Barriers and enablers to the provision of alcohol treatment among Aboriginal Australians: A thematic review of five research projects

Authors


  • Dennis Gray MPH, PhD, Professor and Deputy Director, Mandy Wilson PhD, Research Fellow, Steve Allsop PhD, Professor and Director, Sherry Saggers PhD, Adjunct Professor, Edward Wilkes AOBA, Associate Professor, Coralie Ober RN, DipTchg, GradDip SocSci, AsscDipComWelf, Research Fellow.

Abstract

Introduction and Aims

To review the results of five research projects commissioned to enhance alcohol treatment among Aboriginal Australians, and to highlight arising from them.

Design and Methods

Drafts of the papers were workshopped by project representatives, final papers reviewed and results summarised. Lessons arising were identified and described.

Results

While the impact of the projects varied, they highlight the feasibility of adapting mainstream interventions in Aboriginal Australian contexts. Outcomes include greater potential to: screen for those at risk; increase community awareness; build capacity and partnerships between organisations; and co-ordinate comprehensive referral networks and service provision.

Discussion

Results show a small investment can produce sustainable change and positive outcomes. However, to optimise and maintain investment, cultural difference needs to be recognised in both planning and delivery of alcohol interventions; resources and funding must be responsive to and realistic about the capacities of organisations; partnerships need to be formed voluntarily based on respect, equality and trust; and practices and procedures within organisations need to be formalised.

Conclusions

There is no simple way to reduce alcohol-related harm in Aboriginal communities. However, the papers reviewed show that with Aboriginal control, modest investment and respectful collaboration, service enhancements and improved outcomes can be achieved. Mainstream interventions need to be adapted to Aboriginal settings, not simply transferred. The lessons outlined provide important reflections for future research. [Gray D, Wilson M, Allsop S, Saggers S, Wilkes E, Ober C. Barriers and enablers to the provision of alcohol treatment among Aboriginal Australians: A thematic review of five research projects. Drug Alcohol Rev 2014;33:482-490]

Introduction

For the past two decades, harmful levels of alcohol and other drug (AOD) use among Aboriginal and Torres Strait Islander peoples have been at least twice those in the non-Aboriginal population [1,2]. Although constituting about 2.5% of the population [3], in 2011–2012 Aboriginal Australians constituted at least 13% of those receiving mainstream publicly funded AOD treatment [4]. In response to this long-standing inequity, important policy initiatives have been developed and a broad range of treatment and other interventions has been undertaken by Aboriginal community-controlled organisations (ACCO) and other groups [5,6].

Several reviews summarise the evidence for effectiveness of alcohol treatment in non-Aboriginal populations [7–9] and treatment guidelines based on them have been developed [10]. However, these reviews and those focused specifically on Aboriginal people all conclude that the evidence base for the effectiveness of treatment in this population is limited [11–14]. Their conclusions are reflected by Hunter et al.:

At best there is evidence from controlled trials for some of the recommended interventions (for Indigenous people) in non-Indigenous primary care or hospital populations. Such evidence will be cited, with explicit acknowledgement of the uncertainty that remains about their applicability in Indigenous populations [11].

Gaps in the evidence base include those related to screening and assessment, brief interventions (BIs), withdrawal management, pharmacotherapies, psychosocial interventions, relapse prevention and management, co-existing mental and physical health problems, and integrated case management.

To address some of these gaps, the (then) Australian Government Department of Health and Ageing funded the National Drug Research Institute (NDRI) to conduct a research program aimed at enhancing management of alcohol-related problems among Indigenous Australians. As part of the program, the NDRI funded five projects aimed at trialling and/or evaluating particular interventions. Literature reviews [15–20] and the results of these projects [21–27] have been published separately. The objective of this paper is to review the collective results of the projects, and to highlight lessons arising from them and their implications for improving treatment services.

Method

This review was conducted in a two-stage iterative process. First, in preparation of the final project reports, two workshops were held and attended by representatives of each research team and the NDRI program team, who reviewed the results and discussed the implications. Comprehensive notes of these discussions provided the basis for recommendations for improving treatment services [28] and for the review of the final papers.

