central sydney area health service · 1 central sydney area health service ... and that’s the sad...

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Central Sydney Area Health Service

Aboriginal Health Strategic Plan 2004-2006

Report by Drug Health Services

The authors of this report acknowledge that Central Sydney Area Health Service,

Drug Health Services, is located on the land of the Gadigal people from the Eora

nation. We recognise that Aboriginal culture continues to enrich our community

and encourage both Aboriginal and non-Aboriginal people to continue to work

together to provide positive health outcomes for Aboriginal people.

ACKNOWLEDGEMENTS

This report was prepared by Kate Teasdale, Project Officer, Aboriginal Health, Drug

Health Services (DHS); A/Prof Kate Conigrave, Chairperson, DHS Working Party on

Aboriginal Health; Keren Kiel, Projects Manager, DHS; and Karen Becker, Director,

DHS. We would like to acknowledge the assistance and support of the DHS Working

Party on Aboriginal Health in the compilation and preparation of this report. Our sincere

thanks are also extended to the numerous contributors to the project (Appendix 3),

particularly the staff at the Aboriginal Medical Service Co-op Ltd, Redfern.

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FOREWARD

This report was prepared to guide the Central Sydney Area Health Service (CSAHS)

Aboriginal Health Strategic Plan 2004-2006. It sets out priority issues identified through

consultation with Aboriginal people and experts in the field, and provides a plan of action

for addressing these issues in Central Sydney over the next three years.

Aboriginal people continue to be socially and financially disadvantaged, a situation

worsened by the prevalence of drug and alcohol use and related disorders. Local

Aboriginal people have expressed a strong desire to be actively involved in addressing

drug and alcohol issues within their community, and Drug Health Services is committed

to supporting the community in their efforts. Drug Health Services recognise the

importance of working collaboratively and on an ongoing basis with Aboriginal

communities on a range of prevention, harm reduction, early intervention and community

development programs.

The Central Sydney Area Drug Health Services embraces changes in service provision

which will increase accessibility and quality of care for Aboriginal people.

Karen Becker

Director

Drug Health Services

Central Sydney Area Health Service

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CONTENTS

SECTION ONE

Methodology

Review of National and State Policy documents Literature Review Unpublished Data Sources Consultations Participant Observations Focus Group

Results

Literature Review 1. Impact of substance use 2. Patterns of substance use 3. The effectiveness of interventions

Data 1. Demographic Profile of local Aboriginal population CSAHS 2. Service utilisation by Aboriginal Australians in Drug Health Services,

CSAHS 3. Harm reduction services 4. The need for further data

Consultations 1. Feedback on existing services 2. Access to services 3. Cultural appropriateness 4. Community/NGO involvement 5. Health promotion/education 6. Staff/client relations

Summary SECTION TWO Action Plan – 2004-2006 SECTION THREE Appendices

Appendix 1: CSAHS Steering Committee Terms of Reference Appendix 2: DHS Working Party Terms of Reference & Committee Members Appendix 3: Key Informants consulted in development of the report

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Appendix 4: Focus group questions Appendix 5: References

SECTION ONE

They write these great reports: the Royal Commission into Aboriginal Deaths in custody, Social Justice Reports, and the Bringing them Home report on the stolen generations, the National Aboriginal and Torres Strait Islander Health Strategy. What do they do with them? Jack up their bed, put them on the cupboards so that it looks ok! These things have to be implemented and until they do it’s no good talking to us Aboriginals about another plan because they haven’t actually implemented all these things along the way, and we’re talking about ‘It’s time for our conscience to get another prick again – we better go and do another report’ – and that’s the sad part about it.

The late Puggy Hunter, 1999 (quoted in the National Drug Strategy Aboriginal and Torres Strait Islander Peoples

Complementary Action Plan 2003-2006)4

METHODOLOGY

In May 2003, the CSAHS Aboriginal Health Steering Committee was established to

oversee the development of an Area Aboriginal Health Strategic Plan. The Committee

identified four health priorities to be addressed in the plan. Drug Health was chosen as

a priority area because of significant morbidity and mortality related to substance use,

and the potential for improvements in service provision to achieve health gain.

As such, a Drug Health Working Party on Aboriginal Health was established in June

2003. The Working Party reported to the CSAHS Steering Committee. Its aim was to

identify key issues or areas in which CSAHS can improve its contribution to the

prevention or management of health problems for substance use for local Aboriginal

people. It set out to formulate practical strategies to improve access to treatment and

treatment outcomes, as well as increase prevention efforts and harm reduction. The

short term product of this process is the Drug Health component of the Area Aboriginal

Health Strategic Plan 2002-2006.

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The 8 members of the DHS Working Party included a representative from the Aboriginal

Medical Service Co-op Ltd, Redfern (here abbreviated as AMS), Aboriginal and non-

Aboriginal staff from CSAHS, including both Drug Health and Aboriginal Health

(Appendix 2). Both male and female Aboriginal and non-Aboriginal professionals were

represented.

The Working Party met to discuss and select priority issues and strategies which would

form part of the action plan, and to plan and oversee the development of this document.

This process involved undertaking a review of available literature - including policy

documents - a consultation period, and a client focus group, as detailed below.

Review of National and State Policy Documents

The development of this report has been guided by relevant national and state policies

and documents. In particular, the National Drug Strategy Aboriginal and Torres Strait

Island Peoples Complementary Action Plan 2003-2006 cites six common principles for

addressing substance use for Aboriginal and Torres Strait Islander peoples:

The use of alcohol, tobacco and other drugs must be addressed as part of a

comprehensive, holistic approach to health that includes physical, spiritual,

cultural, emotional and social wellbeing, community development and capacity

building.

Local planning is required to develop responses to needs and priorities set by

local Aboriginal and Torres Strait Islander communities.

Culturally valid strategies that are effective for Aboriginal and Torres Strait

Islander peoples must be developed, implemented and evaluated.

Aboriginal and Torres Strait Islander peoples must be centrally involved in

planning, development and implementation of strategies to address use of

alcohol, tobacco and other drugs in their communities.

Aboriginal and Torres Strait Islander communities should have control over their

health, drug and alcohol and related services.

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Resources to address use of alcohol, tobacco and other drugs must be available

at the level needed to reduce disproportionate levels of drug-related harm among

Aboriginal and Torres Strait Islander peoples.

Literature Review

A literature review was undertaken by searching Medlines, listings of government

policies and reports, perusal of the Internet and other sources, and discussion with

experts in the field. All documents are listed in Appendix 5.

Unpublished Data Sources

Data from CSAHS and state databases on demographics and on treatment service

utilisation were accessed to provide a description of the demographics of the

surrounding Aboriginal population and of recent drug health service utilisation.

Consultations

Broad consultation took place with individuals and organisations in order to better

assess the needs of the community, the extent and quality of existing service provision,

and methods for their improvement. Care was taken to ensure methods of data

collection were culturally and professionally appropriate. Persons and bodies consulted

(Appendix 3) included:

CSAHS staff: Aboriginal and non Aboriginal staff from DHS, including outreach

workers whose work brings them in close contact with the local Aboriginal

community. Other Aboriginal and non-Aboriginal CSAHS staff - from the Social

Work Department, Women’s and Children’s Health, Mental Health, Sexual

Health, Health Promotion, and Area Health Coordinators

AMS staff: Deputy Chief Executive Officer, Drug and Alcohol Unit Coordinator,

Nurse Unit Manager and Doctors

Representatives from selected non-government organisations (NGOs) and

community organisations – including women’s groups, youth and family services,

and substance misuse services. The organisations were chosen because of their

involvement with local Aboriginal people, their knowledge of local drug and

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alcohol issues, and their desire to work collaboratively with CSAHS to continue to

address the needs of Aboriginal people with substance misuse issues

Other Area Health Services (Mid North Coast Area Health Service, North Sydney

Area Health Service, Northern Rivers Area Health Service)

Representatives from NSW Department of Health and the Commonwealth

Department of Health and Ageing; and

National experts in the field - from Perth, Darwin, Alice Springs, Cairns,

Melbourne and Sydney.

