- Email: [email protected]
Injury prevention in Australian Indigenous communities
Injury, Int. J. Care Injured (2008) 39S5, S61–S67
www.elsevier.com/locate/injury
Injury prevention in Australian Indigenous communities Rebecca Iversa, *, Kathleen Claphamb , Teresa Senserricka , Marilyn Lyforda , Mark Stevensona a
The George Institute for International Health, The University of Sydney; b Woolyungah Indigenous Centre, The University of Wollongong, Australia
KEYWORDS Indigenous; Injury; Fatalities; Hospitalisations; Prevention
Summary Injury prevention in Indigenous communities in Australia is a continuing national challenge, with Indigenous fatality rates due to injury three times higher than the general population. Suicide and transport are the leading causes of injury mortality, and assault, transport and falls the primary causes of injury morbidity. Addressing the complex range of injury problems in disadvantaged Indigenous communities requires considerable work in building or enhancing existing capacity of communities to address local safety issues. Poor data, lack of funding and absence of targeted programs are some of the issues that impede injury prevention activities. Traditional approaches to injury prevention can be used to highlight key areas of need, however adaptations are needed in keeping with Indigenous peoples’ holistic approach to health, linked to land and linked to community in order to address the complex spiritual, emotional and social determinants of Indigenous injury. © 2008 Elsevier Ltd. All rights reserved.
Injury in Indigenous Australian populations Aboriginal and Torres Strait Islander people represent a small proportion of the Australian population, yet experience a disproportionate burden of illness, disease and injury. 1,2 The Indigenousa estimated resident population of Australia in June 2006 was 517,200 or 2.5% of the total population. 3 Injury-related deaths among Indigenous people are almost three times that of non-Indigenous people, and injury hospitalisations * Corresponding author. Associate Professor Rebecca Ivers. Director, Injury Division, The George Institute for International Health, PO Box M201, Missenden Road, NSW 2050 Australia. Tel.: +61 2 9657 0361; fax: +61 2 9657 0301. E-mail: [email protected] (R. Ivers). a
are twice as common. In 1998 2000, the average life expectancy at birth for non-Indigenous Australians was 77 years for males and 82 years for females. These figures contrast sharply with 1996 2001 estimates for Indigenous Australians, which projected 59 years for males and 65 years for females. 4 This highlights the need for targeted social, educational and health reforms to improve the health status of Indigenous people and to close the gap in life expectancy between Indigenous and non-Indigenous Australians. 1,2,5 Injury and its prevention is a relatively new focus on the Indigenous health agenda, generally masked by the multitude of well-known health and social concerns. 6 However, injury is increasingly identified as a significant issue in Australian Indigenous communities, both in urban and rural
‘Aboriginal and Torres Strait Islander’ and ‘Indigenous’ are used interchangeably in this paper.
0020-1383/$
see front matter © 2008 Elsevier Ltd. All rights reserved.
S62 settings. Suicide and transport are the leading causes of mortality among both non-Indigenous and Indigenous Australians; however, Indigenous people have twice the suicide rate and almost triple the transport fatality rate of non-Indigenous people. 7–9 Age-standardised injury rates are also higher for Aboriginal and Torres Strait Islander people, 10 with hospitalisations at twice the rate of non-Indigenous people. During 2000 2002, the primary causes of Indigenous injury hospitalisations were assault, falls and transport. 10 Despite this substantial burden of morbidity and mortality, Indigenous injury continues to be largely disregarded within the public health arena. 11
Risk factors for Indigenous injury Data collected during 1997 2000 demonstrate higher rates of death due to injury for Indigenous than non-Indigenous persons across all age groups, with differences most marked from the mid to late teenager years through to the 60s for males and 70s for females. 8 Similar to the broader Australian population, injury deaths occur among Indigenous males at higher rates than among Indigenous females, and increase with level of remoteness. 8 The impact of remoteness is considerable for Aboriginal and Torres Strait Islander people, who constitute a greater proportion of communities living in remote and very remote areas. This also impacts on their access to health care. A 2001 survey of more than 1,200 Indigenous communities determined that 78% were located at a minimum distance of 50 km or more from a hospital. 12 Other key risk factors for injury include low socioeconomic status, 13 mental health issues and alcohol and other drug use; 14 factors prevalent in many Indigenous communities. Early research (1994) found that while the majority of Aboriginal and Torres Strait Islander people either do not drink alcohol or do so infrequently, those that do consume alcohol do so in excess and to a greater extent than in the broader Australian population. 15 Stressful life events can also contribute to injury risk. The Australian Bureau of Statistics reported that, in 2002, 83% of all Indigenous persons surveyed reported at least one stressor compared to 57% of non-Indigenous persons. 16 Almost half of the Indigenous respondents had experienced the death of a family member or close friend in the previous year, almost onethird suffered from a serious illness or disability, and over one-quarter were unemployed. Many risk factors were further compounded by remoteness. Among the Indigenous persons surveyed, those in
R. Ivers et al. remote communities reported greater problems due to alcohol, drugs, family violence, abuse or violent crime, neighbourhood conflicts and sexual assault than those in non-remote areas. Colonisation of Australia and dispossession of Indigenous people from their lands has led to a cycle of disadvantage, poor education, high unemployment, separation of families and over-crowded living conditions, contributing to the increase in these chronic risk factors and impacting Indigenous emotional, spiritual, cultural and social wellbeing. 17 The high burden of injury in Indigenous communities arises due to the complex interplay of these factors and any attempts to address it must therefore be considered within an appropriately comprehensive framework.
