The Western Australian Aboriginal Child Health Survey: findings to date on adolescents

Kalgal Burnbona: An Integrated Model of Care Between the Health and Education Sector

Introduction

Kalgal Burnbona is a framework developed for applying school-based integrated care (SBIC) across Sydney Local Health District (SLHD).

Description

Kalgal Burnbona is an innovative and integrative framework developed to provide holistic, integrated, multidisciplinary child and family centred care to school-aged children from priority populations within SLHD, such as those belonging to the Aboriginal community. The expected outcomes include improved health, behavioural, education and social outcomes. This article contextualises the development of the Kalgal Burnbona framework from its beginnings as a pilot site called Ngaramadhi Space (NS) within the Healthy Homes and Neighbourhoods (HHAN) initiative, through to its evolution to an integrated partnership between the New South Wales (NSW) health and education sector. An example of how the framework can be implemented in other settings within SLHD is described.

Discussion

A tiered approach to integrated care across SLHD is postulated based on evidence from a mixed methods evaluation of NS and in line with the Rainbow Model of Integrated Care (RMIC). Kalgal Burnbona is an example of a community-driven response through collaborative partnerships to improve health, education and social outcomes. The framework described provides structure for multisector teams to work within, recognising that each community and school has its own history and needs.

Conclusion

The Kalgal Burnbona model can be scaled up to serve a wider network of students across SLHD. The initial successes of the model, which include improving access and engagement for children with unmet physical health, mental health and social needs while being accepted by communities provide evidence for policy changes and advocacy that centre on collaborative cross-sector partnerships.

School-Based Integrated Care Within Sydney Local Health District: A Qualitative Study About Partnerships Between the Education and Health Sectors

Introduction

The unmet physical and mental health needs of school-aged children (5-18 years) in New South Wales (NSW), stemming from poor access and engagement with healthcare, can be addressed by school-based integrated care (SBIC) models.This research aims to understand why and how partnerships between the health and education sector, in SBIC models, are important in providing care for children, and to identify the facilitating factors and barriers for implementation.

Methods

A qualitative study was conducted using semi-structured interviews and thematic analysis. The principles of the 'Integrated People-Centred Health Service (IPCHS)' framework and Looman et al's (2021) implementation strategies for integrated care were considered.

Results

Themes within IPCHS framework: Strategy 1: Engaging and empowering people and communities - community-driven models, improved access to healthcare, positive outcomes for children and families, 'connection', and service provision for marginalised populations; Strategy 2: Strengthening governance and accountability - system integration and developing evidence base; Strategy 3: Reorienting the model of care - shifting healthcare to schools reduces inequity and provides culturally safe practice; Strategy 4: Coordinating services within and across sectors - integrating care and stable workforce; Strategy 5: Creating an enabling environment: leadership, stakeholder commitment, and adequate resourcing.

Discussion

Potential strategies for implementing SBIC models across NSW include community consultation and co-design; building multidisciplinary teams with new competencies and roles e.g. linkers and coordinators; collaborative and shared leadership; and alignment of operational systems while maintaining a balance between structure and flexibility.

Conclusion

SBIC models require high-level collaboration across sectors and with communities to provide a shift towards child and family centred care that improves engagement, access and outcomes in health delivery.

Retrospective audit of a school-based integrated health-care model in a specialised school for children with externalising behaviour

AIM

Problematic externalising behaviours in adolescents are associated with high individual and societal burden. A school-based multidisciplinary health clinic, Ngaramadhi Space (NS), was developed at Yudi Gunyi School, a specialised behavioural school in Sydney, Australia, to improve access to holistic health-care and behavioural support. This evaluation aimed to describe the demographics, clinic attendance, health screening, recommendations made, and changes in Strengths and Difficulties Questionnaire (SDQ) scores of students attending the clinic.

METHODS

Retrospective evaluation of students including changes in SDQ scores using descriptive statistics (26 July 2016 to 14 May 2019; n = 79).

RESULTS

Prior to the assessment, few students engaged with a paediatrician or mental health professional (22.8%; 27.8%, respectively). Child protection services were involved with 76%. NS attendance was high (failure-to-attend = 7.6%; cancellations = 8.9%). New issues found at the assessment included: parental separation (31.6%); trauma history (27.8%); substance use (19%); emotional wellbeing concerns (16.5%), learning difficulties (12.7%), domestic violence (12.7%) and medical conditions (10.1%). SDQ teacher reports showed a significant decrease in total difficulties scores (M = 6.2, SD = 6.165, P < 0.05, eta squared = 1.013 (large effect)) and all subsets. No significant differences in parent and self-reported SDQ.

CONCLUSIONS

Students with problematic externalising behaviour have unmet health and social needs. The NS school-based integrated health-care model offers a novel, convenient and innovative way to engage these students. This approach has high initial attendance rates with teacher-reported SDQ results showing some behavioural improvement. Further qualitative studies are required.

Ngaramadhi Space: An Integrated, Multisector Model of Care for Students Experiencing Problematic Externalising Behaviour

Introduction

Behavioural and emotional disorders are a significant cause of morbidity for young people aged 10-19 years. School-based health care (SBHC) provides an innovative approach to addressing these issues within Australia.

Description

We describe an innovative and integrative SBHC model called Ngaramadhi Space (NS) based at a specialised behavioural school called Yudi Gunyi school (YGS) in metropolitan Sydney, Australia. NS was developed in partnership with the Aboriginal community to provide holistic, integrated, multidisciplinary child and family centred care to students experiencing problematic externalising behaviour. We contextualise the historical factors leading to the development of NS, highlighting the importance of effective partnerships between sectors, and providing the theoretical framework and key components underpinning the model of care.

Discussion

In Australia, schools are an under-utilised resource for the delivery of health and support alongside education. Collaboration between sectors can be challenging but allows a more coordinated approach to the management of complex social and health issues. By forming effective partnerships with schools and communities, the health sector has an opportunity to improve access to health and social care in a culturally safe and acceptable way. This is in line with national and international frameworks for improving health service delivery and addressing inequity.

Conclusion

The health sector can play a pivotal role in improving the wellbeing of children by forming effective partnerships with schools and communities. The NS model is a practice-based example of this.

What does the term childhood behavioural disorders mean in the context of Aboriginal culture within Australia? Part 2: Historical and social context

Childhood behavioural disorders (CBDs) are a common reason for referral to paediatric services and are associated with negative individual and societal outcomes. This article addresses how childhood became a distinct entity and how historical changes shaped its definition. Thereafter, the evolution of diagnostic criteria for CBD and associated limitations will be summarised. This will be followed by a discussion about Aboriginal culture, and the impact of colonisation on social and emotional well-being. This will provide a contextual frame for understanding how social and cultural context influences diagnoses of CBD in Aboriginal children. From this, a conversation about the journey moving forward will begin.

De-problematising Aboriginal young peoples' health and well-being through their voice: An Indigenous scoping review

BACKGROUND

The continued use of a deficit discourse when researching Aboriginal and Torres Strait Islander Peoples of Australia is problematic. Understanding and challenging the researchers position and the power of the words they use is important. It will ensure we do not persist in framing Aboriginal and Torres Strait Islander People as a problem to be solved.

DESIGN

Indigenist review of the evidence of Aboriginal young people's health and well-being.

METHODS

This review was conducted using an Indigenist approach to identify texts which amplified the voices of Aboriginal young people of Australia and presents a narrative summary of their accounts. This review is reported in line with the PRISMA-ScR reporting guidelines.