Many persons consulted in Sydney are members of, or have long standing involvement

with, the local Aboriginal community.

Consultations took the form of formal and informal discussions, interviews, discussion at

staff meetings, site visits, phone conversations, and email and mail correspondence.

Consultations with organisations and individuals ranged from a single meeting to

repeated, ongoing contact.

Participant Observations

Participant observation is considered one of the most valid forms of qualitative data

collection for Aboriginal populations.1 This technique allows the observer to be a

respectful and non-intrusive witness of community and group dynamics. Observation

may also provide subsequent opportunities for direct discussion. Participant observation

was conducted in the following settings:

The opioid pharmacotherapy dosing clinic, Royal Prince Alfred Hospital (RPAH) -

the procedure for patients receiving methadone was observed, including

client/staff interactions.

Redfern – attendance at two events held in Redfern, during Drug Action Week

and NAIDOC week

The Resource and Education Program for Injecting Drug Users (REPIDU),

Needle and Syringe Program (NSP) Outreach service, Redfern.

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Joint Clinical review sessions, DHS, RPAH and medical staff from the Drug and

Alcohol Unit of the AMS. This forum, based at RPAH, allows discussion of

issues regarding treatment of shared clients.

Focus Group

Ethical clearance was granted from the Aboriginal Health and Medical Research Council

to conduct a focus group for Aboriginal clients of the CSAHS DHS. The focus group was

co-facilitated by two female DHS staff members – one Aboriginal and one non-

Aboriginal. Methods for conducting the focus group were approved by the DHS

Aboriginal Health Working Party. Questions were developed in consultation with

Aboriginal CSAHS staff (Appendix 4).

Aboriginal clients being dosed at the RPA opioid pharmacotherapy service were invited

personally to attend the focus group via invitations distributed by staff during dosing.

Attendance was voluntary. These clients have continuous exposure to the service due

to the need for daily or second daily dosing. The focus group was held in October and

attended by seven Aboriginal clients (six female, one male). Clients unable to attend on

the day requested another group be conducted. A second focus group for Aboriginal

men is planned for February 2004 and will be conducted by two male Aboriginal

facilitators to provide opportunity for greater male participation.

RESULTS

Literature Review

1. Impact of substance use

Alcohol, tobacco and to a lesser extent other substance use, are significant contributors

to the high burden of mortality and morbidity experienced by Aboriginal people.

Substance use disorders also contribute to domestic disruption including violence, and

to personal, family and community suffering. These in turn are risk factors for future

problems for children of the community.

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Aboriginal people have a lower life expectancy and greater burden of disease than non-

Aboriginal Australians. Alcohol has been estimated to be responsible for nearly one in

every ten (9%) deaths for Aboriginal people in West Australia.2 Across Australia, alcohol

has been said to account for six years of life lost by Aboriginal men, and three years life

lost by Aboriginal women.3 These figures are likely to be underestimates due to

limitations in detecting and reporting alcohol problems.

Smoking has been estimated to be responsible for 14% of deaths for Aboriginal people

in West Australia.2 Either alcohol and/or smoking are well recognised risk factors for

each of the major causes of excess deaths in Aboriginal people. Diseases of the

circulatory system make up 28% of excess deaths in men and 27% in women.4 Smoking

is a one of the best recognised, reversible risk factors for vascular disease.

Deaths from “external causes” including car accidents, assaults and self harm, make up

20% of excess deaths in Aboriginal men and 11% in Aboriginal women.4 Accurate data

as to the role of alcohol in these deaths is not available, but alcohol is a recognised

factor in violent deaths from all causes across the entire Australian community.

Neoplasms and respiratory causes of death (8% and 9% of excess mortality

respectively)4 are known to be associated with alcohol and/or cigarettes. The 9% of

excess deaths from endocrine or metabolic causes in Aboriginal men and 17% in

Aboriginal women4 are more prominently linked with obesity, but both alcohol and

cigarettes are independent risk factors for diabetes. The 5-6% excess deaths from

diseases of the digestive system4 are also likely to include alcohol related causes such

as cirrhosis, oesophageal varices, and alcoholic pancreatitis. So tobacco and alcohol or

other substance misuse play a causal or contributory role in a large number of the major

health concerns of Aboriginal people.

The potential for interactions between different risk factors in Aboriginal individuals is

large. Alcohol, obesity and hepatitis C are independent contributors to liver disease and

two or more of these risk factors often coincide. Similarly alcohol, obesity and smoking

each contribute independently to risk of diabetes; alcohol and cigarettes are independent

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risk factors to neoplasms. In non-remote areas, Aboriginal adults are more likely than

non-Aboriginal adults to be exposed to more than one of these risk factors.4

Hospital separations in CSAHS: In 2001-02, the hospital separation rate for the

Aboriginal population (578 age-standardised separations per 1,000) was almost

twice that of the non-Aboriginal population (322 per 1,000).5 Assault was the

leading cause of hospitalisation, followed by accidental falls and exposure to

inanimate mechanical forces. Other important causes of hospitalisation were

transport accidents (particularly for Aboriginal males), complications of medical

and surgical care, and intentional self-harm.5 It is unclear to what extent

medical and surgical complications are related to substance use, and there are

a multitude of other potential influences, however substance misuse in

Aboriginal and non-Aboriginal populations affects compliance with treatment.

Also, heavy drinking increases the risk of infections and other complications of

surgery.6, 7 In NSW in 1999-00, the most common causes of injury-related

hospital separations among Aboriginal people were interpersonal violence

(19.9%), falls (19.6%), self-inflicted injury (8.8%), and transport accidents

(6.5%).8

Foetal alcohol syndrome: The incidence of Foetal Alcohol Syndrome (FAS) in

Australia is not known however an audit of all cases of birth defects in Western

Australia found a far greater prevalence of FAS among Aboriginal (2.76 per

1000) compared with non-Aboriginal children (0.02 per 1000).9 Overseas reports

present a much higher incidence of FAS in Aboriginal groups than in non-

Aboriginal groups, and report a higher overall incidence. This may be due to

some under-diagnosis or under-reporting, or both.10 The average birthweight of

babies born to Aboriginal mothers in 2000 was around 200 grams less than for all

babies.15 Babies born to Aboriginal women in 1998-2000 were almost twice as

likely to be of low birthweight (12.8%) than were those born to non-Aboriginal

women (6.5%).16 Excessive alcohol use is a significant contributor to low

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birthweight in Aboriginal infants in North Queensland17, with Aboriginal babies in

that region weighing on average 450 grams less than non-Aboriginal babies.18

Neonatal abstinence syndrome may affect babies born to mothers with opiate,

alcohol or other drug dependence. There is currently limited national data on the

incidence of this syndrome in Australia, and still less data on the differences in

rates between babies born to Aboriginal and non-Aboriginal mothers. Certainly

at RPAH, Aboriginal infants are over-represented among births where the mother

has a drug related problem. Of the 60,720 babies delivered at RPAH between

1990 and 2003, 2% of births were Aboriginal but 18% of babies whose mothers

had evidence of a drug or alcohol problem were Aboriginal (Osborn and Beeby,

unpublished data).

Crime: Aboriginal prison populations are increasing faster than non-Aboriginal

prison populations. There were 4,818 prisoners recorded as Aboriginal in

Australia (20% of the prisoner population) at 30 June 2003.19 The proportion of

prisoners identified as Aboriginal had risen from 15% in 1993.19 Aboriginal

persons were 16 times more likely than non-Aboriginal persons to be in prison in

2003.19 Alcohol has been reported to be third among six major factors underlying

the high rates of arrest amongst Aboriginal people.20 Imprisonment may in turn

result in introduction to illicit drug use.

Domestic violence: Aboriginal people in NSW are between 2.7 times and 5.2

times more likely than non-Aboriginal people to become victims of crime.21

Several reports have highlighted a relationship between domestic violence in

particular, and drug and alcohol use in Aboriginal communities. Between 70 and

90 per cent of assaults involving Aboriginal people are estimated to have

occurred while under the influence of alcohol or other drugs.22

Motor vehicle accidents: For deaths identified as Aboriginal in 2002, the next

most frequent causes of death, after deaths from cardiovascular disease, were

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injuries (including transport accidents, intentional self-harm and assault) (15.6%

of deaths).23 There is limited data available on the prevalence of alcohol as a

factor in non-fatal motor vehicle accidents where there was an Aboriginal driver.

