Aboriginal Health Media Alert @AlanTudgeMP Speech : “No child will live in poverty” – 30 years later, a new direction

 Entrenched disadvantage

” Entrenched disadvantage or impoverishment is perhaps the toughest overall challenge in Australia, but arguably the most important to address. We cannot solve it by doubling the number of services once again. We cannot solve it by having another step-increase in welfare payments.

Rather, we need collectively to put our minds to the underlying factors, which have changed since Hawke’s day, and be clear eyed about how to tackle them.”

Social fabric of communities declined ?

 ” Noel Pearson frequently notes that over the last 30 or 40 years, despite formal racism ending and a huge increase in money invested in remote communities, the social fabric of them has declined.

The dysfunction that characterises many of the remote communities today was not there in the 60s and 70s. Children went to school then; the men had jobs; and the respect for elders was strong.”

Are Aboriginal communities over serviced ?

 ” In Aboriginal communities, the extent of service growth has reached close to saturation level. The Auditor-General found that Aboriginal communities now have one service for every five residents. At the time of writing its report in 2013, it found that Wilcannia, for example, had 102 funded services from 18 state and federal agencies, with 17 further proposed. Its Indigenous population was 474.

In other areas, there are a similar array of services. They are not always coordinated and some are more useful than others. But along with welfare increases, the services sector has meant that we have a situation today where no one need go hungry.”

Welfare and cash less Debit cards

 ” I have been overseeing the development and implementation of the Cashless Debit Card for the last two years, which works to limit the amount of welfare cash than can be spent on drugs and alcohol. To date it is working effectively and we plan on expanding it further. Thirty one percent of participants say they are better able to care for their children as a result.

In addition, we are introducing trials of drug testing of welfare recipients to identify issues and assist them to get off their addictions.”

The Hon Alan Tudge MP Minister for Human Services July 20

Watch video here

Thirty years ago, almost to the day, the then Prime Minister Bob Hawke made the statement that by 1990, “no Australian child will live in poverty.” It was a powerful message, signalling that government policy would be geared towards those least fortunate and least capable of looking after themselves.

But thirty years on, poverty still exists among children and more generally. On just one measure, around 29,000 children are homeless at some point in any given year. We are one of the richest countries in the world, and have experienced 25 years of uninterrupted economic growth, yet impoverishment still exists in our nation. How can this be?

Today, I would like to discuss the nature of poverty in Australia, particularly amongst children, and how we are faring 30 years after Hawke’s pledge. My main argument is that the primary approach to tackling child poverty over the last 30 years – higher income support payments and more community services – will not provide the solution to significantly reducing entrenched impoverishment over the next 30 years.

Rather, we will have to collectively address what I call the ‘pathways to poverty’ more systemically. These include welfare and other dependencies, poor education standards and family breakdown. This is the focus of much of the government’s efforts.


There is no good single definition of poverty. The most commonly cited definition, and that used by the OECD, is that a person is in poverty when their disposable income is less than 50 percent of that of the median household income.

On this measure, there are three million Australians living in poverty, including 731,000 children (17.4 percent of all children), according to the last Poverty Report by ACOSS. Compared to a decade ago, the poverty rate – again using this measure – has slightly dropped overall, but the proportion of children living in poverty has increased by two percent.

This measure of poverty is useful in identifying the pockets of low income and for highlighting wealth inequality. For example, it shows that children in lone parent families are more than three times more likely to be in the low income category than children in coupled families. But this is about the end of its usefulness. The measure says nothing about the absolute level of income. As long as there was any wealth inequality, the measure would say that there was poverty, even if everyone was very well off in absolute terms. Moreover, it would suggest that if we made middle income Australians worse off, the poverty rate would decline because the median income would dip.

Absolute poverty or absolute deprivation is a more useful measure for assessing the well-being of very poor Australians. That is, can people afford the basics for themselves and their children such as food, clothing, shelter and education? I believe this is also how most Australians would conceptualise poverty and what they would be concerned about from a policy perspective.

On this measure, we are doing better in large part because of the approach to impoverishment over the last 30 years: higher social security payments and an increase in the number of social services. The Parliamentary Library notes “over the last thirty years, a combination of income transfer and program responses, such as funding for homelessness services, have more or less ameliorated the worst effects of poverty for most Australians… Few Australians live in absolute poverty.”

This is not surprising when one examines the welfare payment increases over this time. For example:

  •  A couple on an unemployment benefit with one to two children today receives between 27 percent and 38 percent more in real terms than they would have done thirty years ago.
  •  A single parent on an unemployment benefit with one to two children today receives between 34 percent and 67 percent more in real terms than they would have done thirty years ago.
  •  A person on an unemployment benefit without children today receives around 10 percent more in real terms than thirty years ago.

Today, an unemployed couple with three children would receive about $48,000 in welfare payments each year. This is the equivalent to a $60,000 salary. A single mother on a parenting payment with two children would receive over $31,000 in payments each year. On top of that, they may be eligible for a public house and many other free services. The welfare system allows for advances on payments and emergency payments in times of crisis. Tens of millions is provided in the form of emergency relief on top of this.

These figures I quote are not a lot of money, but nor is it complete deprivation. It is a good safety net to ensure that no one need go hungry or without clothing, shelter and the basics.

The greatest challenge is perhaps being an unemployed person with no children. This payment is modest, but as the Minister for Social Services, Christian Porter, has pointed out, the number of unemployed people who live just on this payment is very small – less than one percent – and then they typically come off the payment quickly.

The increases in welfare payments described above has been complemented by a significant increase in social services over the last 30 years. Today, there are programs and services for a vast array of social problems; homelessness, activities after school, breakfast programs, domestic violence initiatives, mental health, youth programs and more.

In Aboriginal communities, the extent of service growth has reached close to saturation level. The Auditor-General found that Aboriginal communities now have one service for every five residents. At the time of writing its report in 2013, it found that Wilcannia, for example, had 102 funded services from 18 state and federal agencies, with 17 further proposed. Its Indigenous population was 474.

In other areas, there are a similar array of services. They are not always coordinated and some are more useful than others. But along with welfare increases, the services sector has meant that we have a situation today where no one need go hungry.

This does not mean that people don’t struggle. We know they do. The Social Policy Research Centre survey in 2010 found, for example, that almost one in five have insufficient funds to have a week’s holiday away from home each year; almost one in ten struggled to get comprehensive home or car insurance and many struggled to afford regular dental checks.

There are still very significant problems, which I will come to, but we should be collectively proud that absolute poverty is now rare in Australia.

However, while absolute poverty is rare, impoverishment still exists in many pockets. We see it acutely in remote Indigenous communities, but it is apparent in many other pockets of Australia including in the suburbs of our largest cities.

It is not complete lack of income that is always the problem, but a general dysfunction that means that children’s potential is not able to be maximised.

The most acute and tragic example of this is Fetal Alcohol Spectrum Disorder, which affects an estimated 25 percent of babies in some places. In essence, their brain is affected from the alcohol abuse of their mother.

Over 225,000 children suffer from abuse or neglect or were at risk of suffering from this last year – a “national shame” according to Father Frank Brennan.

As I mentioned at the outset, around 29,000 children are homeless at some stage in any given year.

Around 1 in 14 Year 9 students (7 percent) do not meet the national minimum standard for reading. Thousands of young Australians go through the education system and remain functionally illiterate. I have met teenagers who sign their name with an ‘X’.

One in eight children live in a jobless household.

This is the real impoverishment today and comes about despite the increases in welfare payments, increases in social services and an economy which has grown for 25 years straight.

Noel Pearson frequently notes that over the last 30 or 40 years, despite formal racism ending and a huge increase in money invested in remote communities, the social fabric of them has declined. The dysfunction that characterises many of the remote communities today was not there in the 60s and 70s. Children went to school then; the men had jobs; and the respect for elders was strong.

But it is not an indigenous issue; it is a human issue. It is just that we see the issues most acutely in the remote communities and, therefore, they provide lessons for the rest of Australia.

And this comes to my main point. Few suggest that increasing the level of welfare payments and significantly increasing the number of services in remote locations will improve the circumstances of children in those areas. There are sometimes big payments delivered in the form of royalties (which is the equivalent of a large increase in income support payments) but they don’t make the difference.

This is the same across Australia. We have done well in alleviating absolute poverty through higher welfare payments and more social services, but this formula will not provide the step-change improvement to addressing modern impoverishment over the next thirty years.

My concern is that many in the social services sector and even many in the business community believe that an increase in welfare payments remains the primary solution to modern impoverishment. Further, the focus on higher payments means that less thought is given to the fundamental reasons why impoverishment exists despite the increases in payments over the years.

If more money was the answer, we would have solved many of the problems years ago. Unfortunately the challenges of modern impoverishment are more complex. We need the best minds put towards the issues in a more sophisticated manner. I would like to see the business groups and ACOSS, and other groups with a commitment to addressing disadvantage, examine the underlying issues of modern impoverishment as much as they argue for higher payments.

The goal must be broader than ending relative inequality (which underpins the standard definition of poverty) or even absolute poverty (which is largely, although not completely, addressed in Australia). Fundamentally, it is more about providing the best opportunity for children and adults to have the choice and opportunity to achieve their potential. In this regard, it is Nobel Laureate Amartya Sen’s definition of poverty that is most useful in my  view.

That is, alleviation of poverty is actually about people having the capability and freedom to participate in society and choose their own destiny.

An Australian may be relatively wealthy in global terms and be without hunger or lack of clothing but if their education is poor, or they have drug or alcohol addictions, then their capabilities and choices will be limited. Their potential is not able to be realised.


A good way to think about modern impoverishment and how we can better address it is to consider what I call the ‘pathways to poverty.’

This name – the pathways to poverty – and the framework that I want to briefly outline has come from the United Kingdom’s Centre for Social Justice. But my experience from working on indigenous issues for over 15 years and my work in the welfare portfolio informs my belief that it is also a useful framework for Australia. It is a useful framework for thinking about how to maximise choice and opportunity.

The Centre for Social Justice outlines five pathways to poverty that require attention.

The first is family breakdown. As the Centre for Social Justice notes, the “family is where the vast majority of us learn the fundamental skills for life; physically, emotionally and socially it is the context from which the rest of life flows.” Wherever there are strong families – regardless of their makeup – there are typically strong capable children. Children don’t tend to go hungry when part of a strong family.

Unfortunately, over the last few decades family breakdown and family dysfunction have become more common, particularly in the least advantaged sections of society.

One of the more remarkable changes of our society in the last 30 or 40 years is the growth in sole parent families. In the mid-1970s, 9.2 percent of families with children under 15 were sole parent; today it is 15.8 percent. I make no judgment on any of these families – I grew up in one of them – but a breakdown of family structure contributes to impoverishment for many. As I noted above, single parent families are more than three times more likely to be living in relative income poverty compared to couples with children.

Care for the elderly can also be compromised when families break apart.

The second pathway to poverty is ‘worklessness’. Work is the most effective route out of poverty, both in absolute and relative terms. If we examine ACOSS’s poverty report (which looks at relative poverty), we find that 62 percent of unemployed people are in their definition of poverty, whereas only four percent of full time workers fit their definition. By working, people’s capabilities are strengthened. The reverse is also true; long term welfare dependence diminishes capability and confidence.

It is commonly said, and it is true, that the best form of welfare is a job.

Our goal must be not only the creation of jobs – which is central to the government’s agenda – but the elimination of impediments to people taking up work when it is available.

Reducing welfare dependency is a critical part of the welfare reform agenda, which Minister Porter, the Minister for Employment, Michaelia Cash and I have been leading. We have strengthened the compliance system to encourage able people to maximise their opportunities of finding work. Minister Porter has initiated the Priority Investment approach (modelled from the successful New Zealand initiative) to fund and harness the ideas of the private and community sector to reduce dependency and encourage people into work. Minister Cash has initiated the PaTH program to reduce the risk to businesses of offering opportunities to unemployed people and to encourage those people to take them up. We now have mobility incentives in place so that people are more able to move if work is not available in the immediate region.

This is a huge task to address what, in many cases, has become intergenerational welfare dependence. But it is essential work to addressing impoverishment.

The third pathway is drug and alcohol addictions. This is a further factor that is seen acutely in remote communities, but is increasingly common throughout disadvantaged communities across Australia. The Centre for Social Justice summarises it well; “Addiction to drugs and alcohol remains a shocking feature of life in many disadvantaged neighbourhoods. It shreds the fabric our society. It wrecks families, ruins childhood, causes mental illness, encourages welfare dependency, and fuels a revolving door of crime and incarceration.”

This has got worse in recent decades and there is no easy solution to this.

A great deal has been done to crack down on the supply of drugs (and in some places to limit alcohol availability). But with drugs like ‘ice’, which is synthetic and easily manufactured, we will never be able to beat it on the supply side alone.

This is why we have been looking at the demand side, as well as providing structured support to assist people get off their addiction.

I have been overseeing the development and implementation of the Cashless Debit Card for the last two years, which works to limit the amount of welfare cash than can be spent on drugs and alcohol. To date it is working effectively and we plan on expanding it further. Thirty one percent of participants say they are better able to care for their children as a result.

In addition, we are introducing trials of drug testing of welfare recipients to identify issues and assist them to get off their addictions.

We are also reforming the reasonable excuse rules for job-seekers so that their addiction is only accepted as a reasonable excuse for non-compliance with their mutual obligations if they are receiving treatment for their addition.

This has been complemented by the provision of over $685 million for treatment and support services.

Ultimately, though, we need to change cultural attitudes towards drug taking. Most young people still take drugs for the first time because of social reasons. We have changed cultural attitudes towards other addictions, including smoking, and can do so with drugs.

The fourth pathway is education failure. Australia has a very good education system but there is complete education failure in some pockets. In the Northern Territory, only a quarter of children attend school often enough to learn effectively (which is about 80 percent of the time). Thousands of children leave the school system after ten years functionally illiterate.

Again, this is neither an indigenous issue, nor one that has always been apparent. Rather, it is apparent in the suburbs of our cities, and at least in the indigenous context, has got worse in the last few decades. In the 1970’s, schooling was the norm with Noel Pearson reflecting that no one from his grandfather’s generation was illiterate.

