Rachel Molloy, MSIA; Bev Greet, VACCHO; Ken Knight, MAHS
On 28 March 2004 Mildura celebrated the launch of Australia’s first ever Indigenous friendly socially marketed condom brand, snake condoms. Approximately 2,000 people attended Snakefest, the free concert, which featured performances by prominent Australian chart toppers including Shakaya and Mercury 4, as well as hip hop artists Brothablack, Little G and R&B singer Dalys. The event was jointly hosted by Aaron Pedersen, Channel 9’s ‘Water Rats’ Indigenous star, and Rachel Molloy, Marie Stopes International Australia’s (MSIA) National Marketing and Program Manager. Snake condoms are part of a new condom social marketing campaign that promotes subsidised condoms. By using marketing approaches that educate, change attitudes and positively affect social behaviour in terms of safer sex practices, the initiative aims to help reduce unplanned teenage pregnancies and the spread and incidence of sexually transmitted infections (STIs) including HIV/AIDS among Indigenous communities. The initiative was prompted by the worrying sexual and reproductive health trends impacting Indigenous people. Rates for teenage pregnancy and STIs are remarkably high among the Aboriginal population, and the rate of HIV/AIDS notification is increasing. The new snake condoms brand is the culmination of 18 months of close collaboration between MSIA, the Victorian Aboriginal Community Controlled Health Organisation (VACCHO) and the Mildura Aboriginal Health Service. The project was piloted in Mildura and surrounding towns. As a result of the campaign:
Based on the successes of the pilot, a nation-wide expansion strategy is being formulated, to allow Indigenous people from all over Australia to benefit from this innovative campaign. Why condom social marketing?Condom social marketing has also been used to great effect in many Marie Stopes’ programs internationally. Social marketing aims to ensure that condoms reach the groups who most need them, in an affordable and accessible way, so the product is typically subsidised and made available through both traditional and non-traditional outlets. As pointed out by the U.S. Agency for International Development, ‘Social marketing has been the single most important contribution that the family planning field have made to the prevention of HIV/AIDS and other STIsi.’ The World Health Organisation confirms this approach and acknowledges that ‘condom social marketing programs have succeeded in increasing the use of condoms in many countriesii.’ The idea for the snake condoms social marketing initiative arose from an earlier VACCHO-MSIA initiative, PhotoVoice, during which young Indigenous people in three communities (including Mildura) used photography as a means to identify their important sexual and reproductive health issues. One of the very strong messages to come from this initiative was the need for better access to condoms to help young people practise safe sex and reduce unwanted pregnancies and STIs. Further research also identified a range of social and cultural barriers to condom use in Indigenous communities, particularly, that the distribution of free condoms has had little or no impact. It was also generally felt that condom brands in the marketplace targeted white Australians and were not in any way culturally relevant to Indigenous Australians. Therefore, to overcome these barriers, a new condom brand needed to be developed which was highly appealing to Indigenous people. The brand
As suggested by a number of young Indigenous people, the new condom was named snake, which is symbolic of Indigenous culture. Most importantly, snake lends itself to some fun and cheeky innuendo to which teenagers can relate.
The snake condoms logo also integrated preferences cited by the Mildura community, including strong use of the colours of the Aboriginal flag, as well as a blend of traditional and modern Indigenous art. The product
The priceMost young people that took part in the research viewed condoms as being too expensive, so MSIA and VACCHO needed to ensure that the new brand was affordable and didn’t compete with other products such as alcohol or cigarettes. The condoms also needed to be available at a subsidised price, but without being ‘too cheap’ which would create the perception that they are poor quality. Taking these factors into account, it was decided that the recommended retail price for snake condoms be $2.00, which is affordable to even the most vulnerable groups. All proceeds from the condom sales contribute to project sustainability, thus reducing reliance on donor funding. The distributionIn addition to traditional retail outlets such as supermarkets, chemists, local convenience stores, service stations and the MAHS, snake condoms are also available at late night eateries, burger vans and pubs and cafes. Most importantly, they are being distributed via a peer seller network. For the first time in Australia, young Indigenous people have been trained as peer sellers and are distributing the new condom brand at parties and other places where young people gather – as this is where many key decisions regarding sexual behaviour are being made. They buy the condoms at a subsidised price and retain any profits that they make from sales to the community. The advertising
In addition, branded merchandise was developed to reinforce brand awareness. This includes men’s and women’s T-shirts, caps, visors and key-ring condom holders.
An educational flyer was developed to increase knowledge and awareness about the importance of using a condom, as well as the importance of correct and consistent use. These are being widely distributed by retail outlets stocking the brand, as well as through the peer seller network.
