Australian and New Zealand Journal of Public Health

Sports Food and Beverage

Indigenous Health General Public Health

The Journal of the Public Health Public Health Association ISSN 1326-0200 AssociationAUSTRALIA of Australia Inc. Vol. 43 No. 4, 2019 Australian and New Zealand Journal of Public Health

Statement of policy Most of the disciplines embraced by PHAA publish journals that carry articles about facets of health, illness and health care. However, there is no The Australian and New Zealand Journal of Public Health is the other Australian journal that gives an overview of research across the broad journal of the Public Health Association of Australia. PHAA members range of PHAA interests, nor does any other journal aim to attract more have training in almost all of the human, natural and social sciences, at than one or two of the many levels of workers in health care assessment various levels of professional status. Some are employed to analyse the and delivery. The Australian and New Zealand Journal of Public Health ideological, social or empirical features of the health service. Some begin invites contributions which will add to knowledge in its fields of interest. It from a basic, some from an applied, perspective; others come to research will give priority, after normal refereeing processes, to papers whose focus by reflecting on the work they do in health care – for example, organising and content is specifically related to public health issues. industrial health services in a particular locality, trying to implement a patient-held record system or using lay helpers in a domiciliary care system. Others carry out formal epidemiological research Subscriptions into the correlates and causes of disease and of health-related Please address all inquiries about subscriptions, membership, advertising behaviour. and other PHAA matters to the Public Health The Australian and New Zealand Journal of Public Health Association of Australia Inc., PO Box 319, Curtin, ACT 2605. is published six times a year, in February, April, June, August, Phone (02) 6285 2373; Fax (02) 6282 5438; October and December. Its contents are subject to normal e-mail [email protected]; www.phaa.net.au refereeing processes. Finished discussions of research projects are the staple diet of the Journal, but there is space for reviews, views and historical pieces from time to time. The Journal is Editorial office indexed by Australian Public Affairs Information Service, Please address all editorial correspondence to: Current Contents, Excerpta Medica, Index Medicus, the The Editors, Australian and New Zealand Journal of Public Health, Cumulative Index to Nursing & Allied Health Literature and e-mail [email protected] Social Sciences Citation Index and is available on microfiche from University Microfilms International.

Editor-in-Chief: Editors: Dr Nikki Percival Dr Sandar Tin Tin Professor John Lowe Australian Centre for Public and Population Health School of Population Health, The University of Research, University of Technology Sydney, NSW Auckland, New Zealand Adj. Assoc. Professor Priscilla Robinson Dr Hassan Vally School of Public Health, La Trobe University, School of Psychology and Public Health, Victoria La Trobe University, Victoria Dr Melissa Stoneham Assoc. Professor Luke Wolfenden Public Health Advocacy Institute WA, School of Medicine and Public Health, Curtin University, WA The University of Newcastle, NSW

Editorial Board

Professor Ross Bailie Dr Rhys Jones Professor Andre Renzaho Menzies School of Health Research, Te Kupenga Hauora Māori, University of Humanitarian and Development Studies, Northern Territory Auckland, New Zealand Western Sydney University, New South Wales Dr Sandra Campbell Professor John Lynch Professor Peter Sainsbury Centre for Chronic Disease Prevention, James School of Public Health, University of Adelaide, Director, Population Health, South Western Cook University, Queensland South Australia Sydney Local Health District, New South Wales Professor Donna Cross Professor Robyn McDermott Professor Cindy Shannon Telethon Kids Institute, Western Australia Centre for Chronic Disease Prevention, James Pro-Vice Chancellor (Indigenous Education), Cook University, Queensland The University of Queensland Professor Joan Cunningham Menzies School of Health Research, Professor Robert McGee Professor Alan Shiell Northern Territory Dunedin School of Medicine, University of School of Psychology and Public Health, Otago, New Zealand La Trobe University, Victoria Professor Chris Del Mar Faculty of Health Sciences and Medicine, Bond Professor Terry Nolan Assoc. Prof. David Thomas University, Queensland School of Population and Global Health, The Tobacco Control Research, Menzies School of University of Melbourne, Victoria Public Health, Northern Territory Professor Kevin Dew School of Social and Cultural Studies, Victoria Dr Yin Paradies Professor Gavin Turrell University of Wellington, New Zealand Faculty of Arts and Education, Deakin University, School of Public Health and Social Work, Victoria Queensland University of Technology Professor Annette Dobson School of Public Health, University of Professor Alison Venn Queensland, Queensland Menzies Institute for Medical Research, University of Tasmania ANZJPH

The Australian and New Zealand Journal of Public Health is the journal of the Public Health Association of Australia Inc. Volume 43, Number 4 August 2019

Contents Editorial 305 The Public Health Association of Australia’s advocacy to prevent suicide Samantha Battams, Fiona Robards Commentary 307 Listen, understand, collaborate: developing innovative strategies to improve health service utilisation by Aboriginal and Torres Strait Islander men Kootsy Canuto, Stephen Harfield, Gary Wittert, Alex Brown 310 The important role of charity in the welfare system for those who are food insecure Fiona H. McKay, Rebecca Lindberg Indigenous Health 313 Feasibility and acceptability of opportunistic screening to detect atrial fibrillation in Aboriginal adults Rona Macniven, Josephine Gwynn, Hiroko Fujimoto, Sandy Hamilton, Sandra C. Thompson, Kerry Taylor, Monica Lawrence, Heather Finlayson, Graham Bolton, Norman Dulvari, Daryl C. Wright, Boe Rambaldini, Ben Freedman, Kylie Gwynne 319 Anaemia in early childhood among Aboriginal and Torres Strait Islander children of Far North Queensland: a retrospective cohort study Dympna Leonard, Petra Buttner, Fintan Thompson, Maria Makrides, Robyn McDermott 328 Participant profile and impacts of an Aboriginal healthy lifestyle and weight loss challenge over four years 2012-2015 Anne C. Grunseit, Erika Bohn-Goldbaum, Melanie Crane, Andrew Milat, Aaron Cashmore, Rose Fonua, Angela Gow, Rachael Havrlant, Kate Reid, Kiel Hennessey, Willow Firth, Adrian Bauman 334 Breast screening attendance of Aboriginal and Torres Strait Islander women in the Northern Territory of Australia Kriscia A. Tapia, Gail Garvey, Mark F. McEntee, Mary Rickard, Lorraine Lydiard, Patrick C. Brennan 340 Limited progress in closing the mortality gap for Aboriginal and Torres Strait Islander Australians of the Northern Territory Tom Wilson, Yuejen Zhao, John Condon Food and Beverage 346 The frequency and magnitude of price-promoted beverages available for sale in Australian supermarkets Christina Zorbas, Beth Gilham, Tara Boelsen-Robinson, Miranda R.C. Blake, Anna Peeters, Adrian J. Cameron, Jason H.Y. Wu, Kathryn Backholer 352 Development of Australia’s front-of-pack interpretative nutrition labelling Health Star Rating system: lessons for public health advocates Michael Moore, Alexandra Jones, Christina M. Pollard, Heather Yeatman

Editor-in-Chief: Prof. John Lowe Book Review Editor: Jo-Anne Rayner Production: Journal Assist Pty Ltd. Food and Beverage cont. 355 The performance and potential of the Australasian Health Star Rating system: a four-year review using the RE-AIM framework Alexandra Jones, Anne Marie Thow, Cliona Ni Mhurchu, Gary Sacks, Bruce Neal Sport 366 Unhealthy sport sponsorship at the 2017 AFL Grand Final: a case study of its frequency, duration and nature Tegan Nuss, Maree Scully, Melanie Wakefield, Helen Dixon 373 Challenges for sport organisations developing and delivering non-traditional social sport products for insufficiently active populations Kiera Staley, Alex Donaldson, Erica Randle, Matthew Nicholson, Paul O’Halloran, Rayoni Nelson, Matthew Cameron General Public Health 382 Epidemiology of hospitalised traumatic brain injury in the state of New South Wales, Australia: a population-based study Ilaria Pozzato, Robyn L Tate, Ulrike Rosenkoetter, Ian D Cameron 389 New and old hotspots for rickettsial spotted fever acquired in Tasmania, 2012–2017 Gabriela Willis, Kerryn Lodo, Alistair McGregor, Faline Howes, Stephanie Williams, Mark Veitch 395 Public health and natural hazards: new policies and preparedness initiatives developed from an Australian bushfire case study Rachel Westcott, Kevin Ronan, Hilary Bambrick, Melanie Taylor Letter 401 Observed vaping and smoking in outdoor public places: piloting objective data collection for policies on outdoor vaping George Thomson, Johanna Nee-Nee, Kirsty Sutherland, Rebecca Holland, Miriam Wilson, Nick Wilson

2019 vol. 43 no. 4 Australian and New Zealand Journal of Public Health 304 Editorial

doi: 10.1111/1753-6405.12909 with a spike in the suicide rate,16 research from Spain showed that this trend is more The Public Health Association of pronounced for those aged 35 to 54 years and unemployed males.13 In addition, the link Australia’s advocacy to prevent suicide between increasing inequalities and suicide and the trend in suicide inequity is not often Samantha Battams,1 Fiona Robards2 part of the discourse on suicide. 1. Southgate Institute of Health, Society and Equity, Flinders University, South Australia 2. The University of Sydney, Faculty of Medicine and Health, New South Wales What is the opportunity to prevent suicide? n December 2018, the Public Health Is there suicide inequality? Suicide prevention activity covers a broad Association of Australia (PHAA) endorsed Suicide and suicidality disproportionally range of policy and program activity that its first Suicide Prevention Policy. The I affect those who are poor and Aboriginal may include: limiting access to the means purpose of this article is to outline some and Torres Strait Islanders. Suicide is related of suicide through legislation and policy; concerning trends in suicide and suicide to unemployment and periods of economic provision of education on mental health inequality, the opportunities to prevent crisis.16 Research from both Australia and and suicide prevention, including in schools, suicide and the role of public health. Europe has indicated a recent increase in workplaces and across community venues; Suicide trends suicide inequality. In Europe, there were 1.82 providing support and transition for those more suicides in the lowest SES group than affected by changing workplace conditions The Australian suicide rate decreased in the in the highest in the 1990s, and 2.12 more and retrenchment; training frontline workers period from 1994–1998 (17.8 per 100,000) suicides from the lowest to highest group in on understanding suicide; provision of to 2009–2013 (12.3 per 100,000).1 However, the 2000s.8 In Australia, suicide inequality in timely access to mental health information, recent trends have showed a slight increase in older males (35–64 years) increased by 29% support and services; timely community the standardised suicide death rate between from 1999–2003 to 2004–2008, associated based support for those who have exhibited 2007 (10.6 per 100,000 people) and 2016 with an increase in suicide rates in low SES suicidality or have made a suicide attempt; (11.7 per 100,000 people).2 The suicide death regions.1 The PHAA is committed to reducing and postvention support for those bereaved rate is now higher than the rate from motor health inequality and has recently updated its by suicide. vehicle accident deaths, and suicide is the health inequity policy. leading cause of death of young Australians.3 Additionally, suicide prevention strategies should consider the complex way in Population groups most at risk include males Framing suicide prevention (especially the middle-aged and older age which individual, relationship/family level, group),4 Aboriginal and Torres Strait Islanders Risk factors for suicide are often framed workplace, societal/community, political and and those of lower socioeconomic status in terms of individual psychological or life economic factors may overlap. Investment in (SES). Suicide is a major cause of premature experience factors; for example, experience of tailored, multi-sectoral and community-level mortality for Aboriginal and Torres Strait a mental health condition or a sudden ‘crisis’ interventions and prevention for populations Islander people, with a rate of suicide (23.8 event, previous attempts at suicide, or having at high risk of suicide and self-harm is per 100,000) more than twice the Australian a friend or family member who has died by required. national average. Indigenous young people suicide. However, the risk factors for mental Given the role of inequality in suicide, suicide (aged 15–24 years) are particularly vulnerable, health conditions, suicide and suicidality are prevention advocacy should also consider with the suicide rate in 2016 almost four multifactorial, operate at many levels and the social determinants of health and policies times that of non-Indigenous young people. may overlap. They may involve individual, to reduce health inequities. More research Some groups from culturally and linguistically relationship/family level, workplace, societal/ is required on the social determinants of diverse backgrounds are also at higher risk of community, political and economic levels. For suicide. suicide, with suicide rates initially associated example, gender and cultural factors linked with country of birth5 and the experience of to intimate partner violence may contribute Why the PHAA Policy Position detention for asylum seekers.6 Suicidality has to the problem of suicide, as the experience Statement is important also been associated with the experience of of intimate partner abuse has been linked 9 The Policy Position Statement makes several disability in Australian men.7 Deaths from to suicidality. Perceived racism has also important requests. It calls on the Australian suicide have recently increased for Australian been linked to suicidality, with a mediating Government to support and fully resource women; in 2017, the age-standardised suicide role of depression and moderating role of 10 national and state and territory suicide rate for females was higher than that of the religiosity. Male-dominated industries such prevention and mental health strategies, previous ten years.14 In addition, deliberate as the construction industry have also been including those for Aboriginal and Torres self-harm is a significant issue in Australian linked to higher suicide rates (especially for 11 Strait Islander people, and to develop specific society, particularly for young women: the men), with research showing that those strategies for high suicide risk groups, rate of hospitalisation for females due to in the most unskilled occupations are most 12 including middle-aged men. self-harm was 40% higher than for males from at risk within the construction industry. 1999–2000 to 2011–2012.15 While economic crises are associated This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Trends for the future include monitoring the increasing suicide inequality in Australia and understanding how socioeconomic inequalities have an impact upon suicide and interact with other issues, including individual, cultural and political/economic factors.

References 1. Too L, Law P, Spittal M, Page A, Milner A. Widening socioeconomic inequalities in Australian suicide, despite recent declines in suicide rates. Soc Psychiatry Psychiatr Epidemiol. 2018;53(9):969-76. 2. Australian Bureau of Statistics. 3303.0. - Causes of Death, Australia, 2016. (AUST): ABS; 2016. 3. Australian Bureau of Statistics. 3303.0 - Causes of Death, Australia, 2017. Underlying Causes of Death (Australia) Table 1.3. Canberra (AUST): ABS; 2018. 4. Burns RA. Sex and age trends in Australia’s suicide rate over the last decade: Something is still seriously wrong with men in middle and late life. Psychiatry Res. 2016;245:224-9. 5. Ide N, Kolves K, Cassaniti M, De Leo D. Suicide of first- generation immigrants in Australia, 1974-2006. Soc Psychiatry Psychiatr Epidemiol. 2012;47(12):1917-27. 6. Dudley M, Steel Z, Mares S, Newman L. Children and young people in immigration detention. Curr Opin Psychiatry. 2012;25(4):285-92. 7. Milner A, Bollier A-M, Emerson E, Kavanagh A. The relationship between disability and suicide: Prospective evidence from the Ten to Men cohort. J Public Health (Oxf). 2018. doi: 10.1093/pubmed/fdy19. 8. Lorant V, de Gelder R, Kapadia D, Borrell C, Kalediene R, Kovacs K, et al. Socioeconomic inequalities in suicide in Europe: The widening gap. Br J Psychiatry. 2018;212(6):356-61. 9. McLaughlin J, O’Carroll RE, O’Connor RC. Intimate partner abuse and suicidality: A systematic review. Clin Psychol Rev. 2012;32(8):677-89. 10. Walker RL, Salami TK, Carter SE, Flowers K. Perceived racism and suicide ideation: Mediating role of depression but moderating role of religiosity among African American adults. Suicide Life Threat Behav. 2012;44(5):548-59. 11. Milner A, King T. Men’s work, women’s work and suicide: A retrospective mortality study in Australia. Aust N Z J Public Health. 2019;43(1):27-32. 12. Milner A, Niven H, LaMontagne A. Suicide by occupational skill level in the Australian construction industry: Data from 2001 to 2010. Aust N Z J Public Health. 2014;38(3):281-5. 13. Córdoba-Doña JA, San Sebastián M, Escolar-Pujolar A, Martínez-Faure JE, Gustafsson PE. Economic crisis and suicidal behaviour: The role of unemployment, sex and age in Andalusia, southern Spain. Int J Equity Health. 2014;13:55. 14. Australian Bureau of Statistics. 3303.0 - Causes of Death, Australia, 2017. Canberra (AUST): ABS; 2018. 15. Harrison JE, Henley G. Suicide and Hospitalised Self-harm in Australia: Trends and Analysis. Injury Research and Statistics Series No.: 93. Canberra (AUST): Australian Institute of Health and Welfare; 2014. 16. Nordt C, Warnke I, Seifritz E, Kawohl, W. Modelling suicide and unemployment: A longitudinal analysis covering 63 countries, 2000–11. Lancet Psychiatry. 2015;2(3):239-45. Correspondence to: Dr Samantha Battams, Southgate Institute of Health, Society and Equity, Flinders University, SA 5042; e-mail: [email protected]

doi: 10.1111/1753-6405.12922 lack of men’s voices is also consistent within discussions of Aboriginal and Torres Strait Listen, understand, collaborate: Islander men and their under-utilisation of health services. developing innovative strategies to The available data detailing Aboriginal and Torres Strait Islander health service improve health service utilisation by use is patchy17,18; however, most indicates that Aboriginal and Torres Strait Islander men Aboriginal and Torres Strait Islander men use PHCSs at lower rates than their female Kootsy Canuto,1,2,3 Stephen Harfield,1,3 Gary Wittert,2 Alex Brown1,2,3,4 counterparts, especially for preventative healthcare. Many authors suggest Aboriginal 1. Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, South Australia and Torres Strait Islander men tend to delay 2. Freemasons Foundation Centre for Men’s Health, University of Adelaide, South Australia care, often presenting at a time of advanced 3. Centre of Research Excellence in Aboriginal Chronic Disease Knowledge Translation and Exchange (CREATE), University of Adelaide, South Australia or serious illness.1,10,11,19 Yet, access and 4. Sansom Institute for Health Research, University of South Australia utilisation are a function of multiple, complex and interacting factors that enable (or inhibit) Aboriginal and Torres Strait Islander here’s been enough talk, now is the the lifestyle ‘choices’ of these men.12-14 Such men from accessing and using available time for action. Primary health care blame is unhelpful, unwarranted and – in care. These issues may include a lack of Tservices (PHCSs) need to collaborate some cases – directly harmful. It is also continuity of care, cultural factors pertaining and develop innovative strategies to increase often a result of an ideological position that to communication and understanding, the use of health services by Aboriginal seeks to place the onus of people’s own counteracting social pressures, and both self- and Torres Strait Islander men. Currently, misfortunes on themselves, thus, ignoring the determination and control. Essentially, as Aboriginal and Torres Strait Islander men pervasive effects of disadvantage, inequality Hayman et al. observed, part of the problem are viewed as being disinterested in their and structural racism on illness and its derives in the fact that “Aboriginal and Torres health, thus, the blame is being placed on determinants. In addition, racism continues Strait Islander people are not sufficiently the individuals themselves for their under- to shape Australian policies, laws and involved in planning, delivering and utilisation of PHCSs. In contrast to this community perceptions, and plays an equally evaluating relevant healthcare services”.20(p485) misconception, studies have found that pivotal role in framing the social determinants The perception that Aboriginal and Torres Aboriginal and Torres Strait Islander men of health for Aboriginal and Torres Strait Strait Islander men are both disinterested in 12 are interested in their health but many face Islander people. and reluctant to engage with their health is a 1-7 significant barriers that hinder access. In The causes of male health disadvantage common assumption, which, perhaps, stems response, Aboriginal and Torres Strait Islander are both complex and interwoven. from little being done to listen to and learn men have identified strategies for PHCSs to Marmot15 suggested poverty and inequality from their perspectives. Others, such as reduce barriers and increase their use, which are largely responsible for the significant life Brown et al. instead posit that Aboriginal and fundamentally includes working with local expectancy deficit faced by Aboriginal and Torres Strait Islander men are very interested 1,5-7 men to develop innovative strategies. Torres Strait Islander people; however, the in their health and wish to engage with Aboriginal and Torres Strait Islander men are social determinants, which play a significant primary and other healthcare services, yet frequently described as having the worst part in the ill health of these same men, are are rarely consulted on what they seek and health and social statistics in Australia. The but one facet in addition to a litany of other how services can better meet their needs, and life expectancy gap8 and burden of disease9 contributing factors that must urgently be seldom informed about alternate approaches remains unacceptably high. The ill health addressed. to healthcare access and use.21 Herein lies of Aboriginal and Torres Strait Islander the enormous challenge facing services and men is demonstrable across virtually all Health seeking policy makers alike. 10 measures of mortality and morbidity; Generally, Australian men are considered Health service utilisation is critical, this group also experiences high rates of reluctant to seek help for their own as access to and appropriate use of suicide, homelessness, unemployment and health issues. As Smith et al. explained, comprehensive and high-quality PHCSs imprisonment, all of which contribute directly “it is commonly held that men delay help can have a significant effect in the health and indirectly to ill health and many other seeking because they are ignorant about and wellbeing of marginalised and 11 markers of wellbeing. and disinterested in their health”.16(p1) Such disadvantaged populations.22-24 PHCSs and Unfortunately, the commentary that often generalisations hide important contextual key stakeholders must first understand the accompanies these statistics remains largely and more complete understandings of the reasons surrounding this phenomenon of negative and either explicitly or implicitly reasons for poor healthcare use and rarely under-utilisation, although identifying the places blame and personal responsibility include the laymen’s perspectives relating to barriers faced is simply not enough. Health for ill health and social disadvantage on men’s help-seeking practices.16 Indeed, the services must be willing and able to make

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the necessary changes to improve access, In 2009, the National Health and Hospitals Strait Islander health and policy. Building on evaluate their strategies, share their findings Reform Commission recommended an these strengths should be the cornerstone and improve continuity of care. A fully investment strategy for Aboriginal and Torres of future health and development, and an committed, reliable and sustained approach Strait Islander people’s health, stating this essential investment in the future generations is essential, as band-aid solutions will not and investment should be “proportionate to of Aboriginal and Torres Strait Islander people. have not worked. health need[s], the cost of service delivery, A recent systematic review of primary and the achievement of desired outcomes. healthcare interventions for Indigenous Barriers This requires a substantial increase on people with chronic disease highlighted 28(p20) The barriers to health service use for current expenditure”. Despite this, the five key enablers and inhibiting factors Aboriginal and Torres Strait Islander people 2014–2015 Australian Federal Budget saw for program development to affect “upon were explored in the 2014–2015 Aboriginal aggressive budget cuts to Aboriginal and intervention implementation and/or and Torres Strait Islander Health Survey Torres Strait Islander affairs and health, sustainability within a [primary health conducted by the Department of the particularly preventative healthcare, which care] setting”.31(p9) These included design Prime Minister and Cabinet.19 This review has significantly affected the extent to which attributes, workforces, the importance of found that 35% of respondents believed health services can provide them necessary patient-provider partnerships, the adequate 29 they had been treated unfairly within the amenities. development of clinical pathways and previous 12 months because they were an Improving health services will not be the only mechanisms to improve access to services. Aboriginal or Torres Strait Islander person. change required to close the life expectancy Essentially, these findings should be Of those, 13% reported they had avoided gap, as systemic problems of social and considered when attempting to implement seeking healthcare due to experiencing unfair economic disparity, discrimination and a strategies specific to the needs of Aboriginal treatment in the past.19 lack of empowerment exist. To address this and Torres Strait Islander men. The participants in three additional health crisis, changes in economic policy, The time has come to collaborate and share studies exploring the barriers and enablers improvements in education for Aboriginal knowledge and experiences, to put aside for primary healthcare access faced by and Torres Strait Islander males, access to individual egos and to be honest – even Indigenous men all felt health services sport and recreation facilities and programs, about our collective failures to adequately and staff needed to be more culturally development of sustainable employment and purposefully engage men. Findings need appropriate, while many also thought opportunities, a commitment to cultural to be published, including unsuccessful they lacked information regarding maintenance, improved engagement with programs, to help others learn from past services available at primary health care correctional services as well as increased experiences. We need to stop describing centres.1,3,25 Additional barriers included health awareness are all needed. Essentially, problems and blaming individuals, and distrust and fear of health services, as well as addressing healthcare in isolation from start acknowledging Aboriginal and Torres shame and stigma around sensitive health sociocultural and economic factors will only Strait Islander men as the dynamic, essential issues. This highlighted the importance ever have a limited effect. Notably, the 2016 elements of families, communities and of safe and supportive spaces for Aboriginal Close the Gap Progress and Priorities report societies they have always been.32 The and Torres Strait Islander men especially when outlined many recommendations including: inherent personal and cultural strengths dealing with sensitive health, social and the introduction of ‘Closing the Gap Targets’ and attributes of Aboriginal and Torres cultural concerns, an issue previously to reduce imprisonment; increasing focus Strait Islander men must be unshackled, raised by community-based Indigenous on the needs of Aboriginal and Torres Strait and positive energy directed towards the researchers.26 Islander people with disabilities; a national development of new ways forward by men inquiry into racism and institutional racism in Gender-specific services can certainly and their communities, who are empowered healthcare; and a reform of the Indigenous play another major role in establishing and supported to do so. Advancement Strategy.30 and sustaining accessible and culturally Funding alone will not close the life appropriate care.1,5,7,27 For example, the well- Despite the many barriers, Aboriginal expectancy gap. PHCSs can have established Aboriginal community-controlled and Torres Strait Islander men are putting the latest technology in purpose-built centres, organisation Danila Dilba Health Service in up their hands in a collective show of employ some of the best staff available, 1,5,11 Darwin demonstrates that gender-specific need to encourage change and to be and provide a plethora of programs, but healthcare services are both a viable and responsible for leading the way in the fight to all of this remains ineffective if the men highly accessed service.27 In addition, PHCSs turn around generations of disadvantage. themselves choose not to use them. In the can increase their cultural appropriateness by Torres Strait Islands, there is an expression Looking forward employing male health practitioners, offering derived from traditional dance called ‘mark choices to clients regarding the gender of As Marmot suggested, “wider social policy time’, which refers to a dancer stepping in their practitioner and holding men’s-only will be crucial to reduction of inequalities beat with the music while remaining on the clinic days or times when men can visit these in health”.15(p1103) The development of male spot. Although you are moving, you are also facilities and communicate with male staff for health policy must rely on the strengths that going nowhere. Likewise, PHCSs and key all their health needs. already exist within Aboriginal and Torres stakeholders need to urgently rethink the Insufficient healthcare resourcing contributes Strait Islander men and communities, rather future direction of engaging Aboriginal and towards the under-use of PHCSs for than the deficit approach that is currently Torres Strait Islander men and must no longer Aboriginal and Torres Strait Islander people. favoured to frame Aboriginal and Torres simply ‘mark time’.

Short-term funding is also problematic. It References 18. Deeble J. Assessing the Health Service Use of Aboriginal and Torres Strait Islander Peoples. Canberra (AUST): is common for programs or interventions 1. Canuto K, Wittert G, Harfield S, Brown A. “I feel more National Health and Hospitals Reform Commission; implemented by PHCSs to cease due to comfortable speaking to a male”: Aboriginal and Torres 2009. funding cuts, despite their outcomes. In Strait Islander men’s discourse on utilizing primary 19. Department of the Prime Minister and Cabinet. Access health care services. Int J Equity Health. 2018;17:185. to services compared with need Aboriginal and Torres fact, as O’Dea explained, “the challenge is 2. Isaacs AN, Maybery D, Gruis H. Mental health services Strait Islander. In: Health Performance Framework 2014 to sustain these interventions over the long for aboriginal men: Mismatches and solutions. Int J Ment Report. Canberra (AUST): Government of Australia; Health Nurs. 2012;21(5):400-8. 2014. term in the frequently under-resourced 3. Isaacs AN, Maybery D, Gruis H. Help seeking by 20. Hayman NE, Wenitong M, Zangger JA, Hall EM. primary health care clinics”.33(p5) Services Aboriginal men who are mentally unwell: A pilot study. Strengthening cardiac rehabilitation and secondary Early Interv Psychiatry. 2013;7(4):407-13. prevention for Aboriginal and Torres Strait Islander also have to manage the fallout from 4. Adams M, Collins VR, Dunne MP, De Kretser DM, peoples. Med J Aust. 2006;184(8):485. defunded programs which includes the loss Holden CA. Male reproductive health disorders among 21. Brown A, Scales U, Beever W, Rickards B, Rowley K, of engagement, rapport and trust with local Aboriginal and Torres Strait Islander men: A hidden O’Dea K. Exploring the expression of depression problem? Med J Aust. 2013;198(1):33-8. and distress in aboriginal men in central Australia: A Aboriginal and Torres Strait Islander men, not 5. Wenitong M, Adams M, Holden CA. Engaging qualitative study. BMC Psychiatry. 2012;12(1):1-13. to mention the subsequent turnover of staff Aboriginal and Torres Strait Islander men in primary 22. Briscoe A. Indigenous men’s health: Access strategy. care settings. Med J Aust. 2014;200:632-3. Aborig Isl Health Work J. 2000;24(1):7-11. that affects continuity of care. Despite the 6. Hayman N. Medical and Clinical Issues for Indigenous 23. Davy C, Harfield S, McArthur A, Munn Z, Brown A. Access issues of funding, which is often outside of Men. Aborig Isl Health Work J. 2000;24:4-6. to primary health care services for Indigenous peoples: 7. Brown A, Blashki G. Indigenous male health A framework synthesis. Int J Equity Health. 2016;15:163. the control of PHCSs, prioritising engagement disadvantage–linking the heart and mind. Aust Fam 24. Ware V. Improving the Accessibility of Health Services with local Aboriginal and Torres Strait Physician. 2005;34(10):813-19. in Urban and Regional Settings for Indigenous People. Islander men (and the broader community) is 8. Phillips B, Morrell S, Taylor R, Daniels J. A review of Canberra (AUST): Australian Institute of Health and life expectancy and infant mortality estimations for Welfare; 2013. essential. Engagement is a low-cost exercise Australian Aboriginal people. BMC Public Health. 25. Hughes CK. Factors associated with health-seeking for most PHCSs, with the exception of some 2014;14(1):1. behaviors of Native Hawaiian men. Pac Health Dialog. 9. Australian Institute of Health and Welfare. Australian 2004;11(2):176-82. remote services or those currently severely Burden of Disease Study: Impact and Causes of Illness and 26. Bulman J, Hayes R. Mibbinbah and spirit healing: under-resourced, but it does require a change Death in Australia 2011. Australian Burden of Disease Fostering safe, friendly spaces for indigenous males in Study Series No.: 3. Canberra (AUST): AIHW; 2016. Australia. Int J Men Health. 2011;10(1):6-25. of attitude. 10. Brown A, Walsh W, Lea T, Tonkin A. What becomes of the 27. Danila Dilba Health Service. Engaging ATSI Males to our Aboriginal and Torres Strait Islander men broken hearted? Coronary heart disease as a paradigm Clinic [PowerPoint Slides]. Canberra (AUST): National of cardiovascular disease and poor health among Aboriginal Community Controlled Health Organisation; hold the key to their future, as they know indigenous Australians. Heart Lung Circ. 2005;14(3):158- 2017. what they need and what will get them 62. 28. National Health and Hospitals Reform Commission. A 11. Adams M, Danks B. A Positive approach to addressing Healthier Future for all Australians: Final Report June 2009. through the doors. These men need – and indigenous male suicide in Australia. Aborig Isl Health Canberra (AUST): Government of Australia; 2009. want – to take their health in their own Work J. 2007;31(4):28-31. 29. Russell L. Impact of the 2014-15 Federal Budget on hands; however, it is unrealistic to expect 12. Eckermann A, Dowd T, Chong E, Nixon L, Gray R, Indigenous Programs and Services. Sydney (AUST): Johnson S. Binan Goonj: Bridging Cultures in Aboriginal University of Sydney Menzies Centre for Health Policy; them to improve their current situation Health. 3rd ed. London (UK): Elsevier Health Sciences 2014. alone. Proper engagement with and APAC; 2010. 30. Close the Gap Campaign Steering Committee. Close 13. Rix E, Barclay L, Wilson S. Can a white nurse get it? the Gap: Progress and Priorities Report 2016. Canberra commitment to Aboriginal and Torres Strait ‘Reflexive practice’ and the non-Indigenous clinician/ (AUST): Australian Human Rights Commission; 2016. Islander men’s health is a logical first step researcher working with Aboriginal people. Rural 31. Gibson O, Lisy K, Davy C, Aromataris E, Kite E, Lockwood Remote Health [Internet]. 2014 [cited 2017 Feb C, et al. Enablers and barriers to the implementation for PHCSs. Ultimately, a collaborative effort 6];14:2679. Available from: http://www.rrh.org.au/ of primary health care interventions for Indigenous from researchers, PHCSs, peak health bodies articles/subviewnew.asp?ArticleID=2679 people with chronic diseases: A systematic review. and government is required to empower 14. Australian Health Ministers’ Advisory Council. Aboriginal Implement Sci. 2015;10(1):1-11. and Torres Strait Islander Health Performance Framework 32. Hammond C. Making positive resources to engage Aboriginal and Torres Strait Islander men and 2017. Canberra (AUST): Government of Australia; 2017. Aboriginal men/fathers. Aborig Isl Health Work J. their communities to develop and implement 15. Marmot M. Social determinants of health inequalities. 2010;34(5):23-5. Lancet. 2005;365(9464):1099-104. 33. O’Dea K. (2005). Preventable chronic diseases among new engagement strategies. Sadly, if this is 16. Smith JA, Braunack-Mayer A, Wittert G, Warin M. “It’s Indigenous Australians: The need for a comprehensive not the case, closing the life expectancy gap sort of like being a detective”: Understanding how national approach. Heart Lung Circ. 2005;14(3):167–71. Australian men self-monitor their health prior to will remain nothing more than an advertising seeking help. BMC Health Serv Res. 2008;8:1-10. Correspondence to: Mr Kootsy Canuto, slogan. 17. Australian Department of Health and Ageing. National Wardliparingga Aboriginal Research Unit, Aboriginal and Torres Strait Islander Health Plan 2013- South Australian Health and Medical Research 2023. Canberra (AUST): Government of Australia; 2013. Institute, Adelaide, South Australia; e-mail: [email protected]

doi: 10.1111/1753-6405.12916 would be eroded by inflation. Until recently, the welfare payment awarded to those on The important role of charity in the a range of pension payments (including the aged, disability, and carer pension) was welfare system for those who are indexed to 27.7% of male total average weekly wages.7 This indexation resulted in food insecure a larger annual increase in benefit for those receiving these payment types as a way to 1 2 Fiona H. McKay, Rebecca Lindberg ensure that pensioners maintained a certain 1. School of Health and Social Development, Deakin University, Victoria standard of living, relative to the rest of the 2. The Institute for Physical Activity and Nutrition (IPAN) and School of Exercise and Nutrition Sciences, population. Other benefits, particularly those Deakin University, Victoria provided to job seekers and students, have been indexed to the Consumer Price Index number of changes have been made One of the more substantive changes has (CPI) rather than wages, meaning that these to the Australian welfare system been to the eligibility criteria for a number of payments have not had a rate increase in real 5 Aover the past two decades that have welfare payments, for example, the Parenting terms for more than 20 years.8 significant ramifications for household food Payment Single. Before 2006, single parents Further compounding these inequalities security. Of greatest concern are changes on this payment were able to remain on the in payment rates are years of different made by the Australian Government that have benefit until their youngest child turned 16.2 benchmarking, resulting in a large gap resulted in payments such as Youth Allowance, Changes in 2006 saw the child’s age lowered between pension rates and the payments Newstart and the Parenting Payment to to eight years, with subsequent changes made to potential workforce participants. fall below the poverty line (see Table 1). To lowering it to six years. If, at this time, parents For example, recipients who are no longer compensate for low welfare payments, many were still in need of financial assistance, they actively encouraged into employment, Australians now rely on the private sector and were encouraged to apply for the Newstart including those aged over 65 and disability on charities for food aid and other essentials Allowance, a benefit otherwise provided pensioners, receive $926.20 per fortnight to mitigate the impacts of austerity. In this to employment seekers at a fortnightly for a single, or $1,396.20 per fortnight for commentary, we discuss the hypothesis rate several hundred dollars less than the a couple.9 These payments put recipients that food charity is an inexpensive policy Parenting Payment, and with a range of above the Australian poverty line of $866 per alternative to ensuring an adequate standard mutual obligation requirements.5 There is a fortnight for a single person living alone after of living for welfare-reliant households. We body of research that shows that this welfare housing cost have been paid.10 However, the conclude by predicting the significant public payment change has had a detrimental effect situation is different for those recipients who health ramifications of this approach. on families, with some forced to move into are of working age but who are un- or under- insecure housing, often foregoing food.6 Twenty years in the making employed, with payments falling below the Mutual obligation requirements, and poverty line, putting recipients at an elevated While Australia has a comprehensive welfare differences in indexation, mean that not risk of poverty.10 Under these payment types, system, providing a range of payments and all welfare recipients and their benefits are a single recipient of the Newstart allowance services to individuals and families across treated equally. Like many other countries, with no children receives $555.70 and a the life span, a change instigated by Prime welfare payments in Australia are indexed in couple receives $1,003.40 per fortnight, while Minister John Howard in the late 1990s has order to maintain their real value over time; a student on a Youth Allowance payment seen the culture of welfare in Australia move without indexation, the value of benefits is eligible for a maximum of $455.20 per from a rights-based entitlement system to a system based on ‘mutual obligation’. Table 1: Most common welfare payments in Australia.a Mutual obligation is underpinned by the Payment type Recipient Indicative maximum goal of increasing the economic and social payment for a single participation of citizens, with the expectation (per fortnight) b that any person who can should be employed Aged Pension Aged 65.5 years $926.20 b or completing further education.1,2 The effect Disability Pension Have a permanent and diagnosed disability or medical condition, or get a $926.20 Department of Veterans’ Affairs special rate disability pension due to total and of this expectation is that individuals on permanent incapacity. different support categories receive different Newstart Between 22 and 65.5 years of age, be looking for employment. $692.90c payment types with stricter entitlement rules AusStudy At least 25 years of age, in full-time education. $592.40c based on their theoretical ability to enter Youth Allowance Less than 24 years of age, in full-time study or apprenticeship or 16–21 years of age $592.40c 1 the workforce. This is problematic; while and looking for full-time work. recipients complete compulsory employment Parenting Payment Primary carer of child under eight years of age if single, or six years of age if partnered. $990.30d skills and related activities to access income Notes: support, the number of job seekers outstrips a: Source: Australian Department of Human Services. Payment Rates [Internet]. Canberra (AUST): Government of Australia; 2019 [cited 2019 Jan 11]. the number of jobs available.3,4 Available from: https://www.humanservices.gov.au/individuals/services/centrelink. Totals correct at 10 June 2019. b: Maximum rate, may include Energy supplement, Pension supplement The Australian welfare system has been c: May include Rent assistance further reformed over the past two decades. d: May include Rent assistance and Family Tax benefit This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

fortnight.9 While these recipients may also skipping meals, or bulking out meals with to try to understand their experiences of the be eligible for other benefits including rent simple carbohydrates, as well as increasingly welfare system and how these fit into the assistance or a family tax benefit, even with accessing a range of food aid charities for charitable food sector. We found that many these additional benefits, all payments all or most of their weekly groceries.6 This people perceive the support they receive as fall below the poverty line. The Australian is consistent with recent research showing a privilege and a gift and assume that their Government justifies these low rates on that food insecurity is more prevalent in own issues – rather than systemic issues – are the grounds that they are intended to households where members receive a the cause of their hunger and inability to provide only short-term relief, and that a payment type with a low financial value, such meet the cost of living. Our conclusion is that more generous rate would discourage the as the Newstart or Parenting Payment as their food aid is masking the impacts of a severely unemployed from seeking employment.11 main source of income.14 ineffective social welfare system. The Australia Government currently spends Coping strategies for a $135 shortfall The rise of food charity in Australia $157 billion on welfare, or around $6,500 per According to Australian Council of Social Food aid has grown across Australia since person. This includes cash payments, welfare Services (ACOSS), after taking account of the 1990s, with rapid increase over the services and unemployment benefits.18 There housing costs, more than 10% of people live past decade (see Figure 1). While there are have been calls in recent years to increase the below the poverty line in Australia, closer to thousands of emergency relief programs Newstart allowance, both by a cash amount 20% for children.10 When looking at the depth providing subsidised and free meals across and also by changing the indexation so that of poverty for those below the poverty line, the country, including those that offer pre- Newstart is more closely aligned with the ACCOS suggests that one-in-eight people are, packaged food parcels, school breakfasts, cost of living in Australia; such a change is on average, about $135 short per week, with and prepared meals, there are four major projected to lift more than 300,000 people many of those who live below the poverty national food banking and rescue programs out of poverty, costing the government line relying on some form of welfare benefit that support this front-line sector. These $3.2 billion dollars in the first year.19 Such an as their main source of income.10 As a way to main organisations – FareShare, OzHarvest, increase would also reduce the burden on cope with the increasing cost of living and SecondBite and Foodbank Australia – charities, even those government funded; the low welfare entitlement, many welfare together rescued approximately 19 tonnes currently, the Federal Government spends recipients, especially Newstart recipients, of food in 2008–2009 for re-distribution; more than $200 million across 180 relief are turning to charity for assistance. This by 2016–2017, our estimates suggest this agencies to help Australians in need, with assistance may come in the form of cash sector has almost tripled in size (51,126 $4.5 million in funding to three organisations, payments to cover the costs of utilities, legal tonnes). While publicly available documents Foodbank, SecondBite and OzHarvest.20 This and medical advice, or material and food aid. are unclear on the precise types of food federal funding of food relief is, however, Households on low incomes are more likely distributed, or the extent to which these modest in comparison to the billions that are to be food insecure (see Box 1), as essentials foods meet Australian Dietary Guidelines projected to be needed to ensure all citizens such as housing and utility bills are prioritised or are able to meet the cultural and dietary of Australia have a minimum standard of over food. Few welfare recipients have the preferences of food-insecure Australians, living. This short-term saving though, will discretionary income to purchase the foods these tonnes of charitable food are a mix of have long-term costs. they require from the two main retailers, with perishable surplus food from farms, quick Crystal ball gazing research suggesting that the cost of a week’s service restaurants, bakeries and retailers, groceries for a single person is $122, going as well as shelf-stable products from food In Australia, thanks largely to entrenched up to $336 for a couple with children.13 These manufacturers including pasta, breakfast inequality, it can take up to four generations households employ an array of strategies to cereal, tinned foods and sugar-sweetened to move out of poverty, that is from the feed themselves and their families, with many beverages. bottom 10% of income to the mean income calling on family and friends for assistance, Over the past few years, we have interviewed in society.21 Escaping or avoiding poverty hundreds of Australians who were using or is easier if welfare payments sit close to the 15-17 Box 1: Definition and Dimensions of Food Insecurity had used emergency food relief. What we poverty line, as is often the case for aged (adapted from reference 12). found is that the term ‘emergency food relief’ pensioners who may own their home, have is a misnomer. Many of the participants we no dependent children and have some Food insecurity exists when individuals, households or even spoke with had been accessing emergency superannuation. However, for a majority of whole communities, have inadequate access to healthy affordable culturally appropriate food. food relief for years, with some inter- those receiving Youth Allowance, Newstart, or generational users obtaining half or more a Parenting Payment with entitlements that This experience can have: of their dietary requirements from church fall well below the poverty line, it is almost Quantitative dimensions. Where individuals run low on food, go without eating, and/or restrict portions. groups, community centres and/or outreach impossible to break out of poverty – further Qualitative dimensions. Where individuals have limited services. A range of reasons have led people embedding and fostering intergenerational dietary variety and increase dietary monotony, as well as not to rely on these frontline services, including poverty. being able to meet preferences for healthy and/or cultural poor health (both chronic and acute), If there is a not a substantial change in foods. long-term and short-term unemployment, the level of poverty in Australia and the Psychological dimensions. Where individuals feel uncertain/ high costs of living, domestic violence and trends to date continue, what are the public worried about food supplies, have feelings of deprivation and family breakdowns. We have spoken to lack of agency/choice/dignity. health impacts for up to four generations of people of all age groups, and across rural, Social dimensions. Where individuals are unable to maintain Australian households who will likely need regional, and metropolitan areas in Victoria, socially prescribed ways of acquiring and/or eating food. food charity to cope? Some of the most

CHARITABLE FOOD SECTOR 51,126 TONNES PER ANNUM 46,576

41,514

37,298

33,500

33,000 31,390 29,000

25,345

24,460

21,923 21,000

19,600

19,485 19,000 19,078 17,573 15,626

11,000 10,000 Commentary 5,780 5,200 4,525 4,300 3,900 3,669

2,538 2,399 1,650 1,600 1,312 1,250 1,180 846 839 702 665 661 571 560 540 545 422 240 222

Figure 1: Charitable food sector tonnes per annum. FareShare CHARITABLE FOOD SECTOR OzHarvest 51,126 SecondBite TONNES PER ANNUM Foodbank Australia 46,576 Sector total (FS+OH+SB+FBA) 41,514 The data in this figure was extracted principally from annual reports. Where organisations reported on meals, a 500g meal was assumed in order to calculate kilograms and tonnes. Typically financial years were reported on, but occasionally calendar years were used to prepare the figure. For these 37,298

33,500 reasons the data is indicative approximates only. 33,000 31,390 29,000

25,345

24,460

21,923 21,000

19,600

19,485 19,000 19,078 17,573 15,626

11,000 10,000 5,780 5,200 4,525 4,300 3,900 3,669

2,538 2,399 1,650 1,600 1,312 1,250 1,180 846 839 702 665 661 571 560 540 545 422 240 222

Note: FareShare The data in this figure was extracted principally from annual reports. Where organisations reported on meals, a 500g meal was assumed in order to calculate kilograms and tonnes. Typically financial years were reported on, but occasionallyOzHarvest calendar years were used to prepare the figure. For these reasons the data is indicative approximates only. SecondBite Foodbank Australia concerning include the potential negative References 15. McKay FH, Dunn M.Sector Food security total (FS+OH+SB+FBA) among asylum The data in this figure was extracted principally from annual reports. Where organisations reported on meals,seekers a 500g inmeal Melbourne. was assumed Aust Nin Z order J Public to Health. effect of the overreliance on charity for health 1. Cook K. Neoliberalism, welfare policy and health: A 2015;39:344-9. in termscalculate of suboptimalkilograms and nutrition. tonnes. PreviousTypically financial yearsqualitative were reported meta-synthesis on, but of singleoccasionally parents’ experience calendar years16. were Lindber usedg toR, Lawrenceprepare theM, Caraherfigure. ForM. Kitchens these and of the transition from welfare to work. Health. researchreasons has the found data isthat indicative food charities approximates are not only. pantries—helping or hindering? the perspectives of 2012;16:507-30. emergency food users in Victoria, Australia. J Hunger in a position to provide sufficient quality or 2. McKenzie HJ, McHugh C, McKay FH. Life on newstart Environ Nutr. 2017;12:26. allowance: A new reality for low-income single mothers. 17. Haines BC, McKay FH, Dunn M, Lippi K. The role of social quantity of food, instead providing people J Fam Stud. 2019;25(1):18-33. 22 enterprise in food insecurity among asylum seekers. with food for approximately three days. Our 3. Australian Bureau of Statistic. 6354.0 - Job Vacancies, Health Soc Care Community. 2018;26:829-38. crude snapshot of the growth of the food Australia, Nov 2018. Canberra (AUST): ABS; 2018. 18. Australian Institute of Health and Welfare. Australia’s 4. Department of Jobs and Small Business. Vacancy Welfare 2017. Canberra (AUST): AIHW; 2017 banking and rescue organisations (Figure 1) Report. Canberra (AUST): Government of Australia; 19. Australian Council of Social Service. Raise the Rate 2018. suggests that, for the one million estimated 2018. Strawberry Hills (AUST): ACOSS; 2018. 5. Jovanovski N, Cook K. How Australian welfare reforms food insecure households, there was 51 20. Fletcher P, MP. Media Release: Liberal-National shape low-income single mothers’ food provisioning Government Invests Over $200 Million to Support million kilograms of food available in 2016/17. practices and their children’s nutritional health. Crit Australians Experiencing Hardship. Canberra (AUST): Public Health. 2019. doi.org/10.1080/09581596.2019. That is not even one kilogram per food Ministers for the Department of Social Services; 2018 1577951 21. Organisation for Economic Co-operation and insecure household per week. 6. McKenzie HJ, McKay FH. Food as a discretionary item: Development. A Broken Social Elevator? How to Promote The impact of welfare payment changes on low- Also of concern is the erosion of dignity for Social Mobility. Paris (FRA): OECD; 2018. income single mother’s food choices and strategies. J 22. Bazerghi C, McKay FH, Dunn M. The Role of Food Banks many of those who are forced to rely on Poverty Soc Justice. 2017;25:35-48. in Addressing Food Insecurity: A Systematic Review. J 7. Department of Social Services. Social Security Guide. charity for their essential needs. Research Community Health. 2016;41:732-40. Canberra (AUST): Government of Australia; 2019. 23. Garthwaite K. Stigma, shame and’people like us’: An highlights the inherent shame associated 8. Deloitte. Analysis of the Impact of Raising Benefit Rates. ethnographic study of foodbank use in the UK. J Poverty with the use of emergency food relief. While Melbourne (AUST): Deloitte; 2018 Soc Justice. 2016;24:277-89. 9. Australian Department of Human Services. Payment 24. Costello EJ, Compton SN, Keeler G, Angold A. the food might be ‘free’, there are hidden Rates [Internet]. Canberra (AUST): Government of Relationships between poverty and psychopathology: ‘costs’ of social stigma and shame, with these Australia; 2019 [cited 2019 Jan 11]. Available from: A natural experiment. JAMA. 2003;290:2023-9. https://www.humanservices.gov.au/individuals/ feelings having the potential to worsen 25. Zhang M. Links between school absenteeism and child services/centrelink/age-pension/eligibility/payment- poverty. Pastor Care Educ. 2003;21:10-17. existing health problems and create further rates 26. Brooks-Gunn J, Duncan GJ. The effects of poverty on 10. Davidson P, Saunders P, Bradbury B, Wong M. 2018 23 children. Future Child. 1997;7(2):55-71. humiliation. Finally, of great concern is the Poverty in Australia. Sydney (AUST): Australian Council large number of children living in poverty of Social Service; 2018. 11. Mendes P. The changing nature of the Australian in Australia – up to one in five. The research welfare state: A critical analysis of the ACOSS campaign Supporting Information shows that those growing up in poverty are to increase the Newstart Allowance. Aust J Polit Sci. Additional supporting information may be more prone to behavioural problems than 2015;50:427-41. 12. Loopstra R. Interventions to address household food found in the online version of this article: 24 other children, are more likely to be absent insecurity in high-income countries. Proc Nutr Soc. from school,25 and have poorer overall health 2018;77:270-81. Supplementary Table 1: The rise of food 26 13. Australian Securities and Investments Commission. charity in Australia. and wellbeing. A reliance on food aid and Australian Spending Habits 2016. Gippsland (AUST): other charities is unlikely to diminish without Government of Australia; 2018. Correspondence to: Dr Fiona H. McKay, School of 14. Temple J, Booth S, Pollard C. Social Assistance Payments Health and Social Development, Faculty of Health, some significant changes to the Australian and Food Insecurity in Australia: Evidence from the welfare system. Household Expenditure Survey. Int J Environ Res Public Deakin University, Locked Bag 20000, Geelong, Health. 2019;16(3):455. VIC 3220; e-mail: [email protected]

Feasibility and acceptability of opportunistic screening to detect atrial fibrillation in Aboriginal adults

Rona Macniven,1,2 Josephine Gwynn,1,2 Hiroko Fujimoto,1 Sandy Hamilton,3 Sandra C. Thompson,3 Kerry Taylor,4 Monica Lawrence,5 Heather Finlayson,6 Graham Bolton,6 Norman Dulvari,7 Daryl C. Wright,8 Boe Rambaldini,1 Ben Freedman,1,2 Kylie Gwynne1

trial fibrillation (AF) is an established Abstract antecedent for stroke and other Aforms of cardiovascular disease.1 Objective: Examine the feasibility and acceptability of an electrocardiogram (ECG) attached Cardiovascular disease is the main cause to a mobile phone (iECG) screening device for atrial fibrillation (AF) in Aboriginal Controlled of mortality among Aboriginal and Torres Community Health Services (ACCHS) and other community settings. Strait Islander people in Australia (hereafter Methods: Semi-structured interviews were conducted with ACCHS staff in urban, rural Aboriginal people).2 and remote communities in three Australian states/territories. Quantitative and qualitative Handheld electrocardiogram (ECG) devices questions identified the enabling factors and barriers for staff and Aboriginal patients’ have been recommended internationally as receptiveness to the device. Mean quantitative scores and their standard deviation were preferred screening tools for the diagnosis calculated in Microsoft Excel and qualitative questions were thematically analysed. of atrial fibrillation.3 These devices can Results: Eighteen interviews were conducted with 23 staff across 11 ACCHS. Quantitative data attach to mobile phones, are typically found staff were confident in providing iECG screening and managing the referral pathway, referred to as iECG and have demonstrated and thought the process was beneficial for patients. Qualitative data highlighted the usefulness effectiveness and acceptability in clinical of the device to undertake opportunistic screening and acceptability in routine practice, and provided opportunities to engage patients in education around AF. and community settings such as dental vans, Conclusion: The iECG device was well accepted within ACCHSs and was feasible to use to pharmacies4 and in general practice.5,6 Both screen for AF among Aboriginal patients. systematic and opportunistic screening of adults for AF increased the detection Implications for public health: The device can be used in clinical and community settings rate of new cases compared with routine to screen Aboriginal people for atrial fibrillation to help reduce rates of stroke and other practice and opportunistic screening has cardiovascular diseases. greater cost-effectiveness than systematic Key words: indigenous health, rural and remote health, primary health care, screening screening.7 Competence and confidence of nurses facilitated iECG screening whereas a A scoping review on AF in Indigenous high for Aboriginal Australians as for other lack of staff availability and technical issues populations internationally found higher Australians.10 One study in Western Australia 6 obstructed screening. A recent study found AF hospitalisation rates relative to other reporting on AF as the primary outcome,11 the majority of iECG-screened participants populations and occurrence at younger conducted in a hospital inpatient setting, were satisfied with the device, finding it easy ages and with more comorbidity.9 National found higher rates in comparison with to use without restricting activities or causing data reports the AF rate, as either a principal non-Aboriginal counterparts. A further study 8 anxiety. or additional diagnosis, was 1.4 times as of hospital admissions found AF to occur

