Indigenous health: Exam hints & questions from readings

'Meaning of health statement' from the national strategic framework for Indigenous health. (Dr Jennings suggests memorising this for the exam)

"For Aboriginal and Torres Strait Islander peoples health does not just entail the freedom of the individual from sickness but requires support for healthy and interdependent relationships between families, communities, land, sea and spirit. The focus must be on spiritual, cultural, emotional and social well-being as well as physical health."

Quotes from 'Exploring what sexual health nurses need to know and do in order to meet the sexual health needs of young Aboriginal women in Adelaide.'

"I found it very different and extremely difficult coming to work in the city compared to working in traditional/rural areas. In my previous work with traditional people it was really clear who was related to whom and where everyone sat in the community. I knew where everyone fitted. It was clear to me who I could talk to... Here in the city, I don't know who to talk to; I don't know the correct way to go about doing things... When I talk to other non-Aboriginal people, they don't seem to know either...and there is no Aboriginal health worker [easily] available [at work] to support me (nurse participant)." "Being an Aboriginal sexual health nurse, I have to work at it twice as long to build up trust for the clinical work to happen. People see me as Auntie, an Elder, and they think that I am going to go and talk to their mothers or Aunties [grandmothers] about their business. It takes a long time for them to believe and trust that I won't. And most of the community doesn't recognise me as a Registered Nurse. They think I am a health worker. It is hard for them to understand my role here. It takes a long time for them to understand it (Aboriginal nurse participant).'' "We accept someone into the community when we can see that they are genuine and care for the Aboriginal people. She has been working in the community for a while now. We Elders watched her, saw the way she was working and where her heart was. We saw that she was there for the community, and she cared. Then trust and respect grew. We sent the young women to see her. They had to check her out for themselves, and she had to earn their trust too. Now we know we can tell and share things [cultural knowledge] with her (Elder woman)." "The city has different cultural politics. With traditional women I found the issues and family groups are more clearly defined. You know if someone is from this area, then they have these boundaries and family groups. But in the city, the sub cultures are not so clear and the boundaries seem to be hidden (nurse participant)." "We need to introduce the importance of culture in programs, regardless if it is on urban country or not. Especially for the lost ones out there, who don't know who to turn to, if they are getting some cultural input by what they are achieving, at least they are learning something about themselves. It is a way to pass down some of the learning and teaching (Elder woman)." "No matter where we are, what part of Australia, women do not have anything to do with Men's Business and visa versa.Once they have gone through the law, once they have danced with the traditional women there are things a woman can and can't do. Here in suburbia we still regard Aboriginal culture as Aboriginal culture, regardless. You don't play with stuff like that (Elders group)." "With you, you have come a little bit over to where I am, for you to understand what we do and how we feel about things a bit. It is not fair for someone to say, you go back over the line and you don't do what these people here tell you, you do what I tell you. I'm your boss (Elder women)."

Appropriate use of terminology when referring to Indigenous Australians

- Aboriginal and Torres Strait Islander: inclusive term, best one to use, always capitalise - ATSI: offensive, don't use - Aboriginal: use as adjective not noun (ie. Aboriginal person) - Indigenous Australian: Non-specific, prefer to use other term however can use, always capitalise

What are some of the essential messages from the communication chapter that can be applied across Australia?

- Allow extra time - Allow the concept of "this is where I am from, where are you from?" to be part of the introduction Eye contact - Allow silence - Names of deceased persons may not be used - Respect men's and women's business, get a colleague of same sex as patient if needed - Indirect questions and answers - Avoid complex questions and jargon - Explain using imagery - Respect confidentiality - Be honest, sincere and respectful

'It had to be my choice': Indigenous smoking cessation and negotiations of risk, resistance and resilience (research by Dr Chelsea Bond). Dr Bond's qualitative (interview-based) research from Inala, Brisbane, focused on the positives in successful quitters, not the barriers to quitting. What do participants say when they feel 'lectured' to about smoking? What life events were linked to successfully quitting? What were the positive values of health professionals noted by the successful quitters?

