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.     

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.     

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.     

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.     

The facilitators and barriers of physical activity among Aboriginal and Torres Strait Islander regional sport participants

Background : Disparities in health perspectives between Indigenous and non‐Indigenous populations are major concerns in many of the world's well‐developed nations. Indigenous populations are largely less healthy, more prone to chronic diseases, and have an earlier overall mortality than non‐Indigenous populations. Low levels of physical activity (PA) contribute to the high levels of disease in Indigenous Australians. Method : Qualitative analysis of structured one‐on‐one interviews discussing PA in a regional setting. Participants were 12 Indigenous Australian adults, and 12 non‐Indigenous Australian adults matched on age, sex, and basketball division. Results : Most participants reported engaging in regular exercise; however, the Indigenous group reported more barriers to PA. These factors included cost, time management and environmental constraints. The physical facilitators identified by our Indigenous sample included social support, intrinsic motivation and role modelling. Conclusion : Findings describe individual and external factors that promote or constraint PA as reported by Indigenous Australian adults. Results indicate that Indigenous people face specific barriers to PA when compared to a non‐Indigenous sample. Implications for public health: This study is the first to compare the perspective of Indigenous Australians to a matched group of non‐Indigenous Australians and provides useful knowledge to develop public health programs based on culturally sensitive data.     

Combining longitudinal studies showed prevalence of disease differed throughout older adulthood

ObjectivesDisease prevalence rates are often generalized across the older adult age range. By pooling self-reported health data from five Australian longitudinal studies of aging, we were able to present disease prevalence rates by 5-year age bands and sex. We also investigated the influence of education on prevalence at each age range and compared our observed prevalence rates with those from the 2001 National Health Survey (NHS) to see if existing data could be used to augment national estimates.Study Design and SettingWe used data on 12,718 adults between 60 and 105 years of age from the Dynamic Analyses to Optimise Ageing (DYNOPTA) project.ResultsHypertension and arthritis were the most prevalent diseases, with approximately 30% of males and 45% of females having either condition. Nearly all diseases were most prevalent amongst older adults in their 70s and lower for individuals in their 60s, and 80s and older. The effect of education varied by disease and older age group. Prevalence rates from DYNOPTA were generally similar to those reported by the NHS.ConclusionDisease prevalence is not consistent across older adulthood. Combining longitudinal studies provided a sufficient sample to estimate precise age divisions and can be used to supplement national estimates for specific populations.     

A bibliometric analysis of research on Indigenous health in Australia, 1972-2008

Objective: To determine the growth patterns and citation volume of research publications referring to Indigenous health in Australia from 1972 to 2008 compared to seven selected health fields. Methods: Web of Science was used to identify all publications (n=820) referring to the health of Indigenous Australians authored by Australian researchers, 1972 to 2008. Citations for each publication were also captured. Growth was compared with selected health fields as well as with overall Australian research publications. Results: Research publications referring to Indigenous health, while remaining relatively small in number, grew at an average annual rate of 14.1%, compared with 8.2% across all fields of Australian research. The growth rate shown was equal second highest in our seven categories of health and medical research. However, Indigenous publications were cited significantly less than the Australian average. Conclusions: While there has been positive growth in publications referring to Indigenous health, the attention paid to this research through citations remains disappointingly low. Implications: Given that research concentration and impact can be an index of how seriously a nation considers a health problem, the low visibility of Australian research examining Indigenous health does not demonstrate a level of concern commensurate with the gravity of Indigenous health problems. Further investigation for the reasons for lower citations may identify potential intervention strategies.     

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.     

