Alcohol use in Australia: Interventions for Indigenous Groups and Nursing Roles

Alcohol use in Australia: Interventions for Indigenous Groups and Nursing Roles

Introduction

Consumption of alcohol is a major constituent of Australian culture and hence is commonly used in parties, alongside family meals and entertainment joints. The consumption rates are quite higher than in many countries, with only 10% of Australian adults keeping away from the drink and an overwhelming 80% recording as active consumers (Livingston, 2015). Males have higher consumption rates (around 85%) compared to females at 75% but a majority of such consumption is generally at a low immediate risk. This is partly because of the robust regulation framework that has been put in place by local and national authorities with respect to the sale, purchase and general commercialization of alcohol. Lifetime risk is increased in instances where one consumes more than two standard drinks in a day and the majority of Australian users barely cross that line. However, there are an estimated 17.4% of people who exceed this limit thus increasing health risks. Among these are 25% of males who have increased lifetime risks significantly in the process (Medina-Mora et al., 2015). Another group at high risk of inappropriate alcohol use is teenagers, with 66% of Australian 15-17 year olds reported to have never consumed alcohol. Though still leaving around a third at risk, the statistics are impressively progressive given that only a half (49%) had not consumed alcohol in 2011-2012 (Livingston, 2015).

As it emerges above, only a small portion of the total Australian drinkers are at a problematic level. However, the percentage contributes to a huge health burden with high risk drinking behavior associated with about 3,000 deaths annually and around 5% of all types of cancers (Wilson et al., 2010). Apart from serious health effects including increased risk of mental disorders, excessive alcohol usage is associated with social problems with a huge number of cases of domestic violence and child abuse attributed to it. The Aboriginal and Torres Strait Islander people have been disproportionately affected by alcohol given their complex cultural and historical interactions with the colonialists (Clough & Bird, 2015). Alcohol use was institutionalized as a form of rewards for the indigenous population during the colonial period hence incubating an alcohol abuse culture. Additionally, dispossession, ethnic contempt and racism, heavy chronic disease burdens and other significant factors have led indigenous groups into alcohol abuse. Statistics indicate that indigenous men are seven times more likely to die of alcohol related problems in comparison to non-indigenous groups. Additionally, the indigenous population carries at least twice the disease burden than the non-indigenous population (Lee et al., 2014). This paper discuses risk and protective factors for alcohol use in an indigenous population, explores a program addressing the problem and explains the role of the nurse in the process. 

Risk and Protective Factors 

There are a number of risk and protective factors that can be associated with problematic alcohol use among Aboriginal and Torres Strait Islander people in Australia. Risk factors refer to conditions, characteristics and attributes that enhance an individual’s likelihood of developing disease or getting harm (WHO Management of Substance Abuse Unit, 2014). On the other hand, protective factors are skills, strengths, resources and other characteristics in an individual that increase their resilience and coping strategies when dealing with stressors and help them reduce or eliminate risks. With respect to the Aboriginal and Torres Strait Islander people, there are more risk than protective factors with regard to alcohol use.

Risk Factors

Decades of research dating back to the 70s have strongly associated the health status of indigenous people in Australia with the social determinants of health. These are many facets of individual life from family background, income levels, occupation, levels of education among others that determine exposure to health risks (Lee et al., 2014). Not all the social determinants of health translate to risk factors of alcohol abuse among the Aboriginal and Strait Islander people following efforts to promote equality in some of them. Examples include education and level of employment where concerted efforts have been made to raise the social status of indigenous people (Clough & Bird, 2015). Nevertheless, they continue to lag behind in a number of social indicators both locally and internationally and still face some of the risks in line with alcohol abuse and the use of other psychoactive substances. Multiple sources have indicated that low income, unemployment and lack of education are major risk factors of problematic alcohol use amongst the indigenous people. There is strong evidence linking high economic standing and lower alcohol abuse cases amongst the indigenous people. The frustration of unemployment and consequent low income has dragged a significant number of the indigenous population into excessive drinking, majorly as a source of solace. The three factors are interconnected and lead to poor quality of life which exposes the indigenous population to risk of alcohol misuse and abuse.

