THE ABORIGINAL AND TORRES STRAIT ISLANDER HEALTH NARRATIVE – EPIGENETICS AND EARLY

CHILDHOOD

TODAYS CHILDREN – TOMORROWS FUTURE

EARLY CHILDHOOD CONFERENCE 2015

DR MARK WENITONG

SENIOR MEDICAL ADVISOR APUNIPIMA CAPE YORK HEALTH COUNCIL ASSOCIATE PROF (ADJUNCT) JCU

…not just the physical well-being of an individual but refers to the social, emotional and cultural well-being of the whole Community in which each individual is able to achieve their full potential as a human being, thereby bringing about the total well-being of their Community…..

…While we work with individuals for Aboriginal and Torres Strait Islander’s, its always about family and community…

NACCHO DEFINITION OF HEALTH AND WELLBEING – CONTEXT OF EARLY YEARS

Indigenous life expectancy for 2013

AIHW

Future - While the Australian health system is gearing up for the aging population we are looking at a much younger population with increased middle age = CD

Life Expectancy - National• 69.1 years for males (10.6 years lower)• 73.7 years for females (9.5 years lower )

75% Aboriginal and Torres Strait Islander die before 65 yrs, 25% non Aboriginal and Torres Strait Islander before 65 yrs

Cape York median Age at Death

52 males, 56 females (Qld non Indigenous 76 males, 82 females –

Health Indicators Cape York 2009, QH)

SMR CY 2010 : 1.9 (all cause mortality)

Age Structure: Ref - The burden of disease and injury in Qld Aboriginal and Torres Strait Islander people 2014 QH

QUEENSLAND

POPULATION DEMOGRAPHICS RICHARD CINCCOTTA

In utero environment / genetics / epigenetics / FASD

Early life experiences and adult behaviour

Environment, safety, community/family functioning

Early relationships, adaptive/maladaptive responses

Access to quality early childhood programs, education, health

Poverty, nutrition, access, neuro-cognitive development

Cultural influences, program acceptability

INFLUENCES INDIGENOUS

HOUSEHOLD COMPOSITION REF - AIHW 2015

• In 2011,Indigenous households comprised an average of 3.3 people compared with 2.6 people in other households.

• 21% Indigenous households were a one-parent family with dependent children in 2011 compared with 6% of other households.

CARERS VALUES

• Aboriginal and Torres Strait Islander children aged 0–14 years died at more than twice the rate of non-Indigenous children.

• Indigenous aged 5–14 years, external causes was leading cause of death at 3 times the rate for non‑Indigenous children.

• The hospitalisation rate for assault on Indigenous children was more than 5 times the rate for non-Indigenous children.

• Indigenous children were hospitalised for burns and scalds at twice the rate of other children.

• The pneumonia hospitalisation rate for Indigenous aged 0–4 years was more than 3 times the rate.

• Nearly 12% of Indigenous children who received a Child Health Check had chronic otitis media—more than 3 times the rate the World Health Organization classes as epidemic.

Hence, easy to see why it’s a deficit approach to an Aboriginal and Torres Strait Islander early childhood narrative.

STATS AIHW 2015

UNPACKING CAUSATION- AND PERSONAL AGENCY – BOTH IMP ( BAKER IDI BROWN, ADAPTED WENITONG 2014)

Policy perspective - adult Social and developmental health perspective – early childhood

Bad health behaviours Allostatic LoadAdverse childhood eventsDevelopmental neurobiology

Bad choices Social determinants, ACE,Poverty trap

Lazy ACE, lack of infrastructure/employmentTrauma, loss of control, depression, poverty trap

Fat Poor access to good nutrition, epigenetics, poverty trap, depression, ACE

Abbot: Get some Nikes and go for a run Me: Get some decent board-shorts mate.2-3% of the population make up 10% of the elite sportspeople – there is personal agency

BIOLOGICAL – ANC EPIGENETICS IMPLICATIONS

• Eg poor maternal nutrition/stress pulls switches re histone modification, RNA methylation to influence physical expression so that baby is physiologically set up for famine conditions when born and central fat storage as adult. (is heritable across next generation)

• Rethink patient narrative re adult risk behavior without losing sense of agency

• Policy implications of political ideology are where resources are invested

Involved in regulation of obesity, metabolic syndrome, inflammation………fecal transplants….11 yr olds T2D

MICROBIOME

PHYSIOLOGICAL - ALLOSTATIC LOAD (REF- MCEWAN)

ACE - ADVERSE CHILDHOOD EXPERIENCES – REF- FELLETTI - CENTERS FOR DISEASE CONTROL WEBSITE

• This study compared people who had experienced four or more categories of childhood exposure including physiological, physical, and sexual abuse, or household dysfunction with those who had experienced none.

