Australian Indigenous

Theses

Ivers, R. (1998). 'Healthy adult checks' - An evaluation of preventive health activities for adults in two remote Aboriginal communities. Unpublished Master of Public Health thesis, University of Sydney, Sydney.

Morris, P.S. (1998). Improving the medical management of otitis media and other chronic bacterial respiratory diseases in rural and remote Australian Aboriginal children: A systematic approach. Unpublished Doctor of Philosophy thesis, University of Sydney, Sydney.

Thompson, S.J. (1997). Questionnaire development in epidemiology: A case study - the social epidemiology of diabetes in Melbourne Aborigines. Unpublished Doctor of Philosophy thesis (Epidemiology), University of California, Berkley.

Ivers, R. (1998).

Aim
The aim of this study was to assess whether Aboriginal adults in two remote communities in the Top End of the Northern Territory had received preventive interventions over a two-year period according to the recommendations of the Royal Australian College of General Practitioners and to other recommendations on preventive interventions that may be relevant to Aboriginal adults. The aim was to find out whether people had records of being under-screened or over-screened, to compare opportunistic screening with mass screening, and to discover if age and sex made a difference to whether a person had received adequate preventive interventions.

Method
The sample group included Aboriginal people who lived for most of the time in either of two remote communities in the Top End. Four hundred and four medical records were assessed for presentations over a two-year period, and for presentations at mass screening activities. Records were assessed for evidence of specific preventive interventions and for a 'package' of basic preventive health items.

Results
Adults in the two communities had between zero and 101 presentations to the health centre in two years, with a mode of four consults and a mean of 14.6 consults. Ninety-nine per cent of adults had had a visit recorded in the two-year period. Women had presented more often than men. Older people had presented more often than younger people. Young men were less likely to attend more than ten times in the two-year period. Old women were the most likely to attend more than ten times in the two-year period. In the two-year period, 42.3% of people had attended a mass screening activity. Middle aged men were the most likely to have attended a screening activity. Old men were the least likely to have attended screening activities. Of specific interventions, blood pressure was the most frequently recorded (recorded in 90.8% of medical records during a two-year period). Fifty-nine per cent of women 18-70 years of age had had a Pap smear in the study period. Items such as asking about tobacco and alcohol were frequently recorded at screening activities but not opportunistically. Some interventions, such as asking about nutrition and annual dental examinations, were infrequently recorded (13.9% and 13.1% respectively). Only 18.3% of adults had records of a 'package' of a combination of history of tobacco and alcohol, blood pressure, Pap smear, mammogram and delivery of appropriate vaccinations. People who had attended mass screening were more likely to have received preventive interventions than people who had received preventive care opportunistically. Young men were the least likely to attend for preventive health care and old men and women were least likely to have received a package of appropriate preventive interventions.

Conclusion
Many Aboriginal adults in these two remote communities had not had preventive health interventions as recommended by guidelines. Very few had had more preventive health interventions than are recommended. Mass screening proved to be an effective way of delivering preventive care, but most people had attended the health centres providing the opportunity for preventive interventions. More emphasis needs to be placed on ensuring that old people receive preventive health care.

Morris, P.S. (1998).

The link between ill-health has been appreciated for some time. The extremely high rates of persistent and sever otitis media, rhinosinusitis and bronchitis seen in rural and remote Aboriginal children are another striking illustration. Previous research by the Menzies school of Health Research has indicated that, in the case of otitis media, disease begins in the first few weeks of life and that the impact of poverty is mediated through early and heavy colonisation of the nasopharynx with potential respiratory pathogens. This is consistent with data from other populations with high rates of respiratory bacterial disease.

The role of medical care and medical research in improving health outcomes for rural and remote Aboriginal children has a controversial history. Most of the debate revolves around the importance of medical care given in the underlying socioeconomic causes of disease, and whether medical researchers have benefited at the expense of their Aboriginal participants. Chapters 2 and 3 present the theoretical reasons why improved medical care could have enormous health benefits in this population, but advises that maximum benefit will only be achieved if there is a commitment to more applied clinical research. The systematic review of randomised controlled trials addressing the Aboriginal health problems (Chapter 4) shows that Aboriginal Australians are disadvantaged by the lack of well designed clinical research. While not addressing the motives and intentions of the research community, it supports the need to orientate researchers toward intervention studies.

Chapters 5 and 6 continue with the "evidence-based medicine" theme and suggest potential area where medical practice might be improved. A comprehensive and explicit review of the available medical literature is used to address the following clinical issues: 1) clarification of the diagnostic criteria; 2) the anticipated prognosis 3) provision of effective therapy. These systematic reviews emphasise the lack of research evidence addressing many fundamental aspects of clinical care for respiratory mucosal infections in rural and remote Aboriginal children.

