Remote Australia Online

ISSUE ADDRESSED: Food insecurity in remote Western Australian (WA) Indigenous communities. This study explored remote community store managers' views on issues related to improving food security in order to inform health policy. METHODS: A census of all remote WA Indigenous community store managers was conducted in 2010. Telephone interviews sought managers' perceptions of community food insecurity, problems with their store, and potential policy options for improving the supply, accessibility, affordability and consumption of nutritious foods. Descriptive analyses were conducted using SPSS for Windows version 17.0. RESULTS: Managers stated that freight costs and irregular deliveries contributed to high prices and a limited range of foods. Poor store infrastructure, compromised cold chain logistics, and commonly occurring power outages affected food quality. Half of the managers said there was hunger in their community because people did not have enough money to buy food. The role of nutritionists beyond a clinical and educational role was not understood. CONCLUSIONS: Food security interventions in remote communities need to take into consideration issues such as freight costs, transport and low demand for nutritious foods. Store managers provide important local knowledge regarding the development and implementation of food security interventions. SO WHAT? Agencies acting to address the issue of food insecurity in remote WA Indigenous communities should heed the advice of community store managers that high food prices, poor quality and limited availability are mainly due to transport inefficiencies and freight costs. Improving healthy food affordability in communities where high unemployment and low household income abound is fundamental to improving food security, yet presents a significant challenge.

This paper examines co-creative video outputs that have originated from, or relate to, remote Indigenous communities in Australia. Scholarly work on remote media has mostly operated at the interface of media studies and anthropology, seeking to identify how cultural systems shape the production, distribution and reception of media in Aboriginal communities. This paper looks instead at content themes, funding sources and institutions during the 2010-2013 period, and examines the factors that may be determining the quantity of co-creative outputs, as well as the types of stories that get produced. I argue that the focus on culture has obscured important shifts in remote media policy and funding, including a trend towards content designed to address social disadvantage.

It is well accepted that actions to enhance food security and nutrition outcomes in remote Indigenous Australian communities have limited success when focusing on single factors and could far better be addressed by working across the whole food system. The formation of multi-sector groups to collectively work towards improved food security could facilitate this approach. This study sought to elicit the perceptions of a range of stakeholders on the enablers, barriers and perceived benefits of a multi-sector participatory approach that was developed and trialled with four communities to improve food security. Semi-structured interviews were used to collect data from 60 persons and transcripts were examined using thematic analysis. Findings revealed that there is support in engaging a diverse range of stakeholders in a process of community-led action to support incremental improvement. The employment and support of local community co-ordinators, the multi-sectoral and structured approach, the use of participatory tools, and the facilitation approach were identified as key enablers. Main barriers cited were competing demands and time restraints while a slowing in momentum and lack of timely communication of actions for follow-up were areas needing improvement. Perceived changes in the availability and accessibility of healthy food and improvements in retail practice were believed by participants to derive from (i) creating a supportive environment; (ii) bringing people together; and, (iii) increasing knowledge and capacity. This study offers insight into understanding where the opportunities are in supporting a multi-sectoral approach to improving food security in remote Indigenous Australia.

Background: Poor nutrition contributes to high rates of coronary heart disease among Australian Aboriginal populations. Since late 1993, the Aboriginal community described here has operated a healthy lifestyle program aimed at reducing the risk of chronic disease.Objective: We evaluated the effectiveness of a community-directed intervention program to reduce coronary heart disease risk through dietary modification.Design: Intervention processes included store management policy changes, health promotion activities, and nutrition education aimed at high-risk individuals. Dietary advice was focused on decreasing saturated fat and sugar intake and increasing fruit and vegetable intake. Evaluation of the program included conducting sequential, cross-sectional risk factor surveys at 2-y intervals; measuring fasting cholesterol, lipid-soluble antioxidants, and homocysteine concentrations; and assessing smoking status. Nutrient intakes were estimated from analysis of food turnover in the single community store.Results: There was a significant reduction in the prevalence of hypercholesterolemia (age-adjusted prevalences were 31%, 21%, and 15% at baseline, 2 y, and 4 y, respectively; P < 0.001). There were significant increases in plasma concentrations of α-tocopherol, lutein and zeaxanthin, cryptoxanthin, and β-carotene across the population. Retinol and lycopene concentrations did not change significantly. Mean plasma homocysteine concentrations decreased by 3 μmol/L. There was no significant change in smoking prevalence between the 2 follow-up surveys. There was an increase in the density of fresh fruit and vegetables and carotenoids in the food supply at the community store.Conclusion: This community-directed dietary intervention program reduced the prevalence of coronary heart disease risk factors related to diet.