- Another participant stated how the broadcasting of health threats on television made her resistant to contemplating smoking behavioural change. For this participant, health promotion was not an altruistic endeavour undertaken by caring health professionals, but instead was symbolic of colonial assertions of power and control over Aboriginal people. - "I used to think they were forcing it on the people to watch it on TV. I just seen it as the health department taking your choice away, your freedom. . .your right. Whether it's because me being an Aboriginal woman you know, the white man being authority all the time. . .I don't know but I just see it as the white man telling us you can't do this, you can't do that. I think I might have tended to smoke a little bit longer. I was saying to Maureen, 'They're not going to tell me to give up smoking.' I want it to be my choice. (Aunty Mavis, 55 years) - Here, 'government' is seen as not acting in the best interests of the people, and in fact, is seen to be entrenching social disadvantage and reinforcing stigmatisation of such groups. Health risk narratives have contributed to the stigmatisation of smoking behaviour, which have produced mixed results for Indigenous people. For some, it has reinforced distrust and resentment leading to the use of the body as a site of resistance. - All the accounts of Indigenous ex-smokers identified a significant life event and most commonly positive life events as the stimulus for behavioural change. These events included; a new job or promotion, a new or improved relationship, relocation to a new community or workplace, reaching an age milestone, and/or the embracing of a new identity role which was seen as incongruent with one's smoking identity (for example becoming an expectant mother, a grandparent, community worker or being converted to a new religion). - Among the few who recounted a negative life event, it was most commonly a health crisis, although one participant recalled a marriage breakdown. - Almost half of all participants identified a health care provider as the integral support in encouraging and enabling smoking cessation. What was intriguing here was despite the distrust and scepticism of Indigenous people towards the state and health authorities, this was overcome through the development of trusting and respectful relationships. Some participants reported that the health care professionals they met respected them and did not talk down to them. - "I tell you, we got the best doctors in the world here. . . Not talking down to us, talking to us, do you understand? This is what a black fella can't take, he can't take it when a man talks down to him. He can't take that he'll get up and say, 'Yeah, yeah, yeah,' walk out and do the same thing. But when you sit down and talk with him, talk to him, he takes notice. That's what these fellas do here honestly, I tell you the best staff in the world here." (Uncle Richard, 54 years) - Such trusting and respectful relationships between health care professionals, the health care system and the state significantly created the possibility for Indigenous people to be influenced by mainstream health promotion campaigns, access smoking cessation supports and health care services.

What are the top 5 causes of the health gap?

- Cardiovascular disease - Diabetes - Mental disorders - Chronic respiratory disease - Injuries

What are the leading 4 causes of mortality among Indigenous Australians?

- Cardiovascular disease (25%) - Cancer (20%) - External causes of injury and poisoning (15%) - Endocrine, metabolic and nutritional disorders (including diabetes) (9.1%)

Targets of the 'Close the gap' initiative

- Close the life expectancy gap within a generation (by 2031) - Halve the gap in mortality rates for Indigenous children under five within a decade (by 2018) - Ensure access to early childhood education for all Indigenous four year olds in remote communities within five years (by 2013) - Halve the gap in reading, writing and numeracy achievements for children within a decade (by 2018) - Halve the gap for Indigenous students in year 12 attainment rates (by 2020) - Halve the gap in employment outcomes between Indigenous and non-Indigenous Australians within a decade (by 2018)

Solutions to substance use issues in Indigenous communities.

- Detox/rehabilitation centres - Diversion/dry out centres (harm minimization) - Substance use health workers and medical treatments - Alcohol restriction - Employment, education and community empowerment projects Note that community ownership and drive is a common factor to all successful solutions.

Building blocks for 'closing the gap'

- Early childhood - Schooling - Health - Economic participation - Healthy homes - Safe communities - Governance and leadership

Policy eras in Indigenous Australian history

- Era of European settlement (1790-1990s); - Era of separation and protection (1890s-1940s); - Era of assimilation (1940s-1950s); - Era of self-management and self determination http://www.naccho.org.au/aboriginal-health/overview/

Experiencing discrimination affects Indigenous Australians' trust in what services?

- Health care services (doctors, hospitals) - Legal system (police, security, lawyers, courts)

How to frame culturally-sensitive communication, particularly in mental health

- Learn about the person's culture and their concept of mental illness - Know what is normal and what is not, in the person's culture - Know what is culturally appropriate communication - Do not shame the person, their family or community - Use community and family supports https://mhfa.com.au/sites/default/files/AMHFA-Guidelines-Compilation-November-2012.pdf Pages 2, 3

What are some of the reasons Indigenous Australians may delay presenting to the hospital for chest pain?

- Limited knowledge of symptoms and a lack of awareness of the need for urgent treatment - Competing personal and family demands that may be seen as higher priorities than the individual's own health (e.g. caring for family members, and cultural or community events) - Cultural beliefs - Fear of hospitals, which may be perceived as places to go to die or as being unfriendly to Aboriginal and Torres Strait Islander patients based on previous personal or family encounters - Lack of available or affordable transport - Lack of communication options for calling for assistance - Long distance to the nearest hospital - Lack of understanding of the diagnostic and treatment pathways, and inability to have family involvement in decision making - Going to the nearest Aboriginal community controlled health service before going to hospital or calling an ambulance - Inappropriate triage at first contact between a health service provider and patient due to inadequate understanding of the symptoms and signs of ACS on the part of the health care provider

Types of illicit substance use reported by Indigenous Australians to be a problem.

