Prevalence of Everyday Discrimination and Relation with Wellbeing among Aboriginal and Torres Strait Islander Adults in Australia

Protective Factors Against e-Cigarette Use Among First Nations People Aged 16-24 in the Next Generation Youth Wellbeing Study

ISSUE ADDRESSED

Adolescent e-cigarette use is increasing and is associated with subsequent smoking. This study examines potential protective factors associated with not vaping among First Nations adolescents in Australia to inform community programs.

METHODS

The 'Next Generation: Youth Wellbeing Study' is a cohort study of First Nations adolescents aged 10-24 years from urban, rural and remote communities in Central Australia, Western Australia and New South Wales. Analysis of self-reported vaping from 16 to 24-year-olds, collected 2018-2020, using multi-level mixed-effects Poisson regression to estimate age-site-adjusted prevalence ratios (PRs) for never-vaping in relation to various factors.

RESULTS

Among 419 participants, 65% were female, 75% had never vaped, 49% had never smoked and 82% lived in smoke-free homes. Never vaping was more common among those who had: never-smoked (PR = 1.78, 95%CI: 1.56-2.04); never used cannabis (1.89, 1.60-2.24); non-smoking friends (1.38, 1.26-1.51); good mental health (1.15, 1.01-1.30), never diagnosed with depression (1.21, 1.01-1.46) or anxiety (1.31, 1.08-1.57); and no experiences of racism (1.21, 1.08-1.36), no negative criminal justice system experiences (1.25, 1.11-1.41), or vicarious racism through negative media (1.24, 1.10-1.39).

CONCLUSIONS

Most First Nations adolescents have never vaped, with potential protective factors being better mental health, no other substance use and fewer experiences of racism and justice system interactions. Comprehensive community adolescent prevention programs are needed to prevent vaping and protect future health, including preventing nicotine addiction and future smoking. SO WHAT?: Policies and programs must address e-cigarettes directly as well as structural factors, promoting broader adolescent wellbeing, centring culture and family in a strengths-based approach.

Relationships between social determinants of health and healthy body composition among Aboriginal and Torres Strait Islander youth in the Next Generation: Youth Well-being study

ISSUE ADDRESSED

Little is currently known about the relationships between body composition and the social determinants of health among Aboriginal and Torres Strait Islander youth in Australia, which could help inform policy responses to address health inequities.

METHODS

This study aimed to explore the relationship between various social factors and healthy body mass index (BMI) and waist/height ratio (WHtR) among Aboriginal and Torres Strait Islander youth aged 16-24 years. Baseline survey data from 531 participants of the 'Next Generation: Youth Well-being study' were used. Robust Poisson regression quantified associations between healthy body composition and self-reported individual social factors (education, employment and income, government income support, food insecurity, home environment, relationship status, racism), family factors (caregiver education and employment) and area-level factors (remoteness, socioeconomic status).

RESULTS

Healthy body composition was less common among those living in a crowded home (healthy WHtR aPR 0.67 [0.47-0.96]) and those receiving government income support (healthy BMI aPR 0.74 [0.57-0.95]). It was more common among those with tertiary educated caregivers (healthy BMI aPR 1.84 [1.30-2.61]; healthy WHtR aPR 1.41 [1.05-1.91]) and those in a serious relationship (healthy BMI aPR 1.33 [1.02-1.75]).

CONCLUSIONS

Social factors at the individual and family level are associated with healthy body composition among Aboriginal and Torres Strait Islander youth. SO WHAT?: The findings of this study highlight the potential for health benefits for youth from policies and programs that address social inequities experienced by Aboriginal and Torres Strait Islander people in Australia.

Co-design in healthcare with and for First Nations Peoples of the land now known as Australia: a narrative review

Increasing use of co-design concepts and buzzwords create risk of generating 'co-design branded' healthcare research and healthcare system design involving insincere, contrived, coercive engagement with First Nations Peoples. There are concerns that inauthenticity in co-design will further perpetuate and ingrain harms inbuilt to colonial systems.Co-design is a tool that inherently must truly reposition power to First Nations Peoples, engendering both respect and ownership. Co-design is a tool for facilitating cultural responsiveness, and therefore a tool for creating healthcare systems that First Nations People may judge as safe to approach and use. True co-design centres First Nations cultures, perspectives of health, and lived experiences, and uses decolonising methodologies in addressing health determinants of dispossession, assimilation, intergenerational trauma, racism, and genocide.Authentic co-design of health services can reduce racism and improve access through its decolonising methods and approaches which are strategically anti-racist. Non-Indigenous people involved in co-design need to be committed to continuously developing cultural responsiveness. Education and reflection must then lead to actions, developing skill sets, and challenging 'norms' of systemic inequity. Non-Indigenous people working and supporting within co-design need to acknowledge their white or non-Indigenous privileges, need ongoing cultural self-awareness and self-reflection, need to minimise implicit bias and stereotypes, and need to know Australian history and recognise the ongoing impacts thereof.This review provides narrative on colonial load, informed consent, language and knowledge sharing, partnering in co-design, and monitoring and evaluation in co-design so readers can better understand where power imbalance, racism, and historical exclusion undermine co-design, and can easily identify skills and ways of working in co-design to rebut systemic racism. If the process of co-design in healthcare across the First Nations of the land now known as Australia is to meaningfully contribute to change from decades of historical and ongoing systemic racism perpetuating power imbalance and resultant health inequities and inequality, co-designed outcomes cannot be a pre-determined result of tokenistic, managed, or coercive consultation. Outcomes must be a true, correct, and beneficial result of a participatory process of First Nations empowered and led co-design and must be judged as such by First Nations Peoples.

Factors associated with not smoking among Aboriginal and Torres Strait Islander adolescents and young people: Analysis of data from the 2014 to 15 National Aboriginal and Torres Strait Islander Social Survey

ISSUE ADDRESSED

Smoking rates have been steadily declining among Aboriginal and Torres Strait Islander people. Examining the factors associated with not smoking in young people is crucial for understanding the motivations and influences that lead individuals to adopt healthy behaviours.