Improvements in Indigenous mortality in the Northern Territory over four decades

OBJECTIVE: To provide the first report of long-term mortality trends over recent decades for an Indigenous Australian population. Very little information is available about improvements over time, or lack thereof, in the health status of Indigenous Australians. METHODS: Internally consistent time series of deaths and population data were produced for the Indigenous population of the Northern Territory (NT) for 1966--2001. Time trends for Indigenous mortality rates and differentials between NT Indigenous and total Australian rates were examined for 1967--2000. RESULTS: NT Indigenous mortality declined in all age groups and both sexes. The decline was greatest in age group 0-4 (85%). In those aged five years and over, NT Indigenous mortality declined by 30% in females and 19% in males. However, these declines did not keep pace with the relative decline for the total Australian population, so that mortality rate ratios (NT Indigenous to total Australian) increased for all age groups except 0-4 years. NT Indigenous mortality declined for communicable, maternal, perinatal and nutritional conditions by 62%, and for injury by 33%, but did not decline for non-communicable diseases. CONCLUSIONS: Indigenous mortality has improved in the NT in recent decades, but the relative gap between Indigenous and other Australians has increased. IMPLICATIONS: Reductions in NT Indigenous mortality reported here may provide some reassurance that improvement in Indigenous health is possible and has occurred, but even greater effort will be required to accelerate the pace of improvement.     

Prison health and public health responses at a regional prison in Western Australia

Objective: To describe the health of inmates in a Western Australian regional prison and evaluate the coverage of public health interventions. Design: Cross‐sectional audit of all paper‐based and electronic medical notes of inmates at one regional prison in Western Australia. Setting: A mixed medium‐security prison in regional Western Australia. Participants: 185 prisoners, 170 men and 15 women Main Results: The prisoners were mainly young (70% < 35 years of age) and Indigenous (84%). Fifty two percent of prisoners had at least one chronic health condition. There was a significantly higher prevalence of diabetes to that found in the general Indigenous population (15% vs 6% p=0.001), and a significantly lower prevalence hepatitis C (4.5%) compared with both national (29–61%) and State (20%) data. Screening for sexually transmitted infections and blood borne viruses within the first month of incarceration was achieved for 43% of inmates. Vaccination coverage for influenza (36%) and pneumococcal disease (12%) was low. Conclusion: This study makes visible the burden of disease and reach of public health interventions within a largely Indigenous regional prisoner population. Our study demonstrates that the additional risks associated with being Indigenous remain in a regional Australian prison but also shows that interventions can be delivered equitably to Indigenous and non‐Indigenous inmates. Implications: Ongoing monitoring of prisoner health is critical to take advantage of opportunities to improve public health interventions with timely STI and BBV screening and increased vaccinations rates.     

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.     

The oral health status and treatment needs of Indigenous adults in the Kimberley region of Western Australia

Objective: The oral health of Indigenous Australians, whether urban or rural, is significantly poorer than their non‐Indigenous counterparts, and it would be expected that the oral health of rural and remote Indigenous Australians would be particularly poor, although the extent of this extra disadvantage has not been thoroughly documented. The aim of this study was to assess the oral health status and oral health needs in a sample of adult residents of selected towns and remote communities in the Kimberley region of North‐west Australia. Design: A cross‐sectional survey (dental examinations and oral health questionnaires) was carried out. Setting: Rural and remote communities in the Kimberley region of Western Australia. Participants: Adults in four selected communities. Results: The mean Decayed, Missing and Filled Teeth (DMFT) score for all participants was 9.8 (SD 8.3). The mean DMFT increased with increasing age. Only 7.3% of people were caries‐free. A total of 13% of participants had periodontal pockets of 6 mm or more, and only 3% had no periodontal disease. More than a third (37%) of all participants had advanced periodontal disease. Only 21% of participants did not need any dental treatment. Conclusions: The oral health of Aboriginal and Torres Strait Islander people are listed as one of the priority areas of Australia's National Oral Health Plan. Based on the above results, oral health is clearly an important priority in the Kimberley.     

Indigenous health program evaluation design and methods in Australia: a systematic review of the evidence

