Hepatitis B virus (HBV) infection remains an important cause of morbidity and mortality in Aboriginal and Torres Strait Islander people, who have high rates of infection compared with non-Indigenous Australians. An article published in the Medical Journal of Australia this month looks at a study aimed at increasing the evidence base around HBV in Aboriginal and Torres Strait Islander people through an analysis of routine clinical encounter data.
Concluding that a substantial proportion of patients tested were susceptible to HBV, with a high percentage potentially infectious compared with the general population. High levels of active infection and susceptibility to infection suggest many opportunities for transmission and indicate the potential benefit of routine HBV testing and vaccination in this population.
Article by:Tammy M Kimpton, BMed, President, Australian Indigenous Doctors’ Association, Canberra, ACT.
Pictured above second from right at last weeks AIDA launch
The Australian Indigenous Doctors’ Association urges all medical professionals to support and participate in the values it hopes will be embedded in future health policy
This year, we will see the development of a new National Aboriginal and Torres Strait Islander Health Plan to guide governments in improving the health of Aboriginal and Torres Strait Islander Australians.1 Development of the Health Plan will be led by the Minister for Indigenous Health, with the support of a stakeholder advisory group to bring together the government and organisations with expertise in Indigenous health.2
The aim of this Health Plan is to shape the tone, direction and content of Indigenous health policy into the future. Apart from becoming familiar with the evidence and government priorities on areas of Indigenous health that relate to our work, medical professionals should note the particular values and themes that the Australian Indigenous Doctors’ Association (AIDA) wants to see embedded throughout the document; these include culture, partnership, Indigenous leadership and workforce. These principles are inextricably linked and are important not only to federal policy development and implementation but also to individual medical professionals in a range of areas, including in our day-to-day interactions with patients, care planning and staff recruitment and development.
Workforce will need to be an important feature of the Health Plan because building an adequate health workforce is crucial to delivering high-quality, sustainable health services for Indigenous people. The Indigenous medical workforce in Australia is growing, but Indigenous people are still underrepresented in this area. In 2011, the intake of first-year Indigenous medical students in Australian universities reached parity at 2.5% — for the first time matching the proportion of Australia’s population made up of Indigenous people.3 To ensure that the Indigenous medical workforce continues to grow, academic, professional and cultural support is essential. In particular, Indigenous medical students and doctors are more likely to stay and thrive in learning and working environments that consistently demonstrate cultural safety.3
The solution to both a stronger workforce and further improvements in Indigenous health is partnership: our people working alongside non-Indigenous people in order to achieve an agreed goal. Such partnerships are seen in collaboration agreements which spread across the medical education continuum. Agreements currently exist between AIDA and Medical Deans Australia and New Zealand, and AIDA and the Confederation of Postgraduate Medical Education Councils; an agreement will soon be launched between AIDA and the Committee of Presidents of Medical Colleges. This collaboration did not happen overnight; it was a lengthy process, with trust being built over time and through each organisation demonstrating its commitment to improving Indigenous health. These best-practice models are available on the AIDA website (http://www.aida.org.au/partnerships.aspx) and should be recognised by all medical professionals as a best-practice framework for improving Aboriginal and Torres Strait Islander Health.
