Family-centred interventions for Indigenous early childhood well-being by primary healthcare services.

BACKGROUND: Primary healthcare, particularly Indigenous-led services, are well placed to deliver services that reflect the needs of Indigenous children and their families. Important characteristics identified by families for primary health care include services that support families, accommodate sociocultural needs, recognise extended family child-rearing practices, and Indigenous ways of knowing and doing business. Indigenous family-centred care interventions have been developed and implemented within primary healthcare services to plan, implement, and support the care of children, immediate and extended family and the home environment. The delivery of family-centred interventions can be through environmental, communication, educational, counselling, and family support approaches. OBJECTIVES: To evaluate the benefits and harms of family-centred interventions delivered by primary healthcare services in Canada, Australia, New Zealand, and the USA on a range of physical, psychosocial, and behavioural outcomes of Indigenous children (aged from conception to less than five years), parents, and families. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was 22 September 2021. SELECTION CRITERIA: We included randomised controlled trials (RCTs), cluster RCTs, quasi-RCTs, controlled before-after studies, and interrupted time series of family-centred care interventions that included Indigenous children aged less than five years from Canada, Australia, New Zealand, and the USA. Interventions were included if they met the assessment criteria for family-centred interventions and were delivered in primary health care. Comparison interventions could include usual maternal and child health care or one form of family-centred intervention versus another. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were 1. overall health and well-being, 2. psychological health and emotional behaviour of children, 3. physical health and developmental health outcomes of children, 4. family health-enhancing lifestyle or behaviour outcomes, 5. psychological health of parent/carer. 6. adverse events or harms. Our secondary outcomes were 7. parenting knowledge and awareness, 8. family evaluation of care, 9. service access and utilisation, 10. family-centredness of consultation processes, and 11. economic costs and outcomes associated with the interventions. We used GRADE to assess the certainty of the evidence for our primary outcomes. MAIN RESULTS: We included nine RCTs and two cluster-RCTs that investigated the effect of family-centred care interventions delivered by primary healthcare services for Indigenous early child well-being. There were 1270 mother-child dyads and 1924 children aged less than five years recruited. Seven studies were from the USA, two from New Zealand, one from Canada, and one delivered in both Australia and New Zealand. The focus of interventions varied and included three studies focused on early childhood caries; three on childhood obesity; two on child behavioural problems; and one each on negative parenting patterns, child acute respiratory illness, and sudden unexpected death in infancy. Family-centred education was the most common type of intervention delivered. Three studies compared family-centred care to usual care and seven studies provided some 'minimal' intervention to families such as education in the form of pamphlets or newsletters. One study provided a minimal intervention during the child's first 24 months and then the family-centred care intervention for one year. No studies had low or unclear risk of bias across all domains. All studies had a high risk of bias for the blinding of participants and personnel domain. Family-centred care may improve overall health and well-being of Indigenous children and their families, but the evidence was very uncertain. The pooled effect estimate from 11 studies suggests that family-centred care improved the overall health and well-being of Indigenous children and their families compared no family-centred care (standardised mean difference (SMD) 0.14, 95% confidence interval (CI) 0.03 to 0.24; 2386 participants). We are very uncertain whether family-centred care compared to no family-centred care improves the psychological health and emotional behaviour of children as measured by the Infant Toddler Social Emotional Assessment (ITSEA) (Competence domain) (mean difference (MD) 0.04, 95% CI -0.03 to 0.11; 2 studies, 384 participants). We assessed the evidence as being very uncertain about the effect of family-centred care on physical health and developmental health outcomes of children. Pooled data from eight trials on physical health and developmental outcomes found there was little to no difference between the intervention and the control groups (SMD 0.13, 95% CI -0.00 to 0.26; 1961 participants). The evidence is also very unclear whether family-centred care improved family-enhancing lifestyle and behaviours outcomes. Nine studies measured family health-enhancing lifestyle and behaviours and pooled analysis found there was little to no difference between groups (SMD 0.16, 95% CI -0.06 to 0.39; 1969 participants; very low-certainty evidence). There was very low-certainty evidence of little to no difference for the psychological health of parents and carers when they participated in family-centred care compared to any control group (SMD 0.10, 95% CI -0.03 to 0.22; 5 studies, 975 parents/carers). Two studies stated that there were no adverse events as a result of the intervention. No additional data were provided. No studies reported from the health service providers perspective or on outcomes for family's evaluation of care or family-centredness of consultation processes. AUTHORS' CONCLUSIONS: There is some evidence to suggest that family-centred care delivered by primary healthcare services improves the overall health and well-being of Indigenous children, parents, and families. However, due to lack of data, there was not enough evidence to determine whether specific outcomes such as child health and development improved as a result of family-centred interventions. Seven of the 11 studies delivered family-centred education interventions. Seven studies were from the USA and centred on two particular trials, the 'Healthy Children, Strong Families' and 'Family Spirit' trials. As the evidence is very low certainty for all outcomes, further high-quality trials are needed to provide robust evidence for the use of family-centred care interventions for Indigenous children aged less than five years.

