Critically analyse access to a health services for a cultural group other than your own within our community. -- Aboriginal and/or Torres Strait Islanders (ATSI)

Table Of Contents

Title	1
1.  Introduction	3
2.   Aboriginal And Torres Strait Islander (ATSI) And Health Services	3
3.   Maternity Related Problems to Aboriginal And Torres Strait Islanders	4
4.   Difficulties In Offering Proper Maternity Care	6
5.   Recommendations: How maternity services and care can be improved for women of ATSI?	6
6.   Conclusion	8
7.   References	9

Introduction

A theory of social determinants identifies that health and inequality in population is established by several interrelated social factors. Similarly, it is a fundamental principle of human rights decree that all rights are integrated and that influencing on the pleasure of one right will influence the enjoyment of others. Due to this synergy, human rights discussion offers a framework for evaluating the likely health impacts of government programs and policies on Indigenous peoples. The social determinants affect the health status of the population indirectly and directly through lifestyle risk factors and access to, or/and utilisation of the health care system. In Australia, providing improvement and easy access to the health of the indigenous people is still a big challenge for the government of Australia. 

Aboriginal And Torres Strait Islander (ATSI) And Health Services

Aboriginal and Torres Strait Islander (ATSI) are the indigenous people of Australia with distinct histories, identities, and cultural practices.  The national statistics for them may mask significant geographic disparities in their health and social wellbeing. The health construct of ATSI is not merely regarding the physical wellbeing of the person. It is the cultural, emotional and social wellbeing of the whole community, a notion that is generally overlooked by conventional health services. It is thus expected that conventional health services suffer from added challenges in an attempt to gain the trust of Torres Strait Islander and Aboriginal people. The most prominent area suffering in this regard is the maternity.  Aboriginal and Torres Strait Islander females and children persist to experience greater rates of morbidity and mortality in comparison to non-Indigenous females and children (Kildea & Wardaguga, 2009). About delivery of such maternal care, ATSI health services put emphasis on the value of a holistic approach towards their health care, where mental, ethical and social wellbeing is associated with its cultural and historical context. Nevertheless, there is an uneven burden of unfavourable perinatal effects for mothers and their children of Aboriginal and Torres Strait Islander, including high maternal mortality rate.  And this rate is four fold high compared to Australian females. In ATSI there is wide difference in pre-term birth percentage (13.5% against 8.0%), perinatal deaths rates (17.1 percent against 8.8 percent per one thousands births) and low birth weight percentage (12.0 percent against 6.0 percent) ( Jongen,  McCalman , Bainbridge  & Tsey, 2014; Australian Bureau of Statistics, 2015).

The causes behind the sobering inequality are diverse and multifaceted.  This paper will critical analysis the maternity issue among ATSI women, difficulty to use maternity services for them owing to their culture and social determinant and will also present the recommendation to improve the current situation.

Maternity Related Problems to Aboriginal And Torres Strait Islanders

The maternity period is a unique stage of life for women since it may bring lots of challenges as well as opportunities with it. Since the reproductive health outcomes for mothers and infants of Aboriginal and Torres Strait Islander are considerably poorer; they even deteriorate with growing distance where the provision of such services becomes more difficult (Murphey & Best, 2012).  In fact, a lot of Aboriginal and Torres Strait Islander women at present do not have access to quality primary maternity care. Even in rural and distant areas such women in particular are being deprived of access to first-class care from the complete variety of health expertise. They can only receive such a care that is inconsistent and does not meet their social and cultural requirements.

At present the provision of maternity services to women of Aboriginal and Torres Strait Islander is greatly inadequate.  The pregnant women of ATSI often face seclusion from a partner, friends, family, and culture and society for the birth of their babies and this may cause a great impact on their wellbeing.  Too much stress, separation from familiar and fostering people, environment and cultural ways, brings about apprehension, sorrow and loneliness at a vital phase. While several urban promotes the values of family-friendly birth settings and offer choices for community midwifery services, a lot of female in remote areas and of Aboriginal and Torres Strait Islander face dislocation from the families (Hancock, 2009) and this serves as risk factors for causing high stress levels .  The use of alcohol tobacco and other drugs pregnancy in the women of this community is also found to be high which lack their proper health education and awareness.  Due to cultural difference women of ATSI feel uncomfortable for regular medical checkups and suffer from such unhealthy activities.