CONTEXT: Lynch syndrome (LS), also referred to as hereditary non-polyposis colorectal cancer, is a familial cancer syndrome characterised by young age of onset of colorectal and other extra-colonic cancers. Most studies suggest that LS accounts for approximately 1% of all colorectal cancers (CRC). The identification of persons with a mutation for this syndrome is of major clinical importance because regular and life-long surveillance has been shown to improve their survival through early cancer detection. However, the identification of LS among CRC patients is a major challenge because there are no specific distinguishing clinical features. Clinical criteria based on family history of cancer and age of cancer diagnosis have been proposed. For various reasons, these are not well utilised and clinicians often fail to refer high-risk CRC patients for genetic assessment of LS. The low rate of referrals to the single, state-wide familial cancer program in Western Australia led to calls for a more sensitive and specific means of detecting LS cases. Virtually all tumours from LS patients are characterised by the molecular features of microsatellite instability (MSI) and loss of expression of mismatch repair proteins detected by immunohistochemistry (IHC). It was recently established that routine MSI and IHC testing in CRC patients aged under 60 years was an effective screening tool to identify previously unrecognized LS cases. This approach has now become routine practice in Western Australia and has led to the identification of more than 20 new LS families, including the Indigenous family described in this report. ISSUES: Population-based screening programs can identify individuals who may not be aware of their at-risk status, who may have little prior knowledge of their medical condition and who may have limited access to tertiary health services. This report describes some challenges met when following up a positive screening result for LS in an individual residing in a remote community more than 2000 km from the state's only Family Cancer Clinic. The challenges included finding the patient, arranging genetic counselling and testing, informing him of the result and providing advice regarding life-long surveillance. Also discussed are issues relating to management of the extended kindred in terms of cultural sensitivities, intra-familial communication and involvement of the local health providers, as well as the provision of genetic counselling, testing and surveillance services for patients living in remote regions. Prior to this study, there were no known Indigenous families with LS in Australia. LESSONS LEARNED: The likelihood of finding hereditary cancer syndromes in Indigenous families living in remote communities is low. However, advances in modern diagnostic screening technologies will result in the identification of an increased number of at-risk individuals, some of whom will be from minority groups or from remote communities. Despite geographical isolation and cultural differences, hereditary cancer syndromes can be managed in individuals and families living in rural and remote areas. The key issues identified from this case are flexibility with standard clinical genetic protocols and the presence of a local medical practitioner who takes an active interest in delivery of the genetic testing and surveillance strategies.

BACKGROUND: This study took place in a remote community on the Ngaanyatjarra Lands, Western Australia. Ngaanyatjarra women's cultural practices have been subject to erosion during the past 70 years. Women are now expected to birth hundreds of kilometres from home and, due to financial barriers, without family support. Older women lament their lack of input into, and control of, contemporary birthing services. RESEARCH QUESTION: In order to provide culturally appropriate maternity services we asked: What issues would the Ngaanyatjarra women of the community like to see resolved in the area of antenatal and birthing services? PARTICIPANTS AND METHODS: Eligible participants were any Ngaanyatjarra women of the study community who had birthed at least once. We utilised a participatory research methodology. 36 women were interviewed. FINDINGS: This paper discusses one finding related to support for child-bearing women. The role is important in many ways. Ngaanyatjarra women did not traditionally have their support persons with them during labour and birth, nor do they necessarily expect them to be present in current times. Most women do, however, wish to have a support person with them during antenatal checkups and when they travel to town to await birth. CONCLUSION: Aboriginal women from remote communities should be able to have a support person with them when they access regional birthing services, but the nature of this role must not be assumed. A culturally appropriate service has input from the community, provides options and respects choices.