Other social disruption: While alcohol and other drug misuse may be a symptom

of social disadvantage, and of personal suffering, it then contributes to producing

further social disruption, including disruption to the nurturing of children and

distress. Nine per cent of surveyed urban Aboriginal people reported that drinking

caused them to take time off their regular commitments such as work or

education.24 The overwhelming majority (95%) of Aboriginal urban survey

respondents regarded alcohol as a serious problem and 63% considered either

alcohol abuse or alcohol-related violence as the most serious issue facing

Indigenous communities today.24

2. Patterns of substance use

Alcohol: While urban Aboriginal people are more likely to be abstainers than non-

Aboriginal people, among those who drink there are high rates of heavy drinking

(68% urban Aboriginal drinkers compared with 11% non-Aboriginal drinkers).24

Across Australia, one in two Aboriginal and Torres Strait Islander people

consumed alcohol in a way that put them at risk of alcohol-related harm in the

short-term. More than half (59%) of the drinkers surveyed in the National Drug

Strategy, urban Aboriginal and Torres Strait Islander Survey had tried to reduce

their drinking in the past 12 months.24

Tobacco: Regular smoking is over twice as common among Aboriginal people

than among the remainder of the population. In 1994 more than half (54%) of

urban Aboriginal and Torres Strait Islander people were current smokers,

compared with 29% of the general population.24 In contrast, Aboriginal people

were less likely than non-Aboriginal to rate smoking as an important cause of

drug-related deaths in household surveys.24

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Illicit drug use: Illicit drug use, and misuse of prescribed medications is increasing

in prevalence among Aboriginal people. In household surveys, over half (57%)

of Aboriginal people report having tried an illicit drug, compared with 37% of the

non-Aboriginal population.25 In particular, higher rates of cannabis use were

reported by Aboriginal people (50% lifetime use compared with 33% for non-

Aboriginal), but other illicits had also been used more commonly (25% in a

lifetime by Aboriginal people compared with 18% of non-Aboriginal people). As

with lifetime use, current cannabis use was also reported by twice as many

Aboriginal respondents as non-Aboriginal (27% versus 13%) and other illicit

drugs were used by 14% of Aboriginal people (compared with 8% non-

Aboriginal). Aboriginal people are greatly over-represented among injecting drug

users. In the 2001 National Drug Strategy Household Survey 29% of injecting

drug users in New South Wales identified as Aboriginal or Torres Strait Islander.

As these figures are based on household surveys and small numbers of

respondents, they need to be interpreted with caution.

Needle sharing appears to be increasing among some Aboriginal people who are

injecting drug users. The Australian Needle and Syringe Program (NSP) finger

prick survey indicates that the percentage of respondents who re-used another’s

syringe in Redfern increased between 2001 and the second half of 2003.26, 27

Re-using syringes greater than five times also significantly increased from 2001.

In keeping with this, the prevalence of HIV positivity among users of Needle

Syringe Services is higher in Redfern (3.2%) compared with national (1.3%) and

state (2.0%) levels.27 The rate of HCV prevalence for Redfern (69%) is similar to

that of NSW (71%), though significantly higher than the national level (44%).27

The high levels of drug use by Aboriginal people and other Australians residing

within the Central Sydney Area is probably contributed to by socio-economic

disadvantage, psychological stress and the movement of Aboriginal (and other)

people with drug and alcohol problems into areas known to have a ready supply

of illicit drugs. It is difficult to ascertain numerically how this meets the potential

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demand for treatment, and what proportion of Aboriginal people find the service

unapproachable.

3. The effectiveness of interventions

Intervention for substance use disorders (be they alcohol, tobacco, prescribed

medications or illicits) ideally involves use of prevention, early intervention, treatment

and harm reduction. There is now a considerable body of evidence for the effectiveness

of a variety of measures in each of these categories, but less evidence exists for their

effectiveness specifically within an Aboriginal community. Existing evidence has

typically been in remote communities. Despite the fact that the Australian Aboriginal

population appears to be becoming increasingly urbanized (67.6% in the 1991 Census

up to 72.6% in 1996)28, 29, few prevention or treatment efforts have been specifically

evaluated in urban Aboriginal populations.

It is clearly important that interventions are evidence based wherever possible, and that

all new interventions are evaluated. For example, simply telling school children of any

cultural background about the risks of drugs may not reduce their drug use, and in some

cases may increase their curiosity about drugs. In contrast, measures that increase a

young person’s sense of belonging, and quality of schooling may reduce substance use

by up to 25%.30 Similarly, simple contingency measures, such as use of facilities like a

swimming pool, only by those who attend school regularly can impact on school

attendance31 and potentially on substance use.

Standard health promotion messages typically reach those with greater education better

than the socially disadvantaged. It is likely to be harder again to reach those of a

different culture from the educators. Health promotion exercises reported as effective in

Aboriginal communities have typically involved community driven or supported

approaches, and often broader initiatives which enhance culture, community

empowerment and sense of belonging.1, 4 These strategies address underlying risk and

protective factors and enhance the community’s capacity to identify and address health

issues.

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A good example is the initiative to stop petrol sniffing in a remote Aboriginal community,

which not only involved restricting supply of petrol, but also increasing training and

employment opportunities, and increasing community involvement in setting key

directions.32

Early intervention: can be either community or health service based. Given that

persons with substance use disorders may be more marginalised and be less

likely to access health services, there is likely to be a role for outreach services.

There is good evidence that doctors have a poor rate of implementing early

intervention for alcohol use among all their patients.33 An audit of medical

records in two CSAHS hospitals conducted in 2001-03 confirm that this is a local

as well as a generalized problem (unpublished hospital audits conducted by Drug

Health Services). The same audits revealed poor implementation of interventions

for smoking cessation, and in particular, minimal use of nicotine patches among

inpatients, including patients of European descent. These audits did not record

Aboriginality, but it is unlikely that there is better application of these measures in

Aboriginal clients than among the general hospital population. Furthermore,

there is little data available on the effectiveness of these measures in this group.

It may also be that traditional western models of one-to-one psychotherapy or

behavioural interventions need modification to be appropriate to Aboriginal

cultures.34 Models that consider whole families or whole communities, in addition

to individuals, may also be more relevant. This is particularly so where there is a

high background rate of substance use disorders, and in some cases this may be

seen as the community norm. Even in the broader community there is a growing

attempt to support one-to-one interventions with attempts to raise community

awareness of the need for, and availability of, treatment.

Treatment of established substance use problems: There is good evidence for

the effectiveness of a number of treatment modalities among general

populations, but very little data available on the effectiveness of these treatments

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among an Aboriginal population. Potential for impaired communication with

Aboriginal clients, and lack of understanding of their needs has been identified as

a concern in general medicine.35 There is little data available as to how this

impacts on drug health services.

Shared Care: As some Aboriginal patients have complex health and social

needs, and holistic care is more culturally appropriate than fragmented care, high

levels of cooperation between health and other services, with good shared care

need to exist. Attention to social factors such as housing can have a significant

impact on prognosis in substance use disorders.

Studies among Aboriginal Injecting Drug Users (IDUs) in NSW have not included

in-depth questions on drug treatment services, so little data is available on their

appropriateness. A study conducted on a New South Wales methadone dosing

unit in 1999, however, revealed that it attracted and retained Aboriginal clients at

a higher rate than other dosing units in NSW (1 month retention 81.8% compared

with a State retention rate of 75.3%; 3 month retention rate 67.5% versus a State

retention rate of 60.7%).36 The Unit differed from conventional dosing units by

offering more flexible services including arrangements for clinic attendance.

Client focus groups conducted for the study suggested that the client retention

rate depended on developing trust between client and treating staff, and that

Aboriginal clients felt they were more likely to develop this trust with Aboriginal

workers.