METHODS

Secondary analysis was undertaken of data collected as part of the National Aboriginal and Torres Strait Islander Social Survey (NATSISS) 2014-15 (n = 1456). Factors associated with not smoking were explored with three multivariate regressions: (1) socio-demographic characteristics; (2) health, social and emotional factors; and (3) cultural identity characteristics.

RESULTS

Overall, 66% of Aboriginal and Torres Strait Islander young people aged 15-24 years did not smoke. Factors associated with not smoking included being younger, female, and engaged in study or employment. Those who lived with no smoking in the house, had lower illicit drug and alcohol use, and participated in Aboriginal or Torres Strait Islander sports carnivals were also more likely to be non-smokers.

CONCLUSIONS

Study findings reinforce the influence of social determinants on smoking behaviour. Efforts to reduce smoking among Aboriginal and Torres Strait Islander young people should focus on removing barriers to education and employment, promoting positive peer and family influences within households, taking a multi-drug approach to cessation, and considering cultural identity and its role in promoting healthy lifestyles. SO WHAT?: Understanding the protective factors associated with not smoking in young Aboriginal and Torres Strait Islander people will help with developing effective policies and initiatives to improve health outcomes.

The heart of the matter: a re-iteration of the role of the social determinants of health in addressing health inequity in Central Australia

The persisting life-expectancy 'gap' between First Nations and non-First Nations Australians is fundamentally driven by the social determinants of health. These include income and social protection, access to adequate housing and food security, among others. These factors are particularly prominent in Central Australia. Inadequate housing has led to some of the highest rates of Streptococcus pyogenes infection in the world, which in turn drives an extremely high prevalence of rheumatic heart disease. Food insecurity and inadequate social protection manifesting as energy insecurity result in inadequate nutrition and have resulted in a huge burden of diabetes in Central Australia. These factors, combined with social exclusion, racism and the pervasive effect of colonisation, also drive a high rate of alcohol misuse. Only by prioritising equity in these 'social determinants' and emphasising the importance of First Nations leadership in formulating and implementing solutions will health inequity be addressed.

Modelling prevalent cardiovascular disease in an urban Indigenous population

OBJECTIVE

Studies have highlighted the inequities between the Indigenous and non-Indigenous populations with respect to the burden of cardiovascular disease and prevalence of predisposing risks resulting from historical and ongoing impacts of colonization. The objective of this study was to investigate factors associated with cardiovascular disease (CVD) within and specific to the Indigenous peoples living in Toronto, Ontario, and to evaluate the reliability and validity of the resulting model in a similar population.

METHODS

The Our Health Counts Toronto study measured the baseline health of Indigenous community members living in Toronto, Canada, using respondent-driven sampling. An iterative approach, valuing information from the literature, clinical insight and Indigenous lived experiences, as well as statistical measures was used to evaluate candidate predictors of CVD (self-reported experience of discrimination, ethnic identity, health conditions, income, education, age, gender and body size) prior to multivariable modelling. The resulting model was then validated using a distinct, geographically similar sample of Indigenous people living in Hamilton, Ontario, Canada.

RESULTS

The multivariable model of risk factors associated with prevalent CVD included age, diabetes, hypertension, body mass index and exposure to discrimination. The combined presence of diabetes and hypertension was associated with a greater risk of CVD relative to those with either condition and was the strongest predictor of CVD. Those who reported previous experiences of discrimination were also more likely to have CVD. Further study is needed to determine the effect of body size on risk of CVD in the urban Indigenous population. The final model had good discriminative ability and adequate calibration when applied to the Hamilton sample.

CONCLUSION

Our modelling identified hypertension, diabetes and exposure to discrimination as factors associated with cardiovascular disease. Discrimination is a modifiable exposure that must be addressed to improve cardiovascular health among Indigenous populations.

Looking out across the front yard: aboriginal peoples' views of frailty in the community - A qualitative study

OBJECTIVE

Frailty is one of the most significant challenges to healthy ageing. Aboriginal Australians experience some of the highest levels of frailty worldwide, and despite this, no studies have explored frailty from an Aboriginal perspective. This is important because Aboriginal understandings and priorities in frailty may differ from Western/mainstream frailty frameworks. Furthermore, this lack of research severely hampers healthcare planning and service delivery. As a starting point, this study aims to understand the experiences, attitudes, and perceptions that Aboriginal older adults hold regarding frailty.

DESIGN

A qualitative study that utilized the Indigenous research method of Yarning for data collection as a culturally appropriate process for engaging Aboriginal peoples. Yarning circles and one-on-one yarns with 22 Aboriginal adults aged 45+ years living in one Australian capital city took place online and over the phone to explore the views that Aboriginal adults hold around frailty. Data were analysed thematically by Aboriginal researchers.

RESULTS

Seven key thematic areas were identified: (1) Keep in with culture; (2) Physical markers of frailty; (3) Frailty throughout the life course; (4) Social, cultural, and psychological understandings of frailty; (5) We want information about frailty; (6) Appropriate and positive wording; (7) Frailty assessment.

CONCLUSIONS

There was interest and engagement in the concept of frailty by Aboriginal older adults and approaches to frailty that extend beyond the physical to address cognitive, psychosocial, cultural and spiritual domains are likely to be more acceptable to this population. Culture and community connectivity are essential elements in preventing and alleviating frailty and have wider positive implications for Aboriginal health and wellbeing. Existing tools in practice to assess frailty are not aligned with Aboriginal cultural norms. Culturally appropriate frailty assessment methods co-designed with the community which incorporate holistic and multidimensional approaches are urgently needed.

Our Health Counts Toronto: Commercial tobacco use among Indigenous peoples in Toronto

OBJECTIVE

Fueled by the commercial tobacco industry, commercial tobacco use continues to be the leading preventable cause of premature death in Canada, with opportunities to improve health outcomes. The objective of this research was to work with Indigenous partners to generate Indigenous population prevalence estimates of commercial tobacco use in Toronto, and examine the association between smoking and sociodemographic, cultural, resiliency, and social variables.

METHODS

Respondent-driven sampling (RDS) was used to generate prevalence estimates of commercial tobacco use and potentially associated sociodemographic, cultural, resiliency, and social connection variables for Indigenous adults living in Toronto. Statistical analysis examined associations between smoking and variables theorized to be predictors of tobacco use.