Objective: Indigenous Australians experience a disproportionately higher burden of disease compared to non‐Indigenous Australians. High‐quality evaluation of Indigenous health programs is required to inform health and health services improvement. We aimed to quantify methodological and other characteristics of Australian Indigenous health program evaluations published in the peer‐reviewed literature. Methods: Systematic review of peer‐reviewed literature (November 2009–2014) on Indigenous health program evaluation. Results: We identified 118 papers describing evaluations of 109 interventions; 72.0% were university/research institution‐led. 82.2% of evaluations included a quantitative component; 49.2% utilised quantitative data only and 33.1% used both quantitative and qualitative data. The most common design was a before/after comparison (30.5%, n=36/118). 7.6% of studies (n=9/118) used an experimental design: six individual‐level and three cluster‐randomised controlled trials. 56.8% (67/118) reported on service delivery/process outcomes (versus health or health risk factor outcomes) only. Conclusions: Given the number of Indigenous health programs that are implemented, few evaluations overall are published in the peer‐reviewed literature and, of these, few use optimal methodologies such as mixed methods and experimental design. Implications for public health: Multiple strategies are required to increase high‐quality, accessible evaluation in Indigenous health, including supporting stronger research‐policy‐practice partnerships and capacity building for evaluation by health services and government.     

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.     

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.     

Closing the Gaps: competing estimates of Indigenous Australian life expectancy in the scientific literature

Objective: Closing the gap in life expectancy between Indigenous and other Australians within a generation is central to national Indigenous reform policy (Closing the Gap). Over time, various methods of estimating Indigenous life expectancy and with that, the life expectancy gap, have been adopted with differing, albeit non‐comparable results. We present data on the extent of the gap and elucidate the pattern of use and interpretations of the different estimates of the gap, between 2007 and 2012. Methods: An extensive search was conducted for all peer‐reviewed health publications citing estimates of and/or discussing the life expectancy of Indigenous Australians, for the period 2007–2012. Results: Five predominant patterns of citation of the gap estimates were identified: 20 years, 17 years, 15–20 years, 13 years, and 11.5 years for males and 9.7 years for females. Some authors misinterpret the most recent estimates as reflecting improvement from the 17‐year figure, rather than the result of different methods of estimation. Support for the direct methods used to calculate Indigenous life expectancy is indicated. Conclusions and Implications: A specific estimate of the life expectancy gap has not been established among stakeholders in Indigenous health. Agreement on the magnitude of the gap is arguably needed in order to evaluate strategies aimed at improving health outcomes for Indigenous Australians. Moreover, measuring progress towards ‘closing the gap’ depends on the availability of comparable estimates, using the same techniques of measurement to assess changes over time.     

Nutrition Risk Measured Online in Community-Living Older Australians

Abstract

Many community-living older adults experience the condition of malnutrition and the causes are complex and multi-factorial. This study examined nutrition risk in a sample of community-living older Australians (n?=?77, age ≥65 years) using an online, self-administered survey consisting of two validated questionnaires (SCREEN II and SF-12). We found a significant relationship between health status and nutrition risk; those with higher self-rated health status had lower nutrition risk. Forty percent of the participants were categorized at high nutritional risk, 26% at moderate nutritional risk and 34% not at nutritional risk. The most common nutrition risk factors were: (i) weight perception (perceiving weight to be more than it should); (ii) food avoidance; (iii) low intake of milk, milk products and alternatives; and (iv) finding meal preparation a chore. Many nutrition-risk factors were consistent with population survey data highlighting the need for greater awareness of nutritional requirements for healthy ageing.     

Social and emotional outcomes of Australian children from Indigenous and culturally and linguistically diverse backgrounds

Objectives: 1) profile the living environments and 2) examine the social and emotional outcomes of Australian children from Indigenous and cultural and linguistically diverse (CALD) backgrounds at school entry. Method: Secondary analysis of cross‐sectional data collected in Wave 1 of the Longitudinal Study of Australian Children (n=4,735). Child mental‐health outcomes were measured using parent report of the Strengths and Difficulties Questionnaire (SDQ). Results: Significant differences in family and neighbourhood characteristics, including parental income, maternal education, maternal parenting quality and neighbourhood safety, were found in children of Indigenous and CALD backgrounds compared to the reference group of Australian‐born, English‐speaking children. After controlling for family and neighbourhood characteristics, significant differences in parent‐reported SDQ total difficulties were found for Indigenous children. Significant differences in emotional difficulties and peer problems subscales were found for children with overseas‐born mothers regardless of English proficiency. Conclusions: Children from Indigenous and CALD backgrounds experience poorer mental health outcomes at school entry than their Australian‐born English‐speaking peers. They are also more likely to be exposed to risk factors for poor child mental‐health outcomes within their family and neighbourhood environments.