In the last decade, there has been limited research conducted on injecting drug

use amongst Aboriginal people, and available information is therefore based

largely on anecdotal evidence. A literature review on injecting drug use within

urban Aboriginal communities from the Aboriginal Drug and Alcohol Council (SA)

Inc.), reports that access to services by South Australian Aboriginal IDUs is low.37

Cultural issues, fear of breach of confidentiality and shame are identified as the

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main barriers to treatment38-40 Similarly, Aboriginal IDUs from the Lower Murray

region of South Australia reported rarely accessing drug and alcohol services.40

In Victoria, Lehmann and Frances (1998) found that Aboriginal IDUs were not

receiving any treatment, or receiving it too late.41 A survey conducted by a

Victorian needle and syringe program reported two thirds of the Aboriginal users

who wanted to detoxify, did not.38 Service was reported as too slow, and

Aboriginal IDUs found it easier to continue use rather that receive treatment. In

Brisbane, young injectors in particular, were not benefiting from peer education

or harm reduction programs. This was primarily due to the high number of young

Aboriginal IDUs relying on friends to supply their injecting equipment rather than

accessing Needle and Syringe Programs where education was available.42

Data

1. Demographic Profile of local Aboriginal population CSAHS

At the 2001 census, 4112 persons (0.9%) of the population of the CSAHS geographic

confines identified themselves as Aboriginal and/or Torres Strait Islanders. This

comprised about 3.4% of the New South Wales Aboriginal population,43 though the

proportion who identified as Aboriginal is less than the average of 2% across the state.44

The majority of Aboriginal people reported that they lived in the Sydney Local

Government Area (LGA) (including the suburbs of Redfern and Waterloo) and the South

Sydney LGA of Central Sydney (2.3% of the LGA). In Marrickville, 1.3% of the LGA

identified as Aboriginal and 1.0% in the Leichhardt LGA. All figures, however, are likely

to be under enumerated due to the transient nature of some Aboriginal communities and

the under-recording of Aboriginal origin status.

Consistent with data on reduced life expectancy, only 3.4% of the Aboriginal population

of CSAHS was aged 65 years and older, compared with 12.3% of the general CSAHS

population. There was also a larger proportion of Aboriginal children aged under 14

years (29.2%) compared with non-Aboriginal children (16.1%).43

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2. Service Utilisation by Aboriginal Australians in Drug Health Services, CSAHS

Aboriginal Australians are over-represented in CSAHS Drug Health treatment services.

Aboriginal persons make up approximately 0.9% of the CSAHS population, but make up

10% of Drug Health episodes of care (ranging from 3.7% at Canterbury to 15.2% at

RPAH in the financial year 2002-3) and 26% of the clients being dosed for opioid

maintenance treatment at RPAH.

It is striking that although alcohol problems are far more prevalent than illicit drug use

disorders in both Aboriginal and non-Aboriginal populations, the Drug Health Services

are far more commonly accessed for treatment of opioid dependence (67.7% Aboriginal

presentations compared with 17.4% for alcohol). This may be because more culturally

appropriate services for alcohol dependence are available through Aboriginal community

controlled health services, but may also be because heavy alcohol consumption is less

often perceived as a health problem. A higher proportion of Aboriginal clients left

treatment without notice (32.4%) than clients overall (25.0%). No data is available on

whether the higher rate of departure could be due to dissatisfaction with treatment

services, social stressors or other factors. They were most likely to leave in the first three

months of treatment (41% of clients leaving for any reason, compared with 27% for

clients overall).

3. Harm reduction services

During the period March 2002 to March 2003, Resource and Education Program for

Injecting Drug Users (REPIDU) in CSAHS reported that Aboriginal and or Torres Strait

Islanders made up 22% of total client visits (unpublished data). In a 2001 CSAHS

publication, REPIDU was estimated to provide 120-200 occasions of service per day to

Aboriginal and or Torres Strait Islander people in the Redfern area around the year

2000.45

4. Need for further data

The process of literature review, consultation and data collection is seen as ongoing.

The working party in particular notes the need to consider a number of separate

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geographic concentrations of Aboriginal people in CSAHS and not focus on any one

community.

Consultations A consultation process was conducted between May 2003 and December 2003. The

aim of this was to allow key informants to comment on their perspective of problems

related to substance misuse issues for the local Aboriginal population, to identify

strengths in the current service provision and indicate areas for improvement.

Information was obtained via consultations (one to one interviews, group meetings,

email and phone conversations, and informal discussions), a client focus group, and

participant observation at the point of service provision and key events. Participants

comprised CSAHS staff, AMS staff, and external stakeholders. Results have been

combined to protect confidentiality and because a number of common themes emerged:

1. Feedback on existing services Royal Prince Alfred Hospital, Drug Health Service (RPA DHS): More feedback was

available on the RPA DHS than other parts of CSAHS due to the higher number of

Aboriginal clients accessing that service, the proximity of the AMS to RPA, and the

shared care of clients for opioid maintenance therapy - where AMS is the prescriber and

RPA is the dosing point.

Overall there was a favourable acknowledgement that aspects of the service had been

adapted in recent years to improve services to Aboriginal clients. In particular, priority

access to appointments was valuable, as delays can mean loss of opportunities in

exploring a window of motivation from the client (patients referred from the AMS Drug

and Alcohol Unit are seen within 24 hours). Generally there is good communication with

the AMS on shared care clients (eg where RPA provides opioid maintenance

pharmacotherapy for patients with an AMS prescriber).

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Clinical review meetings between the AMS and RPA DHS staff are held monthly to

provide an opportunity to discuss issues relating to clients. The meetings clearly

demonstrate staff knowledge of, and commitment to, their clients. Relations between

the AMS and DHS staff were described as functional and healthy. In August 2003, in

addition to the Clinical Reviews, the Nurse Unit Manager of the AMS also commenced

fortnightly visits to the RPA Drug Health Unit.

The RPA DHS dosing unit operates between 8.45am and 11.15am for methadone

dosing, and 11.45am and 12.30pm for buprenorphine dosing, both seven days a week.

Dosing hours have recently been extended to include Sunday dosing. The dosing

sessions provide opportunity for daily contact between staff and clients, and staff

therefore appear to have developed an in-depth knowledge of their clients, including

family relations. The RPA DHS staff provide a supportive and caring service, reiterated

by clients attending a focus group.

A focus group of seven Aboriginal opioid pharmacotherapy clients (6 women, 1 man)

provided further feedback on the RPA Drug Health Service. Clients reported on the

challenges of community stigma regarding methadone maintenance pharmacotherapy

and substance dependence. The focus group experience was valued as a means of

mutual sharing and support and clients expressed the desire for an ongoing Aboriginal

support group. Other themes emerging from the focus group include:

Imprisonment - difficulty escaping the cycle of drug use and

imprisonment, and the lack of support services once released.

Quality of service at RPA - the majority of participants were very happy

with the service they received at RPA. Some commented that they felt

the staff were supportive and concerned for their welfare.

Barriers to treatment – Transport (physical), low self esteem (emotional)

and community attitudes (social).

21

Client needs/recommendations – participants stressed the need for an

on-going support group for female pharmacotherapy clients, and

employment of an Aboriginal Liaison Officer(s) at RPA.

Resource and Education Program for Injecting Drug Users (REPIDU): REPIDU

operates from a fixed site in both Redfern and Canterbury providing sterile injecting

equipment, needle disposal containers, health education information and resources to

intravenous drug users to reduce the spread of blood borne viruses such as Hepatitis C

and HIV. Secondary services operate from a variety of locations around Central Sydney

and outreach services include areas such as Redfern and Riverwood.

The McKinnon Unit, Rozelle: Whilst some Aboriginal clients indicated they would prefer

an Aboriginal run and staffed detoxification unit, others stated that having a range of

service providers to choose from was equally important and fundamental to receiving

appropriate, timely and quality health care. The McKinnon Unit was regarded as a

professional and quality service, and an acceptable choice for Aboriginal people entering

a detoxification program. McKinnon regularly has Aboriginal clients and receives good

feedback. Staff recommendations for continued care included the recruitment of an

Aboriginal Liaison Officer for Drug Health Services and working more closely with other

services to ensure holistic health care.

