Joanne N. Luke

Racism and health among urban Aboriginal young people

BackgroundRacism has been identified as an important determinant of health but few studies have explored associations between racism and health outcomes for Australian Aboriginal young people in urban areas.MethodsCross sectional data from participants aged 12-26 years in Wave 1 of the Victorian Aboriginal Health Services Young Peoples Project were included in hierarchical logistic regression models. Overall mental health, depression and general health were all considered as outcomes with self-reported racism as the exposure, adjusting for a range of relevant confounders.ResultsRacism was reported by a high proportion (52.3%) of participants in this study. Self-reported racism was significantly associated with poor overall mental health (OR 2.67, 95% CI 1.25-5.70, p = 0.01) and poor general health (OR 2.17, 95% CI 1.03-4.57, p = 0.04), and marginally associated with increased depression (OR 2.0; 95% CI 0.97-4.09, p = 0.06) in the multivariate models. Number of worries and number of friends were both found to be effect modifiers for the association between self-reported racism and overall mental health. Getting angry at racist remarks was found to mediate the relationship between self-reported racism and general health.ConclusionsThis study highlights the need to acknowledge and address racism as an important determinant of health and wellbeing for Aboriginal young people in urban areas of Australia.

Suicide Ideation and Attempt in a Community Cohort of Urban Aboriginal Youth: A Cross-Sectional Study

BACKGROUND There has been increasing attention over the last decade on the issue of indigenous youth suicide. A number of studies have documented the high prevalence of suicide behavior and mortality in Australia and internationally. However, no studies have focused on documenting the correlates of suicide behavior for indigenous youth in Australia. AIMS To examine the prevalence of suicide ideation and attempt and the associated factors for a community1 cohort of Koori2 (Aboriginal) youth. METHOD Data were obtained from the Victorian Aboriginal Health Service (VAHS) Young Peoples Project (YPP), a community initiated cross-sectional data set. In 1997/1998, self-reported data were collected for 172 Koori youth aged 12-26 years living in Melbourne, Australia. The data were analyzed to assess the prevalence of current suicide ideation and lifetime suicide attempt. Principal components analysis (PCA) was used to identify closely associated social, emotional, behavioral, and cultural variables at baseline and Cox regression modeling was then used to identify associations between PCA components and suicide ideation and attempt. RESULTS Ideation and attempt were reported at 23.3% and 24.4%, respectively. PCA yielded five components: (1) emotional distress, (2) social distress A, (3) social distress B, (4) cultural connection, (5) behavioral. All were positively and independently associated with suicide ideation and attempt, while cultural connection showed a negative association. CONCLUSIONS Suicide ideation and attempt were common in this cross-section of indigenous youth with an unfavorable profile for the emotional, social, cultural, and behavioral factors.

Health literacy: health professionals’ understandings and their perceptions of barriers that Indigenous patients encounter

BackgroundDespite the growing interest in health literacy, little research has been done around health professionals’ knowledge of health literacy or understandings of the barriers to health literacy that patients face when navigating the health care system. Indigenous peoples in New Zealand (NZ), Canada and Australia experience numerous inequalities in health status and outcomes and international evidence reveals that Indigenous, minority, and socio-economically disadvantaged populations have greater literacy needs. To address concerns in Indigenous health literacy, a two-pronged approach inclusive of both education of health professionals, and structural reform reducing demands the system places on Indigenous patients, are important steps towards reducing these inequalities.MethodsFour Indigenous health care services were involved in the study. Interviews and one focus group were employed to explore the experiences of health professionals working with patients who had experienced cardiovascular disease (CVD) and were taking medications to prevent future events. A thematic analysis was completed and these insights were used in the development of an intervention that was tested as phase two of the study.ResultsAnalysis of the data identified ten common themes. This paper concentrates on health professionals’ understanding of health literacy and perceptions of barriers that their patients face when accessing healthcare. Health professionals’ concepts of health literacy varied and were associated with their perceptions of the barriers that their patients face when attempting to build health literacy skills. These concepts ranged from definitions of health literacy that were focussed on patient deficit to broader definitions that focussed on both patients and the health system. All participants identified a combination of cultural, social and systemic barriers as impediments to their Indigenous patients improving their health literacy knowledge and practices.ConclusionsThis study suggests that health professionals have a limited understanding of health literacy and of the consequences of low health literacy for their Indigenous patients. This lack of understanding combined with the perceived barriers to improving health literacy limit health professionals’ ability to improve their Indigenous patients’ health literacy skills and may limit patients’ capacity to improve understanding of their illness and instructions on how to manage their health condition/s.