In the second stage—guided by the notes from workshops—the final papers were reviewed and thematic analyses conducted independently by two of the authors (D. G. and M. W.). These analyses were combined, reviewed and, where appropriate, modified by the other authors. The following sections include summaries of the key publications from each project (see Table 1) and a discussion of emergent themes.

Table 1. NDRI Enhancement of Treatment Program research paper summaries
Paper and lead agencyAimsMethodsKey findings
  1. ACCHS, Aboriginal Community-Controlled Health Services; BI, brief intervention; NDRI, National Drug Research Institute.

Training and tailored outreach support to improve alcohol screening and BIs in ACCHSs [13]

National Drug and Alcohol Research Centre (NDARC)

Measure effect of training and outreach support on delivery of alcohol screening and BIs in four ACCHSs.Pre- and post-assessment of alcohol information recorded in the electronic patient information systems of four ACCHSs, 12 months before and 6 months after, implementation of an intervention.Implementing evidence-based alcohol screening and BI in ACCHSs may take time and require multiple strategies specific to individual services, but has potential for improving detection of clients with alcohol problems. Study provided modest evidence that training and outreach support can result in improvements in alcohol screening in ACCHSs.

The Alcohol Awareness project: community education and BIs in an urban Aboriginal setting [14]

Sydney South West Area Health Service

Conduct pilot study of community-based education and BIs in an urban Aboriginal setting.Community-based groups offered interactive alcohol education session (n = 9) and screened 47 (81%) participants. Screening for alcohol use conducted prior to education. Scores quantified and result returned to participant post session. Confidential feedback and one-on-one BIs offered.While labour intensive, the process reached a number of individuals in need of assistance with alcohol. Study highlighted low awareness of drinking guidelines and treatment options among participants, however, illustrated that community-based approaches have potential to raise awareness and promote discussion around drinking with community members.

‘Can I have a Walan Girri?’ The development of an Indigenous-led model of service development and delivery for problematic alcohol use amongst Indigenous people in the Australian Capital Territory [15]

Winnunga Nimmityjah Aboriginal Health Service (Winnunga)

Design, implement and evaluate a culturally mediated case management model including SBI and reference to country for ACCHS clients experiencing problematic alcohol use.Review of existing models for integrated assessment, care planning, care delivery and care review. Pre-test quantitative staff survey of training needs (n = 34). Development of case management instrument including complementary policy and procedural documents and staff training package.High staff turnover delayed development and inhibited implementation of instrument and evaluation of effectiveness during study period. Despite this, findings illustrated that, with good partnerships, capacity building and clear procedures, comprehensive case management can be developed and adapted for local contexts.

The Grog Mob: lessons from the evaluation of a multi-disciplinary alcohol intervention for Aboriginal clients [16]

Central Australian Aboriginal Congress (Congress)

Trial and evaluate a non-residential treatment program offering pharmacotherapy, psychological and social support for Aboriginal clients with alcohol problems.Process and outcome evaluation involving qualitative interviews with program staff and key stakeholders (n = 32), and quantitative review of client contact and outcome data (n = 49).Identified process-related issues including staff recruitment and retainment, and need for flexibility in program application. Limited conclusions could be drawn on client outcomes due to small numbers. Nonetheless, evaluation demonstrated feasibility of project and evidence of high demand for it.

Aboriginal-mainstream partnerships: exploring the challenges and enhancers of a collaborative service arrangement for Aboriginal clients with substance related issues [17]

Aboriginal Drug and Alcohol Service

Explore factors that challenged and/or enhanced a government-initiated partnership between one Aboriginal and four mainstream services providing alcohol rehabilitation and support services to Aboriginal clients.Semi-structured qualitative interviews with staff (n = 16). Collection of observational data. Partnership forum to discuss findings and resolve identified issues.Identification of several key issues impacting on the partnership including cultural, historical, structural and personal considerations. Enhancers included the potential for maximising treatment options for Aboriginal clients.

