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Keywords:

  • Indigenous Australians;
  • brief intervention;
  • resources

Abstract

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Conclusion and implications
  7. Acknowledgements
  8. References

Objective: Little is known about the content and quality of brief intervention kits specifically targeting SNAP risk factors (smoking, poor nutrition, alcohol misuse or physical inactivity) among Indigenous Australians. This paper reviews the type and quality of these kits.

Methods: Brief intervention kits were primarily identified by contacting 74 health-related organisations in Australia between 1 February 2007 and 4 March 2007.

Results: Ten brief intervention kits met inclusion criteria: four targeted smoking; three targeted alcohol; one targeted alcohol, smoking and other drugs; one targeted alcohol, other drugs and mental health; and one targeted all SNAP risk factors. Brief intervention kits were reviewed using criteria developed from clinical guidelines for SNAP risk factors and guidelines for evaluating health promotion resources. Three kits met all review criteria. Five kits were consistent with evidence-based guidelines, but lacked a training package, patient education materials and/or behavioural change strategies. All kits used images and language identifiable with Indigenous Australia, however, their cultural appropriateness for Indigenous Australians remains unclear.

Conclusions and implications: The specific content of the missing components should be guided by the best-available evidence, such as established mechanisms for health care provider feedback to patients as a behaviour change strategy, as well as the needs and preferences of health care providers and patients.

Smoking, poor nutrition, alcohol misuse and physical inactivity (SNAP) are universally recognised as key risk factors for chronic diseases, such as cardiovascular disease, diabetes and renal disease,1 all of which contribute significantly to premature and excess mortality and morbidity among Indigenous Australians.2 The disproportionately high burden of SNAP-related harm borne by Indigenous Australians,3–6 highlights the urgent need for cost-effective interventions to reduce this level of harm. There is relatively strong evidence from the non-Indigenous population that brief intervention is cost-effective for reducing SNAP-related harm,7–10 however, the extent to which this intervention is utilised in health care provision to Indigenous Australians is relatively unclear.11,12

Although difficult to define precisely, brief intervention describes a range of activities typically delivered in health care settings, such as general practice, community counselling and hospital emergency departments. Brief intervention may target the presenting problem or opportunistically address some other evident risk factor.13 Typical brief intervention activities include screening, the provision of brief advice, counselling techniques such as motivational interviewing, and referral to specialist support as required.14

Brief intervention resource kits have been shown to simplify clinical guidelines, improve health care providers’ access to clinical tools and training, provide a structural framework for brief intervention delivery, and allow more accurate comparisons of the cost-effectiveness of brief intervention in different settings.7,15 Consequently, there is interest in combining brief intervention kits with practical training, to provide healthcare providers with both the necessary tools for brief intervention, such as screening instruments and clinical decision-making guides, and the skills to use them appropriately. For example, Australian-based researchers have developed Drink-Less15 and the Drinking Detective, evidence-based brief intervention kits and training packages for alcohol.16 Similarly, Smoke-screen, a program to facilitate the uptake of tobacco brief intervention by GPs in primary care, was widely disseminated during the 1990s17 and has since been extensively studied.16,18

Brief intervention kits specifically targeting Indigenous Australians have been developed.19–21 Although qualitative evidence suggests these kits are acceptable to some Indigenous Australian communities,12,21,22 there are no published reviews of the type and quality of these kits. Given this limited information, and the potential for the dissemination of Indigenous-specific evidence-based brief intervention kits to facilitate the delivery of brief intervention to Indigenous Australians, a review of brief intervention kits specifically targeting reductions in SNAP-related harm among Indigenous Australians was undertaken. Specifically, this review has two aims: first, to identify Indigenous-specific brief intervention kits targeting reductions in SNAP-related harm; and second, to review the quality of these kits, including their evidence-based components, content and patient education materials.

Method

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Conclusion and implications
  7. Acknowledgements
  8. References

Identifying resources

A brief intervention kit was defined as a set of resources specifically designed to support health care providers to deliver brief intervention for SNAP risk factors to Indigenous Australians.

