Barriers and enablers to the provision of alcohol treatment among

Aboriginal Australians: A thematic review of ve research projects

DENNIS GRAY
1
, MANDY WILSON
1
, STEVE ALLSOP
1
, SHERRY SAGGERS
1
,
EDWARD WILKES
1
& CORALIE OBER
2
1
National Drug Research Institute, Curtin University of Technology, Perth, Australia, and
2
Queensland Alcohol and Drug
Research and Education Centre, University of Queensland, Brisbane, Australia
Abstract
Introduction and Aims. To review the results of ve research projects commissioned to enhance alcohol treatment among
Aboriginal Australians, and to highlight arising from them. Design and Methods. Drafts of the papers were workshopped
by project representatives, nal papers reviewed and results summarised. Lessons arising were identied and described.
Results. While the impact of the projects varied, they highlight the feasibility of adapting mainstream interventions in
Aboriginal Australian contexts. Outcomes include greater potential to: screen for those at risk; increase community awareness;
build capacity and partnerships between organisations; and co-ordinate comprehensive referral networks and service provision.
Discussion. Results show a small investment can produce sustainable change and positive outcomes. However, to optimise and
maintain investment, cultural difference needs to be recognised in both planning and delivery of alcohol interventions; resources
and funding must be responsive to and realistic about the capacities of organisations; partnerships need to be formed voluntarily
based on respect, equality and trust; and practices and procedures within organisations need to be formalised. Conclusions.
There is no simple way to reduce alcohol-related harm in Aboriginal communities. However, the papers reviewed show that with
Aboriginal control, modest investment and respectful collaboration, service enhancements and improved outcomes can be
achieved. Mainstream interventions need to be adapted to Aboriginal settings, not simply transferred. The lessons outlined
provide important reections for future research. [Gray D, Wilson M, Allsop S, Saggers S, Wilkes E, Ober C. Barriers and
enablers to the provision of alcohol treatment among Aboriginal Australians: A thematic review of ve research
projects. Drug Alcohol Rev 2014;33:48290]
Key words: alcohol, Aboriginal, screening, brief intervention, treatment.
Introduction
For the past two decades, harmful levels of alcohol and
other drug (AOD) use among Aboriginal and Torres
Strait Islander peoples have been at least twice those in
the non-Aboriginal population [1,2]. Although consti-
tuting about 2.5% of the population [3], in 20112012
Aboriginal Australians constituted at least 13% of those
receiving mainstream publicly funded AOD treatment
[4]. In response to this long-standing inequity, impor-
tant policy initiatives have been developed and a broad
range of treatment and other interventions has been
undertaken by Aboriginal community-controlled
organisations (ACCO) and other groups [5,6].
Several reviews summarise the evidence for effective-
ness of alcohol treatment in non-Aboriginal popula-
tions [79] and treatment guidelines based on them
have been developed [10]. However, these reviews and
those focused specically on Aboriginal people all con-
clude that the evidence base for the effectiveness of
treatment in this population is limited [1114]. Their
conclusions are reected by Hunter et al.:
At best there is evidence from controlled trials for
some of the recommended interventions (for Indig-
enous people) in non-Indigenous primary care or
hospital populations. Such evidence will be cited,
with explicit acknowledgement of the uncertainty
Dennis Gray MPH, PhD, Professor and Deputy Director, MandyWilson PhD, Research Fellow, Steve Allsop PhD, Professor and Director, Sherry
Saggers PhD, Adjunct Professor, Edward Wilkes AOBA, Associate Professor, Coralie Ober RN, DipTchg, GradDip SocSci, AsscDipComWelf,
Research Fellow. Correspondence to Professor Dennis Gray, National Drug Research Institute, Curtin University, GPO Box U1987, Perth, WA
6845, Australia. Tel: +61 8 9266 1600; Fax: +61 8 9266 1611; E-mail: d.gray@curtin.edu.au
Received 3 October 2013; accepted for publication 20 February 2014.
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R E V I E W
Drug and Alcohol Review (September 2014), 33, 482490
DOI: 10.1111/dar.12137
2014 Australasian Professional Society on Alcohol and other Drugs
that remains about their applicability in Indigenous
populations [11].
Gaps in the evidence base include those related to
screening and assessment, brief interventions (BIs),
withdrawal management, pharmacotherapies, psycho-
social interventions, relapse prevention and manage-
ment, co-existing mental and physical health problems,
and integrated case management.
To address some of these gaps, the (then) Australian
Government Department of Health and Ageing funded
the National Drug Research Institute (NDRI) to
conduct a research program aimed at enhancing man-
agement of alcohol-related problems among Indig-
enous Australians. As part of the program, the NDRI
funded ve projects aimed at trialling and/or evaluating
particular interventions. Literature reviews [1520] and
the results of these projects [2127] have been pub-
lished separately.The objective of this paper is to review
the collective results of the projects, and to highlight
lessons arising from them and their implications for
improving treatment services.