For Aboriginal and Torres Strait Islander peoples, health is not just about an individual’s physical wellbeing; it is a holistic concept that encompasses the social, emotional and cultural wellbeing of the entire community. AIDA asserts that the Health Plan needs to embed Aboriginal and Torres Strait Islander cultures at its centre in recognition of the importance of culture to the health and wellbeing of Indigenous people. As medical professionals, we must also embed culture in the provision of health services to Aboriginal and Torres Strait Islander people, as evidence shows correlations between increased cultural attachment and better health and wellbeing.1 In achieving this, it is important that the Health Plan be developed and conducted through genuine partnerships between governments, Indigenous organisations and communities, not only because such an approach is consistent with what is contained in the United Nations Declaration on the Rights of Indigenous Peoples, but because it makes good sense.4
AIDA recommends creating strong partnerships with Indigenous organisations and communities to guarantee Indigenous participation in decision making and showcase strong Indigenous leadership in communities.3
Aboriginal and Torres Strait Islander leadership, particularly through the peak national health bodies, is paramount in providing government with professional advice from Indigenous health practitioners in developing the Health Plan.3 AIDA recognises that Aboriginal and Torres Strait Islander community-controlled health organisations play a central role in the health of Indigenous people; however, it is also important that members of the non-Indigenous mainstream health workforce play their role in delivering equitable services for Aboriginal and Torres Strait Islander people. It is expected that the National Aboriginal and Torres Strait Islander Health Plan will be released later this year. I encourage you, upon reading it, to ask yourself what your role is in delivering quality and culturally appropriate health care to Aboriginal and Torres Strait Islander people, and to consider how this role could be strengthened. As members of the health workforce, we need to locate ourselves within the Health Plan and implement strategies in partnership with Indigenous communities and organisations. AIDA argues that this combination of strategic action and partnership is critical to achieving equitable health and life outcomes for Aboriginal and Torres Strait Islander people.
1School of Public Health, University of Sydney, Sydney, NSW.
2Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, Perth, WA.
Regular monitoring and supportive federal and state public policy are critical to closing the gap in child health
Health and wellbeing of children and young people are the keys to human capability of future generations. Human capability includes the capacity to participate in economic, social and civil activities and be a valued contributor to society;1 it means that not only can you usefully live, work and vote, but you can be a good parent to your children. Thus there is no better investment that the state can make than to influence factors that will enhance the health and wellbeing of children and youth.
There were an estimated 200 245 First Nations2 children aged 0–14 years in Australia in 2011, comprising 4.9% of the total child population and 35% of the total First Nations population.3 With such a high proportion of children compared with the non-Aboriginal population, the First Nations population is much younger, with fewer adults per child to care for them. An Australian Research Alliance for Children and Youth report adds to evidence from the most recent Australian Institute of Health and Welfare report on the health of Australia’s children to document the growing divide between the health of First Nations and other Australian children.3,4
Child health indicators include mortality rates (Box, A), prevalence of chronic conditions, indicators of early development (including rates of dental decay [Box, B]), promotion of early learning (eg, adults reading to children in preschool years) and school readiness assessed with the Australian Early Development Index (Box, C).3 Risk factors for poor child health include: teenage pregnancies; smoking and alcohol exposure during pregnancy; pregnancy outcomes such as stillbirths, low birthweight and preterm births; the proportion of children aged 5–14 years who are overweight or obese; and the proportion of children aged 12–15 years who are current smokers. In addition, indicators of the level of safety and security of children — including rates of accidental injury, substantiated reports of child abuse and neglect, evidence of children as victims of violence, and indicators of homelessness and crime — further highlight how poorly Aboriginal children fare during childhood.
Owing to significant gaps in available data, Australia is not included in UNICEF reports relevant to First Nations children, including The children left behind: a league table of inequality in child well-being in the world’s rich countries.5 This report is important for many First Nations children who experience conditions near the bottom because it focuses on closing the gap between the bottom and the middle:
We should focus on closing the gap between the bottom and the middle not because that is the easy thing to do, but because focusing on those who do not have the chance of a good life is the most important thing to do.5
