Experiences of racism among Aboriginal and Torres Strait Islander adults living in the Australian state of Victoria: a cross-sectional population-based study.

BACKGROUND: Racism is a key determinant of the health of Indigenous Australians that may explain the unremitting gap in health and socioeconomic outcomes between Indigenous and non-Indigenous Australians. We quantified the population-based prevalence of experiences of racism of Indigenous adults in the Australian state of Victoria and investigated whether this was independent of social determinants and lifestyle risk factors. METHODS: We combined data from the 2011, 2012 and 2014 Victorian Population Health Surveys to obtain a sample size of 33,833 Victorian adults, including 387 Indigenous adults. The survey is a cross-sectional, population-based, computer-assisted telephone interview survey conducted annually. Using logistic regression, experiences of racism was the dependent variable and Indigenous status the primary independent variable of interest. Secondary independent variables included age, sex, rurality, socioeconomic status, social capital, and lifestyle risk factors. RESULTS: Indigenous Victorian adults were four times more likely than their non-Indigenous counterparts to have experienced racism in the preceding 12 months; odds ratio (OR) = 4.3 (95% confidence interval (CI): 3.2-5.8). Controlling for social determinants and lifestyle risk factors attenuated, but did not eliminate, the association between experiences of racism and Indigenous status; OR = 3.1 (95% CI: 2.2-4.3). The social determinants of age and social trust made the largest contribution to the attenuation of the association. Education also had a large impact on the association, but in the opposite direction, suggesting that a low level of education may be protective against experiences of racism. When the non-Indigenous comparison group consisted of adults of mainly Anglo-Celtic origin, Indigenous adults were seven times more likely (OR = 7.2; 5.3-9.7) to have experienced racism. CONCLUSIONS: Racism directed against Indigenous Victorians is significant and cannot be ascribed to any specific attributes such as socioeconomic status or lifestyle risk factors. We argue that a human rights-based approach to policy-making for the elimination of systemic and interpersonal racism offers an opportunity and viable alternative to current policy-making, that continues to be dominated by a paternalistic approach that reinforces racism and the resulting inequities. PLEASE NOTE: Throughout this document, the term Indigenous is taken to include people of Aboriginal and Torres Strait Islander descent. While not our preferred term, Indigenous is used in preference to Aboriginal and Koori as not all Indigenous people living in Victoria are Aboriginal or Koori. We recognise that, with the exception of the term 'Koori', these terms are Eurocentric having been imposed upon a people of many nations with distinct languages and cultures. The use of such terms is akin to referring to the peoples of the continent of Europe as 'Europeans'.

Inequalities in the social determinants of health of Aboriginal and Torres Strait Islander People: a cross-sectional population-based study in the Australian state of Victoria.

INTRODUCTION: Aboriginal Australians are a culturally, linguistically and experientially diverse population, for whom national statistics may mask important geographic differences in their health and the determinants of their health. We sought to identify the determinants of health of Aboriginal adults who lived in the state of Victoria, compared with their non-Aboriginal counterparts. METHODS: We obtained data from the 2008 Victorian Population Health Survey: a cross-sectional computer-assisted telephone interview survey of 34,168 randomly selected adults. The data included measures of the social determinants of health (socioeconomic status (SES), psychosocial risk factors, and social capital), lifestyle risk factors, health care service use, and health outcomes. We calculated prevalence ratios (PR) using a generalised linear model with a log link function and binomial distribution; adjusted for age and sex. RESULTS: Aboriginal Victorians had a higher prevalence of self-rated fair or poor health, cancer, depression and anxiety, and asthma; most notably depression and anxiety (PR = 1.7, 95% CI; 1.4-2.2). Determinants that were statistically significantly different between Aboriginal and non-Aboriginal Victorians included: a higher prevalence of psychosocial risk factors (psychological distress, food insecurity and financial stress); lower SES (not being employed and low income); lower social capital (neighbourhood tenure of less than one year, inability to get help from family, didn't feel valued by society, didn't agree most people could be trusted, not a member of a community group); and a higher prevalence of lifestyle risk factors (smoking, obesity and inadequate fruit intake). A higher proportion of Aboriginal Victorians sought help for a mental health related problem and had had a blood pressure check in the previous two years. CONCLUSIONS: We identified inequalities in health between Aboriginal and non-Aboriginal Victorians, most notably in the prevalence of depression and anxiety, and the social determinants of health (psychosocial risk factors, SES, and social capital). This has implications for evidence-based policy development and may inform the development of public health interventions.

