'Where's your country?' New approaches for working with problematic alcohol use among Indigenous Australians in an urban setting.

Guthrie, Jill ; Lovett, Ray ; Dance, Phyll 等

Introduction

Conversations between Indigenous Australians meeting each other for the first time often include the question, 'Where's your country?'. 'Country' is used by Indigenous Australians to refer to land which for them has historical and cultural significance. The association between Indigenous Australians and country and emerging literature on the importance to wellbeing of maintaining that association suggests that dislocation from country may have significance for treatment and rehabilitation of problematic alcohol drinking. Our paper has two parts: it describes a project conducted between 2008 and 2009 that evolved into a PhD commencing late 2009 (RL undertaking, PD and JG supervisory panel members); it then describes the PhD, which hypothesises that some people may be living on country from which they may not derive Indigenous cultural identity and that problematic alcohol use is associated with that dislocation.

Background: initial project

Winnunga Nimmityjah, the Australian Capital Territory's only Aboriginal Community-Controlled Health Organisation (ACCHO), is a major primary health care provider for many Indigenous (and some non-Indigenous) people in the Australian Capital Territory and region. The trust between Winnunga Nimmityjah and the National Centre for Epidemiology and Population Health at The Australian National University emanates from collaborations during the 1990s (Humes et al. 1993; Moloney et al. 1993), which subsequently continued (2 Pac et al. 2005; Dance, Brown and Bammer 2000; Dance et al. 2000, 2004a, 2004b; Guthrie et al. 2005, 2006; Lovett et al. 2008). The initial project, one of five funded to 'enhance the management in primary health care settings, of alcohol-related problems among Indigenous Australians' on key areas identified in the National Drug Strategy's Aboriginal and Torres Strait Islander Complementary Action Plan (Gray 2008:3), aimed to develop a case management tool incorporating screening instruments together with brief intervention (1) and assessment, including discussion with clients about country. It incorporated a literature review to ascertain where country features as an element of health.

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Literature review

Mathews' depiction of the impact of colonisation (Figure 1) shows how Indigenous people were 'marginalised by the dominant white culture in land that was originally theirs' (Mathews 1997:274).

Dispossession of land underpins poor health for Indigenous Australians, often contributing to problematic alcohol use (Brady 1995; Chenhall 2007; Commonwealth Department of Health and Aged Care 1999; Mathews 1991, 1997; NACCHO 2003; NHMRC 2001). Compared with other Australians, a smaller proportion of Indigenous people consumes alcohol, although a greater proportion does so at harmful levels (AIHW 2005). Ample evidence illustrates its effects on Indigenous families and communities (Brady 1992, 1994, 2002; Gray and Saggers 2003; Hunter 1992). Consequently, sanctions against alcohol in some Indigenous communities have existed for some time (Brady 1995, 1996; Gray and Saggers 2003; Rowse 1993). During 2000-04 an estimated 1145 Indigenous Australians died at an average age of 35 years from alcohol-attributable injury and disease (Chikritzhs et al. 2007). Social, physical and emotional morbidity associated with problematic alcohol use includes 'family disruption, child abuse, unemployment, depression, suicide, violence, homicide, road deaths ... incarceration ... sexually transmitted infections ... injuries ... mental health problems ... cancers [and] foetal alcohol syndrome' (NACCHO and Chronic Disease Alliance of Non-Government Organisations 2003:114).

The National Aboriginal Health Strategy recognises that holistic care should be provided by ACCHOs (Anderson 2004; NATSIHC for AHMC 2003), including treatment for alcohol and other drugs (NACCHO 2003). Incorporating country into holistic care is evident in remote settings, although apparently not specifically for treating problematic alcohol use: the Walungurru community has a program that addresses social dislocation for people with kidney disease leaving home for dialysis treatment and enables return to country (Rivalland 2006), and a strong desire has been shown among Indigenous people receiving palliative care to be looked after and to die on country (McGrath 2007). Residential drug and alcohol treatment programs for Indigenous peoples recognise the importance of culture (for example, Northern Territory Council for Aboriginal Alcohol Program Services) but not specifically as a cultural component (Strempel et al. 2004). Addressing effects of colonisation, including dispossession and loss of culture, is central to treatment at Benelong's Haven; however, its approach emphasises the importance of Alcoholics Anonymous principles (based on Christian notions) to 'Aboriginal cultural values' (Chenhall 2007:207). While ACCHO service provision generally is holistically based, assessment tools and health professionals using them are largely grounded within a Western medical model, which may not incorporate cultural factors or Indigenous understandings of health.