While there has been progress, particularly in educational outcomes, the gap in healthy child development in safe and secure environments is disturbing. It has resulted from of a variety of complex social circumstances, due to colonisation, marginalisation and forced removals. To effectively and successfully interrupt and reverse these generational traumas on today’s children, careful and sensitive First Nations-led programs are required. Programs in Canada and Australia have shown that the major protective and healing effects of strong culture are immensely powerful, even in urban situations, which highlights the value of strong government support for such programs in Australia. For example, putting First Nations children and youth into cultural programs is more effective than incarceration for preventing recidivism, and increased recognition of Aboriginal cultures in school curricula increases rates of high school completion by First Nations students.6
Drawing on our own and overseas data,7 we believe that Australian services have failed to close the gap in child health because they have been developed without involving or engaging First Nations people. When participatory action research methods are used, as has been done with Inuit communities in Nunavut in Canada,8 the use and success of services are dramatic. Such strategies lead to higher levels of local employment, higher self-esteem, and reduced mental illness and substance misuse among First Nations people. British Columbian data on First Nations youth suicide rates have shown that the lowest rates in Canada were in communities with strong culture and Aboriginal control of services (eg, health, education and community safety).9 This means that a major rethink of services for First Nations people is needed, and that centralised policy applied to multiple diverse communities is unlikely to work. Although the policy content of what needs to be done can be developed centrally based on existing evidence (eg, alcohol in pregnancy causes brain damage, early childhood environments are vital to help children to be ready for school, complete immunisation prevents infections, and avoiding sweet drinks prevents obesity and dental decay), development and implementation of services need to be done locally and with community involvement. A great example of this is the strategy to overcome fetal alcohol spectrum disorders (FASD) that was developed by Aboriginal women June Oscar and Emily Carter and the First Nations people of Fitzroy Valley. This comprehensive and effective strategy has enabled the community to think and act beyond the stigma of FASD — community members drove the design and implementation of programs to prevent FASD, and they created opportunities and support mechanisms to enable the best possible treatment for children with FASD.10
Building on the Australian Research Alliance for Children and Youth report,4 we need a consistent national framework for monitoring health status and an understanding of the impact of federal and state policies on First Nations children. Recent policies with the potential to affect First Nations children include: the Northern Territory intervention, the loosening of alcohol restrictions in the Northern Territory, policies aimed at addressing overrepresentation of Aboriginal children in child protection reporting, housing policies (including evictions and the transfer of public housing properties to ownership and management by non-government organisations), policies that have changed financial support for single parents, education policies aimed at assessing school readiness and other policies aimed at closing the gap in health. The effects of these policies on First Nations children need to be considered in regular assessments of public policy, with the needs of children prioritised over competing interests.
The exciting thing is that we now have a growing number of Aboriginal health care providers and other university-trained professionals to employ to make services effective. We have equity in medical student intakes which augurs well for future progress in this critical area. The dream of having appropriate, culturally safe policies, programs and services for our First Nations children can become a reality if it is supported and promoted by all levels of government.
Child health indicators that show a divide between First Nations and other Australian children*
SES = socioeconomic status. LBOTE = language background other than English. * Adapted with permission from A picture of Australia’s children 2012.3† Developmentally vulnerable on one or more Australian Early Development Index domains.
Megan E Passey, BMed(Hons), MPH, MSc, Deputy Director — Research1
Jamie Bryant, PhD, BPsych(Hons), ARC Postdoctoral Research Fellow, School of Medicine and Public Health2
Alix E Hall, BPsych(Hons), PhD Candidate, Priority Research Centre for Health Behaviour2
Robert W Sanson-Fisher, PhD, ClinMPsych, BPsych(Hons), Laureate Professor of Health Behaviour, School of Medicine and Public Health2
1 University Centre for Rural Health — North Coast, University of Sydney, Sydney, NSW.
2 University of Newcastle, Newcastle, NSW.
Aboriginal and Torres Strait Islander women are more than three times more likely to smoke during pregnancy than non-Indigenous women, greatly increasing the risk of poor birth outcomes.
Our systematic review found that there is currently no evidence for interventions that are effective in supporting pregnant Aboriginal and Torres Strait Islander women to quit smoking, which impedes development and implementation of evidence-informed policy and practice.
There is an urgent need for methodologically rigorous studies to test innovative approaches to addressing this problem.