1. Faculty of Medicine and Health, Sydney Medical School, Poche Centre for Indigenous Health, The University of Sydney, New South Wales 2. Charles Perkins Centre D17, The University of Sydney, New South Wales 3. Poche Centre for Indigenous Health, School of Indigenous Studies, The University of Western Australia, Crawley, Western Australia 4. Poche Centre for Indigenous Health, Alice Springs, Northern Territory 5. Poche Centre for Indigenous Health, Flinders University of South Australia, Adelaide, South Australia 6. Brewarrina Multipurpose Service, Brewarrina, New South Wales 7. Albury Wodonga Aboriginal Health Service, Glenroy, New South Wales 8. Tharawal Aboriginal Corporation, Airds, New South Wales Correspondence to: Dr Rona Macniven, Faculty of Medicine and Health, Sydney Medical School, Poche Centre for Indigenous Health, Rm 224, Edward Ford Building A27, The University of Sydney, NSW 2006; e-mail: [email protected] Submitted: August 2018; Revision requested: December 2018; Accepted: March 2019 The authors have stated they have no conflict of interest. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Aust NZ J Public Health. 2019; 43:313-18; doi: 10.1111/1753-6405.12905

in Aboriginal people 15 years earlier than co-designed and implemented with the was retained by ACCHS at the end of the full in non-Aboriginal people, as well as higher participating communities and community study for ongoing use in routine practice. All overall rates in comparison to non-Aboriginal services. The full protocol of a study to interviewees provided informed verbal and people and higher long-term mortality conduct opportunistic screening for AF written consent to take part. rates among the Aboriginal patients.12 among Aboriginal adults that included However, little data on the prevalence of the examination of the feasibility and Measures AF in Australian Aboriginal communities is acceptability of the device has been The study measures were developed in 18 available. described elsewhere. The study was partnership with Aboriginal investigators Given the limited available and inconsistent approved by Aboriginal Health and Medical and communities in each of the three states/ data on AF, and acknowledged importance Research Council (AHMRC) of NSW (1135/15), territories that the study was conducted as a risk factor for cardiovascular disease, the Western Australian Aboriginal Health in to ensure their contextual integrity. early screening and detection holds promise Ethics Committee (WAAHEC) (HREC706) and Face validity of the measures were also in improving clinical and population the Central Australian Human Research Ethics determined through this co-design process. outcomes. Early screening and detection Committee in the NT. Quantitative and qualitative questions usually occurs in primary health care settings identified the enabling factors and barriers and for Aboriginal people the Aboriginal Participants for AHWs and other ACCHS staff using the Community Controlled Health Services Interviewees were 18 ACCHS staff (Aboriginal iECG in their roles and Aboriginal patients’ (ACCHS) play a pivotal role in delivering and non-Aboriginal), including AHWs receptiveness to the iECG as perceived health care in urban, regional and remote and registered nurses (RNs). They were by the iECG screeners. Semi-structured community settings. A key service performed purposefully sampled from the 11 ACCHS interviews included seven quantitative five- by ACCHS is adult health checks, which are involved in the study due to their specific point Likert question items (strongly agree, recommended every two years for Aboriginal involvement in the full study as the ACCHS agree, neither agree nor disagree, disagree, adults aged 15-54 years and comprise contact personnel and/or had responsibility strongly disagree). Staff were asked whether screening of multiple health variables and through their professional role in conducting they felt they were provided with sufficient risk factors including cardiovascular disease iECG screening with patients. Participating training for the study and their confidence in and health promotion.13 The checks are ACCHS were located in urban (major cities, providing iECG screening, and in managing typically conducted by Aboriginal Health N=2), regional (N=7) and remote (N=2) areas the pathway and treatment plan for patients Workers (AHWs) and pathways exist for 19 within New South Wales (NSW; N=7), who required follow-up. Interviewees were subsequent referral to relevant health Western Australia (WA; N=3) and the Northern also asked whether they believed patients professionals and specialists, although these Territory (N=1). At the commencement of the (who were subsequently diagnosed with can be variable depending on location, study, staff received face-to-face training at AF) followed their treatment plan for the remoteness and system factors.14 The their ACCHS in the use of the device, consent condition, whether the process was beneficial feasibility and acceptability of the iECG processes for patients, cardiovascular health for participants (who were screened) and device to health staff working within the promotion and treatment, data collection the time commitment required for the study. Aboriginal Community Controlled Health and the clinical pathway for patients with Five qualitative open-ended questions sector as a tool for determining AF prevalence a non-normal result. The screening process asked interviewees what they thought was among Aboriginal adults is unknown. involved using a dedicated smartphone useful for patients, how patients responded AF is not only often asymptomatic,15 but with an iECG device to screen a patient and to screening, what interviewees liked and Aboriginal Australians are more likely to delay using the device software to transmit the found challenging about the process and accessing the healthcare system until later ECG result to the study database via the any suggestions for improvement (Box 1). in a disease process or may not seek timely telephone data network using an activated Potential participants were able to choose help in emergencies due to issues such as sim card. Internet connectivity was required to take part through a group interview if fear, racism and service access.16,17 However, to transmit the results to a secure website preferred. ACCHS can help overcome these barriers for data storage but was not required for the and has achieved better health outcomes screening itself. Screening occurred from June Procedure for Aboriginal people than mainstream 2016 to February 2018 and the iECG device Data collection occurred during the 17 services. This study aims to determine the second half of 2017. Purposefully sampled feasibility and acceptability to health staff of Box 1: Qualitative open-ended questions. interviewees in each ACCHS were approached opportunistic screening through the use of an by the researcher coordinating the study iECG device to detect AF among Aboriginal 1. What aspects of the screening process do you think were useful for patients? by telephone, face-to-face or by email, as adults within community controlled health 2. How did you feel the patients responded to the screening appropriate, and invited to participate and/ settings. process? or suggest other suitable interviewees within 3. Were there any things you liked about the screening the ACCHS. Interviews were conducted Methods process? Did you find it worked well? at a time and location convenient to the 4. Were there any aspects of the screening process that you interviewees by one of five researchers Study design did not like or were difficult for you? If so, can you describe these in more detail? (RM, HF, SH, KT, HF) with the exception of The study adopted a mixed methods 5. Can you suggest any ways of improving the screening two interviews, which were conducted by design and took place during 2017. It was process? two researchers following the community’s

request. Each of the researchers had tertiary researchers who had conducted the majority Table 1: Interviewee characteristics (N=18). 21 training in qualitative research methods and of the interviews. A member-checking Characteristic Number prior experience of conducting interviews. process was undertaken through consultation State/ Territory Face-to-face interviews were conducted with the Aboriginal investigators and NSW 12 where feasible and typically took place community members to finalise the results WA 4 in private in the staff member’s closed and include their correct interpretation. NT 2 office, or interviews occurred by telephone Geographical classification where distance, travel or time constraints Results Urban 2 existed. Interviews were audio-recorded Regional 13 and transcribed verbatim, other than in the Information on the geographical location Remote 3 Northern Territory where no audio recording and occupational characteristics of the Professional role occurred for cultural reasons in the relevant interviewees as well as the type of interview is RN 9 remote community. In this interview, the presented in Table 1. AHW 4 participants and interviewer talked as a small AHW/RN 2 group in an informal setting with respect Quantitative data AHW/Manager 2 to the participant cultural preferences, Mean score and standard deviation of five- Manager 1 responses were agreed on among the group item Likert scale questions are presented Interview type and data were recorded through the detailed in Table 2. Overall, interviewees reported Face to face 12 field notes of the interviewer. Recruitment they were provided with sufficient training Telephone 6 continued until no new information emerged for their role in the screening study and did from interviews. Interview duration was not believe that the study took too much typically 30 minutes (minimum 15 minutes; Several interviewees also thought they of their time. They expressed confidence maximum 60 minutes). Quantitative could use the device in the future as part of in providing an iECG screening and in responses were recorded in a Microsoft Excel standard adult health checks for Aboriginal managing the referral follow-up pathway spreadsheet and qualitative responses were patients. for patients where required. Most agreed entered into QSR NVivo software version 10 that the process of screening to detect and Theme 2: Acceptability of the iECG among (QSR International) for data management. manage AF in Aboriginal patients, regardless staff and patients Community members from each participating of the diagnosis, was beneficial for patients site were screened for AF using the iECG Most interviewees described how the although less were convinced that most device, and details of this study component device was acceptable for use with patients patients diagnosed with AF would follow are provided in a separate forthcoming in their routine practice and enhanced their treatment plan. publication. In summary: participants were diagnostic and other screening processes recruited from two states (NSW N=419; for early intervention and chronic disease Qualitative data WA N=161) and the NT (N=39) and across management. They spoke of how the device three geographical location types (remote Qualitative data outlining four main themes was particularly useful beyond clinical N=41, regional N=459; and urban N=119); of feasibility; acceptability; use as an settings in the community where it seemed 619 iECG screens were collected; and educational tool; barriers to use are described to have greater acceptability among patients results were recorded as either Unclassified, with exemplary quotes in Figures 1-4. and provided more flexible options. This Normal or Possible AF and referred locally greater acceptability related to comfort and for confirmatory 12 lead ECG where an Theme 1: Feasibility of the iECG for ACCHS anonymity of community-based screening, screening Unclassified or Possible AF result was with participants indicating how some reported. The majority of interviewees spoke about patients could feel uncomfortable with the usefulness of the device to undertake perceived implications of screening results Data analyses opportunistic screening in their roles. in the clinical setting. While all interviewees For the quantitative questions, the five-level Specifically, they found the iECG simple, quick described how the device was generally Likert question items were scored from and easy to use and liked its portable nature. well received by patients, some interviewees 5=strongly agree to 1=strongly disagree. Mean scores and their standard deviation Table 2: Mean score and standard deviation of five-item Likert scale questions were calculated in Microsoft Excel. For the (5=strongly agree; 1=strongly disagree). qualitative questions, thematic analysis20 was Question Percent ‘agree’ or used to capture key themes around feasibility strongly agree’ and acceptability of the device within ACCHS, 1. ‘I was provided with sufficient training for my role in this study’ 88.9% including perceived barriers and enablers 2. ‘I was confident in providing an iECG screening’ 100.0% to its use. An inductive approach was used 3. ‘I was confident in managing the referral pathway for patients who required a confirmation ECG by the GP’ 94.4% to code the data transcripts and identify 4. ‘After a patient was diagnosed with Atrial Fibrillation, I was confident helping support their treatment plan’ 94.4% frequently occurring themes that emerged 5. ‘I believe most patients followed their treatment plan’ 61.1% from the coded content. Data analyses 6. ‘I believe this process of screening to detect and manage AF in Aboriginal patients, regardless of the 83.3% diagnoses, was beneficial for patients’ were conducted and cross-checked by two 7. ‘I believe that this study took too much of my time’ 16.7%

described worry or anxiety expressed by communities, the importance of AHWs Theme 4: Barriers and enablers to using the patients in anticipation of what the device in providing culturally-competent care in device existed might diagnose, or in response to a positive partnership with other health professionals Some challenges or barriers were also or unclassified result for AF. and their expertise was described, taking described. These were a mixture of cultural There were also high levels of acceptability account of complexities around community and logistical issues, but many of the latter of the device and screening process among factors. While patients appeared to be most related to the requirements of the study ACCHS staff, despite some challenges in comfortable with AHWs, conflicting cultural protocol. A number of logistical issues establishing the project into their work issues relating to traditional views regarding were described across urban, regional patterns. Specifically, interviewees spoke the heart, AHW professional authority and and remote communities relating to the of the time benefits of the iECG compared caution around heart health and cultural internet connectivity required to upload to a full ECG test and how it provided an boundaries relating to their professional data collected by the device. Interviewees opportunity to discuss broader aspects that and personal roles in the community were outlined some challenges in ensuring promoted health with patients. In remote described by remote AHWs. These issues patients could receive appropriate follow- related to the management of patients and up within the required time period and that relationships with community members and patients returned for follow-up of unclassified Figure 1: Qualitative interviewee quotes: Feasibility. the interactions of these factors with the roles or positive readings, particularly when the “It worked very well, it was quick, results immediately, just of non-Aboriginal health professionals whose device was used in the community setting. so simplified and when you’re in outreach and there’s only 2 expertise and lack of cultural conflict could nurses, this sort of technology is good for us, especially when The consent process and paperwork time management is difficult.” [Remote AHW/RN] provide clarity for patients and support the requirements of the study were also initial screening by AHWs. “It’s portable, provides opportunistic testing away from described by interviewees as a barrier to the main clinic, gave the patients a visual that they found both their and their patients’ participation. interesting.” [Regional RN] Theme 3: Use as an educational tool Interviewees spoke about how training “We really liked this because we can make this part of their Several interviewees described how the procedures delivered by the researchers and adult health check.” [Remote AHW] iECG device provided unique opportunities onsite assistance helped to overcome some of “I can include the iECG in the regular routine with Blood to engage patients in education around AF the barriers described. They also highlighted Pressure etc.” [Remote AHW/RN] and their heart, and to empower patients how educational resources would also help to find out more about their heart health. overcome barriers around knowledge of AF Figure 2: Qualitative interviewee quotes: Some staff also spoke of how using the and the screening process. Acceptability. device for screening led them to want to learn more about AF and cardiovascular disease “A very good tool for me as it was a fast way of diagnosis. It Discussion sped up the diagnostic procedure and sped up the treatment themselves in their professional role. pathway.” [Urban RN] Our findings demonstrate the feasibility and “If we were out in the field, on outreach so could have family acceptability of a portable, handheld iECG do it where they felt more comfortable in their own home. device for the screening and detection of Wherever we did it they were happy and it didn’t take up too Figure 4: Qualitative interviewee quotes: Barriers AF within ACCHS and related community much time.” [Regional RN] and enablers to use. settings across a range of urban, regional and “There was excitement through to the other end of the scale “Internet coverage is very slow for us, staff don’t always have remote areas in Australia. – absolute fear about what the iECG would actually disclose.” email, we shouldn’t have to be faced with this stuff. I could [Remote AHW] personally see that if the ECG was ok but if I couldn’t upload it Several studies have previously established “I liked how it was simple, 30 seconds, much easier than a to Dr in town I would have to have a backup plan.” [Remote the feasibility and acceptability of a range AHW/RN] regular 12 lead ECG so that was really good.” [Regional RN] of screening tools among Aboriginal “I liked the fact that it a good tool for generating yarning about “The difficulty is that the 24-hour requirement to be followed populations22,23 as well as iECG devices in up by the Dr is hard here as the Dr only comes here once a your heart and what was normal.” [Urban RN] mainstream populations.5,7 This study is the week.” [Remote AHW/RN] “It’s better to involve the nurse and doctor to talk about the first to examine these factors in relation to the treatment plan, because AHWs don’t really know enough about “The issue was getting them back to clinic for any follow up iECG screening tool in Aboriginal populations. this AF. Also some people don’t like health workers involved required.” [Regional RN] Our quantitative data found that both because they worry about privacy because we are part of the “Sometimes it [the device] couldn’t decide the diagnosis when community. Even though we know we have to keep things it was clearly sinus rhythm and that was a bit frustrating.” Aboriginal and non-Aboriginal ACCHS staff confidential, some people don’t want to see us.” [Remote AHW] [Urban RN] were confident in providing iECG screening “I think from screening tool without needing to have all the and managing the referral follow-up pathway, Figure 3: Qualitative interviewee quotes: Use as an data entered into the phone… I think that would be really and felt the process was beneficial for educational tool. useful tool, just like taking blood pressure, taking pulse. I think patients. The feasibility and acceptability of it’s just because this is a study that you have to collect data “Opening that dialogue around heart health, whether it was screening tools within the ACCHS setting on the person, and getting consent all that sort of issues.” having that conversation if they had a preexisting condition, 23 [Regional RN] has been described previously and our asking about what medication they are on. It was a good findings confirm the usefulness of screening engagement tool for people who would otherwise not be “I think the best time was when you guys were here being a engaged in that kind of conversation.” [Regional AHW/RN] part of it, that was really valuable. It’s difficult to overcome the in this setting across urban, rural and remote barriers we did face, I can’t think of a way other than having settings. Interviews confirmed the feasibility “I would like more training in AF to be up to date about that someone at the service that could solely do it.” [Regional RN] heart problem and having cardiac resources around AF that and usefulness of iECG screening in the are culturally appropriate and respectful and in language.” “Having cardiac resources around AF that are culturally community setting despite several barriers. [Remote AHW] appropriate and respectful and in language.” [Remote AHW] These findings are consistent with the results

of the screening process that achieved Table 3: Future suggestions for iECG device use. recruitment of 619 Aboriginal patients aged Finding Future suggestion 45 years and over across the 11 ACCHS, Theme 1: Feasibility of the iECG for ACCHS screening Provide up to date devices in ACCHSs 18 reported in detail separately. Theme 2: Acceptability of the iECG among staff and patients Include in Indigenous adult health checks Community settings, such as events and Theme 3: Use as an educational tool Provide further training to ACCHSs staff on the device home visits, gave opportunities to engage Theme 4: Barriers and enablers to using the device existed Streamline screening & follow-up processes with patients’ family members and the wider local Aboriginal community and to achieve in remote areas where a doctor may device and its results among some people. undertake broader preventive screening only provide weekly community visits, yet Overall, we therefore consider the study to beyond the traditional clinical service. Given the screening process was considered to give accurate data about the feasibility and known barriers experienced by Aboriginal have overall benefits in identifying patients acceptability of the device for screening. Our people in engaging with the health sector potentially at risk of AF to ACCHSs staff findings summary and suggestions for future for health promotion,24 iECG screening in that may not otherwise have occurred. use are outlined in Table 3. community settings enhances opportunities Few interviewees reported actual barriers for health promotion and engagement. This to patient engagement with the device Conclusion is particularly valuable in rural and remote generally positively received. Only a small settings where disparities in health service number of participants, mainly AHWs in Overall, the iECG device was well accepted provision exist25 as well as among Aboriginal remote areas, expressed patient concern, within ACCHS and was feasible to use to populations broadly.26 fear and confusion related to the device and screen for AF among Aboriginal patients Our qualitative data also highlighted the its results. Strategies described to overcome in both clinical and community settings. A usefulness of the device to undertake these reported barriers included supporting number of barriers to screening within these opportunistic screening and its acceptability the positive interpersonal relationships that settings were identified, but solutions to 29 in routine practice, specifically in providing provide trust between AHWs and patients. overcome these barriers emerged and the an easy-to-use resource to assist cardiac The barrier related to obtaining participant use of the device created interest in relevant diagnosis that was favoured by patients. consent and related research paperwork training and educational resources. Screening These are positive enablers to achieving would not exist outside of the research through the iECG device is a feasible and 18 greater access to, and update of, preventive processes. The protocol for this study stated acceptable way to look for untreated AF and treatment services within primary that the local Aboriginal healthcare workforce in a community or clinic setting. It has the care, known to be linked with better health would collect the data, however, this was potential, if widely utilised and followed up, outcomes.26 A couple of interviewees not the case in all participating sites (Table to reduce the unfortunate outcome of stroke suggested incorporating the iECG screening 1). This was due to a variety of reasons: AHW that is experienced at a younger age and tool into Aboriginal adult health checks, availability and role in the clinical setting; higher rates by Aboriginal people, and to which provide comprehensive health hesitancy from a few AHWs to collect the contribute to improving the health literacy assessments and enable opportunities data, requiring more support and time to and health of Aboriginal people. to provide health advice and risk factor become confident in the use of the iECG than modification.27 This would align with the was feasible for the research team to deliver Acknowledgements interviewee recommendations of the at the site; cultural issues around privacy; In memory of Norman Dulvari whose potential for the iECG device to be used as an and concern about giving ‘bad news’ to contribution to this research was invaluable educational tool for wider health promotion participants.However, the final study sample and without whom would not have been the and a component of empowerment through gave a broader perspective of the ACCHS success it has. improving health literacy28; we recommend screening process including managers as well the process of formal addition to adult health as AHWs and RNs. The authors acknowledge the Aboriginal checks13 be investigated further. Strengths of this study include the Health and Medical Research Council of examination of a novel device in both a New South Wales and the support and Several barriers to screening were described clinic and community setting, the multi-site participation of the communities involved in by ACCHS staff. These included a lack of recruitment of interviewees across three the design and conduct of the study and the time to complete screening, logistical states/territories, urban, regional and remote participants for contributing their time and and technical issues with the device, areas and across a range of professional roles perspectives. implementation of the protocol such as a within ACCHS. The study was designed and lack of opportunity for timely follow-up with implemented in close collaboration with a doctor, and internet connectivity issues. References communities and community services, an Some of these barriers related only to the 1. Allan V, Honarbakhsh S, Casas J-P, Wallace J, Hunter approach vital to achieving culturally relevant R, Schilling R, et al. Are cardiovascular risk factors also study protocol, not the use of the device associated with the incidence of atrial fibrillation?: A acceptance and engagement in cardiac care.30 itself, such as the requirement to upload data systematic review and field synopsis of 23 factors in While the study participants gave many 32 population-based cohorts of 20 million participants. to the study and so would not be present positive perspectives of the screening, some Thromb Haemost. 2017;117(5):837-50. in ongoing use or might be overcome with 2. Australian Institute of Health and Welfare. difficulties were also described such as the an upgraded smartphone. The 24-hour Cardiovascular Disease, Diabetes and Chronic Kidney difficulty in obtaining consent and ensuring Disease—Australian Facts: Aboriginal and Torres Strait time period required for follow-up with Islander People. Cardiovascular, Diabetes and Chronic follow-up took place, as well as fear of the a doctor was reported as challenging to Kidney Disease Series No.: 5. Canberra (AUST): AIHW; 2015.

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Anaemia in early childhood among Aboriginal and Torres Strait Islander children of Far North Queensland: a retrospective cohort study

Dympna Leonard,1 Petra Buttner,1 Fintan Thompson,1 Maria Makrides,2,3 Robyn McDermott1

naemia is a global health issue that Abstract particularly affects women and young Achildren.1 Causes of anaemia include Objective: Early childhood anaemia affects health and neurodevelopment. This study describes nutrient deficiencies – lack of folate, vitamin anaemia among Aboriginal and Torres Strait Islander children of Far North Queensland. B12 and/or iron-infections, inflammation and Methods: This retrospective cohort study used health information for children born between genetic conditions.1 2006 and 2010 and their mothers. We describe the incidence of early childhood anaemia Anaemia in the first thousand days, from and compare characteristics of children and mothers where the child had anaemia with conception to age two years, can compromise characteristics of children and mothers where the child did not have anaemia using bivariate the health of mothers and their pregnancy and multivariable analysis, by complete case (CC) and with multiple imputed (MI) data. outcomes as well as the health and early Results: Among these (n=708) Aboriginal and Torres Strait Islander children of Far North childhood development of their children.2 Queensland, 61.3% (95%CI 57.7%, 64.9%) became anaemic between the ages of six and 23 The most common cause of anaemia in early months. Multivariable analysis showed a lower incidence of anaemia among girls (CC/MI life is iron deficiency, as iron requirements p<0.001) and among children of Torres Strait Islander mothers or both Aboriginal and Torres increase due to expanding blood supply and Strait Islander mothers (CC/MI p<0.001) compared to children of Aboriginal mothers. A higher other tissue growth.1,3 Prevention of iron incidence of anaemia was seen among children of mothers with parity three or more (CC/MI deficiency and/or anaemia is necessary for p<0.001); children born by caesarean section (CC/MI p<0.001); and children with rapid early optimal child health and development.2,4 growth (CC/MI p<0.001). During the first months of life, the main Conclusion: Early childhood anaemia is common among Aboriginal and Torres Strait Islander source of iron is not breast milk or infant children of Far North Queensland. Poor nutrition, particularly iron deficiency, and frequent formula but the iron provided to the baby infections are likely causes. by its mother during the last ten weeks of Implications for public health: Prevention of early childhood anaemia in ‘Close the Gap’ pregnancy.5 Iron status of an infant at birth initiatives would benefit the Aboriginal and Torres Strait Islander children of Far North reflects the iron status of the mother during Queensland – and elsewhere in northern Australia. 6 pregnancy. In low-income settings, anaemia Key words: anaemia, Aboriginal, Torres, child, mother, Queensland of a mother in pregnancy is a strong predictor of anaemia in the early life of her child.7 life.6,8 After this, nutrient-dense solid foods with high rates of food insecurity compared Birthweight matters, as smaller babies have rich in iron are required.10,11 Traditionally, to other Australians, especially among those smaller iron endowment.6 Cord clamping Aboriginal and Torres Strait Islander living in remote locations.15-17 Food insecurity practices at birth are also important, as Australians consumed many iron-rich foods increases the risk of anaemia among women delayed clamping can increase body iron such as insects, shellfish, animal blood and and their children.18 of the newborn by about 30% compared to organs.12-14 Today, however, Aboriginal and early clamping.8,9 Anaemia among Aboriginal and Torres Strait Torres Strait Islander people consume diets Islander children is a long-standing concern in A baby of healthy birthweight, born at full that are less nutritious than the diets of other remote communities in the Northern Territory term to a well-nourished mother, typically 15 Australians. These nutrient-poor diets, often and Western Australia.19-22 A recent Northern has sufficient iron for the first six months of commencing from early life, are associated Territory report showed 29.0% of children

1. Australian Institute of Tropical Health and Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook University, Queensland 2. Healthy Mothers, Babies and Children, South Australian Health and Medical Research Institute 3. Discipline of Paediatrics, School of Medicine, The University of Adelaide, South Australia Correspondence to: Ms Dympna Leonard, Australian Institute of Tropical Health and Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook University, PO Box 6811, Cairns, QLD 4870; e-mail: [email protected] Submitted: December 2018; Revision requested: March 2019; Accepted: April 2019 The authors have stated they have no conflict of interest. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Aust NZ J Public Health. 2019; 43:319-27; doi: 10.1111/1753-6405.12911

aged six to 23 months (n=956) were anaemic and de-identified by the Queensland Health Longitudinal information on child growth in 2016/17.23 Statistical Services Branch. The process of and haemoglobin levels was recorded on Comparable information on anaemia among securing this information has been previously the Ferret system. To ensure independence 29 other Australian children is limited. Localised described. Briefly, data recorded between of events for statistical analysis, only the first surveys (2010) reported 1–6% of toddlers had 2000 and 2015 were extracted from the child born to each mother between 2006 and iron deficiency anaemia increasing to 14% Queensland Perinatal Data Collection 2010 was included. 30 among those of Asian background, while one (PDC) ; the Queensland Health Pathology Ethics approval was granted by Queensland 31 national survey from 1995 reported that 2% Services Data Collection (Auslab) ; and Health Far North Queensland Human of 1–4-year-old children were anaemic.24-26 the community health services electronic Research Ethics Committee (HREC/15/ record system, Ferret,32 used mainly in In remote Far North Queensland (Map 1), QCH/50-980) in June 2015. Approval under remote Far North Queensland (Map 1 and 71.5% of the population are Aboriginal and/ the Queensland Public Health Act 2005 Supplementary Table 1). or Torres Strait Islander people (n=14,107).27 A was granted by the Director-General of recent audit from eight Cape York Aboriginal Study data were provided for two cohorts of Queensland Health in February 2016. The communities reported that 32.3% of children Aboriginal and Torres Strait Islander children complete linked de-identified data was aged six to 23 months were anaemic.28 and their mothers: the Cape York cohort provided to the research group in May 2017. However, published information is lacking for and the 2009–2010 cohort. The Cape York the wider Far North Queensland region. cohort includes children of the remote Cape Study variables and definitions York communities only, born between 2006 The current study was undertaken to Anaemia was defined as per Queensland and 2008. The 2009–2010 cohort includes investigate anaemia among Aboriginal Health clinical guidelines (haemoglobin <105 children born to Aboriginal and/or Torres and Torres Strait Islander mothers and their g/L from six to 11 months; haemoglobin Strait Islander mothers with a Queensland 33 children in Far North Queensland. Here we <110g/L for children from 12 to 23 months). Perinatal Data Collection (PDC) record of birth describe early childhood anaemia, defined Children aged six to 23 months, with at least in 2009 or 2010 in Far North Queensland, as anaemia at age six to 23 months, and one haemoglobin level recorded below which includes the Torres region, Cape the characteristics associated with early the respective criteria for age at the date York and Cairns and Hinterland. Children childhood anaemia among Aboriginal and of measurement, were considered to have included in this analysis are those with a Torres Strait Islander children. anaemia. The haemoglobin levels reported Ferret record in addition to a PDC record. The here for children were measured on capillary Ferret system was implemented mainly in blood using a HemoCue®. Methods discrete Aboriginal and Torres Strait Islander Some characteristics are as reported on communities across Far North Queensland the Perinatal Data Collection30 (mother’s This retrospective cohort study used (Map 1). Twelve of these localities were usual residence, ethnicity, parity, smoking information from three existing health in Cape York, 21 in the Torres region and in pregnancy, pregnancy induced service data collections, extracted, linked five in the Cairns and Hinterland region.

Map 1: Caption Far North Queensland – Hospital and Health Service boundaries and localities of Ferret electronic health records system.

hypertension; baby’s sex, gestational age The appropriate SEIFA decile ranking was Multivariable logistic regression analyses at birth, birthweight, method of birth). allocated to each mother based on her usual were conducted to identify independent Birthweight z-scores adjusted for sex and place of residence. risk factors for early childhood anaemia for gestational age, for babies with gestational the complete case analysis. Backward and age of 33 weeks or more were calculated Statistical analysis forward stepwise modelling procedures ST using the INTERGROWTH-21 Neonatal Categorical variables were described were initially conducted to establish basic 34,35 Size Calculator. The INTERGROWTH- using absolute and relative frequencies. multivariable models for the combined st 21 standards for newborns are designed The distributions of numerical variables cohorts. Characteristics that were not part to complement the WHO Child Growth were assessed; symmetrically distributed of the basic models were assessed for 34 Standards. Weight for age z-scores for numerical characteristics were described potential confounding effects. A confounder the first weight measure at age four to six using mean values, 95% confidence intervals was assumed to be a variable that changed months recorded on the Ferret system (95%CI), and ranges; numerical values estimates of characteristics in the basic model 42 were calculated using the STATA ‘zscore06’ with a skewed distribution were described by 10% or more. module, which is based on the 2006 World using median, inter-quartile ranges (IQR) Multivariable multiple imputation was Health Organization sex-specific child growth and ranges. The cumulative incidence of conducted using Stata’s MI commands 36,37 standards. anaemia between age six to 23 months was for sequential imputation using chained Where measurements were available, presented with 95% confidence interval equations. Missing values were imputed z-score-change was calculated (z-score for (95%CI). Mean haemoglobin levels using for BMI of mother; parity; smoking during the first weight measurement at age four the first haemoglobin reading for each child, pregnancy; mother anaemic in the third to six months minus birthweight z-score for and incidence of anaemia were presented trimester of pregnancy; mother with pre- weight for gestational age). Z-score-change by six-month age groups (six–11 months, existing diabetes; mother with gestational is a measure of change in weight for age 12–17 months, 18–23 months). Children were diabetes; number of antenatal visits five or z-scores in the first months of life. A positive included in one or more of the six-month age more; feeding method to age four months; value indicates an increase in weight for intervals if the appropriate measurements and z-score-change from birth to age four to age, a negative value indicates a decline in were available at that age but once only in six months. Low RCF and B12 levels before weight for age, while a zero value indicates analysis for the six to 23-month age group. or during pregnancy were not imputed no change in weight for age (Supplementary Characteristics of the children and their because these characteristics were missing Table 2). mothers were compared between those in close to 80% of cases. Examination of Other characteristics (maternal body mass children who had early childhood anaemia patterns of missing data was conducted using index [BMI] and age; baby’s prematurity and those who did not, using bivariate logistic Pearson’s chi-square and Fisher’s exact tests and/or low birthweight) were derived regression analyses adjusted for cohort. to compare the occurrence of missing values from Perinatal Data Collection information The following characteristics were considered in characteristics (Supplementary Table 3). using criteria specified by the Australian during multivariable analyses (Cohort 1 Patterns of missing values were assessed and 43 Institute of Health and Welfare and the “2009-2010 cohort” n=407; Cohort 2 “Cape judged to be “missing at random”. Linear National Health and Medical Research York cohort” n=301): sex of the baby; regression was used to impute missing Council, unless otherwise referenced.38,39 birthing method (non-instrumental vaginal, values of continuous characteristics; logistic Information on maternal glucose tolerance, instrumental vaginal, caesarean section); regression was used to impute missing haemoglobin, ferritin, red cell folate (RCF) gestational age of baby; whether baby was values of dichotomous characteristics; and vitamin B12 levels are as recorded on premature or not; birthweight of baby; ordinal logistic regression was used to the Queensland Pathology Auslab system. z-score-change (z-score for weight for age impute missing values of the categories of Maternal anaemia in the third trimester of at first weight at age four to six months less BMI. Imputation models were based on the pregnancy was defined as an Auslab record z-score for birthweight); feeding method following variables with nil missing data: early of mother’s haemoglobin level <110 g/L as to age four months (only breast milk, only childhood anaemia; sex of baby; gestational per Queensland Health clinical guidelines, infant formula, both breast milk and formula); age of baby; baby premature; birthing measured on a date between estimated day ethnicity of mother (Aboriginal, Torres Strait method; birthweight of baby; pregnancy 186 of pregnancy and the date of birth of the Islander, both); region of residence of mother; induced hypertension, ethnicity of mother, child.24,40 Supplementary Table 2 provides SEIFA category for residence of mother; age age of mother, SEIFA index; antenatal care further details on definitions including of mother when baby was born; BMI category received; and cohort. Forty imputed data sets implausibility criteria. Implausible values were of mother (underweight, normal weight, were created. Multivariable logistic regression considered missing. overweight, obese); categories of parity (0-2, analyses were conducted to identify independent risk factors for early childhood The Socio-Economic Index for Areas (SEIFA >=3); smoking during pregnancy; five or anaemia for imputed data. 2011) ranks Australian Bureau of Statistics more antenatal care visits; pregnancy induced Statistical Local Areas (SLA) by deciles of hypertension; mother had pre-existing Results of multivariable models for relative socio-economic advantage and diabetes; mother had gestational diabetes); complete case and imputed data analyses disadvantage.41 A ranking of ‘1’ indicates low RCF level before or during pregnancy; are presented as odds ratios (OR) and 95% greatest relative disadvantage while a ranking low B12 level before or during pregnancy; confidence intervals. P values of less than of ‘10’ indicates greatest relative advantage. mother anaemic in the third trimester of 0.05 were considered statistically significant. pregnancy.

Figure 1: Flow diagram – early childhood anaemia among two cohorts of Aboriginal and Analysis was conducted using Stata version FigureTorres 1: Flow Strait diagram Islander – early children childhood and anaemia their mothers among two in cohorts Far North of Aboriginal Queensland; and Torres data Strait available Islander 13 (StataCorp, Lakeway Drive, College Station, childrenand exclusions and their mothers in Far North Queensland; data available and exclusions. Texas).

Cape York Aboriginal and/or Torres Babies (n = 2167) with a Perinatal Strait Islander babies (n = 434) born Data Collection (PDC) record of birth Results between 2006 and 2008, included in to an Aboriginal and/or Torres Strait previous study. Perinatal Data Islander mother (n = 1993) in Far Collection (PDC) records located for 381 North Queensland (FNQ) in 2009 or Linked de-identified data was provided in babies and their mothers (n = 339) 2010 May 2017 for 2,548 Aboriginal and Torres Strait Islander children born to 2,332 mothers in Far North Queensland between 2006 and

PDC records available for n = 2548 babies and their 2010. Ferret records were available for 1,155 mothers n = 2332 children of 1,074 mothers. The number of children for whom this information was

Children n = 380 of n = 339 mothers had Ferret Children n = 775 of n = 735 mothers had Ferret available is close to the estimated 1,147 longitudinal health record longitudinal health record child residents based on census population

figures for those localities (Figure 1, Map 1, Supplementary Table 4). Information was Exclusions: Exclusions: excluded where the mother was non-  Non‐Indigenous mother n = 15  Mother not resident in FNQ n = 5  Mother not resident in FNQ n = 10  Second birth (n = 43) to same mother Indigenous (n=15), not resident in Far North  Second birth (n = 40) to same  Third birth (n = 1) to same mother Queensland (n=15) and where the child was mother  Second born twin n = 3 not the first child born to his/her mother  Second born twin n = 3  Mothers already included in Cape York cohort (n = 78) in the cohort years (n=90). Seventy-eight mothers were excluded from the 2009–2010

After exclusions: After exclusions: cohort because they were already included  Children n = 312  Children n = 645 in the Cape York cohort. After exclusions, the  Mothers n = 312  Mothers n = 645 number of unique mother and child pairs was 957 (Figure 1). 957 unique mother and child pairs Ferret records showed at least one visit to health services between age six and 23 months for 904 (94.5%) of these 957 children, Child seen by health services aged 6 to 23 months of whom 708 (74.0%) had a haemoglobin n = 904 level recorded at least once between the ages of six and 23 months (Supplementary Tables 5 and 6). No significant differences were seen Child seen by health services and haemoglobin between children for whom haemoglobin measured aged 6 to 23 months measurements were available and those n = 708 Figure 2. Incidence of Anaemia among Aboriginal and Torres Strait Islander children (n = 708) of Far North Queenslandwithout haemoglobin from age 6 tomeasurements, 23 except months, and by 6 month age groups (%, 95% confidence interval) that children from Cape York were more likely to have been seen by health services and Figure 2: Incidence of anaemia among Aboriginal and Torres Strait Islander children (n = 708) of Far North have had a measurement of haemoglobin Queensland from age six to 23 months, and by six-month age groups (%, 95% confidence interval). made, compared to children from elsewhere (p<0.001), see Supplementary Tables 5 and 6. Of these 708 children, 61.3% (95%CI 57.7%, 6 ‐ 23 months (n=708) 64.9%) had at least one haemoglobin measure showing anaemia; the incidence of anaemia by six-month age groups was 18 ‐ 23 months (n=462) highest at 12–17 months (Figure 2). Mean

group haemoglobin was above the level indicating

12 ‐ 17 months (n=515) anaemia (105 g/L) at six to 11 months;

Age 109.8 g/L (95%CI 108.7,110.9) but below the level indicating anaemia (110 g/L) at 6 ‐ 11 months (n=492) 12–17 months; 109.3 g/L 95%CI 108.3, 110.3) and close to that level (110 g/L) at 18–23 0.0 20.0 40.0 60.0 80.0 months; 111.8 (95%CI 110.8, 112.8), see Incidence of anaemia (%; 95%CI) Supplementary Figure 1. Among children anaemic at six to 11 months who had subsequent haemoglobin measurements, 102 out of 150 (68%) were also anaemic at

12–17 months and 69 out of 138 (50%) at higher incidence of early childhood anaemia Aboriginal and Torres Strait Islander children 18–23 months. among children of mothers who smoked of Far North Queensland with the incidence Haemoglobin measurements were not in pregnancy compared to children of of anaemia being 61.3% between the age available for 249 children between the age mothers who did not smoke in pregnancy of six and 23 months. Many children with of six and 23 months. If it is assumed that (MI p=0.023), see Table 3. Birthweight, age anaemia before the age of 12 months were all these children did not have anaemia, of mothers and anaemia of mothers in the still anaemic in the second year of life. Mean the number of children without anaemia third trimester of pregnancy were found to be haemoglobin levels were low; below the (n=249 + 274) would be n=523. Under this confounding factors in multivariable analyses. diagnostic level for anaemia from 12 to 17 hypothetical assumption, the incidence of months. Our findings are consistent with early childhood anaemia would be 45.4% Discussion reports of high rates of early childhood (95%CI 42.2%, 48.5%). anaemia among Aboriginal and Torres Strait Islander infants and young children elsewhere Bivariate analysis (n=708) showed the This study shows that early childhood in northern Australia.24,44,45 incidence of early childhood anaemia was anaemia was common among these (n=708) higher among boys (65.8%) compared to girls (56.5%, p<0.001) and among children born Table 1a: Incidence of Early Childhood Anaemia (anaemia between age six and 23 months) among Aboriginal and by caesarean section (69.5%) compared to Torres Strait Islander children (n=708) of Far North Queensland by characteristics of the children. those born by vaginal birth (57.7%, p<0.001). Characteristics of children n Child ever anaemic P value Children who had early childhood anaemia age 6–23 months (logistic regression adjusted for had lower mean birthweight (3,159g vs. n (%) [95%CI] cohort – unless stated otherwise) 3,217g, p=0.01) and lower mean birthweight Cohorts: z-score (+0.082 vs. +0.274, p=0.001), and Both combined 708 434 (61.3%) [57.7%, 64.9%] n/a higher mean gains in z-score (+0.254 v-0.013, 2009–2010 births cohort 407 199 (48.9%) [44.1%, 53.8%] chi2 <0.001 p<0.001) for weight for age in early life, see Cape York cohort 301 235 (78.1%) [73.4%, 82.8%] Tables 1a and 1b). Gender: Children of Aboriginal mothers (71.4%) had Male 363 239 (65.8%) [60.9%, 70.7%) <0.001 Female 345 195 (56.5%) [51.3%, 61.8%] higher incidence of early childhood anaemia Birth method: than children of mothers who were Torres Vaginal 473 273 (57.7%) [53.2%, 62.2%] base Strait Islander (46.9%) or both Aboriginal and Vaginal/Instrumental 35 22 (62.9%) [46.0%, 79.7%] <0.001 Torres Strait Islander (43.9%, p<0.001), see Caesarean 200 139 (69.5%) [63.1%, 75.9%] <0.001 Table 2). Birth Weight category: Multi-variable analysis (Table 3) showed Low birth weight (<2,500g) 81 52 (64.2%) [53.5%, 74.9%] 0.008 higher incidence of early childhood anaemia Normal (2,500–4,000g) 580 355 (61.2%) [57.2%, 65.2%] base among children born by caesarean section Marcosomic (>=4,000g) 47 27 (57.4%) [42.8%, 72.1%] 0.782 compared to children born by vaginal birth Gestational age category: (p<0.001), children with higher gains in Preterm (<37 weeks) 82 50 (61.0%) [50.2%. 71.8%] 0.893 weight for age (p<0.001) and children of Full-term (>=37 weeks) 626 384 (61.3%) [57.5%, 65.2%] mothers with a parity of three children or Feeding method birth to 4-6 months; n=544 (164 missing) more (p<0.001), and lower incidence of early Only breast milk 228 157 (68.9%) [62.8%, 74.9%] base childhood anaemia among girls compared Only infant formula 56 30 (53.6%) [40.1%, 67.0%] 0.249 to boys (p<0.001). Children whose mothers Breast milk and formula 260 159 (61.2%) [55.2%, 67.1%] 0.018 were Torres Strait Islander (p<0.001) or both Aboriginal and Torres Strait Islander Table 1b: Incidence of Early Childhood Anaemia (anaemia between age six and 23 months) among Aboriginal and (p<0.001) had lower incidence of early Torres Strait Islander children (n = 708) of Far North Queensland by characteristics of the children. childhood anaemia compared to children Characteristics of children All Ever anaemic age Not anaemic age P value whose mothers were Aboriginal (Table 3). The n=708 6–23 months 6–23 months (logistic regression analysis was repeated using mother’s region n=434 n=274 adjusted for cohort) of residence instead of mother’s ethnicity. Gestational age at birth weeks 39 39 39 0.036 – median (IQR) [range] (38–40) (38–40) (38–40) Children of mothers who were resident in the [26–42] [27–42] [26–42] Torres Strait and Northern Peninsula Area (MI Birth weight - grams mean 3,181 3,159 3,217 0.010 p=0.003) and children of mothers resident (95% CI) [range] (3,136, 3,225) (3,102, 3,215) (3,145, 3,288) in Cairns and Hinterland (MI p=0.005) had [800–5,320] [800–5,320] [960–4,780] lower incidence of early childhood anaemia Z-score for birth-weight for +0.16 +0.082 +0.274 0.001 compared to children of mothers resident in gestational age mean (95%CI) (+0.07, +0.24) (-0.021, +0.18) (+0.142, +0.405) [range] n=692 (missing n=16) [-2.9–+4.3] [-2.9–+4.3] [-2.4–+3.2] Cape York (Supplementary Table 7). n=692 n=426 n=266 Multi-variable analysis showed disparate Z-score-change birth to first 0.16 +0.254 -0.013 <0.001 results in respect of smoking in pregnancy. weight at age 4 -6 months (+0.057, +0.255) (+0.125, +0.382) (-0.167, +0.140) Multiple imputation analysis, but not mean (95% CI) [range] [-3.7–+3.7] [-3.7–+3.7] [-3.5–+3.0] n=527(missing n=181) n=527 n=334 n=193 complete case analysis, showed significantly

The finding of more early childhood anaemia newborn.8,9 Caesarean births are increasing Our findings show that children of among children born by caesarean or vaginal/ among Indigenous mothers; this finding may Aboriginal mothers had higher incidence instrumental births may reflect the urgency be particularly relevant for the Torres Strait of early childhood anaemia compared to of such births, with early cord clamping where diabetes in pregnancy and births by children of mothers who were Torres Strait reducing transfer of placental blood to the caesarean section are common.46,47 Islander or both Aboriginal and Torres Strait Islander. Further analysis by mother’s region Table 2: Incidence of Early Childhood Anaemia (anaemia between age six and 23 months) among Aboriginal and of residence showed the same pattern. Torres Strait Islander children (n = 708) of remote Far North Queensland by characteristics of their mothers These results reflect the different history of Characteristics of mothers n Child ever anaemic P value Aboriginal people of Cape York compared age 6–23 months (logistic regression to people of the Torres Strait. Government n (%) [95%CI] adjusted for cohort) policies forcibly relocated Queensland Ethnicity Aboriginal people from their traditional lands Aboriginal 423 302 (71.4%) [67.1%, 75.7%] base to mission settlements, some of which are Torres Strait Islander 228 107 (46.9%) [40.4%, 53.5%] <0.001 now the remote communities of Cape York.48 Both Aboriginal and Torres Strait Islander 57 25 (43.9%) [30.6%, 57.1%] <0.001 This “large scale relocation did not occur Region of residence in the Torres Strait”.48 Despite Government Cairns and Hinterland 56 29 (51.8%) [38.3%, 65.3%] 0.025 restrictions and impositions, Torres Strait Cape York 442 318 (72.0%) [67.7%, 76.2%] base Islander peoples largely remained on their Torres Strait and Northern Peninsula Area 210 87 (41.4%) [34.7%, 48.1%] 0.023 traditional lands, a key factor in preserving SEIFA – usual residence cultural continuity, including traditional food Mother resident in SEIFA 1 620 377 (60.8%) [57.0%, 64.7%] 0.509 systems.48 Mother resident in SEIFA 2 - 10 88 57 (64.8%) [54.6%, 75.0%] Body Mass Index of mothers (n=481, missing n=227) The high cost of nutritious food has been Underweight (9.8%) 47 34 (72.3%)[59.1%, 85.6%] 0.037 widely reported, while household food Healthy weight (35.8%) 172 93 (54.1%) [46.5%, 61.6%] base insecurity is exacerbated by smoking.49,50 The Overweight (25.2%) 121 63 (52.1%) [43.0%, 61.1%] 0.459 implications of poor health of mothers on Obese (29.3%) 141 68 (48.2%) [39.9%, 56.6%] 0.032 the future health of their children have been Teenage mothers raised previously.51 The intergenerational Teenage mother 163 95 (58.3%) [50.6%, 65.9%] 0.162 association reported here, of high parity Mother age 20 years or older 545 339 (62.2%) [58.1%, 66.3%] and maternal smoking with early childhood Antenatal visits (missing n=1) anaemia, reflects the shared experiences of Less than 5 visits 83 43 (51.8%) [40.8%,62.8%] <0.001 food insecurity of these mothers and their 5 visits or more 642 390 (62.5%) [58.7%, 66.3%] children in a context of poverty and social Parity (missing n=233) disadvantage that is particularly challenging nil to 2 277 161 (58.1%) [52.3%, 64.0%] 0.103 in Cape York.48 3 or more 198 127 (64.1%) [57.4%, 70.9%] The limitations of this study are those Smoked in pregnancy (n=703, missing n=5) associated with the use of routine health Yes 439 275 (62.6%) [58.1%, 67.2%] 0.020 service data, including missing information.29 No 264 155 (58.7%) [52.7%, 64.7%] The multiple imputation methodology was Gestational Diabetes (n=421, missing n=287) used to adjust for missing values and results Yes 75 42 (56.0%) [44.5%, 67.5%] 0.329 are presented for both complete case and No 346 198 (57.2%) [52.0%, 62.5%] multiple imputation analyses. However, Pre-existing Diabetes (n=587, missing n=121) some information was not recorded on Yes 33 23 (69.7%) [53.1%, 86.2%] <0.001 No 554 330 (59.6%) [55.5%, 63.7%] the electronic data collections accessed for Pregnancy Induced Hypertension (PIH) this study. For example, information about Yes 45 31 (68.9%) [54.8%, 83.0%] 0.026 treatment of anaemia was not available for No 663 403 (60.8%) [57.1%, 64.5%] mothers or children. It may be that treatment Anaemia in third trimester (n=657, missing n=51) of maternal anaemia protects the unborn Yes 336 202 (60.1%) [54.9%, 65.4%] 0.014 child from subsequent anaemia, but this No 321 199 (62.0%) [56.7%, 67.3%] hypothesis could not be tested. Similarly, the Iron deficiency in pregnancy (n=385, missing n=323) lack of information on treatment of children Yes 185 110 (59.5%) [52.3%, 66.6%] 0.775 meant that the effect of treatment at first No 200 123 (61.5%) [54.7%, 68.3%] diagnosis of early childhood anaemia on Low Red Cell Folate (RCF) before/during pregnancy (n=158, missing n=550) subsequent haemoglobin levels could not be Yes 20 16 (80.0%) [60.8%, 99.2%] <0.001 assessed. No 138 71 (51.5%) [43.0%, 59.9%] In addition, many (26.0%) of the 957 children Low B12 before/during pregnancy (n=131, missing n=577) with a Ferret record did not have a measure Yes 22 7 (31.8%) [10.7%, 53.0%] 0.151 of haemoglobin recorded between the age of No 109 62 (56.9%) [47.4%, 66.3%] six and 23 months; most (n=196, 20.5%) were

Table 3: Risk factors for Early Childhood Anaemia (n=708); multi-variable analysis – complete case analysis and analysis with imputed data. Complete case analysis Imputed data analysis n=329 n=708 Characteristic Anaemia No Anaemia Odds-ratio p-value Number Anaemia No Anaemia Odds-ratio p-value n=203 n=126 (95% CI)a of missing n=434 n=274 (95% CI)a values (%) (61.7%) (38.3%) (61.3%) (38.7%) Sex of child 0 Male 115 (56.7%) 59 (46.8%) 1 239 (55.1%) 124 (45.3%) 1 Female 88 (43.4%) 67 (53.2%) 0.63 (0.59, 0.67) P<0.001 195 (44.9%) 150 (54.7%) 0.62 (0.55, 0.71) P<0.001 Z-score-change from birth to 4 to 6 months / / 1.3 (1.2, 1.4) p<0.001 181 (25.6%) / / 1.2 (1.1, 1.3) P<0.001 Age of motherb / / 0.97 (0.92, 1.02) P=0.224 0 / / 0.99 (0.98, 1.00) P=0.096 Ethnicity of mother 0 Aboriginal 144 (70.9%) 55 (43.7%) 1 302 (69.6%) 121 (44.2%) 1 Torres Strait Islander 46 (22.7%) 54 (42.9%) 0.34 (0.21, 0.53) P<0.001 107 (24.7%) 121 (44.2%) 0.35 (0.22, 0.56) P<0.001 Both 13 (6.4%) 17 (13.5%) 0.26 (0.17, 0.39) P<0.001 25 (5.8%) 32 (11.7%) 0.28 (0.19, 0.42) P<0.001 Parity 233 (32.9%) Up to 2 children 124 (61.1%) 79 (62.7%) 1 284 (65.4%) 193 (70.4%) 1 3 or more children 79 (38.9%) 47 (37.3%) 2.1 (1.7, 2.5) P<0.001 150 (34.6%) 81 (29.6%) 1.8 (1.4, 2.5) P<0.001 Birth method 0 Vaginal 125 (61.6%) 100 (79.4%) 1 273 (62.9%) 200 (73.0%) 1 Vaginal instrumental 8 (3.9%) 3 (2.4%) 3.1 (1.9, 5.2) P<0.001 22 (5.1%) 13 (4.7%) 1.4 (1.1, 1.9) P=0.013 Caesarian 70 (34.5%) 23 (18.3%) 3.0 (2.9, 3.1) P<0.001 139 (32.0%) 61 (22.3%) 1.7 (1.4, 2.1) P<0.001 Mother anaemic in third trimesterb 51 (7.2%) No 103 (50.7%) 63 (50.0%) 1 216 (49.8%) 131 (47.8%) 1 Yes 100 (49.3%) 63 (50.0%) 1.0 (0.5, 2.2) P=0.934 218 (50.2%) 143 (52.2%) 0.89 (0.77, 1.03) P=0.122 Mother smoked during pregnancy 5 (0.7%) No 75 (37.0%) 50 (39.7%) 1 156 (35.9%) 109 (39.8%) 1 Yes 128 (63.1%) 76 (60.3%) 1.0 (0.7, 1.5) P=0.964 278 (64.1%) 165 (60.2%) 1.2 (1.02, 1.3) P=0.023 Notes: Both models were adjusted for the confounding effect of birth weight (no missing values imputed). a: 95% CI = 95% confidence interval. b: Mother anaemic in third trimester and mothers’ age were identified as confounding variables in complete case data analysis. Imputed data are averages of 40 imputations. seen by health services but haemoglobin The information presented here is for adult man: Estimated Average Requirement levels were not recorded. Children in Cape children born between 2006 and 2010. It is (EAR) child seven to 12 months – 7mg; EAR York were more likely to be seen and to have possible that the situation in respect of early male aged 19 years or more – 6mg.55 Milk a haemoglobin level recorded than children childhood anaemia has changed. However, in is not a rich source of iron; during the first from elsewhere. No other differences were Cape York in 2014 and 2015, about one-in- months of exclusive breastfeeding, a baby identified. However, the reason for this three children aged six to 23 months were draws on iron stores acquired before birth missing data is not known and there may anaemic (n=155, 32.3% anaemic, 95%CI from the mother.5 Subsequently the small be an unidentified bias in the availability of 24.8%, 39.7%) indicating that early childhood quantity of solid food consumed by young relevant information. anaemia continues to be a problem in children must provide most of these high iron 28 10 Another limitation of our study is that Cape York. Comparable information is requirements. Consequently, iron-rich and/ haemoglobin levels were measured on not available from elsewhere in Far North or iron-fortified first foods are recommended 11 capillary blood using HemoCues®. The Queensland. in Australia. use of capillary blood and these devices There is no information to identify the Two studies in the Northern Territory showed may underestimate haemoglobin levels, cause(s) of the anaemia reported here. the association of iron deficiency with which would result in overestimation of Nutrient deficiencies such as iron deficiency childhood anaemia in similar settings. In one the incidence and prevalence of anaemia.52 cause anaemia, as do chronic infections.1,54 study, among young Aboriginal children Validation studies suggest that the Iron deficiency is the ‘usual suspect’ as a (n=74) with anaemia, most (n=62, 84%) had HemoCue® is suitable for screening purposes nutrition-related cause of anaemia in early iron deficiency anaemia, with folate deficiency but, where anaemia is suspected, other life because of the high requirements for iron and chronic infections identified as causes methods should also be used.53 However, due to rapid growth.10 Iron requirements per of anaemia in the other children.21 Another health service protocols for diagnosis and kilogram of body weight are higher at six to Northern Territory study among school-age treatment of anaemia in remote Far North 12 months than at other stages of the life children with anaemia (n=201) found that iron Queensland are based on HemoCue® cycle.5 Australian estimates show that the therapy was effective in resolving anaemia measurements.33 daily iron requirements of a child aged seven among 83% of the 66 children for whom to 12 months are higher than those of an follow-up measurements were available.22

