Aboriginal people experience a

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1 MINORITY GROUPS The oral health care experiences of NSW Aboriginal Community Controlled Health Services Megan A. Campbell, 1 Jennifer Hunt, 1 David Walker, 2 Rodger Williams 1 Aboriginal people experience a disproportionate burden of oral disease compared with other Australians. 1 In New South Wales (NSW), Aboriginal children have about twice the levels of dental caries for both deciduous and permanent teeth as non-aboriginal children 2 and, although dental caries is preventable, this situation is worsening in NSW and around Australia. 3 Available evidence suggests that the high prevalence of dental caries continues through life, with 57% of Aboriginal adults affected by caries compared with 25% of non- Aboriginal adults. 3 Periodontal disease is also more common among Aboriginal adults. 4 The impacts of oral disease on people s lives are pervasive. Dental caries and periodontal disease cause significant morbidity through pain, infection and tooth loss, resulting in deteriorating function. 3 Oral disease also contributes to the chronic disease burden through worsening of cardiovascular disease 5 and diabetes mellitus 6 outcomes two important causes of death and disability among Aboriginal people. 7 In Australia and internationally, oral disease is an indicator of deprivation, with population oral health mirroring the gradient of social and material conditions. 1,8 Aboriginal people are less likely to live in areas and have socioeconomic circumstances that support access to healthy foods, oral hygiene products and preventive and restorative care. 9,10 Aboriginal people may also access oral health services less often than their burden of disease necessitates because of distance, cost and cultural barriers. 1 Abstract Objectives: Aboriginal people continue to experience a disproportionately heavy burden of oral disease. A range of oral health services may be available to Aboriginal communities, including those provided by Aboriginal Community Controlled Health Services (ACCHSs). This study explored the oral health care experiences and activities of ACCHSs to inform policy and program decision making. Methods: Mixed methods, including an online survey and semi-structured interviews with senior ACCHS staff, were used. Areas of inquiry included perceived community need for oral health care, oral health care models, accessibility of other oral health services and barriers to providing oral health care. Twenty-nine NSW ACCHSs participated in the study. Results: The activities of NSW ACCHSs in oral health care are diverse and reflect the localised approaches they take to delivering primary health care. ACCHSs commonly face barriers in delivering oral health care, as do Aboriginal communities in accessing other oral health services. Conclusion: NSW ACCHSs are important but under-acknowledged providers of a range of oral health services to Aboriginal communities and are well placed to provide this care as part of their comprehensive primary health care model. Implications: ACCHS roles in improving Aboriginal oral health would be strengthened by greater acknowledgement of their contributions and expertise and the development of transparent, long-term funding policies that respond to community need. Key words: Aboriginal health, oral health, primary health care, dental services A variety of national and state policy and program responses to the poor oral health of Aboriginal peoples have included: Healthy Mouths Healthy Lives: Australia s National Oral Health Plan and Oral Health 2020: A strategic framework for dental health in NSW. 12 Each identifies Aboriginal communities as a key target group and acknowledges the need to improve access to oral health services for Aboriginal people. Until late 2012, the Medicare Chronic Disease Dental Scheme funded private dental care for adults with a chronic disease, including Aboriginal people 13 and as of 1 January 2014 the Child Dental Benefits Scheme funds basic dental care for eligible children. 14 In NSW, oral health services are provided by private dentists, public oral health services and Aboriginal Community Controlled Health Services (ACCHSs). ACCHSs provide culturally appropriate, comprehensive primary health care to Aboriginal communities 15 and this often includes oral health care. However, there is little published information on 1. Aboriginal Health & Medical Research Council, New South Wales 2. Faculty of Dentistry, University of Sydney, New South Wales Correspondence to: Dr Jennifer Hunt, Aboriginal Health & Medical Research Council, PO Box 1565, Strawberry Hills, New South Wales, 2012; jhunt@ahmrc.org.au Submitted: April 2014; Revision requested: June 2014; Accepted: August 2014 The authors have stated they have no conflict of interest. Aust NZ J Public Health. 2015; 39:21-5; doi: / vol. 39 no. 1 Australian and New Zealand Journal of Public Health 21

