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Preference: Indigenous Health

1

Reports indicate that changes are needed to close the gap for Indigenous health

Major changes in health services are needed to redress health disparities

Two recently released reports from the Australian Institute of Health and Welfare (AIHW) make it clear that there must be major changes in the way health services for Indigenous Australians are delivered and funded if we are to improve Indigenous health and health care and ensure real returns on the substantial investments that are being made.1,2

These reports show Australia’s level of financial commitment to Indigenous health. In the 2010–11 financial year total spending on Indigenous health was $4.552 billion,1 almost double that spent in 2004–05. This was $7995 for every Indigenous Australian, compared with $5437 for every non-Indigenous Australian;1 over 90% of this funding came from governments. The surest sign that this money was not well invested in prevention, early intervention and community services is that most of it (on average $3266 per person but $4779 per person in remote areas) was spent on services for patients admitted to hospitals, while spending on Medicare services and medicines subsidised by the Pharmaceutical Benefits Scheme (PBS) on a per-person basis was less than that for non-Indigenous Australians by $198 and $137, respectively.2

The series of AIHW reports since the 1995–96 financial year highlights both where progress has been made and where programs have failed. There have been considerable increases in funding for primary care, acute care and community and public health. The 2010–11 data do not reflect the full implementation of the Indigenous Chronic Disease Health Package, but do suggest that the measure to subsidise PBS copayments for patients with chronic disease is having an effect, specifically in more remote areas where PBS spending is higher than in regional areas.

On the other hand, it is obvious that access to primary care services in remote areas remains limited, and access to referred services such as specialists and diagnostics is poor for Indigenous people everywhere, even in major cities. Per-person spending on non-hospital secondary services is about 57% of that for non-Indigenous people.2 Indigenous Australians receive nearly all their secondary care in hospitals.

The hospital data hammer the story home. In 2010–11, the overall age-standardised separation rate of 911 per 1000 for Indigenous people was 2.5 times that for non-Indigenous people; for people living in the Northern Territory the rate was 7.9 times that for non-Indigenous people.3

About 80% of the difference between these rates was accounted for by separations for Indigenous people admitted for renal dialysis, but further examination highlights how a lack of primary care and prevention services drives increased hospital costs. In 2010–11, total expenditure on potentially preventable hospitalisations for Indigenous Australians was $219 million or $385 per person, compared with $174 per non-Indigenous Australian.3 For all Australians most of this spending is for chronic conditions like complications from diabetes, but, too often, Indigenous Australians are hospitalised for vaccine-preventable conditions like influenza and pneumonia, acute conditions like cellulitis, and injury.

Avoidable hospitalisations are an important indicator of effective and timely access to primary care, and provide a summary measure of health gains from primary care interventions. The inescapable reality is that current primary care interventions are not working.

We know what the problems are. Around two-thirds of the gap in health outcomes between Indigenous Australians and other Australians comes from chronic diseases such as cardiovascular disease, diabetes, respiratory diseases and kidney disease.4 Suicide and transport accidents and other injuries are also leading causes of death.5 Half of the gap in health between Indigenous and non-Indigenous Australians is linked to risk factors such as smoking, obesity and physical inactivity.6 A number of studies have found that between a third and half of the health gap is associated with differences in socioeconomic status such as education, employment and income.7

The 2006 Census (the latest available data) found that 39% of Indigenous people were living in “low resource” households (as defined by the Australian Bureau of Statistics8), almost five times the non-Indigenous rate.9 Such disparities in income limit Indigenous people’s capacity to pay for health care and provide some context for why they are more likely to use public hospitals than privately provided services that require copayments.

There are commitments from all the major stakeholders, political parties and policymakers to close the gap. There is a new National Aboriginal and Torres Strait Islander Health Plan 2013–2023. And, arguably, there are enough funds if these are spent wisely. What is needed is a new approach to how health care is developed for and delivered to Indigenous Australians.

The approach needs to be grounded in three broad principles:

  • Adhering to the principle of “nothing about me without me”.10 Shared decision making must become the norm, with patients and their needs at the centre of a system they drive.

  • Addressing the social determinants of health, in particular, the impact of poverty.

  • Addressing cultural barriers in the way that Indigenous people want.

These are not new ideas and all the right words are in the new national health plan, as they were in the previous strategy document — cross-portfolio efforts, partnership, sustainability, culturally competent services, community, a rights-based approach to providing equal opportunities for health. What we must do is move beyond these fine words to meaningful action.

We have the exemplar of how to do this with Aboriginal Community Controlled Health Organisations (ACCHOs), and we need to (i) provide increased opportunities for engagement, collaboration and service delivery with ACCHOs and (ii) expand this way of working into mainstream services. This will require a different approach to policy development and implementation.11

The key barriers to health care for urban and remote populations alike relate to availability, affordability and acceptability12 and the dominance of biomedical models of health.13 ACCHOs are a practical expression of self-determination in Indigenous health and health service delivery,14 and have been very successful at reducing many of the barriers that inhibit Indigenous access to mainstream primary care.15 Importantly, ACCHOs provide both cultural safety, which allows the patient to feel safe in health care interactions and be involved in changes to health services, and cultural competence, which reflects the capacity of the system to integrate culture into the delivery of health services.16

However, the success of the design and work practices of ACCHOs have had little influence on the mainstream health system17 which remains, necessarily, the source of health care for many Indigenous people. And it can be argued that the current funding and regulatory practices of Australian governments are a heavy burden and consume too much of the scarce resources of ACCHOs in acquiring, managing, reporting and acquitting funding contracts.18

Governments and all stakeholders, including Indigenous people themselves, need to be bold enough to redesign current mainstream health policies, programs and systems to better fit Indigenous health concepts, community needs and culture. This approach should not be seen as radical — it is where we are currently headed with Medicare Locals. We should not ignore the fact that ACCHOs have led the way in developing a model of primary health care services that is able to take account of the social issues and the underlying determinants of health alongside quality care.19 Tackling these reforms will therefore benefit all Australians, but especially those Indigenous people who currently feel disenfranchised. Without real and meaningful change, we are all condemned to more government reports bearing sad, bad news and a continual yawning gap of Indigenous disadvantage.

Training opportunities key to closing health gap

There are many factors contributing to the gap in health and life expectancy experienced by Aboriginal peoples and Torres Strait Islanders. These factors range from the adverse health impacts of early life circumstances, right through to the high prevalence of chronic cardiovascular diseases.

Research shows that chronic disease deaths could be halved among Aboriginal peoples and Torres Strait Islanders by timely and systematic diagnosis, and within a short period of time also. Similarly, appropriate culturally safe support from trained health and medical professionals for mothers and babies in the early years could ameliorate the life-long health impacts of a poor start in life for Aboriginal and Torres Strait Islander children.

A proper supply of health practitioners and medical professionals working with Aboriginal and Torres Strait Islander communities would go some way to breaking this circuit of poor health. However, what is most needed, but is in limited supply, are health and medical professionals who are fully skilled in best practice service provision to Aboriginal people and Torres Strait Islanders.

We know what best practice models of primary health care for Aboriginal people and Torres Strait Islanders involve (the AMA published a major report on this in 2011-12). But there are very few opportunities for doctors and health practitioners – either in training or once qualified – to gain hands on experience and excellence in skills and knowledge working in real situations with expert practitioners and researchers doing cutting edge work in Aboriginal health.

To rectify this the AMA believes that there is a great need for centres of excellence in Aboriginal and Torres Strait Islander health which can:

  • conduct research on models and approaches to health conditions and risks besetting Aboriginal people and Torres Strait Islanders;
  • provide best practice primary care services based on that research;
  • provide practical training and experience to doctors, health professionals and trainees who take visiting placements at the centres for varying periods of time; and
  • offer accreditation in Aboriginal and Torres Strait Islander health to those centres which take placements and meet requirements.

The AMA believes there needs to be a national network of these Teaching Health Centres of Excellence, given that different areas of Australia have different Aboriginal and Torres Strait Islander populations with different characteristics and needs.

To fulfil all the above roles, each Teaching Health Centre of Excellence would need to be formed as a collaboration between Aboriginal community-controlled health services, government health services and clinics, and universities involved in teaching and applied research in Aboriginal and Torres Strait Islander health.

Practical teaching would encompass students from medicine, nursing, allied health and Aboriginal Health Workers at Diploma, Advanced Diploma, Graduate and Post-Graduate level. As students and visiting doctors pass through these centres of excellence and take their posts up elsewhere, they could take back with them knowledge, skills and expertise in the delivery of high quality, culturally competent primary care.

The AMA has advocated for the establishment of a national network of Teaching Health Centres of Excellence in the past, and has resolved to impress upon the new Federal Government the need for these centres of innovation to close the gap.

Reform can fix health gap

Professor Ian Ring, Professorial Fellow at the Australian Health Services Research Institute, University of Wollongong, suggests the review of Indigenous funding being headed by Tony Mundine, Chair of the Federal Government’s Indigenous Advisory Council, could pave the way for real improvements in Aboriginal health.

This article was first published in The Canberra Times on 28 October, 2013.

A recent episode of Q&A echoed traces of the widespread view that much money has been spent on Aboriginal health and other matters, with relatively little to show for it – and that the money must have been eaten up by a bloated bureaucracy, was misdirected, or corruptly or incompetently used.

All of these may be true, but only to a very limited extent. The reality is that, until recently, the Federal Government, through its own programs, was spending less per capita on Aboriginal health than it was on the rest of the population – despite Aboriginal people being at least twice as sick.

That changed with the introduction of the National Partnership Agreements (NPAs) involving the Commonwealth and all State and Territory governments, which injected $1.6 billion into Aboriginal health and $4.6 billion over four years to 2012-13 into health, education, housing, employment and remote services as part of the Closing the Gap programs. Australia went from having a degree of international opprobrium because of its neglect of Aboriginal issues to becoming internationally competitive in terms of indigenous policy and funding.