Existing Indigenous injury policies Development of national injury prevention policy in Australia began in 1981 when the World Health Organisation (WHO) published the Global Strategy for Health for All by the Year 2000. 18 The Federal Government set up a commission to report on the health status of the Australian population to focus on the development of health-related policy relating to the prevention of disease and injury. The Australian Health Ministries Advisory Council (AHMAC) and the National Health and Medical Research Council (NHMRC) identified seven priority health areas for action: cardiovascular disease, cancer, injury, mental health, diabetes, asthma and arthritis and musculoskeletal conditions. The National Injury Prevention Plan: Priorities for 2001 2003 19 and the National Injury Prevention Plan: Priorities for 2001 2003 Implementation Plan 20 were released in August 2001 to encourage a consistent and integrated approach to preventing injury. These Plans highlighted a need to develop a separate plan to address the issue of injury prevention for Aboriginal and Torres Strait Islander people. Following on from this, the Aboriginal and Torres Strait Islander Injury Prevention Action Committee (ATSIIPAC), through the Australian Government Department of Health and Ageing, commissioned a review of literature, programs, activities and evidence 6,21 that were used to form the basis of the National Aboriginal and Torres Strait Islander Safety Promotion Strategy. 17 This Strategy is a partner document to the National Injury Prevention and Safety Promotion Plan: 2004 2014 22 and focuses specifically on the Aboriginal and Torres Strait Islander population. It addresses intentional and unintentional injury, self-harm and harm to
Injury prevention in Australian Indigenous communities others, and embraces Indigenous people living within discrete communities and within society more broadly, whether in urban, rural or remote areas. 17 At the state level, only New South Wales has a policy specifically addressing Indigenous issues. 23 The Aboriginal Safety Promotion Strategy specifically targets Indigenous safety due to the limitations of mainstream injury prevention and safety promotion strategies to directly address or have clear relevance to the priority issues for Indigenous people in New South Wales. The strategy aims to significantly reduce the burden of unintentional and intentional injury among Indigenous people and to focus agencies and organisations from all sectors on the role they can play in promoting Indigenous safety and preventing injury. Surveillance projects in Shoalhaven, 24 Mid North Coast 25 and Blacktown 26 further confirmed that injury and trauma are a major health concern among Indigenous communities in New South Wales.
Quality of existing Indigenous injury programs As part of the development of the National Aboriginal and Torres Strait Islander Safety Promotion Strategy, a comprehensive review of injury prevention activity among Aboriginal and Torres Strait Islander peoples was completed. 21 The review highlighted a broad range of injury-related activities being undertaken within Aboriginal and Torres Strait Islander communities, mostly driven by community-based organisations. The review found that although many of the implemented programs were perceived by the community to be of some value, most were not rigorously evaluated. The report concluded that injury prevention is complex in these communities, and factors impeding program success include distance, a lack of organisational coherence and a lack of funding security. Few projects were found to address the underlying economic marginalisation faced by most Aboriginal and Torres Strait Islander people, particularly in rural and remote areas where opportunities for employment and education are extremely limited; even though the need to address such underlying issues is widely recognised as being fundamental to improvements in all other areas of health and safety. The report found that, in general, such programs failed to benefit the communities, often due to funding issues, such that programs were rarely or poorly evaluated and successful programs
S63 failed to gain continued funding, or failures in partnerships and cooperative efforts. There was also found to be a severe lack of capacity at the community level. A ‘whole of government’ approach to injury prevention is needed to address these issues. This approach could reduce duplication, focus resources, promote the best use of skills and expertise and encourage sustainability of effort through the strengthening of cross-government networks and partnerships. 27 Government organisations commonly work in silos, with health, local government, welfare, education, housing and transport all operating independently from each other. Given the paucity of research and interventions to prevent Indigenous injury, building the links between these areas is likely to improve injury outcomes for all Australians.
Adopting an appropriate injury prevention model There are many models that may be used to approach injury prevention. A widely used and effective model is the Haddon matrix. 28 William Haddon Jr applied the principles of epidemiology to injury research and intervention programs. He illustrated that injury could be examined from an epidemiologic framework, that is, one involving the interaction of three factors: the host, environment and agent. For injury prevention, these could be conceptualised as human factors, the physical and socio-cultural environment, and energy and its channels. These could be addressed by intervening in three spheres: education and behaviour change, legislation and enforcement, and engineering and technology; see Fig. 1. The model can be further extended to a matrix, showing the complex interplay between the three factors. Haddon’s Matrix, used to elucidate risk factors at the individual level, examines the risk factors of injury according to three event phases and is a further elaboration of the classical epidemiological triad: interactions between host, agent and environment. Figure 2 shows an example of the Haddon matrix to prevent or reduce the severity of road traffic injuries among Indigenous populations. Further developing this concept, Runyan has described an extended Haddon’s Matrix, which acknowledges the importance of “local context” in determining the appropriate intervention(s) and implementing it in a culturally-appropriate way, 29 which could also be used in this context. Injury risk factors in Indigenous communities are complex and multifactorial. Factors contributing
S64
R. Ivers et al. The INJURY Triangle
Education and behaviour change
human factors
Legislation and enforcement
Engineering and technology energy and its channels
physical, socio-cultural environment
Fig. 1. The epidemiological triad, the injury triangle. Crash Phase ? ?