Introduction to heavy drinking and misuse of alcohol as an exchange commodity during the colonial period posed a cultural risk. Though the indigenous people were exposed to alcohol prior to the arrival of the Europeans, the latter was a game changer. First, alcohol was previously prepared locally and was consumed within manageable limits. This may have been due to culturally instilled discipline or the unavailability of resources to prepare excessive amounts. The Europeans availed alcohol in large amounts for the Aboriginal and Strait Islander people, institutionalizing alcohol use and misuse in the process (Wilson et al., 2010). The amounts increased in the region significantly since the arrival of the ‘First Fleet’, with alcohol forming an important part of the colonial life in Australia (Livingston, 2015). Many indigenous people developed a taste for the drink and the number of both low risk and high risk drinkers went up. Later, the colonists introduced alcohol as an item of exchange for sex and labor, further entrenching the drinking culture. The indigenous people moved from a group of average social drinkers to heavy drinkers who abuse alcohol to great extents. In the process of dealing with the colonists, there was dispossession, illnesses, death and many other negative experiences from their confrontations. With life becoming frustrating, the indigenous population turned to alcohol for solace (Wilson et al., 2010).  Apparently, the colonists not only introduced the indigenous population to alcohol misuse but exposed them to harsh treatment that sustained an alcohol abuse culture.

Restriction of alcohol access to the Aboriginal and Torres Strait Islander people also set them up into alcohol abuse and misuse. After introducing them to alcohol misuse and abuse, the colonists sought to restrict access to alcohol by the indigenous people lest they denounced their identity and accepted to be assimilated (Clough & Bird, 2015). In the late 1920s, laws were enacted by the states and the territories to deny alcohol sale to indigenous people with few exceptions for those assimilated to the greater society. These laws did not however circumvent the locals’ desire for alcohol and instead led them into abusing the substance by taking illicit brews and practicing unhealthy drinking habits such as drinking without taking any food (Fitts, et al., 2017). The discrimination became a civil rights matter and with progressive repeals of laws denying them access, the Aboriginal and Torres Strait Islander people were able to access alcohol again and share public spaces where alcohol drinking was done. Instead of moderating alcohol use and quitting their old habits developed during the restrictive era, they continued with irresponsible drinking behavior (Fitts, et al., 2017). The history of restriction thus serves as another risk factor to indigenous alcohol use.

Protective Factors

There has been a number of government propelled efforts to reduce social inequalities among the indigenous people. A number of programs have been rolled out to ensure that they have access to education and employment in order to reduce the numbers at risk of alcohol and substance abuse. Evidence suggesting that higher levels of income are related to less alcohol and substance abuse amongst the Aboriginal and Torres Strait Islander people has motivated such interventions (Bird, Fitts & Clough, 2016). Thusly, there have been a number of interventions that are geared towards improving social and living conditions in the hope that they shall improve overall health of the indigenous population in the long run. The Council of Australian Governments (COAG) has identified several foundational blocks that form the basis of the improvement efforts. These include improved homes, safer communities, schooling and economic participation (Clough et al., 2016). Their implementation continues to reduce exposure to alcohol abuse amongst the indigenous population. 

Increased cultural sensitivity in non-indigenous health and human services in Australia is an emerging protective factor to alcohol abuse. It is apparent that majority of the health problems affecting the indigenous population are either misunderstood or ignored due to their complex cultural orientation. Without taking into account aspects of their history and culture, it is impossible to make significant advancements in improving indigenous health facilities and services accessed by such populations. There have been shifts in recent times with organizations, non-indigenous health facilities and other resources taking into account cultural considerations. Language barrier, patient education and partnership between non-indigenous and indigenous health and human services institutions are some notable examples. The indigenous people are more understood and appreciated, with cases of discrimination on the decline. Traditionally, they have suffered from racial and ethnic abuse, leading to low self esteem and further indulgence into drug and substance abuse. However, the increasing cultural sensitivity which comes with awareness, appreciation and empathy has increased their resilience. 