Provision of assisted reproductive technologies (ART) to Aboriginal and Torres Strait Islander peoples: Limited engagement in an online survey of Medical Directors of ART services.

Current knowledge about infertility and access to infertility treatment among Aboriginal and Torres Strait Islander peoples is extremely limited. We conducted an online survey of Medical Directors of registered ART providers in Australia (n = 59) to obtain preliminary information on this topic. Six (10%) Directors responded; only two reported routinely collecting the Aboriginal and Torres Strait Islander status of clients. While the low response rate prevents generalising the findings, the poor engagement may indicate gaps in awareness of fertility issues for this group. This warrants further investigation, to understand whether Aboriginal and Torres Strait Islander people are appropriately accessing infertility care.

Infertility in Aboriginal and Torres Strait Islander people: A cause for concern?

In many Aboriginal and Torres Strait Islander communities, women and men are disproportionately affected by a range of risk factors for infertility including sexually transmitted infections, polycystic ovary syndrome and obesity. However, very little is known about the occurrence of infertility in this group or how Aboriginal and Torres Strait Islander people access fertility treatments. This opinion piece aims to reflect on current evidence concerning infertility risk factors and infertility per se among Aboriginal and Torres Strait Islander people, highlighting gaps in the literature about access and outcomes in this group.

Benefits of modest weight or waist circumference loss in a remote North Queensland Indigenous population.

OBJECTIVE: To quantify the potential benefit to individuals of differing magnitudes of weight or waist circumference loss in an Indigenous population. METHOD: Data were from the Well Person's Health Check, a cohort study in 19 rural Indigenous communities in Far North Queensland. Baseline data were collected between 1998 and 2000 from 2,583 people aged 15 to 75, an estimated participation rate of 44.5%. Follow-up data were collected between 2004 and 2007 from 729 participants. Associations between change in weight and waist circumference for those who were overweight or obese (n=486) with changes in serum lipids, fasting glucose, blood pressure and Gamma-Glutamyltransferase (GGT) were estimated using linear regression. RESULTS: Weight or waist circumference loss was associated in a dose response fashion with blood pressure reduction (e.g. 10% or greater weight loss compared with no weight loss was associated with reduction of 11.3 mmHg systolic (95% confidence interval -17.8, -4.8). Those with greater waist circumference loss had a greater reduction in GGT (-8.3, 95% confidence interval -23.5, 6.8) but there was no apparent increase in GGT reduction with increasing weight loss, although these were measured with low precision. There was no apparent effect of either weight or waist circumference loss on serum lipids and fasting glucose in this population. CONCLUSIONS: This study shows potentially large beneficial effects of weight or waist circumference loss over several years in a remote living Indigenous cohort. The associations were large enough to be of clinical benefit, despite weight loss being modest for most.

Pre-pregnancy predictors of hypertension in pregnancy among Aboriginal and Torres Strait Islander women in north Queensland, Australia; a prospective cohort study.