Pre-crash
? ? ? ? ?
Crash
? ?
?
Post-crash
? ?
Human Factors Licensed driving Speed reduction Alcohol non-use Drug non-use Absence of fatigue Safe pedestrian behaviour
? ? ? ? ?
Use of protective equipment o Seat belts o Child restraints o Helmets Non carriage outside vehicle (e.g., utility tray) Non overcrowding to reduce person to person impacts
?
Management of pre-existing health conditions Improved emergency response Improved care & rehabilitation
?
?
?
Vehicle factors Vehicle maintenance Anti-lock braking systems Electronic Stability Control Frontal & rear collision warning systems Intelligent Speed Adaptation Vehicle occupant protection o Frontal and side airbag systems o Restraint systems Front end design improvements to reduce pedestrian injury o Energy absorbing bumper & bonnet o Low engine position o Pedestrian airbag systems Vehicle design to prevent entrapment, fire Automatic vehicle alerts to emergency services
?
?
? ?
? ?
Environmental Factors Appropriate transport systems & road engineering o Road quality o Visibility o Public transport o Separation of pedestrian & vehicular traffic Removal or protection from external fixed objects, such as narrow trees and poles o Roadside hardware, including wirerope barriers Pedestrian safety barriers Energy-absorbing road surfaces for pedestrians
Measures to improve speed of emergency response due to remoteness Improved access to trauma care
Fig. 2. Adaptation of Haddon’s Matrix: Examples of prevention of road traffic injuries among Australian Indigenous communities.
to injury in the Indigenous population include the context or setting, socio-economic factors and environmental, historical, spiritual and emotional psycho-social factors. Improving the health status of a disadvantaged, marginalised and culturally distinct population is a complex task and requires complex solutions. In general, Indigenous approaches to injury and safety promotion should reflect Indigenous approaches to health: holistic, linked to land and community. Key to improvements in health is an understanding of the linkages between health and community, disadvantage and social justice. A comprehensive public health model that addresses injury in Indigenous communities can incorporate strategies that address a holistic, practical and culturally relevant approach, developed at the community level, in partnership and collaboration with the local community. The
development of such a model addresses the needs of the community and underpins the values and principles of community engagement, consultation and ownership.
Measuring injury The few existing publications highlighting the burden of injury in Indigenous Australians are almost exclusively limited to Government reports based on routinely collected data sources. The limitations of these sources have, however, been highlighted, 7,30,31 and reporting is effectively limited to three states and the Northern Territory due to poor quality data in the four remaining jurisdictions. 9,31,32 Styles et al. report that some progress has been made in terms of data collection but there are still significant gaps in surveillance in Australia. 7
Injury prevention in Australian Indigenous communities For example, in 2006, New South Wales had the largest Indigenous estimated resident population (148,200), 3 but did not and still does not collect Indigenous status in standard databases such as driver licensing and road crash databases. While identification and recording of Indigenous status can be challenging for some collections, identification can be relatively straightforward at the point of driver licensure or motor vehicle registration and could be readily incorporated into existing data collection systems with little change to infrastructure at the macro or micro level. The lack of quality data or funded research of data collections contributes to a lack of indepth understanding of the burden of injury in Indigenous communities and key risk factors. Knowing how and why injuries occur is important for the design of interventions. Data sources from death certificates, hospitalisation data, coronial reports, surveys, evaluation studies, socioeconomic research and properly conducted trials are all important sources of information. However, many public health initiatives undertaken in Aboriginal health and community settings are based on local knowledge and expertise of Aboriginal health and community workers where resources and funding are scarce and quality information such as this is not always available. 21 Existing data collections need to be exploited as much as possible and new reliable collections established, such as collection of Indigenous status at point of licensure or motor vehicle registration, such that high quality research and developments can be achieved. For example, identification of Indigenous drivers would allow improved identification of the involvement of Indigenous people in road crashes, allowing resources to be diverted to areas of need and specific interventions targeting those at most risk. Over-sampling of Indigenous people in general population-based studies is a further means to collect more useful data. Observational studies are also necessary in some settings where basic data collection is poor, such as in New South Wales, but in other settings conduct of observational studies may slow development of much needed interventions.
Intervention development, implementation and evaluation Mainstream injury prevention strategies have previously not worked well within Indigenous communities. Often organisations have left the service
S65 provision to Aboriginal service providers where capacity is limited and generally under-resourced. Traditional approaches to injury prevention are often too limiting and rigid, and applying these within an Indigenous context is inadequate. In contrast, there is much diversity in community-based safety promotion and injury prevention interventions in Australia. Whilst community programs have the advantage of building collective vested interest and avoiding ownership of any one agency, they also have the disadvantage that no one agency is responsible financially or for leading such projects. Addressing a well-coordinated ‘whole-of-community approach‘ through community capacity building is the first step to successful intervention. Community interventions appear to be most successful where a multiple of agencies work together with the community, and where the community sets the agenda for priority projects and has ownership over these. Developing sustainability of interventions is achievable when safety is a recognised and prioritised issue and is incorporated into a single integrated community plan (including health and social issues plans, crime prevention and economic development plans). This in turn strengthens participation and partnerships and pools limited resources. Comprehensive injury prevention and safety promotion community interventions that are innovative, targeted, include a multi-strategic approach (education and advocacy; environmental and design; and legislation and enforcement strategies) with a rigorous evaluation component have promise in working towards the reduction of injury within Indigenous communities. Intervention strategies in the Indigenous community need to go beyond traditional longitudinal or intervention strategies and draw on ethnographic and other qualitative research that explores the major differences in history, local conditions, social structures and culture between Indigenous Australians and non-Indigenous Australians. There are a number of programs that aim to increase the awareness of interpersonal violence and injury in the Indigenous community throughout Australia; however, little is known of the success of these interventions as they have not been evaluated for their effectiveness. 21 Evaluation is crucial for assessing the effect a program or strategy has had within the local community, its cost effectiveness, whether the program achieved what was expected, and to identify opportunities for improvement.