Difficulties In Offering Proper Maternity Care

The magnitude and lasting nature of disparity in provision of maternity care to Aboriginal and Torres Strait Islander women is partially due to cultural and traditional values of these people. The notion of gender specific scaffolds among ATSI people conveys that women and men have dissimilar needs, life experiences, degrees of authority, access to information from diverse sources to help decision making and approaches of expressing sickness(Kildea, Kruske, Barclay, & Tracy, 2010). Those dissimilarities impact on the manner that women and men of ATSI interact with the health services.  Furthermore, culturally, it is not easy for women of Aboriginal and Torres Strait Islander to seek medical help early in their pregnancy. For a large number of Indigenous women, their primary visit to a medical centre or hospital is on the day of labour.  As a result it becomes difficult to recognise antenatal complications in such women as early as possible and likewise, premature birth rates and mortality rates rise in them.

As with the Indigenous Australian population, family violence is an unseen concern. A study demonstrated that family violence causes major influence on the health of Indigenous women compared to women of other Australian groups.  Due to the family fear, they avoid consulting a health service and therefore escape those issues which can be prevented if detected earlier. Early and ongoing maternity care facilitates a plan of care to be made in the first trimester. Lack of care and late visiting to get the antenatal care increases the rates of perinatal morbidity and mortality (Rumbold et al, 2012). This also affects their reproductive health outcomes and presents challenges to healthcare provider to identify them and offer them with pertinent treatment accordingly. The ATSI women have least awareness regarding how to be cautious in pregnancy because they lack a proper health education due to less exposure to it. Women with comorbidities need to be conscious of the effect of their diseases on pregnancy, in addition to, the effect of pregnancy on their existing health comorbidity.  

Additionally, social, financial and psychological problems which generate stress, a lack of control over situations and unproductive self-management are believed to be the greater determinants (Whiteside, Tsey & Cadet, 2009).  Their financial resources are less which also prevent them for undergoing proper medical advice and help.

Recommendations: How maternity services and care can be improved for women of ATSI?

In spite of cultural and social resistance, it is the duty of the health care provider to provide culturally safe maternity health care. A policy should be developed which tackle such issues and endorses education of not only indigenous women but also of practitioners regarding delivery of maternity services to challenging patients.  Since cultural, spiritual, and social wellbeing is very important to the people of Aboriginal and Torres Strait Islander it is imperative that their health needs be considered in this background. Cultural safety offers a practical framework to improve the provision of maternity services to ATSI women and their families (Reibel & Walker, 2010).  This can be offered by developing a multi-agency move towards service delivery in line with the fact that maternity services for indigenous people cannot address health inequalities singly.

“The Council of Australian Governments (COAG) recognises that strategies aimed at achieving improvements in any particular area will not work in isolation – the building blocks must fit together through the integration of policy ideas and an agreed approach to their implementation” (Aboriginal Health Council of Western Australia, 2011)

It is the duty of the government as well as health practitioner to make sure that Aboriginal and Torres Strait Islander women should have access to first-rate maternity services. And, these services must be culturally safe, offer continuous care and access to the greatest expertise (Australian Government, 2009). Nurses can help filled the gap by enhancing communication, by addressing social, cultural and emotional health needs of and Aboriginal and Torres Strait Islander women.  Considering the disparity in health services to indigenous community, the nurses can play a role in improving the care of Aboriginal and Torres Strait Islander pregnant women by removing those disparities and giving equal treatment opportunities.  They can encourage women living in rural or remote areas to get an early maternal care and can work to get them access to such services. Early access to maternity service is a sign of the victory of this approach (Bar-Zeev, Barclay, Farrington & Kildea, 2012).