RESULTS

Culture and connection are critical components of Aboriginal young people's health and well-being. Aboriginal young people describe feeling of powerlessness to influence health and well-being of their community, and they understood the risks they and their communities faced. Young people identified the importance of connection to culture, community and Elders as crucial to their social and emotional well-being.

CONCLUSION

By harnessing an Indigenous analysis, we were able to reveal a strong counter narrative of strength and resilience within their historical, social, and political contexts through the storied accounts of Aboriginal young people.

RELEVANCE TO CLINICAL PRACTICE

Most of the currently available evidence about Aboriginal health and well-being is immersed in deficit discourse. Literature reviews being the foundation of research and informing nursing practice, we call for a purposeful shift towards the adoption of an Indigenist strength-based approach which emphasises the strength and resilience of Aboriginal young people.

Cohort profile: South Australian Aboriginal Birth Cohort (SAABC)-a prospective longitudinal birth cohort

PURPOSE

The South Australian Aboriginal Birth Cohort (SAABC) is a prospective, longitudinal birth cohort established to: (1) estimate Aboriginal child dental disease compared with population estimates; (2) determine the efficacy of an early childhood caries intervention in early versus late infancy; (3) examine if efficacy was sustained over time and; (4) document factors influencing social, behavioural, cognitive, anthropometric, dietary and educational attainment over time.

PARTICIPANTS

The original SAABC comprised 449 women pregnant with an Aboriginal child recruited February 2011 to May 2012. At child age 2 years, 324 (74%) participants were retained, at age 3 years, 324 (74%) participants were retained and at age 5 years, 299 (69%) participants were retained. Fieldwork for follow-up at age 7 years is underway, with funding available for follow-up at age 9 years.

FINDINGS TO DATE

At baseline, 53% of mothers were aged 14-24 years and 72% had high school or less educational attainment. At age 3 years, dental disease experience was higher among children exposed to the intervention later rather than earlier in infancy. The effect was sustained at age 5 years, but rates were still higher than general child population estimates. Experiences of racism were high among mothers, with impacts on both tooth brushing and toothache. Compared with population estimates, levels of self-efficacy and self-rated oral health of mothers at baseline were low.

FUTURE PLANS

Our data have contributed to a better understanding of the environmental, behavioural, dietary, biological and psychosocial factors contributing to Aboriginal child oral and general health, and social and emotional well-being. This is beneficial in charting the trajectory of cohort participants' health and well-being overtime, particularly in identifying antecedents of chronic diseases which are highly prevalent among Aboriginal Australians. Funding for continued follow-up of the cohort will be sought.

TRIAL REGISTRATION NUMBER

ACTRN12611000111976; Post-results.

Systems integration to promote the mental health of Aboriginal and Torres Strait Islander children: protocol for a community-driven continuous quality improvement approach

BACKGROUND

Systems integration to promote the mental health of Aboriginal and Torres Strait Islander children works towards developing a spectrum of effective, community-based services and supports. These services and supports are organised into a coordinated network, build meaningful partnerships with families and address their cultural and linguistic needs, to help children to function better at home, in school, in the community, and throughout life. This study is conducted in partnership with primary healthcare (PHC) and other services in three diverse Indigenous Australian communities. It entails conceptualising, co-designing, implementing, and evaluating the effectiveness of systems integration to promote the mental health and wellbeing of Indigenous school-aged children (4-17 years). This paper outlines a protocol for implementing such complex community-driven research.

METHODS/DESIGN

Using continuous quality improvement processes, community co-designed strategies for improved systems integration will be informed by narratives from yarning circles with Indigenous children and service providers, and quantitative data from surveys of service providers and audits of PHC client records and intersectoral systems. Agreed strategies to improve the integration of community-based services and supports will be modelled using microsimulation software, with a preferred model implemented in each community. The evaluation will investigate changes in the: 1) availability of services that are community-driven, youth-informed and culturally competent; 2) extent of collaborative service networks; 3) identification by PHC services of children's social and emotional wellbeing concerns; and 4) ratio of children receiving services to identified need. Costs and benefits of improvements to systems integration will also be calculated.

DISCUSSION

The study will provide evidence-informed, community-driven, and tested models that can be used for implementing systems integration to promote the mental health and wellbeing of Indigenous children. It will identify the situational enablers and barriers that impact systems integration and determine the extent to which systems integration improves service availability, systems and child outcomes. Evidence for the cost effectiveness of systems-level integration will contribute to national mental health policy reform.

Opportunities and challenges for physical rehabilitation with indigenous populations

Indigenous peoples in colonised countries internationally experience a disproportionately high burden of disease and disability. The impact of many of these conditions, such as musculoskeletal pain, can be ameliorated by participating in physical rehabilitation. However, access by Indigenous peoples to physical rehabilitation is low. Overcoming barriers for Indigenous peoples to access high-quality, effective, culturally secure physical rehabilitation should be a priority. Physical rehabilitation outcomes for Indigenous peoples can be enhanced by addressing health system, health service, and individual clinician-level considerations. System-level changes include a greater commitment to cultural security, improving the funding of physical rehabilitation to Indigenous communities, building the Indigenous physical rehabilitation workforce, and developing and using Indigenous-identified indicators in quality improvement. At the health service level, physical rehabilitation should be based within Indigenous health services, Indigenous people should be employed as physical rehabilitation professionals or in allied roles, and cultural training and support provided to the existing physical rehabilitation workforce. For clinicians, a focus on cultural development and the quality of communication is needed. Indigenous ill-health is complex and includes societal and social influences. These recommendations offer practical guidance toward fair, reasonable, and equitable physical rehabilitation outcomes for Indigenous peoples.

Culture counts: the diverse effects of culture and society on mental health amidst COVID-19 outbreak in Australia

Since COVID-19 first emerged internationally, Australia has applied a number of public health measures to counter the disease' epidemiology. The public heath response has been effective in virus testing, diagnosing and treating patients with COVID-19. The imposed strict border restrictions and social distancing played a vital role in reducing positive cases via community transmission resulting in 'flattening of the curve'. Now is too soon to assess the impact of COVID-19 on people's mental health, as it will be determined by both short- and long-term consequences of exposure to stress, uncertainty, loss of control, loneliness and isolation. The authors explored cultural and societal influences on mental health during the current pandemic utilising Geert Hofstede's multidimensional construct of culture and determined psychological and cultural factors that foster resilience. We also reflected on the psychological impact of the pandemic on the individual and the group at large by utilising Michel Foucault' and Jacques Lacan' psychoanalytic theories. Remote Aboriginal Australian communities have been identified as a high-risk subpopulation in view of their unique vulnerabilities owing to their compromised health status, in addition to historical, systemic and cultural factors. Historically, Australia has prided itself in its multiculturalism; however, there has been evidence of an increase in racial microaggressions and xenophobia during this pandemic. Australia's model of cultural awareness will need to evolve, from reactionary to more reflective, post COVID-19 pandemic to best serve our multicultural, inclusive and integrated society.

