Structural modelling of wellbeing for Indigenous Australians: importance of mental health.

BACKGROUND: Australia provides health care services for Indigenous peoples as part of its effort to enhance Indigenous peoples' wellbeing. However, biomedical frameworks shape Australia's health care system, often without reference to Indigenous wellbeing priorities. Under Indigenous leadership the Interplay research project explored wellbeing for Indigenous Australians in remote regions, through defining and quantifying Indigenous people's values and priorities. This article aimed to quantify relationships between health care access, mental and physical health, and wellbeing to guide services to enhance wellbeing for Indigenous Australians in remote regions. METHODS: Indigenous and non-Indigenous researchers worked with Indigenous people in remote Australia to create a framework of wellbeing priorities. Indigenous community priorities were community, culture and empowerment; these interplay with government priorities for Indigenous development of health, education and employment. The wellbeing framework was further explored in four Indigenous communities through a survey which measured aspects of the wellbeing priorities. Indigenous community researchers administered the survey in their home communities to 841 Indigenous people aged 15 to 34 years from June 2014. From the survey items, exploratory factor analysis was used to develop constructs for mental and physical health, barriers to health care access and wellbeing. Relationships between these constructs were quantified through structural equation modelling. RESULTS: Participants reported high levels of health and physical health (mean scores (3.17/4 [SD 0.96]; and 3.76/4 [SD 0.73]) and wellbeing 8.07/10 [SD 1.94]. Transport and costs comprised the construct for barriers to health care access (mean access score 0.89/1 [SD 0.28]). Structural equation modelling showed that mental health, but not physical health was associated with wellbeing (ß = 0.25, P < 0.001; ß = - 0.038, P = 0.3). Health care access had an indirect positive relationship with wellbeing through mental health (ß = 0.047, P = 0.007). Relationships differed significantly for participants in remote compared with those in very remote communities. CONCLUSIONS: Greater attention to mental health and recognition of the role of services outside the health care sector may have positive impacts on wellbeing for Indigenous people in remote/ very remote Australia. Aggregation of remote and very remote populations may obscure important differences between Indigenous communities.

Australian Indigenous Land Management, Ecological Knowledge and Languages for Conservation.

Many Indigenous Australians hold cultural, ecological and language knowledge, but common representations of Indigenous Australians focus on social disadvantage and poor comparisons with other Australians in education, employment and health. Indigenous Land Management works with Indigenous people's cultural, ecological and language expertise, employing Indigenous people in activities contributing to biodiversity conservation. The Interplay research surveyed 841 Indigenous people in remote communities. Those employed in land management reported greater participation in cultural activities, language knowledge, and belief that their land was looked after. These related assets provide an opportunity for policy approaches based on Indigenous people's strengths and contribution to Australia.

Indigenous land management as primary health care: qualitative analysis from the Interplay research project in remote Australia.

BACKGROUND: For Indigenous Australians, health transcends the absence of disease, and includes the health and wellbeing of their community and Country: their whole physical, cultural and spiritual environment. Stronger relationships with Country and greater involvement in cultural practices enhance the wellbeing of Indigenous Australians, and those in more remote regions have greater access to their Country and higher levels of wellbeing. However this does not translate into improvements in clinical indicators, and Indigenous Australians in more remote regions suffer higher levels of morbidity and mortality than Indigenous people in non-remote areas, and other Australians. The Interplay research project aimed to explore how Indigenous Australians in remote regions experience high levels of wellbeing despite poor health statistics, and how services could more effectively enhance both health and wellbeing. METHODS: Indigenous Australians in remote regions, together with researchers and government representatives developed a wellbeing framework, comprising government and community priorities: education, employment and health, and community, culture and empowerment respectively. To explore these priorities Indigenous community researchers recruited participants from diverse Indigenous organizations, including Indigenous land management, art, business development, education, employment, health and municipal services. Fourteen focus groups and seven interviews, involving 75 Indigenous and ten non-Indigenous service providers and users were conducted. These were recorded, transcribed and analyzed, using thematic analysis, based on the wellbeing framework. RESULTS: Research participants highlighted Indigenous land management as a source of wellbeing, through strengthened identity and empowerment, access to traditional food sources, enjoyable physical activity, and escape from communities where high levels of alcohol are consumed. Participants described how collaboration and partnerships between services, and recognition of Indigenous languages could enhance wellbeing, while competition between services undermines wellbeing. Indigenous land management programs work across different sectors and promote collaboration between services, serving as a source of comprehensive primary health care. CONCLUSIONS: Developing primary health care to reflect distinctive health needs of Indigenous Australians will enhance their health and wellbeing, which includes their communities and Country. Indigenous land management consolidates aspects of comprehensive primary health care, providing both clinical benefits and wellbeing, and can provide a focus for service collaboration.