Results

Training and tailored outreach support for alcohol screening and BI

The National Drug and Alcohol Research Centre (NDARC) project sought to embed screening and BIs in the practice of four collaborating Aboriginal community-controlled health services (ACCHS) [22]. This involved: staff training in use of the screening questions in patient information and records systems (PIRS) and BIs; providing tailored follow-up support to particular ACCHSs; and assessing changes in the frequency of screening and BIs in the six months pre- and post-intervention. Screening questions in the PIRS are similar to those in Alcohol Use Disorders Identification Test (AUDIT)-C [29,30], and training was based on materials including those from the ‘Drinkless Program’ (a package for use by health practitioners in detection and treatment of risky drinking) [31].

Despite inter-site variation, overall the percentage of clients screened increased significantly in the six months post-intervention (9.5% to 19.2%)—a critical improvement, as increasing case identification is the first step in improving care. Of clients with a valid screen, almost 40% were considered at risk of harm. Impact of the intervention on the provision of BIs was more modest. Of clients ‘at risk’ (39 pre, 77 post), the percentage receiving a BI increased from 28.2% to 36.4%. While not statistically significant, in clinical terms the increase represents some success. The authors note other evidence shows that transfer and uptake of interventions is a long-term process, and given more time they believe that the number of BIs would further increase. The study demonstrates the potential of screening in primary health care settings for identifying those at risk and providing appropriate services.

Community intervention in an Aboriginal urban setting

Based on an audit showing few Aboriginal people were accessing AOD services, the Sydney South West Area Health Service (SSWAHS) project sought to assess the potential role of ‘community-based education and brief intervention’ in reducing harm [23]. It aimed to do so by screening members of community groups (using AUDIT); by conducting interactive education sessions (based on ‘Drinkless Program’ materials [31]) to increase awareness of alcohol-related harms, alcohol guidelines and availability of services; and by feeding back AUDIT scores and providing one-to-one BIs for those at risk. The number of groups (8) and individuals (58) for whom education sessions were conducted was modest and, although 21 (44.7%) had AUDIT scores indicating potentially problematic drinking, none sought the option of a BI. The paper identifies process issues (including those relating to production of resources and recruitment) important in conducting such an intervention and provides some qualitative support for the approach taken and its potential to increase awareness (an important end in itself). The approach is labour intensive, but the authors suggest potential economies of funding, staffing and training if it became a routine element of service provision. Nevertheless, the issue of cost-effectiveness requires further investigation.

An Indigenous-led model of service development and delivery

The objective of the project conducted jointly by Winnunga Nimmityjah Aboriginal Health Service and the National Centre for Epidemiology and Population Health was to develop a comprehensive, culturally mediated, case-management and care-planning tool—incorporating alcohol screening and BI—including specific questions about ‘belonging’ and ‘country’ designed to facilitate client engagement with the health service. This tool became known as Walan Girri (Wiradjuri for ‘strong future’) [24].

Prior to implementation, a survey was undertaken to assess staff training needs, and a training program developed. However, post-test evaluation of the training program was precluded by high staff turnover. Staff and management turnover, changes in membership of the research team, and the way Walan Girri evolved led to prolonged development and implementation. This and low numbers meant outcome evaluation could not be completed within the project time frame. Nevertheless, on the basis of the trial, Walan Girri is now being used within Winnunga and the descriptive case study of the project provides several broadly applicable lessons, including the importance of partnerships, capacity building and the formalisation of procedures; issues raised by staff turnover; and small numbers of research participants. Importantly, it also led to an Aboriginal team member completing a PhD project to validate screening measures incorporated into Walan Girri [32].

A multidisciplinary alcohol intervention for Indigenous clients

The ‘Grog Mob’ project—conducted by Central Australian Aboriginal Congress (Congress), a large ACCHS—aimed to trial and evaluate a referral system and provision of three streams of care (medical, psychological and social) for clients with alcohol-related problems [25]. Evaluation was based on documentary data, key stakeholder interviews and review of client health records. Limited data precluded strong conclusions about client outcomes, but process evaluation identified issues arising out of implementation, including problems of staff recruitment and training and the need for flexibility in implementation. Nevertheless, the evaluation demonstrated that the project was feasible and that strong demand for it existed. On this basis, the project has received ongoing funding from both the Northern Territory and Australian Governments.

