Rozprawy doktorskie na temat „Aboriginal Australians – Health and hygiene – Research”

As Australia’s leading agency for funding health research (expending over $400 million in 2006), the National Health and Medical Research Council (NHMRC) has a major responsibility to improve the evidence base for health policy and practice. There is an urgent need for better evidence to guide policy and programs that improve the health of Indigenous peoples. In 2002, NHMRC endorsed a series of landmark policy changes to acknowledge its ongoing role and responsibilities in Indigenous health research—adopting a strategic Road Map for research, improving Indigenous representation across NHMRC Council and Principal Committees, and committing 5% of its annual budget to Indigenous health research. This thesis examines how these policies evolved, the extent to which they have been implemented, and their impact on agency expenditure in relation to People Support. Additionally, this thesis describes the impact of NHMRC policies in reshaping research practices among Indigenous populations.

Master of Philosophy
As Australia’s leading agency for funding health research (expending over $400 million in 2006), the National Health and Medical Research Council (NHMRC) has a major responsibility to improve the evidence base for health policy and practice. There is an urgent need for better evidence to guide policy and programs that improve the health of Indigenous peoples. In 2002, NHMRC endorsed a series of landmark policy changes to acknowledge its ongoing role and responsibilities in Indigenous health research—adopting a strategic Road Map for research, improving Indigenous representation across NHMRC Council and Principal Committees, and committing 5% of its annual budget to Indigenous health research. This thesis examines how these policies evolved, the extent to which they have been implemented, and their impact on agency expenditure in relation to People Support. Additionally, this thesis describes the impact of NHMRC policies in reshaping research practices among Indigenous populations.

"January 2003." Bibliography: 10.1-10.11 leaves. This thesis presents results from the Katherine Region Diabetic Retinopathy Study (1993-1996). These results provide the first detailed information on the basic epidemiology of diabetic retinopathy and impaired vision in an Aboriginal diabetic population.

Self determination has been recognised as a basic human right both internationally and, to an extent, locally, but it is yet to be fully realised for Aboriginal Peoples in Australia. The assertion of Aboriginal community control in Aboriginal health has been at the forefront of Aboriginal peoples' advocacy for self determination for more than thirty years. Aboriginal Community Controlled Health Services and their representative organisations have been the site of considerable resistance and contestation in the struggles involved in trying to improve Aboriginal health experiences. Drawing on some of these experiences I explore the apparent inability of policy and decision makers to listen to systematic voices calling for change from the Aboriginal Community Controlled Health sector. It is government inability to act more fully on clear and repeated messages that is a source of much disquiet within representative Aboriginal organisations. Such disquiet is grounded in a belief that colonial notions continue to influence decision making at policy, practice and research levels resulting in a significant impediment to the realisation of self determination and associated human rights in Aboriginal health matters and Aboriginal Affairs more broadly.

This thesis concerns the relationship between ideology, values, beliefs, politics, language, discourses, public policy and health outcomes. By examining the origins of federal health policy concerning Aboriginal and Torres Strait Islander Peoples 1972-2001 I have explored the idea that the way a problem is constructed through language determines solutions enacted to solve that problem, and subsequent outcomes. Despite three decades of federal policy activity Aboriginal and Torres Strait Islander children born at the start of the 21st Century could expect to live almost 20 years less than non-Indigenous Australians. Explanations for the gap include that the colonial legacy of dispossession and disease continues to wreak social havoc and that both health policy and structures for health services have been fundamentally flawed. The research described in this thesis focuses on the role of senior Federal politicians in the health policy process. The research is grounded in theory which suggests that the values and beliefs of decision makers are perpetuated through language. Using critical discourse analysis the following hypotheses were tested: 1. That an examination of the language of Federal politicians responsible for the health of Aboriginal and Torres Strait Islander Peoples over three decades would reveal their beliefs, values and discourses concerning Aboriginal and Torres Strait Islander Peoples and their health 2. That the discourses of the Federal politicians contributed to policy discourses and frames in the Aboriginal and Torres Strait Islander health policy environment, and 3. That there is a relationship between the policy discourses of the Aboriginal and Torres Strait Islander health policy environment and health outcomes for Aboriginal and Torres Strait Islander Peoples. The hypotheses were proven. I concluded that there was a relationship between the publicly-expressed values and beliefs of politicians responsible for health, subsequent health policy and resulting health outcomes. However, a model in which theories of discourse, social constructions of people and problems, policy development and organisational decision-making were integrated did not adequately explain the findings. I developed the concept of "policy imagination" to explain the discrete mechanism by which ideology, politics, policy and health were related. My research suggests that the ideology and values which drove decision-making by Federal politicians responsible for the health of all Australians contributed to the lack of population-wide improvement in health outcomes for Aboriginal and Torres Strait Islander Peoples in the late 20th Century.