Injury prevention through employment as a priority for wellbeing among Aboriginal people in remote Australia.

ISSUE ADDRESSED: Injuries lead to more hospitalisations and lost years of healthy life for Aboriginal people than any other cause. However, they are often overlooked in discussion of relieving Aboriginal disadvantage. METHODS: Four Aboriginal communities with diverse geography, culture and service arrangements participated in the Interplay Wellbeing project. In each community, Aboriginal researchers conducted focus groups and interviews arranged through Aboriginal organisations to explore wellbeing. A total of 84 participants contributed to 14 focus groups and eight interviews, which were recorded, transcribed and coded. This article reports on injury and possibilities for prevention, unanticipated themes raised in discussions of wellbeing. RESULTS: Interpersonal violence, injury and imprisonment emerged as themes that were linked with employment and wellbeing. Employment in Aboriginal ranger programs provides meaningful activity, which strengthens people's identity and cultural integrity. This can avert interpersonal violence through empowering women and reducing alcohol access and consumption. CONCLUSION: Ranger programs may provide a much-needed opportunity to control escalating rates of injury for Aboriginal people in remote communities. SO WHAT?: The manifold benefits of Aboriginal ranger programs include reducing violence and its injury and criminal justice consequences.

Interplay wellbeing framework: a collaborative methodology 'bringing together stories and numbers' to quantify Aboriginal cultural values in remote Australia.

BACKGROUND: Wellbeing has been difficult to understand, measure and strengthen for Aboriginal people in remote Australia. Part of the challenge has been genuinely involving community members and incorporating their values and priorities into assessment and policy. Taking a 'shared space' collaborative approach between remote Aboriginal communities, governments and scientists, we merged Aboriginal knowledge with western science - by bringing together stories and numbers. This research aims to statistically validate the holistic Interplay Wellbeing Framework and Survey that bring together Aboriginal-identified priorities of culture, empowerment and community with government priorities including education, employment and health. METHOD: Quantitative survey data were collected from a cohort of 842 Aboriginal people aged 15-34 years, recruited from four different Aboriginal communities in remote Australia. Aboriginal community researchers designed and administered the survey. RESULTS: Structural equation modeling showed good fit statistics (χ/df = 2.69, CFI = 0.95 and RMSEA = 0.045) confirming the holistic nature of the Interplay Wellbeing Framework. The strongest direct impacts on wellbeing were 'social and emotional wellbeing' (r = 0.23; p < 0.001), 'English literacy and numeracy' (r = 0.15; p < 0.001), 'Aboriginal literacy' (r = 0.14; p < 0.001), 'substances' (lack thereof; r = 0.13; p = 0.003), 'work' (r = 0.12; p = 0.02) and 'community' (r = 0.08; p = 0.05). Correlation analyses suggested cultural factors have indirect impacts on wellbeing, such as through Aboriginal literacy. All cultural variables correlated highly with each other, and with empowerment and community. Empowerment also correlated highly with all education and work variables. 'Substances' (lack thereof) was linked with positive outcomes across culture, education and work. Specific interrelationships will be explored in detail separately. CONCLUSION: The Interplay Wellbeing Framework and Survey were statistically validated as a collaborative approach to assessing wellbeing that is inclusive of other cultural worldviews, values and practices. New community-derived social and cultural indicators were established, contributing valuable insight to psychometric assessment across cultures. These analyses confirm that culture, empowerment and community play key roles in the interplay with education, employment and health, as part of a holistic and quantifiable system of wellbeing. This research supports the holistic concept of wellbeing confirming that everything is interrelated and needs to be considered at the 'whole of system' level in policy approaches.

