Strengthening Aboriginal and Torres Strait Islander health policy: lessons from a case study of food and nutrition.

OBJECTIVE: To examine key factors influencing the prioritisation of food and nutrition in Aboriginal and Torres Strait Islander health policy during 1996-2015. DESIGN: A qualitative policy analysis case study was undertaken, combining document analysis with thematic analysis of key informant interviews. SETTING: Australia. PARTICIPANTS: Key actors involved in Aboriginal and Torres Strait Islander health policy between 1996 and 2015 (n 38). RESULTS: Prioritisation of food and nutrition in policy reduced over time. Several factors which may have impeded the prioritisation of nutrition were identified. These included lack of cohesion among the community of nutritionists, Aboriginal and Torres Strait Islander leaders and civil society actors advocating for nutrition; the absence of an institutional home for nutrition policy; and lack of consensus and a compelling policy narrative about how priority nutrition issues should be addressed. Political factors including ideology, dismantling of public health nutrition governance structures and missing the opportunities presented by 'policy windows' were also viewed as barriers to nutrition policy change. Finally, the complexity and multifaceted nature of nutrition as a policy problem and perceived lack of evidence-based solutions may also have constrained its prioritisation in Aboriginal and Torres Strait Islander health policy. CONCLUSIONS: Future advocacy should focus on embedding nutrition within holistic approaches to health and building a collective voice through advocacy coalitions with Aboriginal and Torres Strait Islander leadership. Strategic communication and seizing political opportunities may be as important as evidence for raising the priority of Aboriginal and Torres Strait Islander health issues.

Not just a policy; this is for real. An affirmative action policy to encourage Aboriginal and Torres Strait Islander peoples to seek employment in the health workforce.

Delivery of culturally safe healthcare is critical to ensuring access to high-quality care for indigenous people. A key component of this is for Aboriginal and Torres Strait Islander people to be participants in the health workforce. The proportion of indigenous people in the health workforce should at least equate to the proportion in the population served. We describe the development and implementation of a successful affirmative action employment policy at Monash Health, one of Australia's largest Academic Health Centres, and provide perspective on its adoption.

Why it's time to recognise Indigenous peoples in the Constitution.

OBJECTIVE: This article provides an overview of why it is proposed that the Australian Constitution be changed to recognise Aboriginal and Torres Strait Islander peoples. It then establishes what changes are needed to the Constitution. CONCLUSION: The Australian Constitution fails to recognise Indigenous peoples, and still enables discrimination against them. This provides a sound case for changing the document.

The practice of surrogacy in New Zealand.

BACKGROUND: Commercial surrogacy is prohibited in New Zealand by the Human Assisted Reproductive Technology Act 2004 (HART Act). However, altruistic clinic-assisted surrogacy is permitted. Couples wishing to attempt altruistic surrogacy must apply for approval to a statutorily appointed ethics committee. One of seven principles that underpin the HART Act stipulates that the needs, values and beliefs of Maori (NZ's indigenous population) should be considered and treated with respect. AIM: This paper reviews the outcomes of surrogacy applications since the HART Act was established and the uptake of surrogacy by Maori. METHODS: The authors examined the demographic data provided to the ethics committee by way of surrogacy applications and the outcome data provided by fertility clinics. This paper reviews the outcomes for surrogacy applications: the number accepted/declined, the number of live births, those applications discontinued and uptake by Maori. RESULTS: Of 104 applications for surrogacy between 2005 and 2010, 4 (3.8%) were declined. By July 2011, of 100 approved, there have been 26 (26%) live births; 52 (52%) were discontinued, and 22 (22%) remain ongoing. Maori are much less likely to utilise surrogacy. Of the 104 original applications, 9 (8.6%) Maori women were willing to act as a surrogate, and 2 (1.9%) were intended mothers. 7 (6.7%) Maori were partners of a surrogate, with 2 (1.9%) intending mothers having Maori partners. CONCLUSIONS: The process of surrogacy applications is comprehensive and robust, resulting in few being declined. Further research is required to discover why applications are discontinued and why, despite explicit attempts to meet the needs of Maori, few utilise surrogacy.

Decentralization, democratization, and health: the Philippine experiment.