The aim of this project was to account for and characterise the extent of genetic variation within and between sympatfic host-associated populations of dog-derived and human-derived Sarcoptes scabiei.

Until recently, there was no dementia screening tool for Indigenous Australians and a paucity of information on the extent of dementia in Indigenous Australians. This thesis describes the development and validation of a tool to assess cognitive impairment in remote Indigenous Australians with the primary purpose of determining the prevalence of dementia and other associated conditions in this population. The tool was reevaluated with the larger prevalence sample and a short version of the tool was developed and evaluated. The Kimberley Indigenous Cognitive Assessment (KICA) tool was validated with Indigenous Australians aged over 45 years from the Kimberley region of Western Australia (n=70). The results were later confirmed in a larger sample from the remote Kimberley (n=363), and an additional sample in rural and remote areas of the Northern Territory (n=47). The KICA results were compared to independent consensus diagnoses using DSM-IV and ICD-10. Interpreters were used whenever participants were not proficient in English. These data led to the determination of a cut-off score of 33/34 out of a possible total score of 39 for the cognitive component of the KICA (KICA-Cog), with a sensitivity of 0.93 and specificity of 0.95 and AUC of 0.98. The tool is now widely used within remote areas of Australia. A short version of the KICACog (sKICA-Cog) was developed and found to be a valid brief screening tool for dementia in the Kimberley population, and had a cut-off score of 20/21 out of a possible 25, with a sensitivity of 0.89, specificity of 0.95 and AUC of 0.98. The sKICA-Cog should be used in combination with the KICA cognitive informant questionnaire (KICA-IQ). The KICA-IQ cut-off score of 2/3 out of a possible 16 was determined, with a sensitivity of 0.76 and specificity of 0.84 and AUC of 0.91. Using the validated KICA, the prevalence of dementia and cognitive impairment not dementia (CIND) was determined in a semi-purposive sample consisting of 363 Indigenous Australians aged over 45 years from 6 Aboriginal communities and one town in the Kimberley region. Participants were screened with the full KICA and 165 participants had an independent specialist review with consensus diagnoses. The prevalence of dementia was 12.4%, 5.2 times greater than the Australian prevalence of 2.4%, after age adjustment. The prevalence of CIND was 8.0%. Characteristics associated with dementia included older age, male gender (OR 3.1, 95% CI 1.4, 6.8), no formal education (OR 2.7, 95% CI 1.1, 6.7), smoking (OR 4.5, 95% CI 1.1, 18.6), previous stroke (OR 17.9, 95% CI 5.9, 49.7), epilepsy (OR 33.5, 95% CI 4.8, 232.3) and head injury (OR 4.0, 95% CI 1.7, 9.4). Other factors associated with dementia included incontinence, falls and poor mobility. The KICA is a valid assessment tool for rural and remote Indigenous Australians. The prevalence of dementia amongst Indigenous Australians is substantially higher than generally found in non - Indigenous Australians and other populations in the developed and developing world.