Canterbury Drug Health Services: While the Drug Health Service at Canterbury Hospital

has had few occasions of care for Aboriginal clients, staff at that service expressed a

desire to better address the needs of the local Aboriginal population with a view to

attracting and retaining Aboriginal clients. Areas for further enquiry were highlighted,

including identifying from which service local Aboriginal IDUs were accessing services,

and whether the security arrangements at Canterbury Hospital DHS might appear

deterring to newcomers.

2. Access to services

22

Barriers to treatment – physical, social and emotional - were a recurring theme.

During consultation, the following issues were discussed:

More Aboriginal Liaison Officer(s) (ALO) in DHS are required to assist

Aboriginal people to access services and make services more friendly for

Aboriginal people. Currently CSAHS Drug Health Services employs 11

Aboriginal workers.

Flexibility is important: for example a drop-in service would increase

accessibility of medical clinics

Overly busy or “formal” services may appear unfriendly

Aboriginal people should be given the choice of Aboriginal and/or non-

Aboriginal service providers; and

There are a lack of services for young Aboriginal drug users.

3. Cultural appropriateness

A view repeatedly expressed was the need for service providers to be culturally

appropriate in order to be effective (ie to attract, retain and help clients). Again,

suggestions to achieve this included:

Recruiting more Aboriginal staff - offering Aboriginal traineeships to attract

applicants

Creating a relaxed and non-judgmental environment

Displaying more appropriate visual material (eg posters, Aboriginal art,

pamphlets etc) to improve communication

Reducing reliance on the printed word

Reviewing intake and assessment procedures to ensure they don’t act as a

deterrent to attendance; and

Conducting more cultural awareness training for DHS staff.

4. Aboriginal Community/NGO and community organisation involvement

23

Some CSAHS staff commented that CSAHS could build on and strengthen its working

relationships with NGOs and community organisations and should continue to network

with the community. In the Redfern/Waterloo area, in particular, injecting drug use has

become a serious concern and health threat to the Aboriginal people living in this area

and to visiting Aboriginal persons or temporary residents. The change in character of the

area has been of concern to Aboriginal people, some of whom have expressed a desire

to become actively involved in strengthening and healing their community.

One local community organisation stated that the Aboriginal community would benefit

from more outreach services. They particularly expressed a desire for educational input

from CSAHS DHS. For cultural appropriateness, they suggested that sessions should

be delivered on site so participants did not need to travel far.

5. Health Promotion/education

A number of CSAHS employees stressed the need to make current health promotion

initiatives more culturally appropriate and meaningful, and also to develop specific

initiatives for the Aboriginal community. There was comment that potential clients were

not attracted to treatment options offered by the service and/or were not making

informed decisions about their healthcare because of a lack of appropriate material and

information. CSAHS should consider cultural differences and levels of literacy when

developing health promotion campaigns. Again, community involvement in the process

was deemed critical to success, and in the absence of Aboriginal case workers,

Aboriginal clients could be a powerful influence in bringing in other members of their

community to treatment, spreading a positive word about RPA dosing and dispersing

information.

6. Staff/client relations

During the consultation period, CSAHS staff discussed the following challenges:

Client privacy/flexibility of dosing:

24

o Some Aboriginal clients have expressed concerns about their privacy:

particularly if their family is unaware they are on the

methadone/buprenorphine program, their attendance for daily dosing at a

fixed hour, provides visible evidence that they are or have been a drug user.

Comment was made that longer and more flexible dosing hours would assist

with this issue.

Client no-shows:

o Staff expressed difficulty in dealing with clients who repeatedly fail to attend

appointments/dosing sessions. They were unsure how to address this.

Currently patients are assessed on an individual basis and their

circumstances taken into consideration. Staff were more likely to be flexible

with clients who were “nice”, “well behaved”, “not a problem” etc.

Brief intervention:

o Staff attempts to educate clients (eg on the potential hazard of mixing alcohol

with heroin) has occasionally resulted in violent/aggressive confrontations.

Staff requested training to more effectively educate clients in a non

threatening manner.

Sensitivity/cultural appropriateness

o The impact of the stolen generation on Aboriginal people needs to be

considered when working with children where DOCS is involved.

o Barriers working with more reserved clients – staff expressed difficulties

knowing how to communicate? How to pick up if anything is wrong? The

presence of Aboriginal staff member(s) would help to address these issues.

o How best to support clients to enable “compliance” with treatment

requirements? Should patients or systems adapt?

Dual diagnosis – patients often have comorbid mental health issues which provide

assessment and management challenges.

25

SUMMARY

Substance misuse by Aboriginal people is widely regarded as a symptom of community

marginalisation and disadvantage, and may also contribute to a cycle of ongoing

suffering, lack of well being and loss. It also plays a major role in lowering the health

status and life expectancy of Aboriginal people.

Within Central Sydney, Aboriginal communities have expressed a strong concern about

alcohol and other drug related harm, and a desire to be involved in creating sustainable

solutions. Following broad consultation, focus groups and extensive community

discussions, priority areas have been established for improving access to services and

treatment for Aboriginal people:

Developing and strengthening partnerships with the Aboriginal community and

community services;

Increasing cultural appropriateness of clinical services;

Reducing barriers to treatment;

Providing coordinated and integrated healthcare for the individual, family and

community; and

Developing culturally appropriate prevention initiatives;

Central Sydney Area Drug Health Services has a responsibility and commitment to work

with the local Aboriginal people to improve their health and reduce the harm from

substance use.

The Drug Health Services Aboriginal Health Action Plan 2004 – 2006 provides a

platform to address priority areas over the next three years and emphasizes the

importance of delivering holistic healthcare.

26

SECTION 2

ACTION PLAN 2004-2006

Issue Objective Outcomes Time Frame Potential

Partner(s) Responsible position

Need to increase cultural appropriateness of clinical services

1. Provide a more culturally appropriate clinical environment

1.1 Ongoing/continued consultation and involvement of Aboriginal people in service development and implementation. 1.2 Provision of culturally appropriate written and visual resources in DHS clinical settings

April 2004 December 2004

Aboriginal Health Coordinator, AMS Aboriginal Health Coordinator, AMS, NGOs, Community members

Director DHS, Project Officer - Aboriginal Drug Health Project Officer - Aboriginal Drug Health, DHS Aboriginal Health Liaison Officers (AHLOs)*, DHS Aboriginal Health Promotion Officer (AHPO)*, Managers DHS, Health Promotion and Community Services Manager DHS

27

Issue Objective Outcomes Time Frame Potential Partner(s)

Responsible position

2. Increase number of Aboriginal staff in DHS

1.3 Development, distribution and use of local written and visual resources 1.4 Existing policies and procedures in all DHS clinical settings have been reviewed and developed to ensure the intake and assessment needs of Aboriginal clients are met 2.1 Identify funding for recruitment of 2 FTE Area DHS Aboriginal Health Liaison Officers to: Provide liaison and

support to Aboriginal clients at Area DHS,

June 2005 and on-going February 2005 and on-going October 2004

AMS, NGOs, community organisations, community members CSAHS Aboriginal staff members CSAHS Aboriginal Employment Officer

Managers DHS, Project Officer - Aboriginal Drug Health, DHS AHLOs*, DHS AHPO* DHS Managers – Clinical Services, Project Officer – Aboriginal Drug Health Director DHS

28



and To support the

development of Aboriginal Drug health strategies across the Area

2.2 Recruit to the above positions 2.3 Enhance retention of Aboriginal staff through support and professional development opportunities. 2.4 Ensure strategies for recruitment for all positions identify equal opportunities for employment of Aboriginal staff 2.5 Identification of

February 2005 Current and on-going June 2004 June 2004

CSAHS Aboriginal Employment Officer CSAHS Aboriginal Employment Officer

Director DHS Director DHS, CSAHS Aboriginal Employment Officer, Project Officer – Aboriginal Drug Health Director DHS, CSAHS Aboriginal Employment Officer Project Officer -

29



3. Increase cultural awareness among DHS staff

traineeships within DHS for Aboriginal staff 3.1 Provision of cultural awareness training to all existing and new DHS staff