S66 It is clear that health agencies, both Government and non-government, have a key role to play in Indigenous injury prevention and safety promotion. Development of reliable and valid measures of injury morbidity and mortality, excellent clinical management post-injury and health promotion campaigns are vital elements of injury prevention programs. Moving beyond the traditional public health model requires broader cooperation. The Haddon Matrix for injury prevention 28,29 highlights the myriad of factors that influence crash and injury, many of which are not influenced by traditional health approaches.
The way forward The World Health Organisation has called for a systems approach to prevention of road traffic injury. 33 Styles and Edmonston, in their review of Indigenous road injury solutions in Australia, have also recommended a focus on quality data, community approaches and capacity building, as well as stronger links with Indigenous researchers and other health agencies. 7 Successful approaches to injury prevention can build on the traditional public health approach but, importantly, need to incorporate concepts of Indigenous health and wellbeing. Examining injury via frameworks such as the Haddon Matrix reminds us that injury prevention and safety promotion must include a broader approach, including agencies and interventions other than public health alone. Despite over 20 years of National Policy Development, injury remains a major concern for both Indigenous and non-Indigenous Australians. 27 There is a clear need for strong advocacy and close co-operation between Government and non-government agencies and Indigenous communities. Injury prevention in Indigenous settings is complex. Injury intersects significantly with a number of other complex societal issues and therefore injury prevention programs cannot be implemented in isolation. Community capacity and community leadership is vital and must in turn be integrated with sustained funding sources and a well-supported multi-sectoral approach.
Conflict of interest statement and role of the funding source statement The authors have no conflict of interest for this paper. Rebecca Ivers is funded by an NHMRC Career Development Award, Teresa Senserrick by an NHMRC Population Health Capacity Building Grant
R. Ivers et al. in Injury Prevention, Acute Care and Rehabilitation and Mark Stevenson by an NHMRC Senior Research Fellowship.
References 1. Aboriginal & Torres Strait Islander Social Justice Commissioner. Social justice report 2005. Report No: 3/2005. Sydney NSW, 2005. 2. Oxfam Australia. Close the gap: solutions to the Indigenous health crisis facing Australia. Fitzroy VIC: Oxfam Australia, 2007. 3. Australian Bureau of Statistics. Population distribution, Aboriginal and Torres Strait Islander Australians, 2006. ABC Category No. 4705.0. Canberra ACT, 2007. 4. Australian Institute of Health and Welfare. Australia’s health 2006. AIHW Category No. AUS 73. Adelaide SA, 2006. 5. Stevenson MR, Wallace LJ, Harrison J, et al. At risk in two worlds: injury mortality among indigenous people in the US and Australia, 1990 92. ANZJPH 1998;22:641 4. 6. Moller J, Thomson N, Brooks J. Injury prevention activity among Aboriginal and Torres Strait Islander peoples. Volume 1: Current status and future directions. Canberra ACT: Australian Government Department of Health and Ageing, 2003. 7. Styles T, Edmonston C. Australian Indigenous road 2005 update. Canberra ACT: Australian safety Transport Safety Bureau Report No. CR 225, 2006. 8. Helps YLM, Harrison JE. Reported injury mortality of Aboriginal and Torres Strait Islander people in Australia, 1997 2000. Adelaide SA: Australian Institute of Health and Welfare, 2004. 9. Harrison JE, Berry JG. Injury of Aboriginal and Torres Strait Islander people due to transport, 2001 02 to 2005 06. Adelaide SA: Australian Institute of Health and Welfare, 2008. 10. Helps YLM, Harrison JE. Hospitalised injury of Australia’s Aboriginal and Torres Strait Islander people: 2000 02. Adelaide SA: Australian Institute of Health and Welfare, 2006. 11. Desapriya E, Pike I, Subzwari S. Injury-related mortality and indigenous people. Lancet 2006;368:576. 12. Australian Institute of Health and Welfare. National summary of the 2001 and 2002 jurisdictional reports against the Aboriginal and Torres Strait Islander health performance indicators. Statistical Information Management Committee, AIHW Category No. 12. Adelaide SA, 2004. 13. Cubbin C, LeClere FB, Smith GS. Socioeconomic status and injury mortality: individual and neighbourhood determinants. J Epidemiol Commun Health 2000;54: 517 24. 14. McLeod R, Stockwell T, Rooney R, et al. The influence of extrinsic and intrinsic risk factors on the probability of sustaining an injury. Acc Anal Prev 2003;35:71 80. 15. National Drug Strategy. National drug strategy household survey urban Aboriginal and Torres Strait Islander peoples supplement 1994. Canberra ACT: Australian Government Publishing Service, 1994. 16. Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander social survey 2002. ABS Category no. 4714.0. Canberra ACT, June 2004. 17. National Public Health Partnership. The national Aboriginal and Torres Strait Islander safety promotion strategy. Canberra ACT: NPHP, July 2004.
