CHRONIC KIDNEY DISEASE IN THE INDIGENOUS

POPULATION (PUBLIC HEALTH)

z5113058

AUGUST 21, 2017

WORD COUNT = 1932
Criteria
1. Detail the socio-economic risk factors of chronic kidney disease with respect to the Australian
Indigenous population.
(1.2.1 Identifies environmental, psychological, social and cultural issues which contribute to health
problems in a scenario (e.g. sexuality, stress, family relationships, risky behaviours))
2. Outline the specific health care needs of the Australian Indigenous population that are addressed
currently by Australian healthcare, specifically in relation to chronic kidney disease?
(1.2.3 Identifies health care needs of different groups in society (e.g. the elderly, indigenous people,
immigrant groups and refugees).)
3. Assess the equity of healthcare provision, comparing the Indigenous and general population's access
to facilities required of chronic kidney disease.
(1.2.5 Understands equity and its implications for health care delivery for individual and population
based approaches.)
4. Outline some of the barriers that may prevent Indigenous Australians from accessing the services they
need to treat chronic kidney disease?
(1.2.7 Describes how people living in Australia access (or are unable to access) their health care system.)

Chronic Kidney Disease in Indigenous Australia

Risk factors of Chronic Kidney Disease Relevant to the Indigenous Population
There is a large variety of risk factors that affect the risk of chronic kidney disease, relevant to
the indigenous population. Some of these will be discussed in more detail in this section.

Table 1 Risk factors of chronic kidney disease relevant to Aboriginals (Australian Institute of Health and Welfare, 2011)

Hypertension
It has been definitively shown that Stage 2, 3 and 4 hypertension has been correlated with a
higher risk of developing chronic kidney disease in men (see Table 2). There are, unfortunately,
not many studies that study hypertension as a risk factor for chronic kidney disease in females
(Haroun et al., 2003).
 Table 2: Relative risk of chronic kidney disease in men given the underlying hypertensive disorder (Klag et al., 1996)

Hypertension is also more common among Aboriginals compared to the non-indigenous

population (see figure 1), with an indigenous person being 1.2 times more likely to have
hypertension compared to a non-indigenous person. Here hypertension is defined as having a
blood pressure greater than 140/90.

Figure 1: Comparison of Hypertension incidence among indigenous and non-indigenous populations (Australian Bureau of
Statistics, 2015)
Low Birth Weight
Low birth weight is a risk factor for chronic kidney disease, as birth weight is directly related to
kidney size and thus, nephron count in the adult kidney (Figure 2) (Spencer, Wang, & Hoy,
2001).
Furthermore, low nephron number is associated with glomerular hypertension (figure 3,
resulting in a higher probability of getting chronic kidney disease (Hoy, Hughson, Singh,
Douglas-Denton, & Bertram, 2006).
Indigenous babies have a lower average weight compared to non-indigenous babies (Table 3)
and this is a risk factor for developing chronic kidney disease.

Figure 2: The observed linear relationship between birth weight and glomerular number (Hughson, Farris, Douglas-Denton, Hoy,
& Bertram, 2003)

Figure 3: Average glomerular number of subjects sorted by whether they have hypertension or not (Hoy et al., 2006)
Table 3: Birthweight for indigenous vs. non-indigenous babies (Australian Institute of Health and Welfare, 2014)

Tobacco Smoking
Smoking is a major risk factor for chronic kidney disease, and it is especially relevant to the
aboriginal population as there is a much higher rate of tobacco smoking among indigenous
Australians compared to non-indigenous.
The relative risk of chronic kidney disease for a former smoker is 1.14 compared to a non-
smoker, and the relative risk is 1.38 for a current smoker(Shankar, Klein, & Klein, 2006).
According to data from 2008, Indigenous Australians aged 15 and over were greater than twice
as likely to be smokers when compared to the corresponding non-indigenous population
(Australian Institute of Health and Welfare, 2011).

