Indigenous Australians Research Articles

Comparison of Lung Cancer Surgery Outcomes in Queensland for Indigenous and Nonindigenous Australians

IntroductionIndigenous Australians (Aboriginal and Torres Strait Islander) have lower overall survival from lung cancer compared with nonindigenous Australians. Indigenous Australians receive higher rates of chemotherapy and/or radiotherapy. The equity of peri-operative care and thoracic surgical outcomes in Australian indigenous populations have not been contemporarily evaluated. MethodsWe performed a retrospective registry analysis of the Queensland Cardiac Outcomes Registry Thoracic Database evaluating all adult lung cancer resections across Queensland from January 1, 2016 to April 20, 2022. Evaluating the time from diagnosis to surgery, operative data, and postoperative morbidity and mortality comparing Aboriginal and/or Torres Strait Islander people with nonindigenous Australians. ResultsThere were 31 patients (2.56%) of 1208 who identified as indigenous. The mean age at surgery was 68.2 years versus 66 years in the indigenous and nonindigenous, respectively (p = 0.23). There was female predominance among indigenous patients (n = 28, 90.32%, p < 0.01) and the average body mass index was lower (22.52 versus 27.09, p < 0.01). There was no variation in the surgical parameters or histopathologic distribution of cancer type between groups. Multivariable logistic regression analysis suggested that indigenous patients were at elevated risk of blood transfusion (relative risk 3.9, p = 0.014, OR = 9.01, 95% confidence interval [CI]: 2.25–36.33, p < 0.01) and had greater transfusion requirements (risk ratio 4.08, p = 0.0116 and OR = 12.67, 95% CI: 2.25–71.49, p < 0.01); however, the influence of low absolute number of transfusions must be acknowledged here. Indigenous status was not associated with increased intensive care unit admission (OR = 1.79, 95% CI: 0.17–18.80, p = 0.62), return to operating theater (OR = 2.1, 95% CI: 0.24–18.15, p = 0.50), new atrial fibrillation (OR = 0.52, 95% CI: 0.07–4.01, p = 0.55), prolonged air leak (OR = 0.29, 95% CI: 0.04– 2.16, p = 0.228), or pneumonia postoperatively (OR = 4.77, 95% CI: 0.55–41.71, p = 0.16). With only three deaths, no meaningful trends were observed. Time from diagnosis to surgery was comparable in the indigenous and nonindigenous groups (88.6 d, 95% CI: 54.26–123.24 versus 86.2 d, 81.40–91.02, p = 0.87). Postoperative length of stay was not numerically or statistically different between groups. (indigenous 7.54 d versus nonindigenous 7.13 d, p = 0.90). ConclusionsIndigenous patients are more likely to receive a blood transfusion than nonindigenous patients during lung resection. Reassuringly, the perioperative care provided to indigenous Australians undergoing lung resection in Queensland seems to be comparable to that of the nonindigenous population.

Community-Acquired, Bacteraemic Acinetobacter Baumannii Pneumonia: A Retrospective Review of Cases in Tropical Queensland, Australia.

Community-acquired Acinetobacter pneumonia (CAAP) typically presents with rapid progression to fulminant disease and is complicated by high mortality. Australian epidemiological studies are few. We conducted a retrospective study on bacteraemic cases of CAAP over twenty years (2000-2019) in North Queensland. Cases were selected on microbiologic, clinical, and radiographic parameters. Data on patient demographics were obtained, along with microbial, antibiotic, mortality and climatic data. 28 cases of CAAP were included. Nineteen (67.9%) were male, twenty-three (82.1%) were Indigenous Australians, and the mean age was 45.9 years. Most presentations were of moderate to severe pneumonia (25/28 (89.3%)). Furthermore, 90% of cases had two or more risk factors. The strongest risk factors for CAAP were alcohol excess and tobacco use. No statistically significant difference in presenting severity, ICU admission or mortality was seen between dry- and wet-season disease. Dry-season disease accounted for 35.7% of cases. Overall mortality was 28.6%. Early use of meropenem or gentamicin reduced mortality irrespective of presenting severity (mortality 17.6%) Non-targeted antibiotic therapy was associated with a non-significant difference in mortality of 44.4%. Early administration of targeted antibiotics can mitigate a high mortality rate. The choice of antibiotic therapy for community-acquired pneumonia should be based on severity, risk factors and clinical suspicion of CAAP rather than seasonality.

