Acceptability of programme budgeting and marginal analysis as a tool for routine priority setting in Indigenous health.

OBJECTIVE: This study aimed to examine the acceptability of programme budgeting and marginal analysis (PBMA) as a tool for priority setting in the Indigenous health sector. METHODS: The study uses a mix of quantitative and qualitative methods. A survey of key decision makers in Indigenous health in Victoria was conducted to assess the acceptability of PBMA as a potential tool for priority setting. Respondents comprised 24 bureaucrats from the Victorian Department of Human Services (DHS) and 26 senior executives from the aboriginal community controlled health sector (ACCHS) in Victoria. The survey instrument included both closed-ended and open-ended questions and was administered face-to-face by a trained researcher in 2007-2008. Closed-ended questions were analysed using descriptive statistics, and content analysis was used for the open-ended ones. RESULTS: The PBMA was well received as having the potential to improve priority setting processes in Indigenous health. Sixty-nine percent of the DHS respondents felt that PBMA was acceptable as a routine decision-making tool, and nearly 80% of ACCHS respondents thought that PBMA was intuitively appealing and would most probably be an acceptable priority setting approach in their organisations. The challenges of using PBMA were related to resource constraints and data intensity. CONCLUSION: Programme budgeting and marginal analysis is potentially acceptable within the ACCHS and was perceived as useful in terms of assisting the decision maker to maximise health outcomes, but data systems need to be re-oriented to address its significant data needs. IMPLICATION: Proper guidelines need to be developed to facilitate PBMA application within the Indigenous-controlled community health sector. Copyright © 2015 John Wiley & Sons, Ltd.

Priority setting in Indigenous health: assessing priority setting process and criteria that should guide the health system to improve Indigenous Australian health.

INTRODUCTION: The health of Indigenous Australians is worse than that of other Australians. Most of the determinants of health are preventable and the poor health outcomes are inequitable. The Australian Government recently pledged to close that health gap. One possible way is to improve the priority setting process to ensure transparency and the use of evidence such as epidemiology, equity and economic evaluation.The purpose of this research was to elicit the perceptions of Indigenous and non-Indigenous decision-makers on several issues related to priority setting in Indigenous-specific health care services. Specifically, we aimed to:1. identify the criteria used to set priorities in Indigenous-specific health care services;2. determine the level of uptake of economic evaluation evidence by decision-makers and how to improve its uptake; and 3. identify how the priority setting process can be improved from the perspective of decision-makers. METHODS: We used a paper survey instrument, adapted from Mitton and colleagues' work, and a face-to-face interview approach to elicit decision-makers' perceptions in Indigenous-specific health care in Victoria, Australia. We used mixed methods to analyse data from the survey. Responses were summarised using descriptive statistics and content analysis. Results were reported as numbers and percentages. RESULTS: The size of the health burden; sustainability and acceptability of interventions; historical trends/patterns; and efficiency are key criteria for making choices in Indigenous health in Victoria. There is a need for an explicit priority setting approach, which is systematic, and is able to use available data/evidence, such as economic evaluation evidence. The involvement of Indigenous Australians in the process would potentially make the process acceptable. CONCLUSIONS: An economic approach to priority setting is a potentially acceptable and useful tool for Aboriginal Community Controlled Health Services (ACCHS). It has the ability to use evidence and ensure due process at the same time. The use of evidence can ensure that health outcomes for Indigenous peoples can be maximised - hence, increase the potential for 'closing the gap' between Indigenous and other Australians.

Suicide ideation and attempt in a community cohort of urban Aboriginal youth: a cross-sectional study.

BACKGROUND: There has been increasing attention over the last decade on the issue of indigenous youth suicide. A number of studies have documented the high prevalence of suicide behavior and mortality in Australia and internationally. However, no studies have focused on documenting the correlates of suicide behavior for indigenous youth in Australia. AIMS: To examine the prevalence of suicide ideation and attempt and the associated factors for a community1 cohort of Koori2 (Aboriginal) youth. METHOD: Data were obtained from the Victorian Aboriginal Health Service (VAHS) Young People's Project (YPP), a community initiated cross-sectional data set. In 1997/1998, self-reported data were collected for 172 Koori youth aged 12-26 years living in Melbourne, Australia. The data were analyzed to assess the prevalence of current suicide ideation and lifetime suicide attempt. Principal components analysis (PCA) was used to identify closely associated social, emotional, behavioral, and cultural variables at baseline and Cox regression modeling was then used to identify associations between PCA components and suicide ideation and attempt. RESULTS: Ideation and attempt were reported at 23.3% and 24.4%, respectively. PCA yielded five components: (1) emotional distress, (2) social distress A, (3) social distress B, (4) cultural connection, (5) behavioral. All were positively and independently associated with suicide ideation and attempt, while cultural connection showed a negative association. CONCLUSIONS: Suicide ideation and attempt were common in this cross-section of indigenous youth with an unfavorable profile for the emotional, social, cultural, and behavioral factors.

