Effects of food policy actions on Indigenous Peoples' nutrition-related outcomes: a systematic review

Measuring Food and Water Security in an Aboriginal Community in Regional Australia

OBJECTIVE

To measure current levels and experiences of food and water security in Walgett to guide a community-led program and to provide a baseline measure.

DESIGN

A community-led cross-sectional survey conducted in April 2022 by trained local researchers.

SETTING

Walgett, a regional town in NSW, Australia.

PARTICIPANTS

A total of 251 Aboriginal adults.

MAIN OUTCOME MEASURED

Food and water security levels and experiences were measured using the Household Food Insecurity Access Scale (HFIAS) and Household Water InSecurity Experiences (HWISE) Scale. The relationship between food and water insecurity was determined through linear regression analysis.

RESULTS

Almost half of the respondents experienced food insecurity (46%) or water insecurity (44%) in the last 12 months. Most participants attributed food insecurity to difficulties with food affordability (71%) and availability (63%). More than four in five participants reported relying on purchased or donated bottled water due to main water source interruption (83%) or quality concerns (86%). Water insecurity was associated with food insecurity; HFIAS score increased by 0.43 points for every point higher on the HWISE scale.

CONCLUSIONS

This study is the first to measure levels and experiences of food and water security in an Aboriginal community in Australia using validated tools. The results highlight the interconnectedness of food and water insecurity and provide evidence of levels far higher than Australian national level estimates and comparable to low- and middle-income countries. A holistic government response alongside community-led efforts are needed to increasefood and water security to improve health and well-being in remote Aboriginal communities.

Promoting healthy school food environments and nutrition in Canada: a systematic review of interventions, policies, and programs

CONTEXT

The school food environment is a critical interface for child and adolescent nutrition, and there is a need to understand existing literature on Canadian school food environments to identify equity gaps and opportunities, and empower decision-makers to plan for future action.

OBJECTIVE

Literature on Canadian school food and nutrition interventions, policies, programs, and their effects on diets and nutritional status are synthesized and appraised in this systematic review.

DATA SOURCES

A search strategy was developed for each database used (Medline, Embase, PsycINFO, ERIC, Cochrane Collaboration, Canadian Electronic Library, BiblioMap), with a combination of free text and controlled vocabulary, for articles published from 1990 to 2021. Unpublished data and grey literature were also searched.

DATA EXTRACTION

Quantitative and qualitative studies with an observational or intervention study design, reviews, or program evaluations conducted in Canadian schools with participants aged 5-19.9 years were included. Key study characteristics and risk of bias were extracted independently by 2 investigators using a standardized tool.

DATA ANALYSIS

A total of 298 articles were included (n = 192 peer reviewed and 106 from the grey literature), which were mostly conducted in Ontario (n = 52), British Columbia (n = 43), and Nova Scotia (n = 28). Twenty-four interventions, 5 nonevaluated programs, and 1 policy involved Indigenous populations. Overall, 86 articles measured and reported on effectiveness outcomes, including dietary intake; anthropometry; knowledge, attitudes, and practices; and physical activity. The literature remains largely heterogenous and primarily focused on nutrition education programs that use subjective assessments to infer changes in nutrition. A key facilitator to implementation and sustainability was community engagement, whereas key barriers were staff capacity, access to resources and funding, and consistent leadership.

CONCLUSIONS

This review provides insight into Canadian school food and nutrition interventions, programs, and policies and uncovers important evidence gaps that require careful examination for future evaluations. Governments must create supportive environments that optimize nutrition for children and adolescents through equitable policies and programs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022303255.

Paper 6: engaging racially and ethnically diverse interest holders in evidence syntheses

OBJECTIVES

To inform methods for centering racial health equity in syntheses, we explored (1) how syntheses that assess health-related interventions and explicitly address racial health inequities have engaged interest holders and (2) guidance for engaging racially and ethnically diverse interest holders.

STUDY DESIGN AND SETTING

We systematically identified evidence syntheses (searches limited to January 1, 2020, through January 25, 2023) and guidance documents (no search date limits) for this overview. From syntheses we extracted data on engagement rationale and processes and extracted approaches suggested from guidance documents. We summarized findings qualitatively.

RESULTS

Twenty-nine of the 157 (18%) eligible syntheses reported using engagement. Syntheses typically lacked robust detail on why and how to use and structure engagement and outcomes/effects of engagement, though syntheses involving Indigenous populations typically included more detail. When reported, engagement typically occurred in early and later synthesis phases. We did not identify guidance documents that specifically intended to provide guidance for engaging racially/ethnically diverse individuals in syntheses; some related guidance described broader equity considerations or engagement in general.

CONCLUSION

This review highlights gaps in understanding of the use of engagement in racial health equity-focused syntheses and in guidance specifically addressing engaging racially and ethnically diverse populations. Syntheses and guidance materials we identified reported limited data addressing the whys, hows, and whats (ie, rationale for, approaches to, resources needed and effects of) of engagement, and we lack information for understanding whether engagement makes a difference to the conduct and findings of syntheses and when and how engagement of specific populations may contribute to centering racial health equity. A more informed understanding of these issues, facilitated by prospective and retrospective descriptions of engagement of diverse interest holders, may help advance actionable guidance and reviews.

PLAIN LANGUAGE SUMMARY

We identified evidence syntheses (a kind of research that identifies and summarizes findings of individual studies or publications to address research questions) that looked at studies of interventions to improve differences in effects on health for racial or ethnic populations to see (1) if and how they incorporated perspectives of interest holders, people with an interest in the subject being studied; (2) what guidance for how to engage or involve racially or ethnically diverse interest holders exists. We found that 29 of 157 syntheses addressing interventions to improve differences in effects on health reported involving interest holders but typically did not provide much detail about how to involve people. Syntheses that involved Indigenous people usually had more information, but overall, the syntheses did not have much information about how to involve people and what the impact of involving them may be. We did not find guidance information that specifically set out to provide information about engaging racially/ethnically diverse individuals in syntheses; some related guidance described considerations about involving people in syntheses in general. This review highlights gaps in understanding of how to engage people in racial health equity-focused syntheses and in guidance specifically addressing engaging racially and ethnically diverse populations. Syntheses and guidance materials we identified reported limited information about whys, hows, and whats (ie, reasons to use, how to do, and resources needed and effects of) related to engagement, and we lack information to help understand whether engagement makes a difference in doing syntheses and when and how engagement of specific populations may help to address racial health equity.

Nutritional interventions for indigenous adults in Canada - opportunities to sustain health and cultural practices: a scoping review

Indigenous People in Canada possess rich cultural traditions, intertwined with a strong connection to nature. However, colonisation and contemporary challenges have given rise to changes in lifestyle and culture, resulting in health and nutrition disparities within these communities. The goal of this review was to explore the available literature of existing Indigenous nutrition programs for adults in Canada. Arksey and O'Malley's scoping review protocol was used to conduct the search between July 2020 and February 2023. Articles were obtained from MEDLINE (Ovid), PsycInfo, Embase (Ovid), CINAHL (EBSCO), Web of Science, Scopus (Elsevier), Canadian Business and Current Affairs (Proquest), and Google Scholar. We identified 24 publications, with 19 being unique interventions. Common themes among programs included integrating traditional foods and cultural values, adapted programming to local needs, empowering community members, using a multidisciplinary collaboration, and leveraging social activities, all of which highlight the need for holistic strategies amid complex historical, social, and environmental factors. Overall, this review emphasises the need for continued support and development of Indigenous-led nutritional initiatives to promote health and well-being among Indigenous adults in Canada. Ensuring culturally relevant and sustainable solutions is crucial for addressing nutritional health disparities and fostering long-term positive outcomes.