Multimorbidity and health-related quality of life amongst Indigenous Australians: A longitudinal analysis

BackgroundThe burden of multimorbidity has been observed worldwide and it has significant consequences on health outcomes. In Australia, health-related quality of life (HRQoL) is comparatively low amongst Aboriginal and/or Torres Strait Islanders, yet no studies have examined the effect of multimorbidity on HRQoL within this at-risk population. This study seeks to fill that gap by employing a longitudinal research design.MethodsLongitudinal data were derived from three waves (9, 13, and 17) of the household, income and labour dynamics in Australia (HILDA) Survey. A total of 1007 person-year observations from 592 Aboriginal and/or Torres Strait Islander individuals aged 15 years and above were included. HRQoL was captured using the 36-item Short-Form Health Survey (SF-36), and multimorbidity was defined using self-reports of having been diagnosed with two or more chronic health conditions. Symmetric fixed-effects linear regression models were used to assess how intraindividual changes in multimorbidity were associated with intraindividual changes in HRQoL.ResultsApproximately 21% of Indigenous Australians were classified as experiencing multimorbidity. Respondents had statistically significantly lower HRQoL on the SF-36 sub-scales, summary measures, and health-utility index in those observations in which they experienced multimorbidity. Among others, multimorbidity was associated with lower scores on the SF-36 physical-component scale (β = − 6.527; Standard Error [SE] = 1.579), mental-component scale (β = − 3.765; SE = 1.590) and short-form six-dimension utility index (β = − 0.075; SE = 0.017).ConclusionThis study demonstrates that having multiple chronic conditions is statistically significantly associated with lower HRQoL amongst Indigenous Australians. These findings suggest that comprehensive and culturally sensitive health strategies addressing the complex needs of individuals with multimorbidity should be implemented to improve the HRQoL of Indigenous Australians.

Aldosterone and renin concentrations and blood pressure in young Indigenous and non-Indigenous adults in the Northern Territory: a cross-sectional study.

To evaluate aldosterone and renin levels and aldosterone-to-renin ratios (ARRs) in young Indigenous and non-Indigenous adults in the Northern Territory, and their association with blood pressure levels. Cross-sectional study; single time point sub-study of two prospective birth cohort studies. Participants in the Aboriginal Birth Cohort (ABC) - born to Indigenous mothers at the Royal Darwin Hospital during 1987-1990 - and the Top End Cohort (TEC) - people born to non-Indigenous mothers in Darwin, recruited during 2007-2009 - aged 32-35 years at the time of this sub-study. Plasma aldosterone and direct renin concentrations; ARRs (positive screening test result for primary aldosteronism defined as > 70 pmol/mU); systolic and diastolic blood pressure. A total of 255 ABC (205 in remote, 50 in urban locations) and 76 TEC members participated. Median aldosterone concentration was similar for all three groups. The median renin concentration was 7.5 mU/L (interquartile range [IQR], 4.1-12.4 mU/L) in the TEC group, 12.4 mU/L (IQR, 5.1-19 mU/L) in the urban ABC group, and 29.3 mU/L (IQR, 15.0-52.9 mU/L) in the remote ABC group. The median ARR was 10 pmol/mU (IQR, 6-19 pmol/mU) in the remote ABC group, 28 pmol/mU (IQR, 16-70 pmol/mU) in the urban ABC group, and 43 pmol/mU (IQR, 26-74 pmol/mU) in the TEC group. Thirteen urban ABC participants (26%), 21 TEC participants (28%), and six people in the remote ABC group (3%) had ARR values above 70 pmol/mU. Adjusted for age and body mass index (BMI), mean systolic and diastolic blood pressure were lower for women than men in all participant groups; after adjusting for age, sex, and BMI, larger ARR was associated with higher systolic blood pressure in the TEC group but not the two ABC groups. Screening test results for primary aldosteronism were positive for about one-quarter of urban Indigenous and non-Indigenous participants. A prospective study that includes confirmatory testing would more accurately assess the prevalence of primary aldosteronism among Indigenous Australians in the Northern Territory.

Management approaches to conserve Australia's marine ecosystem under climate change.