Method
This review was conducted in a two-stage iterative
process. First, in preparation of the nal project reports,
two workshops were held and attended by representa-
tives of each research team and the NDRI program
team, who reviewed the results and discussed the impli-
cations. Comprehensive notes of these discussions pro-
vided the basis for recommendations for improving
treatment services [28] and for the review of the nal
papers.
In the second stageguided by the notes from
workshopsthe nal papers were reviewed and the-
matic analyses conducted independently by two of the
authors (D. G. and M. W.). These analyses were com-
bined, reviewed and, where appropriate, modied by
the other authors. The following sections include sum-
maries of the key publications from each project (see
Table 1) and a discussion of emergent themes.
Results
Training and tailored outreach support for alcohol
screening and BI
The National Drug and Alcohol Research Centre
(NDARC) project sought to embed screening and BIs
in the practice of four collaborating Aboriginal
community-controlled health services (ACCHS) [22].
This involved: staff training in use of the screening
questions in patient information and records systems
(PIRS) and BIs; providing tailored follow-up support to
particular ACCHSs; and assessing changes in the fre-
quency of screening and BIs in the six months pre- and
post-intervention. Screening questions in the PIRS are
similar to those in Alcohol Use Disorders Identication
Test (AUDIT)-C [29,30], and training was based on
materials including those from the Drinkless Program
(a package for use by health practitioners in detection
and treatment of risky drinking) [31].
Despite inter-site variation, overall the percentage of
clients screened increased signicantly in the six
months post-intervention (9.5% to 19.2%)a critical
improvement, as increasing case identication is the
rst step in improving care. Of clients with a valid
screen, almost 40% were considered at risk of harm.
Impact of the intervention on the provision of BIs was
more modest. Of clients at risk (39 pre, 77 post), the
percentage receiving a BI increased from 28.2% to
36.4%. While not statistically signicant, in clinical
terms the increase represents some success. The
authors note other evidence shows that transfer and
uptake of interventions is a long-term process, and
given more time they believe that the number of BIs
would further increase. The study demonstrates the
potential of screening in primary health care settings
for identifying those at risk and providing appropriate
services.
Community intervention in an Aboriginal urban setting
Based on an audit showing few Aboriginal people were
accessing AOD services, the Sydney South West Area
Health Service (SSWAHS) project sought to assess the
potential role of community-based education and brief
intervention in reducing harm [23]. It aimed to do so
by screening members of community groups (using
AUDIT); by conducting interactive education sessions
(based on Drinkless Program materials [31]) to
increase awareness of alcohol-related harms, alcohol
guidelines and availability of services; and by feeding
back AUDIT scores and providing one-to-one BIs for
those at risk. The number of groups (8) and individuals
(58) for whom education sessions were conducted was
modest and, although 21 (44.7%) had AUDIT scores
indicating potentially problematic drinking, none
sought the option of a BI. The paper identies process
issues (including those relating to production of
resources and recruitment) important in conducting
such an intervention and provides some qualitative
support for the approach taken and its potential to
increase awareness (an important end in itself). The
approach is labour intensive, but the authors suggest
potential economies of funding, stafng and training if
Alcohol treatment in Aboriginal settings 483
2014 Australasian Professional Society on Alcohol and other Drugs
Table 1. NDRI Enhancement of Treatment Program research paper summaries
Paper and lead agency Aims Methods Key ndings
Training and tailored outreach
support to improve alcohol
screening and BIs in ACCHSs
[13]
National Drug and Alcohol
Research Centre (NDARC)
Measure effect of training and
outreach support on delivery
of alcohol screening and BIs
in four ACCHSs.
Pre- and post-assessment of
alcohol information recorded
in the electronic patient
information systems of four
ACCHSs, 12 months before
and 6 months after,
implementation of an
intervention.
Implementing evidence-based
alcohol screening and BI in
ACCHSs may take time and
require multiple strategies
specic to individual services,
but has potential for
improving detection of clients
with alcohol problems. Study
provided modest evidence
that training and outreach
support can result in
improvements in alcohol
screening in ACCHSs.
The Alcohol Awareness project:
community education and BIs in
an urban Aboriginal setting [14]
Sydney South West Area Health
Service
Conduct pilot study of
community-based education
and BIs in an urban
Aboriginal setting.
Community-based groups
offered interactive alcohol
education session (n = 9) and
screened 47 (81%)
participants. Screening for
alcohol use conducted prior
to education. Scores
quantied and result
returned to participant post
session. Condential
feedback and one-on-one BIs
offered.
While labour intensive, the
process reached a number of
individuals in need of
assistance with alcohol. Study
highlighted low awareness of
drinking guidelines and
treatment options among
participants, however,
illustrated that
community-based approaches
have potential to raise
awareness and promote
discussion around drinking
with community members.