But what results have we seen from this allocation of additional funds? In a four-year program, the funds start out at low levels in the first year and build up progressively over the next three. The funds then need to be used to employ people, who need to be recruited and trained, and then it takes more time for the programs in which they work to become fully effective.

Taking the $100 million allocated to smoking, for example, the very earliest we could hope to see any kind of significant change in smoking would be picked up by the next smoking surveys, the results of which will be available next year.

Given the lag between smoking reduction and improvements in smoking-related diseases, the earliest we could see measurable changes in heart and lung mortality may not be until 2020.

The apparent lack of progress from data currently available tells us about the lack of progress before the additional $1.6 billion hit the ground and is just what we would expect to see at this stage, rather than indicating a waste of funds or a misallocation of resources.

But was the money optimally allocated? Almost certainly not, and for reasons that are crying out to be dealt with by the Mundine review. The programs funded by the NPAs all made sense individually but, collectively, they missed the point, and in no sense approximated the comprehensive long-term action plan promised in the statement of intent. The problem was not in the policy determined by governments, or in the funding, but in the bureaucratic implementation of those policies.

The programs were determined by officials in State and Territory governments with insufficient genuine consultation with the people who run the Aboriginal community controlled health services (ACCHS).

Nobody seemed to have asked that, if we want to halve the child mortality gap in 10 years and the life expectancy gap in a generation, what services do we need to achieve those goals?

And nobody seems to have wondered how it was possible to have healthy mothers and babies, and to get on top of chronic diseases, without adequate provision for mental health services.

The limited evidence available clearly shows that ACCHS run by and for Aboriginal people eclipse mainstream general practice in the identification of risk factors, performance of health checks, care planning and the management of Aboriginal and Torres Strait Islander patients.

So, instead of asking what services would produce the best return on investment, the decision seems to have been taken to allocate new funds to perpetuate current patterns of use between mainstream and ACCHS health services.

Too many senior officials still cling to the notion that in Australia’s cities and towns mainstream services are the answer – in the absence of evidence that this is so, and in the face of evidence that it isn’t. There is a real risk that mainstreaming will be seen as some kind of solution, when the reality is that there needs to be sensible arrangements for mainstream and ACCHS services to work together, as in the Urban Indigenous Health Institute.

While current levels of indigenous health funding go a long way to redressing the previous shortfall in health expenditure, estimated by health economists at about $500 million a year, inequities in the share of mainstream program funding received by Aboriginal people is still an issue.

So what does this mean for the Mundine review and the new Government? Three issues stand out.

First, bureaucratic reform is essential. That means substantially fewer public servants, but those that remain need to have the requisite skills and experience. There is broad agreement that the main functions of Aboriginal health should remain with the Department of Health, preferably led by an Indigenous official. But a small, high-level group in the Department of the Prime Minister and Cabinet, to ensure that the new Prime Minister’s requirement to deliver for Aboriginal people is met, is an essential component of the new arrangements.

Second, the recently formulated National Aboriginal and Torres Strait Islander Health Plan isn’t really a plan in any meaningful sense, but could become one if the implementation plan foreshadowed in it is developed in genuine partnership with Aboriginal people, and involves officials with the requisite skills, experience and training. But that implementation plan needs to also include mental health and, this time, to wrestle successfully with mainstreaming.

Third, and most important, it is time for Aboriginal communities to play a more central role in the design and conduct of their own services, bearing in mind that some of the best health services in Australia are run by the ACCHS sector.

If the Mundine review and the Abbott government can successfully address these issues Australia, in the not too distant future, could complete the long transition from international opprobrium to leading the world in Indigenous health.

Utility of exercise electrocardiography testing for the diagnosis of coronary artery disease in a remote Australian setting

Coronary artery disease (CAD) remains the leading cause of death in Australia, both in the general population and also among Aboriginal and Torres Strait Islander peoples (referred to henceforth as Indigenous Australians).1 Indigenous Australians are three times as likely to suffer a major coronary event than are non-Indigenous Australians,2 and cardiovascular disease remains the leading cause of Indigenous mortality and the main contributor to the mortality gap between Indigenous and non-Indigenous Australians.3 Furthermore, the burden and severity of other diseases that predispose to CAD are higher among Indigenous Australians.4

Patients with an acute coronary syndrome (ACS), as defined by electrocardiography results and biochemical markers, proceed to coronary angiography, which is considered the gold standard diagnostic tool for CAD; however, its use is limited due to its invasive nature, cost and accessibility.5 In the absence of a definite ACS, less invasive, and often more accessible, exercise stress testing is used. Stress testing determines the significance of a patient’s symptoms by indicating whether functional myocardial ischaemia occurs and therefore whether further investigations, including coronary angiography, are needed.

Alice Springs Hospital (ASH), in the Northern Territory, services a dispersed population of 45 000 people spread over 1 million square kilometres, of whom 44% are Indigenous Australians.6 ASH is about 1500 kilometres from the nearest angiography facilities and relies on exercise electrocardiography testing (EET) to prioritise patients for further investigation of possible CAD. Patients with a “positive” test are typically referred for coronary angiography, and patients with a “negative” test are usually reassured and assumed to be at low risk of significant CAD.7 Inconclusive test results typically lead to referral for stress echocardiography — the timing of which is reliant on the frequency of visiting cardiologists. Consequently, the results of EET are heavily relied upon to inform a diagnosis and management plan. In non-Indigenous populations, the usefulness of EET has been reflected in its reported high negative predictive value of 99%.8–11 We chose to retrospectively audit the performance of EET in our local population, as its diagnostic utility in a setting with a significant proportion of Indigenous Australians has not been studied. In addition, we assessed the significance of inconclusive EET results with regard to subsequent clinical outcomes, as patients with inconclusive results may be at increased risk of CAD-related events while waiting for further diagnostic testing.

Methods

We undertook a retrospective audit of data for patients with suspected CAD who underwent EET between 1 June 2009 and 31 May 2010. We excluded patients with a pre-existing diagnosis of CAD and those not permanently residing in the NT. Data collected included patient demographics, CAD risk factors, results of the EET, and clinical outcomes for the following 2 years as documented in the patients’ medical records.

ASH uses the Bruce protocol for conducting EET, aiming to achieve a target age- and sex-based heart rate, exercise duration and workload (based on metabolic equivalents [METS]).9 A positive result was one or more of: angina during exercise; ST-segment depression that was > 1 mm and/or downsloping; reduction in blood pressure of > 10 mmHg from baseline and/or multiple ventricular premature complexes or runs of ventricular tachycardia. A negative test result was recorded if the patient was asymptomatic with a normal electrocardiogram and blood pressure response on completion of maximal testing. A patient who failed to complete the test for reasons other than those that would classify the test as being positive was reported as having an inconclusive test result.10

Clinical outcomes were reviewed for 2 years after EET for details of subsequent coronary angiography results consistent with CAD, readmission to ASH for investigation of chest pain and readmission to ASH with a separation diagnosis of an ACS. Our assessment of the overall utility of EET was based on the risk of having a coronary angiogram suggestive of either CAD or an ACS within 24 months of testing.

Statistical analysis was undertaken using Stata12 (StataCorp). Continuous variables were compared using the Wilcoxon rank-sum test; categorical variables were compared using the χ2 test. Continuous non-parametric data are presented as medians with interquartile range, and categorical variables are presented as percentages with binomial confidence intervals. Logistic regression models were created using a backwards stepwise approach, including in the first model all variables shown in univariable models to be related to test outcome, as well as variables that differed between Indigenous and non-Indigenous subjects at baseline. All statistical tests were two-sided and P less than 0.05 was taken to indicate statistical significance. Ethics approval for the study was provided by the Central Australian Human Research Ethics Committee.

Results

We reviewed the medical records and EET results of 268 patients who met our inclusion criteria. Descriptive data related to these patients are presented in Box 1. Indigenous identity was not reported for 10/268 patients (3.7%). Indigenous patients were significantly younger than non-Indigenous patients and were more likely to be women. They were also twice as likely to have been diagnosed with one or more chronic diseases (OR, 2.0; 95% CI, 1.1–3.7), particularly diabetes mellitus (OR, 5.9; 95% CI, 3.3–10.7) and chronic kidney disease (OR, 12.2; 95% CI, 4.1–36.1), compared with non-Indigenous patients.

The results of EET and outcomes over the subsequent 24 months are outlined in Box 2. Indigenous patients were less likely to reach a maximum heart rate or adequate workload (> 10 METS) (OR, 10.3; 95% CI, 5.3–20.3). In turn, this translated to a higher proportion of Indigenous patients having inconclusive test results compared with non-Indigenous patients (57/108 v 32/150; P < 0.001) and a lower proportion having positive (6/108 v 21/150; P = 0.03) and negative (45/108 v 97/150; P < 0.001) test results (Box 2). In logistic regression modelling, the major factors independently associated with an inconclusive result were a diagnosis of one or more chronic diseases (OR, 6.0; 95% CI, 2.5–14.1) and identifying as Indigenous (OR, 3.7; 95% CI, 2.1–6.6).

Compared with patients with an inconclusive or negative EET result, patients with a positive result were more likely to proceed to coronary angiography (21/34; P < 0.001) and were significantly more likely to present to hospital with chest pain in the following 2 years (11/28; P = 0.001). Indigenous patients were less likely than non-Indigenous patients to proceed to coronary angiography (10/34 v 24/34, respectively; P = 0.114), and more likely to present with an ACS in the following 2 years (4/108 v 2/139, respectively; P = 0.25); however, neither of these differences were statistically significant. Overall, the risk of presenting with an ACS within 24 months significantly increased as the result of EET moved from negative to inconclusive to positive (OR, 4.4; 95% CI, 1.4–14.0). A similar relationship to EET results was seen for re-presentation with chest pain within 12 months (OR, 2.0; 95% CI, 1.3–3.1) and re-presentation with chest pain within 24 months (OR, 2.0; 95% CI, 1.3–2.9).

