Table of Contents
Closing the Gap Current
Implementation of the Closing the Gap
Culturally Safe Strategy
The following academic essay will focus on the Closing the Gap in regards to outcomes between the Indigenous and non-Indigenous Australians within 25 years, focusing on the disadvantage among the Aboriginal and Torres Strait Islander people with respect of child mortality to Rheumatic heart disease (RHD). Northern Territory had the highest number of RHD, with high prevalence being shown among the males in the age group of 5-14 years and 15-24 years and among the females in the age group of 15-24 years. The overall rate of number of new RHD cases have increased in the Indigenous population in comparison to the non-Indigenous was 125 time more. Of the new cases diagnosed 60% were below the age of 25 years with higher prevalence found in females Indigenous than the males. Among the new RHD cases, children in the age of 0-14 mostly experienced mild RHD which is classified as a Priority 3 and 12% among the age 5-14 years had to undergo surgery for the treatment (Cannon et al., 2017; Australian Institute of Health and Welfare, 2020). The Indigenous child death rate was 163/100,000 in comparison to non-Indigenous children of 75/100,000 (Australian Institute of Health and Welfare, 2018). The biggest difference from RHD death rate ratio (43.1) was seen in 5-24 years age group of Indigenous to non-Indigenous (Colquhoun et al., 2015).
RHD is a chronic disease associated with poor living conditions, and low socio-economic status and its prognosis depends upon the health care received and can either progress or regress over time. To address this, providing secondary prevention through regular benzathine penicillin G (BPG) has been shown to be economically effective and clinical benefits as well to prevent further progression of RHD. Poor adherence from the Indigenous population has led to them continual suffering from RHD. This progress done has to be spread more in the community areas and the benefits of secondary prevention told to them so the childhood mortality rate from RHD can be reduced and the Gap met (Cannon et al., 2017; de Dassel et al., 2018).
The need to address the Gap is important as an Indigenous child is twice as likely to die in comparison to non-Indigenous due to difference in their health status, accessing the health services and socio-economic factors. The Indigenous child mortality rate of 0-4 years was 172.3/100,000 was targeted to reduce to 112.3/100,000 in 2018, but it is not on track. The risk of death for an Indigenous child is highest in the Northern Territory with the biggest gap difference. In the age group of 0-4 years the perinatal period conditions; sudden infant death syndrome; accidents and injuries and respiratory systems deaths account for 90% of the gap difference between the Indigenous children and non-Indigenous children. The period of 1998-2015 has seen a decline of 13% in Indigenous childhood mortality rate majorly being accounted from accidents, injuries and other external causes leading them to die 3.7 times more likely than their non-Indigenous counterparts (Australian Institute of Health and Welfare, 2018). The external cause of death for the Indigenous children needs to be addressed and the risk reduction needs to be done from “transport accidents, drowning, accidental suffocation and assault”. The gap represented between the Indigenous and non-Indigenous children is due to a much deeper effect from their colonisation history, disruption in their cultural identity, racism, and other environmental and economic conditions. Their low socio-economic conditions, lower education levels, poor location of house and less accessible to the health care of the Indigenous mothers and is also a major contributor to the child’s mortality rate (Australian Institute of Health and Welfare, 2018).
One of the strategies has been to provide echocardiographic screening for the Indigenous children for early diagnosis and timely intervention will improve their health. Screening of the Indigenous school children by doing echocardiographic screening allowed the researchers for comparison between children who were at high risk of RHD and those who were at low risk. Through this strategy the Indigenous high risk children population were found to be at an overall prevalence of definite RHD of 8.6 / 1000. The prevalence of definite RHD was 15.0 / 1000 in NT’s Top End, twice as much of the earlier reported number (Roberts et al., 2015).
This number highlights the disadvantaged faced by the Indigenous community who live in extremer remote regions and with added risk factors such as poor economic condition and overcrowded housing tend to increase that risk multiple fold. This issue to economic funding and housing has not been addressed properly as of yet. The strategy of using echocardiographic screening could not be implemented properly because the remote distances of the living communities, the logistics involved, travelling methods also determine the cost where plane is fast but expensive and road is cheap but slow (Roberts et al., 2015). The cultural difference also plays a major role as they parents and previous generations are not willing to grant testing on their children leading to no consent. Even after the follow up with the health care team proved to be the biggest challenge for a comprehensive review of the children a single protocol must be established to address these problems along with the review of cardiologist and ensuring the number of health care force is increased to meet the needs of the Indigenous community staying in remote areas (Roberts et al., 2015).
Strains of group A Streptococcus (GAS) cause majority of the health problems and deaths from RDH, pathological testing for the Indigenous population will go a long way in early diagnosis and treatment. More research needs to be carried out to properly address this strategy (Roberts et al., 2015). Population living in places where resources are scarce, limited access to medical services and overcrowding have a high chance of suffering from GAS infections which can lead to majorly (79%) RHD and (95%) acute rheumatic fever with sore-throat the most common symptoms being presented (Hand et al., 2020; de Dassel et al., 2018). Secondary prophylaxis as mentioned earlier from the BPG vaccine, it is a useful tool for preventing the further progression of RHD in the Indigenous population (Cannon et al., 2017).