2 Campbell et al. Article the contribution of these services to the oral health of Aboriginal people or the challenges ACCHSs experience in delivering oral health care. This study was initiated by the Aboriginal Health & Medical Research Council (AH&MRC), the peak body for ACCHSs in NSW, to explore the oral health activities and experiences of NSW ACCHSs and make this information available to inform the future development of oral health policy and programs in NSW and elsewhere. Methods The study used a mixed methods approach and received ethics approval from the AH&MRC Ethics Committee. A project advisory group of AH&MRC staff provided oversight and guidance to the study. All 50 AH&MRC member services were invited to participate in the study, including 41 ACCHSs and nine Aboriginal Community Controlled Health Related Services (ACCHRSs). ACCHRSs provide specialist services to Aboriginal communities, such as drug and alcohol residential rehabilitation and aged care. Invitation to the study was through an to the chief executive officer of each service. To enhance response rates, the study was promoted via ACCHS staff networks coordinated by the AH&MRC. An online survey was developed using SurveyMonkey software. 16 Areas explored through the survey included the range of oral health services provided by ACCHSs, types of health professionals involved in the service, funding models and perception of community need for oral health care. The survey was completed by 27 of 41 ACCHSs (66% response), and two of nine ACCHRSs (22% response). In view of the low ACCHRS response rate, only the responses of ACCHSs have been included in this paper. Interviews were undertaken with a subgroup of participating ACCHSs to explore themes identified in the survey in greater detail. Purposive sampling was employed to recruit ACCHSs to the interviews to ensure a range of experiences and activities would be captured. The interview sampling frame included remoteness, region, ACCHS size and whether it reported delivering an oral health service. Nine ACCHSs were recruited to, and participated in, the interviews. Interviews were conducted by telephone and recorded using written notes including illustrative quotes. Case studies to illustrate aspects of ACCHS models of oral health service delivery were recorded as part of the interviews. Survey data were analysed quantitatively for questions with sufficient responses. Percentages were calculated using either all participating ACCHSs, or all those with an oral health service, as the denominator, as appropriate. Interviews were analysed qualitatively by the primary researcher who generated a list of themes and these were used to code the data. Emerging themes were also explored in subsequent interviews. Data and themes were discussed and interpreted with the project advisory group throughout the interview and analysis phases. A draft report was circulated to participating ACCHSs, and their feedback incorporated; permission was sought for the inclusion of case studies that identified the ACCHS involved. Results Oral health services delivered by ACCHSs Participating ACCHSs described a broad range of models for delivering oral health services to Aboriginal communities in NSW. Of the 27 ACCHSs that undertook the survey, 15 (56%) said they were delivering an oral health service at the time of the survey. Eight of these (30%) reported providing a full-time service, six (22%) a part-time service and one ACCHS (4%) an intermittent service. The service provided by the 15 ACCHSs with an oral health service differed in a variety of ways, including the specific services offered, workforce involved in delivering care, patient eligibility for services and payment arrangements including patient co-payments. ACCHSs participating in surveys and interviews identified a range of oral health services. These included: oral health promotion programs screening programs including at schools preventive oral health care including cleaning and scaling acute and emergency treatment restorations and root canal therapy surgery including procedures under general anaesthetic provision of oral hygiene products, dentures and mouth guards. ACCHS oral health teams varied from one or two oral health staff, who primarily offered acute oral health care, to larger teams that included Aboriginal Health Workers (AHWs), who had received specific oral health training and/or specialists such as oral surgeons. These larger teams reported being able to provide a broader range of services. Of the 15 ACCHSs with an oral health service, 14 (93%) employed a dentist, six (40%) a dental therapist, four (27%) an oral health therapist and three (20%) an AHW. Four ACCHSs (27%) said they employed other oral health professionals, including dental hygienists, an oral surgeon and an orthodontist. ACCHSs who participated in interviews were asked to reflect on factors affecting their oral health service model. They explained that the range of services provided was a balance or compromise between resources (availability of staff and funding) and local need; in particular, they reported attempting to fill gaps in oral health care available to the community through other services. Developing eligibility criteria for patients who could access ACCHS services was also described as being a compromise between meeting local needs and the limitations of ACCHS resources. Some rural and remote ACCHSs made oral health services available to all community members, both Aboriginal and non-aboriginal, and they noted this was because there were few alternative oral health services available. Other ACCHSs described more targeted eligibility criteria such as providing oral health care only to Aboriginal people and their families or to low income employed adults who were ineligible for public oral health care and unable to afford private care. In