Table 4: Smoking rates by indigenous status (Australian Institute of Health and Welfare, 2011)

Australian Healthcare and Indigenous Health Needs

Availability of Health Resources in Remote and Rural Areas
Those suffering from chronic or end stage renal disease will require access to dialysis
equipment for either peritoneal dialysis or haemodialysis, unless the patient receives a renal
transplant (Australian Indigenous HealthInfoNet, 2017).
In the case of indigenous patients living in remote areas, they may be forced to move to
regional centres or cities to receive adequate treatment. In doing this, they are often subject to
socio-cultural alienation, which can be very debilitating. However, as of 2013, dialysis
equipment is available to patients in remote communities. Once cleared by their nephrologist,
they can undergo self-care training and then can manage themselves at their homes, given the
dialysis equipment (Stumpers & Thomson, 2013).
Subsidisation of Healthcare Costs for Indigenous Patients in Need
Many indigenous Australians, especially those living in remote areas may not have the finances
required for the health costs that chronic kidney disease would necessitate.
As per the Indigenous Australians Health Program, indigenous patients receive funding towards
most of the financial costs of chronic kidney disease, for example, the clinical consultations,
specialist consultations, dialysis equipment and even transport costs (Australian Government
Department of Health, 2017).

Equity In Chronic Kidney Disease, Indigenous vs. Non-Indigenous

According to Braveman and Guskin in their 2003 article, equity can be defined as an ethical
value, inherently normative, grounded in the ethical principle of distributive justice and
consonant with human rights principles. In essence equity refers to a state in which all
population groups have an equal opportunity to be healthy, implying resource allocation
targeting disadvantaged population groups in order to equalise them with the non-
disadvantaged population group (Braveman & Gruskin, 2003).
In assessing the equity of chronic kidney disease management between Indigenous and Non-
indigenous Australians, the following criteria are assessed-
1. Healthcare funding
2. Access to the required health facilities and staff
3. Access to dialysis equipment

Aboriginal Australians are 2.1 times more likely than non-Aboriginals to have chronic or end
stage kidney disease (Australian Bureau of Statistics, 2014). Thus, in order to achieve equity,
Aboriginals must receive more funding and access to healthcare compared to the non-
Indigenous population.
According to data from 2006-07, 12% of hospital CKD expenditure was for indigenous
Australians, and expenditure per person for indigenous Australians was $187 compared to $33
for non-indigenous Australians (Australian Institute of Health and Welfare, 2011).
Data also shows that Aboriginals have a higher rate of dialysis treatment compared to non-
indigenous patients. There is also a higher rate of kidney transplants for indigenous Australians
as opposed to non-indigenous Australians (table 5) (Australian Government Department of the
Prime Minister and Cabinet, 2014).
However, it is important to note that aboriginals living in remote areas are at a greater risk of
kidney disease compared to those living in regional or urban areas (Australian Institute of
Health and Welfare, 2011). As seen in table 6 there is also a significantly larger proportion of
Aboriginal Australians living in remote areas when compared to their non-indigenous
counterparts (Australian Bureau of Statistics, 2013). Often, in order to receive adequate
treatment, people living in remote areas might have to relocate to regional or urban areas.
Since connection to the land is a vital part of Aboriginal identity, this having to relocate may
have a significant detrimental effect on their emotional and social wellbeing (Australian
Indigenous HealthInfoNet, 2017). This is an important factor to consider, as the same
disadvantage is not as pronounced for non-indigenous Australians suffering from chronic or end
stage kidney disease, due to the fact that a high proportion of them live in urban or regional
areas and have adequate access to the required healthcare (table 6) (Australian Bureau of
Statistics, 2013).

Table 5: Dialysis and transplant treatment rates by Indigenous status (Australian Government Department of the Prime Minister
and Cabinet, 2014)

Table 6: Residence of the Australian population by indigenous status and remoteness (Australian Bureau of Statistics, 2013)

The higher proportion of Aboriginals living in remote areas is also important when considering
their access to healthcare facilities and staff, but access to indigenous healthcare staff is
another important requirement for an aboriginal patient. As can be seen in table 7, the number
of aboriginal general and specialist medical practitioners is extremely low, especially in remote
areas. Most of the aboriginal practitioners live in urban areas, which does not reflect the need
for more practitioners in remote areas (Australian Institute of Health and Welfare, 2009).
Table 7: Medical workforce by indigenous status (Australian Institute of Health and Welfare, 2009)

Considering the above points, while the equity of healthcare delivered to indigenous chronic
renal patients is by no means perfect, the government has made substantial efforts to make
sure that the nations healthcare resources are delivered to them. With $881 million in health
care expenditure specifically targeted on Aboriginal health for the 2017-18 budget, it is sure
that Australia is progressing towards a more equitable healthcare system (Cutler & Olin, 2017).