Australia's coastal marine ecosystems have a deep cultural significance to Indigenous Australians, include multiple World Heritage sites, and support the nation's rapidly growing blue economy. Yet, increasing local pressures and global climate change are expected to undermine the biological, social, cultural, and economic value of these ecosystems within a human generation. Mitigating the causes of climate change is the most urgent action to secure their future; however, conventional and new management actions will play roles in preserving ecosystem function and value until that is achieved. This includes strategies codeveloped with Indigenous Australians that are guided by traditional ecological knowledge and a modeling and decision support framework. We provide examples of developments at one of Australia's most iconic ecosystems, the Great Barrier Reef, where recent, large block funding supports research, governance, and engagement to accelerate the development of tools for management under climate change.

Significance and prognostication of mediastinal lymph node enlargement on chest computed tomography among adult Indigenous Australians.

There is a lack of data on chest computed tomography (CT) findings on mediastinal lymph node enlargement (MLE), including normal size threshold of less than 10 or 15 mm for MLE among Indigenous Australians. In this study, we assessed the significance and the applicability of the current guidelines for the threshold for abnormal MLE among adult Indigenous Australians. Patients who underwent chest CT between 2012 and 2020 among those referred to undergo lung function test (spirometry) were assessed for the presence of MLE which were classified as Group A (no measurable nodes), Group B (<10 mm), Group C (≥10 to 14.99 mm) and Group D (≥15 mm). Of the total 67 patients identified to have MLE, 49 patients had at least two CT scans available for assessment over a median follow-up period of 101.3 weeks (IQR: 62.4, 235.6) and were included in the analysis. Evidence of chronic lung disease was common, with a significant proportion demonstrating either COPD or bronchiectasis and a high proportion with smoking history (93%). During the first CT scan, 34/49 (69%) had >10 mm nodes, of which 12/34 (35%) reduced in size, 22/34 (65%) remained stable, and 3/34 (9%) had malignancy on follow-up. Despite most patients demonstrating the presence of significant MLE with varying size and in most >10 mm, the majority remain stable or benign in nature and only a minor proportion showed evidence of lung malignancy. Further prospective studies are needed in the characterisation of MLE among Indigenous patients.

Working with Indigenous Australian communities designing a nutritional mHealth tool during the Covid-19 pandemic

Enacting a research project that is beneficial and meaningful for Indigenous communities and agencies in Australia remains a challenge in both the research and nutrition fields. This article describes how the Mums and Bubs Deadly Diets project is embedding Indigenous ways of knowing and doing and partnering with Indigenous communities to co-design mobile health technology. Each step in the process of developing and implementing this project has been actively conscious of the intentions of the Australian Institute of Aboriginal and Torres Strait Islander Studies Code of Ethics and the National Ethics Standards for working with Indigenous Australians. Describing the project’s approach, methods of negotiation and responses to challenges, administering institutions and Indigenous communities, including coronavirus disease-19, provides the opportunity to reflect and forward plan for future projects.

Closing the gap in Indigenous Australian cancer care: Initiatives to foster cultural safety and improve access to radiation therapy

IntroductionAboriginal and Torres Strait Islander peoples receive a poorer cancer prognosis compared to non-Indigenous Australians. Indigenous access to cancer care is limited by several factors, including differences in cultural understanding surrounding cancer and distrust of mainstream health institutions. It is believed that radiation therapy is being under-utilised by the Indigenous community. In response, several strategies were implemented to increase presentation and attendance by Indigenous Australians at a rural, private radiation therapy practice. MethodsA local Indigenous health service, Traditional Owners and Elders and the clinic's Reconciliation Action Plan Working Group were consulted to implement initiatives to reduce barriers to engaging in healthcare. One of these initiatives involved community consultation to select a culturally safe, Indigenous word to name one of the clinic's linear accelerators. Indigenous patient referrals into the clinic were tracked using an oncology information system. It is expected that by implementing several culturally safe strategies, there would be an increase in utilisation of the radiation therapy service and therefore, a decrease in Indigenous cancer burden across the local region. If strategies were yielding positive outcomes, there would be scope to implement these at other sites across a broader monitored network. ResultsCurrently, service utilisation is being monitored to determine whether initiatives have been successful. Initial data evaluation has been conducted and results are showing increased service utilisation by the Indigenous community. ConclusionWork has been undertaken to implement strategies to improve cultural safety and improve access to radiation therapy for Indigenous cancer patients. Preliminary results show an increase in the number of presentations to the clinic for radiation therapy treatment.

