Primary and Preventitive Care

By Paula Williams

Special needs of the people living in the circumpolar regions health promotion and prevention, care and rehabilitation
(to be identified in research 2010) global waming conditions of mental and physical wellbeing in response to climate change.

General population requirements is todevelop an understanding of the nature and scope of human health and wellbeing, and of the health and fitness industry looking at subjects such as nutrition, lifestyle, preventative health, and alternative medicine globally:

What is Health & Wellbeing?
Health and Fitness are simply some of many the different words used to describe people being in good condition. There are many different services and products on offer which promise to improve or maintain a state of wellbeing, and any (or all) of these goods and services might be considered to be part of the health and fitness industry. These can include things as variable as medical services through to fitness, sport, recreation and food. There are three aspects to health:
  • Emotional or Mental health (Healthy thoughts & attitudes)
  • Structural Health (The health of the body is structurally sound ‑the bones, muscles, organs etc. are physically in good condition ‑not damaged ‑performing the functions they should perform)
  • Chemical Health (The chemicals in our body are correct ‑there are no toxic chemicals ‑the tissues are made up of the appropriate balance of nutrients etc.).

Build on the concept.as follows:
1. Industry Overview
2. Modern Lifestyle Problems
3. Human Nutrition
4. Healthy Eating
5. Stress Management
6. Preventative Health
7. Alternative Medicine
8. Basic First Aid
Developing an understanding of health and wellbeing that can be applied to design a personal fitness program. Below is a list of some activities
  • Create a resource file of health and fitness related businesses, contacts, services etc.
  • Interview people to learn how they rate their health and fitness and what they do to improve/maintain them.
  • Identify ways to overcome a health/fitness problem in your own life.
  • Identify different food allergies and ways to deal with them.
  • Identify eating and nutritional disorders and describe possible treatments.
  • Explain how age, level of activity, gender and other factors affect their dietary needs.
  • Explain the principle of food combining.
  • List the effects of alcohol abuse.
  • Explain how high self esteem is achieved, and consider positive and negative effects.
  • Identify services in your area that offer natural therapies and what they entail.
  • Find out what first aid courses are available in your region, and what is entailed.
  • List items that should be kept in a basic first aid kit.

1) Recommendation for nutrition in our country/area. Take the development of diabetes, obesity, traditional diet and contaminants into account.

Australian Aborigines and Torres Strait Islanders from a National perspective:
The major causes of diet-related mortality and morbidity today in the Indigenous population are diabetes, cardiovascular disease, and renal disease. When poor nutrition occurs coupled with other risk factors, such as smoking, physical inactivity and alcohol abuse including over-nutrition across the life cycle it can have detrimental effects to one’s health.

As health professionals we have become aware that poor nutrition amongst indigenous population has a propensity of a number of disease risks, including cardiovascular disease, diabetes, some cancers, obesity, gall bladder disease, iron-deficiency anaemia, dental caries, and renal disease. The dietary risk factors for cardiovascular disease amidst the indigenous communities appears to have stemmed from saturated fat from meat and processed foods, lack of fresh fruit and vegetables, high salt intake, excess energy intake, and alcohol consumption. However, it is difficult to determine, the precise extent to which diet contributes to disease, because disease is also caused and influenced by behavioural, biological, congenital, and environmental factors. As we have learnt Flora’s legacy is not unique to Cape York peninsular nor far North Queensland but is seen Nationally across all states of Australia throughout a widespread of Indigenous populations. Some however, fare better than others and this depends on the area of access and growth with regards to indigenous health workers and educational wellness programs including primary and preventative health care services provided by local and state governments.