Indigenous Australians: Barriers to Healthcare Access for Chronic and End Stage Kidney
Disease
Unavailability of Indigenous Health Care Workers
Proper treatment of indigenous patients requires the presence of indigenous health care
workers that can attend to the specific social, emotional and medical needs of an indigenous
patient (Australian Indigenous HealthInfoNet, 2017). As was discussed in the previous sections,
many aboriginals, especially those in remote areas are unable to access healthcare from
aboriginal practitioners. This is a problem that must be addressed in the future, to help
aboriginals access the healthcare system.
Distance to Medical Facilities
For the sizeable proportion of Aboriginal Australians living in remote areas, access to healthcare
is much more difficult due to the distance that must be travelled to reach the closest kidney
specialist or dialysis centre (Australian Indigenous HealthInfoNet, 2017). Although it is now
possible to conduct dialysis treatment at home, consultation, and home dialysis training might
require travel over large distances to reach a regional kidney centre (Barnes, Marfan, & Brown,
2010).
Reflection
This negotiated assignment has been very insightful to me, and has given me my preliminary
experience in posing a research question to myself, which has aided my development into a
self-directed learner. It allowed me to first assess areas of weakness in my medical knowledge
and then fortify them through online research.
This assignment taught me a lot about aboriginal access to healthcare and opened my eyes to
the difficulties they face, and also showed me the important things to consider when treating
an aboriginal patient.
Initially, my assignment had focussed on both chronic and end stage kidney disease, but I later
changed to focus on chronic kidney disease. This was because there was too much information
to convey and I felt like I had to focus my assignment to keep within the word limit.
This project increased my awareness of the indigenous population and their access to
healthcare, introduced me to the definition of equity and also made me aware of the logistical
difficulty of achieving equitable healthcare in Australia.
Overall, this assignment was a very instructive experience that aided my growth into a socially
aware and self-directed practitioner.

