Whither the Aborigine

Objectives. The purpose of this study was to delineate and describe the local palliative care services available to residents of remote Aboriginal communities in northern Manitoba; to identify attitudes and beliefs ab0ut death, dying and palliative care in these communities; and to explore obstacles related to palliative care service delivery from the perspectives of culture and geographic isolation.Study Design. Forty-four in-depth semi-strn.ctured interviews were conducted with a reputational sample of key informants including Aboriginal people resident in remote communities, community elders and religious leaders, doctors, nurses and allied health care providers working in First Nations Communities, as well as specialist service providers in Winnipeg. Thematic qualitative analysis was done on the data collected. Data collected from interviews with northern physicians and nurses was coded and analyzed.Results. Currently, many Aboriginal people living in remote communities are transported to large urban centers to die, isolated from friends, family and their culture. However, the majority of Aboriginal people and health care providers interviewed reported that Aboriginal people living in remote communities would prefer to die at home. The issues surrounding palliative care provision in remote Aboriginal communities are cultural and geographic. Culturally sensitive care requires that patients have access to family supports and traditional services if requested. Geographic isolation requires that:1. patient-specific care plans be created for use in the remote community;2. effective lines of communication are established between remote health care providers and urban specialists;3. health care providers and family care-givers be properly trained to fill their respective roles; and4. appropriate guidelines and resources be available in the community to support this type of care.Conclusions. Providing the equipment, supports and education necessary for home-based palliative care in remote Aboriginal communities can be an effective way of addressing the medical, psycho-social, and spiritual needs of these patients. (Int J Circumpolar Health 2004; 63: 25–38)

BackgroundIn Australia generally, smoking prevalence more than halved after 1980 and recently commenced to decline among Australia's disadvantaged Indigenous peoples. However, in some remote Indigenous Australian communities in the Northern Territory (NT), extremely high rates of up to 83% have not changed over the past 25 years. The World Health Organisation has called for public health and political leadership to address a global tobacco epidemic. For Indigenous Australians, unprecedented policies aim to overcome disadvantage and close the 'health gap' with reducing tobacco use the top priority. This study identifies challenges and opportunities to implementing these important new tobacco initiatives in remote Indigenous communities. Methods: With little empirical evidence available, we interviewed 82 key stakeholders across the NT representing operational- and management-level service providers, local Indigenous and non-Indigenous participants to identify challenges and opportunities for translating new policies into successful tobacco interventions. Data were analysed using qualitative approaches to identify emergent themes.ResultsThe 20 emergent themes were classified using counts of occasions each theme occurred in the transcribed data as challenge or opportunity. The 'smoke-free policies' theme occurred most frequently as opportunity but infrequently as challenge while 'health workforce capacity' occurred most frequently as challenge but less frequently as opportunity, suggesting that policy implementation is constrained by lack of a skilled workforce. 'Smoking cessation support' occurred frequently as opportunity but also frequently as challenge suggesting that support for individuals requires additional input and attention.ConclusionsThese results from interviews with local and operational-level participants indicate that current tobacco policies in Australia targeting Indigenous smoking are sound and comprehensive. However, for remote Indigenous Australian communities, local and operational-level participants' views point to an 'implementation gap'. Their views should be heard because they are in a position to provide practical recommendations for effective policy implementation faithful to its design, thereby translating sound policy into meaningful action. Some recommendations may also find a place in culturally diverse low- and middle-income countries. Key words: tobacco policy implementation, challenges, opportunities, remote Indigenous Australian communities.

To examine marijuana use by youth in a remote Aboriginal community in Northern Australia over a 5-year period. Participant observation, structured and unstructured interviews. Remote Indigenous Australian community. Young Aboriginal people and adult community members. Emergent themes of the attitudes towards marijuana use among remote Indigenous residents are reported. Restrictions in the availability of alcohol and petrol have led to increased use of marijuana with serious social and community consequences. Efforts to control licit substances, such as alcohol, in remote communities need to be addressed in the context of understanding of the dynamics of alcohol and drug use in totality as well as interventions that address underlying structural and social inequalities.