- Marajuana, hashish or cannbis resin - Non-medical use of analgesics and sedatives - Amphetamine or speed - Kava - Other

Health concerns associated with experiencing discrimination

- Mental health concerns (e.g. anxiety) - Risky health behaviours - Avoiding accessing health care services

Meanings of the following terms: Murri, Koori, sorry business

- Murri: Aboriginal people in and from QLD and north-west NSW - Koori: Aboriginal people in and from parts of NSW and Victoria - Sorry business: The period of mourning for deceased Aboriginal or Torres Strait Islander people

Otitis media in Indigenous children

- Otitis Media is one of the commonest childhood illnesses, affecting 80% of Australian children overall by the age of 3 years - The proportion of Indigenous children suffering otitis media and its complications is disproportionately high; up to 73% by the age of 12 months

Misconceptions about housing for Indigenous communities What are the statistics the Health Habitat team find for the amount of problems caused by vandalism, compared to the amount of problems from lack of routine maintenance?

- People prefer to live in overcrowded housing (whereas lack of housing, and families on never-ending housing wait-lists, is usually the case). - The poor standard of housing in remote communities is caused by neglect and vandalism. Stats: - Lack of routine maintenance = 70% - Faulty construction = 21% - Damage, misuse or vandalism = 9%

What are the big 3 areas of injury?

- Road traffic accidents - Suicide - Homicide and violence

What are the social determinants of health?

- The social gradient - Stress - Early life - Social exclusion - Work - Unemployment - Social support - Addiction - Food - Transport

Positive reasons for identifying Aboriginal and Torres Strait Islander patients in general practice.

- To assess disease risk - Aboriginal and Torres Strait Islander patients are at higher risk of certain diseases, such as cardiovascular disease, diabetes and renal disease. To make appropriate treatment decisions, knowing someone's indigenous status will allow you to more accurately measure their risk. - To provide appropriate screening and treatment - there are different recommendations for screening for some conditions in Aboriginal and Torres Strait Islander patients of certain ages. For example, the National guide to a preventive health assessment in Aboriginal people recommends screening for diabetes and renal disease from the age of 15-17, whereas the RACGP 'red book' only recommends this from age 45-49 upwards for diabetes, and age 50 onwards for renal disease. - To offer appropriate immunisations - there are different recommendations for Indigenous Australian patients with respect to immunisations. - To enhance access to medication - there are some medications that are available on the Pharmaceutical Benefits Scheme (PBS) for Aboriginal and Torres Strait Islander patients, such as some antifungal medications and ciproflaxcin ear drops, as well as other medications that are subsidised through the PBS Closing the Gap Co-payment Measure, once the patient and doctor participate in the Closing the Gap program. - To ensure access to particular Medicare Benefits Schedule (MBS) item numbers - there are particular MBS items available only for Aboriginal or Torres Strait Islander people, such as the Aboriginal Health Check (AHC), which aims to identify risk factors for chronic disease and provide early intervention. The AHC allows access to five funded allied health consultations. - To facilitate access to Aboriginal or Torres Strait Islander outreach workers who can provide support and advice to prevent or treat chronic disease. - To access extra income for your practice if it participates in the Indigenous Practice Incentives Program (PIP). - To provide the possibility of auditing the quality of your care for Aboriginal and Torres Strait Islander people. NOTE: When the BEACH study asked GPs to routinely identify their Aboriginal and Torres Strait Islander patients, the proportion of Aboriginal and Torres Strait Islander patients went up from 1.2% to 2.4%.

'Take-home' messages from story about Sally and baby Bob (child health nurse addressed underlying issue - Sally was scared to bathe her baby, rather than just providing medical intervention for the problem -scabies).

- Warm, non-confrontational communication styles can give much better outcomes for patients - Social determinants - overcrowded housing can contribute to many health issues - Social determinants (the positives) - sometimes social interventions (helping a mother bathe a child) are more powerful than medical interventions. - Health systems - this is patient-centred care at its finest. Paediatric hospital outpatients or mainstream GP clinic (with 15 minute appointments) would be unlikely to be able to deliver this sort of care.