Injury prevention in Australian Indigenous communities 18. World Health Organization. Global strategy for health for all by the year 2000. Geneva, Switzerland, 1981. 19. National Public Health Partnership. National injury prevention plan: priorities for 2001 2003. Canberra ACT: Department of Health and Aged Care, 2001. 20. National Public Health Partnership. National injury prevention plan: priorities for 2001 2003 implementation plan. Canberra ACT: Department of Health and Aged Care, 2001. 21. Clapham K. Injury prevention activity among Aboriginal and Torres Strait Islander people. Vol. 2: Programs, projects and actions. Canberra ACT: Department of Health and Ageing, 2004. 22. National Public Health Partnership. The National Injury Prevention and Safety Promotion Plan: 2004 2014. Canberra ACT: NPHP, 2004. 23. New South Wales Health. Aboriginal Safety Promotion Strategy. Sydney NSW: NSW Health, 2003. 24. Royal T, Westley-Wise V. Shoalhaven Aboriginal injury surveillance and prevention project. Unanderra NSW: Illawarra Area Health Service, 2001. 25. Mid North Coast Aboriginal Health Partnership. Mid North Coast Aboriginal injury surveillance project report. Kempsey NSW: Mid North Coast Aboriginal Health Partnership, 2001. 26. Western Sydney Area Health Service. Blacktown Aboriginal injury surveillance and prevention project report. Parramatta NSW: Western Sydney Area Health Service, 2003. 27. Mitchell R, McClure R. The development of national
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28.
29. 30.
31.
32.
33.
injury prevention policy in the Australian health sector: and the unmet challenges of participation and implementation. ANZHP 2006;3:11. Haddon Jr W. The changing approach to the epidemiology, prevention, and amelioration of trauma: the transition to approaches etiologically rather than descriptively based. Am J Public Health 1968;58: 1431 8. Runyan C. Using the Haddon matrix: introducing the third dimension. Inj Prev 1998;4:302 7. McFadden M, McKie K, Mwesigye S-E. Estimating road trauma in the Australian Indigenous population. Canberra ACT: Australian Transport Safety Bureau Report No. OR 22, 2000. Harrison JE, Miller ER, Weeramanthri TS, et al. Information sources for injury prevention among Indigenous Australians. Status and prospects for improvement. Adelaide SA: Australian Institute of Health and Welfare, Injury Research and Statistics Series Number 8, 2001. Berry JG, Nearmy DM, Harrison JE. Injury of Aboriginal and Torres Strait Islander people due to transport, 1999 00 to 2003 04. AIHW Catalogue no. INJCAT 100. Canberra ACT: Australian Institute of Health and Welfare and Australian Transport Safety Bureau, May 2007. Peden M, Scurfield R, Sleet D, et al. World report on road traffic injury prevention. Geneva, Switzerland: World Health Organisation, 2004.
www.elsevier.com/locate/injury
Injury prevention in Australian Indigenous communities Rebecca Iversa, *, Kathleen Claphamb , Teresa Senserricka , Marilyn Lyforda , Mark Stevensona a
The George Institute for International Health, The University of Sydney; b Woolyungah Indigenous Centre, The University of Wollongong, Australia
KEYWORDS Indigenous; Injury; Fatalities; Hospitalisations; Prevention
Summary Injury prevention in Indigenous communities in Australia is a continuing national challenge, with Indigenous fatality rates due to injury three times higher than the general population. Suicide and transport are the leading causes of injury mortality, and assault, transport and falls the primary causes of injury morbidity. Addressing the complex range of injury problems in disadvantaged Indigenous communities requires considerable work in building or enhancing existing capacity of communities to address local safety issues. Poor data, lack of funding and absence of targeted programs are some of the issues that impede injury prevention activities. Traditional approaches to injury prevention can be used to highlight key areas of need, however adaptations are needed in keeping with Indigenous peoples’ holistic approach to health, linked to land and linked to community in order to address the complex spiritual, emotional and social determinants of Indigenous injury. © 2008 Elsevier Ltd. All rights reserved.
Injury in Indigenous Australian populations Aboriginal and Torres Strait Islander people represent a small proportion of the Australian population, yet experience a disproportionate burden of illness, disease and injury. 1,2 The Indigenousa estimated resident population of Australia in June 2006 was 517,200 or 2.5% of the total population. 3 Injury-related deaths among Indigenous people are almost three times that of non-Indigenous people, and injury hospitalisations * Corresponding author. Associate Professor Rebecca Ivers. Director, Injury Division, The George Institute for International Health, PO Box M201, Missenden Road, NSW 2050 Australia. Tel.: +61 2 9657 0361; fax: +61 2 9657 0301. E-mail: [email protected] (R. Ivers). a
are twice as common. In 1998 2000, the average life expectancy at birth for non-Indigenous Australians was 77 years for males and 82 years for females. These figures contrast sharply with 1996 2001 estimates for Indigenous Australians, which projected 59 years for males and 65 years for females. 4 This highlights the need for targeted social, educational and health reforms to improve the health status of Indigenous people and to close the gap in life expectancy between Indigenous and non-Indigenous Australians. 1,2,5 Injury and its prevention is a relatively new focus on the Indigenous health agenda, generally masked by the multitude of well-known health and social concerns. 6 However, injury is increasingly identified as a significant issue in Australian Indigenous communities, both in urban and rural
‘Aboriginal and Torres Strait Islander’ and ‘Indigenous’ are used interchangeably in this paper.