Brief intervention kits were identified using three steps:

1. Identifying phone contacts

Phone contacts for state/territory representative bodies of Aboriginal Community Controlled Health Services (ACCHSs) (n=7) were obtained from the National Aboriginal Community Controlled Health Organisation (NACCHO),23 and a list of phone contacts for NSW-based ACCHSs (n=40) were obtained from the Aboriginal Health and Medical Research Council (AH&MRC).24 In addition, phone contacts for state and commonwealth government health departments (n=8) and NGO health organisations (n=6) in Australia were obtained from the Australian Government Department of Health and Ageing.25

2. Phone survey

The first author (AC) contacted all organisations identified in Step One (n=61) by telephone. Phone contacts were asked if their organisation knew of brief intervention kits specifically targeting reductions in smoking, poor nutrition, alcohol misuse or physical inactivity in Indigenous Australians. If the phone contact answered yes, additional questions were asked to determine the type, purpose and availability of the kit. A copy of the kit was requested if it was relevant to this review or if its relevance was unclear by the information provided. If the phone contact answered no, they were asked if they knew of organisation/s or person/s that could assist. Additionally, all phone contacts were asked if they knew of heath promotion programs targeting Indigenous Australian communities, on the basis that resources are often utilised in such programs. Eight additional organisations were contacted about information provided by initial phone contacts.

3. Examination of Indigenous resource guides

Edition five (2005) of the ‘Indigenous Health Promotion Resources Guide’, a publication of health promotion resources targeting Indigenous Australians,26 and the Indigenous health Infonet, a web-based Indigenous health resource,27 were examined. Five organisations not identified in steps one or two were contacted through this process.

In total, 74 organisations were consulted by telephone. Fifteen resource kits were identified, of which eight proved relevant to this review. In addition, three brief intervention kits were identified opportunistically in 2008, of which two were available for inclusion in this review.

Review criteria

Brief intervention kits were reviewed using criteria adapted from clinical guidelines applicable to each SNAP risk factor,17,28–31 and guidelines for developing health consumer publications31 and evaluating health promotion resources.32 Specific review criteria included resource format, brief intervention components, content of information and readability of patient brochures. Readability was assessed as there is strong evidence of a difference between the reading levels of written materials and reading skills of target populations.33 Flesch Reading Ease (formula A) was used to assess the readability of patient brochures.34 A Flesch Reading Ease score from 0–100 represents the percentage of the population who would be expected to understand a written passage. The higher the rating, the easier the passage is to understand. Scores in the range of 60 to 70 indicate plain English.34 Flesch Reading Ease has been used previously to evaluate written materials for Indigenous Australians.35 The cultural appropriateness of brief intervention kits for Indigenous Australians was unable to be assessed; it is likely to be an important determinant of their acceptability, which is a component of both evidence-based care,36 and the extent to which they are routinely adopted into the delivery of Indigenous-specific health care.37

Results

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Conclusion and implications
  7. Acknowledgements
  8. References

Ten brief intervention kits were identified: four for smoking,38–41 three for alcohol,42–44 and one each for alcohol, smoking and other drugs,45 alcohol and other drugs46 and smoking, alcohol nutrition and physical activity.47 The brief intervention kits and their characteristics are summarised in Table 1.

Table 1.  Brief intervention kits and their characteristics. Thumbnail image of

Target group and format

Alcohol

Alcohol kits (n=6), targeted alcohol only (n=3);42–44 alcohol and smoking (n=1);45 alcohol and other drugs (n=1);46 and alcohol, smoking, nutrition and physical activity (n=1).47 Three kits were flipcharts,42,44,45 two resource packages46,47 and one a CD-ROM.43

Brief intervention component/s

Brief intervention components of kits targeting alcohol (n=6) included: screening tool (n=5),42–44,46,47 clinical decision-making tool (n=5),42–44,46,47 behavioural change strategies (n=4),42,43,46,47 patient brochures (n=3)43,45,47 and training package (n=2).46,47

Consistency with evidence-based guidelines

The consistency of the content of alcohol kits with evidence-based guidelines was assessed in relation to definitions of standard drinks and drinking risk, and harm reduction strategies.

