Sandra Eades

The Study of environment on Aboriginal resilience and child health (SEARCH): study protocol

BackgroundAboriginal Australians have a life expectancy more than ten years less than that of non-Aboriginal Australians, reflecting their disproportionate burden of both communicable and non-communicable disease throughout the lifespan. Little is known about the health and health trajectories of Aboriginal children and, although the majority of Aboriginal people live in urban areas, data are particularly sparse in relation to children living in urban areas.Methods/DesignThe Study of Environment on Aboriginal Resilience and Child Health (SEARCH) is a cohort study of Aboriginal children aged 0-17 years, from urban and large regional centers in New South Wales, Australia. SEARCH focuses on Aboriginal community identified health priorities of: injury; otitis media; vaccine-preventable conditions; mental health problems; developmental delay; obesity; and risk factors for chronic disease. Parents/caregivers and their children are invited to participate in SEARCH at the time of presentation to one of the four participating Aboriginal Community Controlled Health Organisations at Mount Druitt, Campbelltown, Wagga Wagga and Newcastle. Questionnaire data are obtained from parents/caregivers and children, along with signed permission for follow-up through repeat data collection and data linkage. All children have their height, weight, waist circumference and blood pressure measured and complete audiometry, otoscopy/pneumatic otoscopy and tympanometry. Children aged 1-7 years have speech and language assessed and their parents/caregivers complete the Parental Evaluation of Developmental Status. The Study aims to recruit 1700 children by the end of 2010 and to secure resources for long term follow up. From November 2008 to March 2010, 1010 children had joined the study. From those 446 children with complete data entry, participating children ranged in age from 2 weeks to 17 years old, with 144 aged 0-3, 147 aged 4-7, 75 aged 8-10 and 79 aged 11-17. 55% were male and 45% female.DiscussionSEARCH is built on strong community partnerships, under Aboriginal leadership, and addresses community priorities relating to a number of under-researched areas. SEARCH will provide a unique long-term resource to investigate the causes and trajectories of health and illness in urban Aboriginal children and to identify potential targets for interventions to improve health.Background Aboriginal Australians have a life expectancy more than ten years less than that of non-Aboriginal Australians, reflecting their disproportionate burden of both communicable and non-communicable disease throughout the lifespan. Little is known about the health and health trajectories of Aboriginal children and, although the majority of Aboriginal people live in urban areas, data are particularly sparse in relation to children living in urban areas. Methods/Design The Study of Environment on Aboriginal Resilience and Child Health (SEARCH) is a cohort study of Aboriginal children aged 0-17 years, from urban and large regional centers in New South Wales, Australia. SEARCH focuses on Aboriginal community identified health priorities of: injury; otitis media; vaccine-preventable conditions; mental health problems; developmental delay; obesity; and risk factors for chronic disease. Parents/caregivers and their children are invited to participate in SEARCH at the time of presentation to one of the four participating Aboriginal Community Controlled Health Organisations at Mount Druitt, Campbelltown, Wagga Wagga and Newcastle. Questionnaire data are obtained from parents/caregivers and children, along with signed permission for follow-up through repeat data collection and data linkage. All children have their height, weight, waist circumference and blood pressure measured and complete audiometry, otoscopy/pneumatic otoscopy and tympanometry. Children aged 1-7 years have speech and language assessed and their parents/caregivers complete the Parental Evaluation of Developmental Status. The Study aims to recruit 1700 children by the end of 2010 and to secure resources for long term follow up. From November 2008 to March 2010, 1010 children had joined the study. From those 446 children with complete data entry, participating children ranged in age from 2 weeks to 17 years old, with 144 aged 0-3, 147 aged 4-7, 75 aged 8-10 and 79 aged 11-17. 55% were male and 45% female. Discussion SEARCH is built on strong community partnerships, under Aboriginal leadership, and addresses community priorities relating to a number of under-researched areas. SEARCH will provide a unique long-term resource to investigate the causes and trajectories of health and illness in urban Aboriginal children and to identify potential targets for interventions to improve health.