Conclusion

In conclusion, there are growing rather than declining challenges to the provision of safe maternity services to Aboriginal and Torres Strait Islander women. Transforming the approach care is delivered could endorse significant improvements. The cultural aspect should be considered because it is from within the community and culture that actual optimistic changes in the people’s health commence.

References

AHMAC (2012). Aboriginal and Torres Strait Islander Health Performance Framework 2012 report. Canberra: AHMAC.

Australian Bureau of Statistics (2015). 'Births, Australia, 2014', ABS, Canberra, Retrieved from: <www.abs.gov.au>.

Australian Government (2009). Steering Committee for the Review of Government Service Provision, Overcoming Indigenous Disadvantage Report. Canberra, ACT: Commonwealth of Australia: Retrieved from: http://www.pc.gov.au/research/ongoing/overcoming-indigenous-disadvantage/key-indicators-2014

Bar-Zeev SJ, Barclay L, Farrington C, Kildea S. (2012). From hospital to home: the quality and safety of a postnatal discharge system used for remote dwelling Aboriginal mothers and infants in the top end of Australia. Midwifery 28, 366–373.

Hancock, H. (2009). Low birth weight in Aboriginal babies: A need for rethinking Aboriginal women’s pregnancies and birthing. Women and Birth 20, 77–80.

Heffernan, B., Iskandar, D. & Freemantle, J. (2012), The History of Indigenous Identification in Victorian Health Datasets, 1980-2011: Initiatives and Policies Reported by Key Informants. Lowitja Institute, Melbourne.

Jongen C,  McCalman J , Bainbridge R and Tsey K. (2014). Aboriginal and Torres Strait Islander maternal and child health and wellbeing: a systematic search of programs and services in Australian primary health care settings. BMC Pregnancy and Childbirth, 14, 251.

Kildea S, Kruske S, Barclay L, Tracy S (2010) ‘Closing the Gap’: How maternity services can contribute to reducing poor maternal infant health outcomes for Aboriginal and Torres Strait Islander women Rural and Remote Health 10, 1383. 

Kildea S, Wardaguga M. (2009). Childbirth in Australia: Aboriginal and Torres Strait Islander Women. In: H Selin, P Stone (Eds). Childbirth across cultures, ideas of pregnancy, childbirth and the postpartum period in many of the worlds cultures. Amherst: Springer, 275-287.

Murphey E, Best E. (2012).  The Aboriginal Maternal and Infant Health Service: a decade of achievement in the health of women and babies in NSW. N S W Pub Health Bull 23, 68–72.

Reibel, T & Walker, R. (2010). Antenatal services for Aboriginal women: the relevance of cultural competence. Quality in Primary Care 18, 65–74.

Rumbold, A, Bailie, R, Si, D, Dowden, M, Kennedy, C, Cox, R, O’Donoghue, L, Liddle, H, Kwedza, R & Thompson, S. (2011).Delivery of maternal health care in Indigenous primary care services: baseline data for an ongoing quality improvement initiative’, BMC pregnancy and childbirth 11, 1, 16.

Whiteside M, Tsey K, Cadet-James Y. (2009). Empowerment as a social determinant of Indigenous Australian health - the case of the Family Wellbeing Programme. In Social Work and Global Health Inequalities. Edited by Bywaters P, McLeod E, Napier L. Bristol, UK: Policy Press; 165–171.

Diagnostic Accuracy

Diagnostic Accuracy

Diagnosis and management of cardiac disease represents most important challenges to the present health care system, influencing a great number of patients every year. However, the accurate diagnosis of cardiac disease has been possible now by means of several important tests, including Exercise test, Routine Echo study, Coronary CT study, Stress Echo and Cardiac Catheterization. Additionally, early diagnosis of chest pain and assessment of risk for heart attacks can help prevent complications in the long run.