Making it on the breadline - improving food security on the Anangu Pitjantjatjara Yankunytjatjara Lands, Central Australia

BACKGROUND

This longitudinal case study describes the efforts and impacts of community-controlled service organisations on the Anangu Pitjantjatjara Yankunytjatjara (APY) Lands in Central Australia to tackle food security since the 1980s, with a focus on the last decade, particularly during a year of concerted action from mid-2018.

METHODS

The co-designed study comprised an interrupted time series with controls. Availability, affordability, accessibility and sales of foods in the community retail stores on the APY Lands were monitored regularly from 2014 to mid-2022, including by local research teams. Store nutrition policy was updated early 2018. For a year from mid-2018, of the eight communities with stores: (i) two were the focus for concerted intervention, including support from a locally based project officer to help implement the policy and action 105 community requests for nutrition activities (ii) three received usual support to implement the policy; and (iii) three were subject to 'business as usual'. From mid-2019, all communities/stores received usual service, from 2020 with some restrictions related to the COVID-19 pandemic. Results were compared over time, across different community/store groups and with controls.

RESULTS

In the 12 months from mid-2018, all food security metrics improved most in the two focus communities. Impacts were less marked in the communities without additional support to implement the revised nutrition policy, and even less apparent, although more varied, in the other three communities/stores. Dietary intake improved only in the two focus communities. In all communities from early 2020 most gains eroded due to impacts of the COVID-19 pandemic and other external stressors. Food security metrics, including price of healthy food, appeared more resilient in the focus communities, although diet quality worsened. At all times assessed, healthy diets were unaffordable for welfare-dependant households.

CONCLUSIONS

This co-designed study demonstrates the effectiveness of community-led approaches, confirming that it is possible to improve food security and diet in remote Aboriginal communities. However, sustained action and monitoring, dedicated resources and employment of local people are critical for success. Results also highlight that low incomes are a major barrier to food security.

Perspective: Nutrition Health Disparities Framework: A Model to Advance Health Equity

Disparities in nutrition, such as poor diet quality and inadequate nutrient intake, arise from multiple factors and are related to adverse health outcomes such as obesity, diabetes, cardiovascular disease, and some cancers. The aim of the current perspective is to present a nutrition-centric socioecological framework that delineates determinants and factors that contribute to diet and nutrition-related disparities among disadvantaged populations. The Nutrition Health Disparities Framework (NHDF) describes the domains (biological, behavioral, physical/built environment, sociocultural environment, and healthcare system) that influence nutrition-related health disparities through the lens of each level of influence (that is, individual, interpersonal, community, and societal). On the basis of the scientific literature, the authors engaged in consensus decision making in selecting nutrition-related determinants of health within each domain and socioecological level when creating the NHDF. The framework identifies how neighborhood food availability and access (individual/built environment) intersect with cultural norms and practices (interpersonal/sociocultural environment) to influence dietary behaviors, exposures, and risk of diet-related diseases. In addition, the NHDF shows how factors such as genetic predisposition (individual/biology), family dietary practices (interpersonal/behavioral), and food marketing policies (societal) may impact the consumption of unhealthy foods and beverages and increase chronic disease risk. Family and peer norms (interpersonal/behavior) related to breastfeeding and early childhood nutrition interact with resource-poor environments such as lack of access to preventive healthcare settings (societal/healthcare system) and low usage of federal nutrition programs (societal/behavioral), which may increase risk of poor nutrition during childhood and food insecurity. The NHDF describes the synergistic interrelationships among factors at different levels of the socioecological model that influence nutrition-related outcomes and exacerbate health disparities. The framework is a useful resource for nutrition researchers, practitioners, food industry leaders, and policymakers interested in improving diet-related health outcomes and promoting health equity in diverse populations.

Pathways between foodways and wellbeing for first nations Australians

BACKGROUND

Supporting the health and wellbeing of Aboriginal and Torres Strait Islander peoples (hereafter respectfully referred to as First Nations peoples) is a national priority for Australia. Despite immense losses of land, language, and governance caused by the continuing impact of colonisation, First Nations peoples have maintained strong connections with traditional food culture, while also creating new beliefs, preferences, and traditions around food, which together are termed foodways. While foodways are known to support holistic health and wellbeing for First Nations peoples, the pathways via which this occurs have received limited attention.

METHODS

Secondary data analysis was conducted on two national qualitative datasets exploring wellbeing, which together included the views of 531 First Nations peoples (aged 12-92). Thematic analysis, guided by an Indigenist research methodology, was conducted to identify the pathways through which foodways impact on and support wellbeing for First Nations peoples.

RESULTS AND CONCLUSIONS

Five pathways through which wellbeing is supported via foodways for First Nations peoples were identified as: connecting with others through food; accessing traditional foods; experiencing joy in making and sharing food; sharing information about food and nutrition; and strategies for improving food security. These findings offer constructive, nationally relevant evidence to guide and inform health and nutrition programs and services to harness the strengths and preferences of First Nations peoples to support the health and wellbeing of First Nations peoples more effectively.

Improving economic access to healthy diets in first nations communities in high-income, colonised countries: a systematic scoping review

BACKGROUND

Affordability of healthy food is a key determinant of the diet-related health of First Nations Peoples. This systematic scoping review was commissioned by the Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women's Council (NPYWC) in Central Australia to identify interventions to improve economic access to healthy food in First Nations communities in selected high-income, colonised countries.

METHODS

Eight databases and 22 websites were searched to identify studies of interventions and policies to improve economic access to healthy food in First Nations communities in Australia, Canada, the United States or New Zealand from 1996 to May 2022. Data from full text of articles meeting inclusion criteria were extracted to a spreadsheet. Results were collated by descriptive synthesis. Findings were examined with members of the NPYWC Anangu research team at a co-design workshop.

RESULTS

Thirty-five publications met criteria for inclusion, mostly set in Australia (37%) or the US (31%). Interventions (n = 21) were broadly categorised as price discounts on healthy food sold in communities (n = 7); direct subsidies to retail stores, suppliers and producers (n = 2); free healthy food and/or food vouchers provided to community members (n = 7); increased financial support to community members (n = 1); and other government strategies (n = 4). Promising initiatives were: providing a box of food and vouchers for fresh produce; prescriptions for fresh produce; provision/promotion of subsidised healthy meals and snacks in community stores; direct funds transfer for food for children; offering discounted healthy foods from a mobile van; and programs increasing access to traditional foods. Providing subsidies directly to retail stores, suppliers and producers was least effective. Identified enablers of effective programs included community co-design and empowerment; optimal promotion of the program; and targeting a wide range of healthy foods, particularly traditional foods where possible. Common barriers in the least successful programs included inadequate study duration; inadequate subsidies; lack of supporting resources and infrastructure for cooking, food preparation and storage; and imposition of the program on communities.