Chapter 7 provides the first description of the diagnostic features of otitis media, rhinosinusitis and bronchitits for infants living in a remote Aboriginal community. For otitis media, asymptomatic bulging of the tympanic membrane is the best predictor of subsequent disease. The differences in clinical presentation compared with other populations emphasise the need for local data when the generalisability of research evidence is questioned. The concept of "pus producing" infections appears to be useful in distinguishing low-risk from very high-risk groups. A study examining the consistency of diagnosis using video images of pneumatic otoscopy identified considerable variability between six independent experts. The analysis suggests that even experts may underestimate the severity of disease in high-risk populations. Chapter 8 contributes to the unique longitudinal data already collected by the Menzies School of Health Research. Children enrolled in the first published prospective study involving remote Aboriginal children documented frequent attendances at the local health clinic (on average 38 by 1 year of age). "Sick" visits are most commonly for respiratory tract infections (5 per year), skin infections (2 per year), and diarrhoea (2 per year). Infants rarely present with ear infections. Failure to thrive also affects more than 50% of infants but is rarely described until the child is malnourished.

Chapter 8 also describes the changes in tympanic membrane appearance over time. The persistence of suppurative disease, even within a randomised controlled trial where 50% of infants are receiving long term antibiotic therapy and additional antibiotic use is common, is remarkable. Most severe disease starts in the first 18 months of life and improvement prior to 5 years of age is unusual. A study of school children conducted in another otitis-prone community documents that there are a small portion of children who change "ear states" over a four to six month period. However, this could result in considerable differences over longer periods, especially considering the relative lack of medical interventions applied within this age group.

Chapter 9 describes the available data from 2 randomised controlled trials of antibiotic. In COMIT 1 (Chronic Otitis Media Intervention Trial 1), children are randomised to amoxycillin or placebo when asymptomatic OME is present and this continues for up to 6 months. Fifty children have completed the study (required sample size of 120) but the results already have important implications for clinical practice. Only one child had aerated middle ears at the completion of the study. Antibiotics appear to have a limited effect on OME even in high risk populations. However, there has been a dramatic improvement in rates of AOM and perforation in infants within the community. It is not clear whether this is due to this research program, or other factors. The advantages of the randomised design in assessing specific interventions in these circumstances are clear.

In COMIT 2 children with CSOM were treated with standard therapy (topical framycetin-gramicidin-dexamethasone drops) and randomised to high or low compliance strategies with or without amoxycillin. The effect of amoxycillin was measured by its impact on the amount of nasal discharge. Fifty children completed the study. After six weeks of intensive therapy, only 5% of ears were dry. This is considerably less than the cure rates usually reported in the literature. The effect of amoxycillin on nasal discharge was not statistically significant, but there was a trend toward improvement. If these children do represent important transmitters of infection then modest benefits are worth pursuing. Further work examining these issues is currently in progress.

In summary, systematic reviews and the original research in this thesis support the view that chronic suppurative respiratory disease is a vicious circle of inflammation which promotes a state of persistent bacterial infection. Affected individuals may be important transmitters of infection. Medical interventions able to limit either severity of disease or spread of infection have enormous implications for disadvantaged children throughout the world. For otitis media, suppurative disease first presents as an asymptomatic bulging tympanic membrane. This is a chronic condition hat rarely resolves spontaneously. The preliminary clinical trial results have described the potential benefits and limitations of antibiotic therapy. Further trials are urgently required if we are to maximise the impact of effective medical therapy in high risk populations.

Thompson, S.J. (1997).

This thesis addresses the limitations of the epidemiological method applied cross-culturally, using as a case-study the social epidemiology of non-insulin dependent diabetes mellitus (NIDDM) in Aborigines living in Melbourne, Australia. Methods of anthropology were used to complement social epidemiological methods for the development and administration of a culturally sensitive and meaningful questionnaire.

The overall research design consisted of three stages and employed a mixture of qualitative and quantitative methods. The first stage was an ethnographic study based at an Aboriginal community-controlled health service. The results of the ethnographic analysis were used in the second stage for the development and refinement of a quantitative questionnaire for NIDDM and in the final stage, the questionnaire was administered in a pilot case-control study.

The wider socio-cultural context plays an important role in the way in which Aboriginal people experience and understand diabetes and its risk factors. The family has a major influence on an individual's food habits, their exercise patterns, stress, and, for people living with diabetes, the management of their diabetes. For Melbourne Aborigines, family and community priorities far outweigh individual needs and so individual behavior is best examined within the context of family and community. Connections to extended family, land and past are important for health and well-being. Diabetes is experienced as a series of acute illnesses and is perceived as unpredictable like many other aspects of Aboriginal life.

Within this broader context, the study has identified more specific socio-cultural categories of risk. In the case-control pilot study, not only did the findings show that the questionnaire instrument was culturally valid and reliable, but also that the process of the development of the instrument in partnership with the affected community, resulted in ownership and empowerment.

Conclusion
The application of anthropological methods to epidemiology resulted in the development of a culturally sensitive and appropriate epidemiological questionnaire that has closer links to public health intervention because it includes the measurement of socio-cultural categories, behavioral factors within their social and cultural context and is tailored to sub-groups of gender and social strata in the Melbourne Aboriginal community. The ethnographic process facilitated community participation and ownership of both the questionnaire and research process.

Last updated: 11 July, 2003