Disease profiles in the Indigenous Australian population are suggestive of a common complement control haplotype.

Aboriginal and Torres Strait Islander People (respectfully referred to as Indigenous Australians herein) are disparately burdened by many infectious and chronic diseases relative to Australians with European genetic ancestry. Some of these diseases are described in other populations to be influenced by the inherited profile of complement genes. These include complement factor B, H, I and complement factor H-related (CFHR) genes that can contribute to a polygenic complotype. Here the focus is on the combined deletion of CFHR1 and 3 to form a common haplotype (CFHR3-1Δ). The prevalence of CFHR3-1Δ is high in people with Nigerian and African American genetic ancestry and correlates to a higher frequency and severity of systemic lupus erythematosus (SLE) but a lower prevalence of age-related macular degeneration (AMD) and IgA-nephropathy (IgAN). This pattern of disease is similarly observed among Indigenous Australian communities. Additionally, the CFHR3-1Δ complotype is also associated with increased susceptibility to infection with pathogens, such as Neisseria meningitidis and Streptococcus pyogenes, which also have high incidences in Indigenous Australian communities. The prevalence of these diseases, while likely influenced by social, political, environmental and biological factors, including variants in other components of the complement system, may also be suggestive of the CFHR3-1Δ haplotype in Indigenous Australians. These data highlight a need to define the Indigenous Australian complotypes, which may lead to the discovery of new risk factors for common diseases and progress towards precision medicines for treating complement-associated diseases in Indigenous and non-Indigenous populations. Herein, the disease profiles suggestive of a common complement CFHR3-1Δ control haplotype are examined.

“It’s research, our input can grow”: identifying health research priorities with Aboriginal and Torres Strait Islander communities—study protocol

BackgroundIn Australia, Aboriginal and Torres Strait Islander (Indigenous) families have strong, cohesive, and nurturing cultural practices that contribute to effective family functioning and child rearing. These practices can lead to positive effects on children and communities, and include kinship relations, traditional knowledge systems, collective community focus, respect for Elders contributions, and spirituality. However, poor health and wellbeing outcomes exist across the lifespan for Indigenous Australians. Health programs, services and research that support Indigenous women, babies and their families are a critical investment to improve birthing and health outcomes and impact the life trajectories of Indigenous Australians.AimThe Indigenous Health Research Priorities study aims to identify the research priorities for families during the perinatal and early childhood period through a co-designed and collaborative process. This has been led by communities to determine the priorities identified with and for local Indigenous families in Queensland. This paper aims to report on engagement and involvement with Indigenous communities to identity health research priorities for families and presents preliminary findings of the research process including participants’ demographic information and feedback on the yarning sessions, as part of the study protocol.MethodsThe study protocol showcases the Participatory Action Research approach, yarning sessions with clients and staff of three community-controlled health services to date, and Delphi workshop methods to prioritise the health issues identified during the yarns with corresponding communities. The study will undertake qualitative data collection and analysis to identify and report on community and health service research priorities for Indigenous families in Queensland. A short survey was conducted to collect participants’ demographic information. A feedback form with five open-ended questions was also administered to collect data on participants’ views and satisfaction with the research process.Preliminary resultsThis protocol paper reports on the participant demographic information and feedback on the research process and reactions to participating in the yarning sessions. There have been 12 yarning sessions in Far North Queensland to date. The qualitative analysis of these will be reported on in future, with South East Queensland and further sites to follow. Feedback from 61 community members and health professionals has highlighted they valued sharing stories, being heard, and feeling hopeful. Preliminary findings will be reported.DiscussionIdentification of health research priorities will allow each organisation and region of Queensland to develop research initiatives and the translational outcomes that are a focus for their community members.