The hypothesis central to this study is that the implementation of a canine breeding and parasite control program in Aboriginal communities results in a reduction in the reservoir of zoonotic parasites within communities. The effect of the parasite and breeding control program on the health status of dogs as well as the population characteristics of dogs in communities was also investigated. The study was conducted in 17 Aboriginal communities of the Kimberley region of Western Australia, divided into three regions according to cultural and geographical attributes. All dogs from each community were permanently identified using a microchip system. Owners of dogs were asked the usual location of their animals, the origins of their dogs and the whereabouts of any missing animals at subsequent visits. Every three months dogs were treated with 200ygikg iverrnectin (a potent endo- and ecto-parasiticide) subcutaneously and adult female dogs were treated with an injectable contraceptive (10-30mgkg proligestone) at the request of their owners. At the time of treatment, dogs were assessed for ecto-parasites and photographs taken for later comparison and diagnosis of alopecic skin conditions. Faecal and blood samples were collected every three to six months and skin scrapings were collected from dogs that were refractory to treatment. The samples were used to determine internal parasite prevalence (using formal ethyl acetate sedimentation), blood parameters (for anaemia status) and evidence of scabies or Demodex infestation. A pilot study at one group of communities, involving weekly assessment of dogs after one iverrnectin treatment, showed that the treatment was effective in reducing the prevalence of scabies (as determined by clinical evaluation), hookworm and ticks. The treatment resulted in improvement in animal health as evidenced by a reduction in the number of dogs with anaemia. The long-term use of the ivermectin treatments at the other communities showed that over a period of three years, the prevalence of scabies and hookworm had reduced at most areas. The initial scabies prevalence varied from 17 to 52% and reduced to below 10% for all communities. The hookworm infection rates were affected by seasonal factors, as was evidenced by a seasonal variance in prevalence. Animals that were treated with ivermectin, though, had lower prevalences of hookworm than those that were not. There was a reasonable compliance rate for contraceptive treatments for female dogs (greater than 60% at each visit) and fewer puppies were born within communities when compared with rates before and after the establishment of the treatment program. High rates of acquisition of puppies from other communities continued to maintain the dog population numbers despite the reduction in breeding within communities. The dog population was young, biased towards male dogs, and very unstable (almost 50% of dogs died or went missing in a one year period). The rate of dog ownership across the Kimberley varied according to the region investigated and always remained higher or equal to ownership rates at the town centres of the Kimberley Region (as determined by a survey conducted during the study). Overall the canine parasite and breeding control program resulted in a reduction in scabies and hookworm prevalence in dogs (and hence a reduction in the potential zoonotic transmission), a reduction in dog breeding within communities, an improvement in dog health, and an understanding in the dynamics and health status of dogs within communities.

[Truncated abstract] Indigenous Australians suffer cardiovascular disease (CVD) at a rate six times greater than the general population in Australia and while the incidence of CVD has been reduced dramatically amongst the majority of non-indigenous Australians and amongst Indigenous populations in other countries in the last 30 years, there has been little change in the figures for Aboriginal Australians, showing that heart health campaigns have little impact, for this group of people. Aims : The principal aims of this study were firstly, to determine and record the barriers to the development and delivery of CVD prevention programs amongst Indigenous Australians and secondly, to develop an alternative, effective and culturally sensitive method of delivering heart health messages. Methods and results : The study was qualitative research undertaken in three South-West towns of Western Australia where the incidence of CVD was high amongst the Aboriginal community members. The use of semi-formal interviews, informal individual consultation, observation, and focus groups were methods implemented to obtain information. The first phase of the research was to identify the barriers which affected the Aboriginal Health Workers’ ability to deliver specialist educational programs. Questionnaires and interviews with the Aboriginal Health Workers and other health professionals in the towns, and community focus groups were undertaken in this phase of the study. The second phase of the research was aimed at developing an alternative strategy for delivering heart health messages. The focus changed to adopt more traditional ways of passing on information in Indigenous communities. The idea of small gatherings of friends or family with a trusted community member presenting the health message was developed. The third phase of the research was to implement this new approach. Lay educators who had been identified within focus groups and by Aboriginal Health Workers were trained in each of the towns and a protocol involving discussions of health issues, viewing a video on CVD, produced by the National Heart Foundation, sharing in a ‘heart healthy’ lunch and partaking in a ‘heart health’ knowledge game which was developed specifically for the gatherings. Several of these gatherings were held in each of the towns and they became known as ‘HeartAware parties’.

