Week Six - Indigenous Health Policy Challenges and Successes -Maternal and Child Health Program at Debarl Yerrigan

1. Week Six - Indigenous Health Policy � Challenges and Successes -Maternal and Child Health Program at Debarl Yerrigan

2. Today�s session Indigenous Health Policy � Challenges, Successes, Obstacles and How to Make a Difference Prof Mike Daube Indigenous Maternal and Child Health Kathy Webster

3. Indigenous Maternal Child and Family Health The Global Health Short Course Katherine Webster Midwife, Child and Family Health Nurse, Mental Health Nurse, Academic Board Charles Darwin University

4. Overview To examine cultural differences particularly child rearing practices and child development. Explain the �Our Time Program� run through Derbarl Yerrigan and Health Department Western Australia Community Health � Aboriginal Child and Adolescent Health Team. Review of literature, international and national and state health policies.

5. The Individualism Index

6. The Individualism Index Majority of the world are collectivist (Latin America, SE Asia) The rich (G8) countries are individualist (US, Australia and UK) Middle of the index includes India, Middle East, Japan (Hofstede & Hofstede 2005)

7. Definition of Collectivist Societies where people are integrated into strong cohesive in-groups which throughout people's lifetimes continue to protect them in exchange for unquestioning loyalty.

8. Definition of Individualist Societies in which ties between individuals are loose: everyone is expected to look after him or herself and his/her immediate family. Responsible for your own conscience vs rules/goals of the group.

11. So What Does This Mean? Effects on Relationships Influences on Decision making Methods of Communication Approaches to Child rearing

12. Relationship is Everything Emphasis is placed on personal relationships. Describe themselves by referring to the groups they belong to, the land which they are from. Friendships are predetermined. Reinforced through obligations Sharing Resources Financial Rituals ceremonies (e.g. births, deaths).

13. Decision Making Groups goals takes precedence, members are responsible for the group. Little distinction is made between leaders and members; leadership is normally shared. Personal opinion does not exist. If there is no established group opinion a family conference is held. Oral agreements is enough Spend more time getting to know you before transactions take place.

14. Slower Walking Speed

15. Communication Silence (no need to state the obvious) Information is often left implicit Much goes unsaid Higher use of non verbal communication Indirectness is valued Social network is primary source of information In Individualist �being truthful is highly regarded and indicative of a sincere and honest person. Children are always told to tell the truth If they tell other peoples opinion they are considered weak.

16. Communication (cont.) Children learn that opinion is determined by the group Direct confrontation is considered rude and undesirable. The word NO is rarely used. Reluctant to say no for fear of offending So yes may not mean yes

17. Communication: (Bain 2005) A hypothetical sentence is typically not recognised in traditional Aboriginal language: e.g. If we get money, what do you want? Traditional Aboriginal people do use abstraction but they maintain a direct link with reality while Western people break that link. (Bain 2005) e.g. Fathers and fatherhood The term 'fatherhood' is not recognised because it does not link directly to something, or someone, concrete or real.

18. The Health Encounter with Non-Indigenous Worker Cut to the chase You tell me what's wrong or how can I help you (ambiguity and will be eliminated by direct explicit communication) Fill silence with more questions No attempt to understand the other Sign this consent White health professional seems insulting, impolite, insensitive intrusive and unnecessary Aboriginal parents appears vague, underhanded, dishonest in reluctance to be explicit

19. Collectivist Children and Development Child is rarely alone and responsibility of all. Learns to trust a multitude of people. Development is child led Children are self reliant and autonomous Encouraged to regulate their own behaviour and development

20. Collectivist Children and Development Kids are not 'trained' but expected to unfold at their own pace and in their own way with minimal interference from the adult world (Reid 1982) Carers' do not initiate contact � the child is the active agent. Aboriginal babies are not seen as helpless: have the capacity to demand what they need (Kearins 1984)

21. Collectivist Children and Development Participation in activities cooperative and voluntary (Child does what is expected, not what s/he is told). Parents do not appear to attach special significance around developing milestones. No concept of the word �no�.

22. Collectivist Children and Development Anything that a child should not touch is removed from their reach or child is distracted. Free to explore the world and tell family members what they need. Control vs Autonomy

23. Children are sacred Highly valued and included in community life. Totally integrated there are no separate arrangements made for the children. Children are always heard, seen and never considered a nuisance.

25. Gross Motor Development Remote dwelling Aboriginal babies are often held up right from an early age. 'Increases the infants levels of alertness and may have a facilitating effects on attention' (Konner 1977 cited in Kearins 1984, p19). Infants as young as three weeks of age observed holding their heads up for three -four minutes at a time and by six weeks, having full head control (Hamilton, 1981).