Indigenous Australians experience poorer health than non-Indigenous Australians, with cardiometabolic diseases (CMD) being the leading causes of morbidity and mortality. Built environmental (BE) features are known to shape cardiometabolic health in urban contexts, yet little research has assessed such relationships for remote-dwelling Indigenous Australians. This study assessed associations between BE features and CMD-related morbidity and mortality in a large sample of remote Indigenous Australian communities in the Northern Territory (NT). CMD-related morbidity and mortality data were extracted from NT government health databases for 120 remote Indigenous Australian communities for the period 1 January 2010 to 31 December 2015. BE features were extracted from Serviced Land Availability Programme (SLAP) maps. Associations were estimated using negative binomial regression analysis. Univariable analysis revealed protective effects on all-cause mortality for the BE features of Education, Health, Disused Buildings, and Oval, and on CMD-related emergency department admissions for the BE feature Accommodation. Incidence rate ratios (IRR’s) were greater, however, for the BE features Infrastructure Transport and Infrastructure Shelter. Geographic Isolation was associated with elevated mortality-related IRR’s. Multivariable regression did not yield consistent associations between BE features and CMD outcomes, other than negative relationships for Indigenous Location-level median age and Geographic Isolation. This study indicates that relationships between BE features and health outcomes in urban populations do not extend to remote Indigenous Australian communities. This may reflect an overwhelming impact of broader social inequity, limited correspondence of BE measures with remote-dwelling Indigenous contexts, or a ‘tipping point’ of collective BE influences affecting health more than singular BE features.

BackgroundIndigenous residents living in remote communities in Australia’s Northern Territory experience higher rates of preventable chronic disease and have poorer access to appropriate health services compared to other Australians. This study compared health outcomes and costs at different levels of primary care utilisation to determine if primary care represents an efficient use of resources for Indigenous patients with common chronic diseases namely hypertension, diabetes, ischaemic heart disease, chronic obstructive pulmonary disease and renal disease.MethodsThis was an historical cohort study involving a total of 14,184 Indigenous residents, aged 15 years and over, who lived in remote communities and used a remote clinic or public hospital from 2002 to 2011. Individual level demographic and clinical data were drawn from primary care and hospital care information systems using a unique patient identifier. A propensity score was used to improve comparability between high, medium and low primary care utilisation groups. Incremental cost-effectiveness ratios and acceptability curves were used to analyse four health outcome measures: total and, avoidable hospital admissions, deaths and years of life lost.ResultsCompared to the low utilisation group, medium and high levels of primary care utilisation were associated with decreases in total and avoidable hospitalisations, deaths and years of life lost. Higher levels of primary care utilisation for renal disease reduced avoidable hospitalisations by 82-85%, deaths 72-75%, and years of life lost 78-81%. For patients with ischaemic heart disease, the reduction in avoidable hospitalisations was 63-78%, deaths 63-66% and years of life lost 69-73%. In terms of cost-effectiveness, primary care for renal disease and diabetes ranked as more cost-effective, followed by hypertension and ischaemic heart disease. Primary care for chronic obstructive pulmonary disease was the least cost-effective of the five conditions.ConclusionPrimary care in remote Indigenous communities was shown to be associated with cost-savings to public hospitals and health benefits to individual patients. Investing $1 in primary care in remote Indigenous communities could save $3.95-$11.75 in hospital costs, in addition to health benefits for individual patients. These findings may have wider applicability in strengthening primary care in the face of high chronic disease prevalence globally.

In Australia, Aboriginal and Torres Strait Islander people score poorly on national mainstream indicators of wellbeing, with the lowest outcomes recorded in remote communities. As part of a ‘shared space’ collaboration between remote Aboriginal communities, government and scientists, the holistic Interplay Wellbeing Framework and accompanying survey were designed bringing together Aboriginal priorities of culture, empowerment and community with government priorities of education, employment and health. Quantitative survey data were collected from a cohort of 841 Aboriginal people aged 15–34 years, from four different Aboriginal communities. Aboriginal community researchers designed and administered the survey. Structural equation modelling was used to identify the strongest interrelating pathways within the framework. Optimal pathways from education to employment were explored with the concept of empowerment playing a key role. Here, education was defined by self-reported English literacy and numeracy and empowerment was defined as identity, self-efficacy and resilience. Empowerment had a strong positive impact on education (β = 0.38, p < .001) and strong correlation with employment (β = 0.19, p < .001). Education has a strong direct effect on employment (β = 0.40, p < .001). This suggests that education and employment strategies that foster and build on a sense of empowerment are mostly likely to succeed, providing guidance for policy and programs.