Indigenous women and smoking during pregnancy: Knowledge, cultural contexts and barriers to cessation

Despite active tobacco control efforts in Australia, smoking prevalence remains disproportionately high in pregnant Indigenous women. This study investigated the place of smoking in pregnancy and attitudes towards smoking within the broader context of Indigenous lives. Focus groups and in-depth interviews were used to collect data from 40 women, and ten Aboriginal Health Workers (AHWs) in Perth, Western Australia. The research process and interpretation was assisted by working with an Indigenous community reference group. Results demonstrated the impact of contextual factors in smoking maintenance, and showed that smoking cessation even in pregnancy was not a priority for most women, given the considerable social and economic pressures that they face in their lives. Overwhelmingly, smoking was believed to reduce stress and to provide opportunities for relaxation. Pregnancy did not necessarily influence attitudes to cessation, though womens understanding of the consequences of smoking during pregnancy was low. Reduction of cigarette intake during pregnancy was seen as an acceptable and positive behaviour change. The AHWs saw their role to be primarily one of support and were conscious of the importance of maintaining positive relationships. As a result, they were often uncomfortable with raising the issue of smoking cessation with pregnant women. The stories of Indigenous women and AHWs provided important insight into smoking during pregnancy and the context in which it occurs.

Ten principles relevant to health research among Indigenous Australian populations

riting in the Journal about Indigenous health in 2011, Sir Michael Marmot suggested that the challenge was to conduct research, and to ultimately apply findings from that research, to enable Indigenous Australians to lead more flourishing lives that they would have reason to value. 1 As committed Indigenous health researchers in Australia, we reflect Marmot’s ideal — to provide the answers to key questions relating to health that might enable Indigenous Australians to live the lives that they would choose to live. As a group, we have over 120 collective years’ experience in Indigenous health research. Over this time, particularly in recent years as ethical guidelines have come into play, there have been many examples of research done well. However, as the pool of researchers is constantly replenished, we hold persisting concerns that some emerging researchers may not be well versed in the principles of best practice regarding research among Indigenous Australian populations. Implementing any research methodology among Indigenous Australian groups will work best when the following 10 principles are met. These principles are reflected in the many documents related to working and researching with Indigenous Australians; for example, the National Health and Medical Research Council (NHMRC) ethical guidelines for research among Aboriginal and Torres Strait Islander people. 2 In this article, we set out these principles in one short, accessible document. Essential principles

Infant care practices in a metropolitan Aboriginal population

Objective: To describe sleeping position, room and bed‐sharing, tobacco smoke exposure and infant feeding for a sample of Australian Aboriginal infants from a metropolitan area.

Type 2 diabetes in Indigenous populations: Quality of intervention research over 20 years

BACKGROUND A robust evidence base is needed to reduce the disproportionately high rates of diabetes-related mortality and complications among Indigenous peoples. OBJECTIVE This study aimed to evaluate the quantity and methodological quality of published intervention research on Type 2 and gestational diabetes in the Indigenous populations of Australia, Canada, New Zealand, and the United States from 1989 to 2008. A robust evidence base is needed to reduce the disproportionately high rates of diabetes-related mortality and complications among Indigenous peoples. METHODS Systematic searches of Medline, Embase, and EBM Reviews identified publications focused on Type 2 or gestational diabetes in Indigenous peoples published between 1 January 1989 and 31 December 2008. Total publication number and proportion of research involving interventions over time were examined. The quality of intervention studies was evaluated using Cochranes Effective Practice and Organisation of Care (EPOC) criteria. RESULTS Total publication number increased significantly over the 20 years (p<0.004). Research was predominantly descriptive (87%), with the proportion of research involving interventions increasing from 3% in 1989-1993 to 12% in 2003-2008 (χ(2)=12.42, df=3, p=0.006). However, only 25% (95%CI: 9-41%) of intervention studies met the EPOC methodological quality criteria; other studies lacked sufficient controls or measurements over time. CONCLUSIONS Increases in the amount of high-quality intervention research for prevention and treatment of Type 2 and gestational diabetes among Indigenous populations of these countries are needed.