Can I have a Walan Girri? The
development of an
Indigenous-led model of service
development and delivery for
problematic alcohol use amongst
Indigenous people in the
Australian Capital Territory [15]
Winnunga Nimmityjah Aboriginal
Health Service (Winnunga)
Design, implement and
evaluate a culturally
mediated case management
model including SBI and
reference to country for
ACCHS clients experiencing
problematic alcohol use.
Review of existing models for
integrated assessment, care
planning, care delivery and
care review. Pre-test
quantitative staff survey of
training needs (n = 34).
Development of case
management instrument
including complementary
policy and procedural
documents and staff training
package.
High staff turnover delayed
development and inhibited
implementation of
instrument and evaluation of
effectiveness during study
period. Despite this, ndings
illustrated that, with good
partnerships, capacity
building and clear
procedures, comprehensive
case management can be
developed and adapted for
local contexts.
The Grog Mob: lessons from the
evaluation of a multi-disciplinary
alcohol intervention for
Aboriginal clients [16]
Central Australian Aboriginal
Congress (Congress)
Trial and evaluate a
non-residential treatment
program offering
pharmacotherapy,
psychological and social
support for Aboriginal clients
with alcohol problems.
Process and outcome
evaluation involving
qualitative interviews with
program staff and key
stakeholders (n = 32), and
quantitative review of client
contact and outcome data
(n = 49).
Identied process-related issues
including staff recruitment
and retainment, and need for
exibility in program
application. Limited
conclusions could be drawn
on client outcomes due to
small numbers. Nonetheless,
evaluation demonstrated
feasibility of project and
evidence of high demand for
it.
Aboriginal-mainstream
partnerships: exploring the
challenges and enhancers of a
collaborative service
arrangement for Aboriginal
clients with substance related
issues [17]
Aboriginal Drug and Alcohol
Service
Explore factors that challenged
and/or enhanced a
government-initiated
partnership between one
Aboriginal and four
mainstream services
providing alcohol
rehabilitation and support
services to Aboriginal clients.
Semi-structured qualitative
interviews with staff (n = 16).
Collection of observational
data. Partnership forum to
discuss ndings and resolve
identied issues.
Identication of several key
issues impacting on the
partnership including
cultural, historical, structural
and personal considerations.
Enhancers included the
potential for maximising
treatment options for
Aboriginal clients.
ACCHS, Aboriginal Community-Controlled Health Services; BI, brief intervention; NDRI, National Drug Research Institute.
484 D. Gray et al.
2014 Australasian Professional Society on Alcohol and other Drugs
it became a routine element of service provision. Never-
theless, the issue of cost-effectiveness requires further
investigation.
An Indigenous-led model of service development
and delivery
The objective of the project conducted jointly by
Winnunga Nimmityjah Aboriginal Health Service and
the National Centre for Epidemiology and Population
Health was to develop a comprehensive, culturally
mediated, case-management and care-planning tool
incorporating alcohol screening and BIincluding spe-
cic questions about belonging and country designed
to facilitate client engagement with the health service.
This tool became known as Walan Girri (Wiradjuri for
strong future) [24].
Prior to implementation, a survey was undertaken to
assess staff training needs, and a training program
developed. However, post-test evaluation of the training
program was precluded by high staff turnover. Staff and
management turnover, changes in membership of the
research team, and the way Walan Girri evolved led to
prolonged development and implementation. This and
low numbers meant outcome evaluation could not be
completed within the project time frame. Nevertheless,
on the basis of the trial, Walan Girri is now being used
within Winnunga and the descriptive case study of the
project provides several broadly applicable lessons,
including the importance of partnerships, capacity
building and the formalisation of procedures; issues
raised by staff turnover; and small numbers of research
participants. Importantly, it also led to an Aboriginal
team member completing a PhD project to validate
screening measures incorporated into Walan Girri [32].
A multidisciplinary alcohol intervention for
Indigenous clients
The Grog Mob projectconducted by Central
Australian Aboriginal Congress (Congress), a large
ACCHSaimed to trial and evaluate a referral system
and provision of three streams of care (medical, psycho-
logical and social) for clients with alcohol-related prob-
lems [25]. Evaluation was based on documentary data,
key stakeholder interviews and review of client health
records. Limited data precluded strong conclusions
about client outcomes, but process evaluation identied
issues arising out of implementation, including prob-
lems of staff recruitment and training and the need for
exibility in implementation. Nevertheless, the evalu-
ation demonstrated that the project was feasible and
that strong demand for it existed. On this basis, the
project has received ongoing funding from both the
Northern Territory and Australian Governments.