Do Indigenous Australians age prematurely? The implications of life expectancy and health conditions of older Indigenous people for health and aged care policy.

OBJECTIVE: To assess whether Indigenous Australians age prematurely compared with other Australians, as implied by Australian Government aged care policy, which uses age 50 years and over for population-based planning for Indigenous people compared with 70 years for non-indigenous people. METHODS: Cross-sectional analysis of aged care assessment, hospital and health survey data comparing Indigenous and non-indigenous age-specific prevalence of health conditions. Analysis of life tables for Indigenous and non-indigenous populations comparing life expectancy at different ages. RESULTS: At age 63 for women and age 65 for men, Indigenous people had the same life expectancy as non-indigenous people at age 70. There is no consistent pattern of a 20-year lead in age-specific prevalence of age-associated conditions for Indigenous compared with other Australians. There is high prevalence from middle-age onwards of some conditions, particularly diabetes (type unspecified), but there is little or no lead for others. CONCLUSION: The idea that Indigenous people age prematurely is not well supported by this study of a series of discrete conditions. The current focus and type of services provided by the aged care sector may not be the best way to respond to the excessive burden of chronic disease and disability of middle-aged Indigenous people.

Indigenous aged care service use and need for assistance: how well is policy matching need?

AIM: To investigate the effectiveness of the Australian Government's aged care planning framework for Indigenous Australians, particularly the use of a lower planning age of 50 years. METHODS: We analysed published data and administrative datasets relating to population demographics, aged care assessments, admissions and usage, need for assistance and expenditure, comparing the Indigenous 50-69 and 70+ age groups with the non-Indigenous 70+ age group. RESULTS: Indigenous people aged 50-69 years have much lower utilisation, and a different pattern of utilisation, of aged care services than either Indigenous or non-Indigenous people aged 70 and over. Community-based services are much more important for Indigenous than non-Indigenous people, regardless of age. CONCLUSION: The planning framework conflates the diverse needs of Indigenous people across a wide age range and does not set a meaningful target for service provision. It has not ensured the right balance of services across geographic areas and between different levels of care.

Indigenous participation in an informal national indigenous health policy network.

UNLABELLED: OBJECTIVE; To determine and describe the features of Indigenous participation in an informal national Indigenous health policy network. DESIGN: A questionnaire was administered during 2003-04. Through a snowball nomination process a total of 227 influential persons were identified. Of these, 173 received surveys of which 44 were returned, a return rate of 25%. OUTCOME MEASURES: These data were analysed to detect the existence of network groups; measure the degree of group interconnectivity; and measure the characteristics of bonds between influential persons. Demographic information was used to characterise the network and its groups. RESULTS: Indigenous people were integral to the network due to their high representation, their distribution throughout the 16 groups, and the interconnections between the groups. The network was demographically diverse and multiple relational variables were needed to characterise it. Indigenous and non-Indigenous people had strong ties in this network. CONCLUSION: Social network methods made visible an informal network where Indigenous and non-Indigenous people relate in a complex socio-political environment to influence national Indigenous health policy. What is known about the topic? The participation of Indigenous people is acknowledged as important in health, but there is criticism of the lack of real opportunities for Indigenous people to participate in national Indigenous health policy processes.

Ethics review of multisite studies: the difficult case of community-based indigenous health research.

Researchers have longstanding concerns about the logistical and administrative burdens posed by ethics review of multisite studies involving human participants. Centralised ethics review, in which approval by one committee has authority across multiple sites, is widely touted as a strategy for streamlining the process. The Harmonisation of Multi-centre Ethical Review (HoMER) project is currently developing such a system for Australia. It is unclear how centralised review will work for multisite Indigenous health research, where the views of local stakeholders are important and community consultation is mandatory. Our recent experience in conducting the National Indigenous Eye Health Survey (NIEHS) shows how elaborate the current ethics approval and community consultation processes can be, and points to several lessons and ideas to guide pending reforms.

