data. Conclusions : Applying an algorithm to both numerator and denominator data reduced numerator‐denominator incompatibility, to more accurately report rates of Indigenous SUDI and measure the gap in Indigenous infant mortality. Implications for public health : Estimation of the true magnitude of the disparity is restricted by under‐identification of Indigenous status in death records. Data linkage improved the reporting of Indigenous infant mortality. Accuracy in reporting of measures is integral to determining genuine progress towards Closing the Gap.     

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

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

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

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

Sampling and recruitment methodology for a national eye health survey of Indigenous Australians

Objective: To review the process of sample selection and highlight the methodological difficulties encountered during a nationwide survey of Indigenous Australians, to determine the prevalence and causes of vision impairment and evaluate access to and utilisation of eye care services. Methods: Using a multi‐stage, random cluster sampling methodology, 30 geographic areas stratified by remoteness, were selected to provide a representative population of approximately 3,000 Indigenous Australians aged 5–15 and 40 years and older, and a small non‐Indigenous sample in selected remote areas. Recruitment was adapted to local conditions. The rapid assessment methodology included a questionnaire, tests of visual acuity, trachoma grading, frequency doubling perimetry and non‐mydriatic fundus photography. Results: The number of people examined was 2883/3662 (78.7%) Indigenous and 136 (83.4%) non‐Indigenous. The percentage of the expected population who were enumerated during the survey varied; discrepancies were largest in urban areas (34.5%) compared to very remote areas (97.1%). Conclusions: The unexpected variation in predicted population numbers and participation rates could be explained in part by local circumstances, degree of urbanisation, interpretation of the definition of ‘Indigenous’ and time constraints. Implications: For successful recruitment, a community‐specific approach is essential, including collaboration with local organisations and liaison with health workers of each gender.     

Beliefs about bowel cancer among the target group for the National Bowel Cancer Screening Program in Australia

Objective: To assess awareness of and intentions and self‐reported participation in the National Bowel Cancer Screening Program (NBCSP) in Australia and the program's impact on knowledge of and beliefs about bowel cancer. Method: Cross‐sectional, computer‐assisted telephone surveys of Western Australians aged 55–74 years conducted in April 2007 (n = 505) and June 2008 (n = 500) measured beliefs about the prevalence of bowel cancer, its preventability, impact of early detection on life expectancy, knowledge of the symptoms and tests for bowel cancer, and awareness of and participation in the NBCSP. Results: In 2008, awareness of the Program was 58%. Seventy‐seven per cent of those invited to participate in the program agreed to do so. The vast majority believed bowel cancer to be preventable (83%), with early treatment making ‘a great deal of difference’ to life expectancy (85%). Awareness of blood in faeces as a sign of bowel cancer increased from 64% in 2007 to 75% in 2008 (p<0.01). Awareness of FOBT as a test for bowel cancer increased from 54% in 2007 to 70% in 2008 (p<0.01). Conclusions: The NBCSP appears to have increased knowledge of bowel cancer. Implications: Education and screening campaigns are required to further increase perceived prevalence of bowel cancer and to increase knowledge of symptoms and risk factors.