The sensitivity, specificity and positive and negative predictive values of EET in our sample are summarised in Box 3.

Discussion

EET clearly represents a cheap, non-invasive diagnostic modality for screening patients presenting with suspected CAD. Our findings provide reassurance that, when maximal testing can be completed, EET has performance characteristics that are at least equivalent to those reported in the literature.8 Even when inconclusive results were included, the lack of a positive EET continued to confer a low risk of a subsequent presentation with an ACS. While the presence of chronic disease was the main predictor of an inconclusive EET there was also an independently elevated risk associated with being Indigenous. This may be related to physical and social factors, including familiarity with treadmill exercise, and fitness.

A focus should be to reduce the proportion of inconclusive tests. In general, an image-based myocardial stress study, typically echocardiography with dobutamine, is performed when the EET result is inconclusive. These tests are conducted by visiting cardiologists, but waiting periods are variable and may extend to months. In the interim, a person with possible CAD may go without treatment and be at risk of a preventable adverse outcome — demonstrated in our study by the high rates of loss to follow-up and re-presentation with an ACS. Possible solutions include enhanced orientation and education of patients before they undergo EET, and greater use of Indigenous language translators.

Our study was limited by its reliance on retrospective collection of data that were non-standardised. The information gathered was limited to data documented at the time of the EET. Similarly, follow-up of patients re-presenting with ACS or chest pain was restricted to those who presented to ASH. Nonetheless, as the only referral hospital servicing the Central Australian region, most clinically significant events in remote clinics would have been captured. This limitation could be overcome by repeating the audit prospectively.

In summary, EET is likely to remain a useful and important tool in determining the risk of CAD among patients in regional and remote Australian locations where onsite specialist cardiology services are limited. Further attention should be given to how inconclusive test results could be reduced. Positive initiatives may include greater involvement of Indigenous people in the health care workforce associated with EET, exploring patients’ understanding of the concepts of CAD and exercise, and educating patients and health care providers. Greater use of myocardial stress testing modalities that do not require specialist cardiologists, such as cardiac computed tomography angiography, or training local staff to perform stress echocardiography could also be considered as means of enhancing the care of patients with inconclusive results.

1 Descriptive details of 268 patients who underwent exercise electrocardiography testing 1 June 2009 – 31 May 2010

All patients

Indigenous patients

Non-Indigenous patients

No.

Proportion (95% CI)*

No.

Proportion (95% CI)*

No.

Proportion (95% CI)*

P†

Age in years, median (IQR)

–

49.0 (41.6–57.5)

–

45.7 (39.1–55.3)

–

51.0 (44.9–58.6)

0.004‡

Total number

268

100%

108

40.3%

150

56.0%

–

Women

118

44.0% (38.0%–50.2%)

64

59.3% (50.0%–68.7%)

52

34.7% (27.0%–42.4%)

< 0.001

History of smoking

103/245

42.0% (35.8%–48.5%)

48/100

48.0% (37.9%–58.2%)

55/145

37.9% (30.0%–46.4%)

0.12

Family history of CAD

67/155

43.2% (35.3%–51.4%)

24/45

53.3% (37.9%–68.3%)

43/110

39.1% (29.9%–48.9%)

0.10

Any chronic disease

189/262

72.1% (66.3%–77.5%)

88/108

81.5% (72.9%–88.3%)

101/148

68.2% (60.1%–75.6%)

0.02

Diabetes mellitus

80/250

32.0% (26.3%–38.2%)

57/107

53.3% (43.7%–62.9%)

23/143

16.1% (10.0%–22.2%)

< 0.001

Hypertension

132/252

52.4% (46.0%–58.7%)

71/107

66.4% (56.6%–75.2%)

61/145

42.1% (33.9%–50.5%)

< 0.001

Dyslipidaemia

139/237

58.6% (52.1%–65.0%)

71/98

72.4% (62.5%–81.0%)

68/139

48.9% (40.4%–57.5%)

< 0.001

Renal impairment (eGFR < 60 mL/min/1.73 m2)

18/215

8.4% (5.0%–12.9%)

14/98

14.3% (8.0%–22.8%)

4/111

3.6% (1.0%–9.0%)

0.02

Albuminuria (ACR > 3.4 mg/mmol)

26/48

54.2% (39.2%–68.6%)

25/38

65.8% (48.6%–80.4%)

1/8

12.5% (0.3%–52.7%)

0.02

Renal impairment or albuminuria

35/216

16.2% (11.6%–21.8%)

31/99

31.3% (22.4%–41.4%)

4/111

3.6% (1.0%–9.0%)

< 0.001

* Unless otherwise indicated. † χ2 unless otherwise indicated. ‡ Wilcoxon rank-sum test. ACR = albumin : creatinine ratio. CAD = coronary artery disease.
eGFR = estimated glomerular filtration rate. IQR = interquartile range.

2 Exercise electrocardiography testing results and patient outcomes

All patients

Indigenous patients

Non-Indigenous patients

No.

Proportion (95% CI)*

No.

Proportion (95% CI)*

No.

Proportion (95% CI)*

P

Exercise electrocardiography test result

Positive

31/268

11.6% (8.0%–16.0%)

6/108

5.6% (2.1%–11.7%)

21/150

14.0% (8.9%–20.6%)

0.03

Inconclusive

90/268

33.6% (28.0%–39.6%)

57/108

52.8% (42.9%–62.5%)

32/150

21.3% (15.1%–28.8%)

< 0.001

Negative

147/268

54.9% (48.7%–60.9%)

45/108

41.7% (32.3%–51.5%)

97/150

64.7% (56.5%–72.3%)

< 0.001

Coronary angiography performed

34/268

12.7% (8.9%–17.3%)

10/108

9.3% (4.5%–16.4%)

24/150

16.0% (10.5%–22.9%)

0.11

Proportion of coronary angiograms that were positive

18/34

52.9% (35.1%–70.2%)

5/10

50.0% (18.7%–81.3%)

13/24

54.2% (32.8%–74.4%)

0.82

Acute coronary syndrome

Within 1 year

4/263

1.5% (0.4%–3.8%)

3/108

2.8% (0.6%–7.9%)

1/145

0.7% (0–3.8%)

0.12

Within 2 years

6/255

2.4% (0.9%–5.1%)

4/108

3.7% (1.0%–9.2%)

2/139

1.4% (0.2%–5.1%)

0.25

Acute coronary syndrome and/or positive angiogram

Within 1 year

20/263

7.6% (4.7%–11.5%)

7/108

6.5% (2.6%–12.9%)

13/145

9.0% (4.9%–14.8%)

0.47

Within 2 years

21/255

8.2% (5.2%–12.3%)

8/108

7.4% (3.3%–14.1%)

13/139

9.4% (5.1%–15.5%)

0.59

Readmission with chest pain

Within 1 year

55/264

20.8% (16.1%–26.2%)

28/108

25.9% (18.0%–35.2%)

25/146

17.1% (11.4%–24.2%)

0.09

Within 2 years

67/256

26.2% (20.9%–32.0%)

35/108

32.4% (23.7%–42.1%)

30/140

21.4% (14.9%–29.2%)

0.05

* Unless otherwise indicated.

3 Diagnostic utility of exercise electrocardiography testing*

Prevalence of outcome†

Sensitivity

Specificity

Positive predictive value

Negative predictive value

All patients

All test results (n = 268)

8.5% (5.2%–12.3%)

61.9% (38.4%–81.9%)

94.0% (90.2%–96.7%)

48.1% (28.7%–68.1%)

96.5% (93.2%–98.5%)

Inconclusive results excluded (n = 178)

9.0% (5.1%–14.4%)

86.7% (59.5%–98.3%)

90.8% (85.0%–94.9%)

48.1% (28.7%–68.1%)

98.6% (94.9%–99.8%)

Indigenous patients

All test results (n = 108)

7.4% (3.3%–14.1%)

37.5% (8.5%–75.5%)

97.0% (91.5%–99.4%)

50.0% (11.8%–88.2%)

95.1% (88.9%–98.4%)

Inconclusive results excluded (n = 51)

9.8% (3.3%–21.4%)

60.0% (14.7%–94.7%)

93.5% (82.1%–98.6%)

50.0% (11.8%–88.2%)

95.6% (84.9%–99.5%)

Non-Indigenous patients

All test results (n = 150)

9.4% (5.1%–15.5%)

76.9% (46.2%–95%)

93.7% (87.9%–97.2%)

55.6% (30.8%–78.5%)

97.5% (92.9%–99.5%)

Inconclusive results excluded (n = 118)

9.2% (4.5%–16.2%)

100% (69.2%–100%)

91.9% (84.7%–96.4%)

55.6% (30.8%–78.5%)

100% (96.0%–100%)

* All values are % (95% CI). † Defined as coronary angiogram suggestive of coronary heart disease or an acute coronary syndrome within 24 months of testing.

Cooperation vital to close health gap

The AMA has urged the Federal, State and Territory government to put partisanship to one side and begin to work together on plans to boost Aboriginal and Torres Strait Islander health.

AMA President Dr Steve Hambleton welcomed the long-awaited launch last week of the Commonwealth’s National Aboriginal and Torres Strait Islander Health Plan as an important first step in developing a coordinated approach to dramatically improve Indigenous health in the next 10 years.

The Plan, developed in partnership with Aboriginal and Torres Strait Islander people, calls for a greater focus on child health and development and the social determinants of illness and disease as part of efforts to close the gap and establish health equality by 2031.