Fingernail cortisol as a marker of chronic stress exposure in Indigenous and non-Indigenous young adults

Cumulative exposure to stress over a long period can negatively impact an individual's health. Significant advancements in biomarkers of chronic stress have been made, with the use of fingernails recently explored. Cross sectional data from the Australian Aboriginal Birth Cohort (Indigenous) and Top End Cohort (non-Indigenous) were used to investigate the associations (sociodemographic and emotional) of fingernail cortisol in Indigenous and non-Indigenous young adults. Details on sociodemographic (age, gender, and Indigenous identification), smoking and alcohol use, emotional wellbeing, and emotional stress (perceived stress and stressful events), and fingernail samples were obtained face-to-face. Fingernail samples were analyzed for 179 Indigenous and 66 non-Indigenous participants (21-28 years). Indigenous participants were subjected to higher rates of stressful events compared to non-Indigenous (Median 6.0; interquartile range (IQR) 4, 9 vs. 1.0; IQR 0, 2; p < .001). Median cortisol levels were similar between Indigenous and non-Indigenous participants (4.36 pg/mg; IQR 2.2, 10.0 vs. 3.87 pg/mg: IQR 2.0, 9.7; p = .68). However, Indigenous participants had a higher cortisol level on adjustment for emotional distress and exposure to stressful events (Geometric Mean 1.82; 95CI: 1.07-3.09), with a negative association with increasing number of stressful events (Geometric Mean 0.94; 95CI 0.90, 0.99). Collection of fingernails was an easily conducted, well-tolerated method to measure stress markers in this multicultural cohort. Indigenous young adults experienced a high number of stressful events which was associated with a lowering of fingernail cortisol levels.Lay abstractChronic stress can impact negatively on health and emotional wellbeing. A fingernail sample provided a culturally acceptable, noninvasive method of measuring chronic stress in Indigenous and non-Indigenous young adults. Cortisol levels, a marker of chronic stress, were different between Indigenous and non-Indigenous young adults and were influenced by emotional status and occurrence of multiple stressful events.

Barriers and facilitators of sport and physical activity for Aboriginal and Torres Strait Islander children and adolescents: a mixed studies systematic review

BACKGROUND

Participation in sport and physical activity could minimise the inflated risk of poor physical health outcomes for Aboriginal and Torres Strait Islander children and adolescents. This review aimed to synthesise existing quantitative and qualitative literature regarding barriers and facilitators to physical activity and sports participation in Aboriginal and Torres Strait Islander children.

METHODS

Literature was systematically searched to include studies reporting barriers or facilitators to physical activity and/or sports participation in Aboriginal and Torres Strait Islander children aged 0-18 years. Using a pre-established taxonomy based on the social-ecological model, a deductive analysis was performed. Quality appraisal was performed using the Mixed Methods Appraisal Tool.

RESULTS

Of 3440 unique articles, nine studies were included with n = 10,061 total participants. Of the nine included studies one reported on participants from urban areas, two from regional and three from remote areas. Three were from representative samples of the Aboriginal and Torres Strait Islander population. Barriers were reported in all nine studies: 18 individual, 9 interpersonal, 27 community and 4 at the policy level (58 total); Facilitators were reported in five studies: 12 individual, 11 interpersonal, 11 community and 3 policy level (37 total).

CONCLUSIONS

Research in this area is lacking with some states in Australia not represented and small samples. Strategies for improving participation in sport and physical activity by Aboriginal and Torres Strait Islander children and adolescents need to integrate a comprehensive identification of barriers and facilitators with a social-ecological understanding of how community and cultural factors can impact individual participation.

Drafting the Aboriginal and Islander Mental Health Initiative for Youth (AIMhi-Y) App: Results of a formative mixed methods study

BACKGROUND

Culturally responsive, strengths-based early-intervention mental health treatment programs are considered most appropriate to influence the high rates of psychological distress and suicide experienced by Aboriginal and Torres Strait Islander youth. Few early intervention services effectively bridge the socio-cultural and geographic challenges of providing sufficient and culturally relevant services in rural and remote Australia. Mental Health apps provide an opportunity to bridge current gaps in service access if co-designed with Aboriginal and Torres Strait Islander youth to meet their needs.

AIMS

This paper reports the results of the formative stage of the AIMhi-Y App development process which engaged Aboriginal and Torres Strait Islander youth in the co-design of the new culturally informed AIMhi-Y App.

METHODS

Using a participatory design research approach, a series of co-design workshops were held across three sites with five groups of young people. Workshops explored concepts, understanding, language, acceptability of electronic mental health tools (e-mental health) and identified important characteristics of the presented applications and websites, chosen for relevance to this group. An additional peer supported online survey explored use of technology, help seeking and e-mental health design elements which contribute to acceptability.

RESULTS

Forty-five, Aboriginal and Torres Strait Islander youth, aged 10-18 years, from three sites in the Northern Territory (NT) were involved in the workshops (n = 29). Although experiencing psychological distress, participants faced barriers to help seeking. Apps were perceived as a potential solution to overcome barriers by increasing mental health literacy, providing anonymity if desired, and linking young people with further help. Preferred app characteristics included a strength-based approach, mental health information, relatable content and a fun, appealing, easy to use interface which encouraged app progression. Findings informed the new AIMhi-Y App draft, which is a strengths-based early intervention wellbeing app for Aboriginal and Torres Strait Islander youth.

CONCLUSIONS

Research findings highlight the need, feasibility and potential of these types of tools, from the perspective of Aboriginal and Torres Strait Islander youth.

"If you don't speak from the heart, the young mob aren't going to listen at all": An invitation for youth mental health services to engage in new ways of working

AIM

Aboriginal and Torres Strait Islander young people are more likely to experience mental health issues or end their life by suicide than non-Aboriginal youth, but are less likely to access mental health services for support. Systemic change is required if mainstream youth mental health services are to be relevant and culturally secure for Aboriginal and Torres Strait Islander young people.

METHODS

Building Bridges (2017-2019) is a three-year participatory action research project being conducted in partnership with the Nyoongar community and three mainstream youth mental health services in Perth, Western Australia. The project involves Nyoongar Elders and Aboriginal and Torres Strait Islander young people working directly with senior management and key staff of youth mental health services to co-design, implement and evaluate a framework for systems change. The aim of the project is to increase Aboriginal and Torres Strait Islander young people's engagement with services and improve mental health outcomes for young people and their families.

RESULTS

This paper outlines the engagement process that underpinned the first phase of the project. Our research methods are premised by an investment in establishing safe spaces for the Elders, young people and service staff to engage in open, honest dialogue. We present two key activities that illustrate this process of building trust and deepening understanding, namely: spending time "On Country" and engaging in a "storying" process.

CONCLUSIONS

Building Bridges demonstrates the centrality of trusting relationships for systemic change and the way in which meaningful engagement is at the core of both the process and the outcome.

Stress beyond coping? A Rasch analysis of the Perceived Stress Scale (PSS-14) in an Aboriginal population

The history of colonization contributed to Aboriginal and Torres Strait Islanders becoming one of the most disadvantaged groups in Australia. The multiple social inequalities, and therefore the constant insecurities for many about low income, poor living conditions, unemployment, and discrimination, generate chronic stress in this population. In the Baby Teeth Talk Study, an oral-health randomized controlled trial, the Perceived Stress Scale (PSS-14) was administered to 367 pregnant Aboriginal women at baseline. The aim of the present study was to evaluate the validity and reliability of the PSS-14 in an Aboriginal population. The study analysed: (a) model fit; (b) dimensionality; (c) local dependence; (d) differential item functioning; (e) threshold ordering and item fit; (f) targeting; (g) reliability; and (h) criterion validity. The dimensionality analysis indicated a two-factor structure, with negatively and positively worded items clustering together and 21.7% (95% Agresti-Coull C.I. [17.8%, 26.2%]) statistically significant t-tests between the persons' estimates. After the creation of composite items, the revised Perceived Distress (χ2 (21) = 11.74, p = 0.946) and Perceived Coping (χ2 (28) = 17.63, p = 0.935) subscales fitted the Rasch model. Reliability was modest (PersonSeparationIndexdistress = 0.72; PersonSeparationIndexcoping = 0.76). The latent correlation between the Perceived Distress and Perceived Coping subscales was r = 0.14. It is hypothesized that the social inequalities experienced by the Aboriginal population are so pronounced that even Aboriginal pregnant women that perceived themselves as coping well with life challenges ended up endorsing items regarding high levels of stress. The present research showed that a revised PSS-14 is a culturally valid and modestly reliable psychological instrument to measure stress in a population of pregnant Aboriginal women in Australia.