Exploring clinical predictors of cardiovascular disease in a central Australian Aboriginal cohort

Introduction: For Aboriginal populations, predicting individuals at risk of cardiovascular disease (CVD) is difficult due to limitations and inaccuracy in existing risk-prediction algorithms. We examined conventional and novel risk factors associated with insulin resistance and the metabolic syndrome and assessed their relationships with subsequent CVD events. Design: Longitudinal cohort. Methods: Aboriginal people (n = 739) from Central Australia completed population-based risk-factor surveys in 1995 and were followed up in 2005. Principal components analysis (PCA), regression and univariate analyses (using ROC defined cut-off points) were used to identify useful clinical predictors of primary CVD. Results: PCA yielded five components: (1) lipids and liver function; (2) insulin resistance; (3) blood pressure and kidney function; (4) glucose tolerance; and (5) anti-inflammatory (low fibrinogen, high HDL cholesterol). Components 2, 3 and 4, and age were significant independent predictors of incident CVD, and smoking approached significance. In univariate analysis fasting glucose ≥4.8 mmol/l, total:HDL cholesterol ratio ≥5.7, non-HDL cholesterol ≥4.3 mmol/l, gamma-glutamyl transferase ≥70 U/l, albumin creatinine ratio ≥5.7 mg/mmol, systolic blood pressure ≥120 mmHg and diastolic blood pressure ≥70 mmHg were useful predictors of CVD. The co-occurrence of three or more risk variables (fasting glucose ≥4.8 mmol/l, total:HDL cholesterol ratio ≥5.7, blood pressure (systolic ≥120 mmHg; diastolic ≥70 mmHg; albumin:creatinine ratio ≥5.7 mg/mmol and smoking) had sensitivity of 82.0% and specificity of 59.9% for predicting incident CVD. Conclusion: Age is the strongest predictor of CVD for this population. For clinical identification of individuals at high risk, screening for the combination of three or more of hyperglycaemia, dyslipidaemia, hypertension, albuminuria and smoking may prove a useful and efficient strategy.

Cardiovascular disease medication health literacy among Indigenous peoples: design and protocol of an intervention trial in Indigenous primary care services

BackgroundCardiovascular diseases (CVD) are leading causes of mortality and morbidity among Indigenous people in New Zealand, Australia and Canada and are a major driver of the inequities in life expectancy between Indigenous and non-Indigenous people in these countries. Evidence-based pharmaceutical management of CVD can significantly reduce mortality and morbidity for persons diagnosed with CVD or for those at intermediate or high risk of CVD. Health literacy has been identified as a major barrier in the communication and implementation of appropriate pharmaceutical management plans for CVD. Addressing health literacy is particularly relevant in Indigenous populations where there are unique health and adult literacy challenges.Methods/designThis study will examine the effect of a customized, structured CVD medication programme, delivered by health professionals, on the health literacy of Indigenous people with, or at risk, of CVD. Primary outcomes are patient’s knowledge about CVD medications; secondary outcomes examine changes in health literacy skills and practices. The study will employ a multi-site pre-post design with multiple measurement points to assess intervention efficacy. Participants will be recruited from four Indigenous primary care services in Australia, Canada and New Zealand. Three educational sessions will be delivered over four weeks. A tablet application will support the education sessions and produce a customized pill card for each participant. Participants will be provided with written information about CVD medications. Medication knowledge scores, and specific health literacy skills and practices will be assessed before and after the three sessions. Statistical analyses will identify significant changes in outcomes over each session, and from the pre-session one to post-session three time points.DiscussionThis study will make an important contribution to understanding the effect of a structured primary care-based intervention on CVD health literacy in Indigenous populations. The study also illustrates the incorporation of Indigenous health research principles and processes in clinical trials and provides insights that may be useful in other contexts.Trial registrationAustralian and New Zealand Clinical Trials Register (ACTRN12612001309875; date of registration 18/12/2012).

The metabolic syndrome and CVD outcomes for a central Australian cohort

We investigated if the metabolic syndrome (MetS) and its component risk factors predict cardiovascular disease (CVD) for Aboriginal people from central Australia. WHO (HR 2.83), NCEP (1.80) and IDF (2.47) definitions of the MetS all had positive associations with CVD, however offered little above individual MetS components for hyperglycaemia.