Is peer review useful in assessing research proposals in Indigenous health? A case study.

BACKGROUND: There has been considerable examination and critique of traditional (academic) peer review processes in quality assessment of grant applications. At the same time, the use of traditional research processes in Indigenous research has been questioned. Many grant funding organisations have changed the composition of their peer review panels to reflect these concerns but the question remains do these reforms go far enough? In this project we asked people working in areas associated with Aboriginal health research in a number of capacities, their views on the use of peer review in assessing Indigenous research proposals. METHODS: In semi-structured interviews we asked 18 individuals associated with an Australian Indigenous research funding organisation to reflect on their experience with peer review in quality assessment of grant applications. We also invited input from a steering group drawn from a variety of organisations involved in Aboriginal research throughout Australia and directly consulted with three Aboriginal-controlled health organisations. RESULTS: There was consensus amongst all participants that traditional academic peer review is inappropriate for quality assessment in Indigenous research. Many expressed the view that using a competitive grant review system in Aboriginal health was counterintuitive, since good research transfer is based on effective collaboration. The consensus within the group favoured a system which built research in a collaborative manner incorporating a variety of different stakeholders in the process. In this system, one-off peer review was still seen as valuable in the form of a "critical friend" who provided advice as to how to improve the research proposal. CONCLUSION: Peer review in the traditional mould should be recognised as inappropriate in Aboriginal research. Building research projects relevant to policy and practice in Indigenous health may require a shift to a new way of selecting, funding and conducting research.

Accessibility and quality of care received in emergency departments by Aboriginal and Torres Strait Islander people.

OBJECTIVES: To examine the accessibility and quality of care received in emergency departments by Aboriginal and Torres Strait Islander people compared with other Australians. METHODS: We examined 2004-05 data from the National Non-admitted Patient Emergency Department Care database from the Northern Territory and Western Australia, the only jurisdictions where Indigenous identification in the database was considered acceptable. RESULTS: In the NT, Indigenous people were 1.7 times as likely to present to an emergency department as non-Indigenous people. Indigenous patients in the NT and WA do not appear to use EDs for "primary care" problems more than non-Indigenous patients. More NT Indigenous patients walked out before being seen or before their treatment was completed. However, Indigenous patients generally waited a similar time, and often slightly shorter, to be seen as similar non-Indigenous patients in WA and the NT. CONCLUSIONS: We recommend the regular monitoring of equity in the accessibility and quality of ED care for Indigenous people compared with other Australians. Indigenous identification in the database needs to improve so monitoring of ED performance can extend beyond WA and the NT.

The national Indigenous health performance measurement system.

This article reviews the development of the national Indigenous performance measurement system over the last decade. Data were collected from the published and unpublished literature and review of government websites, facilitated by key informant interviews which provided information about the policy context. A number of innovations have occurred over the last decade, including the development of a conceptual framework to underpin a system-wide approach to performance measurement that is aligned with nationally agreed strategic goals. The development of mechanisms to oversee Indigenous health strategy and health data development create formal mechanisms that potentially link data development and performance measurement priorities. Innovation in the development of processes to support health system performance improvement is evident, but this needs to be prioritised, particularly with respect to those components of the health system that are not Indigenous-specific.

The social determinants of being an Indigenous non-smoker.

OBJECTIVE: To examine the association between various social factors and being a non-smoker in a national survey of Aboriginal and Torres Strait Islander people aged 15 and over. METHODS: We analysed data from the 2002 National Aboriginal and Torres Strait Islander Social Survey (n=9,400) using logistic regression. RESULTS: About a half (51.2%) of the Aboriginal and Torres Strait Islander population aged 15 years and over smoked, 33.4% had never smoked, and 15.4% were ex-smokers. Higher socio-economic position (as measured by each of nine variables) was strongly associated with being a non-smoker rather than a smoker, after controlling for age and gender. There was a clear income gradient: increasing household income was associated with increasing likelihood of being a non-smoker. Indigenous people who had been arrested in the last five years were 4.5 times less likely to be non-smokers, adjusted for age and gender. Indigenous people who had been removed from their natural family were half as likely to be a non-smoker. CONCLUSIONS: Different groups within the Indigenous population have quite different smoking behaviours, although the prevalence of smoking is very high in all groups. The poorest and most socially disadvantaged are the least likely to be non-smokers. IMPLICATIONS: Indigenous tobacco control programs need to consider additional targeting of more disadvantaged groups. Tobacco control programs should work with broader campaigns to ameliorate social disadvantage among Indigenous peoples.

