Indigenous Health Gap Research Articles

The Evolutionary History of Human Microbiota and Why it Matters for Human Health Today

Understanding the evolutionary history of microbial communities within the human body (microbiota) will provide key insights into the origins of numerous modern‐day diseases. Ancient microbial DNA preserved in calcified dental plaque (calculus) now provides an opportunity to reconstruct past oral microbiota and examine how these microbes are linked with health and disease through time. We use High Throughput Sequencing to obtain ancient and modern microbial DNA from dental calculus on four continents over the past 48,000 years, reconstructing distinct oral microbiota evolutionary histories at each location. Highly resolved microbiota histories in Europe suggest that local environments, adoption of different diets, interbreeding with other hominids, and exposure to the Industrial Revolution are key drivers of microbiota shifts over time and likely underpin both oral and chronic disease origins. On other continents, oral microbial communities were distinct from those in Europe, highlighting the need to include diverse populations in evolutionary reconstructions. For example, South American oral microbiota was influenced by corn utilization and adaptation to specific environments (i.e., high altitude vs coastal) and contained distinct species linked with oral disease. As microbiota histories in each location are distinct, we theorize that they play distinct roles in the development of disease, both oral and systemic, across different populations, with profound implications for the Indigenous health gap. Together, these data provide the first glimpse of global human microbiota evolution in real‐time and provide the foundation to understand why certain bacterial communities are now linked to disease in a modern world.

Two-Eyed Seeing and developmental origins of health and disease studies with indigenous partners.

Globally, mortality of Indigenous persons is greater than that of their non-Indigenous counterparts, which has been shown to be disproportionately attributable to non-communicable diseases. The historically subordinate position that Indigenous Knowledge (IK) held in comparison to Western science has shifted over the last several decades, with the credibility and importance of IK now being internationally recognized. Herein, we examine how Marsahall's (2014) Two-Eyed Seeing can foster collaborative and culturally relevant Developmental Origins of Health and Disease (DOHaD) studies for health and well-being by using '..the best in Indigenous ways of knowing…[and] the best in Western (or mainstream) ways of knowing…and learn to use both these eyes for the benefit of all.' At its core, Two-Eyed Seeing also includes the principles of ownership, control, access and possession, and Community-Based Participatory Research, which further reinforces the critical role of Indigenous peoples taking active roles in DOHaD research. Additionally, we also present a partnership model for working with Indigenous communities that includes the principles of respect, equity and empowerment. As researchers begin to fill the gap in Indigenous health, we outline how Two-Eyed Seeing should form the basis of DOHaD studies involving Indigenous communities. This model can be used to develop and guide projects that result in robust and meaningful participatory partnerships that have impactful uptake of research findings.

Closing the indigenous health gap in Canada: Results from the TransFORmation of IndiGEnous PrimAry HEAlthcare delivery (FORGE AHEAD) program