Traditional Diet:
Indigenous groups in Australia before colonisation lived in a diverse range of climatic conditions and terrains, varying from tropical to temperate climates, and from coastal regions to the centre. Indigenous people were nomadic hunter-gatherers and depended on naturally occurring plants, animals and fish. The roles of males were primarily the hunters of large game whilst the roles of the women were the gatherers of plants and sometimes small game. If food and water were plentiful, large groups of Indigenous people would camp for weeks or months before moving to a new location. However, semi-nomadism, often associated with this lifestyle, was less evident among coastal groups such as Torres Strait Islanders. Hence, prior to the European colonisation of Australia the indigenous people were healthy, fit, and strong. The traditional indigenous diet, was high in protein, low in sugars, high in complex carbohydrates with a low glycaemic index (GI) and high in micronutrients. Thus, their staple diet was generally low in energy density and high in nutrient density. Kangeroo meat has no fat and is extremely lean meat. In addition season and location greatly influenced the composition and diversity of the food supply. However, with global warming causing flash floods, drought and bush fires this has changed the patterns for hunting and gathering. In addition to colonisation this has changed too as in Flora’s[[#_ftn1|[1]]] example where many tribes were forced to live with other tribes in confined missions that restricted their movement as nomads for hunting and gathering let alone as an identity for a specific tribe for that local region who have hunted and collected their own land’s fauna and flora in time immemorial. For example, the diet of Torres Strait Islander people contained more seafood than that of Aboriginal people which was consistent with their location. Thus, Torres Strait Islanders, along with Aboriginal people living in coastal areas, had extensive knowledge of the marine environment. In particular they possessed knowledge of feeding patterns of marine animals and tidal movements. This is evident with the food supply in the Torres Strait which varied between islands. These Islanders depended on subsistence agriculture and trading much more than Aboriginal people did where fishing, hunting, and foraging were supplementary to horticultural activities and knowledge of ‘Bush Tucker’[[#_ftn2|[2]]].

As we have learnt in the past, Indigenous people’s hunter-gatherer methods of obtaining food involved physical activity and social interaction. However, this all changed when the transition to a European diet occurred. Rather these changes in lifestyle have been problematic for many Indigenous people in the last century. The causes of current inadequacies in nutritional intake among Indigenous people are many not to mention the other contributing factors which are legacies of western colonisation such as the low socioeconomic status including the, environmental and geographic factors which have influenced the availability of healthy and affordable food to the indigenous communities. This started to occur when many Indigenous groups became established on cattle stations, government settlements, or missions, where their diets consisted mainly of introduced western foods. Some of these foods were highly processed with added preservatives and other contaminants so as to endure long periods of transportation and storage. These additives subsequently were generally high in sugar, salt, and fat. This was the complete opposite to their traditional dietary intake. This dependence transformed eventually into a ‘Western’ diet[[#_ftn3|[3]]]. It also included role changes and a reduction in physical activity leading to obesity especially in the women. This was because the Aboriginal women lost much of their food-gathering and food-processing role, and spent more time sitting around camps or settlements. Up until the early 1970’s the Aboriginal Men were more often employed in the workforce. However, this soon changed by the mid 1970’s by a reduction in rural employment opportunities and the introduction and availability of social welfare benefits, and freely available alcohol which sadly led to a decline in the physical activity of men in Indigenous settlements.

Vulnerability to obesity and non-insulin-dependent diabetes mellitus has been common cause now among Indigenous groups today and has also been identified among other groups that have been subjected to similar rapid lifestyle changes. This has been seen amongst the Inuits in Canada, the Pima Indians and Native Americans. This is a direct outcome of a rapid change in the diet of many Indigenous people from basically a fibre-rich, high-protein, low-saturated-fat traditional diet to one high in refined carbohydrates and saturated fats. Ultimately this manifests into increased risk of diet-related disease coupled by an increased energy intake and continued dietary imbalances. As in Flora’s legacy she is one of many who are now statistically suffering the effects of poor nutrition and growth born from alcoholic, heavy smoking and poor nutritional family background. All these factors can have strong congenital effects in pregnancy and to a child’s early life which can have lifelong consequences. Healthy nutrition in pregnancy is crucial for the mother, as it influences both her health and that of her baby. Low dietary-energy intake, malnutrition, inadequate weight gain during pregnancy, and low pre-pregnancy weight can lead to intra-uterine growth retardation, which in turn can reduce birthweight. In addition the prevalence of low birthweights below 2.5 Kg is now of particular concern amongst teenage pregnancies within the indigenous population which is increasing the risk of infant mortality and other health problems. This is a reflection not only by the nutritional health of the mother, but also the duration of pregnancy, number of babies previously born, high maternal age and low socioeconomic status, as well as risk factors such as substance abuse in pregnancy in particular cigarette smoking and alcohol consumption not to mention sexual transmittable disease. These current inadequacies in Indigenous nutrition are another example of the substantial disadvantages experienced by many Indigenous people in Australia today, to which more concerted efforts are now being made in this country by the Federal government to ‘close the gap’