Their income might be higher today, but a child who is functionally illiterate has few options in life.

While the states and territories have primary responsibility for school education, the Turnbull Government is contributing, including through its indigenous education initiatives as well as the extra funding to the Smith Family’s Learning for Life program.

The final pathway is indebtedness and lack of financial capability. If one is not in control of their finances, it is very difficult to be in control of one’s life. There is little data on the extent of this problem at the most disadvantaged end of the spectrum. In 2013-14, 30 percent of low income households had household debt three or more times the household disposable income. This is up from 22 percent a decade earlier. The Social Policy Research Centre survey, that I mentioned earlier, found that 18 percent of people did not have $500 in savings for an emergency situation.

There are several programs in place to try and alleviate this problem, but I am not convinced that we have the formula just right yet. For example, we provide $100 million each year to improve people’s financial wellbeing or capability, yet only 4 percent of people who seek emergency relief are connected to financial management assistance. One in five people with more than 50 percent of their income from welfare say they have difficulty understanding financial matters.

We need to do better in this space, acknowledging that some have very basic capability and, therefore, need quite intense income management while others would benefit from financial management assistance to be on a much better footing.


These ‘pathways to poverty’ can be debated by well-meaning people. Some of them interact with each other and, perhaps, there are other factors that should be included, such as housing security and mental health.

My intent in outlining this framework was not to provide the solution to each of the problems – an impossible task in 30 minutes – but to provide an alternative way to think about impoverishment in Australia today and a flavour of government initiatives which contribute towards alleviating it.

Entrenched disadvantage or impoverishment is perhaps the toughest overall challenge in Australia, but arguably the most important to address. We cannot solve it by doubling the number of services once again. We cannot solve it by having another step-increase in welfare payments.

Rather, we need collectively to put our minds to the underlying factors, which have changed since Hawke’s day, and be clear eyed about how to tackle them.


NACCHO Aboriginal Health and Smoking : Download Tackling Indigenous Smoking Program prelim. evaluation report

 ” The overall goal of the national Tackling Indigenous Smoking (TIS) program is to improve the health of Aboriginal and Torres Strait Islander people through local population specific efforts to reduce harm from tobacco.

The purpose of this preliminary report is to provide a mid-term evaluation of progress to date in implementing the first year of the three year (2015-2018) TIS program.

The TIS programme with a budget of $116.8 million over 3 years ($35.3 million in 2015-16; $37.5 million in 2016-17 and $44 million in 2017-18) was announced by the Government, on 29 May 2015.”

Download 133 page PDF report Here :

NACCHO Download Dept Health Tackling Indigenous Smoking Evaluation June 2017

The report found the program is operating effectively, using proven approaches to change smoking behaviours, and delivering evidence-based local tobacco health promotion activities. I am pleased the report recommends it continues,

Smoking is the most preventable cause of disease and early death among Aboriginal people and accounts for almost one-quarter of the difference in average health outcomes between indigenous and non-indigenous Australians.

“The program provides grants in 37 urban, rural, regional and remote areas to assist local communities to develop localised anti-smoking campaigns

Minister Ken Wyatt

Read over 100 plus NACCHO articles published in past 5 years

This mid-term evaluation looks at progress to date of the TIS program, particularly in terms of regional grants delivering localised Indigenous tobacco interventions.

Source of intro

See list all 35 Recipients below

It does not look at long-term impact in relation to a reduction of smoking rates at a national level.

Findings focus on (see in full below 1-9)

  • the shift to TIS
  • community engagement and partnerships
  • localised health promotion
  • access to quit support
  • contribution to evidence base
  • National Best Practice Unit and TIS portal
  • governance and communications.

A number of key recommendations emerging from the evaluation are included in the report.(see Below Part 2)


1. Shift to TIS

Since the implementation of the TIS program, all grant recipients are primarily focused on planning for, and/or delivering, targeted and tailored activities that directly address reduction of smoking prevalence within communities.

For some grant recipients, broader health promotion activities without a clear link to tobacco reduction have dropped off significantly as a result of the shift to TIS, whilst for others the integration of healthy lifestyle and tobacco control strategies has been successful. There are varying degrees of clarity among grant recipients about the extent to which there is flexibility to tap into healthy lifestyle activities under the new guidelines.

2.Community engagement and partnerships

Community engagement and involvement in the design and planning of localised TIS programs is a key priority for grant recipients, and a key indicator of successful TIS activities.

While challenges were identified in terms of handling competing priorities in community, adhering to cultural protocols, and the change in focus of the TIS program and uncertainty about ongoing funding, in the main, grant recipients have demonstrated substantial progress in involving community in design and planning and garnering support for TIS activities.

This is evidenced by the popularity of community events hosted/attended by the TIS team and the proactivity of local community and Elders in advocating for tobacco control.

The success of the TIS program and the capacity for grant recipients to operate as a multi-level population health program in their region is highly dependent upon the quality and reach of partnerships between grant recipients and other agencies/organisations.

Whilst challenges to regional collaborations were reported, overall there has been a noticeable increase in the reporting of grant recipient collaboration and partnerships, representing an important shift to both a wider regional focus and wider community approach to tobacco reduction.

3.Localised health promotion

At the local level, a range of multi-component health promotion activities around tobacco control are being undertaken by grant recipients, in collaboration with external stakeholders. Local partnerships are crucial to the successful implementation of localised health promotion activities through facilitating access to priority populations, supporting capacity-building and enabling a broader population reach to achieve awareness and understanding of the health impacts of smoking and quitting pathways. viii

Increased levels of community support and ownership for local solutions to tackling Indigenous smoking are being seen across the TIS sites.

4.Community education

Community education, is being undertaken by all grant recipients. This manifests in a range of ways, including health promotion activities at community/sporting events, drama shows and comedy and social marketing.

The involvement of local champions and Elders in local education and awareness raising events and activities is recognised as central to tobacco control messages resonating with target audiences.

It has also been recognised that targeting priority groups, such as young people and pregnant women, requires the adaptation of messages so that they resonate with those groups.

Grant recipients are partnering with key local organisations (e.g. schools, other AMS etc.) to overcome some of the challenges around access to these priority groups.

Many grant recipients have established or showed progress in establishing social marketing campaigns to supplement other health promotion activities. Campaigns are developed largely through a strength-based approach, with ‘local faces and local places’ taking precedence. Grant recipients have acknowledged the challenges in measuring the impact of social marketing campaigns although some are demonstrating a commitment to collecting data on awareness, and influences on motivations and attempts to quit.

5.Smoke-free environments

An area that has been recognised by grant recipients as requiring attention is the promotion and establishment of smoke-free environments, particularly in rural and remote locations. Modelling smoke-free environments within the grant recipients’ own workplace is one way in which this issue is being addressed, with some evidence of success.

Challenges to the implementation of smoke-free workplaces include getting support from senior leaders or Board members who smoke, and organisations where tobacco control is not the main priority. Monitoring the compliance of smoke-free environments presented an additional challenge to grant recipients. Some external organisations have requested support to become smoke-free, and successful examples of smoke-free environments including smoke-free community events are evident.

Shifting attitudes around second-hand smoke (e.g. smoking indoors and in cars) and some evidence of behaviour change were reported by grant recipients and community members.

6.Access to quit support

TIS funded organisations are encouraged to take a systems approach to activity planning. The TIS program is part of a larger preventive health care system, all connected in different ways such as through referral pathways, and client appointments.

A key component of the TIS program is therefore enhancement of referral pathways and promoting access to quit support. Grant recipients have developed a range of opportunities for community members to achieve smoking cessation, with referral pathways having been established in two key areas: clinic-based referrals within their organisation and referrals made during localised TIS health promotion activities.

For some, successful referral pathways are dependent upon grant recipients partnering with external organisations.

Improving access to culturally appropriate support to quit has been a key focus of the grant recipients over the past 12 months.

Quitline enhancements are a component of the TIS program and data suggests that referrals to Quitline are higher in urban and some rural areas. Continuing to build strong partnerships between grant recipients and Quitline will be key to increasing referrals from local TIS programs into Quitline where appropriate.

Another key focus for grant recipients has been in increasing the skills of TIS workers and other professionals in contact with Aboriginal and Torres Strait Islander people to provide smoking cessation education and brief interventions. Quits kills training, and other smoking cessation education programs, have been accessed to support this goal.

7.Contributions to evidence base

The shift to delivering activities based in evidence and focusing more on outcomes than outputs has been welcomed by grant recipients, in the main, and has provided greater direction for activities and a goal to work towards.

A range of activities were undertaken by grant recipients to develop or strengthen their evidence base and work towards measurable outcomes. Collecting data remained challenging for some remote grant recipients operating in contexts with low literacy levels and where English is not the first language. Health service grant recipients wanting to collect population level data was also challenging when services are operating on different databases within a region and where there was an unwillingness to share data.

Overall, grant recipients expressed a willingness to focus on outcomes, and the confidence and capability to obtain data, although interpreting and reporting on data was presented as a challenge.

8.National Best Practice Unit and TIS portal

Advice and guidance around monitoring, measuring and further improving local TIS programs is provided to grant recipients through the NBPU TIS. Grant recipients have indicated that they value the support and advice provided through the NBPU TIS and this has aided in building their confidence and capacity to undertake monitoring and evaluation activities.

Some grant recipients reported that an additional level of support from NBPU TIS was needed. Resistance to change is common in any business when new processes are set in place. NBPU TIS therefore expected, and has witnessed, some resistance to this change. However, it continues to engage with grant recipients and support significant processes of change, not just reporting and compliance.

Another component of the work of the NBPU TIS is the development and ongoing maintenance and improvement of the Tackling Indigenous Smoking Resource and Information Centre (TISRIC) and its home, the TIS Portal (hosted by Australian Indigenous HealthInfoNet).

Information and resources to support grant recipients in planning, monitoring, and evaluating activities, as well as information on workforce development is provided through the TIS Portal.

In addition, the Portal hosts an online forum (TIS Yarning Place) that enables grant recipients from across the country to share information and ask questions. Evaluation findings suggest that, whilst grant recipients are utilising the TIS Portal, some grant recipients have identified opportunities to enhance the useability of the TIS Portal.

9.Governance and communications

Various components of support are provided to grant recipients by the department and the NBPU TIS regarding the new focus and priorities and expectations of the TIS program.

To ensure consistent program messaging, and to enhance performance reporting, a range of initiatives were undertaken in the latter half of 2016 to clarify the roles and responsibilities of the various ‘players’ in the national TIS program.

The loss of experienced staff due to funding uncertainty has represented a significant challenge for several grant recipients in their planning and implementing activities.

Particularly in remote areas, recruitment has been an issue for many grant recipients due to the mix of skills demanded of TIS staff. Grant recipients report continued issues attracting and retaining staff with only short term contracts under the new TIS program.

Despite these concerns, indications are that providing grant recipients are given sufficient time and support to execute their Action Plans, they are on track for achieving stated tobacco reduction outcomes. The key risk to this is workforce stability, which would be mitigated by timely advice about the outcome of ongoing funding arrangements.

A number of key recommendations have emerged out of the evaluation findings:

Overall recommendations

1. Department: The TIS program in its current form should be continued, with a move away from short-term funding cycles.

2. Department: Provide immediate advice about the funding of TIS from June 2017 to end of current funding cycle.

Shift to TIS

3. Department: Provide clarity around what is allowable in relation to healthy lifestyle activities within the current iteration of the TIS program  Community engagement and partnerships

4. Grant recipients: Continue to broker partnerships and leverage relationships.

5. NBPU TIS: Continue to build capability of grant recipients to broker partnerships and leverage relationships through the distribution and promotion of relevant resources.

Community education and awareness

6. Grant recipients: Continue to identify and prioritise key groups, especially pregnant women.

7. Grant recipients: Ensure evidence-based best practice community education models (including monitoring and evaluation approaches) are sought and adopted where appropriate.

8. NBPU TIS: Ensure the evidence-based best practice community education models (including monitoring and evaluation approaches) are available, particularly for priority target groups such as pregnant women and activities around social marketing.

Smoke-free environments

9. Grant recipients: Continue to explore implementing smoke-free workplaces and enhance support for smoke-free public spaces.

10. National Coordinator: Lead a dialogue between regional leaders, including CEOs, Board members of TIS and non-TIS funded organisations around establishing smoke-free environments.

Access to quitting support

11. Grant recipients: Continue to strengthen partnerships with Quitline and other quit support structures where appropriate.  Contribution to larger evidence base

12. Grant recipients: Build on routine and existing data sources to reduce data collection burden.

National support

13. Grant recipients: Continue to seek feedback from NBPU TIS regarding M&E activities where required.

14. NBPU TIS: Continue to respond to feedback from GRs around M&E needs and TIS portal content and use ability.

15. Department: Articulate the role of the National coordinator  in the context that the program has evolved and as such his role has evolved. Governance and communication

16. Department: Provide greater clarification of TIS funding parameters, especially in terms of incorporation of healthy lifestyle activities and one-on-one smoking cessation support.

The Tackling Indigenous Smoking (TIS) regional tobacco control grants aim to improve the wellbeing of Aboriginal and Torres Strait Islander people through population health activities to reduce tobacco use. It is an initiative of the Australian Government Department of Health (DoH).

At the end of 2015, a number of organisations were notified of their success in gaining a TIS grant for culturally appropriate tobacco cessation programs. The grants were awarded to a variety of service providers across the nation.

The 35 organisations that have commenced their programs are:

With the program funding provided until 2018, the successful organisations will work towards the intended outcomes of the TIS programme, including:

  • encouraging community involvement in and support for local tobacco control activities
  • increasing community understanding of the dangers of smoking and chewing tobacco
  • improving knowledge, skills and a better understanding of the health impacts of smoking.

NACCHO Aboriginal Health Research Alert : Comparisons of the characteristics of care in #ACCHOs and mainstream #PHC Primary Health Care

 ” Implications for public health: To increase utilisation of primary health care 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.

Download this research PDF

NACCHO Download What Indigenous Australian clients value


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.