the survey and interviews, ACCHSs described a range of oral health linkages and partnerships between their ACCHS and other organisations, including with other ACCHSs, private dentists and public oral health services either locally or at the Sydney Dental Hospital. In one case, the oral health service was provided by the ACCHS and the Local Health District in partnership using Local Health District facilities (Case study 1). Interviewed ACCHSs described developing complex referral processes designed to ensure community members could access timely and affordable oral health care. These approaches included negotiating with private providers for reduced or waived fees, referring to a broad range of services around the state, providing transport and financial support to assist with fees. Transport and financial assistance were emphasised by participating 22 Australian and New Zealand Journal of Public Health 2015 vol. 39 no. 1

3 Minority Groups Aboriginal oral health ACCHSs as important strategies for increasing Aboriginal peoples access to oral health services. In reflecting on the broad range of strategies used by ACCHSs to find oral health care for community members, interviewed ACCHSs commented that this reflected the way ACCHSs provide care more generally, by using a range of opportunities and being resourceful when their services are unable to provide care directly. Participating ACCHSs described a range of funding models for oral health services in the survey and interviews. Funding from the Centre for Oral Health Strategy, NSW Ministry of Health was the only source of specific oral health funding identified. Ten ACCHSs (66% of those with oral health services) reported receiving specific oral health funding from the Centre for Oral Health Strategy. Other sources of funding used by ACCHSs to provide oral health care included core ACCHS funding, patient co-payments, private health insurance and until its closure the Medicare Chronic Disease Dental Scheme (CDDS). These sources of funding and revenue were relied on by all participating ACCHSs, including those receiving specific dental funding from the Centre for Oral Health Strategy. However, ACCHSs without specific dental funding appeared more likely to depend particularly on patient co-payments. Where ACCHSs used patient co-payments, these were calculated to take account of a range of factors such as Aboriginality, age, employment status and ability to pay. Case study 1 provides an example of a partnership model between an ACCHS and the Local Health District to provide oral health care to ACCHS clients. Case study 2 provides an illustrative example of a comprehensive and localised approach to ACCHS-delivered oral health care. Case study 1: Yerin Aboriginal Health Service, Wyong, Central Coast Yerin Aboriginal Health Service has partnered with its local government-sector organisation (Local Health District) to provide an oral health service to Yerin clients. This service, located at Local Health District facilities, operates two evenings each week. This model was developed by the ACCHS and Local Health District, with NSW Health funding, to address the high levels of acute and chronic oral disease in the local Aboriginal community and in recognition of the contribution of oral disease to poor health outcomes. Low-income, employed Aboriginal adults are targeted by the program, as they were judged to have the highest unmet need in the community. A liaison officer at Yerin assists the program by managing appointments, supporting patients, undertaking health promotion activities, ensuring the service is culturally appropriate and liaising with all stakeholders. Case study 2: Biripi Aboriginal Corporation Medical Centre, Taree, Mid North Coast Biripi Aboriginal Corporation Medical Centre offers comprehensive primary health care to the Taree community and integrates oral health care with general health and wellbeing. A wide range of services are provided to the local Aboriginal community including oral health promotion in schools, check-ups, cleaning and scaling, restorations, root canal therapy and adult and paediatric oral surgery under general anaesthetic. Biripi runs a holistic school screening program providing local primary school children with health screens that include oral health. Children are linked into Biripi for follow up and treatment. In the past three years, an estimated 1,600 to 1,700 patients attended the oral health service. Initially, a high number of extractions were being performed, due to the high burden of oral disease. However, Biripi staff reported this need has been largely addressed, allowing increased time to be spent on prevention and regular check-ups: We know that we re winning now with that kind of return of patients (for routine maintenance). Biripi staff reported a minimal need to refer to other oral health services because of the broad range of care they provide. Biripi has well-established relationships with private hospitals to ensure Biripi clients can access oral surgery, performed by Biripi staff. Barriers for ACCHSs in delivering oral health care Surveyed and interviewed ACCHSs described a range of different approaches to delivering oral health services and commented that this reflected the ACCHS approach to comprehensive and culturally appropriate primary health care for the local community. The challenges faced by participating ACCHSs in providing