Several of the risk factors identified here are opportunity to impact neurodevelopment 14. Food Standards Australia New Zealand. Indigenous 2 Food 2010 Composition of Indigenous Foods of Australia- consistent with iron deficiency as a cause of and brain function through the lifespan”. updated [Internet]. Canberra (AUST): FSANZ; 2015 [cited the anaemia: birth by caesarean section; rapid Prevention of early childhood anaemia, 2018 Jul]. early growth; and boys compared to girls, as included as a key strategy to ‘Close the Gap’ 15. Australian Bureau of Statistics. 4727.0.55.005- Australian Aboriginal and Torres Strait Islander Health Survey: boys typically have higher early weight gains between Aboriginal and Torres Strait Islander Nutrition Results-Food and Nutrients 2012-13. Canberra than girls.56,5 Australians and other Australians,65 would (AUST): ABS; 2016. 16. Eades SJ, Read AW, McAullay D, McNamara B, O’Dea K, Infections are another probable cause benefit the Aboriginal and Torres Strait Stanley FJ. Modern and traditional diets for Noongar of anaemia in these children, with high Islander children of Far North Queensland – infants. J Paediatr Child Health. 2010;46(7-8):398-403. 17. Leonard D, Aquino D, Hadgraft N, Thompson F, Marley J. rates of infectious diseases reported for and elsewhere in northern Australia. Poor nutrition from first foods: A cross sectional study of Aboriginal and Torres Strait Islander children complementary feeding of infants and young children in six remote Aboriginal communities across northern 57 of remote Far North Queensland. There is a Acknowledgements and Australia. Nutr Diet. 2017;74(5):436-45. bidirectional relationship between infectious 18. Moradi S, Arghavani H, Issah A, Mohammadi H, Mirzaei funding K. Food insecurity and anaemia risk: A systematic review disease and nutrition status; frequent illness and meta-analysis. Public Health Nutr. 2018;21(16):1-13. impairs nutrition status and poor nutrition Dympna Leonard was supported by a 19. Brewster DR. Iron deficiency in minority groups in status increases susceptibility to infection.58 Australia. J Paediatr Child Health. 2004;40:422-3. National Health and Medical Research Council 20. Edmond K. Anaemia in mothers and infants living The immune response to infections restricts post-graduate scholarship APP1092732. in disadvantaged communities. J Trop Pediatr. iron availability to infectious organisms; when 2014;60(6):407-8. Other agencies provided non-financial 21. Kruske SG, Ruben AR, Brewster DR. An iron treatment prolonged, this immune response can lead to support to this research. We acknowledge trial in an Aboriginal community: Imporving non- anaemia.59 adherence. J Paediatr Child Health. 1999;35:153-8. and thank the Aboriginal and Torres Strait 22. Udovicich C, Perera K, Leahy C. Anaemia in school-aged However, the diagnosis of anaemia based on Islander leaders of the key community- children in an Australian Indigenous community. Aust haemoglobin only, as in this study, cannot controlled health service organisations in J Rural Health. 2017;25(5):285-9. 23. Northern Territory Health. Healthy Under Five Kids identify the cause(s) of anaemia. The lack of far north Queensland who considered and 2017-18. Darwin (AUST): Government of the Northern information on the causes of early childhood endorsed the proposed research, providing Territory; 2018. 24. Pasricha S-R, Flecknoe-Brown SC, Allen KJ, et al. anaemia is not only a limitation of this study the support that made this research possible. Diagnosis and management of iron deficiency but also a limitation of methods currently In addition, we acknowledge and thank the anaemia: A clinical update. Med J Aust. 2010;193(9):525- available to identify causes of anaemia in 32. Queensland Health Data Custodians and their 25. Zhou SJ, Gibson RA, Gibson RS, Makrides M. Nutrient early childhood; in particular, the assessment research and data management staff for their intakes and status of preschool children in Adelaide, of iron status is complex in the presence of assistance and support for this work. South Australia. Med J Aust. 2012;196(11):696-700. 26. Mackerras D, Hutton SI, Anderson PR. Haematocrit 60,54 infection. levels and anaemia in Australian children aged 1-4 years old. Asia Pac J Clin Nutr. 2004;13(4):330-5. Prevention of early childhood anaemia References 27. Queensland Statistician’s Office. Resident Population is important as successful treatment of Profile 2017 [Internet]. Brisbane (AUST): State 1. World Health Organization. Nutritional Anaemias: Tools anaemia may not reverse the associated Government of Queensland; 2017 [cited 2017 Jul 11]. for Effective Prevention and Control. Geneva (CHE): WHO; 28. Apunipima Cape York Health Council. Anaemia in Young 2 neurological deficits. Where the prevalence 2017 Children of Cape York: Results of a Chart Audit. Cairns of early childhood anaemia is high (20% 2. Georgieff MK, Ramel SE, Cusick SE. Nutritional (AUST): Apunipima Cape York Health Council; 2016. influences on brain development. Acta Paediatr. 29. Leonard D, Buettner P, Thompson F, Makrides M, or more), WHO recommends interventions 2018;107(8):1310-21. McDermott R. Linking ‘data silos’ to investiate anaemia that combine promotion of breastfeeding 3. Zimmermann MB, Hurrell RF. Nutritional iron deficiency. among Aboriginal and Torres Strait Islander mothers Lancet. 2007;370:511-20. and children in Far North Queenland. Aust N Z J Public and healthy food with home fortification 4. Prado EL, Dewey KG. Nutrition and brain development Health. 2018;42(5):256-62. of solid foods using multi-micronutrient in early life. Nutr Rev. 2014;72(4):267-84. 30. Queensland Health. Queensland Perinatal Data 5. Domellöf M. Iron requirements in infancy. Ann Nutr preparations for babies/children aged six Collection Manual for the Completion of Perinatal Data. Metab. 2011;59(1):59-63. Brisbane (AUST): State Government of Queensland; 1,61-63 to 23 months. Such interventions have 6. Scholl TO. Maternal iron status: Relation to fetal growth, 2016. been demonstrated to be acceptable, safe length of gestation, and iron endowment of the 31. Queensland Health. Queensland Health Pathology neonate. Nutr Rev. 2011;69 Suppl 1:23-9. Services. Cairns (AUST): State Government of and effective in the prevention and treatment 7. Balarajan Y, Ramakrishnan U, Özaltin E, Shankar AH, Queensland; 2016. of early childhood anaemia in low-income Subramanian SV. Anaemia in low-income and middle- 32. Queensland Health. Ferret-Better Health Outcomes income countries. Lancet. 2011;378(9809):2123-35. Project. Cairns (AUST): State Government of settings where the infectious disease burden 8. Dewey KG, Chaparro CM. Iron status of breast-fed Queensland; 2005. is high.61-63 One such intervention, the infants. Proc Nutr Soc. 2007;66(3):412-22. 33. Queensland Health. Primary Clinical Care Manual: 9. McDonald SJ, Middleton P, Dowswell T, Morris PS. Effect Fred Hollows Foundation Early Childhood Paediatrics. 9th ed. Carins (AUST): State Government of timing of umbilical cord clamping of term infants on of Queensland; 2017. Nutrition and Anaemia Prevention Project maternal and neonatal outcomes. Cochrane Database 34. Villar J, Ismail LC, Victora CG et al. International standards (ECNAPP), was successfully piloted in six Syst Rev. 2013 Jul 11;(7):CD004074. for newborn weight, length and head cicumference by 10. Dewey KG. The challenge of meeting nutrient needs gestational age and sex: The Newborn Cross-Sectional remote communities across northern of infants and young children during the period of Study of the INTERGROWTH-21st Project. Lancet. Australia in 2010–2012.64 Nutrition-focused complementary feeding: An evolutionary perspective. 2014;384(9946):857-68. J Nutr. 2013;143(12):2050-4. 35. Intergrowth-21st Network. Newborn Size Pakage interventions will be strengthened by 11. National Health and Medical Research Council. Infant [Internet]. Version 1.3.5. Oxford (UK): University of complementary interventions to improve Feeding Guidelines. Canberra (AUST): NHMRC; 2013. Oxford Oxford Maternal & Perinatal Health Institute; 12. O’Dea K, Jewell PA, Whiten A, Altmann SS, Strickland food security and reduce infections in early 2014 [cited 2018 Apr]. Availabe from: https:// ST, Oftland OT. Traditional diet and food preferences intergrowth21.tghn.org/newborn-size-birth/#c4 58 life. of Australian aboriginal hunter-gathers. Philos Trans R 36. de Onis M, Onyango A, Borghi E, et al. Worldwide Soc Lond B Biol Sci. 1991;334(1270):233-40; discussion implementation of the WHO Child Growth Standards. Improved nutrition in the first one thousand 240-1. Public Health Nutr. 2012;15(9):1603-10. days of life – through pregnancy up to 13. Lee AJ. The transition of Australian aboriginal diet and nutritional health. World Rev Nutr Diet. 1996;79:1-52. the age of two years – provides “a golden

37. World Health Organization. WHO Child Growth 58. Dewey KG, Mayers DR. Early child growth: How do Supplementary Table 5: Far North Standards: Methods and Development: Length/height- nutrition and infection interact? Matern Child Nutr. for-age, Weight-for age, Weight-for-length, Weight-for- 2011;7 Suppl 3:129-42. Queensland Aboriginal and/or Torres Strait height and Body Mass Index-for-age. Geneva (CHE): 59. Ganz T. Iron in innate immunity: Starve the invaders. Islander children with a Ferret record (n = WHO; 2006. Curr Opin Immunol. 2009;21(1):63-7. 957): comparing those seen by health services 38. National Health and Medical Research Council. 60. Lynch S, Pfeiffer CM, Georgieff MK, et al. Biomarkers of Australian Dietary Guidelines. Canberra (AUST): NHMRC; nutrition for development (bond)-iron review. J Nutr. at age six to 23 months (n = 904) with those 2013. 2018;148 Suppl 1:1001-67. not seen (n = 53). 39. Australian Institute of Health and Welfare. Australia’s 61. Dewey KG, Yang ZY, Boy E. Systematic review and meta- Mothers and Babies 2015-in brief. Canberra (AUST): analysis of home fortification of complementary foods. Supplementary Table 6: Far North AIHW; 2017. Matern Child Nutr. 2009;5(4):283-321. Queensland Aboriginal and/or Torres Strait 40. Queensland Health. Primary Clinical Care Manual: Sexual 62. Nyhus Dhillon C, Sarkar D, Klemm RD, et al. Executive and Reproductive Health. 9th ed. Cairns (AUST): State summary for the micronutrient powders consultation: Islander children with a Ferret record seen Government of Queensland; 2016. Lessons learned for operational guidance. Matern Child by health services at age six to 23 months (n 41. Australian Bureau of Statistics. Australian Census of Nutr. 2017;13 Suppl 1. doi: 10.1111/mcn.12493. Population and Housing 2011: Socio-Economic Indexes 63. Bhutta ZA, Das JK, Rizvi A, et al. Evidence-based = 904) - comparing those with at least one for Areas (SEIFA). Canberra (AUST): ABS; 2013. interventions for improvement of maternal and child haemoglobin measure (n = 708) with those 42. Kleinbaum DG, Kupper LL, Morgenstern H. nutrition: What can be done and at what cost? Lancet. Epidemiologic Research. Principles and Quantitative 2013;382(9890):452-77. with no haemoglobin measure (n = 196) at Methods. New York (NY): Van Nostrand Reinhold; 1982. 64. Aquino D, Marley J, Senior K, et al. The Early Childhood age six to 23 months. 43. Sterne JAC, White IR, Carlin JB, et al. Multiple imputation Nutrition and Anaemia Prevention Project-Summary for missing data in epidemiological and clinical Report. Darwin (AUST): The Fred Hollows Foundation; Supplementary Table 7: Risk factors for research: Potential and pitfalls. BMJ. 2009;338:b2393. 2013. Early Childhood Anaemia (anaemia between 44. Aquino D, Leonard D, Hadgraft N, Marley J. High 65. Department of the Prime Minister and Cabinet. Closing prevalence of early onset anaemia amongst Aboriginal the Gap-Prime Ministers Report 2018. Canberra (AUST): six and 23 months) among Aboriginal and and Torres Strait Islander infants in remote northern Government of Australia; 2018. Torres Strait Islander children of Far North Australia. Aust J Rural Health. 2018;26(4):245-50. Queensland (n = 708): Results of multi 45. Bar-Zeev SJ, Kruske SG, Barclay LM, Bar-Zeev N, Kildea SV. Adherence to management guidelines for growth Supporting Information variable analysis using region of residence of faltering and anaemia in remote dwelling Australian mother instead of ethnicity in imputed data Aboriginal infants and barriers to health service delivery. BMC Health Serv Res. 2013;13:250. Additional supporting information may be model (all other variables as in Table 3). 46. Thompson F, Dempsey K, Mishra G. Trends in Indigenous found in the online version of this article: and non-Indigenous caesarean section births in the Northern Territory of Australia, 1986-2012: A total Supplementary Figure 1: Mean population-based study. BJOG. 2016;123(11):1814-23. 47. Falhammar H, Davis B, Bond D, Sinha AK. Maternal and haemoglobin (g/L) (with 95% confidence neonatal outcomes in the Torres Strait Islands with a interval) for Aboriginal and Torres Strait sixfold increase in type 2 diabetes in pregnancy over islander children of Far North Queensland by six years. Aust N Z J Obstet Gynaecol. 2010;50(2):120-6. 48. Australian Law Reform Commission. Pathways to six month age groups. Justice-An Inquiry into the Incarceration Rate of Aboriginal and Torres Strait Islander Peoples (ALRC Report 133). Supplementary Table 1: Data collections Canberra (AUST): Government of Australia; 2017. used to source information to investigate 49. Queensland Health. Healthy Food Access Basket 2014 [Internet]. Cairns (AUST): Queensland Health; 2014 Early Childhood Anaemia (anaemia at age [cited 2018 Nov 29]. Available from: https://www. six to 23 months) among Aboriginal and health.qld.gov.au/research-reports/reports/public- Torres Strait Islander children in Far North health/food-nutrition/access/guidelines 50. Markwick A, Ansari Z, Sullivan M, McNeil J. Social Queensland. determinants and lifestyle risk factors only partially explain the higher prevalence of food insecurity among Supplementary Table 2: Definitions of Aboriginal and Torres Strait Islanders in the Australian variables used to describe characteristics of state of Victoria: A cross-sectional study. BMC Public Aboriginal and Torres Strait Islander children Health. 2014;14(598):1-10. 51. McDermott R, Campbell S, Li M, McCulloch B. The health (born between 2006 and 2010) and their and nutrition of young indigenous women in north mothers in Far North Queensland. Queensland-intergenerational implications of poor food quality, obesity, diabetes, tobacco smoking and Supplementary Table 3: “Missingness” of alcohol use. Public Health Nutr. 2009;12(11):2143-9. characteristics in analysis of risk factors for 52. Gwetu TP, Chhagan MK, Craib M, Kauchali S. Hemocue validation for the diagnosis of anaemia in children: A early childhood anaemia in 708 Aboriginal semi-systematic review. Pediat Therapeut. 2013;4:187. children from North Queensland. 53. Sanchis-Gomar F, Cortell-Ballester J, Pareja-Galeano H, Banfi G, Lippi G. Hemoglobin point-of-care testing: The Supplementary Table 4: Early childhood HemoCue system. Lab Autom. 2013;18(3):198-205. 54. Stoltzfus RJ, Klemm R. Research, policy, and anaemia among two cohorts of Aboriginal programmatic considerations from the Biomarkers and Torres Strait Islander children and Reflecting Inflammation and Nutritional Determinants their mothers in Far North Queensland; of Anemia (BRINDA) Project. Am J Clin Nutr. 2017;106 Suppl 1:428-34. comparisons of study participant numbers 55. National Health and Medical Research Council. with census information. Nutrient Reference Values for Australia and New Zealand. Canberra (AUST): NHMRC; 2006. 56. World Health Organization. MultiCentre Growth Study Velocity Report. Geneva (CHE): WHO; 2009. 57. Rothstein J, Heazlewood R, Fraser M, Paediatric Outreach Service. Health of Aboriginal and Torres Strait Islander children in remote Far North Queensland: findings of the Paediatric Outreach Service. Med J Aust. 2007;186(10):519-21.

Participant profile and impacts of an Aboriginal healthy lifestyle and weight loss challenge over four years 2012-2015

Anne C. Grunseit,1,2 Erika Bohn-Goldbaum,1,2 Melanie Crane,1,2 Andrew Milat,1,3 Aaron Cashmore,3,4 Rose Fonua,5 Angela Gow,5 Rachael Havrlant,6 Kate Reid,5 Kiel Hennessey,6 Willow Firth,7 Adrian Bauman1,2

ositive health impacts from small-scale or local lifestyle behaviour change Abstract Pinterventions for Aboriginal Australians Objective: To explore participation, consistency of demographic and health profiles, and short- have been demonstrated. For example, term impacts across six Aboriginal Knockout Health Challenge (KHC) team-based weight loss Canuto et al.1 observed decreased weight, competitions, 2012 to 2015. body mass index (BMI) and blood pressure Methods: Data comprised one competition each from 2012 and 2013 and two per year in among urban Aboriginal women after 12 2014 and 2015. We compared baseline and change (pre- to post-competition) in weight, fruit weeks of a structured exercise and diet and vegetable consumption, physical activity and waist circumference (baseline only) across program. A small trial of a 12-week supervised competitions using mixed models. exercise program2 demonstrated improved Results: Numbers of teams and participants increased from 2012 to 2015 from 13 and 324 to 33 BMI, waist and glucose metabolism measures and 830, respectively. A total of 3,625 participants registered, representing 2,645 unique people in Aboriginal men. Although this and other (25.4% repeat participation). Participants were mainly female and >90% were classified obese 3-5 short-term clinical interventions have at baseline. Baseline weight and weight lost (between 1.9% and 2.5%) were significantly lower shown positive effects, and cultural aspects in subsequent competitions compared with the first. Improvements in fruit and vegetable were incorporated, they were more focused consumption and physical activity were comparable across competitions. on treatment of disease and individuals and Conclusion: The KHC has increasing and sustained appeal among Aboriginal communities, therefore may not achieve population-level attracting those at risk from lifestyle-associated chronic disease and effectively reducing weight change for Aboriginal Australians. Activities and promoting healthy lifestyles in the short term. of daily living or sport-focused interventions may confer greater benefits because of Implications for public health: Community-led programs generated by, and responsive to, access, affordability and their ability to build Aboriginal Australians’ needs can demonstrate consistent community reach and sustained social capital among Aboriginal Australians.6-8 program-level lifestyle improvements. Team sports provide physical health and Key words: physical activity, obesity, intervention, Aboriginal and Torres Strait Islander, weight personal development opportunities and loss may provide a platform for community (facilities and sponsors) often affecting Australian adults have been evaluated.11,12 development benefits (social connection, participation in Aboriginal communities.8 Three early interventions had variations in cultural identity and life skills) through approach (including health education,13-15 community sporting clubs.8-10 Unfortunately, Community-based lifestyle behaviour environmental and policy changes14) and these seldom achieve measurable and duration (six weeks13 to a few years14,15) sustained large-scale community reach, change interventions but demonstrated waist13,15 and weight particularly for Aboriginal peoples, Comparatively few community-based reductions,13 reduced sedentary behaviour,14 with barriers such as costs of transport, physical activity (PA) and nutrition and increased vigorous PA.14 In a review of membership and a lack of sport infrastructure interventions targeting Aboriginal

1. The Australian Prevention Partnership Centre, New South Wales 2. Sydney School of Public Health, University of Sydney, New South Wales 3. Centre for Epidemiology and Evidence, NSW Ministry of Health, New South Wales 4. School of Public Health and Community Medicine, University of NSW, New South Wales 5. NSW Office of Preventive Health, New South Wales 6. Agency for Clinical Innovation, New South Wales 7. South Coast Women’s Health and Welfare Aboriginal Corporation, New South Wales Correspondence to: Dr Anne C. Grunseit, The Australian Prevention Partnership Centre, Sydney School of Public Health, Level 6, Charles Perkins Centre, University of Sydney, Camperdown, NSW 2006; e-mail: [email protected] Submitted: January 2019; Revision requested: April 2019; Accepted: May 2019 The authors have stated the following conflict of interest: Authors Fonua, Gow and Reid have a non-financial competing interest in that they work for the organisation that operates the program. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Aust NZ J Public Health. 2019; 43:328-33; doi: 10.1111/1753-6405.12914

PA or sport programs targeting Aboriginal of the Knockout Health Challenge (KHC), term impacts on participants’ risk profiles and Torres Strait Islander people, MacNiven across the state of New South Wales (NSW). were consistent and sustained across six found 39 programs addressing PA or sport in The lag between evidence generation competitions, 2012 to 2015. adults operating in or since 2012, primarily and implementation at scale is a major in the grey literature. Only 25 reported any impediment to health improvement for Methods evaluation data, few are publicly available Aboriginal people, as it denies or delays and not all include health outcomes.12 Of the community access to effective programs. Study design and data collection three including weight-related outcomes, Change in participant outcomes from only one was evaluated and showed The NSW Aboriginal Knockout Health baseline to completion for each competition significant reductions in waist circumference, Challenge was monitored for prize allocation and weight and BMI, and significant increases The community-based interventions ongoing delivery of the program using in intake of vegetables and of fruit.16 described above were not sustained over single group pre-post design. Written Together, these results suggest that effects time and were relatively small-scale, and the consent allowed the use of these data for of community-based PA interventions with studies evaluating them were published more prize calculation and research purposes. Aboriginal Australians can result in modest than 10 years ago. More recently, the NSW This analysis used information from one KHC but significant changes in risk profiles, but Aboriginal KHC has been running team-based competition from 2012 and 2013 and two more evaluations are needed to build the competitions in weight loss through PA and per year in 2014 and 2015. A summary of the evidence base. healthy eating in NSW, Australia, with up data collected over the years 2012–2015 is to 830 participants per competition (www. shown in Table S1. Prior to each competition, Impact of lifestyle-related disease on nswknockouthealthchallenge.com.au). participants joined a team and recorded Aboriginal populations Community teams with 20 to 30 Aboriginal their name, date of birth, and gender on a It is clear that non-communicable adults compete in the KHC for prize money registration form. From 2013, self-reported chronic diseases (NCDs) continue to be that funds community initiatives in health, current smoking status and fruit and leading contributors to disease burden of sport, nutrition or fitness. Teams are formed vegetable intake (servings of each on a Australians.17 They are particularly prevalent through existing social networks and local typical day) was recorded and, from 2014, among Aboriginal and Torres Strait Islander promotional activities and self-determine PA (frequency in last 7 days of 20 minutes or Australians and are responsible for much the frequency and type of activities they do, more vigorous PA, 30 min or more of walking, of the health gap between Indigenous and but all include one group PA training and and 30 min or more of moderate PA) was non-Indigenous Australian populations.18 one healthy eating activity. In 2012 and 2013, included using validated questions.21 Starting In 2013, 29% of Aboriginal and Torres Strait there was one 17-week competition, with weight (to nearest 0.1kg), height (cm), and Islander Australian adults were overweight two 10-week competitions in 2014 and two waist measurement (cm) were measured and 37% were obese, these rates being 1.2 12-week competitions in 2015. The Challenge objectively by a doctor or registered nurse and 1.6 times higher, respectively, than in has links to the Koori Knockout competition and also documented on the registration the non-Indigenous population.19 Other (https://www.facebook.com/nswkko/) and form. Registration and consent forms were contributors to NCD development include the Rugby League more generally, which collated by team managers and forwarded dietary and PA habits: 42% of Aboriginal and promote the event. Community engagement to the event organisers. At the conclusion of Torres Strait Islander adults residing in urban is further strengthened through Challenge the competition, participants’ weights were and regional areas consume adequate fruit, Town Committees20 comprising volunteers recorded by a health professional and self- but only 5% consume the recommended across local government, health services and reported lifestyle risk factors via questionnaire vegetable intake; just over half do not meet land councils who support and promote the using the same questions as at registration. the recommended amount of PA, comparable Challenge in their local area. Further details to non-Indigenous populations.19 Smoking are provided in the Supplementary Materials Participants 16 rates among Aboriginal and Torres Strait and elsewhere. An initial evaluation in Participants from teams with 20 members Islander people aged 15 and over have been 2013 showed significant reductions in or more at registration were included in the estimated at 44%, 2.6 times higher than waist circumference, weight and BMI and analysis. A total of 3,625 participants were 19 among non-Indigenous people. For this significant increases in intake of vegetables registered for the six competitions from 2012 16 population, 37% of the burden of disease is and of fruit at the end of the KHC. to 2015, representing 2,645 unique people, preventable through addressing these and Given the lack of large-scale sustained as 671 (25.4%) people took part in more than other modifiable risk factors such as alcohol interventions, in combination with a paucity one competition. 18,19 consumption. Therefore, scaled-up of peer-reviewed studies on community- community-wide program evaluations are based interventions in this population– Data treatment and measures required to build a comprehensive evidence 8 especially sport-based interventions – we Data for the six competitions were merged, base for NCD prevention with this population. compared participation and intervention- with probabilistic record matching by Evaluation of scaled-up interventions is level impacts of the KHC over four years. participant name, sex and date of birth particularly important as it provides evidence Specifically, we examined whether the KHC through an independent data linkage that promising interventions are feasible, continued to attract a relevant demographic agency (The Centre for Health Record appropriate and effective when implemented and at-risk population, the extent of complete Linkage – http://www.cherel.org.au). Where across diverse communities or, as in the case and repeat participation, and whether short- a range was given for health behaviours,

the lowest number was entered (e.g. 2–3 Ethics approval for the secondary analysis Registrant profile across competitions serves of vegetables was recoded as two was provided by the Aboriginal Health and Participants’ baseline health characteristics serves) because people tend to over-estimate Medical Research Council (Project #1125/15). for the six competitions are shown in Table healthy behaviours.22-24 Adequate PA was 2; beta coefficients with 95%CI comparing defined as three or more vigorous sessions/ Results across competitions are in Supplementary week; or five or more walking or moderate Table S2. sessions/week; or 1–2 vigorous sessions/week Participation over competitions and 3–4 walking or moderate sessions/week, Baseline weight, adjusted for gender and age, Participation and competition completion according to previous procedures.25 Fruit was significantly lower for all competitions rates for the 3,625 participants (including and vegetable intakes were also categorised compared with 2012 except for competition 3 repeat participants) are shown in Table 1. for meeting current dietary recommended (beta=-1.09 [95%CI: -2.39, 0.21], p=0.100) and levels of two serves of fruit and five serves of The number of teams registering sufficient marginally lower in competition 5 (beta=- vegetables per day.26 members to start the competition increased 1.27 [95%CI: -2.61, 0.08], p=0.065). However, across four competitions: 2012, 2013 and the all competitions attracted registrants with Analysis first competitions in 2014 and 2015. Second an average of Class 2 obesity (https://www. competitions in 2014 and 2015 attracted cdc.gov/obesity/adult/defining.html). The Across the six competitions, the number of many repeat participants (almost half of smallest significant weight loss (adjusted teams, registrants and mean age of registrants those registering in 2014) with the majority for age and sex) was 1.7kg (competition 3) were calculated for each competition, along of repeaters carrying over from the first and largest 2.8kg (competition 4), with BMI with the proportion in each competition to the second competitions (207/227 and following a similar pattern of results. Starting who were male/female, repeat registrants, 178/246, respectively). The number of unique waist circumference only differed significantly and completers of the competition (had participants for 2014 (both competitions from 2012 in competition 4 (2014), by an both start and end weight). The intraclass combined) was 1,105 and for 2015 was 1,226. average of 3.76cm (95%CI: -7.51, -0.01; correlation (ICC) for the primary variable of The completion rate dropped from almost p=0.049). interest (percentage weight change) within three-quarters in the first competition in 2012 teams ranged between 0.064 (competition 6, In terms of change in other risk factors, to around half to two-thirds of registrants 2015) to 0.295 (competition 1, 2012) across there were no significant differences the six competitions, demonstrating a clear thereafter. The majority of participants were between the first competition where clustering effect for team, which was stronger female, and the average age of participants this was measured and subsequent for the early KHCs. Over all competitions, the was 39.1 years (SD=12.5). competitions in the proportion of registrants ICC for person was 0.170. meeting PA or vegetable consumption Baseline health characteristics (weight, waist circumference, meeting minimum fruit and Table 1: Participation in Aboriginal Knockout Health Challenges 2012 to 2015. vegetable consumption, and sufficient PA) Challenge Year 2012 2013 2014 2015 were compared across competitions with competition 1 2 3 4 5 6 2012 as the reference category for weight Teamsa 13 22 30 18 33 22 and waist circumference, 2013 for smoking, Registrants (start) 324 585 828 484 830 574 fruit and vegetable intake and 2014 for Repeat participants NA 112 (19.2%) 167 (20.2%) 227 (46.9%) 231 (27.8%) 246 (42.3%) PA. Crossed random effects rather than Completersb 239 (73.8%) 379 (64.9%) 544 (65.7%) 259 (53.5%) 531 (64.0%) 323 (56.3%) nested models were used to account for the Males 89 (27.5%) 159 (27.7%) 229 (27.7%) 132 (27.3%) 237 (28.6%) 123 (21.6%) clustering of observations within person Females 235 (72.5%) 416 (72.4%) 599 (72.3%) 352 (72.7%) 592 (71.4%) 447 (78.4%) and within team because people did not Age in years (SD) 38.5 (11.7) 40.1 (13.6) 39.4 (12.5) 38.5 (11.9) 38.8 (12.4) 39.0 (12.2) uniquely nest within teams but changed Notes: 27 teams across competitions. Linear models a: To be eligible to start in a competition a team must have at least 20 registered members were used for continuous variables, and logit b: Participant had both start and end weight. models with QR decomposition were used for dichotomous outcome variables.28 Table 2: Participant health characteristics at start of each competition 2012-2015. To examine the consistency of short-term Competition (year) impacts, difference scores were calculated by At start of competition 1 (2012) 2 (2013) 3 (2014) 4 (2014) 5 (2015) 6 (2015) N=324 N=585 N=828 N=484 N=830 N=574 subtracting baseline from post-intervention Mean weight in kg (SD) 102.2 (21.6) 98.5 (22.4)** 100.9 (22.9) 97.0 (22.9)** 97.1 (24.2) 97.2 (23.0)** scores for each competition. Crossed random Mean BMI (SD) 37.1 (7.5) 35.7 (7.8)* 36.6 (7.7) 35.1 (7.7)** 35.4 (8.0) 35.6 (8.1)* effects models on the difference scores using Mean waist in cm (SD) 115.8 (15.8) 113.3 (16.8) 115.9 (18.3) 111.0 (18.1)* 111.4 (19.3) 112.6 (18.3) the same reference competitions described Meet fruit rec n (%) NA 258 (47.4) 367 (57.4)* 239 (61.0)** 367 (44.3) 259 (46.8) above were generated; differences were Meet veg rec n (%) NA 46 (8.4) 65 (8.7) 63 (14.5) 67 (8.1) 43 (7.8) normally distributed so linear models were Sufficient PA n (%) NA NA 416 (51.4) 231 (50.0) 460 (51.9) 264 (47.7) used for all outcomes. A threshold of 0.05 Daily smoker n (%)a NA 153 (28.7) 248 (30.0) 142 (29.3) 254 (31.3) 127 (23.4) was used for statistical significance and all Notes: analyses were conducted using Stata 14.2 * Significantly different compared with competition 1 (compared with competition 2 for fruit, vegetables and smoking, and competition 3 for PA) at p<0.05, (College Station, TX, USA) and included ** at p<0.01 gender and age (continuous) as fixed effects. a: The model did not converge for current smoker; no formal comparison available.

recommendations at baseline; the latter repeat) registrants showed the same pattern may in part be due to efforts made by KHC was consistently very low with less than of effects (Table S4). By contrast, the change organisers to incentivise, promote and adapt 10% meeting vegetable guidelines for all in fruit and vegetable consumption and the intervention over time. For example, except one competition (Table 2). However, sessions of walking, moderate and vigorous there are start-up funds for teams and free registrants had higher odds of meeting PA were comparable across the competitions. t-shirts, caps and water bottles for individual fruit recommendations in competitions 3 Only in competition 6 was there a marginally participants, a strategy found to be effective (adjusted odds ratio (AOR)=1.58; 95%CI: 1.09, higher increase in vegetable consumption in engaging Aboriginal people in the 1 2.27) and 4 (AOR=1.92; 95%CI: 1.27, 2.92) compared with competition 2, when it was Deadly Step program.30 Moreover, the KHC than competition 2. Smoking rates appeared first measured (beta= 0.37, 95%CI: -0.03, 0.77; is led by local Aboriginal communities and similar for the first four competitions and p=0.072). participants are local Aboriginal people. dropped in the last competition. The program is promoted by the NSW Aboriginal Rugby League Knockout, which Discussion Change compared across engenders team spirit according to previous research,20 and prize funds can be used to competitions Community engagement in program design support local teams joining that competition, Table 3 shows health characteristics at the and implementation is considered a critical leveraging one sport intervention with determinant of program effectiveness of beginning and end for each competition. another. KHC program staff visit teams, healthy lifestyle programs for Aboriginal and Beta coefficients and 95%CI for comparisons informally gathering information about Torres Strait Islander people,14,29 yet few of of the magnitude of change pre- to post- what program components work well these types of programs are evaluated and competition compared with competition and what needs to change. Therefore, the reported in the peer review literature. The 1 (competition 2 for fruit and vegetable sustainability and growth of KHC may be due KHC is an example of a community-led (and consumption and competition 3 for the PA to the flexibility and adaptability required government-supported) intervention run measures) are given in Table S3. for successful intervention on complex over successive years and reaching many Despite the varying competition duration issues in populations coping with multiple hundreds of Aboriginal Australians at risk of across the years (see methods above), there disadvantage.13,14 chronic disease due to lifestyle risk factors. An were few discernible systematic differences in initial evaluation of the 2013 KHC indicated In years with two competitions (2014 and competition outcomes. The analysis showed participants felt they benefitted not only 2015), the second competition attracted a that although short-term impacts were physically, but also from feeling more socially smaller number of participants than the first. modest, there were consistent changes across connected, with improved self-esteem, The second competition in a year runs in the years in the direction of improvements reduced stress and better linkages with their the coldest months which likely contributes in health indicators. In detail, the amount local Aboriginal Medical Service.20 Our study to the reduced participation, as previous of weight lost was greatest in competition of six successive competitions during 2012– research shows PA participation drops in 31 1 whether measured by per cent weight 2015 extends these findings by examining colder months ; the majority of participating lost, kilograms or BMI (Tables 3 and S3). temporal changes in participation and impact teams are based in regional areas, which are Participants who completed competition 1 effect size, making this one of the few studies subject to colder temperatures and may have lost on average about 5% of their starting to examine sustainability of healthy lifestyle less access to all-weather facilities. Organisers body weight, but the average percentage programs for Aboriginal Australians. could consider the feasibility of partnering weight lost for subsequent competitions with organisations with indoor facilities to It is clear the KHC attracts and retains the was between 1.9% and 2.5%, adjusted for enhance the attractiveness of the second interest and active participation of the sex and age (Table S3). A supplementary competition in each year. target population. Increasing participation analysis including only new (as opposed to Completion rates in the KHC were highest for the first competition (74%) and Table 3: Pre and post participant health characteristics from pre to post competition 2012-2015 and percent subsequently were between 55% and weight change. 65%. Attrition rates among weight loss Competition (year) interventions in the literature vary between Outcome 1 (2012) 2 (2013) 3 (2014) 4 (2014) 5 (2015) 6 (2015) 23% and 90% and depend on intervention N=239 N=379 N=544 N=259 N=531 N=324 characteristics, setting, population and length % weight change -4.7 -2.3** -2.2** -2.8 -2.7** -2.6** of the intervention.32 The vast majority of research examining attrition in weight loss pre post pre post pre post pre post pre post pre post interventions targets mainstream populations Weight kg 103.0 98.1 97.2 95.0** 101.0 98.7** 95.2 92.6** 98.4 95.7** 97.0 94.5** in intensive clinic-based programs. One BMI 37.5 35.8 35.1 34.4** 36.0 35.2** 33.9 33.2** 35.3 34.4** 35.0 34.0** community-based six-month weight loss Fruit serves/day NA 1.6 2.0 1.8 2.2 1.9 2.1 1.3 1.7 1.5 1.9 program reported a 47% completion rate,33 Veg serves/day NA 2.3 2.8 2.2 2.8 2.7 3.0 2.0 2.6 2.1 3.0 lower than that found here and perhaps Walking NA NA 2.2 3.0 1.9 2.6 2.1 2.7 1.9 2.8 demonstrating the strength of the group- Moderate PA NA NA 1.6 2.5 1.7 2.4 1.6 2.2 1.5 2.2 based approach of the KHC.34 Team-based Vigorous PA NA NA 1.8 2.5 1.6 2.2 1.9 2.5 1.7 2.4 weight loss has been effective in other Notes: 9 * Significantly different compared with competition 1 (compared with competition 2 for fruit and vegetables, and competition 3 for walking, moderate and populations, but may be particularly vigorous PA) at p<0.05, ** at p<0.01 effective for retention in the KHC because

the format capitalises on local pride and Research is mixed as to whether repeat overestimation of impact. However, given social connections.6,35 The completion rate weight loss attempts are associated with the consistency of the findings over the observed for the KHC therefore fares well greater likelihood of weight loss.44,45 Worick six competitions, it is more likely that the and may even be slightly underestimated, et al. (1993) reported that although repeat effects were associated with participation. because completion was defined as providing participants in their worksite team weight Thirdly, there was no information retained both start weight and final weight, and loss annual competition lost weight, they on teams that did not make the minimum participants may take part in KHC activities also risked ‘weight cycling’, whereby weight 20-registrant cut-off point at the start of until the end but not provide a final weight. lost during the competition was regained in each competition; these data have been 46 The health profile for eating, smoking and the inter-competition period. The 2013 KHC collected since 2016. Finally, because KHC PA behaviours of registrants attracted evaluation showed almost one-third of those was a real-world competition and relied on to subsequent competitions showed no followed up regained weight nine months non-research staff to collate data, baseline 20 difference compared to the first competition post-competition. Our analysis showed that estimates of behaviours in some cases may where that behaviour was measured, but the weight lost and change in diet and PA have taken place once competition activities registrants weighed significantly less in behaviours were similar whether the analysis commenced, thereby possibly biasing impact competitions 2–6 compared with the first. It is was on all participants or confined to only estimates downwards. Further, self-report unclear why; we did not observe a sustained those who were new to the KHC. Future measures may also introduce biases towards downward trend. One possible explanation research could examine within-individual more healthy behaviours; however, the is that those who were most motivated and patterns of weight from the end of one primary outcome of weight was objectively most in need participated in the first KHC. competition to the start of the next to further measured at both pre- and post-intervention Despite this, around three-quarters of KHC investigate inter-competition regain and and showed patterns consistent with the registrants met the definition of obesity. maintenance and associated correlates. other self-reported health behaviours. Further, prevalence of meeting guidelines, KHC, despite being a ‘weight loss challenge’, especially for vegetable consumption, was targets other healthy lifestyle factors and low, demonstrating the KHC consistently showed consistent improvements across six Conclusion attracts those at high risk of chronic disease. competitions, including increased fruit and The KHC has shown to promote (at least) KHC registrants also reflect the broader vegetable intake and increased proportion short-term reductions in weight and Aboriginal population in terms of PA and fruit of people achieving recommended levels improvements in lifestyle-related risk intake, although they fare somewhat better of PA, which benefit health. Previous factors promoting healthy lifestyles among on smoking rates and recommendations epidemiological studies have shown that Aboriginal communities in NSW. Addressing for vegetable consumption.19 The KHC is those who meet recommendations for PA the key chronic disease risk factors, the therefore well-targeted. have better health outcomes than those KHC has potential to make an important who do not within the same weight class.47 The predominance of females (up to 78%) contribution to closing the gap in health Smoking behaviour was not a focus of the is disproportionate to their representation outcomes between Aboriginal and non- 36 intervention until 2018, when referrals to a in the ‘at-risk’ population, but reflects Indigenous people. Future research should 37 smoking cessation program were formally other volunteer weight loss programs. explore characteristics of non-completers included. Future analyses may examine Aboriginal and Torres Strait Islander men have and qualitatively explore non-completion, poor health-seeking behaviours compared changes in smoking outcomes among reduced participation in the second to their female counterparts, for reasons participants. competition in the year, and factors that ranging across cultural (e.g. traditional hinder or encourage male participation in gender-related law) and societal (sex-specific Strengths and limitations the KHC. Finally, future analyses should focus difference in health) factors.38 Introduction Despite growing evidence for effective on repeating participants and their patterns of measures to increase male participation in community-based lifestyle interventions of weight maintenance, regain or further future Challenges are warranted and could for Aboriginal people, previous studies loss between finishing and starting a new include informal consultations to better have been conducted in a single Aboriginal competition. understand the program needs of Aboriginal community, with one notable exception – the men; actively engaging more men in team evaluation of the 2013 KHC. Our evaluation management and program coordination and across six different competitions offers Acknowledgements support roles; or enlisting male Aboriginal unique insights into program implementation The authors would like to acknowledge Dr health workers to promote the KHC as used in at scale and under real-world conditions, 39 Erin Passmore’s contribution to initiating the other settings. addressing a gap in the intervention research project and facilitating access to the data. Losing at least 5% of body weight is evidence base.48 Limitations include, first, considered to be clinically meaningful40 and the absence of a control group, meaning the Data availability while this threshold was not achieved, on effects observed may be unrelated to KHC average, the percentage lost is comparable participation but are unlikely in the absence The datasets generated and/or analysed with other lifestyle behaviour change of any intervention. Second, attrition rates, during the current study are not publicly programs.41,42 For four competitions it although comparable to other weight loss available due to the conditions of ethics exceeded 2.5%, where benefits for glycaemic interventions, were high and those lost approval. Data are available from the authors measures start to improve,43 despite an to follow-up may have lost less weight or upon reasonable request and with permission increasing proportion of repeat participation. not made behavioural changes, risking an of the NSW Ministry of Health.

Funding 15. Chan L, Ware R, Kesting J, Marczak M, Good D, Shaw 36. Australian Bureau of Statistics. 4727.0.55.006 - Australian J. Short term efficacy of a lifestyle intervention Aboriginal and Torres Strait Islander Health Survey: The work was funded by the National Health programme on cardiovascular health outcome Updated Results, 2012–13. Canberra (AUST): ABS; 2014. in overweight Indigenous Australians with and 37. Fink JT, Smith DR, Singh M, Ihrke DM, Cisler RA. Obese and Medical Research Council of Australia without type 2 diabetes mellitus: The healthy lifestyle employee participation patterns in a wellness program. (NHMRC) through its Partnership Centre programme (HELP). Diabetes Res Clin Pract. 2007;75:65- Popul Health Manag. 2016;19(2):132-5. grant scheme [grant number GNT9100001]. 71. 38. Wenitong M, Adams M, Holden CA. Engaging Aboriginal 16. Passmore E, Shepherd B, Milat A, Maher L, Hennessey and Torres Strait Islander men in primary care settings. NSW Health, ACT Health, the Australian K, Havrlant R, et al. The impact of a community-led Med J Aust. 2014;200(11):632-3. Government Department of Health, the program promoting weight loss and healthy living 39. Andrology Australia. Engaging Aboriginal and Torres in Aboriginal communities: The New South Wales Strait Islander Males in Primary Care Settings. Melbourne Hospitals Contribution Fund of Australia Knockout Health Challenge. BMC Public Health. (AUST): Monash University School of Public Health and and the HCF Research Foundation have 2017;17(1):951-60. Preventive Medicine Andrology Australia; 2018. 17. Australian Institute of Health and Welfare. Australian 40. Magkos F, Fraterrigo G, Yoshino J, Luecking C, Kirbach contributed funds to support this work as Burden of Disease Study: Impact and Causes of Illness and K, Kelly SC, et al. Effects of moderate and subsequent part of the NHMRC Partnership Centre grant Death in Australia 2011. Canberra (AUST): AIHW; 2016. progressive weight loss on metabolic function and 18. Australian Institute of Health and Welfare. Australian adipose tissue biology in humans with obesity. Cell scheme. The contents of this paper are solely Burden of Disease Study: Impact and Causes of Illness and Metab. 2016;23(4):591-601. the responsibility of the individual authors Death in Aboriginal and Torres Strait Islander People 2011. 41. Vita P, Cardona-Morrell M, Bauman A, Singh MF, Moore Canberra (AUST): AIHW; 2016. M, Pennock R, et al. Type 2 diabetes prevention in the and do not reflect the views of the NHMRC or 19. Australian Institute of Health and Welfare. The Health and community: 12-month outcomes from the Sydney funding partners. Welfare of Australia’s Aboriginal and Torres Strait Islander Diabetes Prevention Program. Diabetes Res Clin Pract. Peoples. Canberra (AUST): AIHW; 2015. 2016;112:13-19. 20. ARTD Consultants. Evaluation of the NSW Knockout 42. 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Breast screening attendance of Aboriginal and Torres Strait Islander women in the Northern Territory of Australia

Kriscia A. Tapia,1 Gail Garvey,1,2 Mark F. McEntee,3 Mary Rickard,1,4 Lorraine Lydiard,5 Patrick C. Brennan1

he national population-based breast Abstract screening program, BreastScreen TAustralia, was implemented in 1991 Objective: To compare breast screening attendances of Indigenous and non-Indigenous with the objective of reducing breast women. cancer mortality through early detection Methods: A total of 4,093 BreastScreen cases were used including 857 self-identified of asymptomatic breast cancers using Indigenous women. Chi-squared analysis compared data between Indigenous and non- mammography. The target participation rate Indigenous women. Logistic regression was used for groupings based on visits-to-screening for biennial screening is 70% of all women frequency. Odds ratios and 95% confidence intervals were calculated for associations with low aged 50–74 years, with the program having attendance. extended the upper target age range from 69 Results: Indigenous women were younger and had fewer visits to screening compared with to 74 years from 2013. However, this objective non-Indigenous women. Non-English speaking was mainly associated with fewer visits for has not been met with rates remaining Indigenous women only (OR 1.9, 95%CI 1.3-2.9). Living remotely was associated with fewer around 18% to 15% lower than the target visits for non-Indigenous women only (OR 1.3, 95%CI 1.1-1.5). Shared predictors were younger since 1996 when uptake data began to be age (OR 12.3, 95%CI 8.1-18.8; and OR 11.5, 95%CI 9.6-13.7, respectively) and having no family calculated.1-3 In addition, inequities between history of breast cancer (OR 2.1, 95%CI 1.3-3.3; and OR 1.8, 95%CI 1.5-2.1, respectively). subgroups of women exist with Aboriginal and Torres Strait Islander women, referred Conclusions: Factors associated with fewer visits to screening were similar for both groups to hereafter as Indigenous women, and of women, except for language which was significant only for Indigenous women, and women living remotely having the lowest remoteness which was significant only for non-Indigenous women. rates of attendance at screening and relatively Implications for public health: Health communication in Indigenous languages may be key in 4 poorer breast cancer outcomes. The efficacy encouraging participation and retaining Indigenous women in BreastScreen; improving access of breast screening in reducing mortality for remote-living non-Indigenous women should also be addressed. depends upon adequate population Key words: breast cancer, screening, participation, Aboriginal and Torres Strait Islander coverage,5 therefore improving participation across all groups of women is crucial to Standards Remoteness Areas classification attendance (41%) is lower than all states effective national cancer control. (ASGSRA).7 Furthermore, the NT has the and territories combined.2,8 Breast cancer is The BreastScreen program was implemented highest proportion of Indigenous residents the most common non-melanoma cancer in the Northern Territory (NT) in 1994. The compared to other Australian states or in Australian women and the number NT has the smallest population in Australia territories, with up to 30% of the population one cancer in NT women.8 Therefore, with dispersed across a geographical area that identifying as Aboriginal and/or Torres Strait evidence that screening prevents 43 deaths makes up 17.5% of the country’s total Islander. Regarding breast screening, the in 10,000 women screened,9 concerted efforts 6 land mass. It has the lowest population NT consistently has the lowest participation to improve screening attendance are needed. density in Australia with the capital city, rates in the nation. NT Indigenous attendance A lower uptake of mammographic screening Darwin, classified as ‘outer regional’ based is less than half of the national rate (24% is not uncommon among Indigenous on the Australian Statistical Geographical vs. 55%, respectively) and the overall NT peoples around the world and the reasons

1. Faculty of Health Sciences, The University of Sydney, New South Wales 2. Charles Darwin University, Wellbeing and Preventable Chronic Diseases Division Menzies School of Health Research, Northern Territory 3. Department of Medicine, University College Cork, Ireland 4. BreastScreen New South Wales 5. BreastScreen Northern Territory Correspondence to: Ms Kriscia A. Tapia: Faculty of Health Sciences, The University of Sydney, New South Wales; e-mail: [email protected] Submitted: December 2018; Revision requested: April 2019; Accepted: May 2019 The authors have stated they have no conflict of interest. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Aust NZ J Public Health. 2019; 43:334-9; doi: 10.1111/1753-6405.12917

for this are multifaceted. While some reasons of the NT Department of Health and Menzies visits to screening and ages to determine cut- for non-participation by Indigenous and School of Health Research (HREC 2016-2627). off points for these variables for Indigenous non-Indigenous women may be similar, Written consent to use personal information and non-Indigenous women. Using these cultural beliefs around breast cancer and for evaluation and research was collected cut-off points, chi-squared tests were used to fatalistic views on health are reported as from women prior to having a screening derive odds ratios (OR) and 95% confidence having significant influence on Indigenous mammogram and only consenting women’s intervals (CI). A p-value <0.05 was considered screening behaviours.10 In addition, systematic data was made available to researchers. significant. barriers to screening are also evident for This consent request is written in the client In the second stage of analysis, we Indigenous Australians, including geographic information form routinely collected by investigated Indigenous and non-Indigenous isolation, lack of means of transportation to BreastScreen NT, a population screening women separately and focused on potential attend services, and a shortage of culturally program. associations with numbers of visits to 11,12 competent facilitators to screening. The study was performed retrospectively screening above and below the cut-off point. Evidence in the US, Canada, Alaska, Pacific using a client data sample retrieved from Categorical variables such as age group, Islands, and New Zealand show that BreastScreen NT. The sample consisted previous breast cancer diagnosis, family Indigenous women are more likely to be of 4,093 women (857 self-identified as history of breast cancer, main language, 13-15 underrepresented in breast screening Indigenous and 3,236 reported being non- geographic remoteness, current breast lump, and have higher breast cancer mortality rates Indigenous) aged between 40 and 85 years and case outcome were analysed using 14-16 compared with non-Indigenous women. who were screened between 30 March and chi-squared tests. Logistic regression was A similar scenario is reported for Indigenous 24 November 2015. BreastScreen NT sends used to derive odd ratios (OR) and 95% and Australian women who, despite lower postal invitations to women aged 50 to 74 confidence intervals (CI). Next, multivariate breast cancer incidence, have poorer health years old to attend screening every two years; stepwise logistic regression was performed outcomes and higher rates of death from however, screening is free for women from 40 on variables with univariate significance to breast cancer when compared with other years of age. Mammograms were performed determine predictive factors for low screening 17 Australian women. Australian Indigenous at permanent screening facilities in the NT attendance. Factors with p values <0.02 were women are also younger and more likely in Darwin, Palmerston, and Alice Springs; retained in the model. to have advanced tumours at the time of women located in remote to very remote BM SPSS© version 24 statistical software was diagnosis compared with non-Indigenous communities in the NT were screened via 18-20 used for the analyses. women, making treatment options limited the BreastScreen NT mobile bus unit. Digital and the tumours potentially more aggressive. image files were sent electronically to Sydney Results National and local strategies to improve Breast Clinic (SBC) in NSW for radiologist accessibility have been implemented with interpretation. Women in this study had visited screening some success, such as the mobile screening Women’s radiologist-reported findings between one and 21 times in their lifetime. vans that travel to remote communities,21 the and self-reported personal details such as That is, for some women, this was their process of block bookings of appointments Indigenous status, date of birth, residential first time attending screening, for those on for Indigenous women,11 evidence-based and address, main language spoken, family the highest end of the range it was their culturally sensitive materials developed by history of breast cancer, previous breast twenty-first visit, and other women ranged Indigenous health experts,22 and involvement cancer, current breast lump, and use of somewhere in between. Figure 1 displays of Indigenous health care workers.23 Despite hormone replacement therapy (HRT) in the proportions of Indigenous and non- these efforts, Indigenous Australians’ the past six months were stored on the Indigenous women according to the number attendance at screening remains around 16% NT Department of Health computerised of times they have attended screening. lower compared with non-Indigenous women database. NT Department of Health personnel (37% vs. 53%, respectively, in 2015) . Table 1 shows that Indigenous women had extracted the data and provided de-identified fewer visits to screening compared with There is currently limited information on the information to researchers. The number of non-Indigenous women with medians of screening characteristics of women in the NT screening rounds that a woman has attended two visits (IQR 1-3) and three visits (IQR as they relate to indigeneity and attendance. was generated by the NT database system 2-7), respectively. Indigenous women were The aim of the current work is to investigate based on number of entries. Women’s younger than non-Indigenous women with variables associated with attendance at residential postcodes were categorised median ages of 54 years (IQR 48-60 years) and BreastScreen for women in the NT. With by the researchers based on the ASGSRA 57 years (IQR 52-63 years), respectively. significant differences shown previously classification. In the NT, only three categories There was a higher proportion of Indigenous between NT women in the screening are available: outer regional, remote and very 24 women residing in remote areas (67.7%) population, a further aim is to measure the remote. variations between Indigenous and non- compared with outer regional areas (13.3%), and 71.3% of Indigenous women Indigenous women’s screening attendances. Data analysis mainly spoke another language at home. In the first stage of analysis, base-line Methods In contrast, non-Indigenous women had differences between Indigenous and non- more than half of the population (56.9%) Data collection Indigenous women’s characteristics and living in outer regional areas than in remote screening attendances were explored. Next, locations (36.2%), and 84.2% mainly spoke Ethical approval was obtained from the Receiver Operating Characteristics (ROC) English at home. Both groups of women Human Research Ethics Committee (HREC) curve analyses were employed for number of reported similar experiences with HRT use

Figure 1 Distribution of Indigenous (n=857) and non-Indigenous women (n=3236) per and personal and family histories of breast numberFigure of 1: Distributionvisits to of BreastScreen Indigenous (n=857) NTand non-Indigenous in 2015. women (n=3236) per number of visits to cancer with greater proportions answering BreastScreen NT in 2015. negatively. Further similarities were shown Screening attendance of Indigenous and non-Indigenous women in that larger proportions of Indigenous and 1 non-Indigenous women reported no breast 2 lump at screening, and majorities in both 3 4 groups had normal mammograms at this 5 round of screening. 6 7 ROC curve analyses determined that 55 years 8 and 3 visits were the cut off-points for age 9 10 and frequency of attendance at screening, 11 respectively, as shown in Table 2. Indigenous 12 Indigenous women were 1.8 times as likely to be under 13 Visit number Visit 14 Non‐Indigenous 55 years of age (OR 1.8, 95%CI 1.5–2.0; 15 p<0.001) and more than 3 times as likely to 16 17 have fewer than 3 visits to screening (OR 3.3, 18 95%CI 2.8–3.9; p<0.001) than non-Indigenous 19 women. 20 21 Table 3 shows the unadjusted results of the 45 40 35 30 25 20 15 10 5 0 5 10 15 20 25 30 35 40 45 two-tailed tests based on screening visits Proportion of women (%) above and below the cut-off point. The following describes the variables associated with low screening attendance (<3 visits). Women were likely to have attended Table 1: Characteristics of Indigenous and non-Indigenous women screened in the NT in 2015. screening less than 3 times if: they were Variables Indigenous Non-Indigenous younger than 55 years compared with N=857 N=3,236 older women (Indigenous: OR 10.8, 95%CI Median age (y) at screening (Q1, Q3) 54 (48,60) 57 (52,63) 7.4–15.7; p<0.001; and non-Indigenous: OR min, max age (y) at screening 40,79 40,85 10.7, 95%CI 9–12.6; p<0.001), had not had a Median number of screening visits (Q1, Q3) 2 (1,3) 3 (2,7) previous breast cancer diagnosis compared min, max number of screening visits 1,19 1,21 a with women who had a been diagnosed Place of residence (%) with breast cancer in the past (Indigenous: Outer regional 118 (13.3) 1,823 (56.9) OR 7.5, 95%CI 2.0–28.0; p<0.001; and non- Remote 579 (67.7) 1,172 (36.2) Indigenous: OR 2.0, 95%CI 1.2–3.4; p<0.05); Very remote 159 (18.6) 209 (6.5) b live in remote locations compared with Main language (%) non-remote women (Indigenous: OR 1.5, English 245 (28.7) 2,721 (84.2) 95%CI 1.1–2.4; p<0.05; and non-Indigenous: Other-language 610 (71.3) 511 (15.8) c OR 1.5, 95%CI 1.3–1.7; p<0.001), and if they HRT use within 6 months (%) do not have a family history of breast cancer No 840 (98) 2,950 (91.4) compared with women who do (Indigenous: Yes 17 (2) 278 (8.6) d OR 2.3, 95%CI 1.6–3.3; p<0.001; and non- Family history of breast cancer (%) Indigenous: OR 1.3, 95%CI 1.1–1.5; p<0.001). No 613 (80.7) 1,961 (66.1) Yes 147 (19.3) 1,007 (33.9) Speaking a main language other than English Previous breast cancer (%) was associated with low attendance for No 485 (98.6) 3,161 (97.7) Indigenous women (OR 2.3, 95%CI 1.7–3.2; Yes 12 (1.4) 75 (2.3) p<0.001) but not for non-Indigenous women, Current breast lump (%) while presenting with a current breast lump No 828 (96.6) 3,121 (96.4) was significant for non-Indigenous women Yes 29 (3.4) 115 (3.6) (OR 1.8, 95%CI 1.3–2.7; p<0.05) but not for Case decision (%) Indigenous women. Normal 729 (92.4) 3,039 (93.9) Both Indigenous and non-Indigenous women Recalled 65 (7.6) 197 (6.1) whose cases were recalled to assessment at Notes: the time of data collection were likely to have a: Visitors (n=33) were excluded had fewer visits to screening than cases that b: Not known (n=6) was excluded c: Not known (n=1) was excluded were reported as normal (Indigenous: OR 5.4, d: Not known (n=365) were excluded 95%CI 2.1–13.6; p<0.001; non-Indigenous: OR 1.9, 95%CI 1.4–2.6; p<0.001). Multiple logistic regression analysis reported that significant predictors for low screening

attendance for Indigenous women were breast lump and no previous breast cancer whereas the overall rate for the entire target younger age (OR 12.3, 95%CI 8.1–18.8; diagnosis, which had univariate significance, population has remained steady.2 Also, more p<0.001), being recalled to assessment during were non-significant and removed from the of the screening rounds for Indigenous this screening round (OR 5.4, 95%CI 1.8–13; model. These results are shown in Figure 2. women were initial screens than for other p<0.001), no family history of breast cancer women,25 a report in line with the findings of (OR 2.1, 95%CI 1.3–3.3; p<0.02), and mainly Discussion this study. The increased national Indigenous speaking a language other than English (OR participation rate, although still about 19% 1.9, 95%CI 1.3–2.9; p<0.02). Remoteness It is widely reported that Indigenous lower compared with the general population, and having no past breast cancer diagnosis, Australian women have a lower survival rate is a positive step towards better Indigenous which had univariate significance, were non- and a younger age profile when diagnosed population coverage. The improvement significant and removed from the model. For with breast cancer in comparison with their may be attributed to the BreastScreen non-Indigenous women, predictors for low non-Indigenous counterparts.4 It is also well National Accreditation Standards (NAS) screening attendance were younger age (OR documented that Indigenous women have which recommend BreastScreen services 11.5, 95%CI 9.6–13.7; p<0.001), being recalled consistently lower attendance at screening to implement strategies that increase to assessment during this screening round for breast and cervical cancers than the rest access and participation for underserved (OR 1.8, 95%CI 1.3–2.6), no family history of the population.1,17 However, in recent populations. Some of the ways in which of breast cancer (OR 1.8, 95%CI 1.5–2.1; years, a 5% increase in national breast BreastScreen is trying to reduce systematic p<0.001), and living remotely (OR 1.3, 95%CI screening participation has been reported barriers to screening are, improved record- 1.1–1.5; p<0.02). Presenting with a current for Indigenous women aged 50–69 years, keeping of Indigenous data, targeted and culturally appropriate health promotion, Table 2: OR and 95% CI of Indigenous and non-Indigenous women’s cut-off ages and number of visits to screening. growing the Indigenous health workforce, Variables Indigenous non-Indigenous P value OR (95% CI) and more access points for consumers to N=857 N=3,236 screening sites.1,26,27 However, closing the <55 years 458 (53.4%) 1,269 (39.2%) < 0.0001 1.8 (1.5-2.0) gap on breast screening participation is ≥55 years 399 (46.6%) 1,967 (60.8%) a complex challenge that requires deep <3 visits 607 (70.8%) 1,360 (42%) < 0.0001 3.3 (2.8-3.9) understanding of the logistical, cultural and ≥3 visits 250 (29.2%) 1,876 (58%) health communication needs of Indigenous Notes: Australians.11 P values obtained from Chi-squared test

