INTRODUCTION

The healthcare system in Australia is currently facing the dual challenge of maximizing the health outcome of the population and containing the cost. The national health priority areas are the collaborative initiative of commonwealth and state and territory government. The Australian health ministry has endorsed six NPHA including diabetes mellitus. Indigenous population like Aboriginal and Torres Islander people have a higher incidence, prevalence, mortality, disability and morbidity related to diabetes. When diagnosed with diabetes indigenous population also have poor health outcomes.  Among indigenous communities’ social determinants play a crucial role in determining the course and occurrence of disease. Hence addressing these social determinants is essential while developing the appropriate intervention. This essay emphasis on diabetes as national priority areas experienced by indigenous communities and its relation with social determinant in their well-being. The second part of the essay discusses the current health promotion and prevention program implemented to diabetes and how it addresses the health inequalities toward the indigenous communities.

PART 1

DIABETES PREVALENCE IN INDEGENOUS COMMUNITIES

The wide gap between the indicators of health among the indigenous and non-indigenous population is a constant challenge for the government and has been addressed by the WHO as a human right concern ("Closing the gap performance report 2017", 2018). This gap can be observed due to associated factor-like inaccessibility of health services, lesser opportunities, health disparity and inequality (Jones et al., 2019). Like any other country, diabetes has imposed a great public health concern due to its increasing epidemic nature. Cultural, economic, ecological and social determinant affects the indigenous population to a larger extent. The determinants like education, income, geographical factors and food securities predisposes them for the development of diabetes (Macniven et al., 2016). Indigenous communities are at risk of developing diabetes because of increased obesity rate, change in the diet, lack of physical activities and identity crisis causing stress. The at-risk population exhibiting these behaviors are predisposed to a higher incidence of diabetes. With incidence rate being four time higher, the mortality rate is six times more owing to diabetic complications being the second leading cause of od death (Burrow & Ride, 2016). The disease often progresses at a faster pace as being associated with comorbid habits like cigarette smoking, alcohol, drug abuse, sedentary lifestyle. The repeated need for care and hospitalization imposes a financial as well as emotional burden on the family along with the physical pain. In indigenous communities, the death rates due to diabetes are higher comparatively urging for identification of gap and its addressal. The contributing factors for diabetes reflect on the combination of broad viewpoint including historical context, cultural influences, social determinant and proximal risk factors (Mitrou et al., 2014). The nutrition and physical activity survey and health measure survey conducted by the Australian Bureau of Statistics, 2013 found multiple modifiable and non-modifiable risk factors contributing to higher disease prevalence within the population. The survey found that 46% of the Aboriginal and Torres Islander people below 2 years of age or above have inadequate intake of fruits and ninety-two percent have lower than the recommended value of vegetable intake.

SOCIAL DETERMINANTS AND THEIR IMPACT ON ABORIGINAL AND TORRES ISLANDER COMMUNITIES

Social determinant has complex interaction through which they influence the health outcomes and chances of developing diabetes. The social determinants are interdependent on each other which then decides the health outcomes of the population. Education, employment, income, social and physical environment may not directly impact the disease development and progression per se but through indirect effect. These imposed in the form of choices, behavior, skills, lifestyle, care plan response, self-care and self-management.  There is a significant relationship between the literacy rate and the prevalence of diabetes among Aboriginal and Torres Islander communities. Health literacy within the individual of the community can improve the health outcomes (Waterworth et al, 2015). Health literacy is known to be critical for the efficient implementation of the healthcare policies and implementation. The literacy ability of the community influences the buying capacity of the family which affects the nutritional intake. Despite multiple governmental efforts, the literacy rate in Aboriginal and Torres Islander communities remain low for benchmark grade years 3,5,7,9 corresponding to non- indigenous population (Australian Bureau of Statistics, 2016). 

Indigenous people do not enjoy equal access to the health infrastructure which include safe drinking water and housing. Poor education and literacy affect the capacity of the people to use re health information, similarly poor income reduces the accessibility of the facilities. Poverty earlier in life can affects the calories distribution which predisposes to chronic diseases like diabetes in later life. Less finances, crowded housing and unemployment exposes Aboriginal and Torres islander adults to prolonged psychological demands and stress. The chronic stress for considerable time impacts the immunity of the body and metabolic dysfunction causing pre-diabetic or hyperinsulinemia. These conditions in the future cause diabetes (Hill, Ward, Grace & Gleadle, 2017). Indigenous population have lesser employment opportunities owing to discrimination and racism. Unemployment is hugely associated with reduced positively and wellbeing. Unemployment has both a direct and indirect impact. Directly it affects the physical and mental equilibrium whereas indirectly it affects the accessibility of services. The increased prevalence of diabetes along with comorbidities among Aboriginal and Torres Islander people is mostly exacerbated by a lack of equitable access to preventative healthcare services (Beckett et al., 2018). Unfavourable social determinant creates a negative state of economical insecurities with the compromised and risky living condition. The physical and social environment surroundings of Aboriginal and Torres Islander communities develop either mistrust in the institutional policies or lack of reach to them (Schultz et al, 2019).