EvaluationCultural Perspectives conducted the benchmark and evaluation studies in collaboration with the MAHS. These studies served as pre-project and post-project indicators, evaluating the effectiveness of the manner in which the project was conducted and the impact of the Condom Social Marketing for Indigenous Australia Mildura area pilot initiative. The respondents were Indigenous people between 13 and 30 years. The findingsCondom useSince the launch of the snake condoms brand in Mildura, there has been a significant improvement in the rates of condom use among sexually active respondents of the targeted community. Survey respondents were asked how often they used condoms when having sex. As can be noted in the following table, the results indicate that the evaluation respondents are more likely to ‘always use a condom’ (58%) than among the benchmark respondents (40%). The research also showed an increase from 15% to 19% in the number of respondents who ‘usually use a condom’.
Similarly the respondents in the evaluation were much more likely to have used a condom during the last act of sexual intercourse (62%) than the benchmark survey respondents (42%). Attitudes toward unsafe/unprotected sexSince the launch of a socially marketed condom brand in the Mildura community, there have been significant shifts in attitudes of members of the targeted groups. The results indicate that the evaluation survey respondents, were considerably more likely than the benchmark survey respondents to be worried when they have unsafe/unprotected sex. As can be noted in the following table, there was a significant increase from 21% to 46% in the number of respondents who were ‘really worried’ about unsafe/unprotected sex. Similarly, there was a significant decrease from 34% to 11% in the number of respondents who ‘do not worry’ about unsafe/unprotected sex at all.
As can be noted in the following graphs, Indigenous people aged 16-30 have a high recall and purchase of snake condoms – with a greater proportion of evaluation respondents recalling and purchasing snake condoms compared with any other brand in the piloted area.
Sales achievedSince snake condoms were launched in Mildura on 28th March, 2004, over 15,000 condoms have been sold. This outcome is extremely positive considering the relatively small Indigenous population of Mildura (3,000-5,000 people) and once again indicates the popularity of the brand among members of the targeted community. The conclusionIn conclusion, the response to the Condom Social Marketing Initiative for Indigenous Australia has been extremely positive, especially given the relatively short time frame since its inception. The initiative has been a remarkable opportunity to promote sexual and reproductive health and the prevention of STIs, including HIV/AIDS, as well as providing contraceptive protection for young Indigenous people. As a result of the campaign, the availability and accessibility of condoms has significantly improved. By making condoms more accessible to Indigenous people at places where they regularly gather and at times when they are making decisions about their sexual behaviour, this initiative has helped reach new groups of potential users. Also, making condoms more available has raised their visibility and made them more familiar to Indigenous people, helping to overcome taboos. Furthermore, by creating a product that is culturally relevant and highly appealing to the Indigenous community, this initiative has encouraged them to actually buy the product and use it. The recommendationsThe project partners strongly endorse the introduction of a nationwide campaign so that the same sexual and reproductive health benefits can be offered to other Indigenous communities across the country. It will only be when the elements of a nationwide strategy are implemented, that there will be possibility of lasting change. Partnerships with key Indigenous organisations, local community input for guiding programming decisions, as well as working within the principles of Aboriginal self-determination and community control were key to the success of the initiative. A big thank you to the local Indigenous community in Mildura for making the initiative possible. Further informationMSIA and VACCHO are currently gathering expressions of interest from communities around Australia. If you think your community would benefit from this campaign, please contact Rachel Molloy on (03) 9593 9651 or email rachel.molloy@mariestopes.org.au The snake condoms initiative has been made possible by the Commonwealth Government Office for Aboriginal and Torres Strait Islander Health, cummins&partners, Cultural Perspectives, Virgin Blue and 99.5 Star FM. Endnotesi U.S. Agency for International Development, Social Marketing for STI Prevention, 1999 |
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Local youth worked closely with the MSIA, VACCHO, MAHS and cummins&partners advertising agency throughout the product development phase.
Snake condoms (and the safe sex message) are being promoted through a print, poster, transit and radio advertising campaign.
The HealthInfoNet visits Darwin to conduct workshops and participate at the Chronic Diseases Network Conference
Glenda Trevaskis and Sam Burrow from the HealthInfoNet recently visited Darwin to conduct HealthInternet workshops and participate at the 8th annual Chronic Diseases Network Conference. Negotiations with the NT Department of Health and Community Services (NTDHCS) and local key Indigenous health worker training providers lead to arrangements to conduct two separate ½ day workshops to provide Internet training to Indigenous health workers, prior to the commencement of the conference.