Most common life stressors

1. Death of a family member or close friend 2. Serious illness 3. Not able to get a job 4. Mental illness 5. Alcohol-related problems

Headings and layout of preventative health check

1. Lifestyle - Smoking - Overweight/obesity - Physical activity - Alcohol - Gambling 2. Child health - Immunisation - Anaemia - Growth failure - Childhood kidney disease 3. The health of young people - Psychosocial - Unplanned pregnancy - Illicit drug use 4. Dental health 5. Rheumatic heart disease 6. Eye health - Visual acuity - Trachoma and trichiasis 7. Hearing loss 8. Sexual health and bloodborne viruses 9. Antenatal care 10. Mental health - Prevention of depression - Prevention of suicide 11. Respiratory health - Pneumococcal disease prevention - Influenza prevention - Asthma - Chronic obstructive pulmonary disease - Bronchiectasis and chronic suppurative lung disease 12. Cardiovascular disease prevention 13. Chronic kidney disease prevention and management 14. Type 2 diabetes prevention and early detection 15. Prevention and early detection of cancer - Prevention of cervical cancer - Prevention and early detection of liver (hepatocellular) cancer - Prevention and early detection of breast cancer - Prevention and early detection of colorectal (bowel) cancer - Early detection of prostate cancer 16. Preventive health for the elderly - Osteoporosis - Falls - Dementia

What percentage of Indigenous Australians live in QLD? Which state has the highest population?

28.5% of Indigenous Australians live in QLD. NSW has highest Indigenous Australian population (31%).

Healthy country, healthy people: the relationship between Indigenous health status and "caring for country" (MJA article) How many community elders were co-authors of this research? Imagine a research meeting using local values, meeting in the elder's preferred location, compared to meeting in a University conference room. Which method of collaboration will be most likely to get the best input from the team?

3 community elders were co-authors (Dean Yibarbuk, Charlie Gunabarra, Albert Mileran). Using local values would get best input from team.

How many times a week do most people need haemodialysis?

3 times per week

Do more Indigenous Australians live in remote and very remote areas (Alice Springs), or urban and regional areas (Brisbane, Cairns)?

4/5 of population live in urban and regional areas while 1/5 of population live in remotes areas.

Most common life stressors for kids

?Can't find answer in readings? (other people couldn't either)

How does the peak age of death compare between Indigenous and non-Indigenous males?

A relatively large proportion of Indigenous deaths occur before 'old age', 65% of deaths among Indigenous people occur before the age of 65, compared with 19% of deaths among non-Indigenous people. Across all age groups, death rates for Indigenous males and females are consistently higher than the rates for their non-Indigenous counterparts. The largest differences are for people aged 35-44, with male and female Indigenous death rates 3.9 and 4.5 times the non-Indigenous rates, respectively.

Can appropriately resourced health services do much to alleviate the gap? What else needs to be addressed?

Addressing the multitude of health problems facing Indigenous Australians is complex and will require a wide range of initiatives to increase preventive and curative efforts and particularly to strengthen Indigenous health services. However, responses from within the health sector alone are not sufficient. There is an urgent need to address the social and economic disadvantages that contribute to the poor health status of Indigenous Australians. This is in keeping with the broader Indigenous concept of health which acknowledges that improving Indigenous health is about improving the physical well-being of an individual within a context of improving the social, emotional and cultural well-being of the whole community.

From the last AIHW report: "The age-standardised incidence rate for end-stage renal disease for Indigenous Australians more than doubled between 1991 and 2008, from 31 to 76 per 100,000 population". What is happening to the incidence rate from 1996 to 2012 in this report?

Between 1996 and 2012, the change in the age-standardised incidence rates for treated end-stage kidney disease for Indigenous Australians was not statistically significant, while rates for non-Indigenous Australians rose significantly by 26%, although from a smaller base.

What are the largest causes of vision loss and blindness in children and adults?

Biggest causes of LOW VISION: - Refractive error (54%) - Cataracts (27%) - Diabetic retinopathy (12%) Biggest causes of BLINDNESS: - Cataracts (32%) - Refractive error (14%) - Optic atrophy (14%)

Most common cause of blindness in Indigenous Australian populations

Cataracts (most common cause of low vision = uncorrected refractive error)

Consider the difference between top-down, government driven programs, and bottom-up, community driven programs (e.g. Yuendumu petrol sniffing program).

Community driven programs tend to be more successful but are usually funded less.

Do Aboriginal and Torres Strait Islander Australians receive the same level of coronary procedures as non-Indigenous Australians? What is the difference? (Note this difference in health service provision is seen in many areas. This is the health access paradox - those who most need services are often least likely to get them).

Compared with other Australians, Indigenous Australians hospitalised with ACS have: - 40% lower rate of being investigated by angiography - 40% lower rate of percutaneous coronary intervention (PCI) - 20% lower rate of coronary artery bypass graft (CABG) surgery

What is 'cultural blindness' otherwise termed 'difference blindness'? Consider an example of a situation where treating people exactly the same, regardless of their differences, may result in unfair poor treatment being received.