26. Gross Motor (cont.) More likely to be independent in developmental tasks such as interaction, self dressing and self feeding (Brown, 2000). Children mix widely with children of varying ages. By the time a child is 4 yrs can be up to 0.5 km from adults (Kearins 1984).

27. Language Development Massive verbal instruction Visual learner beliefs a myth?? Uses visual attention to emphasise the verbal message (for children) Rapid language development Introduces stories around relationship and kinship system from birth Adapted language for children Once older often don't give visual attention when listening

28. Parents as Teachers Objective of activities is the development of self-reliance (so to assist would interfere with this) (Leidloff, 1985) Overt control of children seen as being damaging to children's autonomy and health Western children told what to do, how to behave Observational or visual learning may lead to slower acquisition of language skills when compared to non-Aboriginal children (Brown, 2000)

29. Discipline The adult does not believe that they are better able to make the decision for the child. No such thing as 'spoiling' (Kearins, 1984). No such thing as a 'bad' child (Liedloff 1985) To 'want', 'like' or 'need' something are all seen as the same concept (even when no money). Not considered to be disobedient as there is no expectation for a child to obey another Don't fight amongst themselves (not competitive)

30. Illness/Injury Appear to pay little attention to skin sores, pain or illness They do not seek attention from adults when injured Adults do not fuss over the children. If something is dangerous the mother may observe closely, or distract the child rather than forbidding the activity Children will then often change activity, as they become aware of the dangers to the previous activity (Kearins, 1984)

31. Malnutrition Anorexia caused from overcrowding If a child is under nourished because they have not demanded sufficient food, it may be assumed that there is no further parental responsibility (Folds, 2001) Further complicated considering problem solving and decision making needs to consult family and/or wider group

32. Summary - Individualism and Collectivism It appears we have opposing �Child rearing philosophies �Communication styles Remember cultures change We need to stop concentrating on the behaviour and try to determine what INFORMS the behavior

33. �Our Time Program� run through Derbarl Yerrigan and Health Department Western Australia Community Health � Aboriginal Child and Adolescent Health Team, Coolarbaroo and City of Gosnells and City of Stirling.

34. Our Time Program Chronic conditions such as diabetes, cardiovascular disease and heart disease represent a serious escalating health burden for Indigenous populations across Australia. Social disadvantage, inactive lifestyle and poor nutrition are major contributors to chronic disease among Indigenous peoples (O�Dea 2005 p.167). Many programs have been tried with limited success. A new family approach addressing physical exercise, nutrition, social inclusion, health literacy, Health care and school readiness is now being trialled. A collaboration of services are involved including the Child and Maternal Health team at Derbarl Yerrigan Health Services in Perth, Western Australia with the Health Department of Western Australia (Community Aboriginal Adolescent and Child Health CAACH).

35. This new program is an innovative outreach service, orchestrating the redesign of health delivery. This is achieved through reducing inequalities, demonstrated by addressing issues of social inclusion, health literacy and providing a continuum of care. It is in addressing these social determinants that the �solutions to ill health lie� (McMurray, 2007 p.30).

37. Exercise Program The exercise program has involved the following classes. Zumba Belly dancing Aqua aerobics Fit ball Kick boxing Gym class Swimming lessons

38. School Readiness Program Child health checks/antenatal care Dietary deficiencies addressed Hearing impediments addressed with the ear health team from Derbarl Yerrigan Health Service/Dr Harvey Coates and Ms Ann Jacobs, Speech Therapist. Noongar language. Fine/gross motor skills Take home books Family functioning & parenting education sessions

39. School Readiness Program Curtin University provide speech therapy to the children with Masters students under the supervision of Ann Jacobs.

40. Health Assessments and Follow-up Health assessments and referrals provided for clients. Letters of support written for Department of Housing and other support letters where required. Court mandates for teenage pregnant women and court reports provided. Regular HB and blood pressure testing.

41. NUTRITION Education session � how to make high iron balanced meals on a small budget. Mission Australia provides fruit and vege from Canning Vale Markets to the clients to take home.