An Aboriginal–mainstream partnership

The project conducted in Perth by Aboriginal Alcohol and Drug Service (AADS) is a case study exploring factors challenging or enhancing an Aboriginal–mainstream partnership for the provision of counselling, withdrawal management and residential rehabilitation for Aboriginal clients [26]. The partnership—entered into at the behest of a government funding agency—was between AADS, a non-Aboriginal withdrawal centre, and two mainstream residential treatment facilities (at which 12 dedicated Aboriginal beds were purchased). The case study was based on semi-structured interviews with 16 staff members from the partner organisations.

The partnership was fraught with tension and the authors describe a range of structural, historical, cultural and personal factors—compounded by client complexity and the ‘paternalism of the funding agency'—which challenged the partnership and the intervention. Nevertheless, both Aboriginal and non-Aboriginal informants saw the potential of such partnerships. A key lesson arising from the project is that to be successful such partnerships must be voluntary, equitable, accountable and based on trust.

Discussion

The projects raise a range of issues and here we consider the most salient and the lessons arising from them.

Additional resources have impact

The projects demonstrate that modest additional resources can produce change and enhance outcomes. A small amount of additional resources led to increased capacity to deliver services; improved case identification; increased client engagement; improved interagency and community collaboration; and development of more appropriate assessment tools and resources. As these became embedded in service provision, the initial investment has continued to have a positive effect and the success of the NDARC and Congress projects led to the allocation by government agencies of additional funds, two and 36 times greater, respectively, than the original investment of about $250 000 in each project.

The importance of culture

The papers demonstrate that interventions effective in non-Aboriginal communities cannot simply be implemented in Aboriginal settings without consideration of cultural differences. The AADS paper shows that ACCOs are not simply the equivalent of mainstream health services managed by Aboriginal communities. ACCOs, their practices and values reflect the groups that established them and which they serve. These cultural elements affect the relationships between Aboriginal and mainstream organisations, implementation of specific interventions within ACCOs, and patient–practitioner relationships. Concern with the initial engagement of patients with a service, which conditions future interactions, is a key element in the development of Walan Girri; recognition of cultural differences is central to modifications to the AUDIT and ‘Drinkless’ materials by the SSWAHS team; and the clash of cultural values and failure to recognise differences, highlighted in the AADS study, demonstrates how provision of quality care can be undermined. Strategies for going beyond rhetoric and ensuring the operationalisation of culture in psychotherapeutic practice are outlined in a review by Smith and others and these have broad applicability in the Aboriginal AOD field [33].

The potential of screening and BI

The potential for screening and BIs among Aboriginal Australians has long been recognised. They are included in the Medicare Benefits Schedule's ‘Health Assessment for an Aboriginal and Torres Strait Islander Adult’ (Item 715) [34]. With qualifications, use of AUDIT and BIs is recommended in Aboriginal-specific alcohol treatment guidelines and a guide to preventive health assessment of Aboriginal people [13,35]. In addition, either AUDIT or AUDIT-C is included in two of the PIRS commonly used in ACCHSs. Nevertheless, a number of issues relating to screening and BIs in Aboriginal settings have been identified [13,36–41].

Questions have arisen about the length of the AUDIT and to address this, in non-Aboriginal populations, abbreviated versions have been tested in both clinical and community-survey settings [30,42]. The results show that AUDIT-C is effective in identifying those drinking at hazardous levels and that a single question on consumption from the AUDIT (‘How often do you have six or more drinks on one occasion?’) is also useful in identifying those who drink at hazardous levels [30].