RESULTS

The findings indicated that 36.3% (95%CI 28.2-44.5) of the Indigenous population in Toronto do not smoke, and 63.6% (95%CI 55.5-71.7) reported smoking. Univariate analysis of demographic, social, and cultural variables found age and employment to be statistically significantly different between adults who smoked and adults who did not smoke. Indigenous adults who were above the before-tax low-income cut-off (LICO) were more likely to smoke compared to those who were below the before-tax LICO. Indigenous adults who completed high school were more likely to smoke compared to those who did not complete high school, similarly to those who were unemployed compared to those who were employed. However, those who were not in the labour force (student or retired) were less likely to smoke compared to those who were employed. These effects remained after adjustment for age, gender, and LICO. Indigenous adults with stable housing were 20% less likely to smoke compared to those experiencing homelessness. Adults who had at least one close friend or family member to confide in were more likely to smoke compared to those who did not have any close friends or family members. Indigenous adults were more likely to smoke if they participated in Indigenous ceremony compared to those who did not participate.

CONCLUSION

The Indigenous population in Toronto continues to experience smoking prevalence nearly four times greater than that in the general population. This highlights the need for accurate population data to inform programs and policies and address the social determinants of health.

The social determinants of Aboriginal and Torres Strait Islander adults who do not smoke in regional Australia

INTRODUCTION

Commercial tobacco use was systematically embedded as a valuable commodity through colonisation that continues to be exploited for profit by the Tobacco Industry. There have been significant declines in current smoking prevalence among Aboriginal and Torres Strait Islander peoples 18 years and over, from 55% in 1994 to 43% in 2018-2019. This paper seeks to better understand smoke-free behaviours, and to systematically quantify associations between a range of SDOH and non-smoking/never-smoking among Aboriginal and Torres Strait Islander adults (≥18) living in regional Australia.

OBJECTIVE

To explore the social determinants of health (SDOH) related to non- and never-smoking among Aboriginal and Torres Strait Islander peoples in regional Australia.

DESIGN

Cross-sectional analysis of the NATSIHS, weighted to the Aboriginal and Torres Strait Islander adult population living in regional Australia, was conducted. Participants were characterised as people who were current smokers, never-smokers and non-smokers (ex- and never-smokers). The social determinants of health exposures related to socioeconomic position, well-being and access to healthcare.

SETTING

Regional Australia is distinct from urban and remote areas, based on the ASGS Remoteness Structure (ABS) 2018-2019.

PARTICIPANTS

Aboriginal and Torres Strait Islander adults (≥18 years) who were selected, consented and asked questions about smoking in the National Aboriginal and Torres Strait Islander Health Survey (NATSIHS 2018/19).

RESULTS

High income was associated with non-smoking (Prevalence Ratio [PR] = 2.07; 95% CI: 1.66-2.57) and never-smoking (PR = 2.02; 1.46-2.79), as was completing year 10 (non-smoking PR = 1.34; 1.12-1.61 and never-smoking PR = 1.56; 1.20-2.03). Better food security was associated with a higher prevalence of never-smoking (PR = 2.42; 1.48-3.98). Lower psychological distress scores were associated with non-smoking (PR = 1.30; 1.10-1.53) and never-smoking (PR = 1.56; 1.21-2.01). Never-smoking was more frequent in participants reporting no experiences of unfair treatment (PR = 1.59; 1.22-2.06). Having a usual healthcare provider was associated with non-smoking (PR = 1.38; 1.02-1.86). Positive exposure to the SDOH were associated with non- and never-smoking among Aboriginal and Torres Strait Islander adults in regional Australia. Structural and systemic changes to address the SDOH, including discrimination and racism, are expected to accelerate non-smoking behaviours and improve health outcomes for Aboriginal and Torres Strait Islander peoples.

A phase III multisite randomised controlled trial to compare the efficacy of cannabidiol to placebo in the treatment of cannabis use disorder: the CBD-CUD study protocol

BACKGROUND

Cannabis use disorder (CUD) is increasingly common and contributes to a range of health and social problems. Cannabidiol (CBD) is a non-intoxicating cannabinoid recognised for its anticonvulsant, anxiolytic and antipsychotic effects with no habit-forming qualities. Results from a Phase IIa randomised clinical trial suggest that treatment with CBD for four weeks reduced non-prescribed cannabis use in people with CUD. This study examines the efficacy, safety and quality of life of longer-term CBD treatment for patients with moderate-to-severe CUD.

METHODS/DESIGN

A phase III multi-site, randomised, double-blinded, placebo controlled parallel design of a 12-week course of CBD to placebo, with follow-up at 24 weeks after enrolment. Two hundred and fifty adults with moderate-to-severe CUD (target 20% Aboriginal), with no significant medical, psychiatric or other substance use disorders from seven drug and alcohol clinics across NSW and VIC, Australia will be enrolled. Participants will be administered a daily dose of either 4 mL (100 mg/mL) of CBD or a placebo dispensed every 3-weeks. All participants will receive four-sessions of Cognitive Behavioural Therapy (CBT) based counselling. Primary endpoints are self-reported cannabis use days and analysis of cannabis metabolites in urine. Secondary endpoints include severity of CUD, withdrawal severity, cravings, quantity of use, motivation to stop and abstinence, medication safety, quality of life, physical/mental health, cognitive functioning, and patient treatment satisfaction. Qualitative research interviews will be conducted with Aboriginal participants to explore their perspectives on treatment.

DISCUSSION

Current psychosocial and behavioural treatments for CUD indicate that over 80% of patients relapse within 1-6 months of treatment. Pharmacological treatments are highly effective with other substance use disorders but there are no approved pharmacological treatments for CUD. CBD is a promising candidate for CUD treatment due to its potential efficacy for this indication and excellent safety profile. The anxiolytic, antipsychotic and neuroprotective effects of CBD may have added benefits by reducing many of the mental health and cognitive impairments reported in people with regular cannabis use.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trial Registry: ACTRN12623000526673 (Registered 19 May 2023).

Connecting the Dots of Care: A pilot study linking Aboriginal and/or Torres Strait Islander peoples with diabetes care in hospital, using hospital pharmacists

Background

Diabetes is common among Aboriginal and/or Torres Strait Islander peoples, yet often undetected in hospital.