Indigenous Health Minister Warren Snowdon said that the Government was determined, with the support of peak Indigenous groups including the National Aboriginal Community Controlled Health Organisation, to take a broader approach to Indigenous health to encompass developmental and social issues including violence and alcohol abuse as well as stamping out racism and inequality in the health system.

“In this plan we signal the need to expand our focus on children’s health to broader issues in child development,” Mr Snowdon said. “We have much more work to do in developing robust research and data systems. I am also resolved that we will tackle the difficult and distressing issues of violence, abuse and self harm.”

Shadow Indigenous Health Minister Andrew Laming said the Plan was an essentially empty statement short on detail, and accused the Government of springing the announcement on Indigenous health groups.

“The plan…contains little detail,” Dr Laming told The Australian. “[It] appears to be yet another exercise in political spin, lacking any substance, and fails to say how we are going to get there.”

But Mr Snowdon said the plan, developed following a series of 17 consultations held with Aboriginal and Torres Strait Islander communities and the receipt of more than 140 written submissions, would provide guidance for State and Territory governments about what the Commonwealth saw as priorities, and make sure they were taken into account in future intergovernmental agreements to improve Indigenous health.

The Minister used the announcement to intensify the pressure on the states and territories yet to commit to a new five-year National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes after the first deal expired last month.

So far, only the Commonwealth and Victoria have committed to a new five-year agreement, while Western Australia has pledged funds for just one year.

Dr Hambleton said a renewed agreement was vital, not only to ensure recent improvements in Indigenous health were sustained and built upon, but also to shepherd through the changes outlined in the Federal Government’s Health Plan.

The AMA President said that, now the Plan had been released, there needed to be detailed and comprehensive commitments from all those involved  – governments and medical and community groups – to ensure it was implemented.

Dr Hambleton said clear and measurable targets should be developed, as well as plans for how they were to be met.

He said this needed to be underpinned by appropriate funding and strategies to ensure the necessary workforce was available.

Underlying it all, he said, there had to be a solid requirement that all governments work together in genuine partnership, and with the guidance of Indigenous health leaders and communities.

“A National Implementation Plan is not truly national unless it has all the states and territories on board in a spirit of cooperation with the Commonwealth,” the AMA President said.

Adrian Rollins

 

Birthweight and fasting glucose and insulin levels: results from the Aboriginal Birth Cohort Study

The concerning rise in type 2 diabetes in Indigenous populations continues, with different hypotheses put forward to explain the phenomenon. International evidence links the fetal nutrition proxies of low birthweight (LBW) and fetal growth restriction (FGR) to chronic diseases in adult life.1 The developmental origins of health and disease (DOHaD) hypothesis states that undernutrition in utero results in permanent changes through epigenetic mechanisms that later influence disease development (http://www.mrc. soton.ac.uk/dohad). The highest risk for type 2 diabetes is reported when LBW or FGR is followed by later overweight or obesity, suggesting a mismatch between intrauterine and postnatal nutrition.2

Despite recent improvements, Australian Aboriginal LBW rates remain double those of the non-Aboriginal population.3 National Aboriginal rates of FGR are unknown, but in a Northern Territory study, 25% of Aboriginal newborns were defined as fetal growth restricted.4

Concurrently, not only are Australian Indigenous rates of overweight and obesity increasing — they currently range from 37% for ages 15–24 years to 74% for those aged over 55 years5 — but 10%–30% of Aboriginal people are now estimated to have type 2 diabetes.6

The high-risk combination of LBW and later obesity has been shown to be the greatest risk for elevated blood pressure in a cross-sectional community study of a NT Aboriginal population.7 More recently, a retrospective study in one NT community linked LBW and later chronic disease in Australian Aboriginal people8 and suggested LBW may be a contributor to the current high rates of type 2 diabetes in the Aboriginal population.

Using data from a prospective life-course Aboriginal birth cohort study, our aim was to examine the relationships of glucose and insulin metabolism with birth and current adolescent size.

Methods

We conducted a prospective life-course study of an NT Aboriginal birth cohort.

The recruitment and follow-up of this birth cohort has been previously published.9,10 In brief, 686 Aboriginal babies out of a possible 1238 born at the Royal Darwin Hospital (1987–1990) were recruited into the study. There were no significant differences in the mean birthweight, sex ratio or birthweight frequencies between those recruited (686), those with gestational age estimation (603) and those not recruited. At follow-up (2005–2008) in over 40 NT locations, 68 participants could not be found (9.9%). Of the remainder, 27 had died, 11 refused consent, 111 were traced but were unable to be examined for logistical reasons,10 and 469 who had complete perinatal and adolescent data were examined.

The birth measures of weight, gestational age estimations and follow-up anthropometric measures have previously been described.4,10 Within 4 days of birth, the same neonatal paediatrician performed a gestational age assessment using the Dubowitz scoring system.11 LBW was defined as birthweight < 2500 g, FGR as birthweight < 10th percentile for gestational age, and large for gestational age as birthweight > 90th percentile for gestational age, using an Australian population reference standard contemporary with cohort recruitment.12

Adolescents were measured in light clothing while barefoot. Height was measured to the nearest millimetre using a portable stadiometer and weight was measured to the last complete 0.1 kg with a digital electronic scale (TBF-521, Tanita).

Participants were asked to fast from midnight before the examination. Blood samples were taken at the time of examination, collected in fluoride oxalate tubes after application of anaesthetic cream to the venepuncture site, separated after collection (for a minority of samples, this was up to a maximum of 2–3 hours) and transported in cold-boxes to Darwin.

Fasting glucose levels were measured enzymatically using a modular analyser (Roche Diagnostics), fasting insulin levels were measured by immunoassay (AxSYM, Abbott Laboratories), and glycated haemoglobin concentrations by high-pressure liquid chromatography (PDQ, Primus Diagnostics). Insulin resistance was estimated from fasting insulin and glucose concentrations using homoeostatic model assessment (HOMA-IR).13

Cross-sectional growth outcomes were described by z scores for weight for age (WAZ) and height for age (HAZ) using the 2000 Centers for Disease Control and Prevention (CDC) sex-specific growth reference.14 Undernutrition was defined as 2 standard deviations (SDs) below zero and overweight was defined as 2 SDs above zero, according to World Health Organization criteria.15

Fasting was defined as an overnight fast of 8 hours or more, and 134 participants satisfied this criterion and had complete perinatal and follow-up data.

Residence at the time of follow-up was defined as remote (residence in defined remote Aboriginal communities) or other (including the twin cities of Darwin and Palmerston and the greater Darwin area).

Statistical analysis

The clinical characteristics were summarised as means (SD), and if not normally distributed, as geometric means (SD) and as category percentages. Characteristics were compared between sexes using the t test (for normally distributed values) and the χ2 test (for categorical values). Non-normal data were transformed to yield normal distribution before t tests were performed.

Representativeness of the fasting sample, as described above, was tested using t, Wilcoxon and χ2 tests, depending on the distribution of the test variable.

For analyses, birthweight, and adolescent height, weight and body mass index (BMI) were continuous variables, while birthweight for gestational age was dichotomised at the 10th percentile for FGR and at the 90th percentile for large for gestational age.

The relationships of fasting insulin, glucose and HOMA-IR measures to the birth size and current adolescent size were each analysed in standard regression models using the approach recommended by Lucas and colleagues16 adjusted for gestational age, sex, and contemporary age using Stata, version 11 (StataCorp).

In order to maintain the assumptions of regression-dependent variables, fasting insulin, glucose and HOMA-IR values were transformed using the natural log transformation. Each outcome variable was tested in separate univariate models for each of the birth measures (eg, model 1), then adjustment for height (eg, model 1a) or weight (eg, model 1b) was added to the model, then an interaction term between the birth measures and adolescent weight or height was added. Lastly, the outcome variables were tested in separate univariate models for adolescent height (eg, model 3) and weight (eg, model 4). Models were separately analysed with current-residence regression coefficients and were then back-transformed using exponentiation, presenting ratios for ease of interpretation.

The percentage of total variance in the outcome measures, accounted for by early life size and later adolescent size, were estimated by the difference in the coefficients of determination (R2) between fully adjusted birth models with and without the measure of interest.

Ethics

The Human Research Ethics Committee of the Northern Territory Department of Health and Families and Menzies School of Health Research, including the Aboriginal Ethics Sub Committee, which has the power of veto, approved the study. Written consent was obtained in the form of an itemised consent with participants allowed to refuse individual procedures.

Results

One hundred and thirty-four participants had complete perinatal and follow-up data and fasting insulin and glucose measures. Box 1 shows the comparison of the fasting subset with the complete cohort and the subset of participants who did not have fasting values. This fasting subset was not significantly different from the non-fasting subset in the perinatal measures, the follow-up measures and the levels of non-fasting biomarkers (glycated haemoglobin and C-reactive protein) associated with type 2 diabetes. There were 59 males and 75 females with a mean age of 18.14 (SD, 1.1) years. The birth and adolescent characteristics of this fasting subset are shown in Box 2. As expected, females were significantly shorter (P < 0.01) and lighter (P < 0.01). Only one participant had a fasting glucose > 7 mmol/L and there were no participants with fasting glucose values of 6.1–6.9 mmol/L.

For the fasting dataset, using the international CDC reference,14 the mean WAZ scores were negative for both males and females. The proportions of males and females with WAZ < − 2 (undernutrition) were 18.6% and 17.3%, respectively. At follow-up, none of the 33 fasting adolescents who had been fetal growth restricted at birth had a WAZ > 2 (overweight/obesity). Only one participant had a WAZ > 1, with a similar profile occurring for those who had LBW.

Birthweight had a significant positively directed association with fasting glucose but not with fasting insulin levels. For every kg increment in birthweight, adolescent fasting glucose levels rose by 7% (P = 0.002) (Box 3). This positively directed association of birthweight with fasting glucose levels remained after adjustment for adolescent height or weight, which accounted for 6% and 3% of the variation in fasting glucose levels, respectively.

