Indigenous health

In reply

Siaw‐Teng Liaw · Vicki Wade

To the Editor: We strongly agree with St Clair and colleagues1 that telehealth is a “game changer” for the provision of health services to Aboriginal and Torres Strait Islander communities in Australia. For more than 15 years, we have been engaging with Indigenous communities throughout Queensland, to plan and establish telehealth services for a range of clinical disciplines, including diabetes, ear, nose and throat, and aged care. Telehealth is contributing to positive changes in our health system and this is evidenced in our recent studies highlighting the value of telehealth for Aboriginal and Torres Strait Islander people. A systematic review of the outcomes of using telehealth for the provision of care to Aboriginal and Torres Strait Islander people reported improved social and emotional wellbeing, clinical outcomes and access to health services.2 Other benefits included improved screening rates and reduced need for travel.3 This review reinforced the importance of partnerships between Aboriginal community controlled health services (ACCHSs) and public hospitals. Telehealth also helps with the delivery of culturally appropriate care. In a qualitative investigative study,4 we found that telehealth allowed specialist care to be delivered from Aboriginal medical services which were familiar to the patient and local care providers. According to this study, a telehealth consultation with a specialist held in the ACCHS resulted in less stress and greater convenience; and also meant that an Indigenous health worker could be present during the telehealth appointment to provide advocacy and support for the patient.4 Telehealth also reduced out‐of‐pocket expense for the patient. These factors contributed to the interpretation of culturally appropriate services. Telehealth is already benefiting Indigenous people throughout Australia. All studies recognise the pivotal role of ACCHSs as advocates for telehealth. While telehealth applications are predominantly reported in rural and remote areas, we believe that telehealth is just as important for the delivery of specialist health care services to metropolitan ACCHSs, in lieu of community members attending mainstream health services. Telehealth is one mechanism to help close the gap. Telehealth empowers community health services and can improve equity of access to health services in rural and remote — and urban — settings.

Anthony C Smith · Nigel R Armfield · Liam J Caffery

To the Editor: In the recently published article by Morgan and colleagues1 and associated podcast, the authors raised the issue of future research into the outcomes of identification of Aboriginal and Torres Strait Islander peoples in hospital. The implementation of a visual identification methodology has previously been described2 and was put in place in partnership with the hospital department of Aboriginal health. The purpose of this identification initiative was to encourage all medical professionals who care for Aboriginal and Torres Strait Islander patients to question what they can do to assist them while they are in hospital. We describe here the positive outcomes of this process. In addition to hospital pharmacists,2 the visual alert system is also used by other departments and professionals within the hospital, such as cardiothoracic care, the emergency department (ED), Aboriginal health, and speech pathology, as well as ward‐based nursing and medical staff. The Aboriginal and Torres Strait Islander patients’ identification system is used by health care providers within the hospital to easily identify the patients they need to visit, to provide culturally appropriate resources and services and links to other services, and to enhance the care patients receive and enable them to remain in a caring hospital environment. At ward level, nursing and medical staff use the identification system to highlight the referral process needed to link with Aboriginal health workers — connecting the right resources to the right people. Because of the visual alert,2 staff feel more aware of the cultural needs of the patient before they meet them. Specifically in the ED, there is a system‐wide approach that firstly identifies Aboriginal and Torres Strait Islander patients presenting to the ED using the visual alert at triage, and then implementing initiatives that aim to reduce the level of “did not wait for treatment” episodes. The Heart and Lung Stream at St Vincent's Hospital uses the system to identify Aboriginal and Torres Strait Islander patients early during their admission in order to provide culturally specific education, resources and follow‐up after hospital discharge. We encourage others to explore this initiative in their hospital, together with cultural responsiveness training, to enhance the care of Aboriginal and Torres Strait Islander peoples during and after their hospital visit.

Susan A Welch · Sonia Robinson · Tamra Langley · Pauline Deweerd

In reply

David JR Morgan · Martin Whitely · Tania Harris

TO THE EDITOR: Skin disease contributes to the health disadvantage of Indigenous Australians, and the recent publication of the healthy skin guidelines is welcome.1 Scabies is a significant health problem for some remote Indigenous communities, and the healthy skin guidelines describe a series of community‐based scabies control programs. These programs resulted in initial reductions in prevalence of scabies, but they were not sustained, as human scabies was eventually reintroduced.1 The guidelines used a systematic literature review to ensure that all relevant research was included. However, since the review of scabies was limited to studies of human scabies, implications of canine scabies may have been overlooked.2,3 Therefore, a statement such as “dog control programs are of no benefit to the community control of human scabies infestations” requires scrutiny. Canine scabies mites are distinguishable from human scabies mites by genotyping.4 Clinically, canine scabies can cause a transient human infestation, with no ongoing transmission cycle. The lesions of canine scabies occur primarily on body areas that have been in contact with dogs, and are intensely itchy after a shorter period compared with lesions of human scabies. The infestation is self‐limiting unless the person is reinfested.5 As with human scabies, the intense itch from infestation by canine scabies can lead to scratching and skin trauma, providing an entry point for bacterial infection. Complications such as post‐streptococcal glomerulonephritis and chronic renal disease can also arise from canine scabies. Moreover, outbreaks of scabies in humans can be caused by repeated transmission of canine scabies.5 Management of people affected by canine scabies includes treatment of affected dogs and their contacts.3 Comprehensive dog health programs provide broad‐based community benefits, including reduced injuries from dog attacks, improved community and workplace safety, reduced sleep disturbance from barking and fighting dogs, and enhanced dogs’ appearance, behaviour and wellbeing. Dogs are considered family members in some Aboriginal and Torres Strait Islander communities, sharing housing, bedding and food; hence, human and dog health and wellbeing are intimately linked. No trials have yet examined the impact of dog health programs on scabies transmission in humans or other health outcomes in the remote Indigenous communities where scabies is a public health problem.2 Without evidence from trials, the impact, or lack thereof, of dog health programs on human health is speculative.