Wide disparities remain between the health status of Aboriginal and Torres Strait Islander peoples (hereafter Indigenous Australians) and non-Indigenous Australians.1,2

Chronic diseases, including cardiovascular disease, diabetes and psychosocial illness caused by the history of colonisation, account for the bulk of the disparities.3

Inadequate access to primary health care (PHC) services responsive to Indigenous clients’ holistic needs, modifiable socioeconomic factors including low income, poor education, poor living conditions and social exclusion are principal contributors to the higher chronic disease burden in the Indigenous population.1–3 Increasing Indigenous Australian engagement with effective PHC, conceived in the comprehensive Indigenous Australian sense, is critical to reduce chronic disease in Indigenous communities and mitigate the disparities in health.3,4

Australia’s culturally diverse Indigenous peoples’ understanding of accessible, appropriate, quality PHC is different and broader than Western notions.3,5 From the Indigenous Australian perspective it is care conceived in the holistic Aboriginal way, that incorporates body, mind, spirit, land, environment, custom, socioeconomic status, family and community.5 The Indigenous Australian construct includes essential, integrated care based upon practical, scientifically sound and socially acceptable procedures and technology made accessible to communities as close as possible to where they live through their full participation in the spirit of self-reliance and self-determination and a comprehensive approach to supporting health.5

Importantly, all Indigenous Australians have the right to easily accessible, comprehensive, PHC delivered in a way that is respectful of Indigenous cultures, as well as to be involved in design and delivery of the PHC services they receive.6,7 International evidence investigating factors that increase accessibility and quality of PHC for Indigenous people, points to maximising community ownership and control, a robust indigenous managerial and clinical workforce, and the ability to deliver models of care that embrace Indigenous knowledge systems.3,8

Aboriginal Community Controlled Health Organisations (ACCHOs) are incorporated organisations, governed by boards of members elected by local Indigenous communities that aim to meet basic needs in Indigenous communities.5 ACCHOs function as knowledge and resource bases for Indigenous communities to advocate for their rights.5,9 The first ACCHO was established in 1971 in Redfern, in response to the failure of mainstream services to cater for the needs of its Indigenous peoples’ and desire for self-determination.5,9

By 2015 there were 138 ACCHOs in Australia 10 diverse with respect to their years of operation, budget and workforce sizes, and their governance, funding and service delivery models.10,11 Some ACCHOs employ medical practitioners and other staff, including Aboriginal Health Workers (AHWs) and provide a range of clinical and other services; others do not have a locally based medical practitioner, and rely only on AHWs.5,9,10 Assessments of health care quality based on Western informed measures have established that quality of clinical standards varies across ACCHOs and that many ACCHOs are achieving best practice standards.12

In addition to ACCHOs, state and territory funded Indigenous health organisations, which are concentrated in the Northern Territory and have varying degrees of community control, also play a role in providing culturally appropriate services in Indigenous communities.10 Of the 203 Indigenous PHC organisations in 2014/15, 68% were ACCHOs, 25% were government-run services, and 18% were mainstream non-government organisations.10Recent policy13 for improving Indigenous health in Australia reflects a strong commitment by government to implementing community control to enable better PHC quality and access, as well as to provide ACCHOs with the support they require to help achieve this goal. The policy commitment to building ACCHOs has been in place for more than 25 years.14

However implementation of the policy has been fraught with ongoing difficulties.11,14 ACCHOs rely on government funding, which they receive largely through three main Commonwealth sources: Medicare; contract funding for core PHC services; and contract funding for specific programs. Whilst some ACCHOs access the funding and workforce they require to deliver services that are responsive to community needs, and have been identified as offering exemplar models of care for Indigenous peoples15 the evidence relevant to the implementation of Indigenous control of health care in Australia,11,14,16–18 shows that many, particularly emerging organisations, struggle to navigate complex funding and accountability arrangements.

Evidence points to various inefficiencies in the funding and governance arrangements and questions their ability to support quality care provision that is responsive to each community’s unique needs and meets needs of all clients within communities.14In the context of increasing debate regarding the merits of mainstreaming Aboriginal PHC, we systematically reviewed qualitative evidence to document and understand how ACCHO clients perceive the characteristics and value of care provided by ACCHOs compared to care provided in mainstream PHC.

Our motivation was that the findings from existing qualitative studies, in academic and grey literature, on how ACCHO clients’ experience and perceive the nature and value of care provided in ACCHOs, and compared to in mainstream PHC services, had not yet been synthesised, yet synthesising the qualitative client perceptions might offer insights for health practitioners and policy makers on how best to improve Indigenous Australians’ access to PHC services that offer appropriate, quality care.

MethodThis review forms part of a larger systematic review project.19 We followed Joanna Briggs institute (JBI) guidance for systematic review of qualitative evidence20 and the PRISMA reporting guidelines.21 We took two steps to better align with ethical standards relevant to research involving Indigenous Australians22 and enable Indigenous specific contextual and cultural knowledge to inform the evidence appraisal and interpretation:23,24 1) Indigenous and non-Indigenous personnel were included in the review team; and 2) input was sought, at key stages in the review, from a reference group of Indigenous Australian community leaders and Indigenous people with expertise in PHC service delivery in Indigenous Australian communities.

Population and context: Indigenous clients (including family members, all ages) of ACCHOs.

Phenomena of interest: Perspectives on the characteristics and/or value of care provided by an ACCHO and the characteristics and/or value of care provided by one or more ACCHOs compared to the characteristics and value of care provided by one or more mainstream PHC services. ACCHOs were defined as non-government organisations operated by an Indigenous community, through an elected board of management. Mainstream providers were defined as general practitioner services. A service ‘characteristic’ was defined as a client identified attribute or feature of the PHC service, and a value as a client expressed experience of the worth or impact of the PHC service. Only perspectives evidenced by client voice were included.

Search and study selectionWe searched electronic sources for peer reviewed and grey literature studies meeting the inclusion criteria published in English, between April 1971 (date of first ACCHOs) and 30 April 2015. We searched the following databases using database specific search strings: Pubmed; Scopus; Healthbusinesselite; Econlit and Informit (Indigenous peoples databases).

Using generic search terms, we searched Google Scholar (advanced), Indigenous HealthInfoNet (Health Bibliography and Australian Indigenous Health Bulletin), Australian Policy Online, the Centre for Economic Policy website and Lowitja Institute websites. We hand searched references of two recent literature reviews, and the included studies. The search strategy is provided in Supplementary File 1, available online. The PubMed search string was:((health services, indigenous[mh] OR community health services[mh] OR primary health care[mh] OR rural health services[mh] OR community networks[mh] OR delivery of health care[mh] OR health planning[mh] OR community controlled health service*[tiab] OR indigenous health service*[tiab] OR community health service*[tiab] OR primary health care[tiab] OR rural health services[tiab] OR community networks[tiab] OR delivery of health care[tiab] OR health planning[tiab]) AND ((Aborig*[tw] OR Indigenous[tw] OR (Torres Strait[tw] AND Islander*[tw]) OR Oceanic Ancestry Group[mh] OR koori[tw] OR tiwi[tw]) AND (.au[ad] OR australia*[ad] OR Australia[mh] OR Australia*[tiab] OR Northern Territory[tiab] OR Northern Territory[ad] OR Tasmania*[tiab] OR Tasmania[ad] OR New South Wales[tiab] OR New South Wales[ad] OR Victoria*[tiab] OR Victoria[ad] OR Queensland[tiab] OR Queensland[ad]))) AND ((“1971/01/01”[PDat]: “2015/12/31”[PDat]))The search results were imported into an Endnote database (Thomson Reuters), where duplicates were removed. Title and abstract of the remaining records were then screened by JG for eligibility against the inclusion criteria, and full texts of potentially relevant studies set aside for further examination. JG, OG, DC independently reviewed the full-text articles against the inclusion criteria, noting reasons for exclusions. Uncertainty about whether the organisation was an ACCHO was resolved by contacting authors.

Quality assessment and data extractionWe used the critical appraisal and data extraction tools in the JBI Qualitative Assessment and Review Instrument (JBI-QARI).20 Two of the non-Indigenous authors (JG, DC) independently assessed quality of the studies that met the inclusion criteria, and two of the Indigenous Australian authors (OG, KK) crosschecked a 20% sample of the assessments for uniformity and accuracy. One reviewer (JG) extracted descriptive study data from the included studies. Three non-Indigenous members of the review team (JG, ZM, MS) extracted findings from the included studies for the phenomena of interest. Only client perceptions that were supported by an illustration, in the form of a client voice, were extracted. A 20% sample of the extracted findings was checked for accuracy by two of the Indigenous Australian authors (KO, OG). The confirmation of accuracy ensured that Indigenous Australian perspectives were applied in the quality appraisal and data extraction.

SynthesisWe used meta-aggregation20 to synthesise, separately, the client perceptions on the: 1) characteristics and value of care provided by ACCHOs; 2) characteristics of care provided by ACCHOs compared to mainstream PHC providers; and 3) value of care provided by ACCHOs compared to mainstream PHC providers. Meta-aggregation is grounded in the philosophic traditions of pragmatism and Husserlian transcendental phenomenology. The overall emphasis in this approach is on producing findings from existing studies that are credible in the sense that they reflect the meaning of the included studies, and inform practice-level lines of action that have applicability to healthcare policy or practice. Meta-aggregation embodies the complex nature of critical understanding, while ensuring the findings developed from the synthesis of study findings are meaningful and practical.20 For each synthesis, we followed the two-step thematic analysis approach of meta-aggregation. First, we developed categories of findings with similar meaning, and second, we developed synthesised findings describing the categories. To develop the categories, the first two authors (who led the synthesis), working independently, read and re-read the assembled findings with their supporting illustrations to understand their meaning, and grouped them into categories of similar findings, reflecting the main themes in the findings relating to the phenomena of interest.They then compared and discussed the two interpretations, and developed consensus-based categories of the identified themes.

To develop the synthesised findings, which in meta-aggregation represent overarching descriptions of the categories20, these same authors (OG and JG) first worked individually, and then together. OG’s interpretation of category meanings, and appropriate synthesised findings was privileged to ensure that the synthesised findings were informed by unique knowledge of Aboriginal and Torres Strait Islander culture and the context surrounding Aboriginal PHC, held by Indigenous Australians. AB guided the first author through the process of identifying the key cross-cutting themes in the synthesised findings, thereby ensuring that the second level analysis was also informed by Indigenous Australian expert knowledge. The draft categories, synthesised findings and interpretation of the themes emergent in the synthesised findings, were reviewed by all the other authors.

Description of studies

Our search identified 4,405 records. From these, 816 duplicates were removed, leaving 3,589 for title and abstract screening against the review eligibility criteria. We excluded 3,468 of these for not meeting the inclusion criteria, leaving 112 for full text examination. Of these, six were not accessible, 19 did not offer findings for the phenomena of interest, 36 did not use qualitative methods, and for 51 we were uncertain whether participants were ACCHO clients. This left nine articles reporting nine studies. An additional article reporting one of the nine studies was identified in the references of one included article, resulting in 10 included articles,25,34 reporting nine studies. Supplementary file 2 provides the search results and study selection. The list of citations excluded at full text examination is available from the corresponding author.The results from the methodological quality assessment are provided in Supplementary file 3.

One was rated high quality,28 seven were rated good quality,27,29,34 and one, reported in two articles, was rated moderate quality.25,26 A lack of clarity about how researchers’ values and prior knowledge influenced studies was the main methodological concern potentially undermining the credibility of the findings that informed our syntheses. It is not possible without further information to comment on whether researchers’ values and knowledge enhanced the validity of findings or introduced bias.Details on the characteristics of each included study are provided in Supplementary File 4. All the studies were published between 2004 and 2014. Six used mixed methods.25–27,30,31,33,34 Four used focus groups and interviews,27,31–33 four used only interviews,25,26,28,30 and one used only focus groups. 34 Five of the studies adjusted their methodology to align with the unique ethical and methodological standards relevant to research with Indigenous Australians.28–30,33,34 Based on an estimation of 75 participants in one study that employed focus groups,27 a total of 811 study participants informed the meta-syntheses (including 640 from one study).31 There was good geographic representation in the ACCHO sample.

Synthesised findingsA diagrammatic representation of the three meta-aggregations of the ACCHO client perceptions is provided in Supplementary File 5.

Care in ACCHOsOur synthesis of the client perceptions on the characteristics and value of ACCHO care, extracted from the nine included studies,25–34 produced four synthesised findings.