Adolescent inhalant abuse leads to other drug use and impaired growth; implications for diagnosis.

OBJECTIVE: Abuse of inhalants containing the volatile solvent toluene is a significant public health issue, especially for adolescent and Indigenous communities. Adolescent inhalant abuse can lead to chronic health issues and may initiate a trajectory towards further drug use. Identification of at-risk individuals is difficult and diagnostic tools are limited primarily to measurement of serum toluene. Our objective was to identify the effects of adolescent inhalant abuse on subsequent drug use and growth parameters, and to test the predictive power of growth parameters as a diagnostic measure for inhalant abuse. METHODS: We retrospectively analysed drug use and growth data from 118 Indigenous males; 86 chronically sniffed petrol as adolescents. RESULTS: Petrol sniffing was the earliest drug used (mean 13 years) and increased the likelihood and earlier use of other drugs. Petrol sniffing significantly impaired height and weight and was associated with meeting 'failure to thrive' criteria; growth diagnostically out-performed serum toluene. CONCLUSIONS: Adolescent inhalant abuse increases the risk for subsequent and earlier drug use. It also impairs growth such that individuals meet 'failure to thrive' criteria, representing an improved diagnostic model for inhalant abuse. Implications for Public Health: Improved diagnosis of adolescent inhalant abuse may lead to earlier detection and enhanced health outcomes.

A prospective study of neurocognitive changes 15 years after chronic inhalant abuse.

AIMS: In a previous study, neurological and cognitive deficits reflecting central nervous system (CNS) disruption from chronic inhalant abuse showed substantial recovery after 2 years' abstinence. Functional recovery was progressive, with recovery rates dependent on the degree of impairment prior to abstinence, and severity and duration of initial abuse. Persistent deficits occurred in those with previous 'lead encephalopathy' from leaded petrol abuse. The current study examined recovery in the same cohort 15 years after baseline. DESIGN: Prospective cohort design. SETTING: Two remote Aboriginal communities in Arnhem Land, Australia. PARTICIPANTS: Using baseline group classifications, 27 healthy controls, 60 ex-chronic inhalant abusers and an additional 17 with previous lead encephalopathy were assessed. MEASUREMENTS: Standard neurological, ocular-motor and cognitive functions and blood lead levels. FINDINGS: Chronic (non-encephalopathic) inhalant abusers showed elevated blood lead levels and abnormal scores on most tasks at baseline. At 2 years' abstinence, blood lead was reduced but remained elevated and most scores had normalized. By 15 years, blood lead and all performance scores were equivalent to healthy controls for this group (P > 0.05). The encephalopathic group was more severely impaired on all scores at baseline and showed little improvement, if any, across all tests after both 2 and 15 years' abstinence. Blood lead for this group declined, and was not significantly different to controls after 15 years. CONCLUSIONS: Some inhalant abusers experience severe and persistent neurological deficits, suggesting irrecoverable damage attributable to lead encephalopathy. In the absence of this encephalopathy long-term abstinence from inhalants may allow recovery of normal brain function.

Oral health and social and emotional well-being in a birth cohort of Aboriginal Australian young adults.

BACKGROUND: Social and emotional well-being is an important component of overall health. In the Indigenous Australian context, risk indicators of poor social and emotional well-being include social determinants such as poor education, employment, income and housing as well as substance use, racial discrimination and cultural knowledge. This study sought to investigate associations between oral health-related factors and social and emotional well-being in a birth cohort of young Aboriginal adults residing in the northern region of Australia's Northern Territory. METHODS: Data were collected on five validated domains of social and emotional well-being: anxiety, resilience, depression, suicide and overall mental health. Independent variables included socio-demographics, dental health behaviour, dental disease experience, oral health-related quality of life, substance use, racial discrimination and cultural knowledge. RESULTS: After adjusting for other covariates, poor oral health-related items were associated with each of the social and emotional well-being domains. Specifically, anxiety was associated with being female, having one or more decayed teeth and racial discrimination. Resilience was associated with being male, having a job, owning a toothbrush, having one or more filled teeth and knowing a lot about Indigenous culture; while being female, having experienced dental pain in the past year, use of alcohol, use of marijuana and racial discrimination were associated with depression. Suicide was associated with being female, having experience of untreated dental decay and racial discrimination; while being female, having experience of dental disease in one or more teeth, being dissatisfied about dental appearance and racial discrimination were associated with poor mental health. CONCLUSION: The results suggest there may be value in including oral health-related initiatives when exploring the role of physical conditions on Indigenous social and emotional well-being.