Objective

To identify how urban hospital pharmacists can detect if Aboriginal and/or Torres Strait Islander patients have diabetes or a higher chance of getting diabetes.

Methods

A multi-methods study used data from patients, and researcher field notes. Aboriginal and/or Torres Strait Islander peoples admitted to hospital over 12-weeks (July-October 2021) were prospectively identified from admissions lists. A hospital pharmacist-researcher visited eligible patients. Consenting participants had their blood glucose and HbA1c checked. Participants with HbA1c > 6.5% (no known diabetes) or 7% (known diabetes) were referred for endocrinology review during their stay. Test results and resultant diabetes plan were shared with their general practitioner. Two days after discharge, participants were called to gauge views on their hospital-based diabetes care. Barcode technology recorded pharmacist time. Voice-recorded field notes were thematically analysed. Ethics approval was obtained.

Results

Seventy-two patients were eligible for inclusion, 67/72 (93%) consented to take part. Sixty-one (91%) patients returned a HbA1c < 6.5, of which, 4/61 (6.5%) returned a HbA1c, 6-6.4. They were contacted to yarn about diabetes prevention. Six of the 67 (9%) qualified for endocrine review, 5 had known diabetes, one newly diagnosed. None were known to endocrinology. All participants telephoned were satisfied with their hospital-based diabetes care. Pharmacist time for initial introductory yarn, consenting process, organisation of HbA1c and results discussion was 20 min or 40 min if referred for endocrine review. Field notes guided understanding of service implementation.

Conclusion

This novel pharmacist-led diabetes screening service for Aboriginal and/or Torres Strait Islander peoples appeared to provide a unique opportunity for screening and referral links in a holistic way. Future research is required to test this model by upscaling to include more pharmacists and other chronic disease screening and referral pathways.

Employee perceptions of race and racism in an Australian hospital

BACKGROUND

Racism contributes to health inequities faced by people of colour and marginalised groups. Despite widespread recognition of the impacts of racism, mitigating strategies and legislation have been largely unsuccessful. Research into racism in healthcare has mostly examined personal experiences of healthcare workers and patients, assuming that the definitions of racism and race are similarly understood by all. However, ethnicity and race are often conflated, and racism seen as primarily interpersonal and ahistorical.

PURPOSE

This paper explores hospital employee understandings of racism, its impacts and how to reduce it.

METHODS

Forty-nine staff within one Australian hospital participated in individual qualitative interviews regarding the definition, impact, and ways of reducing racism. Interviews were analysed with a reflexive thematic analytic approach using a Postcolonial framework.

RESULTS

Participants described racism as being experienced by marginalised groups of people in Australia. They identified that racism has detrimental effects on health and wellbeing. Not all were clear regarding what constituted racism: it was not described as an ideology created to justify colonial distribution of power and resources. Some thought that racism was individual prejudice while others noted it was also structural in nature. Participants commonly defined race as involving physical or cultural differences, suggesting that discredited historical and colonial concepts of race continue in Australian society. While many felt that education was the best way to reduce racism and its impacts, some participants noted that being educated did not necessarily change racist behaviour.

CONCLUSIONS

The lack of accurate understanding of the concept of race and racism likely contributes to the relatively poor effect of current strategies to combat racism. As an initial part of deeper systemic anti-racist reform, this research supports calls for anti-racist education to clarify the definition of racism as an ideology.

Amplifying Older Aboriginal and Torres Strait Islander Women's Perspectives to Promote Digital Health Equity: Co-Designed Qualitative Study

BACKGROUND

Digital health is becoming ubiquitous, and we must ensure equity in access. Indigenous people across most high-income countries typically have not benefited as much as other citizens from usual health care systems and technologies. Despite Aboriginal and Torres Strait Islander people's clear interest in, and enthusiastic use of, new technologies, little research has examined the needs or interests of older Aboriginal and Torres Strait Islander women.

OBJECTIVE

This study prioritizes the perspectives of older Aboriginal and Torres Strait Islander women, tapping into their expertise associated with Indigenous ways of knowing, being, and doing, as well as their unique position within their families and communities, to design a model for using digital technologies to improve health for themselves and their families as well as their communities.

METHODS

Older Aboriginal and Torres Strait Islander women from 4 partner organizations were recruited for this study. This co-designed qualitative research included citizen scientists in shaping the protocol as well as collecting, analyzing, and interpreting data. We used yarning, an Indigenous research method validated for use in health research with Indigenous people and seen as respectful and culturally safe, as a primary research tool. The use of Indigenous methodologies and our iterative process enabled us to deeply explore and incorporate perspectives from all participants and ensure that the perspectives of Indigenous citizen scientists with lived experience were privileged. The data-checking methods also used a yarning methodology, which ensured that the findings and translational model derived from the findings were validated by the participants.

RESULTS

Participants comprised 24 Aboriginal and Torres Strait Islander women aged ≥41 years and including 3 generations that did not grow up with the internet: seniors, baby boomers, and Generation X. The key findings in this research were that older women use various digital technologies to improve health and well-being for themselves and their families as well as their communities. Older Aboriginal women want a culturally sensitive cyberspace that caters specifically to their needs and includes relevant content and functionality that are accessible and efficient. Our translational model highlights the conditions necessary for anyone to use digital health technologies, summarizes the essential elements needed to promote equity in digital health, and illuminates the unmet needs and requirements for older Aboriginal and Torres Strait Islander women to fully benefit from digital health technologies.

CONCLUSIONS

Health is a fundamental right. As we move toward greater reliance on digital health solutions, we must recognize and address the concerns of the smaller populations of people who differ in their needs. We must urgently address the financial, connectivity, and other limiting factors highlighted by older Aboriginal and Torres Strait Islander women in this study that limit equitable access to digital health tools.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1177/20552076221084469.

Exposure to the Family Wellbeing program and associations with empowerment, health, family and cultural wellbeing outcomes for Aboriginal and Torres Strait Islander peoples: a cross-sectional analysis

BACKGROUND

Empowerment is an internationally recognised concept commonly incorporated in First Nations and in this instance Aboriginal and Torres Strait Islander health and wellbeing programs. The Family Wellbeing Program is an empowerment program developed in partnership with Aboriginal and Torres Strait Islander peoples that has been widely delivered to Aboriginal and Torres Strait Islander communities across Australia for close to 30 years. To date, there has been limited quantitative analysis of how this program is linked to health and empowerment outcomes.