AimsTransFORmation of IndiGEnous PrimAry HEAlthcare Delivery (FORGE AHEAD) partnered with local clinical and community teams in 11 First Nations (FN) communities across Canada to develop quality improvement (QI) initiatives aimed at improving T2DM. MethodsPre-post mixed-methods case study design was used. The 18-month intervention included community and clinical readiness, development of a community diabetes registry and clinical system, and QI activities. Participants consisted of community members, 18 yrs and older, with diabetes. Changes in clinical outcomes and clinical practice guideline (CPG) recommendations were assessed pre and post intervention using multilevel regression (patients nested within communities) adjusted forindividual andcommunity baseline characteristics. ResultsNo significant change in HbA1c orsBP, but a small reduction indBP(−0.75 mmHg, p < 0.05) and LDL (−0.09 mmol/L, p < 0.05) was observed in 2008 adults with T2DM (mean age: 60·5 (SD:14·6) years; female: 57·2%). Individuals not at CPG targets at baseline had significant reductions in: %HbA1c (N = 616): −0.40 (95%CI:−0·55,−0·24),sBP (N = 561): −7·67 mmHg (95%CI:−9·23, −5·72),dBP (N = 291): −7·46 mmHg (95%CI:−8·69, −6·26), LDL (N = 450): −0·37mmo/l (95%CI:−0·44, −0·29).Annual HbA1c (OR: 1·95; 95%CI:1·66, 2·29), BP (OR: 1·78; 95%CI:1·52, 2·09), LDL (OR: 1·27; 95%CI:1·10, 1·47) and CKD screening (OR: 6·37; 95%CI:5·16, 7·92)increased but retinopathy screening decreased (OR: 0·68; 95%CI:0·57, 0·82). No significant change in foot exams (OR: 0·97; 95%CI:0·76, 1·23) or BMI recordings (OR: 0·96; 95%CI:0·82, 1·12) was seen. Overall, individualsweremorelikely to receive ≥75% of CPG recommended services compared to baseline (OR: 1·51; 95%CI:1·27, 1·80). ConclusionsFORGE AHEAD is the first Canadian study to demonstrate that a FN community-led QI intervention can lead to diabetes improvements.

120 - Closing the Indigenous Health Gap in Canada: Results From the TransFORmation of IndiGEnous PrimAry HEAlthcare Delivery (FORGE AHEAD) Program

Indigenous peoples in Canada experience substantially higher rates of type 2 diabetes mellitus (T2DM) and related complications. The FORGE AHEAD program collaborated with First Nation Indigenous communities across Canada to implement a community-driven quality improvement (QI) program to improve T2DM care.

A retrospective on reconciliation by design.

It is well-established that Indigenous Peoples continue to experience a lower level of health than non-Indigenous Peoples in Canada. For many health leaders, finding practical strategies to close the gap in health disparities remains elusive. In this retrospective study, we will illustrate our own experience of transformational change using design and systems thinking tools toward a primary outcome of multi-stakeholder alignment. Using this approach enabled three Indigenous Provincial/Territorial Organizations (IPTOs) representing more than 150 First Nations communities from Saskatchewan, Manitoba, and Ontario to establish the largest community-led, collaborative approach to health transformation in Canada at the time. These IPTOs have gone on to pursue some of the most ambitious health transformation initiatives in Canada and in September 2018, were granted $68 million in funding support by the Government of Canada. If health leaders are looking at an alternative approach to closing the gap in Indigenous health, alignment thinking has shown promising results.

The economic benefits of eliminating Indigenous health inequality in the Northern Territory.

To estimate the potential economic benefits of closing the Indigenous health gap by quantifying the economic burden associated with Indigenous health inequality in the Northern Territory. A cost-of-illness study was conducted from a societal perspective for NT residents for the period 2009-2013. The total cost of the Indigenous health gap was estimated by calculating the cost differences between Indigenous and non-Indigenous populations in health services, lost productivity and lost life-years on the basis of data from the 2011 census, as well as on burden of disease, health expenditure, welfare, taxation and other published financial data. The total and per capita costs in three categories were analysed: direct health costs, the indirect costs of lost productivity, and intangible costs associated with premature deaths. The excess cost of the Indigenous health gap was estimated to be $16.7 billion for the 5-year study period, equivalent to 19% of the NT gross state product. The excess costs associated with the Indigenous health gap included 22% caused by higher health expenditure for servicing the gap, 35% attributable to lost productivity caused by illness, and 43% associated with lost life-years. Our findings highlight the long term potential benefits of the Australian governments' Closing the Gap initiative for the NT. Successful implementation of this initiative will require improving government services by combating discrimination, developing local economies, overcoming poverty, and reducing the disadvantages associated with remoteness.