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The workshops were conducted at the Danila Dilba Education and Training Centre on 22 September, 2004. They aimed to provide a hands-on opportunity for Indigenous health workers to:
- improve their Internet skills and knowledge;
- enhance their utilisation of the HealthInfoNet website; and
- provide feedback on how the website could be developed to better meet their information needs.
A total of twenty-one Indigenous health workers from NTDHCS, the Katherine West Health Board and Danila Dilba Medical Services attended. Participants were shown how to access the website, were provided with information about different aspects of the site, and were taken through a number of exercises which allowed them to explore the site at their own pace.
Given the diverse background of workshop participants and differences in their access to and use of computer technology, the workshops were well received and provided constructive feedback for developing the site further. Health workers in other areas have expressed interest in workshops of this type and with adequate funding opportunities may exist to develop and conduct similar workshops in other States and Territories in the future.
In the two days following the workshops HealthInfoNet staff attended the Chronic Diseases Network Conference – The Turning Tide: Action and Improvements in Chronic Disease. The conference was hosted by the Chronic Diseases Network and the Good Health Alliance NT and held from 23-24 September, 2004. The conference aimed to bring together local, national and international speakers to talk about the results of working in innovative and creative ways and improving the ways we work together to support and build healthier communities.
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Conference presentations included:
• Dr. Dianne Howard, Endocrinologist, RDH, Darwin, NT. Historical perspectives of chronic disease in the NT
• Prof. David Simmons, University of Auckland, NZ. The Pacific Perspective – Chronic Disease
• Des Rogers, Director, Red Centre Produce, NT. Risky Business – a personal perspective
• Prof. Kerin O’Dea, Director, Menzies School of Health Research, Darwin, NT. Tackling chronic disease: how research can inform future strategies
• Dr. Christine Connors, Program Director, Preventable Chronic Diseases, Darwin, NT. Thinking Differently
• Malcolm Battersby, Director of the Human Behaviour and Health Research Unit and Senor Lecturer in Psychiatry, Flinders University, SA. Lessons from America
• Dr. Paul Ireland, National Institute of Clinical Studies. Filling the Gaps – The Gaps Report
• Peter Holt, Indigenous Program Coordinator, Fred Hollows Foundation. Developing new partnerships – philanthropic organisations and business
• Anne Kemp, CEO, Diabetes Australia NT and Health Living, NT. Good health for a good country – impact of non government organisations on chronic disease
• Inez Carter, Apunipima Cape York Health Council, Qld. Giving kids a good start – Foetal Alcohol Syndrome Project
Sam and Glenda conducted a HealthInternet café at the conference to give delegates an informal opportunity to learn about web-based health information and other HealthInfoNet services such as training and website development. They also participated in a concurrent session which explored the use of communication technologies to support Indigenous yarning and the sharing of health information.
Whilst visiting Darwin a number of meetings were arranged with other organisations and individuals involved in Indigenous health to promote and discuss the benefits of utilising HealthInfoNet services. The organisations included the Aboriginal Medical Services Alliance NT (AMSANT), Office for Aboriginal and Torres Strait Islander Health (OATSIH), NT Menzies School of Health Research, Cooperative Research Centre for Aboriginal Health (CRC) and Batchelor Institute of Indigenous Tertiary Education. The visit to Batchelor Institute provided another opportunity to spend time with Indigenous health worker students to demonstrate the use of the website, and to discuss how the information available might be used in their day-to-day practice.
For further details about the 8th annual Chronic Diseases Network Conference view the Northern Territory Department of Health and Community Services website.
We would like to thank the workshop and conference participants who provided written permission for us to display their photos here
New national qualifications for Aboriginal health workers and Torres Strait Islander health workers due in 2005
| The following summary has been adapted from the October/November 2004 Community Services and Health Industry Skills Council media release.
The national system for vocational qualifications has undergone significant development in the last 7 years. New national qualifications have been developed and updated across all industries including in health and community services. The Community Services and Health Industry Skills Council (Skills Council – view website) is developing new national competencies and qualifications for Aboriginal health workers and Torres Strait Islander health workers. It is anticipated new national health worker qualifications will be available in 2005. The development of new national qualifications is consistent with the Aboriginal and Torres Strait Islander National Strategic Framework (view download information) prepared by the Australian Health Minister’s Advisory Council (AHMAC – view website) in April 2002. The Framework supports development of national qualifications by the Community Services and Health Industry Skills Council to enable ‘greater clarity of the scope of practice and competence of workers using the job title Aboriginal Health Workers and to support comprehensive primary health care practice roles at various levels and undertaking different types of work in different work contexts’. The qualifications are being developed based on information from health workers and employers and according to guidelines established by the National Training Quality Council (NTQC – view information). Information collected to develop competencies and qualifications relates to the make-up of work roles and functions required for the delivery of health services to communities. The new qualifications will allow for a continuation of successful training and assessment strategies and for the development of the Aboriginal and Torres Strait Islander health worker workforce. A second draft of the competencies and qualifications is now available for validation by stakeholders from October to December 2004. Further project information and copies of the draft can be obtained from the current project page of the Skills Council website (view webpage) or on CD-ROM. Alternatively, contact: Natalie Collison |
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5th National Indigenous Environmental Health Conference
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The 5th National Indigenous Environmental Health Conference was hosted by NSW Health for the enHealth Council and the National Indigenous Environmental Health Forum (NIEHF). The conference was held at Terrigal, Central Coast, NSW on 3 – 4 November 2004.