METHODS

Cross sectional analysis of Mayi Kuwayu, the National Study of Aboriginal and Torres Strait Islander Wellbeing, baseline data (n = 9,843) recruited using multi-mode random sampling including mail out survey and in community convenience sampling. Logistic regression models were performed to calculate Prevalence Ratios (PRs) and 95% Confidence Intervals (CIs) to examine the association between personal control, life satisfaction, general health, family wellbeing and cultural wellbeing outcomes for Family Wellbeing participants (n = 718) versus non-participants (n = 9,125).

RESULTS

Compared with non-FWB participants, FWB participants are more likely to be female (67.1% versus 58.4%), be aged 35-54 (41.8% versus 32.0%) and live in a remote area (17.7% versus 10.4%) and have educational attainment at the Year 12 level or above (57.8% versus 53.2%). Family Wellbeing participation was associated with a 13% higher reporting of family functioning, a 74% higher reporting of cultural participation and a 21% in higher reporting of local decision making in the local community compared to non-FWB participants. There were significant associations between FWB exposure compared to non-FWB exposure including reporting lower levels of health risk factors including quitting alcohol (26.4% versus 20.4%), regular exercise (67.7% versus 66.3%), quitting smoking (33.4% versus 31.9%). and e. FWB participants who had experienced both prison and youth detention were nearly double that of Non-FWB (3.5% versus 1.4%) and more reported being removed from their families as children (Stolen) (7.0% versus 4.1% Non-FWB).

CONCLUSION

There are significant associations between Family Wellbeing exposure and organisation and community level empowerment outcomes, but only for some individual level empowerment outcomes. There is a lower reporting health risk factors including increased physical exercise, reduced alcohol use and smoking; and educational attainment among FWB participants compared to non-FWB participants. The results suggest individual, community and organisational empowerment needs to be explored further with more robust study designs that can attribute causality and direction of association.

The role of structural racism and geographical inequity in diabetes outcomes

Diabetes is pervasive, exponentially growing in prevalence, and outpacing most diseases globally. In this Series paper, we use new theoretical frameworks and a narrative review of existing literature to show how structural inequity (structural racism and geographical inequity) has accelerated rates of diabetes disease, morbidity, and mortality globally. We discuss how structural inequity leads to large, fixed differences in key, upstream social determinants of health, which influence downstream social determinants of health and resultant diabetes outcomes in a cascade of widening inequity. We review categories of social determinants of health with known effects on diabetes outcomes, including public awareness and policy, economic development, access to high-quality care, innovations in diabetes management, and sociocultural norms. We also provide regional perspectives, grounded in our theoretical framework, to highlight prominent, real-world challenges.

Enabling dads and improving First Nations adolescent mental health: a pragmatic randomised controlled study

INTRODUCTION

There are few empirically supported social and emotional well-being programmes for First Nations adolescents, and we found none targeting those living in Aboriginal communities in remote areas of Australia. The dearth of social and emotional well-being programmes is concerning given that adolescents in remote Australia are at much greater risk of mental disorder and suicide. Our pragmatic community-based research intervention 'Enabling Dads and Improving First Nations Adolescent Mental Health' is designed by and for First Nations people living in remote communities to promote and support the parenting role and examine the interconnection between men's parenting knowledge and adolescent mental health. The aim is to improve adolescent mental health by strengthening the participating father's empowerment, parenting confidence and engagement in the parenting role. The words Aboriginal, First Nation and Indigenous are applied interchangeably, as appropriate, throughout the article.

METHODS AND ANALYSIS

The intervention is currently being conducted in five remote First Nations communities in Far North Queensland, Australia. The project is funded by the Medical Research Future (MRFF UNSW RG200484), and staff recruitment and training began in early December 2020. The aim is to recruit 100 men and dyad adolescents, that is, in each of the five community sites, we will recruit 20 men and adolescent dyads at baseline. To date, we have complete data collection in one community, and fieldwork will begin in the final community in September 2023.The intervention involves a pragmatic randomised controlled trial, using a novel and culturally designed and manualised parenting programme with men (Strong Fathers, SF). The comparison group is receiving a culturally congruent and familiar yarning/relaxation (YR) condition. The SF component focuses on reinforcing knowledge related to parenting adolescents, promoting father's empowerment, and increasing their confidence and engagement with the adolescent. The second component systematically measures and examines differences in adolescent social and emotional well-being before and after their father's involvement in either the SF or YR. The adolescent is blind to the father's group allocation. The outcome measures for the men include parenting knowledge, attitudes and beliefs; a First Nations measure for empowerment; the Harvard Trauma Questionnaire (Indigenous) used to assess post-traumatic stress disorder symptoms; and alcohol use. The adolescent mental health outcomes are measured by a culturally congruent social and emotional well-being measure.

ETHICS AND DISSEMINATION

Ethics approval was granted from the Aboriginal Health and Medical Research Council of Australia: Human Research Ethics Committee (1711/20). Results will be verbally shared at community meetings and conferences, and reports will be produced for community stakeholder use. Data will be available for community-controlled health services and stakeholders. Findings will also be published in peer-reviewed journals, and summaries will be provided to the funders of the study as well as male participants and adolescents.

Racial microaggressions and interculturality in remote Central Australian Aboriginal healthcare

BACKGROUND

An epidemic of type 2 diabetes in remote Aboriginal people in Central Australia, contributes to high rates of morbidity and mortality. Remote non-Aboriginal Health Care Workers (HCW) and the Aboriginal people they serve inhabit a complex cultural interface. This study aimed to recognise racial microaggressions in the everyday discourse of HCWs. It proposes a model of interculturality for remote HCWs that avoids racialisation and essentialising of Aboriginal people's identities and cultures.

METHODS

Semi-structured in-depth interviews were undertaken with HCWs from two Primary Health Care services in very remote Central Australia. Fourteen interviews were analysed from seven Remote Area Nurse, five Remote Medical Practitioners and two Aboriginal Health Practitioners. Discourse analysis was employed to explore racial microaggressions and power relations. NVivo software assisted in the thematic organisation of microaggressions according to a predefined taxonomy.