The significant association with fasting glucose levels also remained when birthweight was categorised as birthweight for gestational age. For adolescents who had been fetal growth restricted at birth, fasting glucose levels were 7% less than for those who were not fetal growth restricted at birth (P = 0.003), and these relationships remained the same after adjustment for adolescent height and weight, again accounting for 6% and 3% of the variation in fasting glucose levels (Box 3).

Current height, weight and BMI had significant and positively directed associations with both fasting insulin and glucose levels in univariate models, with the regression ratio and percentage of variation explained being greatest for the fasting adolescent insulin and HOMA-IR measures.

For every kg increment in weight, cm increment in height or index point in BMI, fasting insulin levels rose by 3%, 3% and 9%, respectively (Box 4), and HOMA-IR by 3% (95% CI, 1.02–1.04; P < 0.01), 3% (95% CI, 1.01–1.06; P = 0.01) and 10% (95% CI, 1.08–1.13), respectively (data for HOMA-IR not shown), while for fasting glucose, the changes were 0.1% increase for every kg increment in weight, 0.2% for every cm increment in height, and 0.7% for every index point in BMI (Box 3).

Repeat analysis of all models with the inclusion of the remote status variable did not change any of the associations previously found. Regression models (models 3, 4 and 5 in Box 3 and Box 4) of height, weight and BMI were also reanalysed, with adjustment for birthweight, which did not change the results presented.

Apart from these main effects, there were positive and significant interactions between birthweight and height for insulin (P = 0.006) and HOMA-IR (P = 0.015) (data not shown). This allows for an extra increment in insulin and HOMA-IR values for participants who moved from higher birthweight to higher adolescent height. Hence, for a fixed current height, those adolescents with higher birthweights had higher measures of insulin and HOMA-IR values.

Discussion

In this adolescent cohort, there were no negatively directed associations between birthweight and either fasting glucose, insulin concentrations or the insulin-resistance measure, with no evidence of the U-shaped associations described for populations with similar high rates of type 2 diabetes in adult life. A positively directed association occurred for birthweight with fasting glucose levels. Consistent with these findings, those adolescents who had been fetal growth restricted at birth had lower fasting glucose concentrations. In contrast, even in this young and lean population, there were positively directed associations of current adolescent height and weight with fasting glucose and insulin concentrations and the insulin-resistance measure, albeit of a relatively trivial magnitude for fasting glucose. For fasting glucose levels, the effect of birthweight and current weight was similar (R2, 0.070 v 0.076), but for fasting insulin levels, the effect of current weight was considerably stronger than birthweight (R2, 0.299 v 0.019). These overall findings are similar to findings for these Aboriginal cohort participants at 11 years of age.17

The proportions of males and females with undernutrition (WAZ < − 2) were 18.6% and 17.3%, respectively, which far exceeded the expected 2.3% using the CDC sex-specific growth reference.14 Hence, compared with this international reference, there was a marked excess of undernutrition in this cohort. Importantly, the findings of no associations between LBW and FGR with higher fasting adolescent insulin and glucose levels were contrary to the DOHaD hypothesis, and suggest that the adverse effects of poor fetal nutrition may be concealed by the persistent undernutrition in these Aboriginal adolescents.

The main strength of this study is that the data have been prospectively collected from a contemporary Australian Indigenous population. This is in contrast to many of the other studies examining the DOHaD hypothesis, which are retrospective studies.

Unusually for this type of cohort, at the time of recruitment less than 10% of mothers had homebirths.9 The single-point tertiary hospital recruitment meant birth measurements were standardised, and reliable gestational age estimations were all made by the one neonatal paediatrician within 4 days of birth. Hence, the better fetal growth surrogate of birthweight adjusted for gestational age was available for analysis. Further, all follow-up biological measures were directly collected.

The difficulty in obtaining reliable fasting blood samples in the field is reflected in the small sample size. However, a number of significant associations were present despite this sample size. A further limitation due to the age of participants is the necessity of using intermediary biomarkers of diabetes instead of the preferred specific disease end point. Socioeconomic status (SES) factors are potential confounders in this study and standard SES indicators were collected, such as years of schooling, house ownership and employment. There are limitations of standard measures in capturing the multidimensional differences within populations similar to this cohort population.18 In the absence of adequate discriminatory measures of SES, we used only remote current residence as an objective surrogate measure of SES. Including this variable made only a limited difference to the significance of one association.

Our findings are in contrast to the predominant literature of the DOHaD hypothesis describing inverse associations between birthweight and later fasting insulin and glucose levels. While these reports are mainly retrospective studies from developed populations,1 similar findings have been reported from Aboriginal populations19 and five low- or middle-income-country birth cohorts.20

Similar findings to our study have been reported in a young lean population of Guatemalan men and women at a mean age of 24 years.21 Further, in the Newcastle Thousand Families Study, at 49–51 years of age, adult lifestyle factors explained larger proportions of variances for fasting and 2-hour glucose compared with early-life measures.22,23 A contemporary study of British children, based on maternal recall of birthweight, reports current size as the main determinant of insulin and glucose concentrations in childhood.24

The growth outcomes in our study suggest that a major nutritional mismatch between fetal and adolescent life has not occurred. It is likely that the permanent changes in response to undernutrition in utero have remained appropriate in this undernourished adolescent population with low rates of the high-risk combination of LBW- or FGR-associated later obesity or overweight.

Given the high prevalence of overweight and obesity currently seen in the adult Aboriginal population,6 it is likely that the growth trajectory will positively change in this cohort and the high-risk combination for chronic disease of LBW or FGR followed by overweight or obesity will become more common over the next decade. Then the relationships of LBW or FGR with chronic biomarkers may become apparent, consistent with the DOHaD hypothesis. With the follow-up of this cohort at the age of 26 years currently underway, we are well placed to determine if and when the effects of poor intrauterine nutrition are potentiated by the onset of overweight and obesity.

In the meantime, our findings suggest that the current high rates of type 2 diabetes observed in the adult Aboriginal population are more likely to be decreased by strategies targeted to improve lifestyle factors in childhood and adolescence, rather than those focusing on improving birthweight alone.

1 Comparison of the fasting sample and the original cohort: Aboriginal Birth Cohort 1987–2008

Mean (SD)*

Characteristic

Original cohort with
gestational age data
(n = 603)

Fasting participants
with complete data
(n = 134)

P†

Birthweight, g

3013 (654)

3027 (689)

0.78

Low birthweight‡

18.2%

16.4%

0.54§

Gestational age, weeks

38.74 (1.96)

38.67 (2.11)

0.69

Fetal growth restriction**

27.5%

24.6%

0.39§

Large for gestational age††

7.8%

9.7%

0.35§

Male

52.9%

44.0%

0.28§

Remaining original cohort at follow-up
(n = 469)

Current age, years

18.30 (1.09)

18.14 (1.12)

0.06

Weight for age, z score

− 0.63 (1.62)

− 0.47 (1.63)

0.20

Height for age, z score

− 0.28 (0.92)

− 0.21 (0.97)

026

Body mass index, kg/m2

21.49 (5.63)

21.68 (5.47)

0.63

Glycated haemoglobin

5.20% (0.40%)

5.18% (0.42%)

0.49

C-reactive protein, mg/L

5.02 (7.48)

4.99 (7.78)

0.97

SD = standard deviation. * Unless otherwise specified. † t test unless otherwise specified. ‡ < 2500 g. § χ2 test. Wilcoxon test. ** Birthweight < 10th percentile for gestational age. †† Birthweight > 90th percentile for gestational age.

2 Birth and current adolescent characteristics of 134 fasting Aboriginal adolescents

Mean (SD)*

Characteristic

Total (n = 134)

Male (n = 59)

Female (n = 75)

P†

Perinatal

Birthweight, g

3027 (689)

3178 (730)

2908 (635)

0.02

Gestational age, weeks

38.7 (2.1)

38.7 (2.4)

38.6 (1.9)

0.79‡

Low birthweight§

16.4%

10.2%

21.3%

0.08

Fetal growth restriction

24.6%

20.3%

28.0%

0.31

Large for gestational age**

9.7%

11.9%

8.0

0.56

Adolescent

Age, years

18.14 (1.12)

18.11 (1.01)

18.17 (1.20)

0.77

Weight, kg

61.49 (20.06)

70.37 (23.74)

54.5 (13.0)

< 0.01‡

Weight for age, z score

− 0.47 (1.62)

− 0.24 (1.74)

− 0.65 (1.52)

0.15

Weight for age, z score < − 21

17.9%

18.6%

17.3%

0.84

Height, cm

167.33 (9.26)

174.41 (7.61)

161.76 (6.12)

< 0.01

Height for age, z score

− 0.21 (0.97)

− 0.21 (1.02)

− 0.21 (0.95)

0.98

Height for age, z score − 214

3.0%

5.1%

1.3%

0.32††

Body mass index, kg/m2

21.68 (5.47)

22.83 (6.35)

20.78 (4.50)

0.04‡

Weight for age, z score > 215

6.7%

13.5%

1.3%

0.09

Fasting glucose, mmol/L

4.64 (0.59)

4.78 (0.46)

4.53 (0.65)

0.01‡

Fasting insulin, mU/L

8.36‡‡ (2.40)

7.47‡‡ (2.54)

9.16‡‡ (2.28)

0.19

HOMA-IR

1.71‡‡ (2.53)

1.58‡‡ (2.71)

1.83‡‡ (2.39)

0.38

Glycated haemoglobin

5.16%‡‡ (1.08%)

5.19%‡‡ (1.08%)

5.14%‡‡ (1.08%)

0.48

C-reactive protein, mg/L

1.88‡‡ (4.84)

2.03‡‡ (4.07)

1.78‡‡ (5.53)

0.64

HOMA-IR = insulin resistance estimated using homoeostatic model assessment. SD = standard deviation. * Unless otherwise specified. † t test unless otherwise specified. ‡ Unequal t test. § < 2500 g. Birthweight < 10th percentile for gestational age. ** Birthweight > 90th percentile for gestational age. †† Fisher’s exact test. ‡‡ Geometric mean.