Table 3: Association of factors with screening attendance for Indigenous (n=857) and non-Indigenous (n=3,236) women in BreastScreen NT. Variable Indigenous Non-Indigenous Less than 3 3 or more P value OR (95% CI) Less than 3 3 or more P value OR (95% CI) visits N (%) visits N (%) reference is 1 visits N (%) visits N (%) reference is 1 Age <55 years 416 (90.8) 42 (9.2) < 0.001 10.8 (7.4-15.7) 942 (74.2) 327 (25.8) < 0.001 10.7 (9-12.6) ≥55 years 191 (47.9) 208 (52.1) 418 (21.3) 1,549 (78.7) Previous breast cancer No 604 (71.5) 241 (28.5) < 0.001 7.5 (2.0-28.0) 1,340 (42.4) 1,821 (57.6) < 0.05 2.0 (1.2-3.4) Yes 3 (25) 9 (75) 20 (26.7) 55 (73.3) Case decision Recalled 60 (92.3) 5 (7.7) < 0.001 5.4 (2.1-13.6) 113 (57.4) 84 (42.6) < 0.001 1.9 (1.4-2.6) Normal 547 (69.1) 245 (30.9) 1,247 (41) 1,792 (59) Family history of breast cancer No 461 (75.2) 152 (24.8) < 0.001 2.3 (1.6-3.3) 856 (43.7) 1,105 (56.3) < 0.05 1.3 (1.1-1.5) Yes 84 (57.1) 63 (42.9) 374 (37.1) 633 (62.9) Main language Other language 464 (76.1) 146 (23.9) < 0.001 2.3 (1.7-3.2) 199 (38.9) 312 (61.1) 0.129 0.8 (0.7-1.0) English 141 (57.6%) 104 (42.4) 1,158 (42.6) 1,563 (57.4) Place of residence Remote 533 (72.2) 205 (27.8) < 0.05 1.5 (1.1-2.4) 647 (46.8) 735 (53.2) < 0.001 1.5 (1.3-1.7) Non-remote 74 (62.2) 45 (37.8) 694 (37.9) 1,139 (62.1) Current breast lump Yes 22 (75.9) 7 (24.1) 0.544 1.3 (0.6-3.1) 65 (56.5) 50 (43.5) < 0.05 1.8 (1.3-2.7) No 585 (70.7) 243 (29.3) 1,295 (41.5) 1,826 (58.5) HRT within 6 months No 598 (71.2) 242 (28.8) 0.101 2.2 (0.8-5.8) 1,245 (42.1) 1,712 (57.9) 0.723 1.0 (0.8-1.3) Yes 9 (52.9) 8 (47.1) 114 (41.1) 164 (59) Note: P values derived from Chi-squared test

Figure 2. Factors associated with less than 3 screening visits for Indigenous (n=857) and Our results show that younger Indigenous Figure 2: Factors associated with less than 3 screening visits for Indigenous (n=857) and non-Indigenous women women were more likely to have attended non-Indigenous women (n=3236) in the NT. (n=3,236) in the NT. BreastScreen for the first and second time in 2015 than older Indigenous women and non-Indigenous women. This suggests that young Indigenous women, arguably a critical target group given the age profile of breast cancer in Indigenous Australians,4 are demonstrating initial engagement with the screening program. What our data do not show, however, is whether these Indigenous women are likely to have continuous and regular attendance at screening beyond their second visit. While limited with the absence of women’s data over time, our findings could imply that although young Indigenous women are engaging with initial screening, significant attrition may be occurring after the second visit. With BreastScreen Australia’s aim of reducing breast cancer mortality through early detection, women’s ongoing participation in the program is critical. Association between low attendance and living remotely are shown for both also imply that continued attendance reported breast lumps in 1.3% of women Indigenous and non-Indigenous women; beyond three visits may wane with those screened in a population-based program however, it only remains significant in the for whom English is not the main spoken found that the risk of breast cancer was multivariate model for Indigenous women. language, a finding supported by other sevenfold for women with lumps reported at Geographic remoteness is widely reported to researchers who have shown that language screening compared to women with other present barriers to screening in Australia1,17 can be a significant barrier to health for many symptoms (including nipple retractions 10,13,33,34 36 and is of particular importance in the NT, Indigenous cultures around the world. and secretions). Given that the risk is high with approximately two-thirds of the overall For example, it is reported that there is for women with breast lumps reported at population living in remote to very remote no word for cancer in many Indigenous screening, and with screening attendance locations.28 There have been national efforts languages, including Australian languages, for all women being lower than the national to improve access to screening via the mobile which immediately presents difficulties average in the NT, improving participation in 35 screening van that travels to remote areas when promoting screening. While it is well BreastScreen NT is critically important. and indeed may account for the increase in established that women of diverse cultural A factor previously associated with low participation of NT women in recent years.8 backgrounds have historically lower uptake screening re-attendance in Australia and 1,27 However, overall participation rates are to screening in Australia, tracking whether elsewhere is when a woman was previously still lower compared with other states and these women remain in the program beyond recalled to assessment with a false-positive territories of Australia, and evidence of poorer their initial attendance as a true measure of result.2,37,38 In the first round of screening, overall health continues to be reported with appropriate engagement in NT should be the with high recall rates (up to 10.8% reported increasing geographic remoteness.29-32 focus of further work. in 2012),29 and low positive predictive values The characteristic that was significant for Non-Indigenous women presenting with a (1.1% of women attending a first screen Indigenous women but not for others in our current breast lump were associated with in 2015 had an invasive breast cancer or 2 dataset was language, in that Indigenous having fewer than three visits to screening in DCIS detected), low return attendance of women who mainly spoke a language other the unadjusted results. While BreastScreen recalled women in subsequent rounds is than English were likely to have fewer than Australia (BSA) targets asymptomatic women, unsurprising. Maintaining high sensitivity three attendances compared with English- there is a small group of women who present and specificity in the BreastScreen program speaking Indigenous women and compared to screening with symptoms, particularly is one of the overarching goals of the NAS with other women. This result, coupled in the early screening rounds. The reported and therefore this must be evident, even 27 with the earlier finding that Indigenous rate of symptomatic screening according with the first screening round. Our results compared with non-Indigenous women to BreastScreen screening data from 1996 show that women who had attended fewer were more likely to attend BreastScreen for to 2005 is slightly higher for Indigenous screenings happened to have been recalled 25 the first and second time in 2015, suggests women than non-Indigenous women. Our to assessment in this round; however, that Indigenous women are engaging with study, however, found the opposite – that limitations in the data mean we can only initial screening in the NT, where culturally the association with a current breast lump estimate how a false positive would affect and linguistically appropriate strategies have only had univariate significance for non- these women’s decisions about subsequent been implemented to meet the needs of Indigenous women. A study in Finland which screening rounds. The current work reaffirms Indigenous peoples.8 However, our results included self-reported or radiographer- the importance of diagnostic efficacy to

long-term BreastScreen engagement and in breast cancer incidence, mortality and 18. Gibberd A, Supramaniam R, Dillon A, Armstrong BK, provides new evidence that this finding is not O’Connell DL. Are Aboriginal people more likely to be survival for Indigenous and non-Indigenous diagnosed with more advanced cancer? Med J Aust. unique to any single grouping of women. women, strategies to optimise engagement 2015;202(4):195-9. with the screening program should be 19. Roder D, Webster F, Zorbas H, Sinclair S. Breast screening To improve access and program retention and breast cancer survival in Aboriginal and Torres Strait for diverse groups within the screening targeted to meet the logistical, cultural and Islander women of Australia. Asian Pac J Cancer Prev. population, the NAS recommend Screening health communication needs of Australian 2012;13(1):147-55. 20. Dasgupta P, Baade PD, Youlden DR, Garvey G, Aitken JF, and Assessment Services (SAS) to provide women. Wallington I, et al. Variations in outcomes for Indigenous equitable service to women who are women with breast cancer in Australia: A systematic review. Eur J Cancer Care (Engl). 2017;26(6):e12662. culturally and linguistically diverse, are References 21. Australian Health Ministers’ Advisory Council. Aboriginal Indigenous, live in rural and remote areas and and Torres Strait Islander Health Performance Framework are from lower socioeconomic backgrounds.26 1. Australian Department of Health and Ageing. 2014 Report. Canberra (AUST): AHMAC; 2015. Evaluation of the BreastScreen Australia Program – 22. Garvey G, Cunningham J, Valery PC, Condon J, Roder Although an evaluation of the program in Evaluation Final Report – June 2009. Canberra (AUST): D, Bailie R, et al. Reducing the burden of cancer for 2014 found that BreastScreen Australia SAS Government of Australia; 2009. Aboriginal and Torres Strait Islander Australians: 2. Australian Institute of Health and Welfare. BreastScreen Time for a coordinated, collaborative, priority- uniformly performed well across the high- Australia Monitoring Report 2014–2015. Canberra driven, Indigenous-led research program. Med J Aust. priority standards and performance indicators (AUST): AIHW; 2017. 2011;194(10):530-1. 3. Australian institute of Health and Welfare. BreastScreen 23. Karvelas P. Sect. Indigenous Health News: Programs (for benign biopsy rates, cancer detection Australia Monitoring Report 1998–1999 and 1999–2000. Close the Gap on Indigenous Breast Cancer Screening. rates and interval cancer rates), researchers Canberra (AUST): AIHW; 2003. The Australian. 2014 October 14. reported that SAS with high numbers of 4. Tapia KA, Garvey G, Mc Entee M, Rickard M, Brennan 24. Tapia KA, Garvey G, McEntee MF, Rickard M, Lydiard L, P. Breast cancer in Australian Indigenous women: Brennan PC. Mammographic densities of Aboriginal diverse participants failed to meet the Incidence, mortality, and risk factors. Asian Pac J Cancer and non-Aboriginal women living in Australia’s standard for time between screening Prev. 2017;18(4):873-84. Northern Territory. Int J Public Health. 2019;64. doi. 27 5. World Health Organization. WHO Guidelines Approved org/10.1007/s00038-019-01237-w and assessment. That is, attendance at by the Guidelines Review Committee. WHO Position Paper 25. Cancer Australia. Study of Breast Cancer Screening assessment within the recommended 28 days on Mammography Screening. Geneva (CHE): WHO; 2014. Characteristics and Breast Cancer Survival in Aboriginal after being recalled was lower for services 6. Australian Bureau of Statistics. 1270.0.55.005 - Australian and Torres Strait Islander Women of Australia. Surry Hills Statistical Geography Standard (ASGS): Volume 5 - (AUST): Cancer Australia; 2012. p. 83. with high cultural diversity. The reasons are Remoteness Structure, July 2011. Canberra (AUST): ABS; 26. BreastScreen Australia. Breastscreen Australia National unclear and warrant further investigation; 2011. Accreditation Standards, October 2015. Canberra (AUST): 7. Australian Institute of Health and Welfare. Rural, Cancer Australia; 2016. however, the concern is that longer times to Regional and Remote Health: A Guide to Remoteness 27. Roder DM, Ward GH, Farshid G, Gill PG. Influence of assessment may affect health outcomes for Classifications. Canberra (AUST): AIHW; 2004. service characteristics on high priority performance these women. While strategies have been 8. Zhang X, Condon J, Douglas F, Bates D, Guthridge S, indicators and standards in the BreastScreen Australia Garling L, et al. Women’s Cancers and Cancer Screening in program. Asian Pac J Cancer Prev. 2014;15(14):5901-8. implemented at state levels to try to increase the Northern Territory. Darwin (AUST): Northern Territory 28. Australian Bureau of Statistics. 2075.0 - Census of screening participation, attendance at post- Department of Health; 2012. Population and Housing - Counts of Aboriginal and Torres 9. Marmot MG, Altman DG, Cameron DA, Dewar JA, Strait Islander Australians, 2011. Canberra (AUST): ABS; screening assessment should be carefully Thompson SG, Wilcox M. The benefits and harms of 2011. considered at the SAS level, particularly for breast cancer screening: an independent review. Br J 29. Australian Institute of Health and Welfare. BreastScreen Indigenous women who are reportedly less Cancer. 2013;108(11):2205-40. Australia Monitoring Report 2011–2012. Canberra 10. Kolahdooz F, Jang SL, Corriveau A, Gotay C, Johnston (AUST): AIHW; 2014. p. 99. likely to attend post-screening assessment N, Sharma S. Knowledge, attitudes, and behaviours 30. Australian Institute of Health and Welfare. BreastScreen within the recommended 28 days.25 towards cancer screening in indigenous populations: Australia Monitoring Report 2013–2014. Canberra A systematic review. Lancet Oncol. 2014;15(11):e504-16. (AUST): AIHW; 2016. There were a few limitations in this study. 11. Pilkington L, Haigh MM, Durey A, Katzenellenbogen 31. Australian Institute of Health and Welfare. Rural, Longitudinal data would have allowed us JM, Thompson SC. Perspectives of Aboriginal women Regional and Remote Health: Indicators of Health System on participation in mammographic screening: A Performance. Canberra (AUST): AIHW; 2008. to provide a broader scope of women’s step towards improving services. BMC Public Health. 32. Roder D, Zorbas HM, Kollias J, Pyke CM, Walters attendance at BreastScreen in the NT. As data 2017;17(1):697. D, Campbell ID, et al. Analysing risk factors for 12. Roder D, Webster F, Zorbas H, Sinclair S. Breast screening poorer breast cancer outcomes in residents of lower were only collected from an eight-month and breast cancer survival in Aboriginal and Torres Strait socioeconomic areas of Australia. Aust Health Rev. period in a program of biennial screening, Islander women of Australia. Asian Pac J Cancer Prev. 2014;38(2):134-41. the information about women’s screening 2012;13(1):147-55. 33. Shahid S, Bessarab D, Howat P, Thompson SC. 13. Martins T, Hamilton W, Ukoumunne OC. Ethnic Exploration of the beliefs and experiences of behaviours over time could not be surmised. inequalities in time to diagnosis of cancer: A systematic Aboriginal people with cancer in Western Australia: A A further limitation of this study is the lack review. BMC Fam Pract. 2013;14(1):197. methodology to acknowledge cultural difference and 14. Moore SP, Antoni S, Colquhoun A, Healy B, Ellison- build understanding. 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Limited progress in closing the mortality gap for Aboriginal and Torres Strait Islander Australians of the Northern Territory

Tom Wilson,1 Yuejen Zhao,2 John Condon3

he long-standing health and mortality Abstract disadvantage of Aboriginal and Torres Strait Islander Australians is Objectives: To assess whether progress is being made towards reducing Aboriginal and Torres T 1-3 well known and is generally worse in Strait Islander inequality in life expectancy and under-five mortality in the Northern Territory. the Northern Territory than in other states Methods: Life tables for five-year periods from 1966–71 to 2011–16 were calculated using and territories. As part of efforts to monitor standard abridged life table methods with Aboriginal and Torres Strait Islander deaths and progress with mortality and life expectancy population estimates as inputs. The latter were calculated using reverse cohort survival. and help inform appropriate policy and Results: In 2011–16, life expectancy at birth for the Aboriginal and Torres Strait Islander service responses, it is useful to construct population was 68.2 years for females and 64.9 years for males. Limited progress in under-five life tables on a regular basis to obtain life mortality rates has been made in recent years. expectancy and other mortality statistics. Life expectancy at birth is a valuable summary Conclusions: Although Aboriginal and Torres Strait Islander life expectancy has increased in the indicator – not only of mortality conditions, long run, the gap with all-Australian life expectancy has not narrowed. The gap in under-five but also of the general health and wellbeing mortality rates is much lower than it was in the 1960s and 1970s, but progress has been limited of a population – and it is one of the key over the past decade. ‘Closing the Gap’ indicators.4 When the Implications for public health: The ‘Closing the Gap’ target of halving the gap in under-five Closing the Gap targets were announced by mortality by 2018 will not be met in the Northern Territory, and there is no evidence yet of the Council of Australian Governments in progress on the target to eliminate the gap in life expectancy by 2031. 2008, the aim was to close the life expectancy Key words: Aboriginal and Torres Strait Islander, life expectancy, Northern Territory, mortality, gap within a generation (by 2031) and halve Closing the Gap the under-five mortality rate within 10 years (by 2018).5 Estimated Resident Populations (ERPs), 2010–12 Aboriginal and Torres Strait Unfortunately, creating life tables for which form the denominators of a wide Islander life tables for Australia, the ABS the Aboriginal and Torres Strait Islander range of demographic and socioeconomic applied adjustment factors to account for population is not straightforward. The measures, are also likely to have problems. the under-identification of Aboriginal and disadvantage of Aboriginal and Torres Strait They originate from census counts that Torres Strait Islander deaths.3 The adjustment Islander Australians with regards to health miss about one-in-six Aboriginal and Torres factors were calculated from the Census Data and mortality is compounded by a statistical Strait Islander people and, although ERPs are Enhancement Indigenous Mortality Project, disadvantage in which the coverage, corrected for census net undercount, they a study undertaken by the ABS that linked consistency and quality of population data still contain some limitations including age 2011 Census records with deaths recorded is far from ideal. The Australian Bureau of heaping, a limited available time series, and in the 12 months following the Census.6 Statistics (ABS) advises that most births and inconsistency over time. Unfortunately, adjustment factors could not deaths of Aboriginal and Torres Strait Islander Creating robust life tables is therefore be applied to individual states and territories Australians are likely to be recorded, but not challenging in this difficult data environment due to small numbers by age group. all are specifically identified as Indigenous.3 and adjustments must be made to data The Northern Territory is the one jurisdiction Aboriginal and Torres Strait Islander to rectify the deficiencies. In calculating where the coverage and quality of Aboriginal

1. Northern Institute, Charles Darwin University, Northern Territory 2. Northern Territory Department of Health 3. Menzies School of Health Research, Charles Darwin University, Northern Territory Correspondence to: Dr Tom Wilson, Northern Institute, Charles Darwin University, Ellengowan Drive, Darwin, NT 0909; e-mail: [email protected]. Submitted: October 2018; Revision requested: April 2019; Accepted: May 2019 The authors have stated they have no conflict of interest. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Aust NZ J Public Health. 2019; 43:340-5; doi: 10.1111/1753-6405.12921

and Torres Strait Islander demographic to 2011–16 (from 1 July in one year to 30 periods from 1966–71 to 2011–16 by sex and data is good, and the application of June five years later). The number of deaths five-year period-cohort were also obtained under-identification adjustment factors is was obtained directly from the ABS and from the ABS. unnecessary. Available evidence suggests the Condon et al. dataset. ABS Aboriginal Aboriginal and Torres Strait Islander there is very good coverage of Aboriginal and Torres Strait Islander ERPs were used as population estimates were calculated using 3,7 and Torres Strait Islander deaths. The ABS population estimates for 2016, but those reverse survival from 30 June 2016 ERPs Indigenous Mortality Project discovered the for earlier years were calculated specifically going back in five-year increments to 30 June Northern Territory had the highest rate of for this study. The reason for doing so is 1966. Zero net overseas migration and zero consistent reporting between census and because Aboriginal and Torres Strait Islander net change in Indigenous identification were death registrations, compared to the other ERPs are inconsistent from one census year assumed. Figure 1 illustrates the principle of states and territories; 95% of linked records to another and are not available prior to the calculations for one cohort over one five- had consistent Indigenous identification 1986. For comparative purposes, abridged year period. In this example, the population across both sources (compared to 62%, life tables were calculated for the Australian aged 40–44 in 2011 was calculated as the nationally). The number of deaths recorded population as a whole for the same five-year population of the same cohort in 2016 (then as Indigenous in death registrations was time periods. We also decomposed Aboriginal aged 45–49) plus the deaths that occurred actually 2% higher than the number of deaths and Torres Strait Islander life expectancy to the cohort over the 2011–16 period identified as Indigenous from the linked improvements between 1966–71 and 2011– minus cohort net migration. The shaded census records. Northern Territory death 16 to determine which age-specific mortality parallelogram represents the cohort deaths registration forms have recorded Indigenous rates contributed the most to life expectancy and net migration while the thick vertical status since September 1988 and Aboriginal changes. The decomposition method of lines are the cohort populations in 2011 11 and Torres Strait Islander deaths data are Arriaga was applied. and 2016. This calculation was applied to all available from the ABS from this time. Death Counts of deaths to Aboriginal and Torres cohorts by sex for all periods from 2011–16 counts for earlier years back to 1967 were Strait Islander residents of the Northern back to 1966–71 – with one exception. 7 estimated by Condon et al. by inferring Territory by sex and ages 0, 1–4, and then An adjustment was made to the ‘starting’ Indigenous status from other information five-year age groups up to 85+ for individual 2016 populations aged 0–4. The number of supplied on death registration forms. A years 1967 to 2001 were obtained from the Aboriginal and Torres Strait Islander 0–4-year- blind test of this method for a period where Condon et al. dataset. Deaths for the second olds obtained from reverse survival for earlier Indigenous status was officially recorded in half of 1966 were assumed to be the same years was found to be higher than Aboriginal death records found that 95% of recorded as those for the first half of 1967. Aboriginal and Torres Strait Islander ERPs published for Indigenous deaths were correctly inferred as and Torres Strait Islander deaths for five-year those years, indicating a systematic under- such. periods from 1 July to 30 June for 2001–06, estimation of the population in the 0–4 age The time series of deaths for the Northern 2006–11 and 2011–16 were obtained from group. We therefore increased the 0–4-year- Territory Aboriginal and Torres Strait Islander the ABS for the same age and sex groups. old ERP in 2016 by a factor of 1.02 for females population now stretches half a century. Deaths from the ABS were also obtained in and 1.05 for males; the average ratios of The aim of this paper is to summarise life five-year period-cohort form (e.g. the cohort reverse survived population estimates to expectancy and under-five mortality trends aged 25–29 in 2011 and aged 30–34 in ERPs for this age group over the years 1996 for the Northern Territory Aboriginal and 2016) for population estimation calculations. to 2011. The effect of this adjustment on life Torres Strait Islander population over this Aboriginal and Torres Strait Islander ERPs expectancy at birth was less than 0.1 years. 2,8,9 period, in part updating earlier work. for 30 June 2016 by sex and five-year age The resulting population estimates dataset 12 Our statistics differ from those of the ABS group were obtained from the ABS. Census spans 50 years and is fully consistent and other researchers by covering a longer net interstate migration counts for five-year with the 2016 ERPs for ages 5+ and the period – from mid-1966 to mid-2016 – and demographic components of change over by the creation of life tables based on a set of that period. However, it should be noted population estimates that are consistent over Figure 1: Illustration of reverse survival. that the population estimates and life tables the whole study period. We also examine life used for this study are not perfect. The 2016 expectancy across the age spectrum and not ERPs that provide the starting point for the just at birth. earlier population estimates are not precise figures but are estimates based on census Data and Methods counts adjusted for net under-enumeration, people temporarily away from their usual ସହିସଽ Life tables were calculated using the standard ܲ residence on census night, plus the small abridged life table method,10 which requires timing difference between the census in age-sex-specific deaths and populations August and the 30 June reference date of the as input data. We used the usual ages of 0, ସ଴ିସସ ERP. There is almost certainly some degree 1–4, and then five-year age groups up to the ܲ of error in these data. Population estimates highest open-ended age group of 85-plus. for earlier years are based on the assumption

To reduce random variation, we calculated 2011 2016 that all components of demographic change life tables for five-year periods from 1966–71 Note: P denotes population, D deaths and N net migration in the calculations are accurate, including the Figure 1: Illustration of reverse survival Note: P denotes population, D deaths and N net migration 2019 vol. 43 no. 4 Australian and New Zealand Journal of Public Health 341 © 2019 The Authors Wilson, Zhao and Condon Article

assumption of zero net overseas migration estimates that form the denominators of A decomposition of increases in Aboriginal and zero net identification change. This last age-specific death rates. The new Aboriginal and Torres Strait Islander life expectancy at assumption is the most uncertain for recent and Torres Strait Islander life expectancy birth between 1966–71 and 2011–16 was years. Available evidence from the Australian figures are also similar to equivalent statistics undertaken to reveal which age-specific Census Longitudinal Dataset (ACLD) suggests published by the ABS. ABS Aboriginal and mortality rates contributed most to the net identification change between 2011 and Torres Strait Islander life expectancy at birth increases (Table 1). For females, 45% of the 2016 was low for the Northern Territory13 and estimates for the Northern Territory for increase was due to improvements in under- much lower than in any other jurisdiction in 2010–12 were 68.7 years for females and 63.4 five mortality, while for males it was about Australia. Due to the small sample size and for males.3 Our estimates, interpolated to the 50%. Other contributions to life expectancy census errors, we are not fully convinced of same reference dates, are close to these at increases were distributed across other age the existence of this phenomenon in the 68.3 and 64.0 years, respectively. groups, although with relatively smaller Northern Territory, but careful attention will need to be paid to future updates to the ACLD when 2021 Census data are added. Figure 2: Northern Territory Aboriginal and Torres Strait Islander and all-Australian life expectancy at birth, ACLD data suggests no net identification 1966-71 to 2011-16. change occurred in the Northern Territory between 2006 and 2011. It is also assumed that all data inputs for the population estimates and life tables refer to the Aboriginal and Torres Strait Islander population defined in exactly the same way, although it is known that indigeneity is identified or recorded in slightly different ways in different data collections.14 Our assumptions almost certainly do not hold precisely.

Results Life expectancy at birth Figure 2 presents life expectancy at birth estimates for the Northern Territory Source: authors’ calculations Aboriginal and Torres Strait Islander Figure 2: Northern Territory Aboriginal and Torres Strait Islander and all-Australian life Note: 95% confidence intervals shown for Aboriginal and Torres Strait Islander life expectancy population from 1966–71 to 2011–16. expectancy at birth, 1966-71 to 2011-16 Equivalent statistics for the Australian Source: authors’ calculations Note: 95% confidence intervals shown for Aboriginal and Torres Strait Islander life expectancy population as a whole are also shown (by the Figure 3: Northern Territory Aboriginal and Torres Strait Islander life expectancy at selected ages by sex, dashed lines). In 2011–16, life expectancy 1966-71 to 2011-16. stood at 68.2 years for Aboriginal and Torres Strait Islander females in the Northern Territory and 64.9 years for males. For Australia as a whole, life expectancy in 2011– 16 reached 84.9 years for females and 80.8 years for males. Over the entire study period of 1966–71 to 2011–16, Aboriginal and Torres Strait Islander life expectancy at birth in the Northern Territory increased by an average of 3.1 years per decade for females and 2.7 years per decade for males. Most recently, between 2006–11 and 2011–16, male life expectancy increased by an impressive 1.9 years, although there was no significant change for females. The new Northern Territory Aboriginal and Torres Strait Islander life expectancy figures presented here are very close to estimates published previously for 1966–71 to 2006–11 using the same methods.8 Minor differences FigureSource: authors’ 3: calculationsNorthern Territory Aboriginal and Torres Strait Islander life expectancy at selected Note: 95% confidence intervals shown are due to slight changes in the population ages by sex, 1966-71 to 2011-16 Source: authors’ calculations Note: 95% confidence intervals shown 342 Australian and New Zealand Journal of Public Health 2019 vol. 43 no. 4 © 2019 The Authors Indigenous Health Closing the Gap in Indigenous mortality

contributions from the childhood ages of between 15 and 19 years below all-Australian increasing from 0.00198 to 0.00253 for 5–14 and younger adult age groups. In life expectancy. females and from 0.00204 to 0.00230 for contrast, for the Australian population as a As the graphs in Figure 4 show, the life males. whole, most life expectancy gains over this expectancy gaps vary by age. For females, the period have been contributed by mortality life expectancy gap at age 25 has fluctuated Discussion and conclusions declines in the older adult age groups. over time but was not appreciably different Aboriginal and Torres Strait Islander life in 2011–16 and 1966–71. At ages 50 and 75, The updated life expectancy and under-five expectancy at ages other than birth have the gap has increased slightly. In contrast, mortality rates for the Northern Territory also increased over the long run. Figure male life expectancy gaps for ages 25, 50 and Aboriginal and Torres Strait Islander 3 illustrates trends in life expectancy at 75 were larger in 2011–16 than in 1966–71. population presented here mostly show birth (age 0) and at ages 25, 50 and 75 over In part, this is due to substantial gains in all- limited amounts of improvements in recent the study period. For example, female life Australian male life expectancy over the past years, especially for females. Although expectancy at age 50 has increased from 18.1 50 years. Aboriginal and Torres Strait Islander life years in 1966–71 to 24.4 years by 2011–16 expectancy has increased in the long run, (+6.3 years), while for males of the same age Childhood mortality the gap has failed to narrow. In fact, for it has increased from 17.8 years to 22.1 (+4.3 The other mortality-related target of Closing males, the gap across the adult ages has years). For both genders, most of the increase the Gap was to halve the gap in under-five increased over time. The original target of in the adult ages has occurred since the mortality within 10 years. Figure 5 shows the completely closing the life expectancy at early 1990s, reflecting sustained declines in mortality rates for 0–4-year-old Aboriginal birth gap within a generation (by 2031) was mortality rates across most age groups above and Torres Strait Islander children in the ambitious at the time of its announcement, age 50 since then. Northern Territory from 1966–71 to 2011–16 and probably unachievable. It not only These increases in Aboriginal and Torres Strait alongside equivalent rates for Australia as requires improvement in absolute terms Islander life expectancy are undoubtedly a whole (shown by the dashed lines). The but improvement at a faster rate than all- positive developments but, if the Closing the steep decline in childhood mortality rates in Australian life expectancy; this would need Gap goal is to be met, life expectancy not the 1960s, 1970s and 1980s represents great to happen at a very rapid pace to completely only needs to be increasing, but increasing success in combating perinatal, respiratory close the gap by 2031. at a much faster rate than all-Australian life and infectious causes of death.15 However, Among the disappointing statistics expectancy. Figure 4 illustrates the gap in progress in lowering under-five mortality overall, there is some good news. Male life life expectancy at birth and selected other appears to have stalled between 2006–11 expectancy at birth in the Northern Territory ages. In 2011–16, the difference in life and 2011–16, with mortality rates for females increased by 1.9 years between 2006–11 expectancy at birth between the Northern changing from 0.00290 (95%CI 0.00248- and 2011–16. In addition, the Aboriginal and Territory Aboriginal and Torres Strait Islander 0.00332) to 0.00328 (0.00285-0.00371), and Torres Strait Islander infant mortality rate population and the Australian population as a from 0.00322 (0.00277-0.00366) to 0.00317 has fallen dramatically over the past half whole stood at 16.7 years for females and 15.9 (0.00275-0.00360) for males. In 2011–16, century – by 86% from 1966–71 to 2011–16. years for males. Aside from a narrowing of the these rates were still approximately four times The probability of a newly born Aboriginal gap for Aboriginal and Torres Strait Islander those of the Australian population as a whole, and Torres Strait Islander child in the Northern females between 1966–71 and 1971–76, both which were 0.00076 for females and 0.00087 Territory dying before their first birthday is male and female Aboriginal and Torres Strait for males. Over this most recent period, the now 1.2% for females and 1.3% for males. Islander life expectancy at birth has remained gap in the under-five mortality rate widened, Nonetheless, these statistics are still above

Table 1: Contribution to life expectancy at birth increases between 1966-71 and 2011-16 from mortality changes by age group, Northern Territory Aboriginal and Torres Strait Islander population and Australian population. Northern Territory Aboriginal and Australian population Torres Strait Islander population Ages Females Males Females Males

Δe0 (%) 95% CI Δe0 (%) 95% CI Δe0 (%) 95% CI Δe0 (%) 95% CI 0–4 6.35 (45.2%) 6.16-6.54 6.04 (50.1%) 5.87-6.22 1.27 (12.2%) 1.26-1.28 1.58 (12.2%) 1.58-1.59 5–14 0.09 (0.7%) 0.02-0.17 0.16 (1.3%) 0.08-0.23 0.16 (1.6%) 0.16-0.17 0.25 (1.9%) 0.24-0.25 15–24 0.63 (4.5%) 0.51-0.76 0.45 (3.7%) 0.33-0.57 0.22 (2.1%) 0.22-0.23 0.65 (5.0%) 0.64-0.66 25–34 0.66 (4.7%) 0.54-0.77 0.92 (7.6%) 0.8-1.04 0.23 (2.2%) 0.22-0.23 0.35 (2.7%) 0.35-0.36 35–44 1.45 (10.3%) 1.33-1.56 1.23 (10.2%) 1.12-1.34 0.48 (4.6%) 0.47-0.49 0.64 (4.9%) 0.64-0.65 45–54 1.27 (9.0%) 1.2-1.33 1.18 (9.8%) 1.13-1.23 0.98 (9.5%) 0.97-0.99 1.51 (11.7%) 1.51-1.52 55–64 2.12 (15.1%) 2.08-2.16 0.75 (6.2%) 0.7-0.79 1.62 (15.7%) 1.62-1.63 2.85 (21.9%) 2.84-2.85 65–74 1.05 (7.5%) 0.88-1.22 1.09 (9.0%) 0.89-1.29 2.44 (23.6%) 2.44-2.44 3.17 (24.4%) 3.17-3.17 75+ 0.44 (3.1%) 0.08-0.79 0.25 (2.1%) -0.1-0.61 2.94 (28.5%) 2.93-2.96 1.97 (15.2%) 1.96-1.98 Total 14.06 (100%) 13.57-14.56 12.07 (100%) 11.57-12.57 10.35 (100%) 10.33-10.37 12.99 (100%) 12.96-13.01 Source: authors’ calculations Note: Δe0 denotes change in life expectancy at birth

Figure 4: The Northern Territory Aboriginal and Torres Strait Islander life expectancy gap at selected ages by sex, 1966-71 to 2011-16.

Note:(a) Gap calculatedFemales as Northern Territory Aboriginal and Torres Strait Islander life expectancy minus that for Australia as a(b) whole. 95%Males confidence intervals shown. the equivalent all-Australian probabilities Figure 4: The Northern TerritoryFigure Aboriginal 5: The mortality rates and of 0 –To4 year-oldrres Aboriginal Strait and Islander Torres Strait Islanderlife expectancychildren in the Northern gap Territory, at (0.3% for females and 0.4% for males), leaving 1966-71 to 2011-16. roomselected for improvement. ages by sex, 1966-71 to 2011-16 HowNote: can lifeGap expectancy calculated at birth as beNorthern Territory Aboriginal and Torres Strait Islander life expectancy minus that for increased?Australia If Aboriginal as a whole. and Torres 95% Strait confidence intervals shown. Islander childhood mortality (across ages 0–14 years) were to fall to the same rates experienced by the Australian population as a whole in 2011–16, the gain in life expectancy at birth would be about one year for both males and females. So, future life expectancy gains must come from the adult age groups. Halving the difference in 2011–16 age- specific mortality rates between the Northern Territory Aboriginal and Torres Strait Islander population and the Australian population as a whole at ages 15 and above would add about six years to both male and female Aboriginal Source: authors’ calculations and Torres Strait Islander life expectancy at FigureNote: 95% confidence 5: The intervals mortality shown for Aboriginal rates andof Torres 0-4 Strait year Islander old mortality Aboriginal rates and Torres Strait Islander children in birth. That is the scale of improvement that the Northern Territory, 1966-71 to 2011-16 would clearly indicate a move towards closing Source: authors’ calculations the gap. Note:The other 95% confidenceClosing the intervals Gap targets shown focused for Aboriginal andmortality Torres gap Strait depends Islander on, mortality and can rates only Our findings suggest that current approaches on education and employment, which are follow, substantial and sustained progress to tackling Aboriginal and Torres Strait fundamentally necessary (albeit not sufficient in the social, economic and environmental Islander mortality inequalities are struggling on their own) to an individual’s capacity to circumstances of Aboriginal and Torres Strait to make headway. Previous research shows control their own destiny and contribute to Islander Australians. a combination of six selected risk factors the wellbeing of their family, community and explain 60–70% of the Aboriginal and environment. Substantial progress in housing, Acknowledgement Torres Strait Islander life expectancy gap education, hygiene, nutrition, employment in the Northern Territory: socioeconomic and income is required to improve the This work was funded by a Charles Darwin disadvantage, smoking, alcohol abuse, mortality outcomes of the Northern University Start-Up grant. obesity, pollution and intimate partner Territory’s Aboriginal and Torres Strait Islander 16 violence. Socioeconomic disadvantage population as measured by life expectancy at Ethical standards (such as relatively poor education, housing, birth and under-five mortality. The inequality The study was ruled exempt from ethics hygiene, nutrition and income) is the in mortality between Aboriginal and Torres review by the Human Research Ethics largest contributor, responsible for between Strait Islander and other Australians is the Committee of Charles Darwin University. one-third and one-half of the gap in life cumulative effect of disadvantage in almost expectancy at birth. every stage and aspect of life. Closing the

References 1. Australian Institute of Health and Welfare. The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples. Canberra (AUST): AIHW; 2015. 2. Wilson T, Condon J, Barnes T. Improvements in Northern Territory Indigenous life expectancy, 1967-2004. Aust N Z J Public Health. 2007;31(2):184-8. 3. Australian Bureau of Statistics. 3302.0.55.003 - Life Tables for Aboriginal and Torres Strait Islander Australians, 2010- 2012. Canberra (AUST): ABS; 2013. 4. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework 2017 Report. Canberra (AUST): AIHW; 2017. 5. Council of Australian Governments. National Indigenous Reform Agreement (Closing the Gap). Canberra (AUST): COAG; 2009. 6. Australian Bureau of Statistics. 3302.0.55.005 - Death Registrations to Census Linkage Project – Key Findings for Aboriginal and Torres Strait Islander Peoples, 2011-2012. Canberra (AUST): ABS; 2013. 7. Condon JR, Barnes T, Cunningham J, Smith L. Demographic Characteristics and Trends of the Northern Territory Indigenous Population, 1966 to 2001. Darwin (AUST): Cooperative Research Centre for Aboriginal Health; 2004. 8. Wilson T. New population and life expectancy estimates for the Indigenous population of Australia’s Northern Territory, 1966-2011. Plos One. 2014;9(5):e97576. 9. Georges N, Guthridge SL, Li SQ, Condon JR, Barnes T, Zhao Y. Progress in closing the gap in life expectancy at birth for Aboriginal people in the Northern Territory, 1967-2012. Med J Aust. 2017;207(1):25-30. 10. Preston SH, Heuveline P, Guillot M. Demography: Measuring and Modelling Population Processes. Oxford (UK): Blackwell; 2001. 11. Arriaga EE. Measuring and explaining the change in life expectancies. Demography. 1984;21:83-96. 12. Australian Bureau of Statistics. 3238.0.55.001 - Estimates of Aboriginal and Torres Strait Islander Australians, June 2016. Canberra (AUST): ABS; 2018. 13. Biddle N, Markham F. Indigenous Identification Change Between 2011 and 2016: Evidence from the Australian Census Longitudinal Dataset. CAEPR Topical Issue No.: 1. Canberra (AUST): Australian National University Centre for Aboriginal Economic Policy Research; 2018. 14. Australian Bureau of Statistics. 4726.0 - Perspectives on Aboriginal and Torres Strait Islander Identification in Selected Data Collection Contexts. Canberra (AUST): ABS; 2013. 15. Tay EL, Li SQ, Guthridge S. Mortality in the Northern Territory, 1967-2006. Darwin (AUST): Northern Territory Department of Health; 2013. 16. Zhao Y, Wright J, Begg S, Guthridge S. Decomposing Indigenous life expectancy gap by risk factors: A life table analysis. Popul Health Metr. 2013;11(1):1-9.

The frequency and magnitude of price-promoted beverages available for sale in Australian supermarkets

Christina Zorbas,1 Beth Gilham,1 Tara Boelsen-Robinson,1,2 Miranda R.C. Blake,1,2 Anna Peeters,1 Adrian J. Cameron,1 Jason H.Y. Wu,3 Kathryn Backholer1

oor dietary intakes and obesity are Abstract leading risk factors for preventable non-communicable diseases such as Objective: Price promotions are used to influence purchases and represent an important P 1 diabetes, heart disease and some cancers. target for obesity prevention policy. However, no long-term contemporary data on the extent In Australia, two-thirds of adults and one- and frequency of supermarket price promotions exists. We aimed to evaluate the frequency, quarter of all children were overweight or magnitude and weekly variation of beverage price promotions available online at two major obese in 2014-15.2 The food environment is Australian supermarket chains over 50 weeks. a key driver of these public health issues due Methods: Beverages were categorised into four policy-relevant categories (sugar-sweetened to the ubiquitous availability and marketing beverages, artificially-sweetened beverages, flavoured milk and 100% juice, milk and water). of cheap energy-dense, nutrient-poor The proportional contribution of each category to the total number of price proportions, the foods and beverages that contain excessive proportion of price promotions within the available product category, the mean discount, and 3 amounts of sugar, salt and saturated fats. weekly variation in price promotions were calculated. Non-alcoholic beverages, including sugar- Results: For Coles and Woolworths respectively, 26% and 30% of all beverages were price sweetened beverages (SSBs), are the largest promoted in any given week. Sugar-sweetened beverages made up the greatest proportion contributors to added sugars in the daily diets of all price promotions (Coles: 46%, Woolworths: 49%). Within each product category, the of Australians (37%)4,5 and have thus been proportion of sugar-sweetened and artificially-sweetened beverages that were price promoted identified as a key policy target to improve was similar, higher than the other categories and reasonably constant over time. Diet drinks population diets.6 and sugar-sweetened soft drinks were most heavily discounted (by 29-40%). Price promotions (also referred to as Conclusions: Beverage price promotions are used extensively in Australian supermarkets, ‘temporary price discounts’ or ‘specials’) undermining efforts to promote healthy population diets. are widely used by retailers and food manufacturers to influence consumer Implications for public health: Policies restricting price promotions on sugar-sweetened purchasing patterns. Price promotions result beverages are likely to be an important part of strategies to reduce obesity and improve in a short-term sales uplift of a particular population nutrition. product by enticing consumers to purchase in Key words: Sugar-sweetened beverages, food policy, price promotions, obesity greater quantities and/or temporarily switch brands or shopping habits.7 Accordingly, the than 30 jurisdictions.6 SSB taxes aim to reduce The limited evidence examining the extent UK government and public health groups in demand for SSBs via an increase in their of beverage price promotions to date Australia have recently called for regulations prices. In contrast, price promotions aim to suggests that SSBs are more commonly restricting price promotions on unhealthy increase demand via a temporary reduction price promoted compared to non-sugary foods and beverages as part of a broader in prices and may thereby attenuate the beverages. A cross-sectional in-store audit regulatory strategy to address childhood effects of a SSB tax. Similar policies to restrict of price promotions across a nation-wide obesity.8-10 Beverage price promotions are the influence of price promotions on alcohol sample of food stores (including 955 of particular interest given the potential of have previously been recommended in supermarkets) in the United States during price promotions to undermine SSB taxes, Australia,11 with legislative bans on multi- 2010-12 revealed that there was a higher which have now been introduced in more buys implemented in Scotland in 2011.12 prevalence of price promotions among SSBs

1. Global Obesity Centre, Institute for Health Transformation, School of Health and Social Development, Deakin University, Geelong, Victoria 2. School of Public Health and Preventive Medicine, Monash University, Victoria 3. The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales Correspondence to: Ms Christina Zorbas, Deakin University, Locked Bag 20000, Geelong, VIC 3220; e-mail: [email protected] Submitted: October 2018; Revision requested: February 2019; Accepted: March 2019 The authors have stated the following conflict of interest: AJC is an academic partner on a healthy supermarket intervention trial that includes Australian local government and supermarket retail (IGA) collaborators. No funding was received from IGA for this trial, which was funded by the Australian National Health and Medical Research Council, VicHealth and Deakin University. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Aust NZ J Public Health. 2019; 43:346-51; doi: 10.1111/1753-6405.12899

(18.2%) compared to non-sugary beverages two for $15, three for $10; two for the price The validity of using online data for this (12.1%).13 Similarly, a four-week examination of one). Data was not collected for beverages project was confirmed in a prior study where of beverage price promotions in New Zealand requiring significant preparation before we tested the correlation between food and during 2007 highlighted that less healthy consumption, such as tea, coffee beans, beverage availability and price, online and beverages, such as SSBs (44.1%), were more chocolate syrups and drink powders (with in-store, for both Coles and Woolworths. likely to be price promoted compared to the exception of cordial, a concentrated In that study, we randomly selected 96 healthier beverages (14.9%).14 However, these sugar-sweetened beverage requiring water products from four categories (breakfast studies were short-term and were conducted for preparation, being a popular children’s cereals, cereal based bars, juices and sugar- eight and eleven years ago, respectively. With beverage in Australia). A complete audit of sweetened beverages) using the Australian significant week-to-week fluctuation in price the price of all ready-to-drink beverages and Food Switch database (>40,000 supermarket promotions, a current assessment to quantify cordials (regardless of whether they were food and beverage products).16 We found a price promotions throughout the year is price promoted or not) was conducted in May high correlation (>90%) for the availability required to understand which products are 2017 by one member of the research team of products and the presence of price promoted, the degree of price discounting (BG). This audit was conducted manually by promotion for a given product, online and and how trends vary across seasons. recording the data into a Microsoft Excel™ in-store (unpublished results). In this study, we conducted a weekly spreadsheet and combined with the weekly systematic audit of all non-alcoholic beverage data on price-promoted beverages to Beverage classification price promotions available for sale online determine the proportion of each beverage Each beverage was classified into one of at two major Australian supermarket chains category that was price promoted each week. four policy-relevant6 categories (‘SSBs’, (accounting for 67% of the grocery market Four trained researchers collected the ‘Artificially-Sweetened Beverages’ (ASBs), share),15 over 52 weeks. We additionally data on a rotating roster. For the first 26 ‘flavoured milk and 100% juice’, ‘milk and audited all non-alcoholic beverages available weeks, price data was manually collected water’; see Table 1). Flavoured milk and 100% for sale online at each supermarket (with and by entering the product information into fruit or vegetable juices were not included without a price promotion) to calculate the an excel spreadsheet. For the remaining in the SSB category because, although these proportion of each beverage category that 26 weeks, data collection was conducted products contain sugar, they typically have a was price promoted each week. We aimed using an automated online scraping tool, higher nutritional value compared to other to examine the frequency and magnitude of which extracted and exported the necessary SSBs, and consequently are often exempt beverage price promotions, and whether this information into a spreadsheet. This data from interventions and policies targeting differed by beverage category or season. was manually checked each week to ensure sugary drinks, including most SSB taxes.6 information was extracted for the correct Milk and water were purposely classified as Methods number of products, with a random 50 distinct from ASBs because of the nutritional products checked for data accuracy (all importance of these products within a Data collection of which indicated 100% accurate data healthy diet.17 Data was collected weekly for 52 weeks extraction). Two weeks of data were excluded from November 2016 to November 2017 due to data collection errors, leaving 50 Data analysis from the online websites of the two major weeks of data for analysis. The proportion of beverages on price Australian supermarket chains, Coles and promotion in any given week within the Woolworths. Weekly data collection was Table 1: Categories for beverages sold at the available product category (number of selected to align with the price promotion two major Australian supermarkets (Coles and price-promoted beverages within a product cycle in these supermarkets (updated Woolworths) between November 2016 and category/total number of beverages within weekly on Wednesdays). The following data November 2017. that beverage category), and the proportional was collected weekly for all non-alcoholic Major category Sub-major category contribution of each beverage category to beverage product types (single purchase the total number price-promoted beverages Sugar-Sweetened Soft drink items that may include, for example, a single (number of all price-promoted beverages Beverages (SSBs) Flavoured water, ice tea, sports or can or a 24-pack of cans; hereafter referred energy drinks within a product category/total number of to as ‘beverage/s’) where the sale price was Fruit-flavoured drinks (<99% juice) price-promoted beverages), was calculated. less than the regular retail price: product Flavoured mineral water (sugar- We additionally calculated the mean discount name, volume, pack size, regular retail sweetened) (%) for each beverage category across the 50 price, promotional price and whether the Cordial weeks for each beverage category. promotion was a ‘multi-buy’ promotion. A Artificially-Sweetened Diet soft drink Weekly variation in the proportion of each Beverages (ASBs) price promotion was defined as a temporary Diet flavoured water, ice tea, sport price-promoted beverage category and the drinks or energy drinks price reduction. Products advertised as proportion of multi-buys for each beverage Flavoured mineral water (no sugar) ‘everyday low price’ were not considered a category was assessed graphically over the Diet cordial price promotion as the prices for these items one-year of data collection. did not vary across weeks. A ‘multi-buy’ price Flavoured milk and Flavoured milk 100% juice Analyses were conducted using Microsoft promotion was defined as a price promotion 100% fruit or vegetable juice Excel™. that required consumers to purchase more Milk and water Plain full- or low-fat milk than one unit to receive the discount (i.e. Plain still or sparkling water

Results Table 2: Weekly mean number and proportion of beverages on price promotion, by beverage category, for the two major Australian Supermarkets (Coles and Woolworths) between November 2016 and November 2017. Price promotions Beverage Category Beverages in Mean number Mean % Mean % of Mean price Across both supermarkets, an average of 971 product line, of price of product all beverage change, % beverages product types were available for n (% of all promoted line price price (SD) sale each week (Coles n=960; Woolworths beverages) beverages per promoted promotions n=982), of which 40% were SSBs (Coles week, n (SD) (SD) (SD) n=381; Woolworths n=397), 13 and 15% for Coles ASBs (Coles n=120; Woolworths n=143), 28 Total 960 (100) 247 (30) 26 (3) 100 -33 (9) SSBs 381 (40) 115 (18) 30 (5) 46 (4) -36 (11) and 24% for flavoured milks and 100% juice Cordial 47 (5) 11 (7) 23 (15) 4 (3) -27 (9) (Coles n=270; Woolworths n=236) and 20 and Flavoured water, ice tea, sports and energy 94 (10) 27 (7) 28 (7) 11 (2) -38 (10) 21% for plain milk and water (Coles n=189; drinks Woolworths n=206) (Table 2). Fruit-flavoured drink (<99%) 79 (8) 25 (8) 31 (11) 10 (3) -33 (14) On average, in any given week 26% and 30% Flavoured mineral water (sugar-sweetened) 21 (2) 7 (4) 32 (21) 3 (2) -36 (6) of all beverages were price promoted for Soft drink 140 (15) 46 (9) 33 (6) 19 (3) -39 (10) Coles and Woolworths, respectively (Table ASBs 120 (13) 40 (7) 33 (6) 16 (2) -39 (9) 2). When examining price promotions within Diet cordial 8 (1) 1 (2) 14 (27) 0 (1) -32 (11) each policy-relevant beverage category, Diet flavoured water, ice tea, sports and 27 (3) 8 (3) 30 (10) 3 (1) -40 (8) findings from both supermarkets indicated energy drinks that the proportions of price promotions Flavoured mineral water (no sugar) 31 (3) 7 (4) 22 (14) 3 (1) -35 (8) within beverage categories was similar for Diet soft drink 54 (6) 24 (4) 44 (8) 10 (2) -40 (10) SSBs and ASBs (Coles: 30% of all SSBs vs. Flavoured milk and 100% juice 270 (28) 66 (14) 24 (5) 27 (5) -26 (9) 33% of all ASBs; Woolworths: 37% of all SSBs Flavoured milk 73 (8) 19 (8) 26 (12) 8 (3) -25 (8) 100% fruit or vegetable juice 197 (21) 47 (13) 24 (6) 19 (4) -27 (9) vs. 38% of all ASBs), with this finding being Milk and Water 189 (20) 27 (7) 14 (4) 11 (3) -32 (10) consistent across the 50 weeks of the study. Milk 137 (14) 16 (5) 12 (4) 7 (2) -30 (11) The proportion of price-promoted products Water 52 (5) 11 (4) 21 (7) 4 (2) -34 (9) was lowest for the ‘milk and water’ category Woolworths with a weekly average of 14% for Coles and Total 982 (100) 297 (54) 30 (6) 100 -26 (11) 15% for Woolworths (Table 2). SSBs 397 (40) 145 (27) 37 (7) 49 (4) -28 (12) Across all price-promoted beverages (not Cordial 62 (6) 15 (8) 24 (13) 5 (2) -21 (8) within beverage categories), the greatest Flavoured water, ice tea, sports and energy 106 (11) 45 (9) 43 (9) 15 (3) -28 (12) number of price promotions were for SSBs drinks (46% and 49% for Coles and Woolworths, Fruit-flavoured drink (<99%) 84 (9) 31 (8) 36 (10) 10 (2) -22 (10) respectively), followed by flavoured Flavoured mineral water (sugar-sweetened) 39 (4) 10 (6) 27 (14) 3 (2) -29 (7) milk and 100% juice (27% and 22% of all Soft drink 106 (11) 44 (12) 42 (11) 15 (3) -34 (10) price-promoted beverages for Coles and ASBs 143 (15) 55 (11) 38 (8) 18 (3) -30 (11) Woolworths, respectively), ASBs (16% and Diet cordial 13 (1) 6 (4) 49 (30) 2 (1) -19 (5) 18% of all price-promoted beverages for Diet flavoured water, ice tea, sports and 39 (4) 15 (4) 39 (10) 5 (1) -29 (11) energy drinks Coles and Woolworths, respectively) and Flavoured mineral water (no sugar) 31 (3) 8 (4) 26 (12) 3 (1) -28 (8) water and plain milk (11% and 10% of all Diet soft drink 60 (6) 25 (7) 41 (12) 8 (2) -34 (10) price-promoted beverages for Coles and Flavoured milk and 100% juice 236 (24) 66 (19) 28 (8) 22 (4) -20 (8) Woolworths, respectively). In total, 73% Flavoured milk 75 (8) 17 (8) 23 (11) 6 (3) -21 (8) and 71% of price promotions (across all 100% fruit or vegetable juice 161 (16) 49 (16) 30 (10) 16 (4) -20 (8) price-promoted beverages) were for sugary Milk and Water 206 (21) 30 (10) 15 (5) 10 (3) -23 (9) drinks (SSBs and flavoured milk and 100% Milk 140 (14) 15 (5) 11 (4) 5 (2) -22 (9) juice combined), at Coles and Woolworths, Water 66 (7) 15 (6) 23 (10) 5 (2) -24 (9) respectively. Note: Across the year, the mean price reduction Mean % of each product line promoted each week (third data column) was calculated by dividing the total number of price promoted products within a product category by the total number of products available within the category; % of all price promotions (fourth data column) was calculated by dividing for all beverages was similar for both the total number of price promoted beverages within a category by the total number of price promoted beverages. supermarkets at -33% for Coles and -26% for Woolworths. Price-promoted diet soft drinks The proportion of each beverage category ASBs price promoted in any given week was (Coles: -40%; Woolworths: -34%) and diet that was price promoted each week similar across the year. flavoured water, ice tea, sports and energy was relatively constant over time for drinks (Coles: -40%; Woolworths: -29%) both supermarkets, with both Coles and Multi-buy price promotions were most heavily discounted, followed by Woolworths demonstrating a peak during On average, in any given week, 4% and 8% sugar-sweetened soft drinks (Coles: -39%; th the week of December 14 for both SSBs and of all beverages were available as a multi- Woolworths: -34%). ASBs (Figure 1). The proportion of SSBs and buy promotion (a subset of price-promoted

348 Australian and New Zealand Journal of Public Health 2019 vol. 43 no. 4 © 2019 The Authors Food and Beverage Beverage price promotions beverages) in Coles and Woolworths, Discussion price promotions in four New Zealand respectively (Table 3). A similar proportion of supermarkets reported that the majority of all SSBs and ASBs were promoted as multi- This is the first study to systematically and all price promotions were for ‘red’ (drink less) buys at each store (Coles: 6% and 7% of all comprehensively quantify the extent and beverages (44.1%) compared to ‘amber’ (drink SSBs and ASBs, respectively; Woolworths: 11% magnitude of price-promoted beverages in moderation; 40.9%) and ‘green’ (drink most) and 12% for all SSBs and all ASBs). available for sale, over a 12-month period, in beverages (14.9%).(14) Our study further Of all multi-buy promotions in a given week, Australian supermarkets. We demonstrate revealed that a much higher proportion of all the majority were for the SSB category that the frequency of price promotions price promotions were for sugary beverages (52% and 59% for Coles and Woolworths, for sugary drinks (SSBs, flavoured milk and (73% and 71% for Coles and Woolworths, respectively). When combining all sugary 100% juice combined) is approximately respectively) compared to non-sugar drinks (SSBs, flavoured milks and 100% proportional to their availability. On average, beverages. Similarly, a 2010-12 cross- juice), the multi-buys for these beverages sugary drinks constitute two-thirds of all sectional audit of price promotions in 955 US made up more than three-quarters of all beverage product types available for sale supermarkets showed a greater prevalence multi-buy offers (Coles: 74%, Woolworths: and around two-thirds of all price-promoted of price promotions among SSBs (18.2%) 75%). The proportion of multi-buys offered beverages in any given week. Within each compared to non-sugary beverages (12.1%) 13 within each beverage category was variable beverage category, the proportion of all products. However, our contemporary across beverage categories and across beverage products available for sale with a results suggest that this proportion is much supermarkets. Within the beverage categories price promotion did not markedly differ for higher and, on average, approximately one- available at Coles, multi-buys were most SSBs and ASBs (approximately one-third of third of all SSB products are price promoted. common within the flavoured mineral water all SSBs and ASBs are price promoted in any The strengths of our study include the (sugar-sweetened) category (Coles: 16%, given week). The mean discount for price- comprehensive nature of data collection, Woolworths: 12%), whereas for Woolworths, promoted beverages is also similar across covering 50 weeks of price promotions cycles beverages within the categories flavoured beverage types, with an overall mean price within a year, across all seasons and holiday water, ice teas, sports and energy drinks discount of 33% and 26% for Coles and events. Our data is further strengthened (Coles: 3%, Woolworths: 14%) and artificially Woolworths, respectively. by our audit of all beverages available for sweetened water, ice teas, sports drinks were Our conclusions are similar to previous sale, which allowed us to examine the most commonly promoted as a multi-buy international studies of shorter duration. extent of price promotions relative to their (Coles: 4%; Woolworths: 15%). A 2007 four-week audit of beverage availability. However, this complete audit of all available beverages was also limited Figure 1: Weekly variation in the proportion of each beverage category price promoted at Coles and Woolworths. to just one collection point, mid-way through the data collection period. Our study is further limited to the availability of price promotions and does not reflect customer purchasing behaviour. The health implications of beverage price promotions depend on their influence on healthy and unhealthy beverage choices – a function of both the frequency and magnitude of price promotions on healthy and unhealthy beverages and consumer responses to such price promotions. While studies from the UK and US show that the impact of price promotions on purchasing behaviour is similar for healthy and less healthy foods,18,19 comparable analyses are not available in the Australian context. Finally, it is important to acknowledge that ‘everyday low prices’ were not included as a price promotion in our study as we were interested in temporary (not ‘everyday’) price reductions. Australian supermarkets use ‘everyday low prices’ on items such as plain milk as a tactic to increase market competitiveness, which may explain the lower proportion of price promotions in the water and plain milk category.