Closing the indigenous health gap.

On 24 March 2008, Prime Minister Kevin Rudd, the leader of the Federal Opposition, and health sector leaders signed a pledge to close the indigenous health gap by 2030 and the equity gap in health service provision by 2018. This is a big challenge - Indigenous Australians have a life expectancy 17 years less than non-Indigenous Australians and a burden of disease 2.5 times higher.

An unsuspected ecdysteroid/steroid phosphatase activity in the key T-cell regulator, Sts-1: surprising relationship to insect ecdysteroid phosphate phosphatase.

The insect enzyme ecdysteroid phosphate phosphatase (EPP) mobilizes active ecdysteroids from an inactive phosphorylated pool. Previously assigned to a novel class, it is shown here that it resides in the large histidine phosphatase superfamily related to cofactor-dependent phosphoglycerate mutase, a superfamily housing notably diverse catalytic activities. Molecular modeling reveals a plausible substrate-binding mode for EPP. Analysis of genomic and transcript data for a number of insect species shows that EPP may exist in both the single domain form previously characterized and in a longer, multidomain form. This latter form bears a quite unexpected relationship in sequence and domain architecture to vertebrate proteins, including Sts-1, characterized as a key regulator of T-cell activity. Long form Drosophila melanogaster EPP, human Sts-1, and a related protein from Caenorhabditis elegans have all been cloned, assayed, and shown to catalyse the hydrolysis of ecdysteroid and steroid phosphates. The surprising relationship described and explored here between EPP and Sts-1 has implications for our understanding of the function(s) of both.

Mutual obligation, shared responsibility agreements & indigenous health strategy.

Since 2004 the Howard Coalition government has implemented a new policy framework and administrative arrangements as part of its program of reform in Indigenous affairs. In this paper I will describe both the parameters of this reform program and review the processes established to support the implementation of national Indigenous health strategy. In particular, I will consider both the shift from a policy framework based on 'self-determination' to one based on 'mutual obligation', and the implementation of Shared Responsibility Agreements (SRAs) that are based on the latter principle. I will use the example of the Mulan SRA to illustrate the difficulties in articulating the 'new arrangements' with current approaches to Indigenous health planning and strategy implementation. I conclude that 'new arrangements' pose a number of problems for Indigenous health planning and strategy that need to be addressed.

Long-term trends in Indigenous deaths from chronic diseases in the Northern Territory: a foot on the brake, a foot on the accelerator.

OBJECTIVE: To examine trends in Northern Territory Indigenous mortality from chronic diseases other than cancer. DESIGN: A comparison of trends in rates of mortality from six chronic diseases (ischaemic heart disease [IHD], chronic obstructive pulmonary disease [COPD], cerebrovascular disease [CVD], diabetes mellitus [DM], renal failure [RF] and rheumatic heart disease [RHD]) in the NT Indigenous population with those of the total Australian population. PARTICIPANTS: NT Indigenous and total Australian populations, 1977-2001. MAIN OUTCOME MEASURES: Estimated average annual change in chronic disease mortality rates and in mortality rate ratios. RESULTS: Death rates from IHD and DM among NT Indigenous peoples increased between 1977 and 2001, but this increase slowed after 1990. Death rates from COPD rose before 1990, but fell thereafter. There were non-significant declines in death rates from CVD and RHD. Mortality rates from RF rose in those aged > or = 50 years. The ratios of mortality rates for NT Indigenous to total Australian populations from these chronic diseases increased throughout the period. CONCLUSIONS: Mortality rates from IHD and DM in the NT Indigenous population have been increasing since 1977, but there is evidence of a slower rise (or even a fall) in death rates in the 1990s. These early small changes give reason to hope that some improvements (possibly in medical care) have been putting the brakes on chronic disease mortality among Aboriginal and Torres Strait Islander peoples.

Sudden infant death syndrome and unascertainable deaths: trends and disparities among Aboriginal and non-Aboriginal infants born in Western Australia from 1980 to 2001 inclusive.