Social determinants and lifestyle risk factors only partially explain the higher prevalence of food insecurity among Aboriginal and Torres Strait Islanders in the Australian state of Victoria: a cross-sectional study.

BACKGROUND: The prevalence of food insecurity is substantially higher among Australians of Aboriginal or Torres Strait Islander descent. The purpose of this study is to explain the relationship between food insecurity and Aboriginal and Torres Islander status in the state of Victoria. METHODS: Data were obtained from the 2008 Victorian Population Health Survey; a cross-sectional landline computer-assisted telephone interview survey of 34,168 randomly selected Victorians aged 18 years and older; including 339 Aboriginal and Torres Strait Islanders. We categorised a respondent as food insecure, if in the previous 12 months, they reported having run out of food and not being able to afford to buy more. We used multivariable logistic regression to adjust for age, sex, socioeconomic status (household income), lifestyle risk factors (smoking, alcohol consumption and obesity), social support (ability to get help from family, friends or neighbours), household composition (lone parent status, household with a child, and household size), and geographic location (rurality). RESULTS: Aboriginal and Torres Strait Islanders (20.3%) were more likely than their non-Aboriginal and Torres Strait Islander counterparts (5.4%) to have experienced food insecurity; odds ratio (OR) = 4.5 (95% CI; 2.7-7.4). Controlling for age, SES, smoking, obesity and inability to get help from family or friends reduced the odds ratio by 38%; OR(adjusted) = 2.8 (1.6-5.0). CONCLUSIONS: Social determinants and lifestyle risk factors only partially explained the higher prevalence of food insecurity among Aboriginal and Torres Strait Islanders in Victoria. Further research is needed to explain the disparity in food insecurity between the two populations in order to inform and guide corrective action.

Future predictions of body mass index and overweight prevalence in Australia, 2005-2025.

To predict current and future body mass index (BMI) and prevalence of overweight and obesity in Australian children and adults based on sex, age and year of birth (cohort). These predictions are needed for population health planning and evaluation. Data were drawn from 11 cross-sectional national or state population surveys conducted in Australia between 1969 and 2004. These included representative population samples of children (n= 27,635) and adults (n= 43,447) aged 5 years or older with measured height and weight data. Multiple linear regression analyses of measured log-transformed BMI data were conducted to determine the independent effects of age and year of birth (cohort) on ln(BMI) for males and females, respectively. Regression coefficients for cohort obtained from these analyses were applied to the National Nutrition Survey 1995 data set to predict mean BMI and prevalence of overweight (BMI 25-29.99 kg/m(2)) and obesity (BMI ≥ 30 kg/m(2)) in 2005, 2015 and 2025. Based on past trends, BMI is predicted to continue to increase for both males and females and across the age span. This would result in increases in the prevalence of overweight and obesity of between 0.4 and 0.8% per year, such that by 2025 around one-third of 5-19 year olds will be overweight or obese as will 83% of males and 75% of females aged 20 years and over. The increases in prevalence and mean BMI predicted in this study will have significant impacts on disease burden, healthcare costs and need for prevention and treatment programmes.

Assessing cost-effectiveness in obesity (ACE-obesity): an overview of the ACE approach, economic methods and cost results.

BACKGROUND: The aim of the ACE-Obesity study was to determine the economic credentials of interventions which aim to prevent unhealthy weight gain in children and adolescents. We have reported elsewhere on the modelled effectiveness of 13 obesity prevention interventions in children. In this paper, we report on the cost results and associated methods together with the innovative approach to priority setting that underpins the ACE-Obesity study. METHODS: The Assessing Cost Effectiveness (ACE) approach combines technical rigour with 'due process' to facilitate evidence-based policy analysis. Technical rigour was achieved through use of standardised evaluation methods, a research team that assembles best available evidence and extensive uncertainty analysis. Cost estimates were based on pathway analysis, with resource usage estimated for the interventions and their 'current practice' comparator, as well as associated cost offsets. Due process was achieved through involvement of stakeholders, consensus decisions informed by briefing papers and 2nd stage filter analysis that captures broader factors that influence policy judgements in addition to cost-effectiveness results. The 2nd stage filters agreed by stakeholders were 'equity', 'strength of the evidence', 'feasibility of implementation', 'acceptability to stakeholders', 'sustainability' and 'potential for side-effects'. RESULTS: The intervention costs varied considerably, both in absolute terms (from cost saving [6 interventions] to in excess of AUD50m per annum) and when expressed as a 'cost per child' estimate (from