This is primarily a study of dietary practices and nutrient intakes in relation to health in an urban Aboriginal community in New South Wales. It examines the assumption that poor diet is one of the major, if not the major, contributing factors in poor Aboriginal health. The data indicate that in the community studied dietary patterns were consistent with those of the wider society. Intakes of nutrients were not always optimal compared with recommended dietary intakes (RDIs) for Australia, but compared to the rest of the Australian population, and different sub-sections within it, they were not as poor as expected. In particular, the high fat, high sugar, largely vitamin deficient diet frequently assumed to be ubiquitous in Aboriginal communities is not supported by this study. Consequently, it is argued that the importance of the role of diet in poor Aboriginal health may have been over-stated. In re-evaluating the current emphasis on diet and other 'lifestyle' factors it is suggested that the scope of the analysis needs to be considerably broadened to include other factors which may be more ambiguous in terms of their effects on health. What seems particularly important is the high level of stress evident in the community studied. This stress seems to be derived from a particular set of historical and contemporary social conditions which, it is argued, need to be more fully considered as part of the totality of environmental factors which impinge on the health of Aborigines in settled Australia.

This research addresses the ways in which alcohol problems among indigenous Australians have been conceptualised and acted upon by the people themselves, and by government policy-makers. The thesis considers two main questions. First, how has it eventuated that Aborigines have become excluded from national and international innovation in the management of drug and alcohol problems? Second, are mainstream models of best practice for alcohol intervention, particularly secondary prevention activities, acceptable to and feasible for Aboriginal people? I examine how the growth of the indigenous rights movement came to underpin assertions of cultural difference from other Australians, which in turn influenced the growth of separate community-controlled health and other organisations. National policymakers found it difficult to deal with demands for the recognition of cultural difference through the provision of special funds and separate services. As a result of this increased sensitivity, national policies often gave inadequate consideration to indigenous issues. Alcohol problems in particular received little expert attention, and the division of community-controlled alcohol programs from health services for Aborigines exacerbated these shortcomings. Aboriginal approaches to alcohol were influenced by a small group of charismatic activists who pursued a unitary position and remained insulated from the changes in policy and practice available to the wider population. While the health services came to be influenced by an all encompassing 'Aboriginal' definition of health - associated with the broad WHO definition of health emanating from the Alma-Ata Declaration of 1978 - alcohol programs maintained a narrow, disease-based focus. Cultural difference is presented throughout the thesis as being a crucial issue, and it is analysed as a political construct with continuing salience in the face of the unequal distribution of resources. The constructions of difference are discussed and contested in the areas of culture and healing, in health, and in approaches to alcohol problems. I demonstrate that the politics of difference has masked the fact that many Aboriginal dependent drinkers manage to give up drinking, either on their own or with the encouragement of a health professional, just as do others in the population. The politics of difference is also implicated in the rejection of innovative and varied approaches to alcohol problems emanating from mainstream treatment research. This has deprived Aboriginal people experiencing serious alcohol problems of access to a range of interventions which could assist them much earlier in their drinking careers. Some relevant approaches include brief and opportunistic interventions delivered by health professionals, which are found to be relevant and feasible for use with Aboriginal clients of primary health care services.

