To date, there has been only limited research investigating the musculoskeletal health of Indigenous Australians. Nevertheless, the pain and disability associated with musculoskeletal conditions are thought to be high. This thesis reports on the outcomes of a cross-sectional survey and clinical assessment designed to measure the prevalence of musculoskeletal conditions, and uses them to inform the development of a community-based musculoskeletal training program for Indigenous Australians living in one of the largest rural Indigenous communities in Australia. There were three separate community-based studies comprising this thesis: The first describes the development of measures for assessing the prevalence of musculoskeletal conditions and the associated risk factors and barriers to managing these conditions for people living in this Community. The development of a screening survey and clinical assessment protocol was based on a literature search, existing validated measures, feedback from Indigenous focus groups and pilot testing with Indigenous people in order to achieve cultural appropriateness. The second study piloted the research tools, then measured and assessed the prevalence of musculoskeletal conditions, associated risk factors and barriers to managing these conditions in the Community. The third study describes the development and implementation of a preliminary community-based intervention delivered by AHWs that responded to the outcomes of the prevalence study. It assessed the cultural acceptability of a musculoskeletal training program (MTP), as well as piloting an approach to assessing changes in skills and knowledge of Aboriginal Health Workers (AHWs) who participated in the MTP. The conduct of these studies reiterates the difficulties associated with conducting studies in Indigenous Communities according to mainstream concepts, which rely on randomly selecting participants in order to achieve generalisability to the larger population. Beyond empowering Indigenous people through sustainable, community-based training initiatives, lies the immediate need to improve access to musculoskeletal health services and to remove this current and considerable barrier to improving the musculoskeletal health of Indigenous Australians. The conclusions of this thesis highlight the importance of giving consideration to cultural sensitivity and collaboration in planning health service delivery to Indigenous people. The application of the community-based model used in this study may have the potential to be seeded in Communities throughout the country as a step towards promoting the musculoskeletal health of Indigenous people living in rural Australia and beyond. / PhD Doctorate

The thesis examines the history of Central Australia and specifically the development of health services in the Northern Territory. The continuing colonial realtionships between Aboriginal and non-Aboriginal Australia are explored as a reason for the peristence of poor Aboriginal health status, including the cycle of vself destructive behaviours. It rovides an explanation of the importance of community agency to address community problems, and the potential of community controlled ABoriginal health services as vehicles for such community action.

The bureaucratic measure of health service, health performance indicators, suggest that we are not effective in our legislative responsibility to deliver suitable health care to some of the populations we are meant to serve. Debate has raged over the years as to the reasons for this, with no credible explanation accepted by those considered stakeholders. One thing is clear though, we have gone from being a culture believing that the needs of the many far outweigh those of the few, to one where we are barely serving the needs of the 'any'. This is most evident in the care delivered to the Aboriginal and Torres Strait Islander people of Australia.

Background: Aboriginals are overrepresented in Canada’s HIV epidemic and are more likely to be infected with HIV through injection drug use (IDU) than non-Aboriginals. However, little research has investigated the outcomes of combination antiretroviral therapy (cART) among Aboriginal HIV-patients or compared outcomes between Aboriginal and non-Aboriginal HIV-patients. Objectives: The primary objectives of this research were to 1) compare all-cause and HIV-related mortality rates between Aboriginal and non-Aboriginal HIV-patients after they start cART, 2) determine if Aboriginal patients were less likely to achieve virological suppression and more likely to experience subsequent treatment failure after starting cART; 3) describe and compare the health-related quality of life (HRQL) of Aboriginal and non-Aboriginal HIV-patients; and 4) describe the life stability of Aboriginal and IDU HIV-patients treated with cART and explore associations between life stability, clinical status, and HRQL. Methods: This research was conducted in northern Alberta, Canada using a clinical database, vital statistics data, and data collected through interview and a self-administered HRQL questionnaire. Data analyses included multivariable Cox proportional hazards models and multiple linear and logistic regression models. Results: After starting cART, Aboriginals suffer higher rates of all-cause and HIV-related mortality than non-Aboriginals. Furthermore, Aboriginals are less likely to achieve virological suppression after starting cART and, among those who achieve suppression, Aboriginals experience higher rates of virological failure ≥1 year after suppression. Aboriginal IDUs, Aboriginal non-IDUs, and non-Aboriginal IDUs reported similarly worse physical HRQL compared to non-Aboriginals non-IDUs. Among Aboriginals and IDUs, factors significantly associated with poor clinical status were unemployment, lower income, not completing high school, homelessness, and perceiving that one’s current life was not much better compared to before starting cART. Similarly, factors significantly associated with lower HRQL in this group were unemployment, perceiving that one’s current health or one’s current life was not much better compared to before starting cART, and having a current CD4 cell count ≤350 cells/μL. Conclusions: Overall, after starting cART, Aboriginal HIV-patients suffer worse outcomes than non-Aboriginal HIV-patients. Future research should investigate adherence among Aboriginals and IDUs treated with cART and explore their treatment experiences to develop interventions to improve the prognosis of these vulnerable populations.