• It found a 4-12x increased health risk for alcoholism, drug abuse, depression, and suicide attempt;

• A 2-4x increase in smoking, poor self- rated health, and increased chance of 50 or more sexual intercourse partners and sexually transmitted disease. In addition, they had a 1.4 to 1.6-fold increase in physical inactivity and severe obesity. (Felitti1998)

WANGETTI school screen• 60% children between 13-18 had significant adverse experiences –

none had an intervention – though interventions can modify later outcomes

WA ABORIGINAL CHILD HEALTH SURVEY

Primary carers of Aboriginal children reported extraordinary levels of stress.

• Over one in five (22%) Aboriginal children aged 0–17 years were living in families where 7–14 major life stress events had occurred over the preceding 12 months.

• Primary carers of Aboriginal children experienced over three times the average number of life stress events reported by carers of non-Aboriginal children in the 1993 WA CHS.

Longitudinal study of Aboriginal and Torres Strait Islander children

Wave 4 results – key stressor scores:

- household member in trouble with police

- cared for by someone other than usual carer

- scared by some-ones behaviour

Less high scores

- housing events, money worries, drug/alcohol problems in family, harassed

Consider in context of current policy and assumed stressors

Ref- https://www.dss.gov.au/about-the-department/national-centre-for-longitudinal-studies/overview-of-footprints-in-time-the-longitudinal-study-of-indigenous-children-lsic

FOOT PRINTS IN TIME

Zubrick and colleagues (2005) found that children in the Western Australian Aboriginal Child Health Survey (WAACHS) who had experienced up to two major life events during the previous twelve months had a 15 per cent chance of developing clinically significant social and emotional difficulties.

This rose to 25 per cent for children who had experienced three to six major life events and:

42 per cent for children who had experienced seven or more.

WAACHS

FIGURE 11: EXPERIENCE OF THREE OR MORE EVENTS BY NUMBER OF WAVES, PER CENT

WAVE 4

https://www.dss.gov.au/about-the-department/national-centre-for-longitudinal-studies/overview-of-footprints-in-time-the-longitudinal-study-of-indigenous-children-lsic

POVERTY THINKING

I started out with nuthin…and still got plenty left…

• NATSIS ABS – income significantly less urban/remote (inc mining areas)

• Duflo (economist) – interaction between Hope, poverty, mental health.

• David Campbell - Economic Rationality in Choosing between Short-Term Bad-Health Choices and Longer-Term Good-Health Choices

• The difference between having only enough to survive, versus having enough to apply to your capabilities…….

Issue Etiology Adult CD mortality (SNAP) bad choices, poor nutrition, tobacco, alcohol

misuse (SNAP)

Bad choices, risk factors Developmental etiology - ACE, epigenetics, microbiome, family functioning, neglect, normalized behavior, allostatic loadEconomic - poverty choices, Infrastructural support, health access, non healthy environment.

Poor family functioning, neglect, Relative poverty (trap), lack of employment, stressors, Indigenous specific – systematic (as above) at “Peoples” level, intercultural space, lack of infrastructure, lack of investment

Community dysfunction/poverty Indigenous specific – Systematically socially marginalized, economically marginalized, young demography, poorly conceived policy, political drivers. Lack of control. Fast modernisation

Marginalization historical/contemporaryAim at rebuilding social fabric, self determining, community structures, not quick fix programs, Capability, DRIP, re-colonization!

MASLOW HIERARCHY OF NEEDS - BACK TO BASICS

MY CHILDREN’S HIERARCHY OF NEED

Who has the largest influence on safe Aboriginal and Torres Strait Islander communities?

• Engaging dads• Family protector role• Conscript re smoking/alcohol reductions• Paternal role• Teaching young men/culture/law/ID

( Ref – Apunipima Cape York Health Council program)

FATHERS?

Yarrabah Men’s Group (NHMRC PAR, TSEY,K)• Spend more time with the kids• Don’t argue in front of kids• Teach your kids to read• ……

Cape York MJ Survey (Clough JCU)

Main reason for stopping gunja – • Family role model• Employment• Cost

DRIVERS FOR DADS

SATISFIED CARERS?