oral health services were common among those interviewed. They believed ACCHSs to be the most appropriate service to provide oral health care to Aboriginal communities; however, they described feeling frustrated that they were limited in their capacity to do so. Funding and workforce issues were identified as the two main barriers to ACCHSs providing oral health care and services. ACCHSs without an oral health service reported lack of funding to be the primary reason they were unable to provide an oral health service, and ACCHSs with oral health services reported insufficient funding to be the main barrier to providing the level of oral health service they felt was needed in the community: We just don t have enough funding to deal with the demand. People think we have unlimited resources, but we ve got less than [the Local Health District] have We have to work with what we ve got. Interviewed ACCHSs framed these issues in the context of broader funding issues, including the impacts of short-term and intermittent funding that is often broken into multiple streams. These ACCHS funding models were described as being an impediment to developing sustainable and effective health care models, including in oral health care. Interviewed ACCHSs reported being unaware of the reasons why some ACCHSs but not others received specific oral health funding, and they expressed concern about whether funding decisions were needs based. There were strong views that more funding should be available to ACCHSs for oral health services: There are a lot more problems in the Indigenous community than the rest of the community so that tells me that we should get more funding. The Medicare Chronic Disease Dental Scheme (CDDS), which the Commonwealth Government stopped during the course of this study, was described by some ACCHSs as an important additional source of revenue for oral health services; however, not all ACCHSs said their experience with the CDDS was positive. It was commented that the effort required to implement the necessary processes to claim through the CDDS had just started to be worthwhile when its closure was announced. Other interviewees reported that their ACCHS had decided against implementing these processes, given the resources required to do so and uncertainty of the future of the CDDS. Funding was also described as the main barrier to recruiting and retaining oral health staff. Eight of the 15 ACCHSs with oral health 2015 vol. 39 no. 1 Australian and New Zealand Journal of Public Health 23

4 Campbell et al. Article services (53%) reported difficulties with staff recruitment and retention, and this included those in urban, rural and remote regions. Interviewed ACCHSs explained that inadequate funding prevented ACCHSs from offering competitive salaries: To pay people properly...that s an AMS (ACCHS) struggle If we want to keep someone who is competent and qualified we d struggle because they really get very little money. We can t retain them They go and work for [the Local Health District]. We train them up and then they leave. For rural and remote regions, ACCHSs stated that location was a further barrier to recruiting and retaining oral health staff: Not only is it no funding it s trying to get dentists to country areas. These workforce challenges meant that oral health services were provided only intermittently by some ACCHSs, or that oral health care was dependent on fly-in fly-out oral health staff or visiting teams from the Sydney Dental Hospital. Interviewed ACCHSs with fly-in fly-out staff commented that while this model allowed oral health services to be provided at least some of the time, there were several challenges. These included the service being vulnerable to closure if staff were unable to continue attending, and the significant time and financial resources required of the ACCHS to negotiate visit dates, transport and accommodation requirements. It was also commented that this type of service is challenging for both fly-in fly-out staff and local staff as there is less time to develop ways of working together. Two ACCHSs described the experience of hosting a visiting oral health team from the Sydney Dental Hospital for 12-week periods. These ACCHSs reported similar issues to those with fly-in fly-out staff; temporary services placed considerable pressure on the ACCHS including needing to allocate support staff to prepare for the visit and manage appointments. Concern was expressed about services that roll into town for 8-10 weeks and then you never know if they re coming back. It was commented that these approaches, where the ACCHS had little control over the arrangements of the visit, could be disempowering for ACCHSs, and could be considered as inconsistent with community control. Finally, the high burden of oral disease in Aboriginal communities was identified by interviewed ACCHSs as an important challenge to providing oral health care. Of the ACCHSs surveyed, 23 (79%) stated that community need for oral health care was far from being met. Four ACCHSs (14%) said community need was only moderately being met and no ACCHS said community need was being met. During interviews, ACCHSs explained further, saying that, in some cases, sections of the community were having their needs met by the ACCHS or other services, but overall there was a high unmet need for oral health care in their communities. This high burden of