Gestational diabetes and the risk of subsequent Type 2 diabetes in Australian Aboriginal women living in a remote community

OBJECTIVE: The Western Desert Kidney Health Project (WDKHP) is an innovative clinical screening, arts-health and community development program, staffed by Aboriginal health workers. The WDKHP is aimed at prevention and early detection, improving the chance of better management of kidney disease among people in 10 predominantly Aboriginal communities in rural Western Australia. This paper aimed to understand community responses to the WDKHP in three of these communities. METHODS: Interviews were undertaken with 26 Aboriginal people living in three remote communities. Community responses were analysed with attention to the social organisation of participants in each community and a focus on the perspectives of key groups, identified here as 'Community Leaders', 'Homelanders', 'Refuge Seekers' and 'Dislocated'. RESULTS: Participants from all groups reported that the WDKHP was highly acceptable, and an effective means of drawing attention to the need for prevention, early detection and management of diabetes and kidney disease. The integration of Aboriginal health workers to explain the project contributed to the high rates of participation in clinical screening. CONCLUSIONS: Outreach clinical services can be an appropriate method of engaging people in remote communities in addressing diabetes and kidney disease. IMPLICATIONS: The remote community setting can act as an 'enabler' of healthy lifestyle for Aboriginal people, particularly when augmented by well-designed outreach programs.

SUMMARY: Background: Rates of albuminuria and haematuria are extremely high with haematuria prevalence as high as 30–50% in adults of some Aboriginal groups. Dipstick testing of urine is routinely carried out in Aboriginal communities and as part of school screening programmes. Evaluation of the many affected individuals has traditionally included renal ultrasound examination, which involves considerable expense and logistic problems in remote communities. The present study was conducted to evaluate the usefulness of ultrasound in this setting. Methods: A population survey was conducted in a remote community. Urine dipstick analysis and the albumin : creatinine ratio (ACR; g/mol) were measured in 1440 people over 5 years of age (89% of the eligible population), and a detailed renal ultrasound examination was performed in a random subset of 647 people (41.1% of the whole group), 276 aged 5–19 years and 371 over 20 years of age. Results: Urine dipstick proteinuria (>1+) was present in 8.5% (23/271) of those aged 5–19years and 37.9% (132/348) in those aged over 20 years; pathological albuminuria (ACR > 3.4) was present in 7.6% (21/276) and 54.7% (203/371), respectively, and isolated haematuria was present in 7.7% (21/273) and 11.5% (40/347), respectively. Eight ultrasound abnormalities were found. Ultrasound findings did not change the management of any individual. Conclusion: Renal ultrasound added little to the evaluation of people with asymptomatic proteinuria or haematuria in this setting. In this scenario, ultrasound examination could be reserved for the cases with an unusual presentation where findings are likely to influence the prognosis or treatment, or in preparation for a renal biopsy.

We conducted an open label pilot study to investigate the feasibility of providing fish oil supplements containing n-3 PUFA to children in a remote, primarily Indigenous, Northern Territory (NT) school in preparation for a larger, placebo-controlled intervention. We were able to detect significant improvements in achievement relative to age in a cohort of children generally described as underachieving over a relatively short period of fish oil supplementation, warranting follow-up in larger, controlled trials in this population.