BACKGROUND: Compared to other Australian women, Indigenous women are frequently at greater risk for hypertensive disorders of pregnancy. We examined pre-pregnancy factors that may predict hypertension in pregnancy in a cohort of Aboriginal and Torres Strait Islander women in north Queensland. METHODS: Data on a cohort of 1009 Indigenous women of childbearing age (15-44 years) who participated in a 1998-2000 health screening program in north Queensland were combined with 1998-2008 Queensland hospitalisations data using probabilistic data linkage. Data on the women in the cohort who were hospitalised for birth (n = 220) were further combined with Queensland perinatal data which identified those diagnosed with hypertension in pregnancy. RESULTS: Of 220 women who gave birth, 22 had hypertension in the pregnancy after their health check. The mean age of women with and without hypertension was similar (23.7 years and 23.9 years respectively) however Aboriginal women were more affected compared to Torres Strait Islanders. Pre-pregnancy adiposity and elevated blood pressure at the health screening program were predictors of a pregnancy affected by hypertension. After adjusting for age and ethnicity, each 1 cm increase in waist circumference showed a 4% increased risk for hypertension in pregnancy (PR 1.04; 95% CI; 1.02-1.06); each 1 point increase in BMI showed a 9% adjusted increase in risk (1.09; 1.04-1.14). For each 1 mmHg increase in baseline systolic blood pressure there was an age and ethnicity adjusted 6% increase in risk and each 1 mmHg increase in diastolic blood pressure showed a 7% increase in risk (1.06; 1.03-1.09 and 1.07; 1.03-1.11 respectively). Among those free of diabetes at baseline, the presence of the metabolic syndrome (International Diabetes Federation criteria) predicted over a three-fold increase in age-ethnicity-adjusted risk (3.5; 1.50-8.17). CONCLUSIONS: Pre-pregnancy adiposity and features of the metabolic syndrome among these young Aboriginal and Torres Strait Islander women track strongly to increased risk of hypertension in pregnancy with associated risks to the health of babies.

Pre-pregnancy predictors of diabetes in pregnancy among Aboriginal and Torres Strait Islander women in North Queensland, Australia.

To identify pre-pregnancy risk factors for diabetes in pregnancy among a cohort of Australian Indigenous women. Data on 1,009 Indigenous women of childbearing age who participated in a 1998-2000 health screening program in far north Queensland were linked to Queensland hospitalisations data. Women who attended hospital after their health check for a pregnancy-related condition were identified. The data on women who were hospitalised for birth were also linked to Queensland perinatal data. Of 220 women who gave birth, 23 had diabetes in the pregnancy following their health check. A strong predictor of having a subsequent pregnancy affected by diabetes was suboptimal glucose control before conception. The presence of the metabolic syndrome predicted over a threefold increase in risk among non-diabetic women after adjustment for age and ethnicity (PR, 3.50; 95% CI, 1.54-8.00). For each 1-cm increase in waist circumference, there was an age-adjusted increase in risk of 4% for diabetes in pregnancy (1.04; 1.01-1.06). For each 1-mmHg increase in blood pressure (systolic and diastolic), there was an age-adjusted increase in risk of 3% (1.03; 1.01-1.05 and 1.03; 1.00-1.07, respectively). Associations between hypercholesterolaemia and dyslipidaemia and diabetes in the subsequent pregnancy were diminished after adjustment for age and ethnicity. The risk for women with "hyper-triglyceridaemic waist" phenotype before pregnancy was diminished by adjustment for age, ethnicity and baseline fasting glucose. Alcohol intake, smoking, level of physical activity and red cell folate showed little effect. Identification of women at particularly high risk for future diabetes in pregnancy, given their pre-pregnancy health, is important so that they can manage their risks and where overweight or obesity is a factor, interventions aimed at weight management should be implemented.

Incidence of type 2 diabetes in two Indigenous Australian populations: a 6-year follow-up study.