  • a) 
    Standard drink – Five alcohol kits 42–44,46,47 defined a standard drink and provided information on low-risk alcohol use consistent with the standard drinks guide.19 All kits (n=5) illustrated different types and sizes of alcoholic drinks, identified the number of standard drinks within each, and provided recommendations for monitoring individual alcohol use.
  • b) 
    Drinking risk – Five alcohol kits 42–44,46,47 defined drinking risk (low, risky, binge and high) consistent with clinical guidelines.19 Advice to pregnant women for reducing risk varied: three kits recommended alcohol abstinence42–44 and two reduction.45,47
  • c) 
    Harm reduction strategies – All alcohol kits (n=6) recommended appropriate harm reduction strategies,42–47 of which the most common were to reduce the number of drinks consumed in one session (e.g. eat before/when drinking and drink slowly) (n=4 kits) and abstain from alcohol when taking medication, driving, swimming or operating machinery (n=4 kits). One alcohol kit recommended abstinence for alcohol-dependent drinkers.
Identified health effects

All alcohol kits identified both short and long-term negative health effects of alcohol misuse.42–47 The most common short-term negative health effect was sickness (e.g. hangover, vomiting or headache) (n=6 kits),42–47 followed by injury (n=5 kits).42–44,46,47 Three alcohol kits identified negative health effects for the baby of a mother consuming alcohol during pregnancy, of which the most common were physical and/or mental growth abnormalities.43–45

The most commonly identified long-term health effects were problems with diabetes control (n=6 kits),42–47 followed by brain and heart-related conditions (n=5 kits),42–46 and fetal alcohol syndrome (n=3 kits).43–45

Flesch reading ease (formula A)

Patient brochures in alcohol kits recorded Flesch Reading Ease scores of 6644 and 62.47

Smoking
Target group and format

Smoking kits (n=6), targeted smoking only (n=4);38–41 smoking and alcohol (n=1);45 and smoking alcohol, nutrition and physical activity (n=1).47 Smoking in pregnancy and around babies was the focus of two kits.38,45 Four kits were resource packages39–41,47 and two were flipcharts.38,45

Brief intervention component/s

Brief intervention components of kits targeting smoking (n=6) included, screening tools (n=3),40,41,47 clinical decision-making tools (n= 4), 39–41,47 behavioural strategies (n=4),39–41,47 patient education brochures (n=5)38–41,47 and training package (n=5).39–41,46

Consistency with evidence-based guidelines

The consistency of the content of smoking kits with evidence-based guidelines was assessed in relation to quit methods and harm reduction strategies.

  • a) 
    Quit methods – Four of the six smoking kits identified evidence-based quit methods,39–41,44,47 including bupropion (n=5); nicotine replacement therapy (NRT) (n=5); cold turkey (n=4); and quit support group (n=4). Two kits recommended reducing the number of cigarettes smoked to quit smoking,40,45 one of which recommended cessation within two weeks of reducing the number of cigarettes smoked.40
  • b) 
    Harm reduction strategies – Five of the six smoking kits recommended strategies to reduce the effects of passive smoking,38–41,45 of which the most common were home and car smoke-free zones (n=5); smoke outside (n=5) and do not smoke around babies, children and/or older people (n=3).
Identified health effects

Five of the six smoking kits identified short and long-term negative health effects, including the effects of passive smoking and the negative social consequences of smoking.38–41,45 The most common short-term health effects were breathlessness (n=5), followed by coughing (n=3). The most common long-term health effects were respiratory-related diseases (e.g. lung cancer, emphysema) (n=5).

Cost (n=5), followed by kids dislike it (n=3) were the most commonly identified negative social consequences of smoking. Chest infections and asthma (n=5), followed by SIDS (n=3) and ear infection (n=2) were the most commonly identified effects of passive smoking.

Smoking and pregnancy

Five smoking kits identified risks to unborn babies, the most common of which was low birth weight (n=5), followed by premature birth (n=4) and SIDS (n=3).38–41,45

Flesch Reading Ease (formula A)

Five smoking kits contained patient brochures. Flesch Reading Ease scores of these brochures were, 74;38 80;41 86;39 and 82 (n=2).40,47

Nutrition and physical activity
Target group and format

One kit targeted nutrition and physical activity in combination with smoking and alcohol (n=1).47

Brief intervention components

Brief intervention components of the nutrition and physical activity kit included, screening tools, clinical decision-making tools, behavioural strategies, training package and patient education brochures.47

Consistency with evidence-based guidelines

The consistency of the nutrition and physical activity kit with evidence-based guidelines was assessed in relation to weight management guidelines and harm reduction strategies.