Diabetes in Indigenous Australians occurs at a younger age and at almost four times the rate of non-Indigenous Australians. While the cause for this health disparity is multi-factorial, recent studies suggest that nutrition, and particularly magnesium intake, may play a role in onset of diabetes and related pathologies. No study has ever examined whether there is any relationship between diabetes and magnesium intake in Indigenous Australians, and the present study therefore sought to establish whether any such interrelationship existed. As part of this study, dietary magnesium intake was estimated in an urban cohort of Aboriginal and Torres Strait Islander subjects and compared to the average Australian dietary intake. An ecological study then explored environmental correlates, and specifically the magnesium level in drinking water, to diabetes mortality. Finally, total and free serum magnesium concentrations were determined to identify any differences in magnesium status between diabetic and non-diabetic Indigenous and non-Indigenous Australians, and also to compare which of the two parameters was a more sensitive measure of magnesium status and diabetic risk. All Aboriginal and Torres Strait Islander people that were recruited for this study were patients of the Townsville Aboriginal and Islander Health Services, Townsville, North Queensland, who presented for health monitoring and subsequently required fasting blood tests as part of that routine care. Additional non-Indigenous people were recruited from five GP practices in the Townsville area. Inclusion criteria included persons over the age of 15 (Tanner Stage 5) who had lived in the Townsville area for at least ten days. Exclusion criteria included chronic diarrhoea, alcoholism or binge drinking in the past two weeks, use of diuretics, consumption of magnesium supplements, reduced renal function (urinary albumin to creatinine ratio exceeding > 2.5 mg/mmol in men and > 3.5 mg/mmol in women), severe mental illness, pregnancy, or breastfeeding. Our results indicated that 60% of the Indigenous people assessed in this study had a dietary intake of magnesium that was below the estimated average magnesium requirement for half the national population. Additionally, the average magnesium intake in Indigenous Australians was significantly less than the intake of non-Indigenous Australians (p<0 .001). A significant negative correlation was found between the incidence of diabetes related mortality and the concentration of magnesium in drinking water in Queensland, confirming previous reports from the USA that drinking water magnesium may be an important factor in development of diabetes. The needs assessment study confirmed that diabetes in both Indigenous and non-Indigenous Australians was associated with reduced levels of total serum magnesium, and more importantly, that total serum magnesium was lower in Indigenous Australians who did not have diabetes compared with their non-Indigenous counterparts (p=<0.001). In the absence of diabetes, the prevalence of hypomagnesaemia was 17.2% for the non-Indigenous but 36.9% for the Indigenous subjects. Finally, the ionic serum magnesium analysis confirmed the results of the total serum magnesium study, and demonstrated that ionic magnesium was strongly correlated to the total magnesium concentration (r: 0.75. p < 0.001), with the relationship being apparent irrespective of either diabetic (r: 0.66 to 0.81. p<0.001) or ethnicity (r = 0.71 to 0.81. p<0.001)." We conclude that although not causal, the evidence suggests that magnesium may be a significant contributing factor to diabetes in Australia, especially for Aboriginal and Torres Strait Islander peoples, and that further investigation of the potential relationship between magnesium and diabetes in the Australian Indigenous populations, and possible corrective interventions, is highly warranted.
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Thesis (Ph.D.) - University of Adelaide, School of Medical Sciences, 2008