Synthesised Finding 1: ACCHOs’ accessibility was highly valued. Clients identified ACCHOs’ transport services, proactive service provision, culturally safe care, range of services and welcoming environment as contributing to ACCHOs’ accessibility. Five categories informed this synthesised finding; each of them described a different characteristic that, from the clients’ perspective, contributed to accessibility. Proactive service provision was described as ACCHOs having outreach services (e.g. home visits), staff who were easily contactable, and staff meeting patients in public areas such as shopping centres.25–27 Culturally safe care was described as care delivered by providers who were good,28 who understood clients and knew how to meet their needs,29 who spent sufficient time with patients and who respected culture,29 in an environment that made clients feel comfortable.34 ACCHOs’ welcoming environment was described as including an emotional and relational dimension.27,29,33 The relational dimension was reflected in clients’ relating how they felt welcome in ACCHOs because they saw people who were familiar to them, and who understood them, both in the waiting room and in the clinical space.27,28 Clients indicated that they valued this because it gave them a sense of belonging.27,28 The emotional dimension of the welcoming environment was evidenced in descriptions of ACCHOs as social meeting places, where friends offered and received support.28,29 The following client voices are illustrative of how clients described ACCHOs’ welcoming environment:

“I just, just ah come here on my one day off and sit out here, have a talk with my mates…there’s always someone you know here… it’s a social event too…”29(p200)

“We share a lot. You know when you meet people you talk about things…If we go in and I know someone we’ll have a good yarn…?”29(p200)

Synthesised Finding 2: The way ACCHOs delivered care was highly valued. Clients valued staff taking the time to know and care for clients; personalised care tailored to self-perceived need; continuity of care; and appropriate communication. Clients related that they experienced feelings of belonging and confidence when accessing services with these service qualities. Four categories of findings informed this synthesised finding. The first was that clients experienced and valued staff, including doctors, taking their time with them.29 In the words of one client: “That’s the thing AMSs do really well, they take their time. There are not time limits”.29 ACCHOs providing healthcare in a personalised way tailored to client needs was the second category. These findings indicated that clients perceived ACCHOs as delivering care in a way that was responsive to their background27 by people who understood them.29 Clients also reported that the way staff provided care made them feel: known;29,33 less isolated (belonging);29,33 more confident;28 less anxious;30 cared for;30 accepted;28,29,30 supported;29 and encouraged.30 The third category was provision of information in a way that was understandable.27,30 Continuity of care was the last category, described as ongoing care and support for various problems in a client’s life over time.27,29

Synthesised Finding 3: Particular qualities of ACCHO staff were highly valued. These included Aboriginal identity of some of the ACCHO workforce, including AHWs; and staff who understood Indigenous clients and therefore behaved respectfully. Two categories informed this synthesised finding. The first was that clients valued the following behavioural qualities of staff: respectful and non-judgemental behaviour;27 staff taking time to know the client’s background and listen to their needs;29 sensitivity, kindness and reassurance;25,26 and trustworthiness.28,29 One said the way ACCHO staff allowed clients to talk about anything made you “feel at home”.27 The second category concerned how clients valued the Aboriginal identity of some ACCHO staff29,33 and the employment of AHWs.28 The following client voice illustrates how some clients described the value of AHWs:

“It was a whole new world…she was like a social worker I guess, we could talk to them individually, she was lovely. She explained everything, she took you in to how you know it all worked and was going to happen…you couldn’t have found so much difference between her, and the doctors who just tell you.”28(p6)

Synthesised Finding 4: A comprehensive, holistic approach to PHC was highly valued. The inclusion of non-clinical care, such as community events, group activities and enhanced supports available through community networks, had a positive impact on peoples’ wellbeing. Two categories informed this synthesised finding. The first was that non-clinical services, including ACCHOs’ social services, cultural events,33 and group activities such as diabetes camps30 and bush camps,33 were a valued characteristic. Clients pursued the opportunity group programs gave them to spend time with people who shared similar experiences, and to connect with community and culture.30,33 One client described the group-based activities as “a really great healing process”.33(p359) The second category of findings acknowledged and described perceived positive impacts of ACCHOs on client wellbeing.27,28,30,32 The impacts identified were: increased confidence;27,28 enhanced knowledge about how to manage conditions and actively engage in health decision making;30 pride in being part of the local Aboriginal community and its health service; better health;28,32 and better mental health.32

Comparisons of the characteristics of care in ACCHOs and mainstream PHC

Synthesis of the findings from three included studies contrasting the client perceptions of the characteristics of care in ACCHOs and mainstream PHC produced one synthesised finding which identified two differences between ACCHOs and mainstream PHC providers.28,29,33Synthesised Finding 5: While relationships were characterised by respect and understanding in ACCHOs, in mainstream services there was often a lack of respect and no shared understanding between providers and clients, or among clients. ACCHO clients described being discriminated against (also couched as being treated “differently”),28 patronised,28 assaulted and threatened29 by staff in mainstream services and contrasted this with staff in ACCHOs, including “behind the door in the clinical consultation space”,29 treating clients with respect and understanding rather than challenging or denying cultural identity.29 The second category was client-provider and provider-provider relationships in ACCHOs being characterised by high levels of trust,29 shared similar meanings29 and caring supportive relationships33 contrasting with a lack of mutual understanding and an absence of trust in the relationships within mainstream services.29
Comparisons of valued characteristics of care in ACCHOs and mainstream

Synthesis of findings from six of the included qualitative studies contrasting the value of care across the two sectors, identified three unique highly valued characteristics of care provided by ACCHOs compared to mainstream PHC providers.27–29,32–34

Synthesised Finding 6: ACCHO clients identified three unique highly valued characteristics of ACCHOs compared to mainstream PHC services: (1) accessibility, which clients described in terms of welcoming and safe spaces; (2) the way ACCHOs delivered care, in a culturally safe way tailored to need; and (3) comprehensive holistic care. The first point was that clients preferred ACCHOs because of their greater accessibility, which was related to additional services and their more welcoming environment.27,29,32,34 Clients described ACCHO waiting rooms as meeting and speaking environments “where people happen to be sick”,29 contrasted with mainstream services’ waiting rooms, described as quiet, formal sick places where you felt isolated.29 Clients signalled that relationships and support associated with companionship experienced in ACCHOs’ and Aboriginal staff were key to why ACCHOs were more accessible.32

“I used to go…all the way into [suburb] to see the AMS workers, and um I’d see a lot of people, it’s a great place to get together with a lot of people, a special place, and you see different ones, and have a yarn to…I’ve been away for a while, and um I always come back… In the [non-Indigenous] service you’re in, you’re out. There’s no friendliness…”28(p4–5)

“There’s always someone that you know, another family member or an old school chum or people you’ve played football with, and you’ve got that companionship there. If you were to go to the doctor’s surgery uptown and then just sitting there, oh god, I’m wishing to get out of there super quick.”33(p358)

“I was going to a doctor in Cleveland, and I didn’t feel comfortable there, but being here, where there’s other people around, yeah I felt comfortable when I came here the first time…there were Aboriginal nurses as well…and you could relate to them a bit more.32(p.6)

The second and third categories informing synthesised finding six, concerned differences in the way care was delivered across the two settings.27,29,3

Clients indicated they valued how staff in ACCHOs understood their holistic health care needs – signalled for example by references to be able to “talk to the AMS staff about anything and everything”– and were respectful,29(p202) and contrasted this with experiencing lack of understanding and inadequate care in mainstream PHC services.


Our systematic review identified a small body of studies reporting qualitative data on client perceptions that when synthesised offers useful insights into how Indigenous clients view the nature and value of care provided in ACCHOs, and comparison to in mainstream PHC providers. Importantly, the findings from the syntheses contrasting care across the sectors mirrored those from the synthesis of clients’ perceptions of ACCHOs’ characteristics and value. Overall, our synthesis points to three unique, highly valued characteristics of care provided in ACCHOs compared to in mainstream providers. The first is ACCHOs’ unique accessibility. Clients perceive ACCHOs’ welcoming environment, which includes a social, emotional and physical aspect and supports cultural safety; ACCHOs’ flexible, responsive and proactive approach to care provision; and ACCHOs’ additional services, including transport and outreach as factors contributing to ACCHOs unique accessibility. The second unique, highly valued ACCHO characteristic is ACCHOs’ culturally safe care. This was described by clients as care delivered by staff, many Aboriginal, who feel known to clients, understand client needs and respect culture, in an environment where clients feels comfortable, supported and that they belong. The third was comprehensive care, that is, care responsive to holistic health needs.

Relationships, understanding and respect for culture central to clients’ view of accessible, appropriate, quality health care

High levels of trust and mutual understanding in the relationships between clients and health care providers, as well as close relationships between clients, were central themes in our syntheses. The presence of people from the local community, and involvement of Indigenous people in the service, was also central themes. Our synthesis therefore reinforces existing literature that has highlighted relationships,3,35 respect for culture and for Indigenous knowledge, and the involvement of Indigenous people in providing care, as central to Indigenous clients’ perceptions of accessible, appropriate and quality health care.

Why care provided by mainstream PHC providers will not substitute for ACCHO care

The description of ACCHOs’ characteristics and value compared to mainstream PHC providers highlights two distinct but equally important reasons why the care provided by mainstream providers cannot serve as a substitute for the care provided by ACCHOs for Indigenous clients. First, as has been previously noted,3 the characteristics of accessible and culturally safe care are such that mainstream PHC providers cannot achieve them using a tick-box approach and without fundamental change. Key elements, including the support offered by relationships amongst clients, will be difficult for mainstream providers to replicate. Second, mainstream services are not perceived by all Indigenous Australians as offering care that is responsive to holistic health needs. Moreover, mainstream PHC providers are ill-equipped to provide clients with a broad range of PHC programs tailored to self-perceived holistic health needs. They are focused on delivering clinical services designed largely to meet the needs of the majority, non-Indigenous population and to meet business objectives, and they are unlikely to transition to providing the additional services Indigenous Australians seek.

Additional insights on how ACCHOs improve Indigenous health

Our findings offer additional insights into the way ACCHOs contribute to improving the health and wellbeing of Indigenous Australians. Moreover, the clients’ references to positive impacts of ACCHOs on their confidence;27,28 on their knowledge about how to manage conditions and actively engage in health decision making;30 on their pride in being part of the local Aboriginal community and its health service; and on their mental health32 supports the conclusion of a recent review on ACCHOs’ impacts on Indigenous health,36 that ACCHOs are important not only because their health care helps to improve Indigenous Australians’ health, but also because of how they help to address the socioeconomic factors that contribute to high levels of chronic disease in Indigenous communities.

Strengths and limitations

The overall quality of the included studies was good. A second strength of our review is the steps we took to align our review methodology with the ethical and methodological requirements relating to research involving Indigenous Australians. These steps are important because they are called for by the unique standards for ethical research with Indigenous Australians, and because incorporating local contextual and cultural knowledge specific to Indigenous people adds to the credibility and relevance of the review findings and should aid their transferability into practice and policy.20,21

The small number of studies contributing to the syntheses, particularly the two comparing care across the sectors, is a limitation of our review. Neither the included ACCHO population nor the ACCHO client population were representations of their diverse total populations in Australia, potentially limiting the transferability of the findings. Another limitation relates to our inability (given data constraints) to explore potential variations in the perspectives of clients with different characteristics, e.g. males versus female, people of low and high socio-economic status. Third, whilst we did not extract findings from studies in which it was clear that the comparator was care in the hospital setting, we cannot be certain that references to “mainstream services” did not include this setting. We did not consider how clients’ perceptions of the characteristics and value of ACCHOs’ care compare with their perceptions of characteristics and value of other Indigenous PHC provider types. It is expected that Indigenous services, with high levels of local community involvement in the planning and delivery of their services, may be perceived by clients as having similar characteristics and value as ACCHOs. Fifth, there may be studies published since the end date of our search, that meet our review inclusion criteria, which may offer unique additional insights about how ACCHO clients perceive the characteristics and value of care provided by ACCHOs, and compared to mainstream providers, or they may confirm our synthesised findings.


Mainstream practitioners that seek to improve the accessibility and quality of their care for Indigenous peoples should: 1) invest in understanding Indigenous clients’ needs and learn how to be respectful of Indigenous clients’ culture; 2) adopt a flexible and proactive approach to providing care for Indigenous people (for example, they need to be prepared to meet clients outside of normal operating hours and engage in outreach activities); and 3) invest in making the clinic welcoming for Indigenous clients, for example, by putting up posters and other artefacts that are representative of Indigenous culture. However, for many Indigenous Australians, the care provided by mainstream PHC providers will not be a substitute for ACCHO care tailored to meet holistic health needs of Indigenous clients and their communities. Australian governments therefore should remain committed to the implementation of community control and should prioritise reforms to make the funding and accountability arrangements more enabling of rapid growth in the ACCHO sector and more supportive of high-quality, comprehensive, effective service provision by ACCHOs. To this end, government should look to the recommendations offered by recent research on barriers and facilitators regarding implementing Indigenous community control in PHC which offers useful guidance on reforms required in funding and accountability frameworks.11,14,16–18 In addition to building better funding and accountability arrangements for the ACCHO sector, governments need to continue to prioritise initiatives, for example best practice guideline development and dissemination, that enable all relevant treatments for comprehensive holistic health care being informed by scientific evidence. Ensuring that all ACCHOs have access to, and have the capacity to use, appropriate continuous quality improvement systems, for identifying their strengths and where system change is required to further strengthen the service and improve the health outcomes for clients accessing these services, is also important.37


The qualitative evidence on how Indigenous Australian ACCHO clients perceive the characteristics and value of care provided by ACCHOs, and compared to in mainstream PHC providers facilitates understanding why mainstream PHC provider care cannot be a substitute for ACCHO care. It also offers insights into how ACCHOs address socioeconomic factors that contribute to chronic disease in Indigenous communities. This sends a cautionary note to policy makers intent on mainstreaming Aboriginal PHC and underscores the importance of implementing the reforms to the funding and accountability arrangements for ACCHOs, that have been identified as important to support ACCHOs’ delivering quality services that are effective and meet holistic needs of clients in Indigenous communities. Mainstream PHC practitioners can learn from best-practice examples in the ACCHO sector how to improve the accessibility and quality of their care for Indigenous clients.


Judith Gomersall (JG), Odette Gibson (OG), Judith Dwyer (JD), Alex Brown (AB) and Edoardo Aromataris (EA) led the conceptualisation of the review. JG and OG led the writing of the protocol. The research governance group established to guide the work of the NHMRC Centre of Research Excellence in Aboriginal Chronic Disease Knowledge Translation and Exchange (CREATE) reviewed the protocol. JG performed the search and abstract review. OG, Drew Carter (DC) and EA conducted the full text examination. EA, an experienced systematic reviewer, provided oversight during the search and study selection process. EA and Zachary Munn (ZM) provided technical advice about appropriate review method. Two non-Indigenous Australian members of the review team, DC and JG, assessed the quality of studies. Their assessments were reviewed by two Indigenous Australian members of the team, OG and Kootsy Kanuto (KK). Matthew Stephenson (MS), ZM and JG (all non-Indigenous Australians) extracted the data from the included studies. Two Indigenous members of the review team, OG and Kim O’Donnell (KO), reviewed their data extraction. KO, OG, MS, JG and DC participated in a workshop convened to develop an initial set of categories for the meta-aggregation. OG and JG then worked together on the meta- aggregation with OG’s perspective being privilege due to her unique insider Aboriginal knowledge. AB, a senior Indigenous Australian health researcher with expert knowledge of Aboriginal health and the Aboriginal health sector, guided JG through the second level analysis, the interpretation of the synthesised findings. JG, OG JD and EA led the writing of the paper, which was reviewed by all authors. The findings of the review were presented to representatives of the CREATE leadership group prior to submission of this article for publication, and feedback received integrated. The authors thank the participants of the CREATE leadership group for the invaluable guidance and time they provided during this review. We also thank Harold Stewart and Stephen Harfield for participating in the workshop held at the beginning of the synthesis stage of the review. Finally, we thank Sandeep Moola for assistance during the data extraction stage of the review.