Researching and reorienting mentorship practices to empower the success of Indigenous Australian young people

This article discusses mentorship provided to Indigenous Australian secondary school leavers. The authors suggest that although current scholarship in the field is insightful, there is a dearth focussing on mentorship provided during the post-secondary school transitional phase. Also, much literature problematizes Indigenous mentees and is contextually bound to individual programs, singular communities or cohorts. Although governments, industries, communities and further education providers have funded and facilitated many mentorship programs across the nation, little systemic or institutional impact has been made. Current data demonstrates a continuous downward trajectory in the full engagement of Indigenous Australian secondary school leavers, that is, those who are full-time working, studying or both studying and working (Australian Bureau Statistics, 2021; Department of Prime Minister and Cabinet, 2018). This is concerning as the post-secondary school transitional phase is cited as a critical stage for combating or embedding inequities young Indigenous Australians often endure intergenerationally (O’Shea, McMahon, Priestly, Bodkin-Andrews &amp; Harwood, 2016). By centring national and international First Nations scholars the authors argue for reconceptualisations of Indigenous mentee success through Indigenous ontological lenses and reorientations of mentorship frameworks towards approaches which strengthen young peoples’ connections with culture, community, Elders and Country.

Natural History of Oral HPV Infection among Indigenous South Australians.

This study aims to describe the natural history of and identify the risk factors associated with oral human papillomavirus (HPV) infections in an Australian Indigenous cohort. A longitudinal cohort study design, with baseline (2018), 12-month, and 24-month data obtained from Indigenous Australians aged 18+ years in South Australia, was performed. Face-to-face interviews were conducted, and saliva samples for HPV testing were collected at each time point. Basic descriptive analyses were conducted to calculate prevalence, incidence, persistence, clearance, and incidence proportions of any HPV infection. Multivariable logistic regression analyses with adjusted prevalence ratios (PRs) were conducted to identify risk factors associated with oral HPV infection. Among 993 participants with valid saliva samples, 44 HPV types were identified. The prevalence of infection with any oral HPV infection was 51.3%, high-risk HPV was 11%, and types implicated in Heck's disease (HPV 13 or 32) was 37.4%. The incidence, persistence, and clearance of any and high-risk HPV infections were 30.7%, 11.8% and 33.3% vs. 9.3%, 2.8%, and 9%, respectively. Our findings indicate that the prevalence, incidence, and persistence of oral HPV infection in a large sample of Indigenous Australians were high, and clearance was low. Oral sex behaviours and recreational drug use were risk factors associated with incident high-risk HPV infection.

Cultural diversity and Indigenous participation on Australian corporate boards: Harder but better decisions

AbstractThis study explores Indigenous Australians' participation on corporate boards. We confirm the significant under‐representation of Indigenous Australians on corporate boards. Using data collected from semi‐structured interviews with business leaders, we explore their perceptions of cultural diversity and pathways to directorships provided by corporate Australia for Indigenous Australians. Australian business leaders perceive the importance of cultural diversity (particularly in terms of its myriad benefits such as enhanced decision making), acknowledge the problem of limited diversity, and provide insights to improve diversity. Key pathways for Indigenous Australians include skills and experience, education and training, reputation, networking and organisational support.

Molecular epidemiology of hepatitis B among Indigenous Australians in Queensland and the Torres Strait Islands.

Chronic hepatitis B virus (HBV) infection is a major health problem for all Indigenous Australians. Post-2000, Hepatitis B surface antigen prevalence has decreased, although remaining four times higher among Indigenous compared with non-Indigenous people. This study aimed to characterise the HBV from Indigenous populations in Queensland and the Torres Strait Islands. Serum samples were collected, with consent, from people within Queensland Indigenous communities prior to 1990 as part of the Queensland Health vaccination programme. Ethics approval was subsequently obtained to further characterise the HBV from 93 of these stored samples. HBV DNA was extracted and genotype was obtained from 82 samples. HBV full genome sequencing was carried out for a subset of 14 samples. Seventy-eight samples were identified as genotype C (2 × C12, 3 × C13 and 73 × C14), one sample as genotype A (A2) and three samples as genotype D (1 × D2, 1 × D3 and 1 × D4). The HBV/C sequences identified were most closely related to sequences isolated from Papua New Guinea and Indonesia (Papua Province). The HBV isolated from the Torres Strait Islanders was notably different to the HBV/C4 strain isolated from Indigenous people of mainland northern Australia, with no evidence of recombination. This reflects the differences in culture and origin between Torres Strait Islanders and mainland Indigenous people.