Using breath carbon monoxide to validate self-reported tobacco smoking in remote Australian Indigenous communities

BackgroundThis paper examines the specificity and sensitivity of a breath carbon monoxide (BCO) test and optimum BCO cutoff level for validating self-reported tobacco smoking in Indigenous Australians in Arnhem Land, Northern Territory (NT).MethodsIn a sample of 400 people (≥16 years) interviewed about tobacco use in three communities, both self-reported smoking and BCO data were recorded for 309 study participants. Of these, 249 reported smoking tobacco within the preceding 24 hours, and 60 reported they had never smoked or had not smoked tobacco for ≥6 months. The sample was opportunistically recruited using quotas to reflect age and gender balances in the communities where the combined Indigenous populations comprised 1,104 males and 1,215 females (≥16 years). Local Indigenous research workers assisted researchers in interviewing participants and facilitating BCO tests using a portable hand-held analyzer.ResultsA BCO cutoff of ≥7 parts per million (ppm) provided good agreement between self-report and BCO (96.0% sensitivity, 93.3% specificity). An alternative cutoff of ≥5 ppm increased sensitivity from 96.0% to 99.6% with no change in specificity (93.3%). With data for two self-reported nonsmokers who also reported that they smoked cannabis removed from the analysis, specificity increased to 96.6%.ConclusionIn these disadvantaged Indigenous populations, where data describing smoking are few, testing for BCO provides a practical, noninvasive, and immediate method to validate self-reported smoking. In further studies of tobacco smoking in these populations, cannabis use should be considered where self-reported nonsmokers show high BCO.

Diabetes in pregnancy among indigenous women in Australia, Canada, New Zealand and the United States: a systematic review of the evidence for screening in early pregnancy

Recently proposed international guidelines for screening for gestational diabetes mellitus (GDM) recommend additional screening in early pregnancy for sub‐populations at a high risk of type 2 diabetes mellitus (T2DM), such as indigenous women. However, there are criteria that should be met to ensure the benefits outweigh the risks of population‐based screening. This review examines the published evidence for early screening for indigenous women as related to these criteria. Any publications were included that referred to diabetes in pregnancy among indigenous women in Australia, Canada, New Zealand and the United States (n = 145). The risk of bias was appraised. There is sufficient evidence describing the epidemiology of diabetes in pregnancy, demonstrating that it imposes a significant disease burden on indigenous women and their infants at birth and across the lifecourse (n = 120 studies). Women with pre‐existing T2DM have a higher risk than women who develop GDM during pregnancy. However, there was insufficient evidence to address the remaining five criteria, including the following: understanding current screening practice and rates (n = 7); acceptability of GDM screening (n = 0); efficacy and cost of screening for GDM (n = 3); availability of effective treatment after diagnosis (n = 6); and effective systems for follow‐up after pregnancy (n = 5). Given the impact of diabetes in pregnancy, particularly undiagnosed T2DM, GDM screening in early pregnancy offers potential benefits for indigenous women. However, researchers, policy makers and clinicians must work together with communities to develop effective strategies for implementation and minimizing the potential risks. Evidence of effective strategies for primary prevention, GDM treatment and follow‐up after pregnancy are urgently needed. Copyright

Diabetes in pregnancy among indigenous women in Australia, Canada, New Zealand and the United States.

