Aboriginal #Health #Research debate : Controlled experiments won’t tell us which #Indigenous health programs are working

 ” For example, it is known anecdotally in Alice Springs that some Aboriginal Australians who could benefit from kidney dialysis treatment prefer, instead, to go back to their community to be on country.

While this can be detrimental to their physical health, it has important cultural significance for them.

The RCT approach in this situation would undoubtedly demonstrate the health benefits of kidney dialysis. But understanding this problem in the context of real lives requires different methodologies.

Unless we design research programs to consider why people would rather stay on country than receive effective health treatments, Aboriginal health may not improve.

From the Conversation August 2017

Picture above Some Aboriginal Australians who could benefit from kidney dialysis treatment prefer to go back to their community to be on country instead. WESTERN DESERT/AAP

Read over 40 NACCHO Research posts published over the past 5 years

Described as “one of the simplest, most powerful and revolutionary tools of research”, the randomised controlled trial (RCT) has yielded a great deal of important information in the health sciences. It is usually held up as the “gold standard” for gathering medical evidence.

The RCT can tell us which procedure or treatment is more effective under tightly controlled situations. This evidence is useful and important, but we also need to know things like what people want from health services, which treatments are preferred, and why some people stick to treatment regimes and some people don’t.

These issues are particularly relevant to remote Australia and Aboriginal and Torres Strait Islander health, where high levels of illness and early death persist, and where what applies to the tightly controlled conditions of a laboratory rarely translates.


Read more: Why are Aboriginal children still dying from rheumatic heart disease?


The government is rolling out its A$40 million plan to evaluate Indigenous health programs. The Evidence and Evaluation Framework aims to strengthen reporting, monitoring and evaluation for programs and services provided to Indigenous Australians.

As Indigenous Affairs Minister Nigel Scullion said last year:

When you don’t know anything about any of the programs, then you’re just relying on gut feelings, and that’s not good enough.

So, the framework will provide information about where government money is being spent, what works and why.

However, from a Western biomedical perspective, the randomised controlled trial is afforded an elevated position in establishing what works and why. While some recommend using RCTs to evaluate Indigenous programs, it is critical to keep in mind why this form of evidence-gathering is not always appropriate in this context.

Randomised controlled trials aren’t real life

In health and medical research, the RCT involves randomly assigning people to different groups and giving the groups different treatments. The random allocation to groups precludes there being systematic differences between participants at the start of the study.

At the end of the study, any differences between the groups can be attributed to the treatment and not some other factor. RCTs, therefore, are an elegant and efficient way of ruling out competing explanations for an observed effect.

However, research participants and scenarios in randomised controlled trials are often unlike the patients and settings to which the evidence will ultimately be applied. For example, RCTs have demonstrated that psychological treatments delivered through the internet can be effective for a wide range of disorders. But in real-world settings, adherence rates to internet treatments are very low, so the RCT result has little practical meaning.

The issue of which particular outcome should take priority can also be difficult to resolve through the RCT approach to research. Most RCTs prioritise the clinical perspective, such as a measurable change in a particular health outcome. However, there can be a mismatch between what doctors view as success and what patients and their loved ones perceive as a positive outcome following drug or other forms of treatment.

For example, it is known anecdotally in Alice Springs that some Aboriginal Australians who could benefit from kidney dialysis treatment prefer, instead, to go back to their community to be on country. While this can be detrimental to their physical health, it has important cultural significance for them.

The RCT approach in this situation would undoubtedly demonstrate the health benefits of kidney dialysis. But understanding this problem in the context of real lives requires different methodologies. Unless we design research programs to consider why people would rather stay on country than receive effective health treatments, Aboriginal health may not improve.

How best to gather evidence

Valuable work can be conducted by health professionals and service providers collecting data during their regular daily activities. The model of the “scientist-practitioner” often observed in clinical psychology could be applied to great effect in remote Australia.

This model promotes a seamless transition between science and practice in which the individual is both researcher and clinician. Scientist-practitioners adopt a critical stance to their clinical practice and routinely demonstrate, through evaluation, the value of the service they are providing.

Such a model was used in a GP practice in rural Scotland. Here, they found one simple change in how appointments were scheduled almost doubled the number of patients (in a six-month period) able to access a psychology service within a reasonable time after referral from their GP.

Rather than clinicians advising patients when to attend the next appointment, systems were organised so patients booked appointments in the same way they would to see a GP. The changes were quantified by clinician-researchers who collected these data in the course of their routine clinical practice.

After this change, patients were able to access the service within two weeks of being referred, rather than waiting for seven months as had been the case. Access to services is typically problematic in rural areas, so discovering a cost-effective means of improving access is an important outcome.

The results were so substantial and sudden that they were unequivocal. A large expensive RCT wasn’t necessary to demonstrate this simple change had made important improvements.


Read more: Aboriginal – Māori: how Indigenous health suffers on both sides of the ditch


This sort of approach could easily be applied in remote Australian settings. An RCT is not the only way, nor even the best way in all situations, to eliminate alternative reasons for the treatment outcomes obtained. Many important questions are ignored or refashioned inappropriately when only one methodology predominates.

Especially in the area of Indigenous health, the health and medical community must be guided by what patients want, not just by what health professionals know how to do.

Aboriginal Health and the @AusLawReform inquiry into the incarceration rate of Aboriginal peoples

 

” The Terms of Reference for this Inquiry ask the ALRC to consider laws and legal frameworks that contribute to the incarceration rate of Aboriginal and Torres Strait Islander peoples and inform decisions to hold or keep Aboriginal and Torres Strait Islander people in custody.

ALRC Home page

Download this 236 page discussion paper

discussion_paper_84_compressed_no_cover

Full Terms of reference part B below

The ALRC was asked to consider a number of factors that decision makers take into account when deciding on a criminal justice response, including community safety, the availability of alternatives to incarceration, the degree of discretion available, and incarceration as a deterrent and as a punishment

The Terms of Reference also direct the ALRC to consider laws that may contribute to the rate of Aboriginal and Torres Strait Islander peoples offending and the rate of incarceration of Aboriginal and Torres Strait Islander women.

Submissions close on 4 September 2017.

Make a submission

Part A Proposals and Questions

1. Structure of the Discussion Paper

1.40     The Discussion Paper is structured in parts. Following the introduction, Part 2 addresses criminal justice pathways. The ALRC has identified three key areas that influence incarceration rates: bail laws and processes, and remand; sentencing laws and legal frameworks including mandatory sentencing, short sentences and Gladue-style reports; and transition pathways from prison, parole and throughcare. These were the focus of stakeholder comments and observations in preliminary consultations.

1.41     Part 3 considers non-violent offending and alcohol regulation. It provides an overview of the detrimental effects of fine debt on Aboriginal and Torres Strait Islander peoples, including the likelihood of imprisonment in some jurisdictions. Fine debt can be tied to driver licence offending, and the ALRC asks how best to minimise licence suspension caused by fine default. Part 3 also looks at ways laws and legal frameworks can operate to decrease alcohol supply so as to minimise alcohol-related offending in Aboriginal and Torres Strait Islander communities.

1.42     Part 4 discusses the incarceration of Aboriginal and Torres Strait Islander women. It contextualises Aboriginal and Torres Strait Islander female offending within experiences of trauma, including isolation; family and sexual violence; and child removal. It outlines how proposals in other chapters may address the incarceration rates of Aboriginal and Torres Strait Islander women, and asks what more can be done.

1.43     Part 5 considers access to justice, and examines ways that state and territory governments and criminal justice systems can better engage with Aboriginal and Torres Strait Islander peoples to prevent offending and to provide better criminal justice responses when offending occurs. The ALRC places collaboration with Aboriginal and Torres Strait Islander organisations at the centre of proposals made in this Part, and suggests accountability measures for state and territory government justice agencies and police. The remoteness of communities, the availability of and access to legal assistance and Aboriginal and Torres Strait Islander interpreters are also discussed. Alternative approaches to crime prevention and criminal justice responses, such as those operating under the banner of ‘justice reinvestment’, are also canvassed.

2. Bail and the Remand Population

Proposal 2–1        The Bail Act 1977 (Vic) has a standalone provision that requires bail authorities to consider any ‘issues that arise due to the person’s Aboriginality’, including cultural background, ties to family and place, and cultural obligations. This consideration is in addition to any other requirements of the Bail Act.

Other state and territory bail legislation should adopt similar provisions.

As with all other bail considerations, the requirement to consider issues that arise due to the person’s Aboriginality would not supersede considerations of community safety.

Proposal 2–2        State and territory governments should work with peak Aboriginal and Torres Strait Islander organisations to identify service gaps and develop the infrastructure required to provide culturally appropriate bail support and diversion options where needed.

3. Sentencing and Aboriginality

Question 3–1        Noting the decision in Bugmy v The Queen [2013] HCA 38, should state and territory governments legislate to expressly require courts to consider the unique systemic and background factors affecting Aboriginal and Torres Strait Islander peoples when sentencing Aboriginal and Torres Strait Islander offenders?

If so, should this be done as a sentencing principle, a sentencing factor, or in some other way?

Question 3–2        Where not currently legislated, should state and territory governments provide for reparation or restoration as a sentencing principle? In what ways, if any, would this make the criminal justice system more responsive to Aboriginal and Torres Strait Islander offenders?

Question 3–3        Do courts sentencing Aboriginal and Torres Strait Islander offenders have sufficient information available about the offender’s background, including cultural and historical factors that relate to the offender and their community?

Question 3–4        In what ways might specialist sentencing reports assist in providing relevant information to the court that would otherwise be unlikely to be submitted?

Question 3–5        How could the preparation of these reports be facilitated? For example, who should prepare them, and how should they be funded?

4. Sentencing Options

Question 4–1        Noting the incarceration rates of Aboriginal and Torres Strait Islander people:

(a)     should Commonwealth, state and territory governments review provisions that impose mandatory or presumptive sentences; and

(b)     which provisions should be prioritised for review?

Question 4–2        Should short sentences of imprisonment be abolished as a sentencing option? Are there any unintended consequences that could result?

Question 4–3        If short sentences of imprisonment were to be abolished, what should be the threshold (eg, three months; six months)?

Question 4–4        Should there be any pre-conditions for such amendments, for example: that non-custodial alternatives to prison be uniformly available throughout states and territories, including in regional and remote areas?

Proposal 4–1        State and territory governments should work with peak Aboriginal and Torres Strait Islander organisations to ensure that community-based sentences are more readily available, particularly in regional and remote areas.

Question 4–5        Beyond increasing availability of existing community-based sentencing options, is legislative reform required to allow judicial officers greater flexibility to tailor sentences?

5. Prison Programs, Parole and Unsupervised Release

Proposal 5–1        Prison programs should be developed and made available to accused people held on remand and people serving short sentences.

Question 5–1        What are the best practice elements of programs that could respond to Aboriginal and Torres Strait Islander peoples held on remand or serving short sentences of imprisonment?

Proposal 5–2        There are few prison programs for female prisoners and these may not address the needs of Aboriginal and Torres Strait Islander female prisoners. State and territory corrective services should develop culturally appropriate programs that are readily available to Aboriginal and Torres Strait Islander female prisoners.

Question 5–2        What are the best practice elements of programs for Aboriginal and Torres Strait Islander female prisoners to address offending behaviour?

Proposal 5–3        A statutory regime of automatic court ordered parole should apply in all states and territories.

Question 5–3        A statutory regime of automatic court ordered parole applies in NSW, Queensland and SA. What are the best practice elements of such schemes?

Proposal 5–4        Parole revocation schemes should be amended to abolish requirements for the time spent on parole to be served again in prison if parole is revoked.

6. Fines and Driver Licences

Proposal 6–1        Fine default should not result in the imprisonment of the defaulter. State and territory governments should abolish provisions in fine enforcement statutes that provide for imprisonment in lieu of unpaid fines.

Question 6–1        Should lower level penalties be introduced, such as suspended infringement notices or written cautions?

Question 6–2        Should monetary penalties received under infringement notices be reduced or limited to a certain amount? If so, how?

Question 6–3        Should the number of infringement notices able to be issued in one transaction be limited?

Question 6–4        Should offensive language remain a criminal offence? If so, in what circumstances?

Question 6–5        Should offensive language provisions be removed from criminal infringement notice schemes, meaning that they must instead be dealt with by the court?

Question 6–6        Should state and territory governments provide alternative penalties to court ordered fines? This could include, for example, suspended fines, day fines, and/or work and development orders.

Proposal 6–2        Work and Development Orders were introduced in NSW in 2009. They enable a person who cannot pay fines due to hardship, illness, addiction, or homelessness to discharge their debt through:

  • work;
  • program attendance;
  • medical treatment;
  • counselling; or
  • education, including driving lessons.

State and territory governments should introduce work and development orders based on this model.

Question 6–7        Should fine default statutory regimes be amended to remove the enforcement measure of driver licence suspension?

Question 6–8        What mechanisms could be introduced to enable people reliant upon driver licences to be protected from suspension caused by fine default? For example, should:

(a)     recovery agencies be given discretion to skip the licence suspension step where the person in default is vulnerable, as in NSW; or

(b)     courts be given discretion regarding the disqualification, and disqualification period, of driver licences where a person was initially suspended due to fine default?

Question 6–9        Is there a need for regional driver permit schemes? If so, how should they operate?

Question 6–10      How could the delivery of driver licence programs to regional and remote Aboriginal and Torres Strait Islander communities be improved?