CONCLUSIONS

The review identified 21 initiatives aimed at increasing affordability of healthy foods in First Nations communities, of which six were deemed promising. Five reflected the voices and experiences of members of the NPYWC Anangu research team and will be considered by communities for trial in Central Australia. Findings also highlight potential approaches to improve economic access to healthy foods in First Nations communities in other high-income colonised countries.

TRIAL REGISTRATION

PROSPERO CRD42022328326.

Development and Functionality of a Parsimonious Digital Food Frequency Questionnaire for a Clinical Intervention among an Indigenous Population

Nutrition-related chronic diseases are a major problem among Indigenous populations. Appropriate dietary intake assessment tools are needed for nutritional surveillance and intervention; however, tools designed to measure the habitual dietary intake of Indigenous persons are largely lacking. We developed a digital food frequency questionnaire (FFQ) to measure habitual consumption among Australian Aboriginal adults and support personalized nutrition counseling. The primary contributors to energy, select nutrients, and inter-person variation (83 food groups) were identified from nationally representative 24 h recall (24HR) data, and they accounted for >80% of the total intake and inter-person variation of the nutrients of interest. Based on community input, a meal-based FFQ format was adopted, with a main food/beverage list of 81 items and the capacity to report on >300 additional items via the digital platform. The nutrient database was based on the Australian Food and Nutrient Database. Data for the first 60 study participants (70% female; median age: 48 years) were used to assess the FFQ's utility. The participants' median [IQR] reported energy intake (10,042 [6968-12,175] kJ/day) was similar to their median [IQR] estimated energy expenditure (10,197 [8636-11,551] kJ/day). Foods/beverages on the main FFQ list accounted for between 66% and 90% of the participants' reported energy and nutrient intakes; the remainder came from participant-selected extra items. The digital FFQ platform provides a potentially valuable resource for monitoring habitual dietary intake among Aboriginal adults and supporting chronic disease prevention and management interventions.

Diet change and sustainability in Indigenous areas: characteristics, drivers, and impacts of diet change in Gunayala, Panama

Many Indigenous communities around the world have been experiencing rapid and profound diet changes. This case report uses a Sustainability Science lens to understand the characteristics of diet change in Indigenous Gunas communities of Panama, as well as its drivers and sustainability impacts. We use primary information collected through interviews with 30 experts and 232 household surveys in three Gunas islands  characterised by different levels of development, western influence, and cultural erosion. We observe a rapid westernization of diets that has been mainly driven by closer interaction with tourists and the Panamanian society, as well as broader development processes. However, this diet change has a series of intersecting sustainability impacts related to food security, health, and socio-cultural and environmental change. It is necessary to understand the intersection of these phenomena when designing programs and interventions that seek to prevent or mitigate negative diet changes in Gunayala, and other  Indigenous contexts more broadly.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11625-023-01325-0.

Relationship between discretionary food intake and sex, body image, health, and geographical remoteness among Indigenous Australian adolescents

AIM

Determine the discretionary energy intake of Indigenous Australian adolescents and its relationship with sex, body image, health, and geographical remoteness.

METHODS

Cross-sectional data from the 2012 to 2013 National Aboriginal and Torres Strait Islander Nutrition and Physical Activity Survey (n = 264, 15-17 years). Dietary data were collected using an Automated Multiple-Pass Method, anthropometric data by trained interviewers; self-perceived measures of body weight, level of satisfaction with current weight, and self-assessed health were self-reported. General linear models were used to investigate predictors.

RESULTS

Discretionary energy intake contributed 35.4% and 54.2% of total energy intake for males and females, respectively, primarily from the sub-groups: soft drinks; pastries; potatoes; sugar, honey and syrups; cordials; and potato snacks. Discretionary energy intake was associated with higher energy intake (p < 0.001) and self-perceived body weight (p = 0.022), while sex had significant interactions with self-assessed health (p_sex  = 0.005), satisfaction with current weight (p_sex  < 0.001), and geographical remoteness (p_sex  = 0.007). Contribution of discretionary energy intake to total energy intake was greatest for males with an increased risk of metabolic complications (50% vs. 37%; p > 0.05), those who perceived themselves to be overweight (56% vs. 27%; p < 0.001), and those who were dissatisfied with their weight (56% vs. 19%; p < 0.001), compared to females. No differences were found by dieting status, risk of metabolic complications, and under-reporting of energy intake.

CONCLUSIONS

Discretionary energy intake was excessive among Indigenous Australian adolescents and had relationships with self-perceived health, weight satisfaction, and geographical remoteness, which was moderated by sex. To successfully reduce discretionary food intake among Indigenous Australian adolescents, further research is required to develop sex specific and culturally appropriate strategies.

Seeking Sweetness: A Systematic Scoping Review of Factors Influencing Sugar-Sweetened Beverage Consumption in Remote Indigenous Communities Worldwide

It is well-established that remote Indigenous communities have higher rates of sugar-sweetened beverage (SSB) consumption than non-Indigenous counterparts, which results in higher rates of chronic diseases such as type 2 diabetes mellitus (T2DM), obesity, and kidney disease. The aetiology leading to this behaviour remains understudied and overlooked. Therefore, the aim of this literature review is to understand the underpinning factors that contribute to SSB consumption in remote Indigenous communities. Studies were identified through five databases (n = 2529) and grey literature searching (n = 54). Following the PRISMA guidelines, each paper was assessed for eligibility, which left 34 studies for inclusion in the review. Within these papers, 37 different factors were found to influence SSB consumption in remote Indigenous communities. These were organised according to the Determinants of Nutrition and Eating (DONE) framework. SSB consumption was found to influence intake through each main level of the framework; individual (n = 9), interpersonal (n = 18), environmental (n = 9), and policy (n = 3). Preference was identified to be the most common factor to influence intake (n = 19), followed by health literacy (n = 15) and community availability (n = 12). Despite this, interventions to reduce SSB intake have never targeted this factor. This paper highlights the importance of a multi-level whole-of-system approach and suggests that an individual’s taste/preference should shape the direction of future research and intervention in this area.

Contribution of natural food environments to nutritional intake and biomarker status: insights from the women of indigenous santhal communities of Jharkhand, India

BACKGROUND

Many indigenous communities reside in biodiverse environments replete with natural food sources but show ​poor access and utilization.

METHODS

To understand the links between indigenous food access, dietary intakes, and biomarkers, we conducted a cross-sectional study among women of the Santhal Community (n = 211) from 17 villages in the Godda district of Jharkhand, India. Survey methods included household surveys, dietary intake assessment (24 HDR) and micronutrient and inflammatory biomarkers' estimation.