Alcohol Management Plans (AMPs)

Alcohol Management Plans are a recent instrument adopted by the Australian government to address alcohol misuse in the indigenous population.  The plans are quite variable depending on region given that they are tailored for specific populations. They entail a great sense of community participation in planning, review and implementation but operate on the same principle of harm minimization (Wilson et al., 2010). Consequently, they operate on demand and supply factors of alcohol as well as harm reduction across board. Their application to indigenous communities has been conspicuous given the drinking problem identified with such groups. However, this has sparked controversy on the political front with references being made to past alcohol restrictive policies targeting the indigenous communities. Apart from civil rights issues, there have been debates on the effectiveness of broad spectrum restrictions in comparison to ad hoc approaches that target problem drinkers. Nevertheless, the programs have recorded a number of successes in reducing alcohol abuse and associated harm. For instance, Margolis et al. (2007) investigated the effectiveness of supply reduction through AMPs to serious injuries in indigenous communities in Australia. Comparison of injury rates in pre and post-AMP suggested an injury decline rate of about 52%. There are hopes of even better results as the policy framework continues to take shape.

There have been arguments that AMPs have offered mixed results and hence need significant improvement going forward. A recent study by Clough et al. (2017) affirms such arguments and presents the need for urgent remedies. The above study detailed the experiences of Aboriginal and Strait Islander people with AMPs in 10 out of 15 indigenous communities in Queensland. Though there were slim majorities that agreed that AMPs had made the community safer, reduced violence, increased safety and school attendance of children, improved personal safety and reduced violence against women, there was a stronger argument on various unfavorable outcomes. These included non-reduction of alcohol availability, increased binge drinking and cannabis use, failure to reduce general drinking behavior and increased fines, incarcerations and criminal records resulting from drinking behavior. Therefore, AMPs tended to increase criminalization and binge drinking despite the sole desire to reduce alcohol abuse among indigenous communities. According to Smith et al. (2013), the most effective AMPs are those that are negotiated at the community level. This encompasses involving community members and the key stakeholders in deciding which measures are the best for a given community in harm reduction. The design of AMPs in this regard also changes from making direct interventions to empowering the community to develop their own solutions based on local conditions (Clough et al., 2016). Other notable features of community negotiated AMPs include the mobilization of support for health and enforcement agencies. This helps to make their influences more profound and in the end stop alcohol abuse. 

Role of the Nurse in AMPs

Nurses have a prominent role in AMPs as educators. This is due to the cultural complexity of the Aboriginal and Strait Islander people which reduces their access and equity in relation to health services. For one, the indigenous people have negative attitudes towards any non-indigenous health services and perceive such as an extended plan to exclude and mistreat them. This is even more profound with respect to AMPs given the history of alcohol restriction laws targeting the Aboriginal and Strait Islander people. This has subjected AMPs to civil rights debates which call for a clear communication on the need for the programs among indigenous people, their benefits and more importantly, the effects of alcohol on their health. AMPs are unlikely to succeed amongst indigenous communities without the input of nurse educators as they would be treated with skepticism and disdain. Nurses should therefore be involved in all implementation efforts, largely to engage the indigenous masses and enlighten them on the benefits of such programs.

Nurses are also involved in the planning of interventions within Alcohol Management Programs (AMPs). The conflicting results of AMPs and the apparent need for improvement calls for the involvement of nurses in determining the best structure of the program that shall reduce current unfavorable outcomes. Their professional expertise is needed in making such programs culturally sensitive and appropriate, as well as including the best interventions for specific communities (Clough et al., 2016). There is a simmering debate on whether universal harm reduction approaches should be taken instead of community specific measures, which calls for the experience and expertise of nurses. Other aspects of the programs such as quality assurance and evaluating the effectiveness of various approaches taken can be best carried out by nurses in line with the best practices. Therefore, nurses have multiple roles to play in the planning, review and improvement of AMPs, particularly in the reduction of some undesirable outcomes of the program. 