Recommendation for nutrition in Australia for Indigenous population

There have been some recommendations for a national strategy and action plan (NATSINSAP) in Australia 2000-2010. These National approaches to improving the nutritional health of Indigenous people are guided by the National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan 2000-2010 which was developed as part of an overall national nutrition strategy, Eat Well Australia: a national framework for action in public health nutrition, 2000-2010,. Both strategies were endorsed by the Australian Health Ministers’ Conference in August 2001. NATSINSAP, saw that poor diet is central to the poor health and disproportionate burden of chronic disease experienced by Indigenous Australians, hence, provides a framework for action across all levels of government, in conjunction with partners from industry and the non-government sector. The NATSINSAP identified the following seven priority areas to build on efforts to improve access to nutritious and affordable food across urban, rural and remote communities:
o food supply in remote and rural communities;
o food security and socioeconomic status;
o family-focused nutrition promotion;
o nutrition issues in urban areas;
o the environment and household infrastructure;
o Aboriginal and Torres Strait Islander nutrition workforce; and
o national food and nutrition information systems

To help progress key areas, a NATSINSAP Project Officer, working under the guidance of a national Steering Group and Reference Group, has been funded by OATSIH until October 2008.


In conclusion, Flora (case study) and her family t
hroughout their lives, are just part of many Indigenous people who suffer major disorders of nutrition and growth. We now know that at birth, Indigenous babies are substantially lighter than non-Indigenous babies. Most significantly, the proportion of Indigenous babies of low birthweight is more than twice that of non-Indigenous babies[[#_ftn4|[4]]]. From birth, the growth of most Indigenous infants tends to be satisfactory until breast milk becomes insufficient by itself, at which time they need complementary food and become unfortunately and sad to say more directly exposed to the substandard environment in which many of these Indigenous people live. At this time, they become vulnerable to a wide range of infections, in many cases entering the vicious synergistic cycle of infection-malnutrition. Many Indigenous people carry this legacy of impaired growth into early adulthood, where it has a significant impact on the health of mothers, and of the next generation. From the early adult years, and increasingly even earlier, many Indigenous people start to gain weight excessively, eventually becoming overweight or obese. Associated with the high levels of overweight and obesity in adulthood, there are now alarming levels of chronic disease, particularly cardiovascular disease and diabetes mellitus.

The underlying factor common to these growth and nutritional problems is the extreme social disadvantage experienced by many Indigenous people, seen in low levels of education, high levels of unemployment, low incomes, and a sub-standard physical environment. Hence, NATSINSAP 2010’s view is of the central role that nutrition and diet-related diseases will play in addressing at least two of the targets set for ‘closing the gap’ between Indigenous and other Australians - to halve the 17-year gap in life expectancy within a generation, and to halve the gap in infant and childhood mortality within a decade - it is clear that commitments to redressing the underlying social disadvantages experienced by many Indigenous people will need to be accompanied by expansion of key initiatives in the area of public health nutrition.


2) What is the health care system for delivery at service in relation to Cervix Cancer Flora's legacy, and in relation to sexual transmitted diseases in your country/area (see article)

According to the recent National Health & Medical Research Council (NHMRC) cervical cancer is now an uncommon disease[[#_ftn5|[5]]] in Australia, and that mortality from the disease is one of the lowest in the developed world bettered only by Finland. However, this is only good news if you are one of the majority of Australian women who is not of Aboriginal or Torres Strait Islander origin.