3 Size at birth and adolescent height and weight: relationships with fasting glucose (mmol/L) concentrations among Aboriginal adolescents (n = 134)*

Model

Ratio

95% CI

P

R2†

Model 1: birthweight, kg

1.07

1.03–1.11

0.002

0.070

Model 1a: adjusted for child height

1.07

1.02–1.11

0.005

0.057

Model 1b: adjusted for child weight

1.05

1.00–1.09

0.035

0.030

Model 2: FGR‡ v non-FGR§

0.93

0.89–0.98

0.003

0.062

Model 2a: adjusted for child height

0.93

0.89–0.98

0.006

0.055

Model 2b: adjusted for child weight

0.95

0.90–0.99

0.028

0.033

Model 3: current height, cm

1.002

0.99–1.01

0.179

0.013

Model 4: current weight, kg

1.001

1.001–1.003

0.001

0.076

Model 5: body mass index

1.007

1.003–1.01

< 0.001

0.089

FGR = fetal growth restriction. * All models adjusted for gestational age, sex and contemporary age. † Difference between fully adjusted birth models with and without the measure of interest. ‡ Birthweight < 10th percentile for gestational age. § Birthweight ≥ 10th percentile for gestational age.

4 Size at birth and adolescent height and weight: relationships with fasting insulin concentrations (mU/L) among Aboriginal adolescents (n = 134)*

Model

Ratio

95% CI

P

R2†

Model 1: birthweight, kg

1.28

0.94–1.73

0.112

0.019

Model 1a: adjusted for child height

1.12

0.82–1.54

0.471

0.004

Model 1b: adjusted for child weight

0.87

0.66–1.15

0.326

0.005

Model 2: FGR‡ v non-FGR§

0.92

0.65–1.31

0.656

0.002

Model 2a: adjusted for child height

1.01

0.71–1.43

0.961

0

Model 2b: adjusted for child weight

1.27

0.94–1.71

0.120

0.012

Model 3: current height, cm

1.03

1.01–1.05

0.006

0.055

Model 4: current weight, kg

1.03

1.02–1.03

< 0.001

0.299

Model 5: body mass index

1.09

1.07–1.12

< 0.001

0.307

FGR = fetal growth restriction. * All models adjusted for gestational age, sex and contemporary age. † Difference between fully adjusted birth models with and without the measure of interest. ‡ Birthweight < 10th percentile for gestational age. § Birthweight ≥ 10th percentile for gestational age.

Specialists sign up to Indigenous initiative

The nation’s specialist medical colleges will upgrade their curricula and identify Aboriginal medical trainees under a landmark agreement struck with the peak body of Indigenous doctors.

The Australian Indigenous Doctors’ Association (AIDA) and the Committee of Presidents of Medical Colleges (CPMC) have signed a Collaboration Agreement that includes measures to support the training of Indigenous practitioners and to improve the ability of all doctors to work competently with Aboriginal and Torres Strait Islander people.

AIDA Chief Executive Officer Romlie Mokak told Australian Medicine that the Agreement was one of a number of formal partnerships recently developed by his organisation with peak medical education and training organisations.

The announcement came as the nation’s governments missed a deadline to renew their commitment to closing the health gap between Indigenous Australians and the rest of the community, heightening concerns that recent gains made will be squandered.

The nation’s first $1.6 billion, five-year National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes expired in 30 June, and so far only the Commonwealth and Victoria have committed to a new five-year deal.

The failure of the many of the states to so far commit to a fresh Closing the Gap plan has come amid signs that an increasing number of Indigenous students are training to become doctors.

AIDA estimates there are currently around 175 Indigenous medical graduates and 300 Indigenous medical students.

Mr Mokak said that in the last two years Indigenous students had comprised 2.5 per cent of all medical school admissions, putting them at parity with their presence in the broader population.

“That would have been unheard of 10 years ago,” he said. “Over the next three to four years, as people graduate, we will see a steady rise in the number of Indigenous graduates.”

But Mr Mokak said increase in graduate numbers alone was not enough, and had to be accompanied by improved support for Indigenous students through pre-vocational and vocational training.

“Our focus is the whole continuum. We are not focused on a particular level of training or particular specialty,” he said. “Support for graduates at the junior doctor level is critical, [and] we want more people to know about pathways in specialist areas.”

 CPMC Chair Professor Kate Leslie said Aboriginal and Torres Strait Islander doctors were “significantly under-represented” in the medical workforce, and all 15 specialist medical college Presidents are committed to leading the change with our partners AIDA”.

Under the Agreement, the Colleges will collate data on the number of Aboriginal trainees and practitioners within their ranks, and every year each College will send either its President or Chief Executive to spend time at an Indigenous health service, to gain first-hand experience of the conditions and challenges faced.

Mr Mokak said that, just as important as encouraging more Indigenous people into medical training was efforts to improve awareness of Indigenous culture, society and outlook among the broader medical community.

To help achieve this, AIDA is working with each College to upgrade their curricula by “providing guidelines for each speciality of things in the training of your Fellows which we would think would be necessary to know,” he said.

Mr Mokak said these initiatives could serve as an example of how to achieve improvements across a wide range of areas, not just medicine.

“If we get this agenda right in medicine, we are sending a significant message to the rest of the health system that if doctors are able to tackle these issues, it should be the same for all health professions, and all professions more broadly,” he said. “We see this as not only important work for medicine, but important work for the whole country.”

Adrian Rollins

Future initiatives to improve the health and wellbeing of Aboriginal and Torres Strait Islander peoples

Continuing to close the health gap will require innovation; long-term, systematic approaches that improve the quality and integrity of data; collaborations and partnerships that reflect an ecological approach to health, and recognition of the proper place and contribution of Aboriginal and Torres Strait Islander peoples in Australian society

At long last there are signs that the gaps between the health of Aboriginal and Torres Strait Islander people and non-Indigenous people are closing — but systematic, long-term action needs to continue both within and outside the health system to realise true health equality, and for us to know that we have achieved it.

According to the 2012 report of the Aboriginal and Torres Strait Islander Health Performance Framework, a number of positive trends in Aboriginal and Torres Strait Islander health include:

  • the mortality rate has declined significantly (by 33%) between 1991 and 2010 among people living in Western Australia, South Australia and the Northern Territory combined;

  • deaths due to avoidable causes decreased significantly in WA, SA and the NT combined, down 24% between 1997 and 2010;

  • deaths from respiratory disease decreased significantly from 1997 to 2010, and the gap with non-Indigenous Australians has also narrowed; and

  • mortality among infants aged less than 1 year declined by 62% between 1991 and 2010, perhaps reflecting the benefits of immunisation, improved access to primary health care services, the use of antibiotics and earlier evacuation to hospital for acute infections.1

Of course there remain areas where the gap persists or in some cases has grown, including chronic disease, injury, cancer, disability and low birthweight babies. It appears that in some areas (such as cancer) improvements in the quality, accessibility and impact of treatment are resulting in significantly improved death rates for non-Indigenous Australians, but Aboriginal and Torres Strait Islander people are missing out. The causes of this discrepancy seem to lie in disparities in stage at diagnosis, treatment received and survival rates.

Cutting across these trends are persistent gaps in the quality of data. Our inability to know whether large investments made in recent years in Aboriginal and Torres Strait Islander health are paying off should be a major focus for future strategies. In general, our population does not seem to be benefiting from the same level of sophisticated population-level tracking, health assessment or data integrity that majority populations take for granted.2 Good data are crucial, not just to know the impact of what we have done, but to guide what we are doing.

In this context it is pleasing to see the recent process of developing a new national plan to guide future investments in Aboriginal and Torres Strait Islander health, developed through a collaborative process including Aboriginal and Torres Strait Islander peak bodies, communities, services, researchers, advocates and clinicians.3 The new national plan needs to set directions for the next 10 years and expand and align with an ecological view of health, include concepts important to Aboriginal and Torres Strait Islander peoples and influence other sectors that affect health, such as education, employment, housing and early childhood development. This multifocal approach could have implications for the design, implementation and evaluation of projects, and will necessitate a reconceptualisation of partnerships and collaborations, while fostering innovations and knowledge exchange.

Finally, we will need to redress some of the less palatable aspects of the health system that contribute to inequality, such as racism.4 Embodied in dubious practices, disparities in access and subtle variations in effort within health and other institutions and programs, racism has had and continues to have a real and damaging impact on the health of Aboriginal and Torres Strait Islander people. It is clear that full health equality cannot be achieved until racism and other practices that deny our status and rights as the original and First Peoples of Australia can be overcome. My hope is that not only do we redress racism in health and other systems, but that this nation recognises and enables each and every Aboriginal and Torres Strait Islander person the opportunity to rise to the full potential of our existence.