Antenatal smoking is the most important modifiable cause of adverse pregnancy outcomes.1 Indigenous Australian women are more than three times more likely to smoke during pregnancy than non-Indigenous women.2 As a result, adverse outcomes are more frequent in Indigenous than non-Indigenous babies, with smoking as an independent risk factor.3
Reviews of antenatal smoking interventions have shown effective cessation strategies for pregnant women.1 However, persistently high rates of smoking during pregnancy among Indigenous women suggest that current interventions have had limited impact. Finding ways to effectively reduce smoking in pregnant Indigenous populations is a high priority. Previous systematic reviews have examined smoking cessation interventions for Indigenous peoples; however, none has specifically investigated smoking cessation among pregnant Indigenous women.4,5
We undertook a systematic review to examine the effectiveness and methodological quality of smoking cessation interventions targeting pregnant Indigenous women. In December 2012 we searched MEDLINE, PsycINFO, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and Cochrane databases with appropriate search terms, and checked reference lists of retrieved articles. Papers were included if they reported a smoking cessation intervention aimed at pregnant Indigenous women, included a control group and provided cessation results specifically for pregnant Indigenous women. Only peer-reviewed, English-language papers were included. We extracted data and assessed methodological quality against Effective Practice and Organisation of Care quality criteria.6
Of 59 identified papers only two met eligibility criteria: one from the United States with Alaskan Native women,7 and one from Australia with Aboriginal and Torres Strait Islander women.8 Both involved culturally tailored interventions specifically developed for the target group, and used face-to-face counselling, structured follow-up, attempts to involve family members and nicotine replacement therapy (NRT). Both studies found no treatment effect and had a number of limitations (Box).
This lack of evidence of effective smoking cessation interventions for pregnant Indigenous women prevents implementation of evidence-based programs and highlights a critical need for methodologically rigorous testing of possible strategies.
What interventions should we test?
Evidence from research with Indigenous populations, and with pregnant women generally, provides guidance about the strategies that hold promise for pregnant Indigenous women. These strategies are outlined as follows.
Tailor interventions to local culture
Interventions for Indigenous people need to be culturally secure and locally tailored in order to increase acceptability and accessibility.4,5,9 Involving local people in developing and tailoring intervention resources to the local context is critical for improving cultural appropriateness, building ownership and enhancing a sense of autonomy, all of which are important in successful cessation.10
Include routine assessment and support
Smoking cessation guidelines for pregnant women recommend a systematic approach to cessation where every woman is asked about her smoking status, with smokers followed up and supported to quit in a respectful manner.11 Health professionals may be reluctant to repeatedly assess smoking status due to concerns that it may be deleterious to their relationship with women and the women’s engagement with care.9,12–14 However, most Indigenous women expect antenatal care to include smoking cessation advice.15 Systems to support routine assessment and support should be included in intervention trials.
Provide relevant information
Indigenous women’s knowledge of specific risks of smoking while pregnant is often vague.9,15,16 Providing information on the harms of smoking and benefits of cessation may motivate some women to attempt to quit. Discussing the woman’s role as a mother and a role model for her family may be more motivating for some Indigenous women than health risk narratives and should be addressed in intervention trials.
Deliver cessation support through all antenatal providers
Overall, 78% of Indigenous women attend five or more antenatal visits during their pregnancies.2 Providing cessation support through routine antenatal care overcomes barriers to attending separate services.13 A collaborative approach between midwives, Aboriginal Health Workers (AHWs) and doctors, all providing consistent advice and support, will reinforce the importance of cessation. The credibility of medical practitioners may be a significant motivating factor for some women. In cases where midwives provide much of the care, the close relationship and frequent contact allows ongoing support. AHWs’ cultural knowledge and strong links with local families will enhance implementation of cessation support.14 In a survey of Indigenous women, over 70% of women felt that support from these professionals was likely to be helpful.17
Involve other members of the community
The high prevalence of smoking in Indigenous communities has resulted in smoking being “normalised” as a socially acceptable behaviour, with frequent triggers to smoke and cigarettes being readily available.9,16,18 Smoking is important in social relationships, and cessation can lead to feelings of isolation.18,19 Supportive environments for quitting have aided cessation among Indigenous ex-smokers.10 Trialling interventions that incorporate mechanisms to provide a supportive, pro-cessation environment, such as involving household members in supporting women, peer support groups and whole community interventions should be further explored.20
Interventions that incorporate strategies to prevent smoking relapse result in fewer women relapsing in late pregnancy.1 Up to 80% of women who quit during pregnancy relapse within 1 year.21 Specific relapse prevention support should be provided during pregnancy and postpartum, including information about the effects of environmental tobacco smoke on the baby, support to make a smoke-free home and support for household members to quit smoking.21 Relapse prevention strategies have not been examined among Indigenous women and should be included in future trials.