0020-1383/$
see front matter © 2008 Elsevier Ltd. All rights reserved.
S62 settings. Suicide and transport are the leading causes of mortality among both non-Indigenous and Indigenous Australians; however, Indigenous people have twice the suicide rate and almost triple the transport fatality rate of non-Indigenous people. 7–9 Age-standardised injury rates are also higher for Aboriginal and Torres Strait Islander people, 10 with hospitalisations at twice the rate of non-Indigenous people. During 2000 2002, the primary causes of Indigenous injury hospitalisations were assault, falls and transport. 10 Despite this substantial burden of morbidity and mortality, Indigenous injury continues to be largely disregarded within the public health arena. 11
Risk factors for Indigenous injury Data collected during 1997 2000 demonstrate higher rates of death due to injury for Indigenous than non-Indigenous persons across all age groups, with differences most marked from the mid to late teenager years through to the 60s for males and 70s for females. 8 Similar to the broader Australian population, injury deaths occur among Indigenous males at higher rates than among Indigenous females, and increase with level of remoteness. 8 The impact of remoteness is considerable for Aboriginal and Torres Strait Islander people, who constitute a greater proportion of communities living in remote and very remote areas. This also impacts on their access to health care. A 2001 survey of more than 1,200 Indigenous communities determined that 78% were located at a minimum distance of 50 km or more from a hospital. 12 Other key risk factors for injury include low socioeconomic status, 13 mental health issues and alcohol and other drug use; 14 factors prevalent in many Indigenous communities. Early research (1994) found that while the majority of Aboriginal and Torres Strait Islander people either do not drink alcohol or do so infrequently, those that do consume alcohol do so in excess and to a greater extent than in the broader Australian population. 15 Stressful life events can also contribute to injury risk. The Australian Bureau of Statistics reported that, in 2002, 83% of all Indigenous persons surveyed reported at least one stressor compared to 57% of non-Indigenous persons. 16 Almost half of the Indigenous respondents had experienced the death of a family member or close friend in the previous year, almost onethird suffered from a serious illness or disability, and over one-quarter were unemployed. Many risk factors were further compounded by remoteness. Among the Indigenous persons surveyed, those in
R. Ivers et al. remote communities reported greater problems due to alcohol, drugs, family violence, abuse or violent crime, neighbourhood conflicts and sexual assault than those in non-remote areas. Colonisation of Australia and dispossession of Indigenous people from their lands has led to a cycle of disadvantage, poor education, high unemployment, separation of families and over-crowded living conditions, contributing to the increase in these chronic risk factors and impacting Indigenous emotional, spiritual, cultural and social wellbeing. 17 The high burden of injury in Indigenous communities arises due to the complex interplay of these factors and any attempts to address it must therefore be considered within an appropriately comprehensive framework.
Existing Indigenous injury policies Development of national injury prevention policy in Australia began in 1981 when the World Health Organisation (WHO) published the Global Strategy for Health for All by the Year 2000. 18 The Federal Government set up a commission to report on the health status of the Australian population to focus on the development of health-related policy relating to the prevention of disease and injury. The Australian Health Ministries Advisory Council (AHMAC) and the National Health and Medical Research Council (NHMRC) identified seven priority health areas for action: cardiovascular disease, cancer, injury, mental health, diabetes, asthma and arthritis and musculoskeletal conditions. The National Injury Prevention Plan: Priorities for 2001 2003 19 and the National Injury Prevention Plan: Priorities for 2001 2003 Implementation Plan 20 were released in August 2001 to encourage a consistent and integrated approach to preventing injury. These Plans highlighted a need to develop a separate plan to address the issue of injury prevention for Aboriginal and Torres Strait Islander people. Following on from this, the Aboriginal and Torres Strait Islander Injury Prevention Action Committee (ATSIIPAC), through the Australian Government Department of Health and Ageing, commissioned a review of literature, programs, activities and evidence 6,21 that were used to form the basis of the National Aboriginal and Torres Strait Islander Safety Promotion Strategy. 17 This Strategy is a partner document to the National Injury Prevention and Safety Promotion Plan: 2004 2014 22 and focuses specifically on the Aboriginal and Torres Strait Islander population. It addresses intentional and unintentional injury, self-harm and harm to
Injury prevention in Australian Indigenous communities others, and embraces Indigenous people living within discrete communities and within society more broadly, whether in urban, rural or remote areas. 17 At the state level, only New South Wales has a policy specifically addressing Indigenous issues. 23 The Aboriginal Safety Promotion Strategy specifically targets Indigenous safety due to the limitations of mainstream injury prevention and safety promotion strategies to directly address or have clear relevance to the priority issues for Indigenous people in New South Wales. The strategy aims to significantly reduce the burden of unintentional and intentional injury among Indigenous people and to focus agencies and organisations from all sectors on the role they can play in promoting Indigenous safety and preventing injury. Surveillance projects in Shoalhaven, 24 Mid North Coast 25 and Blacktown 26 further confirmed that injury and trauma are a major health concern among Indigenous communities in New South Wales.