Aims: (1) To evaluate the acceptability and validity of an intervention based on urine tests for diagnosis and treatment of gonorrhoea and chlamydia in men in remote Aboriginal communities. (2) To provide a prevalence estimate of these infections in the male population in the surveyed communities. Methods: First-void urine samples from 460 men in remote communities and 33 men in the Alice Springs Gaol were tested for gonorrhoea and chlamydia with at least one of polymerase chain reaction (PCR), enzyme immunoassay (EIA) and culture (gonorrhoea only). Results: One hundred and three men (20.9%) were infected with gonorrhoea or chlamydia. The prevalence of infection for gonorrhoea only was 11.7%, for chlamydia only 4.1% and for dual infection 5.1%. Eighty-eight infected men and 45 of their sexual partners were recorded as having been treated within two months of testing. PCR tests detected the largest number of infections and were the easiest to use. Conclusions: The prevalence of these infections was higher than anticipated. Urine PCR tests were acceptable to men and are well suited to the remote-community setting. As an effective alternative to urethral swabs, they permit a range of community-based strategies to address high rates of infection with gonorrhoea and chlamydia.

This study explored the views of key stakeholders on cultural appropriateness of primary health care (PHC) services for Aboriginal people. A total of 78 participants, including healthcare providers, administrative team members (n=24, ~30% of study sample) and Aboriginal community members (n=54, ~70% of study sample) living in remote North West Queensland participated in the study. Outcome measures were assessed by administering survey questionnaires comprising qualitative questions and various subscales (e.g. provider behaviours and attitudes, communication, physical environment and facilities, and support from administrative staff). Descriptive statistics were used to present quantitative findings, whereas inductive thematic analysis was used for qualitative data. In contrast to the views of PHC providers, a significant number of Aboriginal people did not perceive that they were receiving culturally appropriate services. Although PHC providers acknowledged cultural awareness training for familiarising themselves with Aboriginal culture, they found the training to be general, superficial and lacking prospective evaluation. PHC providers should understand that culturally inappropriate clinical encounters generate mistrust and dissatisfaction. Therefore, a broad approach involving culturally respectful association between PHC providers, Aboriginal consumers and administrative staff is required to bring sustainable changes at the practice level to improve the health of Aboriginal people.

INTRODUCTION AND AIMS: In Arnhem Land's remote Aboriginal communities [Northern Territory], very high smoking rates and overcrowding mean high exposure to Environmental Tobacco Smoke. This study compared smokers who restrict their smoking in these environments with those who do not. DESIGN AND METHODS: In 2008-2009, 258 smokers (137 males and 121 females) aged >/= 16 years, provided information permitting categorisation of those who 'RESTRICT' their smoking in the house, car or workplace from those who do 'NOT RESTRICT'. Univariable and multivariable logistic regressions compared 'RESTRICT' and 'NOT RESTRICT' groups by gender, age group, daily use, tobacco consumption, time-to-first-cigarette and quit intentions. Those in the 'RESTRICT' group explained their motivations, summarised using qualitative data analysis. RESULTS: Men were almost twice as likely to 'NOT RESTRICT' their smoking (odds ratio = 1.88, 95% confidence interval = 1.14-3.08, P = 0.013). Time-to-first-cigarette was the strongest predictor to 'NOT RESTRICT' in women (odds ratio = 3.48, 95% confidence interval = 1.44-8.41, P = 0.006) with daily consumption the strongest predictor in men (odds ratio = 3.15, 95% confidence interval = 1.39-7.18, P = 0.006). Men and women shared similar motivations for restricting smoking. DISCUSSION AND CONCLUSIONS: Smoke-free homes and workplaces are important opportunities to reduce exposure to Environmental Tobacco Smoke in remote Indigenous communities.

Issue addressed: As part of a project addressing the nutritional health of Aboriginal people in western New South Wales (NSW), various environmental issues which may influence food habits were researched. Environmental issues researched included the extent and type of external advertising, food price and availability and takeaway food outlets. Methods: Four communities in western NSW participated in the study. The number, type and size dimensions were observed for all external advertising within the participating towns. The managers of takeaway food outlets within the participating towns were interviewed in relation to attitudes to adopting healthier food alternatives, food preparation practices and food marketing. The price and availability of food in the participating communities were recorded and compared to Woolworths in a larger regional centre. Results: Approximately 90 per cent of advertising focuses on unhealthy food options such as alcohol, soft drinks, takeaway foods and ice-cream. The majority of takeaway food shops do not wish to introduce healthier foods to their menus. The range of average prices for the selected food products was higher than those offered by a national food chain. So what? Recommendations have been formulated for each of these areas to improve nutritional status of Aboriginal people living in western NSW. Those recommendations complement the work of the Aboriginal Nutrition Project.