Recently proposed international guidelines for screening for gestational diabetes mellitus (GDM) recommend additional screening in early pregnancy for sub‐populations at a high risk of type 2 diabetes mellitus (T2DM), such as indigenous women. However, there are criteria that should be met to ensure the benefits outweigh the risks of population‐based screening. This review examines the published evidence for early screening for indigenous women as related to these criteria. Any publications were included that referred to diabetes in pregnancy among indigenous women in Australia, Canada, New Zealand and the United States (n = 145). The risk of bias was appraised. There is sufficient evidence describing the epidemiology of diabetes in pregnancy, demonstrating that it imposes a significant disease burden on indigenous women and their infants at birth and across the lifecourse (n = 120 studies). Women with pre‐existing T2DM have a higher risk than women who develop GDM during pregnancy. However, there was insufficient evidence to address the remaining five criteria, including the following: understanding current screening practice and rates (n = 7); acceptability of GDM screening (n = 0); efficacy and cost of screening for GDM (n = 3); availability of effective treatment after diagnosis (n = 6); and effective systems for follow‐up after pregnancy (n = 5). Given the impact of diabetes in pregnancy, particularly undiagnosed T2DM, GDM screening in early pregnancy offers potential benefits for indigenous women. However, researchers, policy makers and clinicians must work together with communities to develop effective strategies for implementation and minimizing the potential risks. Evidence of effective strategies for primary prevention, GDM treatment and follow‐up after pregnancy are urgently needed. Copyright

Rationale and design of the Kanyini Guidelines Adherence with the Polypill (Kanyini-GAP) study: a randomised controlled trial of a polypill-based strategy amongst indigenous and non indigenous people at high cardiovascular risk.

BackgroundThe Kanyini Guidelines Adherence with the Polypill (Kanyini-GAP) Study aims to examine whether a polypill-based strategy (using a single capsule containing aspirin, a statin and two blood pressure-lowering agents) amongst Indigenous and non-Indigenous people at high risk of experiencing a cardiovascular event will improve adherence to guideline-indicated therapies, and lower blood pressure and cholesterol levels.Methods/DesignThe study is an open, randomised, controlled, multi-centre trial involving 1000 participants at high risk of cardiovascular events recruited from mainstream general practices and Aboriginal Medical Services, followed for an average of 18 months. The participants will be randomised to one of two versions of the polypill, the version chosen by the treating health professional according to clinical features of the patient, or to usual care. The primary study outcomes will be changes, from baseline measures, in serum cholesterol and systolic blood pressure and self-reported current use of aspirin, a statin and at least two blood pressure lowering agents. Secondary study outcomes include cardiovascular events, renal outcomes, self-reported barriers to indicated therapy, prescription of indicated therapy, occurrence of serious adverse events and changes in quality-of-life. The trial will be supplemented by formal economic and process evaluations.DiscussionThe Kanyini-GAP trial will provide new evidence as to whether or not a polypill-based strategy improves adherence to effective cardiovascular medications amongst individuals in whom these treatments are indicated.Trial RegistrationThis trial is registered with the Australian New Zealand Clinical Trial Registry ACTRN126080005833347.

Early life influences on cardio-metabolic disease risk in aboriginal populations—what is the evidence? A systematic review of longitudinal and case–control studies

BACKGROUND We systematically reviewed the published evidence for the developmental origins of health and disease hypothesis among aboriginal populations from Australia, Canada, New Zealand and the USA. METHODS Medline, EMBASE and the Informit Health databases were systematically searched (March 2012) using medical subject headings and keywords for studies that examined the effect of prenatal factors and birth outcomes on later life (≥3 years) cardio-metabolic diseases. Quality of studies was independently assessed by two reviewers using a risk of bias assessment tool; main findings from studies with a low to moderate risk of bias were summarised qualitatively. RESULTS In all, 844 studies were found; 50 were included in the review of which 41 had a low-moderate risk of bias. There was strong evidence for an association between birth weight and type 2 diabetes (6/7 studies), impaired kidney function (6/7 studies) and high blood pressure (5/6 studies), whereas there was limited evidence for an association with metabolic abnormalities (4/7 studies) and adiposity (4/7). Exposure to maternal diabetes was strongly associated with type 2 diabetes (9/10 studies) and metabolic abnormalities (5/7 studies), whereas the association with adiposity was low (3/9 studies); the limited number of studies, to date, also show a relationship with high blood pressure (2/2 studies). CONCLUSIONS This review highlights that interventions to reduce the burden of cardio-metabolic disease among aboriginal populations should focus on improving maternal health, particularly by reducing the prevalence of diabetes in pregnancy. Future research should also be directed towards potential protective actions, such as breastfeeding.