The conference theme ‘Today, tomorrow – together’ followed from the previous conference (2002) ‘It’s in our hands – let’s take the lead’, and promoted the benefits of team work in creating healthy living environments and improving health and social outcomes.
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The themes of the conference were:
- Environmental health workforce development
- Housing issues and planning
- Local, regional and national initiatives
- Community capacity building/partnerships
- Community food supply and nutrition
- Environmental health services in communities
The keynote speaker was Hal Wootten AC QC, founding President of the first Aboriginal Legal Service from 1970 to 1973, a former Judge of the Supreme Court, a Royal Commissioner into Aboriginal Deaths in Custody and a Deputy President of the National Native Title Tribunal.
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Presentations and workshops covered a wide range of environmental topics and focused on projects, workforce, and training (view program). Delegates were able to share information, explore positive initiatives and consider lessons learned. Delegates included:
Aboriginal health workers
Aboriginal health workersDiana Hay from the Aboriginal & Islander Health Worker Journal and Jane Burns from the Australian Indigenous HealthInfoNet ran a joint display. Diana provided information about the Journal and the Journal’s Indigenous health promotion resources guide. Jane conducted a HealthInternet café to give delegates an informal opportunity to learn about web-based environmental health information and other available HealthInfoNet services such as, training and website development.
Veterinarian and Burke’s Backyard presenter Dr Chris Brown officially launched AMRRIC (Animal Management in Rural and Remote Indigenous Communities) at the conference. AMRRIC, a non-profit organisation, works to promote and provide guidance, support and education to veterinary services in remote localities.
For further details view the conference information on the NSW Health website.
We would like to thank the conference participants who provided written permission for us to display their photos here
Dr Sandra Eades: first Aboriginal doctor to be awarded a PhD
| The following summary has been adapted from the 13 September 2004, University of Western Australia media release and David King’s article in The Australian, 15th September 2004.
Dr Sandra Eades has become Australia’s first Aboriginal medical doctor to be awarded a Doctorate of philosophy for her investigation of the health of Aboriginal women and children in the Perth area. ‘Dr Eades has provided a vital, detailed and multi layered analysis of the state of health of many Aboriginal families in Perth and I know has been pivotal in raising awareness among Aboriginal families to improve the health of pregnant women and children’, said Professor Stanley, Director of the Telethon Institute for Child Health Research in Western Australia. With the assistance of 274 urban Aboriginal families, Dr Eades examined a range of factors that influence poor birth outcomes and health in the first 12 months of life. The ‘Bibbulung Gnarneep’ Solid Kid Study was the first to demonstrate a strong link between infant health outcomes and social factors such as maternal educational level and access to housing. The risk of significant illness in infants was found to be higher if mothers had completed less than Year 10 secondary schooling or lived in a house in a bad state of repair. Dr Eades’ study found factors such as high blood pressure before pregnancy, vaginal bleeding during pregnancy and maternal consumption of excess spirits during pregnancy were all associated with poorer birth outcomes. It also found that 65 percent of mothers in the study smoked during pregnancy and 82 percent of infants were exposed to passive smoke in the home, a finding that reflects the frequent occurrence of respiratory illness among Aboriginal infants exposed to tobacco smoke. Dr Eades has developed a follow up study to test whether a culturally appropriate behavioural intervention can assist pregnant Indigenous women to quit smoking during pregnancy. For further information: |
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Launch of the CDAMS Indigenous Health Curriculum Framework
| The following summary has been adapted from the 25 August 2004, University of Melbourne media release.