42. EDUCATIONAL SESSIONS Parenting Family function Brain Development Attachment Infectious Diseases (impetigo, HIN1) Ear Health Hearing Speech Development Internet use Primary preventative health issues, SIDS, Screening for Breast Cancer

43. EDUCATIONAL PARTNERS Asthma foundation Country and rural oral health, UWA Breast Screening WA SIDS and KIDS Cancer Council of WA Ngala Royal Life Saving Western Australia Pap smears HDWA

44. Collaborating Organisations Coolabaroo Early Years Program Coolabroroo Aboriginal Housing Mercy Care Mission Australia Yale primary school Balga Primary school Gosnells City Council Library Boronia�s Pre-release Centre Acacia Prison Rural and Remote Oral Health Ngala Aboriginal Child and Adolescent Health Team Parenting research Centre Forensic Mental Health Nutritionalist Department of Juvenile Justice

45. Collaborating Organisations David Wirrapunda Foundation Royal Life Saving Western Australia Department of Recreation and Sport South Metropolitan Area Health Service Mental Health

46. Literature Review Intersectorial Collaboration The Canadian Institute of Advanced Research (2002) reported that the social and economic conditions of a person�s life are responsible for 50% of their health status, with 25% being attributed to health care systems, 10% to the physical environment and the remaining 15% to biology and genetic endowment. Therefore the social factors impinging upon health are required to be addressed so that health can be attained.

47. Closing the Gap The recently released report, �Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health�, issued by the World Health Organisation�s Commission on Social Determinants of Health (2008) echoed the same sentiments. The report provides actionable recommendations for achieving health equity on a global scale, and doing so with urgency: within one generation. In framing health inequalities as an issue of social justice and by addressing the structural drivers of health inequality, the Commission acknowledged that we must expand on the traditional approaches and highlighted biomedical pathways and their proximate causes. Culture and ethnicity are, according to O�Campo, Maritt, Shankardass and Lofters (2009), structural drivers of health inequality and those that determine one�s social position. With a person having a marginalized ethnicity and culture within a more dominant culture this will impact on who the person interacts with and how they access information to direct them through life. This leads us in health to work on the �causes of the causes� (CSDH 2008) in the daily life of our Indigenous clients.

48. Social Inclusiveness Through interfacing with clients intersectorially social inclusiveness is facilitated. The NHRC (2005) defines social inclusion as a situation where all people feel valued and can participate in health and health related decision making. Because the clients are being able to access services in their local communities this engenders a sense of belonging to their community. Hudson-Rodd (1992) found that for the Canadian Indigenous people, having a sense of belonging to their community engenders wellness, both physically and mentally.

49. Bronfenbrenner Model In order to support families effectively an ecological perspective has been adopted; an example being the Bronfenbrenner Model, (Bronfenbrenner 1979) has been adopted. This model explains that a child spends most of their time with their family and highlights why any intervention to assist a child has to be directed to their family. The model demonstrates how child development is determined by the child�s experiences in these settings, for example, is some one showing the child appropriate ways to behave, is some one talking and reading to the child, is there any books in the home to be read. Are there materials for the child to play with? The following model shows the child in the centre and the diagram shows how health, education and other community learning intersects.

51. Accessing Child Health Services Daly and Smith (2005) provide evidence to suggest that universal mainstream child health services are underused by many within the Aboriginal population. In most cases, according to Aslam and Kemp (2005 p.33), �it appears that retention within the service rather than initial access may be the key issue�. Amid the wide range of contributory factors hypothesised for this poor engagement are a general mistrust of mainstream services, reduced health care awareness resulting from low levels of parental education, a belief that the service misunderstands Indigenous cultural beliefs and as well as having inadequate culturally appropriate service provision Schmied (2008) claims that whilst the universal health service must continue to demonstrate the provision of services suitable for all through persistent efforts to ensure families are aware of the options available, other targeted options have also to be considered to meet the specific needs of the Aboriginal population.

52. Exercise The World Health Organisation (WHO 2006) estimates that two million deaths per year can be attributed to physical inactivity, making physical inactivity one of the worlds leading global challenges. According to the Oxford Health Alliance (2009), physical inactivity is a risk factor for three of the four leading chronic diseases (cardio vascular disease, type 2 diabetes, and some cancers, but not lung disease) that collectively count for more than 50% of all deaths world wide.

53. Exercise and Mental Health It is recognised by the Beyond Blue Foundation (2009) that physical health and mental are not mutually exclusive but inter-related. It is well recognised that exercise has an impact on mental health and well being. Exercise is now considered a primary treatment for mild to moderate depression.(Tzar 2009). The self concept of parents and carers is related to the identity formation of children (Schachter & Ventura 2008). Through developing a healthy self concept of parents through exercise, engagement with others in the community, and developing a sense of belonging, we are assisting in the positive identity formation of children. It is also recognized by the Australian Parenting network that exercise is recommended stress reliever.