Cultural blindness = not recognizing cultural differences. Examples of cultural blindness from readings: - "An Aboriginal man, Mr K, was from the desert and he was wheeled in a wheelchair [to the Aboriginal health service]. I knew him well. He was a proud independent man and for him to agree to get into a wheelchair meant that the pain must have been excruciating. But he played it down, hardly complained because he was stoic, a tough old guy from the bush. So, even if he was asked to rate his level of pain, he wouldn't admit it was high. I wrote a detailed letter to accompany him but the health care professionals [in ED] did their own assessment based on his response. They didn't match his expression of symptoms with culturally appropriate care. - The medical team on the ward will do a ward round and the Aboriginal patient is probably a little bit shy, a bit overwhelmed, spends a lot of time looking at the floor and looking away, not making eye contact, and the staff take that the wrong way... either [that] they don't understand or they don't care or they're not interested. They don't appreciate that there is a cultural aspect to that as well. So, then they're probably a bit dismissive of that patient and perhaps don't explain things as well to that patient as perhaps they might to someone else who they felt was engaging.

EXAM HINTS GIVEN IN CLASS

EXAM HINTS GIVEN IN CLASS

When did the first Aboriginal or Torres Strait Islander doctor in Australia graduate? How does that compare to New Zealand and North American indigenous peoples?

First Indigenous Australian doctor graduated in 1984. The first indigenous doctors in North America and New Zealand graduated in 1889 and 1899, respectively.

How is job security and job type linked to cardiovascular disease?

Higher rates of unemployment cause more illness and premature death. The health effects start when people first feel their jobs are threatened, even before they actually become unemployed. This shows that anxiety about insecurity is also detrimental to health. Job insecurity has been shown to increase effects on mental health (particularly anxiety and depression), self-reported ill health, heart disease and risk factors for heart disease. Because very unsatisfactory or insecure jobs can be as harmful as unemployment, merely having a job will not always protect physical and mental health: job quality is also important (securely employed vs. insecurely employed).

Which 18-34yo Indigenous Australians should be offered screening for cholesterol and chronic kidney disease? How does this compare for non-Indigenous Australians? What evidence (from the background reading) supports this different screening recommendation?

INDIGENOUS AUSTRALIANS: Aged 18-34 years and one or more of the following is present: - family history of premature CVD or CKD - overweight/obesity - smoking, diabetes - elevated BP NON-INDIGENOUS AUSTRALIANS: Aged 45-49, screen cholesterol: - Every 5 years - Every 2 years for increased risk. - Every 12 months with increased CV risk and existing chronic disease Aged 45-49, screen for kidney disease: - Every 1-2 years with high risk - Every 12 months with hypertension or diabetes Evidence to support this difference - ?higher rates of chronic kidney disease at a younger age among Indigenous Australians?

Why identifying Aboriginal and Torres Strait Islander status is important

Implementing preventive health assessments requires healthcare providers to identify the target population. Identifying Aboriginal and Torres Strait Islander status is a necessary precondition for participating in the Closing the Gap initiative, agreed by the Australian Government and the Council of Australian Governments in 2008.

Is poor literacy a possible problem with patient understanding of procedures?

In the urban environment, language is usually not presumed to be an issue (although literacy levels may be), but for patients referred from regional and remote settings English is likely to be a second language, resulting in additional communication barriers. It is essential that interpreters are made available on request.

What are Indigenous smoking rates compared to non-Indigenous Australians?

Indigenous people aged 15 and over are 2.6 times as likely as their non-Indigenous counterparts to smoke daily.

What is 'institutional racism'? Consider an example of institutional racism.

Institutional racism refers to societal systems or patterns that have the net effect of imposing oppressive or other-wise negative conditions against identifiable groups based on race or ethnicity.Institutional racism can occur when a system or institution discriminates against people. It can occur unbeknownst to well-meaning individuals in the health system, and is different from personal racism. The difference in eye health provision between Indigenous and non-Indigenous Australians could be considered an example of institutional racism. Other examples from readings: - Hospital systems founded on a Western biomedical model of care and managed by mainly white middle class Australians living in the metropolitan area often fail to understand the language and realities of Aboriginal people living in remote areas. - The clerks are sometimes nervous to ask about ethnicity. Theoretically they should ask everyone who comes through whether they are Aboriginal but that doesn't always happen. - Addresses again potential for mistakes. For example the clerks sometimes ask 'are you at the same address?' and the patient will say 'yes' because there is no time frame given and they may have been at the same address for 3 months but they don't realise that the hospital record has a much older address. Also patients can be distracted or can't hear through the glass barrier or are just overwhelmed by all the questions so it is easier to say 'yes'. What the clerks should say is 'what is your current address? - They will be asked who their GP is - and some people may not know what a GP is. Up north in the country they are not called GPs, they are called doctors, the clinic doctor or whatever. If the clerk deems they do not have a doctor, it is written down as 'nil GP' and there is no obligation to challenge that. If they are not sure they can write down 'GP unknown' and then they are under obligation to sort that out as a KPI. I think there is a tendency to put 'nil' as a default because it is less hassle.