Closing the Gap in Indigenous health: why section 19(2) of the Health Insurance Act matters

There is a pressing need to address the poor health and justice outcomes experienced by Indigenous Australians, who are over‐represented in adult prisons by an age‐standardised factor of 13 and in youth detention by a factor of 24.1,2 Numerous government reports emphasise the need to Close the Gap,3 and special provisions have been made to address Indigenous health inequity, including an exemption under section 19(2) of the Health Insurance Act 1973 (Cwlth) to permit Aboriginal Community Controlled Health Services (ACCHS) access to Commonwealth funding, even if they are funded by state governments.4 This policy seems sensible given the poor health outcomes experienced by many Indigenous people, and the evidence that Indigenous‐specific services can play a role in ameliorating these outcomes in custodial settings.5 Unfortunately, the thousands of Indigenous Australians who cycle through custodial facilities each year — arguably those most in need of health services — are excluded from Commonwealth‐subsidised health care under section 19(2), limiting the services available to them.4 Adult and youth custodial facilities are crucial sites for identifying and treating chronic diseases prevalent in Indigenous Australians, yet the current system excludes incarcerated people from Commonwealth‐subsidised health care and requires an awkward, and often unsuccessful, transition between custodial and community health services.5 The predictable results are poor continuity of care and poor health outcomes.5 Although some ACCHS provide limited in‐reach (in‐custody) services, under section 19(2), they are prevented from claiming Commonwealth subsidies for this service.4,5 Consequently, such services are typically limited and ad hoc.

Should the governments of 'developed' countries be held responsible for equalizing the indigenous health gap?

Across the globe there is significant variation between and within indigenous populations in terms of world view, culture, and socio-political forces. However, many indigenous groups do share a striking commonality: greater rates of non-communicable diseases and shorter life expectancies than non-indigenous compatriots. Notably, this health gap persists for 'developed' countries, including Australia, Canada, New Zealand and the United States. The question of who is responsible for equalizing the gap is complicated. Using Australia as an exemplar context, this commentary will present arguments 'for' and 'against' the governments of developed nations being held liable for closing the indigenous health gap. We will discuss the history and nature of the health gap, actions needed to 'close the gap', and which party has the necessary resources to do so.

Establishing the value of Indigenous eye health programs: health needs, economic priority and performance assessment approaches

The aim of this paper was to compare three different approaches that are used in support of additional funding of health programs, using Indigenous eye health programs (IEHPs) as an example. These approaches are Heath and Health Care Needs, Economic Priority (Value for Money) and Conformity with Health Services Performance Standards. A review of relevant literature was conducted to identify relevant benchmarks and assess IEHPs. In terms of health needs, vision loss is the fourth highest contributor to the Indigenous health gap. Additional funding for Indigenous eye treatment services to remove the gap is estimated at A$28.1million per annum. As an economic priority, IEHPs (specifically for refractive error, cataract, diabetic retinopathy and trachoma) demonstrate excellent value for money and compare favourably with other better-researched health programs. Evaluation of health performance measures indicated that IEHPs also perform well, as judged by Australian performance standards for health services generally and Indigenous health services more specifically, the later involving local delivery, including care coordination through Aboriginal-controlled community health services. The value of IEHPs was demonstrated using all three approaches. Different approaches are likely to be more or less persuasive with different audiences. The application of these approaches is relevant to other health programs. WHAT IS KNOWN ABOUT THIS TOPIC? Supporters of additional funding for health programs frequently use the impact of this additional funding on the health and health care needs of the affected populations and individuals. Indigenous Eye Health programs are considered for illustrative purposes. This argument is not necessarily persuasive to funders of health programs. WHAT DOES THIS PAPER ADD? This paper demonstrates that two further approaches, namely Economic Priority and Conformity with Health Performance Measure Standards, both demonstrate good arguments in support of additional funding and that these outcomes may be more persuasive to funders of health programs. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Practitioners are able to harness additional approaches with a higher likelihood of success of submissions for additional funding for the program they are promoting.

Does Australia have the appropriate health reform agenda to close the gap in Indigenous health?