Exercise or stress testing is one of the simple yet well-established tests that have been in common clinical use for several decades. Exercise stress testing offers a less expensive, non-invasive technique of risk stratification before coronary angiography, and if it comes to be negative, then it may actually suggest avoiding angiography (Ellestad, 2003). Exercise testing has a specificity of 70% and a sensitivity of 78% for identifying any disease in the coronary artery. Therefore, it cannot be employed to diagnose ischaemic heart disease unless the chance of coronary artery disease is taken into consideration (Whaley, Brubaker, Otto and Armstrong, 2006).

Stress testing is often performed for an early assessment of patients with suspected heart disease, particularly coronary heart disease. Stress testing has been in use since the late 1920s as a suitable, non-invasive way to evaluate exercise induced myocardial ischemia (Master and Oppenheimer, 1929).  The myocardial oxygen demand is increased by the exercise increases and it may not be met when a stenosis of a coronary artery is present, leading to ischemia of the heart muscles. This is presented as a change in ST segment on the ECG, in addition to symptoms. ST segment depression is the most consistent indicator of ischaemia induced by exercise.  

Echocardiography, on the other hand, has raised the diagnostic precision of non-invasive cardiac assessment. It helps to monitor cardiac functions. By the help of sound waves Echocardiography differentiates body tissues of dissimilar density.  This test is required where there is complaint of heart murmur, heart attack, unexplained chest pains, congenital heart defect and rheumatic fever. It determines the shape and size of the heart along with how well it is working (Yong, Wu, Fernandes, Kopelen, Shimoni, Nagueh et al., 2002). It also helps to identify the problems with the heart’s valves and thrombosis formation within the vessels. A number of different types of echocardiography are performed nowadays, including Doppler echocardiography, M-mode echocardiography, Stress echocardiography, etc. The sensitivity and specificity of echocardiography are 80% and 100% with regard to ventricular dysfunction and heart failure respectively (Yong, Wu, Fernandes, Kopelen, Shimoni, Nagueh et al., 2002).

Stress echo usually involves the utilisation of Doppler and 2-D echocardiography to verify the doubt of coronary artery disease, and in case the disease is present, it helps to find out its severity (Elhendy, Windle and Porter, 2001). This test is carried out at rest and following pharmacological or physical stress and the images obtained are then compared with each other. It is performed as soon as the patient is asked to stop exercising in order take images of the heart functioning under stress. This test is harmless non-invasive and has rare complications. The results from echocardiography stress test are quite reliable.

Coronary computed tomography is a cardiac imaging test that assists in determining if thrombosis formed has constricted the coronary arteries of a patient (Hoffmann, Shi and Schmitz, 2005). Coronary arteries are the main blood vessels that supply blood to the heart. Thrombosis or plaque is composed of different substances present in the blood, for example calcium, cholesterol, and fat that deposit inside the arteries.

Computed tomography, also known as a CT scan, is a similar diagnostic test to conventional x-rays, but it generates numerous images of the inside of the body.  Coronary CT angiogram procedure utilizes intravenous dye containing iodine (Kuettner, Beck, Drosch, et al., 2005). Coronary CT serves as a major new test in the diagnosis of coronary artery disease. This test plays a great role in the diagnosing of diseases in patients with high risk of developing coronary disease, and in those patients who have undecided findings with treadmill or other medical testing (Achenbach, Giesler, Ropers,et al., 2001). The patients at high risk are usually cigarette smokers, diabetics, patients with high levels of cholesterol and hypertensive patients.

In case the CT scan comes out normal or shows only mildly abnormality, the chances of a severe obstruction of the coronary arteries decrease. On the other hand, if the CT scan is considerably abnormal, then the need of cardiac catheterization may occur, in order to see if stenting, angioplasty, or coronary bypass surgery is required.