Racism as a determinant of social and emotional wellbeing for Aboriginal Australian youth.

OBJECTIVE: To explore the associations between self-reported racism and health and wellbeing outcomes for young Aboriginal Australian people. DESIGN, SETTING AND PARTICIPANTS: A cross-sectional study of 345 Aboriginal Australians aged 16-20 years who, as participants in the prospective Aboriginal Birth Cohort Study, were recruited at birth between 1987 and 1990 and followed up between 2006 and 2008. MAIN OUTCOME MEASURES: Self-reported social and emotional wellbeing using a questionnaire validated as culturally appropriate for the study's participants; recorded body mass index and waist-to-hip ratio. RESULTS: Self-reported racism was reported by 32% of study participants. Racism was significantly associated with anxiety (odds ratio [OR], 2.18 [95% CI, 1.37-3.46]); depression (OR, 2.16 [95% CI, 1.33-3.53]); suicide risk (OR, 2.32 [95% CI, 1.25-4.00]); and poor overall mental health (OR, 3.35 [95% CI, 2.04-5.51]). No significant associations were found between self-reported racism and resilience or any anthropometric measures. CONCLUSIONS: Self-reported racism was associated with poor social and emotional wellbeing outcomes, including anxiety, depression, suicide risk and poor overall mental health.

Recovery from central nervous system changes following volatile substance misuse.

This review examines cognitive, neurological, and neuroanatomical recovery associated with abstinence from volatile substance misuse (VSM). Articles describing functional or structural brain changes longitudinally or cross-sectional reports comparing current and abstinent users were identified and reviewed. A significant lack of empirical studies investigating central nervous system recovery following VSM was noted. The few case reports and group studies identified indicated that cognitive and neurological impairments appear to follow a progression of decline and progression of recovery model, with the severity of impairment related to the duration and severity of misuse, blood lead levels among leaded petrol misusers, and the duration of abstinence for recovery. By contrast, severe neurological impairment known as lead encephalopathy from sniffing leaded petrol occurred as more catastrophic or abrupt damage to cerebellar processes that may never fully recover. Neuroanatomical damage may not recover even with prolonged abstinence.

Cognitive recovery during and after treatment for volatile solvent abuse.

BACKGROUND: Cognitive impairment reflecting CNS disruption in chronic solvent abusers can resolve within two years of abstinence. However, the specific time course for recovery has yet to be determined empirically. This study monitored cognition among solvent (i.e., gasoline) abusers throughout 8 weeks of residential treatment. It also investigated the extent to which solvent-related cognitive impairments persisted following discharge. METHODS: Non-drug using healthy controls (n=33) and solvent abusers (n=29) who had inhaled gasoline, regularly or episodically, for an average of 4.3 years (SD=2.7) were assessed. Using linear mixed model analyses, solvent abusers were compared to healthy controls throughout treatment at baseline, two weeks, four weeks and six weeks, on visual motor, attention, learning, memory, and executive function tasks. Ten users who maintained abstinence were reassessed an average of 12 months later (SD=2.8) and were compared to healthy controls (n=12) retested at the same time interval using ANCOVA while controlling for age and baseline performance. RESULTS: At baseline, solvent abusers showed cognitive deficits on visual motor, learning and memory, paired associate learning, and executive functions. Paired associate learning performance improved within 6 weeks of abstinence, however, impairments in visual motor speed, learning and memory, and executive function persisted throughout and in some cases beyond treatment. CONCLUSIONS: Cognitive deficits exist for solvent abusers upon treatment entry. Some impairments resolve within weeks of abstinence, while memory and executive function improves gradually over months to years of abstinence, and might never fully recover.