oral disease was described as being a particular challenge for new ACCHS oral health services and also where ACCHS oral health services were limited. In these instances, interviewed ACCHSs reported having to catch up on the high level of acute oral health issues before they were able to address prevention and provide maintenance oral health care: There are so many patients and only limited appointments with the dentist They mostly see clients to relieve them of pain. Barriers for community members accessing private and public oral health services ACCHSs reported in surveys and interviews that many Aboriginal community members relied on public and private oral health care in addition to services provided by ACCHSs. However, several barriers to accessing both public and private oral health services were identified including distance, waiting times and cost. Interviewed ACCHSs emphasised the importance of providing transport for community members where distance to public oral health services was perceived as a barrier by community members. Surveyed ACCHSs reported variable public oral health service waiting times which ranged from less than three months to more than three years. Where waiting lists were particularly lengthy, interviewed ACCHSs said community members rarely contacted the public oral health service and viewed it as being inaccessible. ACCHSs commented in interviews that models of care differed between public oral health services and ACCHSs, and expressed concern that the public oral health care in their area was fragmented; there were reports that community members had complained that they received only minimal care before being returned to the waiting list. Interviewed ACCHSs reported concern that opportunities for oral health promotion had been missed because of a focus on acute problems. Racism was also reported by an ACCHS to be a barrier for Aboriginal people to access local public oral health services. Private oral health care was described in interviews as being relatively inaccessible to many Aboriginal people due to cost. The exception to this was accessing private care through the Medicare Chronic Disease Dental Scheme (CDDS). While some ACCHSs reported in interviews that the CDDS increased availability of private oral health services to the local community, others described feeling frustrated with its design and implementation. First, concern was expressed that the strict eligibility criteria excluded those with poor oral health who did not have chronic disease. Second, significant barriers were identified in accessing private oral health services through the CDDS, including limited availability of medical practitioners to provide referrals and of private dentists to provide care, and the unwillingness of some local dentists to participate: We approached all the local private dentists... Would they be interested in seeing our clients? And it was a flat no. Discussion The findings of this study provide a snapshot of the activities, experiences and challenges of NSW ACCHSs in oral health. Although not all NSW ACCHSs participated in the study, the sample included ACCHSs representing varying sizes, locations and levels of involvement in delivering oral health care. In addition, while a broad interview sampling frame was used, there were many similarities in the oral health experiences and challenges expressed. This suggests that the views contained in this report are likely to also reflect those of other ACCHSs in NSW. ACCHSs provide comprehensive culturally appropriate primary health care that is designed to meet the needs of their local community, 15 and for many ACCHSs in NSW this includes providing oral health care. Participating ACCHSs described offering a diverse range of oral health services that differed in several important aspects, including range of services offered, eligibility, co-payment requirements and funding models. These differing approaches were described by ACCHSs as reflecting a locally 24 Australian and New Zealand Journal of Public Health 2015 vol. 39 no. 1

5 Minority Groups Aboriginal oral health tailored response to the needs of their community within resource constraints. This is consistent with the literature on how ACCHSs provide care more broadly, by being grounded in local knowledge and directed by, and accountable to, the community. 15 ACCHSs are an important component of the health system generally, and of the oral health system. 15 ACCHSs offer several advantages in delivering oral health care over other service providers, including care being integrated with other health activities as part of comprehensive primary health care, and having the expertise to provide culturally appropriate support. Despite the important role of ACCHSs in the oral health system, they experience significant barriers to providing oral health care. ACCHSs in this study demonstrated an acute awareness of, and were affected by, the high burden of oral disease among Aboriginal peoples. The gap in oral health outcomes between Aboriginal and non-aboriginal children and adults is widely documented 1,3,4 and, despite several strategies and policies aimed at reducing this gap, the burden on communities remains large. 