David P. Thomas

Smoking behaviours in a remote Australian Indigenous community: The influence of family and other factors

In Australia, tobacco smoking is more than twice as common among Indigenous people as non-Indigenous people. Some of the highest smoking rates in the country are in remote Indigenous communities in the Northern Territory of Australia. Owing to this high prevalence, tobacco use today is the single biggest contributing risk factor for excess morbidity and mortality among Indigenous Australians. Despite this, there is a lack of published research which qualitatively explores the social context of Indigenous smoking behaviour or of meanings and perceptions of smoking among Indigenous people. The aim of this study was to understand why Indigenous people start to smoke, the reasons why they persist in smoking and the obstacles and drivers of quitting. We conducted semi-structured interviews with a purposive sample of 25 Indigenous community members in two remote communities in the Northern Territory and 13 health staff. The results indicate that there is a complex interplay of historical, social, cultural, psychological and physiological factors which influence the smoking behaviours of Indigenous adults in these communities. In particular, the results signal the importance of the family and kin relations in determining smoking behaviours. While most community participants were influenced by family to initiate and continue to smoke, the health and well being of the family was also cited as a key driver of quit attempts. The results highlight the importance of attending to social and cultural context when designing tobacco control programs for this population. Specifically, this research supports the development of family-centred tobacco control interventions alongside wider policy initiatives to counter the normalisation of smoking and assist individuals to quit.

The social determinants of being an Indigenous non-smoker

Objective: To examine the association between various social factors and being a non‐smoker in a national survey of Aboriginal and Torres Strait Islander people aged 15 and over.

Clinical consultations in an aboriginal community-controlled health service: a comparison with general practice.

Abstract: Clinical consultations at Danila Dilba, an Aboriginal community‐controlled health service in Darwin, were compared with consultations in Australian general practice. We described 583 consultations, using a questionnaire based on the International Classification of Primary Care. The methods were similar to those of the Australian Morbidity and Treatment Survey (AMTS) of consultations in Australian general practice undertaken by the University of Sydney Family Medicine Research Unit. Compared with Australian general practice consultations, consultations with Danila Dilba were more complex: more young patients, more new patients, more home visits, more problems managed, more new problems and more consultations leading to emergency hospital admission. Skin infections, diabetes mellitus, chronic alcohol abuse, rheumatic heart disease (or rheumatic fever) and chronic suppurative otitis media were much more commonly managed at study consultations at Danila Dilba than at consultations with general practitioners in the AMTS. Nearly all patients saw an Aboriginal health worker first, and nearly half the consultations were with Aboriginal health workers alone. The results suggest possible limitations of fee‐for‐item Medicare funding of Aboriginal community‐controlled health services compared with existing block grant funding

A systematic review of barriers and facilitators to participation in randomized controlled trials by Indigenous people from New Zealand, Australia, Canada and the United States

Issue: Many randomized controlled trials (RCTs) are conducted each year but only a small proportion is specifically designed for Indigenous people. In this review we consider the challenges of participation in RCTs for Indigenous peoples from New Zealand, Australia, Canada and the United States and the opportunities for increasing participation. Approach: The literature was systematically searched for published articles including information on the barriers and facilitators for Indigenous people’s participation in health-related RCTs. Articles were identified using a key word search of electronic databases (Scopus, Medline and EMBASE). To be included, papers had to include in their published work at least one aspect of their RCT that was either a barrier and/or facilitator for participation identified from, for example, design of intervention, or discussion sections of articles. Articles that were reviews, discussions, opinion pieces or rationale/methodology were excluded. Results were analysed inductively, allowing themes to emerge from the data. Key findings: Facilitators enabling Indigenous people’s participation in RCTs included relationship and partnership building, employing Indigenous staff, drawing on Indigenous knowledge models, targeted recruitment techniques and adapting study material. Challenges for participation included both participant-level factors (such as a distrust of research) and RCT-level factors (including inadequately addressing likely participant barriers (phone availability, travel costs), and a lack of recognition or incorporation of Indigenous knowledge systems. Implication: The findings from our review add to the body of knowledge on elimination of health disparities, by identifying effective and practical strategies for conducting and engaging Indigenous peoples with RCTs. Future trials that seek to benefit Indigenous peoples should actively involve Indigenous research partners, and respect and draw on pertinent Indigenous knowledge and values. This review has the potential to assist in the design of such studies.

Smoking prevalence trends in Indigenous Australians, 1994-2004: a typical rather than an exceptional epidemic

BackgroundIn Australia, national smoking prevalence has successfully fallen below 20%, but remains about 50% amongst Indigenous Australians. Australian Indigenous tobacco control is framed by the idea that nothing has worked and a sense of either despondency or the difficulty of the challenge.MethodsThis paper examines the trends in smoking prevalence of Australian Indigenous men and women aged 18 and over in three large national cross-sectional surveys in 1994, 2002 and 2004.ResultsFrom 1994 to 2004, Indigenous smoking prevalence fell by 5.5% and 3.5% in non-remote and remote men, and by 1.9% in non-remote women. In contrast, Indigenous smoking prevalence rose by 5.7% in remote women from 1994 to 2002, before falling by 0.8% between 2002 and 2004. Male and female Indigenous smoking prevalences in non-remote Australia fell in parallel with those in the total Australian population. The different Indigenous smoking prevalence trends in remote and non-remote Australia can be plausibly explained by the typical characteristics of national tobacco epidemic curves, with remote Indigenous Australia just at an earlier point in the epidemic.ConclusionReducing Indigenous smoking need not be considered exceptionally difficult. Inequities in the distribution of smoking related-deaths and illness may be reduced by increasing the exposure and access of Indigenous Australians, and other disadvantaged groups with high smoking prevalence, to proven tobacco control strategies.