RESULTS

The diversity in access to foods from different natural sources expressed as Food access diversity index was low. This led to poor consumption and thus a low Minimum Dietary Diversity. The mean nutrient intake was less than the estimated average requirement for all nutrients. Women with higher dietary diversity scores had higher nutrient intakes. Thiamine and calcium intakes were significantly higher in women consuming indigenous foods than non-consumers. One-fourth of the women had elevated levels of inflammatory biomarkers. The prevalence of iron deficiency was approximately 70%. Vitamin A insufficiency (measured as retinol-binding protein) was observed in around 33.6% women, while 28.4% were deficient. Household access to natural food sources was associated with specific biomarkers. The access to kitchen garden (baari) was positively associated with retinol-binding protein levels and negatively with inflammatory biomarkers, while access to ponds was positively associated with ferritin levels.

CONCLUSION

The findings highlight the role of access to diverse natural foods resources, including indigenous foods, for improving nutrition security in indigenous communities. Nutrition and health programs promoting indigenous food sources should include the assessment of biomarkers for effective monitoring and surveillance.

Standardisation and application of a novel multiplex assay for estimating micronutrient status and inflammatory markers in women of Sauria Paharia and Santhal tribes of Jharkhand

This study aimed to document the method standardisation and assessment of micronutrient and inflammatory markers in women from indigenous tribal communities of Jharkhand using a low-volume, high-throughput assay. This cross-sectional study was done among women of the reproductive age group from Sauria Paharia and Santhal tribal households (HH) in selected villages. Capillary blood samples were collected from the women during a HH survey to estimate ferritin, soluble transferrin receptor, retinol binding protein 4 and inflammatory biomarkers, C-reactive protein (CRP) and α-1-acid glycoprotein (AGP) using a multiplex assay. Vitamin D and Hb were estimated using an LC-MS technique and cyanmethaemoglobin method, respectively. A multiplex Luminex-based method was developed and standardised. The assay was used to estimate biomarkers in samples from 413 women (178 and 235 from Sauria Paharia and Santhal tribes, respectively). Over 51 % of women had raised CRP or AGP levels. Fe status was significantly better in Sauria Paharia compared with the Santhal women. Anaemia prevalence was 72 % among Santhal women. The proportion of women with Fe deficiency increased after adjusting for inflammation. The overall prevalence of vitamin A deficiency and insufficiency was 25 and 34 %, respectively, with similar prevalence in both tribes. All Santhal women had sufficient vitamin D levels, while 25 and 20 % of Sauria Paharia women had insufficient and deficient vitamin D levels, respectively. Our low-volume, high-throughput multiplex assays may provide a feasible approach for assessing nutritional biomarkers in nutritionally vulnerable hard-to-reach communities.

Structural interventions that affect racial inequities and their impact on population health outcomes: a systematic review

Structural racism is the historical and ongoing reinforcement of racism within society due to discriminatory systems and inequitable distribution of key resources. Racism, embedded within institutional structures, processes and values, perpetuates historical injustices and restricts access to structural factors that directly impact health, such as housing, education and employment. Due to the complex and pervasive nature of structural racism, interventions that act at the structural level, rather than the individual level, are necessary to improve racial health equity. This systematic review was conducted to evaluate the effects of structural-level interventions on determinants of health and health outcomes for racialized populations. A total of 29 articles are included in this review, analyzing interventions such as supplemental income programs, minimum wage policies, nutrition safeguard programs, immigration-related policies, and reproductive and family-based policies. Most studies were quasi-experimental or natural experiments. Findings of studies were largely mixed, although there were clear benefits to policies that improve socioeconomic status and opportunities, and demonstrable harms from policies that restrict access to abortion or immigration. Overall, research on the effects of structural-level interventions to address health inequities is lacking, and the evidence base would benefit from well-designed studies on upstream policy interventions that affect the structural determinants of health and health inequities and improve daily living conditions.

High prevalence of chronic malnutrition in indigenous children under 5 years of age in Chimborazo-Ecuador: multicausal analysis of its determinants

Background

Despite the multiple initiatives implemented to reduce stunting in Ecuador, it continues to be a public health problem with a significant prevalence. One of the most affected groups is the rural indigenous population. This study aimed to analyze the prevalence of chronic malnutrition in indigenous children under 5 years of age and its association with health determinants, focusing on one of the territories with the highest prevalence of stunting.

Methods

A cross-sectional study in 1,204 Kichwa indigenous children under the age of five, residing in rural areas of the counties with the highest presence of indigenous in the province of Chimborazo-Ecuador. A questionnaire on health determinants was applied and anthropometric measurements were taken on the child and the mother. Stunting was determined by the height-for-age z-score of less than 2 standard deviations, according to the World Health Organization´s parameters. Data were analyzed using bivariate and multivariate Poisson regression.

Results

51.6% (n = 646) of the children are stunted. Height-for-age z-scores were significantly better for girls, children under 12 months, families without overcrowding, and families with higher family income. The variables that were significantly and independently associated with stunting were: overcrowding (PR 1.20, 95% CI 1–1.44), the mother required that the father give her money to buy medicine (PR 1.33, 95% CI 1.04–1.71), the father did not give her money to support herself in the last 12 months (1.58, 95% CI 1.15–2.17), mother’s height less than 150 cm (PR 1.42, 95% CI 1.19–1.69) and the child was very small at birth (PR 1.75, 95% CI 1.22–2.5).

Conclusion

One out of every two rural indigenous children included in this study is stunted. The high prevalence of stunting in the indigenous and rural population is multicausal, and requires an intersectoral and multidisciplinary approach. This study identified three fundamental elements on which public policy could focus: (a) reduce overcrowding conditions, improving economic income in the rural sector (for example, through the strengthening of agriculture), (b) provide prenatal care and comprehensive postnatal care, and (c) promote strategies aimed at strengthening the empowerment of women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14327-x.

Indigenous Foods to Address Malnutrition: An Inquiry into the Diets and Nutritional Status of Women in the Indigenous Community of Munda Tribes of Jharkhand, India

Background

Indigenous people globally experience poor nutrition outcomes, with women facing the greater burden. Munda, a predominant tribe in Jharkhand, India, live in a biodiverse food environment but yet have high levels of malnutrition.

Objectives

To assess diets and the nutritional status of Munda tribal women and explore associations with their Indigenous food consumption, dietary diversity, and socioeconomic and demographic profiles.

Methods

A cross-sectional study with a longitudinal component to capture seasonal dietary intake was conducted in 11 villages of the Khunti district, Jharkhand. Household surveys and FFQs, supplemented with 2-d 24-h dietary recall and anthropometric assessments on 1 randomly selected woman per household were conducted.