1 This study shows that this gap also creates challenges for ACCHSs in providing oral health care when community need is not matched by resources. Despite the efforts of ACCHSs to reduce barriers to private and public dental care, the combined oral health services of public, private and ACCHS-delivered oral health care is not meeting the needs of Aboriginal communities. ACCHSs consistently identified that inadequate and unstable funding is a major barrier to being able to provide increased oral health care. Some ACCHSs rely on mainstream programs, such as the CDDS, to support their service. While the CDDS ceased operating during this study, the concerns of ACCHSs regarding the CDDS identified in this study are likely to also relate to current and future government initiatives, including the Child Dental Benefit Scheme. 17 In particular, ACCHSs will be required to invest resources to establish processes for Medicare claiming through the Child Dental Benefit Scheme, and community members may continue to face access issues similar to the CDDS, where private dentists are unwilling to participate. ACCHSs are the only sector providing a broad range of essential primary health care services, including oral health services, from short-term fragmented funding that comes from multiple sources. 18 There is good evidence that ACCHSs are overburdened by current funding models and reporting requirements 18,19 and that adequately resourcing comprehensive primary health care over a long period of time can improve Aboriginal health outcomes. 20 Oral health funding, like other types of funding, needs to be long term to ensure sustainable and appropriate models of oral health service delivery can be delivered and supported. Increased levels of funding would allow ACCHSs to provide a broader range of oral health promotion and clinical oral health services to a larger proportion of Aboriginal communities. A transparent and needs-based approach to funding decisions is necessary to ensure the equitable and efficient distribution of available resources. To our knowledge, this is the first paper to outline the oral health experiences and activities of ACCHSs. Efforts to improve the oral health of Aboriginal communities would be strengthened by greater acknowledgement and consideration of ACCHS expertise and experiences in oral health. References 1. Williams S, Jamieson L, MacRae A, Gray C. Review of indigenous oral health. Aust Indigenous Health Bull. 2011;11(2): Centre for Oral Health Strategy NSW. The New South Wales Child Dental Health Survey Sydney (AUST): New South Wales Department of Health; Slade GD, Spencer AJ, Roberts-Thomson KF. Australia s Dental Generations: The National Survey of Adult Oral Health Canberra (AUST): Australian Institute of Health and Welfare; Jamieson L, Armfield JM, Roberts-Thomson KF. Oral Health of Aboriginal and Torres Strait Islander Children. Adelaide (AUST): Australian Research Centre for Population Oral Health; Demmer RT, Desvarieux M. Periodontal infections and cardivascular disease: The heart of the matter. J Am Dent Assoc. 2006;137: Taylor GW, Borgnakke WS. Periodontal disease: Associations with diabetes, glycaemic control and complications. Oral Dis. 2008;14(3): Centre for Epidemiology and Evidence. The Health of Aboriginal People of NSW: Report of the Chief Health Officer. Sydney (AUST): New South Wales Ministry of Health; Marmot M, Bell R. Social determinants and dental health. Adv Dent Res. 2011;23(2): Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander Social Survey, Canberra (AUST): ABS; The Cancer Council NSW. NSW Healthy Food Basket Cost, Availability and Quality Survey. Sydney (AUST): Cancer Coucil New South Wales; 2007 [cited 2014 Mar 3]. Available from: foodbasket 11. National Advisory Committee on Oral Health. Healthy Mouths Healthy Lives: Australia s National Oral Health Plan Adelaide (AUST): South Australian Department of Health; Centre for Oral Health Strategy NSW. Oral Health 2020: A Strategic Framework for Dental Health in NSW. Sydney (AUST): New South Wales Ministry of Health; Department of Health and Ageing. Dental Health: Chronic Disease Dental Scheme [Internet]. Canberra (AUST): Commonwealth of Australia; 2012 [cited 2014 Mar 3]. Available from: gov.au/internet/main/publishing.nsf/content/ dental+care+services 14. Department of Human Services. Child Dental Benefits Schedule [Internet]. Canberra (AUST): Commonwealth of Australia; 2014 [cited 2014 Mar 3]. Available from: medicare/child-dental-benefits-schedule 15. Couzos S, Murray R. Aboriginal Primary Health Care: An Evidence-based Approach. 3rd ed. Melbourne (AUST): Oxford University Press; SurveyMonkey: online survey tool software. Palo Alto (CA): SurveyMonkey; Plibersek T. $4 Billion Dental Spend on Children, Low Income Adults and the Bush. Media Release, 29 August Canberra (AUST): Aged and Community Services Australia; Martini A, Marlina U, Dwyer J, Lavoie J, O Donnell K, Sullivan P. Aboriginal Community Controlled Health Service Funding: Report to the Sector. Melbourne (AUST): Lowitja Institute; Dwyer J, O Donnell K, Lavoie J, Marlina U, Sullivan P. The Overburden Report: Contracting for Indigenous Health Services. Darwin (AUST): Cooperative Research Centre for Aboriginal Health; Griew R, Tilton E, Cox N, Thomas D. The Link Between Primary Health Care and Health Outcomes for Aboriginal and Torres Strait Islander Australians. A Report for the Office for Aboriginal and Torres Strait Islander Health. Canberra (AUST): Commonwealth Department of Health and Ageing; vol. 39 no. 1 Australian and New Zealand Journal of Public Health 25