Similar profile of cognitive impairment and recovery for Aboriginal Australians in treatment for episodic or chronic alcohol use.

AIMS: The cognitive impairment and recovery associated with chronic alcohol abuse and subsequent abstinence is well understood. However, the recovery profile following heavy episodic or 'binge' use, which is common among some Australian Aboriginal users, has not been investigated thoroughly and no empirical studies have examined chronic use in this population. The aim of this study was to identify and compare cognitive impairment and recovery associated with chronic and episodic alcohol use among Aboriginal Australians. DESIGN: Longitudinal case-control design. SETTING: Residential alcohol treatment programmes in northern Australia. PARTICIPANTS: Forty chronic alcohol users, 24 episodic users and 41 healthy controls [mean age = 34.24; standard deviation (SD) = 9.73]. MEASUREMENTS: Cognitive assessments of visual motor, attention, memory, learning and executive functions at baseline (start of treatment), then 4 weeks and 8 weeks later. Reassessment of 31% of participants an average of 11 months later (SD = 4.4) comparing those who remained abstinent (n = 5), those who relapsed (n = 11) and healthy controls (n = 19). FINDINGS: At baseline, chronic and episodic alcohol users showed impaired visual motor, learning, memory and executive functions. With the exception of visual motor impairment, all deficits had improved to normal levels within 4 weeks. Visual motor deficits had normalized within 11 months. Performances did not differ at any time between chronic and episodic alcohol groups. CONCLUSIONS: In Aboriginal Australians, episodic drinking is associated with similar patterns of impairment and recovery as chronic alcohol use. Most cognitive deficits appear to recover within the first month of abstinence, while persisting visual motor problems recover within 1 year.

Detecting psychological symptoms related to substance use among Indigenous Australians.

INTRODUCTION AND AIMS: Substance misuse and psychological comorbidities can be common and may impact negatively on treatment outcomes. However, without appropriate tools, detecting psychological symptoms for Indigenous people can be difficult. This study assessed the appropriateness of an eight-item screening tool (based on Strong Souls) for measuring any relationships between substance use and psychiatric symptoms for Indigenous Australians. DESIGN AND METHODS: Indigenous Australians attending secondary or tertiary education institutions or substance use rehabilitation facilities in the Northern Territory (n = 407; mean age = 27.82) were assessed for depressive, anxiety and psychotic symptoms. The group represented 45 language groups from 95 urban and remote communities. English comprehension was measured on a scale from 0 (no understanding) to 10 (excellent understanding; M = 7.99, SD = 2.31). Ordinal regression analyses examined any associations between demographic and substance use factors and psychological symptoms. RESULTS: Compared with non-users, current cannabis users were significantly more likely [odds ratios (ORs) = 2.2-4.4] to experience depressive or anxiety symptoms. Frequent cannabis users experienced more symptoms than occasional users. Prior-inhalant users were more likely to feel lonely (OR = 2.18) compared with non-inhalant users. Frequent alcohol users were less likely (OR = 0.44) to feel sad than non-users. These results are interpreted with respect to previous research and methodological limitations. DISCUSSION AND CONCLUSIONS: Symptoms of depression or anxiety may be common for individuals seeking treatment for substance misuse and with minor improvement, these eight-items may provide a useful screen for psychological symptoms in Indigenous Australians.

The mysterious practice of petrol sniffing in isolated indigenous groups.

The practice of petrol sniffing is a unique and poorly understood phenomenon that is associated with substantial morbidity, mortality and social devastation in affected remote Indigenous communities. For these groups and for the wider community, much mystery has surrounded the practice and its effects. Here we introduce the epidemiology of petrol sniffing among Indigenous groups internationally, review its impact on the brain, behaviour and social functions and summarise related interventions.

Assessing cognition following petrol sniffing for Indigenous Australians.