54. Exercise and Stress Levels The Raising Children Well Network (viewed 2010) explains that stress is a normal part becoming a parent. It is recognised that Indigenous women due complex social situation for example, living in over crowded accommodation, this may well be exacerbated. Exercise is a well recognised stress reliever (Raising Children Well Network, is there a date or a source you can cite here) Stressed parents who utilize avoidance coping strategies are more likely to overreact when disciplining their children and report increased abuse potential (Rodriguez, 2010) therefore by engaging parents, grandparents and carers in exercise classes we are anticipated this will assist with developing their capacity to parent through decreasing their stress levels.

55. Ear Health and Swimming Additionally we are holding this group at the local recreational facilities that have swimming pools is related to research by Lehmann et al. (1992) which indicates that regular swimming in chlorinated pools is associated with decreased rates of ear and skin disease. Otitis Media is recognised as being proliferative in Aboriginal children and higher of skin disease is also noted (Lehmann et al 1992). This is therefore a preventative strategy to decrease these rates of disease. According to the Royal Life Saving Western Australia ([RLSWA] 2010), drowning rates for Indigenous children a much higher than the non- Indigenous population.

56. Health Literacy Poor health literacy is recognised in the Indigenous population (McMurray 2009). It is demonstrated by presenting for medical intervention at the tertiary stages of the disease process. Health literacy according to Kickbusch (2009) involves knowing about how the body functions and signs of dysfunction. Low levels of health literacy comes at a cost to the individual and the community through higher health care costs, as tertiary treatments are more costly than primary health interventions. Health literacy is not just knowing how to read but knowing how to navigate through life, keeping health in mind and in practice (Kickbusch 2009). At a basic level it is about people knowing where available services are, and being able to act and follow verbal and written instruction (Mc Murray, 2007).

57. Continuum of Care Olds et al. (2010) longitudinal study found that the involvement of a home visiting nurse promotes better educational outcomes and decreased rates of imprisonment of the population serviced. Although home visiting is not occurring within the program on a large scale because of the small number of staff, having weekly client contact is likely not only, to bring about better health outcomes, but also, in the long term, better socio-economic outcomes; these are identified by the WHO (2008) as a dominant precursor for health.

58. Nutrition O�Dea (p.168, 2005) states �the first 2-3 years of life are recognized as being critical� in terms of healthy child development and he goes further in his review of child health programs to state the following.� "The development of a systematic approach to improve nutritional status of infants is well recognised as a priority in the primary health care setting. The provision of subsidized food is likely to be very cost effective intervention. This could be integrated into education and support sessions delivered by maternal and child health nurses and specialist Aboriginal Health Workers." (p.169, 2005).

59. Chronic Disease Medical management of chronic disease must become the broader component of �comprehensive primary health which encompasses advocacy for a healthier environment� (O�Dea, p.168. 2005). The National Chronic Disease Strategy (Australian Government Department of Health and Aging, 2006) recognises that the health system cannot work in isolation from other sectors and services, and must take a leadership role in advocating, engaging and partnering with other sectors to influence the social and environmental factors that determine the burden of chronic disease. Effectively this means, in real terms, that the response to chronic disease prevention and care requires a whole of government and whole of community response.

60. Chronic Disease (cont.) Nurturing a Healthy Start is for: better health promotion and prevention, early detection and intervention and management of risk, better access to primary health care, and better access to and coordination of health and other services for children with chronic or severe health or developmental concerns.

61. Chronic Disease (cont.) The NCDS recommends that Aboriginal Community Controlled Health Services provide culturally appropriate services for their communities, their links with other mainstream health and related services need to be well developed to support integration and access to culturally safe and appropriate care and support at all times. This is essentially what the HFL attempts to bring into action.

62. School Readiness Teaching children a second language has many advantages apart from teaching culture. The processes involved in teaching the sound system, vocabulary and grammar are the same skills required to teach phonological awareness which according to the research is the single best predictor of early literacy success (Gillon 2004). Vocabulary development is linked to reading comprehension as is grammar (Hoover and Gough, 1990). It has been well documented that� the high incidence of Middle Ear Disease in Aboriginal children contributes to poor Phonological Awareness �(Yonowitz and Yonowitz, 2000 ) and that children� with poor sound awareness are highly at risk for poor literacy outcomes (Silburn and Walker 2007).