Statement of Modifications
1. The focus on end stage kidney disease was taken out, and the assignment was solely
focused on chronic kidney disease.
a. This was done as is became clear that I did not have enough words to talk about
statistics for both diseases separately.
2. The feedback suggestion of adding details about social determinants of health was
disregarded
a. There were not enough words to add another criteria element, and the social
determinants of health seemed to add little to the overall aim of the report.
Bibliography
Australian Bureau of Statistics. (2013). Estimates of Aboriginal and Torres Strait Islander Australians,
June 2011. Australian Bureau of Statistics Retrieved from
http://www.abs.gov.au/ausstats/abs@.nsf/mf/3238.0.55.001.
Australian Bureau of Statistics. (2014). Australian Aboriginal and Torres Strait Islander Health Survey:
Biomedical Results, 2012-13. Retrieved from
http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4727.0.55.003~2012-
13~Main%20Features~Chronic%20Kidney%20Disease~113
Australian Bureau of Statistics. (2015). Australian Aboriginal and Torres Strait Islander Health Survey:
First Results, Australia, 2012-13. Australian Bureau of Statistics Retrieved from
http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/333847137425C483CA257C2F00145BCF?op
endocument.
Australian Government Department of Health. (2017). Indigenous Australians' Health Program
Guideline. Retrieved from
http://www.health.gov.au/internet/main/publishing.nsf/Content/09AEEA5F377AEBB5CA257F1
C00159135/$File/IAHP-Programme-Guideline.pdf.
Australian Government Department of the Prime Minister and Cabinet. (2014). Kidney disease.
Retrieved from https://www.pmc.gov.au/sites/default/files/publications/indigenous/Health-
Performance-Framework-2014/tier-1-health-status-and-outcomes/110-kidney-disease.html.
Australian Indigenous HealthInfoNet. (2017). Summary of Aboriginal and Torres Strait Islander health,
2016. Retrieved from http://www.healthinfonet.ecu.edu.au/health-facts/summary
Australian Institute of Health and Welfare. (2009). Aboriginal and Torres Strait Islander health labour
force statistics and data quality assessment. Canberra: Canberra: AIHW Retrieved from
http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442458714.
Australian Institute of Health and Welfare. (2011). Chronic kidney disease in Aboriginal and Torres Strait
Islander people. Retrieved from http://www.aihw.gov.au/publication-detail/?id=10737419983
Australian Institute of Health and Welfare. (2014). Birthweight of babies born to Indigenous mothers.
Retrieved from http://www.aihw.gov.au/publication-detail/?id=60129548202
Barnes, J., Marfan, J., & Brown, D. (2010). The self-care dialysis program. The Chronicle, 1, 10-11.
Braveman, P., & Gruskin, S. (2003). Defining equity in health. Journal of Epidemiology & Community
Health, 57(4), 254-258.
Cutler, H., & Olin, E. (2017). An overview of the 2017-18 federal health budget. Retrieved from
https://www.mq.edu.au/research/research-centres-groups-and-facilities/prosperous-
economies/centres/centre-for-the-health-economy/documents/Budget-
summary_170511_05.pdf
Haroun, M. K., Jaar, B. G., Hoffman, S. C., Comstock, G. W., Klag, M. J., & Coresh, J. (2003). Risk factors
for chronic kidney disease: a prospective study of 23,534 men and women in Washington
County, Maryland. Journal of the American Society of Nephrology, 14(11), 2934-2941.
Hoy, W., Hughson, M., Singh, G., Douglas-Denton, R., & Bertram, J. (2006). Reduced nephron number
and glomerulomegaly in Australian Aborigines: a group at high risk for renal disease and
hypertension. Kidney international, 70(1), 104-110.
Hughson, M., Farris, A. B., Douglas-Denton, R., Hoy, W. E., & Bertram, J. F. (2003). Glomerular number
and size in autopsy kidneys: the relationship to birth weight. Kidney international, 63(6), 2113-
2122.
Klag, M. J., Whelton, P. K., Randall, B. L., Neaton, J. D., Brancati, F. L., Ford, C. E., . . . Stamler, J. (1996).
Blood pressure and end-stage renal disease in men. New England Journal of Medicine, 334(1),
13-18.
Shankar, A., Klein, R., & Klein, B. E. (2006). The association among smoking, heavy drinking, and chronic
kidney disease. American journal of epidemiology, 164(3), 263-271.
Spencer, J., Wang, Z., & Hoy, W. (2001). Low birth weight and reduced renal volume in aboriginal
children. American Journal of Kidney Diseases, 37(5), 915-920.
doi:http://dx.doi.org/10.1016/S0272-6386(05)80006-X
Stumpers, S., & Thomson, N. (2013). Review of kidney disease among Indigenous people. Retrieved from
http://www.healthinfonet.ecu.edu.au/chronic-conditions/kidney/reviews/our-review
Appended Parts
Original Criteria
1. Detail the socio-economic risk factors of chronic and end stage kidney disease with respect to the
Australian Indigenous population.
(1.2.1 Identifies environmental, psychological, social and cultural issues which contribute to health
problems in a scenario (e.g. sexuality, stress, family relationships, risky behaviours))
2. Outline the specific health care needs of the Australian Indigenous population that are addressed
currently by Australian healthcare, specifically in relation to chronic and end stage kidney disease?
(1.2.3 Identifies health care needs of different groups in society (e.g. the elderly, indigenous people,
immigrant groups and refugees).)
3. Assess the equity of healthcare provision, comparing the Indigenous and general population's access
to facilities required of chronic and end stage kidney disease.
(1.2.5 Understands equity and its implications for health care delivery for individual and population
based approaches.)
4. Outline some of the barriers that may prevent Indigenous Australians from accessing the services they
need to treat chronic and end stage kidney disease?
(1.2.7 Describes how people living in Australia access (or are unable to access) their health care system.)

Original Plan
Week 2: Research the risk factors and statistics of kidney disease in Australia (focussing on the
Indigenous population)
Week 3: Research and read about the Australian healthcare systems, and methods adopted to provide
improve healthcare access for Indigenous population
Week 4 - 5: Write the report based on the research done in weeks 2-3
Week 6: Final editing, formatting and reflection.

