NACCHO MJA health news: Improving the health of Aboriginal children in Australia

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Article by:

Sandra J Eades, BMed, PhD, Professor1
Fiona J Stanley, MB BS, MSc, MD, Professor2
1 School of Public Health, University of Sydney, Sydney, NSW.
2 Telethon 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.

NACCHO smoking health news: How will we close the gap in smoking rates for pregnant Indigenous women?

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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.
Summary
  • 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.9,1214 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

Address relapse

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.

Other substances

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

Training providers

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.

Possible challenges

Conducting complex behavioural intervention trials is difficult. Potential challenges include:

Random allocation

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.

Conclusions

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.

Social media: How will your Aboriginal health services put the public in public health information dissemination

 Using new communications technologies to allow people to directly receive relevant and up-to-the-minute public health information could benefit the health of millions,” says Professor Robert Steele .

Copies of the relevant peer-reviewed publications for this study are available on the

Health Informatics Computation and Innovation Lab website

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Article first published University of Sydney

NACCHO Social media Project

NACCHO is currently assisting with the research for a major national health sector magazine on how our Aboriginal community controlled heath sector is using social media to Close the Gap (e.g. smoking campaigns, healthy lifestyle etc.)

Developing social media policies in ACCHO

If your mob has a positive story to tell or requires assistance developing a social media policy for your staff and/or organisation, contact  media@naccho.org.au

You can follow NACCHO on TWITTER,FACEBOOK or COMMUNIQUE BLOG here

The research, by Professor Robert Steele and PhD candidate Dan Dumbrell

 According to new research from the University of Sydney, micro-blog-based services such as Twitter could be a promising medium to spread important information about public health.

The research, by Professor Robert Steele and PhD candidate Dan Dumbrell, indicates social media networks such as Twitter have distinct and potentially powerful characteristics that distinguish them from traditional online methods of public health information dissemination, such as search engines. This research is part of Professor Steele’s broader investigations on the impacts of emerging technologies on health and health care.

“Using new communications technologies to allow people to directly receive relevant and up-to-the-minute public health information could benefit the health of millions and change the paradigm of public health information dissemination,” says Professor Steele, Head of Discipline and Chair of Health Informatics at the University’s Faculty of Health Sciences.

“Twitter has a powerful characteristic in that it is members of the public who distribute public health information by forwarding messages from public health organisations to their followers.”

According to Professor Steele, this provides a new way for public health organisations to both engage more directly with the public and leverage individuals’ networks of followers, which have ‘self-organised’ by topic of interest. Major social networks currently have hundreds of millions of users and continue to grow rapidly.

While most public health information is sought through online search engines, it has previously been found that relevant public health documents are not always successfully located and disseminated due to the user’s search methods.

Important public health information that may benefit from micro-blogs could include communicable disease outbreaks, information about natural disasters, promotion of new treatments and clinical trials, and dietary and nutrition advice.

“When you look for information on a search engine, algorithms and computers determine the most important results. With social media networks, you have a ‘push’ mechanism, where interested individuals are directly alerted to public health information. You also have a prodigious network of users whose time and effort to find and follow relevant accounts, and to filter which information is forwarded or retweeted represents a powerful aggregate human work effort.”

The researchers examined a sample of more than 4,700 tweets from 114 Australian government, non-profit and for-profit health-related organisations. Each of the tweets was categorised according to the health condition mentioned, the type of information provided, whether a hyperlink was included, and whether there were any replies or retweets.

Non-profit organisations made up almost two-thirds of the group, and had a much higher average following than their for-profit counterparts. The majority of tweets in the sample, 59 percent, were non condition-specific, followed by tweets about mental health, cancer and lifestyle (fitness and nutrition).

“Most major health conditions were present in the twittersphere, but we were somewhat surprised by the proportions,” says Professor Steele.

“Four of the government’s National Health Priority Areas were underrepresented in our sample, including asthma, arthritis and musculoskeletal conditions, injury prevention and control, and obesity. These conditions only made up 1.7 percent of health-related tweets.”

For-profit organisation tweets were dominant in the maternity, pharmaceutical and dental areas, most likely because of their potential as a source of commercialisation or potential profit.

However, despite having the largest average number of tweets, for-profit organisations also had the lowest number of average followers, indicating consumers were more likely to reject sites they considered promotional or sales-based.

Non-profit Twitter accounts provided the majority of tweets in the sample, with a large number of fundraising and awareness-raising tweets.

However, despite having a far lower average number of tweets, government accounts were found to be the most successful at disseminating public health information, with the greatest number of average followers and re-tweets.

There were also a number of common characteristics to highly re-tweeted public health advice tweets. Actionable tweets, which provided readers with information to act upon in relation to their health, were highly successful, along with time relevance and relation to particular events, a personally directed style of language and rhetorical questions.

Interestingly, perceived acuteness of health risk and need for others to be informed also drove information dissemination.

“The real-time insight Twitter gives us into exactly how consumers react to and spread public health information is unprecedented,” says Professor Steele.

“With further research, it’s likely Twitter will change how we disseminate public health information online. In addition, our ability to analyse pathways, reach, and the identity of information recipients could provide new possibilities for analytical techniques and software tools to further improve public health information dissemination.

 

Copies of the relevant peer-reviewed publications for this study are available on theHealth Informatics Computation and Innovation Lab website or by contacting robert.steele@sydney.edu.au