PART2

HEALTH PROMOTION PROGRAM

It is highly recommended that health promotion and education program for diabetes prevention should be tailored as per the needs of communities, families and individuals. Health education is necessary to acknowledge the awareness for risk of developing diabetes. Health promotion and education should encompass the positive attitude required to lower the risk. The health education aims to focus on challenging the perception and misinterpretation related to the disease in Aboriginal and Torres Islander people. Among the early years of life, the education program and interventional plan should include the systemic approach to improve the nutritional status of infants and children. This step is essential in critically considering the risk factors which can predispose to Diabetes in later years of life. The foundation of the education program is based on the fact that healthy children make healthy choices. Younger generation which is healthy in mind body and mentally develop better coping mechanism, self-regulation and resilience. When they become young adults, they make better choices.  The program specially designed for school children, allow them to have necessary knowledge in their school environment influencing their informed decisions. Nutrition education has an essential role in improving the nutrition-based health issues designed to provide easy access to healthy food and intervention for diabetes control.  A program developed for Aboriginal and Torres Strait Islander communities should be efficiently aligned with the individual dignity and cultural belief of the community. The program directly engages the individuals for a better understanding of the beliefs and lifestyle to address and manage the modifiable risk factors. 

THE DEADLY CHOICES PROGRAM

Deadly Choices is a “The Institute for Urban Indigenous Health” flagship health program started in 2010, operating across south-east Queensland under license across Australia and funded by the Commonwealth Department of Health & Ageing ("Deadly Choices saving lives", 2018). The purpose is to empower communities to make better choices as an individual and the family (Malseed, et al., 2014). These may include eating good food, exercising daily, avoiding alcohol and smoking or other drug abuse. The program also encourages them to have access to the local community-controlled health service and complete the annual health check-ups (famously known as 715) and adapt better living through strength-based approaches. The deadly choices program operates through school programs, community events, community ambassadors’ network for engaging the population. The deadly choices program is conducted on a school basis for addressing the chronic diseases among young Aboriginal and Torres Strait students. It has an early childhood education program or Deadly kindles which recognizes the health and education being an interdependent entity. Hence health services are integrated into the educational settings. Being chronic illness diabetes not only impact the physical condition of the individual but over well-being, families and community. Diabetes has been identified as major community issue due to the disease burden, prolonged absentee from work, high economical expenditure and disability. All these led to the negative outcomes at the community, state and national level.

It is a seven-week school-based program which covers topic like nutrition, smoking, physical activities, health services, chronic diseases like diabetes and leadership. Children between the age of 7 years to 12 years are mainly focused. The program provides health education and opportunity for the participant toward physical activity with facility for repeated health check-ups. A recent evaluation of the program found that participant in the program has shown a significant improvement over the period in attitude, information, knowledge and self-efficiency associated with a chronic disease like diabetes. Health checks ups provide screening and prevention od with the risk factors. The implementation of the program among school students from the community has significantly increased their breakfast frequency with better vegetable and fruits consumption per day. The physical activity also has increased. The students who took part in the program showed a significant improvement in their knowledge of chronic diseases and associated attributes in comparison to the control group.

HOW “DEADLY CHOICES PROGRAM”ADDRESSES HEALTH INEQUALITIES

Continuous quality improvement programs through indigenous primary health care services like AMC and Aboriginal Community Controlled Health Services in Australia helps in achieving the goal of addressing health inequalities through integrated partnership. The program is targeted for better self-management, diet modification, lifestyle change, screening test compliance and reducing risk behaviors (Gardner et al.,2018). The program address on some of the essential Social determinant of health by acknowledging health inequalities like lack of health literacy, no access to healthcare services, lesser opportunities to avail health resources, skewed health resources available in the physical environment and discrimination by health professionals ("Deadly Choices Health Promotion Initiative Evaluation Report", 2013). The school-based initiative provides equal opportunities to children to avail health services. The program through its health check-up also empowers the indigenous population to overpower their social and physical environment that purpose the restrictive challenges. The program focusses on reducing the barrier between the provider and Aboriginal and Torres Islander communities to reduce the health disparity prevalent within the community.

CONCLUSION

Conditions like diabetes are known to be associated with greater economic burden due to decreased productivity an increasing expenditure. Hence identifying the gap and improving the service within the at-risk and disadvantaged communities helps in controlling diabetes as a national goal. The interventional program identified to address the national health priority areas diabetes should be able to provide services to the indigenous population targeting long term follow. These are crucial to identify the changes within the attitude of the individuals of the community. Comprehensive, culturally competent care should be purposed through health promotion program for identifying the complex and diverse need and goals.  Acknowledging health inequalities should be the key focus area of health promotion program in order to achieve the desired outcome through collaborative participation. Deadly choices launched in 2010 by the government of Australia is providing equal opportunities to the at-risk indigenous population to get easy access to the health services counteracting on social and physical barriers.