This thesis examines social work practice within a rural Aboriginal community in north-west Victoria, Australia. It places the engagement of social work and the Aboriginal community in an historical context from 1970 until 2007. Historically, there has been a legacy of policies and practices enforced upon Aboriginal people in the name of welfare. This thesis examines pre-colonised Aboriginal Australia and provides an overview of the impact of colonisation as an historic context to the more recent experience of Aboriginal Australians and the provision of welfare services in the community of study. Policies prior to the 1970s were directly aimed at assimilation and absorption of Aboriginal people into white society. Policies from the 1970s onwards saw a significant change in philosophy, espousing self-determination and self-management of Aboriginal affairs by Aboriginal people. This has been followed in recent years by more directive policies and a shift away from the commitment to self-determination. Regardless of the philosophy of the time, what is evident is the failure of policy and practice to make a positive impact on the lives of Aboriginal people. Data shows an over-representation of Indigenous children and young people in out-of-home care, of children and adults in the justice system, and also that the life expectancy of Indigenous Australians remains significantly below that of non-Indigenous Australians. Some remote Aboriginal communities are acknowledged to be in a state of crisis in relation to violence, alcohol and drug dependency, and the abuse of women and children. This analysis will endeavour to discuss the impact this legacy has had on both the Aboriginal community and social work as a profession, and how it continues to have an impact today. I also highlight how the experience of this one Indigenous community is reflective of policies, practices and philosophies in Australia's engagement with its Indigenous population. Therefore, parallels can be drawn regarding the wider Indigenous experience, from the analysis of this one Aboriginal community's journey in relation to welfare and social work.

We evaluated a community-driven initiative established to prevent substance misuse and increase respect for culture and their elders among young people in a group of remote Aboriginal communities in Arnhem Land, Northern Territory (NT), Australia. The Youth Development Unit provided a range of training, recreational and cultural activities within a community development framework to all young people in the community. Methods of operation, community acceptability, perceived impact and likely ability to meet goals were assessed. Data included community, staff and stakeholder interviews and observation. School attendance, youth apprehension rates and information on levels of substance use were compared 2 years before and after the initiative was implemented. Interviewees reported increased youth training and recreational opportunities, increased communication between local agencies, overall satisfaction with programme delivery and optimism that it could achieve its goals. Suggested improvements included even more training, cultural programmes and other activities and employment of more community-based Indigenous staff. The importance of key staff, involvement of a respected Indigenous staff member and community engagement were noted as probable contributors to its success. Indigenous young people in Australia remain one of the most disadvantaged and vulnerable groups. Community-driven preventive initiatives offer enhanced youth resilience and connectedness in remote Aboriginal communities and alternatives to substance use.

78.2 Impact of Climate Change on the Health and Well-Being of Indigenous Communities in Australia

Sustainable Development Goal 6.1 seeks universal access to safe drinking water for all by 2030, yet persistent disparities remain even in high-income countries. Indigenous, remote and small communities are disproportionately affected by poor drinking water quality, but comparable evidence to evaluate performance across communities is very limited due to inconsistent monitoring and reporting. To this end, we constructed a community-level meta-panel dataset of 839 communities (4,137 observations) across 4 Australian jurisdictions (Northern Territory, South Australia, Victoria and Western Australia) and Ontario, Canada, over the period 2018–2022. Drinking water quality was assessed using the Australian Drinking Water Guidelines and Canadian Boil Water Advisories. Logistic regression was employed to estimate the probability of accessing good-quality drinking water, with Indigenous status, remoteness, population size and socio-economic condition as key explanatory variables. Results reveal systematic disparities: Indigenous and very remote communities are statistically significantly less likely to have good-quality drinking water than non-Indigenous and regional communities after controlling for other factors. Our findings indicate that structural inequities – rather than geographic or demographic variation alone – are critical determinants of poor drinking water outcomes in small, Indigenous communities in both Australia and Canada.