Quality of existing Indigenous injury programs As part of the development of the National Aboriginal and Torres Strait Islander Safety Promotion Strategy, a comprehensive review of injury prevention activity among Aboriginal and Torres Strait Islander peoples was completed. 21 The review highlighted a broad range of injury-related activities being undertaken within Aboriginal and Torres Strait Islander communities, mostly driven by community-based organisations. The review found that although many of the implemented programs were perceived by the community to be of some value, most were not rigorously evaluated. The report concluded that injury prevention is complex in these communities, and factors impeding program success include distance, a lack of organisational coherence and a lack of funding security. Few projects were found to address the underlying economic marginalisation faced by most Aboriginal and Torres Strait Islander people, particularly in rural and remote areas where opportunities for employment and education are extremely limited; even though the need to address such underlying issues is widely recognised as being fundamental to improvements in all other areas of health and safety. The report found that, in general, such programs failed to benefit the communities, often due to funding issues, such that programs were rarely or poorly evaluated and successful programs
S63 failed to gain continued funding, or failures in partnerships and cooperative efforts. There was also found to be a severe lack of capacity at the community level. A ‘whole of government’ approach to injury prevention is needed to address these issues. This approach could reduce duplication, focus resources, promote the best use of skills and expertise and encourage sustainability of effort through the strengthening of cross-government networks and partnerships. 27 Government organisations commonly work in silos, with health, local government, welfare, education, housing and transport all operating independently from each other. Given the paucity of research and interventions to prevent Indigenous injury, building the links between these areas is likely to improve injury outcomes for all Australians.
Adopting an appropriate injury prevention model There are many models that may be used to approach injury prevention. A widely used and effective model is the Haddon matrix. 28 William Haddon Jr applied the principles of epidemiology to injury research and intervention programs. He illustrated that injury could be examined from an epidemiologic framework, that is, one involving the interaction of three factors: the host, environment and agent. For injury prevention, these could be conceptualised as human factors, the physical and socio-cultural environment, and energy and its channels. These could be addressed by intervening in three spheres: education and behaviour change, legislation and enforcement, and engineering and technology; see Fig. 1. The model can be further extended to a matrix, showing the complex interplay between the three factors. Haddon’s Matrix, used to elucidate risk factors at the individual level, examines the risk factors of injury according to three event phases and is a further elaboration of the classical epidemiological triad: interactions between host, agent and environment. Figure 2 shows an example of the Haddon matrix to prevent or reduce the severity of road traffic injuries among Indigenous populations. Further developing this concept, Runyan has described an extended Haddon’s Matrix, which acknowledges the importance of “local context” in determining the appropriate intervention(s) and implementing it in a culturally-appropriate way, 29 which could also be used in this context. Injury risk factors in Indigenous communities are complex and multifactorial. Factors contributing
S64
R. Ivers et al. The INJURY Triangle
Education and behaviour change
human factors
Legislation and enforcement
Engineering and technology energy and its channels
physical, socio-cultural environment
Fig. 1. The epidemiological triad, the injury triangle. Crash Phase ? ?
Pre-crash
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Crash
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?
Post-crash
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Human Factors Licensed driving Speed reduction Alcohol non-use Drug non-use Absence of fatigue Safe pedestrian behaviour
? ? ? ? ?
Use of protective equipment o Seat belts o Child restraints o Helmets Non carriage outside vehicle (e.g., utility tray) Non overcrowding to reduce person to person impacts
?
Management of pre-existing health conditions Improved emergency response Improved care & rehabilitation
?
?
?
Vehicle factors Vehicle maintenance Anti-lock braking systems Electronic Stability Control Frontal & rear collision warning systems Intelligent Speed Adaptation Vehicle occupant protection o Frontal and side airbag systems o Restraint systems Front end design improvements to reduce pedestrian injury o Energy absorbing bumper & bonnet o Low engine position o Pedestrian airbag systems Vehicle design to prevent entrapment, fire Automatic vehicle alerts to emergency services
?
?
? ?
? ?
Environmental Factors Appropriate transport systems & road engineering o Road quality o Visibility o Public transport o Separation of pedestrian & vehicular traffic Removal or protection from external fixed objects, such as narrow trees and poles o Roadside hardware, including wirerope barriers Pedestrian safety barriers Energy-absorbing road surfaces for pedestrians
Measures to improve speed of emergency response due to remoteness Improved access to trauma care
Fig. 2. Adaptation of Haddon’s Matrix: Examples of prevention of road traffic injuries among Australian Indigenous communities.
to injury in the Indigenous population include the context or setting, socio-economic factors and environmental, historical, spiritual and emotional psycho-social factors. Improving the health status of a disadvantaged, marginalised and culturally distinct population is a complex task and requires complex solutions. In general, Indigenous approaches to injury and safety promotion should reflect Indigenous approaches to health: holistic, linked to land and community. Key to improvements in health is an understanding of the linkages between health and community, disadvantage and social justice. A comprehensive public health model that addresses injury in Indigenous communities can incorporate strategies that address a holistic, practical and culturally relevant approach, developed at the community level, in partnership and collaboration with the local community. The
development of such a model addresses the needs of the community and underpins the values and principles of community engagement, consultation and ownership.