Perceived racism may partially explain the gap in health between Aboriginal and non-Aboriginal Victorians: A cross-sectional population based study.

BACKGROUND: There is a persistent gap in the health of Aboriginal Victorians compared with non-Aboriginal Victorians, where Aboriginal Victorians have poorer health. Currently, the most commonly touted explanation for this gap revolves around health behaviours known as 'lifestyle risk factors'. Yet the gap in health is similarly matched by persistent gaps in social and economic outcomes that reflect past and ongoing discrimination of Aboriginal peoples across Australia. Perceived racism has been implicated as a key determinant of the gap in health between Indigenous and non-Indigenous peoples across the world. We sought to determine the contribution of perceived racism to the gap in health and how this compared with the contribution of lifestyle risk factors and other determinants of health such as socioeconomic status. METHODS: We combined data from 2011, 2012 and 2014 Victorian Population Health Surveys (VPHS) to obtain a sample size of 33,833 Victorian adults, including 387 Aboriginal adults. The VPHS is a population-representative, cross-sectional, computer-assisted telephone interview survey conducted annually. Using logistic regression, poor self-reported health status was the dependent variable and Aboriginal status was the primary independent variable of interest. Secondary independent variables included age, sex, perceived racism, socioeconomic status, and lifestyle risk factors. RESULTS: Aboriginal Victorians were almost twice as likely as non-Aboriginal Victorians to report poor health; OR=1.9 (95% confidence interval; 1.3-2.6). Perceived racism explained 34% of the gap in self-reported health status between Aboriginal and non-Aboriginal Victorians, followed by: smoking (32%), unhealthy bodyweight (20%), socioeconomic status (15%), excessive consumption of alcohol (13%), and abstinence from alcohol consumption (13%). In contrast, physical inactivity made no contribution. Together, perceived racism and smoking explained 58% of the gap, while all secondary independent variables explained 82% of the gap. CONCLUSIONS: Perceived racism may be an independent health risk factor that explains more than a third of the health gap between Aboriginal and non-Aboriginal Victorians; equivalent in strength to smoking. The recognised failure of the Australian government's Closing the Gap strategy may be due in part to the failure to consider other determinants of the health gap beyond the lifestyle risk factors, namely racism, which may act to damage health through multiple pathways at multiple points along the causal chain.

A randomized controlled trial of the cost-utility of second-generation antipsychotics in people with psychosis and eligible for clozapine.

OBJECTIVE: To assess whether clozapine is likely to be more cost-effective than other second-generation antipsychotics (SGAs) in people with schizophrenia. METHODS: An integrated clinical and economic multicenter, rater-blind, randomized controlled trial (RCT) compared clozapine to the class of other SGAs, using the perspectives of the National Health Service, social support services, and patients. The practice setting was secondary and primary care in the United Kingdom; patients were followed for 1 year. Incremental cost-effectiveness ratios (ICERs), net benefit statistics, and cost acceptability curves were estimated. RESULTS: The ICER for clozapine was 33,240 pound per quality-adjusted life-year (QALY) (range 23,000-70,000 pound for the sensitivity analyses). The proportion of simulations when clozapine was more cost-effective than other SGAs reached 50% if decision-makers are prepared to pay 30,000 pound to 35,000 pound per QALY. This is at the top of the range of acceptable willingness-to-pay values per QALY implied by decisions taken by the National Institute for Health and Clinical Excellence (NICE). CONCLUSIONS: This study adds to a limited body of evidence comparing clozapine to other SGAs and is the first economic and clinical RCT to compare clozapine to the class of other SGAs using the lower cost of generic clozapine and a pragmatic trial design. Policy decisions by the NICE suggest that additional reasons would be needed to accept clozapine as effective and efficient if it had a high probability of having ICERs more than 35,000 pound per QALY. The results and limitations of the analysis suggest that there is still a need for further economic evaluation of clozapine.