Conclusion

Alcohol abuse is a major health problem affecting indigenous communities in Australia. The Aboriginal and Torres Strait Islander people are affected by twice the health burden resulting from alcohol abuse than non indigenous people among other disproportionate effects.  Alcohol abuse is related to a number of cancers, injuries and mental illnesses thus the need to address it. Elsewhere, there are a number of risk factors of alcohol abuse including social inequalities such as low income, unemployment and low levels of education. Others include the cultural risk introduced by the institutionalization of alcohol as an exchange commodity and substance of abuse by the colonists to the indigenous communities and the restrictive laws that followed. Protective factors on the other hand include programs aimed at reducing social inequalities in education and employment as well as the apparent increase in cultural sensitivity of various health and human services in Australia. The Alcohol Management Program (AMP) is an example of an intervention in indigenous groups that has recorded significant success in reducing alcohol abuse and related harms. However, the program has several challenges that still call for improvement. Effectiveness can be enhanced by involving the community in planning and empowering them to come up with their own solutions. Nurses are required in the program not only as nursing educators but also as stakeholders in planning to help reduce the currently evident negative outcomes of the program. 

References

Bird, K., Fitts, M. S., & Clough, A. R. (2016). Alcohol management plans in Indigenous communities in Queensland (Australia) may have unintended implications for the care

Clough, A. R., & Bird, K. (2015). The implementation and development of complex alcohol control policies in indigenous communities in Queensland (Australia). International Journal of Drug Policy, 26(4), 345-351.

Clough, A. R., Margolis, S. A., Miller, A., Shakeshaft, A., Doran, C. M., McDermott, R., … & Fitts, M. S. (2017). Alcohol management plans in Aboriginal and Torres Strait Islander (Indigenous) Australian communities in Queensland: community residents have experienced favourable impacts but also suffered unfavourable ones. BMC public health, 17(1), 55.

Clough, A. R., Margolis, S. A., Miller, A., Shakeshaft, A., Doran, C. M., McDermott, R., … & Robertson, J. A. (2016). Alcohol control policies in Indigenous communities: a qualitative study of the perceptions of their effectiveness among service providers, stakeholders and community leaders in Queensland (Australia). International Journal of Drug Policy, 36, 67-75.

Fitts, M. S., Robertson, J., Towle, S., Doran, C. M., McDermott, R., Miller, A., … & Clough, A. R. (2017). ‘Sly grog’and ‘homebrew’: a qualitative examination of illicit alcohol and some of its impacts on Indigenous communities with alcohol restrictions in regional and remote Queensland (Australia). BMC Research Notes, 10(1), 360.

Lee, K. S., Harrison, K., Mills, K., & Conigrave, K. M. (2014). Needs of Aboriginal Australian women with comorbid mental and alcohol and other drug use disorders. Drug and alcohol review, 33(5), 473-481.

Livingston, M. (2015). Understanding recent trends in Australian alcohol consumption. Canberra, Australia: Foundation for Alcohol Research and Education.

Margolis, S. A., Ypinazar, V. A., & Muller, R. (2007). The impact of supply reduction through alcohol management plans on serious injury in remote indigenous communities in remote Australia: a ten-year analysis using data from the Royal Flying Doctor Service. Alcohol & Alcoholism, 43(1), 104-110.

Medina-Mora, M. E., Monteiro, M., Room, R., Rehm, J., Jernigan, D., Sánchez-Moreno, D., & Real, T. (2015). Alcohol Use and Alcohol Use Disorders. Disease Control Priorities, 4, 127-43.

Smith, K., Langton, M., D’Abbs, P., Room, R., Chenhall, R., & Brown, A. (2013). Alcohol management plans and related alcohol reforms. Indigenous Justice Clearinghouse.

WHO Management of Substance Abuse Unit. (2014). Global status report on alcohol and health, 2014. World Health Organization.

Wilson, A., Stearne, A., Gray, D., & Saggers, S. (2010). The harmful use of alcohol amongst Indigenous Australians. Australian Indigenous HealthInfoNet.