7. Justice Procedure Offences—Breach of Community-based Sentences

Proposal 7–1        To reduce breaches of community-based sentences by Aboriginal and Torres Strait Islander peoples, state and territory governments should engage with peak Aboriginal and Torres Strait Islander organisations to identify gaps and build the infrastructure required for culturally appropriate community-based sentencing options and support services.

8. Alcohol

Question 8–1        Noting the link between alcohol abuse and offending, how might state and territory governments facilitate Aboriginal and Torres Strait Islander communities, that wish to do so, to:

(a)     develop and implement local liquor accords with liquor retailers and other stakeholders that specifically seek to minimise harm to Aboriginal and Torres Strait Islander communities, for example through such things as minimum pricing, trading hours and range restriction;

(b)     develop plans to prevent the sale of full strength alcohol within their communities, such as the plan implemented within the Fitzroy Crossing community?

Question 8–2        In what ways do banned drinkers registers or alcohol mandatory treatment programs affect alcohol-related offending within Aboriginal and Torres Strait Islander communities? What negative impacts, if any, flow from such programs?

9. Female Offenders

Question 9–1        What reforms to laws and legal frameworks are required to strengthen diversionary options and improve criminal justice processes for Aboriginal and Torres Strait Islander female defendants and offenders?

10. Aboriginal Justice Agreements

Proposal 10–1       Where not currently operating, state and territory governments should work with peak Aboriginal and Torres Strait Islander organisations to renew or develop Aboriginal Justice Agreements.

Question 10–1      Should the Commonwealth Government develop justice targets as part of the review of the Closing the Gap policy? If so, what should these targets encompass?

11. Access to Justice Issues

Proposal 11–1       Where needed, state and territory governments should work with peak Aboriginal and Torres Strait Islander organisations to establish interpreter services within the criminal justice system.

Question 11–1      What reforms to laws and legal frameworks are required to strengthen diversionary options and specialist sentencing courts for Aboriginal and Torres Strait Islander peoples?

Proposal 11–2       Where not already in place, state and territory governments should provide for limiting terms through special hearing processes in place of indefinite detention when a person is found unfit to stand trial.

Question 11–2      In what ways can availability and access to Aboriginal and Torres Strait Islander legal services be increased?

Proposal 11–3       State and territory governments should introduce a statutory custody notification service that places a duty on police to contact the Aboriginal Legal Service, or equivalent service, immediately on detaining an Aboriginal and Torres Strait Islander person.

12. Police Accountability

Question 12–1      How can police work better with Aboriginal and Torres Strait Islander communities to reduce family violence?

Question 12–2      How can police officers entering into a particular Aboriginal or Torres Strait Islander community gain a full understanding of, and be better equipped to respond to, the needs of that community?

Question 12–3      Is there value in police publicly reporting annually on their engagement strategies, programs and outcomes with Aboriginal and Torres Strait Islander communities that are designed to prevent offending behaviours?

Question 12–4      Should police that are undertaking programs aimed at reducing offending behaviours in Aboriginal and Torres Strait Islander communities be required to: document programs; undertake systems and outcomes evaluations; and put succession planning in place to ensure continuity of the programs?

Question 12–5      Should police be encouraged to enter into Reconciliation Action Plans with Reconciliation Australia, where they have not already done so?

Question 12–6      Should police be required to resource and support Aboriginal and Torres Strait Islander employment strategies, where not already in place?

13. Justice Reinvestment

Question 13–1      What laws or legal frameworks, if any, are required to facilitate justice reinvestment initiatives for Aboriginal and Torres Strait Islander peoples?

Part B The Term of reference

ALRC inquiry into the incarceration rate of Aboriginal and Torres Strait Islander peoples

I, Senator the Hon George Brandis QC, Attorney-General of Australia, refer to the Australian Law Reform Commission, an inquiry into the over-representation of Aboriginal and Torres Strait Islander peoples in our prisons.

It is acknowledged that while laws and legal frameworks are an important factor contributing to over‑representation, there are many other social, economic, and historic factors that also contribute. It is also acknowledged that while the rate of imprisonment of Aboriginal and Torres Strait Islander peoples, and their contact with the criminal justice system – both as offenders and as victims – significantly exceeds that of non‑Indigenous Australians, the majority of Aboriginal and Torres Strait Islander people never commit criminal offences.

Scope of the reference

  1. In developing its law reform recommendations, the Australian Law Reform Commission (ALRC) should have regard to:
    1. Laws and legal frameworks including legal institutions and law enforcement (police, courts, legal assistance services and prisons), that contribute to the incarceration rate of Aboriginal and Torres Strait Islander peoples and inform decisions to hold or keep Aboriginal and Torres Strait Islander peoples in custody, specifically in relation to:
      1. the nature of offences resulting in incarceration,
      2. cautioning,
      3. protective custody,
      4. arrest,
      5. remand and bail,
      6. diversion,
      7. sentencing, including mandatory sentencing, and
      8. parole, parole conditions and community reintegration.
    2. Factors that decision-makers take into account when considering (1)(a)(i-viii), including:
      1. community safety,
      2. availability of alternatives to incarceration,
      3. the degree of discretion available to decision-makers,
      4. incarceration as a last resort, and
      5. incarceration as a deterrent and as a punishment.
    3. Laws that may contribute to the rate of Aboriginal and Torres Strait Islander peoples offending and including, for example, laws that regulate the availability of alcohol, driving offences and unpaid fines.
    4. Aboriginal and Torres Strait Islander women and their rate of incarceration.
    5. Differences in the application of laws across states and territories.
    6. Other access to justice issues including the remoteness of communities, the availability of and access to legal assistance and Aboriginal and Torres Strait Islander language and sign interpreters.
  2.  In conducting its Inquiry, the ALRC should have regard to existing data and research[1] in relation to:
    1. best practice laws, legal frameworks that reduce the rate of Aboriginal and Torres Strait Islander incarceration,
    2. pathways of Aboriginal and Torres Strait Islander peoples through the criminal justice system, including most frequent offences, relative rates of bail and diversion and progression from juvenile to adult offending,
    3. alternatives to custody in reducing Aboriginal and Torres Strait Islander incarceration and/or offending, including rehabilitation, therapeutic alternatives and culturally appropriate community led solutions,
    4. the impacts of incarceration on Aboriginal and Torres Strait Islander peoples, including in relation to employment, housing, health, education and families, and
    5. the broader contextual factors contributing to Aboriginal and Torres Strait Islander incarceration including:
      1. the characteristics of the Aboriginal and Torres Strait Islander prison population,
      2. the relationships between Aboriginal and Torres Strait Islander offending and incarceration and inter‑generational trauma, loss of culture, poverty, discrimination, alcohol and drug use, experience of violence, including family violence, child abuse and neglect, contact with child protection and welfare systems, educational access and performance, cognitive and psychological factors, housing circumstances and employment, and
      3. the availability and effectiveness of culturally appropriate programs that intend to reduce Aboriginal; and Torres Strait Islander offending and incarceration.
  3. In undertaking this Inquiry, the ALRC should identify and consider other reports, inquiries and action plans including but not limited to:
    1. the Royal Commission into Aboriginal Deaths in Custody,
    2. the Royal Commission into the Protection and Detention of Children in the Northern Territory (due to report 1 August 2017),
    3. Senate Standing Committee on Finance and Public Administration’s Inquiry into Aboriginal and Torres Strait Islander Experience of Law Enforcement and Justice Services,
    4. Senate Standing Committee on Community Affairs’ inquiry into Indefinite Detention of People with Cognitive and Psychiatric impairment in Australia,
    5. Senate Standing Committee on Indigenous Affairs inquiry into Harmful Use of Alcohol in Aboriginal and Torres Strait Islander Communities,
    6. reports of the Aboriginal and Torres Strait Islander Social Justice Commissioner,
    7. the ALRC’s inquiries into Family violence and Family violence and Commonwealth laws, and​
    8. the National Plan to Reduce Violence against Women and their Children 2010-2022.

The ALRC should also consider the gaps in available data on Aboriginal and Torres Strait Islander incarceration and consider recommendations that might improve data collection.

  1. In conducting its inquiry the ALRC should also have regard to relevant international human rights standards and instruments.

Consultation

  1. In undertaking this inquiry, the ALRC should identify and consult with relevant stakeholders including Aboriginal and Torres Strait Islander peoples and their organisations, state and territory governments, relevant policy and research organisations, law enforcement agencies, legal assistance service providers and the broader legal profession, community service providers and the Australian Human Rights Commission.

Timeframe

  1. The ALRC should provide its report to the Attorney-General by 22 December 2017.

 

Aboriginal #Nutrition Health and #Sugar : @healthgovau Health Star Rating System review closes 17 August

 ” The Health Star Rating System has been marred by anomalies. Milo powder (44% sugar) increased its basic 1.5 Stars to 4.5 by assuming it will be added to skim milk. About one in every seven products bearing health stars goes against the Department of Health’s own recommendations.

Those of us working in public health question why obvious junk foods get any stars at all.”

See Sugar, sugar everywhere MJA insight article in full Part 3 below

  ” In 2012-13, Aboriginal and Torres Strait Islander people 2 years and over consumed an average of 75 grams of free sugars per day (equivalent to 18 teaspoons of white sugar)1. Added sugars made up the majority of free sugar intakes with an average of 68 grams (or 16 teaspoons) consumed and an additional 7 grams of free sugars came from honey and fruit juice. “

ABS Report abs-indigenous-consumption-of-added-sugars 

See Part 1 below for Aboriginal sugar facts

The Health Star Rating (HSR) Advisory Committee (HSRAC), responsible for overseeing the implementation, monitoring and evaluation of the HSR system is undertaking a five year review of the HSR system.

The five year review of the system is well underway, with a public submission process opening on 8 June 2017 on the Australian Department of Health’s online Consultation Hub.

Since the consultation period has been opened there has been strong interest in the system from stakeholders representing a diverse range of views.

To ensure that as much evidence as possible is captured, along with stakeholders’ views on the system, a further two week extension to the consultation period has been agreed and it will now close on 17 August 2017

See full survey details Part 2 Below

Part 1 Aboriginal sugar facts

ABS Report

abs-indigenous-consumption-of-added-sugars

Aboriginal and Torres Strait Islander people consume around 14 per cent of their total energy intake as free sugars, according to data from the Australian Bureau of Statistics (ABS).

The World Health Organization (WHO) recommends that free sugars contribute less than 10 per cent of total energy intake.

Director of Health, Louise Gates, said the new ABS report showed Aboriginal and Torres Strait Islander people are consuming an average of 18 teaspoons (or 75 grams) of free sugars per day (almost two cans of soft drink), four teaspoons more than non-Indigenous people (14 teaspoons or 60 grams).

OTHER KEY FINDINGS

    • Aboriginal and Torres Strait Islander people derived an average of 14% of their daily energy from free sugars, exceeding the WHO recommendation that children and adults should limit their intake of free sugars to less than 10% of dietary energy.
    • Free sugars made the greatest contribution to energy intakes among older children and young adults. For example, teenage boys aged 14-18 years derived 18 per cent of their dietary energy from free sugars as they consumed the equivalent of 25 teaspoons (106 grams) of free sugars per day. This amount is equivalent to more than two and a half cans of soft drink. Women aged 19-30 years consumed 21 teaspoons (87 grams) of free sugars, which contributed 17 per cent to their total energy intake.
    • The majority (87%) of free sugars were consumed from energy dense, nutrient-poor ‘discretionary’ foods and beverages. Two thirds (67%) of all free sugars consumed by Aboriginal and Torres Strait Islander people came from beverages, led by soft drinks, sports and energy drinks (28%), followed by fruit and vegetable juices and drinks (12%), cordials (9.5%), and sugars added to beverages such as tea and coffee (9.4%), alcoholic beverages (4.9%) and milk beverages (3.4%).
    • Intakes were higher for Aboriginal and Torres Strait Islander people living in non-remote areas where the average consumption was 78 grams (18.5 teaspoons), around 3 teaspoons (12 grams) higher than people living in remote areas (65 grams or 15.5 teaspoons).
    • Aboriginal and Torres Strait Islander people consumed 15 grams (almost 4 teaspoons) more free sugars on average than non-Indigenous people. Beverages were the most common source of free sugars for both populations, however Aboriginal and Torres Strait Islander people derived a higher proportion of free sugars from beverages than non-Indigenous people (67% compared with 51%).

Part 2 @healthgovau Health Star Rating System review closes 17 August

Introduction

The Health Star Rating (HSR) Advisory Committee (HSRAC), responsible for overseeing the implementation, monitoring and evaluation of the HSR system, is undertaking a five year review of the HSR system. The HSR system is a front-of-pack labelling (FoPL) scheme intended to assist consumers in making healthier diet choices. The findings of the review will be provided to the Australia and New Zealand Ministerial Forum on Food Regulation (Forum) in mid‑2019.

In parallel with this consultation on the HSR system five year review, the HSRAC is conducting a dedicated investigation of issues and concerns raised about the form of the food (‘as prepared’) rules in the Guide for Industry to the HSR Calculator. These enable additional nutrients to be taken into account when calculating star ratings based on foods prepared according to on-label directions. A specific consultation process seeking input into this investigation opened on 19 May 2017 and will close at 11.59 pm 30 June 2017. The form of the food (‘as prepared’) consultation can be viewed on the Australian Department of Health’s Consultation Hub.