The NHMRC (GNT1061242) supported this project. The contents of the published material are solely the responsibility of the Administering Institution, a Participating Institution or individual authors and do not reflect the views of NHMRC.

Aboriginal Health Please support the @MaiWiruSCF #Sugar Challenge Palyaringkunytjaku – Towards Wellbeing

“ The rates of obesity and insulin resistance syndrome in our communities are now so high that the majority of the adult population over 35 will be affected.

This provides a situation in which we are not aiming to target a subset or at risk group of the population with a nutrition strategy but our whole population is both at risk and suffering disease.”

Professor Paul Torzillo, Medical Director of Nganampa Health Council said in Fighting for “Good Food” (Mai Wiru), submitted by Lorenzo Piemonte, International Diabetes Foundation (2015)

 ” Congratulations, Mai Wiru. They are excited to be taking 10 influential Anangu senior women on a nutrition education retreat so they can experience first hand how a healthy diet feels, and can consequently extend lives in the APY Lands – to do this though, they need your help

Friends,please share this and support it. I met so many wonderful people when I spent two day in the APY Lands last week – they deserve our help.”

Indigenous Health Minister Ken Wyatt

Amata was an alcohol-free community, but some years earlier its population of just under 400 people had been consuming 40,000 litres of soft drink annually.

The thing that I say in community meetings all the time is that, the reason we’re doing this is so that the young children now do not end up going down the same track of diabetes, kidney failure, dialysis machines and early death, which is the track that many, many people out here are on now,”

Mai Wiru, meaning good health, and managed by long-time community consultant John Tregenza.

See Previous NACCHO Post Aboriginal Health and Sugar TV Doco: APY community and the Mai Wiru Sugar Challenge Foundation

Palyaringkunytjaku – Towards Wellbeing is the brain child of Inawantji (Ina) Scales, a young Pitjantjatjara woman from the APY Lands.

Ina has seen too many family and friends, too many Anangu (people from the Anangu Pitjantjatjara Yankunytjatjara Lands) die from diet related illnesses.

Watch video

Ina wants to give Anangu the same opportunity Hope For Health has given Yolngu in the top end

See fundraising website

In 2016 Ina met with Damon Gameau, the founding director of the Mai Wiru Sugar Challenge Foundation.

She told him of her sadness from watching so many people become ill and pass away, she also told of her personal experience from visiting Living Valley Springs and the happiness she felt at now understanding the solutions.

Ina asked Damon for his help, and the Foundation’s help, to share her experiences with other people on the APY Lands.

Here we are today, raising funds to send 10 senior and influential women to an intensive health and nutrition retreat where they will learn and be able to personally experience firsthand, the benefits of healthy eating and living.

By providing a culturally appropriate setting with language interpretation, we will free participants to focus, distraction free, on learning the extensive information that will be provided.

These strong community leaders will then be able to return to community to share their experiences and become healthy living champions.

This is a 2 week trip with an interpreter and staff member to support the women through their learning and experiences, and further to be able to support the women on their return to community.

This will also ensure longer lasting results and help participants maximise their learnings and minimise any stumbling blocks they come across.

Our aim is to have an intensive and immediate impact for these women, enabling them to experience the benefits of healthy eating and living, and to expand their understanding of the impacts of foods on their bodies, to understand the how and why foods have such influence over us.

In their roles in community they can then spread the word about their positive experience and help others make healthier choices.

The participants are being selected based on their location and their capacity to influence on their return.

As a result, these women will become healthy living champions, sharing their knowledge and experience in their regions.

We can’t do it without you.

Help Ina make a good impact on the health of her people, of the Anangu nation.

  • The rate of kidney failure in Aboriginal communities is 15 x the rest of Australia; Type 2 diabetes is 3 x the national average.
  • For too long now high Aboriginal death rates have been attributed to alcohol consumption. The communities and region of the APY lands have now been alcohol free for 40 years yet average life span on the lands is just 55; 20 years lower than the rest of Australia. This is because of poor diet.
  • Professor Paul Torzillo, Medical Director of Nganampa Health Council said in Fighting for “Good Food” (Mai Wiru), submitted by Lorenzo Piemonte, International Diabetes Foundation (2015) “The rates of obesity and insulin resistance syndrome in our communities are now so high that the majority of the adult population over 35 will be affected. This provides a situation in which we are not aiming to target a subset or at risk group of the population with a nutrition strategy but our whole population is both at risk and suffering disease.”
  • Dr Amanda Lee et al in the Australian and New Zealand Journal of Public Health, Nutrition in remote Aboriginal communities: Lessons from Mai Wiru and the Anangu Pitjantjatjara Yankunytjatjara Lands, (2015), state that more than 75% of Indigenous deaths result from potentially avoidable causes. This includes type 2 diabetes, a preventable, non-communicable chronic disease. About 70% of Aboriginal and Torres Strait Islander adults, and 38% of Aboriginal and Torres Strait Islander children were considered overweight or obese in 2015, with an additional 8% of children who are underweight, another major contributor to the avoidable deaths.
  • Communities on the APY Lands have a long history of being proactive, for example, communities took back management of their stores to ensure food security (the availability and affordability of healthy food and essential items on a daily basis through their local store).
  • There are programs in place that address nutrition and health, but the scale of the problem necessitates a spot fire approach and they are struggling to extend and achieve the progressive results needed to combat chronic health and nutrition issues in the Aboriginal population.
  • The success of service delivery in remote communities depends on the level of community involvement and buy-in. By providing an intensive experience with ongoing support community members will be empowered to create and manage change in their communities.

To make this program fly we need your wonderful support to get there!

We know you’re all very busy people and this is why we appreciate your help more than you can know! Here is a list of 10 things that you could do to help us make Ina’s dream of Palyaringkunytjaku – Towards Wellbeing a reality.

  1. Share our emails – when you receive our emails – share them with your friends and networks.
  2. Share our Social Media posts – Follow us on Facebook and invite your friends to do the same.
  3. Talk to your friends, family, colleagues – tell them what we are doing and how they can support us.
  4. Give us a call. We are looking for more support and are ready to answer calls. We can talk in more detail about the project and who knows where a conversation may lead. Email info@maiwirufoundation.org
  5. Hold a fundraising event. Be creative – a donation box at your work for a month, hold a concert, a dinner party with tickets, a raffle, a physical challenge among your friends, a percentage of your office mates salaries for a month. Design your own style of fundraising.
  6. Create your own campaign under this ‘Palyaringkunytjaku’ umbrella – simply click the button at the bottom of the screen that says ‘Fundraisers – Create Your Own’. You can select one of the impact levels and let your friends and family know what the funds raise will enable. You might like to do ‘6 Spoons in June (and July)’ for the length of this campaign and ask for sponsorship, as an incentive
  7. Keep a close eye on our campaign-we need to hit the target, so if we get close and time is short consider donating again to get us over the top
  8. Have you got something special to give? Relevant health products or services? Donate towards our perks or retreat or help with distributing perks to donors.
  9. Send a message through your networks. Do you have a voice in your community? Do you have a big social media following? Perhaps a lot of professional networks? One or two emails during the campaign from you could result in thousands of dollars towards our very important work. We have email templates for you to use and technical support available if you require. Email: info@maiwirufoundation.org
  10. Did we mention sharing our social media, emails and talking to people you know about what we are doing? When people hear and understand your passion, they can be inspired to jump on board.

All donations are tax deductible.

What happens if we get more or less than $63,500?

By hitting $63,500 we can make Ina’s dream a reality and take 10 participants from the APY Lands on this program, means Palyaringkunytjaku can go ahead as Ina hoped.

There are always many people from the APY Lands who would benefit from this experience,, therefore the amount we raise will directly impact on the number of people Ina and the Mai Wiru Foundation are able to support.

The Mai Wiru Sugar Challenge Foundation is an indigenous community-led initiative, implementing nutrition programs in central Australia’s remote APY Lands. After two years of consultation, and multiple visits from nutritionists to indigenous communities, the team are working on three key projects: opening healthy living cafes, funding permanent nutritionists on the ground, and intensive nutrition workshops.

Melbourne filmmaker Damon Gameau embarked on a unique experiment to document the effects of a high sugar diet on a healthy body, consuming only foods that are commonly perceived, or promoted to be ‘healthy’. Damon’s now acclaimed documentary The Sugar Film raises awareness of the hazards of any diet containing too much sugar. In making the film Damon included a segment about an innovative health program initiated by Indigenous communities in the Anangu Pitjantjatjara Yankunytjatjara(APY) Lands, where stores were stocking healthy foods and nutritionists were advising customers on the best food choices. Damon determined to give back to the APY communities who featured in That Sugar Film by supporting them in their mission to take control of their own nutrition and improve the health status of Aboriginal families on the APY Lands.

Damon founded the Mai Wiru (Good Food) Sugar Challenge Foundation, a not-for-profit enterprise working with APY communities in an indigenous-led initiative to improve their health.

The health challenges of Aboriginal people are well documented, with current research identifying a 10 year gap between the life expectancy of indigenous and non-indigenous males and indigenous and non-indigenous females. The report published by the Australian Institute of Health and Welfare : Indigenous Health (2014) found that ‘The largest gap in death rates between Indigenous and non-Indigenous Australians was in circulatory disease deaths (22% of the gap) followed by endocrine, metabolic and nutritional disorders (particularly diabetes) (14% of the gap)’.

You can start your own campaign to raise money for Palyaringkunytjaku – with a goal for one of the impact levels below:

  • For the flights – 1 participant (12 in total) = $767
  • For the 2 week health workshop – per participant (10 participants) = $5,990
  • Meals during transit per person – 4 days (12 people) = $300
  • Vehicle expenses – hire, mileage, fuel, maintenance. Pickup and return to community – 3 vehicles for all participants = $11,169
  • Accommodation Alice Springs – per person 2 nights (each direction) twin share = $150

What happens if we get more or less than $63,500?

By hitting $63,500 we can make Ina’s dream a reality and take 10 participants from the APY Lands on this program, it means Palyaringkunytjaku can go ahead as Ina hoped. There are always many people from the APY Lands who would benefit from this experience, therefore the amount we raise will directly impact on the number of people Ina and the Mai Wiru Foundation are able to support

If you would prefer to make a donation by bank transfer/direct deposit, please see our bank account details below. Please advise by email – info@maiwirufoundation.org – when donation is made so we can issue a tax receipt. Thank you.

Account Name: Mai Wiru Sugar Challenge Foundation
Bank: Suncorp
BSB: 484 799
Acct No: 507433042
Description: Please enter your email address

NACCHO Aboriginal Hearing Health : 94 per cent of Indigenous inmates in the NT have significant hearing loss


” Eighty four per cent of adults and 96 per cent of juveniles detained in the Northern Territory are Indigenous, though they only make up 25 per cent of the population.

In my research I found that hearing-impaired Aboriginal people are more likely to be arrested and charged with crimes because they cannot explain themselves to police or give adequate instructions to their solicitor, are less likely to be viewed as a credible witnesses in court, and tend to have misunderstandings with corrections staff.”

Psychologist Dr Damien Howard ( see his PowerPoint presentation below ) 


 ” Ministers agreed that the ear and hearing health of Aboriginal and Torres Strait Islander children is an important issue that impacts on their health, education, and employment outcomes.

Accordingly, Ministers agreed to explore the feasibility of a national approach to reducing the burden of middle ear disease and associated hearing loss on Aboriginal and Torres Strait Islander people. This is an important step towards achieving Closing the Gap targets. “

COAG Health Council Communique  24 March 2017

Read over 30 previous NACCHO articles Ears and Hearing

When Aboriginal prisoners appear before a magistrate waiting to be sentenced in Darwin, a guard is usually sitting in the dock right beside them. Troy Vanderpoll used to be one of those prison officers.

Article originally published

The Aboriginal inmate is asked a few questions. He nods in agreement with the magistrate, repeating, “yes”, over and over again.

The session finishes, the inmate stands, and the court moves on to the next case.

The man turns to the guard: “How much did I get?”

Mr Vanderpoll is Indigenous himself, and used to work as the Aboriginal Liaison Officer in Northern Territory prisons.

He spent a lot of time with Aboriginal inmates, and noticed that some of the men seemed withdrawn, and did their best to avoid interacting with guards, parole officers and judges — even when it was in their best interests.

Hidden epidemic

In 2010, Mr Vanderpoll spoke to a local psychologist, Damien Howard, who had a theory on why that was — a hidden epidemic of hearing loss.

Damien had studied the impact of hearing loss on Indigenous people for more than two decades, but had never seen research published on hearing levels of adult prisoners in the Northern Territory.

Before Mr Vanderpoll became a prison guard, he was a medic in the Australian Army, where he learned how to conduct hearing testing. In the defence forces, biannual checks are mandatory.

In response to Mr Vanderpoll and Dr Howard’s interest, Robert Miller — then acting superintendent of Darwin Correctional Centre and Mr Vanderpoll’s stepfather — commissioned the pair to conduct hearing testing for Aboriginal inmates.

Mr Vanderpoll tested the hearing of volunteers at correctional centres in Darwin and Alice Springs, and Dr Howard helped compile the results.

The findings made news headlines: 94 per cent of the inmates tested had significant hearing loss.

The result reflected a wider public health issue: in remote communities, up to 45 per cent of Aboriginal people have hearing loss, often due to preventable childhood ear diseases.

Presentation  : Health practitioners improving communication with Indigenous patients and family members with hearing loss.

Mr Miller had by then worked in Corrections for over 25 years. The result was a revelation.

“I think it shocked all of us that the hearing loss was so great,” he says.

“The doors open and the memory goes back: some prisoners seemed to be not talking to you, ignoring what you’re saying. You understand now that he’s got a hearing problem, no wonder he couldn’t hear what I was saying.

“If you don’t know about it then you may just think that the prisoner is being ignorant or rude in not responding to something that you’ve said.”

Then there were the inmates who Mr Vanderpoll realised must have been deaf in one ear.

“Sometimes you’re talking to someone and they completely ignore you because they’re facing the wrong way,” he says.