An Aboriginalmainstream partnership
The project conducted in Perth by Aboriginal Alcohol
and Drug Service (AADS) is a case study exploring
factors challenging or enhancing an Aboriginal
mainstreampartnership for the provision of counselling,
withdrawal management and residential rehabilitation
for Aboriginal clients [26]. The partnershipentered
into at the behest of a government funding agencywas
between AADS, a non-Aboriginal withdrawal centre,
and two mainstream residential treatment facilities (at
which 12 dedicated Aboriginal beds were purchased).
The case study was based on semi-structured interviews
with 16 staff members from the partner organisations.
The partnership was fraught with tension and the
authors describe a range of structural, historical, cul-
tural and personal factorscompounded by client
complexity and the paternalism of the funding
agencywhich challenged the partnership and the
intervention. Nevertheless, both Aboriginal and non-
Aboriginal informants saw the potential of such part-
nerships. A key lesson arising from the project is that to
be successful such partnerships must be voluntary,
equitable, accountable and based on trust.
Discussion
The projects raise a range of issues and here we con-
sider the most salient and the lessons arising from
them.
Additional resources have impact
The projects demonstrate that modest additional
resources can produce change and enhance outcomes.
A small amount of additional resources led to increased
capacity to deliver services; improved case identica-
tion; increased client engagement; improved intera-
gency and community collaboration; and development
of more appropriate assessment tools and resources. As
these became embedded in service provision, the initial
investment has continued to have a positive effect and
the success of the NDARC and Congress projects led
to the allocation by government agencies of additional
funds, two and 36 times greater, respectively, than the
original investment of about $250 000 in each project.
The importance of culture
The papers demonstrate that interventions effective in
non-Aboriginal communities cannot simply be imple-
mented in Aboriginal settings without consideration of
cultural differences. The AADS paper shows that
ACCOs are not simply the equivalent of mainstream
health services managed by Aboriginal communities.
Alcohol treatment in Aboriginal settings 485
2014 Australasian Professional Society on Alcohol and other Drugs
ACCOs, their practices and values reect the groups
that established them and which they serve. These cul-
tural elements affect the relationships between Aborigi-
nal and mainstream organisations, implementation of
specic interventions within ACCOs, and patient
practitioner relationships. Concern with the initial
engagement of patients with a service, which conditions
future interactions, is a key element in the development
of Walan Girri; recognition of cultural differences is
central to modications to the AUDIT and Drinkless
materials by the SSWAHS team; and the clash of cul-
tural values and failure to recognise differences, high-
lighted in the AADS study, demonstrates how provision
of quality care can be undermined. Strategies for going
beyond rhetoric and ensuring the operationalisation of
culture in psychotherapeutic practice are outlined in a
review by Smith and others and these have broad appli-
cability in the Aboriginal AOD eld [33].
The potential of screening and BI
The potential for screening and BIs among Aboriginal
Australians has long been recognised. They are
included in the Medicare Benets Schedules Health
Assessment for an Aboriginal andTorres Strait Islander
Adult (Item 715) [34]. With qualications, use of
AUDIT and BIs is recommended in Aboriginal-specic
alcohol treatment guidelines and a guide to preventive
health assessment of Aboriginal people [13,35]. In
addition, either AUDIT or AUDIT-C is included in
two of the PIRS commonly used in ACCHSs. Never-
theless, a number of issues relating to screening
and BIs in Aboriginal settings have been identied
[13,3641].
Questions have arisen about the length of the
AUDIT and to address this, in non-Aboriginal popu-
lations, abbreviated versions have been tested in both
clinical and community-survey settings [30,42]. The
results show that AUDIT-C is effective in identifying
those drinking at hazardous levels and that a single
question on consumption from the AUDIT (How
often do you have six or more drinks on one occasion?)
is also useful in identifying those who drink at hazard-
ous levels [30].
Results of the NDARC project suggest that use of
either AUDIT-C or the single consumption question is
also effective in Aboriginal settings and is preferable to
use of the full AUDIT as a screening tool. While seem-
ingly at odds with SSWAHSs report that they success-
fully used the full AUDIT, SSWAHS was conducting
screening and alcohol awareness education in commu-
nity groups especially convened for the purpose without
the distraction of pressing health problems and busy
clinic schedules. In such situations, the full AUDIT can
provide a more nuanced assessment with the potential
for more appropriate intervention.
ACCHS clients have reportedly had difculty under-
standing some of the AUDIT questions that have had
to be claried and reworded [36,37]. Questions in the
PIRS used by the ACCHSs in the NDARC study are
similar to, but do not follow, the wording recommended
in the AUDIT manual. The SSWAHS team modied
the wording of the questions to suit the client group
and give some examples of this. This is consistent with
the AUDIT manual, which notes questions may need
to be adapted to specic languages, cultures and stand-
ards [29], and is appropriate given the documented
differences between Standard and Aboriginal varieties
of English [43].