The HSR system

The HSR system is a public health and consumer choice intervention designed to encourage people to make healthier dietary choices. The HSR system is a voluntary FoPL scheme that rates the overall nutritional profile of packaged food and assigns it a rating from ½ a star to 5 stars. It is not a system that defines what a ‘healthy’ or ‘unhealthy’ food is, but rather provides a quick, standardised way to compare similar packaged foods at retail level. The more stars, the healthier the choice. The HSR system is not a complete solution to assist consumers with choosing foods in line with dietary guidelines, but should be viewed as a way to assist consumers to make healthier packaged food choices.  Other sources of information, such as the Australian Dietary Guidelines and the New Zealand Eating and Activity Guidelines, also assist consumers in their overall food purchasing decisions.

The HSR system aims to:

1. Enable direct comparison between individual foods that, within the overall diet, may contribute to the risk factors of various diet related chronic diseases;

2. Be readily understandable and meaningful across socio-economic groups, culturally and linguistically diverse groups and low literacy/low numeracy groups; and

3. Increase awareness of foods that, within the overall diet, may contribute positively or negatively to the risk factors of diet related chronic diseases.

The HSR system consists of the graphics, including the words ‘Health Star Rating’, the rules identified in the HSR system Style Guide, the algorithm and methodology for calculating the HSR identified in the Guide for Industry to the HSR Calculator, and the education and marketing associated with the HSR implementation.

The HSR system is a joint Australian, state and territory and New Zealand government initiative developed in collaboration with industry, public health and consumer groups. The system is funded by the Australian government, the New Zealand government and all Australian jurisdictions during the initial five year implementation period.

From June 2014, food manufacturers started to apply HSRs to the front of food product packaging. Further information on the HSR system is available on the HSR website. The New Zealand Ministry for Primary Industries (MPI) website also provides information on the HSR system in New Zealand.

Purpose and scope of the review
The five year review of the HSR system will consider if, and how well, the objectives of the HSR system have been met, and identify options for improvements to and ongoing implementation of the system (Terms of reference for the five year review).

With a focus on processed packaged foods, the objective of the HSR system is:

To provide convenient, relevant and readily understood nutrition information and /or guidance on food packs to assist consumers to make informed food purchases and healthier eating choices.

The HSRAC has agreed that the areas of communication, system enhancements, and monitoring and governance will be considered when identifying whether the objectives of the HSR system have been achieved.

Although HSRAC will need to be a part of the review process, a degree of independence is required and independent management and oversight of the review is an important factor to ensure credible and unbiased reporting. An independent consultant will be engaged to undertake the review. Specific detail about the scope of the review will be outlined in the statement of requirement for the independent consultant. A timeline for the five year review of the HSR system has been drafted and will be updated throughout the review.

Next steps in the review process

As part of the five year review, HSRAC is seeking evidence based submissions on the consultation questions provided in this discussion paper.

This consultation is open to the public, state and territory governments, relevant government agencies, industry and public health and consumer groups.

Making a submission

The HSRAC is seeking submissions on the merits of the HSR system, particularly in response to the consultation questions below. The aim of the questions is to assist respondents in providing relevant commentary. However, submissions are not limited to answering the questions provided.  Please provide evidence or examples to support comments. Some areas of this review are technical in nature therefore comments on technical issues should be based on scientific evidence and/or supported by research where appropriate. Where possible, please provide citations to published studies or other sources.

While the HSRAC will consider all submissions and proposals put forward, those that are not well supported by evidence are unlikely to be addressed as part of the five year review.

Enquiries specifically relating to this submission process can be made via email to: frontofpack@health.gov.au. Please DO NOT provide submissions by email.

After the consultation period closes the HSRAC will consider the submissions received and will prepare a summary table of the issues raised which will be published on the HSR website. All information within the summary table will be de-identifiable and will not contain any confidential material.

HSRAC will treat information of a confidential nature as such. Please ensure that material supplied in confidence is clearly marked ‘IN CONFIDENCE’ and is provided in a separate attachment to non-confidential material. Information provided in the submissions will only be used for the purpose of the five year review of the HSR system and will not be used for any other purpose without explicit permission.

Please see the Terms of Use and Privacy pages at the bottom of this page for further information on maintaining the security of your data.

For further information about the HSR system, including its resources and governance structure, please refer to the Australian HSR website and the New Zealand MPI website.

Part 3 Sugar Sugar MJA Insights

Originally published Here

IT’S hard to escape sugar, not only in what we eat and drink, but also in the daily news and views that seep into so many corners of our lives.

There’s nothing new about concern over sugar. I can trace my own fights with the sugar industry back to the 1960s, and since their inception in 1981, the Australian Dietary Guidelines have advised limiting sugary foods and drinks. The current emphasis in many articles in newspapers, magazines, popular books and online blogs, however, go further and recommend eliminating every grain of the stuff from the daily diet.

Taking an academic approach to the topic, the George Institute for Global Health has published data based on the analysis of 34 135 packaged foods currently listed in their Australian FoodSwitch database. They found added sugar in 87% of discretionary food products (known as junk foods in common parlance) and also in 52% of packaged foods that can be described as basic or core foods.

The George Institute’s analysis is particularly pertinent to the Department of Health’s Health Star Rating System, and found that some of the anomalies in the scheme could be eliminated by penalising foods for their content of added sugars rather than using total sugars in the product, as is currently the case.

The definition of “added sugars” used in Australia also needs attention, a topic that has been stressed in the World Health Organization’s guidelines. I will return to this later.

In Australia, the nutrition information panel on the label of packaged foods must include the total sugars present. This includes sugars that have been added (known as extrinsic sugars) as well as any sugars present naturally in ingredients such as milk, fruit or vegetables (intrinsic sugars).

There is no medical evidence to suggest that intrinsic sugars are a problem – at least not if they occur in “intact” ingredients. If you consume fruit, for example, the natural dietary fibre and the bulk of the fruit will limit the amount of the fruit’s intrinsic sugars you consume. However, if the sugar is extracted from the structure of the fruit, it becomes easy to consume much larger quantities. Few people could munch their way through five apples, but if you extract their juice, the drink would let you take in all the sugar and kilojoules of five apples in less than a minute.

The Australian Dietary Guidelines do not include advice to restrict fruit itself because there is high level evidence of its health value. The guidelines do, however, recommend that dried fruit and fruit juice be restricted – the equivalent of four dried apricot halves or 125 mL juice consumed only occasionally.

Contrary to the belief of some bloggers, Australia’s dietary guidelines have never suggested replacing fat with sugar. That was a tactic of some food companies who marketed many “low” or “reduced” fat foods where the fat was replaced with sugars or some kind of refined starch.

The wording of Australia’s guideline on sugar has changed. The initial advice to “avoid too much sugar” led to the sugar industry’s multimillion dollar campaign “Sugar, a natural part of life”. This included distributing “educational” material to the general public, politicians, doctors, dentists, pharmacists and other health professionals discussing the importance of a “balanced diet”.

In spite of fierce lobbying by the sugar industry, the next revision of the guidelines retained a sugar guideline, although it was watered down to “eat only moderate amounts of sugars”. Some school canteen operators reported that they had been confronted by sweet-talking sellers of junk foods omitting the word “only” from this guideline.

The evidence for sugar’s adverse effects on dental health have long been known, but the evidence against sugar and its potential role in obesity and, consequently, in type 2 diabetes and other health problems has grown stronger. The most recent revision of the National Health and Medical Research Council’s Dietary Guidelines, therefore, emphasises the need to “limit” added sugars and lists the foods that need particular attention.

Sugary drinks have been specifically targeted because the evidence against them is strong and extends beyond epidemiological studies. Double-blind trials now clearly link sugary drinks with weight gain, the only exceptions being a few trials funded by the food industry.

Added sugar is not the only topic for public health concern, and hence the government’s Health Star Rating System was set up to introduce a simple front-of-pack labelling scheme to assist Australians reduce their intake of saturated fat, salt and sugars from packaged foods.

A specially commissioned independent report (Evaluation of scientific evidence relating to Front of Pack Labelling by Dr Jimmy Chun Yu Louie and Professor Linda Tapsell of the School of Health Sciences, University of Wollongong) found that added sugars were the real problem, but the food industry argued that the scheme should include total sugars because this was already a mandatory inclusion on food labels and routine chemical analysis couldn’t determine the source of sugars.

This was a strange argument since food manufacturers know exactly how much sugar they add to any product, just as they know how many “offset” points the Health Star Rating System allows for the inclusion of fruit, vegetable, nuts or legumes. The content of these ingredients is only disclosed on the food label if used in the product’s name.

The Health Star Rating System has been marred by anomalies. Milo powder (44% sugar) increased its basic 1.5 Stars to 4.5 by assuming it will be added to skim milk. About one in every seven products bearing health stars goes against the Department of Health’s own recommendations.

Those of us working in public health question why obvious junk foods get any stars at all.

How can caramel topping or various types of confectionery, such as strawberry flavoured liquorice, each get 2.5 stars? Why do some chocolates sport 3.5 stars, while worthy products such as Greek yoghurt without any added sugars get 1.5 and a breakfast cereal with 27% sugar gets four stars?

The fact that over a third of Australian’s energy intake comes from discretionary products (40% for children) is the elephant in the room for excess weight. We need to reduce consumption of these products and allotting them health stars is not helping.

It’s clearly time to follow our dietary guidelines and limit both discretionary products and added sugar. Of the nutrients used in the current algorithm for health stars, the George Institute’s analysis shows that counting added rather than total sugars has the greatest individual capacity to discriminate between core and discretionary foods.

However, in moving to mandate added sugars on food labels and using added sugars in health stars, it’s vital to define these sugars. The World Health Organization has done so: “Free sugars refer to monosaccharides (such as glucose, fructose) and disaccharides (such as sucrose or table sugar) added to foods and drinks by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates”.

Regular sugar in Australia could be described as cane juice concentrate. It has no nutrients other than its carbohydrate. Fruit juice concentrates are also just sugars with no nutrients other than carbohydrates. At present the Health Star Rating System allows products using apple or pear juice concentrate to be counted as “fruit” and used to offset the total sugars. This is nonsense, and gives rise to confectionery, toppings and some breakfast cereals scoring stars they do not deserve.

Other ways to boost health stars also need attention. Food technologists boast they can manipulate foods to gain extra stars (Health Star Rating Stakeholders workshop, Sydney, 4 August 2016). For example, adding wheat, milk, soy or other protein powder, concentrated fruit purees or a laboratory-based source of fibre such as inulin will all give extra “offset” points to reduce adverse points from saturated fat, sugar or salt. Indeed, some food technologists have even suggested they could revert to using the especially nasty trans (but technically unsaturated) fatty acid from partially hydrogenated vegetable oils to replace naturally occurring saturated fat.

My alternative is to go for fresh foods and minimise packaged foods. If the stars look too good to be true, check the ingredient list. But remember that Choice found sugar may go by more than 40 different names. Buyer beware!

Aboriginal Health #Garma2017 : #Makarrata ,canoes and the #UluruStatement @TurnbullMalcolm @billshortenmp Full Speech transcripts

 ” Djapiri said Bill and I are in the same canoe and on this issue we certainly are – but we are not alone, we are not alone in the canoe. We are in the same canoe with all of you as well and we need to steer it wisely to achieve our goal, to achieve that goal of Makarrata.

Beyond Constitutional Recognition, that work continues every day. I reflect on the Makarrata discussion of the late 70’s and 80’s. A list of demands was sent to the Minister for Aboriginal Affairs in 1981. It called for rights to land and resources, compensation, the creation of Aboriginal schools, medical centres and an Aboriginal bank.

Despite a final agreement not being reached at the time, we have achieved some of the policies called for. The Commonwealth provided $433 million to 137 Aboriginal Medical Services across the country last financial year.

As Prime Minister I will continue to do all I can to ensure that being an Aboriginal and Torres Strait Islander Australian means to be successful, to achieve, to have big dreams and high hopes, and to draw strength from your identity as an Indigenous person in this great country.

That’s why, as we renegotiate the Closing the Gap targets with the various state and territory jurisdictions later this year, my Government has insisted on a strengths based approach.

Indigenous people are not a problem to be solved.

You are our fellow Australians. Your cultures are a gift to our nation.”

Selected extracts from the full Prime Minister Speech 5 August Garma see Part 2 Full Speech

Download full copy Garma 2017 PM full Speech

” Djapirri said, she told me of a dream of a canoe, paddled by the Prime Minister and myself.

That in itself is an arresting image. Two captains. But in all seriousness, we appreciated I think the power of that illusion, the power of that dream.

Here at Garma, on the lands of the Gumatj, we gather to talk about a Yolngu word. Makarrata.

It is not just now a Yolngu word – I put it to you it’s a national test.

Coming together, after a struggle.

And for the first Australians, it has been a very long struggle indeed.

– A struggle against dispossession and discrimination, exclusion and inequality.

– A struggle against violence and poverty, disease and diminished opportunity.

– A struggle for better health, for better housing, for safer communities, more jobs, for longer lives.

– A struggle against injustice and racism: from the sporting field to the courts of our land.

Above all, a struggle for a better future for their children: a struggle to be counted, to be heard, to be recognised.

At Uluru, you gave us the statement from the heart.

A call for:

– A voice enshrined in the Constitution

– A declaration to be passed by all parliaments, acknowledging the unique place of the first nations in Australian history, their culture, their connection.

And a Makarrata Commission to oversee a process of agreement-making and truth-telling.

All three of these objectives speak to the long-held and legitimate aspirations of our First Australians:

– A proper acknowledgment of Aboriginal histories and the dispossession that followed upon the arrival of the Europeans

– A bigger say in the issues which affect you – no more ‘solutions’ imposed without consultation or consent

And a more lasting settlement, a new way forward, a new pathway including through treaties.