A cardiac catheterization, also known as angiogram, is a procedure that helps to get the direct information of the patterns of blood flow and blood pressures within the heart. The catheterization is basically placing of small intravenous tubes in the artery and vein of a leg, neck or the arm (Leopold and Faxon, 2015). Via these intravenous tubes the thinner tubes, known as catheters, are passed into the circulation. This catheter is then moved slowly via the circulation so that it reaches the heart. From the heart it is then passed to certain chambers of the heart and to the arteries and veins joined to the heart. The pressures in the cardiac chambers can be measured.   Most of the time during this process of catheterization an angiogram is also carried out. This is performed by injecting a dye or contrast via the catheter into a chamber or a blood vessel of the heart.  As the dye is perceptible by X-ray, the blood flow through the heart is noted. Valves and blood vessels also become visible and evaluated for abnormalities. An angiogram needs much more X-rays compared to a simple chest X-ray’s need (Leopold and Faxon, 2015). Hence, the test is done only when there is an absolute indication. Nevertheless, a number of studies have been established no long-term adverse effects of angiography and cardiac catheterization in people who had undergone such tests.

Thus, a prompt and precise assessment of acute chest pain has enormous implications for morbidity and mortality of the patient as well as health care economics (Schillinger, Sodeck, Meron, Janata et al., 2004).  The majority of patients with chest pain in the emergency department have no bothersome electrocardiographic abnormalities, in addition to any history of coronary artery disease. Same is the case with Fed and this presents a little challenge to physicians. In this regard, for this particular patient, the most appropriate tests would be Echocardiography and Coronary CT. These tests are chosen because via echo the structure and function of heart of the patient can be evaluated and through Coronary CT the coronary arteries can be assessed. In this way, several causes of chest pain pertaining to heart can be indentified and excluded.

The principal goal of the assessment of patients with sudden chest pain in the emergency department is precise risk stratification and detection or exclusion of acute coronary syndromes, rather than the identification of coronary artery disease (Sun, Lin, Davidson, Dong et al., 2008). According to a research by Tong, Kaul, Wang et al (2005) echocardiography not only provides information regarding the shape and size of the heart but also reveals areas of scanty blood flow to the heart, regions of cardiac heart muscle not contracting normally, and preceding injury to the cardiac muscle as a result of poor blood flow. Overall, it gives a complete picture and is simple to detect the causes of chest pain by detecting poor flow of blood to the cardiac muscles.

Likewise, coronary CT approach helps established the immediate cause of chest pain i.e. acute coronary syndrome and also reveals cardiac problems in high risk patients as mentioned above.  A study by Laudon et al (2010) found cardiac coronary CT approach specific for the evaluation of possible acute coronary syndrome; the quantification of coronary artery calcium. The elevated the coronary artery calcium score, the greater the likelihood of an unstable plaque present in the coronary artery tree that may associate with a patient's chest pain. A studies by Chang, Choi, Choi, et al. (2008) and Goldstein, Gallagher, O'Neill, et al. (2007) stated that cardiac CT angiography facilitate early discharge of patients and also lower the cost than common standard assessment algorithms. Hoffmann U, Nagurney, Moselewski, et al. (2006) studied coronary CT angiography and found the 100% sensitivity for distinguishing acute coronary syndrome while the specificity found was 54%.

Conversely, other tests like Stress echo and stress testing require patient being stable and capable of undergoing a physical activity. Since Fred is in pain and has an arthritis and walk with the support of a cane, therefore he cannot undergo such testings. No doubt, stress testing is the first line diagnostic test, yet considering the condition of the patient, this test cannot be advised here.  It is his right to be comfortable while undergoing cardiac evaluation. Cardiac catheterization is little invasive and is not needed for now when non-invasive can help established the diagnosis. Furthermore, it is done when other factors or tests suggest that a person has chronic heart disease (Maron, Stone, Berman, Mancini, et al., 2011).

In Fred, the test will carried out with the following order. At First, the routine Echo study will be carried out in order to check the function and structure of the heart. It is better to go with the non-invasive first considering the condition of this patient (Sharples, Hughes, Crean, Dyer et al., 2007).  Following this coronary CT study will be conducted to determine the cause within the coronary arteries since the use of coronary calcium scoring via coronary CT is a first line testing approach for lower risk groups, as it is expected to be cost-effective.