Association of Modifiable Risk Factors With Dental Caries Among Indigenous and Nonindigenous Children in Australia

Importance

Although the prevalence of untreated dental caries among Indigenous Australian children greatly exceeds the prevalence observed among non-Indigenous children, the associations of dental caries with risk factors is considered to be the same.

Objective

To estimate the association of modifiable risk factors with area-based inequalities in untreated dental caries among Indigenous and non-Indigenous Australian children using decomposition analysis.

Design, Setting, Participants

Cross-sectional study using data from Australia's National Child Oral Health Study 2012-2014, a nationally representative sample of both Indigenous and non-Indigenous children aged 5 to 14 years. Data analyses were completed in November 2018.

Main Outcomes and Measures

Outcomes were the mean number of decayed tooth surfaces in the primary dentition for children aged 5 to 10 years and mean number of decayed tooth surfaces in the permanent dentition for children aged 8 to 14 years. The area-based measure was the school-based Index of Community Socio-Educational Advantage, with individual-level variables including sex, equivalized household income, tooth-brushing frequency, sugar-sweetened beverage (SSB) consumption, time from last dental visit, and residing in an area with water fluoridation.

Results

There were 720 Indigenous children aged 5 to 10 years, 14 769 non-Indigenous children aged 5 to 10 years, 738 Indigenous children aged 8 to 14 years, and 15 631 non-Indigenous children aged 8 to 14 years. For area-based inequalities in primary dentition among Indigenous children, two-thirds of the contribution was associated with SSB consumption (65.9%; 95% CI, 65.5%-66.3%), followed by irregular tooth brushing (15.0%; 95% CI, 14.6%-15.5%) and low household income (14.5%; 95% CI, 14.1%-14.8%). Among non-Indigenous children, almost half the contribution was associated with low household income (47.6%; 95% CI, 47.6%-47.7%), followed by SSB consumption (31.0%; 95% CI, 30.9%-31.0%) and residing in an area with nonfluoridated water (9.5%; 95% CI, 9.5%-9.6%). For area-based inequalities in permanent dentition among Indigenous children, 40.0% (95% CI, 39.9%-40.1%) of the contribution was associated with residing in an area with nonfluoridated water, followed by low household income (20.0%; 95% CI, 19.7%-20.0%) and consumption of SSBs (20.0%; 95% CI, 19.9%-20.1%). Among non-Indigenous children, the contribution associated with low household income, SSB consumption, and last dental visit more than a year ago were each 28.6%.

Conclusions and Relevance

The association of modifiable risk factors with area-based inequalities in untreated dental caries among Indigenous and non-Indigenous Australian children differed substantially. Targets to reduce SSB consumption may reduce oral health inequalities for both groups; however, Indigenous children require additional focus on oral hygiene.

Hair cortisol and cortisone as markers of stress in Indigenous and non-Indigenous young adults

Chronic, ongoing stress can impact negatively on health and wellbeing. Indigenous Australians are at an increased risk of experiencing multiple stressors. Hair glucocorticoids have been used as a marker for chronic stress. This study aimed to assess the associations of hair cortisol and cortisone with sociodemographic (age, gender, Indigenous Identification), substance use, emotional wellbeing, and emotional stress, in a cohort at increased risk of stressful events and psychological distress. Cross-sectional data (age 21-28 years) are presented from two Australian longitudinal studies; the Aboriginal Birth Cohort (n = 253) and non-Indigenous Top End Cohort (n = 72). A third of the cohort reported psychological distress, with Indigenous participants reporting higher rates of stressful events compared to non-Indigenous (6 vs. 1; p < .001). Significantly higher levels of cortisone were seen in Indigenous women compared to non-Indigenous women (β 0.21; p = .003). A positive association with age was present in hair cortisol and cortisone in Indigenous young adults (β 0.29 and β 0.41; p < .001, respectively). No association with substance use, emotional wellbeing or emotional stress was seen. Sub-analysis in women suggested a possible curvilinear relationship between hair cortisone and the number of stressful events. In this culturally diverse cohort, hair sampling provides a noninvasive, easily conducted and generally well tolerated mechanism to measure stress markers. The association with age, even in this narrow age range, likely represents the manifold changes in circumstances (financial independence, becoming parents, increased risk of substance use and mental illness) that occur during this transitional period of life, particularly for young Indigenous women. LAY ABSTRACT Chronic stress can impact negatively on health and emotional wellbeing. A hair sample is an easy way to measure chronic stress in Indigenous and non-Indigenous young people. The markers of chronic stress, cortisol and cortisone, were different between Indigenous and non-Indigenous, men and women and increased with age in Indigenous young adults.

Follow-up of an Intervention to Reduce Dental Caries in Indigenous Australian Children: A Secondary Analysis of a Randomized Clinical Trial

Importance

Testing the long-term usefulness of a childhood intervention and determining the best age of implementation are important for translation and policy change.

Objectives

To investigate among children aged 3 years the long-term effectiveness an intervention that aimed to reduce dental caries among South Australian Aboriginal children and to assess if children in the delayed intervention (DI) group had any benefit from the intervention from ages 2 to 3 years and if the intervention usefulness was greater when delivered between pregnancy and age 2 years (immediate intervention [II] vs ages 2 to 3 years [DI]).

Design, Setting, and Participants

Secondary analysis of a randomized clinical trial. The study enrolled 448 pregnant women across South Australia, Australia, at baseline (February 1, 2011, to May 30, 2012), with 223 randomly allocated to the II group and 225 to the DI group. Three-year follow-up data were collected November 2014 to February 2016.

Interventions

The intervention comprised dental treatment to mothers, fluoride varnish application to children, and motivational interviewing delivered together with anticipatory guidance. This was delivered during pregnancy and at child ages 6, 12, and 18 months for the II group and at child ages 24, 30, and 36 months for the DI group.

Main Outcomes and Measures

The mean number of decayed teeth measured at child age 3 years.

Results

There were 324 children at age 3 years (52.3% male). The mean number of decayed teeth at age 3 years was 1.44 (95% CI, 1.38-1.50) for the II group and 1.86 (95% CI, 1.89-2.03) for the DI group (mean difference, -0.41; 95% CI, -0.52 to -0.10). The predicted mean number of decayed teeth at age 3 years for the DI group was 2.15. Between ages 2 and 3 years, the caries increment for the II group was 0.82 (95% CI, 0.75-0.89), compared with 0.97 (95% CI, 0.87-1.17) for the DI group (P = .05).

Conclusions and Relevance

At the 3-year follow-up, II children had less dental caries than DI children, DI children developed dental caries at a lower trajectory than predicted had the intervention not been received at ages 2 to 3 years, and the caries increment was less between ages 2 to 3 years among II children compared with DI children. This study suggests that the best time to implement the intervention is earlier rather than later infancy.

Trial Registration

Australian and New Zealand Clinical Trial Registry Ideintifier: ACTRN12611000111976.