These ideas are not new – but the Uluru statement did articulate these with new clarity, a new passion, a new sense of truth and purpose “

Selected extracts The Hon Bill Shorten speech  Garma 5 August 2017 see in full Part 3 Below

Download full speech Garma 2017 PM full Speech

Part 1 Media Coverage

View NITV Media coverage

When it comes to Aboriginal constitutional reform, picture Malcolm Turnbull and Bill Shorten sitting in a canoe – and the opposition leader thinks he’s the only one paddling.

The Labor leader has backed a referendum question on an indigenous voice to parliament, while the prime minister has failed to commit bipartisan support.

The two politicians are moving together downstream, struggling to balance the boat to achieve reconciliation, Gumatj leader Djapirri Mununggirritj has told Garma Festival in northeast Arnhem Land.

Mr Shorten called it an “arresting image” but said he was disappointed Mr Turnbull dismissed his end of year referendum question deadline as “very ambitious”.

“We support a declaration by all parliaments, we support a truth telling commission, we are not confronted by the notion of treaties with our first Australians,” he said.

Mr Turnbull acknowledged many Aboriginal leaders were disappointed the government didn’t give “instant fulfilment” to the Referendum Council’s recommendations.

He described the Yolgnu elder’s canoe analogy as apt, saying his cabinet will give the matter careful consideration to keep the aspiration of Makarrata, or coming together after a struggle, from capsizing.

An “all or nothing approach” to constitutional change risks rocking the boat, resulting in a failed referendum, and Mr Turnbull called for time to develop a winnable question to put to Australian voters.

“We are not alone in the canoe, we are in the canoe with all of you and we need to steer it wisely to achieve that goal of Makarrata,” he said.

Mr Turnbull said there’s still many practical questions about what shape the advisory body would take, whether it would be elected or appointed and how it would affect Aboriginal people around the country.

Specifically, he questioned what impact the voice to parliament would have on issues like child protection and justice, which are largely the legislative domain of state and territory governments.

But Mr Shorten said debate over Aboriginal recognition in the nation’s founding document has dragged on for the past decade.

“I can lead Mr Turnbull and the Liberal party to water but I can’t make them drink,” he said.

Having led the failed 1999 republic referendum campaign, Mr Turnbull warned that Australians are “constitutionally conservative”, with just eight out of 44 successful since federation.

But Mr Shorten said “Aboriginal Australians do not need a balanda [white person] lecture about the difficulty of changing the constitution”.

Mr Shorten’s proposal of a joint parliamentary committee to finalise a referendum question has been met with cynicism by indigenous leaders.

The Above AAP

 

 Part 2 PRIME MINISTER Garma SPEECH :

Ngarra buku-wurrpan bukmak nah! Nhuma’lanah.

Ngarra Prime Minister numalagu djal Ngarra yurru wanganharra’wu nhumalangu bukmak’gu marrigithirri.

Ngarra ga nhungu dharok ga manikay’ ngali djaka wanga’wu yirralka.

I acknowledge and pay respect to your country, and your elders.

As Prime Minister, I’m here to talk to you and learn from you.

I acknowledge and respect your language, your song lines, your dances, your culture, your caring for country, and your estates.

I pay my respects to the Gumatj people and traditional owners past, present and future, on whose land we are gathered.

I also acknowledge other Yolngu people, First Peoples from across the country and balanda here today including Bill Shorten, Nigel Scullion and all other Parliamentary colleagues but above all I acknowledge our Parliamentary colleagues, Indigenous Parliamentary colleagues. Truly, voices of First Australians in the Parliament. Thank you for being here today and for the wisdom you give us, you together with my dear friend Ken, so much wisdom in the Parliament.

I offer my deep respect and gratitude to the Chairman of the Yothu Yindi Foundation, Dr Galarrwuy Yunupingu for hosting Lucy and me with your family. It was lovely to camp here last night and the last music was beautiful, serene and like a lullaby sending us all off to our dreams. Thank you. Emily was the last singer – beautiful.  And of course we woke here to the beautiful sounds of Gulkala.

I again as I did yesterday extend our deep condolences to the family of Dr G Yunupingu at this very sad time. He brought the Yolngu language to the people of Australia and his music will be with us forever.

I’ve come here to North East Arnhem Land to learn, participate respectfully and can I thank everyone so far I’ve had the chance to talk with. I am filled with optimism about our future together as a reconciled Australia.

Last month scientists and researchers revealed new evidence that our First Australians have been here in this land for 65,000 years.

These findings show that Indigenous people were living at the Madjedbebe rock shelter in Mirarr Country, at Kakadu east of Darwin, 18,000 years earlier than previously thought.

Among the middens, rock paintings, remains, plants and ochre, was the world’s oldest-known ground-edge axe head.

These findings place Australia on centre stage in the story of human origin, including mankind’s first long-distance maritime voyage – from Southeast Asia to the Australian continent.

Our First Peoples are shown as artistically, as technologically advanced, and at the cutting edge of technology in every respect.

Importantly, they confirm what Aboriginal people have always known and we have known – that your connection, your intimate connection to the land and sea are deep, abiding, ancient, and yet modern.

This news is a point of great pride for our nation. We rejoice in it, as we celebrate your Indigenous cultures and heritage as our culture and heritage – uniquely Australian.

As Galarrwuy said yesterday as he spoke in Yolngu, he said: “I am speaking in Australian.” Sharing, what a generosity, what a love, what a bigness he showed there as he does throughout his life and his leadership.

I want to pay tribute to the work of so many of you here today, who are leading the healing in communities, building bridges between the old and new, and looking for ways to ensure families and communities are not just surviving, but thriving.

Particularly the Indigenous leaders who every day wear many hats, walk in both worlds, and yet give tirelessly for their families and their communities. You often carry a very heavy load, and we thank you.

Where western astronomers look up at the sky and look for the light, Yolngu astronomers look also deep into the dark, using the black space to uncover further information, to unravel further mysteries.

So while we are both looking at the night sky, we are often looking at different parts. And yet through mutual respect, sharing of knowledge and an openness to learning, together we can see and appreciate the whole sky.

Those same principles are guiding us toward Constitutional Recognition.

The final Referendum Council report was delivered, as you know, on the 30th of June. Bill Shorten and I were briefed by the Referendum Council two weeks ago. The report was a long time coming and I know some would like an instant fulfillment of its recommendations.

Let me say, I respect deeply the work of the Referendum Council and all of those who contributed to it, and I respect it by considering it very carefully and the Government is doing so, in the first instance with my colleagues, including Ken Wyatt the first Indigenous Australian to be a Federal Minister, and together we consider it with our Cabinet. That is our way, that is our process, that is how we give respect to serious recommendations on serious matters.

And I do look forward to working closely and in a bipartisan way with the Opposition as we have done to date.

Djapiri said Bill and I are in the same canoe and on this issue we certainly are – but we are not alone, we are not alone in the canoe. We are in the same canoe with all of you as well and we need to steer it wisely to achieve our goal, to achieve that goal of Makarrata. Thank you again Galarrwuy for that word.

We share a sense of the significance of words. I love words and language. There is a great definition. What is the difference between poetry and prose? The best definition of poetry that I have ever found is that which cannot be translated, it can only be felt.

The Referendum Council’s report as Marcia reminded us is the fourth major report since that time and it adds immensely to the depth of knowledge. It gave us the Uluru Statement from the Heart, and I congratulate all those who attended on reaching an agreement. That was no small task.

It tells us that the priority for Aboriginal and Torres Strait Islander peoples is to resolve the powerlessness and lack of self-determination experienced – not by all, but certainly by too many.

I have been discussing it with leaders, the leaders of our First Australians and will continue to do so as we develop the next steps.

But there are still many questions:

What would the practical expression of the voice look like? What would the voice look like here for the Yolngu people? What would it look like for the people of Western Sydney, who are the largest population of Aboriginal peoples in Australia?

Is our highest aspiration to have Indigenous people outside the Parliament, providing advice to the Parliament? Or is it to have as many Indigenous voices, elected, within our Parliament?

What impact would the voice have on issues like child protection and justice, where the legislation and responsibility largely rest with state and territory governments?

These are important questions that require careful consideration. But the answers are not beyond us.

And I acknowledge that Indigenous Australians want deeper engagement with government and their fellow Australians, and to be much better consulted, and represented in the political, social and economic life of this nation.

We can’t be weighed down by the past, but we can learn from it.

Australians are constitutionally conservative. The bar is surmountable, you can get over it but it is a high bar. That’s why the Constitution has often been described as a frozen document.

Now many people talk about referendums, very few have experienced leading a campaign. The 1999 campaign for a Republic – believe me, now, one of the few subjects on which I have special knowledge – the 1999 campaign for a Republic has given me a very keen insight into what it will take to win, how hard it is to win, how much harder is the road for the advocate for change than that of those who resist change. I offer this experience today in the hope that together, we can achieve a different outcome to 1999. A successful referendum.

Compulsory voting has many benefits, but one negative aspect is that those who for one reason or another are not interested in an issue or familiar with it, are much more likely to vote no – it reinforces an already conservative constitutional context.

Another critical difference today is the rise of social media, which has changed the nature of media dramatically, in a decade or two we have a media environment which is no longer curated by editors and producers – but freewheeling, viral and unconstrained.

The question posed in a referendum must have minimal opposition and be clearly understood.

A vital ingredient of success is popular ownership. After all, the Constitution does not belong to the Government, or the Parliament, or the Judges. It belongs to the people.

It is Parliament’s duty to propose changes to the Constitution but the Constitution cannot be changed by Parliament. Only the Australian people can do that.

No political deal, no cross party compromise, no leaders’ handshake can deliver constitutional change.

Bipartisanship is a necessary but far from a sufficient condition of successful constitutional reform.

To date, again as Marcia described much of the discussion has been about removing the racially discriminatory provisions in the Constitution and recognising our First Australians in our nation’s founding document.

However, the Referendum Council has told us that a voice to Parliament is the only option they advise us to put to the Australian people. We have heard this, and we will work with you to find a way forward.

Though not a new concept, the voice is relatively new to the national conversation about constitutional change.

To win, we must all work together to build a high level of interest and familiarity with the concept of a voice, and how this would be different, or the same, as iterations of the past like the National Aboriginal Conference or the Aboriginal and Torres Strait Islander Commission.

We also need to look to the experience of other countries, as we seek to develop the best model for Australia.

The historic 1967 Referendum was the most successful in our history because of its simplicity and clarity. The injustices were clearly laid out – Indigenous people were not enjoying the rights and freedoms of other citizens. The question was clearly understood – that the Commonwealth needed to have powers to make laws for Indigenous Australians. And the answer seemed obvious – vote yes to ensure the Commonwealth gave Indigenous people equal rights.

To succeed this time around, we need to develop enough detail so that the problem, the solution and therefore the question at the ballot box are simple, easily understood and overwhelmingly embraced.

One of the toughest lessons I learnt from the Referendum campaign of ‘99 was that an ‘all or nothing’ approach sometimes results in nothing. During the campaign, those who disagreed with the model that was proposed urged a “no” vote, arguing that we could all vote for a different Republic model in a few years. I warned that a “no” vote meant no republic for a very long time.

Now, regrettably, my prediction 18 years ago was correct. We must avoid a rejection at a referendum if we want to avoid setting Makarrata reconciliation back.

We recognise that the Uluru statement is powerful because it comes from an Indigenous-designed and led process. And because it comes from the heart, we must accept that it is grounded in wisdom and truth.

It is both a lament and a yearning. It is poetry.

The challenge now is to turn this poetry that speaks so eloquently of your aspiration into prose that will enable its realisation and be embraced by all Australians.

This is hard and complex work. And we need to take care of each other as we continue on this journey. We need to take care of each other in the canoe, lest we tip out of it.

Yesterday afternoon was a powerful show of humanity. As we stood together holding hands – Indigenous and non-Indigenous people – we stood together as Australians. As equals.

And we will have the best chance of success by working together. This cannot be a take it or leave it proposal. We have to come to the table and negotiate in good faith, and I am committed to working with you to find a way forward.

Galarrwuy – you gave us your fire words yesterday, thank you again. We will draw on them as we look to light the path forward for our nation.

And when considering how to do that, we are inspired by the success of the Uluru process. The statement that emerged from Uluru was designed and led by Indigenous Australians and the next steps should be too.

To go to a referendum there must be an understanding between all parties that the proposal will meet the expectations of the very people it claims it will represent.

Now we have five Aboriginal members of our Parliament. They will be vital in shaping and shepherding any legislation through the Parliament. They too are bridge builders, walking in both worlds, and their contribution to the Parliament enriches us all.

The Australian Parliament and the nation’s people – Indigenous and non-Indigenous – must be engaged as we work together to find the maximum possible overlap between what Indigenous people are seeking, what the Australian community overall will embrace and what the Parliament will authorise.

I have been learning that the word Makarrata means the ‘coming together after a struggle’— Galarrwuy told us a beautiful story this morning about a Makarrata here in this country. And a Makarrata is seen as necessary, naturally, if we are to continue our path to reconciliation.

But just like the night sky, reconciliation means different things to different people. This complexity convinces me that our nation cannot be reconciled in one step, in one great leap. We will only be reconciled when we take a number of actions, both practical and symbolic.