Results of the NDARC project suggest that use of either AUDIT-C or the single consumption question is also effective in Aboriginal settings and is preferable to use of the full AUDIT as a screening tool. While seemingly at odds with SSWAHS's report that they successfully used the full AUDIT, SSWAHS was conducting screening and alcohol awareness education in community groups especially convened for the purpose without the distraction of pressing health problems and busy clinic schedules. In such situations, the full AUDIT can provide a more nuanced assessment with the potential for more appropriate intervention.

ACCHS clients have reportedly had difficulty understanding some of the AUDIT questions that have had to be clarified and reworded [36,37]. Questions in the PIRS used by the ACCHSs in the NDARC study are similar to, but do not follow, the wording recommended in the AUDIT manual. The SSWAHS team modified the wording of the questions ‘to suit the client group'—and give some examples of this. This is consistent with the AUDIT manual, which notes questions may need to be adapted to specific languages, cultures and standards [29], and is appropriate given the documented differences between Standard and Aboriginal varieties of English [43].

Ascertainment of consumption levels is an issue, with few people (Aboriginal or otherwise) having a clear understanding of the concept of a ‘standard drink’ and the amounts poured or consumed as ‘a drink’ generally. The SSWAHS team simply recorded ‘the number of drinks reported by participants’, judging that potential loss of specificity ‘… would be outweighed by increased comfort for subjects in completing the survey’ [23]. While a practical solution in a clinical (as opposed to a research) setting, it would be useful to attempt to quantify what is lost.

The SSWAHS paper raises the broader issue of community understanding of alcohol-related harm and options for addressing it. Although the total number of people screened was small, they tended to consume alcohol episodically at high levels, had little knowledge of current drinking guidelines and knew little about interventions other than residential treatment. This suggested that mass media campaigns have had little impact, lack of knowledge of other interventions precluded their uptake and screening itself has a potentially significant role in raising awareness.

Partnerships in research in research and practice

Partnerships are a key element in reducing alcohol-related harm among Aboriginal Australians [5], and each of the papers addresses this issue. All involved collaboration between AOD service providers and university-based research centres. In four instances, providers took the lead roles and, in the other, a research centre did so but based on previously established relationships with ACCHSs. As a consequence, the projects tackled issues of relevance to the service providers themselves.

The AADS paper highlights structural, historical, cultural and personal impediments to effective partnerships. The partnership itself was involuntary (at least from the perspective of AADS) and emerged from a funding agency decision. It reflected unequal power relations between the funding agency and the non-Aboriginal partners on the one hand and AADS on the other, creating an atmosphere of distrust. This was compounded by poor knowledge among partners of each other's services; divergent views regarding staff skills and competencies, including the relative importance of clinical and cultural competencies; communication difficulties; staff turnover; and the paternalism of the funding agency. Despite these challenges, most staff saw the value of partnerships, with the qualification that they be voluntary, equitable, accountable and based on trust, and that they engender community control.

In contrast, the Winnunga paper describes collaboration between researchers and health service staff built upon: existing relationships; strong community control, ownership and management of the project; and consultation with staff on implementation of the intervention. Similarly, the partnership between SSWAHS, the University of Sydney and ACCHSs was successful because relationships between partners had developed over a considerable period prior to the current project. Such research collaborations might be less fraught than those between service providers, as the parties are not in competition as providers often are.

A positive outcome of the program process was the close network established between practitioners and researchers. Staff from each of the projects met at workshops in which they shared ideas in the development of research proposals and reports. They also shared training on screening and BIs and project materials. This collegiate approach to project development and the funding of projects was particularly suited to research in ACCOs not established primarily to conduct research and led to significant improvements in research design, process and outcomes. As such, the model provides an efficient complement to research funding through bodies such as the NHMRC, the processes of which are time-consuming, challenge resources and processes within small ACCOs, and require considerable work with little likelihood of success.