Social determinants in the sexual health of adolescent Aboriginal Australians: a systematic review

While research indicates that Aboriginal and Torres Strait Islander adolescents may be at increased risk of some sexually transmitted infections, there is limited information about factors that may place these young people at more risk of adverse sexual health than their non-Indigenous counterparts. Current research has tended to focus on surveillance-type data, but there is an increasing need to understand social determinants of sexual health risk. This systematic review assessed the evidence of social determinants impacting on Aboriginal and Torres Strait Islander adolescents' sexual health in Australia. Published, English-language literature was searched across key databases from 2003 to 2015. Fourteen studies were included in the qualitative synthesis. Findings suggest that social determinants such as access to healthcare, poverty, substance use, educational disadvantage, sociocultural context, gender inequalities, status and identity, and social disadvantage impacted on Indigenous adolescents' sexual behaviours and sexual health risk. Evidence from the literature included in the review suggests that peer education may be an acceptable and appropriate approach for addressing such issues. There remains a need for programmes and services to be community-developed and community-led, thus ensuring cultural appropriateness and relevance. However, there is also a significant need for such programmes to be effectively and rigorously evaluated with data that goes beyond surveillance, and seeks to unpack how sexual norms are experienced by Indigenous adolescents, particularly outside of remote Australia - and how these experiences act as either risk or protective factors to good sexual health and positive social and emotional well-being.

The School Contextual Effect of Sexual Debut on Sexual Risk-Taking: A Joint Parameter Approach

BACKGROUND

Previous research has identified individual and school-level characteristics that are associated with sexual risk-taking, but the impact of school-level mechanisms on sexual risk-taking is not well understood. We examine the aggregated effects that early sex at the school level have on risky sexual behaviors.

METHODS

We use 3 waves of data from the National Longitudinal Study of Adolescent Health. An individual's first sexual intercourse before age 15 was recorded along with various risky sexual behaviors at debut. Two variables at respondent's later stage of life were also included: having sex in exchange for drugs or money, and contraction of sexually transmitted disease (STD). Longitudinal analysis was conducted using a joint parameter model that tested unobserved school effects on individual behaviors simultaneously.

RESULTS

An increase in early sexual initiation at the school level was associated with higher probability of sexual debut, along with increased involvement in sexual risk-taking controlling for student family background.

CONCLUSIONS

School behavioral mechanisms are directly related to sexual health behaviors among youth. Our findings have implications for school-based interventions, education programs, and the role of parents.

Flying blind: trying to find solutions to Indigenous oral health

Objective The aim of the present study was to identify all published evidence about oral health in Indigenous children in Australia and to determine trends in Indigenous oral health over time. Methods PubMed was used to search for published peer-reviewed articles that reported caries (decay) prevalence rates and/or caries experience (based on caries indices) in Indigenous children. Studies included in the analysis needed to report clinical oral health data (not self-reported dental experiences), and articles were excluded if they reported caries in only a select, specific or targeted sample (e.g. only children undergoing hospital admissions for dental conditions). Results The review identified 32 studies that met the inclusion criteria. These studies reported data from the Northern Territory (n=14), Western Australia (n=7), South Australia (n=7), Queensland (n=7), New South Wales (n=1), Australian Capital Territory (n=1) and Tasmania (n=1). Of the studies, 47% were in rural locations, 9% were in urban locations and 44% were in both rural and urban locations. Data are limited and predominantly for Indigenous children living in rural locations, and there are no published studies on caries in Indigenous children living in Victoria. Conclusions The present study documents the published prevalence and severity of caries in Indigenous children living in Australia and highlights that limited oral health data are available for this priority population. Although risk factors for oral disease are well known, most of the studies did not analyse the link between these factors and oral disease present. There is also inconsistency in how caries is reported in terms of age and caries criteria used. We cannot rely on the available data to inform the development of policies and programs to address the oral health differences in Indigenous populations living contemporary lives in metropolitan areas. What is known about the topic? Many studies report that Indigenous people have poorer general health in Australia compared with non-Indigenous people. What does this paper add? This paper documents the available published prevalence and experience of caries for Indigenous children in Australia. It demonstrates significant limitations in the data, including no Victorian data, inconsistency with reporting methods and most data being for Indigenous children who are living in rural locations. What are the implications for practitioners? It is important for practitioners to have access to oral health data for Indigenous children in Australia. However, the present study highlights significant knowledge gaps for this population group and identifies ways to collect data in future studies to enable more meaningful comparisons and policy development.

Psychosocial factors associated with the mental health of indigenous children living in high income countries: a systematic review

BACKGROUND

Indigenous children living in high income countries have a consistently high prevalence of mental health problems. We aimed to identify psychosocial risk and protective factors for mental health in this setting.

METHODS

A systematic review of studies published between 1996 and 2016 that quantitatively evaluated the association between psychosocial variables and mental health among Indigenous children living in high income countries was conducted. Psychosocial variables were grouped into commonly occurring domains. Individual studies were judged to provide evidence for an association between a domain and either good mental health, poor mental health, or a negligible or inconsistent association. The overall quality of evidence across all studies for each domain was assessed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) guidelines.

RESULTS

Forty-seven papers were eligible (mainland US 30 [64%], Canada 8 [17%], Australia 7 [15%], Hawaii 4 [9%]), including 58,218 participants aged 4-20 years. Most papers were cross-sectional (39, 83%) and measured negative mental health outcomes (41, 87%). Children's negative cohesion with their families and the presence of adverse events appeared the most reliable predictors of increased negative mental health outcomes. Children's substance use, experiences of discrimination, comorbid internalising symptoms, and negative parental behaviour also provided evidence of associations with negative mental health outcomes. Positive family and peer relationships, high self-esteem and optimism were associated with increased positive mental health outcomes.

CONCLUSIONS

Quantitative research investigating Indigenous children's mental health is largely cross-sectional and focused upon negative outcomes. Indigenous children living in high income countries share many of the same risk and protective factors associated with mental health. The evidence linking children's familial environment, psychological traits, substance use and experiences of discrimination with mental health outcomes highlights key targets for more concerted efforts to develop initiatives to improve the mental health of Indigenous children.

Prevalence and profile of Neurodevelopment and Fetal Alcohol Spectrum Disorder (FASD) amongst Australian Aboriginal children living in remote communities

BACKGROUND

Despite multiple risk factors for neurodevelopmental vulnerability, few studies have assessed neurodevelopmental performance of Australian Aboriginal children. An important risk factor for neurodevelopmental vulnerability is prenatal alcohol exposure (PAE), which places children at risk for Fetal Alcohol Spectrum Disorder (FASD).

AIMS

This study assesses neurodevelopment outcomes in a population of Australian Aboriginal children with and without PAE.

METHODS AND PROCEDURES

Children born in 2002/2003, and living in the Fitzroy Valley, Western Australia between April 2010 and November 2011, were eligible (N=134). Sociodemographic and antenatal data, including PAE, were collected by interview with 127/134 (95%) consenting parents/caregivers. Maternal/child medical records were reviewed. Neurodevelopment was assessed by clinicians blinded to PAE in 108/134 (81%) children and diagnoses on the FASD spectrum were assigned.

OUTCOMES AND RESULTS

Neurodevelopmental disorder was documented in 34/108 children (314.8 per 1000). Any diagnosis on the FASD spectrum was made in 21/108 (194.4 per 1000) children (95% CI=131.0-279.0).

CONCLUSIONS AND IMPLICATIONS

Neurodevelopmental impairment with or without PAE is highly prevalent among children in the Fitzroy Valley. Rates of diagnoses on the FASD spectrum are among the highest worldwide. Early intervention services are needed to support developmentally vulnerable children in remote communities.