Feedback Document
Your submission DJS8VC6 has been approved.
Below is the text of your submission, with feedback:
The assignment will explore the effect of the Sociocultural and economic features that put the
Indigenous population at higher risk of chronic and end stage kidney disease. It will also explore
their access to healthcare for chronic and end stage kidney disease.
Feedback:
Interesting;Researchable
In the holidays, a cousin showed me a video about how Indigenous people were affected by
kidney disease. I found it to be very powerful and also very interesting, so I decided to do the
negotiated assignment on it. Link to video: https://www.youtube.com/watch?v=xwrCxa-BR6w
I expect to gain a greater understanding of the issues behind indigenous access to healthcare,
with respect to kidney disease and also learn about the deeper mechanisms to how and why
the indigenous population is usually more at risk for most diseases. The almost universal
disadvantage that the
indigenous population faces, with respect to healthcare has always intrigued me. As a future
practitioner, it is paramount that I understand the specific issues that this population faces.
Also, it is a practitioner's duty to ensure their patients are given the best possible treatment,
specific to
their social and cultural context. Doing this assignment will thus certainly assist my growth into
a future practitioner.
Feedback:
Succinct statement of aim;Aim relates well to course themes
Social and Cultural Aspects of Health and Disease
Feedback:
Appropriate to topic and aim
The assignment process will involve research from google scholar and pubmed and other
databases and search engines for defining sociocultural risk factors for end stage and chronic
kidney disease. It will also involve searches through Australian statistical archives for data on
incidence and
mortality of chronic and end stage kidney disease among the indigenous population. Also, I will
have to consult reliable government websites regarding the facts about indigenous access to
healthcare services such as dialysis.
Feedback:
Your proposal is appropriate to topic, aim and timeframe
The report will be a 2000 word long assignment report and reflection, there will be no
supporting files.
Feedback:
This is appropriate;Remember you need to include a statement of modification;Remember to
include your original proposal and feedback;Other (see comment)
Your statement of modifications should be included within the 2000 word limit.
1. Detail the socio-economic risk factors of chronic and end stage kidney disease with respect to
the Australian Indigenous population;(1.2.1 Identifies environmental, psychological, social and
cultural issues which contribute to health problems in a scenario (eg sexuality, stress, family
relationships, risky behaviours));2. Outline the specific health care needs of the Australian
Indigenous population that are addressed currently by Australian healthcare, specifically in
relation to chronic and end stage kidney disease?;(1.2.3 Identifies health care needs of different
groups in
society (eg the elderly, indigenous people, immigrant groups and refugees).);3. Assess the
equity of healthcare provision, comparing the Indigenous and general population's access to
facilities required of chronic and end stage kidney disease.;(1.2.5 Understands equity and its
implications for
health care delivery for individual and population based approaches.);4. Outline some of the
barriers that may prevent Indigenous Australians from accessing the services they need to treat
chronic and end stage kidney disease?;(1.2.7 Describes how people living in Australia access (or
are unable to
access) their health care system.)
Feedback:
These criteria relate to topic well;These criteria clearly specify a standard for assessment for the
marker to assess your work against;Other (see comment)
You may like to refer to ecological model of health as well.
Schedule for weeks 2 to 6
Week 2: Research the risk factors and statistics of kidney disease in Australia (focussing on the
Indigenous population);Week 3: Research and read about the Australian healthcare systems,
and methods adopted to provide improve healthcare access for Indigenous population;Week 4
- 5: Write the report
based on the research done in weeks 2-3;Week 6: Final editing, formatting and reflection.
Overall Comments:
An interesting proposal.If you have any queries about the content of your submission please
contact your Course Convenor.
Search Strategy
A wide range of online resources were consulted. The resources that were used were either
peer reviewed journal article, government reports, or statistical reports. Google was used to
search for government and statistical reports, while Google Scholar was used for peer reviewed
articles. Overall, 24 online resources were consulted. 9 of them were statistical reports, 1 was a
government report, 1 was a magazine article, 1 was a financial review, and 9 were peer
reviewed journal articles. 3 were miscellaneous articles used for definitions.
The search terms used were:
1. Chronic Kidney Disease
2. Aboriginal
3. Chronic renal disease
4. Dialysis
5. Access + medical facilities
6. Remote + rural
7. Equity
8. Equity + burden of disease
9. Aboriginal + equity + chronic kidney disease