Whilst it is important that women understand the meaning of an abnormal result, and that the need for colposcopy[[#_ftn6|[6]]] and possible travel to a distant centre for treatment in the event of an abnormality being detected, is explained clearly and in appropriate language to women before they consent to screening it is not however, always easy to explain this to the Indigenous female community. In addition the association between vaginal examinations and the diagnosis and treatment of sexually-transmitted
infections such as syphilis is another reason why some indigenous women are fearful about cervical screening. Again, more education and information, appropriately and respectfully provided, is essential. It has been observed by many health workers that indigenous women in particular prefer internal examinations and Pap smears to be performed by another woman, hence the real effort that has gone into providing such services and training in Australia especially with the introduction of the Nurse practitioner[[#_ftn7|[7]]] and Aboriginal Health Worker. It has been suggested that indigenous women health workers might be trained to perform cervical screening and in North Queensland, NSW and WA many have undergone such training. However it has been reported that many women in smaller communities prefer intimate examinations done by women from outside the community, and therefore the value of such health worker training may lie more in educating their communities than in the actual provision of services. It would seem that the provision of more information about the reasons for performing Pap smears, and the consequences, both positive and negative, of screening programs, is pivotal to increasing the participation rates amongst indigenous women especially in QLD where incidences of cervical cancer mortality rate amongst indigenous women is now 10 times greater than the average national rate across Australia. A further problem is the fact that a high proportion of smears from indigenous communities requires the woman to be re contacted for a further consultation and similar to Flora possibly to undergo a colposcopy. As was identified in the case study of Flora it is not that the health services and quality of health professionals and health providers with the availability of the Royal Flying Doctor Service in rural and remote areas in the outback are lacking because the infrastructure and ehealth informatics are all available across Australia. Rather the health services provides the same provision to the non indigenous women which has had profound improvement especially in women’s health of primary and preventative care of Cervical cancer and early detection. It is basically the mindset of the indigenous community that needs to be nurtured and understood in order to earn that trust we need to collaborate and communicate with them more effectively for their future health and wellbeing. Hence, there is significant mutual benefit when Indigenous health workers work alongside community members and other service providers.This also included working with local administrators, medical and nursing staff and other organisations and departments, to help build partnerships in health.


The importance of communicating, listening, and responding to indigenous women has been emphasised by many working in the area of women’s health. The Royal Women's Hospital in Victoria supports all Aboriginal and Torres Strait Islander women and provides a number of services to support Aboriginal and Torres Strait Islander women and their families within the hospital. They also raise the profile of and promote issues to do with Indigenous women's health within the hospital and broader community. In addition, they liaise between Indigenous women, the hospital and relevant external agencies and act as advocates where necessary on behalf of Indigenous women and their families. One of their key focus is to ensure Indigenous women and their families understand medical terms and procedures relating to their health care and to work with hospital staff to increase cultural awareness and sensitivity of health care services for Indigenous women and provide support to Indigenous women with respect to their social, emotional and cultural needs. In 2004 the National Cervical Screening Program’s Aboriginal and Torres Strait Islander Women’s Forum collaboratively identified five key principles of practice and ten workplace practice standards which support the provision of culturally effective and culturally safe service delivery. Members of the Forum endorsed the development of a set of practice standards and guidelines to assist the development of appropriate service delivery in all States and Territories. Thus a set of principles of practice, standards and guidelines were developed for providers of cervical screening services for Indigenous Women. These principles were developed to assist in breaking down some of the barriers faced by Indigenous women when attending health services for cervical screening, and to maximise their access to the cervical screening pathway. Hence or the more reason for training Indigenous health workers. The role of the Indigenous Area Health Worker (AHW) is pivotal as they act as advocates on behalf of the community health services in the rural and remote. By talking in their local language using known cultural idiosyncracies specific to certain tribal cults bridges the fear and demystifies the unknown. Similar to Flora many of the women in the outlying areas in Australia have no line of communication and low literacy. Hence, they don’t know what is going on there at the health service or what they are offering. Communication channels takes time and so does trust something we white people have to build after the ‘stolen generation’[[#_ftn8|[8]]] and colonisation of assimilation and segregation. It is important to liaise through the local Indigenous Health Worker or Liaison Officer as Indigenous people don’t trust systems or services that have not had their input during the development stages. Many hospitals need to be built near rivers or water as the land and the rivers are part of their healing process. Therefore Indigenous people of that community need to be involved right through the process from beginning to end when building services and infrastructure in the community. This includes during any planning phases of service provision and community members have to be involved at every stage after that too for services to work properly"[[#_ftn9|[9]]] There are now Aboriginal Women's Health Business Committees,[[#_ftn10|[10]]] consisting largely of Aboriginal women outside the hospital which meet regularly to advise hospital staff about health issues of importance to Aboriginal women, including offering guidance in the development of culturally sensitive and appropriate service delivery. The Committee also offers assistance with policy development around Aboriginal women's health issues.