Background: Some strains of non–multidrug-resistant, methicillin-resistant Staphylococcus aureus (nmMRSA) in Australia are likely to have emerged from strains of methicillin-susceptible S. aureus (MSSA) in remote Aboriginal communitiesObjectiveTo describe the clinical epidemiology of infection due to community-associated MRSA strains in an Australian tropical hospital setting with a significant Aboriginal population and to compare infections caused by community-associated strains of MRSA, health-care–associated strains of MRSA, and MSSA strains with respect to demographic risk factors and clinical outcomesMethodsWe queried the microbiology database for the Top End of the Northern Territory, Australia, to determine population incidences for S. aureus infection and conducted a prospective matched case-control study to compare infection due to nmMRSA, MSSA, or multidrug-resistant MRSA at the Royal Darwin HospitalResultsThe annual incidence of S. aureus bacteremia was 65 cases per 100,000 population, but in the Aboriginal population the incidence was 172 cases per 100,000 population (odds ratio [OR] compared with non-Aboriginal population, 5.8 [95% confidence interval {CI}, 3.8–8.9). Female sex (adjusted OR [aOR], 1.5 [95% CI, 1.1–2.0) and remote residence (aOR, 1.8 [95% CI, 1.2–2.5]) were associated with the isolation of nmMRSA rather than MSSA, but disease spectrum and outcomes were similar. Among those from whom nmMRSA was isolated, Aboriginal patients were younger (aOR for each additional year, 0.94 [95% CI, 0.92–0.96]), more likely to be female (aOR, 3.8 [95% CI, 1.7–8.5]), and more likely to reside in a remote community (aOR, 29 [95% CI, 8.9–94]) than non-Aboriginal patients. The presence of Panton-Valentine leukocidin in nmMRSA was associated with double the odds of sepsis (aOR, 2.2 [95% CI, 1.1–4.6])ConclusionsThe association of nmMRSA infection with female sex and remote residence supports the hypothesis that nmMRSA arose from MSSA strains in remote Aboriginal communities where staphylococcal disease is highly prevalent. The similar clinical spectrum and outcomes for nmMRSA infection and MSSA infection suggest that virulence is not correlated with resistance phenotype

A portable nuclear medicine (NM) processing system was established in Kalgoorlie and an acute myocardial perfusion scintigraphy (MPS) service was provided for the local regional hospital. After scanning the patient, the data were processed on a laptop computer and JPEG images were transmitted to a secure Web server. A secure email message, with the URL link enclosed and a provisional indication of normal or abnormal findings, was sent to the referring clinician from the NM facility. Use of the Internet allowed for a group consultation between the NM technician, the referrer and the cardiologist in Perth. During a three-month study period, 42 patients were referred for exclusion of acute coronary syndrome. Of these, 21 (50%) demonstrated abnormal perfusion studies, two of which were classified as requiring urgent medical intervention. Seventeen studies were normal (41%) and four (10%) were designated equivocal. There was an alteration in the treatment plan for 32 patients (76%), including four for whom admission or further investigation was deemed unwarranted. The results suggest that MPS findings, distributed via the Internet, allow for earlier risk stratification and have a direct affect on clinical decision making.