Photo: 94 per cent of Indigenous inmates in the Northern Territory have significant hearing loss. (ABC RN: Jake Duczynski)

Aboriginal men in NT prisons regularly use hand gestures — but Mr Vanderpoll and Dr Howard say that was no clear indication of hearing loss. Aboriginal spoken languages in the Northern Territory include signing, and many inmates speak English as a second or third language.

“The boys are always signing. Always, whether they can hear or not, they’re still signing,” Mr Miller says.

If Mr Vanderpoll and Dr Howard were shocked by the results, so too were the inmates. Most prisoners had no idea they had hearing problems before the study.

“They’d grown up with it. That had been their whole life,” Mr Vanderpoll says.

But whether they know they have it or not, hearing loss impacted their experiences in the justice system.

Mr Vanderpoll began having conversations with prisoners who admitted avoiding interacting with the parole board because of their hearing loss, giving up a chance for a reduced sentence.

“Anything that put them in a position where they had to talk to a stranger or be reviewed by a stranger was so shocking or so scary to them, that they’d rather stay in prison and complete their full time without any chance of parole,” he says.

“If you’ve got hearing issues, you don’t want to be put into that position.”

Interpreter shortage

While most hearing impaired and deaf Aboriginal inmates Mr Vanderpoll worked with didn’t ask for an interpreter in legal situations, the service might not have been available for them anyway.

There is only one professionally-qualified Auslan interpreter available for inmates across the entire Northern Territory, meaning that many deaf people miss out.

The interpreter, Liz Temple, readily admits that she does not have fluency in the local Aboriginal sign languages that most prisoners with hearing loss use.

She often relies on Aboriginal consultants, such as Jody Barney, a deaf Indigenous woman who often works in the region and has knowledge of multiple Aboriginal sign languages. However, funding for such services is limited.

Instead, corrections officers often play quasi-interpreters for inmates, says Mr Vanderpoll.

“You’d listen to the magistrate and you’d just lean over to the prisoner and just tell him what’s happening as it’s happening in real time. I think the reason that works is because they’re more comfortable.”

Their findings led Robert Miller to wonder whether hearing loss plays a role not only in Aboriginal people’s experience of prison, but also contributes to them ending up there in the first place.

“You can understand why Indigenous incarceration is so high. I’m not saying it’s the only reason, but I think it had quite an impact,” he says.

Eighty four per cent of adults and 96 per cent of juveniles detained in the Northern Territory are Indigenous, though they only make up 25 per cent of the population.

In his research, Howard found that hearing-impaired Aboriginal people are more likely to be arrested and charged with crimes because they cannot explain themselves to police or give adequate instructions to their solicitor, are less likely to be viewed as a credible witnesses in court, and tend to have misunderstandings with corrections staff.

Signs of change

Once the report was released, Mr Vanderpoll and Dr Howard were hopeful things would begin to change.

Mr Miller cobbled together funding for eight hearing aids, as he recalls — at a cost of less than $2,000.

“It wasn’t huge, but when you’re spending government money it’s got to be justified,” he says.

He had hoped that the small pilot program would eventually be funded by the government.

“There was no money in the Darwin Correctional Centre budget for hearing assistance,” he says.

Before the Darwin trial, in his eight years in NT prisons, Mr Vanderpoll says he saw only two people wearing hearing aids.

He recalls watching inmates putting on the new devices, realising what they had been missing.

“They could understand what they were supposed to be hearing in the first place,” he says.

Mr Vanderpoll hoped to implement a comprehensive training program for guards, who he says often had good relationships with inmates.

“I don’t think you can highlight that enough, that when they’re in prison, the officers aren’t their enemies.”

Still, there were correctional officers who got it, and those who didn’t, the ones who are “coming in yelling and screaming”.

The officers with the best rapport with the prisoners, Mr Vanderpoll observed, were those who made an effort to communicate.

“There’s a lot of knowledge. Some have 30 years of dealing with Indigenous inmates and they have developed a really good set of listening skills and speaking skills. We were trying to map that out so we could disseminate that in some form of training.”

Hope and disappointment

Their 2011 report made a number of recommendations that they believed could improve the way the justice system caters for hearing-impaired Aboriginal people — including routine testing of new inmates’ hearing, better access to hearing aids, and improved training for police, the judiciary and correctional staff.

Mr Vanderpoll’s biggest hope was to see records of inmates’ hearing levels shared between police and the courts.

“So that when [police] deal with someone, they bring that person up and say, ‘All right, he’s deaf in the left ear,’ and they can be aware of that when they’re dealing with them,” he says.

Mr Vanderpoll left the NT Department of Correctional Services in 2013, and now works for the state’s Department of Trade, Business and Innovation, while Mr Miller has retired.

To Dr Howard’s knowledge, none of the 2011 report’s recommendations have been implemented.

The NT Department of Corrections never contacted him about the report.

The Department of the Attorney General and Justice said that as part of an initial training program, correctional officers learned to deal with prisoners with impairments, including hearing loss.

Mr Vanderpoll’s idea of record sharing went nowhere. “That’s the most disappointing part,” he says.

Hearing loss remains ‘the smoking gun’

In the aftermath of the abuse of Aboriginal teenagers by guards at Don Dale Youth Detention Centre in 2016, Dr Howard told the royal commission that hearing loss amongst Aboriginal adults and young people continues to be the “smoking gun” contributing to very high rates of detention — and communication problems with police and guards.

“With rare exceptions, governments and corrections agencies in all jurisdictions, as well as the criminal justice research organisations, have displayed a perplexing disinterest in this important issue,” Dr Howard says.

“A common response of government and Corrections is to classify Aboriginal hearing loss only as a “health problem”.

When asked if audiological testing was now conducted for adult prisoners entering the correctional system, the NT Department of the Attorney General and Justice referred the ABC to the Department of Health.

The Department of Health says adult prisoners are asked if they have hearing issues when they enter prison. Yet as Mr Vanderpoll and Dr Howard’s research found, many inmates are unaware of their hearing loss.

The NT Department of Corrections provides prisoners with a hearing aid if they have a referral from a medical practitioner.

Juvenile detainees in Darwin and Alice Springs are now given a hearing screening test undertaken by a nurse. The service began this year.

Mr Miller says people in the Department of Corrections “try really hard” to deliver services under increasingly strained resources.

“The government’s on you every year to be tight … people are not interested in prisoners at all,” Mr Vanderpoll says.

“I think that a lot of the problems that we face today, like Don Dale, was because the money’s been stripped from Corrections, over and over again, and people don’t want to hear about it.

“The prison is always run well because of communication. When it doesn’t run well, when there’s riots and stuff like that, it’s because of a lack of communication.

“You can have all of the foundation skills-type training in the world. You can have mathematics, English, et cetera. You can send people to alcohol rehabilitation courses.

“You can do all these things with people, but if they can’t even hear what you’re saying, how is it going to make a difference?”

Ear trouble training for teachers

NACCHO Aboriginal Children’s Health #NDW2017 : Indigenous child health improves when fruit and veg are cheap: study

“There were definitely positive short-term health outcomes and, from our perspective, we observed children’s health was better on this program, as they were sick less often and required less antibiotics,”

Lead author of the study, Dr Andrew Black, from the University of South Australia’s School of Population Health.

“There is compelling evidence that improved diet is associated with improved health outcomes, however evidence on how best to encourage healthier diets at a population level is limited,”

Julie Brimblecombe, Senior Research Fellow at Menzies School of Health Research said that the study ( Julie was not involved ) was unique in that it was initiated and driven by an Aboriginal controlled health service. However, she said more needs to be done to assess the feasibility of this scheme being implemented on a large scale.

Originally published in The Conversation

Providing subsidised fruit and vegetable scheme to low-income Indigenous families in northern New South Wales improves children’s health and significantly reduces antibiotic use, a new study has found.

The new findings, published in the Medical Journal of Australia, showed that eating fruit and vegetables improved the children’s levels of haemoglobin, reduced emergency department attendances and hospital visits for illness.

The researchers analysed data from health assessments, audits and blood testing of children aged 17 years and under from 55 families who attended three Aboriginal community-controlled health services and received a weekly box of subsidised fruits and vegetables.

The participants were assessed 12 months before the program and again 12 months later, between December 2008 and September 2010.

The results of this study showed that the children’s haemoglobin levels significantly increased and the level of prescriptions of oral antibiotics markedly decreased compared to the year previous to the program. However iron deficiency and anaemia did not change significantly.

“I think the nutritional impacts of eating more fruit and vegetables have broader health impacts in the long term but that’s definitely something we’re interested in, the sustainability of this approach.”

said the lead author of the study, Dr Andrew Black, from the University of South Australia’s School of Population Health.

Dr Black said that for all the families involved in the study, the cost of fresh produce is a barrier to consumption of adequate daily fruit and vegetables.

“For a proportion of these families, who are struggling generally with issues in their lives, providing subsidised food isn’t adequate by itself. There are a lot more challenges than making food cheaper for those families, but it’s an important step and helps a significant number of people,” he said.

Dr Black said that “families lined up to participate” in the program.

“They saw value in it and that enthusiasm is wonderful and it is potentially useful for health policy decision-makers to see the importance in this,” he said.

Filling foods

Professor Amanda Lee, an indigenous nutrition expert from the Queensland University of Technology said the study showed that “it’s clear we are losing the battle to improve nutrition in indigenous communities.”

“We need more innovative solutions and fiscal interventions, particularly subsidisation of healthy foods, show a lot of promise.”

Professor Lee said that objective measured data in remote communities showed that Aboriginal and Torres Strait Islander people may eat less than one serve a day of fruit or vegetables.

“People know what to do but they can’t access the fruit and vegetables, they cant afford them or they are not available,” said Professor Lee, who was not involved in the study.

“Fruit and vegetables are quite expensive in rural and regional communities, about 30% more. When people are hungry and they don’t have enough food, you buy food that will fill you up and fruit and vegetables don’t always do that. People are buying take-away, deep fried foods and bread to fill them up because they are hungry.”

Julie Brimblecombe, Senior Research Fellow at Menzies School of Health Research said that the study was unique in that it was initiated and driven by an Aboriginal controlled health service.

However, she said more needs to be done to assess the feasibility of this scheme being implemented on a large scale.

“There is compelling evidence that improved diet is associated with improved health outcomes, however evidence on how best to encourage healthier diets at a population level is limited,” said Dr Brimblecombe, who was not involved in the study.

“Evidence is also needed on the cost effectiveness of such interventions to inform policy and to make sure at a population level we are getting the best value and outcomes for money invested.”

Aboriginal Eye Health #NDW2017 : Fact check: Has trachoma among Indigenous kids fallen from 20pc to 4pc ?

” On the final day of the Uluru convention on a referendum for Indigenous constitutional recognition, former prime minister Kevin Rudd spoke to the ABC about Indigenous disadvantage since his National Apology to the Stolen Generations in 2008.

Mr Rudd told Radio National on May 26: “One of the programs that we established back then was to eliminate trachoma amongst Indigenous young people. Twenty thousand kids were suffering from trachoma back then at about a 20, 25 per cent rate. We’re now down to about four per cent.”

Is Mr Rudd correct about the incidence and decline of trachoma among Indigenous young people? RMIT ABC Fact Check investigates

Originally Published HERE

NACCHO Declaration

Read over 40 NACCHO Eye Health articles we have published over 5 years

 ” The Roadmap to Close the Gap for Vision has played a part in prompting actions that contribute to this improvement. The Roadmap outlines a whole of system approach to improving Indigenous eye health, and achieving equity between Aboriginal and non-Aboriginal eye health outcomes.

There is however still work to be done on Closing the Gap for Vision. For example, half of Indigenous participants with diabetes had not had the recommended retinal examination.

NACCHO has been involved with the Roadmap from its inception, and had a long relationship with Indigenous Eye Health at the University of Melbourne, and with RANZCO. We’re pleased with the great work and good progress being made.”

 Ms Patricia Turner, Chief Executive Officer, of the National Aboriginal Community Controlled Health Organisation (NACCHO) launching  The 2016 Annual Update on the Implementation of the Roadmap to Close the Gap for Vision November 2016


The verdict

Mr Rudd’s claim is overstated.

In saying that 20,000 kids were suffering from trachoma, Mr Rudd appears to have used data for the number of children living in communities judged to be at risk of having endemic trachoma. The number of children estimated to have trachoma in 2009 was about 3,000.

His rate of 20 to 25 per cent “back then” is supported by a prevalence figure of 21 per cent contained in a 2008 report. However, the rates for 2007 and 2009 were each 14 per cent, and the report for 2009 cautions about the reliability of the 2008 data.

Rates of trachoma among Indigenous children in at-risk communities have declined steadily since 2009. The claim that rates have fallen to about four per cent is supported by recent reliable data.

What is trachoma?

Trachoma is a contagious infection of the eye that, with repeated long-term infections, can result in the eyelashes turning inwards and scratching the cornea, leading to blindness.

Trachoma affects children and preschool-aged children in particular. It is commonly spread through nose and eye secretions, occurs in areas with poor community and personal hygiene, and is associated with overcrowding and reduced access to water.

Australia is the only developed country where trachoma is still endemic, and it occurs primarily in remote Aboriginal communities in Central Australia.

What program did the Rudd government establish?

Professor Hugh Taylor is the Harold Mitchell Professor of Indigenous Eye Health at Melbourne University and when Mr Rudd announced the policy in 2009 he was head of the National Trachoma Surveillance and Reporting Unit, which receives funding from the Federal Department of Health.

Professor Taylor told Fact Check that “after years of either inaction or ineffective action, in 2009 Kevin Rudd committed to eliminate trachoma in Australia by the year 2020”.

Australia adopted a trachoma eradication strategy in line with the World Health Organisation’s 1998 global strategy and based on its SAFE guidelines. SAFE stands for [S]urgery to repair inward eye lashes, [A]ntibiotics, promotion of [F]acial cleanliness, and [E]nvironmental improvements in hygiene and water access.

Mr Rudd’s office told Fact Check the policy he was referring to was a $58 million commitment made in February 2009 to “help tackle eye and ear diseases in Indigenous communities”, with a major focus on trachoma eradication.