Randomized controlled trial of the effect on Quality of Life of second- vs first-generation antipsychotic drugs in schizophrenia: Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS 1).

CONTEXT: Second-generation (atypical) antipsychotics (SGAs) are more expensive than first-generation (typical) antipsychotics (FGAs) but are perceived to be more effective, with fewer adverse effects, and preferable to patients. Most evidence comes from short-term efficacy trials of symptoms. OBJECTIVE: To test the hypothesis that in people with schizophrenia requiring a change in treatment, SGAs other than clozapine are associated with improved quality of life across 1 year compared with FGAs. DESIGN: A noncommercially funded, pragmatic, multisite, randomized controlled trial of antipsychotic drug classes, with blind assessments at 12, 26, and 56 weeks using intention-to-treat analysis. SETTING: Fourteen community psychiatric services in the English National Health Service. PARTICIPANTS: Two hundred twenty-seven people aged 18 to 65 years with DSM-IV schizophrenia and related disorders assessed for medication review because of inadequate response or adverse effects. INTERVENTIONS: Randomized prescription of either FGAs or SGAs (other than clozapine), with the choice of individual drug made by the managing psychiatrist. MAIN OUTCOME MEASURES: Quality of Life Scale scores, symptoms, adverse effects, participant satisfaction, and costs of care. RESULTS: The primary hypothesis of significant improvement in Quality of Life Scale scores during the year after commencement of SGAs vs FGAs was excluded. Participants in the FGA arm showed a trend toward greater improvements in Quality of Life Scale and symptom scores. Participants reported no clear preference for either drug group; costs were similar. CONCLUSIONS: In people with schizophrenia whose medication is changed for clinical reasons, there is no disadvantage across 1 year in terms of quality of life, symptoms, or associated costs of care in using FGAs rather than nonclozapine SGAs. Neither inadequate power nor patterns of drug discontinuation accounted for the result.

Randomized controlled trial of effect of prescription of clozapine versus other second-generation antipsychotic drugs in resistant schizophrenia.

There is good evidence that clozapine is more efficacious than first-generation antipsychotic drugs in resistant schizophrenia. It is less clear if clozapine is more effective than the other second-generation antipsychotic (SGA) drugs. A noncommercially funded, pragmatic, open, multisite, randomized controlled trial was conducted in the United Kingdom National Health Service (NHS). Participants were 136 people aged 18-65 with DSM-IV schizophrenia and related disorders whose medication was being changed because of poor clinical response to 2 or more previous antipsychotic drugs. Participants were randomly allocated to clozapine or to one of the class of other SGA drugs (risperidone, olanzapine, quetiapine, amisulpride) as selected by the managing clinician. Outcomes were assessed blind to treatment allocation. One-year assessments were carried out in 87% of the sample. The intent to treat comparison showed no statistically significant advantage for commencing clozapine in Quality of Life score (3.63 points; CI: 0.46-7.71; p = .08) but did show an advantage in Positive and Negative Syndrome Scale (PANSS) total score that was statistically significant (-4.93 points; CI: -8.82 to -1.05; p = .013) during follow-up. Clozapine showed a trend toward having fewer total extrapyramidal side effects. At 12 weeks participants who were receiving clozapine reported that their mental health was significantly better compared with those receiving other SGA drugs. In conclusion, in people with schizophrenia with poor treatment response to 2 or more antipsychotic drugs, there is an advantage to commencing clozapine rather than other SGA drugs in terms of symptom improvement over 1 year.

Social determinants and psychological distress among Aboriginal and Torres Strait islander adults in the Australian state of Victoria: a cross-sectional population based study.