Use contingency-based financial rewards
Systematic reviews of antenatal smoking cessation interventions have found that financial rewards contingent on successful smoking abstinence are significantly more effective than other interventions.1 However, their efficacy with Indigenous women has not been tested. Australian surveys indicate that contingency-based rewards are considered likely to be helpful by over 90% of Indigenous women and 83% of their antenatal providers.17,22 This approach should be further explored with Indigenous women.
Surveys of pregnant Indigenous women found that tobacco smokers were more than three times more likely than non-smokers to report cannabis or alcohol use, both of which are risk factors for continued smoking.17 Given the known negative impact of these substances on birth outcomes and the interaction between their use and use of tobacco, interventions should include explicit assessment of other substance use, with support to address these if required.11
A lack of protocols and poor smoking cessation support skills have been identified as barriers to providing cessation support to pregnant Indigenous women.12 Well defined protocols detailing specific procedures, and the role of each provider, may assist in increasing provision of support in routine care.13 Training should cover skills in smoking cessation support, supportive communication and using protocols, as well as recording women’s smoking status, cessation behaviour and support provided, to facilitate consistent advice from all team members.
Conducting complex behavioural intervention trials is difficult. Potential challenges include:
As smoking cessation support is provided at both the service and individual level, randomisation at the individual level is inappropriate as contamination between groups is likely. Cluster randomised controlled trials with randomisation of dispersed services may reduce this problem but require larger sample sizes and more participating services, increasing costs and logistics challenges. As services and communities may not be willing to be randomly allocated to “usual care”, it may be more appropriate to undertake a head-to-head comparison of two approaches considered likely to be effective.23
Adherence to protocols
Poor adherence to intervention protocols may occur as a result of unsuitable intervention requirements, inadequate staff training, high staff turnover and lack of systems to support the intervention. Smoking among AHWs has also been identified as a potential barrier to implementation and would need to be addressed as part of the intervention.14,16 Strong organisational support for the implementation and evaluation of strategies is critical to supporting adherence. Collaborative development of the intervention and study design with Indigenous services and pilot studies to assess acceptability and feasibility of the research will help successful implementation.
Given the importance of finding effective strategies to decrease smoking among pregnant Indigenous women, and the current lack of evidence to guide this process, there is an urgent need for rigorous studies to test innovative approaches. While there are many challenges in this research, these may be managed with existing methods for testing complex interventions in diverse settings.24 Without an evidence base, we risk implementing ineffective strategies, failing to improve outcomes and wasting scarce resources.
Article by: Kerry Arabena, Director and Chair of Indigenous Health,1and Chair2 1Onemda VicHealth Koori Health Unit, University of Melbourne, Melbourne, VIC.2National Aboriginal and Torres Strait Islander Health Equality Council, Canberra, ACT.
Continuing to close the health gap will require innovation; long-term, systematic approaches that improve the quality and integrity of data; collaborations and partnerships that reflect an ecological approach to health, and recognition of the proper place and contribution of Aboriginal and Torres Strait Islander peoples in Australian society
At long last there are signs that the gaps between the health of Aboriginal and Torres Strait Islander people and non-Indigenous people are closing — but systematic, long-term action needs to continue both within and outside the health system to realise true health equality, and for us to know that we have achieved it.