Background: Thrombolytic treatment with streptokinase in acute myocardial infarction has proven to be safe and effective in Caucasian populations with relatively low levels of anti-streptokinase IgG and streptokinase resistance. Higher levels of antibodies, as seen in previous recipients of streptokinase therapy, cause more adverse reactions and may result in lower efficacy. Aims: To examine the levels of anti-streptokinase IgG and streptokinase resistance in a population subjected to endemic streptococcal infections. Methods and Results: Thirty Aboriginal adults from a remote community in Northern Australia with endemic streptococcal infections and 15 non-Aboriginal adults from an urban community without endemic infections participated in this study. Aboriginal adults exhibited levels of anti-streptokinase IgG and streptokinase resistance that, respectively, were almost 20 and 15 times greater than the values of non-Aboriginal adults. At least 23% of Aboriginal adults had sufficiently high levels of streptokinase resistance to neutralise a standard 1.5 million unit dose of streptokinase. Conclusions: Aboriginal adults from a remote community had dramatically elevated levels of anti-streptokinase IgG and in vitro streptokinase resistance. Prospective studies are needed to assess the clinical relevance of streptokinase resistance in populations from areas with endemic streptococcal infection.

INTRODUCTION: Many countries are facing an ageing of the nursing workforce and increasing workforce shortages. This trend is due to members of the 'baby boomer' generation leaving the workforce for retirement and a declining pool of younger people entering the nursing profession. New approaches to engaging older nurses in the workforce are becoming common in nursing globally but have yet to be adapted to remote contexts such as the Northern Territory (NT) of Australia. This article reports findings from a qualitative study of 15 participants who explored perceived opportunities for and barriers to implementing flexible strategies to engage older nurses in the NT workforce after they resign from full-time work. METHODS: The study used a descriptive qualitative design. Data were collected using semi-structured interviews with NT nurses approaching retirement (six nurses aged 50 years and over) and their managers (<em>n</em>=9). Clinicians were employed in practice settings that included hospitals, community health and 'Top End' (north of and including the town of Katherine), as well as Central Australian remote area communities. One participant who was employed as primary health centre manager in a remote community also held a clinical role. Managers were employed in both senior and line management positions in community and remote health as well as NT hospitals. RESULTS: Three major themes emerged from the data. First, interview participants identified potential for flexible post-retirement engagement of older nurses and a range of concrete engagement opportunities 'on and off the floor' were identified. Second, the main barriers to post-retirement engagement were an existing focus on the recruitment of younger Australian and overseas-trained nurses, and the remoteness of nursing practice settings from the residential locations of retired nurses. Third, existing informal system of post-retirement working arrangements, characterized by ad hoc agreements between individual nurses and managers, is poorly suited to scaling up. CONCLUSION: A knowledge and change-management approach is required to change employers' views of the value of older nurses. Better engagement of those nurses may assist the NT Department of Health address the severe nursing workforce shortages and prevent the loss of significant remote area nursing knowledge.

Objective: To assess the association between body mass index and the risk of all-cause and disease-specific mortalities in Australian Aborigines in a remote community. Design: A community based cohort study. Participants and setting: 744 Aboriginal adults aged 20 to 77 years in a remote community in Northern Territory. Eighty-seven deaths occurred during the follow-up period of 5,040.8 person-years. Measures: Mortality data for the period of 1992 and June 2000 were collected. Mortality rate ratios for each body mass index quartile was determined using a Cox proportional hazards model with adjustment for age, sex, and smoking and drinking status. Results: An inverse relationship between BMI quartiles and the risk of all-cause, natural, and non-CVD mortality was found. Adjusted rate ratios (95% CI) of all-cause mortality were 0.92 (0.54–1.59), 0.71 (0.40–1.26) and 0.38 (0.19–0.75) for second, third and fourth BMI quartiles, respectively, with the first quartile as the reference. The fourth BMI quartile had the lowest risk of mortality with adjusted rate ratios of 0.38, 0.28, and 0.16 for deaths from all-cause, natural, and non-CVD, respectively. However, the associations between BMI and CVD and renal deaths did not reach statistical significance. Conclusions: BMI and mortality are inversely associated in Aboriginal adults in a remote community. Individuals with relatively higher BMI have a lower risk of death.