Note: shading on graph represents seasons: December-February (Summer); March-May (Autumn); June-August (Winter); September-November (Spring)

Policy implications Table 3: Weekly mean number and proportion of beverages on ‘multi-buy’ price promotion, by product category, We show that, in any given week, the for the two major Australian Supermarkets (Coles and Woolworths) between November 2016 and November 2017. proportion of price-promoted SSBs and ASBs Beverage Category Mean number of Mean % of Mean % of all is similar (Coles: 30% of all SSBs, vs. 33% of multi-buy beverages product line (SD) multi-buys (SD) all ASBs; Woolworths: 37% of all SSBs vs. 38% per week, n (SD) Coles (Total) 41 (25) 4 (3) 100 of ASBs), indicating that these supermarkets SSBs 22 (16) 6 (4) 52 (16) do not distinguish between healthy and Cordial 2 (4) 3 (8) 2 (6) less healthy beverages when setting price Flavoured water, ice tea, sports and energy drinks 3 (3) 3 (4) 9 (13) promotions. Rather, it is likely that these Fruit-flavoured drink (<99%) 5 (6) 7 (7) 12 (12) supermarkets use price promotions as a Flavoured mineral water (sugar-sweetened) 3 (4) 16 (21) 9 (11) way of increasing store traffic and overall Soft drink 9 (8) 6 (6) 21 (16) sales. Nevertheless, the ubiquity of price ASBs 8 (6) 7 (5) 21 (11) promotions on sugary drinks supports Diet cordial 1 (2) 7 (20) 1 (3) recent calls by public health coalitions Diet flavoured water, ice tea, sports and energy drinks 1 (2) 4 (6) 4 (7) and governments for a ban on unhealthy Flavoured mineral water (no sugar) 2 (3) 8 (11) 6 (8) 8-10 food and beverage price promotions. A Diet soft drink 4 (3) 7 (6) 10 (8) modelling study from the UK further supports Flavoured milk and 100% juice 9 (8) 3 (3) 22 (21) these policy recommendations, finding Flavoured milk 0 (0) 0 (0) 0 (0) that, on average, one-fifth of the volume of 100% fruit or vegetable juice 9 (8) 5 (4) 22 (21) price-promoted food and beverages sold Milk and water 1 (2) 1 (1) 5 (15) can be considered to be in addition to what Milk 0 (1) 0 (1) 3 (14) would be sold were the promotion not in Water 1 (1) 1 (2) 2 (6) place (i.e. on top of the substitution effect Woolworths (Total) 79 (30) 8 (3) 100 from non-price-promoted products).20 SSBs 47 (20) 11 (5) 59 (6) We are not aware of any empirical studies Cordial 3 (5) 5 (8) 4 (6) examining behavioural responses to Flavoured water, ice tea, sports and energy drinks 16 (7) 14 (7) 20 (8) removing price promotions on sugary drinks. Fruit-flavoured drink (<99%) 11 (6) 13 (8) 15 (9) Such evidence would help refine these policy Mineral water (sugar sweetened) 5 (5) 12 (12) 6 (5) recommendations. Soft drink 12 (8) 11 (8) 14 (8) This research highlights that public health ASBs 17 (9) 12 (6) 21 (6) SSB pricing interventions may need to extend Diet cordial 2 (3) 13 (20) 2 (3) beyond a tax on SSBs and consider policies Diet flavoured water, ice tea, sports and energy drinks 6 (3) 15 (8) 8 (4) Flavoured mineral water (no sugar) 3 (3) 9 (10) 4 (4) that reduce the influence of price promotions Diet soft drink 7 (5) 11 (8) 8 (5) on consumer purchasing behaviour. With Flavoured milk and 100% juice 11 (5) 5 (2) 16 (7) international SSB taxes commonly set at Flavoured milk 2 (1) 2 (2) 2 (2) 10-20%, the magnitude and regularity of SSB 100% fruit or vegetable juice 10 (4) 6 (3) 13 (6) price promotions may attenuate the impact Milk and water 3 (3) 2 (2) 4 (3) of any future SSB tax in Australia.6 Policies that Milk 1 (2) 1 (1) 1 (2) reduce the influence of SSB price promotions, Water 3 (3) 4 (4) 3 (3) such as restrictions on unhealthy beverages (and food), would create an even pricing playing field across all supermarkets and may inadvertently reduce the number of price population nutrition. Empirical studies to ameliorate any financial impact to industry promotions for sugary drinks. However, any evaluate the likely impact of such a policy are – a core concern for industry lobbyists. such changes would need to be monitored clearly required. Alternative policy options may include carefully to determine if the changes are likely a restriction on the advertising of price to have the intended public health impact. Funding promotions in-store, as has been suggested This work is supported by a National Heart 21 by the Scottish government, however, more Conclusion Foundation Vanguard grant (101674). research is required to understand the impact AJC is supported by a DECRA fellowship of such policies on beverage choices and Price promotions are used extensively for (DE160100141) from the Australian Research population health. beverages sold in Australian supermarkets, Council and is a researcher within a NHMRC Our results demonstrating that the with the vast majority of available price Centre for Research Excellence in Obesity availability of sugary drinks is proportional promotions for sugary drinks, undermining Policy and Food Systems (APP1041020). JW to price promotion frequency, suggest efforts to promote healthy population diets. is supported by a UNSW Scientia Fellowship. that interventions to increase the relative Policies to restrict price promotions on SSBs The funding sources had no role in the availability of healthier beverages, are likely to be an important part of any design, analysis or writing of this article. compared to unhealthy beverages, may also approach to reduce obesity and improve

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Development of Australia’s front-of-pack interpretative nutrition labelling Health Star Rating system: lessons for public health advocates

Michael Moore,1,2 Alexandra Jones,1 Christina M. Pollard,3 Heather Yeatman4

orking with the food industry Abstract for public health good presents Wchallenges and opportunities. Objectives: To draw advocacy lessons from actions undertaken by public health groups to Differing fundamental foci, for example on assist the development of Australia and New Zealand’s Health Star Rating (HSR) front-of-pack profit versus health, mean that food industry nutrition labelling system. actions can directly contribute to public Methods: The advocacy approaches undertaken by the Public Health Association of Australia health (e.g. supporting growers producing leading up to the time of the adoption of the HSR is examined using a 10 step advocacy fruit and vegetables) or undermine it (such as framework. Key roles in advocacy planning and implementation are described, along with allowing the proliferation of cheap, unhealthy coordinating efforts by health and consumer groups during the HSR development processes. commodities). Results: HSR aims to support consumers to make informed choices to protect from diet- Front-of-pack nutrition labelling systems related diseases, including obesity. The HSR launched despite a number of major obstacles, (FoPL) are recommended by the World owing to a strategic, coordinated advocacy effort undertaken by a guiding coalition. Health Organization as a tool to promote Conclusions: Actions to improve nutrition are often highly contested, particularly if the healthier diets.1 Their development requires desired outcome competes with commercial interests. However, by deploying a structured multi-stakeholder negotiation. However, as approach to public health advocacy it is possible to influence government despite opposition FoPL can change purchasing intent,2 they are from commercial interests. opposed by some industries whose profits rely on foods detrimental to health. Implications for public health: A shared vision and a coordinated effort by public health professionals enabled advocates to overcome undue commercial influence. This paper deals specifically with the process leading to the adoption of the Health Star Key words: advocacy, nutrition, public health, Front of Pack Labelling (FoPL), Health Star Rating (HSR) FoPL in Australia and New Rating (HSR) Zealand up to 2014. The controversies that followed the HSR adoption are outside the Strong leadership, policy entrepreneurship to lead a review into food labelling law scope of this paper.3 We reflect on the Public and a coherent alliance between public and policy in 2011. Consistent with PHAA’s health and consumer groups enabled the Health Association of Australia (PHAA) actions prior call for a colour-coded multiple traffic development of a FoPL system in Australia to improve nutrition for more than a decade lights (MTL) system, Blewett’s final ‘Labelling and could contribute to advancing FoPL leading up to the development of the HSR. Logic’ report found “MTL systems were the standards at the international level.5 These include prioritising both a National most effective in facilitating consumers’ Nutrition Policy and the development of a understanding of the nutrient profiles across 6 health advocacy tool based largely on 10 Background foods within and across food categories”. It sequential steps for planning or evaluating recommended: an interpretative FoPL system public health advocacy4 (see Figure 1). The The Australian Federal Government be developed reflective of a comprehensive lessons we draw are consistent with the commissioned former Federal Labor Health Nutrition Policy (Recommendation 50); a findings of Kumar et al.5 who conclude: Minister and academic, Dr Neal Blewett, MTL FOPL system be introduced that was

1. The George Institute for Global Health, UNSW Sydney, New South Wales 2. UC Health Research Institute, University of Canberra, Australian Capital Territory 3. School of Public Health, Curtin University, Western Australia 4. Faculty of Social Science, University of Wollongong, New South Wales Correspondence to: Adjunct Professor Michael Moore, The George Institute for Global Health, UNSW, Sydney, New South Wales; e-mail: [email protected] Submitted: January 2019; Revision requested: March 2019; Accepted: April 2019 The authors have stated they have no conflict of interest. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Aust NZ J Public Health. 2019; 43:352-4; doi: 10.1111/1753-6405.12906

initially voluntary but mandatory for general shared vision for change (Advocacy Steps 1, Challenges of working with industry 8 or high-level health claims or equivalent 2 and 4, Figure 1). Throughout the process, Within the SPC, an agreed outcome was (Recommendation 51); that government the PHAA and others continued to advocate challenging as the committee comprised of provides advice and support for producers for an interpretative MTL FoPL scheme to be multiple stakeholders. Health and consumer adopting the MTL and educates consumers initiated as part of a National Nutrition Policy. advocates sought clear messages for public (Recommendation 52); and monitoring The consumer and public health guiding health, while industry advocates remained industry compliance and evaluating coalition agreed on a series of principles, protective of their profit motive. At the first food supply and consumer food choice announced in a media statement (Advocacy SPC meeting, the concept of star ratings improvements (Recommendation 53). Step 5, “communicating the vision for buy-in”) – similar to those already in the Australian released on the day of the SPC’s first meeting. market to rate hotels and movies – was Thwarted on traffic lights and next It concluded with calling for: agreed. A label format and suitable criteria for steps ... an interpretive system that includes colours rating individual food and drink products to The Legislative and Governance Forum and symbols that are easy to understand, align with the Australian Dietary Guidelines on Food Regulation (Forum), later to be provides a quick comparison between was required. Collectively, the SPC agreed to the Australia and New Zealand Ministerial different products, and makes healthy “aim for a gold medal – but accept a position 9 Forum on Food Regulation (FoFR), rejected choices easy. on the podium”.10 Recommendation 51, specifically ruling out The guiding coalition also established its A Technical Design Working Group (TDWG) MTL. bottom line, the compromises they would be was established to seek the most effective, The FoFR did accept the more general willing to make – beyond which they would defensible and consistent approach to Recommendation 50: “an interpretative front- walk away – and an agreed public position. applying the Health Stars as the system of-pack labelling system be developed that is Each member of the guiding coalition acted developed.11 Additionally, an Implementation, reflective of a comprehensive Nutrition Policy as a representative of their organisation and Evaluation and Education Working Group 6 and agreed public health priorities”. However, conduit for feedback on negotiations. The (IEEWG) examined regulatory options. Both there was as yet no Nutrition Policy. Ministers process moved quickly and there was little groups had wide representations but limited delegated the process to the Food Regulation time for standard consultation processes and time for deliberations. Vigorous discussion Standing Committee (FRSC), which is made procedures. Each organisation relied on their ensued before reaching agreement for an up of senior public servants. FRSC determined current policy positions for guidance, which HSR scoring system based on a pre-existing the specific members of the FoPL Steering in the case of the PHAA were developed nutrient profiling scoring criteria (NPSC) and Project Committee (SPC) who were through the Food and Nutrition Special already used to for health claims. The drawn from industry, public health and Interest Group (FANSIG). Resource limitations information about the adaptation of the consumer stakeholders. The development and government procedural processes meant NPSC has been recently published as part of of a FoPL was to be a collaborative process, only a small number of technical experts HSR’s five-year review.12 following a set of objectives and principles were present during complex political and The greatest challenge in development of the provided by Ministers that were already technical negotiations. The contested and HSR was having industry renege on agreed a balancing act between health and time-bound nature of policy development positions. profitability.7 The choice of stakeholders by meant that some individuals with extensive FRSC reflects the importance of Advocacy relevant nutrition science expertise who Industry reneges Step 3 “building and maintaining influential had originally advised government were no relationships”. longer involved in direct negotiations. There was initial agreement by industry groups to adopt the scheme, but some The guiding coalition industry members reneged on the position to Figure 2: The ‘Guiding Coalition’. adopt the use of stars and the algorithm. The Prior to the first meeting of the FoPL SPC, 16 Australian Chronic Disease Prevention Alliance guiding coalition moved quickly, consistent public health and consumer organisations Australian Medical Association with Advocacy Step 7: Be Opportunistic. (Figure 2) held a strategy meeting to generate Australian Division of World Action on Salt and Health Parallel to the development of the HSR the a sense of urgency, form a ‘guiding coalition’, Cancer Council Australia guiding coalition members continued to strengthen relationships, and develop a Cancer Council NSW take actions to strengthen outcomes for CHOICE public health benefit, as did industry for Figure 1: The Advocacy Tool. Diabetes Australia commercial benefit. Although the HSR system Step 1: Establishing a Sense of Urgency Diabetes Australia Vic was a collaboratively agreed product, sources Step 2: Creating the Guiding Coalition Dietitians Association Australia revealed industry players were approaching Step 3: Developing and Maintaining Influential Relationships National Heart Foundation Ministers prior to the FoFR meetings intent Step 4: Developing a Change Vision Kidney Health Australia on blocking the agreement. In response to Step 5: Communicating the Vision for Buy-in National Stroke Foundation these actions, the PHAA ‘opportunistically’ Step 6: Empowering Broad-based Action The George Institute for Global Health approached Ministers on the morning of the Step 7: Be Opportunistic Physical Activity, Nutrition and Obesity Research Group Forum meeting, reiterating support for the Step 8: Generating Short-term Wins Obesity Policy Coalition HSR. Ministers rejected industry lobbyists’ Step 9: Never Letting Up Public Health Association Australia approaches, viewing them as ‘reneging’ on Step 10: Incorporating Changes into the Culture University of Wollongong

an agreement. They approved the HSR ‘in adequately aligns with evidence-based 5 Kumar M, Gleeson D, Barraclough S. Australia’s Health Star Rating policy process: Lessons for global policy- principle’ at the Forum meeting in Sydney in dietary advice, particularly that of the making in front-of-pack nutrition labelling. Nutr Diet. June 2013. Australian Dietary Guidelines. During the HSR 2018;75(2):193-199. development, it was agreed that the uptake 6. Blewett N, Goddard N, Pettigrew S, Reynolds C, Yeatman Some supportive food companies were H. Labelling logic: Review of Food Labelling Law and waiting for the algorithm to be made public needed to be ‘widespread and consistent’ and Policy. Canberra (AUST): Australian Department of there was a condition that it remain voluntary Health and Ageing. 2011. via an HSR website to begin using the HSR. 7. Australia New Zealand Food Regulation Ministerial Once the system was ‘live’, any person could unless this did not occur, at which point it Council. Front of Pack Labelling Policy Statement. assess individual food products online for would be made mandatory. By June 2018, in Canberra (AUST): Australian Department of Health Food Regulation Secretariat; 2009. their relative healthfulness according to Australia, the HSR was on more than 10,300 8. FoPL Project Committee. Front of Pack Labelling 16 the algorithm. Other manufacturers, with products and over 3,900 in New Zealand. Project Committee - Objectives and Principles for the However, HSR remains on less than one-third Development of a Front-of-pack Labelling (FoPL) System. products of limited health value, were Canberra (AUST): Australian Department of Health nervous about its impact and sought to of products overall, and these are mostly Food Regulation Secretariat; 2012. those that score well.17 Moreover, Australia 9. Australian Chronic Disease Prevention Alliance. Media lessen the scheme’s effectiveness, including Release: Health and Consumer Alliance Sends Unified seeking to have the HSR website removed. still does not have a wider National Nutrition Message to Govt: Clear Food Labelling a Key to Healthier Policy. Australia. Sydney (AUST): Cancer Coucil Australia; 2012 Industry players continued lobbying to March 26. undermine agreed HSR positions, particularly It is incumbent on public health professionals 10. Moore M. FoPL Steering and Project Committee to maintain their persistence and work to Star Ratings Concept Meeting Notes 2012 March. following the official launch of the HSR Unpublished observations. website in early February 2014. The Australian improve the efficacy of the HSR system 11. Australia and New Zealand Food Regulation Secretariat. Federal Food Minister, at the behest of her (Advocacy Step 9: Never letting up). It also Front-of-pack Labelling Committee and Working Group Meetings. Canberra (AUST): Australian Department of then Chief of Staff and without consulting is critical the HSR is just one of the tools in Health Food Regulation Secretariat; 2018. all other ministers, ordered the HSR website improving nutrition and health outcomes. 12. MPConsulting. Five Year Review of the HSR System - Advocates continue to pursue a National Technical Paper, History and Development of the Health taken down within hours of its launch online. Star Rating Algorithm. Canberra (AUST): Department 18 It was later discovered the Chief of Staff had a Nutrition Policy to guide the development of Health Health Star Rating Technical Advisory Group; and implementation of a comprehensive set 2018. conflict of interest, having previously worked 13. Corderoy A, Massola J. Government official who as a consultant to a major confectionery of public health interventions for improved opposed healthy food website owns shares in food manufacturer and not severed all ties.13 dietary patterns ‘incorporated into the culture’ lobbying company. Sydney Morning Herald. 2014 February 12. (Advocacy Step 10). 14. Corderoy A. Anger as federal food guide is pulled from Timely advocacy web. Sydney Morning Herald. 2014 February 10. 15. Lawrence M, Pollard C. Food labels are about informing The guiding coalition responded quickly to Conclusion choice, not some nanny state. J Home Econ Inst Aust. 2014;21(1):40. the website removal, meeting and agreeing 16. Australia and New Zealand Ministerial Forum. to take turns creating media opportunities to Successful advocacy requires systematic and Australia and New Zealand Ministerial Forum on Food keep the issue on the agenda (Advocacy Step objective reflection on past actions. While Regulation. Communique—29 June 2018 [Internet]. different approaches are required in different Canberra (AUST): Australian Department of Health 8: Generating short term wins). The Sydney Food Regulation Secretariat; 2018 [cited 2019 Mar 21]. Morning Herald health editor wrote the first circumstances, advocacy does have common Available from: http://foodregulation.gov.au/internet/ fr/publishing.nsf/Content/forum-communique-2018- 13 elements. The ten sequential steps applied in story. A week of questioning followed in June the media, in the Senate and through public the development process of the HSR system 17. Jones A, Shahid M, Neal B. Uptake of Australia’s Health on packaged food for public health benefit Star Rating System. Nutrients. 2018,10(8):997. questioning of government. Examples of 18. Public Health Assocation of Australia Food and HSR on foods were published, 66 professors provide an important case study in public Nutrition Special Interest Group. National Nutrition of health called for reinstatement of the health advocacy. Policy. Canberra (AUST): PHAA; 2018. website and public health professionals published advocacy pieces.14 Eventually, References Ministers agreed to reinstate the website with 1. World Health Organization Regional Office for Europe. a compromise to allow all packaged foods to European Food and Nutrition Action Plan 2015-2020: be included and the HSR be on a voluntary Time Frame. Copenhagen (DNK): Euro WHO; 2015. p. 19. basis for five years, subject to a two-year 2. National Heart Foundation of Australia. Report on the review of progress. They later agreed the Monitoring of the Implementation of the Health Star Rating System: Key Findings for Area of Enquiry Two – system would be subject to a comprehensive Consumer Awareness and Ability to Use the Health Star formal five-year review, due in 2019. Rating System Correctly. Canberra (AUST): Australian Department of Health; 2017 July. The HSR represents an important 3 Lawrence MA, Dickie S, Woods JL. (2018) Do improvement in nutrition labelling for nutrient-based front-of-pack labelling schemes support or undermine food-based dietary guideline consumers but concerns remain about the recommendations? Lessons from the Australian Health performance of its algorithm in guiding Star Rating System. Nutrients. 2018;10(1). pii: E32. doi: consumers towards genuinely healthier 10.3390/nu10010032 4. Moore M, Yeatman H, Pollard C. Evaluating success choices.15 The HSR represents an important in public health advocacy strategies. Vietnam J Public improvement in nutrition labelling for Health. 2013;1(1):66-75. consumers. A predominant focus of the review has been to assess whether it

The performance and potential of the Australasian Health Star Rating system: a four-year review using the RE-AIM framework

Alexandra Jones,1,2 Anne Marie Thow,3 Cliona Ni Mhurchu,1,4 Gary Sacks,5 Bruce Neal1,6

nhealthy diets – high in salt, harmful Abstract saturated and trans fats, added sugar and energy – are a leading cause Objective: The Health Star Rating (HSR) is a front-of-pack nutrition labelling system, U 1 of death and disability globally. Australia implemented voluntarily in Australia and New Zealand since 2014. Our aim was to evaluate has some of the highest obesity rates in the HSR’s performance. world: nearly two-thirds of Australian adults Method: We used data from peer-reviewed publications and government-commissioned and one in four children are overweight monitoring and evaluation, websites and communiqués to evaluate HSR’s performance or obese. Unprecedented availability and between June 2014 and October 2018 using the RE-AIM (Reach, Efficacy, Adoption, aggressive marketing of processed and Implementation and Maintenance) framework. pre-packaged foods and beverages are a key Results: Thirty-three peer-reviewed publications, 21 government and three independent driver of obesity and diet-related conditions reports informed the assessment. Awareness and trust in HSR was increasing, though including high blood pressure, heart disease, campaign reach remained low. Consumers liked, could understand and use the HSR logo, type 2 diabetes and dental caries.2 Obesity though effects on purchasing were largely unknown. The algorithm was the focus of a formal is estimated to cost Australia more than $8.6 review. HSR was present on 20-28% of products but biased to those that scored better billion annually.3 (HSR≥3.0). Necessary stakeholders were mostly engaged. Interpretive front-of-pack nutrition labels Conclusions: A substantial body of work supports continuation and strengthening of HSR. (FoPL) are recommended by the World Health Reasonable refinements to HSR’s star graphic and algorithm, action to initiate mandatory Organization (WHO) as an evidence-based implementation, and strengthened HSR governance present the clearest opportunities for policy to promote healthier diets.4,5 These improving public health impact. types of labels use nutrient profiling to assess the nutritional quality of individual foods Implications for public health: Development and implementation of government-led front-of- and display this in a simplified, visual form. pack nutrition labelling systems have the potential to improve public health, while engaging a There is growing evidence that FoPL have diverse set of stakeholders. potential to improve nutrition literacy, guide Key words: food labelling, nutrition, food policy, health star rating, obesity consumer choice and incentivise industry to 11 improve their product formulations.6,7 While standards agency, the Codex Alimentarius and consumer groups. In short, HSR aims not a complete source of dietary advice, FoPL Commission, to commence work developing to “provide convenient, relevant and readily 10 is recognised by WHO as a helpful tool to further international guidance on FoPL. understood nutrition information and/or use in conjunction with interventions aimed In June 2014, Australia and New Zealand guidance on food packs to assist consumers at improving the overall nutritional quality adopted a voluntary FoPL in the form of the to make informed food purchases and 12 of diets.8 At least 16 government-endorsed Health Star Rating system (HSR) following a healthier eating choices”. Its developers schemes in various formats are operating lengthy process of development involving also recognised that the system should aim in over 23 countries.9 This proliferation of federal, state and territory governments in to be aligned with existing health strategies formats has prompted the international food collaboration with industry, public health and guidelines, and provide incentives for

1. George Institute for Global Health, UNSW, Sydney, New South Wales 2. Charles Perkins Centre, The University of Sydney, New South Wales 3. Menzies Centre for Health Policy, The University of Sydney, New South Wales 4. National Institute for Health Innovation, University of Auckland, New Zealand 5. School of Health and Social Development, Deakin University, Melbourne, Victoria 6. Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom Correspondence to: Alexandra Jones, George Institute for Global Health – Food Policy, 1 King St, Newtown, Sydney, NSW 2042; e-mail: [email protected] Submitted: December 2018; Revision requested: April 2019; Accepted: April 2019 The authors have stated the following conflict of interest: Alexandra Jones was a member of the Health Star Rating’s Technical Advisory Group (TAG) between 2017 and 2018. Cliona Ni Mhurchu is a member of the New Zealand Health Star Rating Advisory Group (HSRAG). Neither TAG nor HSRAG had any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Aust NZ J Public Health. 2019; 43:355-65; doi: 10.1111/1753-6405.12908

2019 vol. 43 no. 4 Australian and New Zealand Journal of Public Health 355 © 2019 The Authors Jones et al. Article improvements to the healthiness of the food material specifying how to display one Methods supply.13 of several permitted variants of the HSR 17 The HSR System has three components: an graphic. No fee or charge is payable to any We evaluated HSR with the RE-AIM underlying algorithm, the label graphic and party for HSR use, with manufacturers bearing framework, a method widely used to assess an accompanying education campaign. the cost of updating their own packages. Roll- the public health impact of health promotion out has been accompanied by government- programs.20,21 The five dimensions of the The algorithm assigns a rating from 0.5 funded education campaigns specific to each framework (Reach, Efficacy, Adoption, (least healthy) to 5.0 stars (most healthy) country. Implementation and Maintenance) are in ten half-star increments, assessing both particularly appropriate for evaluating the ‘risk’ components (total energy, total At its adoption, Australian and New Zealand implementation of population health policy, sugars, saturated fat, sodium) and ‘positive’ Food Ministers agreed HSR would remain allowing assessment of both the process and components of food (fibre, fruit, vegetable, voluntary for five years, and subject to a 18 outcomes. In Table 1 we define metrics for nut and legume content (FVNL) and in some two-year review of progress. They later evaluating each of the RE-AIM dimensions as cases, protein). It derives from an existing agreed the system would be subject to a they apply to implementation of HSR. model used to regulate health and nutrient comprehensive formal review, due to be 19 content claims in both countries, embedded delivered by mid-2019. Data sources and criteria for inclusion in the Australia New Zealand Food Standards The aim of this study was to evaluate the Code.14 It was adapted for HSR in consultation extent to which the HSR had achieved its We conducted the evaluation using two with Food Standards Australia New Zealand objectives since implementation and to sources of information: (FSANZ) and technical and nutrition experts, contribute recommendations on how its • Government-issued information on HSR including industry representatives.15,16 public health impact may be enhanced. This implementation (e.g. official websites, Where they elect to utilise the system, food evaluation was independent and separate communiqués, monitoring reports and manufacturers are responsible for correct from the formal review commissioned by commissioned research) and accurate use of government guidance government.

Table 1: Operationalising the RE-AIM Framework for evaluation of the HSR system. Dimension Description Definition in context Metrics for assessment Data sources identified through search (n)a Reach Proportion, and Extent to which the Australian Fraction of population that: Government-commissioned nationally representative representativeness and New Zealand population has • Is aware of the HSR system (unprompted and prompted) surveys on awareness, understanding and use (12) of the target access to HSR • Trust HSR Government-commissioned campaign evaluations (10) population that • Has been exposed to the HSR campaign participates in the policy Efficacy Extent to which the Extent to which HSR is guiding Efficacy of HSR label graphic Independent, peer-reviewed research: RCTs, randomized policy has delivered consumers towards healthier • Consumer understanding and use online surveys, choice experiments, focus groups, cross- outcomes in the choices • Impact on choice and purchasing sectional examination of food supply (28) target population • Impact in driving industry reformulation Government-commissioned nationally representative Efficacy of HSR algorithm surveys (11) • Alignment with current nutrition, medical and behavioural Government-commissioned reports on alignment with sciences literature (content validity) other policies and reformulation (2) • Alignment with other health and nutrition policies Government-commissioned campaign evaluations (10) (construct validity) Independent report benchmarking HSR against • Alignment with health outcomes (predictive validity) international best practice (2) Efficacy of HSR campaign • Consumer understanding • Impact on call to action Adoption The degree to Degree to which HSR is operating Representation of each stakeholder in governance structures for Government websites: HSR; Food Regulation; AusTender, which the necessary as an Australian and New HSR implementation Department of Health (Aus), Ministry of Primary settings have been Zealand governments initiative in Stakeholder analysis of involvement, interest, power and impact Industries (NZ) engaged in the partnership with industry, public of HSR on each actor Government-commissioned media analysis (1) policy health and consumer groups Website and reports of the Independent Reviewer Implementation Extent to which the Extent to which HSR has actually Uptake of HSR on product labels Independent, peer-reviewed research, cross-sectional policy actually has been implemented as intended • Number of products displaying, proportion of food supply examination of food supply (5) been implemented including the number of products • HSR status of those displaying Government-commissioned monitoring and evaluation as intended in the displaying HSR and compliance • Number of manufacturers displaying HSR reports (6) real world of labels with HSR guidance Compliance of labels displayed with HSR Guidance materials materials Maintenance How the policy is Initiatives, implemented as HSR governance Government websites: HSR; Food Regulation; AusTender sustained over time a direct consequence of HSR, • Dedicated funding sources Department of Health (Aus), Ministry of Primary and is evaluated designed to enforce and sustain • Monitoring and evaluation mechanisms Industries (NZ) the intervention and monitor • Enforcement mechanisms, including anomaly and dispute Government-issued communiqués and budget papers its effects processes and other mechanisms to ensure compliance, Reports of the independent reviewer (2) transparency and accountability Notes: a: Data sources may cover more than one outcome or RE-AIM dimension e.g. reports which consolidate data on general HSR awareness, and operation of the HSR campaign

• Secondary data from peer-reviewed and a rating to the average interest, influence to 21% July 2018), and steadily increasing grey literature (e.g. reports produced and position of key HSR stakeholders, and prompted awareness of the HSR system by industry, consumer or public health impact of HSR implementation on them. Our (33% April 2015 to 84% July 2018) (Figure 1). stakeholders). findings for all dimensions combined were Females, younger people, those with higher All materials were publicly available and used to assess HSR’s overall achievement of education, higher income and normal weight obtained using a systematic search strategy its objectives, and to make recommendations were consistently more likely to be aware of outlined in Supplementary Appendix 1. on where its public health impact could be HSR. improved. We limited our search to materials produced In Australia, these surveys showed that trust after HSR’s adoption and, given our focus in HSR among the total population had on implementation, excluded any materials Results steadily increased from 38% in April 2015 23-31 published about HSR’s development to 61% in July 2018 (Figure 1). In New 33 before and after this date. We also excluded We identified 33 relevant peer-reviewed Zealand, trust was 39% in January 2017, and 34 materials concerning use of HSR in other publications, 21 government-commissioned steady at 40% in June 2018. jurisdictions and settings (e.g. on labels in and three independent reports, most of Ten of these surveys evaluated exposure to other countries, or on foods or products for which contained quantitative data relevant the education campaign. Australia’s campaign which it wasn’t intended). We focused on to one of more of the RE-AIM dimensions ran over four waves between 2014 and original analysis, and therefore excluded of Reach, Efficacy and Implementation: see 2017 with eight surveys conducted up until commentaries and editorials that repeated Supplementary Appendix 1. Adoption and July 2018 showing campaign recognition information already included through original Maintenance were primarily assessed through fluctuating between 13 and 25% (Figure research. To keep the exercise manageable, information provided by the Australian and 1).24-31 Evaluators noted funding was ‘modest’ we excluded individual media items, but New Zealand governments through websites compared to other government and private included summary media analysis released and communiqués, facilitating analysis of sector campaigns.25 In New Zealand, reported by government. We included materials stakeholder engagement in HSR’s current recognition rose from 12% in December 2016 published up to and including 1 October operation, governance and funding. to 45% in June 2018 following addition of 2018. television to the marketing mix.33,34 Reach Extraction and coding of data Reach was assessed by the proportion of Efficacy We created a database of materials on HSR the population that were aware of HSR, trust Efficacy was assessed by the extent to implementation. For each item, we extracted it, and had been exposed to the education which HSR was guiding consumers towards standard information including: author(s), campaign. healthier choices. HSR’s efficacy had been title, date and place of publication, type of HSR awareness had been evaluated in the subject of more than 29 peer-reviewed publication (e.g. peer-reviewed research, nine nationally representative surveys in research papers and 15 government- government-commissioned report) and Australia and three in New Zealand.23-34 They commissioned reports covering performance jurisdiction covered (Australia and/or New suggested low, but consistently improving, of one or more of the HSR’s three Zealand). We also extracted information on unprompted awareness (3% April 2015, components: the label graphic, underlying study design, population and/or data relied upon to assist in evaluating the strength of FigureFigure 1: Unprompted 1: Unprompted awareness awareness of HSR, of HSR, prompted prompted awareness awareness of ofHSR, HSR, trust trust in in HSR HSR and and exposure exposure to to the the HSR HSR campaign in Australia the evidence obtained. Finally, we coded campaign in Australia. materials by component of the HSR System 100 reviewed (algorithm, label and/or education campaign), outcome evaluated (awareness, understanding, use, uptake, alignment 80 with existing policies), and relevant RE-AIM dimension. This database is included in Supplementary Appendix 1. 60 population Analysis Outcomes of the literature review were 40 Australian summarised by each RE-AIM dimension % and synthesised where possible in tables and figures to provide an overall view of the 20 degree to which each dimension has been achieved. To evaluate Adoption, we also adapted a stakeholder analysis approach 0 Apr‐15 Oct‐15 Apr‐16 Oct‐16 Apr‐17 Oct‐17 Apr‐18 used by Brugha and Varvasovzsky,22 using findings of the literature review and Unprompted awareness Prompted Awareness Trust Have seen campaign consultation among the authors to assign Note: DataData is providedis provided fromfrom the the date date of the of first the availability first availability in Australia in (April Australia 2015). (April 2015).

algorithm, and accompanying education Zealand studies noted above, HSR was shown of sugars was being considered in the five- campaign. to be ineffective in influencing unprompted year review.59 Twenty-six papers and reports had assessed consumer choice between two breakfast Alignment with existing policies and other 46,47 the efficacy of the HSR graphic, including two cereals and consumers made similar measures of healthiness (i.e. construct validity): 45 randomised controlled trials (RCTs), seven purchases using HSR and MTL. Randomised We identified eight studies that assessed randomised choice experiments, eleven controlled trials examining the impact of FoPL alignment between HSR and the Australian nationally representative surveys, three in the real world identified no effect of HSR on Dietary Guidelines (ADGs). This work 35,36 intercept surveys, two focus group studies, the healthiness of food purchases, despite consistently found that healthy ‘core’ or ‘Five and one policy analysis paper. participants’ stated preference for the HSR Food Group’ (FFG) foods received higher HSRs label format. on average (HSR 3.7-4.0) than ‘discretionary’ HSR ‘star’ graphic Ability to incentivise reformulation: Several foods (HSR 1.9-2.5).61,63-68 Understanding and use: Most research companies reported HSR was guiding The two papers focused on added sugars 51 identified the HSR graphic as easy to reformulation activities but only two papers demonstrated that alignment with the ADGs understand and use. The HSR star logo was systematically assessed HSR’s impact on could be improved by incorporating added 52,53 found to be more likely to be understood reformulation across the food supply. sugars into the HSR algorithm.60,61 and to influence product selection than Research in New Zealand found small but Three papers and one government report the Nutrition Information Panel (NIP),35,36 statistically significant favourable changes attempted to specify overall alignment health and nutrient content claims,37-40 in mean energy density, sodium and fibre in with the ADGs. Two large cross-sectional and alternative FoPL designs including HSR labelled products compared with their examinations of the food supply calculating the Multiple Traffic Light (MTL)35,36,38,41 composition prior to adoption of HSR.52 In HSRs for all products (n=34,000; 65,600) and industry-preferred Daily Intake Australia, these methods were replicated regardless of whether they displayed HSR, Guide.35,36,38,41-44 Several studies confirmed and used to model cost-effectiveness, with found between 82-87% of products had these results in children.40-42,44 These researchers determining HSR a cost-effective HSRs corresponding with a pre-defined experimental findings were consistent with strategy for delivering food reformulation ‘appropriate’ range for core or discretionary government-commissioned monitoring under both voluntary and mandatory using a cut-point of HSR 3.5 (i.e. core foods surveys, where between two-thirds and implementation scenarios.53 scored equal or above this and discretionary three-quarters of consumers consistently foods below this).63,65 Two smaller studies self-reported HSR was easy to understand HSR algorithm (n=1,269; 3,940) reviewed the algorithm and use.23-34 Thirteen peer-reviewed publications and using information from labels on which two government reports assessed the Two New Zealand studies (one intercept HSR was displayed. The findings of these performance of the HSR algorithm using survey and one online experiment) produced studies highlighted that between 39-57% 54,55 45,46 different validation methods. disparate findings though both were of discretionary foods displayed a HSR≥2.5, conducted shortly after HSR adoption, using Alignment with current scientific literature assessed by the study authors as an label designs different from the HSR graphic (i.e. content validity): Food components unacceptable ‘pass’ mark.64,67 Each of these used in practice. In 2018, the intercept included in the algorithm were largely works highlighted HSR ‘outliers’, attributed survey was repeated with an updated label, consistent with those in government-led in some cases to the algorithm and in others producing results more consistent with other FoPL elsewhere.56-58 HSR’s components ‘to to imprecise definitions of unhealthy food.63 findings on consumer understanding and limit’ were the four most common elements Recommendations made for improving the use.47 reported in FoPL globally: energy (used in algorithm including its treatment of sugar, No experiments had assessed use and 41% of systems), sodium (43%), saturated protein, juices, and unpackaged fruits and 56 understanding of HSR’s ‘energy icon only’ fat (35%) and total sugars (41%). Not all vegetables were being considered in HSR’s variant of the label, which displayed only FoPL contained ‘positive’ components. Those five-year review.59-61 used in HSR (FVNL, fibre and protein) were kilojoule (and not star rating) information. In HSR alignment with Australia and New used in several other FoPL elsewhere,57 but government surveys, only 1% of consumers Zealand’s existing health claims legislation 26 lack of transparency in FVNL and fibre values found it easy to understand and use. was found to be good at a cut-point of relied upon to calculate HSR, and changes to Choice and purchasing: Consumers HSR≥3.5; with 97.3% of products over this the ‘tipping point’ for determining eligibility consistently self-reported being influenced by threshold eligible to display a health claim.69 to receive protein points were raised by HSR when shopping23-31,33,34,37,48 but studies While HSR was explicitly designed to focus public health and consumer stakeholders as assessing HSR’s impact on choice and real on packaged and processed foods,11 there is concerns in the five-year review.59 world purchases were less clear. increasing international interest in the impact Two papers focused on incorporating Several studies inferred a shift towards of industrial food processing on health, added or free sugars into HSR60,61 to accord purchasing of more healthy food or beverage particularly the association between high with evidence-based recommendations of choices when compared to no FoPL,43,49 and levels of consumption of ultra-processed Australian and New Zealand food-based suggested that HSR remained a significant foods (UPF) and poor diets.70 Three papers dietary guidelines and updated WHO attribute in driving product choice even when assessed HSR against the NOVA food Guidelines on Sugars Intake.62 A 2017 there were co-existing health claims39,40 or classification system.67,71,72 In a sample of audit suggested added or free sugars were other forms of nutrition information and dairy foods, HSR correctly classified milks, but included in 14% of FoPL globally.56 Treatment marketing on the label.50 In the disparate New not yoghurt and cheeses, based on degree

of processing.72 In a sample of supermarket Zealand evaluated the performance of and position of each stakeholder in HSR own-brand foods voluntarily displaying the HSR campaign.24-31,33,34 The majority implementation, and HSR implementation’s HSR (n=3,940), unprocessed and minimally of respondents reported that they resulting impact on them (Table 2). processed foods had a higher mean (HSR 4.4) understood campaign messages, though Key stakeholders with high interest and a than processed (HSR 3.5) or UPF (HSR 2.5), Australian evaluation noted some persistent supportive position included the Australian 24,25,27 however, 55% of UPF displayed a HSR≥2.5, confusion. In both countries, those who (Commonwealth, State and Territory) and assessed by the authors as a failure to fall had seen the campaign self-reported higher New Zealand governments, each of whom 67 below a designated cut-off of HSR 2.0. A awareness, trust, understanding and use of contributed funding and together retained summary of submissions to the five-year the HSR, and consistently reported carrying ultimate decision-making power on the review acknowledged stakeholder comments out at least one behavioural objective of future of the system through voting rights 73 on degree of processing, but at the time the campaign with around two-thirds self- exercised in the Ministerial Forum on Food of writing the independent reviewer had reporting they had purchased a new product Regulation (Forum). Decisions by politicians 24,25,27,33,34 determined it was outside the reasonable because of its HSR. in the Forum are supported by the work 59 scope of the review. of senior government officials in the Food Alignment with health outcomes (i.e. predictive Adoption Regulation Standing Committee (FRSC). validity): No papers were identified that Adoption was measured as the degree to In New South Wales, State Government assessed the ability of the HSR algorithm to which the necessary stakeholders engaged integrated HSR into its food procurement predict health outcomes, reported as the in HSR implementation. Available data were criteria in schools and hospitals.74 Despite this strongest method for assessing the validity of used to map HSR governance structures formal influence, media analysis up to 2016 nutrient profile models.54,72 (Figure 2) and summarise involvement of noted government representatives rarely each stakeholder (Table 2). Stakeholder participated in public commentary on HSR HSR Campaign analysis was conducted through iterative implementation.75 Eight government-commissioned consultation among the authors, assessing Food manufacturers and retailers have surveys in Australia and two in New the average level of interest, influence high interest and influence, though their

Table 2: Assessment of average interest, influence and position of stakeholders involved in HSR implementation, and impact of HSR on them. Stakeholder Characteristics Involvement in the issue Interest in HSR Influence/Power Position* Impact of HSR on stakeholder Australian Commonwealth Participate in Trans-Tasman Food Regulatory Committees with remit over HSR High High Supportive Medium Government Host FoPL Secretariat – primary public point of contact Facilitate government coordination – e.g. chair Jurisdictional Group and TAG Run Australian education and awareness campaign Administer tender for HSR monitoring and evaluation in Australia and overall Contribute funding to support implementation New Zealand Government Participate in Trans-Tasman Food Regulatory Committees with remit over HSR High Medium Supportive Medium Contribute funding to support implementation, including NZ specific campaign Coordinate and manage NZ HSRAG Coordinate and collate NZ monitoring and evaluation Australian State and Territory Participate in Trans-Tasman Food Regulatory Committees with remit over HSR Medium Medium Supportive Low Governments Selected representatives on HSRAC and TAG Contribute funding to support implementation, including campaign Consider integration of HSR into State-based policies e.g. school canteen guidelines Food manufacturers and retailers Formal representation on HSRAC,TAG and NZ HSRAG High High Somewhat High Responsibility to voluntarily apply HSR on products supportive Provide in-store placement of HSR campaign materials (retailers) Public health community Formal representation on HSRAC, TAG and NZ HSRAG Medium Medium Somewhat Medium ** Conduct and publish research on HSR efficacy and implementation supportive Build awareness of HSR among peers, patients and public in Australia and globally Advocate for improvements to HSR to improve public health impact Consumer groups Formal representation on HSRAC and NZ HSRAG Medium Medium Somewhat Medium Conduct and publish consumer research on HSR efficacy and implementation supportive Build awareness of HSR with consumers and consumer organisations globally Advocate for improvements to HSR to improve consumer utility Notes: Key to abbreviations used: HSR, Health Star Rating; FoPL, Front-of-Pack Label; NZ, New Zealand; TAG, Technical Advisory Group; NZ HSRAG New Zealand Health Star Rating Advisory Group; HSRAC, Health Star Rating Advisory Committee *Possible values for position include: supportive, somewhat supportive, somewhat opposed and opposed **While the majority of papers, policy statements, submissions and media representations from this group were generally supportive, a small number of vocal opponents were noted

Figure 2: Health Star Rating system governance. Figure 2: Health Star Rating System Governance

Australia and New Zealand Minister ial Forum on Food Regulation (Forum) Membership:  Federal, state and territory Ministers responsible for food from Australia and New Zealand  Chaired by Australian Government Minister for Rural Health Responsibilities:  Develop domestic food regulatory policy and policy guidelines for setting domestic food standards  Ultimate authority to make HSR decisions where no HSRAC consensus; ultimate authority to decide whether HSR made mandatory  Decision by consensus where possible, otherwise by vote with six votes required for a decision

Food Regulation Standing Committee (FRSC) – A Forum subcommittee Membership:  Senior officials of departments for which Ministers represented on the Forum have portfolio responsibility Responsibilities:  Coordinate policy advice to Forum, ensure nationally consistent approach to implementation and enforcement of food standards  Absorbs work of previous multi-stakeholder FoPL Steering Committee that developed HSR

Trans-Tasman HSR Advisory Committee (HSRAC) Independent Reviewer (MP Membership: Consulting)  Nine Australian representatives: government (3), industry and retailers (3), public health and Membership: consumer groups (3); one New Zealand representative: chair of NZ HSRAG  Policy evaluation experts Responsibilities Responsibilities  Oversee voluntary implementation, including social marketing and monitoring and evaluation  Conduct multi-stakeholder  Assess potential anomalies identified within the HSR algorithm consultations  Provide advice to FRSC on implementation  Review modelling by TAG

 Foster ongoing collaboration between stakeholders  Produce formal five year  Decision making by consensus, otherwise referral to FRSC and Forum review report considered by HSRAC, FRSC, Forum

New Zealand Ministry of Front-of-Pack Labelling Secretariat Technical Advisory Group (TAG) Primary Industries (MPI) (Secretariat) Membership: Membership: Membership:  Government (4), industry (2), public health  New Zealand  Commonwealth Department of (2) Ministry of Primary Health employees  Chaired by Commonwealth Department of Industries Responsibilities: Health  employees Public contact point for HSR Responsibilities: (unknown number)  Maintain HSR website and  Analyse and review performance of HSR Responsibilities: newsletter calculator and algorithm as directed by  Administer and  Refer matters for interpretation to HSRAC, using data provided by industry monitor HSR HSRAC  Provide evidence to support consideration of implementation in  Facilitate jurisdictional coordination options for the five year review (no NZ  Administer tender for monitoring and recommendations) evaluation

New Zealand HSR Jurisdictional Group Advisory Group (NZ Membership: Key: HSRAG)  Representatives from state and Membership: territory governments Government: Political appointees  Government, (2),  Led by FoPL Secretariat industry (3) public Responsibilities: Government: Public sector employees health (3),  Facilitate information sharing consumer groups between jurisdictions Multi-stakeholder body (1), independent  Brief members on issues being

food consultant (1) considered by HSRAC Commissioned service provider Responsibilities  Support voluntary implementation in NZ Reporting line as specfied in box text

Commissioned monitoring providers Report to relevant advisory committees by agreed timelines and frameworks Note: The Two Year Report prepared by HSRAC refers to additional committees: a multi-stakeholder ‘Social  Heart Foundation (use, understanding and uptake, AUS) Marketing and Advisory Group’ (SMAG) providing  Pollinate (campaign evaluation, AUS) feedback and guidance on the education campaign; and a  Colmar Brunton (campaign evaluation, NZ) Monitoring and Evaluation Reference Network (MERN)  National Institute of Health Innovation, (uptake, NZ) providing opportunity discussion between government  Isentia (Media analysis, AUS) jurisdictions and monitoring organisations. As no further information is publicly available on these groups, they have not been included in this diagram.

participation on HSR governance committees 20.9% in 2018.88 Only ten per cent of new Commonwealth Department of Health. The was limited to those below the governmental products entering the Australian market Secretariat acted as public contact point, Forum and FRSC. In HSR’s voluntary form, between June 2014 and June 2017 chose maintaining the website and newsletter. their power comes primarily from agreeing to display HSR.64 In Australia, more than 118 They also led a Jurisdictional Group, to apply HSR to product labels. Given the manufacturers were using HSR in 2018, but facilitating information sharing on HSR potential business impact of mandatory large retailers Coles, Woolworths and Aldi between Australia’s states and territories. labelling requirements, peak industry were together responsible for more than half In New Zealand, HSR implementation was bodies had indicated their support for HSR, of all uptake.31,83 Uptake was skewed towards administered by the Ministry of Primary conditional on it remaining voluntary.76 Media products that scored at the upper end of the Industries (MPI), who received advice from analysis found industry the most frequently five-star spectrum.31,67,83,85,88 More than 50% their own multi-stakeholder Health Star cited stakeholder conveying favourable of uptake was on UPF foods.67,71 Rating Advisory Group (HSRAG). messages about HSR, including that it helps Legal analysis suggested the Australian Compliance promote products, drives innovation and that Commonwealth Government possessed the 75 industry were acting to introduce it. Government-commissioned monitoring requisite authority to make HSR mandatory if Health and consumer groups participated suggested at least 90% of HSR labels desired.90 in HSR governance committees. On the complied with Style Guide formatting trans-Tasman Health Star Rating Advisory requirements, with errors predominantly Complaint mechanisms 23,31,86 Committee (HSRAC) they had combined of a minor technical nature or related Potential algorithm anomalies can be 85 numbers equal to industry. They influenced to poor legibility. Official monitoring also submitted to HSRAC for consideration; by and supported implementation by suggested >90% accuracy of HSR values, October 2018 there had been 21 submissions, conducting independent research and with incorrect calculations more frequently two of which (tinned vegetables and dairy disseminating information to their own under-reporting, rather than over-stating desserts) were determined to meet the 23,31,87 networks, interest groups and the wider HSR, usually by 0.5 stars. Independent specific definition of ‘anomaly’, warranting public. Common messages conveyed research raised issues concerning inconsistent follow up action.11 An additional dispute by these groups in media analysis were use of the ‘energy icon only’ variant of resolution procedure exists for challenging that HSR could be an effective tool to HSR, particularly on low-scoring non-dairy HSRs on individual products, though to 83,84 communicate with consumers, but also that beverages. date no disputes appear to have been it was being used by industry in ways that registered.11 Outside these processes, HSRAC favoured their own interests.75 In formal Maintenance has dealt with concerns surrounding HSR consultations and policy statements, health Maintenance was assessed by measures taken implementation in an ad hoc manner. For and consumer groups broadly indicated by stakeholders to sustain HSR over time. example, ‘the form of the food – as prepared’ their support for HSR while advocating for Data available directly from government rules in the HSR Style Guide were subject it to be strengthened, made mandatory websites detailed HSR governance structures, to a formal public consultation, additional and complemented with other nutrition complaints mechanisms, frameworks for modelling and additional industry proposals policies.73,77-82 monitoring and evaluation, and funding before ultimate referral to the Forum for committed. resolution. The process took more than 18 Implementation months, with compliance not required by Implementation was measured by the extent Governance structures industry until after 2019.11 to which HSR was appearing on labels as Figure 2 illustrates the governance of HSR intended, assessed by both commissioned in its voluntary status as at October 2018. Monitoring and evaluation framework monitoring and independent publications The trans-Tasman government bodies of Conduct of monitoring in Australia was involving cross-sectional examination of the the Forum and FRSC retained ultimate tendered to the National Heart Foundation food supply. decision-making power on the operation shortly after implementation.91 It included and continuance of HSR. Underneath this, regular reports on consumer awareness Uptake implementation was overseen by the and use, as well as label implementation, Uptake had been examined in five peer- HSRAC, whose remit was to foster ongoing consistency, and nutrient status of products reviewed publications64,67,71,83,84 and six collaboration between government, industry, carrying HSR.11 Similar activities occurred in government-commissioned reports23,31,85-88 public health and consumer groups. HSRAC New Zealand, coordinated by MPI with input covering both Australia and New Zealand. coordinated the HSR education campaign, from academic research organisations.85,88 Results indicated uptake was increasing, as well as monitoring and evaluation of the Regular monitoring of uptake and use was with government issuing a communiqué in system, reporting outcomes to the Forum and supplemented with commissioned evaluation June 2018 that HSR had been displayed on FRSC. HSRAC also received matters submitted of the education campaign24,25,27,33,34 and HSR 10,333 products in Australia and over 3,900 through HSR complaint mechanisms for coverage in media.75 in New Zealand.89 Studies that examined decision making by consensus. Where In 2016, HSRAC issued a combined two-year proportionate uptake suggested HSR was consensus could not be reached, matters monitoring report compiling data from this on between 20-28% of eligible products in were referred to the Forum and FRSC. work.51 Following this, planning commenced the Australian food supply in 2017.31,83,87 Ancillary support was provided by the FoPL for a formal five-year review. An independent Uptake remained lower in New Zealand, at Secretariat (Secretariat) in the Australian reviewer (MP Consulting) was appointed by

tender,59 and a voluntary multi-stakeholder include costs of media buy: in 2017, phase campaign funding was ‘modest’, it made up Technical Advisory Group (TAG) created with four of the campaign alone had a media buy a significant proportion of total spend on specific remit to analyse performance of the of $2.2 million.91 Specific contributions or HSR. Monitoring suggested most people HSR algorithm and provide technical input.11 spending by state and territory governments were aware of HSR from ‘seeing it on pack’, The review involved several rounds of written or by New Zealand for HSR related activities making it arguably more cost-effective for and face-to-face consultation. Feedback were not publicly available and were not government to focus on increasing HSR consolidated and reported online noted the included in this sum. It is not clear what uptake, rather than further spending on main concerns raised, namely that some resources would be made available for awareness campaigns. products high in sugar, fat and salt could sustaining HSR after delivery of the review The bulk of peer-reviewed and government- 73 carry a high rating. Results of TAG modelling report in 2019. commissioned research focused on HSR’s attempted to provide solutions and were efficacy. The ‘star’ graphic was shown to published online with a calculator to test Conclusions be well-liked by consumers, and superior the implications of preferred options on in utility to the industry-preferred DIG. To 92 products. Recommendations on long-term More than four years since voluntary maximise the utility of a single FoPL, the maintenance of HSR, including whether the implementation commenced, a significant DIG and its variants (i.e. Treatwise, energy 90 system should be made mandatory were to body of evidence supports continuation and icon variant of HSR) should now be formally be provided in a report for consideration first strengthening of HSR. Our systematic analysis retired. Innovation in FoPL formats worldwide by HSRAC and then FRSC to inform a decision points to key areas where HSR’s public health suggest opportunities for strengthening by Forum Ministers on the future of HSR in impact can be enhanced (see Box 1). HSR’s graphic design further. Evidence- mid-2019.11 Awareness and trust were reported as based features to enhance visibility and increasing, though unprompted awareness consumer utility such as incorporation of Funding commitments 94 remained modest given HSR’s position as colour (for example, France’s Nutriscore or Comprehensive information on HSR a key pillar of both countries’ responses to the MTL), written government endorsement funding was difficult to obtain due to its 95 96 addressing the huge burden of diet-related (as in Chile and Singapore ) and Canada’s federated, trans-Tasman structure. Budget disease. Lower awareness among Australians proposed rules for positioning FoPL in a documents recorded $5.3 million committed who were overweight, live in rural areas or uniform pack position away from health by Australia’s Commonwealth government 97 experience socioeconomic disadvantage claims provide inspiration for future to HSR for the period 2016-2019, noting suggests opportunity to improve HSR’s utility research and updates to the HSR Style Guide continued involvement and endorsement among these groups. Successful targeted (Box 1). of government was critical to HSR’s efforts in New Zealand with ‘priority’ groups HSR’s efficacy also depends on its independence.93 Tender databases suggested suggest similar attention in Australia would underlying algorithm providing an it distributed about $2 million on monitoring be important to address ongoing health accurate representation of the healthiness and evaluation services, and about $2.3 inequities. of food. Substantial attention has been million up to October 2018 on campaign Exposure to the HSR campaign remained placed on the performance of the HSR development and evaluation.91 This did not disappointing. While evaluators suggested algorithm, predominantly through content and construct validity assessments that Box 1: Recommendations for improving HSR’s public health impact. show its similarities with other nutrient Reasonable refinements to improve efficacy profiling algorithms and tend to support • Strengthen utility of the ‘star’ graphic by considering standardised colour, size and placement, specifying separation from health its performance as a reasonable, albeit claims, ending concurrent use of non-interpretive labels (e.g. Daily Intake Guide, Treatwise, ‘energy icon only’ variant) imperfect, tool to assess nutritional quality. • Implement HSR algorithm improvements to reflect findings of existing research: incorporate added sugars, strengthen treatment of sodium, review treatment of protein, consider treatment of fresh fruit and vegetables including unpackaged Differences in methodologies and ‘cut-points’ • Conduct further high level validation studies to explore link between the HSR of foods, healthier diets, and health outcomes have led to variations in results that highlight Responsive regulatory action to improve uptake challenges in assessing alignment with other • Clear targets with specified timelines (e.g. 80% eligible products within two years of 2019 review completion) and commitment measures of healthiness without pre-defined by Forum to make mandatory on specified date where sufficient progress not demonstrated indicators by which to measure ‘success’, e.g. a • Improve transparency and accountability of uptake monitoring through use of regularly updated, publicly available branded food HSR threshold or band of scores appropriate composition database to delineate ‘healthy’ from ‘unhealthy’ or Strengthen government leadership to improve HSR governance minimally processed from ultra-processed • Renewed and unambiguous public commitment and funding to continue HSR beyond five year review foods. Despite these differences, broadly • Increased public visibility of government leadership at ministerial level • Authority and resource delegated to FSANZ to provide independent technical advice consistent recommendations have emerged • Renewed Terms of Reference for multi-stakeholder involvement, controlling for conflicts of interest, particularly in technical for strengthening algorithm alignment with functions such as algorithm review and determining anomalies existing health policies (Box 1). • Improve transparency of multi-stakeholder committees and public consultations, e.g. agendas and minutes, individual Our assessment also highlighted that the submissions publicly available HSR algorithm has not been subject to more • Reform complaint mechanisms to improve utility, provide expeditious resolution of reasonable concerns raised by all stakeholders, including consumers robust forms of validation. HSR is not unique • Integrate HSR into other government-led nutrition policies e.g. procurement for public settings, criteria for marketing to children, in this respect: a recent systematic review fast food menu labelling found only 10% of nutrient profile models • Situate and support HSR within a comprehensive policy framework e.g. National Obesity or Nutrition Strategy being used in government-led nutrition

policies have been subject to ‘predictive’ Low uptake by industry (particularly information, e.g. no available minutes of validity testing to assess associations with on less healthy products), despite their HSRAC or TAG meetings. health outcomes, e.g. weight gain or cancer public endorsement of HSR supports 58 risk. The most frequently validated of these review of the Terms of Reference for their Implications for public health is the United Kingdom (UK) Ofcom model, engagement. This should take into account 55,58 from which HSR originated. Results of increasing global awareness of the need to Adoption of HSR in 2014 placed Australia and studies assessing its performance in UK prevent and manage conflicts of interest New Zealand among a small but growing and French cohorts have found prospective in the development of national nutrition number of countries using FoPL as one tool 98- 108 associations with health outcomes in most, policies. Notably absent from governance to promote healthier diets. Four years since 103 104 but not all studies. While recognising arrangements outlined in Figure 2 are Food implementation commenced, available the significant commonalities between both Standards Australia New Zealand (FSANZ) evidence supports the continuation and algorithms, further high-level validation could who have the expertise and independence strengthening of HSR. usefully assess any prospective association to conduct many of the functions performed As the formal five-year review draws to a between HSR, healthier diets and health voluntarily by HSRAC and the TAG to date. close in 2019, reasonable refinements to outcomes in Australasian populations. It While a renewed HSRAC may have a role in HSR’s star graphic and algorithm, action could also assess whether variations in HSR’s continuing to promote multi-stakeholder to initiate mandatory implementation and design (e.g. creation of extra dairy categories) collaboration in implementation, delegation strengthened governance – particularly have impacted these associations. of greater technical authority to FSANZ through renewed, visible government to administer and validate the algorithm, While refinements to increase efficacy are leadership – present the clearest monitor uptake, and assess compliance using important, analysis of implementation opportunities to enhance HSR’s public health publicly available branded food composition suggests they are unlikely to drive impact. improvements in impact unless accompanied data, could mitigate real or perceived by radically increased uptake. During its commercial conflicts of interest in HSR’s development in 2013, Forum Ministers agreed governance and facilitate its progressive References HSR would remain voluntary subject to there integration into the formal food regulatory 1. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, system. Adair-Rohani H, et al. A comparative risk assessment being ‘consistent and widespread’ uptake, of burden of disease and injury attributable to 67 risk otherwise a mandatory approach would Linkages between HSR and other health factors and risk factor clusters in 21 regions, 1990-2010: be required.105 Even without performance policies, as done by NSW in procurement A systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2224-60. indicators, it is arguable that uptake of less standards, or by countries like Chile in linking 2. Stuckler D, McKee M, Ebrahim S, Basu S. Manufacturing than one-third of eligible products (mostly FoPL with restrictions on marketing to epidemics: The role of global producers in increased 95 consumption of unhealthy commodities including those that score well), justifies review of children, provide opportunities to further processed foods, alcohol, and tobacco. PLoS Med. HSR’s voluntary status. Mandatory FoPL the utility of HSR. Strategically situating and 2012;9(6):e1001235. 3. PricewaterhouseCoopers. Weighing the Cost of Obesity: are increasing globally, including recent supporting HSR within a comprehensive A Case for Action. Sydney (AUST): PWC; 2015. initiatives in Mexico, Iran, Chile, Sri Lanka, policy framework such as a National Obesity 4. World Health Organization. ‘Best Buys’ and Other Peru, Uruguay and Israel.106 Our findings Strategy will enhance synergies with existing Recommended Interventions for the Prevention and Control of Noncommunicable Diseases, Updated (2017) highlight wide support from consumer and and future interventions to address diet- Appendix 3 of the Global Action Plan for the Prevention public health stakeholders, but not industry, related disease. and Control of Non-Communicable Diseases 2013-2020. Geneva (CHE): WHO; 2017. to make HSR mandatory in Australasia. If a This paper used a systematic approach 5. World Health Organization. Implementation Plan of the mandatory HSR is not yet politically feasible, to synthesising a growing body of WHO Commission on Ending Childhood Obesity. Geneva (CHE): WHO; 2017. a ‘responsive regulatory’ approach provides heterogeneous material on HSR’s 6. Volkova E, Mhurchu CN. The influence of nutrition interim suggestions for how uptake must implementation and efficacy. The strength of labeling and point-of-purchase information on food necessarily be enhanced to improve HSR’s behaviours. Curr Obes Rep. 2015;4(1):19-29. the evidence obtained is importantly limited 7. Vyth EL, Steenhuis IH, Roodenburg AJ, Brug J, Seidell 107 utility to consumers (Box 1). in several areas by study design, the scope JC. Front-of-pack nutrition label stimulates healthier product development: A quantitative analysis. Int J The relative engagement and differential of the analyses done and the magnitude of Behav Nutr Phys Act. 2010;7(1):1. power held by HSR stakeholders (Table 2 the projects completed. Further investment 8. World Health Organization. Nutrient Profiling. Geneva and Figure 2) provide insights into how HSR’s in high-quality research will provide better (CHE): WHO; 2010. 9. World Cancer Research Fund International. WCRF governance can be enhanced. While HSR is insight into the most likely effects of HSR on International Food Policy Framework for Healthy Diets: a multi-stakeholder initiative, government health outcomes, and how best to maximise NOURISHING. London (UK): WCRF; 2019. 10. Codex Alimentarius Commission Committee on retains ultimate responsibility for HSR them through both technical enhancements Food Labelling. Report of the Codex Committee On decision-making and funding. Absence of and improvements in implementation. Food Labelling (Forty-fourth Session); 2017 Oct 16-17; Ascunsion, Paraguay. Rome, Itlay: Food and Agriculture government comment in media analysis Analysis of industry compliance with the HSR Organisation of the United Nations; 2018. suggests opportunity for greater visible algorithm was limited by lack of transparency 11. Australian Government Department of Health. The leadership from government Ministers, surrounding some food components (e.g. Health Star Rating System [Internet]. Canberra (AUST): Front-of-Pack Labelling Secretariat; 2018 [cited 2019 for example, in reiterating government benefits obtained from Fruit, Vegetable Nut May 2]. Available from: http://healthstarrating.gov.au/ endorsement of HSR and communicating and Legume (FVNL) content) as companies 12. Front-of-Pack Labelling Project Committee. Objectives and Principles for the Development of a Front-of-pack positive changes for consumers emanating are not required to display the relevant data Labelling (FOPL) System Endorsed 11 May2012. Canberra from the five-year review. on the label. Our governance assessment was (AUST): Australian Government Department of Health; 2018. to some degree limited by reliance on public