  • a) 
    Weight management guidelines – A reduction in excess dietary intake and increase in energy expenditure was recommended for weight loss and management.47
  • b) 
    Harm reduction strategies – General strategies for improving nutrition included reducing fat and sugar intake, drinking more water and increasing fruit and vegetable intake.47

General strategies for increasing physical activity levels included integrating physical activity in daily activities and increasing participation in community physical activities.47

Identified health effects

Overweight and obesity and increased risk of chronic disease were the most common health effects identified in the nutrition and physical activity kit.47

Flesch Reading Ease (formula A)

Flesch Reading ease scores of nutrition and physical activity brochures were 86 and 71.47

Discussion

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Conclusion and implications
  7. Acknowledgements
  8. References

Potential limitations

All brief intervention kits in use may not have been identified for two main reasons: the kit identification methods employed were inadequate or phone contacts reported erroneously. However, the primary method of contacting key health-related agencies to identify kits snowballed into contacts with other agencies, increasing the range and number of organisations contacted. Further, both the Indigenous Health Promotion Resources Guide and Indigenous HealthInfonet were examined. The potential for erroneous reporting by phone contacts was minimised by requesting to speak with individuals working in the Indigenous health promotion field and requesting a copy of a resource to determine its relevance, if its description by the phone contact was ambiguous. Another limitation is that Australian alcohol guidelines have been revised since this review was completed in 2008.48,49 The key changes include: a reduction in the recommended number of standard drinks per day for men, from four to two to reduce their long-term risk of harm, and from six to four to reduce their short-term risk of harm; no recommended low-risk drinking levels for young people under 18 years of age, or women who are pregnant, planning a pregnancy or breastfeeding, with recommendations for these groups not to drink at all.48 Finally, the cultural appropriateness of these brief intervention kits for specific Indigenous communities remains unclear as their cultural appropriateness was not assessed.

Intervention kits

Three kits met all review criteria.40,41,47 Generally, kits developed with input from government departments or specialist health agencies fulfilled more criteria than those that appeared to be predominantly developed by Indigenous communities. Key components lacking in Indigenous community developed kits included screening and clinical decision-making tools, evidence-based guidelines and a training package. This might suggest a lack of expertise and resources in Indigenous Australian communities to develop evidence-based health resources. As such, development of these missing components by Indigenous communities will most likely require the complementary expertise and resources of health agencies, researchers and government departments, to increase the likelihood that they represent best-evidence practice and are updated periodically, in addition to being acceptable to Indigenous communities. In cases where the development of additional resource components specific to local Indigenous communities is not feasible, the adaptation of evidence-based brief intervention kits from non-Indigenous healthcare settings can be acceptable. 50,51

Only one brief intervention kit targeted nutrition and physical activity.47 Evidence for the effectiveness of brief intervention targeting physical inactivity52 and poor nutrition53 is weak relative to that for alcohol misuse and smoking, possibly reducing the likelihood of kits being developed for these risk factors. Nevertheless, Indigenous Australians experience a disproportionately high burden of harm from poor nutrition and excess weight,54 and routine assessment of physical activity levels and dietary intake is recommended.55 Encouragingly, a brief intervention kit specifically targeting reductions in physical inactivity and poor nutrition in Indigenous communities has recently been piloted.56 This kit was not publicly available at the time of this review.

Brief intervention components

The type and number of brief intervention components in kits varied. For example, four of the six smoking kits39–41,43,45,47 included the stages of change to assess a smoker's readiness to quit smoking, despite a lack of evidence for its effectiveness at modifying patient behavior, and only three kits39–41 included the Fagerstrom, a validated measure of nicotine dependence.17 For alcohol, although five of the six kits included a validated alcohol screening tool (AUDIT-C,47 AUDIT43,45 or IRIS46), only one46 included FLAGS, a common evidenced-based brief intervention approach for alcohol.19,57 This variation in brief intervention components might indicate that kits were developed to meet different project goals and/or for the information and delivery needs of a specific target group. Ideally, however, brief intervention kits should comprise common evidence-based approaches and validated measures. First, the elements involved in these approaches are typically well defined and compatible with more general evidence-based strategies, such as motivational interviewing.58,59 Second, the cost-effectiveness of brief interventions utilising these approaches is generally well demonstrated.60 Third, it may encourage healthcare providers and patients to consider the additional negative consequences of multiple risk factors and prompt efforts to address them simultaneously. Fourth, the inclusion of validated measures is likely to be a more suitable alternative than opting for measures with no established validity, and offers an opportunity to examine their reliability and validity in Indigenous-specific health care settings.