Life, lifestyle and location: examining the complexities of psychological distress in young adult Indigenous and non-Indigenous Australians

Mental health is fundamental to an individual’s health and well-being. Mental health disorders affect a substantial portion of the Australian population, with the most vulnerable time in adolescence and young adulthood. Indigenous Australians fare worse than other Australians on almost every measure of physical and mental health. Cross-sectional data from young adults (21–27 years) participating in the Life Course Program, Northern Territory, Australia, is presented. Rates of psychological distress were high in remote and urban residing Indigenous and urban non-Indigenous young adults. This rate was more pronounced in young women, particularly in Indigenous remote and urban residing women. Young adults with high psychological distress also had lower levels of positive well-being, higher perceived stress levels, experienced a higher number of major life events and were at an increased risk of suicidal ideation and/or self-harm. This study supports the need for a continued focus on early screening and treatment at this vulnerable age. The significant association seen between psychological distress and other markers of emotional well-being, particularly risk of suicidal ideation and/or self-harm, highlights the need for a holistic approach to mental health assessment and treatment. A concerted focus on improving the environs of young adults by lowering levels of stress, improving access to adequate housing, educational and employment opportunity, will assist in improving the emotional health of young adults.

Systematic review of barriers and facilitators to accessing and engaging with mental health care among at-risk young people

INTRODUCTION

This study aims to review the literature on barriers and facilitators to accessing and engaging with mental health care among young people from potentially disadvantaged groups, including young people identified as Aboriginal or Torres Strait Islander (ATSI); culturally and linguistically diverse (CALD); lesbian, gay, bisexual, transgender, queer, or intersex (LGBTQI); homeless; substance using; and youth residing in rural or remote areas.

METHODS

Fourteen databases were searched to identify qualitative and quantitative researches that examined barriers and/or facilitators to mental health care among the six groups of potentially disadvantaged young people.

RESULTS

Out of 62 studies identified, 3 were conducted with ATSI young people, 1 with CALD young people, 4 with LGBTQI young people, 14 with homeless young people, 24 with substance-using young people, and 16 with young people residing in rural or remote areas. Findings generally confirmed barriers already established for all young people, but indicated that some may be heightened for young people in the six identified groups. Findings also pointed to both similarities and differences between these groups, suggesting that ATSI, CALD, LGBTQI, homeless, substance-using, and rural young people have some similar needs with respect to not only mental health care, but also other needs likely to reflect their individual circumstances.

DISCUSSION

This systematic review highlights that young people from potentially disadvantaged groups have distinct needs that must be recognized to improve their experiences with mental health care. Future research of good methodological quality with young people is needed to increase accessibility of, and engagement with, mental health care.

Finding Color in Conformity: A Commentary on Culturally Specific Risk Factors for Violence in Australia

This article outlines the current utility of Indigenous culturally specific risk factors for violence and the ramifications for cross-cultural risk prediction. The Indigenous culturally specific violence risk factor literature has provided a rich body of contextual information outlining Indigenous patterns of criminal behaviour. This information has the capacity to facilitate offender responsivity and treatment targets in addition to assisting clinicians identify the presence of risk markers among Indigenous clients. However, if intended for inclusion in risk prediction models, culturally specific risk items then require further quantitative analysis to establish robust associations and probability estimates for recidivistic outcome.

A systematic review: Identifying the prevalence rates of psychiatric disorder in Australia's Indigenous populations

OBJECTIVE

This review aimed to draw on published literature to identify the prevalence rates of psychiatric disorders in Australia's Indigenous populations, Aboriginal and Torres Strait Islander peoples.

METHOD

A systematic review following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) model was conducted using the following electronic databases: PubMed, Scopus, Web of Science, MEDLINE, PsycINFO, PsycARTICLES, and Informit Indigenous and Health Collections. Studies were included for analysis if they were empirical quantitative studies reporting prevalence rates for any psychiatric disorder in Indigenous people.

RESULTS

Of the 1584 papers extracted by the search strategy, 17 articles met the eligibility criteria and were reviewed in detail. Methodology, sampling strategy and study design varied greatly across these 17 studies. Prevalence rates varied by disorder and are as follows: major depressive disorder (4.3-51%); mood disorders (7.7-43.1%); post-traumatic stress disorder (14.2-55.2%); anxiety disorders (17.2-58.6%); substance dependence (5.9%-66.2%); alcohol dependence (21.4-55.4%); and psychotic disorders (1.68-25%). While the number of studies on community-based Indigenous populations was limited, available evidence suggested that prevalence rates are higher in prison populations compared with community-based studies.

CONCLUSIONS

It was identified that there is limited evidence on the occurrence of psychiatric disorders for Indigenous people in the general community. More research in this area is essential to provide accurate and reliable estimates and to provide a baseline for evaluating the effectiveness of programs aimed at reducing the high mental health burden experienced by Indigenous Australians. Future research needs to ensure that standardised and validated methods are used to accurately estimate the prevalence of psychiatric disorders among Indigenous Australians.

Psychological distress and self-rated oral health among a convenience sample of Indigenous Australians

OBJECTIVES

This study sought to: a) estimate the frequency of poor self-rated oral health as assessed by a summary measure; b) compare frequency according to sociodemographic, behavioral, and psychological distress factors; and (3) determine if psychological distress was associated with poor self-rated oral health after adjusting for confounding.

METHODS

Data were from a convenience sample of Indigenous Australian adults (n = 289) residing in Australia's Northern Territory. Poor self-rated oral health was defined as reported experience of toothache, poor dental appearance or food avoidance in the last 12 months. A logistic regression model was used to evaluate socio-demographic, behavioral, and psychological distress associations with poor self-rated oral health (SROH). Effects were quantified as odds ratios (OR).

RESULTS

The frequency of poor SROH was 73.7 percent. High psychological distress, measured by a Kessler-6 score ≥8, was experienced by 33.9 percent of participants. Poor SROH was associated with high levels of psychological distress, being older, being female, and usually visiting a dentist because of a problem. In the multivariable model, factors that were significantly associated with poor SROH after adjustment for other covariates included having a high level of psychological distress (OR 2.74, 95% CI 1.25-6.00), being female (OR 2.22, 95% CI 1.03-4.78), and usually visiting a dentist because of a problem (OR 3.57, 95% CI 1.89-6.76).

CONCLUSIONS

Poor self-rated oral health and high levels of psychological distress were both highly frequent among this vulnerable population. Psychological distress was significantly associated with poor self-rated oral health after adjustment for confounding.

Challenges and strategies for cohort retention and data collection in an indigenous population: Australian Aboriginal Birth Cohort

BACKGROUND

Longitudinal prospective birth cohort studies are pivotal to identifying fundamental causes and determinants of disease and health over the life course. There is limited information about the challenges, retention, and collection strategies in the study of Indigenous populations. The aim is to describe the follow-up rates of an Australian Aboriginal Birth Cohort study and how they were achieved.

METHODS

Participants were 686 babies enrolled between January 1987 and March 1990, born to a mother recorded in the Delivery Suite Register of the Royal Darwin Hospital (RDH) as a self-identified Aboriginal. The majority of the participants (70%) resided in Northern Territory within rural, remote and very remote Aboriginal communities that maintain traditional connections to their land and culture. The Aboriginal communities are within a sparsely populated (0.2 people/ km2) area of approximately 900,000 km² (347 sq miles), with poor communication and transport infrastructures. Follow-ups collecting biomedical and lifestyle data directly from participants in over 40 locations were conducted at 11.4 years (Wave-2) and 18.2 years (Wave-3), with Wave-4 follow-up currently underway.

RESULTS

Follow-ups at 11 and 18 years of age successfully examined 86% and 72% of living participants respectively. Strategies addressing logistic, cultural and ethical challenges are documented.