In 1991, the Philippines joined a growing list of countries that reformed health planning through decentralization. Reformers viewed decentralization as a tool that would solve multiple problems, leading to more meaningful democracy and more effective health planning. Today, nearly two decades after the passage of decentralization legislation, questions about the effectiveness of the reforms persist. Inadequate financing, inequity, and a lack of meaningful participation remain challenges, in many ways mirroring broader weaknesses of Philippine democracy. These concerns pose questions regarding the nature of contemporary decentralization, democratization, and health planning and whether these three strategies are indeed mutually enforcing.

Te Tiriti o Waitangi compliance in regulated health practitioner competency documents in Aotearoa.

Within Aotearoa (New Zealand) there are systemic health inequities between Maori (the Indigenous people of Aotearoa) and other New Zealanders. These inequities are enabled in part by the failure of the health providers, policy and practitioners to fulfil treaty obligations to Maori as outlined in our foundational document, te Tiriti o Waitangi (te Tiriti). Regulated health professionals have the potential to play a central role in upholding te Tiriti and addressing inequities. Competency documents define health professionals' scope of practice and inform curriculum in health faculties. In this novel study, we critically examine 18 regulated health practitioners' competency documents, which were sourced from the websites of their respective professional bodies. The competencies were reviewed using an adapted criterion from Critical te Tiriti Analysis, a five-phase analysis process, to determine their compliance with te Tiriti. There was considerable variation in the quality of the competency documents reviewed. Most were not te Tiriti compliant. We identified a range of alternative competencies that could strengthen te Tiriti engagement. They focussed on (i) the importance of whanaungatanga (the active making of relationships with Maori), (ii) non-Maori consciously becoming an ally with Maori in the pursuit of racial justice and (iii) actively engaging in decolonisation or power-sharing. In the context of Aotearoa, competency documents need to be te Tiriti compliant to fulfil treaty obligations and policy expectations about health equity. An adapted version of Critical te Tiriti Analysis might be useful for those interested in racial justice who want to review health competencies in other colonial settings.

Cultural safety and the socioethical nurse.

This article explores the social and ethical elements of cultural safety and combines them in a model of culturally safe practice that should be of interest and relevance for nurses, nurse educators and nurse ethicists in other cultures. To achieve this, the article briefly reviews and critiques the main underpinnings of the concept from its origins and development in New Zealand, describes its sociocultural and sociopolitical elements, and provides an in-depth exploration of the key socioethical elements. Finally, a model is presented to illustrate the strong connection between the social and ethical components of cultural safety that combine to produce culturally safe practice through the activities of a 'socioethical' nurse.

From (b)edouin to (a)borigine: the myth of the desert noble savage.

This article examines the myth of the supposed superiority of the desert noble savage over civilized man. With the Bedouin of Arabia and the Aborigines of Australia as its two prime examples, the article argues that two versions of this myth can be traced: one in which the desert noble savage is valorized due to his valour, physical prowess and martial skill (Bedouin); and another, later version, where the desert noble savage is valorized as a pacifist, an ecologist and a mythmaker/storyteller (Aborigines). The article concludes by examining the way in which this turn from one type of desert noble savage to another reflects the manner in which western modernity has shifted its values from Cartesian dualities and Enlightenment rationalism to that of networks, potentialities, ecology and myth.

Did New Zealand's new alcohol legislation achieve its object of facilitating public input? Qualitative study of Maori communities.

BACKGROUND AND AIMS: The Treaty of Waitangi stipulates equality between Maori and non-Maori, yet Maori continue to have substantially poorer health, a driver of which is alcohol-related morbidity. In 2012, the New Zealand government introduced legislation claiming it would facilitate community input on decisions about alcohol. We investigated the experience of Maori communities with the new law. DESIGN AND METHODS: We obtained submissions made to local governments and invited a diverse range of submitters from iwi (tribes), hapu (sub-tribes/clan groups) and Maori service providers, to participate in semi-structured interviews with Maori researchers. We used template analysis to develop hypotheses, and searched for disconfirmatory evidence within interview transcripts and recordings. RESULTS: Participants had committed substantial human resources to write submissions informed by technical knowledge of liquor licensing and relevant research. They reported that local governments did not seem to engage meaningfully with the content of their submissions, and failed in many instances to update participants on how the consultation was progressing. Some observed that the alcohol industry had easier access to local politicians, and therefore expected outcomes to reflect industry interests. DISCUSSION AND CONCLUSIONS: In their response to Maori constituents on proposed alcohol policies, local governments were felt to lack the inclination or capacity to consult meaningfully. By devolving responsibility for alcohol availability while failing to compel and resource local government to give regard to treaty obligations, the new legislation risks widening existing health inequalities between Maori and non-Maori.