This paper provides an analysis of the national Indigenous reform strategy - known as Closing the Gap - in the context of broader health system reforms underway to assess whether current attempts at addressing Indigenous disadvantage are likely to be successful. Drawing upon economic theory and empirical evidence, the paper analyses key structural features necessary for securing system performance gains capable of reducing health disparities. Conceptual and empirical attention is given to the features of comprehensive primary healthcare, which encompasses the social determinants impacting on Indigenous health. An important structural prerequisite for securing genuine improvements in health outcomes is the unifying of all funding and policy responsibilities for comprehensive primary healthcare for Indigenous Australians within a single jurisdictional framework. This would provide the basis for implementing several key mutually reinforcing components necessary for enhancing primary healthcare system performance. The announcement to introduce a long-term health equality plan in partnership with Aboriginal people represents a promising development and may provide the window of opportunity needed for implementing structural reforms to primary healthcare. WHAT IS KNOWN ABOUT THE TOPIC? Notwithstanding the intention of previous policies, considerable health disparity exists between Indigenous and non-Indigenous Australians. Australia has now embarked on its most ambitious national Indigenous health reform strategy, but there has been little academic analysis of whether such reforms are capable of eliminating health disadvantage for Aboriginal people.WHAT DOES THE PAPER ADD? This paper provides a critical analysis of Indigenous health reforms to assess whether such policy initiatives are likely to be successful and outlines key structural changes to primary healthcare system arrangements that are necessary to secure genuine system performance gains and improve health outcomes for Indigenous Australians.WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? For policymakers, the need to establish genuine partnership and engagement between Aboriginal people and the Australian government in pursuing a national Indigenous reform agenda is of critical importance. The establishment of the National Congress of Australia's First Peoples provides the opportunity for policy makers to give special status to Indigenous Australians in health policy development and create the institutional breakthrough necessary for effecting primary healthcare system change.

Contribution of vision loss to the Indigenous health gap

Contribution of vision loss to the Indigenous health gap

Yarning about Indigenous mental health: Translation of a recovery paradigm to practice

Mental health practitioners struggle to translate recovery paradigms into practice. Changing from a focus on remediation of symptoms to a focus on reclaiming life in the community and enhancing protective factors requires a new approach. One new approach that particularly challenges health providers is the equalising of traditional patient-service provider relationships. Given the additional issues of disempowerment and social disadvantage of Indigenous peoples in Australia, equalising relationships and embedding recovery values for Indigenous mental health clients especially require urgent attention. There is also a need to learn more about the meaning of recovery in the Indigenous context and the ways in which it differs from non Indigenous interpretations. The Aboriginal and Islander Mental health initiative (previously the Australian Integrated Mental health initiative) has developed resources and training which seek to address this gap. The resources support a culturally adapted strengths-based approach to assessment and early intervention and are increasing popular in mental health, alcohol and other drug and chronic disease settings. Indigenous people with mental illness are subject to additional complex and toxic combination of social disconnecting factors. Culturally adapted recovery approaches to Indigenous mental illness are thus an important component of closing the gap in Indigenous health.

“Hiding the story”: Indigenous consumer concerns about communication related to chronic disease in one remote region of Australia*

This paper reports on a collaborative qualitative study which explored education and communication practice related to chronic disease from the perspectives of Aboriginal people in a remote region of the Northern Territory, Australia, where the prevalence of chronic disease is extremely high. Most Yolngu (Aboriginal people of Northeast Arnhem Land) do not speak English as their first language and few health staff share the language and cultural background of their clients. Semi-structured interviews were conducted with Yolngu community members and health staff in their preferred language in small groups or individually, in an approach that was flexible and responsive to the concerns and priorities of Yolngu researchers and participants. As well, health education interactions were videotaped to facilitate more in-depth understanding of the strengths and challenges in communication (one video can be viewed at http://informahealthcare.com/doi/abs/10.3109/17549507.2012.663791). An iterative and collaborative process of analysis, interpretation, and verification revealed that communication and education related to chronic disease is highly ineffective, restricting the extent to which Yolngu can make informed decisions in managing their health. Yolngu participants consistently stated that they wanted a detailed and direct explanation about causes and management of chronic disease from health staff, and rarely believed this had been provided, sometimes assuming that information about their health is deliberately withheld. These serious limitations in communication and education have extensive negative consequences for individuals, their families, and health services. These findings also have broader relevance to all areas of healthcare, including allied health services, which share similar challenges in achieving effective communication. Without addressing the profound and pervasive inadequacies in communication, other interventions designed to close the gap in Indigenous health are unlikely to succeed.