To estimate the home range (HR) and investigate the potential predictors for roaming of 58 dogs in four Aboriginal communities in the Northern Territory. Prospective study. Global positioning system (GPS) collars were attached to the dogs for 1-4 days, recording location fixes every 1-3 min. Utilisation distributions (UDs) and extended (95% isopleth) and core (50% isopleth) HRs of dogs were determined. Potential predictors of roaming were assessed. Estimated core (median, 0.27 ha) and extended (median, 3.1 ha) HRs differed significantly (P = 0.0225 and 0.0345, respectively) between the four communities; dogs in the coastal community travelled significantly (P < 0.0001) more per day than dogs in the three inland communities studied. Significant associations were found between extended HR size and sex (P = 0.0050) and sex + neuter (P = 0.0218), and between core HR size and sex (P = 0.0010), neuter status (P = 0.0255) and sex + neuter (P = 0.0025). Entire males roamed more than neutered females. The core HR of dogs with poor/fair body condition scores (BCSs) was larger than dogs with ideal/obese BCSs (P = 0.0394). Neutered male dogs also travelled more per day than entire female dogs (P = 0.0475). Roaming information can be used to inform the management of dogs in remote communities and to design disease control programs. Widespread data collection across the Northern Territory should be undertaken to further investigate the associations found in this study, considering that data were collected during relatively short periods of time in one season.

Infectious diseases contribute a substantial burden of ill-health in Australia’s Aboriginal children. Skin infections have been shown to be common in remote Aboriginal communities, particularly in the Northern Territory, Australia. However, primary care data on skin and other infectious diseases among Aboriginal children living in remote areas of Western Australia are limited. We conducted a retrospective review of clinic presentations of all children aged 0 to 5 years presenting to four clinics located in the Western Desert region of Western Australia between 2007 and 2012 to determine this burden at a local level. Infectious diseases accounted for almost 50% of all clinic presentations. Skin infections (sores, scabies and fungal infections) were the largest proportion (16%), with ear infections (15%) and upper respiratory infections (13%) also high. Skin infections remained high in all age groups; 72% of children presented at least once with skin infections. Scabies accounted for only 2% of all presentations, although one-quarter of children presented during the study for management of scabies. Skin sores accounted for 75% of the overall burden of skin infections. Improved public health measures targeting bacterial skin infections are needed to reduce this high burden of skin infections in Western Australia.

This study aimed to explore the lived experiences of Kimberley Aboriginal people with type 2 diabetes managed by remote Aboriginal Community Controlled Health Services using phenomenological analysis. Semi-structured interviews formulated by Aboriginal Health Workers, researchers and other clinicians were used to obtain qualitative data from 13 adult Aboriginal patients with type 2 diabetes managed in two remote communities in the Kimberley. Together with expert opinion from local Aboriginal Health Workers and clinicians, the information was used to develop strategies to improve diabetes management. Of 915 regular adult patients in the two communities, 27% had type 2 diabetes; 83% with glycated haemoglobin A >10%. Key qualitative themes included: the need for culturally relevant education and pictorial resources; importance of continuous therapeutic relationships with healthcare staff; lifestyle management advice that takes into account local and cultural factors; and the involvement of Aboriginal community members and families in support roles. Recommendations to improve diabetes management in the remote communities have been made collaboratively with community input. This study provides a framework for culturally relevant recommendations to assist patients with diabetes, for collaborative research, and for communication among patients, Aboriginal Health Workers, community members, researchers and other clinicians. Interventions based on recommendations from this study will be the focus of further collaborative research.

Past efforts to address endemic rates of sexually transmissible infections amongst young Aboriginal people living in remote/very remote Australian communities have had limited success. Peer education has been used in youth sexual health promotion but has received limited evaluation and has not been tested in remote Aboriginal settings. The Young Deadly Free youth peer education programme trained Aboriginal young people in 15 remote/very remote communities as peer educators to deliver sexual health education to other young people. Semi-structured interviews were conducted with the project team and regional coordinators to understand the barriers and enablers to implementing peer education in remote communities. Programme credibility, the offer of financial gratuities, and the recruitment of peer educators with prior sexual health knowledge and/or group facilitation experience were identified as programme enablers. Implementation challenges included programme rigidity, cultural sensitivities, and retention and expectations of peer educators. Seven implications for policy and practice are identified to increase the efficacy and long term-impacts of youth peer education. Peer education for youth sexual health promotion in remote communities can be effective if young peer educators are supported appropriately and the peer education programme is part of a comprehensive sexual health promotion strategy.

Trachoma in remote Indigenous Australia: a review and public health perspective