Measuring injury The few existing publications highlighting the burden of injury in Indigenous Australians are almost exclusively limited to Government reports based on routinely collected data sources. The limitations of these sources have, however, been highlighted, 7,30,31 and reporting is effectively limited to three states and the Northern Territory due to poor quality data in the four remaining jurisdictions. 9,31,32 Styles et al. report that some progress has been made in terms of data collection but there are still significant gaps in surveillance in Australia. 7
Injury prevention in Australian Indigenous communities For example, in 2006, New South Wales had the largest Indigenous estimated resident population (148,200), 3 but did not and still does not collect Indigenous status in standard databases such as driver licensing and road crash databases. While identification and recording of Indigenous status can be challenging for some collections, identification can be relatively straightforward at the point of driver licensure or motor vehicle registration and could be readily incorporated into existing data collection systems with little change to infrastructure at the macro or micro level. The lack of quality data or funded research of data collections contributes to a lack of indepth understanding of the burden of injury in Indigenous communities and key risk factors. Knowing how and why injuries occur is important for the design of interventions. Data sources from death certificates, hospitalisation data, coronial reports, surveys, evaluation studies, socioeconomic research and properly conducted trials are all important sources of information. However, many public health initiatives undertaken in Aboriginal health and community settings are based on local knowledge and expertise of Aboriginal health and community workers where resources and funding are scarce and quality information such as this is not always available. 21 Existing data collections need to be exploited as much as possible and new reliable collections established, such as collection of Indigenous status at point of licensure or motor vehicle registration, such that high quality research and developments can be achieved. For example, identification of Indigenous drivers would allow improved identification of the involvement of Indigenous people in road crashes, allowing resources to be diverted to areas of need and specific interventions targeting those at most risk. Over-sampling of Indigenous people in general population-based studies is a further means to collect more useful data. Observational studies are also necessary in some settings where basic data collection is poor, such as in New South Wales, but in other settings conduct of observational studies may slow development of much needed interventions.
Intervention development, implementation and evaluation Mainstream injury prevention strategies have previously not worked well within Indigenous communities. Often organisations have left the service
S65 provision to Aboriginal service providers where capacity is limited and generally under-resourced. Traditional approaches to injury prevention are often too limiting and rigid, and applying these within an Indigenous context is inadequate. In contrast, there is much diversity in community-based safety promotion and injury prevention interventions in Australia. Whilst community programs have the advantage of building collective vested interest and avoiding ownership of any one agency, they also have the disadvantage that no one agency is responsible financially or for leading such projects. Addressing a well-coordinated ‘whole-of-community approach‘ through community capacity building is the first step to successful intervention. Community interventions appear to be most successful where a multiple of agencies work together with the community, and where the community sets the agenda for priority projects and has ownership over these. Developing sustainability of interventions is achievable when safety is a recognised and prioritised issue and is incorporated into a single integrated community plan (including health and social issues plans, crime prevention and economic development plans). This in turn strengthens participation and partnerships and pools limited resources. Comprehensive injury prevention and safety promotion community interventions that are innovative, targeted, include a multi-strategic approach (education and advocacy; environmental and design; and legislation and enforcement strategies) with a rigorous evaluation component have promise in working towards the reduction of injury within Indigenous communities. Intervention strategies in the Indigenous community need to go beyond traditional longitudinal or intervention strategies and draw on ethnographic and other qualitative research that explores the major differences in history, local conditions, social structures and culture between Indigenous Australians and non-Indigenous Australians. There are a number of programs that aim to increase the awareness of interpersonal violence and injury in the Indigenous community throughout Australia; however, little is known of the success of these interventions as they have not been evaluated for their effectiveness. 21 Evaluation is crucial for assessing the effect a program or strategy has had within the local community, its cost effectiveness, whether the program achieved what was expected, and to identify opportunities for improvement.
S66 It is clear that health agencies, both Government and non-government, have a key role to play in Indigenous injury prevention and safety promotion. Development of reliable and valid measures of injury morbidity and mortality, excellent clinical management post-injury and health promotion campaigns are vital elements of injury prevention programs. Moving beyond the traditional public health model requires broader cooperation. The Haddon Matrix for injury prevention 28,29 highlights the myriad of factors that influence crash and injury, many of which are not influenced by traditional health approaches.
The way forward The World Health Organisation has called for a systems approach to prevention of road traffic injury. 33 Styles and Edmonston, in their review of Indigenous road injury solutions in Australia, have also recommended a focus on quality data, community approaches and capacity building, as well as stronger links with Indigenous researchers and other health agencies. 7 Successful approaches to injury prevention can build on the traditional public health approach but, importantly, need to incorporate concepts of Indigenous health and wellbeing. Examining injury via frameworks such as the Haddon Matrix reminds us that injury prevention and safety promotion must include a broader approach, including agencies and interventions other than public health alone. Despite over 20 years of National Policy Development, injury remains a major concern for both Indigenous and non-Indigenous Australians. 27 There is a clear need for strong advocacy and close co-operation between Government and non-government agencies and Indigenous communities. Injury prevention in Indigenous settings is complex. Injury intersects significantly with a number of other complex societal issues and therefore injury prevention programs cannot be implemented in isolation. Community capacity and community leadership is vital and must in turn be integrated with sustained funding sources and a well-supported multi-sectoral approach.
Conflict of interest statement and role of the funding source statement The authors have no conflict of interest for this paper. Rebecca Ivers is funded by an NHMRC Career Development Award, Teresa Senserrick by an NHMRC Population Health Capacity Building Grant
R. Ivers et al. in Injury Prevention, Acute Care and Rehabilitation and Mark Stevenson by an NHMRC Senior Research Fellowship.
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