RESULTS

Seven microaggression themes were identified - racial categorization and sameness, assumptions about intelligence and competence, false colour blindness, criminality and dangerousness, reverse racism and hostility, treatment as second-class citizens and pathologizing culture. A model of interculturality for remote HCWs was based on concepts of the third space, deCentred hybrid identities and small culture formation on-the-go combined with a duty-conscious ethic, cultural safety and humility.

CONCLUSIONS

Racial microaggressions are common in the discourse of remote HCWs. The model of interculturality proposed could improve intercultural communication and relationships between HCWs and Aboriginal people. This improved engagement is required to address the current diabetes epidemic in Central Australia.

Kulay Kalingka, a national cohort study of Aboriginal and Torres Strait Islander peoples' cancer experiences: a study protocol

INTRODUCTION

Aboriginal and Torres Strait Islander peoples are the First Peoples of Australia. Since settler colonisation, Aboriginal and Torres Strait Islander peoples have experienced disparities in health outcomes, including cancer, when compared with non-Indigenous Australians, including higher cancer incidence and mortality rates, and lower participation in cancer screening programmes. Data to monitor and improve outcomes are limited.

AIMS, METHOD AND ANALYSIS

The Kulay Kalingka Study will be a national cohort study aiming to understand Aboriginal and Torres Strait Islander people's beliefs about cancer and experiences with cancer care and treatment, and to improve experiences and outcomes. It will be nested within the Mayi Kuwayu Study, a national community-controlled cohort study of Aboriginal and Torres Strait Islander people (n>11 000), with supplementary in-community recruitment.Mayi Kuwayu Study participants aged ≥18 years who consented to being recontacted, and a diversity of local community members will be invited to participate through completing a questionnaire relevant to their cancer status, aiming to recruit 2800 participants without prior doctor-diagnosed cancer and 700 with a cancer diagnosis.This community-driven data will enable monitoring and reporting of national trends over time and will guide national cancer control research, policy and clinical care, to improve outcomes for Aboriginal and Torres Strait Islander peoples.

ETHICS AND DISSEMINATION

The Kulay Kalingka Study has ethics approval from Australian Institute of Aboriginal and Torres Strait Islander Studies (#EO324-20220414 and REC-0121) and the Australian National University (#2022/465). The Kulay Kalingka Study is being developed with Aboriginal and Torres Strait Islander communities, following the Maiam nayri Wingara Indigenous Data Sovereignty Collective principles. Meaningful, accessible and culturally adapted study findings will be disseminated to Aboriginal and Torres Strait Islander communities through activities including community workshops, reports and feedback sheets, and in other ways as determined by the community. We will also return data to participating communities.

Don't Follow the Smoke-Listening to the Tobacco Experiences and Attitudes of Urban Aboriginal Adolescents in the Study of Environment on Aboriginal Resilience and Child Health (SEARCH)

Preventing smoking among young Aboriginal people is important for reducing health inequities. Multiple factors were associated with adolescent smoking in the SEARCH baseline survey (2009-12) and discussed in a follow-up qualitative study that aimed to inform prevention programs. Twelve yarning circles were facilitated by Aboriginal research staff at two NSW sites in 2019 with 32 existing SEARCH participants aged 12-28 (17 female, 15 male). Open discussion around tobacco was followed by a card sorting activity, prioritising risk and protective factors and program ideas. The age of initiation varied by generation. Older participants had established smoking in their early adolescence, whereas the current younger teens had little exposure. Some smoking commenced around high school (from Year 7), and social smoking increased at age 18. Mental and physical health, smoke-free spaces and strong connections to family, community and culture promoted non-smoking. The key themes were (1) drawing strength from culture and community; (2) how the smoking environment shapes attitudes and intentions; (3) non-smoking as a sign of good physical, social and emotional wellbeing; and (4) the importance of individual empowerment and engagement for being smoke-free. Programs promoting good mental health and strengthening cultural and community connections were identified as a priority for prevention.

A racial bias test with tertiary cancer centre employees: why anti-racist measures are required for First Nations Australians cancer care equity

Objective To examine implicit bias in employees at a cancer centre using an Australian race (Aboriginal-white) Implicit Association Test (IAT), in an attempt to understand a potential factor for inequitable outcomes of First Nations Australians cancer patients. Methods All employees at an Australian cancer centre were invited to take part in a web-based, cross-sectional study using an Australian race IAT. The results were analysed using Welch t-tests, linear regression and ANOVA. Results Overall, 538/2871 participants (19%) completed the IAT between January and June 2020. The mean IAT was 0.147 (s.d. 0.43, P < 0.001, 95% CI 0.11-0.18), and 60% had a preference for white over First Nations Australians. There was no significant mean difference in IAT scores between sub-groups of gender, age or clinical/non-clinical employees. 21% of employees (95% CI 17.65-24.53) had moderate to strong preference for white over First Nations Australians, compared to 7.1% with moderate to strong preference for First Nations over white Australians (95% CI 5.01-9.09). Conclusions Inequitable cancer survival for First Nations patients has been well established and cancer is now the leading cause of mortality. This paper documents the presence of racial bias in employees at one cancer centre. We argue that this cannot be understood outside the history of colonialism and its effects on First Nations Australians, healthcare workers and our society. Further research is required to evaluate measures of racism, its effect on health care, and how to eliminate it.

An intersectionality approach to Indigenous oral health inequities; the super-additive impacts of racism and negative life events

OBJECTIVES

Indigenous Australians experience cumulative forms of oppression. Using intersectionality as the underlying analytical framework, and with oral health as an outcome, we demonstrate how oppressions are interlinked and cannot be treated in isolation. The study aimed to quantify the cumulative effect of two forms of oppression on Indigenous Australian oral health inequities.

METHODS

This observational study was conducted Feb 2018-Jan 2020. Recruitment occurred through Aboriginal Community Controlled Health Organisations in South Australia, Australia. Eligibility included identifying as Indigenous, residing in South Australia and aged 18+ years. Socio-demographic factors, health-related characteristics, experience of racism, negative life events and self-reported oral health outcomes were collected. The main outcomes were fair/poor self-rated oral health and oral health related quality of life, measured by OHIP-14. Effect-measure modification was used to verify differences on effect sizes per strata of negative life events and racism. The presence of modification was indicated by Relative Excess Risk due to Interactions (RERIs).