Rosalie Schultz

To the Editor:Calabria and colleagues1 report that, overall, 9.8% of Aboriginal and Torres Strait Islander adults are at high absolute cardiovascular disease (CVD) risk, reflecting how poorly Australia supports the social and cultural determinants of health for the First Australians. However, this is a different nuance from their statement: “Absolute CVD risk is high among Aboriginal and Torres Strait Islander people”. Aboriginal and Torres Strait Islander people have median age of 23 years,2 and only 1.1% of those in the 18–24 age group are at high risk. The authors note undertreatment with lipid-lowering therapies of Aboriginal and Torres Strait Islander people at high CVD risk; many Aboriginal and Torres Strait Islander people who would benefit are not offered best practice care. However, 13% of people at low CVD risk are on lipid-lowering medication,1 which may be unnecessary treatment, with costs and side effects. As health professionals we need to beware of tendencies to emphasise pathology and risk among Aboriginal people.3 Many health professionals hold ideas of “the passivity, dependency, and non-compliant nature of [the Aboriginal] mob … The perception of Aboriginality as … a health risk, and predictor of unhealthy behaviours … reinforces stereotypical ideas of Aboriginality… and disconnects Aboriginal people from their own identities … [and] stories of strength and survival”.3 There is a tension between our desires to prescribe behaviour to reduce risk and enabling and empowering people to make decisions for themselves. Well intentioned efforts to manage Aboriginal and Torres Strait Islander people may have iatrogenic side effects. For example, health professionals may develop assumptions about people’s behaviour and worthiness to receive treatment,4 while Aboriginal and Torres Strait Islander people themselves may be disconnected from their sense of self-efficacy and community and cultural strengths and identity, contributing to disengagement from health care.3 Like other procedures in health care, absolute CVD risk assessment has costs as well as benefits. Educating community members about absolute CVD risk would promote health literacy and enable people to give informed consent to assessment of this statistic. Numbers hold both face and cultural values, so it is important that Aboriginal and Torres Strait Islander people have control of their statistics.5

Rosalie Schultz

In reply

Raymond W Lovett

To the Editor: The recent guideline review by Almeida and colleagues1 coincides with an international call for action to address the burden of low back pain.2 Low back pain is a major societal problem and the number one cause of disability internationally. Recent guidelines prioritise advice, reassurance and self-management as first line care. Implementing these simple, high value interventions is important in populations, such as Aboriginal Australians, where there has been limited previous recognition of low back pain as a problem. A recent systematic review of musculoskeletal pain among Aboriginal Australians3 summarised that the prevalence of low back pain is higher among Aboriginal Australians and has disproportional impacts. Qualitatively, low back pain has multidimensional effects, including functional, cultural and emotional. Access to both primary and specialist level care is lower for some musculoskeletal pain conditions such as osteoarthritis, and there may be parallels for low back pain. Worryingly, there is evidence that the health care that Aboriginal people receive for low back pain is worse than that received by non-Aboriginal Australians, including care with the potential to cause iatrogenic harm. These include higher rates of opioid prescribing and unhelpful low back pain information. Low back pain is associated with a higher number of comorbid health issues, psychological stress and income poverty, and may contribute to the complex milieu of health burden and disadvantage for some Aboriginal communities. The implementation of effective, high value, first line care described by Almeida and colleagues1 is critical for Aboriginal people with low back pain; however, it needs to be adapted so that it is acceptable, accessible and appropriate. For example, advice and education to reassure patients and encourage self-management may need to be supported by culturally appropriate low back pain information. This could include visual, story-based information that has been developed with input from Aboriginal people.4 Implementing successful self-management requires doctors to develop trusting relationships with patients in services that are culturally secure for Aboriginal people. Effective communication is critical.5 The provision of evidence-informed low back pain care to Aboriginal patients requires better recognition of low back pain as a health issue affecting Aboriginal Australians, and a greater understanding of how such care can be best implemented in Aboriginal communities.

Ivan Lin · Donna B Mak · Juli Coffin · Peter O'Sullivan

In reply

Matheus Almeida · Bruno Saragiotto · Chris G Maher