BACKGROUND: Chronic petrol inhalation can be associated with significant cognitive impairment. While rehabilitation programs can rely on such skills to educate clients and achieve treatment outcomes, cognitive function is rarely assessed on admission. This is particularly true for Indigenous populations where standard assessments are not appropriate. This paper describes a process for assessing cognition in Indigenous Australians. Two studies investigate firstly the demographic factors impacting on cognition for healthy Indigenous Australians and secondly the utility of the assessment process for detecting petrol sniffing related cognitive impairments. METHODS: Study One assessed a naturalistic sample of healthy Indigenous Australians from the Northern Territory (N = 206; mean age = 28.03) on computerised tests of psychomotor speed, visual attention, memory, learning, spatial awareness and executive functions. Multiple regression analyses determined the unique contributions of six factors (age, education, gender, familiarity with computers, regular long term cannabis use and locality) to the variance in performance for this group. Study Two examined group differences in cognitive performance on the same tests between healthy Indigenous Australians (N = 96) and Indigenous petrol sniffers (N = 50; both age restricted to < 26 years) while controlling those factors found to impact on performance from Study One. RESULTS: Age, computer familiarity, and education significantly contributed to the variance in performance measures. While controlling these factors, petrol abuse was associated with poorer performance on complex tasks of psychomotor, visual attention, memory, learning, spatial awareness and executive function. CONCLUSIONS: This assessment process is useful for detecting substance abuse related impairments in Indigenous Australians and when using this assessment process, age and computer familiarity in particular should be controlled for.

Substance use and periodontal disease among Australian Aboriginal young adults.

AIM: To investigate the effects of tobacco, marijuana, alcohol and petrol sniffing on periodontal disease among Australian Aboriginal young adults. DESIGN: Cross-sectional nested within a long-standing prospective longitudinal study. Setting Aboriginal communities in Australia's Northern Territory. PARTICIPANTS: Members of the Aboriginal Birth Cohort study who were recruited from birth between January 1987 and March 1990 at the Royal Darwin Hospital, Northern Territory, Australia. Data were from wave III, when the mean age of participants was 18 years. MEASUREMENTS: Clinical dental examination and self-report questionnaire. FINDINGS: Of 425 participants with complete data, 26.6% had moderate/severe periodontal disease. There was elevated risk of periodontal disease associated with tobacco [prevalence ratio (PR) = 1.59, 95% CI = 1.06-2.40], marijuana (PR = 1.44, 95% CI = 1.05-1.97) and petrol sniffing (PR = 1.83, 95% CI = 1.08-3.11), but not alcohol (PR = 0.92, 95% CI = 0.67-1.27). Stratified analysis showed that the effect of marijuana persisted among tobacco users (PR = 1.47, 95% CI 1.03-2.11). It was not possible to isolate an independent effect of petrol sniffing because all petrol sniffers used both marijuana and tobacco, although among smokers of both substances, petrol sniffing was associated with an 11.8% increased prevalence of periodontal disease. CONCLUSIONS: This is the first time that substance use has been linked with periodontal disease in a young Australian Aboriginal adult population, and the first time that petrol sniffing has been linked with periodontal disease in any population. The role of substance use in periodontal disease among this, and other, marginalized groups warrants further investigation.

Psychological and cognitive assessment of Indigenous Australians.

OBJECTIVE: The aim of the present review was to evaluate the psychological and cognitive assessments that have been considered suitable for Indigenous Australians. This will provide a basis from which future developments can occur, leading to improved mental health services for Indigenous Australians. METHOD: Literature searches of key health science databases were conducted using the following search terms in various combinations: Indigenous, Aboriginal, cognitive, assessment, mental health, social emotional well-being, psychological, Australian. Psychological, mental health or social and emotional well-being assessments as well as cognitive assessments that have been utilized and found suitable in Indigenous Australian populations were reviewed. RESULTS: A limited number of assessments were found and discussed and these varied in their applications. CONCLUSIONS: Further research and development is necessary to establish a national approach to assessing or screening mental health and cognitive function among Indigenous Australians. This is an important and necessary step to improve mental health and related services for Indigenous Australians.