The funding was to be allocated over four years, and according to a press release at the time, included “a major increase in services to address trachoma, which will enable at least 10 regional teams to treat and help prevent the disease in NT, WA, SA and other states where trachoma is identified”.

The 2009-10 federal budget papers spell out $58.4 million in funding over four years for “improving eye and ear health services for Indigenous Australians”.

According to the National Trachoma Surveillance and Reporting Unit, in 2009 the Government committed $16 million over four years towards eliminating trachoma in Australia, and in 2013 committed a further $16.5 million.

The source of the claim

When contacted by Fact Check, Mr Rudd’s spokeswoman said reports for 2008 and 2015 by the National Trachoma Surveillance and Reporting Unit were the source of his claim.

Fact Check was unable to find another consistent, national source of data on the prevalence of trachoma in Indigenous communities. Experts confirmed that there was not any other reliable source.

In the unit’s data collection process, communities are classified as being at risk or not at risk of trachoma and screening of the disease focuses on the at-risk communities.

Screening is administered by local health officials who report the data back to the surveillance and reporting unit for collation and analysis.

Coverage of trachoma screening of at-risk communities has increased over time, due to the increasing level of resourcing of the trachoma eradication program.

20,000 kids with trachoma?

Mr Rudd’s February 2009 media release contains the sentence: “Approximately 20,000 Indigenous children suffer from trachoma in Australia.”

Mr Rudd’s office told Fact Check that “in 2009, it would appear the material provided by the Health Department to the Government referred to 20,000 kids suffering from trachoma”.

His spokeswoman pointed to a May 2009 media release from the then Indigenous affairs minister Jenny Macklin which contained the same sentence and a July 2009 speech by the then parliamentary secretary for social inclusion Ursula Stephens who said: “Trachoma affects approximately 20,000 Indigenous children — a stunning statistic and one that is confronting to government.”

However, a spokeswoman for the Department of Health told Fact Check that “the number of children screened and found to have active trachoma was 997 in 2008 and 575 in 2009”, and “we can confirm that the figure of 20,000 children relates to the number of children resident in potentially at-risk communities (population data), not those screened and found to have trachoma”.

The National Trachoma Surveillance and Reporting Unit’s report for 2009 says there were “20,155 children aged one to nine years resident in the 232 at-risk communities”.

Of these children, 4,116, or 20 per cent, were screened and 575 children had trachoma.

“If those 4,116 children screened were a representative sample of all 20,155 children resident in all at-risk communities, the additional number of children estimated to have trachoma across the three jurisdictions lies between 2,045 and 2,448,” the report said.

It appears that all three ministers were referring to statistics available at the time about the number of children at risk of contracting trachoma, not the number who were suffering from trachoma.

Professor Taylor told Fact Check that “the estimate in 2008 was that there were 20,000 kids in remote communities considered to be at risk of trachoma”.

“This is a rubbery figure because not all the communities had been examined,” he added.

The prevalence of trachoma in 2008

The executive summary of the National Trachoma Surveillance and Reporting Unit’s 2008 report says that “the prevalence of active trachoma in those communities from which data were reported was 21 per cent”.

Of 287 remote Aboriginal communities, 235 were identified as at risk of trachoma in 2008, and 121 were screened and reported data.

The 2008 report focused on the prevalence of trachoma in Indigenous children aged one to nine years old.

Fact Check notes that both the 2007 and 2009 reports show the trachoma prevalence in Aboriginal children aged one to nine years old in communities that reported data in those years to be 14 per cent.

The discussion section of the 2009 report says that “in 2008, there was an abrupt two-fold increase in trachoma prevalence in NT, and an equally abrupt seven-fold decrease in trachoma prevalence in SA, compared with past years. Both of these sudden changes were reversed in 2009”.

The report says the variation in the numbers “suggests that the data from 2008 might be problematic”.

Professor Taylor told Fact Check that “there is an inconsistency in the data and it’s appropriate to acknowledge it, but those are the data that we have, and those are the data that we must use”.

Carleigh Cowling, senior surveillance officer with the National Trachoma Surveillance and Reporting Unit, said the Northern Territory intervention had an impact on the collection of the data in 2008.

“During the intervention, the trachoma screening program was taken over by unusual bodies, whose training was questionable,” she said, adding that “data collected by those teams were not presented in the 2008 report, which does make the data presented problematic”.

The prevalence of trachoma today

The most recent report from the National Trachoma Surveillance and Reporting Unit, published in June 2016 and containing data for 2015, shows that 139 communities were identified as being at risk of trachoma, a decrease of 96 communities since 2008.

Of these 139 communities, 67 were screened and reported data.

The 2015 report focused on children aged five to nine, though reports prior to 2010 focused on children aged one to nine. “It’s an assumption that one to four-year-olds are similar,” Professor John Kaldor, the current head of the National Trachoma Surveillance and Reporting unit, now part of the Kirby Institute at the University of New South Wales, said.

Professor Taylor and Ms Cowling both told Fact Check that though the 2008 report focuses on children aged one to nine and the 2015 report on children aged five to nine, this will have little impact on the comparability of the data from those years.

The results, for children aged five to nine as against one to nine reported in 2008, reveal that the prevalence of trachoma in the communities that screened was 3.7 per cent. The prevalence “using the most recent data carried forward in all at-risk communities” was 4.6 per cent.

The 3.7 per cent is for at-risk communities that screened in 2015, and the 4.6 per cent is for all at-risk communities, meaning those that screened and those that didn’t screen that year but are considered at risk based on previous data.

Professor Kaldor said policy guidelines changed in 2014 so that if a community had high rates of trachoma several years in a row, resources were shifted towards treatment rather than screening.

He and Professor Taylor both agreed that the current prevalence of trachoma among children in affected communities was about 4 per cent.

Professor Kaldor said of hotspots that still exist in Central Australia: “While the drug azithromycin is a big part of combating the disease, there’s the whole issue of fulfilling the other parts of the SAFE strategy to sustainably improve facilities and living conditions.”

“If these are not addressed, the impact of treatment may be short-lived.”

Professor Taylor told Fact Check that “since 2008 we’ve made considerable progress”.

“If you look at closing the gap, it’s actually one area where you can say we’ve made considerable progress,” he said.


NACCHO Aboriginal Diabetes Health #NDW2017 : Targeting sugary drinks in remote Indigenous communities

Part of our healthy food strategy is looking at reducing sugary drinks because consumption of sugary drinks across the whole population, but particularly in remote communities, is very high and high intake of sugary drinks has been linked to obesity, diabetes, heart disease, poor oral health and kidney disease.”

Outback Stores health and nutrition manager, Jen Savenake ( Interview Health Times )

Amata SA was an alcohol-free community, but some years earlier its population of just under 400 people had been consuming 40,000 litres of soft drink annually.

The thing that I say in community meetings all the time is that, the reason we’re doing this is so that the young children now do not end up going down the same track of diabetes, kidney failure, dialysis machines and early death, which is the track that many, many people out here are on now,”

Mai Wiru, meaning good health, and managed by long-time community consultant John Tregenza.

The Sugar Trip on Australian Story  View HERE

All previous NACCHO Diabetes 120 + articles over 5 years

Noting all graphics added by NACCHO

A nutrition strategy to reduce the portion size and availability of soft drink has reduced the consumption of sugary drinks in a remote Indigenous community.

Outback Stores, which provides retail services to more than 30 remote stores on behalf of Indigenous communities across the Northern Territory, Western Australia and South Australia, found its strategy decreased the sale of soft drinks by 10 per cent in six months.

Outback Stores health and nutrition manager, Jen Savenake, an Advanced Accredited Practising Dietitian, says the store joined forces with one local community to trial the implementation of extra measures on top of its usual healthy food strategy.

Ms Savenake says the usual policy features measures such as stocking at least half of its fridges with water and diet drinks, with the remainder comprising sugary drinks.

“Our standard policy around sugary drinks includes things like – we always have the water fridges at the front of the store, where you have to go searching for the sugary drink at the back of the store,” she says.

“We have a special deal on water so that we get Mt Franklin water at $1 and the sugary drinks are 25 per cent more expensive than the diet drinks, and the diet drinks are more expensive than the water.

“We don’t promote sugary drinks ever, so we’ll do promotions on water and diet drinks but never promoting the sugary drinks, so you never see them on the end of the aisle and on discount.”

Download these Info graphics as PDF poster


Despite the existing measures, Ms Savenake says sugary drinks remain a “really big problem”.

“Part of our healthy food strategy is looking at reducing sugary drinks because consumption of sugary drinks across the whole population, but particularly in remote communities, is very high and high intake of sugary drinks has been linked to obesity, diabetes, heart disease, poor oral health and kidney disease.”

As part of the trial, the store stopped selling sugary drinks on school days between 8.30am and 2pm, and also reduced the soft drink portion size.

“We never stock bottles more than 1.25 litres so we haven’t got any 2 or 2.5 litre bottles but what we looked at was reducing the size of the bottle,” she says.

“So now we stock the biggest selling line in our 1 litre bottle rather than 1.25 (litre) so you get a 25 per cent reduction immediately for all of those.

“We also changed from stocking a 375ml can to a 250ml can and from a 600ml bottle to a 390ml bottle.”

Ms Savenake, who presented the preliminary results of the trial at the recent Dietitians Association of Australia’s (DAA) 34th National Conference, says the remote Indigenous community is now experiencing “some big changes” in the amount of sugary drinks being consumed.

Burunga NT in store promotion

“We still actually need some more time to see what the total results are going to be, but we’re getting at least a 10 per cent reduction in sugary drinks over the comparable period.”

Early indications also show an increase in sales of water, dietary drinks, fruit juices and milk drinks.

While different strategies may be needed in different communities, particularly communities with easy access to other stores, Ms Savenake says dietitians working at the food supply level can have an impact on consumption but they also need to work with all their stakeholders to ensure there is community support for these strategies.

“To do this project in the community, we had the support of the whole community…this is not Outback Stores imposing these conditions on the community, this is the community saying – what can we do to improve the health of our people,” she says.

“So we worked with them to develop that and that’s probably one of the most important things that we got out of it, that yes – we can implement the strategies at the food supply level but we need to make sure that people are on board.

“There is actually a case study where one community banned sugary drinks and what happened was they just set up a huge black market, so people would bring boot loads of the stuff and sell it for $10 a can out of the back of the car, and so it didn’t achieve the desired outcomes because people were just spending a whole lot of money on sugary drinks on their alternative supply route.”

Ms Savenake says Outback Stores will continue to examine the strategies in the community and may expand some of the measures, including smaller portion sizes, to more stores in a bid to assist communities to improve their health.

“I’ve been doing this for 20 years but there’s almost like a tipping point where suddenly there’s a broader community awareness that we all need to get involved in doing something to improve our health and working towards healthier food,” she said.

“We’re still providing choice – you can still get it. It might be just a little bit harder to get, the shop is not open all the time so it’s still your choice around what you want to consume but we’re just providing a few incentives to mean that it’s a little bit more expensive, it’s a little bit less available, but if you really want it, it’s still there.”

Aboriginal Health #NAIDOC2017 : New Aboriginal-led collaboration has world-class focus on boosting remote Aboriginal health

“One of the clear innovations that our Centre already offers is acknowledging that the principle of Aboriginal community control is fundamental to research, university and health care partnerships with regional and remote Aboriginal communities,”

Ms Donna Ah Chee Congress CEO said it was satisfying to achieve recognition for the strong health leadership and collaboration that already exists in Central Australia ( see editorial Part 3 below)

  ” The centre’s accreditation this week with the National Health and Medical Research Council proved the “landmark research” by consortium members had “huge potential” to address serious indigenous health issues.

The objective is to evaluate problems and find practical solutions fast, to prevent health problems and give speedy but lasting benefits to patients within community,”

Announcing $222,000 in seed funding, Federal Indigenous Health Minister Ken Wyatt see full story PART 2 from the Australian below

Photo above : Traditional Arrernte owners welcome Ken Wyatt MP to Alice Springs to launch the Central Australia Academic Health Science Centre

An academic health science centre in Central Australia is the first Aboriginal-led collaboration to achieve Federal Government recognition for leadership in health research and delivery of evidence-based health care.

The Federal Minister for Indigenous Health and Aged Care, the Hon Ken Wyatt MP, today announced that the Central Australia Academic Health Science Centre (CAAHSC) was one of only two consortia nationally to be recognised as a Centre for Innovation in Regional Health (CIRH) by Australia’s peak funding body for medical research, the National Health and Medical Research Council (NHMRC).

To be successful in their bid, the 11-member consortium was required to demonstrate competitiveness at the highest international levels across all relevant areas of health research and translation of research findings into health care practice.

With NHMRC recognition, the CAAHSC joins an elite group of Australian academic health science centres that have so far all been based in metropolitan areas including Melbourne,

Sydney and Adelaide. The CAAHSC is also in good company internationally, with long established collaborations including Imperial College Healthcare in the UK and Johns Hopkins Medicine in the USA.

The CAAHSC, whose membership includes Aboriginal community controlled and government-run health services, universities and medical research institutes, was formally established in 2014 to improve collaboration across the sectors in support of health.

Such synergy is vital in order to make an impact in remote central Australia, considering the vast geographical area (over 1 million square kilometres) and the health challenges experienced particularly by Aboriginal residents.

The CAAHSC consortium reflects the importance of Aboriginal leadership in successful research and health improvement in Central Australia.

The Chairperson of CAAHSC is Mr John Paterson, CEO of the Aboriginal Medical Services Alliance Northern Territory, the peak body for the Aboriginal community controlled health services sector in the NT.

With the leadership of CEO Ms Donna Ah Chee, Central Australian Aboriginal Congress was the lead partner on the group’s bid to become a CIRH.

The CAAHSC is a community driven partnership, where Aboriginal people themselves have taken the lead in identifying and defining viable solutions for the health inequities experienced in the Central Australia region.

The CAAHSC partners have a long and successful track record of working together on innovative, evidence-based projects to improve health care policy and practice in the region.

Such projects include a study that examined high rates of self-discharge by Aboriginal patients at the Alice Springs Hospital, which in many cases can lead to poor health outcomes.

This research was used to develop a tool to assess self-discharge risk which is now routinely used in care, and to expand the role of Aboriginal Liaison Officers within the hospital.