Results

Limited access to diverse foods from a natural food environment (Food Accessed Diversity Index score of 0.3 ± 0.3) was observed. More than 90% women in both seasons had usual nutrient intakes below the estimated average requirements for all nutrients except protein and vitamin C; 35.5% of women were underweight. The mean Minimum Dietary Diversity Score among women (MDDS) was low [2.6 ± 0.6 in wet monsoon; 3 ± 0.7 in winters (acceptable ≥5)]. Higher MDDS contributed to higher usual nutrient intakes (P <0.001). Indigenous food intakes in both seasons (wet monsoon and winter) were low, e.g. Indigenous green leafy vegetables [10.5 and 27.8% of the recommended dietary intake (RDI), respectively], other vegetables (5.2% and 7.8% of RDI, respectively), and fruits (5.8 and 22.8% of RDI, respectively). Despite low intakes, the Indigenous food consumption score was positively associated with usual intake of vitamin A, riboflavin, vitamin C, pyridoxine, and calcium (P < 0.05) in the wet monsoon and thiamine, riboflavin, and zinc (P < 0.001) in winters. After adjusting for covariates, Indigenous food consumption was associated with a higher usual intake of vitamin A (P  < 0.001) in the wet monsoon season.

Conclusion

Contextual food-based interventions promoting Indigenous foods and increasing dietary diversity have the potential to address malnutrition in Munda women.

A Socio-Cognitive Review of Healthy Eating Programs in Australian Indigenous Communities

PURPOSE

This paper aims to understand the challenges to healthy eating for Indigenous Australians using a Social Cognitive Theory lens. Understanding the environmental, cognitive, and behavioural barriers to healthy eating for Indigenous populations in Australia will help identify current gaps and highlight future actions needed in this area to close the gap for Indigenous Australians.

STUDY DESIGN

Narrative review of interventions of healthy eating programs in Australian Indigenous communities sourced using a systematic search protocol to understand the environmental, cognitive, and behavioural barriers to healthy eating among Indigenous Australians and to identify gaps and future actions needed to address this from 2010-2020.

RESULTS

The search produced 486 records, after duplicates were removed and the inclusion and exclusion process were utilised, seven interventions were retained in nine studies. The seven interventions had multiple study designs, from randomised control trials to case studies.

CONCLUSIONS

Further work needs to explore the long-term feasibility of providing fruit and vegetable discounts and the impact of remoteness for the delivery of healthy food. Dietary interventions need to be clearly described, and fidelity and process of the design and implementation process to help with replication of work.

Investigating the Intersections of Racial Identity and Perceived Income Adequacy in Relation to Dietary Quality Among Adults in Canada

BACKGROUND

Structural racism and economic marginalization shape dietary patterns in complex ways. Most research examining race and income inequities discount their interactions in shaping dietary intakes. An intersectional approach is needed to identify interconnected sources of social inequities and to more precisely locate dietary inequities.

OBJECTIVES

We examined whether racial identity and perceived income adequacy independently and jointly shape dietary quality, defined using the Healthy Eating Index (HEI) 2015, among a large sample of adults in Canada.

METHODS

Cross-sectional data from 2540 adults (≥18 years of age) in Canada who participated in the 2019 International Food Policy Study were analyzed. Multivariable linear regression models were executed to test the independent associations and interactions between racial identity and perceived income adequacy with HEI-2015 scores. Models were constructed to examine HEI-2015 total and component scores, adjusting for age, gender, and education.

RESULTS

Perceived income adequacy, but not racial identity, was independently associated with HEI-2015 total scores. The interaction between racial identity and perceived income adequacy was significantly associated with HEI-2015 scores. Compared to the reference group (individuals identifying as White and reporting income adequacy), those identifying as Black and reporting income adequacy were associated with lower HEI-2015 scores (β, -7.30; 95% CI, -13.07 to -1.54) and those identifying as Black and reporting income inadequacy were associated with lower HEI-2015 scores (β, -6.37; 95% CI, -12.13 to -0.60). Individuals who identified as indigenous and reported neither income adequacy nor inadequacy had lower HEI-2015 scores (β, -8.50; 95% CI, -13.82 to -3.18) compared to the reference group.

CONCLUSIONS

Findings suggest that racial identity and perceived income adequacy jointly shape dietary quality. Inequities in dietary quality may be missed when intersecting racial identities and socioeconomic positions are not explicitly investigated. To support healthier dietary patterns, strategies must reduce socioeconomic barriers that impose dietary constraints on some racialized groups.

Preserving the food preservation legacy

This paper deals with the question about how early humans managed to feed themselves, and how they preserved and stored food for times of need. It attempts to show how humans interacted with their environments and demonstrate what lessons can be learnt from the about 3.4 million years of food processing and preservation. It includes a discussion about how hominins shifted from consumption of nuts and berries toward meat and learnt to control and use fire. Cooking with fire generated more food-related energy and enabled humans to have more mobility. The main trust of the paper is on historical food preservations, organized from the perspectives of key mechanical, thermal, biological and chemical processes. Emerging food processes are also highlighted. Furthermore, how humans historically dealt with food storage and packaging and how early humans interacted with their given environments are discussed. Learnings from the history of food preservation and culinary practices of our ancestors provide us with an understanding of their culture and how they adapted and lived with their given environments to ensure adequacy of food supply. Collaboration between food scientists and anthropologists is advocated as this adds another dimension to building resilient and sustainable food systems for the future.

Integrated pond aquaculture and regional identity: ethnobiology of the golden humped tench of Poirino highlands, Northwest Italy

BACKGROUND

Social-ecological systems are based on particular species and on their direct and human-mediated interactions. The 'golden humped tench' or tinca gobba dorata, a variety of tench-Tinca tinca (L., 1758)-traditionally bred in artificial ponds called peschiere in Poirino highlands, northwest Italy, is one of such species. The aim of the study is to investigate the traditional farming of the golden humped tench, the associated knowledge, practices, and gastronomy, and to discuss the changes that the tench, the ponds, and their role in the local social-ecological system are going through.

METHODS

The data analyzed were collected in different locations of Poirino highlands during May-September 2021. Fieldwork included semi-structured interviews (n = 23) with current and former tench farmers about the breeding and gastronomy of the tench and the management of the peschiere. The interviewees' selection occurred through an exponential non-discriminative snowball sampling, and interview transcripts were qualitatively analyzed through inductive thematic content analysis.

RESULTS

The golden humped tench has been farmed for centuries in ponds used also to water livestock and to irrigate cultivated fields, and managed by every peasant household in the area. This integrated aquaculture system is underpinned by detailed knowledge on the peschiera ecosystem and on the tench life cycle and supports a gastronomic knowledge that is part of the local heritage. The ongoing process of gastronomic valorization of the tench is sustaining the role of the fish in locals' livelihoods and as a marker of regional identity, but it is also transforming tench farming, already threatened by livelihood change, pesticides, and invasive species, in controversial ways.

CONCLUSIONS

We argue that ponds and tenches are core elements of the local social-ecological system, defining the cultural landscape and engendering a form of regional identity around them. Studying integrated aquaculture systems and associated knowledge and practices is relevant to design sustainable systems of food production and to address possibilities of conservation of biodiversity and livelihoods in aquatic environments.

Cost and affordability of healthy, equitable and more sustainable diets in the Torres Strait Islands

OBJECTIVES

To assess the cost, cost differential and affordability of current and recommended (healthy, equitable, culturally acceptable and more sustainable) diets in the Torres Strait Islands and compare with other Queensland locations.

