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

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

Relationships: the key to effective occupational therapy practice with urban Australian Indigenous children

The aim of this exploratory study was to investigate what constitutes a socially and culturally appropriate occupational therapy service for urban Indigenous Australian families in Brisbane, Queensland. A qualitative methodology was used with data collected in two distinct parts. Part 1 comprised interviews and focus groups with 25 stakeholders in a newly established occupational therapy service for Indigenous children. Part 2 consisted of semi-structured questionnaires completed by 50 occupational therapists in Queensland. Results revealed guidelines for developing culturally relevant practice around 5 main themes. These were the need to: 1. develop effective relationships, 2. develop particular personal qualities, 3. understand the background of both the client and the therapist, 4. both gain and give knowledge, and 5. address logistical issues of service delivery. This study was limited to an evaluation of one service and included only teachers, parents and health service personnel. These practice guidelines could be applied to other settings with other Indigenous children, and their effectiveness evaluated from the perspectives of Indigenous children.     

Culture and healthy lifestyles: a qualitative exploration of the role of food and physical activity in three urban Australian Indigenous communities

Objective: 1) To explore the links between Indigenous Australian children's perspectives on culture, and healthy lifestyle behaviours. 2) To provide insight into how to approach the development of a health intervention targeting lifestyle behaviours in Australian Indigenous children. Methods: Seven semi‐structured focus groups sessions were conducted with Australian Indigenous children aged 5–12 years living on the South Coast of New South Wales. Audio‐recordings were transcribed and thematic analyses were conducted and related to principles of grounded theory. Results: Participants had connections to aspects of Australian Indigenous culture that were embedded in their everyday lives. Healthy lifestyle behaviours (such as healthy eating and physical activity) were found to be interconnected with Australian Indigenous culture and positive emotional wellbeing was identified as an important outcome of connecting Australian Indigenous children to cultural practices. Conclusion: Understanding the importance of culture and its role in healthy lifestyles is critical in the development of health interventions for Indigenous populations. Implication: Health interventions embedded with Australian Indigenous culture may have potential to improve physical and emotional health within Australian Indigenous communities. However, it is unlikely that a ‘one size fits all’ approach to health interventions can be taken.     

Systematic review to inform prevention and management of chronic disease for Indigenous Australians: overview and priorities

Objective: To describe the main characteristics of systematic reviews addressing questions of chronic disease and related risk factors for Indigenous Australians. Methods: We searched databases for systematic reviews meeting inclusion criteria. Two reviewers assessed quality and extracted characteristics using pre‐defined tools. Results: We identified 14 systematic reviews. Seven synthesised evidence about health intervention effectiveness; four addressed chronic disease or risk factor prevalence; and six conducted critical appraisal as per current best practice. Only three reported steps to align the review with standards for ethical research with Indigenous Australians and/or capture Indigenous‐specific knowledge. Most called for more high‐quality research. Conclusion: Systematic review is an under‐utilised method for gathering evidence to inform chronic disease prevention and management for Indigenous Australians. Relevance of future systematic reviews could be improved by: 1) aligning questions with community priorities as well as decision maker needs; 2) involvement of, and leadership by, Indigenous researchers with relevant cultural and contextual knowledge; iii) use of critical appraisal tools that include traditional risk of bias assessment criteria and criteria that reflect Indigenous standards of appropriate research. Implications: Systematic review method guidance, tools and reporting standards are required to ensure alignment with ethical obligations and promote rigor and relevance.     

Disadvantage and discontent: a review of issues relevant to the mental health of rural and remote Indigenous Australians

OBJECTIVE: To provide an overview of the mental health of Aboriginal and Torres Strait Islander residents of rural and remote Australia and to identify associated factors. FINDINGS: Indigenous Australians have higher rates of serious mental disorders and of mental health problems associated with social disadvantage. This disadvantage is greater for Indigenous Australians living outside metropolitan centres. Contrary to romanticised constructions of remote Aboriginal Australia, those living in such settings are not immune to such hardship - which is often unrelenting. The psychological and behavioural problems that emerge as a result are compounded by narrowly focused and inadequate mental health services, with children being particularly vulnerable. CONCLUSION: Indigenous residents of rural and remote Australia experience high levels of mental disorder. Although addressing the predisposing social disadvantage will demand significant whole-of-government investment, ensuring equitable access to effective mental health services is an immediate priority.     