The launch of the CDAMS Indigenous Health curriculum framework by former Governor-General, Sir William Deane and senior Indigenous health authority, Professor Lowitja O’Donoghue, was held on 27August 2004, at the Koorie Heritage Trust, Melbourne. The nationally agreed curriculum framework for the inclusion of Indigenous health content in medical curricula, has resulted from a joint initiative between the Committee of Deans of Australian Medical Schools (CDAMS) and the Office for Aboriginal and Torres Strait Islander Health. The project – hosted and delivered by the VicHealth Koori Health Research and Community Development Unit at the University of Melbourne – was under development for more than 12 months. It involved an audit of existing Indigenous health content in core medical education and the establishment of a nationally agreed curriculum framework. The framework is intended to improve, strengthen and develop training for medical professionals on the health and well-being of Aboriginal and Torres Strait Islander Australians. Professor James Angus (Convenor of the Project Steering Committee and Dean of Medicine, Dentistry and Health Sciences, University of Melbourne) was enthusiastic about the development of the framework and the challenges of working with universities and other key stakeholders to facilitate its implementation. He explained, ‘We believe the framework we have developed will ensure medical students nationwide will receive the right information and skills to enable them to become the best doctors we can produce for the improvement of Indigenous health in Australia’. The framework is expected to be an investment in the training of a more competent medical workforce; in the health and well-being of Aboriginal and Torres Strait Islander people and communities; and in the health status of all Australians. Also attending and speaking at the launch were:
For more information contact: Gregory Philips Elaine Mulcahy |
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Indigenous health initiatives win national awards
| The following summary has been adapted from the 24 August 2004 National Institute of Clinical Studies media release.
The Cochrane Users Award was established by the National Institute of Clinical Studies (NICS), Australia’s national agency for helping close gaps between best available evidence and current clinical practice. Among winners in the second annual award were: the National Aboriginal Community Controlled Health Organisation (NACCHO); and Dr Richard Murray, Medical Director, Population Health, Kimberley Aboriginal Medical Services Council, WA. Winners were selected by a multidisciplinary judging panel that included a consumer representative. The purpose of the award is to recognise health practitioners who make the best use of research evidence contained in the Cochrane Library, an online database of international scientific research which provides reliable evidence about the effects of health care. Dr Heather Buchan (CEO, NICS) reported that the Cochrane Reviews were increasingly being used to influence policy and practice internationally and the high level of entries indicated an exciting range of uses in Australia. Australians have free access to the Cochrane library after the Institute successfully negotiated, on behalf of the Australian Government, for a national licence to the library. Previously the database had only been available with a paid subscription which limited its use. NACCHO was the major winner of the ‘Primary/Community Care’ category and also won a general category award. Its review of the management of otitis media was undertaken in response to significant clinical practice uncertainty about the treatment of ear infections in the Aboriginal population. Calls from Aboriginal leaders for a large scale clinical trial to improve the treatment for chronic suppurative otitis media (CSOM), lead to a double-blind, multi-centre, randomised controlled trial, known as the NACCHO ear trial. It was found that when compared with current Australian guidelines, fluoroquinolone-containing eardrops recommended in the Cochrane Library, were 47% more effective than those previously used by local practitioners. Mr Tony McCartney (NACCHO Chair) explained that NACCHO has recommended that Australian guidelines be changed to reflect the findings and encouraged pharmaceutical bodies and the Therapeutic Goods Administration (TGA) to register topical fluoroquinolones as treatment for CSOM in Australia. Changes have already been made in Western Australia (WA). A general category award went to Dr Richard Murray, Medical Director, Population Health, Kimberley Aboriginal Medical Services Council, WA. The Kimberley Aboriginal Medical Services Council has been working to address the inconsistent clinical responses of health professionals to Aboriginal people, particularly in remote Australia. Dr Richard Murray and Dr Sophie Couzos are editors and contributing authors of the book, Aboriginal Primary Health Care: An Evidence-based Approach, Oxford University Press (now in its second edition), which cites over 80 Cochrane Reviews. The aim of the book is to support clinicians, public health providers and Aboriginal communities in applying effective evidence-based health interventions for health matters such as renal disease, diabetes, ear infections and rheumatic fever. This project has lead to the development of evidence-based initiatives, for example, the introduction of a Medicare rebate for a preventive health assessment in younger Aboriginal people and Torres Strait Islanders. For further information about the awards contact: Kelly Ward For information on how to access and use the Cochrane Library, visit the National Institute of Clinical Studies website. |
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Be Active Australia: A Health Sector Framework for Action 2005 – 2010
| The following summary has been adapted from the Be Active Australia section of the National Public Health Partnership website.