Beyond Constitutional Recognition, that work continues every day. I reflect on the Makarrata discussion of the late 70’s and 80’s. A list of demands was sent to the Minister for Aboriginal Affairs in 1981. It called for rights to land and resources, compensation, the creation of Aboriginal schools, medical centres and an Aboriginal bank.

Despite a final agreement not being reached at the time, we have achieved some of the policies called for. The Commonwealth provided $433 million to 137 Aboriginal Medical Services across the country last financial year. Indigenous Business Australia provides low interest loans to help Indigenous Australians secure economic opportunities including home ownership with 544 new housing loans made last year. The Aboriginal Benefits Account supports Northern Territory Land Councils and provides grants for the benefit of Aboriginal people living in the Territory.

We now spend $4.9 billion on the Indigenous Advancement Strategy.

And we are empowering communities through our Indigenous Procurement policy.

I am pleased to announce today the Commonwealth has officially surpassed half a billion dollars in spending with Indigenous businesses all over Australia. I am looking forward to sharing the full two-year results in October. This is a spectacular increase from just $6.2 million being won by Indigenous businesses only a few years ago under former policies.

Since 2008 the Commonwealth has been helping improve remote housing and bring down rates of overcrowding, with $5.4 billion to build thousands of better homes over ten years.

And the land is returning to its traditional owners.

More than 2.5 million square kilometres of land, or about 34 per cent of Australia’s land mass is today recognised under Native Title. Another 24 per cent is covered by registered claims and by 2025, our ambition is to finalise all current Native Title claims.

So we are standing here on Aboriginal land – land that has been rightfully acknowledged as yours and returned to you. And we are standing here near the birthplace of the land rights movement. A movement of which the Yolngu people were at the forefront.

As a nation we’ve come a long way.

In the Northern Territory, more than 50 per cent of the land is now Aboriginal land, recognised as Aboriginal land.

Just like the land at Kenbi which, on behalf of our nation, I returned to the traditional owners, the Larrakia people last year.

Earlier this year I appointed June Oscar AO, who has been acknowledged earlier, as the first female Aboriginal and Torres Strait Islander Social Justice Commissioner, who has agreed to report on the issues affecting Indigenous women and girls’ success and safety.

And all of that work contributes to a better future for our First Australians.

But there is much more to be done in not just what we do, but how we do it – as we work with our First Australians. We are doing things with our First Australians, not to them.

Now Galarrwuy – I have read and read again your essay Rom Watungu. It too is a story from the heart, of your father, of his life and when his time came, how he handed his authority to you, the embodiment of continuity, the bearer of a name that means “the rock that stands against time”

But rocks that stand against time, ancient cultures and lore, these are the strong foundations on which new achievements are built, from which new horizons can be seen – the tallest towers are built on the oldest rocks.

You, Galarrwuy, ask Australians to let Aboriginal and Torres Strait Islanders breathe and be free, be who you are and ask that we see your songs and languages, the land and the ceremonies as a gift.

As Prime Minister I will continue to do all I can to ensure that being an Aboriginal and Torres Strait Islander Australian means to be successful, to achieve, to have big dreams and high hopes, and to draw strength from your identity as an Indigenous person in this great country.

That’s why, as we renegotiate the Closing the Gap targets with the various state and territory jurisdictions later this year, my Government has insisted on a strengths based approach. Indigenous people are not a problem to be solved. You are our fellow Australians. Your cultures are a gift to our nation.

There’s so much more work to be done.

But in doing so, Aboriginal and Torres Strait Islander people, and all Australians, continue to connect with pride and optimism – with mabu liyan, in Pat’s language from the Yawuru people – the wellbeing that comes with a reconciled harmony with you, our First Australians, our shared history truthfully told and a deeper understanding of the most ancient human cultures on earth, and the First Australians to whom we have so much to thank for sharing them with us.

Thank you so much.

Part 3 Opposition Leader’s Garma Speech

Good morning everybody.

I’d like to acknowledge the traditional owners of the land upon which we meet, I pay my respects to elders both past and present.

I recognise that I stand on what is, was and always will be Aboriginal land.

I acknowledge the Prime Minister and his wife Lucy.

I wish to thank Gallarwuy and the Gumatj for hosting us – and on behalf of my Labor team who are here, Senator Pat Dodson, Senator Malarndirri McCarthy, the Hon Linda Burney, the Hon Kyam Maher, supported also by local Members of Parliament the Hon Warren Snowden and Luke Gosling, and Territory Minister Eva Lawler.

We are very grateful to be part of this gathering.

Also Clementine my daughter asked me to thank you for letting her join in the bunggul yesterday afternoon, she loved it.

At the opening yesterday, we were privileged, all of us, to be at a powerful ceremony, where we remembered Dr G Yunupingu, a man who was born blind – but helped Australians see.

From his island, his words and his music touched the world.

But I also understand that the words of our host were about setting us a test, reminding all of us privileged to be here that there is serious business to be done.

Here at Garma, on the lands of the Gumatj, we gather to talk about a Yolngu word. Makarrata.

It is not just now a Yolngu word – I put it to you it’s a national test.

Coming together, after a struggle.

And for the first Australians, it has been a very long struggle indeed.

– A struggle against dispossession and discrimination, exclusion and inequality.

– A struggle against violence and poverty, disease and diminished opportunity.

– A struggle for better health, for better housing, for safer communities, more jobs, for longer lives.

– A struggle against injustice and racism: from the sporting field to the courts of our land.

Above all, a struggle for a better future for their children: a struggle to be counted, to be heard, to be recognised.

In 2015, the Referendum Council was created with a very clear mission.

To consult on what form Constitutional Recognition should take – how it should work.

To listen to Aboriginal people and to be guided by their aspirations.

And to finally give them a say in a document from which too long they been excluded.

Since then, thousands of the first Australians have explained to the rest us what

Recognition means – for all of us, for our children and indeed for all of our futures.

We asked for your views, we sought your counsel – and, in large numbers, it was answered.

At Uluru, you gave us the statement from the heart.

A call for:

– A voice enshrined in the Constitution

– A declaration to be passed by all parliaments, acknowledging the unique place of the first nations in Australian history, their culture, their connection.

– And a Makarrata Commission to oversee a process of agreement-making and truth-telling.

All three of these objectives speak to the long-held and legitimate aspirations of our

First Australians:

– A proper acknowledgment of Aboriginal histories and the dispossession that

followed upon the arrival of the Europeans

– A bigger say in the issues which affect you – no more ‘solutions’ imposed without consultation or consent

– And a more lasting settlement, a new way forward, a new pathway including through treaties.

These ideas are not new – but the Uluru statement did articulate these with new clarity, a new passion, a new sense of truth and purpose.

And let me speak truthfully on behalf of Labor, the Opposition.

I cannot be any more clear than this: Labor supports a voice for Aboriginal people in our Constitution, we support a declaration by all parliaments, we support a truth-telling commission.

We are not confronted by the notion of treaties with our first Australians.

For us the question is not whether we do these things, the question is not if we should do these things but when and how.

The Parliament needs to be engaged.

The Parliament needs to be engaged now.

The Parliament needs to start the process of engaging with the people of Australia now.

It does not come as a surprise to me, that following upon a report of the

Referendum Council, the Parliament’s next step must be to consider this report.

And in doing so, we must carry its message from the heart of Australia into our hearts as parliamentarians. With optimism, with understanding, not with a desire to find what is wrong, but to find the desire to make these concepts work in the interests of all.

If we were all gathered here now, back in 1891 and 1894 and 1897 to write the Constitution, we would never dream of excluding Aboriginal people from the Census.

But in 1901, they did.

If we were starting the Constitution from scratch, we would not diminish the independence of Aboriginal people – with racist powers.

But in 1901, they did.

And if we were starting on an empty piece of paper, we would, without question, recognise the First Australians’ right to a genuine, empowered voice in the decisions that govern their lives.

Now as you know, we cannot unmake history. We do not get the change to start all over again – but it doesn’t mean that we are forever chained to the prejudices of the past.

The Prime Minister’s observations though are correct about the difficulties of constitutional change. But I ask also that we cannot let the failure of 1999 govern our future on this question.

Voting for a constitutional voice is our chance to bring our Constitution home, to make it better, more equal and more Australian.

A document that doesn’t just pay respect to the weight of a foreign crown, but also recognises the power and value of the world’s oldest living culture, recognises that

Aboriginal people were here first.

And of course, let us reject those who say that symbolic change is irrelevant because dealing with these questions does not mean walking away from the real problems of inequality and disadvantage.

– Talking about enshrining a voice does not reduce our determination to eradicate family violence

– It doesn’t stop us creating good local jobs, training apprentices, treating trachoma or supporting rangers on country.

– It doesn’t distract us from the crisis in out-of-home care, youth suicide or the shocking, growing number of Aboriginal people incarcerated for not much better reason than the colour of their skin.

Aboriginal and Torres Strait Islander peoples don’t have to choose between historical justice and real justice, you don’t have to choose between equality in society and equality in the Constitution – you have an equal right to both.

The Uluru Statement has given us a map of the way forward – and today I finally want to talk about how we follow it, how we take the next step.

Not the obstacles ahead, not the problems, real as they are.

Aboriginal Australians don’t need a balanda lecture about the difficulty of changing the Constitution, our inspiration friends, should not be the 1999 referendum, it should be the 1967 referendum.

You have lived that struggle, every day.

Let me be very clear. In my study of our history, in my experience, nothing has ever been given to Aboriginal people – everything that is obtained has been fought for, has been argued for, has been won and built by Aboriginal people.

Think of the Freedom Riders

Think of the Bark Petition, which Gallarwuy was witness to

Think of the Gurindji at Wave Hill

Eddie Mabo and his fight for justice

Nothing was ever sorted by simply waiting until someone came along said let me do it for you. It is not the way the world is organised.

Every bit of progress has been driven by pride, by persistence by that stubborn refusal to not take no for an answer when it comes to the pursuit of equality.

Now making the case for change and encouraging Australians to vote yes for a recognition, reconciliation, and truth – this is not easy.

But before we can do that we surely must agree on the referendum question that has to be the long overdue next step.

I have written to our Prime Minister, we’ve proposed a joint parliamentary committee – which they’re taking on board, having a look at – to be made up of Government, the Opposition and crossbench MPs – to work with Aboriginal leaders right across Australia.

This committee will have two key responsibilities.

One – advising the Parliament on how to set-up a Makarrata Commission and create a framework for truth-telling and agreement making, including treaties.

Two – what would a voice look like. Whilst there are many questions, none of these are insurmountable.

And three, as a matter of overdue recognition – to endeavour to finalise a referendum question in a timely fashion. There’s no reason why that couldn’t be done by the end of this year.

The issues have been traversed for a decade.

Now friends this is not a committee for the sake of a committee, it’s not another mechanism for delay. It is the necessary process of engagement of the Parliament.

But we have had ten years plus of good intentions, but it is time now perhaps, for more action.

The Parliament does have a key role to play here, in setting the question.

The Parliament could agree on the question this year if we all work together so that the people could vote not long after that.

Voting to enshrine a voice in a standalone Referendum – free from the shadow of an election, or the politics of other questions.

It may seem very hard to imagine, it may seem very hard to contemplate.

But it is possible to imagine a great day, a unifying day, a famous victory, a Makaratta for all.

As I said yesterday, we’ve heard plenty of speeches, there are many fine words… but perhaps people have a right to be impatient after ten years – indeed after 117 years.

So the test I set isn’t what we say here, in this beautiful place.

It’s what we do when we leave.

It’s the honesty of admitting that after the event, what is it that we do.

The test I set for myself is can I come here at future Garmas and look you in the eye and say I have done everything I can, because if I cannot say to you that I have done everything I that I can, then I can’t be truthful with my heart.

Yesterday Gallarwuy spoke with a tongue of fire, he told a powerful truth.

He said that for more than two centuries we had been two peoples – living side-by-side, but not united.

I think that is the challenge for politics too.

Djapirri who just spoke up before me, she’s talked about hope. There is the hope that you refer to, you have the Prime Minister and the Leader of the Opposition. We are here side-by-side, and now we need to be united, not to kick the can down the road, but united on a process that says this parliament will respect what we have heard from Aboriginal people.

Not just at Uluru, but for decades.

In 1967, Aboriginal and Torres Strait Islanders were counted. In 2017, you are being heard.

There is no reason why we can’t enshrine a voice for Aboriginal people in our Constitution.

Djapirri said, she told me of a dream of a canoe, paddled by the Prime Minister and myself. That in itself is an arresting image. Two captains. But in all seriousness, we appreciated I think the power of that illusion, the power of that dream.

My party is ready.

I think Australia is ready.

The fine words that we heard at the opening yesterday, they remind me of the fire dreaming symbol, which is in the front of the Parliament of Australia.

Fire.

That fire dreaming symbol is from central Australia but it is connected isn’t it, by the word of Djapirri yesterday.

Again, that spirit of fire it is a gift from Indigenous people to all Australians and I sincerely will endeavor to make sure that spirit of fire infuses our Parliament.

Aboriginal Health : Rhetoric to Reality: Devolving decision-making to Aboriginal communities

Delivering services to Aboriginal communities, in a way that involves them as genuine partners and produces effective results, remains an ongoing challenge for public services across Australia.

 ” There are three ways of dealing with people: you can do TO them, FOR them or WITH them. The historic experience for Aboriginal people is the done to, or done for, experience. We need to be doing it WITH them.”

As one of the participants in the research said:

Download the report here : rhetoric-to-reality-report

Delivering services to Aboriginal communities, in a way that involves them as genuine partners and produces effective results, remains an ongoing challenge for public services across Australia.