Indigenous people learn collaboratively and are very audio-visual communicators. They are traditionally educated by the elders through collaborative storytelling and image/pictures using dot- style art paintings. Currently, Central Australian Health Workers are using paintings by Margaret Lankin to represent important health and wellbeing document regarding cervical cancer and sexual diseases as one form of strategy to educate the local indigenous women. The painting tells a story about how important it is for women to have regular Well Women's checks. The traditional women supported each other and traditionally, older women taught the younger ones how to look after themselves and their country. Hence, the shapes in the painting represent the women sitting around together having a meeting. The one with the white dots is the lady from the screening place, who has come to talk about breast screening, cervical cancer and Well Women's screening. The circle with yellow, grey and brown dots is the screening place. Circles with white dots are the other communities involved in this big meeting. The footprints with white dots belong to the lady with all the knowledge she's going to pass on to the Aboriginal ladies there. The two ladies sitting in the circles are shamed. They sit there and wait to hear from the other ladies. The footprints with the yellow dots are the ladies who understand now what breast screening, cervical cancer and pap smears are, and how important it is to be screened. The yellow and white dots scattered over the painting are sending a strong message across to all women to be screened every two years.

The paintings represent 4 important key areas:


indigenousppc.JPG

It is important that health staff needs ensures that they are able to provide quality, equitable and effective access to services that feel culturally safe to clients. Therefore, encourage on going participation of clients, community members and staff in service design and delivery. Collaborative decision-making encourages and supports diversity and two-way partnerships and allows clients, community members and staff to share knowledge, skills and experiences to contribute to initiatives together. This would include collaboration in the design, implementation, delivery, maintenance and evaluation of the service. It assists to build social capital and to provide on going quality and equitable and effective access to appropriate services. This principle would also assist in the identification of key stakeholders who can assist with the continuing development, delivery, maintenance, monitoring and evaluation of practices, which work to ensure best practice service provision. The continuing dialogue by clients, community members and staff in decision-making, can guide the effectiveness and efficiency of the service and can determine whether women feel confident in the quality of care provided.

Whilst these criteria are used to assess the standard of the service, they may well differ in each community, individual service or geographical location. These principles of practice are used purely as a working document in progress to identify gaps in service provision and to develop further mechanisms or strategies to breakdown existing or identified barriers.The Aboriginal Women's Health Business Unit also provides secondary consultation and training and education to health professionals, and supports the Aboriginal Women's Health Associates Program at the Royal Women's Hospital through ongoing researching, support and review of the program. Recently at Wu Chopperen Health Service in Cairns QLD a program has been established to give respected older women (Elders) in the community accurate information about cervical screening, in the hope that they will feel able to ‘corroberate’ (Indigenous: discuss at collaborative meeting ) and promulgate this information amongst the younger women. Recently, at the request of indigenous health workers a video was made in Wu Chopperen and at Yarrabah Health Centre using healthcare providers and personnel talking about the importance of cervical screening. Importantly this model will be used as part of further education sessions in clinics and small group sessions throughout the region. In conclusion these case studies like Flora’s legacy and program based projects and research has illuminated clearly that non indigenous Australians need to listen hard if we are to succeed in better informing Aboriginal and Torres Strait Islander women of the value of cervical screening and hopefully decreasing the high mortality rate from this largely preventable cancer amongst Indigenous women not only for today but provide a sustainable health and wellbeing for all indigenous communities living in Australia.