The draft Be Active Australia – a National Physical Activity for Health Action Plan (now renamed Active Australia: A Health Sector Framework for Action 2005 -2010) was released in April 2004 for consultation. Consultations took place in each jurisdiction and 70 submissions, representing over 250 organisations, were received. The Strategic Inter-Governmental forum on Physical Activity and Health (SIGPAH) sought comment from Aboriginal and Torres Strait Islander peoples across Australia through a parallel consultation process undertaken by Innovative Leadership Australia. (View the Bidgerdii Aboriginal and Torres Strait Islanders Corporation submission for the development of the Aboriginal and Torres Strait Islander component of the Plan – PDF – 129KB). On 9 June 2004, a national consensus workshop on the draft plan was held to review the issues raised by Aboriginal and Torres Strait Islander organisations and individuals during the national consultations, as well as to allow participants to make recommendations. Outcomes were presented on 10 June 2004 to the whole-of -population workshop and participants focussed on reaching an agreement on the Plan and implementation issues. SIGPAH met on 11 June 2004 to discuss incorporation of the consultation findings into a final draft and is currently preparing the Plan for National Public Health Partnership (NPHP) Member endorsement to refer to the Australian Health Ministers’ Advisory Council and Health Ministers. For further information view: |
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Aboriginal Health Conference 2004 – Partnerships for Better Health
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The Aboriginal Health 2004 Conference – the third in a series of biennial conferences held in Perth, Western Australia – was conducted 1 – 2 July. The 2004 conference theme – Partnerships for Better Health – recognises the importance of various groups working together to improve the health of Aboriginal people. Conference delegates from across the state included community workers, general practitioners and Aboriginal health workers. The conference program (view program) included a range of Indigenous presentations addressing the health of Indigenous people in community and hospital settings. Issues discussed included:
• social wellbeing;
• communicable diseases;
• renal disease;
• diabetes;
• cardiovascular disease; and
• community projects
The keynote speaker, Dr Sue Gordon, described her life journey and discussed the Inquiry into response by Government Agencies to complaints of family violence and child abuse in Aboriginal Communities.
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A pre-conference Aboriginal health promotion workshop, held on 30 June, supported the conference theme and provided a forum to strengthen participants’ responses to key health issues within their local communities. Discussion focused on the priority areas of smoking, nutrition and physical activity and issues identified by participants during the recent Aboriginal Health Promotion Videoconference Series (AHPVCS) including men’s, maternal and child health.
A HealthInternet café was held at the conference by staff from the Australian Indigenous HealthInfoNet: Bronwyn Gee; Neil Thomson; Natalie Weissofner; Ellie Kirov and Jane Burns. Delegates were provided with an opportunity to learn about the online information resources available on the HealthInfoNet website and other HealthInfoNetservices, such as Internet training.
We would like to thank the conference participants who provided written permission for us to display their photos here
Type 2 diabetes and patterns of alcohol use in a Queensland Aboriginal community
Hilary Bambrick
IntroductionType 2 diabetes is a significant cause of excess Indigenous morbidity and mortality, and cardiovascular disease is the leading cause of Indigenous death [2]. Moderate alcohol consumption may confer some cardiovascular benefits [3], reduce the incidence of diabetes [4], and reduce cardiovascular risk among those who have diabetes [5], but the heavy use of alcohol can contribute to poorer cardiovascular health and may increase serious complications from diabetes, through increasing triglyceride levels [6], and can cause liver and pancreas damage [7]. Fewer Indigenous people consume alcohol than the non-Indigenous people, but when alcohol is consumed, it tends to be at much higher levels [8]. These broad trends do not consider the impact that being diagnosed with diabetes (which is very common among Indigenous people) might have on alcohol use or differences between women and men. Determining such patterns of alcohol use at a community level is especially important given its influence on diabetes management and contribution to overall cardiovascular health. MethodsThis study took place in a large, urbanised Aboriginal community (population approximately 1,200) in southeast Queensland between September and December 2000. Participants with diagnosed type 2 diabetes (49 women, 38 men) were identified through the community hospital database. At the time of the study, the hospital served as an outpatient clinic providing near universal coverage of the community. Participants without diagnosed diabetes (‘never-diagnosed’) were recruited through household sampling (62 women, 55 men) where one person aged over 18 years from each household was randomly selected using a Kish grid. Response rates were high (approximately 90% diagnosed and 70% never-diagnosed eligible people), but men were slightly less likely than women to participate. Participants with diagnosed diabetes were on average 15 years older than never-diagnosed participants (women: diagnosed range 19-71, mean 47 years, never-diagnosed range 18-66, mean 32 years; men: diagnosed range 27-79, mean 49 years; never-diagnosed range 19-65, mean 35 years). Further details on participant selection methods are provided elsewhere [9]. Participants were asked about the frequency of their alcohol consumption (the usual number of days per week on which alcohol was used) and the amount of alcohol they consumed (number of drinks usually consumed on a drinking day). The total number of drinks usually consumed per week was then estimated. The study was approved by the Human Research Ethics Committee at the Australian National University. ResultsOverall, 48% of women and 67% of men in the study (56% of all participants) reported that they consume alcohol. Participants with diagnosed diabetes were less likely to drink than never-diagnosed participants (women RR=0.3, 95%CI 0.2-0.5; men RR=0.7, 95%CI 0.5-0.9). Most of those who did consume alcohol did so on fewer than two days per week. Overall, only 21% of women and 19% of men consumed alcohol on three or more days each week. On a day when alcohol was used, however, the number of drinks consumed tended to be very high (mean=17, range 3.5 to >20). No participant reported consuming just one or two drinks on a day when they were drinking. Figure 1 shows estimated weekly alcohol consumption, usual number of drinking days per week and usual number of drinks consumed on a drinking day for women and men by diabetes diagnosis.