Preliminary outcomes

Our initial research enabled Winnunga Nimmityjah to utilise co-ordinated care for clients experiencing problematic alcohol use by developing a case management tool comprising four screening instruments--

1. Indigenous Risk Impact Screen (IRIS)--screens for alcohol and other drug use and emotional wellbeing (Schlesinger et al. 2007)

2. Severity of Dependence Scale (Lawrinson et al. 2007)

3. Alcohol Use Disorders Identification Test (Dawe et al. 2002)

4. Fagerstr6m Test for Nicotine Dependence (Fagerstr6m and Furberg 2008),

--together with brief intervention and assessment, including discussion about country. Winnunga Nimmityjah's Aboriginal Health Workers collaboratively named the tool 'Walan Girri', observing that in Wiradjuri language these words mean 'strong future', resonating with the Wiradjuri word 'Winnunga', which means 'strong health'. Currently, Walan Girri has been administered to more than 20 Winnunga Nimmityjah clients.

Only one instrument, the IRIS, is validated for use with Indigenous peoples in rural, remote, regional and urban areas in Queensland. (Schlesinger et al. 2007). Our original aim was to evaluate all four instruments, only for clients experiencing problematic alcohol use, in the Australian Capital Territory urban setting. It became evident that achieving this within the envisaged 18-month timeframe was impossible--there had been high Winnunga Nimmityjah staff turnover, and a subsequent decision was taken to case manage all Winnunga Nimmityjah clients. The best outcome was proper validation of the instruments, requiring more participants and longer timeframes. Two capacity-building opportunities presented themselves: (i) training Winnunga Nimmityjah staff in a range of skills including case management, treatment, motivational interviewing, brief intervention and using screening instruments; and (ii) a PhD for an Indigenous scholar.

Future research

The PhD has three aims: validating the instruments in an urban setting; evaluating the case management; and testing the hypothesis that some participants may be living on country from which they do not derive Indigenous identity and whether problematic alcohol use is associated with that dislocation. Dislocation can be physical or ideological. The former is easily understood. Ideological dislocation from country, however, is more complex: we see it as an understanding and belief that country is a significant element of one's Indigenous identity that is profoundly felt regardless of whether one resides on one's own country. In terms of physical connection to country, some work has been conducted on caring for country (e.g. Burgess and Morrison 2007), exploring issues for people returning to country in remote regions. We speculate there may be many Indigenous people for whom returning to country is impossible, but whose ideological connection is nonetheless intact. We know of no research in an urban ACCHO that examines association between (physical or ideological) dislocation from country and health problems, including for problematic alcohol use, suggesting the need for such research and whether changing practice may lead to improved health.

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Many Indigenous Australians are dislocated from country for various reasons. The Australian Capital Territory's heterogeneous Indigenous population was highlighted in two studies (Dance et al. 2000, 2004b): one study (Dance et al. 2000) explored aged care needs with 98 Elders (some referred to language group or country, others could name only state, territory or general geographical location); in the other, of 95 Indigenous people who use illegal drugs, 37 identified as Wiradjuri, five as Wiradjuri/other, seven as Ngunnawal, five were 'Stolen Generations', and 41 were from 'other language groups' (Dance et al. 2004b). Health professionals often feel uncomfortable asking about Indigenous status (Adams, Kavanagh and Guthrie 2004; Brough, Shannon and Haswell-Elkins 2001; Lovett, 2006; Robertson, Lumley and Berg 1995). It is therefore important to develop appropriate communication tools. Working in an urban non-residential ACCHO setting with clients who are at the stage of benefitting from brief intervention, RL's PhD will explore whether discussion about country between an Indigenous client and a health professional prior to health screening can assist with healing. The health professional will use the Aboriginal Australia Map (Horton 1994; Figure 2), accompanied by the words, 'Where's your country?', to open the therapeutic dialogue.

Benefits of using the Aboriginal Australia Map as an ice-breaker were demonstrated at a focus group including Aboriginal Health Workers to facilitate discussions between Indigenous and non-Indigenous participants (see Couzos et al. 2003). A colleague considered its usefulness in the clinical context: 'put the map of Aboriginal Australian languages on the wall in the surgery or in the waiting room ... and then I think I would feel safer in asking the question about Aboriginality directly ...' (Dr Tom Gavronic, Winnunga Medical Officer, personal communication with JG, January 2007).