June 2005 and on-going

Aboriginal Drug Health, DHS Managers CSAHS Aboriginal Health Coordinator, Project Officer - Aboriginal Drug Health

Barriers to treatment for Aboriginal people

4. Explore methods for improving and increasing additional transport services to increase access to treatment for Aboriginal clients 5. Identify the drug & alcohol needs of Aboriginal people

4.1 Planning and consultation process with the CSAHS Aboriginal Health and Transport Advisory Committee 4.2 Reduced number of Aboriginal clients missing treatment/appointments 4.3 Increase in number of Aboriginal clients accessing treatment 5.1 Needs assessment conducted

On-going On-going On-going December 2005

CSAHS Aboriginal Health and Transport Advisory Committee AMS, NGOs, GPs, Aboriginal community

Director DHS Project Officer –Aboriginal Drug Health

30



living in CSAHS 6. Improve outreach services offered by DHS 7. Increase access to brief intervention for Aboriginal youth 8. Advocate potential opportunities for subsidised pharmacotherapies in community pharmacies for

6.1 Enhance the current NSP services to include other identified target areas within CSAHS 7.1 Increased brief and early intervention, opportunistic and formal counselling opportunities for children and young people 8.1 Documented communications with the Pharmacy Guild

June 2005 and on-going Current and on-going June 2005

organisations Redfern Waterloo Street Team (RWST), HIV/AIDS Coordinator CSAHS, NGOs, Aboriginal community organisations RWST, CSAHS Early Childhood, Adolescent Mental Health Services, NGO Youth Services Pharmacy Guild of NSW, Centre for Drug and Alcohol NSW Health, Quality in Treatment Group

Director DHS, DHS Managers, REPIDU Manager DHS Project Manager, Health Promotion and Community Services Manager DHS Project Manager -Shared Care, Manager of Pharmacotherapy Services

31



Aboriginal clients 9 Improve access to Hepatitis C assessment and treatment for Aboriginal clients

8.2 Reduced cost of opioid maintenance treatment for clients 9.1 Increased numbers of Aboriginal clients assessed for Hepatitis C Virus and offered treatment if required

On-going Ongoing

CSAHS Hepatitis Coordinator, Hepatitis C Health Promotion Officer, CSAHS Harm Reduction Interagency

Director DHS, DHS Managers

Development of culturally appropriate prevention initiatives

10. Conduct community awareness campaign/s to reduce the harms associated with heavy alcohol and tobacco use

10.1 Identify funding for recruitment of Aboriginal Health Promotion trainee 10.2 Conduct needs assessment 10.3 Plan, implement and evaluate campaign/s

December 2004 June 2005 December 2006 and on-going

AMS, NGOs, community organisations CSAHS Health Promotion Unit, NGOs, AMS,

Health Promotion and Community Services Manager DHS, Project Officer – Aboriginal Drug Health DHS AHPO*, Health Promotion and Community Services Manager DHS DHS AHPO*, Health Promotion and Community Services

32



11. Increase communication with key representatives of the Aboriginal community to improve awareness regarding substance misuse and range of treatments 12. Reduce the uptake of substance use among children and young people

11.1 Partnerships established between DHS, Aboriginal NGOs and other community stakeholders and services 12.1 Increased collaboration with Early Childhood Services, in line with the DHS Health Plan 12.2 Initiate discussions with schools and youth and family services regarding collaboration

December 2006 June 2004 and on-going June 2005 and on-going

community organisations NGOs, community stakeholders and services CSAHS Early Childhood Services, Director Community Health Schools and youth services in Redfern/Waterloo, Marrickville,

Manager DHS Health Promotion and Community Services Manager DHS, Project Officer - Aboriginal Drug Health Director DHS, CNC – perinatal and family drug health Health Promotion and Community Services Manager DHS

33



Glebe and Leichardt areas, Director Community Health

Coordinated and integrated healthcare for the individual and family

13. Enhance shared care arrangements for the treatment of individuals with drug related health problems

13.1 Maintain and expand where appropriate shared care arrangements between DHS and the AMS 13.2 Review policies and procedures for collaborative care plans between services in CSAHS 13.3 Maintain and expand collaboration with NGOs regarding shared care of clients 13.4 In partnership with NGOs, establish on-going support groups for

Current and on-going June 2005 Current and on-going December 2005 and on-going

AMS Mental Health, Women’s and Children’s, DHS, Early Childhood, Sexual Health NGOs, community organisations AMS, NGOs, Aboriginal community

Director DHS, DHS Managers DHS Managers, Area Program Manager NGO DHS Coordinator, Director DHS Project Officer – Aboriginal Drug Health, DHS

34



Aboriginal pharmacotherapy clients 13.5 Evidence of better coordinated care identified in a file audit at RPAH and Canterbury Hospital

Current and on-going

groups RPA and Canterbury DHS Managers

AHLOs* Project Officer – Aboriginal Drug Health, other DHS Project Officers

Build and nurture partnerships with the Aboriginal community and community services

14. Increase the mutual exchange and sharing of skills and understanding

14.1 Continuation of regular meetings between DHS and the AMS 14.2 Increased number of Aboriginal Health Workers in DHS 14.3 Cultural awareness training for all DHS staff 14.4 Increased partnerships with NGOs and Aboriginal Community Organisations

Current and on-going February 2005 and on-going Current and on-going Current and on-going

AMS AMS, NGOs, Aboriginal community organisations

Project Officer – Aboriginal Drug Health Director DHS, Aboriginal Employment Officer Director DHS, Aboriginal Health Coordinator Director DHS, Project Officer – Aboriginal Drug Health

35

*These positions are not currently resourced and would require approval and acquisition of funding prior to implementation. The estimated cost for two full time equivalent Aboriginal Liaison Officers, and one part time Aboriginal Health Promotion Officer is $175 000 (including goods and services).

36

SECTION THREE APPENDICES APPENDIX ONE CSAHS STEERING COMMITTEE PRINCIPLES FOR THE PLANNING PROCESS

ABORIGINAL HEALTH PLAN FOR CENTRAL SYDNEY

PRINCIPLES FOR THE PLANNING PROCESS

There are several core principles which need to be considered as health needs are identified and strategies developed: Empowerment: A key component to developing an achievable Aboriginal Health

plan is to ensure that the local Aboriginal communities have ownership and control over the directions implicit in the plan. At a strategic level this will be ensured through the ongoing meetings of the Partnership Forum of CSAHS and the AMS, however other mechanisms are required to ensure that ownership is inherent in the planning process. - One method will be to ensure that where working parties are established they

have strong representation by Aboriginal people and all participants listen to what Aboriginal people say. Towards this end it is proposed that each working party has, if feasible, at least one Aboriginal health worker, one representative from the Aboriginal Medical Service and a member of the local Aboriginal community.

- A second way is by ensuring that the consultation process is comprehensive and co-ordinated, that consultation occurs with residents and patients as necessary to inform the directions of the plan, and that consultation also occurs with the CSAHS Aboriginal Health Co-ordinator to ensure that the process and method of the consultation itself is correct.

- A third way is by ensuring that people involved in developing the plan are culturally sensitive of the needs of Aboriginal people. This includes briefing leaders with the key issues around empowerment for Aboriginal communities.

An understanding that the individual’s health needs to be considered in a holistic

way (including a recognition of the impact of past government policy on the broader community’s mental health). The National Aboriginal Health Strategy 1989 also recognises that traditionally Aboriginal people and Torres Strait Islanders have perceived their health not only in terms of the physical health of

37

the individual, but rather in regard to the social emotional and cultural wellbeing of the whole community. This perspective will need to be emphasized in any planning undertaken.

The impact of the age demographics of Aboriginal people also needs to be

recognised. Because Aboriginal people die at an earlier age, the Aboriginal community as a whole tends to be relatively young. At the same time, Aboriginal people in their middle age will have a health profile that is usually found in the broader community in older people. Responsibility for individual and family health is therefore unable to be shared across a large number of family members (including grandparents) as it is in non-indigenous families. As a result, adults within the Aboriginal community have to take on a disproportionately large burden of individual, family and community health and social problems. This will have a substantial impact on the emotional well-being of the individual.