OBJECTIVES: Study objectives were: 1) to describe the differences in the prevalence of CHD risk factors between Aboriginal people in a remote community and the general Australian population; and 2) to compare the predicted risks of CHD events between Aboriginal and non-Aboriginal Australians. DESIGN: A cross-sectional study. PARTICIPANTS: 681 Aboriginal adults aged 25 to 74 years. RESULTS: Aboriginal young adults had substantially higher prevalence of diabetes compared to non-Aboriginal Australians. The prevalence ratios for diabetes were 12.5, 5.6, 3.2, 1.3, and 0.73 for 25-, 35-, 45-, 55-, and 65- to 74-year-old females, respectively. The corresponding values for males were 12.1, 2.7, 2.9, 0.69, and 0.42. Young females had a higher prevalence of obesity, overweight, and abnormal waist circumference, while males and females 45 years and older tended to have a lower prevalence of overweight and abnormal waist circumference. Compared to the general population, Aboriginal adults had a lower prevalence of abnormal total cholesterol but a higher prevalence of abnormal HDL, triglycerides, hypertension, and smoking. The risk ratios of abnormal total cholesterol for females ages 25-34, 35-44, 45-54, 55-64, and 65-75 years were 0.38, 0.53, 0.48, 0.48, and 0.41, respectively. CONCLUSIONS: Aboriginal people in the remote community experienced different levels of CHD risk predictors from the general Australian population. They had a lower prevalence of abnormal total cholesterol and a higher prevalence of abnormal HDL, smoking, diabetes, and hypertension.

OBJECTIVE: To determine the extent to which the Framingham function predicts the risk of coronary heart disease (CHD) in Aboriginal people. DESIGN AND SETTING: Cohort study in an Aboriginal community in the Northern Territory. PARTICIPANTS: 687 Aboriginal people aged 20-74 years were followed up from a baseline examination in 1992-1995 through to 31 December 2003. MAIN OUTCOME MEASURE: First CHD events were identified through hospital and death records during the follow-up period. METHODS: An original Framingham function was used to predict CHD risk according to the duration of follow-up and the values of traditional risk factors, which included age, sex, total cholesterol level, high-density lipoprotein (HDL) cholesterol level, blood pressure, the presence of diabetes, and smoking status. The predicted CHD incidence using the Framingham function was 4.4 per 1000 person-years, while the observed incidence was 11.0 (95% CI, 8.7-13.9) per 1000 person-years. The observed number of CHD events (68) was 2.5 times the number predicted (27) using the Framingham function. The observed incidence was about four and three times the predicted incidence for age groups < 35 and 35-44 years, respectively, and about twice the predicted incidence for those over 45 years of age. The Framingham function was a particularly unreliable predictor for women, especially younger women, in whom the observed CHD rate was 30 times the predicted rate. CONCLUSIONS: The Framingham function substantially underestimates the actual risk of CHD observed in Aboriginal people in a remote community, especially for women and younger adults. This implies that traditional risk factors have different degrees of impact and/or that other factors are contributing to risk. A population-specific risk function is needed.

OBJECTIVE: To determine whether the association between obesity and coronary heart disease (CHD) in Aboriginal adults depends on age. DESIGN, SETTING AND PARTICIPANTS: A cohort study with up to 20 years of follow-up of 849 participants aged 18-76 years in a remote Aboriginal community in the Northern Territory of Australia. MAIN OUTCOME MEASURES: Newly diagnosed CHD cases were identified through hospital records according to ICD codes during the follow-up period. Cox proportional hazard model was used to assess whether the association between obesity and CHD depends on age. RESULTS: During the follow-up period, 171 participants were diagnosed with CHD. On an average, the incidence rate of CHD increased with the increasing baseline BMI, 11.3%, 16.3% and 20.2% for normal weight, overweight and obese groups, respectively. HR of CHD for obesity were 2.6 (95% CI 1.1to 6.3), 1.2 (0.7 to 2.0) and 0.5 (0.1 to 2.1) for those <40, 40-59 and 60+ years, respectively. HRs corresponding to 1 SD increase in BMI were 1.4 (1.0 to 2.0), 1.2 (1.0 to 1.5) and 0.8 (0.5 to 1.2) for those <40, 40-59 and 60+ years, respectively. The interaction terms between age and BMI as category variables or as a continuous variable were statistically significant. CONCLUSIONS: The association between obesity and CHD is stronger for younger adults than for older adults in Aboriginal Australians in the remote community. Our findings suggest that weight control efforts may produce more beneficial effects in CHD prevention in young adults than in older adults.