According to the 2012 report of the Aboriginal and Torres Strait Islander Health Performance Framework, a number of positive trends in Aboriginal and Torres Strait Islander health include:
the mortality rate has declined significantly (by 33%) between 1991 and 2010 among people living in Western Australia, South Australia and the Northern Territory combined;
deaths due to avoidable causes decreased significantly in WA, SA and the NT combined, down 24% between 1997 and 2010;
deaths from respiratory disease decreased significantly from 1997 to 2010, and the gap with non-Indigenous Australians has also narrowed; and
mortality among infants aged less than 1 year declined by 62% between 1991 and 2010, perhaps reflecting the benefits of immunisation, improved access to primary health care services, the use of antibiotics and earlier evacuation to hospital for acute infections.1
Of course there remain areas where the gap persists or in some cases has grown, including chronic disease, injury, cancer, disability and low birthweight babies. It appears that in some areas (such as cancer) improvements in the quality, accessibility and impact of treatment are resulting in significantly improved death rates for non-Indigenous Australians, but Aboriginal and Torres Strait Islander people are missing out. The causes of this discrepancy seem to lie in disparities in stage at diagnosis, treatment received and survival rates.
Cutting across these trends are persistent gaps in the quality of data. Our inability to know whether large investments made in recent years in Aboriginal and Torres Strait Islander health are paying off should be a major focus for future strategies. In general, our population does not seem to be benefiting from the same level of sophisticated population-level tracking, health assessment or data integrity that majority populations take for granted.2 Good data are crucial, not just to know the impact of what we have done, but to guide what we are doing.
In this context it is pleasing to see the recent process of developing a new national plan to guide future investments in Aboriginal and Torres Strait Islander health, developed through a collaborative process including Aboriginal and Torres Strait Islander peak bodies, communities, services, researchers, advocates and clinicians.3 The new national plan needs to set directions for the next 10 years and expand and align with an ecological view of health, include concepts important to Aboriginal and Torres Strait Islander peoples and influence other sectors that affect health, such as education, employment, housing and early childhood development. This multifocal approach could have implications for the design, implementation and evaluation of projects, and will necessitate a reconceptualisation of partnerships and collaborations, while fostering innovations and knowledge exchange.
Finally, we will need to redress some of the less palatable aspects of the health system that contribute to inequality, such as racism.4 Embodied in dubious practices, disparities in access and subtle variations in effort within health and other institutions and programs, racism has had and continues to have a real and damaging impact on the health of Aboriginal and Torres Strait Islander people. It is clear that full health equality cannot be achieved until racism and other practices that deny our status and rights as the original and First Peoples of Australia can be overcome. My hope is that not only do we redress racism in health and other systems, but that this nation recognises and enables each and every Aboriginal and Torres Strait Islander person the opportunity to rise to the full potential of our existence.
Article by: Ruth Armstrong, Senior Deputy Editor – Medical Journal of Australia, Sydney, NSW.
This issue of the MJA, timed to coincide with NAIDOC Week, is devoted to exploring the health status of Australia’s Aboriginal and Torres Strait Islander peoples — particularly our children and young people. Children aged 0–14 years make up 35% of the Australian Indigenous population, write Eades and Stanley.
Data on their health and development are patchy but indicate a growing divide between Indigenous and other Australian children for several risk factors and conditions. Azzopardi and colleagues add a systematic review of the evidence for young people aged 10–24 years into the mix, finding gaps in the observational research for urban settings, mental health and injury, and confirming the well known dearth of interventional studies.
Two studies in this issue add to the scant evidence available by testing simple interventions that might lead to improvements, such as providing subsidised fruit and vegetable boxes to disadvantaged families in regional towns (Black and colleagues) and swimming pools in remote communities (Stephen and colleagues).
Turning our thoughts to the health needs of Indigenous children is always important but is particularly timely now. A federal election, with all its potential for policy upheaval, is just 2 months away. In the first article in our pre-election series, Arabena recognises an urgent need for better data to evaluate existing and future policies, and envisages a plan for health that takes Aboriginal and Torres Strait Islanders’ perspectives, wishes and culture into account, and brings an end to aspects of the health system that contribute to inequality, such as racism.
Independently of the election, the Australian Government is developing a new National Aboriginal and Torres Strait Islander Health Plan for the next decade. Kimpton, president of the Australian Indigenous Doctors’ Association, says the plan will have the best chance of success if it has at its heart some important principles: nurturing of the Indigenous health workforce; genuine, strong partnerships with Indigenous organisations; fostering culture as integral to health and wellbeing; and promoting Indigenous leadership, while involving the whole health system.