CONCLUSIONS

Satisfactory follow-up rates of a prospective longitudinal Indigenous birth cohort with traditional characteristics are possible while maintaining scientific rigor in a challenging setting. Approaches included flexibility, respect, and transparent communication along with the adoption of culturally sensitive behaviours. This work should inform and assist researchers undertaking or planning similar studies in Indigenous and developing populations.

Sexual behaviour, sexually transmitted infections and attitudes to chlamydia testing among a unique national sample of young Australians: baseline data from a randomised controlled trial

BACKGROUND

Chlamydia infection is the most common notifiable sexually transmitted infection (STI) in Australia and mostly affects young people (15 - 25 years). This paper presents baseline data from a randomised controlled trial that aimed to increase chlamydia testing among sexually active young people. The objectives were to identify associations between sexual behaviour, substance use and STI history and explore attitudes to chlamydia testing.

METHODS

This study was conducted in cyberspace. Study recruitment, allocation, delivery of interventions and baseline and follow up data collection all took place online. Participants were 16 - 25 years old and resided in Australia. Substance use correlates of sexual activity; predictors of history of STIs; barriers to and facilitators of chlamydia testing were analysed.

RESULTS

Of 856 participants (79.1% female), 704 had experienced penetrative intercourse. Sexually active participants were more likely to smoke regularly or daily, to drink alcohol, or to have binge drunk or used marijuana or other illicit substances recently. Risk factors for having a history of any STI were 3 or more sexual partners ever, 6 or more partners in the past 12 months, condom non-use and being 20 years or older. Almost all sexually active participants said that they would have a chlamydia test if their doctor recommended it.

CONCLUSIONS

Sexually active young people are at risk of STIs and may engage in substance use risk behaviours. Where one health risk behaviour is identified, it is important to seek information about others. Chlamydia testing can be facilitated by doctors and nurses recommending it. Primary care providers have a useful role in chlamydia control.

TRIAL REGISTRATION

Australian and New Zealand Trials Registry ACTRN12607000582459.

The quality of health research for young Indigenous Australians: systematic review

OBJECTIVE

To assess the extent and quality of the evidence base related to the health and wellbeing of young Indigenous Australians.

STUDY DESIGN

Systematic review of peer-reviewed literature; grading of quality of literature; mapping of sample characteristics and study foci.

DATA SOURCES

English language publications, 1 Jan 1994 - 1 Jan 2011 in MEDLINE, ERIC, CINAHL, EMBASE, ATSIhealth, PsycINFO, the Cochrane Library and the Australian Indigenous HealthInfoNet.

STUDY SELECTION

Inclusion criteria were: published 1 Jan 1994 - 1 Jan 2011; original peer-reviewed research; reported data for Australian Aboriginal and Torres Strait Islanders aged 10-24 2013s; focused on health and wellbeing. Grading for quality included ascertainment of Indigenous status, representativeness of the sample for the target population, and quality of measures of exposure and outcome.

DATA SYNTHESIS

360 peer-reviewed publications met inclusion criteria; 90 (25%) exclusively sampled Indigenous young people. 250 studies (69%) were of good-quality design; 124 of these focused on health outcomes (15 of these evaluated an intervention) and 116 focused on health-risk exposure (26 evaluative). The methodological quality of data improved during 1994-2010; however, only 17% of studies focused on urban populations. A third of good-quality studies of health outcome focused on communicable diseases such as sexually transmitted infections and tuberculosis. There was good-quality data for oral health and substance use, and some data for adolescent pregnancy. Data on mental disorders, injury and cause-specific mortality were limited.

CONCLUSIONS

Despite improvements, there are important gaps in the evidence base for the health of young Indigenous Australians. Our study points to the need for greater research investment in urban settings and with regard to mental disorders and injury, with a further emphasis on trials of preventive and clinical intervention.

Health professionals' views on Indigenous Health and the delivery of healthcare services in the Pilbara

PURPOSE

To explore health professionals' views about Australian Indigenous people's health and the delivery of healthcare to them in the Pilbara region of Western Australia.

METHODS

An open-ended questionnaire was used to gather information from health professionals located across diverse regions in the Pilbara. The responses were analysed with the use of thematic analysis. In the first stage, codes were developed by assigning names to small sections of the interview transcripts. Next, the most salient incisive codes were identified and developed into themes that captured the most important issues.

FINDINGS

Twenty-eight health professionals indicated that the most important health issues were chronic diseases, substance abuse and ear disease. These health issues were often attributed to a cycle of poor health perpetuated throughout generations. Educational initiatives were thought to be integral to intervening in this cycle. Of particular importance in improving the effectiveness of educational initiatives was facilitating the participation of Australian Indigenous peoples to determine the content of such initiatives. The other main issues the health professionals identified were lifting the standard of Australian Indigenous housing and implementing strategies to improve the continuity of healthcare.

CONCLUSION

Educational initiatives need to be prioritised to improve the health of Australian Indigenous people in the Pilbara and the initiatives should be delivered with the involvement of the local community in order to increase the likelihood of sustained behavioural change. Innovative solutions are required to improve the continuity of healthcare in the Pilbara, including increased use of mobile services.

Factors influencing child mental health: A state-wide survey of Victorian children

AIMS

This study aims to estimate the prevalence of mental health problems among Victorian children and to investigate factors associated with poorer mental health.

METHOD

Computer-assisted telephone interviews were undertaken with the parents of 3370 randomly selected Victorian children aged 4 to 12 years. They reported on their child's mental health and special health-care needs as well as their own mental health, family functioning and a range of community and socio-demographic variables. Population estimates and odds ratios (OR) were calculated with 95% confidence intervals (95% CI).

RESULTS

Overall, 11.6% (95% CI = 10.3-12.9%) of Victorian children were estimated to be at risk of having mental health problems. Factors independently placing children at increased risk of mental health problems that were 'of concern' include a child having special health-care needs (OR = 7.89, 95% CI 5.16 to 12.08), unhealthy family functioning (OR = 3.84, 95% CI 2.19 to 6.74), parental mental health problems (OR = 7.89, 95% CI 5.16 to 12.08), neighbourhood safety (OR = 2.47, 95% CI 1.20 to 5.07) and area of residence (OR = 2.01, 95% CI 1.33 to 3.02).

CONCLUSIONS

A significant proportion of Victorian children are at some risk of mental health problems. These limited but important predictors of children's mental health reinforce the need for policy solutions that will extend beyond those offered by traditional mental health service systems.

The Boomerangs Parenting Program for Aboriginal parents and their young children

OBJECTIVE

Using three case studies, this paper describes the development and evaluation of 'The Boomerangs Aboriginal Circle of Security Parenting Camp Program', which is a clinical intervention based on an attachment framework using the Circle of Security and Marte Meo, and drawing on traditional Aboriginal culture.

METHODS

Three mothers from an Aboriginal Australian background with preschool age children attended the 20-session Boomerangs Program, including an initial camp and a second camp after 6 weeks. The camp provided the opportunity for parent empowerment and to explore the strengths and resources of the mother to facilitate better mother-child interactions and relationship, in a naturalistic setting.

RESULTS

All three mothers gave positive feedback on the program in increasing the awareness, sensitivity and responsiveness of their interactions with their children, and this was reflected in the results of the questionnaires and observation of the mother-child interactions during play.

CONCLUSION

This program offers the first ever evaluation of an intense parenting program using camps for Aboriginal Australians. This study is to be considered as an exploratory exercise - a first step in a process of exploring applicability and adapting parenting camps for Aboriginal families.