The the sis is a study of a single community, its health, expectations and aspirations. It is a study of understand in g and responsibility in the context of dependence. The primarily ethnographic work for this thesis was undertaken in Ngukurr over thirteen months between 1999 and 2002. Ngukurr is a remote town on the south east border of Arnhem Land in Australia’s Northern Territory. Its long term residents are Aboriginal people. The thesis presented here examines these people’s understanding of health and illness in their community and their attainment of a good life. My study focuses on issues around people’s engagement with and disengagement from, the management of their health and health service delivery. My thesis is guided by the following questions: • how do people assess their health status? • how a republic health services perceived? • what expectations does the community have about the type and quality of the services provided ? • do people seek an active role in the management of their health ? People’s attitudes to and expectations for their health are examined in the context of a history of direct welfare dependence till the mid nineteen seventies; followed by local self government in which fiscal and administrative responsibility were held by Government or outside individuals. The evidence for health status, morbidity, and mortality among the remote indigenous population is significantly worse than non indigenous Australians and h a s been the subject of extensive Commonwealth and State health programs to little obvious effect. The literature I survey shows that people in poor communities rate their health more highly than the objective data suggests. Ngukurr residents rate their health in a similar way, b u t their apparent satisfaction masks complex beliefs about illness and concerns about health. I demonstrate that the community believes that outside influences are more important than personal actions as a cause of poor health, that there is little respect for the community’s view of health or health services, and in consequence there is little point in taking personal or collective responsibility. Ngukurr residents are not disinterested in health. They are acutely aware of the patterns of morbidity and mortality in their community and consider these to have a negative impact on their quality of life. Their ability to bring about changes in these patterns is limited by different paradigms of health and illness which sometimes appear as fatalism, powerlessness in the non-Aboriginal domain, loss of confidence due to poor communication with non indigenous providers, and consequent low expectations with regard to personal and community health. This creates a challenge for current policies to devolve management responsibility for health services to local communities. Policy makers should make considerable efforts to u n d e rs tan d local health beliefs and value systems and ensure that changes are appropriate, rather than making changes in health systems based on non-indigenous understandings of needs.

The body of work presented in this portfolio addresses the research question: “What is best practice in training and support for General Practitioners in Aboriginal and Torres Strait Islander health?” My 13 papers and monographs describe general practice training and related research conducted from 1998-2018, using a range of methodologies. The research is grounded in partnerships with Aboriginal and Torres Strait Islander peoples and organisations, and rigorous, evidence based research approaches. In this portfolio I discuss the rationale for training health professionals as a strategy for addressing Indigenous health inequity and provide an organisational context in the Australian general practice training setting. My discussion of the papers and monographs is informed by a comprehensive review of the current literature. Reflecting on my research and the current literature, six themes are identified as framing best practice in general practice training in Aboriginal and Torres Strait Islander health, and recommendations for best practice are described under each. The themes are Indigenous leadership and partnerships; organisational commitment; systemic approach; learning approaches; learning content; and assessment and evaluation.