RESULTS

Data were obtained for 1,011 participants, median age 37 years, 66% female and 63% residing in non-metropolitan locations. Over half (52%) had experienced racism in the past 12 months and 85% had experienced one or more negative life events. Around one-third (34%) rated their oral health as fair/poor and the mean OHIP-14 score was 17. A higher proportion of participants who had experienced both racism and negative life events (46%) were male (52%), aged 37+ years (47%), resided in metropolitan locations (57%), reported difficulty paying a $100 dental bill (47%), had fair/poor self-rated oral health (54%) and higher mean OHIP-14 scores (20). The RERIs observed were 0.31 for fair/poor self-rated oral health and 0.23 for mean OHIP-14. The positive RERIs indicated a super-additive effect between racism, negative life events (effect modifier) and self-reported oral health outcomes.

CONCLUSION

The more oppressions participants experienced, in the form of racism and negative life events, the greater the burden of poor self-reported oral health. The study is one of the first to use intersectionality as a theory to explain oral health inequities as experienced by Indigenous Australians.

Population-level contribution of interpersonal discrimination to psychological distress among Australian Aboriginal and Torres Strait Islander adults, and to Indigenous-non-Indigenous inequities: cross-sectional analysis of a community-controlled First Nations cohort study

BACKGROUND

International and population-specific evidence identifies elevated psychological distress prevalence among those experiencing interpersonal discrimination. We aim to quantify the potential whole-of-population contribution of interpersonal discrimination to psychological distress prevalence and Indigenous-non-Indigenous gaps in Australia.

METHODS

We did a cross-sectional analysis of data from Mayi Kuwayu: the National Study of Aboriginal and Torres Strait Islander Wellbeing. Baseline surveys were completed between June 8, 2018, and Sept 28, 2022. We analysed responses from participants who were aged 18 years or older at survey completion, whose surveys were processed between Oct 1, 2018, and May 1, 2021. Sample weights were developed on the basis of national population benchmarks. We measured everyday discrimination using an eight-item measure modified from the Everyday Discrimination Scale and classified experiences as racial discrimination if participants attributed these experiences to their Indigeneity. Psychological distress was measured using a validated, modified Kessler-5 scale. Applying logistic regression, we calculated unadjusted odds ratios (ORs), to approximate incident rate ratios (IRRs), for high or very high psychological distress in relation to everyday discrimination and everyday racial discrimination across age-gender strata. Population attributable fractions (PAFs), under the hypothetical assumption that ORs represent causal relationships, were calculated using these ORs and population-level exposure prevalence. These PAFs were used to quantify the contribution of everyday racial discrimination to psychological distress gaps between Indigenous and non-Indigenous adults.

FINDINGS

9963 survey responses were eligible for inclusion in our study, of which we analysed 9951 (99·9%); 12 were excluded due to responders identifying as a gender other than man or woman (there were too few responses from this demographic to be included as a category in stratified tables or adjusted analyses). The overall prevalence of psychological distress was 48·3% (95% CI 47·0-49·6) in those experiencing everyday discrimination compared with 25·2% (23·8-26·6) in those experiencing no everyday discrimination (OR 2·77 [95% CI 2·52-3·04]) and psychological distress prevalence was 49·0% (95% CI 47·3-50·6) in those experiencing everyday racial discrimination and 31·8% (30·6-33·1) in those experiencing no everyday racial discrimination (OR 2·06 [95% CI 1·88-2·25]. Overall, 49·3% of the total psychological distress burden among Aboriginal and Torres Strait Islander adults could be attributable to everyday discrimination (39·4-58·8% across strata) and 27·1% to everyday racial discrimination. Everyday racial discrimination could explain 47·4% of the overall gap in psychological distress between Indigenous and non-Indigenous people (40·0-60·3% across strata).

INTERPRETATION

Our findings show that interpersonal discrimination might contribute substantially to psychological distress among Aboriginal and Torres Strait Islander adults, and to inequities compared with non-Indigenous adults. Estimated PAFs include contributions from social and health disadvantage, reflecting contributions from structural racism. Although not providing strictly conclusive evidence of causality, this evidence is sufficient to indicate the psychological harm of interpersonal discrimination. Findings add weight to imperatives to combat discrimination and structural racism at its core. Urgent individual and policy action is required of non-Indigenous people and colonial structures, directed by Aboriginal and Torres Strait Islander peoples.

FUNDING

National Health and Medical Research Council of Australia, Ian Potter Foundation, Australian Research Council, US National Institutes of Health, and Sierra Foundation.

Communication and access to healthcare: Experiences of Aboriginal and Torres Strait Islander people managing pain in Queensland, Australia

Background

Pain management requires a multidisciplinary approach and a collaborative relationship between patient-provider in which communication is crucial. This study examines the communication experiences of Aboriginal and Torres Strait Islander patients and Aboriginal and Torres Strait Islander Hospital Liaison Officers (ATSIHLOs), to improve understanding of how pain is managed in and through patient-health professional communication.

Methods

This qualitative study involved a purposive sample of patients attending three persistent pain clinics and ATSIHLOs working in two hospitals in Queensland, Australia. Focus groups and in-depth interviews explored the communication experiences of patients managing pain and ATSIHLOs supporting patients with pain. This study adopted a descriptive phenomenological methodology, as described by Colaizzi (1978). Relevant statements (patient and ATSIHLOs quotes) about the phenomenon were extracted from the transcripts to formulate meanings. The formulated meanings were subsequently sorted into thematic clusters and then integrated into themes. The themes were then incorporated into a concise description of the phenomenon of communication within pain management. Findings were validated by participants.