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Masset G, Scarborough P, Rayner M, Mishra G, Brunner 81. Sacks G for the Food-EPI Australia Project Team. EJ. Can nutrient profiling help to identify foods which Policies for Tackling Obesity and creating Healthier Food diet variety should be encouraged? Results from the Environments: Scorecard and Priority Recommendations Whitehall II cohort. Br J Nutr. 2015;113(11):1800-9. for Australian Governments. Melbourne (AUST): Deakin 102. Adriouch S, Julia C, Kesse-Guyot E, Ducrot P, Peneau S, University; 2017. Mejean C, et al. Association between a dietary quality 82. Vandevijvere S, Mackay S, Swinburn B. Measuring index based on the food standard agency nutrient and stimulating progress on implementing widely profiling system and cardiovascular disease risk among recommended food environment policies: The New French adults. Int J Cardiol. 2017;234:22-7. Zealand case study. Health Res Policy Syst. 2018;16(1):3. 103. Adriouch S, Julia C, Kesse-Guyot E, Mejean C, Ducrot 83. Jones A, Shahid M, Neal B. Uptake of Australia’s Health P, Peneau S, et al. Prospective association between Star Rating System. Nutrients. 2018;10(8):997. a dietary quality index based on a nutrient profiling 84. Brownbill AL, Braunack‐Mayer A, Miller CJHPJoA. system and cardiovascular disease risk. Eur J Prev Health star ratings: What’s on the labels of Australian Cardiol. 2016;23(15):1669-76. beverages? Health Promot J Austr. 2019;30(1):114-18. 104. Mytton O, Forouhi N, Scarborough P, Lentjes M, Luben 85. NZ Ministry for Primary Industries. Health Star Rating: R, Rayner M, et al. Association between intake of less Monitoring Implementation at Year Two. MPI Technical healthy foods defined by the UK’s nutrient profile Paper No.: 2017/09. Wellington (NZ): Government of model and cardiovascular disease: A population-based New Zealand; 2017. cohort study. PLoS Med. 2018;15(1):e1002484. 86. National Heart Foundation of Australia. Report on the 105. Legislative and Governance Forum on Food Regulation. Monitoring of the Implementation of the Health Star Final Communique 27 June 2014. Canberra (AUST): Rating System: Key Findings for AOE1 - Consistency in Australian Government Food Regulation Secretariat; Implementation of the Health Star Rating (HSR) System 2014. with the HSR Style Guide – June 2016 to June 2017. 106. World Cancer Research Fund International. Building Melbourne (AUST): NHF; 2017. Momentum: Lessons on Implementing a Robust Front- 87. National Heart Foundation of Australia. Report on the of-pack Food Label. London (UK): WCRF; 2019. Monitoring of the Implementation of the Health Star 107. Magnusson R, Reeve B. Food reformulation, responsive Rating System: Key Findings for AOE1 – Assessment of the regulation, and “regulatory scaffolding”: Strengthening Health Star Rating (HSR) Displayed on Pack Using the HSR performance of salt reduction programs in Australia Calculator – June 2016 to June 2017. 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Unhealthy sport sponsorship at the 2017 AFL Grand Final: a case study of its frequency, duration and nature

Tegan Nuss,1 Maree Scully,1 Melanie Wakefield,1 Helen Dixon1

ponsorship of elite sport provides a Abstract compelling avenue for unhealthy food Sand sugary drink, alcohol and gambling Objective: To assess the frequency, duration and nature of unhealthy marketing during the companies to promote their products. It is highest-rating sporting event in Australia in 2017. a unique and especially persuasive form of Methods: A content analysis of the 2017 Australian Football League (AFL) Grand Final television 1 marketing and it allows them to advertise broadcast identified episodes of unhealthy food and sugary drink, alcohol and gambling to a mass audience, including children and marketing (and pro-health marketing as a comparison). young adults. Branded sponsorship within an Results: There were 559 unhealthy marketing episodes (47 minutes 17 seconds). Most (81%) elite sport context assumes many forms such were for unhealthy food and sugary drink products, while alcohol (9%) and gambling (10%) as: electronic and fixed signage within the were less frequent. The total duration of unhealthy marketing was delivered primarily via fixed stadium; logos painted on the field; branded advertising (55%), dynamic advertising (32%) and branded objects (11%). For unhealthy food uniforms; naming rights to a series, game or and sugary drinks, at least one episode was visible 25% of the time. For each of alcohol and stadium; product endorsement by players; gambling, at least one episode was visible 4% of the time. Unhealthy food and sugary drink pop-up advertisements or verbal commentary marketing peaked in Quarter 2. Pro-health marketing was limited, with 26 episodes (2 minutes during play; and commercial break 59 seconds). advertisements.2-4 By embedding marketing within the game, sport sponsorship can Conclusions: The 2017 AFL Grand Final broadcast featured a high frequency and extensive cut through advertising clutter, generating duration of unhealthy marketing, especially for unhealthy food and sugary drink brands. immense brand exposure.5 Compared to Implications for public health: Findings strengthen evidence supporting calls to increase traditional forms of advertising (e.g. television, regulation of sport sponsorship by unhealthy brands. radio, print), marketing via sport sponsorship Key words: sport sponsorship, content analysis, food, alcohol, gambling is perceived as a less overt attempt to persuade, is more accepted by consumers is concerning due to the promotion and less directly studied, there is evidence that and has been shown to meet with less normalisation of behaviours associated sponsorship: effectively reaches children 1,6 cognitive resistance. Sponsorship harnesses with adverse health and social outcomes, and increases awareness of unhealthy spectators’ emotional engagement to facilitate particularly for vulnerable groups. Advertising commodities26; can influence children’s transfer of positive and often inextricable of unhealthy food and sugary drinks has perceptions of unhealthy food brands and associations with popular and valued sports, been shown to positively influence diet- sway family food purchases27; increases 1,7 teams or players to a brand or product. It related attitudes and preferences, intentions alcohol consumption in children28; stimulates can create a ‘health halo’, whereby the image and behaviours among children and harmful levels of drinking alcohol among of sport as a healthy activity is transferred to adolescents.11-15 Likewise, exposure to alcohol sportspeople29,30; and can increase awareness, 5,8 sponsor brands, and enhance perception of advertising is associated with positive alcohol attitudes and preferences for sponsor a company’s social responsibility or goodwill expectancies, attitudes and intentions, which products among young adults.8 Emerging in supporting a valued community event, are strong predictors of alcohol use,16-18 and evidence also suggests that gambling particularly when it is believed the event is has been shown to expedite initiation of sponsorship may be particularly harmful 9,10 reliant on the sponsorship. drinking and increase consumption levels to problem gamblers or those recovering From a public health perspective, elite in children and adolescents.19-25 While the from being problem gamblers,31,32 young sport sponsorship by unhealthy products impact of elite sport sponsorship has been males,32,33 adolescents34 and children.35

1. Centre for Behavioural Research in Cancer, Cancer Council Victoria Correspondence to: Dr Helen Dixon, Centre for Behavioural Research in Cancer, Cancer Council Victoria, 615 St Kilda Road, Melbourne, Victoria 3004; e-mail: [email protected] Submitted: January 2019; Revision requested: April 2019; Accepted: May 2019 The authors have stated they have no conflict of interest. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Aust NZ J Public Health. 2019; 43:366-72; doi: 10.1111/1753-6405.12920

Restricting the advertising of unhealthy food episodes for three types of unhealthy (e.g. unhealthy food and sugary drink) and and sugary drink, alcohol and gambling products: unhealthy food and sugary sub-type (e.g. fast food, soft drink, sports products, including via sport sponsorship, has drinks, alcohol and gambling. Food and drink), and type of promotion were coded. consequently been identified as a necessary non-alcoholic drink brands were classified The types of promotions coded comprised strategy to reduce harm related to these as unhealthy if the majority of products the following five categories, with examples products.36-40 sold and promoted under that brand were of these shown in Figure 1: Research examining the extent and nature deemed discretionary food and drink choices 1. Dynamic advertising: Advertising on 48 of tobacco advertising via sport sponsorship in the Australian Dietary Guidelines; that is, revolving or electronic banners or was crucial in building the evidence that led food and drink products not required for a signs within the stadium, including the to Federal Legislation (Tobacco Advertising healthy diet and typically energy-dense and scoreboard. nutrient-poor (e.g. containing high amounts Prohibition Act 1992) banning tobacco 2. Fixed advertising: Advertising on static sponsorship in Australia.41,42 In the past of saturated fat, sodium/salt, or added 48 banners or signage within the stadium. decade, a small number of studies employing sugar). Episodes of pro-health marketing 3. Integrated advertising: Advertising via on- content analysis have identified high volumes (such as moderation messages) were also screen pop-ups and pull-through banners of sponsorship by unhealthy food and identified to examine the extent to which in- or broadcast announcements. sugary drink, alcohol and gambling brands in game advertising may address the potential popular, high-profile sporting codes/events negative health consequences of consuming 4. Commercial break advertising: in Australia2-4,43,44 and New Zealand.45,46 unhealthy food, beverage and gambling Advertisements during commercial breaks. The present study aimed to contribute to products. 5. Branded objects: Logos or other existing studies by quantifying the frequency, The 2017 AFL Grand Final broadcast was identifiable branding on objects used by duration and nature of unhealthy food chosen for study because it was the highest players, umpires and other staff on field. and sugary drink, alcohol, and gambling rating sporting event in Australia in 2017, Marketing episodes that occurred marketing during the highest rating sport watched by more than 2.7 million viewers, simultaneously were coded as separate event in Australia in 2017 – the Australian including 322,000 children under the age of episodes if they were for a different brand 47 47,49 Football League (AFL) Grand Final. 15 years, across major cities in Australia. or type of promotion. For example, if a Marketing delivering pro-health messages The coding framework was developed Coca-Cola electronic banner was visible at was also examined to provide a point of following previous content analysis studies the same time as Coca-Cola fixed signage, comparison. of marketing during sporting events.2-4,43,50 each was coded separately, or if Coca-Cola A marketing episode was coded if the brand fixed signage was visible at the same time as Method name, logo, slogan or readily identifiable McDonald’s fixed advertising, each was coded imagery or messaging (e.g. McDonald’s separately. A content analysis of a digital recording of the Monopoly campaign, Four’n Twenty’s pie The total duration of coded footage was 2 2017 AFL Grand Final television broadcast, image) was clearly visible for at least one hours 6 minutes 37 seconds. All in-game time including commercials as shown in the second. The length of time each episode was was coded, which included the time from Melbourne metropolitan region (televised visible was recorded to the nearest second the first bounce of each quarter to the start free-to-air on Channel 7, 30 September using the timestamp on the video file. For of the between-quarter commercial break 2017), was undertaken to identify marketing each episode, the brand, type of product for Quarters 1 to 3, and to the final siren for Quarter 4 (Quarter 1: 30 minutes 28 seconds; Figure 1: Examples of types of promotions coded (clockwise from top left): fixed advertising (McDonald’s goal posts, Quarter 2: 34 minutes 26 seconds; Quarter 3; Coca-Cola signage within stadium); dynamic advertising (Four’n Twenty electronic banner); integrated advertising 30 minutes 24 seconds; Quarter 4: 31 minutes (McDonald’s on-screen pop-up); branded objects (Gatorade padded blocks); commercial break advertising 19 seconds). Commercial breaks within each (McDonald’s advertisement). quarter (i.e. following goals) were coded, while commercial breaks between quarters, including at half-time, were not coded. Pre-

and post-match footage was not coded. The broadcast was independently coded by two of the researchers, using screens of identical size, via playback using VLC Media Player Version 3.0.2.51 Inter-rater reliability was calculated based on 10 minutes of coding using Krippendorff’s alpha, which is suitable for both nominal and ratio data.52 Inter-rater reliability was acceptable (α>0.8) for coding of episodes (α=0.83) and their duration (α=0.94). Any discrepancies in coding were reviewed by the researchers together until consensus was reached.

Data analysis This corresponds to viewers being exposed advertising. This was predominantly due to The data were analysed using Microsoft Excel to, on average, 4.4 unhealthy marketing McDonald’s branding on the goal posts (15 and Stata MP 14.2.53 Descriptive statistics episodes per minute. The duration of minutes 47 seconds), but also included Coca- were used to analyse the frequency and individual unhealthy marketing episodes Cola signage within the stadium (7 minutes duration of marketing episodes by type of ranged in length, from 1 to 39 seconds 26 seconds), Gatorade signage surrounding product, brand and promotion type, where (median = 3 seconds). More than half (55%) the players’ bench (53 seconds) and Four’n each episode was counted separately. of the total duration of unhealthy marketing Twenty signage within the stadium (11 For each unhealthy product type and for was delivered via fixed advertising, almost seconds). Dynamic advertising accounted unhealthy marketing overall, the total one-third (32%) via dynamic advertising, and for 17% of the total duration of unhealthy proportion of coded game time when 11% via branded objects (e.g. drink bottles). food and sugary drink marketing and marketing was present was calculated where included electronic banners for Coca-Cola (2 episodes that occurred simultaneously Frequency and duration of unhealthy minutes 55 seconds), McDonald’s (2 minutes were not counted separately. That is, the food and sugary drink marketing 8 seconds), and Four’n Twenty (1 minute 4 seconds). Branded objects, which included proportion of coded time when at least The majority (81%, n=452) of unhealthy Gatorade-branded drink bottles, portable one marketing episode was visible was marketing episodes were for fast food, coolers, towels, mats and padded blocks calculated. For each unhealthy product soft drink and sport drink brands (Table positioned on the field’s perimeter, made type and unhealthy marketing overall, 1). Viewers were exposed to an average of up 14% of the unhealthy food and sugary logistic regression with post hoc pairwise 3.6 episodes of unhealthy food and sugary drink marketing duration. Commercial breaks comparisons using Bonferroni correction drink marketing per minute. Promotions for (30 seconds) and integrated advertising were conducted to examine if the proportion McDonald’s made up around half (51%) of the (8 seconds), both for McDonald’s, each of coded time when at least one episode was total duration of unhealthy food and sugary contributed 1% or less of the total unhealthy visible differed by game quarter. drink marketing, amounting to 18 minutes food and sugary drink duration. See Figure 33 seconds. Coca-Cola accounted for 29% of 1 for examples of in-game promotions for the duration of unhealthy food and sugary Results unhealthy food and sugary drink brands. drink marketing, totalling 10 minutes 21 Frequency and duration of unhealthy seconds; Gatorade made up 17% (6 minutes Frequency and duration of alcohol marketing overall 8 seconds); and Four’n Twenty made up 3% (1 minute 15 seconds). marketing Overall, there were 559 episodes of unhealthy Promotions for beer, cider, wine and an marketing during the coded time, totalling As shown in Table 1, two-thirds (67%) of the alcohol retailer accounted for 9% (n=50) 47 minutes 17 seconds duration when each total duration of unhealthy food and sugary of unhealthy marketing episodes (Table 1). episode was counted separately (Table 1). drink marketing was achieved via fixed

Table 1: Frequency and duration (minutes, seconds) of unhealthy and pro-health marketing episodes, by product type and promotion type. Fixed Dynamic Branded objects Commercial break Integrated Total advertising advertising advertising Unhealthy marketing Episodes (%) 282 (62%) 69 (15%) 98 (22%) 2 (<1%) 1 (<1%) 452 Unhealthy food and sugary drinks Duration (%) 24m 17s (67%) 6m 7s (17%) 5m 15s (14%) 30s (1%) 8s (<1%) 36m 17s Episodes (%) 13 (23%) 44 (77%) – – – 57 Gambling Duration (%) 38s (11%) 4m 56s (89%) – – – 5m 34s Episodes (%) 13 (26%) 36 (72%) – 1 (2%) – 50 Alcohol Duration (%) 52s (16%) 4m 4s (75%) – 30s (9%) – 5m 26s Episodes (%) 308 (55%) 149 (27%) 98 (18%) 3 (1%) 1 (<1%) 559 Total unhealthy marketing Duration (%) 25m 47s (55%) 15m 7s (32%) 5m 15s (11%) 1m (2%) 8s (<1%) 47m 17s Pro-health marketing Episodes (%) – – – – – – Healthy eating Duration (%) – – – – – – Episodes (%) – – – – – – Responsible gambling Duration (%) – – – – – – Alcohol harm prevention: Episodes (%) – 25 (100%) – – – 25 Publicly-funded Duration (%) – 2m 53s (100%) – – – 2m 53s Episodes (%) – 1 (100%) – – – 1 Industry-funded Duration (%) – 6s (100%) – – – 6s Episodes (%) – 26 (100%) – – – 26 Total pro-health marketing Duration (%) – 2m 59s (100%) – – – 2m 59s Notes: Where multiple marketing episodes occurred simultaneously each episode was coded as a single episode provided it was a different brand and/or type of promotion (i.e., dynamic, fixed, integrated, commercial, branded objects). Duration was calculated counting each episode separately. Percentages reported to nearest whole number so may not sum to 100.

On average, viewers were exposed to one Proportion of coded footage when Quarter 1 compared to Quarter 2 (p=0.011) episode of alcohol marketing every 2 minutes unhealthy marketing was visible and Quarter 3 (p<0.001), and higher in 32 seconds. The total duration of alcohol Quarter 4 compared to Quarter 3 (p=0.026). Table 2 presents the proportion of coded marketing was made up of promotions for The proportion of time at least one episode of time when at least one episode of each Carlton Draught (71%; 3 minutes 51 seconds), gambling marketing was visible did not differ type of unhealthy marketing was visible. IGA Liquor (21%; 1 minute 7 seconds), across game quarters (X2=4.17, p=0.244). Overall, at least one episode of unhealthy Mercury Cider (6%; 20 seconds) and Wolf marketing (unhealthy food and sugary drinks, Blass (2%; 8 seconds). The total duration of Pro-health marketing alcohol, or gambling) was visible almost alcohol marketing occurred primarily via one-third (30%) of the coded time. There Overall, there were 26 episodes of pro-heath dynamic advertising (75%), which included was a significant association between game marketing, totalling 2 minutes 59 seconds, electronic banners for Carlton Draught (2 quarter and the proportion of time at least when each episode was counted separately, minutes 37 seconds), IGA Liquor (1 minute one unhealthy marketing episode was visible all of which were delivered via dynamic 7 seconds), and Mercury Cider (20 seconds). (X2=44.01, p<0.001). Bonferroni-adjusted post advertising (as per Table 1). The longest pro- Fixed advertising accounted for 16% of the hoc comparisons revealed that unhealthy health marketing episode was 25 seconds total alcohol marketing duration, including marketing was significantly higher in Quarter (median=4 seconds). All pro-health marketing signage for Carlton Draught (44 seconds) and 1 compared to Quarter 3 (p=0.018) and was directed toward alcohol harm prevention Wolf Blass (8 seconds), while a commercial Quarter 4 (p<0.001), and significantly higher and mostly comprised promotions for a break for Carlton Draught (30 seconds) in Quarter 2 compared to Quarter 3 (p<0.001) publicly funded campaign, specifically the contributed 9%. and Quarter 4 (p<0.001). Victorian Government’s Transport Accident Commission’s (TAC) “Towards Zero” and At least one episode of marketing for Frequency and duration of gambling “Drinking. Driving. They’re better apart.” unhealthy food and sugary drinks was visible marketing messages, which appeared on electronic 25% of the coded time (Table 2). There was a banners surrounding the stadium. As shown in Table 1, one-in-ten (10%, significant association between game quarter n=57) unhealthy marketing episodes were and the proportion of time at least one There was one marketing episode for for gambling brands. On average, viewers episode of unhealthy food and sugary drink DrinkWise, an alcohol industry public were exposed to a gambling episode every marketing was visible (X2=54.18, p<0.001), relations initiative,54,55 which appeared on the 2 minutes 13 seconds. The total duration with unhealthy food and sugary drink electronic scoreboard. of gambling marketing was made up of marketing higher in Quarter 2 compared to As per Table 2, at least one episode of pro- promotions for Ladbrokes (58%; 3 minutes 17 Quarter 1 (p=0.002), Quarter 3 (p<0.001), and health marketing was visible 2% of the coded seconds), bet365 (38%; 2 minutes 8 seconds), Quarter 4 (p<0.001). Marketing for unhealthy time. There was a significant association CrownBet (1%; 5 seconds) and SportsBet (1%; food and sugary drink was also significantly between game quarter and the proportion 4 seconds). The majority (89%) of gambling higher in Quarter 1 compared to Quarter 4 of time at least one episode of pro-health marketing duration was achieved via (p=0.013). marketing was visible (X2=10.11 p=0.018), electronic banners promoting Ladbrokes (2 For both alcohol and gambling, at least one with pro-health marketing higher in Quarter 2 minutes 48 seconds) and bet365 (2 minutes episode of marketing was visible 4% of the compared to Quarter 1 (p=0.025). 8 seconds), while 11% was achieved through coded time (Table 2). There was a significant fixed signs for Ladbrokes (29 seconds), association between game quarter and CrownBet (5 seconds), and SportsBet (4 Discussion the proportion of time at least one alcohol seconds). marketing episode was visible (X2=29.22, This study shows that the 2017 AFL Grand p<0.001), with alcohol marketing higher in Final television broadcast included a high frequency and extensive duration Table 2: Proportion of coded time that at least one episode of unhealthy marketing was visible, by product type of unhealthy marketing, particularly for and game quarter. unhealthy food and sugary drink brands. Overall Quarter 1a Quarter 2b Quarter 3c Quarter 4 Marketing for alcohol and gambling products (%) (%) (%) (%) (%) was less prevalent, accounting for about Unhealthy food and sugary drinks 25.0 25.4 30.5a** 22.5b*** 21.1a* b*** one-fifth of all unhealthy marketing episodes. Gambling 4.4 4.6 3.6 4.8 4.6 Overall, marketing for unhealthy products Alcohol 4.3 6.2 4.0a* 2.6a*** 4.3c* dwarfed pro-health marketing, with more Total unhealthy marketing 29.7 31.9 33.8 27.4a* b*** 25.1a*** b*** than twenty times as many episodes of Healthy eating – – –– – such marketing recorded (559 unhealthy Responsible gambling – – –– – compared to 26 pro-health marketing Alcohol harm prevention 2.4 1.6 3.0a* 2.0 2.7 episodes). To our knowledge, this is the Total pro-health marketing 2.4 1.6 3.0a* 2.0 2.7 first study to investigate all three products Notes: (unhealthy food and sugary drinks, alcohol Where multiple marketing episodes occurred simultaneously the time has only been counted once. Hence, the sum of proportions by product type do not equal the overall unhealthy marketing proportion. and gambling) within an AFL match – notably a, b, c: Reference categories for logistic regression analyses. the Grand Final – and to quantitatively *** denotes a significant difference from the reference category, at p < 0.001; ** denotes a significant difference from the reference category, at p < 0.01; examine how marketing for unhealthy brands * denotes a significant difference from the reference category, at p < 0.05. varies across the game.

While it is encouraging that there was some for products that are not legally available to preferences, particularly for children and pro-health marketing addressing alcohol persons under 18 years of age raises serious adolescents.62-65 Although these unhealthy harm prevention, its capacity to cut through questions about the kind of messages elite marketing episodes often occur in brief bursts and impact viewers was likely to have sport is sending young people about alcohol of short duration and typically feature just a been diluted by the fact that the broadcast and gambling. Alcohol sponsorship is known brand or logo, they occur at a high frequency, featured twice as many incidences of pro- to influence children’s product awareness, and there is evidence that this mode of alcohol marketing (50 compared to 26). Most preferences and consumption,28,61 rendering marketing may be more effective than longer, of the alcohol harm prevention marketing the 322,000 Australian children who watched traditional commercial break advertising,66 came from a reputable publicly funded the AFL Grand Final49 vulnerable to such since exposure effects may be stronger when campaign. A minority of pro-health alcohol marketing effects. (To put this figure in stimuli are not consciously attended to.67,68 messaging came from DrinkWise, an alcohol perspective, this is enough children to fill The formation of an environment where industry public relations initiative, which the Melbourne Cricket Ground three times marketing is simultaneously pervasive and has been criticised for potentially benefiting over.) Prior studies indicate that levels of subtle, and also fused with the experience industry more than public health.54,55 alcohol and gambling marketing can vary of the game, is particularly concerning when Alternative publicly funded alcohol education considerably within sporting codes. For considering the strong viewership of televised campaigns are available that demonstrably example, an examination of the 2012 AFL sport by children, who do not recognise the improve audience awareness of specific finals series found the frequency of alcohol commercial intent of sponsorship or have alcohol harms56 and motivate drinkers to marketing ranged between games, likely the cognitive capacity to critically evaluate consume less.57 as a function of venue, with the semi-final advertising messages.69-71 There were 452 marketing episodes for at ANZ stadium in Sydney featuring 570 Findings revealed that unhealthy food and unhealthy food and sugary drink brands episodes compared to the Grand Final at sugary drink marketing was highest in the during the Grand Final and, although the Melbourne Cricket Ground featuring 67 second quarter, coinciding with the time 50 some of these occurred simultaneously, at episodes. Further, a content analysis of eight viewers may be planning their half-time snack least one was visible for 25% of the coded televised AFL matches from 2011 observed or meal. From our study, it is not possible time. The high level of unhealthy food and between two and 123 episodes (or 0.2 and to determine whether this was a deliberate sugary drink marketing in one of the most 11.3 minutes) of gambling marketing per marketing ploy or a chance occurrence. As the watched nationally televised events (sporting game, with free-to-air matches featuring majority of unhealthy food and sugary drink or otherwise) is concerning, given that a greater amount than matches broadcast marketing was delivered via fixed advertising, 4 unhealthy food marketing has been identified on Pay TV. While the level of alcohol and primarily McDonald’s branded goal posts, this as promoting poor diet and contributing to gambling marketing may appear low in pattern of results could be due to particular the obesity epidemic38 and nearly two-thirds isolated games, sports viewers’ exposure camera shots appearing more frequently in of Australian adults and more than one- is likely to be cumulative and can build up the second quarter. It is important to note, quarter of Australian children are above a quickly if they watch several games across however, that the number of points scored healthy weight.58 While unhealthy food and every weekend of the season. during this quarter (a time in which the sugary drink marketing clearly dominated More than half of the unhealthy marketing goal posts typically appear on screen for an both alcohol and gambling marketing in that featured in the Grand Final was fixed extended period) was comparable to the the 2017 AFL Grand Final, this same pattern advertising, with dynamic advertising and other three quarters.72 Alcohol marketing was not evident in an earlier content analysis branded objects, such as drink bottles, also varied between quarters, with higher study that also focused on these three portable coolers, towels, mats and padded prevalence in the first quarter compared to products. Specifically, Lindsay and colleagues2 blocks positioned on the field’s perimeter, the middle quarters, although the magnitude observed higher levels of alcohol marketing also common. As with earlier content of these differences was relatively small. 2-4,44 during the 2012 NRL State of Origin series (an analyses, these results highlight the The ubiquitous nature of unhealthy average of 66 minutes per game) compared myriad strategies sponsors use to create marketing in the 2017 AFL Grand Final to both gambling (9 minutes per game) and a saturated environment in which it is underlines the inadequacies of the current unhealthy food and sugary drink (3 minutes difficult for viewers to avoid this marketing system of largely voluntary and mostly per game) marketing. These contrasting or to separate it from the experience of the self-regulated advertising and marketing in findings are not unexpected, with previous game itself. For example, McDonald’s logos Australia. Both alcohol advertising regulations research suggesting that different sports may around the goal posts ensure the brand is and guidelines pertaining to food advertising be targeted by, or more strongly associated prominent to spectators at key moments in to children exempt marketing that occurs 59,60 with, particular products or that the the game (e.g. when a player is kicking for within sport broadcasts.73-80 Given that products promoted can vary between goal), and dynamic banners flash and revolve, more advertising for unhealthy food and 50 games or between broadcasts of the same allowing brands to intrude even in the sugary drink and alcohol products has been 4 game within sporting codes. middle of exciting play. Additionally, vision observed during televised sport than during In the present study, for each of alcohol and of players drinking from Gatorade-branded any other programming,43,81 this represents gambling marketing at least one episode was bottles potentially signals to the audience clear loopholes in the frameworks intended visible 4% of the coded time. Although less their tacit endorsement of the product. to protect young people. Similarly, although prevalent than unhealthy food and sugary Celebrity endorsement has been shown to a ban on betting and gambling commercials drink marketing, the presence of promotions exert a powerful influence on attitudes and during live sport broadcasts between 5.00 am

370 Australian and New Zealand Journal of Public Health 2019 vol. 43 no. 4 © 2019 Cancer Council Victoria Sport Unhealthy sport sponsorship at the 2017 AFL Grand Final and 8.30 pm was introduced in March 2018, in-game time were coded; we did not, for References the restriction excludes sponsorship (termed example, capture sponsored segments that 1. Meenaghan T. Understanding sponsorship effects. 75 “incidental accompaniment”), meaning that were televised at half-time (e.g. Gatorade Psychol Market. 2001;18(2):95-122. children and other vulnerable groups remain AFL Grand Final Sprint, Macca’s Champion 2. Lindsay S, Thomas S, Lewis S, et al. Eat, drink and gamble: Marketing messages about ‘risky’ products in exposed to gambling advertising embedded Player) or pre-game footage inside the team an Australian major sporting series. BMC Public Health. within the game. Thus, reforms are needed changerooms where Gatorade signage was 2013;13:719. 3. Sherriff J, Griffiths D, Daube M. Cricket: Notching up that place tighter restrictions, or ban prominently displayed. Consequently, our runs for food and alcohol companies? Aust N Z J Public altogether, sport sponsorship by unhealthy study likely provides a conservative estimate Health. 2010;34(1):19-23. brands. of the volume of unhealthy marketing 4. Thomas S, Lewis S, Duong J, et al. Sports betting marketing during sporting events: A stadium and The successful removal of tobacco that featured in the televised coverage of broadcast census of Australian Football League the 2017 AFL Grand Final. Third, this study matches. Aust N Z J Public Health. 2012;36(2):145-52. sponsorship in Australia in the early 5. Meenaghan T, Shipley D. Media effect in commercial 1990s provides a useful model for how focused on a single, broadcast sporting event sponsorship. Eur J Mark. 1999;33(3/4):328-48. other unhealthy product sponsors could and did not assess spectators’ exposure to 6. Lardinoit T, Quester P. Attitudinal effects of combined sponsorship and sponsor’s prominence on basketball feasibly be banned from sport without promotions for unhealthy products at the in Europe. J Advert Res. 2001;41(1):48-58. compromising the viability of these events.82 stadium. Future research should investigate 7. Gwinner KP, Eaton J. Building brand image through the extent and nature of unhealthy and event sponsorship: The role of image transfer. J Advert. Replacing unhealthy sponsorship with 1999;28(4):47-57. health promotion sponsorship, as occurred pro-health sponsorship across multiple 8. Dixon H, Scully M, Wakefield M, et al. The impact sports and venues, including within both live of unhealthy food sponsorship vs. pro-health with tobacco, could form one aspect of sponsorship models on young adults’ food preferences: multi-component strategies to address stadium and broadcast settings, to provide A randomised controlled trial. BMC Public Health. overweight and obesity, and harms related a clearer understanding of how companies 2018;18:1399. 9. Lavack AM. An inside view of tobacco sports to alcohol and gambling.83,84 There are use sport sponsorship to reach and influence sponsorship: An historical perspective. Int J Sports already some examples of this occurring, consumers with marketing for potentially Mark Sponsorship. 2003;5(2):105-28. harmful products. 10. Lipkus IM, Crawford Y, Fenn K, et al. Testing different most notably Western Australia’s Healthway formats for communicating colorectal cancer risk. J partnerships with the Western Australian Health Commun. 1999;4(4):311-24. 11. Andreyeva T, Kelly IR, Harris JL. Exposure to Food Cricket Association (WACA) and West Coast Conclusions Advertising on Television: Associations with Children’s Fever netball team, which include promotion Fast Food and Soft Drink Consumption and Obesity. NBER of their Alcohol. Think Again and LiveLighter The televised broadcast of the 2017 AFL Working Paper No.: 16858. Cambridge (MA): National Bureau of Economic Research; 2011. campaign messages, respectively.85,86 Grand Final featured a high frequency and 12. Borzekowski DL, Robinson TN. The 30-second effect: However, the dearth of pro-health marketing extensive duration of unhealthy marketing, An experiment revealing the impact of television commercials on food preferences of preschoolers. J in the 2017 AFL Grand Final – of which none especially for unhealthy food and sugary Am Diet Assoc. 2001;101(1):42-6. were promoting good nutrition – shows drink brands. Marketing was delivered in 13. Boyland EJ, Halford JC. Television advertising and branding. Effects on eating behaviour and food there is scope for more of these types of repeated brief bursts and via numerous preferences in children. Appetite. 2013;62:236-41. sponsorship relationships, particularly in the promotion types embedded within the 14. Cairns G, Angus K, Hastings G. The Extent, Nature AFL context. It should also be noted that in game, creating a saturated environment in and Effects of Food Promotion to Children: A review of the Evidence to December 2008. Prepared for World addition to the unhealthy and pro-health which marketing is not only hard to avoid Health Organization. Geneva (CHE): World Health brands quantified in our study, many other but difficult to separate from the experience Organization; 2009. 15. Harris JL, Bargh JA, Brownell KD. Priming effects of brands featured throughout the game, of the game itself. Given the effectiveness of television food advertising on eating behavior. Health from car manufacturers and airlines to advertising in driving attitudes, preferences Psychol. 2009;28(4):404-13. 16. Stacy AW, Zogg JB, Unger JB, et al. Exposure to televised electronics producers and retail and media and behaviours related to potentially harmful alcohol ads and subsequent adolescent alcohol use. 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This research was funded by the National Institute on Alcohol Abuse and Alcoholism; 1995. p. 105-21. A number of study limitations should be Health & Medical Research Council’s 19. Anderson P, de Bruijn A, Angus K, et al. Impact of alcohol noted. First, while content analysis enabled Targeted Call for Research into Preventing advertising and media exposure on adolescent alcohol use: A systematic review of longitudinal studies. Alcohol us to document the amount of unhealthy Obesity in 18-24-year-olds (APP1114923). Alcohol. 2009;44(3):229-43. and pro-health sponsor marketing that The funding body was not involved in the 20. Collins RL, Ellickson PL, McCaffrey D, et al. Early design of the study or the collection, analysis adolescent exposure to alcohol advertising and its spectators were potentially exposed to, it relationship to underage drinking. J Adolesc Health. did not measure spectators’ actual exposure and interpretation of data, or in writing 2007;40(6):527-34. to, or recall and recognition of, sponsor the manuscript. MW was supported by 21. Smith L, Foxcroft D. The effect of alcohol advertising, marketing and portrayal on drinking behaviour in brands; this would have required a separate funding from an NHMRC Principal Research young people: Systematic review of prospective cohort study. Second, only promotions that were Fellowship. studies. BMC Public Health. 2009;9:51. visible for at least one second during

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Challenges for sport organisations developing and delivering non-traditional social sport products for insufficiently active populations

Kiera Staley,1 Alex Donaldson,1 Erica Randle,1 Matthew Nicholson,1 Paul O’Halloran,1 Rayoni Nelson,2 Matthew Cameron2

egular physical activity is a leading Abstract factor in promoting good health and Rpreventing chronic disease,1 and Objectives: To explore the challenges that Victorian sporting organisations experience when physical inactivity is a major contributor to developing, delivering or scaling non-traditional social sport products to engage insufficiently the global burden of disease.2 In Australia, active people. more than 30% of all adults are insufficiently Methods: Online Concept Mapping was used to gather qualitative data and analyse it 3 active; 81% of children do not meet the quantitatively. physical activity guidelines;4 and physical Results: A total of 68 participants (27 organisations) brainstormed 158 challenges. The research inactivity is responsible for 2.6% of the total team synthesised these to 71 unique challenges for participants to sort into groups and rate for burden of disease and injuries.5 The term importance (0–5) and ease of overcoming (0–5). A nine-cluster solution – Deliverers; Capacity ‘insufficiently active’ refers to people who to drive the product; Facilities and partnerships; Product development; Sustainable business model; do not meet the Australian Physical Activity Marketing to insufficiently active; Attracting the insufficiently active; Clubs and volunteers; and Guidelines.6 Shifting traditional sport culture – was considered most appropriate. Participants rated the The Australian Federal Government recently Deliverers challenges as the most important (mean=3.52), and the Marketing to insufficiently released a sport-based strategy (Sport 2030) active challenges as the easiest to overcome (2.72). aiming to reduce the number of physically Conclusions: Key ingredients to successfully developing and delivering non-traditional inactive Australians by 15% by 2030.7 At a sport opportunities for insufficiently active populations are: recruiting appropriate product state level, the Victorian Health Promotion deliverers; building the capacity of delivery organisations and systems; and developing Foundation (VicHealth), a statutory products relevant to the delivery context that align with the needs and characteristics of the authority focused on promoting good target population. health and preventing chronic disease, has a strategic imperative to get 300,000 more Implications for public health: A system-wide response is required to address the challenges Victorians engaging in physical activity by associated with sport organisations developing, scaling and delivering innovative social sport 2023.8 Between 2015 and 2018, VicHealth products for insufficiently active populations. endeavoured to encourage the engagement Key words: concept mapping, sport organisations, insufficiently active, social sport products, of new participants not interested or able to physical activity participate in traditional sports9 by investing in two programs – the State Sport Program as insufficiently active into ‘somewhat active’ stagnant or declining participation in many 10 (SSP) and the Regional Sport Program and ‘inactive’. organised and team sports alongside a (RSP) – to facilitate the development of The aims of the SSP and RSP align with growth in informal and lifestyle sport and 13-15 new sport products or scale their existing, previous calls for policy makers to view physical activity participation. There flexible, non-traditional social sport products informal sports as an opportunity to is a growing demand for opportunities to to target insufficiently active members of encourage new user groups to engage in participate in sport that is social, flexible and the community. For the purposes of their sport and physical activity,9 and to respond non-competitive, fits in with busy lifestyles, program work with sports organisations, to shifting physical activity participation and focuses on achieving personal health and to aid communication with the general trends in Australia. These trends, which are and social objectives, rather than winning 13 public, VicHealth also divided those classified also evident internationally,11,12 have included and competition. In short, more people

1. Centre for Sport and Social Impact, La Trobe University, Victoria 2. Victorian Health Promotion Foundation (VicHealth) Correspondence to: Dr Alex Donaldson, Centre for Sport and Social Impact, La Trobe University, Plenty Road, Bundoora, Victoria 3086; e-mail: [email protected] Submitted: November 2018; Revision requested: April 2019; Accepted: May 2019 The authors have stated they have no conflict of interest. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Aust NZ J Public Health. 2019; 43:373-81; doi: 10.1111/1753-6405.12912

want sport opportunities that fit in with their playing or training every week. By contrast, growing proportion of the population who lifestyle, rather than having to fit their lifestyle Triathlon Victoria developed TRIactive, a six- are insufficiently physically active in Australia. around sport.13 week program for beginners with an interest, Sport organisations need to provide but limited experience, in triathlon. Program Methods opportunities that appeal to insufficiently participants trained twice a week as a group active people, reflect the shift towards and aimed to complete a triathlon at the end As a component of the process evaluation more flexible, social offerings, and can of the program. For more information about of VicHealth’s investment in the SSP and leverage the established latent sport delivery the number of social products developed and RSP, we were interested in integrating the infrastructure and systems if they are to scaled up by each SSA, see Supplementary applied knowledge of practitioners (i.e. achieve government goals of addressing Table 1 and https://www.vichealth.vic.gov. of sports that developed and delivered population-level physical inactivity through au/programs-and-projects/vichealth-state- social sport products) with the scientific sport. This paper explores the challenges that sport-program knowledge of researchers and policy makers a group of sport organisations experienced Research findings support exploring and (i.e. VicHealth). Therefore, we employed when they developed and delivered new promoting physical activity participation Concept Mapping (CM), a mixed-method products, or scaled existing social versions from a system or ecological perspective.16 participatory approach to gather qualitative of their sport, for insufficiently active However, most physical activity research has data and analyse it quantitatively.28,29 The key people. It focuses on 21 Victorian State focused on individual participants,17,18 and CM steps of preparation, ideas generation Sporting Associations (SSAs), which are the the relatively small amount of institutional- (brainstorming), statement structuring state governing bodies for sports in the or organisational-level research has been (sorting and rating), and concept mapping Australian state of Victoria and nine Victorian conducted in school, community and analysis, are described in detail elsewhere.30 Regional Sports Assemblies (RSAs), which healthcare settings,18 with an emphasis We used the Concept Systems Global MAX™31 are organisations located in regional areas of on environmental and policy-based web platform to undertake this study. the state that are responsible for supporting interventions.17 To the best of our knowledge, community sport and recreation groups no previous research has been published Sample selection and recruitment within their region. These bodies were funded on the promotion of physical activity at the In mid-March 2018, we invited multiple by VicHealth between 2015-18 through the organisational level from the perspective of contact people (total N=70: RSA=32, SSP and RSP, respectively, to develop and sport organisations that develop and deliver range=2–7 per organisation; SSA=38, deliver – or scale – social sport products to social sport products, and have a focus on range=1–4 per organisation) from each of insufficiently active people. increasing participants’ physical activity levels. the 30 organisations funded through the The number and type of products developed Although most published physical activity RSP/SSP to participate in the CM exercise. or scaled for SSP (range 1–10 products per research has explored the frequency, All participants were identified by VicHealth organisation) and RSP (range 10–38 products patterns, correlates or predictors of physical as integral to the development and delivery per organisation) varied across the 30 funded activity,19 more recent studies explore the of the social sport products within their organisations. They varied in terms of: 1) barriers and facilitators to implementing funded organisation. The emailed invitations delivery models (from set session times physical activity interventions.20–26 This were sent to all participants simultaneously and season lengths requiring commitment research was conducted across a range of and included a hyperlink to the online by participants to attend all sessions, to settings including schools,25 youth-serving brainstorming. Several reminder emails were come-and-try days or pay-as-you-go sessions organisations,20 and healthcare settings.26 sent to all potential participants before the requiring no regular commitment); 2) To date, no previous published research ideas generation step closed after 14 days. business models (for example, centralised has explored the barriers or facilitators to Before undertaking their first CM activity, delivery by paid sport staff; contracting developing and implementing physical participants provided online consent third party deliverers such as personal activity interventions in community sport (implied by self-registering to participate in trainers; paying school or community settings. the study), and were asked to describe: their recreation facility staff to deliver social sport To fill these gaps in the extant literature, gender; the type of sport organisation they products in their facilities; or using volunteer and help address the paucity of research worked for; how long they had worked for coaches to deliver social sport products at examining how informal participation fits the organisation; their position within the community club facilities); and 3) different with traditional sport development structures organisation; and how long they had been program activities (such as modified games and systems,27 this research explored working on developing and delivering social of a traditional sport; skill-based sessions; the challenges that sport organisations sport products funded through the RSP/SSP. fitness-based training using core elements of experienced when developing and delivering All background questions were categorical a sport). social sport products to engage insufficiently with multiple choice responses. For example, RSAs partnered with Netball active people in regular physical activity. The Victoria to scale their existing Rock Up Netball findings of this study can be used to leverage Data collection products in regional locations through three the considerable infrastructure and resources The focus prompt used to brainstorm ideas delivery models: a social netball game; a already invested in sport organisations, in this study was: “Based on your experiences netball-based training session; and a round- to respond to changing trends in physical of the RSP/SSP, what challenges are there robin event day. Participants could just ‘rock- activity participation, and to tackle the to designing, developing and delivering a up’ without pre-registering or committing to

successful program to engage inactive and of statements they were asked to sort. rating, and 57 in the ease of overcoming somewhat active people in sport or physical Participants were also instructed to rate rating. Forty-three participants contributed activity?” The two rating instructions used each challenge on ‘importance’ and ‘ease of data in all phases, while three contributed to were: “On a scale from 0 (least important) overcoming’, using the full six-point scale the ideas generation only. to 5 (most important), how important is (0–5), relative to the other challenges in the Thirty-eight participants represented 19 overcoming this challenge for program list. SSAs (mean 2.0 participants per organisation, success?” and “On a scale from 0 (hardest) to range 1–4, mode 2) while 30 participants 5 (easiest), how easy is this challenge for your Data analysis represented nine RSAs (mean 3.3, range organisation to overcome?” During data analysis, we created a square 2–6, mode 2 and 4). Just over half (53%) We asked participants to brainstorm as symmetric similarity matrix from the sorted of participants were male, and more than many single-thought statements as they data, before applying two-dimensional non- three-quarters described their position as a could in response to the focus prompt (see metric multidimensional scaling to locate program coordinator (60%) or an executive above). As is usual practice in CM studies, each statement as a separate point on an officer (19%). Half (50%) of the participants participants could review the statements X–Y ‘point map’. We then used hierarchical had been employed with their current other participants made, and access the cluster analysis to partition the point organisation for three years or longer, and online platform multiple times. map into groups of statements creating a nearly three-quarters (72%) of participants After the brainstorming had been completed, ‘cluster map’. A detailed description of the had worked on the RSP/SSP program for the authors (KS and AD) conducted multidimensional scaling, including the 12 months or longer. Full details of the multiple rounds of synthesising and editing stress index calculation, and hierarchical participants are available in Supplementary the brainstormed statements to: delete cluster analysis used in the Concept Systems Table 2. 31 statements unrelated to the focus prompt; Global MAX™ web platform, is available The participants brainstormed 158 challenges 28 split compound statements; identify from Kane and Trochim (pp. 87–100). We in response to the project focus prompt. The statements that represented the same also calculated mean importance and ease research team synthesised and edited these idea, and select the statement that best of overcoming ratings for each statement, to 71 unique challenges for participants to captured the essence of the idea; and edit and used them to generate a ’go-zone’ sort and rate (Table 1). Fifty-five participants statements to reflect an agreed meaning. graph, in which we plotted each statement’s sorted the 71 challenges into groups This iterative process involved all members mean ratings on a graph divided into four (mean=7.65 groups; mode=7 groups (11 of the research team and continued until quadrants using the overall mean of each participants); range 4–12 groups). rating as the axes. there was consensus that the final statement The mean importance rating for all challenges list contained a manageable (i.e. not so To select the most appropriate number of was 3.34 out of 5 (Table1). Challenges in many statements that participants would clusters, the research team followed Kane and Cluster 1 (Deliverers) were rated the most 28(pp101-103) be unwilling to sort and rate them all) set of Trochim’s recommended process, important (3.52), while those in Cluster 9 unique (i.e. each idea was represented once), examining the cluster maps for a 6-cluster (Shifting traditional sport culture) were rated clear and pertinent ideas. We cross-referenced solution through to a 12-cluster solution and the least important (2.83). The mean ease the final and original sets of statements to paying particular attention to which clusters of overcoming rating for all challenges was ensure all relevant brainstormed ideas were of statements were split as the number of 2.40. Challenges in Cluster 6 (Marketing to represented in the final set of statements. clusters increased. This negotiated process insufficiently active) were rated the easiest We invited all RSA and SSA contacts (N=70) was used to identify the cluster level that the (2.72), and those in Cluster 5 (Sustainable to participate in the statement structuring, research team believed retained the most business model) the hardest (1.98) to even if they had not participated in the useful detail between clusters, while merging overcome. those clusters that seemed to logically brainstorming. Multiple reminder emails were The research team agreed that a 9-cluster belong together. After agreeing on the most sent to anyone who had not responded or solution: Deliverers (10 challenges); Capacity appropriate cluster level, statements that completed the sorting and rating tasks over to drive the product (6 challenges); Facilities subjectively seemed to belong in an adjacent 14 days in early May 2018. and partnerships (5 challenges); Product cluster were identified and reassigned to the During the statement structuring process, development (12 challenges); Sustainable more appropriate neighbouring cluster.32 each participant sorted the randomised business model (10 challenges); Marketing to synthesised statements into groups that Ethics approval for this study was given by insufficiently active (5 challenges); Attracting made sense to them. They were instructed the Human Research Ethics Committee of the insufficiently active (9 challenges); Clubs to group statements according to similarity La Trobe University (Application Number: E15- and volunteers (12 challenges); and Shifting in meaning, and to name each group based 081 Modification). traditional sport culture (2 challenges) on its theme or contents. Participants could retained the most useful detail while create single-statement groups if they Results merging those clusters that seemed to thought a statement was unrelated to all logically belong together (see Figure 1). The other statements. They were asked to put Sixty-eight individual participants from 28 distances between the individual points every statement somewhere, and to avoid of the 30 funded organisations contributed on the cluster map (Figure 1) represent the creating ‘miscellaneous’ or ‘other’ groups. CM data: 57 in the ideas generation, 55 in degree of similarity between challenges They were also informed that 5 to 15 groups the statement sorting, 60 in the importance (i.e. the challenges grouped together by usually work well to organise the number

Table 1: Statements generated during the concept mapping brainstorming process including the cluster in which each statement fits, mean importance and ease of overcoming ratings and go-zone graph quadrants for each statement. Mean rating Go -zone quadrantb Importancea Ease of All Within overcominga statements cluster