This simple act has multiple effects: it provides a non-confronting way of acknowledging Indigenous status for both client and health professional; it elicits self-reported Indigenous status and country location; and it builds rapport between client and health professional. Moreover, the locus of control, particularly in the context of Australia's post-colonial history, begins to be more equally balanced between health professional and client. Some individuals may be dislocated, physically and/or ideologically, from their country or may not know their country. If so, potential repercussions of that dislocation are integral to case management--a key focus of the PhD. The PhD will also explore how comfortable clients and health professionals feel about using the map. The uniqueness of this approach derives from the notion that, at initial assessment, enabling the client to acknowledge country, or that he or she may be ideologically disconnected, empowers the client to 'think' from his or her own cultural perspective.

Discussion

RL's PhD provides space to explore many questions, including how knowledge of country may be incorporated into health care models and, if ultimately incorporated, how its effect may be evaluated. It remains to be seen whether this will require radical changes to health care models. Drug treatment requires more than simply focusing on alcohol per se. Most screening instruments for assessing problematic alcohol use have not been adapted for use with Indigenous clients. Our argument is that cultural identity should be acknowledged as part of integrated care for improvements in health to occur. We do not underestimate the resource implications of our proposal for other ACCHOs and mainstream agencies. Further, its effects are measurable only longitudinally and will require long-term commitments. Its adoption, however, could lead to a more balanced and culturally safer therapeutic relationship, most notably for Indigenous people experiencing problematic alcohol use.

ACKNOWLEDGMENTS

Commonwealth Department of Health; National Drug Research Institute (jointly co-ordinating the research); Winnunga Nimmityjah Board and Management and Aboriginal Health Workers. RL's PhD is funded by the National Health and Medical Research Council; Alcohol and other Drugs Council of Australia; editing was provided by Ms Sam Faulkner, Dr Cressida Fforde, Professor Colin Groves and Dr Nerelle Poroch; training was provided by Dr Kate Conigrave (treatment of problematic alcohol use), Mr Steve Harnett (co-morbidity and motivational interviewing), Ms Coralie Ober, Mr Robert Assan, Ms Riya Engelhardt (IRIS and brief intervention), Mr Brad Pearce (brief intervention), Ms Deb Smith (motivational interviewing) and Ms Janet Smith (brief interventions related to co-morbidity and benzodiazepine use).

REFERENCES

2 Pac, Ace of Spades, Chantal, Fifty-Cents, Fiona, John (2), Li'l Kim, Master BJ (pseudonyms), Julie Tongs, H Chatfield, Phyll Dance and Jill Guthrie 2005 'I Want to Be Heard': An analysis of needs of Aboriginal and Torres Strait Islander illegal drug users in the ACT and region for treatment and other services--community report, National Centre for Epidemiology and Population Health, The Australian National University and Winnunga Nimmityjah Aboriginal Health Service, Canberra.

Adams, Karen, Anne Kavanagh and Jill Guthrie 2004 'Are you Aboriginal and/or Torres Strait Islander? Improving data collection at BreastScreen Victoria', Australian and New Zealand Journal of Public Health 28:124-7.

AIHW (Australian Institute of Health and Welfare) 2005 Statistics on Drug Use in Australia, Australian Institute of Health and Welfare, Canberra.

Anderson, Ian 2004 'Recent developments in national Aboriginal and Tortes Strait Islander health strategy', Australian and New Zealand Journal of Health Policy 1, <www.pubmedcentral.nih. gov/articlerender.fcgi?artid=544962> accessed 23 September 2008.

Babor Thomas F and John Higgins-Biddle 2001 Brief Intervention for Hazardous and Harmful Drinking: A manual for use in primary care, World Health Organization, Department of Mental Health and Substance Dependence, Geneva.

Brady, Maggie 1992 'Ethnography and understanding of Aboriginal drinking', Journal of Drug Issues 22:699-712.

--1994 'Alcohol use and its effects upon Aboriginal Women' in D Broom (ed.), Double Bind: Women affected by alcohol and other drugs, Allen & Unwin, St Leonards, NSW, pp.53-63.

--1995 'Culture in treatment, culture as treatment: a critical appraisal of developments in addictions programs for Indigenous North Americans and Australians', Social Science and Medicine 41:1487-98.

--1996 'Commentaries on Landau's "The prospects of a harm reduction approach among Indigenous people in Canada", Harm reduction - already happening?', Drug and Alcohol Review 15:407-09.

--2002 'Aborigines and alcohol', Meanjin 61:147-53. Brough, Mark, Cindy Shannon and Melissa Haswell-Elkins 2001 'To be or not to be: Recording Aboriginal identity on hospital records', Pacific Health Dialog 81:47-53.