A new publication, developed by ANZSOG students in conjunction with the NSW Department of Aboriginal Affairs, looks at how the NSW public service can change the way it works with Aboriginal people and better devolve decision making to local communities.

Rhetoric to Reality: Devolving decision-making to Aboriginal communities focuses on what structural and attitudinal changes might be required to deliver better collaborative relationships with Aboriginal communities.

Interactions between Australian public services and Indigenous communities have historically been hampered by a lack of respect, trust and understanding.

The report finds that devolving decision-making to Aboriginal communities should not be seen as an end in itself. It should be a means of practising different ways of working with Aboriginal people that involve sharing knowledge and power, collaborating, and responding to local contexts. If this is done the ultimate result will be better shared outcomes for communities.

Whilst the Australian and international literature highlights many barriers to effective collaboration with Indigenous communities there are very few specific recommendations which go beyond ‘rhetoric’. Rhetoric to Reality provides a range of concrete approaches that NSW Government departments can consider.

 

Shift 1: Connecting to culture, connecting to Country

Key findings

The theme which emerged most clearly from our research was how important it is for public servants to develop and maintain genuine cultural competence. Almost all participants raised some aspect of cultural awareness or competence training as an example of what works and what does not.

Participants felt strongly that the current approach to cultural competence in the public service can be ad hoc, tokenistic, generic and static. Similarly, we found that ideas about cultural awareness, competence, safety or intelligence are not well articulated or understood in the NSW public service. The following statements provided by participants highlight these ideas:

“We’re underdone on comprehensive support for developing cultural competency.”

“I think we can all put our hand up, ‘Yep, job done,’ but then not actually spending any time with Aboriginal communities or adding on that extra layer to think about them.”

“Cultural competency training must be delivered in the most authentic way possible. It has to be real, practical and relevant for staff in their roles.”

“It needs to be honest and delivered by Aboriginal people.”

Research participants considered genuine cultural competence to be critical to changing public sector attitudes and structures. This finding is supported by the literature, which shows that cultural understanding (Zurba et al 2012) and culturally appropriate or safe service delivery (Thomas et al 2015) are important to building relationships with Aboriginal people. Studies have shown that a combination of practices can change structural racism in organisations (Abramovitz & Blitz 2015).

literature also supports the provision of cultural training for staff (Downing & Kowal 2011, Fredericks 2006, Paradies et al 2008). The limitations of cultural awareness training as a stand-alone activity were noted by our research participants and have been noted in previous research (e.g. Downing & Kowal 2011), including the risk of stereotyping, promoting ‘otherness’ and ignoring systemic responses. However, studies have shown it is possible to change prejudiced attitudes towards Aboriginal people through specific education activities (Finlay & Stephan 2000; Pendersen et al 2000 & 2004).

The local decision-making framework recognises that public servants need a level of cultural competence to participate. The Premier’s Memorandum M2015-01 Local Decision Making, states that “NSW agencies will adhere to the principles of local decision-making and ensure staff are educated to respond to the needs of Aboriginal communities in a culturally sensitive and appropriate manner”.

While cultural competence was recognised by our research participants and supported by the literature as a key enabler, the lack of a current framework for the development of genuine cultural competence by public servants persists as a dominant issue in shifting public service structural and attitudinal frameworks.

“The key is having a culturally competent NSW government.”

Below we note a number of recurring ideas for improvement in the understanding and the application of cultural competence in the public service that were raised by research participants.

Accepting that racism and paternalism still exist in the attitudes and structures of the public service and which may be manifested in ‘unconscious bias’ was noted by many participants: “It’s hard to accept we have unconscious bias because people in the public sector are values driven.”

Participants were candid about what they perceive as paternalistic views and subtle forms of racism and bias shown by individuals and institutions: “I believe government and its agencies a lack of faith and trust in Aboriginal people’s ability to make sound decisions in the best interest of their communities.”

Understanding history and the historical trauma experienced by Aboriginal people was viewed as critical. “From a community perspective there is a lot of historical hurt or pain from previous government decisions… You have to let them vent their anger and frustration of the historical decisions that have been made that have had a significant impact on their communities.”

“[A] lot of our staff don’t understand the stolen generation.”

Re-conceptualising cultural competence in the public service as a lifelong journey was seen by many participants as necessary for meaningful change. This includes real experience of working alongside Aboriginal people and communities, and ongoing reflective learning. “We need our staff to keep asking, ‘Why is that the case?’” This finding is supported by the literature, which notes that enhancing a person’s awareness of their biases is critical in reducing modern forms of prejudice and discrimination (e.g. Perry et al 2015).

Building trust was seen as vital. For example, participants talked about public servants, including senior public servants, taking the time before getting down to business to build relationships with Aboriginal people, by having a cuppa on neutral ground, listening and building rapport: “It may take a couple of meetings before you get down to the nitty gritty of developing your relationship with that community.” Building trust and developing genuine relationships were also a strong theme in the literature (Closing the Gap Clearinghouse 2015; Taylor et al 2013; Zurba et al 2012).

Including Country as critical to the development of cultural competence was a universal theme. Participants provided examples of how this could be achieved, including through site-based training, localised activities, travelling

The report’s three key recommendations are that:

  • Cultural competence is most effective when it is localised, ongoing and taught on-Country. Local communities could benefit from being engaged in this teaching.
  • Public-sector leaders who are fully committed to cultural competence are most likely to establish collaboration with Aboriginal communities as a routine approach within government. Examples of successful leadership of this kind should be recognised and publicised across the public sector.
  • Aboriginal public servants should be supported and nurtured, and should be seen as critically important for a culturally competent NSW public service.

Rhetoric to Reality was prepared as part of the capstone Work Based Project subject by ANZSOG Executive Master of Public Administration students Laura Andrew, Jane Cipants, Sandra Heriot, Prue Monument, Grant Pollard and Peter Stibbard. It exemplifies the quality of applied research conducted by ANZSOG’s EMPA students and the potential impact when our students partner with a government agency to help drive change.

The research involved interviews and focus groups with senior executives and frontline public servants in Sydney and regional NSW, to get their perspective on what needed to change to lift the impact of programs on the Aboriginal community.

All recognised the importance of cultural change, and the value of ensuring that successful programs, designed in partnership with local communities, were used as examples to improve results elsewhere.

Rhetoric to Reality will be available across the NSW public service as a valuable resource to ensure that government support for Aboriginal people delivers benefits to those communities.

NACCHO Aboriginal Health @amapresident says Treat Dependence And Addiction As Chronic Brain Disease

Behavioural addictions – such as pathological gambling, compulsive buying, or being addicted to exercise or the internet – and substance dependence are recognised as chronic diseases of the brain’s reward, motivation, memory, and related circuitry,

Substance abuse is widespread in Australia. Almost one in seven Australians over the age of 14 have used an illicit substance in the past 12 months, and about the same number report drinking 11 or more standard alcoholic drinks in a single session.

Left unaddressed, the broader community impacts include reduced employment and productivity, increased health care costs, reliance on social welfare, increased criminal activity, and higher rates of incarceration.”

AMA President, Dr Michael Gannon pictured above with NACCHO Chair on a recent visit to NT ACCHO Danila Dilba

Read view over 170 Articles last 5 years NACCHO Alcohol and other drugs

Substance dependence and behavioural addictions are chronic brain diseases, and people affected by them should be treated like any other patient with a serious illness, the AMA says.

Releasing the AMA’s Harmful Substance Use, Dependence, and Behavioural Addiction (Addiction) 2017 Position Statement today, AMA President, Dr Michael Gannon, said that dependence and addiction often led to death or disability in patients, yet support and treatment services were severely under-resourced.

Download copy Harmful Substance Use, Dependence and Behavioural Addiction (Addiction) – 2017 – AMA position statement

“Substance use does not inevitably lead to dependence or addiction. A patient’s progression can be influenced by many factors – genetic and biological factors, the age at which the use first started, psychological history, family and peer dynamics, stress, and access to support.

“The costs of untreated dependence and addictions are staggering. Alcohol-related harm alone is estimated to cost $36 billion a year.

“Those affected by dependence and addictions are more likely to have physical and mental health concerns, and their finances, careers, education, and personal relationships can be severely disrupted.

“Left unaddressed, the broader community impacts include reduced employment and productivity, increased health care costs, reliance on social welfare, increased criminal activity, and higher rates of incarceration.

“About one in 10 people in our jails is there because of a drug-related crime.

“Given the consequences of substance dependence and behavioural addictions, the AMA believes it is time for a mature and open discussion about policies and responses that reduce consumption, and that also prevent and reduce the harms associated with drug use and control.

“Services for people with substance dependence and behavioural addiction are severely under-resourced. Being able to access treatment at the right time is vital, yet the demand for services outweighs availability in most instances.

“Waiting for extended periods of time to access treatment can reduce an individual’s motivation to engage in treatment.

“While the Government responded quickly to concerns about crystal methamphetamine use with the National Ice Action Strategy, broader drug policy appears to be a lower priority.

“The recently-released National Drug Strategy 2017-2026 again lists methamphetamine as the highest priority substance for Australia, despite the Strategy noting that only 1.4 per cent of Australians over the age of 14 had ever tried the drug.

“The Strategy also notes that alcohol is associated with 5,000 deaths and more than 150,000 hospitalisations each year, yet the Strategy puts it as a lower priority than ice.

“The updated National Drug Strategy is disappointing. The fact that no additional funding has been allocated to the Strategy to date means that any measures that require funding support are unlikely to occur in the short to medium term.

“The Government must focus on those dependencies and addictions that cause the greatest harm, including alcohol, regardless of whether some substances are more socially acceptable than others.

“General practitioners are a highly trusted source of advice, and they play an important role in the prevention, detection, and management of substance dependence and behavioural addictions. Unfortunately, limited access to suitable treatment can undermine GPs’ efforts in these areas.”

 

NACCHO Research Alert : @NRHAlliance Aboriginal health risk factors #rural and #remote populations

 ” Health risk factors like smoking, excessive drinking, illicit drug use, lack of physical activity, inadequate fruit and vegetable intake and overweight have powerful influences on health, and there are frequently clear inter-regional differences between the prevalence of these.

While it can be argued that there is some degree of personal choice involved in whether individuals have a poor health risk profile, there is clear evidence that external factors such as environment, opportunity, and community culture each have very strong influences.

For example, access to affordable healthy food can often be poor in smaller communities and this, coupled with lower incomes in these areas, adversely affects the quality of peoples’ diets, the prevalence of overweight, and consequently the prevalence of chronic disease.”

From the National Rural Health Alliance Research View HERE

National data pertaining to personal health risk factors typically comes from the ABS National Health Survey and the AIHW National Drug Strategy Household Survey (NDSHS). Some State and Territory Health Departments run their own health surveys (which cannot be aggregated nationally with each other or with the ABS survey because of the different methodologies and definitions used (think different State rail gauges). Consequently data describing aspects of health in regional and especially remote areas can be thin (ie with imprecise estimates in some or all areas).

Example 1

Table 14: Fruit and vegetable consumption, Aboriginal and Torres Strait Islander people 15+ years, 2012-13

Roughly 60% of Aboriginal and Torres Strait Islander Australians 15+ in Major cities and regional/rural areas have inadequate fruit intake, closer to 50% in remote areas (compared with around 50% of all Australians 18+ in major cities and regional/rural areas).

Roughly 95% of Aboriginal and Torres Strait Islander Australians 15+ in Major cities and regional/rural areas have inadequate vegetable intake, perhaps higher (98%) in Very remote areas (compared with around 90%-94% of all Australians 18+ in major cities and regional/rural areas).

Example 2

NACCHO provided graphic

Table 16 Below : Overweight and Obesity, Aboriginal and Torres Strait Islander people 15+ years, 2012-13

Aboriginal and Torres Strait Islander people in rural/regional and Remote areas (29%-33%) were a little more likely to be overweight than those in Major cities (28%), with those in Very Remote areas (26%) least likely to be overweight.

Aboriginal and Torres Strait Islander people in Inner regional areas (41%) were more likely to be obese than those in Major cities (38%), but those in Outer regional (36%) and remote areas (~33%) were less likely to be obese.

Overall, Aboriginal and Torres Strait Islander people in Inner Regional areas were most likely to be overweight/obese (70%), those in Major cities, Outer Regional and Remote areas were less likely to be overweight/obese (~66%), while those in Very Remote areas were the least likely to be overweight/obese (59% )

At the time of writing, the most recent National Health Survey was conducted in 2014-15[1], while the most recent AIHW NDSHS[2] was conducted in 2016, with most recently available results from the 2013 NDSHS. The most recent ABS Australian Aboriginal and Torres Strait Islander Health Survey[3] was conducted in 2012-13.

Some organisations (eg the Public Health Information Development Unit (PHIDU)) have calculated modelled estimates for small areas (eg SLA’s and PHN’s), where the prevalence of some risk factors has been predicted based on the age, sex and socioeconomic profile of the population living there.

Some sites (eg ABS) present risk factor data as crude rates, other sites (eg PHIDU) present risk factor data as age-standardised rates.  The advantage of the age-standardised rates is that the effect of age is largely removed from inter-population comparisons.

For example, older populations (eg those in rural/regional areas) would be expected to have higher average blood pressure than younger (eg Major cities) populations even though the underlying age-specific rates happened to be identical in both populations (because older people tend to have higher blood pressure than younger people).