METHODS

The Aboriginal and Torres Strait Islander Healthy Diets ASAP (Australian Standardised Affordability and Pricing) methods protocol was applied in five randomly selected communities in the Torres Strait Islands.

RESULTS

The current diet was 32% more expensive than that recommended; 'discretionary' foods comprised 64% of the current diet cost. Families could save at least A$281.38 a fortnight by switching to recommended diets. However, these cost 35-40% more than elsewhere in Queensland. Recommended diets would cost 35% of median and 48% of welfare household income in the Torres Straits.

CONCLUSIONS

While less expensive than the current diet, recommended diets are unaffordable for most households. Consequently, many Torres Strait Islander families are at high risk of food insecurity and diet-related disease.

IMPLICATIONS FOR PUBLIC HEALTH

Urgent policy action is required to further lower the relative price of recommended diets, and also increase household incomes and welfare supplements to equitably improve food security and diet-related health, and contribute to environmental sustainability in the Torres Strait Islands.

The Navajo Nation Healthy Diné Nation Act: A Description of Community Wellness Projects Funded by a 2% Tax on Minimal-to-No-Nutritious-Value Foods

CONTEXT

To promote the health of the Navajo people, the Navajo Nation passed the Healthy Diné Nation Act (HDNA) in 2014. The HDNA included a 2% tax on "minimal-to-no-nutritional-value" foods and waived 5% sales tax on healthy foods, the first such policy in the United States and any sovereign Tribal nation. Uniquely aligned with Tribal government structures, revenue was directly allocated to 110 small local government entities (Chapters) for self-determined wellness projects.

OBJECTIVE

To characterize HDNA-funded wellness projects, test for variation in project type, and funding amount over time by region and community size.

DESIGN

Longitudinal study assessing funded wellness projects from tax inception through 2019.

SETTING

The Navajo Nation.

PARTICIPANTS

One hundred ten Navajo Nation Chapters receiving funding for self-determined wellness projects.

OUTCOME MEASURES

The categories and specific types of wellness projects and funding over 4 years by region and community size.

RESULTS

Of revenue collected in 2015-2018, more than 99.1% was disbursed through 2019 ($4.6 million, $13 385 annually per community) across 1315 wellness projects (12 per community). The built recreational environment category received 38.6% of funds, equipment/supplies 16.5%, instruction 15.7%, food and water initiatives 14.0%, and social events 10.2%. Most common specific projects were walking trails ($648 470), exercise equipment ($585 675), food for events ($288 879), playgrounds ($287 471), and greenhouses ($275 554). Only the proportion allocated to instruction changed significantly over time (increased 2% annually, P = .02). Smaller communities (population <1000) allocated significantly higher proportions to traditional, agricultural, and intergenerational projects and less to the built environment.

CONCLUSIONS

Through 2019, more than 99% of HDNA revenue was successfully disbursed to 110 rural, Tribal communities. Communities chose projects related to promoting the built recreational environment, agriculture, and fitness/nutrition education, with smaller communities emphasizing cultural and intergenerational projects. These findings can inform other indigenous nations considering similar policies and funding distributions.

Health-risk behaviours among Indigenous Australians with diabetes: A study in the integrated Diabetes Education and Eye Screening (iDEES) project

AIM

To assess the prevalence of modifiable health-risk behaviours among Indigenous Australian adults with diabetes attending a regional Victorian Indigenous primary-care clinic.

DESIGN

A cross-sectional observational single-site study.

METHODS

As part of a multi-study project we administered the Smoking, Nutrition, Alcohol consumption, Physical activity and Emotional wellbeing (SNAPE) survey tool during the study baseline visit to methodically capture health-related behavioural data in the nurse-led integrated Diabetes Education and Eye Screening (iDEES) project in a regional Indigenous primary healthcare setting between January 2018 and March 2020. This descriptive SNAPE study helps address the lack of health behaviour data for Indigenous people with diabetes.

RESULTS

Of 172 eligible adults, 135 (79%) were recruited to the iDEES study, 50 (37%) male. All participated in at least one survey. Median (range) age was 56 (46-67) years; 130 (96%) had Type 2 diabetes of median [IQR] duration 6 (2-12) years. All 135 provided smoking data; 88 (65%) completed all surveys. Forty-nine (36%) and 29 (22%) were current or former smokers, respectively; 5 (6%) met vegetable intake guidelines, 22 (25%) met fruit intake guidelines; 38 [43%] drank alcohol in the past year. On average, participants walked for ≥10 min at a time 4 days/week and sat for an average of 8 h on weekdays; 35 (40%) had minimal-mild, and 30 (34%) had moderate-severe depressive symptoms.

CONCLUSION

Suboptimal modifiable health-risk behaviours and depressive symptoms are common in Indigenous Australian adults with diabetes.

IMPACT

Orderly assessment and reporting of health-risk behaviours using a single multi-component survey instrument (SNAPE tool) during a nurse-led diabetes education clinical visit is feasible and efficient. Such data may facilitate personalised interventions and improve diabetes management at both individual and health service levels.

Concerns and priorities of Aboriginal and Torres Strait Islander peoples regarding food and nutrition: a systematic review of qualitative evidence

BACKGROUND

Aboriginal and Torres Strait Islander Australians experience persistent health and social inequities. Chronic conditions, many of which are diet-related, are leading contributors to the burden of disease and health inequity in Australia. First Nations Peoples have the right to be involved in all policy decisions affecting them. This review aimed to synthesise Aboriginal and Torres Strait Islander Peoples' concerns and priorities about food and nutrition in order to inform policies to improve health equity.

METHODS

MEDLINE, CINAHL, Informit and Google Scholar were systematically searched to identify qualitative studies-published from January 2008-that included data from Aboriginal and/or Torres Strait Islander Peoples about their concerns and priorities related to food and nutrition. Data were extracted from included studies using a pre-determined template and study quality was assessed using the Aboriginal and Torres Strait Islander Quality Appraisal Tool. Qualitative findings were synthesised using inductive thematic analysis and categorised based on an ecological model of health.

RESULTS

Twenty-one studies were included. Key factors influencing food and nutrition were identified across all levels of the ecological framework. These included interpersonal and institutional racism, junk food availability and marketing, food accessibility and affordability, housing conditions, food knowledge and cooking skills, and connection to family and culture.

CONCLUSIONS

Documenting Aboriginal and Torres Strait Islander Peoples' lived experiences of the colonised food system is one step necessary for informing policy to tackle food and nutrition inequities. Based on existing qualitative research, food and nutrition policymakers should prioritise building a supportive food environment by focusing on self-determination; ensuring access to healthy, affordable food and safe housing; and by eliminating systemic racism.

Cultural adaptation of health interventions including a nutrition component in Indigenous peoples: a systematic scoping review

BACKGROUND

Indigenous populations throughout the world experience poorer health outcomes than non-indigenous people. The reasons for the health disparities are complex and due in part to historical treatment of Indigenous groups through colonisation. Evidence-based interventions aimed at improving health in this population need to be culturally safe. However, the extent to which cultural adaptation strategies are incorporated into the design and implementation of nutrition interventions designed for Indigenous peoples is unknown. The aim of this scoping review was to explore the cultural adaptation strategies used in the delivery of nutrition interventions for Indigenous populations worldwide.