Ascertainment of consumption levels is an issue, with
few people (Aboriginal or otherwise) having a clear
understanding of the concept of a standard drink and
the amounts poured or consumed as a drink generally.
The SSWAHS team simply recorded the number of
drinks reported by participants, judging that potential
loss of specicity . . . would be outweighed by
increased comfort for subjects in completing the
survey [23]. While a practical solution in a clinical (as
opposed to a research) setting, it would be useful to
attempt to quantify what is lost.
The SSWAHS paper raises the broader issue of com-
munity understanding of alcohol-related harm and
options for addressing it. Although the total number of
people screened was small, they tended to consume
alcohol episodically at high levels, had little knowledge
of current drinking guidelines and knew little about
interventions other than residential treatment. This
suggested that mass media campaigns have had little
impact, lack of knowledge of other interventions pre-
cluded their uptake and screening itself has a poten-
tially signicant role in raising awareness.
Partnerships in research in research and practice
Partnerships are a key element in reducing alcohol-
related harm among Aboriginal Australians [5], and
each of the papers addresses this issue. All involved
collaboration between AOD service providers and
university-based research centres. In four instances,
providers took the lead roles and, in the other, a
research centre did so but based on previously estab-
lished relationships with ACCHSs. As a consequence,
the projects tackled issues of relevance to the service
providers themselves.
The AADS paper highlights structural, historical,
cultural and personal impediments to effective partner-
ships. The partnership itself was involuntary (at least
from the perspective of AADS) and emerged from a
funding agency decision. It reected unequal power
486 D. Gray et al.
2014 Australasian Professional Society on Alcohol and other Drugs
relations between the funding agency and the non-
Aboriginal partners on the one hand and AADS on the
other, creating an atmosphere of distrust. This was
compounded by poor knowledge among partners of
each others services; divergent views regarding staff
skills and competencies, including the relative impor-
tance of clinical and cultural competencies; communi-
cation difculties; staff turnover; and the paternalism of
the funding agency. Despite these challenges, most staff
saw the value of partnerships, with the qualication that
they be voluntary, equitable, accountable and based on
trust, and that they engender community control.
In contrast, theWinnunga paper describes collabora-
tion between researchers and health service staff built
upon: existing relationships; strong community control,
ownership and management of the project; and consul-
tation with staff on implementation of the intervention.
Similarly, the partnership between SSWAHS, the Uni-
versity of Sydney and ACCHSs was successful because
relationships between partners had developed over a
considerable period prior to the current project. Such
research collaborations might be less fraught than those
between service providers, as the parties are not in
competition as providers often are.
A positive outcome of the program process was the
close network established between practitioners and
researchers. Staff from each of the projects met at work-
shops in which they shared ideas in the development of
research proposals and reports. They also shared train-
ing on screening and BIs and project materials. This
collegiate approach to project development and the
funding of projects was particularly suited to research in
ACCOs not established primarily to conduct research
and led to signicant improvements in research design,
process and outcomes. As such, the model provides an
efcient complement to research funding through
bodies such as the NHMRC, the processes of which are
time-consuming, challenge resources and processes
within small ACCOs, and require considerable work
with little likelihood of success.
Stafng
The difculties of recruiting qualied staff, high staff
turnover rates in the AOD eld in general, and the
Aboriginal eld in particular, have been highlighted
[44,45] and four of the ve papers discuss the negative
impacts of these. IntheWinnunga case, staff turnover led
to abandonment of a plan to conduct a post-intervention
evaluation survey and the other four projects highlight
intra- and inter-service difculties as a consequence of
these factors. In the Congress project, resignation of a
senior therapist and difculty in recruiting a replace-
ment delayed implementation and constrained collabo-
ration with other agencies. Similarly, the SSWAHS team
reported that staff turnover (among factors such as
funerals, illness and other external events) in their own
agency and their partner groups signicantly delayed
recruitment of participants; and the AADS paper iden-
tied staff turnover as a major challenge to the imple-
mentation of partnership arrangements. While these
problems are not easily resolved, they can be ameliorated
by planning for such contingencies and, as both the
Winnunga and AADS papers suggest, by developing
formalised program procedures to minimise disruption
and loss of corporate knowledge if staff move on.
All the projects emphasise the need for appropriate
staff development. As the NDARC andWinnunga proj-
ects highlight, this should be provided to staff at all
organisational levels. Furthermore, as exemplied by
the SSWAHS, AADS and Winnunga projects, this
should go beyond the simple provision of technical
skills to include awareness of the broader and cultural
contexts in which intervention takes place.
Short-term projects
The length of the overall program was constrained by
the funding period, and initially, it was planned to
conduct the individual projects over a 12-month
period. However, all projects exceeded this. This
problem was acute when, as in the case of the Congress
and SSWAHS projects, program structures and referral
networks had to be established and new staff recruited.