Indigenous Austalians and physical activity: using a social-ecological model to review the literature

This paper aims to present what is currently known about Indigenous Australians and their engagement in physical activity and to then challenge some of the 'taken-for-granted' ways of thinking about promoting or researching physical activity with Indigenous Australians. Major health, education and sport databases, as well as government websites were searched using the key terms of physical activity, sport, leisure, recreation, Indigenous and Aboriginal/Aborigine. A social-ecological model of health was adapted and used as an organizing framework to synthesize the literature. It is concluded that socioecological models can be valuable tools for understanding and promoting issues related to physical activity engagement for a range of populations but they may require complementary critical insights, including those from Indigenous perspectives. Productive theoretical spaces where Western and Indigenous knowledges come together can assist health educators to consider the complexity and diversity of Indigenous people's lived experiences when planning and implementing programs.

Characteristics of non-Aboriginal and Aboriginal children and families with substantiated child maltreatment: a population-based study

OBJECTIVES

To investigate specific child and parental factors associated with increased vulnerability to substantiated child maltreatment.

METHODS

A retrospective cohort study of all children born in Western Australia during 1990-2005 using de-identified record linked child protection, disability services and health data. Cox regression was used for univariate and multivariate analysis to determine the risk of substantiated child maltreatment for a number of child and parental factors, including child disability, parental age, socio-economic status, parental mental health, substance use and assault-related hospital admissions. Separate analyses were conducted for Aboriginal and non-Aboriginal children.

RESULTS

This study found a number of child and parental factors that increase the risk of substantiated child maltreatment. The strongest factors were child intellectual disability, parental socio-economic status, parental age and parental hospital admissions related to mental health, substance use and assault.

CONCLUSIONS

Awareness of the factors that make children and families vulnerable may aid the targeting of child maltreatment prevention programmes. To prevent child abuse and neglect it is essential that we have a platform of universal services, which assist parents in their role, as well as targeted services for at-risk families.

Behavioral and mental health challenges for indigenous youth: research and clinical perspectives for primary care

After first discussing historical, community and epidemiologic perspectives pertaining to mental health problems of Indigenous youth and families, this article reviews available research data on behavioral and mental health interventions and the roles that Native and Indigenous research programs are serving. Given the legacy of transgenerational trauma experienced by Indigenous peoples, community-based research and treatment methods are essential for solving these problems. The primary care provider stands in a unique position within the community to offer a "coinvestigator spirit" to youth and families in the pursuit of improving behavioral health. Strategies are presented for using the research literature, and collaborating with communities and families to help solve behavioral and mental health problems.

Australian Indigenous adolescents with chronic conditions: sociocultural context

Scant information is available in the health literature on Australian Indigenous adolescents with chronic conditions and disabilities. Little is known about how Indigenous adolescence differs from mainstream adolescence, or how Indigenous adolescents manage chronic conditions. Health services are encouraged to engage in information sharing with Indigenous clients and to develop a collaborative approach to chronic condition management as a way to improve outcomes.

Seeing white: a critical exploration of occupational therapy with Indigenous Australian people

This paper aims to critique current occupational therapy practice and theory using Indigenous Australian people as a case example. Critical race theory will be used to help question the privileged position of an occupational therapist from a dominant Westernized culture. In-depth interviews were conducted with 15 (eight female and seven male) Indigenous Australian young people about their perspectives of health and physical activity. In addition, the Kawa model was used as an alternative data-collection tool and detailed field notes and researcher reflections were used as data sources. Preliminary analysis of data is used to illustrate the ways in which critical race theory can inform occupational therapy practitioners and researchers about the ways Indigenous Australian young people view their health. Methodological dilemmas are also discussed. The paper is based on preliminary findings and further analysis needs to continue. Cross-cultural research is inherently complex but can offer those from the dominant culture valuable insights into their taken-for-granted assumptions. Further use of critical race theory may prove useful as the occupational therapy profession continues to evolve its understanding of cultural safety.

Health of Aboriginal and Torres Strait Islander children in remote Far North Queensland: findings of the Paediatric Outreach Service

AIM

To describe the pattern of disease and other health problems in children living in remote Far North Queensland (FNQ).

DESIGN, SETTING AND PARTICIPANTS

Retrospective review of the FNQ Paediatric Outreach Service's Medical Director database for the period June 2001 to February 2006. Three subpopulations were compared: children from predominantly Aboriginal communities, predominantly Torres Strait Islander communities, and other communities. All children referred to the service during the study period were reviewed.

MAIN OUTCOME MEASURES

Number of children seen and common diagnoses.

RESULTS

3562 children were referred during the study period, and a total of 3932 diagnoses were made; 56% of the paediatric population of the Aboriginal communities and 23% of the paediatric population of Torres Strait Islander communities were seen. Of 40 separate diseases/health problems reviewed, the three most common reasons for presentation were chronic suppurative otitis media, suspected child abuse and neglect, and failure to thrive. In the paediatric population of Aboriginal communities, the prevalence of fetal alcohol spectrum disorder was at least 15/1000 (1.5%), and in Torres Strait Islander children, rheumatic heart disease prevalence was at least 6/1000 (0.6%). Rheumatic fever rates were among the highest in Australia.

CONCLUSION

Rates of preventable complex and chronic health problems in Aboriginal and Torres Strait Islander children in remote FNQ are alarmingly high. Areas requiring urgent public health intervention include alcohol-related conditions and rheumatic fever.

Indigenous child oral health at a regional and state level

AIM

To compare the dental disease experience of Indigenous and non-Indigenous children in South Australia's mid-north region (regional area) and to assess Indigenous oral health differences at a regional- and state-level.

METHODS

Data were collected from a School Dental Service based in an Aboriginal-owned medical health service and standard school dental clinics in the regional area from March 2001 to March 2006. State-level data were obtained over a 12-month period in 2003. Caries prevalence (per cent dmft or DMFT >0) and severity (mean dmft or DMFT, SiC and SiC10) measures were used to assess dental disease experience.

RESULTS

In the regional area, Indigenous children aged <10 years had 1.6, 1.9, 1.6 and 1.4 times the percent dmft >0, mean dmft, SiC primary and SiC(10) primary, respectively, of their non-Indigenous counterparts, while Indigenous children aged 6+ years had 1.3, 1.7, 1.7 and 1.6 times the percent DMFT > 0, mean DMFT, SiC permanent and SiC10 permanent, respectively, of non-Indigenous children. Indigenous children in the regional area had significantly higher caries prevalence and severity than Indigenous children at a state-level.

CONCLUSION

Indigenous children in South Australia's mid-north region are dentally disadvantaged in comparison with their non-Indigenous counterparts and with the general South Australian Indigenous child population.

Aboriginal incarceration: health and social impacts

Each year up to a quarter of all young Aboriginal men have direct involvement with correctional services, and Aboriginal prisoners currently represent 22% of the total Australian prisoner population. The high rates of repeated short-term incarceration experienced by Aboriginal people in Australia have a multitude of negative health effects for Aboriginal communities and the wider society, while achieving little in terms of increased community safety. Well identified health and social priorities for Aboriginal people affected by incarceration include housing and tenancy support; mental health and wellbeing, including family violence, grief and loss support; substance misuse support; general health services, including hepatitis C management; and social inclusion, including the need for family and community integration, skills development and employment. The post-release period is a crucial time for the provision of integrated health and social services to address these priorities and to break the cycle of incarceration. To achieve significant health gains for Aboriginal people, there is a need to develop a broader collaborative approach to primary health care, incorporating social health and justice perspectives as fundamental components of health care planning. Health and human services have a critical role to play in developing community-based solutions to reduce excessive incarceration rates for Aboriginal people.