The probable outcomes from echocardiography and coronary CT scan would be helpful for the detection of cause of chest pain associated with the heart. Patients with chest pain of sudden origin may have vague results from tests like ECG and thus needs not only functional imaging but further testing. Also, early testing has been shown to improve the health outcomes of the patients.  The most probable outcomes in Fred would be the detection of presence of areas of heart where blood supply is poor or presence of plaque or thrombosis in the coronary artery causing obstruction to blood flow and a chest pain. These tests will help in either detecting or excluding possible cause of chest pain related to heart. If the cause is linked to the problems in the heart, it can be easily detected via both of the selected tests. Since, the frequency of non-cardiac causes of chest pain is common too, these test will help to find whether the cause of chest pain is cardiac or non-cardiac.

References

Achenbach S, Giesler T, Ropers D, et al. Detection of coronary artery stenoses by contrast-enhanced, retrospectively electrocardiographically-gated, multislice spiral computed tomography. Circulation. 2001; 103:2535–2538.

Chang SA, Choi SI, Choi EK, et al. Usefulness of 64-slice multidetector computed tomography as an initial diagnostic approach in patients with acute chest pain. Am Heart J. 2008;156:375-383 

Elhendy A, Windle J, Porter T. Safety and feasibility of dobutamine stress echocardiography in patients with implantable cardioverter defibrillators. Am J Cardiol 2003;92: 475-7.

Ellestad MH. Stress testing : principles and practice. Oxford; New York: Oxford University Press; 2003.

Goldstein JA, Gallagher MJ, O'Neill WW, et al. A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol. 2007;49:863-871 

Hoffmann MH, Shi H, Schmitz BL, et al. Noninvasive coronary angiography with multislice computed tomography. JAMA. 2005; 293:2471–2478.

Hoffmann U, Nagurney JT, Moselewski F, et al. Coronary multidetector computed tomography in the assessment of patients with acute chest pain. Circulation 2006; 114:2251-2260.

Kuettner A, Beck T, Drosch T, et al. Diagnostic accuracy of noninvasive coronary imaging using 16-detector slice spiral computed tomography with 188 ms temporal resolution. J Am Coll Cardiol. 2005; 45:123–127.

Laudon DA, Behrenbeck TR, Wood CM, et al. Computed tomographic coronary artery calcium assessment for evaluating chest pain in the emergency department: long-term outcome of a prospective blind study. Mayo Clin Proc. 2010; 85(4):314-322

 Leopold JA, Faxon DP. Diagnostic Cardiac Catheterization and Coronary Angiography. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J.eds. 'Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill2015.

Maron DJ, Stone GW, Berman DS, Mancini GB, Scott TA, Byrne DW, Harrell FE Jr, Shaw LJ, Hachamovitch R, Boden WE, Weintraub WS, Spertus JA. Is cardiac catheterization necessary before initial management of patients with stable ischemic heart disease? Results from a Web-based survey of cardiologists. Am Heart J.  2011, Dec; 162(6):1034-1043.

Master A, Oppenheimer E. A simple exercise tolerance test for circulatory efficiency with standard tables for normal individuals. Am J Med Sci. 1929; 177:223–43.

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Sharples L, Hughes V, Crean A, Dyer M et al. Cost-effectiveness of functional cardiac testing in the diagnosis and management of coronary artery disease: a randomised controlled trial. The CECaT trial. Health Technol Assess. 2007; 11 (49):1-115.

Sun Z, Lin C, Davidson R, Dong C et al. Diagnostic value of 64-slice CT angiography in coronary artery disease: A systematic review. Eur J Radiol. 2008; 67 (1):78-84.

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Yong Y, Wu D, Fernandes V, Kopelen HA, Shimoni S, Nagueh SF et al. Diagnostic accuracy and cost-effectiveness of contrast echocardiography on evaluation of cardiac function in technically very difficult patients in the intensive care unit. Am J Cardiol 2002; 89:711–8.