63. Menzies on School Readiness Recommendations made by Charles Darwin University and the Menzies School of Health Research report on The School Readiness of Australian Indigenous Children (, Nuton, Lea, Robinson, and Carparetis 2008). The recommendations are as follows; 1) Better antenatal care 2) Dietary Deficiencies to be addressed 3) Hearing Impediments 4) Child behaviour 5) Parenting 6) Family Function 7) Home educational support

65. References Australian Bureau of Statistics 2009, Aboriginal Population in Perth, Western Australia 2008, ABS Canberra viewed 10 April 2010. http://www.ausstats.abs.gov.au/ausstats/subscriber.nsf/0/ Australian Government. 2009. Closing the gap for Indigenous Social Inclusion http://www.socialinclusion.gov.au/Initiatives/Pages/closingthegap.aspx viewed 10th May 2010. Bronfenbrenner E (2006) Bronfenbrenner Ecological Model. http://groups.apu.edu/practicaltheo/LECTURE%20NOTES/YMIN/YMIN%20201/Fall%2007/Bronfenbeenner%27s%20ecological%20system.jpg viewed 10th of May 2010 Beyond Blue (2009) Exercise and Mental health. http://www.beyondblue.org.au/index.aspx?link_id=&gclid=CKDbpOPG6qECFRMZewodM3sdJg accessed 17th May 2010 Canadian Institute for Advanced Research, Health Canada, Population and Public Health Branch 2002 Estimated impacts of determinants of health on health status of the population. Toronto. Centre for Developmental Health, Curtin University of Technology, Telethon Institute for Child Health Research Kulunga Research Network,�(2007) The WA Aboriginal Child Health Survey Communicating policy implications and enabling the uptake of findings, ARACY Access Grid Presentation. Prepared by Silburn S, Walker R, Centre for Developmental Health, Curtin University of Technology, Telethon Institute for Child Health Research Kulunga Research Network,�Perth, Western Australia. Centre for Health Equity Training Research and Evaluation (2005) Home visiting in South Western Sydney: An integrative literature review, description and development of a generic model, prepared by Aslam H & Kemp L. Centre for Health Equity Training Research and Evaluation, Sydney. Daly, A & Smith D (2005). Indicators of the risk to the wellbeing of Australian Indigenous children. Australian Review of Public Affairs, 6(1):52.

66. References Derbarl Yerrigan Health Service 2010 website http://www.derbaryerrigan.com.au Gillon G. 2004. Phonological Awarenes. From research to practice. New York Guilford Press . Gough, P.B., Hoover, W.A., & Peterson, C. (1996). Some observations on the simple view of reading. In C. Cornoldi & Oakhill (Eds.), Reading comprehension difficulties. Hillsdale, NJ: Erlbaum. Hofstede, G., Hofstede, G. (2005) Culture and Organizations: softare of the mind. McGraw-Hill. New York Hudson-Rodd, N 1992 Place and Health in Canada � historical roots of two healing traditions. PHD Thesis University of Ottawa, Ottawa. Kickbsch I, (2009) Improving Health Literacy A Key priority for improving health http://www.adelaide.edu.au/adelaidean/issues/22001/news22021.html Viewed 10th May 2010 Kruske, S. (2008) Child rearing practices and development in remote Australia. Charles Darwin University. Darwin

67. References Lehmann D, Tennant MT, Silva DT, McAullay D, Lannigan F, Coates H, Stanley FJ. (2003) Benefits of swimming pools in two remote Aboriginal communities in Western Australia: intervention study. BMJ. Aug 23; 327(7412): 415-9 McMurray, A. 2007 Leadership in primary health care: An international perspective. Contemporary Nurse. Vol.26: 30-36. McMurray A (2007) Community health and wellness: A socio-ecological approach, 3rd edition, Sydney:Elsevier. McTurk, N.,Nuton, G., Lea, T., Robinson, G., Carparetis, J. (2008) The School Readiness of Australian Indigenous Children: A Review of the Literature. Charles Darwin University & Menzies School of Health Research. National health priority Action Coucil (NHPAC) (2006), National Chronic Disease Strategy, Australian Government Department of Health and Aging. Canberra O�Dea, K (2005). Preventable chronic disease among Indigenous Australians: The need for comprehensive national approach. Heart, Lung and Circulation 14(3), p.167-171 Office of Aboriginal Health, Healthy for Life Department of Health & Aging 2010 http://www.health.gov.au/internet/h4/publishing.nsf/contentframework

68. References

69. Next Week Jim Sharp and Adam Janali Asylum Seekers, Detention Centres and Australia VP of Amnesty Australia, and Afghan asylum seeker Dr Carmen Lawrence Mental Health and Detention Centres

70. See you next week! www.interhealth.org.au/ghsc