Staffing

The difficulties of recruiting qualified staff, high staff turnover rates in the AOD field in general, and the Aboriginal field in particular, have been highlighted [44,45] and four of the five papers discuss the negative impacts of these. In the Winnunga case, staff turnover led to abandonment of a plan to conduct a post-intervention evaluation survey and the other four projects highlight intra- and inter-service difficulties as a consequence of these factors. In the Congress project, resignation of a senior therapist and difficulty in recruiting a replacement delayed implementation and constrained collaboration with other agencies. Similarly, the SSWAHS team reported that staff turnover (among factors such as funerals, illness and other external events) in their own agency and their partner groups significantly delayed recruitment of participants; and the AADS paper identified staff turnover as a major challenge to the implementation of partnership arrangements. While these problems are not easily resolved, they can be ameliorated by planning for such contingencies and, as both the Winnunga and AADS papers suggest, by developing formalised program procedures to minimise disruption and loss of ‘corporate knowledge’ if staff move on.

All the projects emphasise the need for appropriate staff development. As the NDARC and Winnunga projects highlight, this should be provided to staff at all organisational levels. Furthermore, as exemplified by the SSWAHS, AADS and Winnunga projects, this should go beyond the simple provision of technical skills to include awareness of the broader and cultural contexts in which intervention takes place.

Short-term projects

The length of the overall program was constrained by the funding period, and initially, it was planned to conduct the individual projects over a 12-month period. However, all projects exceeded this. This problem was acute when, as in the case of the Congress and SSWAHS projects, program structures and referral networks had to be established and new staff recruited.

The short-term nature of projects exacerbates other problems. The difficulty of recruiting qualified staff (particularly in rural and remote areas) is compounded when agencies can offer only short-term employment contracts. Furthermore, over short terms, delays necessitated by recruitment, training, establishing collaborative relationships and gaining community acceptance have proportionately greater impact. This problem is not unique to research projects and the adverse effects of short-term funding and reporting cycles has been highlighted elsewhere [46] and, in the case of Aboriginal-specific AOD interventions, the number of short-term funded projects has increased [6].

Formalisation

Clearly defined management structures and procedures have been identified as elements of best practice in the provision of Aboriginal AOD services [44]. The papers highlight this and the need to formalise processes within organisations. In the AADS project, problems arose because of the failure to embed working arrangements and commitments in policy and procedures. In the Winnunga case, development of a formal screening instrument, commitment by management and attention to the concerns and training of staff led to improved client engagement with the service. Embedding screening questions and providing training led to significant increases in the number of patients screened in the four ACCHSs in New South Wales. In addition, within Congress, the formalisation of a comprehensive, structured case management system apparently led to improved access to care.

Ethical and rigorous Aboriginal health research

Each project illustrates the challenges and rewards of conducting rigorous and ethical Aboriginal health research. Jamieson et al. provide a useful review of the emerging literature in this area, and principles to guide research [47]. Issues discussed earlier, including small samples due to recruitment difficulties, modified study protocols and extended timelines, along with the sometimes equivocal results consequent on these limitations, are characteristic of many similar studies in Australia and overseas. Concerns about the impact of these factors on the scientific rigour of the research need to be balanced by the overriding importance of Aboriginal control of the research process—from the identification of the research topic and building the capacity of Aboriginal researchers to dissemination and implementation of results [48]. Each of the projects described here has attempted to address these issues.

Conclusion

There is no simple way of reducing alcohol-related harm in Aboriginal communities. It must be based on Aboriginal control, addressed on a number of levels and incorporate tested approaches. The extensive evidence-based literature on interventions to reduce alcohol-related harm cannot simply be transferred from non-Aboriginal to Aboriginal settings. Interventions need to be adapted to those settings and the best processes for doing so need to be identified. The small projects reported upon in this review are a significant step in this direction and show that important improvements can be made with modest investment and a collaborative approach, especially one that respectfully and collegiately explores the relevance of evidence and expertise for Aboriginal people, services and communities.

Acknowledgements

We wish to thank organisations and staff members who participated in each of the projects conducted as part of the ‘Enhancing the management of alcohol-related problems among Indigenous Australians’ program. The program and the individual research projects were funded by a grant to the NDRI from the (then) Australian Government Deparmtnet of Health and Ageing. The NDRI at Curtin University is supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvement Grants Fund.

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