Much of the maternal health care literature on Aboriginal women is biomedical in its focus, covering topics such as gestational diabetes, abnormal birth weight, and infant morality. There has also been some exploration of First Nations womens relationships with health professionals. There is a dearth of literature that addresses First Nations womens choices, experiences, knowledges (traditional and medical), attitudes, beliefs and values surrounding their pregnancies and prenatal health care. This qualitative study conducted by a Mikmaw woman explores Mikmaw womens perceptions of their maternal health, the relationships that support or serve Mikmaw women during their pregnancy, birthing, and postpartum delivery in two First Nations communities in Nova Scotia. The stories of fourteen Mikmaw female participants, ranging from young women to Elders, were explored using a narrative inquiry approach that is consistent with First Nations oral traditions of storytelling. Stories were told in a focus group and individual interviews. Data collection, analysis, and interpretation was guided by an Indigenous framework of two superimposed medicine wheels: (1) holistic model of health (mental, physical, emotional and spiritual), and; (2) maternal health life cycle (becoming a woman, teachings during pregnancy, experiences during birth, motherhood and the fourth trimester: after birthing). This study found that the colonization of birthing has significantly impacted Mikmaw maternal health experiences, and is characterized by a tension between western medical knowledge and Mikmaq traditional knowledge systems that plays out very strongly during this critical period in the life of a woman and her child. In addition, recognition of the socio-cultural context of Mikmaq women is critical to understanding their decision making in regards to maternal health. The results suggest there is a need to create culturally sensitive models of maternal health that incorporate First Nations traditional knowledge of maternity and Western medical knowledge.

This study described the hospital morbidity of 194,persons with Fetal Alcohol Syndrome (FAS), born between 1973-1992, who were identified through a major referral center for Saskatchewan children with disabling conditions. Computerized provincial hospital separation data were obtained for 84% of 101 males and 77% of 93 females. Complete hospitalization histories were obtained for 128 patients, and partial histories for 29 patients. This data provided information on 1,556 hospitalizations from January 1, 1973 to November 30, 1992. At least 54% of study group members experienced morbidity as newborns, and 83% of all females and 91% of all males had experienced at least one other hospitalization (excluding the newborn stay) during their life (based on provincial data combined with information from patient follow-up and record reviews). By November 1992 (provincial data only), the mean number of hospitalizations (SD) for males and females age 15-19 years was 8.4 (7.0) and 10.2 (8.1), respectively. For children <5 years the mean (SD) was 6.0 (5.8) for males and 3.1 (4.7) for females. Age and sex-specific hospital separation rates for the FAS group (based only on provincial data pooled from fiscal years 1987-91) were compared to the 1989-90 Saskatchewan rates. The 95% confidence intervals for the rate ratios indicated significantly higher rates for both males and females with FAS <1 year, 1-4 years and 5-14 years of age, relative to children in general. Comparisons were made using Saskatchewan Registered Indian rates, since 88% of the study group was Aboriginal. The 95% confidence intervals indicated significantly higher rate ratios for males with FAS in all age groups, and for females with FAS age 5-14 years, relative to Registered Indians. The rate ratios for females <1 year and 1-4 years may not have achieved significance because of a possible bias toward underestimation, given the higher proportions of missing data in these groups. The results suggest the high rates of hospitalization in children with FAS are not explicable solely by factors associated with racial identity or ethnicity.

This study described the hospital morbidity of 194,persons with Fetal Alcohol Syndrome (FAS), born between 1973-1992, who were identified through a major referral center for Saskatchewan children with disabling conditions. Computerized provincial hospital separation data were obtained for 84% of 101 males and 77% of 93 females. Complete hospitalization histories were obtained for 128 patients, and partial histories for 29 patients. This data provided information on 1,556 hospitalizations from January 1, 1973 to November 30, 1992. At least 54% of study group members experienced morbidity as newborns, and 83% of all females and 91% of all males had experienced at least one other hospitalization (excluding the newborn stay) during their life (based on provincial data combined with information from patient follow-up and record reviews). By November 1992 (provincial data only), the mean number of hospitalizations (SD) for males and females age 15-19 years was 8.4 (7.0) and 10.2 (8.1), respectively. For children <5 years the mean (SD) was 6.0 (5.8) for males and 3.1 (4.7) for females. Age and sex-specific hospital separation rates for the FAS group (based only on provincial data pooled from fiscal years 1987-91) were compared to the 1989-90 Saskatchewan rates. The 95% confidence intervals for the rate ratios indicated significantly higher rates for both males and females with FAS <1 year, 1-4 years and 5-14 years of age, relative to children in general. Comparisons were made using Saskatchewan Registered Indian rates, since 88% of the study group was Aboriginal. The 95% confidence intervals indicated significantly higher rate ratios for males with FAS in all age groups, and for females with FAS age 5-14 years, relative to Registered Indians. The rate ratios for females <1 year and 1-4 years may not have achieved significance because of a possible bias toward underestimation, given the higher proportions of missing data in these groups. The results suggest the high rates of hospitalization in children with FAS are not explicable solely by factors associated with racial identity or ethnicity.