What disease causes the most burden?

Ischaemic heart disease

Do Indigenous Australians living in cities have similar outcomes to non-Indigenous Australians living in cities?

It is a commonly held misconception that Aboriginal and Torres Strait Islander peoples living in urban centres have outcomes similar to the non-Indigenous urban population.

Should you set aside the same amount of time to consent and explain procedures to Indigenous patients as non-Indigenous patients?

It is essential that considerably more time is set aside for discussions with Aboriginal and Torres Strait Islander patients and their families than might be expected for non-Indigenous patients.

What is the social gradient?

Life expectancy is shorter and most diseases are more common further down the social ladder in each society.

From last AIHW report: "A lower rate of transplantation also contributes to the higher rate of end-stage renal disease prevalence among Indigenous Australians. A study by Cass and others (2007) concluded that transplantations were more likely to be recommended for patients who were young, of normal weight and described as compliant. They were less likely to be recommended for smokers, or for people with diabetes or heart disease. The study also found that geographical location was a significant determinant." The rates are actually about 0.32 for transplant, 0.5 for going onto the waiting list. Have you seen this discrepancy in health care access in any other medical area so far?

Lower rates of coronary procedures.

What is the life expectancy gap for males and females?

Males: 10.6 years (69.1 Indigenous; 79.7 non-Indigenous) Females: 9.5 years (73.7 Indigenous; 83.1 non-Indigenous)

Causes and effects of mistrust of government and authority by Indigenous Australians.

Mistrust of Government and authority (including police, schools, and yes, the health system) driven by past experiences is a common theme across research interviews of Indigenous patients. Being aware of these historical experiences can help us to understand a patient's distress, and anger. Unfortunately, the health system is not an innocent bystander in this story, but an active player, with harmful policies, racist health professionals, and well-meaning health professionals limited by the system all involved. Can lead to Indigenous Australians avoiding accessing health care.

For non-Indigenous nurses, was navigating the cultural issues around sexual health easier in the urban setting, or more difficult?

More difficult.

NO READINGS FOR WEEKS 11 AND 12

NO READINGS FOR WEEKS 11 AND 12

Are affirmative action in education policies targeted only at 'real' Aboriginal people in remote Australia?

No, they are targeted at all Aboriginal people.

Is 'the gap' most contributed to by health status of people who lived remotely, or people who lived non-remotely (cities, towns and closer rural).

Non-remote

Phases in Indigenous Australian history

PRE-CONTACT: - Aboriginal traditions and lifestyle (pre-1700's) CONTACT: - European invasion and settlement (1770's to 1890's) - Protection and segregation (1890's to 1950's) POST CONTACT: - Assimilation (1950's to 1960's) - Integration (1960's to 1972) CONTEMPORARY: - Towards self-determination (1972 to 2000) - The new millennium (2000 onward)

Polysubstance use in Indigenous populations

Polysubstance use, where people may use any of yarndi (marijuana), speed, opiates and other drugs, as well as alcohol. This is seen sometimes in my (Dr Jennings') Brisbane clinical practice.

Alcohol use rates: Indigenous Australians vs. non-Indigenous Australians

Report of consumption of alcohol in the previous 12 months - 71% Indigenous vs 81% non-Indigenous.

How is incarceration status changing?

The age-standardised imprisonment rate of Indigenous people increased significantly between 2000 and 2014 from 1,100 to 1,857 per 100,000 adults. The non-Indigenous rate increased slightly over this period. This resulted in an 82% increase in the gap in imprisonment rates between 2000 and 2014 (from a rate difference of 971 to 1,713 per 100,000 adults).