A multilevel analysis on the relationship between neighbourhood poverty and public hospital utilization: is the high Indigenous morbidity avoidable?

BackgroundThe estimated life expectancy at birth for Indigenous Australians is 10-11 years less than the general Australian population. The mean family income for Indigenous people is also significantly lower than for non-Indigenous people. In this paper we examine poverty or socioeconomic disadvantage as an explanation for the Indigenous health gap in hospital morbidity in Australia.MethodsWe utilised a cross-sectional and ecological design using the Northern Territory public hospitalisation data from 1 July 2004 to 30 June 2008 and socio-economic indexes for areas (SEIFA) from the 2006 census. Multilevel logistic regression models were used to estimate odds ratios and confidence intervals. Both total and potentially avoidable hospitalisations were investigated.ResultsThis study indicated that lifting SEIFA scores for family income and education/occupation by two quintile categories for low socio-economic Indigenous groups was sufficient to overcome the excess hospital utilisation among the Indigenous population compared with the non-Indigenous population. The results support a reframing of the Indigenous health gap as being a consequence of poverty and not simplistically of ethnicity.ConclusionsSocio-economic disadvantage is a likely explanation for a substantial proportion of the hospital morbidity gap between Indigenous and non-Indigenous populations. Efforts to improve Indigenous health outcomes should recognise poverty as an underlying determinant of the health gap.

Hip Hopping the Gap – Performing Arts Approaches to Sexual Health Disadvantage In Young People in Remote Settings

Closing the gap in Indigenous health and wellbeing in remote settings in the Torres Strait and Northern Peninsula Area of Far North Queensland (FNQ) includes addressing a well-documented sexual health disadvantage among young people. Community mobilization around the underlying risk factors influencing sexual health is required. Performing-arts-based workshops were conducted in schools and after-school venues in four remote Aboriginal and Torres Strait islander locations in FNQ in early 2010, to initiate consciousness-raising around the real dimensions of youth sexual health risk. Specific objectives included strengthening operational partnerships at school-level and developing ongoing consultative processes in each location for sexual health reference group development. Results include a significantly strengthened productive partnership with primary and high schools in each location and sixteen production-ready hip hop songs exploring a range of physical, emotional and sexual health themes authored by the students and recorded on site. Additional outcomes included the willingness of community councils and civil society organizations to support local sexual health reference group activity. This initiative, the Indigenous Hip Hop Project, although accompanied by opportunity costs including alternative, more core business uses of staff time and program budget, has demonstrated the power of tapping the creative energy of young people at risk and the potential for mobilizing communities to activism around sexual health disadvantage.

Occupational therapy at the ‘cultural interface’: Lessons from research with Aboriginal and Torres Strait Islander Australians