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.     

An overview of cancer and beliefs about the disease in Indigenous people of Australia, Canada, New Zealand and the US

Objective: Cancer among Indigenous populations in the developed world appears to have increased over past few decades. This article explores issues related to cancer among the Indigenous populations of Australia, Canada, New Zealand and the US and examines variations in the epidemiology, Indigenous peoples' perceptions about cancer and potential effects on care-seeking behaviour.
Methods: A search of peer-reviewed journal articles, government reports, published and unpublished theses and other grey literature was undertaken using electronic databases and citation snowballing. Both epidemiological and qualitative studies were included.
Results: Cancer in Indigenous populations in these four countries is characterised by high incidence and mortality rates for specific cancers and lower survival rates as a result of late diagnosis, lower participation and poorer compliance with treatment. A higher prevalence of many cancer risk factors occurs across these populations. Fear of death, fatalism, payback, shame and other spiritual and cultural issues are reported in the few qualitative studies examining Indigenous beliefs and understanding of cancer which undoubtedly influences participation in cancer screening and treatment.
Conclusions and implications: The holistic approach (physical, mental, emotional and spiritual) to healing and well-being, and the concept that individual, family and community are inseparable underpin Indigenous care-seeking behaviour. Further community-based research is needed to increase understanding of the needs of Indigenous people with cancer, and to guide policy and practice towards more supportive and effective care.     

Promoting the Occupational Health of Indigenous Farmworkers

In the United States, approximately 78% of agricultural farmworkers are immigrants. In Oregon, a growing number of these farmworkers are indigenous and speak an indigenous language as their primary language. This group of farmworkers suffers from linguistic, cultural and geographic isolation and faces a unique set of challenges yet little has been done to identify their health needs. Using data from focus groups, partners from this community-based participatory research project examined indigenous farmworkers' concerns regarding occupational injury and illness, experiences of discrimination and disrespect, and language and cultural barriers. The data revealed examples of disrespect and discrimination based on the languages and cultures of indigenous farmworkers, and a lack of basic occupational health and safety information and equipment. For example, participants mentioned that occupational safety information was inaccessible because it was rarely provided in indigenous languages, and participants felt there were no legal means to protect farmworkers from occupational hazards. Community-based strategies designed to address the occupational health status of farmworkers must consider the unique circumstances of those farmworkers who do not speak Spanish or English.     

Healthy spaces: Exploring urban Indigenous youth perspectives of social support and health using photovoice

Ongoing injustices perpetrated by colonization and racism have resulted in a disproportionate burden of health disparities among Indigenous peoples, with youth being particularly vulnerable. However, very little is known about the health experiences of Indigenous youth, particularly how they understand and interpret such experiences. In collaboration with an Indigenous-led youth program, this research explored the relationship between social support and health among a unique group of Indigenous youth living in Winnipeg, Canada. Through Photovoice, youth revealed how residential mobility and racism negatively influenced the types of social support and relationships formed, and called for improved access to health-promoting social programs.     

Managing alcohol‐related problems among Indigenous Australians: what the literature tells us

Objective: To contextualise and provide an overview of two review papers – prepared as part of a larger research program – dealing with different aspects of the treatment of Indigenous Australians with alcohol‐related problems. Method: The papers were reviewed thematically and compared to identify key issues raised in them. Findings: Together, the papers highlight the paucity of the evidence base for the provision of treatment for Indigenous Australians with alcohol‐related problems. Among the key issues identified are: the need to engage with clients in culturally safe ways; practitioner, organisational and client barriers to engagement; the contexts in which Indigenous drinking and treatment take place; the need to develop rigorous methods of evaluation more appropriate to Indigenous cultural and service provision settings; and the importance of effective partnerships in the provision of services. Conclusion: For those working in the field, the reviews direct attention to the need to review and interrogate our current practice. They also provide clear directions for future research.     

Socioeconomic status and diabetes among urban Indigenous Australians aged 15-64 years in the DRUID study

Background. Diabetes is associated with lower socioeconomic status (SES) in developed countries, but the reverse is true in developing countries. Little is known about the relationship between SES and diabetes among Indigenous populations in developed countries.