While crude rates for the older population will be higher, the age-standardised rates in such a comparison would be the same – indicating a higher rate that is entirely explainable by the older age of one of the populations.

Both crude and age standardised rates are useful in understanding the health of rural and remote populations.

 


[1] http://www.abs.gov.au/ausstats/abs@.nsf/mf/4364.0.55.001

[3] http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4727.0.55.0012012-13?OpenDocumentSmoking

Table 1: Smoking status, by remoteness, 2013 and 2014-15

MC

IR

OR/Remote

Percentage

Current daily smoker (18+) (crude) 2014-15 (a)

13.0

16.7

20.9

Current smoker (18+) (Age standardised) 2014-15 (b) (includes daily, weekly, social etc smoking)

14.6

19.0

22.4

MC

IR

OR

Remote+ Very Remote

Current smoker (daily, weekly, or fortnightly) 14+ (crude) 2013 (c)

14.2

17.6

22.6

24.6

Current smoker (daily, weekly, or fortnightly) 14+ (Age standardised) 2013 (d)

14.2

18.6

23.6

24.4

Mean number of cigarettes smoked per week, smokers aged 14 years or older 2013 (e)

85.9

113.1

109.4

126.2

Sources:

Compared with Major cities (13%), the prevalence of daily smoking by people 18 years and older in Inner regional (17%) and Outer regional/Remote areas (21%) is higher.

The NDSH survey reflects these trends albeit with a slightly different age group (14+) and a different definition of smoking (daily plus less frequently), but the NDSH survey adds detail for remote areas where smoking rates are higher again (around 25% versus around 23% in Outer regional).

In addition, the average number of cigarettes smoked by each smoker is higher in regional/rural areas (~110/week) than in Major cities (86/week), and higher again (126/week) in remote areas.

 

Smoking – exposure, uptake, establishment, quitting

Table 2: Smoking characteristics by Remoteness, 2013, 2014 and 2014-15

MC

IR

OR

remote

8.8

17.8

19.3

27.8

Proportion of pregnant women who gave birth and smoked at any time during the pregnancy (2013, crude, National Perinatal Data Collection, exposure tables, Table 5.1.2 )

8.5

17.0

18.9

27.5

Proportion of pregnant women who gave birth and smoked in the first 20 weeks of pregnancy (2013, crude, National Perinatal Data Collection) exposure tables, Table 5.2.2)

3.6

3.1

4.1

*9.4

Proportion of dependent children (aged 0–14) who live in a household with a daily smoker who smokes inside the home (2013, crude, NDSHS exposure tables, Table 6.3)

2.5

2.0

2.7

*2.9

Proportion of adults aged 18 or older who live in a household with a daily smoker who smokes inside the home (2013, crude, NDSHS, exposure tables, Table 7.3)

16.2

15.4

14.7

15.5

Average age at which people aged 14–24 first smoked a full cigarette (2013, crude, NDSHS, uptake tables, Table 9.3)

17.8

22.7

17.8

28.3

Proportion of 12–17 year old secondary school students smoking at least a few puffs of a cigarette (2014, crude, Australian Secondary Students Alcohol and Drug Survey 2014, uptake tables, Table 10.3

54.7

61.1

64.9

67.2

Proportion of persons (aged 18 or older) who have smoked a full cigarette (2013, crude,  NDSHS, uptake tables, Table 10.8)

2.5

3.4

2.5

3.7

Proportion of secondary school students (aged 12–17) who have smoked more than 100 cigarettes in their lifetime (2014, crude, Australian Secondary Students Alcohol and Drug Survey 2014, transition tables, Table 2.3)

20.2

25.9

44.1

45.2

Proportion of young people (aged 18–24) who have smoked more than 100 cigarettes in their lifetime (2013, crude, NDSHS, transition tables, Table 2.6)

21.3

16.8

19.0

15.5

Quitting: Proportion successfully gave up for more than a month (2013, crude, NDSHS, cessation tables, Table 4.3)

29.2

34.2

31.7

32.9

Quitting, Proportion unsuccessful (2013, crude, NDSHS, cessation tables, Table 4.3)

46.3

48.0

47.4

45.2

Quitting: Proportion any attempt (2013, crude, NDSHS, cessation tables, Table 4.3)

35.2

36.3

36.1

36.0

Mean age at which ex-smokers aged 18 or older reported no longer smoking (2013, crude, NDSHS, cessation tables, Table 11.2)

53.1

51.5

46.3

45.0

The proportion of ever smokers aged 18 or older who did not smoke in the last 12 months (2013, crude, NDSHS, cessation tables, Table 12.3)

4.9

6.0

4.8

7.0

Proportion of secondary school students (aged 12–17) who were weekly smokers (2014, crude, Australian Secondary Students Alcohol and Drug Survey 2014, established tables, Table 1.3)

6.9

9.3

6.8

10.4

Proportion of secondary school students (aged 12–17) who were monthly smokers (2014, crude, Australian Secondary Students Alcohol and Drug Survey 2014, established tables, Table 13.3)

13.0

16.7

21.2

18.8

Proportion of adults aged 18 or older who are daily smokers (2014-15, crude, ABS NHS, established tables, Table 3.3)

10.9

7.8

2.9

n.p.

Proportion of smokers aged 18 or older who are occasional smokers (smoke weekly or less than weekly) (2014-15, crude, ABS NHS, established tables, Table 14.3)

40.1

44.7

42.3

52.7

Proportion of Aboriginal and Torres Strait Islander people aged 18 or older who are daily smokers (2012-13, crude, ABS Australian Aboriginal and Torres Strait Islander Health Survey 2012–13, established tables, Table 8i.3)

Source: http://www.aihw.gov.au/alcohol-and-other-drugs/data/ (sighted 11/7/17)
Note: Those estimates above with asterix have large standard errors and should be treated carefully.

Women in rural and remote areas were much more likely to smoke during pregnancy, with 28% of women in remote areas smoking during pregnancy, compared with 18-19% in regional/rural areas, and 9% in Major cities.

It is unclear whether exposure to environmental tobacco smoke varies by remoteness.

Young people outside major cities appeared to have their first cigarette at an earlier age (~15 years as opposed to ~16 years in Major cities.

Secondary school students in Inner regional (~23%) and remote (~28%) areas were more likely to have had at least a few puffs of a cigarette than those in major cities (~18%).

While 20% of young people in Major cities had smoked more than 100 cigarettes in their lifetime, 26%, 44% and 45% of young people in Inner regional, Outer regional and remote areas had done so.

People outside Major cities were as likely or slightly more likely to have attempted to quit smoking, but were less likely to be successful (and more likely to be unsuccessful).

A higher proportion of secondary students outside Major cities were weekly or monthly smokers (6%, 5% and 7% in IR, OR and remote areas versus 5% in Major cities weekly, 9%, 7%, and 10% in IR, OR and remote areas versus 7% in Major cities monthly).

Table 3: Current daily smoker, Aboriginal and Torres Strait Islander people 15+ years, by Remoteness, 2012-13

MC

IR

OR

R

VR

Crude Percent

Current daily smoker

36.2

40.9

39.8

47.4

51.1

Source: http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4727.0.55.0012012-13?OpenDocument Table 2 (sighted 12/7/17)

Prevalence of smoking amongst Aboriginal and Torres Strait Islander people 15 years and older is around 35%-40% in Major cities and regional/rural areas, and close to 50% in remote areas. Note that while the pattern is similar in Table 2 and Table 3 above, the figures for 18+ and 15+ year olds are slightly different.

Smoking Trends

Table 4: Comparison of declines in smoking rate estimates across remoteness areas, people 18+, based on ABS NHS surveys, 2001 to 2011-12

Survey year

MC

IR

OR/Rem

Australia

Crude percent daily smokers

2001

21.9

21.9

26.5

22.4

2004-05

19.9

23.0

26.2

21.3

2007-08

17.5

20.1

26.1

18.9

2011-12

14.7

18.3

22.2

16.1

2014-15

13.0

16.7

20.9

14.5

Source: ABS National Health Surveys

From Table 4 above, rates of smoking have clearly declined in Major cities areas, but have been slower to decline in Inner regional and Outer regional/Remote areas. Rates of smoking in rural areas, apparently static last decade, now appear to be declining. Rates in Major cities and Inner regional areas have declined to 0.59 and 0.76 times the 2001 rates in these areas. The 2014-15 rate in Outer regional areas is 0.79 times the 2001 rate.

Figure 1: Daily smokers 18 years and older, 2007-08, 2011-12 and 2014-15, NHS

Figure 1: Daily smokers 18 years and older, 2007-08, 2011-12 and 2014-15, NHS

Source: ABS NHS http://www.aihw.gov.au/alcohol-and-other-drugs/data/ established tables, Table 3.3 (sighted 11/7/17)

Figure 2: Smokers 14 years and older, 2007, 2010 and 2013, NDSHS

Figure 2: Smokers 14 years and older, 2007, 2010 and 2013, NDSHS

Source: AIHW NDSHS http://www.aihw.gov.au/alcohol-and-other-drugs/data/ tobacco smoking table S3.12 (sighted 11/7/17)

Note: Smokers include daily, weekly and less frequent smokers.

Figures 1 and 2 above both show clear declines in Major cities and Inner regional areas, but the trend in Outer regional and Remote areas is less clear, with ABS data showing a decline in daily smoking rates for people aged 18+ between 2007-8 and 2014-15, but NDSHS data showing little change in smoking rates for people 14+ between 2007 and 2013.

Alcohol

Table 5: Alcohol risk status, by remoteness, 2013 and 2014-15

Alcohol consumption

MC

IR

OR/Rem

Exceeded 2009 NHMRC lifetime risk guidelines, people 18+, crude %, 2014-15 (a)

16.3

18.4

23.4

Exceeded 2009 NHMRC lifetime risk guidelines, people 15+, age standardised %, 2014-15 (b)

15.7

17.4

22.0

Exceeded 2009 NHMRC single occasion risk guidelines, people 18+, crude %, 2014-15 (a)

42.7

48.5

46

MC

IR

OR

R/VR

Abstainer/ex-drinker, crude %, 14+, 2013 (c)

23.1

18.9

20.5

17.5

Low lifetime risk, crude %, 14+, 2013 (c)

60.2

62

56.9

47.6

High lifetime risk, crude %, 14+, 2013 (c)

16.7

19.1

22.6

34.9

low single occasion risk, crude %, 14+, 2013 (c)

40.4

41.8

38.1

30.8

Single occasion risk less than weekly, crude %, 14+, 2013 (c)

23.5

24.4

23.6

22.8

Single occasion risk at least weekly, crude %, 14+, 2013 (c)

13

14.9

17.8

28.9

Sources:

Table 6: Alcohol consumption against 2009 NHMRC guidelines, Aboriginal and Torres Strait Islander people 15+ years, by Remoteness 2012-13

MC

IR

OR

R

VR

Percent

Exceeded lifetime risk guidelines

18.0

18.7

18.2

22.5

14.3

Exceeded single occasion risk guidelines

56.7

57.4

50.7

59.0

41.4

Source: http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4727.0.55.0012012-13?OpenDocument Table 2 (sighted 12/7/17)

The figures in Table 6 are not strictly comparable with those for the total population in Table 5, because  Table 6 refers to people who are 15 years and older, while Table 5 refers to people who are 18 years and older.

The percentage of the 15+ ATSI population exceeding 2009 NHMRC Lifetime risk guidelines is around 15-20% with little apparent inter-regional variation, compared with, for the total population 18+,  16% in Major cities, increasing to 23% in Outer regional/remote areas.

The percentage of the 15+ ATSI population exceeding the 2009 single occasion risk guidelines is around 50-60%, and around 40% in Very remote areas, compared with, for the total population 18+,  40-50% in Major cities, rural and regional areas.

Alcohol trends

Table 7: Type of alcohol use and treatment for alcohol, by remoteness area (per 1,000 population)

MC

IR

OR

R/VR

single occasion risk (monthly) 2004

287

304

321

370

2007

285

292

312

437

2010

274

312

329

413

2013

250

273

315

422

lifetime risk 2004

200

215

234

262

2007

199

210

238

314

2010

189

225

251

310

2013

167

191

226

349

very high risk – yearly 2004

167

185

206

243

2007

172

183

206

288

2010

161

183

218

266

2013

151

166

194

258

very high risk – monthly 2004

77

84

104

130

2007

78

89

100

153

2010

79

94

113

154

2013

70

70

100

170

very high risk – weekly 2004

21

27

41

38

2007

24

28

24

50

2010

37

43

54

78

2013

27

28

38

70

Closed treatment episodes 2004–05

61

72

60

58

2007–08

76

84

80

129

2010–11

69

96

87

135

2013–14

68

79

93

155

Source: NDSHS,  http://www.aihw.gov.au/alcohol-and-other-drugs/data/  alcohol -supplementary data tables, Table S18

Notes:
Single occasion risk (monthly): Had more than 4 standard drinks at least once a month
Lifetime risk: On average, had more than 2 standard drinks per day
Very high risk (yearly): Had more than 10 standard drinks at least once a year
Very high risk (monthly): Had more than 10 standard drinks at least once a month
Very high risk (weekly): Had more than 10 standard drinks at least once a week

There is a clear increase in the prevalence of people who drink alcohol in such a way as to increase their single occasion risk (eg from car accident, assault, fall, etc) and their lifetime risk (eg from chronic disease – liver disease, dementia, cancer etc) as remoteness increases.

In 2013, single occasion risk ranged from 25% of people 14 years or older in major cities to 42% of people in remote areas, while lifetime risk increased from 17% in major cities to 35% in remote areas.