Building blocks of the 'Close the gap' initiative

The building blocks are interconnected and address several targets; they adopt a holistic view of health, addressing many of the underlying social determinants that influence and affect health. EARLY CHILDHOOD Young Indigenous children need equal opportunities to learn, develop and socialise. Equal access to quality early childhood education and care services, and child care and family support services (such as parenting programs and supports) is an imperative. It is also important that young Indigenous children have access to appropriate facilities and physical infrastructure, a sustainable early childhood education and health workforce, learning frameworks, and opportunities for parental engagement. To address the gaps in Indigenous childhood mortality and early development, the building block includes maternal, antenatal, postnatal and early childhood health. SCHOOLING Responsive and appropriate education is a key element of human development; this is why schooling is an important component of the COAG commitments. This building block implies adequate and appropriate infrastructure, workforce (including sufficient high quality teachers and school leaders), curriculum, literacy and numeracy achievement, opportunities for parents to engage, and school/community partnerships. The COAG commitments also focus on enabling transition pathways into schooling and into work, and post-school education and training. Access to schooling is not only for children; literacy and numeracy skills are relevant at all ages to best access employment opportunities. Life-long learning is promoted and adults constitute an important recipient in this second COAG building block. HEALTH Indigenous access to adequate, preventive and comprehensive primary health care is essential to reduce excess deaths and to close the gaps in early childhood mortality and life expectancy. The COAG commitments in this area recognise the importance of all parts of the health sector. A key component of the commitments is the responsiveness of, and accountability for, achieving government and community health priorities. In its health building block, COAG focuses on prevention, including the promotion of healthy lifestyles at all ages and the related management and treatment of chronic diseases. ECONOMIC PARTICIPATION This building block forms an important component of the Closing the gap campaign, focusing on enhancing employment opportunities, including jobs outside the Community Development Employment Project, business creation opportunities, economic independence (as opposed to welfare dependence) and wealth creation. There are many financial, structural and social incentives that can assist disadvantaged job seekers and these tools contribute to economic participation and community engagement. Coupled with policies addressing barriers to participation (such as desirability of welfare dependency, gambling, etc.), attention to this building block can contribute to establishing factors for positive social norm development. These two goals are seen to be important for adults and parents to become effective role models within the community and family spheres, and for the reform to be sustainable. HEALTHY HOMES This building block, which recognises that a healthy home is fundamental to the health of a population, focuses on improving current poor living conditions, including water and sewage systems, waste collection, and electricity and housing infrastructure. Children are particularly vulnerable to disease transmission in overcrowded and unhygienic houses and form a priority group of the building block. SAFE COMMUNITIES Everyone has the right to be safe from violence, abuse and neglect. It is to secure this state of safety that COAG has committed to improving the law and justice system (including an accessible and effective police and court system), victim support, child protection, and preventive approaches to violence (including perpetrator programs, anger management, alcohol and substance abuse management). GOVERNANCE AND LEADERSHIP Strong governance is essential for sustainable and effective outcomes for communities. In this context, Indigenous communities need to be engaged in the development of reforms within the Closing the gap framework. This building block recognises the importance of skill development for Indigenous people to exercise their rights and responsibilities and to take effective control over the development and implementation of policies that affect their lives.

Should families be included in hospital treatment discussions?

The care plan should be developed with the patient and his or her family in liaison with the Indigenous cardiac coordinator.

There is a move to realising that mainstream health may actually have something to learn from Indigenous approaches to health. Give an example of this.

The integration of elderly family members in Indigenous society, instead of having people in nursing homes, is an example from Babakiueria.

How is education status changing?

The proportion of Indigenous children in their first year of full-time schooling who were developmentally vulnerable on 1 or more domains declined between 2009 and 2012. Attendance rates at government schools for Indigenous students in Year 10 decreased between 2007 and 2013 (6 percentage points or less in each jurisdiction except the Northern Territory, which fell by 13 percentage points). There was little change for Indigenous Year 5 students. Between 2008 to 2014, the proportions of Indigenous students who achieved at or above the national minimum standard for reading and numeracy increased somewhat, although the changes were not statistically significant. Overall, there were no significant changes in the gap in reading or numeracy. Year 12 retention rates for Indigenous students have increased substantially over time—rising from 36% in 2001 to 55% in 2013 (Figure 3.4). The gap between retention rates for Indigenous students and other students fell by 28% over this period. In the decade to 2011, there was steady improvement in Year 12 or equivalent attainment for Indigenous people aged 20-24—increasing from 41% in 2001 to 47% in 2006 and 54% in 2011. Between 2006 and 2011, there was a narrowing of the Year 12 or equivalent attainment gap between Indigenous and non-Indigenous people by 4 percentage points.

Why preventative health assessments are necessary

There is strong evidence that the delivery of clinical preventive health services (immunisation, screening for asymptomatic disease, chemoprophylaxis (using medication to prevent the onset of disease), counselling and other ways to encourage patient behavioural change) improves health outcomes. Primary care providers often miss opportunities for the prevention of chronic disease and associated complications in the Aboriginal and Torres Strait Islander population. When preventive opportunities are missed, this can lead to a higher dependency on hospital care, which increases health costs.