The solutions to many health problems for Indigenous children lie outside the health system, but making our health services accessible, culturally safe and appropriate places will lead to better outcomes for the families who inevitably need them. “Cultural competence” can be a daunting term for doctors. Thackrah and Thompson encourage us to look at our own culture of medicine and the practical realities of patients’ lives when trying to put this difficult concept into practice.
Amid all this thinking and soul searching, there are good examples of what works — innovative health promotion and education programs combining the nurturing effects of “country” with exchanges of new knowledge (Webb and colleagues), and thriving health services where Indigenous families can truly have their health needs met and that also serve as centres of outreach bringing sorely needed medical expertise to remote communities (McGilvray).
As Milroy reminds us in her response to a study that found many Aboriginal children had been exposed to traumatic, potentially health damaging experiences (Askew and colleagues), Indigenous children need access to the best possible health services right now and for years to come.
History tells us that policies fail, and services falter, when they are not developed in consultation with those for whom they are designed. On this point, Eades and Stanley concur: “… we believe that Australian services have failed to close the gap in child health because they have been developed without involving or engaging First Nations people”. At this important time in Australian history, we have yet another chance to get it right. Be it by public policy or individual action, we need to do all we can to make our health services places of healing for Aboriginal and Torres Strait Islander children and their families.
Study author Dr Andrew Black said a broader trial was needed to investigate whether it was feasible to have subsidised healthy food programs in Australia.
“The program could be adapted to target low-income families more generally,” Dr Black and his co-authors wrote.
But Dr Black, who is a general practitioner with a NSW Aboriginal health service and a fellow at the University of South Australia, said the proportion of children with iron deficiency and anaemia did not change.
The study involved children from 55 families who were aged under 18 and lived in northern NSW.
Each family was given a weekly box of subsidised fruit and vegetables, valued at $40 and nutritional information and recipes were provided to families.
A separate study published in the same journal found the health and behaviour of Aboriginal and Torres Straight Islander children in urban areas may be adversely affected by their high-levels of exposure to stressful events.
The study conducted between 2007 and 2010 at a Brisbane indigenous health service found that of 344 indigenous children aged 14 years or under about half had experienced a stressful event in their lives.
There was a strong association between those events and a history of ear and skin infections and parental or carer concerns about the child’s behaviour, the study says.
Eleven per cent of study participants had witnessed domestic violence, while 10 per cent had experienced it personally.
“The risk of not addressing both the causes and the effects of childhood exposure to stressful events is that the disparity between indigenous and non-indigenous Australians is unlikely to improve,” the study authors wrote.
Dr Mark Wenitong, Senior Medical Officer at the Apunipima Cape York Health Council and Part time PHMO at NACCHO pictured bottom left one of the team
A UNIQUE trial of a smoking intervention for pregnant Aboriginal and Torres Strait Islander women is the winner of the 2013 MJA, MDA National Prize for Excellence in Medical Research, for the best research paper published in the Medical Journal of Australia in the previous calendar year.
Entitled “An intensive smoking intervention for pregnant Aboriginal and Torres Strait Islander women: a randomised controlled trial”, the winning paper was authored by Sandra Eades, head of the Indigenous Maternal and Child Health Research Program at the Baker IDI Heart and Diabetes Institute in Melbourne; Rob Sanson-Fisher, Laureate Professor of Health Behaviour at the University of Newcastle; Mark Wenitong, Senior Medical Officer at the Apunipima Cape York Health Council in Cairns; Katie Panaretto, Population Health Medical Officer at the Queensland Aboriginal and Islander Health Council in Brisbane; Catherine D’Este, Professor of Biostatistics at the University of Newcastle; Conor Gilligan, lecturer at the University of Newcastle; and Jessica Stewart, a PhD student at the University of Newcastle.
Smoking rates for Aboriginal and Torres Strait Islander women are high and a particular problem is the prevalence of smoking during pregnancy, which is thought to be about 50%.