Burgess, Christopher P and Joe Morrison 2007 'Country' in B Carson, T Dunbar, R Chenhall and R Bailie (eds), Social Determinants of Indigenous Health, Allen & Unwin, Crows Nest, NSW, pp.177-202.

Chenhall, Richard 2007 Benelong's Haven: Recovery from alcohol and drug use within an Aboriginal Australian residential treatment centre, Melbourne University Press, Carlton, Vic.

Chikritzhs, Tanya, Richard Pascal, Denis Gray, Annalee Stearne, Sherry Saggers and Paul Jones 2007 Trends in Alcohol-attributable Deaths amongst Indigenous Australians, 1988-2004, National Drug Research Institute, Curtin University of Technology, Perth (National Alcohol Indicators Bulletin No. 11).

Commonwealth Department of Health and Aged Care 1999 Review of the Commonwealth's Aboriginal and Torres Strait Islander Substance Misuse Program, Commonwealth Department of Health and Aged Care, Canberra.

Couzos, Sophie, Traven Lea, Reinhold Mueller, Richard Murray and Margaret Culbong 2003 'Effectiveness of ototopical antibiotics for chronic suppurative otitis media in Aboriginal children: A community-based, mulitcentre, double-blind randomised controlled trial', Medical Journal of Australia 179:185-90.

Dance, Phyll, Roslyn Brown and Gabrielle Bammer 2000 "They'll Just Read About Us in Storybooks': Estimations of the number of young Indigenous people using illegal drugs in the ACT and region, National Centre for Epidemiology and Population Health, Canberra.

--Roslyn Brown, Gabriele Bammer and Beverly Sibthorpe 2000 Needs for Residential Aged Care and Other Services by the Older Indigenous Population in the ACT and Region, National Centre for Epidemiology and Population Health, The Australian National University, Canberra.

--Roslyn Brown, Gabriele Bammer and Beverly Sibthorpe 2004a 'Aged care services for Indigenous people in the ACT and surrounds: Analysing needs and implementing change', Australian and New Zealand Journal of Public Health 28:579-83.

--Julie Tongs, Jill Guthrie, David McDonald, Rennie D'Souza, Carmen Cubillo and Gabriele Bammer 2004b "I Want to Be Heard': An analysis of needs of Aboriginal and Torres Strait Islander illegal drug users in the ACT and region for treatment and other services, National Centre for Epidemiology and Population Health, The Australian National University and Winnunga Nimmityjah Aboriginal Health Service, Canberra.

Dawe, Sharon, Natalie Loxton, Leanne Hides, David Kavanagh and Richard Mattick 2002 Review of Diagnostic Screening Instruments for Alcohol and Other Drug Use and Other Psychiatric Disorders, AGPS, Commonwealth Department of Health and Ageing, Canberra.

Fagerstrom, Karl and Helena Furberg 2008 'A comparison of the Fagerstr6m test for nicotine dependence and smoking prevalence across countries', Addiction 103:841-5.

Gray, Denis 2008 'Enhancing the management of alcohol-related problems among Indigenous Australians', Centrelines 2-4.

--and Sherry Saggers 2003 'Substance misuse' in N Thomson (ed.), The Health of Indigenous Australians, Oxford University Press, Melbourne, pp.158-85.

Guthrie, Jill, Phyll Dance, Carmen Cubillo, David McDonald, Julie Tongs, Tom Brideson and Gabriele Bammer 2005 'Approaches to developing a culturally appropriate research team' in L Jackson Pulver and D McDermott (eds), Djiadi No 1.1: Revised monograph of the inaugural Indigenous Health Unit Research Day 2004, Muru Marri Indigenous Health Unit, University of New South Wales, Sydney (Monograph Series), pp.35-44.

--Phyll Dance, Carmen Cubillo, David McDonald, Julie Tongs, David Brideson and Gabriele Bammer 2006 'Working in partnership: Skills transfer in developing a cross-cultural research team', Journal of Community Psychology 34:515-22.

Horton, David 1994 Aboriginal Australia Map, AIATSIS, Canberra, <http://www.aiatsis.gov.au/ asp/map.html> accessed 1 June 2010.

Humes, Glenda, Michelle Moloney, Francesca Baas Becking and Gabriele Bammer 1993 "It Will Kill Us Faster than the White Invasion': Views on alcohol and other drug problems and HIV/AIDS risk in the Canberra/Queanbeyan Aboriginal community on the availability of a 'heroin trial' for Aboriginal heroin users, National Centre for Epidemiology and Population Health, Australian Institute of Criminology in collaboration with Winnunga Nimmityjah Aboriginal Health Service, Canberra.