Refining the concept of cultural competence: building on decades of progress

The impact of culture in the clinical encounter is recognised as a contributing factor to patterns of health service utilisation and is a key focus of cultural competence training.1,2 While some studies have identified beneficial effects of cultural competence on health professionals’ knowledge, attitudes and skills, and on levels of patient satisfaction, few have explored its effects on health outcomes. This is unsurprising given that the factors affecting health outcomes are numerous and complex. The Commission on Social Determinants of Health has noted that health inequalities are largely related to the circumstances of people’s lives and to the services available to treat illness.3 In turn, people’s circumstances and the health care system are shaped by social, political and economic realities. Cultural knowledge is embedded in these circumstances and realities, and helps frame patients’ explanatory models of illness and clinicians’ decision making.2 It has been argued, however, that these two world views can collide in the clinical encounter.4 Cultural competence training aims to improve the quality of health care and reduce health disparities by focusing on communication and trust between patients and health care providers and enhancing provider knowledge about sociocultural factors linked to health beliefs, practices and utilisation of services.5

The idea of educating health professionals to be culturally competent began in earnest in the United States in the 1990s. The term “cultural competence” first emerged in the late 1980s and was defined as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency or amongst professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations”.6 Cultural competence in health care was described as an emerging field in the US in 2002; however, over the past decade it has become firmly embedded in professional accreditation standards.7 In Australia, health professional competencies consistently make reference to cultural competence,8,9 and the concept has received legitimacy with its incorporation into significant health policy documents.10–13

While strategies associated with cultural competence aim to make services more accessible for patients from diverse cultural backgrounds, more recently they have focused on specific groups, particularly Indigenous Australians, where the failure of services to address large disparities in health outcomes is stark and confronting. Connecting Indigenous patients with the health system and communicating effectively can be challenging and has often not been done well (Box 1 and Box 2). Indigenous cultural competence has been identified as a desirable attribute of Australian health professionals.13–18 Perhaps as a result of the plethora of alternative concepts such as cultural safety, cultural awareness and sensitivity, cultural security and humility, and more recently cultural literacy, the use of an overarching term was inevitable, despite most concepts having different frames of reference.17,19 Cultural competence strategies usually target the health workforce with the aim of improving the interactions between the patient, the provider and the health care system, as the intermediate step to improving health care utilisation, service delivery and health outcomes. Many aspects of this concept remain the subject of debate.

Social science perspectives

Limitations of cultural competence highlighted by social scientists working in clinical and academic settings largely fall into three categories: lack of clarity around the concept of culture, inadequate recognition of the “culture of medicine” and the scarcity of outcomes-based research that provides evidence of efficacy in improving health.

Unpacking culture

While it is recognised that a patient’s cultural background may be significant in clinical encounters, lack of clarity about the concept of culture can distort its impact.2,4,20–22 Anthropology, the discipline from which the term “culture” originated, offers many definitions but most make reference to a system of shared meanings or guidelines that are inherited and provide a lens through which to view the world. Contemporary anthropologists stress variations that exist across cultures with respect to beliefs, practices, norms, behaviours and expectations. Helman, for example, notes that culture is “an increasingly fluid concept, which in most societies is undergoing a constant process of change and adaptation”.20 Social scientists stress that cultures are complex, heterogeneous and dynamic, and intricately connected to the social context of people’s lives.2,4,21,22

So how does this understanding of culture differ from its usage in medical settings? Critiques from social scientists suggest that culture is often conflated with race and ethnicity, resulting in reification of existing racial categories.4 Central to this criticism is the failure to recognise diversity within cultures and the concomitant reductionism whereby culture is identified as a variable associated with essential differences between groups. Culture is viewed as a “risk factor” and cultural attributes as potential sources of the problem. Kirmayer noted that culture has been framed in terms of “ethnoracial blocs” which “conflate language, geographic origin, ethnicity and race” and “do not capture the diversity of society and the rapidly growing numbers of people who define themselves in hybrid ways that cut across these categories or escape them entirely”.21 Cultural competence literature tends to associate culture with group membership and shared beliefs and values that influence behaviour in health care settings.21 Not only does this approach underestimate cultural diversity within groups, but the process of “essentialising” culture removes individuals from their complex social worlds in which the structural and material determinants of inequality may be as powerful as cultural influences on health inequity. In an attempt to provide more conceptual clarity around cultural competence, Lo and Stacey coined the term “hybrid habitus” which interprets patients’ cultures as “the broad, less than fully conscious cultural orientations that shape a patient’s sense-making in clinical settings . . . [and] in turn, are shaped by surrounding, intersecting structural forces”.22 These forces may include socioeconomic status, gender, language and experiences of racism, all of which can interact with cultural orientations and influence the clinical encounter. This deeper understanding of culture in all its complexity has practical implications in health care settings. A patient’s culture is not reduced to stereotypical attributes, but rather understood as comprising layers of meaning that extend beyond values, beliefs and practices and are shaped by and in turn shape social structures.

However, any examination of the meaning and use of “culture” needs to consider the culture of medicine itself to assess its role in reproducing or addressing health inequities.

Culture of medicine

In the US, Good and colleagues questioned why disparities in health care continue to exist despite the introduction of cultural competence training in health professional programs.23 They suggested the need for a critical analysis of the culture of medicine where the “social processes within our complex medical institutions” are explored, including the presence of institutional racism, power imbalances and the role of professional socialisation. Taylor reinforces this, noting that cultural competence strategies have an overemphasis on the patient’s culture with scant attention paid to the culture of biomedicine.24 Institutional and professional medical culture is characterised by expert language and efficiency in clinical decision making based on legitimate medical knowledge. Taylor suggests that “it is confidence in the truth of medical knowledge that underwrites physicians’ special power to alleviate suffering”. Medical knowledge is thus not seen as a cultural product but as “real” knowledge which leads her to describe medicine as “perceiving itself to be a ‘culture of no culture’ ”.24 While some may disagree with this, it has consequences for the development of cultural competence curricula that “go beyond focusing on ‘other’ cultural groups, and attend to cultural dimensions of medicine itself”. Central to this discussion is the potential mismatch between professional medical socialisation, institutional practices and cultural competence strategies. Indeed, clinicians sometimes can be at odds with institutional directives and feel constrained by administrative practices that may compromise patient care.

Despite cultural competence training becoming commonplace in medical programs in Australia and elsewhere, few studies have focused on the culture of medicine itself. As Good et al note “rarely do students have the time or the formal sanction to critically analyze the profession and institutions of care to examine how treatment choices, quality of care and research practices are shaped; or how medical culture may produce processes that evolve into institutional racism . . . in clinical practice”.23 Kleinman and Benson go further, suggesting that the culture of biomedicine is “key to the transmission of stigma, the incorporation and maintenance of racial bias in institutions, and the development of health disparities across minority groups”.2 Implementing a more expansive notion of cultural competence that incorporates greater critical analysis of biomedicine has potential for less discordance between institutional culture and strategies aimed to improve culturally informed care.

Problems of measurement and limited outcomes-based research

Finally, critiques of cultural competence by social scientists and others have drawn attention to inadequate measures of the concept and the scarcity of outcomes-based research that links cultural competence strategies to better health.25–30 A study of quantitative measures of cultural competence found many hidden assumptions in survey questions designed to assess the impact of educational interventions, including the notion that frequent contact or immersion experiences necessarily enhance competence.29 Much depends on the kinds of interactions and the quality of the experiences, with contact alone not necessarily fostering insight. Recent studies also have found a lack of rigorous evaluation of cultural competence measurement tools, with few instruments having been validated. Chun noted that cultural competence training is often viewed as “unscientific” due to inadequate measurement techniques that can undermine implementation efforts.27 This is reinforced by findings of a review of the methodological rigour of studies evaluating cultural competence, which found a consistent lack of rigour, the consequence of which “limits the evidence for the impact of cultural competence training on minority health care quality”.26 In addition to rigorous instrument evaluation, qualitative methods, including observations, interviews and reflective journals should supplement traditional survey techniques when determining the effectiveness of cultural competence training.29

The first systematic review of studies assessing whether educational interventions to improve cultural competence were linked to improvements in health outcomes concluded that where an association was established, it tended to be in a positive direction.28 However, the authors identified many methodological limitations of existing studies and drew attention to the overall paucity of high-quality research, concluding that the evidence was not robust. Looking ahead, they noted that “subjective constructs such as patient trust and the quality of the patient experience using validated measures have emerged as outcomes of intrinsic value that should also be considered in the cause-effect dynamic”.28 Inherent in cultural competence measurement issues is the question of who decides whether a health professional has achieved cultural competence; arguably, the patient as the recipient of services is best positioned to make this judgement. The authors noted that because educational interventions are often removed from clinical outcomes, other measures such as enhanced trust between patient and practitioner and a high degree of satisfaction with a clinical encounter are worthy outcomes in health care settings and may also contribute to improved levels of utilisation.28

Conclusion

Social science critiques of cultural competence highlight the lack of conceptual clarity around the use of the term “culture” in clinical encounters, inadequate recognition of the “culture of medicine” and a scarcity of outcomes-based research that provides evidence of efficacy in improving health.

The value of training in cultural competence as an educational intervention will ultimately be validated by enhancing access to and achieving equity of health services and better health outcomes for culturally diverse groups. Given strong evidence that inequities in health arise from inequities in society, cultural competence strategies should not be divorced from addressing the material circumstances of people’s lives, an issue pertinent to the oldest and newest inhabitants of Australia. Perhaps there are unrealistic expectations about what culturally informed health care delivery can achieve in the absence of systematic attention to the structural and financial impediments to implementing the professional advice provided in health encounters. A nuanced and sophisticated understanding of “culture” in clinical settings would be a useful start to discerning the role that cultural competence plays in reducing health disparities in minority groups.

1 No wonder people don’t come back*

One of the Aboriginal doctors was doing a paeds [paediatrics] trip and a patient had been driven overnight from Wiluna. And the doctors barely had time to see them [the family] and then they did not make them welcome, so this Aboriginal doctor was horrified. No wonder people don’t come back. It is the same with ordinary appointments. The reason why people miss appointments is because they can’t see the value of them. And I’ll ask them what happened at their outpatient appointment and they’ll say “They did what you do”. “What did they say?” “They said they will write you a letter”. “Did they examine you?” “Not really”. So there is a sense that these appointments are futile, especially the follow-up ones.

The young doctors that see the patients are afraid to discharge them from the clinic and so when they see them and everything is the same, they rebook them for another appointment for no good reason except they are too nervous to say “you don’t need to come back”.