In 2013, The prevalence of people who drank more than 10 standard drinks in one sitting at least once per week, increased from just under 3% in Major cities to 7% in remote areas.

In 2013-14, there were just under 70 closed treatment episodes per 1,000 people living in Major cities, increasing to around 80 and 90 per 1,000 population in Inner and Outer regional areas, to 155 per 1,000 people living in remote Australia.

 

Illicit drug use 2013

Table 8: Illicit drug use, “recent users” 14+, 2013

MC IR OR remote

Crude percent

Cannabis

9.8

10.0

12.0

13.6

Ecstasy

2.9

1.5

1.6

*1.8

Meth/amphetamine

2.1

1.6

2.0

*4.4

Cocaine

2.6

0.8

*1.1

*2.5

Any illicit drug

14.9

14.1

16.7

18.7

Source: AIHW National Drug Strategy Household Survey, 2013. http://www.aihw.gov.au/alcohol-and-other-drugs/data/  Illicit drug use (supplementary) tables S5.6, S5.11, S5.17, S5.21, S5.26.

Note: * indicates large standard error (therefore some degree of uncertainty)

Illicit drug use appears to be higher in Outer regional and remote areas compared with Major cities and Inner regional areas, in large part due to higher rates of cannabis use in these areas, but with apparent lower use of ecstasy and cocaine in regional areas compared with Major cities.

 

Physical activity

Table 9: Physical inactivity, people 18+, 2014-15

MC

IR

OR/Remote

Percentage of people aged 18+ who undertook no or low exercise in the previous week (crude) (a)

64.3

70.1

72.4

Percentage of people aged 18+ who undertook no or low exercise in the previous week (age standardised) (b)

64.8

68.6

71

Sources:
(a) ABS NHS (http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4364.0.55.0012014-15?OpenDocument Table 6.3)
(b) PHIDU (ABS NHS data) (http://phidu.torrens.edu.au/social-health-atlases/data#social-health-atlas-of-australia-remoteness-areas) sighted 18/7/2017

Note that level of exercise is based on exercise undertaken for fitness, sport or recreation in the last week.

Physical inactivity appears to be more prevalent with remoteness, increasing from 65% of people in Major cities to 71% in Outer regional/remote areas.

Table 10: Average daily steps, 2011-12

MC

IR

OR/Rem

Average daily steps, 18+ years, 2011-12 (a)

7,393

7,388

7,527

Average daily steps, 5-17years, 2011-12 (b)

9,097

9,266

9,160

Sources:

In 2011-12, adults living in Outer regional/Remote areas took slightly more steps than those living in Major cities or Inner regional areas, while the number of steps taken by children and adolescents in regional/Remote areas was slightly greater compared with those in Major cities.

Table 11: Average time spent on physical activity and sedentary behaviour by persons aged 18+, 2011-12

MC

IR

OR/Remote

Australia

Hours

Physical activity(a)

3.9

3.4

3.9

3.8

Sedentary behaviour (leisure only)(b)

29.3

28.0

27.9

28.9

Sedentary behaviour (leisure and work)(b)

40.2

35.2

36.0

38.8

Notes:
(a) Includes walking for transport/fitness, moderate and vigorous physical activity.
(b) Sedentary is defined as sitting or lying down for activities.

Source: ABS 2011-12 Australian Health Survey (Physical activity) http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4364.0.55.0042011-12?OpenDocument  Table 5.1

Adults living in Inner regional and Outer regional/Remote areas were about as likely as (or very slightly less likely than) those in Major cities to be sedentary in their leisure time, but appeared to be slightly less likely to be sedentary overall (ie their work involved a greater level of physical activity).

Table 12: Whether children aged 2-17 years met physical and screen-based activity recommendations, 2011-12

MC

IR

OR/Rem

Crude percentage

Met physical activity recommendation on all 7 days(a)(b)

27.5

34.3

34.2

Met screen-based activity recommendation on all 7 days(b)(c)

28.0

29.7

31.0

Met physical activity and screen-based recommendations on all 7 days (a)(b)(c)

9.7

10.9

14.2

Notes:
(a) The physical activity recommendation for children 2–4 years is 180 minutes or more per day, for children 5-17 years it is 60 minutes or more per day. See Physical activity recommendation in Glossary.
(b) In 7 days prior to interview.
(c) The screen-based recommendation for children 2–4 years is no more than 60 minutes per day, for children 5-17 years it is no more than 2 hours per day for entertainment purposes.

Source:
ABS 2011-12 Australian Health Survey (Physical activity) http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4364.0.55.0042011-12?OpenDocument  Table 14.3

Children in rural and regional Australia appeared more likely (34% vs 28%) to meet physical activity recommendations and slightly more likely (30%vs 28%) to meet screen-based activity recommendations than their Major cities counterparts.

 

Fruit and vegetable consumption

Table 13: Fruit and vegetable consumption, people 18+ years, by remoteness, 2014-15

MC

IR

OR/Remote

Crude Percentage

Inadequate fruit consumption(a)

50.0

50.6

51.2

Inadequate fruit consumption(b)

50.4

48.3

48.0

Inadequate vegetable consumption(a)

93.4

93.5

89.3

Inadequate vegetable consumption(b)

n.p.

n.p.

n.p.

Sources:
(a) ABS NHS (http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4364.0.55.0012014-15?OpenDocument Table 6.3)
(b) PHIDU (ABS NHS data) (http://phidu.torrens.edu.au/social-health-atlases/data#social-health-atlas-of-australia-remoteness-areas) sighted 18/7/2017

Note that adequacy of consumption is based on comparison with 2013 NHMRC guidelines.

Half of adult Australians eat insufficient fruit, with little clear difference between major cities and regional/rural areas.

Around 90% of adult Australians ate insufficient vegetables, with little clear difference between major cities and regional/rural areas.

Table 14: Fruit and vegetable consumption, Aboriginal and Torres Strait Islander people 15+ years, 2012-13

MC

IR

OR

R

VR

Crude Percent

Inadequate daily fruit consumption (2013 NHMRC Guidelines)

59.0

60.6

56.9

54.9

49.1

Inadequate daily fruit consumption (2003 NHMRC Guidelines)

62.1

63.6

59.8

58.3

51.6

Inadequate daily vegetables consumption (2013 NHMRC Guidelines)

95.9

93.5

93.6

94.5

97.9

Inadequate daily vegetables consumption (2003 NHMRC Guidelines)

93.8

90.6

90.5

91.2

96.1

Source: http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4727.0.55.0012012-13?OpenDocument Table 2 (sighted 12/7/17)

Roughly 60% of Aboriginal and Torres Strait Islander Australians 15+ in Major cities and regional/rural areas have inadequate fruit intake, closer to 50% in remote areas (compared with around 50% of all Australians 18+ in major cities and regional/rural areas).

Roughly 95% of Aboriginal and Torres Strait Islander Australians 15+ in Major cities and regional/rural areas have inadequate vegetable intake, perhaps higher (98%) in Very remote areas (compared with around 90%-94% of all Australians 18+ in major cities and regional/rural areas).

 

 

Overweight and Obesity

Table 15: Overweight and Obesity, people 18+ years, by remoteness, 2014-15

MC

IR

OR/Remote

Crude Percentage

Persons, overweight/obese (a)

61.1

69.2

69.2

Age standardised percentage

Males overweight (b)

43.8

41.1

34.3

Males obese (b)

25.8

33.1

38.2

Females overweight (b)

28.9

28.3

30.1

Females obese (b)

25.0

32.4

33.7

People  overweight (b)

36.2

34.4

31.4

People obese (b)

25.4

32.6

35.8

Sources:
(a) ABS NHS (http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4364.0.55.0012014-15?OpenDocument Table 6.3)
(b) ABS NHS http://phidu.torrens.edu.au/social-health-atlases/data#social-health-atlas-of-australia-remoteness-areas

Adults in rural/regional areas are more likely to be overweight or obese than people in Major cities (69% vs 61%).

However, there were inter-regional BMI and gender differences:

  • Compared with those in Major cities, males in Inner regional and especially Outer-regional areas were less likely to be overweight (41% and 34%, vs 44%) but much more likely to be obese (33% and 38% vs 26%).
  • Compared with those in Major cities, females in Inner regional and Outer-regional areas were about as likely to be overweight (~29%) but much more likely to be obese (~33% vs 25%).

 

Table 16: Overweight and Obesity, Aboriginal and Torres Strait Islander people 15+ years, 2012-13

MC

IR

OR

R

VR

Crude Percent

Overweight

27.5

28.8

30.1

32.5

26.4

Obese

37.9

41.3

36.2

33.1

32.3

Overweight/obese

65.4

70.1

66.2

65.6

58.8

Aboriginal and Torres Strait Islander people in rural/regional and Remote areas (29%-33%) were a little more likely to be overweight than those in Major cities (28%), with those in Very Remote areas (26%) least likely to be overweight.

Aboriginal and Torres Strait Islander people in Inner regional areas (41%) were more likely to be obese than those in Major cities (38%), but those in Outer regional (36%) and remote areas (~33%) were less likely to be obese.

Overall, Aboriginal and Torres Strait Islander people in Inner Regional areas were most likely to be overweight/obese (70%), those in Major cities, Outer Regional and Remote areas were less likely to be overweight/obese (~66%), while those in Very Remote areas were the least likely to be overweight/obese (59%).

These figures compare with 61% – the prevalence of overweight/obesity for (predominantly non-Indigenous) people living in Major cities.

 

High blood pressure

Table 17: High blood pressure, people 18+, by Remoteness, 2014-15

MC

IR

OR/Remote

Percentage

Crude % (a)

21.9

27.1

24

Age standardised % (b)

22.7

24.6

22.1

Sources:

(a) ABS NHS (http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4364.0.55.0012014-15?OpenDocument Table 6.3)
(b) ABS NHS http://phidu.torrens.edu.au/social-health-atlases/data#social-health-atlas-of-australia-remoteness-areas

Age for age, people in rural/regional Australia appeared to be as likely, or very slightly more likely to have high blood pressure than their counterparts in Major cities (~23% vs ~24%). However, because people in rural/regional areas are older (on average), the prevalence of people with high blood pressure is higher (~26% vs 22%) than

Updated 31/07/2017
To view archived Risk Factors click here

NACCHO Aboriginal Health and #PSA17Syd Part 2 of 2 Health Minister asks pharmacists to help Close the Gap

“For too long Aboriginal people have suffered shorter lifespans, been sicker and poorer than the average non-Indigenous Australian, however, highly trained pharmacists have a proven track record in delivering improved health outcomes when integrated into multidisciplinary practices,” Ms Turner said.

“Strong international evidence supports pharmacists’ ability to improve a number of critical health outcomes, including significant reductions in blood pressure and cholesterol and improved diabetes control. A number of studies have also supported pharmacists’ cost-effectiveness.

Some ACCHOs have already shown leadership in the early adoption of pharmacists outside of any national programs or support structures. NACCHO and PSA are committed to supporting ACCHOs across Australia to meet the medicines needs in their communities by enhancing support for those wishing to embed a pharmacist into their service.”

NACCHO CEO Pat Turner said disparities in the health between Indigenous and non-Indigenous Australians are confronting.

The Pharmaceutical Society of Australia (PSA) and the National Aboriginal Community Controlled Health Organisation (NACCHO) have welcomed the announcement of a trial to support Aboriginal health organisations to integrate pharmacists into their services.

The trial was announced today by the Federal Minister for Health Greg Hunt at PSA17, PSA’s national conference.

Both PSA and NACCHO thank the Minister for supporting this innovative project that will improve the health of Aboriginal and Torres Strait Islander people.

This practical new trial measure has strong stakeholder support and there is growing evidence pharmacists employed by Aboriginal Community Controlled Health Organisations (ACCHOs) can assist to increase the life expectancy and improve the health of Aboriginal and Torres Strait Islander patients.

PSA and NACCHO celebrate the Federal Government’s initiative to implement these important reforms and to further investigate the development of new funding models to help close the gap between the health outcomes of Aboriginal

PSA National President Dr Shane Jackson said having a culturally responsive pharmacist integrated within an Aboriginal Health Service (AHS) builds better relationships between patients and staff, leading to improved results in chronic disease management and Quality Use of Medicines.

“Integrating a non-dispensing pharmacist in an AHS has the potential to improve medication adherence, reduce chronic disease, reduce medication misadventure and decrease preventable medication-related hospital admissions to deliver significant savings to the health system,” Dr Jackson said.

“Additionally, pharmacists integrated within an AHS have a key role to play in assisting Aboriginal and Torres Strait Islander patients navigate Australia’s complex health system.”

“Local community pharmacies will be first approached to see if they are able to provide a pharmacist to work within the AHS according to service requirements of the AHS. If they are unable to or this is not accepted by the AHS in line with principles of self-determination, then the AHS may employ a pharmacist directly.”

A range of stakeholders, including the Pharmacy Guild of Australia, will be on the advisory group.

This trial has been funded through the 6th Community Pharmacy Agreement Pharmacy Trial Program. PSA and NACCHO wish to credit the Pharmacy Guild of Australia for supporting such an important initiative. This trial aims to improve equity of access for Aboriginal and Torres Strait Islander people and further demonstrate the fundamental role that community pharmacists play in primary health care, strengthening the future for all pharmacists and contributing to a sustainable health system.

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.

POVERTY IN AUSTRALIA

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.

PATHWAYS TO POVERTY

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.

CONCLUSION

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)

Findings

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.