Improving Health in Aboriginal and Torres Strait Islander Mothers, Babies and Young Children - A Literature Review
By Dr Ana Herceg, 2005
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Acknowledgments
The Department of Health and Ageing library staff greatly assisted with this literature review. In particular, Jeanne Houston conducted the database search and Nia Thompson sourced many references. The OATSIH maternal and child health team, in particular Penny Coventry, Sue Green, Joy Savage and Margaret Norington, provided significant input into the content and structure of the review. Drs Patricia Fagan, Sophie Couzos, and Jenny Hunt all provided very helpful input and/or comment at various stages of this review.
Contents
Summary
Background
Aims of the literature review
Methods
3.1 Literature search strategy
3.2 Analysis
Results
4.1 Antenatal care and mother/baby programs
4.3 Birthing centres
4.4 Breastfeeding
4.6 Gastrointestinal parasites and anaemia
4.7 Diarrhoea
4.8 Scabies and skin infections
4.9 Vaccine preventable diseases
4.10 Respiratory infections and asthma
4.11 Otitis media
4.12 Trachoma
4.13 Smoking
4.14 Alcohol and other substance use
4.15 Injury prevention
4.16 Sudden Infant Death Syndrome prevention
4.17 Mental health and social and emotional wellbeing
4.18 Housing and environmental interventions
4.19 Studies reporting improved health outcomes without a specific health intervention
Discussion
References
Summary
Aim
This literature review was designed to collate information on interventions which have been shown to improve health outcomes or intermediate health measures in Aboriginal and Torres Strait Islander mothers, babies and young children. The review was conducted to provide evidence to contribute to the development of a maternal and child health policy in the Office for Aboriginal and Torres Strait Islander Health.
Background
Aboriginal and Torres Strait Islander pregnant women, babies and young children have significantly poorer health outcomes than non-Indigenous Australians, both in the short and long-term. Programs, services and interventions which have been effective in improving health outcomes in the non-Indigenous Australian population have not had the same effect in Aboriginal and Torres Strait Islander populations.
Methods
Seven databases and five web sites were searched for the period 1983-2003. Search terms were a combination of Aboriginal / Indigenous subject terms and infant, preschool, child, mother or family subject terms. Depending on the size and breadth of each database, the searches followed either a four or five-step strategy. Reports of interventions which had no impact or outcome data available were excluded from the review. Analysis of the literature obtained was qualitative, with designation of levels of evidence based on the classification system published by the National Health and Medical Research Council. Where systematic reviews or literature reviews had previously been done these were quoted but not repeated. Additional publications from 2004 were added while the review was being finalised.
Results
There was limited high quality information on successful interventions in Aboriginal and Torres Strait Islander maternal and child health. The majority of studies described in the review were Level III-3: comparative studies with historical control groups.
A number of reports were identified which described improved impacts (antenatal care attendance, antenatal screening and treatment, immunisation rates) or outcomes (mean birthweight, reduction in preterm births) associated with antenatal care and/or mother and baby programs in Aboriginal and Torres Strait Islander communities. All these programs had multiple components and success could not be attributed to any one component or a particular combination of these components. A number of common factors were identified for such services. These factors were:
- community-based and/or community controlled services
- a specific service location intended for women and children
- providing continuity of care and a broad spectrum of services
- integration with other services (e.g. hospital liaison, shared care)
- outreach activities
- home visiting
- a welcoming and safe service environment
- flexibility in service delivery and appointment times
- a focus on communication, relationship building and development of trust
- respect for Aboriginal and Torres Strait Islander people and their culture
- respect for family involvement in health issues and child care
- having an appropriately trained workforce
- valuing Aboriginal and Torres Strait Islander staff and female staff
- provision of transport
- provision of childcare or playgroups.
A number of locally based disease-specific interventions were associated with improved outcomes. These included interventions to control hookworm infections, reduce rates of diarrhoea and anaemia, reduce skin infections, improve immunisation rates and reduce trachoma infection.
Interventions which appeared effective in one location were not necessarily effective in others, and descriptions of how programs were developed and implemented on the ground were lacking.
In many significant areas of Aboriginal and Torres Strait Islander maternal and child health no intervention studies with outcome data were identified. These included tobacco, alcohol and other substance use in pregnancy, mental health, social health, childhood injury and Sudden Infant Death Syndrome. There was almost no evidence on effective health promotion interventions.
Some housing and environmental interventions were associated with improved health outcomes. In addition, a number of studies reported improved health outcomes in particular communities between the 1960s and 1990s, without specific health interventions being put in place. In these locations improved health outcomes were attributed to improved housing and infrastructure, a rise in living standards, improved access to health services and improved treatment and prevention of infectious diseases.
Discussion
The common factors in successful comprehensive maternal and child health programs could be used when developing new services or enhancing existing services. Structured home visiting in particular has a strong international evidence base and could be used more widely for Aboriginal and Torres Strait Islander families.
More attention could be placed on specific areas of Aboriginal and Torres Strait Islander maternal and child health where the burden of disease is high and evidence of effective interventions is lacking. These include tobacco, alcohol and other substance use in pregnancy, mental health, social health, childhood injury and sudden infant death syndrome. A well trained and supported workforce is important for effective maternal and child health programs.
Many of the interventions described in this review were one-off intensive research projects, and these may not be sustainable in the long-term. Further information may be required on how to adapt these research findings successfully into the ongoing practice of health services.
New programs or services need to be evaluated to assess their effectiveness and to add to the currently limited knowledge base on the best ways to improve outcomes. Evaluations should be as high a quality as possible, with good descriptions of the process of development and implementation. New mainstream maternal and child health interventions, programs or services should also be assessed for their impact on and effectiveness for Aboriginal and Torres Strait Islander populations.