Cluster 1: Deliverers 3.52c 2.61c 5 Finding a deliverer who can engage with your target market. 4.29 2.64 1 1 19 Finding the right deliverers with the capacity (time, skill, space). 4.28 2.24 2 2 25 Existing providers/delivers are stuck in their ways and won’t adapt to change. 3.03 2.51 3 4 29 Educate existing providers/deliverers on the formalities of the product. 3.18 3.12 3 3 35 Understanding the need to get product deliverers involved in resource and product development. 3.13 2.83 3 3 43 Getting our providers to run the product in the designed way. 3.17 2.92 3 3 46 Finding an appropriately skilled deliverer that can engage the target market at a cost that suits. 3.92 2.25 2 2 49 Convincing deliverers to take a risk and do something differently (‘break the rules’/challenge existing structures across all levels). 3.22 2.49 34 59 Engaging deliverers that understand the barriers to participation. 3.88 2.81 1 1 71 Developing models that don’t require trained accredited facilitators/coaches. 3.12 2.31 4 4 Cluster 2: Capacity to drive the product 3.49c 2.42c 2 Identifying clubs with the capacity to ensure product sustainability. 3.89 2.90 1 1 8 Community sport organisations not understanding the role of the SSA/RSA in the implementation of the product. 2.67 3.00 3 3 52e Challenges around staff turnover and losing momentum because product development takes time; research, development, testing, 3.25 2.10 4 4 recruitment, retesting, sustainability. 54 The recruitment of participants into products is highly dependent on the quality of partnering ‘gatekeepers’ (agencies and 3.45 2.51 1 3 organisations) who introduce their members into products. 56 Finding local drivers to ensure products are sustained. 4.02 2.12 2 2 67 Ensuring that clubs persist with a product and do not become discouraged with a slow start or low initial interest. 3.72 1.95 2 2 Cluster 3: Facilities and partnerships 3.43c 2.33c 13 Managing expectations of partners. 3.02 2.92 3 3 18 Developing sustainable supports around the delivery of the product (i.e. Councils, local business, other sports, schools). 3.89 2.00 2 2 33 Ensuring products continue as RSA/SSA involvement is withdrawn. 4.14 1.54 2 2 63 Facility access was a huge barrier as the traditional model of our sport takes priority. 2.92 2.49 3 3 68 Access to adequate venues (e.g. with lights). 3.20 2.75 3 3 Cluster 4: Product development 3.40c 2.62c 3 Making sure the product is different enough from your usual offerings whilst not losing what the sport is all about. 3.02 3.20 3 3 7 Creating a product that people with little to no interest in sport/rec, who have sometimes had bad experiences, find interesting, 4.11 2.00 2 2 enticing, and safe. 17 Appropriate time to consult with communities and to then implement products around a variety of needs/expectations. 3.67 2.19 2 2 22 Designing a flexible product that caters for degrees and types of disability, and individual capability and capacity. 3.67 2.63 1 1 24 Developing products to suit the different regions. When each community/town is different in what is available and the people who 3.16 2.75 3 3 work within it. 28 Implementing new and/or adapting existing administration systems for social participation products. 2.67 3.07 3 3 30 Developing a Social Participation Strategy that includes a social player/team pathway. 2.79 2.62 3 3 36 Ensuring products that are social are also flexible (time, cost, insurance, membership, scheduling, competitiveness). 3.90 2.44 1 2 44 Ongoing engagement/feedback with the market when designing/developing the product. 3.73 2.85 1 1 50 Ensuring the product is simple and easy to understand for someone new to the sport. 3.88 3.19 1 1 51 Creating something truly original and engaging in an already crowded health and fitness marketplace. The average person is now 3.23 2.12 4 4 so much more adept at ‘self-exercising’ and has the YouTube world as their oyster. 53 Having an infrastructure that is based on competition makes it challenging to provide the ongoing participation for those wanting 2.98 2.34 4 4 casual and recreational opportunities. Cluster 5: Sustainable business model 3.40c 1.98c 1d The balance between the need for immediate results and sustainable long term participation (e.g. time to research the needs of the 3.82 2.20 2 1 community and design a product that fits that need). 6d Engaging inactive and somewhat active people to participate, while ensuring a sustainable business model. 3.79 1.56 2 2 14 Insurance is tied to traditional sport products/models, and there is little flexibility with the majority of insurances to allow casual or 2.24 2.88 3 3 flexible participation. 15 Building a critical mass for the running of, and social enjoyment of an activity. 3.15 1.88 4 4 37 The need for different Business/Revenue models (depending on location, facility owner, host club/council/etc.). 3.15 2.53 3 3 39 Products’ and ‘Programs’ alone are not enough... we need to address systemic issues as a sector (e.g. cost, access, attitudes etc.). 3.47 1.68 2 2 41 Transitioning inactive or somewhat active people from introductory into ongoing participation (e.g. club products). 3.60 1.44 2 2

Table 1 (cont.): Statements generated during the concept mapping brainstorming process including the cluster in which each statement fits, mean importance and ease of overcoming ratings and go-zone graph quadrants for each statement. Mean rating Go -zone quadrantb Importancea Ease of All Within overcominga statements cluster 45 Ensuring sufficient numbers at products when offering a flexible attendance policy creates uncertainty and impacts on a successful 3.60 1.73 2 2 product. 65d Finding the right cost structure to enable sustainable delivery post a funded pilot/trail, particularly in low SES & isolated towns. 3.58 2.03 2 1 69d Sustainability - transition from free or low cost to full fees (needs to be considered upfront and communicated during initial 3.48 2.05 2 1 products). Cluster 6: Marketing to insufficiently active 3.34c 2.72c 27 Developing a social marketing strategy that showcases the concept in its new social non-competitive format to entice the 3.18 2.90 3 3 participant. 32 Ensuring the value proposition (benefits/sales pitch) is appropriate to the market. 3.67 2.68 1 2 40 Designing a marketing strategy targeting the inactive cohort (where relevant the strategy supports member clubs). 3.46 2.24 2 2 60 A lack of marketing expertise within the project team. 2.93 3.14 3 3 61 Resources (budget allocation) for marketing and promotion to create an ongoing awareness and participant recruitment campaign. 3.47 2.63 1 2 Cluster 7: Attracting the insufficiently active 3.21c 2.14c 11 Participant lack of confidence and self-esteem. 3.05 2.42 3 3 16 At times, the products attracted the ‘sports engaged’ to play more sport. 2.51 2.83 3 3 20 Hard to get participants to commit to coming on a regular basis - regardless if it was free or low cost. 3.61 1.56 2 2 23 Consulting with the less active cohort to understand their motivations. 3.89 2.19 2 1 38 A modified form of a traditional sport is of no interest to this cohort because of their previous personal experiences with sport and 2.68 2.44 3 3 clubs. 42 Changing the mindset of the target participant on what ‘sport’ is to include social sport. 3.57 1.92 2 2 47 Mobilising the inactive/someone active target market ... getting them from ‘contemplating’ physical activity to actually showing up. 3.95 1.25 2 2 58 As a lot of “Active” players are already engaged in this product, it can be very confronting and competitive for a “non-active” player. 3.02 2.54 3 3 They might attend 1 session but not return the following week. 66 Too big a step for participants, from nothing to sport-based activity. 2.62 2.27 4 3 Cluster 8: Clubs and volunteers 3.18c 2.42c 4 Club people are not the right people to engage with this cohort. 2.61 2.88 3 3 9 Limited volunteer base. 3.31 2.22 4 2 12 Making sure it is not overly time intensive to organise for volunteer clubs. 3.59 2.36 2 2 21 Lack of club involvement or engagement in modified sports. 3.15 2.25 4 4 26 Limited expertise, knowledge and skill of volunteers. 2.84 2.71 3 3 31 Individuals in leadership positions, rather than the whole club/committee agree the club will deliver the product, but don’t support 3.08 2.47 3 3 club members to implement. 34 Many clubs/associations struggle to implement their ‘core business’ (eg. field teams and committee roles). Therefore implementing 3.52 1.66 2 2 social and modified sport products is not on their agenda. 48 Club volunteers being targeted by multiple organisations with various priorities; when the priority is club admin, compliance, then 3.17 1.92 4 4 everything else. 55 Volunteers struggled to see the benefits of social and modified sport to the club. 2.78 2.42 3 3 62 Engaging clubs/deliverers in the vision. 4.02 2.53 1 1 64 Getting the clubs across the state to deliver the same product. 2.37 2.80 3 3 70 Identifying club characteristics required for them to have the capacity to deliver the product successfully. 3.68 2.95 1 1 Cluster 9: Shifting traditional sport culture 2.83c 2.43c 10 We’re not geared to deliver to the inactive / somewhat inactive as our membership base is traditionally focused on current 2.59 2.54 3 3 participants / active people. 57 Shifting the thinking of the sport community that the social products are not there to recruit people to our traditional formats. 3.10 2.32 4 2 For all statements 3.34c 2.40c Notes a: 0 (least important/hardest to overcome) to 5 (most important/easiest to overcome); ^60 participants rated all 71 statements for importance and 57 rated all 71 statements for ease of overcoming b: Go Zone Quadrants: 1 (Top right = above mean for both importance and ease); 2 (Bottom right = above mean for importance and below mean for ease); 3 (Top left = below mean for importance and above mean for ease); 4 (Bottom left = below mean for both importance and ease) c: mean importance/ease rating for all the statements in the cluster d: Reassigned from Cluster 1 to Cluster 5 e: Reassigned from Cluster 7 to Cluster 6.

more participants are located closer to each Table 1 for the details of each challenge, had worked for at least 12 months, and 50% other on the map). For example, challenges including its mean importance and ease of for more than two years on the RSP/SSP) #9, #31 and #55 were considered so closely overcoming ratings. who represented a wide variety of sport related that nearly all participants grouped organisations (n=28). In addition, employing them together. By contrast, challenges #61 Discussion Concept Mapping enabled participants to and #71 were considered so unrelated that both identify issues of interest and group almost no one grouped them together. This study is the first published investigation them together. This overcomes some of the The stress index – a representation of how of the challenges faced by sport organisations methodological limitations associated with well the two-dimensional map reflects when they attempt to develop and previous research investigating barriers the square symmetric similarity matrix deliver – or scale – innovative, social sport and facilitators to implementing physical generated from the sorted data – was 0.24, products to increase physical activity among activity interventions, which employed either close to the average stress value across a insufficiently active populations. The findings surveys (in which participants rated their 28 broad range of CM projects. A full list of are internationally relevant, particularly in level of agreement with researcher-selected 23 the challenges within each cluster, including countries where trends are shifting towards items) or semi-structured interviews (in the five challenges that were reassigned to more flexible and social participation in sport which participants’ responses to open-end neighbouring clusters to which there was a and physical activity (e.g. the United Kingdom questions were coded and grouped by 21 better conceptual fit, is provided in Table 1. and the United States),15 and where sport researchers). Figure 2 is a go-zone graph for all 71 development and delivery systems are similar The nine clusters of challenges to developing challenges. The ‘go-zone’ quadrant of to the Australian federated, multi-tiered, and delivering social sport products for challenges in the top right contains the 12 community sport-based system (e.g. Canada insufficiently active populations identified in challenges that were rated above average on and New Zealand).33 this study span the dimensions encompassed both importance and ease of overcoming. A key strength of this study is that it draws on by commonly cited ecological health 34–36 The go-zone graph quadrant for each the reflections of three years of developing promotion models. Cluster 7 highlights challenge (when all challenges and when and delivering social sport products for the challenges related to individual challenges within the same cluster only are insufficiently active populations. The study participants, while Clusters 1 and 4 focus considered) is provided in Table 1. To aid gathered data from a large number of people attention on the challenges involved in interpretation of the go-zone graph, see (n=68) with considerable experience (75% product development and delivery. Clusters 2,

Figure 1: A nine-cluster map of challenges to sport organisations developing and delivering social sport products for insufficiently active populations.

7. Attracting the insufficiently active 11 58 47 42 66 20 38 16 7 23 3 6. Marketing to insufficiently active 27 41 50 51 32 22 4. Program 40 15 44 36 development

6 30 17 24 45 60 39 53 14 28

61 65 69 1 9. Shifting traditional 5. Sustainable 57 37 sport culture 71 business model 10 63 35 18 52 2. Capacity to drive 68 33 the program 49 54 3. Facilities and 43 13 56 12 partnerships 8 62 29 59 64 19 46 67 70 2 21 4 25 5 55 34 9 1. Deliverers 48 31 26 8. Clubs and volunteers Note: Dashed lines indicate clusters before statement reassignment.

3, 5, 6 and 8 identify the challenges associated important to overcome for program success importance and 2.72 for ease of overcoming). with organisational capacity and leveraging (mean=3.52/5), but the two challenges The challenges within the Product partnerships to develop, attract participants rated as the most important to overcome development cluster highlight the need to, and sustain the delivery of new, social (Statements #5 and #19), were both located in to ensure the social sport products being sport products, while Cluster 9 raises this cluster. In addition, the Deliverers cluster offered by sports organisations are developed broader challenges related to the culture was rated as the third easiest (mean=2.61/5) in consultation with potential participants and traditions of sport in the community. In for the participating organisations to and deliverers, meet the needs of the target addition, at least three challenges in nearly overcome. These findings suggest that sport population (which vary across geographical every cluster (except Cluster 9) are located organisations interested in or tasked with locations and sub-populations) and reflect on the right-hand side of the go-zone graph designing, developing and delivering or an understanding of the delivery context, (see Figure 2), indicating that they were scaling social products to inactive people and can be delivered using existing systems, rated above the mean of 3.34 out of 5 for should make sure they recruit deliverers with resources and infrastructure. This approach importance in overcoming to ensure product the capacity to deliver social sport products, is supported by well-cited health promotion success. These findings support previous calls as well as the ability to engage with – and planning frameworks.38,39 The challenges for multi-strategy ecological approaches to understand the participation barriers for – within the Marketing to insufficiently active promote physical activity,16,37 and highlight the target population. Such organisations cluster highlight a need to improve the the need for change at all levels of the sports should consider producing detailed position marketing of social sport products through governance system to maximise participation statements to facilitate the recruitment of a combination of resourcing and upskilling in non-traditional sports in traditional sports appropriate product deliverers, as well as existing staff, allocating time and resources to settings.27 developing comprehensive orientation/ developing appropriate marketing strategies, While acknowledging the need for a training programs to ensure all recruited and recruiting staff with specific marketing system-wide response to the challenges deliverers have the knowledge and skill sets expertise and an understanding of the target associated with developing and delivering required. population. social sport products for insufficiently active The other two relatively important and easy Mapping the nine clusters and 71 challenges populations, recruiting appropriately skilled to address clusters of challenges that emerge that emerged from this study onto the five- and experienced product deliverers is from this study are those related to Product domain, 72-construct framework of common clearly a key challenge and an opportunity development (mean=3.40 for importance and barriers to implementing and scaling up to influence program success. Not only 2.62 for ease of addressing) and Marketing physical activity interventions developed was the Deliverers cluster rated as the most to the insufficiently active (mean=3.34 for by Koorts and colleagues32 reveals that the

Figure 2: Go zone of challenges to sport organisations developing and delivering social sport products for insufficiently active populations.

outcomes of this study are well supported neighbouring clusters. Therefore, despite 5. Australian Institute of Health and Welfare. Impact of Physical Inactivity As a Risk Factor for Chronic Conditions: by highly cited implementation science the project team following standard CM Australian Burden of Disease Study [Internet]. Australian explanatory frameworks. For example, protocol,28 a similar study involving the same Burden of Disease Study Series No.: 15. Canberra Cluster 1 (Delivers) aligns very strongly with participants but conducted by a different (AUST): AIHW; 2017 [cited 2018 Sep 27]. Available from: https://www.aihw.gov.au/reports/burden-of-disease/ the Koorts and colleagues ‘Implementer project team may produce different results. impact-of-physical-inactivity-chronic-conditions/ characteristics’ domain; Cluster 2 (Capacity In addition, as this was a component of the contents/summary 6. Australian Department of Health. Australia’s Physical to drive the product) and Cluster 3 (Facilities process evaluation of VicHealth’s investment, Activity and Sedentary Behaviour Guidelines and the and partnerships) align strongly with their it was beyond the scope of this study to Australian 24-Hour Movement Guidelines [Internet]. Canberra (AUST): Government of Australia; 2019 [cited ‘Delivery setting’ domain; and Cluster 4 examine the effectiveness of the social sport 2019 May 30]. Available from: http://www.health.gov. (Product development) aligns strongly with products developed through the SSP and RSP. au/internet/main/publishing.nsf/Content/health- their ‘Intervention characteristics’ domains.36 However, an impact evaluation to establish pubhlth-strateg-phys-act-guidelines#npa1864 7. Australian Department of Health. 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Epidemiology of hospitalised traumatic brain injury in the state of New South Wales, Australia: a population-based study

Ilaria Pozzato,1 Robyn L Tate,1 Ulrike Rosenkoetter,1 Ian D Cameron1

raumatic brain injury (TBI) is an Abstract important cause of preventable Tmortality and disability across the Objective: To describe the population-based incidence and epidemiological characteristics of lifespan. By 2030, brain injuries due to hospitalised traumatic brain injury (TBI) in New South Wales (NSW), Australia. traffic accidents and falls are expected Methods: One-year statewide hospital admission data from the NSW Department of Health th th to rise to the 7 and 17 major cause of were analysed. TBI cases were identified using a combination of TBI-related diagnostic and 1 death, respectively. TBI ranges from mild to external cause codes from the International Classification of Diseases (ICD-10th Revision). extremely severe injury. Recovery levels are Sociodemographics, causes, associated factors, severity and medical details of hospitalisation similarly variable depending on the severity were examined. of the initial injury, from good outcome Results: There were 6,827 hospitalised TBI cases that met review criteria. Incidence rate was and resumption of premorbid lifestyles 99.1/100,000 population. Incidence in persons older than 75 years of age and residents in to profound disability affecting physical, cognitive and/or behavioural function. remote areas was three times higher. Aboriginal and Torres Strait Islander peoples were 1.7 Although it is a critical public health problem times more likely to sustain a TBI than the general population, and risk was greater for all NSW worldwide, the actual incidence of TBI is residents from areas that were remote and disadvantaged-socioeconomically. Older adults and difficult to establish. those with severe injuries showed prolonged hospitalisation, higher morbidity and mortality. The latest systematic review indicates a Conclusions: Overall TBI incidence in NSW is lower than international estimates. Nevertheless, pooled annual incidence proportion of groups with higher incidence rates and/or poor in-hospital outcomes were identified, 295/100,000 (95% CI, 274-317) for all ages.2 highlighting directions for prevention and future research. Incidence data, however, still vary widely Implications for public health: There is a need for identifying risk factors/barriers and across countries and among studies,3 assessing the impact of recent policies on these population groups. with differences in study methodology Key words: brain injury, epidemiology, incidence contributing most notably to this variability. Injury patterns are also changing, showing criteria for meta-analysis, reporting on Differences in case identification and study that TBI incidence is increasing in low-income incidence of TBI in 1988. That study showed design are the major limitations to current countries and more injuries are occurring much lower rates of 100/100,000 population epidemiological research.8 Evidence strongly among older people in high-income in a defined New South Wales (NSW) suggests population-based studies are the countries,4 which makes it challenging for community.5 Other available Australian best approach to obtain objective estimates estimates to be generalised. data confirmed TBI is less common in and understand epidemiological patterns The incidence of TBI in Australia is not well Australia than in Europe and North America of disease.8 Moreover, while injury patterns established. From the cross-continental (228-331/100,000) or New Zealand (790- in Australian sectors have been previously comparison, Australasia (including Australia 1750/100,000).2 These data included findings investigated,9-12 little is known about and New Zealand data) yielded the highest from the Australian Institute of Health characteristics for the whole population. The incidence proportion of 415/100,000 and Welfare study for the period 2004-05 need for population studies has become even population.2 This finding was of particular (107/100,000 population)6 and a Western more imperative in developed countries, concern, together with the fact that in Australia study for 2003-08 (85.8/100,000 including Australia, where TBI patterns Australia only one study5 met inclusion population).7 have changed over the past decades, with

1. John Walsh Centre for Rehabilitation Research, Sydney Medical School - Northern, Kolling Institute of Medical Research, University of Sydney, Sydney, Australia. Correspondence to: Robyn L. Tate, John Walsh Centre for Rehabilitation Research, Sydney Medical School - Northern, University of Sydney, Level 12, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, 2065; e-mail: [email protected] Submitted: May 2018; Revision requested: July 2018; Accepted: January 2019 The authors have stated they have no conflict of interest. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Aust NZ J Public Health. 2019; 43:382-8; doi: 10.1111/1753-6405.12878

an ageing population resulting in higher Study population and case selection subgroups: for socioeconomic status, the 4 numbers of fall-related injuries. The study population comprised the first most disadvantaged (classifications 1-3) Well-established characteristics of TBI include admissions of residents of any age who versus medium (classifications 4-7) versus least disadvantaged (classifications 8-10);22 some sociodemographic variables (sex, age presented with a TBI to a NSW hospital during for location, metropolitan (classification at injury, socioeconomic status) and injury- the calendar year 2007. The International 1) versus rural (classifications 2-3) versus related factors (mechanism and circumstances Classification of Diseases (ICD-10th revision) remote living location (classification 4-5). of injury). Yet other reports have identified risk diagnostic codes18 from hospital admissions • Cause of injury was classified as follows patterns that warrant further investigation. were used to identify potential TBI cases. using the ICD external cause (E-Codes): For example, Jamieson et al.12 found that The ICD-10th revision does not contain transport accidents, falls, assaults7 and Aboriginal and Torres Strait Islander peoples a specific rubric for TBI, therefore case other mechanisms. Cases with more than are 21 times more likely to incur a TBI due to identification was based on a combination of one E-Code were described as multiple assault, with other studies indicating a higher TBI-related diagnoses and external cause ICD mechanism TBI group and regarded as a risk across all mechanisms of injury.13 Living descriptors.19 A multi-step selection process separate group. in rural and remote areas of the country is was adopted. First, admissions were restricted • Associated factors of TBI risk were another factor commonly associated with to cases with at least one of the following ascertained from the diagnosis codes as higher risk of TBI, but these aspects have only codes (Figure1): skull fracture, intracranial follows: alcohol consumption, drug use, been investigated for sectors of the Australian injury, crushing injury of the head. Second, sports, recreational activities. population (e.g. Aboriginal and Torres Strait cases with a reported period of loss of • Severity was assessed using ICD-code Islander peoples12 and Australian children).14 consciousness (LoC) only were matched with information on post-traumatic amnesia Similarly, factors like socioeconomic patterns external cause of injury (E-Codes) to exclude (PTA) and LoC duration. TBI cases were of TBI in the Australian context and medical LoC due to other medical reasons. All ICD classified as severe (PTA ≥2 weeks and/ details of hospitalisation, such as length of descriptors used in this study are provided or LoC >24 hrs); moderate (PTA 24hrs to stay (LOS), in-hospital mortality and associated as supplementary material (Supplementary 2 weeks and/or LoC 30 min to 24 hrs) and injuries or comorbidities, have been scarcely Table S1). To estimate TBI incidence, only mild (PTA <24hrs and/or LoC <30 min).23 investigated in previous studies. These factors, first-time admissions and first-time TBI • Medical details of hospitalisation: together with injury severity, are major events during the study year were included in-hospital outcomes (LOS, hospital determinants of outcome following TBI15 in the count. In the analysis of medical transfers, in-hospital mortality) and that could inform healthcare planning and details, information from multiple hospital morbidity (injuries associated with TBI and economic impacts of hospital-treated TBI. separations relating to the same injury, i.e. comorbidities from ICD codes). Associated inter-hospital and intra-hospital transfers, This study intended to move the research injuries were categorised as follows: other were incorporated. forward in these areas. The purposes mechanical trauma, complications or other were twofold: estimating the incidence injuries.24 Comorbidities were identified of hospitalised TBI in NSW and describing Epidemiological characteristics according to the Charlson Comorbidity epidemiological characteristics, with detailed extracted Index25 and grouped into five broad analysis of at-risk groups, causes and factors The following personal and injury-related categories: cardiovascular (e.g. ischaemic associated with TBI, as well as severity and characteristics were extracted directly heart disease, hypertension), neurologic medical details of hospitalisation. from the Department of Health database (e.g. stroke, dementia), respiratory (e.g. or derived from the available ICD-codes chronic obstructive pulmonary disease), Method (Supplementary Table S1). digestive (e.g. peptic ulcer disease, liver • Demographic information included age at disease) and systemic (e.g. diabetes Design and data sources injury, gender, country of birth, postcode mellitus, obesity). This is a population-based study of hospital- and Indigenous status. Participants treated TBI in NSW. NSW is the most populous were stratified based on the following Results state of Australia, located on the east coast age categories: 0-9, 10-19, 20-39, 40-69, of the country, covering a geographical 70+ years. Age-specific incidence was Incidence rates, at-risk groups, injury-related area of almost 810,000 square kilometres. computed for five-year age intervals, with characteristics and hospitalisation details Hospital admission data from 166 public and the upper interval being the 75+ years were analysed. private hospitals in metropolitan, rural and age group to allow comparison with other remote areas were obtained from the NSW studies. Incidence of hospital-treated TBI Department of Health for the 2007 calendar • Socioeconomic and geographical A total of 10,175 admissions were initially year. The state’s resident population for the distribution were derived from residential identified using the ICD-codes selection study year was 6.8 million16 and this number postcodes. Socioeconomic status was criteria (Supplementary Figure S1). Of these, was used for the calculation of age- and allocated by mapping postcodes to deciles 2,435 admissions (23.9%) were subsequently sex-specific incidence rates. Census data of the Australian Bureau of Statistics Index excluded as not meeting study inclusion from 2006 were used for comparison of of Relative Socio-Economic Disadvantage criteria. These consisted of 1,165 (11.4%) socioeconomic characteristics.17 Approval scores.20 Remoteness was classified cases with no evidence of TBI, 368 (3.6%) to conduct the study was obtained from the according to the Australian Standard non-residents of NSW, 902 (8.8%) non-acute NSW Population and Health Services Research Geographical Classification.21 Statistical episodes of care. Three-quarters (7,740) were Ethics Committee (HREC/08/CIPHS/56). comparisons involved the following

confirmed TBI cases. A further 913 duplicate (32.3% vs 29.2% respectively, χ2=31.20, df=1, one in five people (18.7%) were under the cases were excluded from the count: 879 p<.001). In addition, there was an association influence of alcohol or recreational drugs, (8.6%) required acute inpatient transfers and between remoteness and socioeconomic accounting for 30% of adults between 20 34 (0.33%) sustained a second TBI during disadvantage in the TBI sample (χ2=1193.54, and 69 years of age. Mild injuries were more the same year, needing multiple admissions. df=4, p<0.001), and this reflected the NSW commonly associated (19.3%) with sport/ The final study population was thus 6,827 general population where there is also a leisure activities (χ2=10.17, df=2, p=0.006), residents of NSW with TBI admitted to a NSW correspondence between remoteness and while one in three people in the moderate- hospital during 2007. The annual incidence socioeconomic disadvantage (χ2=801851.64, to-severe group was under the influence of of hospitalised TBI in NSW was estimated df=4, p<0.001) (Supplementary Table S2). alcohol or drugs (χ2=16.09, df=2, p<0.001). at 99.1/100,000 population (95%CI 96.8 – Yet, the TBI sample had a higher proportion Substance use was strongly associated with 101.5/100,000 population), with a mortality of both remoteness and disadvantage than assault-related TBI compared to other causes rate of 5.9/100,000 population (95%CI 5.3 – the NSW general population (1.4% vs 0.44%, (41.2%; χ2=490.42, df=5, p<0.001), as well as 6.5/100,000 population). χ2=140.91, df=1, p<0.001), which was three with injury occurring during the weekend times higher. compared to week days (22.2%; χ2=59.73, At-risk groups and causes of injury Similar disparities were found in other df=1, p<0.001) (Supplementary Table S4). Figure 1 displays age/sex distribution and features of the data (Supplementary Table injury causes of this cohort. Risk of TBI was S3). The NSW group identifying as Aboriginal Injury severity and medical details of distinctly higher in the 15-19 years and in and Torres Strait Islander residents had a hospitalisation the 75+ years age groups, with rates in older much higher proportion of remoteness Specific injury severity data were available for people being three times the overall incidence and socioeconomic disadvantage (4.5%) 2,925 (43%) cases (Table 1). A total of 122 TBI (298/100,000 vs 99.1/100,000; z=9.99, compared to the NSW general non- cases (4%) were classified as severe, 223 (8%) p<0.001). This represents the first standout Indigenous population (0.35%), a rate that as moderate and 2,580 (88%) as mild (Table 2 feature of the study findings. Falls caused was 12.8 times higher (χ =52450.36, df=1, 1). More than half of moderate-to-severe most brain injuries in NSW (47.6%), followed p<0.001). Even so, at 9.8% the NSW TBI injuries occurred over the age of 40 (χ2=23.52, by transport accidents (25.9%) and assaults Aboriginal and Torres Strait Islander peoples df=8, p<0.01). By contrast, people younger (15.8%). Older people (>70 years) had by far had the highest proportion of remoteness than 19 years of age had the highest rates the highest proportion of fall-related injuries and socioeconomic disadvantage of all (92-94%) of mild TBI. Variation among severity (87.3%). Conversely, TBI in teenagers (10-19 groups, even being twice as high as the and mechanism of injury was statistically years) was more commonly due to motor general Aboriginal and Torres Strait Islander significant (χ2=52.72, df=10, p<0.001). Falls vehicle crashes (40.5%). Twenty-nine per cent population in the state. Overall, risk of were the leading cause of minor-to-moderate of traffic-related TBI among teenagers were sustaining a TBI among Aboriginal and Torres injuries (42-47%), while severe injuries were cycling injuries. Strait Islander peoples was 1.7 times higher mostly (42.6%) due to motor vehicle crashes. Another stand-out feature of the incidence compared to the NSW general population People living in areas of high socioeconomic 2 findings was residency. Occurrence of TBI (3.8% vs 2.2%, χ =81.09, df=1, p<0.001). disadvantage were more likely to sustain by location of residency, socioeconomic severe injuries compared to the general status and indigenous status are described in Factors associated with TBI risk population (41.2% vs 29.2%, χ2=8.49, df=1, Table 1. The NSW TBI population was 2.8 times Personal and environmental factors p=0.003). more likely to live in remote areas compared associated with TBI risk varied with severity Table 1 also provides medical details of to the NSW general population (1.7% vs 0.6%; (Table 1), age and causes (Table 2). At the time hospitalisation for the whole sample and χ2=138.12, df=1, p<0.001), which was higher of the injury, 14.3% of the overall TBI cohort severity spectrum. Average LOS was 6.4 than the relative proportions living in the was involved in sport and leisure activities, days (SD=13.1), with inter-hospital transfers most socioeconomic disadvantaged areas with 40% in the 10-19 years age group. About occurring in 9.2% of cases. Forty per cent of

Figure 1: Age/sex-specific incidence rates per 100,000 and proportion of injury cause by age in NSW, 2007 (n=6,827).

people sustained other mechanical trauma than 70 years of age (63.6%; χ2=372.95, df=4, Not surprisingly, severe TBI, in comparison due to the accident, with one-in-two people p<0.001) or sustained the most severe injuries with the less severe injuries, resulted in having some injury or complications in (44.8%; χ2=400.15, df=2, p<0.001). The median longer LOS of about one month (M=28 days; addition to TBI. One-in-four people had age at death was 62.9 years. The majority of F=301.08, df=2, p<0.001), higher number of pre-existing or simultaneously sustained fatalities resulted from fall-related TBI (67.9%; inter-hospital transfers (more than one facility comorbidities. χ2=93.61, df=5, p<0.001) compared to other in 21.4% of cases), and the highest fatality Overall, fatalities occurred in 5.3% of the causes. rates at 32%. A larger number of associated 2 sample. Those who died were generally older injuries (64.8%; χ =22.1, df=2, p<0.001) Table 1: At-risk groups, associated factors and medical details of first-time hospitalised TBI in NSW (n=6,827) and in a subsample with severity data (n=2,925). NSW 2006 Census Hospitalised Deceased TBI subsample with severity dataa Person/years TBI TBI Total Total Total Mild Moderate Severe Total (n= 6,817,182) (n=6,827) (n=365) (n=2,580) (n=223) (n=122) (n=2,925) N (%) N (%) N (%) N (%) N (%) N (%) N (%) Sociodemographic M:F (ratio) 0.99:1 2.4:1 1.5:1 2.9:1 2.7:1 2.9:1 2.9:1 Male gender 3,411,349 (50) 4793 (70.2) 218 (59.7) 1,926 (74.7) 163 (73.1) 91 (74.6) 2,180 (74.5) Age, years (mean-SD) 38.7 (-) 43.1 (27.1) 69.2 (22.8) 38.9 (23.8) 44.3 (23.3) 43.7 (22.3) 39.5 (23.8) 0-9 876,967 (12.9) 536 (7.9) 6 (1.6) 120 (4.7) 6 (2.7) 2 (1.6) 128 (4.4) 10-19 913,136 (13.4) 1,172 (17.2) 15 (4.1) 584 (22.6) 31 (13.9) 19 (15.6) 634 (21.7) 20-39 1,930,938 (28.3) 1,819 (26.6) 28 (7.7) 801 (31) 67 (30) 36 (29.5) 904 (30.9) 40-69 2,438,428 (35.8) 1,695 (24.8) 84 (23) 685 (26.6) 74 (33.2) 43 (35.2) 802 (27.4) 70+ 657,713 (9.6) 1,605 (23.5) 232 (63.6) 390 (15.1) 45 (20.2) 22 (18) 457 (15.6) Born in Australia 4,703,855 (69) 5,251 (76.9) 243 (71.9) 2,041 (79.1) 158 (70.9) 91 (74.6) 2,290 (80.5) Indigenous status 152,685 (2.2) 260 (3.8) 6 (1.8) 100 (4.0) 7 (3.2) 6 (5.2) 113 (4) Socio-economic status* Low disadvantaged 2,141,608 (33.1) 1,936 (28.8) 126 (35.5) 747 (29.4) 72 (32.7) 26 (21.8) 845 (29.4) Medium disadvantaged 2,437,292 (37.7) 2,613 (38.9) 118 (33.2) 994 (39.2) 84 (38.2) 44 (37) 1,122 (39) High disadvantaged 1,884,400 (29.2) 2,171 (32.3) 111 (31.3) 798 (31.4) 64 (29.1) 49 (41.2) 911 (31.7) Location of residency** Metro 4,948,309 (72.6) 4,482 (66.7) 267 (75.2) 1,651 (65) 160 (72.7) 78 (65.6) 1,889 (65.6) Rural 1,831,085 (26.8) 2,124 (31.6) 85 (23.9) 850 (33.5) 54 (24.5) 38 (31.9) 942 (32.7) Remote 37,788 (0.6) 116 (1.7) 3 (0.8) 39 (1.5) 6 (2.7) 3 (2.5) 48 (1.7) Injury cause Transport accident - 1,768 (25.9) 76 (20.8) 765 (29.7) 70 (31.4) 52 (42.6) 887 (30.3) Fall - 3,247 (47.6) 248 (67.9) 1,104 (42.8) 106 (47.5) 38 (31.1) 1,248 (42.7) Assault - 1,080 (15.8) 14 (3.8) 452 (17.5) 37 (16.6) 15 (12.3) 504 (17.2) Other - 485 (7.1) 6 (1.6) 200 (7.8) 7 (3.1) 5 (4.1) 212 (7.2) 2E-codes - 102(1.5) 9 (2.5) 46 (1.6) 3 (1.3) 7 (5.7) 52 (1.8) No E-code - 145 (2.1) 12 (3.3) 17 (0.7) 0 5 (4.1) 22 (0.8) Associated factors Drug/Alcohol use*** - 1,269 (18.6) 34 (9.3) 520 (20.2) 66 (29.6) 36 (29.5) 622 (21.3) Sport/Recreation*** - 976 (14.3) 9 (2.5) 497 (19.3) 27 (12.1) 15 (12.3) 539 (18.4) Medical details LoS, days (mean -SD) - 6.4 (13.1) 6.8 (12.1) 3.5 (7.5) 7.9 (12.7) 28.4 (38.6) 4.91 (12.2) 2 or more facilities - 632 (9.2) 34 (9.3) 195 (7.5) 35 (15.6) 26 (21.4) 256 (8.7) Deceased - 365 (5.3) - 31 (1.2) 17 (7.6) 39 (32) 87 (3) Associated injuries*** - Other mechanical trauma - 2,351 (34.4) 124 (34) 1,038 (40.2) 87 (39) 46 (37.7) 1,171 (40) Complications - 43 (0.4) 4 (1.1) 6 (0.2) 2 (0.9) 6 (4.9) 14 (0.5) Other injuries - 72 (1.1) 8 (2.2) 24 (0.9) 2 (0.9) 5 (4.1) 31 (1.1) 2 or more injuries - 219 (3.2) 24 (6.6) 50 (1.9) 13 (5.8) 22 (18) 85 (2.9) None - 4,142 (60.7) 205 (56.2) 1,462 (56.7) 119 (53.4) 43 (35.2) 1,624 (55.5) Co-morbidities*** - 1,607 (23.5) 248 (67.9) 397 (15.4) 46 (20.6) 57 (46.7) 500 (17.1) Notes: a: Subsample based on Post-Traumatic Amnesia and Loss of Consciousness codes. *Subsample based on available residential postcodes and ABS scores (2006 Census population, n=6463300; TBI sample: n=6720). **Subsample based on available residential postcodes and ABS scores (2006 Census population, n=6817182; TBI sample, n=6722). ***Percentages of valid case. The data contains occasional missing data values, which are assumed to be random.

and co-morbidities (46.7%; χ2=82.83, df=2, expected from international comparisons, our range of 200-300/100,000 population per p<0.001) was also found. data clearly reveal that greater TBI rates exist annum.2 By contrast, there are considerable Medical details of hospitalisation varied within specific sectors of the NSW population, methodological differences in study design significantly by age and cause of injury (Table together with differences in hospitalisation that make it difficult to compare New Zealand 2). Compared to the other age groups, older outcomes that were not highlighted by estimates with findings of all other countries. 27 people (70-and-older age group) had the previous studies. Feigin and colleagues reported an annual longest LOS (M=10.7 days; F=87.06, df=4, The incidence of 99/100,000 persons per incidence of 790/100,000 population, using p<0.001), and the highest fatality rates (14.5%; year matched the current best estimates multiple sources for case identification that χ2=372.95, df=4, p<0.001). This group also calculated by Tate et al.5 in 1988 in a defined included hospital admissions, as well as community-based assessment and treatment accounted for the largest number (62.8%) of NSW subpopulation, suggesting that the data. Most other epidemiological studies of comorbidities (χ2=2070.96, df=4, p<0.001). rate of hospitalised TBI in NSW has remained TBI, including the present study, are based Of these, cardiovascular and neurological unchanged across a 20-year period, on hospital data only. Another New Zealand diseases were the most frequent, with 30% of notwithstanding methodological differences study28 reported an unusually high incidence older people affected by multiple disorders. between the two studies. The present study (1,750 /100,000 population). That study By contrast, comorbidities and mortality rates used broader inclusion criteria, considering all employed a longitudinal approach that were very low in those <40 years (1-2%). possible signs of TBI in any diagnosis field, as opposed to intracranial injuries6,26 as principal restricted the age range to 0-25 years. diagnosis5,6 used by previous studies. The only There were disparities in TBI risk among Discussion study adopting a similar approach provided population groups. Although Tate et al.5 also a slightly lower incidence of 86/100,000 for found a significant increase of TBI incidence This is the first study to provide population- the same period.7 This small difference may in people aged 75+ years in comparison with based estimates of the incidence of be explained by Moorin et al.7 not including the preceding three decades (χ2=5.66, df=1, hospitalised TBI in the whole of NSW. We cases without a specified external cause of p<0.02), in this study the risk of having a TBI also described specific at-risk groups and injury, as well as TBI caused by self-harm. among older people was found to be almost prevalent causes of injury. Further analysis three times higher than the overall incidence included factors associated with TBI risk, Compared to international studies, NSW had in both studies. This shift in observed TBI injury severity and medical details of TBI the lowest incidence rate, showing rates two patterns is consistent with findings from hospitalisation. Although the overall TBI to three times lower than in Europe and the other high income countries,4 where life incidence in NSW is much lower than United States, respectively, which are in the Table 2: Associated factors and medical details of first-time hospitalised TBI in NSW (n=6827) by age and mechanism of injury. Hospitalised TBI (n=6,827) By age groups By injury mechanism 0-9 10-19 20-39 40-69 +70 Transport Accident Fall Assault Other Two E-codes No E-code (n=536) (n=1,172) (n=1,819) (n=1,695) (n=1,605) (n=1,768) (n=3,247) (n=1,080) (n=485) (n=102) (n=145) N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) Associated factors Drug/Alcohol use*** 0 119 (10.2) 563 (31) 495 (29.2) 92 (5.7) 207 (11.7) 527 (16.2) 445 (41.2) 29 (6) 22 (21.6) 39 (26.9) Sport/Recreation*** 66 (12.3) 480 (41) 267 (14.7) 129 (7.6) 34 (2.1) 348 (19.7) 321 (9.9) 44 (4.1) 220 (45.4) 18 (17.6) 25 (17.2) Medical details LoS, days (mean -SD) 2.9 (7.8) 2.9 (7.1) 4.9 (11.3) 7.4 (16.9) 10.7 (16.2) 7.2 (15.6) 7.1 (11.7) 3.4 (8.1) 2.9 (8.3) 14.1 (33.6) 8.2 (15.8) 2 or more facilities 72 (13.4) 112 (9.6) 142 (7.8) 149 (8.8) 157 (9.7) 152 (8.6) 299 (9.2) 105 (9.7) 31 (6.4) 38 (37.3) 7 (4.8) Deceased 6 (1.1) 15 (1.3) 28 (1.5) 84 (5) 232 (14.5) 76 (4.3) 248 (7.6) 14 (1.3) 6 (1.2) 9 (8.8) 12 (8.3) Associated injuries*** Other trauma 66 (12.3) 424 (36.2) 659 (36.2) 666 (39.3) 536 (33.4) 1,094 (61.9) 888 (27.3) 244 (22.6) 67 (13.8) 40 (39.2) 18 (12.4) Complications 2 (0.4) 2 (0.2) 7 (0.4) 20 (1.2) 12 (0.7) 6 (0.3) 29 (0.9) 4 (0.4) 0 1 (1) 3 (2.1) Other injuries 6 (1.1) 8 (0.7) 19 (1) 29 (1.7) 10 (0.6) 11 (0.9) 27 (0.8) 13 (1.2) 6 (1.2) 6 (5.9) 9 (6.2) 2 or more 5 (0.9) 20 (1.7) 75 (4.1) 75 (4.4) 44 (2.7) 128 (10.3) 55 (1.7) 15 (1.4) 11 (2.3) 7 (6.9) 3 (9.1) None 457 (85.3) 718 (61.3) 1,059 (58.2) 905 (53.4) 602 (62.5) 529 (29.9) 2,248 (69.2) 804 (74.4) 401 (82.7) 48 (47.1) 112 (77.2) Co-morbidities*** Cardiovascular 2 (0.4) 7 (0.6) 43 (2.4) 130 (7.7) 273 (17) 80 (4.5) 322 (9.9) 27 (2.5) 7 (1.4) 6 (5.9) 13 (9) Neurologic 11 (2.1) 15 (1.3) 31 (1.7) 54 (3.2) 172 (10.7) 32 (1.8) 211 (6.5) 20 (1.9) 8 (1.6) 3 (2.9) 9 (6.2) Respiratory 3 (0.6) 6 (0.5) 12 (0.7) 12 (0.7) 12 (0.7) 9 (0.5) 22(0.7) 10 (0.9) 1 (0.2) 1 (1) 2 (1.4) Digestive 0 1 (0.1) 7 (0.4) 18 (1.1) 1 (0.1) 5 (0.3) 16 (0.5) 3 (0.3) 1 (0.2) 2 (2) 0 Systemic 1 (0.2) 6 (0.5) 8 (0.4) 78 (4.6) 88 (5.5) 16 (0.9) 145 (4.5) 10 (0.9) 6 (1.2) 3 (2.9) 1 (0.7) 2 or more 1 (0.2) 3 (0.3) 12 (0.7) 138 (8.1) 462 (28.8) 65 (3.7) 508 (15.6) 16 (1.5) 8 (1.6) 7 (6.9) 12 (8.3) None 518 (96.6) 1,134 (96.8) 1,706 (93.8) 1265 (74.6) 597 (37.2) 1,561 (88.3) 2,023 (62.3) 994 (92) 454 (93.6) 80 (78.4) 108 (74.5) Notes: ***Percentages of valid cases. The data contains occasional missing data values, which are assumed to be random.

expectancy is increasing and falls have use, especially weekend consumption, planning and secondary prevention become the leading cause of sustaining a was also greatly associated with risk of measures. This is an overview incidence study, TBI. Even so, compared to some other studies sustaining a brain injury from assault, and drawing upon retrospective administrative that reported rates of 361/100,00026 and the occurrence of assault-related TBI (15.8%) data. Had specific data been available for a 380,000/100,000,29 the rate of TBI among the nearly doubled compared to Tate et al.5 By control population, we would have been able 85+ year group in the NSW population was contrast, substance use in traffic-related TBI to conduct regression analyses to identify much higher, reaching a peak of 499/100,000 was not as high as previously documented,36 potential predictors/moderators of TBI. population. being in line with our overall finding of Nevertheless, there was a high chance that 5 People living in the most remote areas of decreased traffic-related TBI rates. potentially important predictors/moderators NSW represent another group at high TBI The exploration of medical details highlighted were not contained in this data set, thus risk. While place of residence had previously that not only were brain injuries in older weakening any conclusions drawn from such been found to be associated with a higher people common, but they had relatively long an analysis. This will be a fruitful avenue for risk of sustaining a TBI in specific sectors of LOS and high in-hospital mortality (14.5%). future research. the population,12,14 data across all population While complex care needs and difficulties in sectors were not available. This group was discharge planning may have contributed Implications shown to have a similarly high risk as the 75+ to prolonged LOS in older patients, greater age group, being nearly three times higher mortality rates confirm this group having Public health strategies should be employed compared to the general population. Lower a much worse prognosis than younger to reduce TBI incidence, increase awareness socioeconomic status was also found to be people, which is likely due to physiological of and meet the healthcare demands for associated with occurrence and severity of TBI differences37 that impact on recovery from TBI-related services among identified high- in this study. TBI. Several factors other than injury severity risk groups. Effort is needed to establish In addition, the occurrence of TBI in NSW may be linked to the risk of dying after a TBI whether modifiable risk factors exist in these residents identifying as Aboriginal and Torres in the older population, such as a higher population sectors. For instance, TBI risk 38 Strait Islander was 1.7 times the rate of the number of comorbidities. In population- among older people may be reduced by general population. This finding, supporting based studies, the use of the Charlson targeting anticoagulation,26,40 matching the known ethnicity-related disparities in TBI Comorbidity Index does not allow distinction success of decreased fall-related hip fracture risk,30 allows for a more accurate estimate of between pre-existing and co-occurring rates in this age group.41 the magnitude of risk among Aboriginal and comorbidities, yet these are both believed Consideration should be given to prevention Torres Strait Islander peoples. There are only to have a negative impact on recovery from efforts and making TBI-related services 39 two studies providing data in this regard but injury. Three in four older people had other available in remote and socioeconomically these are limited to small, selected Australian diseases in addition to TBI. Cardiovascular disadvantaged areas. The high representation cohorts, such as assault-related TBI12 and diseases were the most common, at about of Aboriginal and Torres Strait Islander incarcerated young people.31 17%, reinforcing previous hypotheses that peoples in these areas requires culturally cardiovascular morbidity26,40 may further The interrelation among Indigenous status, aware health service provision to reduce complicate recovery from TBI. remoteness and socioeconomic disadvantage barriers to health care access and ensure has not been previously reported. All three Another group with less favorable in-hospital optimal care beyond the issue of medical groups separately have a higher risk of TBI outcome includes people with severe TBI. service availability. In addition, the impact than the general population. Although there Although data were only available for 43% of recent health policy initiatives (e.g. the were associations between remoteness and of the sample, severity rates were in line ‘Close the Gap: National Indigenous Reform socioeconomic disadvantage that reflect with previous studies (mild, 88%; moderate Agreement’ in 2012 and the National 27 the general population distribution, TBI risk 8%; severe 4%) . Severe TBI compared to Aboriginal and Torres Strait Islander Health was higher among all NSW residents living less severe injuries had the longest LOS and Plan 2013–2023) on health outcomes in this in areas that are both remote and highly the highest fatality rates and proportion of group should be assessed. disadvantaged. Among these, Aboriginal and inter-hospital transfers. Beside injury severity, Education about substance use may Torres Strait Islander people had the highest differences between these groups may be contribute to reducing assault-related TBI and proportion of remoteness and socioeconomic partially explained by the high number injury vulnerability during weekends. In fact, disadvantage, being twice as likely to sustain of complications and systemic injuries there are indirect indications that traffic- a TBI compared to the general Aboriginal and associated with severe TBI. related TBI rates and associated substance Torres Strait Islander population. The inclusion of data relating only to use may have fallen as a result of targeted Our analysis of factors associated with TBI hospitalised TBI cases may be a limitation of prevention campaigns by the Australian risk demonstrated that overall, at 19%, there this study. Death before hospital admission government. was a lower incidence of people under the and mild injury for which hospital care was Further research is needed to elicit the influence of substances at the time of their not sought were not included. Furthermore, human and economic impact of in-hospital injury compared to previous estimates of ICD codes are known to not be specific for mortality and prolonged hospitalisation of 30-50%.32,33 Previous research has pointed to identification of hospitalised mild TBI. A older people and people with severe TBI. It alcohol as an important factor associated with strength of this study was the analysis of may be valuable to explore the influence all TBI causes,34 and Wagner et al.35 linked the medical details of TBI hospitalisation, which on these population groups of the latest use of drugs and alcohol more specifically to are rarely available from epidemiological health and disability policy reforms. Among violence-related TBIs. In our study, substance studies, although crucial to inform resource these, there is the introduction of the NSW

Lifetime Care and Support Scheme in 2006 6. Helps Y, Henley G, Harrison J. Hospital separations due to 29. Chan V, Zagorski B, Parsons D, et al. Older adults with traumatic brain injury, Australia 2004–05. Injury research acquired brain injury: A population based study. BMC (first participant entered in January 2007) to and statistics series number 45. (Cat no. INJCAT 116) Geriatr. 2013;13(1):97. provide care services to all severe traffic- Adelaide (AUST): Australian Institute of Health and 30. Lakhani A, Townsend C, Bishara J. Traumatic brain injury related TBI, together with the transition to the Welfare; 2008. amongst indigenous people: A systematic review. Brain 7. Moorin R, Miller TR, Hendrie D. Population-based Inj. 2017;31(13-14):1718-30. National Disability Insurance Scheme in 2016 incidence and 5-year survival for hospital-admitted 31. Moore E, Indig D, Haysom L. Traumatic brain injury, to support recovery of all Australians with traumatic brain and spinal cord injury, Western mental health, substance use, and offending among Australia, 2003-2008. J Neurol. 2014;261(9):1726-34. incarcerated young people. J Head Trauma Rehabil. permanent and substantial disability below 8. Barker-Collo SL, Feigin VL. Capturing the spectrum: 2014;29(3):239-47. the age of 65. By contrast, hospital outcomes Suggested standards for conducting population- 32. Opreanu RC, Kuhn D, Basson MD. The influence of based traumatic brain injury incidence studies. alcohol on mortality in traumatic brain injury. J Am Coll and costs of people over 65 years of age may Neuroepidemiology. 2009;32(1):1-3. Surg. 2010;210(6):997-1007. benefit from significant changes in home and 9. Harradine PG, Winstanley JB, Tate R, et al. Severe 33. Shandro JR, Rivara FP, Wang J, et al. Alcohol and risk traumatic brain injury in New South Wales: Comparable of mortality in patients with traumatic brain injury. J community care services as a result of the outcomes for rural and urban residents. Med J Aust. Trauma Acute Care Surg. 2009;66(6):1584-90. Australian aged care reforms starting from 2004;181(3):130-5. 34. Finfer SR, Cohen J. Severe traumatic brain injury. July 2013. 10. Crowe L, Babl F, Anderson V, et al. The epidemiology Resuscitation. 2001;48(1):77-90. of paediatric head injuries: Data from a referral 35. Wagner AK, Sasser HC, Hammond FM, et al. Intentional centre in Victoria, Australia. J Paediatr Child Health. traumatic brain injury: Epidemiology, risk factors, and 2009;45(6):346-50. associations with injury severity and mortality. J Trauma Conclusion 11. Chang VC, Ruseckaite R, Collie A, et al. Examining Acute Care Surg. 2000;49(3):404-10. the epidemiology of work-related traumatic brain 36. Kraus JF, Morgenstern H, Fife D, et al. 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The injury in the elderly: Increased mortality and worse differences exist in the incidence and Epidemiology of Injury in Western Australia, 2000-2008. functional outcome at discharge despite lower injury in-hospital outcomes among population Perth (AUST): Western Australian Department of Health; severity. J Trauma Acute Care Surg. 2002;53(2):219-24. groups, calling for public health preventive 2011. 39. Kumar RG, Juengst SB, Wang Z, et al. Epidemiology of 14. Berry JG, Jamieson LM, Harrison JE. Head and traumatic comorbid conditions among adults 50 years and older strategy and actions. High TBI rates in older brain injuries among Australian children, July 2000– with traumatic brain injury. J Head Trauma Rehabil. people, remote and socioeconomically June 2006. Inj Prev. 2010;16:198-202. 2018;33(1):15-24. 15. Mollayeva T, Xiong C, Hanafy S, et al. Comorbidity 40. Erlebach R, Pagnamenta A, Klinzing S, et al. 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New and old hotspots for rickettsial spotted fever acquired in Tasmania, 2012–2017

Gabriela Willis,1,2 Kerryn Lodo,1 Alistair McGregor,3 Faline Howes,1 Stephanie Williams,2 Mark Veitch1

ickettsial diseases are caused by Abstract the obligate intracellular bacteria in Rthe order Rickettsiales that can be Objective: To describe the epidemiology and clinical characteristics of Tasmania-acquired transmitted to humans via the bites of fleas, rickettsial disease notified to the Department of Health in Tasmania from 2012 to 2017 lice, ticks or mites.1,2 Australia has several inclusive. endemic rickettsial diseases: flea-borne Methods: Data on rickettsiosis cases acquired and notified in Tasmania between 1 January 2012 murine typhus (R. typhi) and cat flea typhus and 31 December 2017 were analysed descriptively. (R. felis); mite-borne scrub typhus (Orientia Results: Eighteen cases of rickettsial infection notified in Tasmania 2012–17 and likely acquired tsutsugamushi); and the tick-borne spotted in the state met one of three case definitions: 12 confirmed (67%), four probable (22%), and fever group (SFG), which includes Queensland two possible (11%). The mean number of cases per year was 3.0 (population rate 0.6 per tick typhus (R. australis), Flinders Island 100,000 population/year); 60% of cases occurred in November and December. Cases were spotted fever (FISF; R. honei), and Australian more commonly older males. Fever, lethargy, and rash were commonly reported symptoms. spotted fever (R. honei subsp. marmionii).1,3,4 Thirteen cases were likely acquired on Flinders Island, three around Great Oyster Bay and two in Epidemic typhus (R. prowazekii) occurred in the Midlands. Australia in the 18th and 19th centuries but is no longer endemic.1,5 Conclusions: This study extends our knowledge of the epidemiology of rickettsial disease in Tasmania. This is the first account including confirmed cases acquired in the Midlands of Tasmania (population 524,700)6 is an island Tasmania. state of Australia located 240 kilometres south of the mainland, consisting of the Implications for public health: Increased knowledge and awareness of epidemiology of main island of Tasmania and several small, rickettsial infection in Tasmania is essential for timely diagnosis and appropriate treatment. sparsely populated surrounding islands. FISF, These findings bear wider relevance outside Tasmania because visitors may also be at risk. the rickettsial infection typically associated Key words: Rickettsia, infectious diseases, epidemiology, surveillance, Flinders Island spotted with Tasmania, was first described in 1991 on fever Flinders Island, an island in Bass Strait off the north-east tip of Tasmania, by the island’s sole locally acquired R. honei infection have been while rickettsial infection is notifiable in 12 general practitioner (GP), Robert Stewart, who described in Western Australia, while cases Western Australia and Tasmania. In Tasmania, 13 had identified 26 cases of a spotted-fever-like have also been described internationally. cases are notifiable under the Public Health 14 illness over 17 years.7 The causative agent has Symptoms can include sudden onset fever Act 1997. Positive rickettsial serology results been identified as R. honei,1,8 and the reptile and chills, myalgia, transient arthralgia and (antibody titre ≥1:128 to a rickettsial group 7 associated tick Bothriocroton hydrosauri a maculopapular rash. Treatment is usually antigen) occurring in Tasmanian laboratories 2 (Southern Reptile Tick, formerly Aponomma with oral doxycycline; however, azithromycin are forwarded to the Communicable Disease hydrosauri), which commonly feeds from and rifampicin have also been used Prevention Unit (CDPU) and investigated. native reptiles such as blue-tongued lizards successfully. Standardised data collection on cases of and snakes, has been confirmed as its host Rickettsial infection is not nationally notifiable rickettsiosis notified to CDPU was introduced (Figure 1).9,10 Cases have not only been in Australia under the National Notifiable at the beginning of 2012. observed on Flinders Island, but also on Disease Surveillance System (NNDSS), The existing literature on rickettsial infection Schouten Island, Tasmania, and in south- but surveillance currently occurs in three in Tasmania describes cases of FISF on eastern South Australia, where B. hydrosauri jurisdictions. Epidemic typhus caused by R. Flinders Island, one case on Schouten Island11 are also endemic.11 Additionally, two cases of prowazekii is notifiable in New South Wales, and a case of rickettsiosis, assumed to be

1. Communicable Disease Prevention Unit, Public Health Services, Department of Health, Tasmania 2. National Centre for Epidemiology and Population Health, Australian National University, Australian Capital Territory 3. Department of Microbiology and Infectious Diseases, The Royal Hobart Hospital, Tasmania Correspondence to: Dr Gabriela Willis, Public Health Services, Department of Health, GPO Box 125, Hobart, Tasmania 7001; e-mail: [email protected] Submitted: February 2019; Revision requested: March 2019; Accepted: May 2019 The authors have stated they have no conflict of interest. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Aust NZ J Public Health. 2019; 43:389-94; doi: 10.1111/1753-6405.12918

R. honei, acquired on the Freycinet Peninsula at least one of headache, myalgia, rash, or group (STG). SFG antigen included R. australis or Maria Island.15 However, the geographical eschar). (Queensland Tick Typhus), R. honei (FISF), and distribution and other epidemiological R. africae (African Tick Bite Fever); TG antigen characteristics of rickettsial disease in Data collection included R. typhi (murine typhus); and STG Tasmania outside of Flinders Island are not Rickettsial infections were notified to CDPU included Orientia tsutsugamushi. Seven well understood. A cluster of four rickettsial by Tasmanian laboratories and followed cases had one or both samples tested at the infection cases was identified on Flinders up within five days of notification. Further Australian Rickettsial Reference Laboratory Island in December 2017, prompting the details about the illness, contact details, in Geelong, and had titres against specific authors to review the surveillance data. The and permission to contact the patient antigens, rather than groups. These included aim of this study was to review all rickettsiosis were obtained from the testing clinician. R. australis (Queensland Tick Typhus), R. honei notifications in Tasmania over the six years A questionnaire was administered via (FISF), R conorii (Mediterranean Spotted from 2012 to 2017 inclusive and report the telephone to the patient by a public health Fever), R. africae (African Tick Bite Fever) R. clinical and epidemiological characteristics of nurse or doctor, collecting information on rickettsii (Rocky Mountain Spotted Fever) and these cases. demographics, clinical details of the illness, R. felis (cat flea typhus/Flea-borne Spotted history of rickettsial infection and travel Fever) in the SFG; R. typhi (murine typhus) Methods history (overseas, interstate, and intrastate). If and R. prowazekii (Epidemic typhus) in the only one serology test had been performed, TG; and Orientia tsutsugamushi and O. chuto Study population a repeat serology two weeks later was in the STG. IgG titres ≥1:128 were considered Confirmed, probable, and possible recommended to confirm the diagnosis. positive. rickettsiosis cases notified to CDPU between Case details including demographic, 1 January 2012, when the standardised hospitalisation and basic laboratory data Data analysis case report form was introduced, and 31 were entered into the Tasmanian Notifiable Descriptive data analysis was performed December 2017, were included. Cases where Disease Database (TNDD). exploring patterns over time, age and sex travel history was unknown or that were For this retrospective descriptive analysis of distribution, geographic distribution, and likely acquired outside of Tasmania, based notified cases, data were extracted from the clinical and laboratory features of confirmed, on overseas or interstate travel during the TNDD into Excel (Microsoft, Version 16, 2016). probable, and possible cases. Population rates exposure period, were excluded. Confirmed Original case reports were reviewed, and were calculated using the Australian Bureau cases required laboratory definitive evidence, additional data not recorded in the TNDD, of Statistics mid-year Tasmanian population 3 including detection (culture or nucleic including clinical details, tick bite exposure, estimate for each year. Data were analysed acid test) of Rickettsia species in a clinical previous rickettsial disease, travel history, and in Stata/IC (StataCorp LLC, Texas USA, Version specimen, or seroconversion or a fourfold detailed laboratory data, were added to the 15.0). Likely place of acquisition was assessed or greater rise in serum antibody titre to dataset. based on residential location and report of rickettsial group antigen between acute and overseas, interstate, and intrastate travel in convalescent phase sera specimens. Probable Laboratory investigations the 10 days prior to onset of illness. Likely cases required clinical evidence and a single place of acquisition was mapped using All cases had immunoglobulin G (IgG)-specific elevated antibody titre of equal to or greater ArcMap (ESRI, Version 10.6, 2018). antibody titres against Rickettsia antigen than 1:256 to a rickettsial group antigen. performed by indirect immunofluorescence Possible cases required clinical evidence and Ethics assay (IFA). Testing varied depending on a single antibody titre of 1:128 to a rickettsial which pathology provider was used. The Data were collected under the provisions of group antigen. Clinical evidence was defined majority were tested for spotted fever group the Public Health Act of Tasmania (1997), and as a clinically compatible illness (fever and (SFG), typhus group (TG) and scrub typhus the data analysis and report with the approval of the Australian National University Ethics Figure 1: Blotched blue-tongue lizard (Tiliqua nigrolutea) with Southern Reptile Ticks (Bothriocroton hydrosauri), Committee (Protocol 2017/909). Flinders Island, Tasmania. Results

There were 47 rickettsiosis cases in the TNDD notified between 1 January 2012 and 31 December 2017. Of these, 19 did not meet a case definition and five were repeat notifications. Three cases likely acquired outside of Tasmania were excluded: one acquired in South Africa, one acquired in Western Australia, and one acquired in the Northern Territory or Queensland. Additionally, two cases where travel history was unknown were excluded. Eighteen cases Photo courtesy of Robert Stewart. were included in the analysis.