Changing discourses in Aboriginal and Torres Strait Islander health research, 1914-2014

Aboriginal and Torres Strait Islander people strongly assert that health research has contributed little to improving their health, in spite of its obvious potential. The health concerns of Aboriginal and Torres Strait Islander people were largely ignored in early research published in the MJA, which reflected broader colonial history and racial discourses. This began to change with the demise of scientific racism, and changed policies and political campaigns for equal treatment of Indigenous people after the Second World War. In response to pressure from Aboriginal and Torres Strait Islander people and organisations, in parallel to broader political struggles for Indigenous rights since the 1970s, there have been significant and measurable changes to Aboriginal and Torres Strait Islander health research. Many of these changes have been about the ethics of health research. Increasingly, Aboriginal and Torres Strait Islander researchers, communities and organisations are now controlling and decolonising health research to better meet their needs, in collaboration with non‐Indigenous researchers and research organisations.

Use of emergency departments by Aboriginal and Torres Strait Islander people

Objective:  To review published Australian literature about ED care of Aboriginal and Torres Strait Islander peoples.

Comparison of the uptake of health assessment items for Aboriginal and Torres Strait Islander people and other Australians: implications for policy.

BackgroundHealth Assessment (HA) items were introduced in 1999 for Aboriginal and Torres Strait Islander people aged at least 55 years and all Australians aged over 75 years. In 2004 a new item was introduced for HAs among adult Aboriginal and Torres Strait Islander people aged 15–54 years. The new item has been applauded as a major policy innovation however this enthusiasm has been tempered with concern about potential barriers to its uptake. In this study we aim to determine whether there are disparities in uptake of HA items for Aboriginal and Torres Strait Islander people compared to other Australians.MethodThe analysis was based on Health Insurance Commission data. Indigenous status was ascertained based on the item number used. Logistic regression was used to compare uptake of HA items for older people among Aboriginal and Torres Strait Islander people compared to other Australians. Adjustments were made for dual eligibility. Uptake of the HA items for older people was compared to the uptake of the new item for Aboriginal and Torres Strait Islander people aged 15–44 years.ResultsOur analyses suggest a significant and persistent disparity in the uptake of items for older patients among Aboriginal and Torres Strait Islander people compared to other Australians. A similar disparity appears to exist in the uptake of the new adult Aboriginal and Torres Strait Islander HA item.ConclusionFurther engagement of primary care providers and the community around the uptake of the new HA items may be required to ensure that the anticipated health benefits eventuate.

Effect of a Family-Centered, Secondhand Smoke Intervention to Reduce Respiratory Illness in Indigenous Infants in Australia and New Zealand: A Randomized Controlled Trial

Introduction: Secondhand smoke (SHS) is a significant cause of acute respiratory illness (ARI) and 5 times more common in indigenous children. A single-blind randomized trial was undertaken to determine the efficacy of a family centered SHS intervention to reduce ARI in indigenous infants in Australia and New Zealand. Methods: Indigenous mothers/infants from homes with ≥1 smoker were randomized to a SHS intervention involving 3 home visits in the first 3 months of the infants’ lives (plus usual care) or usual care. The primary outcome was number of ARI-related visits to a health provider in the first year of life. Secondary outcomes, assessed at 4 and 12 months of age, included ARI hospitalization rates and mothers’ report of infants’ SHS exposure (validated by urinary cotinine/creatinine ratios [CCRs]), smoking restrictions, and smoking cessation. Results: Two hundred and ninety-three mother/infant dyads were randomized and followed up. Three quarters of mothers smoked during pregnancy and two thirds were smoking at baseline (as were their partners), with no change for more than 12 months. Reported infant exposure to SHS was low (≥95% had smoke-free homes/cars). Infant CCRs were higher if one or both parents were smokers and if mothers breast fed their infants. There was no effect of the intervention on ARI events [471 intervention vs. 438 usual care (reference); incidence rate ratio = 1.10, 95% confidence intervals (CI) = 0.88–1.37, p = .40]. Conclusions: Despite reporting smoke-free homes/cars, mothers and their partners continue to smoke in the first year of infants’ lives, exposing them to SHS. Emphasis needs to be placed on supporting parents to stop smoking preconception, during pregnancy, and postnatal.

Monitoring local trends in Indigenous tobacco consumption

Objective : To compare two methods of monitoring tobacco consumption in remote Indigenous communities.