It is unclear which interventions that have been successful in mainstream Australia, or that have been successful overseas, will work in Aboriginal and Torres Strait Islander communities. Given the limited number of studies of interventions in Aboriginal and Torres Strait Islander communities, the national and international evidence does need to be used as a basis for programs. Factors which are likely to affect whether interventions are transferable to the Aboriginal and Torres Strait Islander community setting are community participation, structure of health services, cultural appropriateness and acceptability of interventions, and social, economic and environmental factors.
Greater inter-agency collaboration could influence the environmental, socio-economic and socio-cultural factors which affect the health of Aboriginal and Torres Strait Islander mothers, babies and children.
1. Background
Aboriginal and Torres Strait Islander pregnant women, babies and young children have poorer health outcomes than non-Indigenous Australians. The perinatal death rate for children of Aboriginal and Torres Strait Islander women is twice the rate for other Australians, and the proportion of babies born with low birthweight is also twice as high (Australian Bureau of Statistics and Australian Institute of Health and Welfare 2003). Aboriginal and Torres Strait Islander children have higher rates of death and illness in almost all disease and injury categories (AIHW 2002). Death rates from Sudden Infant Death Syndrome are five times those of other Australian infants (AIHW 2002).
Nationally and internationally there has been an increased focus on early childhood health and experiences, and their effects on health and wellbeing in later life. This focus encompasses two areas. One is the 'Barker hypothesis', or the association between low birthweight and adult chronic disease (Barker 1998). The second area of focus is on the effects of a child’s social environment on early brain development and its long-term consequences in emotional development, intellectual development and mental health (Stanley 2003).
There is an extensive international literature base around effective prevention and intervention strategies to improve maternal and child health and wellbeing. Implementation of these strategies has resulted in reductions in rates of morbidity and mortality in many areas. An example of this would be the reduction in rates of sudden infant death syndrome in Australia (AIHW 2002). However interventions that have been effective in the mainstream have not necessarily translated into improved health in Aboriginal and Torres Strait Islander populations. Factors contributing to the continued health inequalities between Aboriginal and Torres Strait Islander peoples and other Australians are multiple and interlinked, and include lack of access to appropriate and acceptable health care, socio-economic factors, environmental factors, socio-political factors and specific health risk factors (National Aboriginal and Torres Strait Islander Health Council 2004).
Conventional health service delivery and mainstream health promotion programs have not had the same effect in Aboriginal and Torres Strait Islander maternal and child health as they have in the non-Indigenous Australian population. While the fundamental evidence around effective treatment, clinical care and reduction of risk factors applies to all populations, how these are implemented may differ with the setting and culture. Effective strategies to improve the health of Aboriginal and Torres Strait Islander pregnant women, babies and young children could be the adaptation of mainstream models to suit Aboriginal and Torres Strait Islander peoples in a culturally and socially acceptable way. Alternatively, creation of new models of health service delivery or health promotion could be more effective.
There are many gaps in current knowledge about strategies to improve the health of Aboriginal and Torres Strait Islander pregnant women, young children and babies. This literature review was conducted to collate reports of effective health interventions in Aboriginal and Torres Strait Islander maternal and child health, and to provide evidence to contribute to the development of a maternal and child health policy within the Office for Aboriginal and Torres Strait Islander Health.
2. Aims of the literature review
The aims of the literature review were:
- To identify reports of interventions which have been shown to improve health outcomes or intermediate health measures in pregnancy in Aboriginal and Torres Strait Islander women.
- To identify reports of interventions which have been shown to improve health outcomes or intermediate health measures in Aboriginal and Torres Strait Islander babies and young children (zero to five years of age).
3. Methods
3.1 Literature search strategy
Seven databases were searched for the period 1983-2003: Medline, Australasian Medical Index (AMI), Cinahl, PsycInfo, Health & Society (the health sub-database of the FAMILY database, which is Australian), ATSIHealth and Horizon (the Australian Government Department of Health and Ageing library catalogue).
Five web sites were searched for the Australian material: Menzies School of Health Research, TVW Telethon Institute for Child Health Research, Australian Indigenous Healthinfonet, Cooperative Research Centre for Aboriginal & Tropical Health and the Centre for Community Child Health at the Royal Children’s Hospital Melbourne.
The searches were limited to a publication date from 1983 to 2003 and in English. Individual case reports or case studies were excluded. The search strategy depended on the subject terms and indexing practices of each database. Search terms were a combination of Aboriginal / Indigenous subject terms and infant, preschool, child, mother or family subject terms. Depending on the size and breadth of each database, the searches followed either a four or five-step strategy. A number of references published in 2004 were added before the publication was finalised.
Additional information was sought from sources known to the author, including the PhD theses of Dr Jenny Hunt and Dr Sandra Eades, and by following up the references identified in published articles.
3.2 Analysis
Reports of interventions which had no impact or outcome data available were excluded from the review. Analysis of the literature obtained was qualitative, with designation of levels of evidence based on study types according to the classification system published by the National Health and Medical Research Council (NHMRC) (see below for further explanation of the classification system). Where systematic reviews or literature reviews had previously been done these were quoted but not repeated.
NHMRC designation of levels of evidence
Level I - evidence obtained from a systematic review of all relevant randomised controlled trials.
Level II - evidence obtained from at least one properly designed randomised controlled trial.
Level III-1 - evidence obtained from well-designed pseudo-randomised controlled trials (alternate allocation or some other method).
Level III-2 - evidence obtained from comparative studies with concurrent controls and allocation not randomised (cohort studies), case control studies, or interrupted time series with a control group.
Level III-3 - evidence obtained from comparative studies with historical control, two or more single-arm studies, or interrupted time series without a parallel control group.
Level IV - evidence obtained from case series, either post-test or pre-test and post-test.
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