OBJECTIVE: To estimate the incidence of type 2 diabetes in two ethnically distinct Indigenous populations in north Queensland, Australia. DESIGN, SETTING AND PARTICIPANTS: A community-based follow-up study of 1814 Australian Aboriginal and Torres Strait Islander adults from 1999 to 2007. Participants were initially free of diabetes and lived in 19 remote communities in Far North Queensland. MAIN OUTCOME MEASURES: Fasting blood glucose level; diagnosis of diabetes; blood lipid levels; weight; waist circumference (WC); and blood pressure. RESULTS: Of the 554 adults who completed the study, 100 developed diabetes over 3412 person-years (py) of follow-up. The incidence of diabetes was similar for Aboriginals (29.7 [95% CI, 20.4-38.4] per 1000 py) and Torres Strait Islanders (29.0 [95% CI, 21.8-38.6] per 1000 py) despite large differences in baseline body mass index (BMI) and WC. The age-standardised incidence for both populations was 30.5 per 1000 py. Obesity defined by WC increased the risk of developing diabetes for Aboriginals (rate ratio [RR], 2.0 [95% CI, 1.1-3.6]) and for Torres Strait Islanders (RR, 6.3 [95% CI, 2.5-16.1]) compared with normal WC. Presence of the metabolic syndrome (MetS) was a strong predictor of incident diabetes (adjusted hazard ratio, 2.4 [95% CI, 1.6-3.7]). For both groups, waist-to-hip ratio and the presence of the MetS better predicted diabetes than WC or BMI. CONCLUSIONS: The incidence of diabetes in these Indigenous Australians is nearly four times higher than for the non-Indigenous population and 50% higher than the incidence reported 10 years ago in Australian Aboriginals. Currently used BMI cut-off points are not appropriate for Indigenous Australians to predict diabetes.

Diabetes in the Torres Strait Islands of Australia: better clinical systems but significant increase in weight and other risk conditions among adults, 1999-2005.

OBJECTIVES: To (i) assess changes in clinical indicators of adults diagnosed with diabetes and (ii) estimate changes in risk factors and incidence of diabetes among adults without diabetes living in the Torres Strait and Northern Peninsula Area Health Service District in Queensland from 1999 to 2005. DESIGN AND PARTICIPANTS: (i) Annual audit of clinical records of Torres Strait Islander adults on diabetes registers in 21 primary care clinics, and (ii) a 5-year follow up of a community cohort of 207 Torres Strait Islander adults without diabetes who participated in the Well Person's Health Check in 2000-01 and 2005-06. MAIN OUTCOME MEASURES: Weight, height, waist circumference, fasting blood sugar (those without diabetes) and glycated haemoglobin (HbA1c; those with diabetes) levels, blood pressure (BP), fasting triglyceride and high-density lipoprotein cholesterol levels, urinary albumin-to-creatinine ratio and smoking status. RESULTS: The number of adults included on the diabetes register increased from 555 in 1999 to 1024 in 2005. The mean age of patients diagnosed with diabetes decreased from 53.3 to 51.5 years, and their mean weight increased from 86.8 kg to 95.6 kg. Mean HbA1c level remained unchanged at about 9%, but the proportion with HbA1c level < 7% increased from 18.4% to 26.1%, and the proportion prescribed insulin increased from 14% in 2002 to 22% in 2005. The proportion with BP < 140/90 mmHg increased from 40.3% in 1999 to 66.8% in 2005. In the sample of 207 adults without diabetes, from 2000 to 2006, there was a weight gain of about 1 kg per person per year, and an annual increase in waist circumference of 0.8 cm in men and 1.2 cm in women. Crude incidence of diabetes was 29 (95% CI, 19-41) per 1000 person-years. There was a significant increase in diastolic blood pressure and fasting blood sugar levels, and no change in smoking habits. CONCLUSIONS: Clinical care of adults with diabetes has improved and more people with diabetes are being diagnosed. However, weight gain and high rates of glycaemia remain a challenge and will result in a large burden of complications, including renal failure. Incidence data from this sample extrapolate to 120 (95% CI, 103-147) new cases of diabetes in the District each year. Urgent action to improve nutrition, decrease smoking and increase physical activity is required to improve metabolic fitness in younger people.