The short-term nature of projects exacerbates other
problems. The difculty of recruiting qualied staff
(particularly in rural and remote areas) is compounded
when agencies can offer only short-term employment
contracts. Furthermore, over short terms, delays neces-
sitated by recruitment, training, establishing collabora-
tive relationships and gaining community acceptance
have proportionately greater impact. This problem is
not unique to research projects and the adverse effects
of short-term funding and reporting cycles has
been highlighted elsewhere [46] and, in the case of
Aboriginal-specic AOD interventions, the number of
short-term funded projects has increased [6].
Formalisation
Clearly dened management structures and procedures
have been identied as elements of best practice in the
provision of Aboriginal AOD services [44]. The papers
highlight this and the need to formalise processes
within organisations. In the AADS project, problems
arose because of the failure to embed working arrange-
ments and commitments in policy and procedures. In
the Winnunga case, development of a formal screening
instrument, commitment by management and atten-
tion to the concerns and training of staff led to
Alcohol treatment in Aboriginal settings 487
2014 Australasian Professional Society on Alcohol and other Drugs
improved client engagement with the service. Embed-
ding screening questions and providing training led to
signicant increases in the number of patients screened
in the four ACCHSs in New South Wales. In addition,
within Congress, the formalisation of a comprehensive,
structured case management system apparently led to
improved access to care.
Ethical and rigorous Aboriginal health research
Each project illustrates the challenges and rewards of
conducting rigorous and ethical Aboriginal health
research. Jamieson et al. provide a useful review of the
emerging literature in this area, and principles to guide
research [47]. Issues discussed earlier, including small
samples due to recruitment difculties, modied study
protocols and extended timelines, along with the some-
times equivocal results consequent on these limitations,
are characteristic of many similar studies in Australia
and overseas. Concerns about the impact of these
factors on the scientic rigour of the research need to
be balanced by the overriding importance of Aboriginal
control of the research processfrom the identication
of the research topic and building the capacity of Abo-
riginal researchers to dissemination and implementa-
tion of results [48]. Each of the projects described here
has attempted to address these issues.
Conclusion
There is no simple way of reducing alcohol-related
harm in Aboriginal communities. It must be based on
Aboriginal control, addressed on a number of levels and
incorporate tested approaches. The extensive evidence-
based literature on interventions to reduce alcohol-
related harm cannot simply be transferred from
non-Aboriginal to Aboriginal settings. Interventions
need to be adapted to those settings and the best pro-
cesses for doing so need to be identied. The small
projects reported upon in this review are a signicant
step in this direction and show that important improve-
ments can be made with modest investment and a
collaborative approach, especially one that respect-
fully and collegiately explores the relevance of evidence
and expertise for Aboriginal people, services and
communities.
Acknowledgements
We wish to thank organisations and staff members who
participated in each of the projects conducted as part of
the Enhancing the management of alcohol-related
problems among Indigenous Australians program.
The program and the individual research projects were
funded by a grant to the NDRI from the (then)
Australian Government Deparmtnet of Health and
Ageing.The NDRI at Curtin University is supported by
funding from the Australian Government under the
Substance Misuse Prevention and Service Improve-
ment Grants Fund.
References
[1] Commonwealth Department of Human Services and
Health. National drug strategy household survey: urban
Aboriginal and Torres Strait Islander peoples supplement
1994. Canberra: Australian Government Publishing
Service, 1996.
[2] Australian Institute of Health &Welfare. Substance misuse
among Aboriginal and Torres Strait Islander people. Cat.
no. IHW 40. Canberra: Australian Institute of Health &
Welfare, 2011.
[3] Australian Bureau of Statistics. Census of population and
housingcounts of Aboriginal and Torres Strait Islander
Australians, 2011. Cat. no. 2075.0. Canberra: ABS, 2012.
[4] Australian Institute of Health and Welfare. Alcohol and
other drug treatment services in Australia, 20112012.
Drug treatment series 21. Cat. no. HSE139. Canberra:
AIHW, 2013.
[5] Ministerial Council on Drug Strategy. National drug strat-
egy: Aboriginal and Torres Strait Islander peoples comple-
mentary action plan 20032009. Canberra: National Drug
Strategy Unit, Australian Government Department of
Health and Ageing, 2006.
[6] Gray D, Stearne A, Wilson M, Doyle MF. Indigenous-
specic alcohol and other drug interventions: continuities,
changes and areas of greatest need. ANCD Research Paper
20. Canberra: Australian National Council on Drugs, 2010.
[7] Babor T, Caetano R, Casswell S, et al. Alcohol, no ordinary
commodity: research and public policy, 2nd edn. Oxford:
Oxford University Press, 2010.
[8] Shand F, Gates J, Fawcett J, Mattick R. The treatment of
alcohol problems: a review of the evidence. Canberra: Aus-
tralian Government Department of Health and Ageing,
2003.