Enabling Indigenous wellbeing in higher education: Indigenous Australian youth-devised strategies and solutions

Indigenous youth comprise over half of the Indigenous Australian population; however, there is a scarcity of research that focuses on improving Indigenous Australians’ wellbeing in higher education. The purpose of this study was to identify Indigenous-devised strategies to support wellbeing of salience to Indigenous Australian higher education students. Using Indigenous methodology, Indigenous youth (N = 7; aged between 18 and 25 years) studying at three higher education institutions in Australia participated in semi-structured interviews. Thematic analysis identified strategies and solutions for supporting and enhancing Indigenous youth wellbeing in higher education. Participants suggested that their wellbeing would benefit from increased opportunities for them to gain role models. They also suggested culturally supportive higher education environments were critical and could be achieved by employing more Indigenous academics and Indigenous mentors to implement personalised student support, introducing mandatory cultural competency training for all staff, and employing culturally safe counselling services. Indigenous youth also suggested strategies for enhancing institutional policy such as ensuring Indigenous culture and perspectives were taught across all faculties; developing reconciliation action plans, financial support, and scholarships to require proof of Aboriginality and evidence of hardship; and an institutional wellbeing strategy designed to support Indigenous students’ wellbeing.

Chest pain epidemiology and care quality for Aboriginal and Torres Strait Islander peoples in Victoria, Australia: a population-based cohort study from 2015 to 2019

This study examined chest pain epidemiology and care quality for Aboriginal and Torres Strait Islander ('Indigenous') patients presenting to hospital via emergency medical services (EMS) with chest pain. State-wide population-based cohort study of consecutive patients attended by ambulance for acute chest pain with individual linkage to emergency, hospital admission and mortality data in the state of Victoria, Australia from January 2015 to June 2019. Multivariable models were used to assess for differences in pre-hospital and hospital adherence to care quality, process measures and clinical outcomes. From 204,969 EMS attendances for chest pain, 3890 attendances (1.9%) identified as Aboriginal or Torres Strait Islander. Age-standardized incidence rates were higher overall for Indigenous people (3128 vs. 1147 per 100,000 person-years, incidence rate ratio 2.73, 95% CI 2.72-2.74), this difference being particularly striking for younger patients, women, and those residing in outer regional areas. In multivariable models, adherence to care quality and process measures was lower for attendances involving Indigenous people. In the pre-hospital setting, Indigenous people were less likely to be provided intravenous access or analgesia. In the hospital setting, Indigenous people were less likely to be seen by emergency clinicians within target time and less likely to transferred following myocardial infarction to a revascularization capable centre. Incidence of acute chest pain presentations is high among Indigenous people in Victoria, Australia. Opportunities to improve the quality of care for Indigenous Australians presenting with acute chest pain are identified. National Health and Medical Research Council, National Heart Foundation.

Experience-based codesign approach to improve care in Australian emergency departments for complex consumer cohorts: the MyED project protocol, Stages 1.1–1.3

IntroductionEmergency department (ED) care must adapt to meet current and future demands. In Australia, ED quality measures (eg, prolonged length of stay, re-presentations or patient experience) are worse for older...

Risk Factors Among Indigenous and Non-Indigenous Australians Presenting with New Atrial Fibrillation: A Single Centre, Retrospective Analysis

Risk Factors Among Indigenous and Non-Indigenous Australians Presenting with New Atrial Fibrillation: A Single Centre, Retrospective Analysis

Late Outcomes Following ST-Elevation Myocardial Infarction Amongst Indigenous and Non-Indigenous Australians

Late Outcomes Following ST-Elevation Myocardial Infarction Amongst Indigenous and Non-Indigenous Australians

Indigenous Experience Reports: Addressing Silence and Deficit Discourse in Sentencing

The hyper-incarceration of Indigenous Australians urges analysis of unconscious bias, the application of criminogenic risk assumptions, and structural impediments to consideration of Indigenous experience in sentencing. Disrupting deficit-based discourses requires new approaches to sentencing, in which First Nations voices are heard. This article examines all 149 sentences delivered in the Supreme Court of the Australian Capital Territory between 2009 and 2019, in which the defendant’s Indigenous status was identifiable. We consider the extent and nature of engagement with Indigenous experience, finding a prevailing silence and limited evidence of strengths-based approaches. We argue that listening to First Nations voices in sentencing can provide a counterpoint to deficit discourses and a holistic understanding of the individual and their background, including the ongoing relevance of colonisation in their lives. The use of Indigenous Experience Reports to enable this listening may also promote strengths-based considerations and challenge the efficacy of carceral options.