Laboratory investigations Thirteen of the cases provided their 13 cases with myalgia and/or arthralgia and Fourteen cases (78%) had two blood samples occupation, with five retired (28%), and four included ‘aches whole body’, ‘ankle pain and taken for IFA and four (22%) had one. The working on farms (31%). Other reported swelling’, ‘all joints’, and ‘arthralgia of knees, median time between onset of illness and occupations included a bulldozer driver, a shoulders, and fingers’. the first serology sample was four days (range welder, a retailer and a teacher. Six cases (33%) reported a tick bite, while 0–42 days) and the median time between first three (17%) reported a bite of unknown and second serology samples was 14.5 days Clinical characteristics origin. Hospitalisation status was known for (range 4–43 days). All but one case (95%) reported fever. Other eight cases, with five reporting hospitalisation Twelve (67%) cases demonstrated commonly reported symptoms were lethargy and three reporting no hospitalisation. No seroconversion or a fourfold or greater rise (89%), rash (83%), myalgia and/or arthralgia cases died of their disease. in antibody titre to either SFG or multiple (72%), and headache (72%), see Table 2. Rickettsia species and were classified as Unsolicited reported symptoms included Place of acquisition confirmed cases. An additional four cases chills and/or sweats (n=3), itchiness (n=1), Thirteen cases were likely acquired on (22%) had single high titres and were shortness of breath (n=1), anorexia (n=1), Flinders Island (11 residents and 2 visitors), classified as probable cases (cases 2, 3, 10 and nausea (n=1), sore throat (n=1), dry mouth Table 2: Clinical presentation of cases (n=18). 11). Two cases (11%) had low titres (1:128) (n=1) and photophobia (n=1). Number of cases and were classified as possible cases (cases 4 A description was given for seven of the 15 Symptom reporting symptom & 18; Table 1). persons with a rash and included ‘widespread’ n % or ‘full body’ (n=3), ‘full body sparing face and In the six cases who had IFA against individual Fever 17 95 hands’ (n=1), ‘purpuric rash lower legs’ (n=1), species rather than groups, there was Lethargy 16 89 and ‘mainly on trunk with patches on legs’ evidence of significant cross-reactivity, with Rash 15 83 all cases having positive titres of the same (n=1). One confirmed case reported being red Myalgia/arthralgia 13 72 dilution against several species, including R. and swollen at the location of a suspected tick Headache 13 72 honei (Table 1). bite. A description was given for four of the Other 7 39

Incidence and patterns over time Table 1: Summary of serology results and cases classification, by case. Case Year & quarter Number IgG titre against Rickettsia antigen by IFA Case A mean of 3.0 cases per year were notified number (Q) of onset of blood classification between 2012 and 2017 (range 2 to 4; Figure samples 2). The mean annual rate of notification was 1 Q4, 2011 2 Four-fold increase to SFG (1:512 and 1:8192) Confirmed 0.6 per 100,000 population/year (range 0.4 to 2 Q1, 2012 1 Single positive titre to SFG (1:4096) and TG (1:128) Probable 0.8 per 100,000 population/year). 3 Q1, 2012 1 Single positive titre to SFG (1:1024) Probable The date of onset rather than date of 4 Q3, 2013 1 Single positive titres to multiple species: R. australis, R. honei, R. conorii, Possible R. africae, R. rickettsii (1:128 to all) notification is shown in Figure 2 (one 5 Q4, 2013 2 Seroconversion to multiple species: R. australis, R. honei, R. conorii, R. Confirmed case notified in January 2012 had onset africae, R. rickettsii (1:256 to all) in December 2011). There was a distinct 6 Q4, 2013 2 Four-fold increase to SFG (1:512 and 1:8192) Confirmed seasonal pattern, with 11 of the 17 cases with 7 Q1, 2014 2 Seroconversion to SFG (negative and 1:2048) Confirmed onset during the years 2012 to 2017 (where 8 Q1, 2014 2 Seroconversion to SFG (negative and 1:2048) Confirmed a full calendar year was included) occurring Positive titres to STG (1:256 and 1:128) in the last quarter of the year (mostly in 9 Q2, 2014 2 Seroconversion to multiple species: R. australis (≥1:1024), R. honei Confirmed November and December), four with onset (≥1:1024), R. conorii (1:256), R. africae (1:256), R. rickettsii (1:256), in the first quarter and only two in either the R. felis (1:128), R. prowazekii (1:256), R. typhi (1:128) second or third quarter. 10 Q4, 2014 2 Positive titre to SFG on two samples with no seroconversion (1:2048 and Probable 1:2048) An increase in notifications was noted in 11 Q4, 2015 2 Positive titre to SFG on two samples with no seroconversion (1:16384 Probable the late 2017, with five cases with onset in and 1:32768) the last quarter of 2017 (Figure 2). Three Positive titre to TG with no seroconversion (1: 256 and 1:256) confirmed and one probable case were part 12 Q4, 2015 2 Seroconversion to SFG (negative and 1:1024) Confirmed of an identified cluster on Flinders Island, with 13 Q4, 2016 2 Seroconversion to multiple species: R. australis (≥1:1024), R. honei Confirmed dates of onset between 4 and 27 November (≥1:1024), R. conorii (≥1:1024), R. africae (≥1:1024), R. rickettsii 2017. (≥1:1024), R. felis (≥1:1024) 14 Q4, 2016 2 Seroconversion to SFG (negative to 1:4096) Confirmed Demographic characteristics Positive titres to STG (1:256 and 1:128) 15 Q4, 2017 2 Seroconversion to SFG (negative to 1:8192) Confirmed Twelve cases (67%) were male and six (33%) 16 Q4, 2017 2 Seroconversion to SFG (negative to 1:1024) Confirmed were female. The median age was 60 years 17 Q4, 2017 2 Seroconversion to multiple species: R. australis (≥1:1024), R. honei Confirmed (range 35–77 years). Indigenous status (≥1:1024), R. conorii (≥1:1024), R. africae (≥1:1024), R. rickettsii was unknown for seven cases but, among (≥1:1024), R. felis (1:256), R. prowazekii (≥1:1024), R. typhi (≥1:1024) the remaining 11, none reported being 18 Q4, 2017 1 Single positive titres to multiple species: R. australis, R. honei, R. rickettsii, Possible Aboriginal and/or Torres Strait Islander. R. felis, R. prowazekii, R. typhi (1:128 to all)

2019 vol. 43 no. 4 Australian and New Zealand Journal of Public Health 391 © 2019 The Authors Willis et al. Article with nine being confirmed, two probable, Discussion to mild illness or other factors; clinical and two possible. Three cases were likely presentation is similar to many other illnesses, acquired around Great Oyster Bay: one in Between 2012 and 2017 inclusive, a total of 18 particularly viral infections; and – perhaps Swansea (probable), one in Dolphin Sands confirmed, probable and possible rickettsial most importantly – to diagnose rickettsial (probable), and one in Coles Bay (confirmed). infection cases were notified in Tasmania infection, the clinician must first consider Two further cases were likely acquired in the that were likely acquired in the state, at a it in their differential diagnosis and order Midlands: one in Ross (confirmed) and one in rate of 0.6 per 100,000 population/year. This the appropriate laboratory tests. Making Tunnack (confirmed), see Figure 3. Two of the number may significantly underestimate the diagnostic connection may be further cases acquired around Great Oyster Bay had the true incidence of cases occurring in the hindered by the patient not reporting a tick onset of illness in the first quarter of 2012 and community, due to the limitations inherent bite. In this sample, only 50% reported a bite the cases in the Midlands had onset of illness with passive surveillance data. Some cases of any kind, and only 30% a tick bite. in the first and second quarter of 2014. may not have sought medical advice due Tasmania is a popular tourist destination, with 1.26 million visitors in the year ending Figure 2: Epidemic curve of notified rickettsial infection cases, Tasmania, 2012-2017. December 2017,16 and an estimated 1,500 adults holidaying on Flinders Island per year.17{Tourism Tasmania, 2009 #172} A high proportion of visitors undertake outdoor activities that may put them at risk of tick bites.18 Although it is likely that some visitors to Tasmania will develop rickettsial disease, they may seek medical advice after leaving the island. Treating clinicians outside of Tasmania may not be aware of the risk and not perform the appropriate tests. Additionally, as rickettsial infection is not nationally notifiable, many infections acquired by visitors are unlikely to be captured in the surveillance systems of other jurisdictions. Despite being often described as a mild illness,2 FISF can be severe. Recently, the Figure 3: Likely place of acquisition of rickettsial infection cases, Tasmania, 2012-2017. death of a middle-aged woman due to acute infection of R. honei has been described in Queensland,19 and another severe case was reported in New South Wales that required intensive care (Dr Stephen R. Graves, personal communication). In our surveillance data, half of cases with hospitalisation status reported were hospitalised. This proportion may overestimate true hospitalisation rates, due to the likelihood that this sample is biased towards severe disease. Although much is still unknown about the causes of severe disease and complications, treatment with doxycycline may reduce the risk.2 Furthermore, prompt treatment is likely to reduce burden of disease as duration of illness without treatment is approximately 19 days but can be as long as six weeks.7 This work sheds new light on the geographical distribution of rickettsial infection in Tasmania. Previously cases of FISF in Tasmania have been described only on Flinders Island,7 and Schouten Island off the Freycinet Peninsula on the east coast of Tasmania,11 with one case of rickettsial infection, assumed to be R. honei, acquired on the Freycinet Peninsula or Maria Island,15

an island further down the east coast (Figure clinical history and examination. Lethargy was that the Southern Reptile Tick is distributed 3). As the invertebrate host Bothriocroton reported in 90% of cases, although duration throughout Tasmania. These findings have hydrosauri is distributed throughout could not be ascertained. Chronic fatigue has wider relevance outside Tasmania as its many Tasmania,20 it has been postulated that FISF been previously associated with rickettsial visitors, many of whom undertake outdoor is likely to be distributed more widely, but infection.22,23 activities, may also be at risk. Increased this is the first published evidence of cases We assume that the 18 infections described awareness of potential infection by clinicians likely acquired outside of these locations. Of in this paper represent FISF due to R. honei is essential to accurately diagnose and note, this is the first description of cases likely infection, based on known epidemiology appropriately treat rickettsial infections, thus acquired in other locations around Great of rickettsioses in Australia. However, given reducing the burden of the disease. Although Oyster Bay and of confirmed cases in the the significant cross-reactivity seen with these data add to our understanding of Midlands. A significant limitation of the data, rickettsial serology infection it is possible the epidemiology of rickettsial infection in however, is that there may be testing bias, that another rickettsial species could be Tasmania, our knowledge in this complex with clinicians in areas with known previous responsible for some of these cases. Ixodes area remains incomplete and further work cases more likely to consider rickettsiosis tasmani, another tick common in Tasmania, is needed, particularly with regard to other and test for it. Our impression is that there is has been associated with spotted fever potential human rickettsial pathogens. high awareness of rickettsial infection among elsewhere in Australia.1,24 Izzard et al.24 medical practitioners and the community on found that 55% of I. tasmani ticks collected Acknowledgements Flinders Island, but less awareness elsewhere from Tasmanian Devils in 2005/06 were in Tasmania. polymerase chain reaction (PCR) positive for The authors would like to acknowledge the The seasonal pattern is consistent with a Rickettsia species, subsequently named Clinical Nurse Consultants in CDPU including previous literature and is not unexpected, Candidatus Rickettsia tasmanensis. This tick is Angela Russell, Kate Turner, Nicola Mulcahy, as summer is when reptiles are most active known to bite humans, but further research Juanita Mayne and Bethany Reszke for their and humans are likely to spend more time is needed to understand whether this new expert contribution to collection of data and outdoors, increasing the risk of tick bites. rickettsial species is a potential human the public health management of notified During the cluster of cases on Flinders Island pathogen.3 cases. We would also like to thank all the in November 2017, there were anecdotal The only preventative measure against patients involved for their time and input reports of residents seeing snakes and lizards rickettsial infection is to minimise exposure and the GPs on Flinders Island, in particular with ‘big ticks’ on them, demonstrating the to ticks and thus reduce the risk of tick bites. Dr Alexander John, for their assistance close proximity of humans and Southern Current advice is to wear long sleeves and and input during the identified cluster of Reptile Ticks. Similarly, the preponderance of long pants, use tick repellent on skin and cases in 2017. In addition, thank you to Dr cases among older males has been previously clothes and sleep on a raised camp bed when Stephen R. Graves, Medical Director of the 7,11 described, and is perhaps explained by a camping. In an attempt to raise awareness, Australian Rickettsial Reference Laboratory, higher chance of them working or engaging CDPU has developed a factsheet on FISF and for reviewing an earlier version of this in leisure activities outdoors. has liaised with Environmental Heath Officers manuscript. As an expert in the field of The clinical picture among these cases is and Parks and Wildlife Service Tasmania to rickettsial microbiology and illness, his review consistent with previous reports of FISF distribute information to both residents and and comments were invaluable. Dr Rob and particularly with Stewart’s findings in visitors.25 Stewart of Flinders Island also kindly reviewed 7 a late draft and gave his valuable historical his case series from Flinders Island in 1991. Based on this review, CDPU has changed perspective, in addition to providing the Fever, headache, myalgia and/or arthralgia, the surveillance case definition for rickettsial photo presented in Figure 1. and rash were prominent features. As in infection in Tasmania to include those cases our study, Stewart also reported a varying with a single high titre and clinical evidence distribution of the rash and both blanching as probable cases. The aim of this change References and purpuric lesions. Similarly, rickettsial is to have a more sensitive case definition 1. Graves S, Stenos J. Rickettsioses in Australia. Ann N Y infections occurring in Queensland have that improves Tasmanian rickettsial infection Acad Sci. 2009;1166:151-5. shown a wide variety of dermatological 2. Heymann D. Control of Communicable Diseases Manual. surveillance. 20th ed. Washington (DC): American Public Health manifestations, including maculopapular, Association; 2015. macular, vesicular, and purpuric rashes.21 3. Graves SR, Stenos J. Tick-borne infectious diseases in In our cases, there were no specific reports Conclusion Australia. Med J Aust. 2017;206(7):320-4. 4. Williams M, Izzard L, Graves SR, Stenos J, Kelly JJ. of cough or eschar, although one person First probable Australian cases of human infection This review of rickettsiosis notifications described redness and swelling at the site with Rickettsia felis (cat-flea typhus). Med J Aust. in Tasmania between 2012 and 2017 2011;194(1):41-3. of a suspected tick bite. This contrasts with extends knowledge of the epidemiology 5. Cumpston JHL. Health and Disease in Australia: A History. Stewart’s case series, in which 46% had a Canberra (AUST): AGPS; 1989. of rickettsial infection and FISF within 6. Australian Bureau of Statistics. 3101.0. - Australian cough and 46% had a skin lesion other than Tasmania over recent years. In particular, Demographic Statistics [Internet]. Canberra (AUST): the rash. However, we did not specifically ABS; 2018 [cited 2018 Aug 29]. Available from: http:// it shows that rickettsial infection can be solicit these symptoms and signs, and our abs.gov.au/ausstats/[email protected]/0/D56C4A3E41586764 acquired in locations around Great Oyster CA2581A70015893E?Opendocument clinical data are limited by the collection of 7. Stewart RS. Flinders Island spotted fever: A newly Bay and the Midlands area. It is possible surveillance data via questionnaire over the recognised endemic focus of tick typhus in Bass Strait. that the distribution is wider still, given Part 1. Clinical and epidemiological features. Med J Aust. telephone with the patient, rather than direct 1991;154(2):94-9.

8. Graves SR, Stewart L, Stenos J, Stewart RS, Schmidt E, 15. Chin RH, Jennens ID. Rickettsial spotted fever in 22. Unsworth N, Graves S, Nguyen C, Kemp G, Graham J, Hudson S, et al. Spotted fever group rickettsial infection Tasmania. Med J Aust. 1995;162(12):669. Stenos J. Markers of exposure to spotted fever rickettsiae in south-eastern Australia: Isolation of rickettsiae. Comp 16. Tourism Tasmania. Tasmanian Tourism Snapshot - Year in patients with chronic illness, including fatigue, in two Immunol Microbiol Infect Dis. 1993;16(3):223-33. Ending December 2017 [Internet]. Hobart (AUST): State Australian populations. QJM. 2008;101(4):269-74. 9. Stenos J, Graves S, Popov VL, Walker DH. Aponomma Government of Tasmania; 2017 [cited 2018 Aug 29]. 23. Watts MR, Benn RA, Hudson BJ, Graves S. A case hydrosauri, the reptile-associated tick reservoir of Available from: https://www.tourismtasmania.com. of prolonged fatigue following an acute rickettsial Rickettsia honei on Flinders Island, Australia. Am J Trop au/__data/assets/pdf_file/0010/62992/2017-Q4- infection. QJM. 2008;101(7):591-3. Med Hyg. 2003;69(3):314-17. Tasmanian-Tourism-Snapshot-YE-December-2017.pdf 24. Izzard L, Graves S, Cox E, Fenwick S, Unsworth N, Stenos 10. Whitworth T, Popov V, Han V, Bouyer D, Stenos J, 17. Tourism Tasmania. Flinders Island Vistors Survey Report. J. Novel rickettsia in ticks, Tasmania, Australia. Emerg Graves S, et al. Ultrastructural and genetic evidence Year Ending June 2009 [Internet]. Hobart (AUST): State Infect Dis. 2009;15(10):1654-6. of a reptilian tick, Aponomma hydrosauri, as a host Government of Tasmania; 2009. [cited 2018 Aug 25. Communicable Disease Prevention Unit. Flinders Island of Rickettsia honei in Australia: Possible transovarial 29]. Available from: https://www.tourismtasmania. Spotted Fever- Factsheet [Internet]. Hobart (AUST): transmission. Ann N Y Acad Sci. 2003;990:67-74. com.au/__data/assets/pdf_file/0018/54450/ Tasmanian State Government Department of Health; 11. Unsworth NB, Stenos J, McGregor AR, Dyer JR, Graves Flindersislandreport09.pdf 2018 [cited 2018 Aug 29]. Available from: https:// SR. Not only ‘Flinders Island’ spotted fever. Pathology. 18. Tourism Tasmania. Tasmanian Visitor Survey- TVS www.dhhs.tas.gov.au/publichealth/communicable_ 2005;37(3):242-5. Analyser [Internet]. Hobart (AUST): State Government diseases_prevention_unit/infectious_diseases/ 12. Raby E, Pearn T, Marangou A, Merritt A, Murray R, Dyer of Tasmania; 2018 [cited 2018 Aug 29]. Available from: flinders_island_spotted_fever J, et al. New Foci of Spotted Fever Group Rickettsiae http://www.tourismtasmania.com.au/research/tvs Including Rickettsia honei in Western Australia. Trop 19. Graham RMA, Donohue S, McMahon J, Jennison AV. Med Infect Dis. 2016;1(1):5. Detection of spotted fever group rickettsia dna by deep 13. Graves S, Stenos J. Rickettsia honei: A spotted fever sequencing. Emerg Infect Dis. 2017;23(11):1911-13. group Rickettsia on three continents. Ann N Y Acad Sci. 20. Barker SC, Walker AR. Ticks of Australia. The species 2003;990:62-6. that infest domestic animals and humans. Zootaxa. 14. Australian Department of Health. Australian National 2014;3816(1):1-144. Notifiable Diseases Case Definitions - Appendix B: 21. Stewart A, Hajkowicz K. Heterogeneity in skin Australian State and Territory Notifiable Diseases manifestations of spotted fever group rickettsial [Internet]. Canberra (AUST):Government of Australia; infection in Australia. Australas J Dermatol. 2016 [cited 2018 Aug 29]. Available from: www.health. 2018;59(4):349-51. gov.au/internet/main/publishing.nsf/Content/cda- surveil-nndss-casedefs-statedis.htm

Public health and natural hazards: new policies and preparedness initiatives developed from an Australian bushfire case study

Rachel Westcott,1,2 Kevin Ronan,2,3 Hilary Bambrick,4 Melanie Taylor2,5

n 2015 the Sendai Framework for Disaster Abstract Risk Reduction (SFDRR) was endorsed by Ithe United Nations General Assembly. Objective: Public preparedness for natural hazard events is low. With worsening severe Sendai is a non-binding agreement that weather events due to climate change, public health policy and practices must evolve to more recognises the State has the primary role to effectively engage communities. This study’s findings identify and suggest new strategic public reduce disaster risk but that responsibility health policies to shift the practice of all-hazards preparedness into routine, everyday life. should be shared with other stakeholders Methods: Semi-structured interviews, focus groups and Thematic Analysis were used to including local government and the private investigate the interactions between participant groups: emergency responders and animal sector. It aims to substantially reduce disaster owners. risk and loss of life, livelihoods and health in Results: Three policies designed to improve human safety and well-being are proposed and the economic, physical, social, cultural and discussed. These are (i) a new system of workplace leave, (ii) an innovative regime of financial environmental assets of persons, businesses, incentives for fire-ready properties, and (iii) review of the use of firebreaks on farms and rural communities and countries.1 blocks. The SFDRR has evolved beyond its Conclusion: Policies proposed in this research aim to proactively narrow the awareness- predecessor, the Hyogo Framework for Action preparedness gap and build adaptive capacity to minimise risk to human health in all-hazards 2005-2015, to embrace human health and contexts. Further research could evaluate the efficacy of trialled public policy. wellbeing, and in encompassing science and technology (for example, there were Implications for public health: These new policies seek to contribute to establishing and three references to ‘technology’ in the Hyogo maintaining a culture of preparedness as a routine aspect of everyday life, and thus promote Framework for Action and 19 in the SFDRR).2 and protect public health in the short, medium and long terms. This includes connecting policy development Key words: bushfire, preparedness, public health policy, emergency responders, animal owners and implementation with evidence and facilitating the transformation and transfer of and diverse to enable bottom-up innovation the SFDRR has clear benefits including research into practice. Three components of to meet top-down goals and ideals.4-7 improved preparedness, and discerning ways the SFDRR – health, economic development Beneath Sendai’s overarching principles, fire to translate risk mitigation and reduction and climate change – demonstrate how science explores an expanding spectrum strategies into standard, practical applications public health is situated within Sendai, and 8-10 of fire-related social, economic, physical to curb human suffering. how the boundaries between public health and agricultural sciences. This knowledge and environmental health are increasingly contributes to the successful and dynamic less distinct.3 Public health as a discipline has Objective management of increasingly complex fire accordingly expanded beyond responding problems that affect human populations in The aim of this study is to contribute to the to specific events: collaboration, capacity a changing climate. This study contributes goals of the SFDRR by improving protection building and research need to be widespread to that knowledge base. Implementing of human life and wellbeing in bushfire and

1. Translational Health Research Institute, School of Medicine, Western Sydney University, Sydney, New South Wales 2. Bushfire and Natural Hazards Cooperative Research Centre, Melbourne, Victoria 3. School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, Queensland 4. School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland 5. Department of Psychology, Macquarie University, Sydney, New South Wales Correspondence to: Dr Rachel Westcott, Translational Health Research Institute, School of Medicine, Western Sydney University, Locked Bag 1797, Penrith, New South Wales 2751; email: [email protected] Submitted: October 2018; Revision requested: February 2019; Accepted: March 2019 The authors have stated they have no conflict of interest. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Aust NZ J Public Health. 2019; 43:395-400; doi: 10.1111/1753-6405.12897

other emergencies; to promote ‘fire-fitness’ The presence of animals adds complexity Interested potential participants contacted (an original term coined by the lead author, to owners’ preparedness and planning.20,27 the researcher and some invited others to described in detail on p3 of reference Incidents involving animals have been join from within their own networks. Prior no. 11). This is achieved by establishing identified as a reason why people risk their to taking part, all participants received preparedness behaviours as routine – thereby own welfare and safety.28-31 There is also information sheets covering ethics approval, reducing the awareness-preparedness gap an increasing understanding of the link privacy and contact details, and signed a (i.e. the mismatch between awareness and between effective animal management in consent form. preventative action). From an economic an emergency and the saving of human life, Data were collected from 67 participants via perspective alone, the public cost of natural and a growing awareness of the longer-term 12 semi-structured individual interviews and hazards in Australia is expected to “triple to adverse human health implications of losing seven focus groups (n=55), each between 45 19 24 US$17.7 billion by 2050” (equivalent to animals in an emergency incident. and 90 minutes duration. Gender distribution $AU24.7 billion). Adaptive capacity building is Responding safely and appropriately to a was 46.3% female (n=31) and 53.7% male required in communities around the globe. fire emergency is a realistically attainable (n=36). All participants were aged between At present, household levels of fire-fitness11 in goal – though frequently thwarted by the 18 and 70 years. Approximately two-thirds Australia and elsewhere are low, with fire-safe magnitude of the awareness-preparedness of participants had experienced fire on their routines often assigned a lower priority than gap.20,27 To overcome this requires fire-fitness properties. other competing complexities of everyday to be elevated to ‘business as usual’ status The interview guide was flexible according 12-14 life. Practising considered, timely and safe – as routine as buying groceries or fuelling to group context and composition.37 15-18 action – to be fire-fit – within and outside a car. While the basic human urge to save Major topics were: (1) hazard severity and the fire season is a present-day imperative. a dependent other at the risk of personal likelihood; (2) fire-related animal issues; (3) The awareness-preparedness gap is safety may never be overcome, learned information gathering, communication and narrowing disproportionately slowly coping appraisals and adaptive responses, trust; (4) uncertainty and confidence; (5) compared with the magnitude of public in combination with proactive preparedness mitigation and self-efficacy; and (6) special resources assigned to help people attain routines as part of everyday living, could circumstances and adaptive solutions. 12,13,20-22 facilitate pre-hazard behaviours that overall readiness. Making safe, potentially Thematic Analysis (TA) was chosen because it reduce risk-taking while achieving a more life-saving fire preparedness behaviours a is a flexible qualitative method independent effective response with less trauma and routine element of daily life is one of a suite of theory.35,38 Extraction of experiential anxiety. Therefore, this paper’s research of lifestyle changes people need to adopt material from the data was inductive question is: what preparedness initiatives can due to the escalating influence of climate and contextualist: analysis moved from 23 be learned from the emergency responder- change on natural hazards. This paper descriptive to interpretative and explored animal owner interface in a bushfire at-risk proposes three areas of public health policy latent meanings. Data-driven coding yielded community that can be usefully applied to that aim to actively cultivate sustainable codes that were grouped into ‘like’ clusters generate new public health policy? patterns of routine behaviours to better and then organised into 10 themes. Data enable protection of lives and property, fortify was managed using the Computer Assisted psychological and physical preparedness and Method Qualitative Data Analysis Software (CAQDAS) facilitate resilient and effective responses. system, NVivo 11, on a spreadsheet and a The emergencies literature currently lacks Research participants were firefighters, thematic map and table.11 police officers, rescue officers of the State evidence from animal owners as a diverse Ethics approval for this research was granted Emergency Service (SES), farmers with farm whole. This study, with a combination of by the Human Research Ethics Committee of fire units and animal owners (a diverse participant groups designed specifically Western Sydney University, approval number group owning from one pet to thousands to cross demographic boundaries, records H11118. Names assigned to data extracts are of livestock). Study participants resided and analyses some of the experiences, pseudonyms. expectations and needs of communities who in a bushfire at-risk regional area in South have ‘lived through’ bushfire emergencies, Australia – ‘the driest state in the driest 32 33 and expect to face this hazard again. continent’, chosen for its fire history. Results and discussion A situationalist orientation, i.e. the needs of Emergencies can occur when people, Of the 10 actively identified themes in the the study govern a philosophical paradigm, property, the environment and other assets study, this paper examined data from the indicated a pragmatic approach within a (including animals) intersect adversely seminal ‘preparedness’ theme and from the 4 critical realist ontology and contextualist, with hazards. Animals may be considered ‘farmers’ theme. In summary, the themes experiential epistemology.27,34-36 Active ‘dependent others’ and their welfare is were (1) animal owners and farmers; (2) recruitment by the researcher was assisted frequently linked to human physical and Preparedness, fire-fitness; (3) Complexity 24-26 by leaders in the responder groups. Local psychological health. For livestock of the social microclimate; (4) Trust; (5) businesses with an agriculture or animal farmers, an economic relationship does not Information gathering; (6) Responders; (7) health focus were invited to participate. exclude emotional attachment and both Adaptive safe responses; (8) Maladaptive, Local media helped raise awareness of the are considerations at the responder-owner unsafe responses; (9) The “tree-changers”; and 20,24,27 project, and information flyers were placed interface. (10) Recovery – and are discussed elsewhere in public places such as the local Council in the published literature (tabulated themes offices, public library and some retail outlets.

are described in concise detail on p 217 of not everyone will have the disposable income say forget it. If you think you’re going to do Reference No. 11 ).11,15,27 or the resources to reach their ideal level of [everything] by tomorrow – no. So get rid of those unrealistic expectations … you can’t A serious fire affecting people, their preparedness in one fire season, particularly do 20 or 30 or 40 jobs when you can smell the livelihoods and microclimates is a complex in rural areas where income may be sporadic. smoke, you can only probably do one or two. non-routine social problem that falls within However, a bushfire plan can dynamically the remit of the SFDRR.39 Discerning how map a strategy to attain the desired level of The danger of ‘waiting to smell the smoke’ is people and emergency managers and preparedness over a specified time frame. This described by Penman et al.49 – late decisions responders can better equip communities leads to adaptive capability and confidence are made under duress, with potentially fatal 53,54 to protect themselves, and the things they – self-efficacy and response-efficacy. The consequences. hold dear, is an urgent requirement given the challenge remains how to engage with those The critical challenge is to first defuse increasingly severe weather conditions that who elect not to prepare their homes, their the sometimes overwhelming nature of indicate a ‘new reality’.40 Effectively addressing properties and their social microclimate (such the preparedness task, and to facilitate this requires prioritising innovative as family or workplace group). Complete the transition from knowledge and preparedness initiatives.40-45 consensus is unlikely and some people will understanding to intention and action. remain unconvinced – the problem then is To achieve and maintain fire-fitness, it is Breaking tasks down into manageable how to help people on adjacent land49 and necessary to understand and establish steps and writing a ‘bushfire action plan’ people who live on the outer peri-urban prerequisite conditions that precede and to reduce the need for strategic thinking fringe because they prefer to live with less predispose towards successful preparedness when an emergency situation arises is one social interaction. Local knowledge in such messaging and action outcomes. This way to achieve the former, and is already instances can literally mean the difference foundation, built on medium- to long- actively encouraged by fire authorities between life and death.55,56 term strategies, will help develop a culture as part of ongoing multi-media public of preparedness and is required before a Bushfire prevention and preparedness is outreach. However, an environment substantial shift in the implementation of promoted in Australia and internationally conducive to achieving effective action must 57-61 preparedness practice is generally evident. as everyone’s responsibility. This is necessarily occur before preparedness can not intended to preference the actions be substantially realised – before advertising Preparedness – Be fire-fit: weekly is of an individual over the involvement of and use of messages intended to motivate worth it! community and collaboration between the target audience with fear or ‘shock tactics’, people. Both are important and mutually the effect of which can be short-lived.67,68 The preparedness theme ‘Be fire-fit: weekly inclusive. Both benefit from shared This requires a cultural, paradigm shift, which is worth it!’ was prominent in the data and communication and from the synergy itself can be created incrementally3 via a is the subject theme of this paper because achieved by collaboration among a group of foundation that preferences and facilitates the implied corollary of being prepared people with a common goal. routine, effective preparedness activities. (fire-fit), and of frequency (weekly), is a net Social connectedness and community Thus, hurdles such as lack of time, or the benefit (is worth it). This theme is pivotal to engagement can reduce the dangerous maladaptive responses of ‘action addressing the awareness-preparedness gap negative outcomes of natural hazard inertia’21 or acting impulsively without even and achieving fluency between knowledge emergencies.12,46,62,63 Akama and Ivanka30 a brief dynamic risk assessment can be and action among people at all levels – by discuss the need to understand and overcome. linking science with policy and evidence with promote the real meaning of ‘community’; implementation.1,4,27 the creation of sub-groups bonded by a Shaping policy – cultivating a culture The academic literature exploring common goal, and how self-empowerment of preparedness preparedness considers psychological and 12,51,64,65 can catalyse behaviour change. Future natural hazards are likely to increase physical capability and suggests reasons Individuals, community groups, local, state in severity and frequency due to climate why people do, or do not, prepare.22,46-50 and federal governments, workplaces and change.45,69-71 For this reason, a greater One contributing factor is the dilemma policy development can all contribute to and knowledge-base is urgently needed to shape of competing superimposed tasks.21 For promote this change, increasing the status of policy for disaster preparedness and response48 example, the concurrent desire to save family a culture of preparedness and fire-fitness – to (emphasis added). and home and property can result in action make investment in resilience “gainful”.66 inertia. The present study argues that by Proactively promoting preparedness and However, self-responsibility is the pre- promoting preparedness as ‘business as usual’ the capability to effectively manage risk requisite building block for a strong both outcomes are achievable and could needs strategic awareness and a concurrent community effort. Jayne explained: 12,30,64,72 result in a healthier outcome experience with problem-solving approach. At the less physical and/or psychological trauma. Protection is about self-help as much as it is local level, participants identified several about relying on the services that you’ve got In turn, safely protecting property, including common barriers to preparedness – including … being bush fire ready isn’t easy and simple animals, contributes to building confidence, lack of time, resources, knowledge or and quick and cheap. It’s not that hard … if resilience and well-being, as espoused in the information – as well as the problem of how you just want to pack and go. But being bush 6,51,52 to act appropriately on days that are declared SFDRR. fire ready is no different to any other problem catastrophic (or the equivalent jurisdictional There are some limitations: affording or complexity that people have in their life. nomenclature).73-76 Although this terminology equipment is a potentially limiting factor as So, and I’m really upfront with people, I will

can be shocking for people unfamiliar with ‘personal leave’, which may be made available preparedness and property management Australian bushfire weather conditions, it to employees for many different reasons, could be linked to an existing Local realistically represents weather conditions does not satisfy this requirement. This type Government inspectorate authorised to issue that favour the ignition of potentially of initiative is representative of new policy, fines for the reverse. Additional workload and uncontrollable fires threatening public which will be necessary to manage the costs would foreseeably be offset by savings health and safety. As well, disaster literacy of impact of climate-change induced, worsening given the high cost of recovery after an vulnerable demographics and populations natural hazards.41,48,79 emergency event.19,85 needs to be addressed. Programs aimed at Potentially, colleagues, workmates and A financial incentive for new residents broad acceptance and application need to neighbours encouraged by a CDL policy needing to increase their bushfire knowledge be piloted and evaluated with respect to would be prompted to actively instigate for their own and their community’s health everyone in the community. The quality of shared plans and arrangements within and safety could be achieved by offering public health emergency messaging must be their community networks. This could help discounts linked to their attendance at 77,78 rapid, accurate and useful. Establishing build stronger productive relationships non-compulsory community fire-safety a normalised culture of fire-fitness could between communities and responders, and information sessions. They could be arguably greatly assist in improving disaster help communities better equip themselves encouraged to do so via an invitation literacy. Further commitment is needed to confront barriers to preparedness, accompanying their first Local Government from government to actively demonstrate and dismantle them step by step.30,80,81 rates notice, offering all attendees a a proactive approach to building a culture Subsequently, improved communication and meaningful discount to be applied to the of preparedness from new, evidence- safer decision-making between all parties second year’s fees. To qualify, participation in based initiatives by trialling and evaluating supplements knowledge bases formulated a given number of fire information seminars innovative strategies, as discussed below. cooperatively and collaboratively across would be required, which could be spread government agencies, fire authorities, over a 12-month period to give maximum New policy – Catastrophic Day Leave research findings and community members, opportunity for people to attend. Senior (CDL) depicting the synergistic interface of science firefighter Shane recalled an observation he This research proposes instigating workplace and policy in the SFDRR. often makes to newcomers to the community agreements to help narrow the awareness- regarding shared responsibility, “I point out preparedness gap. On days of high fire Financial incentives and rewarding there are three fire trucks sitting in that shed danger, people are faced with the dilemma best practice and six hundred homes over that hill”. Costs could be met by savings against recovery.19,85 of how to manage required tasks even if Financial inducement or reward can help they have a well-written bushfire survival achieve a societal shift towards establishing In the longer term, public awards and plan. Catastrophic Day Leave (CDL) could a culture of preparedness by implementing a recognition such as ‘Bushfire Best-Prepared effectively assist to alleviate the dilemma. system of rebates or discounts on insurance Towns’, could attract additional funding from The concept of CDL is an analytic construct premiums, local government charges or government or corporate sources and boost – where the analysis shifts to a more other taxes,82 and by actively rewarding ‘best the local tourist economy due to increased constructionist and critically interrogative practice’. Sandy, in the business focus group, publicity, or if preferentially considered as a 34,35 style. unhesitatingly commented, “People respond holiday destination. Proactively promoting Employer-employee negotiations could ‘trade’ very well to financial incentive. There needs a culture of bushfire safety in this way other workplace leave for a certain number to be an incentive for groups to actually come builds community pride as well as strong of CDL days, or work an extra hour a day for together and discuss things.” relationships with emergency services. eight or nine days a fortnight to accrue CDL An example is the French CatNat scheme Value-adding to properties at point-of-sale 31 days. Wilkinson et al. report varied and, at (Catastrophes Naturelles), a public/private by making bushfire compliance a desirable, times, problematic employee experiences scheme based on the principle of national marketable commodity is another financial with employers when requesting leave solidarity: everyone pays for the benefit of incentive. This could be achieved by adding a of absence during the 2013 ‘Red October’ the common good.82,83 In France, household notation on advertising material identifying bushfires in New South Wales, Australia. A policies cover ‘insurable’ risk, and the CatNat ‘bushfire-safer properties’ compliant with formal contractual arrangement for CDL with scheme, created by law in 1982, is designed current relevant Standards,86 and encourage employers could obviate this difficulty and for events considered uninsurable, such as others to similarly ‘value-add’. This strategy promote shared responsibility with mutual natural disasters. It is based on paragraph would need to be aligned with a formal workplace benefits. Initiating CDL as a new 12 of the preamble of the Constitution of system of acknowledging eligible properties. form of workplace leave would have the 27 October 1946, which states: “The Nation Qualifying properties could be given the dual effect of elevating a culture of bushfire declares all French citizens to be equal and option of displaying a gateway notice, or preparedness to ‘business as usual’ status, united in solidarity when faced with loss participate in community ‘fire-ready’ open thus raising active awareness of the need to resulting from natural disasters”.84 days, similar to the familiar ‘open gardens’, to prepare well in the wider community and showcase and educate others to do likewise. Residents who are well prepared and enabling employees to act safely in a timely fully insured need to be recognised and Overarching jurisdictional in-principle manner. For these reasons it is important to acknowledged for their contribution to public support for strategies involving financial name this proposed leave according to the health. A scheme that rewards excellence in incentives is needed, but the success of purpose for which it is intended: generic

a scheme could well depend upon local Farmers who choose to implement effective government and the at-risk communities knowledge and respectful local community fire breaks, whether or not required by themselves. Based on current findings, this consultation as strategies to build ‘fire- regulation, could offset potential economic paper concludes that implementing new fitness’ may be best managed on a locally loss to some degree by being rewarded for practical and achievable policies that work bespoke basis.20 Whole-of-jurisdiction on-farm best-practice preparedness, again across social and workplace contexts are plans may not be functional if applied motivating fire-fitness practice. steps toward achieving this goal. state-wide beyond the parameters of local conditions. This has been a failing in previous Conclusion and implications for References attempts to successfully apply discounts on insurance schemes, for example, and has public health 1. 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doi: 10.1111/1753-6405.12907 were collected on smartphones by filling in a Conclusions standardised online form. Weather data was Observed vaping and As countries increasingly consider recorded at 5.00pm daily. Ethics approval constraining smoking and vaping in outdoor smoking in outdoor public (D18/121) was obtained from the University settings,8,9 it is important to base such policies of Otago. places: piloting objective on objective data. Vaping can be done data collection for policies Results stealthily10 and the devices can be pocketed between puffs, so observers may be less likely on outdoor vaping There was rain on 5/10 days of field work to see vaping compared to smoking. Further with an average temperature of 14°C (range 1 1 studies are required to assess vaping in other George Thomson, Johanna Nee-Nee, 10.5–16.9°C) and average wind speed 1 1 settings and jurisdictions, and to assess trends Kirsty Sutherland, Rebecca Holland, 27kmph (5–45kmph). Totals of 7,977 adult Miriam Wilson,1 Nick Wilson1 in visible vaping over time. patrons, 214 child patrons (8,191 patrons in 1. Department of Public Health, University of Otago, Wellington, New Zealand total), and 114 active vapers were observed Implications for public health during 2,422 venue observations. Active Having the same rules for vaping and The impacts of e-cigarettes, also known as vapers were 6.12 times more likely to be 1-3 smoking for particular outdoor places vaping products, are highly debated and observed at venues without children present 4 provides simplicity in policy communication vaping in public places raises further issues. (2,355 venue observations, 113 active vapers), and implementation. Vaping outdoors raises As we found no published observations of the compared to venues with children present the issue of the exposure of children and point prevalence of vaping in outdoor places, (67 venue observations, three active vapers; non-smokers to the normalisation of the we aimed to pilot: i) the assessment of the 95%CI: 1.9 to 19.2). point prevalence of vaping, and the relative activity, and the possible contribution from A ratio of 10 active smokers to one prevalence of smoking and vaping outside normalisation to the adoption of vaping active vaper was observed at the venues hospitality venues; and ii) the assessment by these groups. The use of nicotine by (1,113/116), with a point prevalence of vaping of the relative prevalence of smoking and non-smoking youth is a matter of public at 1.5% of patrons (116/7,977). During 121 vaping among those walking in downtown health concern.11-13 Some of the health issues static observations of pedestrians at the pavement areas. The context is a high-income around vaping indoors may apply to outdoor three pavement locations, a ratio of 2.9 active country (New Zealand) where e-cigarette areas where people are close together.4 smokers to one active vaper was seen (120 use has been officially encouraged since While our results indicated that in this vapers, 350 smokers – Table 1). On average, 20175 and which has the second-highest setting there was less vaping than smoking, six active vapers and 17 active smokers level of vaping in a 14-country study (at 7.8% the balance is likely to change over time as were observed per hour across these three for daily use of nicotine vaping products smoking decreases and vaping increases. locations. Observers reported that it was among smokers and recent ex-smokers6). Policies on vaping outdoors also need to sometimes difficult to distinguish vaping There is no legislation in New Zealand consider the long-term needs of a future devices from other handheld items and, requiring smokefree or vapefree areas outside post-tobacco smoking situation, where the in the evenings, it was difficult to see the hospitality venues. consumption of nicotine by other means may devices compared to cigarettes as they do not be seen as a public health issue. Methods light up. However, vaping clouds were easy to identify. Observations were made of patrons, Table 1: Comparison of active vaping and active smoking by people walking within 5m of observer at three different smokers, vapers and children sitting in static observation points recorded in 10 min blocks by location and time of day in Wellington city, May 2018. outside areas of 56 hospitality venues in Setting and time of Static Active Active Rate of Rate of active Rate ratio of central Wellington City, New Zealand. These observation observations vapers smokers active vaping smoking active smokers were taken between 3.30pm and 9.00pm (n) (n) (n) observed per observed per to active on weekdays and 12.00pm and 9.00pm on hour hour vapers weekends from 16 to 27 May 2018. The longer Cuba Street weekend observation times were to increase 12 – 4pm 17 28 76 9.9 26.8 2.7 the efficiency of data collection (since 4 – 9pm 25 37 107 8.9 25.7 2.9 more people were at hospitality venues on Waterfront weekends) in a time-constrained study. Ten- 12 – 4pm 16 4 10 1.5 3.8 2.5 minute observations were also made of the 4 – 9pm 24 17 19 4.3 4.8 1.1 number of active smokers and active vapers Courtenay Place passing within a five-metre radius in three 12 – 4pm 17 18 66 6.4 23.3 3.7 defined pavement areas. Detailed methods 4 – 9pm 22 16 72 4.4 19.6 4.5 are available online (see Supplementary File). Total Wellington has some voluntary smokefree 12 – 4pm 50 50 152 6 18.2 3.0 outdoor areas, but these are not situated 4 – 9pm 71 70 198 5.9 16.7 2.8 where the observations were made.7 Data All times all locations 121 120 350 6.0 17.4 2.9 The authors have stated they have no conflict of interest. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

References PUBLIC HEALTH ASSOCIATION 1. Kalkhoran S, Glantz SA. E-cigarettes and smoking cessation in real-world and clinical settings: A systematic review and meta-analysis. Lancet Respir Med. 2016;4(2):116-28. OF AUSTRALIA 2. Warner KE. How to think - not feel - about tobacco harm reduction. Nicotine Tob Res. 2018 Apr 30. doi: 10.1093/ ntr/nty084. 3. Hartwell G, Thomas S, Egan M, et al. E-cigarettes and Working together for better health outcomes equity: A systematic review of differences in awareness and use between sociodemographic groups. Tob Control. 2017;26(e2):85-91. 4. Wilson N, Hoek J, Thomson G, et al. Should e-cigarette use be included in indoor smoking bans? Bull World Health Organ. 2017;95(7):540-1. 5. New Zealand Ministry of Health. Ministry of Health Position Statement – Vaping Products [Internet]. Wellington (NZ): Government of New Zealand; 2017 [cited 2018 Aug 30] October 11. Available from: https:// www.health.govt.nz/our-work/preventative-health- wellness/tobaccocontrol/vaping-smokeless-including- heated-tobacco 6. Gravely S, Driezen P, Ouimet J, et al. Prevalence of awareness, ever-use and current use of nicotine vaping products (NVPs) among adult current smokers and ex- smokers in 14 countries with differing regulations on sales and marketing of NVPs: Cross-sectional findings from the ITC Project. Addiction. 2019 Jan 25. doi: 10.1111/add.14558 7. Wellington City Council. Smokefree Wellington [Internet]. Wellington (NZ): WCC; 2018 [cited 2018 Aug 30]. Available from: https://wellington.govt.nz/ your-council/plans-policies-and-bylaws/policies/ smokefree-wellington 8. Marynak K, Kenemer B, King BA, et al. State Laws Regarding Indoor Public Use, Retail Sales, and Prices of Electronic Cigarettes - U.S. States, Guam, Puerto Rico, and U.S. Virgin Islands, September 30, 2017. MMWR Morb Mortal Wkly Rep. 2017;66(49):1341-6. 9. Institute for Global Tobacco Control. Country Laws Regulating E-cigarettes: Policy Domains [Internet]. Baltimore (MD): Johns Hopkins Bloomberg School of Public Health; 2018 [cited 2018 Aug 31]. Available from: https://www.globaltobaccocontrol.org/e-cigarette/ policy-domains 10. Yingst JM, Lester C, Veldheer S, et al. E-cigarette users commonly stealth vape in places where e-cigarette use is prohibited. Tob Control. 2018 Aug 10. doi: 10.1136/ tobaccocontrol-2018-054432 11. Bartter T. Electronic cigarettes: Aggregate harm. Ann Intern Med. 2015;163(1):59-60. 12. Barrington-Trimis JL, Berhane K, Unger JB, et al. The E-cigarette social environment, e-cigarette use, and susceptibility to cigarette smoking. J Adolesc Health. 2016;59(1):75-80. 13. Stanwick R. E-cigarettes: Are we renormalizing public smoking? Reversing five decades of tobacco control and revitalizing nicotine dependency in children and youth in Canada. Paediatr Child Health. 2015;20(2): 101-5.

Supporting Information

Additional supporting information may be found in the online version of this article: Supplementary File 1: Further details on methods.

Correspondence to: Dr George Thomson, University of Otago, Wellington, Box 7343, Wellington, New Zealand; e-mail: [email protected] Join today and be part of it!

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Copies of the full Notes, including referencing of electronic sources, and of the ‘Uniform requirements’ are available from the Australian and New Zealand Journal of Public Health website at http://onlinelibrary.wiley.com/page/journal/17536405/homepage/ForAuthors.html Editorial Sport 305 The Public Health Association of Australia’s advocacy to 366 Unhealthy sport sponsorship at the 2017 AFL Grand prevent suicide Final: a case study of its frequency, duration and Samantha Battams, Fiona Robards nature Tegan Nuss, Maree Scully, Melanie Wakefield, Helen Dixon Commentary 373 Challenges for sport organisations developing and 307 Listen, understand, collaborate: developing innovative delivering non-traditional social sport products for strategies to improve health service utilisation by insufficiently active populations Aboriginal and Torres Strait Islander men Kiera Staley, Alex Donaldson, Erica Randle, Matthew Nicholson, Kootsy Canuto, Stephen Harfield, Gary Wittert, Alex Brown Paul O’Halloran, Rayoni Nelson, Matthew Cameron 310 The important role of charity in the welfare system for General Public Health those who are food insecure Fiona H. McKay, Rebecca Lindberg 382 Epidemiology of hospitalised traumatic brain injury in the state of New South Wales, Australia: a population- Indigenous Health based study 313 Feasibility and acceptability of opportunistic screening Ilaria Pozzato, Robyn L Tate, Ulrike Rosenkoetter, Ian D Cameron to detect atrial fibrillation in Aboriginal adults 389 New and old hotspots for rickettsial spotted fever Rona Macniven, Josephine Gwynn, Hiroko Fujimoto, acquired in Tasmania, 2012–2017 Sandy Hamilton, Sandra C. Thompson, Kerry Taylor, Gabriela Willis, Kerryn Lodo, Alistair McGregor, Faline Howes, Monica Lawrence, Heather Finlayson, Graham Bolton, Stephanie Williams, Mark Veitch Norman Dulvari, Daryl C. Wright, Boe Rambaldini, Ben Freedman, Kylie Gwynne 395 Public health and natural hazards: new policies and preparedness initiatives developed from an Australian 319 Anaemia in early childhood among Aboriginal and bushfire case study Torres Strait Islander children of Far North Queensland: Rachel Westcott, Kevin Ronan, Hilary Bambrick, Melanie Taylor a retrospective cohort study

Dympna Leonard,Petra Buttner, Fintan Thompson, Maria Letter Makrides, Robyn McDermott 401 Observed vaping and smoking in outdoor public places: 328 Participant profile and impacts of an Aboriginal healthy piloting objective data collection for policies on outdoor lifestyle and weight loss challenge over four years 2012- vaping 2015 George Thomson, Johanna Nee-Nee, Kirsty Sutherland, Anne C. Grunseit, Erika Bohn-Goldbaum, Melanie Crane, Rebecca Holland, Miriam Wilson, Nick Wilson Andrew Milat, Aaron Cashmore, Rose Fonua, Angela Gow, Rachael Havrlant, Kate Reid, Kiel Hennessey, Willow Firth, Adrian Bauman 334 Breast screening attendance of Aboriginal and Torres Strait Islander women in the Northern Territory of Australia Kriscia A. Tapia, Gail Garvey, Mark F. McEntee, Mary Rickard, Lorraine Lydiard, Patrick C. Brennan 340 Limited progress in closing the mortality gap for Aboriginal and Torres Strait Islander Australians of the Northern Territory Tom Wilson, Yuejen Zhao, John Condon

Food and Beverage 346 The frequency and magnitude of price-promoted beverages available for sale in Australian supermarkets Christina Zorbas, Beth Gilham, Tara Boelsen-Robinson, Miranda R.C. Blake, Anna Peeters, Adrian J. Cameron, Jason H.Y. Wu, Kathryn Backholer 352 Development of Australia’s front-of-pack interpretative nutrition labelling Health Star Rating system: lessons for public health advocates Michael Moore, Alexandra Jones, Christina M. Pollard, Heather Yeatman 355 The performance and potential of the Australasian Health Star Rating system: a four-year review using the RE-AIM framework Alexandra Jones, Anne Marie Thow, Cliona Ni Mhurchu, Gary Sacks, Bruce Neal

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