Figure 1. Usual number of drinks per week (A) (calculated by midpoint of number of days * midpoint number of drinks per drinking day), usual number of drinking days per week (B) and usual number of drinks consumed per drinking day (C) for diagnosed (solid line) and healthy (dotted line) women and men. ANOVA was used to test significance. Age was controlled for. NB. ‘Number of drinks’ was not standardised, for example, as one can of beer contains approximately 1.4 ‘standard drinks’, the number of standard drinks consumed may be much higher than the number reported. In Australia, one standard drink contains 10g of alcohol (the amount of alcohol in a ‘standard’ drink varies internationally) [1] .
After controlling for age, differences between diagnosed and never-diagnosed participants were significant for number of drinks per week (ANOVA: women 9.4 versus 34.4, p<0.001; men 10.6 versus 31.2, p=0.004), and number of drinking days per week (women 0.5 versus 1.9, p<0.001; men 0.7 versus 1.7, p=0.011). Women and men with diabetes who did drink were drinking less on a drinking day than others (ANOVA: women 15.5 versus 18.4, p=0.003; men 16.0 versus 16.5, p=0.006). This might be partially related to age, at least among women, as the significance of the differences was reduced when age was included in the model as a covariate (women p=0.48; men p=0.012). The differences between these groups may not be fully explained by the smaller proportion of people with diagnosed diabetes who drink. When only those who did drink were considered, diagnosed men drank significantly less per week than others (14.6 versus 42.4, p=0.039) but were not drinking significantly less often (1.0 versus 2.3 times per week, p=0.079). Diagnosed women who drank were not drinking significantly less per week than other women who drank (26.54 versus 54.2, p=0.156), nor did they drink significantly less often (1.3 versus 2.9, p=0.075). DiscussionOf all study participants, 56% (20% diagnosed women, 69% never-diagnosed women, 53% diagnosed men, 76% never-diagnosed men) reported that they consumed alcohol. This contrasts with the 83% reported for Australia as a whole [2]. People in this community who have had diabetes diagnosed were less likely to consume alcohol than those who had never been diagnosed with diabetes. They also drink less per week, had fewer drinking days per week and consumed less per drinking day. Much of the difference was due to the greater proportion of those with diabetes abstaining from alcohol altogether. Diagnosed women and men consumed less alcohol than never-diagnosed women and men, all those who drank consumed large quantities of alcohol on a drinking day. Low levels of alcohol consumption (such as 1-2 drinks on several days per week) is protective against cardiovascular disease and diabetes [3, 5, 10]. In this study, participants were either non-drinkers or consumed large quantities on a few drinking days per week. According to the Australian alcohol guidelines, the risk of alcohol-related harm can be considered in terms of short-term and long-term risks (Table 1) [11]. Short-term risky or high-risk drinking refers to the quantity consumed on a given drinking day, while long-term risk refers to the usual quantity consumed each week. In the short term, risks include increased likelihood of accidents, physical and sexual assault, and a reduced capacity to protect against sexually transmitted infections and pregnancy. In the long-term, regular heavy drinking by women increases their risk of cardiovascular disease and other chronic degenerative disorders, such as liver damage and diabetes resulting from pancreatitis. Table 1. Australian risk classifications for alcohol-related harm in the short- and long-term [11]
In the Australian population as a whole, 12% of women and 15% of men drink one or more times per week at levels considered either risky or high-risk in the short-term [12]. Prevalence of short-term risky and high risk drinking differed in the current study according to diabetes status, with never-diagnosed women reporting the highest levels and diagnosed women the lowest (20% of diagnosed women, 29% of diagnosed men, 69% of never-diagnosed women, 62% of never-diagnosed men). Many of those with diagnosed diabetes did not drink, but those that did still consumed quantities of alcohol that were risky or high-risk in the short-term. Given the ready availability of simple sugars in alcohol, heavy alcohol consumption among diabetics, even if infrequent, is a serious concern in terms of short-term blood glucose control and long-term contribution to cardiovascular damage. Long-term risky and high-risk drinking has been estimated to occur in approximately 20% of Indigenous Australians, while for Australian women and men the overall prevalences are 9% and 10% respectively [13]. Results from this study indicate that among those who have never had diabetes diagnosed, up to 60% of women and 49% of men are drinking at risky and high-risk levels. The prevalence of long-term risky drinking is, however, much lower among people with diagnosed diabetes, at 6% for women and 16% for