Health Determinants and Educational Outcomes for Indigenous Children

It is well established that Aboriginal and Torres Strait Islander children suffer high rates of both acute and chronic childhood illnesses. It is also well established that their level of academic achievement remains well below that of their non-Indigenous peers. This chapter’s focus is on answering the question of how these two dimensions of socio-health and wellbeing are related. This chapter uses data from the K cohort from LSIC Wave 6 to investigate the relationship between health and education. We found that both individual and family-level health determinants have an adverse affect on educational attainment among children at this age level (mean age of 9 years old). The aim is to make manifest the interaction between health and wellbeing and educational outcomes for Aboriginal and Torres Strait Islander children and their families.

Nutritional predictors of chronic disease in a Central Australian Aboriginal cohort: A multi-mixture modelling analysis

BACKGROUND AND AIMS Chronic diseases (including diabetes, cardiovascular disease, hypertension and chronic kidney disease) are major contributors to the total burden of disease for Aboriginal people. Here we used novel epidemiological modelling to investigate nutritional profiles at a population level associated with chronic disease. METHODS AND RESULTS Multi-mixture modelling, was used to group members of a Central Australian Aboriginal population (n = 444) based on their nutritional profile from a risk factor prevalence survey in 1995. Multi-mixture modelling assigned % membership to four classes; Class 1 (young, low adiposity and lipids, low dietary antioxidants; n = 171.7); Class 2 (older, greater adiposity and lipids; n = 22.6); Class 3 (predominantly female, greater adiposity and antioxidants, low smoking; n = 134.3) and Class 4 (predominantly male, greater lipids and adiposity, low antioxidants, high smoking prevalence; n = 115.4). For persons free of chronic disease (n = 285), incident chronic disease for classes 1, 3 and 4 was determined using follow up hospital, primary health care and death records collected in 2004/05. Fifty-four percent of Class 4 had incident chronic disease, an excess of 3355 events per 100,000 person years relative to Class 1. Incident CVD, hypertension, or CKD was highest for Class 4 and incident diabetes highest for Class 3. CONCLUSION Multi-mixture modelling appears useful in identifying population subgroups of an Aboriginal population at risk of chronic conditions.

Effect of a health literacy intervention trial on knowledge about cardiovascular disease medications among Indigenous peoples in Australia, Canada and New Zealand

Objectives To assess the effect of a customised, structured cardiovascular disease (CVD) medication health literacy programme on medication knowledge among Indigenous people with, or at high risk of, CVD. Design Intervention trial with premeasures and postmeasures at multiple time points. Setting Indigenous primary care services in Australia, Canada and New Zealand. Participants 171 Indigenous people aged ≥20 years of age who had at least one clinical diagnosis of a CVD event, or in Canada and Australia had a 5-year CVD risk ≥15%, and were prescribed at least two of the following CVD medication classes: statin, aspirin, ACE inhibitors and beta blockers. Intervention An education session delivered on three occasions over 1 month by registered nurses or health educators who had received training in health literacy and principles of adult education. An interactive tablet application was used during each session and an information booklet and pill card provided to participants. Primary outcome measures Knowledge about the CVD medications assessed before and after each session. Results Knowledge at baseline (presession 1) was low, with the mean per cent correct answers highest for statins (34.0% correct answers), 29.4% for aspirin, 26.0% for beta blockers and 22.7% for ACE inhibitors. Adjusted analyses showed highly significant (P<0.001) increases in knowledge scores between preassessments and postassessments at all three time points for all medication classes. For the four medications, the absolute increases in adjusted per cent correct items from presession 1 to postsession 3 assessments were 60.1% for statins, 76.8% for aspirin, 71.4% for ACE inhibitor and 69.5% for beta blocker. Conclusions The intervention was highly effective in contextually diverse Indigenous primary healthcare services in Australia, Canada and New Zealand. The findings from this study have important implications for health services working with populations with low health literacy more generally. Trial registration number ACTRN12612001309875.

Response to the Letter by Kawada et al. regarding the manuscript entitled “The metabolic syndrome and CVD outcomes for a central Australian cohort”

[Extract] We thank Dr. Tomoyuki Kawada for their letter and for the important issues raised. We reiterate that the purpose of the study was to assess the clinical utility of the standard definitions of the metabolic syndrome for their application to central Australian populations. Our primary analyses therefore examined the risk of cardiovascular disease (CVD) associated with each definition, adjusting for age and gender as the potential major confounders of these relationships. The WHO, IDF and NCEP definitions all have previously demonstrated utility in predicting excess risk of CVD.