The use of BPG and recommendation that providing the regular secondary prophylaxis for the children who have had a previous history of ARF or current diagnosis of RHD will help in preventing the conditions from happening again (Cannon et al., 2017; Hand et al., 2020; de Dassel et al., 2018). Implementing this strategy also has some pitfalls as the health care staff need to be educated about the BPG, and cultural differences when approaching an Indigenous community to relay to them about the benefits of the vaccine which would be required to be given every 4 weeks for 10 years following the last espied of ARF. There needs to be more widespread practice regarding the vaccination so the mortality rate among the Indigenous children can be reduced, the primary care in those areas need to be improved (Ralph et al., 2018). Adherence to secondary prophylaxis is the best method to be applied in the case of RHD (de Dassel et al., 2018).
One of the major barriers need to be mentioned are the need to reinforce the health care workforce availability in the remote and very remote regions. The community if Indigenous population are still reluctant to adhere to the treatment regimens and the vaccination prophylaxis of RHD. The early diagnosis of children through echocardiography to be used in school children has benefits but overcoming the cultural barrier between the health care team and the parents still remain a big hurdle. Increasing the children’s parents or guardian’s knowledge in health care is a proven method to let more of the Indigenous children get tested and treatment started soon (Cannon et al., 2017; Hand et al., 2020; de Dassel et al., 2018). The poor housing conditions, and low socio-economic status are a major driving factor in the development of RHD as the major causing organism thrives in these types of places. Providing the Indigenous community regardless of their living in cities or remoter areas should be a priority to tackle this situation. Proper housing and better socio-economic conditions will lead to reduced mortality rate and reduced the gap even further. Improving the education status of the mothers of the children will help reduce the overall burden from RHD. For those who area at an advance stage of RHD, specialist surgeries need to be provided for treatment at tertiary level hospitals and not just in the major cities. Lack of health care services, delay in providing them and lack of health care work force is severely denting the Gap’s strategy to address this issue in all levels (Hand et al., 2020; de Dassel et al., 2018; Australian Institute of Health and Welfare, 2018).
Improving the primary health care and enhancing health care equity of the Indigenous population will be an effective culturally safe strategy. The health care force working in the primary health care places need to be aware of the cultural differences in place which leads to mistrust and miscommunication between them and the Indigenous population. Understanding that Indigenous population have a victim of structural violence since the time of colonisation and has had them at a disadvantage in all facets of the social determinants of health (Browne et al., 2016). Even if the Indigenous population are staying in their ancestral dwelling place but have limited to no means of accessing health care is a prime example of that. The discrimination being faced by the Indigenous population has a long history and has deep roots in colonialism and racism, putting them at a disadvantage of not only accessing proper health care services but not being able to afford them, or proper housing or a stable income. Addressing cultural sensitivity and providing the primary health care services based on equity in the health care force will help in this regard (Browne et al., 2016).
Another strategy is through effective engagement between the Indigenous community members and health services. The main reason for this is the Indigenous community not trusting the health care services nor the health care work force. This has arisen from their the lack of popper care in their area, history of colonialism, lack of cultural sensitivity, feeling of being alienated as well as little to no health care force from the Indigenous community themselves has led to this problem (Durey et al., 2016). The coordination between the Indigenous community and health services need to increase mainly through community engagement methods of consultation, health education promotion, collaborating with local Indigenous leaders, and hiring more Indigenous in the health care work force. The health care work force aiming to build such an engagement needs to have knowledge about that particular Indigenous community to respect their cultural heritage and individual identify so trust can be gained and accepted. Only after the trust establishment will the Indigenous community adhere more the health interventions being implemented (Durey et al., 2016).
Addressing any issue to resolve the health indifferences in the Indigenous community is difficult and the same goes for handling the RHD situation and the high-mortality rate among the Indigenous children population. Promoting health education needs to be a priority as the Indigenous community should be made aware that RHD is a preventable condition. But this can only be prevented by following a strict regime. Educating them about vaccine prevention and if the condition has worsened that they are still surgical options that can be applied. But all this is useless they accept the medical help that is available for them. Those in remote and very remote areas have less access to the proper health care services and for them more management needs to be done from the state and national levels to bring the mortality rate down and close the gap. Addressing the housing and sanitation problem will help in reducing being affected by the Group A Streptococcus which is responsible for majority of RHD cases. Improving the overall socio-economic condition of the Indigenous community need to be addressed as well as keeping mind that Indigenous living in city and country have different needs and need to be addressed in accordance with their situation.
Australian Institute of Health and Welfare. (2018). Closing the Gap targets: 2017 analysis of progress and key drivers of change. Retrieved from: https://www.aihw.gov.au/getmedia/e48ac649-2fdd-490d-91cf-4881ab5ef5c2/aihw-ihw-193.pdf.aspx?inline=true
Australian Institute of Health and Welfare. (2020). Acute rheumatic fever and rheumatic heart disease in Australia. Retrieved from: https://www.aihw.gov.au/reports/indigenous-australians/acute-rheumatic-fever-rheumatic-heart-disease/contents/rheumatic-heart-disease/rhd-among-all-australians
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Colquhoun, S. M., Condon, J. R., Steer, A. C., Li, S. Q., Guthridge, S., & Carapetis, J. R. (2015). Disparity in mortality from rheumatic heart disease in indigenous australians. Journal of the American Heart Association, 4(7), e001282. https://doi.org/10.1161/JAHA.114.001282
de Dassel, J. L., de Klerk, N., Carapetis, J. R., & Ralph, A. P. (2018). How many doses make a difference? An analysis of secondary prevention of rheumatic fever and rheumatic heart disease. Journal of the American Heart Association, 7(24), e010223. https://doi.org/10.1161/JAHA.118.010223
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