Much of the maternal health care literature on Aboriginal women is biomedical in its focus, covering topics such as gestational diabetes, abnormal birth weight, and infant morality. There has also been some exploration of First Nations womens relationships with health professionals. There is a dearth of literature that addresses First Nations womens choices, experiences, knowledges (traditional and medical), attitudes, beliefs and values surrounding their pregnancies and prenatal health care. This qualitative study conducted by a Mikmaw woman explores Mikmaw womens perceptions of their maternal health, the relationships that support or serve Mikmaw women during their pregnancy, birthing, and postpartum delivery in two First Nations communities in Nova Scotia. The stories of fourteen Mikmaw female participants, ranging from young women to Elders, were explored using a narrative inquiry approach that is consistent with First Nations oral traditions of storytelling. Stories were told in a focus group and individual interviews. Data collection, analysis, and interpretation was guided by an Indigenous framework of two superimposed medicine wheels: (1) holistic model of health (mental, physical, emotional and spiritual), and; (2) maternal health life cycle (becoming a woman, teachings during pregnancy, experiences during birth, motherhood and the fourth trimester: after birthing). This study found that the colonization of birthing has significantly impacted Mikmaw maternal health experiences, and is characterized by a tension between western medical knowledge and Mikmaq traditional knowledge systems that plays out very strongly during this critical period in the life of a woman and her child. In addition, recognition of the socio-cultural context of Mikmaq women is critical to understanding their decision making in regards to maternal health. The results suggest there is a need to create culturally sensitive models of maternal health that incorporate First Nations traditional knowledge of maternity and Western medical knowledge.

This research focuses on the work of the Urban Aboriginal Community Kitchen Garden Project (the Garden Project). The Garden Project aims to be a culturally appropriate health promotion project with urban Aboriginal people, drawing on traditional Indigenous approaches to health and healing, and rooted in community food work. The project is situated within the context of colonialism, the destruction of traditional foodways, and subsequent increased need for Indigenous people to rely on a dominant food system that is seen as destructive to human and ecological health. The purpose of my research is to describe the Garden Project’s main goals and achievements from the perspective of project leaders, project participants as well as through my own observations and experiences. The research methodology was guided by participatory and community based approaches to research and qualitative methods were employed, focusing primarily on semi-structured interviews with project participants and project leaders. I also participated in and observed the project for two years, from September 2006-September 2008. Data collection and analysis happened through an iterative process of action and reflection. Based on my time with the Garden Project, I suggest that it can be seen simultaneously as a community food security, health promotion, and Indigenous health project. It connects participants with food as a natural product, builds skills around cooking and growing food, and increases knowledge about food system issues. Drawing on the health promotion discourse, it can be seen building community and social support networks, treating the whole person, and empowering participants to take actions around their own health needs. It is rooted in Indigenous approaches to health and healing in the way it promotes individuals’ physical, mental/emotional and spiritual health, the health of the community through cultural revitalization, and the health of the Universe through the opportunity it provides for awareness about ecosystem health. This research project was very site specific. Nevertheless, the findings suggest that food work with urban Indigenous people, carried out in a culturally sensitive manner, may be a powerful leverage point for promoting health with this population. These types of projects can also be vehicles for social change.

Climate change is expected to cause changes in precipitation and runoff patterns, likely increasing the risk of waterborne infectious disease in some areas. In this context, the research objectives were to describe links between weather, water quality, and infectious gastrointestinal illnesses (IGI) in Nunatsiavut, Canada, which necessarily involved evaluating the quality and usefulness of data captured by the local health registry system. For this evaluation, IGI was used as a reference syndrome. Community-based meteorological stations captured weather data; trained local personnel conducted water quality testing. Clinic records provided IGI-related data (2005-2008). This study is the first to systematically gather and describe baseline empirical data on weather, water quality, and health in Nunatsiavut. It showed the necessity of improving Inuit health data quality and monitoring environmental health variables consistently and systematically across all Arctic regions. These data are critical to inform adaptation strategies for managing impacts of climate change on health.