Because of the environmental context (including systemic barriers) in the history

of Aboriginal people, a range of coping mechanisms and strategies have been developed by individuals and families in order to survive. In some cases, while the strategy provides the individual with survival and coping skills, it does not allow them or their family to achieve self determination or to improve their overall lifestyle and circumstances.

Expertise: It will be critical that the planning process draws on clinical expertise

from within the relevant medical discipline and also on the resources, skills and knowledge of other clinical groups, organisations, departments and individuals. This may involve input from representatives from other government or non-government agencies, or seeks input from existing projects or working parties.

Coverage: Each process will need to consider the needs of the whole

community. This could include the needs of the various age groups ie seniors, youth, and children, the family and community, and men and women’s business. Consideration of prevention/health promotion strategies as well as clinical service strategies will also be required.

38

APPENDIX TWO DRUG HEALTH SERVICES WORKING PARTY: MEMBERSHIP

Chair:

A/Prof Kate Conigrave, Staff Specialist, Drug Health Services; Conjoint Associate Professor School of Public Health, and Departments of Psychological Medicine and Medicine, University of Sydney

Members CSAHS:

Mr Nobby Alcala, A/Area Program Manager, Drug Health Services

Ms Karen Becker, Director, Drug Health Services

Ms Natalie Bell, Aboriginal Health Education Officer, Resource and Education Program for Injecting Drug Users (REPIDU), Drug Health Services

Ms Keren Kiel, Projects Manager, Drug Health Services

Mr George Long, Aboriginal Health Coordinator

Ms Kate Teasdale, Project Officer – Aboriginal Health, Drug Health Services Members Aboriginal Medical Service Coop Ltd, Redfern:

Mr Brad Freeburn, Coordinator, Drug and Alcohol Unit In Attendance:

Mr Peter Fernando, Deputy CEO, Aboriginal Medical Service, Redfern

Ms Gay Horsburgh, Manager Review and Service Development, CSAHS

39

APPENDIX THREE KEY INFORMANTS CONSULTED IN THE DEVELOPMENT OF THE PLAN

CSAHS Drug Health Services

Mr Keith Ball, Aboriginal Health Education Officer, REPIDU

Ms Natalie Bell, Aboriginal Health Education Officer, REPIDU

Ms Angie Campillo, Community Services Worker/Clinician, Rozelle DHS

Mr Craig Cooper, Manager, MERIT Program

Mr Shane Cross, Dual Diagnosis Project Officer, Rozelle DHS

Mr Les Davidson, Centralised Intake Officer, RPAH DHS

Ms Belinda Gibson, RN, McKinnon Unit

Ms Helen Griffiths, Manager, RPAH DHS

Ms Elizabeth Haines, RN, RPAH DHS

Mr Ken Hall, Manager, McKinnon Unit

Ms Kristi Hawkins, Community Services Worker/Clinician, Rozelle DHS

Mr Fayyaz Ali Laghari, Health Education Officer, REPIDU

Ms Chantay Link, Aboriginal Health Education Officer, REPIDU

Ms Jane Massa, Senior Health Promotion Officer, Rozelle DHS

Ms Annie Mawson, RN, Ambulatory Detoxification Service, Canterbury DHS

Ms Cassandra Michaels, (Senior Psychologist) Community Services Worker/Clinician, Rozelle DHS

Ms Alisi Nasilai, Redfern/Waterloo Street Team Aboriginal Officer

Ms Lisa O’Brien, A/Operations Manager, REPIDU

Ms Corrina Phillips, A/Program Manager, REPIDU

Ms Christine Pollachini, Manager, Health Promotion and Community Services, DHS

Ms Susan Read, Health Promotion/Smoke-Free Policy Officer, DHS

Ms Jennifer Rosewood, Clinician, MERIT Program

Ms Marcia Sherring, Community Services Worker/Clinician, Rozelle DHS

Ms Barbara Steven, Counsellor, Canterbury DHS

Ms Katrina Stott, RN, RPAH DHS

Ms Sophie Stromeyer, Health Education Officer, REPIDU

40

Ms Jeni Wighton, Clinician, MERIT Program

Ms Samar Zakaria, CNS Canterbury DHS

Other CSAHS Departments

Mr David Aanundsen, Aboriginal Men’s Sexual Health Education Officer

Ms Rubilai Blakeney, Aboriginal Liaison Officer, Social Work Department, RPAH

Sr Alison Bush, Clinical Nurse Consultant, Women’s and Children’s, RPAH

Mr Corey Czok, Aboriginal Liaison Officer, Social Work Department, RPAH

Mr David Gray, Hepatitis C Health Promotion Officer

Ms Anna Haining, Aboriginal Women’s Sexual Health Promotion Project

Ms Gay Horsburgh, Manager, Review and Service Development

Mr George Long, Aboriginal Health Coordinator

Ms Sharon Minniecon, Aboriginal Health Education Officer, Health Promotion Unit

Dr David Osborn, Staff Specialist, Neonatal Medicine

Ms Janice Pritchard-Jones, Hepatitis C Coordinator

Dr Chris Rissel, Director, Health Promotion Unit

Mr Stephen Shaw, Aboriginal Employment Officer

Professor Paul Torzillo, Staff Specialist, Respiratory Medicine

External Organisations

Ms Sue Balding, Aboriginal Liaison Project Officer, Drug and Alcohol Services, NSAHS

A/Prof James Bell, Medical Director, Langton Centre

Dr Maggie Brady, Centre for Aboriginal Economic Policy Research, Australian National University, Canberra

Ms Linda Bunn, Manager, Danila Dilba, Darwin

Ms Helena Clayton, Project Officer, Office for Aboriginal and Torres Strait Islander Health

Ms Gemma Davies, Drugs Program Bureau, NSW Department of Health

Dr John Daniels, Clinical Director, Aboriginal Medical Service, Redfern

Mr Michael Englert, Nurse Unit Manager, Aboriginal Medical Service, Redfern

Mr Peter Fernando, Deputy CEO, Aboriginal Medical Service, Redfern

Dr John Faros, Medical Officer, Aboriginal Medical Service, Redfern

41

Mr Shane Hearn, Lecturer and coordinator of course on Indigenous Health Promotion, School of Public Health, University of Sydney

Professor Wayne Hall, University of Queensland

Ms Esme Holmes, Langton Centre

Professor Ernest Hunter, Professor of Public Health (Mental Health), University of Queensland, Cairns.

Professor Gavin Mooney, Curtin University, Perth

Mr Tony O’Brien, Project Officer, Aboriginal Drug Health, MNCAHS

Ms Susie Purcell, Service Development Officer, Drug Health Services, SWSAHS

Mr Komla Tsey, Senior Lecturer in Public Health, North Queensland Health Qualities Promotion Unit, School of Population Health, University of Queensland

Mr Peter Waples, Public Health Officer, Division of Population Health, NRAHS

Dr Carol Watson, Far West Area Health Service, NSW

Dr Marilyn Wise, Australian Centre for Health Promotion, University of Sydney

42

APPENIDIX FOUR QUESTIONS FOR CLIENT FOCUS GROUP

Aboriginal Client Focus Group Monday 27 October 2003, 11am

Drug Health Services – Central Sydney Area Health Services

1. How did you find out about RPA? 2. What is good about RPA?

3. What is not good about RPA?

4. What would make the service better?

5. What is the best way for us to tell the Aboriginal community about the drug and alcohol services we provide?

6. Comments/questions

43

APPENDIX 5

Kirmayer, L.J., G.M. Brass, and C.L. Tait, The mental health of Aboriginal peoples: transformations of identity and community. Canadian Journal of Psychiatry, 2000. 45(7): p. 607-616.

4. Ministerial Council on Drugs Strategy, National Drug Strategy: Aboriginal and

Torres Strait Islander Peoples Complementary Action Plan 2003-2006. 2003,

Canberra: Commonwealth of Australia.

REFERENCES

1. Gray, D., et al., Evaluating government health and substance abuse programs for

indigenous peoples: a comparative review. Australian Journal of Public Health, 1995. 19(6): p. 567-72.