AIM: To analyse patterns and trends in mortality from unknown causes (sudden infant death syndrome and unascertainable deaths) for all Aboriginal and non-Aboriginal infants born in Western Australia, 1980-2001. METHODS: Using total population linked data, we reviewed all post-mortem reports, including death scene investigations and final causes of death as ascertained by the coroner. Neonatal, post-neonatal and infant mortality rates attributed to unknown causes were calculated and the latter were analysed according to maternal age, geographical location, gestational age, sex and birthweight. Relative risks (95% confidence interval) for Aboriginal infants (compared with non-Aboriginal) were calculated. RESULTS: The proportion of deaths considered to be of unascertainable cause has significantly increased in recent years. In contrast to the non-Aboriginal population, there has been no significant decrease in deaths in the Aboriginal population and the overall relative risk for Aboriginal infants for the most recent years studied was 7.9 (95% confidence interval 5.1-12.2). The relative risk was significantly increased for most categories analysed. CONCLUSION: Reviewing post-mortem reports enabled identification of changes in the classification of deaths due to unknown causes. This provided a more accurate picture of the patterns and long-term trends of such deaths so that programmes can be developed to specifically target those groups most at risk. Adequately funded and evaluated education campaigns aimed at reducing the risk of sudden infant death syndrome among Aboriginal infants are required, as well as sustaining the current efforts that have been so successful for non-Aboriginal infants.

'Individual' harms, Community 'harms': reconciling Indigenous values with drug harm minimisation policy.

This paper uses data on the social context of drug-related harms in the Melbourne Aboriginal Community to inform an alternative model of harm minimisation, and discusses its potential application in programme development. The paper involves a secondary analysis of interviews and focus group discussions with 62 Community members who participated in a qualitative injecting drug use study conducted at the Victorian Aboriginal Health Service in Melbourne. Individuals and families within the Melbourne Aboriginal Community experience significant levels of harm associated with injecting drug use, and face restricted access to appropriate service options. This experience of drug use contributes to a broad range of values within the Community around harm minimisation approaches to programme delivery. We propose a fundamentally distinct harm minimisation model which explicitly acknowledges this range of conflicting values, and reflects the need for a breadth of services and programmes that address these tensions. Policies and funding must support Aboriginal Communities to negotiate through these conflicting Community values to actively create spaces in the service system for both using and non-using Community members. This includes the development of regional approaches which articulate an appropriate mix of services and the roles of Aboriginal and mainstream services in their delivery.

Patterns, trends, and increasing disparities in mortality for Aboriginal and non-Aboriginal infants born in Western Australia, 1980-2001: population database study.

BACKGROUND: Since there are known disparities between Aboriginal and non-Aboriginal populations in Australia, trends in infant mortality rates can be used to assess the effectiveness of programmes designed to improve the health of Aboriginal populations. We have examined mortality rates in these populations in Western Australia. METHODS: We used the most comprehensive and valid total population data available for an Australian state to determine all-cause and cause-specific mortality for Aboriginal and non-Aboriginal infants born in Western Australia from 1980 to 2001. FINDINGS: Overall, infant mortality rates fell in both populations, but less so in Aboriginal (from 25.0 in 1980-84 to 16.1 in 1998-2001) than in non-Aboriginal infants (from 8.4 in 1980-84 to 3.7 in 1998-2001) such that disparities between the two groups increased for all major causes of infant death. The relative risk for Aboriginal compared with non-Aboriginal infants rose from 3.0 (95% CI 2.5-3.6) to 4.4 (3.5-5.5), and there were significantly more potentially preventable deaths, such as those caused by infections (5.9 per 1000 livebirths vs 0.7 per 1000 livebirths, RR 8.5, 95% CI 7.1-10.2). Additionally, for Aboriginal infants, postneonatal mortality rates were higher than neonatal mortality rates (11.2 per 1000 livebirths vs 9.7 per 1000 livebirths), trend analyses showed that previous reductions in deaths due to preterm birth (4.3 per 1000 livebirths--1.4 per 1000 livebirths from 1980-97) were not sustained in the most recent years studied (3.5 per 1000 livebirths), and rates of sudden infant death syndrome did not fall significantly (4.9 per 1000 livebirths vs 4.7 per 1000 livebirths). INTERPRETATION: These increasing disparities between Aboriginal and non-Aboriginal infants, especially in remote areas, demand immediate action in partnership with Aboriginal communities, focusing on both access to primary health care and better living conditions. Implementation and assessment of policies to reduce the continuing social and economic disadvantage faced by Aboriginal families are vital.