In 2008, the Council of Australian Governments announced its goals to improve Indigenous life expectancy, health, education and employment: 'Closing the Gap' (Commonwealth of Australia, 2008). Internationally, occupational therapists seek to promote social justice and human rights through occupation. Despite this effort, Australian occupational therapists have largely remained silent in response to the national agenda of closing the gap in Indigenous health. This article identifies the challenges of research and practice at the 'cultural interface', the juncture where Western knowledge meets the Indigenous knowledge of our clients. The article draws on the first author's research experience with Indigenous peoples. Through a process of reflection on the challenges highlighted by research at the cultural interface, this article identifies a range of professional processes used to negotiate differing and conflicting perspectives. By comparing the research context with occupational therapy practice, the author identifies some of the actions and supports that can be used by occupational therapists to provide culturally appropriate and negotiated interventions with Indigenous people. Although a number of individual occupational therapists work with Indigenous communities and individuals to improve the services offered, it is suggested that the occupational therapy profession needs to work together towards closing the gap. The development of special interest groups, professional networks and a National Position Statement on Indigenous Health would provide the background to developing guidelines for practice with Indigenous clients.

Addressing the gap in Indigenous health: Government intervention or community governance? A qualitative review

The high incidence of sexual abuse of Indigenous children in remote Australia prompted the Australian Government to implement an emergency response of health and welfare measures (the Intervention) in 2007 to protect children and communities from harm. In this article we seek to assess the measures employed in the Intervention against the body of evidence of strategies likely to be effective in reducing Indigenous health disadvantage. Our view is that the emergency response may not have long-term benefit because of the dearth of basic primary health services in remote Aboriginal communities to continue the effort that the Intervention has begun. We conclude that Intervention measures are not sufficiently well aligned with evidence-based health improvement strategies to bring about long-term health gain in Indigenous communities. Governments must reassess the benefit of externally-imposed approaches to reducing health disparity and move to actively build capacity in Aboriginal communities to deliver culturally-relevant health and social services that meet community need.

Indigenous medical workforce development: current status and future directions

The Medical Journal of Australia ISSN: 0025-729X 18 May 2009 190 10 -©The Medical Journal of Australia 2009www.mja.com.auCapacity to Care — Editorialhen Prime Minister Kevin Rudd and representatives ofAustralian health leadership signed a statement ofintent to close the Indigenous health gap by 2030, theycommitted to putting in place by 2018 the primary health servicesand other health infrastructure necessary to achieve this goal.

Commentary: Closing the health gap for Indigenous Australians--will better counting mean better services and investment in the social production of health?

[Extract] Australia enjoys one of the highest life expectancies and one of the best health care systems in the world. Yet the persistence of huge social, economic, educational and health gaps between the first Australians and the rest belies claims to inclusive social policy and universal access to health care. Where other OECD countries appear to have narrowed their Indigenous health gap over past decades, Australia seems uniquely unable to achieve this, and still reports a 17-year difference in life expectancy.

Burden of disease and injury in Aboriginal and Torres Strait Islander Peoples: the Indigenous health gap

Disparities in health status between Aboriginal and Torres Strait Islander peoples and the total Australian population have been documented in a fragmentary manner using disparate health outcome measures. We applied the burden of disease approach to national population health datasets and Indigenous-specific epidemiological studies. The main outcome measure is the Indigenous health gap, i.e. the difference between current rates of Disability-Adjusted Life Years (DALYs) by age, sex and cause for Indigenous Australians and DALY rates if the same level of mortality and disability as in the total Australian population had applied. The Indigenous health gap accounted for 59% of the total burden of disease for Indigenous Australians in 2003 indicating a very large potential for health gain. Non-communicable diseases explained 70% of the health gap. Tobacco (17%), high body mass (16%), physical inactivity (12%), high blood cholesterol (7%) and alcohol (4%) were the main risk factors contributing to the health gap. While the 26% of Indigenous Australians residing in remote areas experienced a disproportionate amount of the health gap (40%) compared with non-remote areas, the majority of the health gap affects residents of non-remote areas. Comprehensive information on the burden of disease for Indigenous Australians is essential for informed health priority setting. This assessment has identified large health gaps which translate into opportunities for large health gains. It provides the empirical base to determine a more equitable and efficient funding of Indigenous health in Australia. The methods are replicable and would benefit priority setting in other countries with great disparities in health experienced by Indigenous peoples or other disadvantaged population groups.