Consistency of content with evidence-based guidelines

Alcohol harm reduction strategies were generally consistent with evidence-based guidelines, although recommendations for alcohol use in pregnancy varied from abstinence, to one standard drink a day, to never becoming intoxicated. These different recommendations most likely reflect uncertainty about safe levels of alcohol consumption in pregnancy.61–62 Written information on FAS, included in three of the five kits targeting alcohol,43–45 should ideally be available for health care providers to routinely give to Indigenous women, since there is evidence that children born to Indigenous women are at substantially greater risk of FAS than those born to non-Indigenous women.63 The relative unavailability of high-quality information for routine use in health care settings is reflected in evidence that only a quarter of health care providers who provide care for pregnant Aboriginal women routinely impart information on the effects of alcohol use in pregnancy and approximately one-fifth never provide such information.64

For smoking, a recommendation in one kit to reduce the number of cigarettes smoked to reduce harm or as an alternative to quitting is inconsistent with the evidence:65,66 cigarette reduction is only recommended when the smoker's goal is to quit smoking within two weeks.17 This inconsistency reflects at least two possibilities: either the intervention kit was developed without adequate reference to evidence-based guidelines; or such a recommendation represents an attempt to establish more realistic goals, given many Indigenous communities are characterised by high rates of smoking,3 an entrenched smoking culture,67 socioeconomic disadvantage,68 and a high proportion of Aboriginal Health Workers who smoke.69 That some kits contained information inconsistent with evidence-based guidelines highlights the need to better define and validate evidence-based guidelines for Indigenous Australians, to reduce uncertainty among health care providers, researchers and policy makers in the Indigenous health field as to what constitutes best practice health care for Indigenous Australians. This requires evidence derived from rigorous intervention trials, across multiple Indigenous communities, to establish the effectiveness of evidence-based guidelines for improving health outcomes among Indigenous Australians. Intervention research is complex, requiring resources, expertise and skills unlikely to be available at the local level. Partnerships between government and research agencies and local Indigenous communities and their healthcare services are, therefore, crucial to increase the likelihood that evaluations of the effectiveness of guidelines for Indigenous Australians are adequately supported and funded and undertaken routinely.70,71

Patient education materials

Three intervention kits did not include patient education materials.42,45,46 Although the provision of information alone is unlikely to result in behavioural change, written materials can reinforce and supplement verbal advice.72 For example, since evidence shows patients remember only a part of each consultation,73 well-designed patient education materials can provide post-consultation reinforcement and promote patient compliance and self care.74

Patient education brochures (n=9) scored in the ‘Easy’ (n=4),39–41,47‘Fairly Easy’ (n=2)38,47 and ‘Standard’ (n=2)44,47 categories, as determined by Flesch Reading Ease.34 This is encouraging, given evidence that a patient's reading level is often lower than their grade level attainted,76 and Indigenous Australians are less likely to complete secondary education and attain post-secondary qualifications than non-Indigenous Australians.77 In addition, one set of brochures provided scope for personalised written advice,45 and all brochures used colour, images and language identifiable with Indigenous Australia, characteristics likely to increase their acceptability to Indigenous Australians.35

Conclusion and implications

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Conclusion and implications
  7. Acknowledgements
  8. References

In conclusion, three of the 10 kits met all review criteria: two targeting smoking40,41 and one all SNAP risk factors.47 Five kits (three alcohol and two smoking)39,43–45,46 were consistent with evidence-based guidelines, but lacked important components, such as patient education materials, training manual and/or behavioural change strategies. As such, sustained dissemination of these kits into Indigenous health care settings and programs may require the development of additional components to maximise their uptake by health care providers and their integration into routine health care. The inclusion of additional components, where necessary and appropriate, should be guided by the best-available evidence and the needs and preferences of health care providers and patients. Alternatively, the adaptation of evidence-based brief intervention kits developed for non-Indigenous health care settings and programs, for routine delivery to Indigenous Australians, might prove to be equally acceptable and cost-effective. In either case, there is an urgent need for best-evidence SNAP resources and appropriate training packages to be disseminated in Indigenous health care settings and programs. In addition, health care providers working in these settings should be well trained and supported to optimally use best-evidence SNAP resources to contribute to reducing SNAP-related harms among Indigenous Australians.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Conclusion and implications
  7. Acknowledgements
  8. References

This research was part of a project funded by the Alcohol Education Rehabilitation Foundation of Australia, and was undertaken while the first author was the recipient of a National Health & Medical Research (NHMRC) post graduate research scholarship in Indigenous Australian Health.

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  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Conclusion and implications
  7. Acknowledgements
  8. References
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