Another collaborative project designed to address the rising rates of diabetes in pregnant women involves the establishment of a patient register and birth cohort in the

Northern Territory to improve antenatal care in the Aboriginal population.

CAAHSC Chair, Mr John Paterson agrees, saying the CIRH would serve as a model for other regional and remote areas both nationally and internationally, particularly in its governance, capacity building, and culturally appropriate approaches to translational research.

Mr Paterson said he hoped NHMRC recognition would attract greater numbers of highly skilled researchers and health professionals to work in Central Australia, and that local Aboriginal people would become more engaged in medical education, research and health care delivery.

He also hopes that achieving status as a CIRH will be instrumental in attracting further resources to the region, including government, corporate and philanthropic support.

Mr Paterson said the consortium is now focussed on building a plan across its five priority areas: workforce and capacity building; policy research and evaluation; health services research; health determinants and risk factors; and chronic and communicable disease.

This will include development of research support ‘apprenticeships’ for Aboriginal people and pursuit of long-term financial sustainability.

The partners of the Central Australia Academic Health Science Centre include: Aboriginal Medical Services Alliance Northern Territory (AMSANT); Baker Heart and Diabetes Institute; Charles Darwin University; Centre for Remote Health (A joint centre of Flinders University and Charles Darwin University); Central Australian Aboriginal Congress; Menzies School of Health Research; Central Australia Health Service (Northern Territory Health); CRANAplus; Flinders University; Ngaanyatjarra Health Service and the Poche Centre for Indigenous Health and Wellbeing.

1.Chronic Conditions

Chronic diseases are the most important contributor to the life expectancy gap between Indigenous and non-Indigenous Australians. Given their impact on premature mortality, disability and health care utilisation in Central Australia it is unsurprising that chronic disease has become the primary focus for addressing Indigenous Australian health disadvantage.

The Central Australia AHSC has considerable research and translation expertise with those chronic conditions that most impact the Aboriginal Australian population, including diabetes, heart disease, renal disease and depression.

Some of our focus areas are: understanding the developmental origins of adult chronic disease through targeted multi-disciplinary research focused on in-utero, maternal and early life determinants; understanding and preventing the early onset and rapid progression of heart, lung and kidney disease and diabetes within Aboriginal people, and developing and supporting capacity development of the chronic disease workforce within Aboriginal communities and health services.

2.Health Determinants and Risk Factors

In order to support the health of Central Australians, we recognise the importance of transcending boundaries between the biological, social and clinical sciences. The Central Australia AHSC takes an interdisciplinary approach to understanding social gradients, their determinants, and pathways by which these determinants contribute to illness, and consequently to forwarding policy responses to reduce health inequalities.

The Central Australia AHSC is interested in exploring the role of stress, intergenerational trauma and other psychosocial factors, as well as uncovering the biological pathways by which social factors impact on cardiometabolic risk, mental illness and other conditions of relevance to Indigenous communities.

3.Health Services Research

As a regional hub servicing a high proportion of Aboriginal people spread across an extensive area, Central Australia serves as an exemplar environment through which to address critical issues of national importance – for instance, targeted and practical research focused on the National Health and Hospital Reform agenda, the ‘Close the Gap’ reforms and the Indigenous Advancement Strategy.

Through health services research, the Central Australia AHSC is chiefly interested in developing and equipping primary care and hospital services with the skills, methods and tools by which to improve health care quality, appropriateness and accessibility.

Towards this goal, we are involved in developing, trialling, evaluating and establishing the cost-effectiveness of novel health system approaches to the identification, management and prevention of acute care, chronic disease and mental illness

4.Policy Research and Evaluation

The Central Australia AHSC brings together the expertise of leading clinician researchers, public health specialists and health service decision makers.

The Central Australia AHSC provides the capacity to evaluate the systems that underpin change management in health care through policy, protocol and evaluation research, and to support quality improvement processes through health provider training.

While being locally relevant, our works also informs jurisdictional and national health policy and practice in Aboriginal and remote health and implementation of national health reforms.

5.Workforce and Capacity Building

Central Australia’s health care workforce encompasses health care providers in hospitals, remote Aboriginal communities, and outreach services, including Aboriginal health practitioners, nurses, allied health providers, general practitioners and specialists.

Remoteness and the challenging work environment often translate to high levels of health provider staff turnover.

The Central Australia AHSC’s ongoing focus on professional development and capacity building facilitates health work force sustainability by providing relevant training and support and by attracting new health care providers who are also involved in research.

Workforce and capacity building undertaken by the AHSC partners includes the delivery of education programs (including tailored remote and Indigenous health postgraduate awards for doctors, nurses and allied health practitioners), growing research capacity (supervised formal academic qualifications and informal mentoring), and conducting research to inform workforce recruitment and retention.

Part 2 World-class focus on boosting remote health

Alice Springs mother Nellie Impu is part of a grim health statistic profoundly out of place in a first-world nation: one in five pregnant Aboriginal women in the Northern Territory has diabetes.

Photo : Nellie Impu, left, with Wayne, Wayne Jr and nurse Paula Van Dokkum in Alice Springs. Picture: Chloe Erlich

From the Australian July 5

For pre-existing type 2 diabetes, that’s at a rate 10 times higher than for non-indigenous women; more common gestational diabetes is 1.5 times the rate.

Mrs Impu became part of that statistic almost five years ago when she was pregnant with son Wayne. So the announcement of a new central Australian academic health science centre, led by the Aboriginal community-controlled health service sector and bringing together a consortium of 11 clinical and research groups, is a big deal for her and many women like her.

The diabetes treatment she underwent while carrying Wayne will continue for more than a decade as part of a longitudinal study.

“We know there is a link ­between mums with diabetes in pregnancy and outcomes for their babies as they grow, including ­future possibilities of type 2 diabetes, which work like this can help us track,” said research nurse Paula Van Dokkum, who works with consortium member Baker IDI Heart and Diabetes Institute.

Wayne is meeting all his childhood development targets, and his mother said the ongoing association with the centre would help her in “trying to make sure he grows up healthy and strong”.

Announcing $222,000 in seed funding, federal Indigenous Health Minister Ken Wyatt said the centre’s accreditation this week with the National Health and Medical Research Council proved the “landmark research” by consortium members had “huge potential” to address serious indigenous health issues.

“The objective is to evaluate problems and find practical solutions fast, to prevent health problems and give speedy but lasting benefits to patients within community,” Mr Wyatt said.

The academic health science centre model, well ­established internationally, brings together health services, universities and medical research institutes to better produce evidence-based care.

The Alice Springs-based enterprise will aim to tackle a ­cancer-causing virus endemic in indigenous central Australia, its only significant instance outside South America and central Africa.

The human T-lymphotropic virus type 1 causes a slow death over 20 years with leukaemia, chronic cough, respiratory problems and respiratory failure. It can be acquired through breast milk in early childhood as well as through blood or sexual contact.

A recent study found HTLV-1 infection rates in a central Australian indigenous community of more than 40 per cent. One result, the inflammatory disease bronch­iectasis, is a leading cause of death for young adults at the Alice Springs hospital.

The program will also address the soaring demand for dialysis in remote communities, with indigenous Australians five times as likely to have end-stage kidney disease than other Australians.

Alice Springs hospital is home to the largest single-standing ­dialysis service in the southern hemisphere, with 360 patients.

Part 3 Alice Springs: the Red Centre of medical innovation

London, Boston, Toronto, Melbourne … and Alice Springs.

Although there may be little in common between these major cities and the heart of Australia’s outback, an announcement this week brings the Red Centre into the company of international players in translational health research, including prestigious institutions such as Imperial College Healthcare in Britain and Johns Hopkins Medicine in the US.

This week, the Central Australia Academic Health Science Centre was given the official seal of approval by the National Health and Medical Research Council.

The Central Australia consortium was one of only two centres recognised as a centre of innovation in regional health for its leadership in health research and delivery of evidence-based healthcare.

And now there’s opportunity in the Red Centre to do even more.

It may well be the most remote academic health science centre in the world, and perhaps the only academic health science centre in the world led by Aboriginal people. With such esteemed recognition for this remote, Aboriginal-led, evidence-based healthcare collaboration, it is hoped that public and private support will also follow.

As a model well established abroad and gaining momentum in Australia, academic health science centres are partnerships between health services, universities and medical research institutes whose collaborative work ensures that translational health research leads to evidence-based care and better health outcomes for patients.

For the 11 partners behind the Central Australia partnership, recognition as a centre for innovation in regional health acknowledges the outstanding collaboration that has existed in this region for several years, and particularly the leadership offered by the Aboriginal sector.

Working with the other partners in the consortium, Aboriginal community-controlled health services are taking the lead in identifying and defining viable solutions for the health inequities experienced in the region.

The work of the Central Australia partners is practical and responsive.

Interested in resolving what had become a troubling issue at Alice Springs Hospital, a resident physician researcher initiated a study that found nearly half of all admitted Aboriginal patients had self-discharged from the hospital in the past, with physician, hospital and patient factors contributing to this practice.

The research findings were used to develop a self-discharge risk assessment tool that is now routinely used in hospital care, and to expand the role of Aboriginal liaison officers within the hospital.

Considering the vast and remote geographical area — more than one million square kilometres — and the health challenges experienced particularly by Aboriginal residents who make up about 45 per cent of the region’s population of about 55,000 people, the Central Australia consortium faces unique and significant challenges. In this respect, Alice Springs may be more like Iqaluit in the Canadian Arctic than London or Baltimore.

But in other ways this relatively small academic health science centre may be at an advantage.

With its closely knit network of healthcare providers, medical researchers, medical education providers and public health experts working together, community-driven approaches to identifying issues and developing evidence-based solutions have become a standard approach in Central Australia.

In this setting of high need and limited resources, working collectively is sensible, practical and necessary.

Importantly, there is the possibility to do a lot more.

The consortium hopes such recognition will help to attract top healthcare providers and researchers, to increase educational offerings and to develop local talent, especially Aboriginal people.

The evidence is resounding. A research oasis in the desert, this centre for innovation is fertile ground for investment by government, corporations and philanthropists alike.

Donna Ah Chee is chief executive of the Central Australian Aboriginal Congress. John Paterson is chief executive of the Aboriginal Medical Services Alliance Northern Territory.

NACCHO Aboriginal Health #SocialDeterminants : #Indigenous education represented a “potent, practical and achievable road to change life expectancy by 12 years

 “Improvements in educational attainment could boost Indigenous life expectancy by as much as 12 years.

While clinicians focus on medical advances to benefit health care, real improvement in Indigenous health will come through attention to factors such as education, gender, power, racism and employment conditions,

These daily living factors constitute the social determinants of health, which are responsible for major health inequalities between population groups.”

 Researchers say Writing in the MJA

Read over 80 NACCHO articles over 5 years about Social Determinants

Dr Michael B Hart of the Social Determinants of Health Alliance, and co-authors, said that education represented a “potent, practical and achievable road to change” that had been overlooked as a force for health improvement.

They pointed to an analysis of evidence that contrasted a difference in life expectancy of 10–12 years between people with less than a high school education and people with an advanced degree, compared with a life expectancy difference of 6 months between people with elevated low-density lipoprotein cholesterol levels versus normal cholesterol levels.

While the MJA authors noted that a causal link between education and health had yet to be found, they said that the estimation that life expectancy could be increased by up to 12 years by improving educational attainment was “too compelling to ignore”.

Professor Steven Larkin, Pro Vice-Chancellor of Indigenous Education and Research at the University of Newcastle, said that the article presented a sophisticated analysis of the problem, but that the lack of evidence regarding causation made it difficult to draw firm conclusions.

“Consequently, we may well ask: does improving education lead to improved health outcomes? Or is it because of your improved health outcomes that you achieve better educational outcomes?” said Professor Larkin, who is also a former CEO of the National Aboriginal Community Controlled Health Organisation and a former adviser to the Australian Medical Association.

He said that it may also be that health and education were more likely to be a part of a broader range of macro socio-economic determinants that had an impact on the holistic quality of life and status of health.

The MJA article noted encouraging trends in education, with the proportion of Indigenous 20–24-olds who had achieved schooling to Grade 12 or equivalent increasing from 45.4% in 2008 to 61.5% in 2014–15.

However, they added, concerns remained, with 2013 Northern Territory data showing that less than half of Indigenous children had reached the Grade 3 minimum reading standard, compared with the national figure of about 90%.

In May of 2017, in acknowledgement of the 50th anniversary of the 1967 referendum, the federal government announced a raft of Indigenous education programs. The $138 million education package includes scholarships and mentoring programs for secondary students, a scholarship fund for students in STEM (science, technology, engineering and mathematics) degrees, as well as a program to raise the aspirations for tertiary studies.

Professor Larkin said that a key barrier to educational attainment was the lack of recognition of the depth of cultural difference.

“There is an underlying assumption of cultural homogeneity in operation here, and that’s one of the major issues for the lack of success and lower levels of Indigenous engagement and participation,” Professor Larkin told MJA InSight. “We basically have teachers who are trained in the Western educational paradigm. They are using Western curricula materials and pedagogy, and they are expecting people who are culturally different and for whom English is a second or third language to automatically be able to comprehend and study effectively under those imposed conditions.”

Professor Larkin said that seeking out more versatile, heterogenous curricula and teaching methods could help improve educational outcomes.

“We have had a pedagogy that has been designed around what constitutes best quality teaching, rather than how do people learn better. It’s a subtle but significant shift.”

He said that underperformance in measures such as NAPLAN (National Assessment Program – Literacy and Numeracy) showed a clear need for a rethink of the assumptions underpinning the delivery of education to Indigenous children.

“It’s not about dispensing with Western education, it’s just saying, can’t we do this in different ways to achieve better outcomes?”

Professor Larkin that said a lack of Indigenous leadership in both education and health was another factor that needed closer consideration.

He said that there was a need for more Indigenous Australians in the roles of employers, managers, decision makers and thought leaders.

“As much as we need non-Indigenous leadership on this, it has to be complemented by Indigenous leadership,” Professor Larkin said. “Non-Indigenous people may have the experience in the field, and they may have a developed understanding, but they are never going to be able to see the reality and understand that reality from an Indigenous point of view.”