Bibliography
Australian Institute of Health and Welfare (2006) Australia's health 2006: the tenth biennial health report of the Australian Institute of Health and Welfare Canberra: Australian Institute of Health and Welfare Sayers D, Powers J (1997) Risk factors for Aboriginal low birthweight, intrauterine growth retardation and preterm birth in the Darwin Health Region Australian and New Zealand Journal of Public Health; 21(5): 524-530

Burns J, Irvine J (2003) Nutrition and growth. In: Thomson N (ed.) The health of Indigenous Australians, South Melbourne, Vic.: Oxford University Press (pp75-92)

Burns J, Thomson N. Overweight and obesity - a major problem for Indigenous Australians. Australian Indigenous HealthBulletin, 2006, 6(4): (Online journal: http:www.healthbulletin.org.au)

Coory M, et al(2002). Participation in cervical cancer screening by women in rural and remote Aboriginal and Torres Strait Islander communities in Queensland. MJA 2002; 177(10): 544-

De Costa, C (2001) The Lancet Flora’s lLegacy; Vo.l 358 December 22/29 , 2001


Farrer, Keith (2005)‘To Feed a Nation, A History of Food Science and Technology’


National Health and Medical Research Council (2000) Nutrition in Aboriginal and Torres Strait Islander peoples: an information paper Canberra: National Health and Medical Research Council

National Health & Medical Research Council Screening to Prevent Cervical Cancer: Guidelines for the Management of Asymptomatic Women with Screen-Detected Abnormalities 2005

O’Brien ED, et al (2000). Cervical cancer mortality in Australia: contrasting risk by Aboriginality, age and rurality. Int J Epidemiology 2000; 29: 813-6.


[[#_ftnref1|[1]]] Caroline De Costa, The Lancet-Vol 358 Dec.22/29,2001
[[#_ftnref2|[2]]] Farrer, Keith (2005)‘To Feed a Nation, A History of Food Science and Technology’
[[#_ftnref3|[3]]] 1999/2009 State of Victoria. Reproduced from the Better Health Channel (www.betterhealth.vic.gov.au)
[[#_ftnref4|[4]]] Nutrition in Aboriginal and Torres Strait Islander Peoples Endorsed 31 July 2000, An Information Paper NHMRC National Health and Medical Research Council
[[#_ftnref5|[5]]] National Health & Medical Research Council Screening to Prevent Cervical Cancer: Guidelines for the Management of Asymptomatic Women with Screen-Detected Abnormalities 2005
[[#_ftnref6|[6]]] Coory M, Fagan P, MullerJ, Dunn N. Participation in cervical cancer screening by women in rural and remote Aboriginal and Torres Strait Islander communities in Queensland. MJA 2002; 177(10): 544-7.
[[#_ftnref7|[7]]] Olly Johnston was NSW first nurse practitioner, as an Indigenous woman she was able to relate to other indigenous woman as a Nurse Practitioner at Goodooga Health Service, continuing her commitment to improving the health of people in remote communities
[[#_ftnref8|[8]]] Rudd KM (2008) Apology to Australia's Indigenous peoples http://www.pm.gov.au/media/speech/2008/speech_0073.cfm
[[#_ftnref9|[9]]] Community Woman, Eidsvold, QLD
[[#_ftnref10|[10]]] 2006 The Royal Women’s Hospital | http:www.thewomens.org.au