Aboriginal and Torres Strait Islander adults in the Australian state of Victoria have a higher prevalence of psychological distress than their non-Aboriginal and Torres Strait Islander counterparts. We sought to explain this inequality, focussing on the social determinants of health. We used population-based survey data from the 2008 Victorian Population Health Survey; a cross-sectional landline computer-assisted telephone survey of 34,168 randomly selected adults. We defined psychological distress as a score of 22 or more on the Kessler 10 Psychological Distress scale. We used logistic regression to identify socio-demographic characteristics and social capital indicators that were associated with psychological distress. We then created multivariable models to explore the association between psychological distress and Aboriginal and Torres Strait Islander status that incorporated all significant socioeconomic status (SES) and social capital variables, adjusting for all non-SES socio-demographic characteristics. Aboriginal and Torres Strait Islander Victorians (24.5%) were more than twice as likely than their non-Aboriginal and Torres Strait Islander counterparts (11.3%) to have psychological distress (odds ratio (OR) = 2.56, 95% confidence interval; 1.67-3.93). Controlling for SES, negative perceptions of the residential neighbourhood, lack of social support from family, social and civic distrust, and all non-SES socio-demographic variables (age, sex, marital status, household composition, and rurality), rendered the previously statistically significant inequality in the prevalence of psychological distress, between Aboriginal and Torres Strait Islander Victorians and their non-Aboriginal and Torres Strait Islander counterparts, insignificant at the p = 0.05 level (OR = 1.50; 0.97-2.32). Psychological distress is an important health risk factor for Aboriginal and Torres Strait Islander adults that has yet to be widely acknowledged and addressed. Addressing the underlying inequalities in SES and social capital may be the key to addressing the inequality in psychological distress.

Opposing socioeconomic gradients in overweight and obese adults.

OBJECTIVE: Investigate the relationship between socioeconomic status (SES) and prevalence of overweight and/or obesity, by sex, using total annual household income as the indicator of SES and the World Health Organization (WHO) recommended ranges of self-reported Body Mass Index (BMI) as the indicator of overweight and/or obesity. METHODS: Total annual household income and BMI data were obtained from the Victorian Population Health Survey (VPHS), an annual computer-assisted telephone survey of the health and well-being of Victorian adults aged 18 years and older. Statistical analysis was conducted using ordinary least squares linear regression on the logarithms of age-standardised prevalence estimates of overweight (25.0-29.9 kg/m(2)), obesity (≥ 30.0 kg/m(2)), and overweight and obesity combined (≥ 25.0 kg/m(2)), by income category and sex. RESULTS: Typical SES gradients were observed in obese males and females, where the prevalence of obesity decreased with increasing income. No SES gradient was observed in overweight females, however, a reverse SES gradient was observed in overweight males, where the prevalence of overweight increased with increasing income. Combining the overweight and obesity categories into a single group eliminated the typical SES gradients observed in males and females for obesity, and resulted in a statistically significant reverse SES gradient in males. CONCLUSIONS: Combining the BMI categories of overweight and obesity into a single category masks important SES differences, while combining the data for males and females masks important sex differences. BMI categories of overweight and obesity should be analysed and reported independently, as should BMI data by sex.

Attitudes to atypical and conventional antipsychotic drug treatment in clinicians participating in the cutlass study.

Objectives To examine clinicians' attitudes regarding the relative benefits and risks of conventional and atypical antipsychotic medication, and the perceived validity of the CUtLASS study. To examine the attitudes of participant clinicians' regarding the operation and administration, and the potential clinical impact of the findings. Method Two hundred and sixty-two clinicians were each sent an anonymous questionnaire, and invited to indicate whether they agreed or disagreed with each of to nine statements (from agree to disagree). Results Of the 112 clinicians who responded, 71% supported the CUtLASS study. Thirty-nine percent agreed with the statement that the clinical efficacy of atypicals was superior to conventional antipsychotics, while 27% disagreed and 34% were undecided. Thus, two-thirds of participating clinicians revealed no uncertainty on a key question being tested in the CUtLASS study. Further, the vast majority (97%) considered that atypicals were associated with less severe side effects. Conclusions In clinical studies, recruitment strategies relying on referrals from clinicians may find that some clinicians identify fewer patients than expected. This can lead to a relatively low yield of potential study subjects and possibly a selection bias. Surveys of clinicians approached to participate in clinical studies provide a potential mechanism to explore attitudes relevant to participant recruitment.