[9] Proude E, Lopatko O, Lintzeris N, Haber P. The treatment
of alcohol problems: a review of the evidence. Sydney: Uni-
versity of Sydney and Sydney South West Area Health
Service, 2009.
[10] Haber P, Lintzeris N, Proude E, Lopatko O. Guidelines for
the treatment of alcohol problems. Sydney: University of
Sydney and Sydney SouthWest Area Health Service, 2009.
[11] Hunter E, Brady M, Hall W. National recommendations for
the clinical management of alcohol-related problems in
Indigenous primary care settings. Canberra: Common-
wealth Department of Health and Aged Care, 1999.
[12] Gray D, Saggers S, Atkinson D, Strempel P. Substance
misuse and primary health care among Indigenous Austral-
ians. Aboriginal and Torres Strait Islander primary health
care review: consultant report no. 7. Canberra: Australian
Government Department of Health and Aging, 2004.
[13] Australian Government Department of Health and Ageing.
Alcohol treatment guidelines for Indigenous Australians.
Canberra: Department of Health and Ageing, 2007.
[14] Gray D, Saggers S, Atkinson D, Wilkes ET. Substance
misuse. In: Couzos S, Murray R, eds. Aboriginal primary
health care: an evidence based approach, 3rd edn. Mel-
bourne: Oxford University Press, 2008:75587.
488 D. Gray et al.
2014 Australasian Professional Society on Alcohol and other Drugs
[15] Gray D, Saggers S, Wilkes E, Allsop S, Ober C. Managing
alcohol-related problems among Indigenous Australians:
what the literature tells us. Aust NZ J Public Health
2010;34:S345.
[16] Shakeshaft A, Clifford A, Shakeshaft M. Reducing alcohol-
related harm experienced by Indigenous Australians: iden-
tifying opportunities for Indigenous primary health care
services. Aust NZ J Public Health 2010;34(S1):415.
[17] Evans I, Conigrave K, Simpson L, Nasilai A, Kiel K, Wade
V Brief intervention: increasing access to the full range of
treatment services for alcohol problems for Aboriginal
and Torres Strait Australians. 2008. Available at: http://
ndri.curtin.edu.au/local/docs/pdf/publications/ (accessed
September 2013).
[18] Guthrie J, Lovett R, Dance P, Ritchie C, Tongs J. Wheres
your country? New approaches for working with problem-
atic alcohol use among Indigenous Australians in an urban
setting. Aborig Stud 2011;1:1007.
[19] Brown J, Hunter E, Conigrave K, dAbbs P, Boffa J,
Gallagher C Multidisciplinary care in the management of
substance misuse and mental health problems in Indig-
enous settings. 2008. Available at: http://ndri.curtin.edu.au/
local/docs/pdf/publications/R246.pdf (accessed September
2013).
[20] Taylor K, Thompson S, Davis R. Residential rehabilitation
for Indigenous Australians: service challenges and inter-
agency opportunities to enhance outcomes. Aust NZ J
Public Health 2010;34(S1):3640.
[21] Clifford A, Shakeshaft A. Evidence-based alcohol screening
and brief intervention in Aboriginal Community-
Controlled Health Services: experiences of health-care pro-
viders. Drug Alcohol Rev 2011;30:5562.
[22] Clifford A, Shakeshaft A, Deans C. Training and tailored
outreach support to improve alcohol screening and brief
intervention in Aboriginal Community Controlled Health
Services. Drug Alcohol Rev 2013;32:729.
[23] Conigrave K, Freeman B, Caroll T, et al. The alcohol
awareness project: community education and brief inter-
vention in an urban Aboriginal setting. Health Promot J
Austr 2012;23:21925.
[24] Lovett R, Dance P, Guthrie J, et al. Can I have a Walan
Girri? The development of an Indigenous-led model of
service development and delivery for problematic alcohol
use amongst Indigenous people in the Australian Capital
Territory. Australian Health Review, in press.
[25] dAbbs P, Togni S, Rosewarne C, Boffa J. The Grog Mob:
lessons from the evaluation of a multi-disciplinary alcohol
intervention for Aboriginal clients. Aust NZ J Public Health
2013;37:4506.
[26] Taylor KP, Bessarab D, Ukich V, Hunter L, Thompson SC.
Aboriginal-mainstream partnerships: exploring the chal-
lenges and enhancers of a collaborative service arrangement
for Aboriginal clients with substance related issues. BMC
Health Serv Res 2013;13:12. Available at: http://www
.biomedcentral.com/1472-6963/13/12 (accessed Septem-
ber 2013).
[27] Taylor KP, Thomson SC. Closing the (service) gap: explor-
ing partnerships between Aboriginal and mainstream health
services. Aust Health Rev 2011;35:297308.