men. The current study found that not only is the prevalence of short-term risky drinking higher among never-diagnosed women than never-diagnosed men, the long-term drinking behaviour of women is at least as risky as that of men. In the past, the heavy consumption of alcohol has been frequently associated with notions of masculinity [14, 15]. A propensity for more general risk-taking is also commonly associated with men rather than with women, especially young men, and particularly those who are disaffected and feel that they have little to lose [16]. The combination of being both male and socially disadvantaged is generally considered to produce the worst outcomes for health [17]. This no doubt remains a very important aspect of alcohol use, but this study demonstrates patterns of consumption by women also need to be addressed more comprehensively. Some of women’s excess risky drinking in comparison to men’s arises from the lower thresholds defining risk for women, but many women reported drinking greater quantities of alcohol than men – amounts that are two and three times those defined as high risk. The use of self-reported alcohol consumption is a limitation of this study. ‘Number of drinks’ consumed was not based on Australian standard drinks, but, given that standard drinks containing 10g of alcohol are frequently smaller than individual items consumed (such as a can of beer which is approximately 1.4 standard drinks), the reporting is likely to underestimate rather than overestimate the number of standard drinks consumed by participants. As total weekly consumption was derived from the midpoints of both alcohol frequency categories (number of days per week) and number of drinks usually consumed, the study may overestimate consumption for some but underestimate for others. Further, the survey questions were framed in the present, and may not indicate longer term drinking patterns. For example, some may have considered themselves to be non-drinkers because it had been several months since they had consumed alcohol. As questions were not asked about past drinking behaviours it cannot be confirmed that being diagnosed with diabetes causes changes to drinking behaviours. Major strengths of the study include the very high response rates (70%-90%), and the willingness of participants to answer questions relating to their alcohol consumption behaviour. Participants’ willingness to take part in the study and awareness that their answers would be kept confidential suggests there is no reason to doubt the integrity of the responses. The age difference between those diagnosed with diabetes and never-diagnosed participants was not a significant factor in the different drinking behaviours of the two groups. Age was found to have an effect only in the amount consumed per drinking day. That fewer people with diagnosed diabetes drank and that those who did drink did so less often than never-diagnosed people is probably primarily due to efforts made to follow diabetes management advice to ‘drink less alcohol’. If so, this success should be built upon, with further efforts to reduce the amount consumed on a drinking day. Changing drinking behaviours of individuals means changing the dominant drinking culture. The pattern of either abstaining from alcohol or consuming risky quantities is probably the result of interlinking factors with deep historical roots. Polarising morality around alcohol use widens the divide between non-drinkers and heavy drinkers, and fails to allow room for moderation, which could confer some cardiovascular benefits. Alcohol may contribute to obesity through supplying excess calories [18], but a review of national data on Indigenous obesity found that those who did not drink alcohol had, on average, a higher body mass index (BMI) than those who drank [19]. This could be because heavy drinking often correlates with heavy smoking, and also because heavy drinking itself may limit the intake of foods. For example, participants in the present study who regularly missed meals sometimes reported that this was because they had been drinking or were ‘grog sick’. The lower BMIs among drinkers found in the review of national data could also be because the behaviour-modifying potential of diabetes diagnosis was not considered. People with diagnosed diabetes may have both a higher BMI and be less likely to consume alcohol than those without. An environment where there are low levels of physical activity combined with a diet that is typically energy-dense promotes both cardiovascular disease and diabetes. The effects of physical inactivity and an energy-dense diet may be exacerbated by the patterns of drinking that are taking place among never-diagnosed people, increasing their future risk of diabetes and cardiovascular disease. Overall, there appears to have been some success in reducing alcohol intake among those who have been diagnosed with diabetes, but considerable emphasis should be placed also on finding strategies to reduce the amount that people drink ‘on a drinking day’. Acknowledgements References
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