How do the 'non-health' building blocks affect health?

They are the social determinants of health.

Inverse care law or Health access paradox

Those most in need of health services are the least likely to get access to services.

Does tobacco or alcohol cause more death and disease?

Tobacco

What's the tribal/language group name of the people from the area now called Brisbane?

Turbal (north) and Yuggera/Jagera (south) people (language names are same as tribe name).

WEEK 1 - Self-reflection and communication

WEEK 1 - Self-reflection and communication

WEEK 10 - Cancer, history and health workers

WEEK 10 - Cancer, history and health workers

WEEK 13 - Respiratory, smoking and positive communication

WEEK 13 - Respiratory, smoking and positive communication

WEEK 14 - Alcohol, substance abuse and community-driven solutions

WEEK 14 - Alcohol, substance abuse and community-driven solutions

WEEK 15 - Close the gap, policy and affirmative action

WEEK 15 - Close the gap, policy and affirmative action

WEEK 16 - Self-reflection and culture of medicine

WEEK 16 - Self-reflection and culture of medicine

WEEK 2 - Indigenous concepts of health and wellbeing: A holistic approach to health

WEEK 2 - Indigenous concepts of health and wellbeing: A holistic approach to health

WEEK 3 - Ischaemic heart disease and "The Gap"

WEEK 3 - Ischaemic heart disease and "The Gap"

WEEK 4 - Renal disease and connection to country

WEEK 4 - Renal disease and connection to country

WEEK 5 - ACCHS, diabetes and preventative health checks

WEEK 5 - ACCHS, diabetes and preventative health checks

WEEK 6 - Eye health and access to health services

WEEK 6 - Eye health and access to health services

WEEK 7 - Ears, housing and kids health

WEEK 7 - Ears, housing and kids health

WEEK 8 - Men's and women's business

WEEK 8 - Men's and women's business

WEEK 9 - Rheumatic heart disease

WEEK 9 - Rheumatic heart disease

Improving access in mainstream general practice

While some Aboriginal and Torres Strait Islander patients prefer to attend ACCHSs, many visit mainstream general practices. The following strategies to improve access to primary care services in this population apply to any primary care setting. Mainstream general practices may like to consider and adapt some of these strategies to better meet the needs of Indigenous patients in their community. - Sensitively ask all patients about Aboriginal and Torres Strait Islander status and record this on all patients records - Regularly update contact details - Aboriginal and Torres Strait Islander patients may move frequently and travel regularly between the bush and the city. While most patients have mobile telephones, the numbers may also change frequently - Employ Aboriginal staff - this helps to make the practice culturally welcoming and helps close the employment gap - Develop a referral list of specialists prepared to bulk-bill Aboriginal patients and negotiate a similar arrangement with pathology and radiology - Be opportunistic in screening - non-fasting blood results can be better than no blood results - If you have a sufficient number of Aboriginal and Torres Strait Islander patients, invite specialists to run clinics at your practice at appropriate intervals - Undertake cultural awareness training and register for the Indigenous Practice Incentive Program - as well as annual health checks, your patients will also be eligible for the pharmaceutical co-payment measure, reducing their out-of-pocket expenses on Pharmaceutical Benefits Scheme medicines

Story of Indigenous people being moved off their land (by massacre) in Bundaberg to make way for sugar cane industry. Dr Spurling's family though not directly involved benefited from this in being able to set up their farm. Two generations later, do you feel that Dr Spurling's family is still experiencing the advantage from this event, compared to a local Bundaberg Aboriginal family of the time (who may have been moved to Cherbourg). How do you think this self-reflection may have changed Dr Spurling's practice?

Yes Made him more aware of the history of Indigenous Australians and how it has led to the health gap that currently exists.

Cancer in Indigenous Australians

http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129551289 Cancer section, pages 97, 98

Anti-tobacco programs for Aboriginal and Torres Strait Islander people.

http://www.aihw.gov.au/uploadedFiles/ClosingTheGap/Content/Publications/2011/ctgc-rs04.pdf Pages 1, 2, 3, 4

Practice tips for working with Indigenous Australians

http://www.community.nsw.gov.au/docswr/_assets/main/documents/working_with_aboriginal.pdf Pages 12, 15, 17, 20

CKD is one of the areas where the 'gap' between Indigenous and non-Indigenous health is most stark. Approximately how many times higher is the incidence for Indigenous Australians aged 55-64yo?

~9-9.5 times higher