[28] Low J, Gray D, Allsop S, Wilkes ET, Garrison E. Enhancing
the management of alcohol-related problems among Indig-
enous Australians: implementation plan. Perth: National
Drug Research Institute, Curtin University, 2013.
[29] Babor T, Higgins-Biddle JC, Saunders JB, Monteiro MG.
AUDIT: the alcohol use disorders identication test.
Guidelines for use in primary care, 2nd edn. Geneva: World
Health Organisation, Department of Mental Health and
Substance Dependence, 2001.
[30] Bush K, Kivlahan D, McDonnell M, Fihn S, Bradley K.
The AUDIT alcohol consumption questions (AUDIT-C):
an effective brief screening test for problem drinking. Arch
Intern Med 1998;158:178994.
[31] The Drinkless Program. New South Wales Health, Sydney
and South Western Sydney Local Health Networks.
2004. Available at: http://www.sswahs.nsw.gov.au/sswahs/
Drinkless/ (accessed September 2013).
[32] Lovett R. Mob and country: a role for identity in
alcohol screening for Indigenous Australians living in the
ACT and region. Canberra: Australian National University,
2013.
[33] Smith TB, Rodrguez MD, Bernal G. Culture. J Clin
Psychol 2011;67:16675.
[34] Australian Government Department of Health and Ageing.
Medicare benets schedule book professional attendances
category 1 operating from 01 January 2011. Canberra: Aus-
tralian Government Department of Health and Ageing,
2011. Available at: http://www.health.gov.au/internet/
mbsonline/publishing.nsf/Content/Downloads-201101
(accessed September 2013).
[35] National Aboriginal Community Controlled Health
Organisation. Royal Australian College of General Practi-
tioners & Chronic Disease Alliance of Non-Government
Organisations. National guide to a preventive health assess-
ment in Aboriginal and Torres Strait Islander peoples (pre-
pared by the National Aboriginal Community Controlled
Health Organisation as lead agency of the Chronic Disease
Alliance of Non-Government Organisations). Melbourne:
RACGP, 2005.
[36] Brady M, Sibthorpe B, Bailie R, Ball S, Sumner-Dodd P.
The feasibility and acceptability of introducing a brief inter-
vention for alcohol misuse in an urban Aboriginal medical
service. Drug Alcohol Rev 2002;21:37580.
[37] Sibthorpe B, Baille R, Brady M, Ball SA, Sumner-Dodd P,
Hall WD. The demise of a randomised controlled trial
in an urban Aboriginal medical service. Med J Aust
2002;176:2736.
[38] Panaretto K, Coutts J, Johnson L, Morgan A, Leon D,
Hayman N. Evaluating performance of and organisational
capacity to deliver brief interventions in Aboriginal and
Torres Strait Islander medical services. Aust NZ J Public
Health 2010;34:3844.
[39] Anderson JF. Screening and brief intervention for hazard-
ous alcohol use within Indigenous populations: potential
solution or impossible dream? Addict Res Theory
2007;15:43948.
[40] Brady M Are brief interventions culturally appropriate for
Aboriginal people? Issues of personal autonomy and inter-
personal authority. Presentation to Criminal Justice
Research Network Seminar, Sydney, 26 July 2007.
[41] Brady M. Giving away the grog: an ethnography of Aborigi-
nal drinkers who quit without help. Drug Alcohol Rev
1993;12:40111.
[42] Aalto M, Alho H, Halme JT, Sepp K. AUDIT and its
abbreviated versions in detecting heavy and binge drinking
in a general population survey. Drug Alcohol Depend
2009;103:259.
[43] Butcher A. Linguistic aspects of Australian Aboriginal
English. Clin Linguist Phon 2008;22:62542.
[44] Strempel P, Saggers S, Gray D, Stearne A. Indigenous drug
and alcohol projects: elements of best practice. ANCD
Alcohol treatment in Aboriginal settings 489
2014 Australasian Professional Society on Alcohol and other Drugs
Research Paper 8. Canberra: Australian National Council
on Drugs, 2003.
[45] Gray D, Green M, Saggers S, Wilkes ET. Review of the
Aboriginal andTorres Strait Islander community-controlled
alcohol and other drugs sector in Queensland. Brisbane:
Queensland Aboriginal and Islander Health Council, 2009.
[46] Dwyer J, ODonnell K, Lavoie J, Marlina U, Sullivan P.
The overburden report: contracting for Indigenous health
services. Darwin: Cooperative Research Centre for Aborigi-
nal Health, 2009.
[47] Jamieson LM, Paradies YC, Eades S, et al. Ten principles
relevant to health research among Indigenous Australian
populations. Med J Aust 2012;197:1618.
[48] Smith LJ. How ethical is ethical research? Recruiting
marginalized, vulnerable groups into health services
research. J Adv Nurs 2008;62:24857.
490 D. Gray et al.
2014 Australasian Professional Society on Alcohol and other Drugs