2. Unwin, C.E., M.S. Gracey, and N.J. Thomson, The impact of tobacco smoking and alcohol consumption on Aboriginal mortality in Western Australia, 1989-1991. Medical Journal of Australia, 1995. 162(9): p. 475-8.

3. Arnold-Reed, D.E., et al., Effects of smoking and unsafe alcohol consumption on aboriginal life expectancy. Medical Journal of Australia, 1998. 168(2): p. 95.

4. Trewin, D. and R. Madden, The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples 2003. 2003, Australian Bureau of Statistics and Australian Institute of Health and Welfare: Canberra.

5. Australian Institute of Health and Welfare, Australian hospital statistics 2001-02. AIHW Cat. No. HSE-20. 2003, Canberra: Australian Institute of Health and Welfare.

6. Shourie, S., et al., Clinical implications of alcohol misuse for surgery, in Comprehensive handbook of alcohol related pathology, V. Preedey, Editor. (in press).

7. Tonnesen, H., et al., Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial. British Medical Journal, 1999. 318: p. 1311-1316.

8. NSW Health Department, The health of the people of NSW: report of the Chief Health Officer. 2002, Sydney: NSW Health Department.

9. Bower, C., et al., Ascertainment of birth defects: The effect on completeness of adding a new source of data. J Paediatr Child Health, 2000. 36: p. 574-576.

10. O'Leary, C., Foetal alcohol syndrome: a literature review. National Alcohol Strategy 2001 to 2003-04 Occasional Paper August 2002. 2002, Canberra: Commonwealth Department of Health and Ageing.

44

15. Australian Institute of Health and Welfare- National Perinatal Statistics Unit, Australia's mothers and babies. AIHW Cat no. PER 21. 2003, Canberra: Australian Institute of Health and Welfare, National Perinatal Statistics Unit.

16. Nassar, N. and E.A. Sullivan, Australia's mothers and babies 1999. 2001. 2001. Australia's mothers and babies 1999. AIHW Cat. No. PER 19. Sydney: AIHW National Perinatal Statistics Unit (Perinatal Statistics Series no. 11).

17. Humphrey, M. and D. Holzheimer, A prospective study of gestation and birthweight in Aboriginal pregnancies in far north Queensland. Australian & New Zealand Journal of Obstetrics & Gynaecology, 2000. 40(3): p. 326-30.

18. Humphrey, M.D. and D.J. Holzheimer, Differing influences on Aboriginal and non-Aboriginal neonatal phenotypes: a prospective study. Medical Journal of Australia, 2001. 174(10): p. 503-6.

19. Australian Bureau of Statistics, Prisoners in Australia. Available at: http://www.abs.gov.au/Ausstats/abs%40.nsf/b0462a212839e1e5ca256820000fe0de/8d5807d8074a7a5bca256a6800811054!OpenDocument Accessed January 30 2004. Catalogue No.4517.0. 2004, Canberra: Australian Bureau of Statistics.

20. Hamilton-Hunter, B., Factors underlying indigenous arrest rates. 2002, Sydney: NSW Bureau of Crime Statistics and Research.

21. Fitzgerald, J. and D. Weatherburn, Aboriginal victimisation and offending: the picture from police records. Crime and Justice Statistics Bureau Brief. 2001, Sydney: NSW Bureau of Crime Statistics and Research.

22. Office of the Status of Women- Department of the Prime Minister and Cabinet, Partnerships Against Domestic Violence: meta evaluation. Bulletin No.6. 2001, Canberra: Commonwealth of Australia.

23. Australian Bureau of Statistics, Causes of death 2002. Cat no. 3303.0. 2003: Canberra: Australian Bureau of Statistics.

24. Commonwealth Department of Human Services and Health, National drug strategy household survey. Urban Aboriginal and Torres Strait Islander Peoples Supplement 1994. Cat no 95 1273 X. 2001, Canberra: Australian Government Publishing Service.

25. Australian Bureau of Statistics/Australian Institute of Health and Welfare, The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples. 1999, ABS: Canberra.

26. MacDonald, M. and J. Zhou, Australian NSP Survey. Prevalence of HIV, HCV and injecting and sexual behaviour among IDU at Needle and Syringe Programs. Redfern 1997-2001. 2002, Sydney: National Centre in HIV Epidemiology and Clinical Research, University of NSW.

27. Buddle, M., J. Zhou, and M. MacDonald, Australian NSP Survey, Redfern 1997-2002. 2003, Sydney: National Centre in HIV Epidemiology and Clinical Research, University of NSW.

28. Australian Bureau of Statistics, Year book of Australia 2002 population. Special article - Aboriginal and Torres Strait Islander Australians: a statistical profile from the 1996 Census. 1301.07. 1999, Canberra. ABS.

29. Australian Bureau of Statistics, Year Book of Australia 2002 Population. Special Article - Aboriginal and Torres Strait Islander Australians: A statistical profile from the 1996 Census. 2002.

http://www.abs.gov.au/Ausstats/abs%40.nsf/b0462a212839e1e5ca256820000fe0de/8d5807d8074a7a5bca256a6800811054!OpenDocument�

http://www.abs.gov.au/Ausstats/abs%40.nsf/b0462a212839e1e5ca256820000fe0de/8d5807d8074a7a5bca256a6800811054!OpenDocument�

45

30. Patton, G., et al., Changing schools, changing health? design and implementation of the Gatehouse Project. Journal of Adolescent Health, 2003. 33(4): p. 231-239.

31. Lehmann, D., et al., Benefits of swimming pools in two remote Aboriginal communities in Western Australia: intervention study. British Medical Journal, 2003. 327: p. 415 - 419.

32. Burns, C.B., et al., Evaluation of strategies used by a remote Aboriginal community to eliminate petrol sniffing. Med J Aust, 1995. 163: p. 82-86.

33. Reid, A.L.A., et al., General practitioners' detection of patients with high alcohol intake. British Medical Journal, 1986. 293: p. 735-737.

34. Ford, S., Bridging cultures: psychologists working with Aboriginal clients. INPSYCH, 2003. October: p. 9-11.

35. Cass, A., et al., Sharing the true stories: improving communication between Aboriginal patients and healthcare workers. MJA, 2002. 167(20 May): p. 466-470.

36. Waples, P., S. Gilmour, and I. van Beek, Indigenous people and the delivery of methadone treatment: Kirketon Road Centre's (KRC) Methadone Access Program (MAP) 1995-1999. 1999, Kirketon Road Centre: Sydney.

37. Holly, C., Review of literature on injecting drug use within urban Indigenous communities. 2001, Aboriginal Drug and Alcohol Council (SA) Inc: Kent Town, South Australia.

38. Lane, J., NU-HIT: A report on the Aboriginal Injecting Drug User Project 1992-93. 1993, Adelaide: AIDS Council of South Australia.

39. Larson, A., What injectors say about drug use: preliminary findings from a survey of indigenous injecting drug users - IDU Working Paper #2. 1996, University of Queensland: Brisbane, Queensland.

40. Shoobridge, J., et al., Using rapid assessment methodology to examine injecting drug use in an Aboriginal community. 1998, National Centre for Education and Training on Addiction/Aboriginal Drug and Alcohol Council,South Australia.

41. Lehmann, T.C. and R. Frances, Victorian Aboriginal Health Service Co-operative Ltd Injecting Drug Use Project. Health Promotion Journal of Australia, 1998. 8(1): p. 51-54.

42. Larson, A., C. Shannon, and C. Eldridge, Indigenous Australians who inject drugs: results from a Brisbane study. Drug and Alcohol Review, 1999. 18: p. 53-62.

43. Wen, L.M., et al., A 2001 demographic profile of the Central Sydney Area Health Service. 2003, CSAHS Division of Population Health: Camperdown, NSW.

44. NSW Department of Health, Ensuring progress in Aboriginal health: a policy for the NSW health system. 1999, NSW Health Department: Sydney.

45. Central Sydney Area Health Service, Drug Health Plan: 2002-2005. 2001, Camperdown, NSW: Central Sydney Area Health Service.