Hunter, Ernest 1992 'Aboriginal alcohol use: A review of quantitative studies', Journal of Drug Issues 22:713-31.

Lawrinson, Peter, Jan Copeland, Saul Gerber and Stuart Gilmour 2007 'Determining a cut-off on the Severity of Dependence Scale (SDS) for alcohol dependence', Addictive Behaviors 32:1474-9.

Lovett, Ray 2006 'ACT public hospital frontline staff attitudes about collecting Indigenous status' (Master's thesis chapter), National Centre for Epidemiology and Population Health, The Australian National University, Canberra.

--Fisher, Jodie, Fadwa Al-Yaman, Phyll Dance and Hassan Vally 2008 'A review of Australian health privacy regulation regarding the use and disclosure of identified data to conduct data linkage', Australian and New Zealand Journal of Public Health 32:282-5.

Mathews, John 1991 'The communication/ dissemination of research findings' in A Duquemin, P D'abbs and E Chalmers (eds), Making Research into Aboriginal Substance Misuse Issues More Effective, National Drug and Alcohol Research Centre, University of New South Wales, Darwin.

--1997 'Historical, social and biological understanding is needed to improve Aboriginal health' in V Asche (ed.), Recent Advances in Microbiology, Australian Society for Microbiology, Melbourne, pp.257-334.

McGrath, Pare 2007 '"I don't want to be in that big city; This is my country here": Research findings on Aboriginal peoples' preference to die at home', Australian Journal of Rural Health 15:264-8.

Moloney, Michelle, Glenda Humes, Francesca Baas Becking and Gabriele Bammer 1993 "Finding Out for Ourselves': An analysis of the needs of Canberra/ Queanbeyan Aboriginal people, especially with regard to alcohol and other drug problems and HIV/AIDS risk, National Centre for Epidemiology and Population Health, Australian Institute of Criminology, in collaboration with Winnunga Nimmityjah Aboriginal Health Service, Canberra.

NACCHO (National Aboriginal Community Controlled Health Organisation) 2003 'Substance misuse' in S Couzos and R Murray (eds), Aboriginal Primary Health Care, Oxford University Press, Melbourne, pp.594-607.

NACCHO and the Chronic Disease Alliance of Non-Government Organisations 2003 'The well person's health check' in S Couzos and R Murray (eds), Aboriginal Primary Health Care, Oxford University Press, Melbourne, pp.61-148.

NATSIHC (National Aboriginal and Torres Strait Islander Health Council) for AHMC (Australian Health Ministers' Conference) 2003 National Strategic Framework for Aboriginal and Torres Strait Islander Health: Framework for action by governments, National Aboriginal and Torres Strait Islander Health Council, Canberra.

NHMRC (National Health and Medical Research Council) 2001 Australian Alcohol Guidelines: Health risks and benefits, National Health and Medical Research Council, Canberra.

Rivalland, Paul 2006 It's More than Machines and Medicine: There's a Yanangu way: Summary report, Cooperative Research Centre for Aboriginal Health, Casurina, NT.

Robertson, Helen, Judith Lumley and Sarah Berg 1995 'How midwives identify women as Aboriginal or Torres Strait Islanders', Australian College of Midwives Journal 8:26-9.

Rowse, Tim 1993 'The relevance of ethnographic understanding to Aboriginal anti-grog initiatives', Drug and Alcohol Review 12:393-9.

Schlesinger, Carla, Coralie Ober, Molly McCarthy, Joanne Watson and Anita Seinen 2007 'The development and validation of the Indigenous Risk Impact Screen (IRIS): A 13-item screening instrument for alcohol and drug and mental health risk', Drug and Alcohol Review 26:109-17.

Strempel, Phillipa, Sherry Saggers, Denis Gray and Annalee Stearne 2004 Indigenous Drug and Alcohol Projects: Elements of best practice 1999-2000, Australian National Council on Drugs, Canberra (Australian National Council on Drugs Research Paper 8).

Jill Guthrie

AIATSIS and National Centre for Epidemiology and Population Health,

The Australian National University

Ray Lovett

AIATSIS and National Centre for Epidemiology and Population Health,

The Australian National University

Phyll Dance

National Centre for Epidemiology and Population Health,

The Australian National University and AIATSIS

Craig Ritchie

Winnunga Nimmityjah Aboriginal Health Service

Julie Tongs

Winnunga Nimmityjah Aboriginal Health Service

NOTE

(1.) In the context of alcohol use, brief interventions are defined as 'practices that aim to identify a real or potential alcohol problem and motivate an individual to do something about it' (Babor and Higgins-Biddle 2001:6).