1) Chronic diseases like cardiovascular disease, diabetes and mental health conditions account for a large proportion of the disease burden among Aboriginal and Torres Strait Islander people. 2) Several government policies aim to reduce health gaps by addressing social determinants, risk factors and improving access to healthcare. 3) Two case studies found some improvements in disease management and outcomes from quality improvement initiatives and specialized treatment programs, but sustaining these gains over the long term remains a challenge.

1. Health Literacy: an
emerging agenda for
Aboriginal and Torres Strait
Islander health?

2. Health Literacy: an emerging agenda
for Aboriginal and Torres Strait
Islander health?
Professor Ian Anderson
Director Research and Innovation Lowitja Institute
Director of Murrup Barak Melbourne Insitutte for
Indigenosu Development & Onemda VicHealth Koori
Health Unit, University of Melbourne

3. Overview
• Context for the Health Literacy Agenda:
• Aboriginal and Torres Strait Islander Burden of
Disease
• Aboriginal and Torres Strait Islander Policy Agenda
• Two Case studies from the literature

4. Our Project
• To develop culturally appropriate health literacy intervention
focussing on CVD medications and communicating with health
professionals about their use to meet evidence based care
standards/targets
• To implement the intervention in 5 primary care sites
• To evaluate within the broader context of services and systems
• To identify issues in relation to transferability and sustainability

5. Source: Nutbeam, D.
(2008). ”The evolving
concept of health
literacy” Social Science
and Medicine: 2072-
2078

6. Framing health literacy: 2
Health literacy as asset:
• Role of health education and communication in
developing competencies
• Means of enabling individual to exert greater control
over their health and range of personal, social and
environmental determinants of health
• Outcome of interventions that build empowerment in
health decision making

7. Source: Nutbeam, D. (2008). ”The
evolving concept of health literacy”
Social Science and Medicine:
2072-207

8. ABORIGINAL AND TORRES
STRAIT ISLANDER BURDEN
OF DISEASE

9. National Burden of Disease
Source: Vos, T et al (2007). “The Burden of Disease and Injury in Aboriginal and Torres Strait Islander Peoples 2003”.

10. Health Gap
Source: Vos, T et al (2007). “The Burden of Disease and Injury in Aboriginal and Torres Strait Islander Peoples 2003”.

11. Risk and BOD
Source: Vos, T., B. Barker, et al. (2008). "Burden of disease and injury in Aboriginal and Torres Strait Islander
Peoples: the Indigenous health gap" International Journal of Epidemiology : 1-8.

12. NT Burden of Disease Study
• Mental health conditions, diabetes and cardiovascular
disease account for 40% of the Aboriginal burden of
disease
• Highest proportion of DALY’s are in the age groups
25-54. Mental health conditions peaked in 15-24 yr
age group. CVD peaked in the 35-44 year age group.
Diabetes peaked in the 45-54 year age group.

13. Source: Zhoa Y et al
(2009). “Burden of
Disease and Injury
in the Northern
Territory”

14. Indigenous Health Gap
• Health Gain for Indigenous Australians requires
(amongst other things):
• Action to address the social determinants of health
• Reduction in individual health risk
• Improved outcomes from health care

16. POLICY AGENDA & HEALTH
LITERACY

17. • Council of Australian Governments
Targets
• Close the LE gap in a generation
• Halve the child mortality gap in 10 years
• Halve the literacy and numeracy gap
• Halve the gap in employment outcomes within a decade
• Halve the gap for Indigenous students in year 12 by 2020
• In five years all Indigenous four year olds in remote Indigenous
communities will have access to quality early childhood education
program

18. • COAG Reform Package:
Commonwealth Component
• Community healthy lifestyle programs.
• Financial incentives for accredited primary care services to
improve quality of care including best practice management of
chronic disease.
• Increase access essential follow-up services such as allied
health, specialist care and Pharmaceutical Benefits Scheme
(PBS) medicines.
• Workforce initiatives.

19. • COAG Package: Commonwealth
Tobacco Component
• Regional coordinators to help communities develop local
smoking reduction strategies and to coordinate initiatives across
all levels of government, as well as health, education and other
services.
• Training for 1000 health and community development
workers in relevant interventions to reduce smoking.
• Access to quit smoking services for 13,000 Indigenous
Australians, including individual, family and community-based
programs over the four years.

20. • COAG Package: Commonwealth
Tobacco Component
• Funding to promote health lifestyles (Education and
development kits will be developed by June 2010; Social
marketing campaign programs will commence in 2010-11).
• Funding for up to 105 healthy lifestyle workers to assist
Indigenous individuals and families throughout Australia who are
at risk of developing a chronic disease to reduce their risk of
chronic disease
• Funding to enhance access to quit-line services

21. • NT Chronic Conditions Prevention &
Management Strategy
• Individual, carer, and family centred care
• Community capacity
• Strategic supports to enable interventions to be
effectively implemented
• Interventions across the care continuum

22. • NT Chronic Conditions Prevention
& Management Strategy
• Action on social determinants of health
• Primary prevention
• Secondary prevention and early intervention
• Self management support
• Care for people with chronic conditions
• Workforce planning and development
• Information, communication and disease management systems
• Quality improvement

23. Policy Agenda
Health Services Infrastructure and Systems
• Financing
• Workforce
• Quality of Care/Care Management Processes
Social determinants & Risk Reduction
Patient processes?
• Self Management Support

24. Program Framework for Indigenous Chronic
Disease
- adapted from WHO Innovative Care for Chronic Conditions Framework
Enabling Policy and Systems
Links
Healthy Health
Communities Services
Infrastructure
Lifestyles programs
Health care
y He
nit alt
organisation
Social Determinants m mu s h
Co rtner T e Ca
am re
Pa
Patients and Families
Outcomes

25. Case Study One
• Study of sustainability of outcomes in a chronic
disease treatment program
• Protocol:
• review of clinical records over 6 years (3 in specialized
treatment program and 3 years after it was integrated in PHC)
• Time series analysis: Outcome measure BP (systolic and
diastolic)
• Bailie et al (2006): Investigating the sustainability of outcomes in a chronic disease
treatment programme” Social Science and Medicine: 1661-1670.

26. Case Study One
Key Findings
• Improvement in BP control in first 6-12 months
• Steady decline (with no significant difference in this
decline in the pre and post program period)

27. Case Study One
Possible reasons for observations
• Non-pharmacological elements responsible for initial
improvements
• Routine repetition of treatment (important for health
service impact) may have a negative impact on patient
motivation

28. Case Study Two
• Implementation of CQI within 12 Indigenous primary
health care centres
• 2 Annual cycles of assessment, feedback, action
planning and implementation
• Main process measures: adherence to guideline
scheduled services; medication adjustment
• Outcomes measures: HBA1C, blood pressure; total
cholesterol;

29. Case Study Two
Key Findings
• Engagement by staff; system development
• Increased adherence to scheduled services
• Increased medication adjustment rates (from a low
base) at one year, not maintained at two
• Improved mean HBA1C, no improved BP and
cholesterol

30. Case Study Two
Author conclusions
• QI acceptable and associated with systems
improvements and some intermediate outcomes
• Medication adjustment presents challenges
• Greater emphasis on staff engagement; organisational
commitment

31. Conclusion
• The Aboriginal and Torres Strait Islander Burden of
Disease and the Policy Agenda point to the need to
focus on those processes and interventions that
support patient engagement and empowerment in the
care process
• Health literacy provides an important frame for the
development of practice