It is a hassle to get a babysitter for your six kids, find transport, wait 4 hours . . . for nothing.

* Transcript notes from an interview with an experienced general practitioner who works at an Aboriginal Medical Service. The GP describes the lost time and opportunity costs for patients travelling
great distances for appointments that may be very brief and perhaps
not even necessary.

2 The heart of the matter*

Another thing is patients are not told enough; it’s a bit of a paternalistic attitude that doctors have anyway, and even more so with Aboriginal patients, they are not given enough information. One story is of a patient who told me he loved this private cardiologist and I was amazed. I couldn’t understand why, because this guy was as rough as guts and the doctor was a posh three-piece suit sort of guy . . . When I asked him he said because the doctor had a fabulous model of a heart and he shows me everything, you know. He just thought that guy was the bee’s knees . . . he took the time to show him pictures of his arteries . . .
so taking the time to show people with models and trying to explain what you’re doing is just fundamental . . .

Of course it’s hard in hospitals because doctors have so little time; but if they don’t explain things properly and patients don’t take their tablets because things aren’t clearly explained then they are wasting their time anyway.

* Transcript notes from an interview with an experienced general practitioner who works at an Aboriginal Medical Service. This excerpt highlights good communication and its importance in breaking down barriers between patient and clinician.

How will we close the gap in smoking rates for pregnant Indigenous women?

Antenatal smoking is the most important modifiable cause of adverse pregnancy outcomes.1 Indigenous Australian women are more than three times more likely to smoke during pregnancy than non-Indigenous women.2 As a result, adverse outcomes are more frequent in Indigenous than non-Indigenous babies, with smoking as an independent risk factor.3

Reviews of antenatal smoking interventions have shown effective cessation strategies for pregnant women.1 However, persistently high rates of smoking during pregnancy among Indigenous women suggest that current interventions have had limited impact. Finding ways to effectively reduce smoking in pregnant Indigenous populations is a high priority. Previous systematic reviews have examined smoking cessation interventions for Indigenous peoples; however, none has specifically investigated smoking cessation among pregnant Indigenous women.4,5

We undertook a systematic review to examine the effectiveness and methodological quality of smoking cessation interventions targeting pregnant Indigenous women. In December 2012 we searched MEDLINE, PsycINFO, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and Cochrane databases with appropriate search terms, and checked reference lists of retrieved articles. Papers were included if they reported a smoking cessation intervention aimed at pregnant Indigenous women, included a control group and provided cessation results specifically for pregnant Indigenous women. Only peer-reviewed, English-language papers were included. We extracted data and assessed methodological quality against Effective Practice and Organisation of Care quality criteria.6

Of 59 identified papers only two met eligibility criteria: one from the United States with Alaskan Native women,7 and one from Australia with Aboriginal and Torres Strait Islander women.8 Both involved culturally tailored interventions specifically developed for the target group, and used face-to-face counselling, structured follow-up, attempts to involve family members and nicotine replacement therapy (NRT). Both studies found no treatment effect and had a number of limitations (Box).

This lack of evidence of effective smoking cessation interventions for pregnant Indigenous women prevents implementation of evidence-based programs and highlights a critical need for methodologically rigorous testing of possible strategies.

What interventions should we test?

Evidence from research with Indigenous populations, and with pregnant women generally, provides guidance about the strategies that hold promise for pregnant Indigenous women. These strategies are outlined as follows.

Tailor interventions to local culture

Interventions for Indigenous people need to be culturally secure and locally tailored in order to increase acceptability and accessibility.4,5,9 Involving local people in developing and tailoring intervention resources to the local context is critical for improving cultural appropriateness, building ownership and enhancing a sense of autonomy, all of which are important in successful cessation.10

Include routine assessment and support

Smoking cessation guidelines for pregnant women recommend a systematic approach to cessation where every woman is asked about her smoking status, with smokers followed up and supported to quit in a respectful manner.11 Health professionals may be reluctant to repeatedly assess smoking status due to concerns that it may be deleterious to their relationship with women and the women’s engagement with care.9,12–14 However, most Indigenous women expect antenatal care to include smoking cessation advice.15 Systems to support routine assessment and support should be included in intervention trials.

Provide relevant information

Indigenous women’s knowledge of specific risks of smoking while pregnant is often vague.9,15,16 Providing information on the harms of smoking and benefits of cessation may motivate some women to attempt to quit. Discussing the woman’s role as a mother and a role model for her family may be more motivating for some Indigenous women than health risk narratives and should be addressed in intervention trials.

Deliver cessation support through all antenatal providers

Overall, 78% of Indigenous women attend five or more antenatal visits during their pregnancies.2 Providing cessation support through routine antenatal care overcomes barriers to attending separate services.13 A collaborative approach between midwives, Aboriginal Health Workers (AHWs) and doctors, all providing consistent advice and support, will reinforce the importance of cessation. The credibility of medical practitioners may be a significant motivating factor for some women. In cases where midwives provide much of the care, the close relationship and frequent contact allows ongoing support. AHWs’ cultural knowledge and strong links with local families will enhance implementation of cessation support.14 In a survey of Indigenous women, over 70% of women felt that support from these professionals was likely to be helpful.17

Involve other members of the community

The high prevalence of smoking in Indigenous communities has resulted in smoking being “normalised” as a socially acceptable behaviour, with frequent triggers to smoke and cigarettes being readily available.9,16,18 Smoking is important in social relationships, and cessation can lead to feelings of isolation.18,19 Supportive environments for quitting have aided cessation among Indigenous ex-smokers.10 Trialling interventions that incorporate mechanisms to provide a supportive, pro-cessation environment, such as involving household members in supporting women, peer support groups and whole community interventions should be further explored.20

Address relapse

Interventions that incorporate strategies to prevent smoking relapse result in fewer women relapsing in late pregnancy.1 Up to 80% of women who quit during pregnancy relapse within 1 year.21 Specific relapse prevention support should be provided during pregnancy and postpartum, including information about the effects of environmental tobacco smoke on the baby, support to make a smoke-free home and support for household members to quit smoking.21 Relapse prevention strategies have not been examined among Indigenous women and should be included in future trials.

Use contingency-based financial rewards

Systematic reviews of antenatal smoking cessation interventions have found that financial rewards contingent on successful smoking abstinence are significantly more effective than other interventions.1 However, their efficacy with Indigenous women has not been tested. Australian surveys indicate that contingency-based rewards are considered likely to be helpful by over 90% of Indigenous women and 83% of their antenatal providers.17,22 This approach should be further explored with Indigenous women.

Other substances

Surveys of pregnant Indigenous women found that tobacco smokers were more than three times more likely than non-smokers to report cannabis or alcohol use, both of which are risk factors for continued smoking.17 Given the known negative impact of these substances on birth outcomes and the interaction between their use and use of tobacco, interventions should include explicit assessment of other substance use, with support to address these if required.11

Training providers

A lack of protocols and poor smoking cessation support skills have been identified as barriers to providing cessation support to pregnant Indigenous women.12 Well defined protocols detailing specific procedures, and the role of each provider, may assist in increasing provision of support in routine care.13 Training should cover skills in smoking cessation support, supportive communication and using protocols, as well as recording women’s smoking status, cessation behaviour and support provided, to facilitate consistent advice from all team members.

Possible challenges

Conducting complex behavioural intervention trials is difficult. Potential challenges include:

Random allocation

As smoking cessation support is provided at both the service and individual level, randomisation at the individual level is inappropriate as contamination between groups is likely. Cluster randomised controlled trials with randomisation of dispersed services may reduce this problem but require larger sample sizes and more participating services, increasing costs and logistics challenges. As services and communities may not be willing to be randomly allocated to “usual care”, it may be more appropriate to undertake a head-to-head comparison of two approaches considered likely to be effective.23

Adherence to protocols

Poor adherence to intervention protocols may occur as a result of unsuitable intervention requirements, inadequate staff training, high staff turnover and lack of systems to support the intervention. Smoking among AHWs has also been identified as a potential barrier to implementation and would need to be addressed as part of the intervention.14,16 Strong organisational support for the implementation and evaluation of strategies is critical to supporting adherence. Collaborative development of the intervention and study design with Indigenous services and pilot studies to assess acceptability and feasibility of the research will help successful implementation.

Conclusions

Given the importance of finding effective strategies to decrease smoking among pregnant Indigenous women, and the current lack of evidence to guide this process, there is an urgent need for rigorous studies to test innovative approaches. While there are many challenges in this research, these may be managed with existing methods for testing complex interventions in diverse settings.24 Without an evidence base, we risk implementing ineffective strategies, failing to improve outcomes and wasting scarce resources.

Quality rating of eligible studies reporting smoking cessation interventions aimed at pregnant Indigenous women, according to Effective Practice and Organisation of Care quality criteria6

Criteria

Patten et al7

Eades et al8

Design

Clinical controlled trial

Randomised controlled trial

Allocation sequence adequately generated?

Unclear

Low risk

Concealment of allocation?

Unclear

Low risk

Baseline outcome measurements similar?

Low risk

Unclear

Baseline characteristics similar?

Low risk

Low risk

Incomplete outcome data adequately addressed?

Unclear

Low risk

Knowledge of allocated interventions prevented?

Unclear

Unclear

Protection against contamination?

High risk

High risk

Selective outcome reporting?

Low risk

Low risk

Free from other risk of bias?

High risk

Low risk

Comments

The low consent rate and the fact that many women did not take part because they were
not ready to quit increases the chances of selection bias. The focus of the study was on feasibility and acceptability rather than on outcomes, although outcomes are reported

High loss to follow-up (33%), but this did not differ
between the groups. Randomisation was by week of
first visit, so the staff who were recruiting the women
were aware of the group allocation. This may have
contributed to the greater numbers recruited to
the intervention group