Association between restriction policies and rate of alcohol-related harm in Australian Aboriginal and Torres Strait Islander communities: a systematic review protocol.

OBJECTIVE: This review aims to examine the association between alcohol restriction policies and rates of alcohol-related harms in Australian Aboriginal and Torres Strait Islander communities. INTRODUCTION: A number of different strategies have been used to reduce the harms and costs associated with excessive alcohol consumption in Aboriginal and Torres Strait Islander communities. These strategies, implemented at federal and state government levels, as well as by individual communities, have aimed to promote reduced alcohol consumption or prohibit consumption entirely. Strategies to address the problems associated with alcohol misuse can be categorized into three types: harm, demand and supply reduction. INCLUSION CRITERIA: This review will consider any kind of quantitative research study that includes Australian Aboriginal and Torres Strait Islander peoples living in communities subject to alcohol control policies due to the imposition of alcohol management plans or other alcohol restriction policies. Included studies will measure physical alcohol-related harms. The secondary outcome of interest will be rates of alcohol consumption measured as alcohol sales per person or as self-reported consumption. Studies published in English from 1998 will be included. METHODS: The proposed systematic review will be conducted in accordance with the JBI methodology for systematic reviews of etiology and risk. Published and unpublished studies will be sourced from multiple databases and resources. Two independent reviewers will screen, appraise and extract data from studies meeting the inclusion criteria. Data synthesis will be conducted and a Summary of Findings will be constructed.

Supporting youth wellbeing with a focus on eating well and being active: views from an Aboriginal community deliberative forum.

OBJECTIVE: Including and prioritising community voice in policy development means policy is more likely to reflect community values and priorities. This project trialled and evaluated a storyboard approach in a deliberative community forum to engage Australian Aboriginal people in health policy priority setting. METHODS: The forum was co-constructed with two Aboriginal community-controlled organisations. A circle storyboard was used to centre Aboriginal community knowledge and values and encourage the group to engage with broader perspectives and evidence. The forum asked a diverse (descriptively representative) group of Aboriginal people in a rural town what governments should do to support the wellbeing of children and youth, particularly to encourage them to eat well and be active. RESULTS: The storyboard provided a tactile device to allow shared stories and identification of community issues. The group identified policies they believed governments should prioritise, including strategies to combat racism and provide local supports and outlets for young people. CONCLUSIONS: An informed deliberative storyboard approach offers a novel way of engaging with Aboriginal communities in a culturally appropriate and inclusive manner. Implications for public health: The identification of racism as a major issue of concern in preventing children from living healthy lifestyles highlights the need for policy responses in this area.

Generating sustainable collective action: Models of community control and governance of alcohol supply in Indigenous minority populations.

Restrictions on the supply of alcohol are amongst the most effective and cost effective interventions to address harmful use. However, despite international human rights bodies recognising that self determination must be pre-eminent in efforts to improve Indigenous health, little is known about the role of Indigenous communities in designing and implementing alcohol controls as well as the degree to which government resourcing and/or regulation is utilised. This commentary explores Australian examples of the governance models used to ensure Indigenous participation and leadership when developing regulatory interventions for alcohol control within communities. We identify four models of Indigenous governance: alcohol control interventions that were community conceived and implemented, government-facilitated community-led, community coalitions backed by government intervention and government initiated community partnerships. Each model is underpinned by specific governance arrangements which incorporate rules and processes that determine authority, accountability and Indigenous participation in decision-making. The aim of this paper is to benchmark these models of governance along a spectrum of community engagement beginning with forms of non-participation and ending with full citizen control. In addition, we put forward recommendations for governments at all levels to facilitate culturally acceptable and robust models of Indigenous governance that have the potential to improve health and social outcomes.