OBJECTIVE: To estimate the lifetime risk of developing hospital-diagnosed chronic obstructive pulmonary disease (COPD) in Aboriginal people living in remote areas. METHODS: A total of 1,374 participants in a remote community were followed up to 20 years. Individuals with hospital-diagnosed COPD were identified through hospital records. The lifetime risk of hospital-diagnosed COPD was estimated using a modified technique of survival analysis. RESULTS: Of the 1,374 participants, 164 were identified as having incident hospital-diagnosed COPD during 21,614 person years of follow-up. After adjusting for the presence of competing risk of death from non-COPD causes, the lifetime risk of COPD was 53% for the overall population, higher in women (61%) than in men (45%). Adjusting for baseline age and smoking status, women had a significantly higher risk of COPD than men with a hazard ratio (HR) = 1.55 (95%CI 1.13-2.14), while men were more likely to die from non-COPD causes than women before being diagnosed as having COPD, HR = 2.30 (95%CI 1.64-3.23). CONCLUSIONS: These Aboriginal people have a high lifetime risk of COPD, and one in two have hospital-diagnosed COPD during their lifetime. Our findings warrant further efforts and resources to combat this condition in remote Aboriginal communities.

Objective To establish the point prevalence of cognitive impairment among a representative group of homeless people in Cairns. The sample included a large number of Aboriginal and/or Torres Strait Islander people. Method This research was conducted among an opportunistic sample of participants residing in a homeless shelter. An interview administered cross-sectional survey was conducted with 60 participants over 12 weeks. The Kimberly Indigenous Cognitive Assessment (KICA-Cog) and a clinical diagnosis by a psychiatrist (using DSM-V criteria) were used to establish cognitive impairment. The 36-item version of the World Health Organisation Disability Assessment Survey 2.0 (WHODAS 2.0) was employed to ascertain limitations in daily living activities. Results Seventy-five percent of participants were Aboriginal and/or Torres Strait Islander people. Thirty-five percent of the sample had a cognitive impairment based on the KICA-cog while over 70% of the sample had a cognitive impairment based on clinical criteria. Being screened for dementia or global cognitive impairment according to the KICA-Cog was significantly correlated with having greater difficulty across the following WHODAS domains: understanding or communicating, self-care, and life activities. Conclusions Many people who are homeless have a cognitive impairment and this impairment impacts their ability to participate in society. A shift in practice is necessary to support homeless populations with a high proportion of Aboriginal and/or Torres Strait Islander people. It is important that culturally appropriate methods—focusing on cognitive health—are employed to support Aboriginal and/or Torres Strait Islander people who are homeless.

Issue addressed The implications of the high cost of water on the poverty and subsequent health of Aboriginal residents in a remote community in Australia. Methods During 2003, a focus group session was held with adults at Umoona Aboriginal community in South Australia. Participants were asked to comment on key issues of concern in the provision of the domestic water supply. Results The Umoona community members in Coober Pedy identified the high cost of water and electricity as key hardship factors. Conclusions Plans under the National Water Initiative to move to full cost recovery for water and the privatisation of public utilities may result in increased hardship for low-income groups such as Aboriginal people. Utility stress (difficulties paying water, electricity, gas or telephone accounts by the due date) increases poverty and relative deprivation, both key factors in the social determinants of health. Increased community service obligations (CSO) and rebates need to be made available to all low-income groups in order to reduce the negative impact of poverty. So what? Health promotion strategies aimed at improving the health status of Aboriginal people, particularly those living in remote communities, need to take into account the complex nature of poverty in many of these communities and the subsequent negative impact this has on the ability of community members to engage in healthy living practices.