Background: Heart disease is a leading cause of the health gap between Aboriginal and non-Aboriginal people in Australia. Higher incidence of acute myocardial infarction (AMI) and higher mortality from AMI are major contributors to the greater burden of disease in Aboriginal people. Much of the research on reducing rates of AMI focuses on individual risk factors, such as smoking, physical activity, cholesterol level and diabetes. However, broader contextual and structural factors, including features of the geographic areas where individuals live, and the hospitals they attend, can have an important impact on health outcomes. Identifying and quantifying contextual and individual factors that influence the higher rates of AMI events and mortality in Aboriginal people will assist in better development and targeting of interventions to tackle these disparities. In this thesis, I develop methods for classifying Aboriginal people in routinely collected hospital data, and use these data to investigate the influence of individual, area of residence, and hospital factors on rates of AMI, mortality from AMI, and procedures after AMI, in Aboriginal people in New South Wales (NSW), Australia. Methods: Routinely collected hospital data for the entire NSW population for the period July 2000 to December 2008 were linked to mortality data from July 2000 to December 2009 using probabilistic methods. Firstly, I investigated the recording of Aboriginal status in the hospital and deaths data, and used linked data to develop and test algorithms to enhance the reporting of Aboriginal status. Then I used (i) multilevel Poisson regression models to estimate the relative rates of first AMI events, accounting for area of residence; (ii) multilevel logistic regression models to estimate the relative mortality after AMI admission, accounting for hospital and admission; and (iii) multilevel Cox proportional hazards models to estimate the relative procedure rates after AMI admission, accounting for hospital of admission. I also sequentially accounted for other individual risk factors, such as the presence of comorbid conditions, to determine their influence on the disparities in outcomes for Aboriginal people. Results: Sixty per cent of the variation in recording of Aboriginal status in routinely collected hospital data was due to the hospital of admission, and status recording was worse in major city compared with more regional and remote hospitals, and in private compared with public hospitals. The number of people reported as Aboriginal, and estimated admission rates and mortality ratios, varied according to the algorithm used to enhance the reporting of Aboriginal status. After accounting for age, sex, and year of admission, rates of AMI in Aboriginal people were more than two times those in non- Aboriginal people, even when comparing within areas of residence. The disparities were particularly large for women and those in younger age groups. There was significant variation in AMI rates by geographic area, with higher rates outside of major city areas and in areas of lower socioeconomic status. The relative Aboriginal to non-Aboriginal disparity in rates was also particularly large in these areas. Aboriginal patients had a similar 30-day mortality risk to non-Aboriginal patients, after adjusting for age, sex, year and hospital, but a higher risk of dying within one year. The latter difference became non-significant after adjustment for comorbid conditions. There was a higher 30-day mortality risk for patients admitted to smaller, more remote hospitals without on-site angiography facilities compared with larger hospitals and those with on-site angiography, respectively. Aboriginal patients had a revascularisation rate 37% lower than non-Aboriginal patients of the same age, sex, year of admission, and AMI type, but a rate 18% lower within the same hospital. Adjustment for comorbid conditions, such as diabetes and renal disease and other individual factors, explained the remaining disparity. Hospitals varied markedly in procedure rates, and this variation was associated with hospital size, remoteness, and facilities. Conclusions: Hospital-level interventions, such as better training of staff, are required to improve the recording of Aboriginal status, particularly in major city and private hospitals. Data linkage of routine administrative data can improve reporting of Aboriginal status, although the impact of the algorithm used to enhance reporting should be explored using sensitivity analysis. My research identified the importance of contextual influences when examining disparities in rates of AMI, and in mortality and procedures after admission for AMI. There was significant variation in overall AMI rates by area, which was partly explained by area-level disadvantage. Even when comparing within areas, Aboriginal people had higher rates of AMI than their non-Aboriginal counterparts. Priority areas for area-level interventions were those with a higher than average disparity and a higher than average rate of AMI for Aboriginal people. While disparities in longer-term mortality and procedure rates within hospitals did not persist after fully adjusting for individual risk factors such as comorbidities, these disparities will remain as long as Aboriginal people have higher rates of comorbid conditions (e.g. diabetes and renal disease) that complicate treatment and survival. For residents of rural and regional areas, both Aboriginal and non- Aboriginal, improving access to larger hospitals or those with specialist treatment facilities could improve surgical rates and outcomes after AMI. However, the main priority must be reducing the early onset of AMI and comorbid chronic conditions, such as diabetes and renal disease, and the subsequent early mortality among Aboriginal Australians. This will require major efforts in primordial, primary and secondary prevention. Priorities include targeting individual risk behaviours, such as smoking, improving the management of early symptoms of cardiac disease, reducing barriers to accessing primary care and cardiac rehabilitation services, and changing community norms about smoking and health behaviours. Interventions must acknowledge the wider historical and contextual causes of the current Aboriginal health disadvantage, and must deal with macro, contextual and individual levels of influence in order to have a significant impact.

Includes publications published as a result of ideas developed in this thesis, inserted at end.
"April 2005"
Includes bibliographical references (leaves 210-242)
242 leaves :
Title page, contents and abstract only. The complete thesis in print form is available from the University Library.
Examines goal setting in people with diabetes as part of chronic disease management in a rural setting. The studies were performed in Eyre Peninsula with a significant (10-20%) Aboriginal population.
Thesis (M.D.)--University of Adelaide, Dept. of General Practice, 2005

Includes publications published as a result of ideas developed in this thesis, inserted at end.
Includes bibliographical references (leaves 210-242)
242 leaves
Examines goal setting in people with diabetes as part of chronic disease management in a rural setting. The studies were performed in Eyre Peninsula with a significant (10-20%) Aboriginal population.
Thesis (M.D.) -- University of Adelaide, Dept. of General Practice, 2005