In this trial — the first of its kind — 263 women attending their first antenatal visit at one of three Aboriginal community-controlled health services were randomly allocated to two pathways.
The intervention group was invited to participate in a program of tailored advice and ongoing support to quit smoking, delivered by a general practitioner and other health care workers.
The “usual care” group received standard advice and support from the GP at scheduled antenatal visits.
There was a high uptake of the intervention by the women to whom it was offered but this was a “negative study” in the sense that smoking rates remained high at 36 weeks of pregnancy — 89% in the intervention group and 95% in the usual care group — a difference that was not statistically significant.
This was in some ways a disappointing outcome, especially as it came on the back of extensive background research and a unique collaboration by this group of researchers from the Baker IDI Heart and Diabetes Institute in Melbourne, the University of Newcastle, the Apunipima Cape York Health Council and the Queensland Aboriginal and Islander Health Council.
However, the judges from the MJA’s Content Review Committee recognised that this research, conducted with robust and transparent methodology in a difficult real-world setting, contributes to the very important endeavour of improving the health of Aboriginal and Torres Strait Islander women and their children.
Sponsored by MDA National, this prize awards the authors a cash prize of $10 000.
Doctors should be able to provide subsidised “prescriptions” for healthy food to people in remote Aboriginal communities, says an Indigenous nutrition expert.
Professor Kerin O’Dea, Professor of Nutrition and Public Health in the Health Sciences Division of the University of South Australia, made the call after a study she co-authored found that people in three remote Aboriginal communities ate mostly processed foods high in sugar and salt and low in fruit and vegetables.
The study collected data on food purchased in three remote Northern Territory communities over a 12-month period and examined food expenditure, estimated per capita intake, nutrient profile and density relative to daily requirements, and major nutrient sources.
The study found that one-quarter of total food expenditure was spent on non-alcoholic beverages, with 15.6% spent on sugar-sweetened soft drinks. As little as 2.2% of money spent went on fruit, and only 5.4% on vegetables. Sugars contributed between 25.7% and 34.3% of energy, of which 71% was refined sugar and sugar-sweetened drinks.
“People in the study communities spend more on food ($379 to $418 per person per month) compared with the expenditure estimated for other Australians ($314 per person per month),“ the study said.
Professor O’Dea said the study highlighted the high cost of food in remote communities, especially perishable foods like fresh fruit, vegetables, and lean meat which should be staple foods.
“We should consider subsidising healthy foods for low income people in remote parts of Australia. I suggest we could have such a system incorporated into primary health care, doctors should be able to provide ‘prescriptions’ for healthy food,” Professor O’Dea said.
“We spend huge amounts on people once they are ill, but are reluctant to support people to remain healthy.”
Dr Vicki Flood, Nutritional Epidemiologist and Associate Professor in Public Health at the University of Woolongong said she could see value in incorporating food prescriptions into the primary health care system to help highlight the importance of a healthy diet.
“Medications are very costly and yet we could achieve improved health with better support for healthier diets, and would likely be a much smaller proportion of other health costs,” Dr Flood said.
“It could be implemented with a whole suite of preventive health strategies. This might include: better access to more affordable healthy foods (eg. reduced cost for fruit and vegetables, including subsidy of transport costs); good interpretative front of pack labelling like traffic light labelling to make it easier for people to identify healthier food choices; support to build capacity among Aboriginal communities about food and nutrition, etc.”
“You want to give people some scope to have healthy food in their diet but you still want them to be free to make that choice. I think it is about encouraging healthy choices to be easier choices.”
Dr Annabelle Wilson, Public Health Research Fellow at Flinders University said supporting people to remain healthy using a strengths-based approach was vital.
“As the authors suggest in the paper a cost benefit analysis of improved dietary intake on health outcomes is an important part of demonstrating why and how this could be done,” Dr Wilson said.
“There is no doubt that the cost of food in remote communities needs to be addressed, in particular the cost of healthy food,”
“I would advocate for a system that reduces the cost of healthy food at the community level, focuses on the health and well-being of all community members, builds local community capacity and is driven by local community members.”