METHODS

Five health and medical databases were searched to January 2020. Interventions that included a nutrition component aimed at improving health outcomes among Indigenous populations that described strategies to enhance cultural relevance were included. The level of each cultural adaptation was categorised as evidential, visual, linguistic, constituent involving and/or socio-cultural with further classification related to cultural sensitivity (surface or deep).

RESULTS

Of the 1745 unique records screened, 98 articles describing 66 unique interventions met the inclusion criteria, and were included in the synthesis. The majority of articles reported on interventions conducted in the USA, Canada and Australia, were conducted in the previous 10 years (n = 36) and focused on type 2 diabetes prevention (n = 19) or management (n = 7). Of the 66 interventions, the majority included more than one strategy to culturally tailor the intervention, combining surface and deep level adaptation approaches (n = 51), however, less than half involved Indigenous constituents at a deep level (n = 31). Visual adaptation strategies were the most commonly reported (n = 57).

CONCLUSION

This paper is the first to characterise cultural adaptation strategies used in health interventions with a nutrition component for Indigenous peoples. While the majority used multiple cultural adaptation strategies, few focused on involving Indigenous constituents at a deep level. Future research should evaluate the effectiveness of cultural adaptation strategies for specific health outcomes. This could be used to inform co-design planning and implementation, ensuring more culturally appropriate methods are employed.

Promoting cultural rigour through critical appraisal tools in First Nations peoples' research

OBJECTIVE

To highlight the emerging ethos of cultural rigour in the use of critical appraisal tools in research involving First Nations peoples.

METHODS

Critical reflection on recent systematic review experience.

RESULTS

The concept of cultural rigour is notably undefined in peer-reviewed journal articles but is evident in the development of critical appraisal tools developed by First Nations peoples.

CONCLUSIONS

Conventional critical appraisal tools for assessing study quality are built on a limited view of health that excludes the cultural knowledge of First Nations peoples. Cultural rigour is an emerging field of activity that epitomises First Nations peoples' diverse cultural knowledge through community participation in all aspects of research. Implications for public health: Critical appraisal tools developed by First Nations peoples are available to researchers and direct attention to the social, cultural, political and human rights basis of health research.

Beyond the black stump: rapid reviews of health research issues affecting regional, rural and remote Australia

CHAPTER 1: RETAIL INITIATIVES TO IMPROVE THE HEALTHINESS OF FOOD ENVIRONMENTS IN RURAL, REGIONAL AND REMOTE COMMUNITIES: Objective: To synthesise the evidence for effectiveness of initiatives aimed at improving food retail environments and consumer dietary behaviour in rural, regional and remote populations in Australia and comparable countries, and to discuss the implications for future food environment initiatives for rural, regional and remote areas of Australia.

STUDY DESIGN

Rapid review of articles published between January 2000 and May 2020.

DATA SOURCES

We searched MEDLINE (EBSCOhost), Health and Society Database (Informit) and Rural and Remote Health Database (Informit), and included studies undertaken in rural food environment settings in Australia and other countries.

DATA SYNTHESIS

Twenty-one articles met the inclusion criteria, including five conducted in Australia. Four of the Australian studies were conducted in very remote populations and in grocery stores, and one was conducted in regional Australia. All of the overseas studies were conducted in rural North America. All of them revealed a positive influence on food environment or consumer behaviour, and all were conducted in disadvantaged, rural communities. Positive outcomes were consistently revealed by studies of initiatives that focused on promotion and awareness of healthy foods and included co-design to generate community ownership and branding.

CONCLUSION

Initiatives aimed at improving rural food retail environments were effective and, when implemented in different rural settings, may encourage improvements in population diets. The paucity of studies over the past 20 years in Australia shows a need for more research into effective food retail environment initiatives, modelled on examples from overseas, with studies needed across all levels of remoteness in Australia. Several retail initiatives that were undertaken in rural North America could be replicated in rural Australia and could underpin future research. CHAPTER 2: WHICH INTERVENTIONS BEST SUPPORT THE HEALTH AND WELLBEING NEEDS OF RURAL POPULATIONS EXPERIENCING NATURAL DISASTERS?: Objective: To explore and evaluate health and social care interventions delivered to rural and remote communities experiencing natural disasters in Australia and other high income countries.

STUDY DESIGN

We used systematic rapid review methods. First we identified a test set of citations and generated a frequency table of Medical Subject Headings (MeSH) to index articles. Then we used combinations of MeSH terms and keywords to search the MEDLINE (Ovid) database, and screened the titles and abstracts of the retrieved references.

DATA SOURCES

We identified 1438 articles via database searches, and a further 62 articles via hand searching of key journals and reference lists. We also found four relevant grey literature resources. After removing duplicates and undertaking two stages of screening, we included 28 studies in a synthesis of qualitative evidence.

DATA SYNTHESIS

Four of us read and assessed the full text articles. We then conducted a thematic analysis using the three phases of the natural disaster response cycle.

CONCLUSION

There is a lack of robust evaluation of programs and interventions supporting the health and wellbeing of people in rural communities affected by natural disasters. To address the cumulative and long term impacts, evidence suggests that continuous support of people's health and wellbeing is needed. By using a lens of rural adversity, the complexity of the lived experience of natural disasters by rural residents can be better understood and can inform development of new models of community-based and integrated care services. CHAPTER 3: THE IMPACT OF BUSHFIRE ON THE WELLBEING OF CHILDREN LIVING IN RURAL AND REMOTE AUSTRALIA: Objective: To investigate the impact of bushfire events on the wellbeing of children living in rural and remote Australia.

STUDY DESIGN

Literature review completed using rapid realist review methods, and taking into consideration the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement for systematic reviews.

DATA SOURCES

We sourced data from six databases: EBSCOhost (Education), EBSCOhost (Health), EBSCOhost (Psychology), Informit, MEDLINE and PsycINFO. We developed search terms to identify articles that could address the research question based on the inclusion criteria of peer reviewed full text journal articles published in English between 1983 and 2020. We initially identified 60 studies and, following closer review, extracted data from eight studies that met the inclusion criteria.

DATA SYNTHESIS

Children exposed to bushfires may be at increased risk of poorer wellbeing outcomes. Findings suggest that the impact of bushfire exposure may not be apparent in the short term but may become more pronounced later in life. Children particularly at risk are those from more vulnerable backgrounds who may have compounding factors that limit their ability to overcome bushfire trauma.

CONCLUSION

We identified the short, medium and long term impacts of bushfire exposure on the wellbeing of children in Australia. We did not identify any evidence-based interventions for supporting outcomes for this population. Given the likely increase in bushfire events in Australia, research into effective interventions should be a priority. CHAPTER 4: THE ROLE OF NATIONAL POLICIES TO ADDRESS RURAL ALLIED HEALTH, NURSING AND DENTISTRY WORKFORCE MALDISTRIBUTION: Objective: Maldistribution of the health workforce between rural, remote and metropolitan communities contributes to longstanding health inequalities. Many developed countries have implemented policies to encourage health care professionals to work in rural and remote communities. This scoping review is an international synthesis of those policies, examining their effectiveness at recruiting and retaining nursing, dental and allied health professionals in rural communities.