TABLE - WENITONG 2015

Sen Capability Framework – socio-political structures

Definition – relevant Declaration of the Rights of Indigenous Peoples

Present/not present in remote indigenous communities

Political Freedoms Freedom of political expression, voting…DRIP 23/24/18/20

√ but called “Activist”Voting post ‘67

Economic facilities Opportunities to utilise economic resources..DRIP 26/32

× Mostly Lacking long term investment/ serious reform

Social Opportunities Education, healthcare…DRIP 14/24/34

× limited opportunities

Transparency guarantees Openness in dealings with others….DRIP 27/19

× often not included in policy that effects them

Protective security Safety net to prevent abject poverty….DRIP 7

× welfare threshold for basic living – but poverty trap

EMPOWERMENT APPROACHESFROM A CLINICIANS POINT OF VIEW

o Critical consciousness – not passive acceptanceo From political consciousness to taking better

self-care/individual health – FWB CY

o ANFPP, self mx, BoP, all examples

o Community control

o Ability to envisage a positive future

SOCIAL DETERMINANTS

Control Environment

EmploymentIncome

discrepancy

wellness

INDIGENOUS DETERMINANTS?

Body Spirit

Land Relationships

wellness

CULTURAL CONTINUITY FACTORS ( CHANDLER, LALONDE)

CULTURAL CONTINUITY

• 100% of pregnant women received 5 or more AN consultations/ visits (av13.8) during pregnancy as per national recommended best practice ( was 83% 2011 QH)

• 50% of women accessed AN care before 13/40

• 31% of the pregnant women also received a comprehensive adult health check ( in addition to routine AN care)

• 53% of pregnant women identified as smokers( down from 72% in previous year)

• 80% of babies born were within normal weight range

• 90% of Cape York babies were born after 36/40

• 78% of babies were recorded as still breast feeding at 6 months

• 95% of children under 5, were recorded as fully immunised ( national average: 88%)

• Over 1685 home visits conducted

APUNIPIMA MATERNAL AND CHILD HEALTH- INC B0P “BABY ONE PROGRAM” 2014-15

DATA

HV Parenting education sessions include health worker led:

• DV• Nutrition• Home safety • Alcohol and gunja• Speech and language• Normal development

BABY ONE

US NURSE LED HV - NY STUDY: CHILD OUTCOME

Notified Abuse / Neglect 0 – 2 yrs

Control Group = 19% p = 0.07

Intervention Group = 4%

NY STUDY: CHILD OUTCOME AT 2-4 YRS

No Treatment Effect

- Child abuse and neglect (but, ↓ seriousness of abuse)

- Children intellectual functioning

Positive Treatment Effect

- Home hazards

- Injuries and ingestions (40% ↓)

- Behavioural and parental coping problems (45% ↓)

- Emergency Department visits (35% ↓)

- Maternal involvement with child

- Punishment (increase)

NY STUDY: MATERNAL OUTCOMES AT 15 YRS

Intervention Control• Verified child abuse/neglect 0.29 0.54 p< .001• Unmarried, low SE status • - Subsequent births 1.3 1.6 p =

0.02• - Interval to 2nd child 65m 37m p

=0.001• - Receiving Welfare 60m 90m p =.005• - Behavioural impairment due

to alcohol and drugs 0.41 0.73 p =0.03• - Arrests 0.16 0.90

p<0.001

NY STUDY: CHILD OUTCOMES, 15 YRS

Intervention Control

• Running away 0.24 0.60 p = 0.003• Arrest 0.20 0.45 p = 0.03• Convictions 0.09 0.47 p < 0.001• Lifetime sex partners 0.92 2.48 p = 0.003• Cigarette / day 1.50 2.50 • Alcohol days in 6m 1.09 2.49 p = 0.03• Drug related behaviour

problems 0.15 0.34 p = 0.08

• Epigenetics – EB Maternal care programs ( NHVP, BoP)

• EB programs - Family functioning and early childhood environment, learning, nutrition – MCH, parenting, early intervention, ANFPP, ABCedenarian, BoP, HIPPY,

• Articulating programs – eg FASD (> 20 orgs)

• Addressing the stressors in carers – police, bereavement.• Paternal programs – engaging dads• Cultural Continuity – community empowerment…EC

• More research – RCT – what does actually work?

PHC INTERVENTIONS

BUILDING RESILIENCE TELETHON CHILD HEALTH

CUNHA & HECKMAN

WHY THE “EARLY CHILDHOOD NARRATIVE” IS IMPORTANT

• The narrative describes the EB for intervention and change- if we neglect it, its ground hog day for Aboriginal and Torres Strait Islander people

• If we have an understanding of the key drivers of poor adult health/health behaviour we can intervene appropriately/early.

• Both individual and community level interventions are needed, but we have enough evidence to “just do it”.

• National policy can invest wisely in EB early childhood programs

• There are multiple positive Aboriginal and Torres Strait Islander family influences we can build on.

• We need to better articulate how we all work together across portfolios etc. Health and welfare, public health, social scientists, educationalists, Aboriginal and Torres Strait Islander people and researchers provide a consistent backbone to drive this agenda as politicians/policy changes