Design. We examined the relationship between measures of SES and the prevalence of diabetes in the DRUID Study, a cross-sectional study of urban Indigenous Australian volunteers in the Darwin region.

Results. Among 777 participants aged 15–64 years included in the analysis, 17.1% had diabetes, ranging from 2.0% among those aged 15–24 years to 50.8% of those aged 55–64 years. After adjusting for age and sex, diabetes was significantly more common among those of lower SES, whether measured by housing tenure, household income, or employment status. For example, compared with those living in a household that was owned/being purchased by its occupants, the relative odds of diabetes was 2.66 (95% confidence interval 1.71–4.15) for those living in rented/other accommodation. The inverse relationship between SES and diabetes was present even among those who had not previously been diagnosed with diabetes. The relationship between disadvantage and diabetes was not mediated to any great degree by obesity.

Conclusions. The relationship between SES and diabetes among Indigenous Australians in this study is consistent with the patterns observed in developed countries, rather than those in some developing countries.     

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.     

The comparison of health status and health services utilisation between Indigenous and non-Indigenous infants in Australia

Objective: To examine the differences in health services utilisation and the associated risk factors between Indigenous and non-Indigenous infants at a national level in Australia.
Methods: We analysed data from a national representative longitudinal study, the Longitudinal Study for Australian Children (LSAC) starting in 2004. We used survey logistic regression and survey multiple linear regression to examine the factors associated with health services utilisation.
Results: Health status of Indigenous infants was poorer than that of non-Indigenous. In comparison to non-Indigenous infants, in the previous 12-month period, the Indigenous infants were significantly less likely to use the following health services: maternal and child health centre or help lines (OR=0.35, 95%CI: 0.24-0.49); maternal and child health nurse visits (OR=0.45, 95%CI: 0.32-0.63); general practitioners (GPs) (OR=0.45, 95%CI: 0.31-0.64); and paediatrician (OR=0.52, 95%CI: 0.35-0.77). In contrast, they were more likely to visit a hospital outpatient clinic (OR=1.82, 95%CI: 1.16-2.85). Mothers' age, education and marital status were associated with certain health services use. Financial status and residential location were the important predictors of the use of health services.
Conclusion: The rates of health services utilisation by Indigenous infants were lower and were associated with mothers' characteristics and socio-economic status.
Implications: The gaps in health services utilisation between Indigenous and non-Indigenous infant requires immediate policy initiatives. Further research is needed to explore the causal pathways between health status, health services utilisation and multiple risk factors at different levels.     

Stakeholder perspectives on the implementation and impact of Indigenous health interventions: A systematic review of qualitative studies

BackgroundEvaluations of health interventions for Indigenous peoples rarely report outcomes that reflect participant and community perspectives of their experiences. Inclusion of such data may provide a fuller picture of the impact of health programmes and improve the usefulness of evaluation assessments.AimTo describe stakeholder perspectives and experiences of the implementation and impact of Indigenous health programmes.MethodsWe conducted a systematic review of qualitative studies evaluating complex health interventions designed for Indigenous communities in high‐income countries. We searched 6 electronic databases (through to January 2020): MEDLINE, PreMEDLINE, Embase, PsycINFO, EconLit and CINAHL and hand‐searched reference lists of relevant articles.ResultsFrom 28 studies involving 677 stakeholders (mostly clinical staff and participants), six main themes were identified: enabling engagement, regaining control of health, improving social health and belonging, preserving community and culture, cultivating hope for a better life, and threats to long‐term programme viability.ConclusionThe prominence of social, emotional and spiritual well‐being as important aspects of the health journey for participants in this review highlights the need to reframe evaluations of health programmes implemented in Indigenous communities away from assessments that focus on commonly used biomedical measures. Evaluators, in consultation with the community, should consistently assess the capacity of health professionals to meet community needs and expectations throughout the life of the programme. Evaluations that include qualitative data on participant and community‐level outcomes can improve decision‐makers'' understanding of the impact that health programmes have on communities.Patient or public contributionThis paper is a review of evaluation studies and did not involve patients or the public.