Results

A total of 21 Aboriginal and Torres Strait Islander participants were involved in this study. Exploration of the communication experiences of patients and ATSIHLOs revealed overlapping themes of important barriers to and enablers of communication that affected access to care while managing pain. Acknowledging historical and cultural factors were particularly important to build trust between patients and health professionals. Some patients reported feeling stigmatized for identifying as Aboriginal and Torres Strait Islander, while others were reluctant to disclose their background for fear of not having the same opportunity for treatment. Differences in the expression of pain and the difficulty to use standard pain measurement scales were identified. Communication was described as more than the content delivered, it is visual and emotional expressed through body language, voice intonation, language and the speed of the conversation.

Conclusion

Communication can significantly affect access to pain management services. Aboriginal and Torres Strait Islander patients highlighted the burden of emotional pain caused by historical factors, negative stereotypes and the fear of discrimination. Pain management services and their health professionals need to acknowledge how these factors impact patients trust and care.

Potential Determinants of Cardio-Metabolic Risk among Aboriginal and Torres Strait Islander Children and Adolescents: A Systematic Review

Prevention initiatives during childhood and adolescence have great potential to address the health inequities experienced by Aboriginal and Torres Strait Islander (Indigenous) populations in Australia by targeting modifiable risk factors for cardio-metabolic diseases. We aimed to synthesize existing evidence about potential determinants of cardio-metabolic risk markers-obesity, elevated blood pressure, elevated blood glucose, abnormal lipids, or a clustering of these factors known as the metabolic syndrome (MetS)-for Indigenous children and adolescents. We systematically searched six databases for journal articles and three websites for relevant grey literature. Included articles (n = 47) reported associations between exposures (or interventions) and one or more of the risk markers among Indigenous participants aged 0-24 years. Data from 18 distinct studies about 41 exposure-outcome associations were synthesized (by outcome: obesity [n = 18]; blood pressure [n = 9]; glucose, insulin or diabetes [n = 4]; lipids [n = 5]; and MetS [n = 5]). Obesity was associated with each of the other cardio-metabolic risk markers. Larger birth size and higher area-level socioeconomic status were associated with obesity; the latter is opposite to what is observed in the non-Indigenous population. There were major gaps in the evidence for other risk markers, as well as by age group, geography, and exposure type. Screening for risk markers among those with obesity and culturally appropriate obesity prevention initiatives could reduce the burden of cardio-metabolic disease.

Evaluation of 'Ask the Specialist': a cultural education podcast to inspire improved healthcare for Aboriginal peoples in Northern Australia

In Australia's Northern Territory (NT) most people who access health services are Aboriginal and most healthcare providers are non-Indigenous; many providers struggle to deliver culturally competent care. Cultural awareness training is offered however, dissatisfaction exists with the limited scope of training and the face-to-face or online delivery format. Therefore, we developed and evaluated Ask the Specialist: Larrakia, Tiwi and Yolŋu stories to inspire better healthcare, a cultural education podcast in which Aboriginal leaders of Larrakia, Tiwi and Yolŋu nations, known as the Specialists, answer doctors' questions about working with Aboriginal patients. The Specialists offer 'counterstories' which encourage the development of critical consciousness thereby challenging racist narratives in healthcare. After listening to the podcast, doctors reported attitudinal and behavioural changes which led to stereotypes being overturned and more culturally competent care delivery. While the podcast was purposefully local, issues raised had applicability beyond the NT and outside of healthcare. Our approach was shaped by cultural safety, critical race theory and Freirean pedagogy. This pilot is embedded in a Participatory Action Research study which explores strategies to improve culturally safe communication at the main NT hospital Royal Darwin Hospital.

A new path to address health disparities: How older Aboriginal & Torres Strait Islander women use social media to enhance community health (Protocol)

Background

Digital health offers a fresh avenue to address health disparities experienced by Aboriginal and Torres Strait Islanders. Despite the scant evidence about how Aboriginal and Torres Strait Islanders access and use health technology, the Australian government has prioritised research that uses technology to enable people to manage their health and promote better health outcomes. Older Aboriginal and Torres Strait Islander women are cultural leaders in their communities, enabling them to provide valuable insights about the safety and efficacy of health care messaging. However, no research has engaged older Aboriginal and Torres Strait Islander, women as partners in digital health research.

Objective

This paper provides a protocol for co-designed translational research that privileges older Aboriginal & Torres Strait Islander women’s cultural expertise to design and test a framework for accessible, culturally safe and feasible digital health technologies.

Methods

This mixed-methods research project will use the collective impact approach, a user-centred, co-design methodology and yarning circles, a recognised Indigenous research methodology. A series of yarning circles with three different communities will elucidate enablers and barriers to access health information; co-create a framework clarifying what works and does not work for digital health promotion in their communities; and test the framework by co-creating three digital health information programs.

Conclusions

Privileging the cultural expertise of older Aboriginal and Torres Strait Islander women will provide a novel perspective and vital guidance that end users and developers can trust and rely upon to create and evaluate culturally safe and efficacious digital health promotion programs.

Alcohol dependence in a community sample of Aboriginal and Torres Strait Islander Australians: harms, getting help and awareness of local treatments

BACKGROUND

Few studies have examined links between current alcohol dependence and specific harms among Indigenous Australians. We investigated these associations as well as help seeking for drinking, awareness of local treatments and recommendations to help family or friends cut down or stop drinking in two Indigenous communities.

METHODS

A representative sample of Indigenous Australians was surveyed in one urban and one remote community in South Australia. Data were collected via the Grog Survey App. Participants were dependent if they reported two or more symptoms of alcohol dependence (ICD-11). Pearson chi-square tests were used to describe relationships between employment by gender, and dependence by awareness of medicines and local treatment options. Multivariate logistic regressions were used to predict the odds of dependent drinkers experiencing harms and getting help for drinking, controlling for age, gender, schooling and income.

RESULTS

A total of 775 Indigenous Australians took part in the study. After controlling for confounders, dependent drinkers were nearly eight times more likely to report a harm and nearly three times more likely to get help for their drinking-compared with non-dependent drinkers. Participants recommended accessing local support from an Aboriginal alcohol and other drugs worker, or a detoxification/ rehabilitation service.

DISCUSSION AND CONCLUSIONS

More support and funding is needed for Indigenous Australians to ensure local treatment options for dependent drinkers are readily available, appropriate and accessible. Involvement of local Aboriginal or Torres Strait Islander health professionals in delivery of care can help ensure that it is appropriate to an individual's culture and context.