STUDY DESIGN

Using scoping review methods, we included primary research - published between 1 September 2009 and 30 June 2020 - that reported an evaluation of existing policy initiatives to address workforce maldistribution in high income countries with a land mass greater than 100 000 km² .

DATA SOURCES

We searched MEDLINE, Ovid Embase, Ovid Emcare, Informit, Scopus, and Web of Science. We screened 5169 articles for inclusion by title and abstract, of which we included 297 for full text screening. We then extracted data on 51 studies that had been conducted in Australia, the United States, Canada, United Kingdom and Norway.

DATA SYNTHESIS

We grouped the studies based on World Health Organization recommendations on recruitment and retention of health care workers: education strategies (n = 27), regulatory change (n = 11), financial incentives (n = 6), personal and professional support (n = 4), and approaches with multiple components (n = 3).

CONCLUSION

Considerable work has occurred to address workforce maldistribution at a local level, underpinned by good practice guidelines, but rarely at scale or with explicit links to coherent overarching policy. To achieve policy aspirations, multiple synergistic evidence-based initiatives are needed, and implementation must be accompanied by well designed longitudinal evaluations that assess the effectiveness of policy objectives. CHAPTER 5: AVAILABILITY AND CHARACTERISTICS OF PUBLICLY AVAILABLE HEALTH WORKFORCE DATA SOURCES IN AUSTRALIA: Objective: Many data sources are used in Australia to inform health workforce planning, but their characteristics in terms of relevance, accessibility and accuracy are uncertain. We aimed to identify and appraise publicly available data sources used to describe the Australian health workforce.

STUDY DESIGN

We conducted a scoping review in which we searched bibliographic databases, websites and grey literature. Two reviewers independently undertook title and abstract screening and full text screening using Covidence software. We then assessed the relevance, accessibility and accuracy of data sources using a customised appraisal tool.

DATA SOURCES

We searched for potential workforce data sources in nine databases (MEDLINE, Embase, Ovid Emcare, Scopus, Web of Science, Informit, the JBI Evidence-based Practice Database, PsycINFO and the Cochrane Library) and the grey literature, and examined several pre-defined websites.

DATA SYNTHESIS

During the screening process we identified 6955 abstracts and examined 48 websites, from which we identified 12 publicly available data sources - eight primary and four secondary data sources. The primary data sources were generally of modest quality, with low scores in terms of reference period, accessibility and missing data. No single primary data source scored well across all domains of the appraisal tool.

CONCLUSION

We identified several limitations of data sources used to describe the Australian health workforce. Establishment of a high quality, longitudinal, linked database that can inform all aspects of health workforce development is urgently needed, particularly for rural health workforce and services planning. CHAPTER 6: RAPID REALIST REVIEW OF OPIOID TAPERING IN THE CONTEXT OF LONG TERM OPIOID USE FOR NON-CANCER PAIN IN RURAL AREAS: Objective: To describe interventions, barriers and enablers associated with opioid tapering for patients with chronic non-cancer pain in rural primary care settings.

STUDY DESIGN

Rapid realist review registered on the international register of systematic reviews (PROSPERO) and conducted in accordance with RAMESES standards.

DATA SOURCES

English language, peer-reviewed articles reporting qualitative, quantitative and mixed method studies, published between January 2016 and July 2020, and accessed via MEDLINE, Embase, CINAHL Complete, PsycINFO, Informit or the Cochrane Library during June and July 2020. Grey literature relating to prescribing, deprescribing or tapering of opioids in chronic non-cancer pain, published between January 2016 and July 2020, was identified by searching national and international government, health service and peek organisation websites using Google Scholar.

DATA SYNTHESIS

Our analysis of reported approaches to tapering conducted across rural and non-rural contexts showed that tapering opioids is complex and challenging, and identified several barriers and enablers. Successful outcomes in rural areas appear likely through therapeutic relationships, coordination and support, by using modalities and models of care that are appropriate in rural settings and by paying attention to harm minimisation.

CONCLUSION

Rural primary care providers do not have access to resources available in metropolitan centres for dealing with patients who have chronic non-cancer pain and are taking opioid medications. They often operate alone or in small group practices, without peer support and access to multidisciplinary and specialist teams. Opioid tapering approaches described in the literature include regulation, multimodal and multidisciplinary approaches, primary care provider support, guidelines, and patient-centred strategies. There is little research to inform tapering in rural contexts. Our review provides a synthesis of the current evidence in the form of a conceptual model. This preliminary model could inform the development of a model of care for use in implementation research, which could test a variety of mechanisms for supporting decision making, reducing primary care providers' concerns about potential harms arising from opioid tapering, and improving patient outcomes.

“The Old Foods Are the New Foods!”: Erosion and Revitalization of Indigenous Food Systems in Northwestern North America

The global “nutrition transition” has had an immense impact on Indigenous Peoples of Northwestern North America. From an original diet comprised of mostly local plant and animal foods, including salmon, game, diverse plants, seaweed and other marine foods, many Indigenous people are now eating mostly imported, refined marketed foods that are generally less healthy, and many are at risk of diet-related diseases such as type 2 diabetes. Nevertheless, Indigenous people have always valued their ancestral foods, and over the last few decades there have been many initiatives throughout the region to restore and revitalize these original foods, and to re-learn Indigenous methods of processing and harvesting them. In this paper we describe the original Indigenous food systems in the study region, and the methods used to sustain and promote the ancestral food species and habitats. We then discuss the impacts of colonization, and describe recent and ongoing Resilience and Resurgence in relation to ancestral foods and food practices, including firsthand experiences with renewing food traditions. These initiatives are often connected with language revitalization and cultural resurgence programs. Led by Indigenous communities, they are undertaken with support of academic, government, and other partners. In all, they have resulted in stronger, more vibrant cultures and generally healthier communities.

The Retail Food Sector and Indigenous Peoples in High-Income Countries: A Systematic Scoping Review

Indigenous Peoples in high-income countries experience higher burdens of food insecurity, obesity, and diet-related health conditions compared to national averages. The objective of this systematic scoping review is to synthesize information from the published literature on the methods/approaches, findings, and scope for research and interventions on the retail food sector servicing Indigenous Peoples in high-income countries. A structured literature search in two major international databases yielded 139 relevant peer-reviewed articles from nine countries. Most research was conducted in Oceania and North America, and in rural and remote regions. Several convergent issues were identified across global regions including limited grocery store availability/access, heightened exposure to unhealthy food environments, inadequate market food supplies (i.e., high prices, limited availability, and poor quality), and common underlying structural factors including socio-economic inequality and colonialism. A list of actions that can modify the nature and structure of retailing systems to enhance the availability, accessibility, and quality of healthful foods is identified. While continuing to (re)align research with community priorities, international collaboration may foster enhanced opportunities to strengthen the evidence base for policy and practice and contribute to the amelioration of diet quality and health at the population level.